A Novel Approach to Support Quality Assurance (QA) of Intensity Modulated Neutron Therapy (IMNT)

PURPOSE/OBJECTIVE(S)

Neutron therapy is a form of high linear energy transfer (LET) radiation treatment shown to be beneficial for the treatment of locally advanced head and neck cancers (HNC) resistant to low LET x-ray and proton therapy treatments. The Clinical Neutron Therapy System (CNTS) at our institution has been in clinical operation for over 35 years, and over 3,400 patients have been treated using 3D conformal neutron radiation therapy. In October of 2022, the clinical commissioning of IMNT was completed and the first-ever patient was treated. A novel patient specific quality assurance (PSQA) program has been developed to support IMNT. We present an analysis of our early experiences and PSQA findings for the first 16+ patients treated with IMNT.

MATERIALS/METHODS

Our pre-treatment IMNT PSQA program includes (1) ionization chamber measurements, (2) a log-file analysis of treatment delivery, and (3) a γ-analysis of the expected and measured doses (fluences) from a novel positron emission portal imaging system based on 12C(n,2n)11C reactions. Patient setup is confirmed on a daily basis with kV portal imaging. We use a modulation factor (MF), defined as the total number of monitor units (MU)/prescribed dose (cGy) per fraction, to identify and help anticipate IMNT plans that may fail our PSQA program.

RESULTS

We have found that IMNT treatments for large, irregularly shaped treatment volumes (e.g., chest wall or head and neck cancers that require treatment of nodes in the lower neck) are more likely to fail PSQA when the MF exceeds 3 MU/cGy. For smaller, more spherical treatment volumes (e.g., base of tongue cancers), plans with a MF up to 3.5 MU/cGy pass our PSQA criteria. Re-optimized plans subsequently passed PSQA with insignificant or no change in tumor coverage and organ-at-risk (OAR) dose. Re-optimized plans also reduced the total number of MU and number of segments, which has the added benefit of decreasing the overall treatment time and patient time on the table. About 10% of early IMNT patients have required plan re-optimization.

CONCLUSION

Our pre-treatment clinical PSQA program and workflow provides useful information to guide IMNT treatment planning and delivery, and helps ensure the safe and accurate delivery of IMNT. Our early experiences suggest IMNT plans with smaller MF values are more likely to pass PSQA than plans with larger values of the MF.

Clinical Outcomes and Immunotoxicity in People with HIV (PWH) after Definitive Chemoradiation (CRT) for Anal Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

Anal cancer disproportionately affects PWH despite antiretroviral therapy. Data on CRT outcomes are limited. Modern IMRT CRT decreases acute toxicity but may exacerbate immune dysregulation from chronic HIV. Although historical CRT has been associated with prolonged CD4 count suppression, little is known about late immunotoxicity in PWH after contemporary CRT. We report clinical outcomes and long term immunotoxicity.

MATERIALS/METHODS

Single-center retrospective review of all PWH confirmed on chart review with anal squamous cell carcinoma without prior pelvic irradiation treated with definitive IMRT CRT. Patient and CRT factors including HIV suppression (<200 copies/mL), mean CD4 count (cells/µL), and receipt of capecitabine (C) or 5-fluorouracil (F) +/- mitomycin (M) were summarized with n (%) or median (interquartile range). Progression-free and overall survival (PFS; OS) were estimated per Kaplan-Meier with 95% confidence intervals and compared with log-rank tests. Mean CD4 count and CD4:CD8 were compared by HIV suppression status (Welch's t-test); longitudinal changes in median CD4 count and CD4:CD8 were compared between baseline vs. nadir (within 6 months of CRT start) and 1-year follow-up for patients with complete data (Wilcoxon signed-rank test).

RESULTS

A total of 23 PWH were treated between 2010-2022, median age 52, median 16 (13 - 19) years after HIV diagnosis; 4 had unsuppressed HIV; AJCC 8th stage I/II/III/IV 5/5/12/1. Radiation dose was median 54 Gy in 30 fractions over 42 (40 - 44) days. Most had C+M (57%); only 43% had 2×M with either C or F. One had neoadjuvant carboplatin/paclitaxel/pembrolizumab. With 2.9 (1.03 - 3.3) years follow-up, median OS was 6.6 (6.2 - unreached [UR]) years. With 2.2 (0.67 - 2.7) years follow-up, median PFS was UR. OS and PFS were similar regardless of HIV suppression status (both P ≥ 0.09). Overall baseline CD4 count was 458 (226 - 484), and CD4:CD8 was 0.54 (0.2 - 0.7). Nadir CD4 was 100 (59 - 126) and CD4:CD8 was 0.3 (0.2 - 0.4). Baseline and nadir CD4 count and CD4:CD8 were lower if HIV-unsuppressed (each P ≤ 0.04). One year after CRT, CD4 count was 252 (102 - 276), while CD4:CD8 was 0.5 (0.2 - 0.7). For 7 patients with repeated values the change in median from baseline to nadir, 6-, and 12-months post-CRT was -282, -549 (both P = 0.02), -480 (P = 0.9) for CD4 counts, and -0.7, -0.5, -0.4 (each P > 0.5) for CD4:CD8 ratios; none had unsuppressed HIV.

CONCLUSION

Definitive IMRT CRT with guideline-concordant doublet chemotherapy for anal cancer in PWH is effective despite unsuppressed HIV. Treatment leads to prolonged immunological changes that may increase the risk of HIV-related morbidity and mortality. Modifiable treatment-related causes of hematoimmunologic toxicity should be investigated further, and immune surveillance after CRT should be considered to better understand impact on quality of life.

Utilization of Services and Clinical Outcomes among American Indian/Alaska Native (AIAN) Women with Breast Cancer at an Academic Medical Center (AMC)

PURPOSE/OBJECTIVE(S)

AIAN patients have worse cancer outcomes than other races and may face barriers in accessing care. Data on healthcare utilization or outcomes for AIAN patients across healthcare systems are limited. We report patient characteristics, treatment patterns, and clinical outcomes for AIAN women with breast cancer seen at a tertiary AMC in the Pacific Northwest.

MATERIALS/METHODS

We performed a retrospective chart review of self-identified AIAN women with an encounter for unilateral breast cancer between January /2000 and January 2021. Patient demographics; AJCC 8th prognostic stage; treatment (surgery, radiation, systemic therapy); were abstracted and summarized with median (interquartile range) or number (%) and compared with χ2 or t-tests. Progression-free (recurrent or new breast cancer) and overall survival (PFS; OS) were estimated per Kaplan-Meier and compared with log-rank tests.

RESULTS

Of 21,013 patients with cancer encounters, 2,168 (10%) self-identified as AIAN and 246 (0.01%) were AIAN women with unilateral breast cancer. The median age at diagnosis was 52 (43 - 53) years; 37% lived in the same county as the AMC while 80% lived in the same state. At diagnosis, 181 (74%) had early-stage (0 - 2A), 24 (10%) locally-advanced (2B - 3), 30 (12%) non-metastatic, and 11 (4%) metastatic disease. Of the 181 (74%) women treated at the AMC, 39% lived in the same county; 86% had curative-intent therapy: 52 (71%) surgery, 114 (37%) radiation, and 65 (64%) systemic therapy; 26% had surveillance, oncoplastic surgery or non-cancer care only. Women who had surgery at the AMC were older (P < 0.01), less likely to live in the same county (40%, P = 0.4), had mostly early-stage disease (81%, P = 0.005), and were more likely to receive adjuvant therapy at the AMC (75%, P < 0.01). Patients treated for metastatic disease at the AMC (19%) rarely lived in the same county (21%, P = 0.03), or had prior treatment at the AMC (32%, P = 0.03); 92% had systemic therapy, 38% radiation, and 12% surgery. With median 6.4 (3.2 - 10.9) years follow-up, median OS for all AIAN patients was 51.4 (unreached [UR] - UR) years. Patients who presented to the AMC with metastatic disease had median OS 13.4 (8.4 - UR) years. With median 5.1 (2.6 - 9.3) years follow-up, median PFS was 20.6 (14.2 - UR) years, and longer for patients who received any curative-intent treatment at the AMC (P = 0.006).

CONCLUSION

Most AIAN women with breast cancer seen at the AMC received curative treatment for early-stage disease with excellent outcomes. Most treated for metastatic disease had no prior treatment at the AMC and may be more likely to transfer care to the AMC to engage with specialized services or clinical trials, particularly for systemic therapy. Understanding the prognostic stage, treatment utilization, and outcomes of the AIAN patients served may allow us to improve cancer services and outcomes for this community.

Intensity-Modulated Neutron Therapy (IMNT) for Head and Neck Cancer: Early Toxicity Outcomes

PURPOSE/OBJECTIVE(S)

Locally advanced head & neck cancers (HNC) are challenging to treat due to abutment of critical, dose-limiting structures. Fast neutron radiotherapy (NT) is a high linear energy transfer (LET) modality that provides better local control than photons for radioresistant cancers such as salivary gland tumors, but there have been concerns of toxicity with 3D conformal neutron therapy in the past. Recent technological advances have enabled the planning and delivery of IMNT, which improves target conformality and may reduce toxicity compared to 3D conformal NT. We report the first clinical evaluation of early toxicity outcomes of IMNT for HNC.

MATERIALS/METHODS

Study is a single-institution retrospective review of all HNC patients treated with curative-intent IMNT from 10/2022 to 2/2023, using a hospital-based cyclotron (50.5 MeV 1H+ beam incident on a Be target) equipped with an isocentric gantry and multileaf collimator (MLC). A commercial treatment planning system with custom neutron-specific scattering kernels was used for IMNT planning using 4-6 fields. Patient-specific quality assurance included ionization chamber measurements and a novel 12C(n,2n)11C positron emission portal imaging system. kV portal imaging was used to confirm patient setup prior to each treatment session. All patients were prescribed 18.4 Gy at 1.15 Gy/fraction, delivered 4 days/week, which is equivalent to an x-ray EQD2 of approximately 70 Gy (RBE ∼ 3.8). Clinical observations suggest the RBE for radioresistant HNC may be as large as 8. Patients underwent weekly toxicity assessment, and acute toxicities were graded (G) by CTCAE v5.0.

RESULTS

Ten patients received IMNT, median age 61 (range 34-78). Primary tumor sites were base of tongue (n = 3), sinonasal (n = 3), parotid (n = 2), submandibular (n = 1), larynx (n = 1). Tumor histologies included adenoid cystic carcinoma (n = 7), other salivary gland carcinomas (n = 2) and mucosal melanoma (n = 1). Most had T4 disease (n = 8) and one had N3b disease. Six had surgical resection with high-risk features, and 6 had gross measurable disease prior to IMNT. None had concurrent systemic therapy. Uninvolved salivary glands were spared in most patients. All patients completed treatment. Median follow up was 22 days (0-48). Acute toxicities (n, G 1, 2, 3) included skin (8, 3, 0), dysgeusia (1, 6, 0), xerostomia (3, 5, 0), mucositis (2, 0, 5), nausea (3, 0, 1). One patient had >10% weight loss and brief admission for supportive care and PEG placement; one patient had prophylactic PEG; both regained oral independence during follow-up. There was no Grade 4+ toxicity.

CONCLUSION

IMNT improves the therapeutic ratio compared to 3D conformal NT and expands indications for NT in patients with radiorefractory tumors. Acute toxicity compares favorably with photons. Longer clinical and toxicity follow-up is anticipated. A prospective trial is planned to evaluate quality of life measures.

The oral microbiota is a reservoir for antimicrobial resistance: resistome and phenotypic resistance characteristics of oral biofilm in health, caries, and periodontitis

BACKGROUND

Antimicrobial resistance (AMR) is an ever-growing threat to modern medicine and, according to the latest reports, it causes nearly twice as many deaths globally as AIDS or malaria. Elucidating reservoirs and dissemination routes of antimicrobial resistance genes (ARGs) are essential in fighting AMR. Human commensals represent an important reservoir, which is underexplored for the oral microbiota. Here, we set out to investigate the resistome and phenotypic resistance of oral biofilm microbiota from 179 orally healthy (H), caries active (C), and periodontally diseased (P) individuals (TRN: DRKS00013119, Registration date: 22.10.2022). The samples were analysed using shotgun metagenomic sequencing combined, for the first time, with culture technique. A selection of 997 isolates was tested for resistance to relevant antibiotics.

RESULTS

The shotgun metagenomics sequencing resulted in 2,069,295,923 reads classified into 4856 species-level OTUs. PERMANOVA analysis of beta-diversity revealed significant differences between the groups regarding their microbiota composition and their ARG profile. The samples were clustered into three ecotypes based on their microbial composition. The bacterial composition of H and C samples greatly overlapped and was based on ecotypes 1 and 2 whereas ecotype 3 was only detected in periodontitis. We found 64 ARGs conveying resistance to 36 antibiotics, particularly to tetracycline, macrolide-lincosamide-streptogramin, and beta-lactam antibiotics, and a correspondingly high prevalence of phenotypic resistance. Based on the microbiota composition, these ARGs cluster in different resistotypes, and a higher prevalence is found in healthy and caries active than in periodontally diseased individuals. There was a significant association between the resistotypes and the ecotypes. Although numerous associations were found between specific antibiotic resistance and bacterial taxa, only a few taxa showed matching associations with both genotypic and phenotypic analyses.

CONCLUSIONS

Our findings show the importance of the oral microbiota from different niches within the oral cavity as a reservoir for antibiotic resistance. Additionally, the present study showed the need for using more than one method to reveal antibiotic resistance within the total oral biofilm, as a clear mismatch between the shotgun metagenomics method and the phenotypic resistance characterization was shown.

Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

INTRODUCTION

System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.

METHODS

This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used.

RESULTS

African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.

CONCLUSIONS

Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.

Influence of the long-term use of oral hygiene products containing stannous ions on the salivary microbiome - a randomized controlled trial

Oral hygiene products containing tin are suitable to prevent erosive tooth wear, yet effects on the oral microbiota are not known yet. Therefore, this study determined the salivary microbiome of 16 participants using products with stannous ions for three years (TG) compared with a control group (CG) to assess their influence on the microbiota. Participants were included in a randomized controlled clinical trial (RCT) with biannual visits. Illumina Miseq sequencing revealed as most abundant genera: Streptococcus (TG 14.3%; CG 13.0%), Veillonella (TG 11.3%; CG 10.9%), Prevotella (TG 7.0%; CG 9.8%), Haemophilus (TG 6.6%; CG 7.2%), Porphyromonas (TG 5.9%, CG 5.1%), Leptotrichia (TG 5.8%; CG 4.9%), Actinomyces (TG 4.0%; CG 4.6%) and Neisseria (TG 5.4%; CG 4.2%). Beta-Diversity was not significantly different between groups at both time points, although significant differences between groups were found for certain taxa after three years. The genus Prevotella was found in higher abundance in CG whereas Neisseria and Granulicatella, health-associated taxa, were found more abundantly in TG. Salivary microbiota after three years reflected a composition associated with oral health, hence continual use as a preventive measure for dental erosion can be considered safe and benefitting oral health for patients with a high risk of erosion.

Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act

The Affordable Care Act (ACA) aims to expand health insurance coverage and minimize financial barriers to receiving health care services for individuals. However, little is known about how the ACA has impacted individuals with mental health conditions. This study finds that the implementation of the ACA is associated with an increase in rate of health insurance coverage among nonelderly adults with serious psychological distress (SPD) and a reduction in delaying and forgoing necessary care. The ACA also reduced the odds of an individual with SPD not being able to afford mental health care. Mental health care access among racial and ethnic minority populations and people with low income has improved during 2014-2016, but gaps remain.

Exploring national trends of patient- and family-centered care among US children

We explored national trends in the receipt of high-quality patient-physician communication and patient empowerment through behavioral health counseling among children in the United States. We used data from the Medical Expenditure Panel Survey from 2010 to 2014. We employed two measures of patient- and family-centered care (PFCC): (1) a composite measure of high-quality patient-physician communication ( n = 34,629) and (2) patient empowerment through behavioral health counseling about healthy eating ( n = 36,527) and exercise ( n = 38,318). We used multivariate logistic regression models to estimate the variation of receiving PFCC by social determinants of health over time. Rates of receiving behavioral health counseling about healthy eating (53-60%) and exercise (37-42%) were lower than the rate of receiving high-quality physician-patient communication (92-93%). Parents were significantly more likely to report receiving high-quality physician-patient communication in 2014 than in 2010 (odds ratio 1.37, confidence interval 1.08-1.67); however, no association was found for empowerment through behavioral health counseling. Low income and parental educational attainment, and lack of insurance were associated with lower odds of receiving behavioral health counseling. Results showed significant variation of physician-patient communication and empowerment by social and demographic factors. The results suggest more providers need to empower parents and their children to self-care through behavioral health counseling.

Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Predictors of responses to immune checkpoint blockade in advanced melanoma

Immune checkpoint blockers (ICB) have become pivotal therapies in the clinical armamentarium against metastatic melanoma (MMel). Given the frequency of immune related adverse events and increasing use of ICB, predictors of response to CTLA-4 and/or PD-1 blockade represent unmet clinical needs. Using a systems biology-based approach to an assessment of 779 paired blood and tumor markers in 37 stage III MMel patients, we analyzed association between blood immune parameters and the functional immune reactivity of tumor-infiltrating cells after ex vivo exposure to ICB. Based on this assay, we retrospectively observed, in eight cohorts enrolling 190 MMel patients treated with ipilimumab, that PD-L1 expression on peripheral T cells was prognostic on overall and progression-free survival. Moreover, detectable CD137 on circulating CD8⁺ T cells was associated with the disease-free status of resected stage III MMel patients after adjuvant ipilimumab + nivolumab (but not nivolumab alone). These biomarkers should be validated in prospective trials in MMel.The clinical management of metastatic melanoma requires predictors of the response to checkpoint blockade. Here, the authors use immunological assays to identify potential prognostic/predictive biomarkers in circulating blood cells and in tumor-infiltrating lymphocytes from patients with resected stage III melanoma.

Supplementary sampling of obturation materials enhances microbial analysis of endodontic treatment failures: a proof of principle study

OBJECTIVES

Root canal treatment failures often correlate with persistent biomaterial-associated endodontic infections. The aim of the present study was to assess the impact of endodontic obturation material sampling from root canals with posttreatment apical periodontitis on improving standard study protocols.

MATERIALS AND METHODS

Samples from previously filled root canals and their corresponding endodontic filling materials were obtained from five root-filled teeth with posttreatment periradicular lesions. After cultivation, the isolated microorganisms were quantified and biochemically identified. Moreover, clone libraries were constructed after the amplification of bacterial 16S ribosomal DNA (rDNA) from the same samples. DNA from selected clones was sequenced to identify microbial species. Transmission electron microscopy (TEM) aided visualization of the detected bacteria.

RESULTS

Overall, 22 taxa of the phyla Firmicutes, Actinobacteria, and Bacteroidetes were detected in both obturation and root canal samples by culture-dependent and culture-independent methods. Root canal fillings sheltered 17 species (3.30-7.50 × 10(3) CFU/ml). Of these, nine were detected solely in the retrieved obturation materials. The reinfected root canals harbored 13 taxa (3.48-7.36 × 10(3) CFU/ml). Obligate and facultative anaerobic bacteria prevailed. The number of different species ranged from 1 to 5 within a single sample. Fungi were not detected.

CONCLUSIONS

Bacteria can colonize both root canals and endodontic fillings in vivo.

CLINICAL RELEVANCE

Integrating the sampling of obturation materials with standard root canal sample collection offers a clearer insight into the actual microbial flora of reinfected root canals and improves the study protocols of secondary/persistent endodontic infections.

New developments in vaccines, inhibitors of anthrax toxins, and antibiotic therapeutics for Bacillus anthracis

Bacillus anthracis, the causative agent responsible for anthrax infections, poses a significant biodefense threat. There is a high mortality rate associated with untreated anthrax infections; specifically, inhalation anthrax is a particularly virulent form of infection with mortality rates close to 100%, even with aggressive treatment. Currently, a vaccine is not available to the general public and few antibiotics have been approved by the FDA for the treatment of inhalation anthrax. With the threat of natural or engineered bacterial resistance to antibiotics and the limited population for whom the current drugs are approved, there is a clear need for more effective treatments against this deadly infection. A comprehensive review of current research in drug discovery is presented in this article, including efforts to improve the purity and stability of vaccines, design inhibitors targeting the anthrax toxins, and identify inhibitors of novel enzyme targets. High resolution structural information for the anthrax toxins and several essential metabolic enzymes has played a significant role in aiding the structure-based design of potent and selective antibiotics.

Identification of nitroso compounds from biotransformation of 2,4-dinitrotoluene

The intermediates of microbial transformation of 2,4-dinitrotoluene by a mixed bacterial culture derived from activated sludge were identified as 2-amino-4-nitrotoluene, 4-amino-2-nitrotoluene, 2-nitroso-4-nitrotoluene, and 4-nitroso-2-nitrotoluene. The biotransformation of 2,4-dinitrotoluene occurred only under anaerobic conditions with an exogenous carbon source. The two nitroso compounds were unstable and could be observed only at the early stage of 2,4-dinitrotoluene anaerobic biotransformation.

Structure-based approach to pharmacophore identification, in silico screening, and three-dimensional quantitative structure-activity relationship studies for inhibitors of Trypanosoma cruzi dihydrofolate reductase function

We have employed a structure-based three-dimensional quantitative structure-activity relationship (3D-QSAR) approach to predict the biochemical activity for inhibitors of T. cruzi dihydrofolate reductase-thymidylate synthase (DHFR-TS). Crystal structures of complexes of the enzyme with eight different inhibitors of the DHFR activity together with the structure in the substrate-free state (DHFR domain) were used to validate and refine docking poses of ligands that constitute likely active conformations. Structural information from these complexes formed the basis for the structure-based alignment used as input for the QSAR study. Contrary to indirect ligand-based approaches the strategy described here employs a direct receptor-based approach. The goal is to generate a library of selective lead inhibitors for further development as antiparasitic agents. 3D-QSAR models were obtained for T. cruzi DHFR-TS (30 inhibitors in learning set) and human DHFR (36 inhibitors in learning set) that show a very good agreement between experimental and predicted enzyme inhibition data. For crossvalidation of the QSAR model(s), we have used the 10% leave-one-out method. The derived 3D-QSAR models were tested against a few selected compounds (a small test set of six inhibitors for each enzyme) with known activity, which were not part of the learning set, and the quality of prediction of the initial 3D-QSAR models demonstrated that such studies are feasible. Further refinement of the models through integration of additional activity data and optimization of reliable docking poses is expected to lead to an improved predictive ability.

Towards species-specific antifolates

Dihydrofolate reductase (DHFR) plays an essential role in cellular biochemistry and has been a well-recognized drug target for over fifty years. Antifolate inhibitors of DHFR, including clinically used therapeutics such as methotrexate, trimethoprim, and pyrimethamine have been successful as anticancer, antibacterial, antifungal and antiparasitic agents. As resistant strains of these microorganisms evolve and as new disease threats arise, the need for new antifolates that are potent and specific for infectious organisms becomes more pressing. Several new antifolates have been reported over the past decade; many of these are potent against a particular species of DHFR, but achieving the goal of potency and selectivity has proven to be more difficult. This review will describe recent advances in attaining species selectivity in developing new antifolates. Specifically, advances in developing inhibitors against Pneumocystis jirovecii and Plasmodium falciparum, the causative agents in pneumocystis pneumonia and malaria, respectively, will be presented.

Methadone in the treatment of chronic nonmalignant pain: a 2-year follow-up

OBJECTIVE

To examine the longitudinal use of methadone in a pain clinic.

DESIGN

Follow-up study of 40 patients initially treated with methadone and re-evaluated 2 years later, comparing those maintained on methadone with those who were switched to other opioids.

SETTING

Pain clinic at a university hospital.

RESULTS

The 14 patients (35%) who stayed on methadone for the duration of the study, had higher employment rates (P <.05) and higher functional ratings (P <.02) than those on other opioids. Side effects were the most common reason (33.4%) for discontinuation of methadone. Dose escalation occurred in 11 of 14 patients (78.6%).

CONCLUSIONS

Chronic pain patients may be safely and effectively treated with methadone. Those not responding or tolerating methadone may be benefited by treatment with other opioids.

Androgen suppression of GnRH-stimulated rat LHbeta gene transcription occurs through Sp1 sites in the distal GnRH-responsive promoter region

Steroids may regulate LH subunit gene transcription by modulating hypothalamic GnRH pulse patterns or by acting at the pituitary gonadotrope to alter promoter activity. We tested direct pituitary effects of the androgen dihydrotestosterone (DHT) to modulate the rat LHbeta promoter in transfected LbetaT2 clonal gonadotrope cells and in pituitaries of transgenic mice expressing LHbeta-luciferase. The LHbeta promoter (-617 to +44 bp)-luciferase construct was stimulated in LbetaT2 cells 7- to 10-fold by GnRH. Androgen treatment had little effect on basal promoter activity but suppressed GnRH stimulation by approximately 75%. GnRH stimulation of LHbeta was also suppressed by DHT in isolated pituitary cells from male or female mice with functional nuclear ARs, but not in male littermates with mutant AR. GnRH stimulation of the LHbeta promoter requires interactions between a complex distal response element containing two specificity protein-1 (Sp1) binding sites and a CArG box, and a proximal element with two bipartite binding sites for steroidogenic factor-1 and early growth response protein-1 (Egr-1). DHT effectively suppressed promoter constructs with an intact distal response element. The distal response element does not bind AR, but AR reduces Sp1 binding to this region. Glutathione-S-transferase pull-down studies demonstrated direct interactions of AR with Sp1, which requires the DNA-binding domain of AR, and weaker interactions with Egr-1. We conclude that androgen suppression of the rat LHbeta promoter occurs primarily through direct interaction of AR with Sp1, with some possible role through binding to Egr-1. These interactions result in interference with GnRH-stimulated gene transcription by reducing cooperation between the distal and proximal GnRH response elements.

Notch signaling in lymphocyte development

Signaling through Notch has been implicated in many cell-fate decisions during lymphocyte development. Recent studies have provided new clues--and raised new controversies--regarding the exact role that Notch signaling plays in the commitment of cells to the T-cell lineage. Progress has also been made in deducing the transcriptional program induced by Notch and the mechanism of oncogenic transformation by Notch in lymphocytes.

Approaches to solving the rigid receptor problem by identifying a minimal set of flexible residues during ligand docking

BACKGROUND

Using fixed receptor sites derived from high-resolution crystal structures in structure-based drug design does not properly account for ligand-induced enzyme conformational change and imparts a bias into the discovery and design of novel ligands. We sought to facilitate the design of improved drug leads by defining residues most likely to change conformation, and then defining a minimal manifold of possible conformations of a target site for drug design based on a small number of identified flexible residues.

RESULTS

The crystal structure of thymidylate synthase from an important pathogenic target Pneumocystis carinii (PcTS) bound to its substrate and the inhibitor, BW1843U89, is reported here and reveals a new conformation with respect to the structure of PcTS bound to substrate and the more conventional antifolate inhibitor, CB3717. We developed an algorithm for determining which residues provide 'soft spots' in the protein, regions where conformational adaptation suggests possible modifications for a drug lead that may yield higher affinity. Remodeling the active site of thymidylate synthase with new conformations for only three residues that were identified with this algorithm yields scores for ligands that are compatible with experimental kinetic data.

CONCLUSIONS

Based on the examination of many protein/ligand complexes, we develop an algorithm (SOFTSPOTS) for identifying regions of a protein target that are more likely to accommodate plastically to regions of a drug molecule. Using these indicators we develop a second algorithm (PLASTIC) that provides a minimal manifold of possible conformations of a protein target for drug design, reducing the bias in structure-based drug design imparted by structures of enzymes co-crystallized with inhibitors.

Assessing the professional development needs of public health professionals

This article describes the major activities associated with designing and implementing a comprehensive, professional development needs assessment of public health professionals in four states of the South Central region of the United States. The instrumentation, research design, and summary results of the needs assessment described in this article may facilitate similar efforts by interested researchers and program developers to assess the public health professional workforce training needs. Results of needs assessments can be useful in designing and evaluating professional development curricula and activities to strengthen public health services in the United States.

Pharmacy student training in United States hospices

Hospice is a quickly growing field in health care in the United States. As the pharmacist's role in providing patient care to persons at the end of life increases, considerations should be given for training pharmacy students in this area. The objectives of this study were to examine the frequency of pharmacy student education and training among United States hospice organizations as well as to describe factors of hospice organizations that are associated with pharmacy student training. This is the first study of which we are aware to address the availability of experiential rotations for pharmacy students in hospice programs. A one-page questionnaire was mailed to 3,762 hospice organizations with addresses obtained from the National Hospice and Palliative Care Organization (NHPCO). Following two mailings, eight weeks apart, 907 responses were obtained. Ninety-four (10 percent) hospices trained pharmacy students, 246 (27 percent) trained medical students, 357 (39 percent) trained social work students, and 623 (69 percent) trained nursing students. These results indicate that the experiential training needs of United States pharmacy students are being addressed. However, further study is warranted to describe the various experiences of pharmacy students within the hospice setting.

The origin and regulation of autopathogenic T cells

A clear understanding of the events surrounding the selection of autoreactive T cells in the thymus and their regulation in the periphery has eluded immunologists for years. However, recent work examining the expression of tissue-specific antigens in the thymus and the biochemistry of disease associated MHC alleles has provided important clues into the generation of the autoreactive T cell repertoire in the thymus. In addition, recent studies focusing on the role of immunoregulatory cytokines and cross-reactive peptide ligands has provided information regarding both the regulation and activation of autoreactive cells in the periphery. An improved understanding of the selection and regulation of autoreactive T cells will undoubtedly aid in the development of strategies for treating autoimmune disease.

Biological derivation of a range of cephalometric norms for children of African American descent (after Steiner)

The purpose of this study was to report a normal range of anteroposterior apical base differences and concomitant interincisor inclinations and locations derived from a sample of American children (12 to 16 years) of African descent with normal occlusion (statistically defined). Standard cephalometric radiographs of 40 boys and 40 girls were traced and the Steiner Analysis performed. In addition to the ANB angle, 6 supplemental anteroposterior apical base separation estimators were measured, mean values established, and correlation (r) associations performed. The range of anteroposterior apical base difference was -0.5 degrees to 9.5 degrees estimated by the ANB angle or a linear distance of +/-6.5 mm using the Wits Appraisal. The angular and linear distance of the upper incisor to NA line (compensations) ranged from a low of 12 degrees and 3 mm to a high of 39 degrees and 14 mm. The angular and linear distance of the lower incisor to the NB line ranged from a low of 17 degrees and 3 mm to a high of 47.5 degrees and 17.5 mm. Biologically, the results suggested a wide range of equally acceptable sagittal apical base relationships and associated compensations in upper and lower incisor inclinations; normal occlusion was viewed as the reference point. Considering the usage of such descriptive terms as "ideal," "acceptable compromises," and "individualized treatment goals," to describe the angulation and inclination of the incisor teeth, the need for a distinction between biologically derived reference norms and esthetic preference reference norms is apparent when analyzing normal occlusion.

Autoantigen-responsive T cell clones demonstrate unfocused TCR cross-reactivity toward multiple related ligands: implications for autoimmunity

It has been suggested that the cross-reaction of a single T cell receptor with multiple different peptide ligands is a mechanism for maintaining a diverse yet compact immune repertoire. In the context of autoimmune disease it is important to understand how this property is balanced against the maintenance of self-tolerance. Specifically, whether the cross-reactivity inherent in the immune system is focused or unfocused will have important consequences for the development of autoimmune disease. If cross-reactivity is "focused," then in an immune response to a foreign antigen all T cell receptors that recognize the foreign antigen will cross-react with a specific autoantigenic peptide. However, if cross-reactivity is "unfocused," an immune response to a foreign antigen will result in the activation of a small number of self-reactive cells within a larger pool of cells specific for the foreign antigen. We have tested whether cross-reactivity is focused or unfocused by generating a panel of T cell clones that respond to two closely related ligands. W144 is an autoantigenic peptide of myelin proteolipid protein, PLP 139-151 (HSLGKWLGHPDKF), and Q144 is an altered peptide of PLP 139-151 bearing a glutamine for tryptophan substitution at position 144. The Q144-responsive clones have a broad degree of cross-reactivity with other position 144 substituted peptides. We find that despite their characteristic responses to Q144 and W144, the patterns of responses of these clones to other structurally related ligands are random, demonstrating that cross-reactivity is unfocused in the absence of selection. Maintaining a diverse range of cross-reactive interactions may limit nonspecific responses to autoantigens.

Divergent and composite gonadotropin-releasing hormone-responsive elements in the rat luteinizing hormone subunit genes

GnRH pulses regulate gonadotropin subunit gene transcription in a frequency-dependent, subunit-specific manner. The alpha-subunit gene is stimulated by constant GnRH and by rapid to intermediate pulse frequencies, while stimulation of LHbeta subunit gene transcription requires intermediate frequency pulses. We have defined the GnRH-responsive elements of the rat LH subunit gene promoters by deletion/mutation analysis and transfection studies in rat pituitary cells and two clonal gonadotrope cell lines. The alpha-subunit gene GnRH-responsive region lies between -411 and -375 bp. The region contains two Ets-domain protein binding sites, and mutating either site obliterates the response. DNA protein binding studies demonstrate the two sites are not equivalent, and that Ets-1 does not mediate this response. Studies of the LHbeta promoter reveal a major GnRH-responsive region between -456 and -342 bp. Within this region, two Sp1 binding sites contribute to the GnRH response, and the 3'Sp1 site is also critical for basal expression. The 5'Sp1 site partially overlaps a CArG box, and mutating the CArG element specifically eliminates the response to pulsatile GnRH. DNA containing this mutation cannot form intermediate mobility complexes with nuclear proteins, but retains Sp1 binding. Mutation of the 3'Sp1 site and either the 5'Sp1 or CArG element partially restores GnRH stimulation, suggesting a downstream element contributes to the full GnRH response. These studies demonstrate that unique composite elements and transcription factors are responsible for GnRH stimulation of the LH subunit genes and may contribute to their differential responses to GnRH pulses.

The crystal structure of thymidylate synthase from Pneumocystis carinii reveals a fungal insert important for drug design

Thymidylate synthase from Pneumocystis carinii (PcTS) is an especially important drug target, since P. carinii is a fungus that causes opportunistic pneumonia infections in immune-compromised patients and is among the leading causes of death of AIDS patients. Thymidylate synthase (TS) is the sole enzyme responsible for the de novo production of deoxythymidine monophosphate and hence is crucial for DNA replication in every organism. Inhibitors selective for P. carinii TS over human TS would be greatly beneficial in combating this disease. The crystal structure of TS from P. carinii bound to its substrate, dUMP, and a cofactor mimic, CB3717, was determined to 2.6 A resolution. A comparison with other species of TS shows that the volume of the closed PcTS active-site is 20 % larger than that of five other TS closed active-sites. A two-residue proline insert that is strictly conserved among all fungal species of TS, and a novel C-terminal closing interaction involving a P. carinii-specific tyrosine residue are primarily responsible for this increase in volume. The structure suggests several options for designing an inhibitor specific to PcTS and avoiding interactions with human TS. Taking advantage of the residue substitutions of P. carinii TS over human TS enables the design of a selective inhibitor. Additionally, the larger volume of the active-site of PcTS is an important advantage for designing de novo inhibitors that will exclude the human TS active-site through steric hindrance.

Tuning T cell activation threshold and effector function with cross-reactive peptide ligands

We have generated a panel of cross-reactive T cells by immunizing SJL mice (I-A(s)) with Q144 peptide, an analog of an autoantigenic peptide (W144) of myelin proteolipid protein (PLP) 139-151 (HSLGKWLGHPDKF) in which W was replaced by Q at position 144. Following immunization with Q144, T cells were expanded in vitro with W144, which is a cross-reactive, suboptimal ligand, for Q144-specific T cells. The T cell clones responded to both ligands and grew normally on the peptide W144, but were hyperstimulated when activated by Q144 in vitro. This hyperstimulation results in a heteroclitic proliferative response with secretion of additional cytokines not induced by W144. Thus expansion of T cells by a suboptimal cross-reactive ligand effectively lowers the activation threshold so that the immunizing antigen becomes a hyperstimulating ligand for the clones. Surprisingly, when the T cell clones are grown on the hyperstimulating ligand Q144, some adapt by increasing their activation threshold. This desensitization results in a loss of response to a number of cross-reactive ligands and the appearance of a more specific T cell response. Long-term culture with the hyperstimulating ligand is sometimes associated with down-regulation of CD4 expression. These results provide an explanation for the common finding of T cell heteroclicity, and suggest that although the specificity and hierarchy of the response of T cells to peptides is determined by the TCR, activation threshold and effector functions are modified by exposure to cross-reactive ligands. This observation has implications for the development and regulation of autoimmune disease.

The structural mechanism for half-the-sites reactivity in an enzyme, thymidylate synthase, involves a relay of changes between subunits

Thymidylate synthase (TS), a half-the-sites reactive enzyme, catalyzes the final step in the de novo biosynthesis of deoxythymidine monophosphate, dTMP, required for DNA replication. The cocrystal structure of TS from Pneumocystis carinii (PcTS), a new drug target for an important pathogen, with its substrate, deoxyuridine monophosphate (dUMP), and a cofactor mimic, CB3717, was determined. The structure, solved at 2.6 A resolution, shows an asymmetric dimer with two molecules of the substrate dUMP bound yet only one molecule of cofactor analogue bound. The structural evidence reveals that upon binding cofactor analogue and forming a covalent bond from the nucleophilic cysteine to the substrate, dUMP, at one active site, PcTS undergoes a conformational change that renders the opposite monomer incapable of forming a covalent bond or binding a molecule of cofactor analogue. The communication pathway between the two active sites is evident, allowing a structural definition of the basis of half-the-sites reactivity for thymidylate synthase and providing an example of such a mechanism for other half-the-sites reactive enzymes.

Crystal structure of a brominated RNA helix with four mismatched base pairs: An investigation into RNA conformational variability

The X-ray crystal structure of a brominated RNA helix with four mismatched base pairs and sequence r(UG(Br)C(Br)CAGUUCGCUGGC)(2) was determined to 2.1 A using the methods of multiwavelength anomalous diffraction (MAD) applied to the bromine K-absorption edge. There are three molecules in the asymmetric unit with unique crystal-packing environments, revealing true conformational variability at high resolution for this sequence. The structure shows that the sequence itself does not define a consistent pattern of solvent molecules, with the exception of the mismatched base pairs, implying that specific RNA-protein interactions would occur only with the nucleotides. There are a number of significant tertiary interactions, some of which are a result of the brominated base pairs and others that are directly mediated by the RNA 2' hydroxyl groups. The mismatched base pairs exhibit a solvent network as well as a stacking pattern with their nearest neighbors that validate previous thermodynamic analysis.

Intravenous catheter blood cultures: utility and contamination

OBJECTIVE

In pediatrics, blood cultures (BCs) are often drawn as intravenous (IV) catheters are placed. This routine minimizes the number of painful and often difficult punctures a child must undergo but results in the discarding of multiple BC bottles when these cultures are later determined to be unnecessary. If the contamination rate of BCs drawn through an indwelling IV did not exceed the contamination rate of BCs drawn at the time of IV placement, BCs could be drawn from the IV without subjecting the patient to another venipuncture. This study was done to compare the contamination rates of BCs drawn by these two methods. Additionally, we sought to determine if the collection of two BCs enhances pathogen recovery.

METHODS

Prospective comparison of contamination and bacteremia rates of BCs drawn by two different methods: the first BC was drawn at the time of IV line placement and the second BC was drawn from the previously placed IV at a later time. Setting. Urban pediatric emergency department with an annual census of 40 000.

PARTICIPANTS

One thousand five hundred sixty-four patients between the ages of 3 days and 22.1 years. The median age was 2.2 years. Sixty-four patients were excluded because we were unable to draw the second BC. Forty-six percent of eligible patients (n = 690) were girls.

RESULTS

Fifty-seven (1.9%) of 3000 grew contaminants: 27 in the first and 30 in the second BC for contamination rates of 1.8% and 2.0%. Thirty-eight (1.3%) of 3000 BCs grew pathogens: 24 represent 12 patients with growth in two out of two cultures and 14 represent 14 patients with growth in one out of two cultures. Pathogen rates were 1.1% (16/1500) with one BC per patient and 1.7% (22/1500) with two BCs per patient.

CONCLUSIONS

There is no difference in the contamination rates of two BCs drawn from the same site at two different times. The collection of two BCs per patient may enhance pathogen recovery.

Effect of metoclopramide dose on preventing emesis after oral administration of N-acetylcysteine for acetaminophen overdose

OBJECTIVE

To determine the effect of the metoclopramide dose on the prevention of vomiting of N-acetylcysteine in acetaminophen overdose.

METHODS

Patients with acetaminophen ingestions receiving metoclopramide prior to emergency department administration of N-acetylcysteine were included. Emergency Department and poison center records were reviewed for administration of metoclopramide pre-N-acetylcysteine and incidence of subsequent vomiting. The treatment group was defined as patients receiving high-dose metoclopramide (20-50 mg intravenously) prior to the loading dose of N-acetylcysteine. Controls were patients receiving standard-dose (< 20 mg intravenously) metoclopramide prior to loading dose of N-acetylcysteine. Outcome was vomiting within 60 minutes of N-acetylcysteine administration.

RESULTS

Twelve of 19 patients (63%) receiving standard-dose metoclopramide vomited N-acetylcysteine. Only 5 of 23 patients (22%) receiving high-dose metoclopramide vomited N-acetylcysteine (crude odds ratio: 6.2; 95% CI [1.3-30.3]). After controlling for confounding in the logistic regression model, the effect of high-dose metoclopramide in preventing vomiting of N-acetylcysteine remained significant (adjusted odds ratio: 17.0; 95% CI [2.6-110.0]).

CONCLUSION

This study supports the efficacy of high-dose metoclopramide to prevent emesis after the oral loading dose of N-acetylcysteine.

Osmol gaps in the pediatric population

OBJECTIVE

To define the osmol gap (OG) range in pediatric ED (PED) patients.

METHODS

This was a blinded, observational patient series involving an urban PED with an annual census of 35,000. All patients presenting to the Hasbro Children's Hospital Emergency Department who required electrolyte determination during their evaluations were enrolled into the study. Exclusionary criteria included the presence of urinary ketones, alcohol ingestion within the preceding 24 hours, or illnesses that are known to change serum osmolarity. Electrolytes, BUN, glucose, and freezing point depression osmolality were measured on a single serum specimen. Additional laboratory information included ethanol and anion gap. The OG was determined using each of three equations previously described in the literature (see Results). The best coefficients for sodium, BUN, and glucose were determined by multiple linear regression.

RESULTS

192 children (90 girls, 102 boys) with a median age of 6.6 years (mean: 7.3 years; range: 7 days to 17.9 years) made up the study population. The mean measured osmolality (+/-SD) for the entire sample was 284.2+/-6.9 mOsm/dL with a range of 265-311 mOsm/dL. Mean osmol gaps with standard deviations varied with the equation used for calculation.

CONCLUSION

Regardless of the equation used, the range of "normal" osmol gaps in the pediatric population is approximately 22 mOsm.

Frozen oral hydration as an alternative to conventional enteral fluids

BACKGROUND

Oral hydration therapy is effective in dehydration, but is often bypassed or may fail.

OBJECTIVE

To compare the tolerance (amount accepted minus amount vomited) of a frozen solution (FS) (Revital-ICE, PTS Labs, Deerfield, Ill) with the conventional glucose electrolyte solution (CS).

DESIGN

Prospective, controlled crossover trial.

SETTING

Pediatric emergency department.

PARTICIPANTS

A convenience sample of 91 children with enteritis, 6 months to 13 years of age, with mild or moderate dehydration.

INTERVENTION

Children were offered either FS or CS. Each group was offered 10 mL/kg of either product during a 90-minute trial period, in 3 equal aliquots, and was monitored for the quantities consumed and vomited. Complete treatment failures (absolute refusal) were crossed over to the alternate product and intake was recorded.

MAIN OUTCOME MEASURES

Tolerance of the full 10 mL/kg of the original product offered and, for treatment failures, the percentage who tolerated the alternate product.

RESULTS

Of the patients who initially received FS, 23 (55%) tolerated the full amount offered, compared with 5 (11%) in the CS group (P < .001). Of the 57% who completely refused CS, after crossover, 20% tolerated the full amount of FS and 33% tolerated between 5 and 9 mL/kg of FS and were discharged from the hospital. The original treatment failures for FS (12%) were crossed over to CS; none tolerated more than 5 mL/kg

CONCLUSIONS

Children with mild or moderate dehydration are more likely to tolerate FS than CS. Conventional solution failures crossed over to FS had a greater tolerance rate than the reverse.

The Master of Public Health program for Arkansas

A unique Master of Public Health (MPH) program has been operating in Arkansas for the past two years. Developed by the faculty of the School of Public Health and Tropical Medicine at Tulane University Medical Center, it offers health professionals the opportunity to earn the MPH degree over a two-year period while remaining in their positions and communities. Most classes are taught on the campus of the University of Arkansas for Medical Sciences (UAMS) in Little Rock. Several courses have been offered by the faculty of the Health Services Administration program and Department of Biology at the University of Arkansas at Little Rock (UALR).

Outbreak of Salmonella food poisoning at Junior World Rowing Championships

This paper describes an outbreak of Salmonella enteriditis occurring at the Junior World Rowing Championships at Poznan, Poland, in August 1995 which was to have a significant effect on the performance of several of the largest national teams.

Sequence variation as a strategy for crystallizing RNA motifs

The determination of RNA structures by X-ray crystallography is an exciting and developing field. At present, the crystallographic characterization of RNA is limited by the difficulty in obtaining large, high quality crystals. This paper outlines several techniques for improving the likelihood of obtaining RNA crystals, for improving the size of those crystals, and for extending the limit of the diffraction maxima. Sequence variations have proven to be more effective in changing the quality of the crystals than variations in crystallization conditions, often making the difference between obtaining true single crystals and multiply twinned crystalline material.

The expression of human endogenous retrovirus-3 in fetal cardiac tissue and antibodies in congenital heart block

Endogenous retrovirus-3 (ERV-3) is an endogenous retrovirus encoding an open reading frame for an envelope protein expressed in placenta. In this study we also found high levels of expression in fetal heart, with peak expression occurring between 11 and 17 weeks of gestation. Antibodies to a peptide corresponding to a predicted epitope of ERV-3 were studied by ELISA in sera from 32 healthy women, 47 women during pregnancy, 19 post-partum, 34 with Sjogren's syndrome (SS), 28 with systemic lupus erythematosus (SLE) and 48 mothers of babies with congenital heart block (CHB). Elevated levels of antibodies to ERV-3 were found in normal pregnancy and in patients with SS or SLE. Compared with normal sera the highest levels occurred in mothers of CHB babies (P < 0.001). Antibodies from sera from three CHB mothers bound to recombinant transmembrane protein of ERV-3 on immunoblots, and to sections of fetal cardiac tissue and placenta. This study has shown evidence of autoimmunization to ERV-3 during pregnancy, with particularly high levels of antibodies in mothers of CHB babies. The expression of ERV-3 in fetal heart and the presence of antibodies in maternal sera suggest a possible role in the pathogenesis of CHB.

HPLC purification of RNA for crystallography and NMR

Homogeneous preparations of milligram quantities of RNA are a prerequisite for their characterization by biophysical methods such as crystallography or NMR spectroscopy. Methods for obtaining milligram quantities of pure synthetic RNA are described in this paper. These methods employ anion exchange HPLC for purifying full-length sequence from failure sequences and incompletely deprotected material. RNA molecules with little or extensive amounts of secondary structure could be purified. In cases where the RNA molecule was tightly folded, the cation in the eluent buffer influenced both the distinction of the peaks during chromatography and the final folded conformation. Finally, two RNA sequences were chemically synthesized, deprotected, purified, and crystallized using this methodology.

Iron poisoning in children

Iron overdose is the most common cause of poisoning death in children. Accidental ingestion is common because iron-containing compounds are readily available, brightly colored, often sugar coated, and frequently considered "harmless vitamins" by parents. The management of iron intoxication is controversial. This article describes the clinical presentation of iron overdose and addresses some of the most recent controversies in management.

Inhibition of mitochondrial and Paracoccus denitrificans NADH-ubiquinone reductase by oxacarbocyanine dyes. A structure-activity study

In this study, we determined that three structurally related oxacarbocyanine dyes, 3,3'-diethyloxacarbocyanine (DiOC2(3)), 3,3'-dipentyloxacarbocyanine (DiOC5(3)), and 3,3'-dihexyloxacarbocyanine (DiOC6(3)), and one oxadicarbocyanine, 3,3'-diethyloxadicarbocyanine (DiOC2(4)), inhibit bovine heart mitochondrial NADH oxidase activity and one of them, DiOC6(3), inhibits Paracoccus denitrificans NADH oxidase activity. The mitochondrial I50 values were 9 microM (DiOC2(3)), approximately 1 microM (DiOC5(3)) and DiOC6(3)), and approximately 3 microM (DiOC2(4)), whereas the I50 value for P. denitrificans was approximately 2 microM (DiOC6(3)). Neither succinate nor cytochrome oxidase (EC 1.9.3.1) activity was inhibited significantly by any of the compounds in either electron transport chain, localizing the inhibitory site of the oxacarbocyanine dyes to the respiratory chain segment between NADH and ubiquinone. With submitochondrial particles (SMP), NADH-dependent reduction of duroquinone and coenzyme Q1 was inhibited markedly by all four compounds with DiOC6(3) being the most potent inhibitor, and the reduction of menadione was inhibited substantially by DiOC6(3). When purified complex I was used, NADH-dependent reduction of ferricyanide was inhibited by DiOC5(3) and coenzyme Q1 reduction was inhibited by all oxacarbocyanines. With P. denitrificans membrane vesicles, DiOC6(3) substantially inhibited NADH-dependent reduction of coenzyme Q1. All the oxacarbocyanines were more effective inhibitors with membrane preparations than with complex I, suggesting that membrane interactions play a role in inhibition. The mechanism of inhibition of the oxacarbocyanines appears to be similar to that of rotenone since (a) essentially only electron acceptors affected by rotenone were affected by the compounds, (b) inhibition of menadione reduction was diminished drastically with rotenone-saturated SMP, and (c) inhibition of coenzyme Q1 was largely eliminated with rotenone-insensitive complex I, and P. denitrificans membrane vesicles.

In vivo kindling does not alter afterhyperpolarizations (AHPs) following action potential firing in vitro in basolateral amygdala neurons

Kindling in vivo results in enhanced glutamatergic synaptic transmission and epileptiform bursting in vitro in neurons of the basolateral amygdala (BLA). We tested the hypothesis that reduction of intrinsic inhibitory mechanisms, such as the slow- and medium-afterhyperpolarizations (s-AHPs, m-AHPs), contributes to the enhanced neuronal excitability observed in kindling-induced epileptogenesis using intracellular recording methodology. In these studies, neurons were recorded from the BLA contralateral to the kindling site. AHPs following depolarizing current-induced (100 ms, 1 nA) action potentials were recorded from BLA neurons of control and kindled animals. We found no difference in the amplitude of the s-AHP and m-AHP, or the duration of the s-AHP between control and kindled neurons. In addition, kindling did not alter the distribution of accommodating/non-accommodating BLA neurons (as assessed from neuronal responses during long (500 ms) depolarizing current injection). It is concluded that an alteration in the neuronal network within the BLA rather than a blockade of an intrinsic inhibitory mechanism underlies the enhanced excitability recorded in BLA neurons following kindling.