Comprehensive Quality of Life Report from a Prospective Clinical Trial of 4DCT-Ventilation Functional Lung Avoidance Radiation Therapy

PURPOSE/OBJECTIVE(S)

Functional imaging has been developed that uses 4DCT images and image processing to generate lung ventilation maps (4DCT-ventilation). 4DCT-ventilation functional avoidance uses 4DCT-images to generate plans that avoid functional regions of the lung with the goal of reducing pulmonary toxicity. A 4DCT-ventilation functional avoidance, phase II, multi-center clinical trial was completed, and patient reported outcomes (PRO) measured. PROs are an essential measure of quality-of-life following radiotherapy. The purpose of this work is to quantify PRO changes for lung cancer patients treated with functional avoidance and to compare PROs against clinical pneumonitis.

MATERIALS/METHODS

Patients with locally advanced lung cancer receiving curative intent radiotherapy (prescriptions of 45-75 Gy) and chemotherapy were accrued. Each patient had a 4DCT-ventilation image generated using 4DCT data. Favorable arc geometry and optimization techniques were used to generate functional avoidance plans. PRO instruments included the Functional Assessment of Cancer Therapy Lung (FACT-L) questionnaire and the Visual Analog Scale (VAS) administered pre-treatment and 3-, 6-, and 12-months post-treatment to gather data on physical, social, emotional, functional, and pulmonary well-being. The percentage of patients with clinically significant decline was calculated using the FACT-TOI (Trial Outcome Index), FACT-LCS (Lung Cancer Subscale), and VAS instruments. To evaluate the correlation between PROs and clinical toxicity, the percentage of clinically significant FACT-LCS decline was compared (Chi-square test) for patients who did or did not experience grade 2+ pneumonitis.

RESULTS

Fifty-nine patients completed baseline PRO surveys. Median age was 65, 83% of patients had non-small-cell lung cancer, with 75% having stage III disease. Clinically significant FACT-TOI decline at, 3, 6, and 12 months was 46.3%, 38.5%, and 26.8%, respectively. The percentage of patients with clinically significant FACT-LCS decline was 33.3%, 33.3%, and 29.3%, at 3 months, 6 months, and 12 months, respectively. The percentage of patients with clinically significant VAS decline at 3, 6, and 12 months was 18.9%, 20.0%, and 18.6%, respectively. Patients who experienced grade 2+ pneumonitis had a greater percentage of clinically significant decline at all time-points with the results reaching significance (p = 0.045) at 6 months.

CONCLUSION

The study presents the first comprehensive evaluation of PROs for patients treated with 4DCT-ventilation functional avoidance. The data show that 20-40% of patients had clinically significant decline and that PROs had a strong correlation with pneumonitis. The PRO data demonstrate that functional avoidance results in low rates of patient reported outcome clinical decline and provide seminal results to be used in phase III studies.

Disease activity trajectories in rheumatoid arthritis: a tool for prediction of outcome

Objective: Predicting treatment response and disease progression in rheumatoid arthritis (RA) remains an elusive endeavour. Identifying subgroups of patients with similar progression is essential for understanding what hinders improvement. However, this cannot be achieved with response criteria based on current versus previous Disease Activity Scores, as they lack the time component. We propose a longitudinal approach that identifies subgroups of patients while capturing their evolution across several clinical outcomes simultaneously (multi-trajectories). Method: For exploration, the RA cohort BARFOT (n = 2829) was used to identify 24 month post-diagnosis simultaneous trajectories of 28-joint Disease Activity Score and its components. Measurements were available at inclusion (0), 3, 6, 12, 24, and 60 months. Multi-trajectories were found with latent class growth modelling. For validation, the TIRA-2 cohort (n = 504) was used. Radiographic changes, assessed by the modified Sharp van der Heijde score, were correlated with trajectory membership. Results: Three multi-trajectories were identified, with 39.6% of the patients in the lowest and 18.9% in the highest (worst) trajectory. Patients in the worst trajectory had on average eight tender and six swollen joints after 24 months. Radiographic changes at 24 and 60 months were significantly increased from the lowest to the highest trajectory. Conclusion: Multi-trajectories constitute a powerful tool for identifying subgroups of RA patients and could be used in future studies searching for predictive biomarkers for disease progression. The evolution and shape of the trajectories in TIRA-2 were very similar to those in BARFOT, even though TIRA-2 is a newer cohort.

Restrictive antibiotic stewardship associated with reduced hospital mortality in gram-negative infection

INTRODUCTION

: Antimicrobial stewardship has an important role in the control of Clostridium difficile infection (CDI) and antibiotic resistance. An important component of UK stewardship interventions is the restriction of broad-spectrum beta-lactam antibiotics and promotion of agents associated with a lower risk of CDI such as gentamicin. While the introduction of restrictive antibiotic guidance has been associated with improvements in CDI and antimicrobial resistance, evidence of the effect on outcome following severe infection is lacking.

METHODS

: In 2008, Glasgow hospitals introduced a restrictive antibiotic guideline. A retrospective before/after study assessed outcome following Gram-negative bacteraemia in the 2-year period around implementation.

RESULTS

: Introduction of restrictive antibiotic guidelines was associated with a reduction in utilization of ceftriaxone and co-amoxiclav and an increase in amoxicillin and gentamicin. Approximately 1593 episodes of bacteremia were included in the study. The mortality over 1-year following Gram-negative bacteraemia was lower in the period following guideline implementation (RR 0.852, P  = 0.045). There was no evidence of a difference in secondary outcomes including ITU admission, length of stay, readmission, recurrence of bacteraemia and need for renal replacement therapy. There was a fall in CDI (RR 0.571, P  = 0.014) and a reduction in bacterial resistance to ceftriaxone and co-amoxiclav but no evidence of an increase in gentamicin resistance after guideline implementation.

CONCLUSION

: Restrictive antibiotic guidelines were associated with a reduction in CDI and bacterial resistance but no evidence of adverse outcomes following Gram-negative bacteraemia. There was a small reduction in one year mortality.

Abstract P3-03-06: Characterization of HER2-positive breast cancer (BC) cells selected for tolerance to trastuzumab-induced antibody-dependent cell-mediated cytotoxicity (ADCC)

Cellular mechanisms of trastuzumab resistance include alteration(s) in cell signaling pathways (PTEN loss, activation of PI3K/Akt signaling), steric hindrance of antibody binding (by Muc-1/Muc-3), over-activation of alternate receptor kinases (HER3/c-Met/IGF-1R), and proteolysis of HER2 extracellular domain harboring target epitopes for antibody-based therapeutics. Prior studies of trastuzumab resistance have focused largely on cells selected ex vivo with the antibody in absence of human immune effector cells. We developed a selection model, wherein human HER2 positive BC cells (BT474, SKBR3) were subjected to acute ADCC (>90% cell death), trastuzumab concentration 100ug/mL, effector-target ratio 100:1, using human peripheral blood mononuclear cells (PBMCs) as effectors. Surviving cells were allowed to recover to confluence over 8-10 weeks, for 10 total rounds of ADCC selection ex vivo. Mock-treated parent, IgG1 isotype control, trastuzumab, and PBMCs alone were used as controls. ADCC assays based on calcein fluorescent labeling of live target cells, revealed significant reduction (maximum 20%, p<0.005) in cell lysis in immune-selected BT474 cell lines compared to parental controls (immune-selected SKBR3 cells exhibited a non-significant trend towards reduced ADCC). Transcriptome-wide next-generation RNA sequencing (Illumina NextSeq 500, 2 x 75 bp paired-end, median of 46 million paired-end reads/sample), coupled with pathway enrichment analysis (Reactome), followed by q-PCR validation, confirmed significant changes in expression in immune-selected cells (compared to parent control) for genes including: ALDH1, ANK1, TMPRSS3, HINT1, DNM2, TNNC1, COL4A4 in BT474; and ALDH1, ANK1, CAMP1, CPE, IDO1 in SKBR3 cells. Whole-genome sequencing (Illumina HiSeq X, 150 bp paired end, 30x coverage) elucidated 180 genes with single nucleotide variations (SNVs) in immune-selected cells compared to parent in BT474 cells, and 215 genes in SKBR3 cells. Thirty-four SNVs were shared in both cell lines. Further screening and validation confirm genes with SNVs demonstrating significant transcript up-regulation. These include: COL4A3, LEP, SOX-9 in BT474; and HLA-B, TNFRSF10B, HLA-B, PSMA6 in SKBR3. In further phenotypic analysis, ADCC-conditioned BT474 cells exhibit an elongated fibroblast-like morphology with multiple processes, in contrast to control. Immune-selected SKBR3 cells (and not BT474 cells) demonstrate significantly increased motility compared to control in transwell migration assays (p<0.001), and demonstrated increased cell proliferation (MTT assay, 10-15%, 48h; p=0.0242) as compared to parent controls. Our data indicate immune-selection by effector cells contributes to ADCC tolerance in vitro, and is associated with distinct genotypic and phenotypic alterations. Future investigation will determine whether Fc-engineered MAbs (afucosylated), antibody drug conjugates (T-DM1), or potentiation of ADCC by co-stimulatory agonist CD137 antibodies will re-sensitize ADCC-tolerance. This investigation will help to elucidate potentially targetable pathways that emerge from immune-selection with trastuzumab.

Citation Format: Biswas T, Fritzemeier R, Mark A, Meißner T, Young B, Jones BL, Pegram M. Characterization of HER2-positive breast cancer (BC) cells selected for tolerance to trastuzumab-induced antibody-dependent cell-mediated cytotoxicity (ADCC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-03-06.

Disparities in disease presentation in the four screenable cancers according to health insurance status

OBJECTIVES

Current guidelines support the use of screening for early detection in breast, prostate, colorectal and cervical cancer. The purpose of this study was to evaluate whether insurance status predicts for more advanced disease in these four currently screened cancers.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results (SEER) database was queried for breast, prostate, colorectal and cervix in patients aged 18-64 years. The database was queried from 2007 to 2011, with 425,614 patients with known insurance status included.

METHODS

Multinomial logistic regression was used to evaluate insurance status and cancer presentation.

RESULTS

Under multivariate analysis for breast cancer, uninsured patients more often had invasive disease (odds ratio [OR]: 1.55), T- (OR: 2.00), N- (OR: 1.59) stage, and metastatic disease (OR: 3.48), and were more often high-grade (OR: 1.21). For prostate cancer, uninsured patients again presented more commonly with higher T-stage (OR: 1.45), nodal (OR: 2.90) and metastatic (OR: 4.98) disease, in addition to higher prostate-specific antigen (OR: 2.85) and Gleason score (OR: 1.65). Colorectal cancer had similar findings with uninsured individuals presenting with more invasive disease (OR: 1.78), higher T (OR: 1.86), N (OR: 1.22), and M (OR: 1.58) stage, in addition to higher carcinoembryonic antigen levels (OR: 1.66). Similar results were seen for cervical cancer with uninsured having higher T (OR: 2.03), N (OR: 1.21), and M (OR: 1.45) stage.

CONCLUSION

In the four cancers detected by screening exams, those without health insurance present with more advanced disease, with higher stage and grade, and more elevated tumour markers.

The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis

BACKGROUND

Following neoadjuvant chemotherapy (NAC), the optimal strategies for postmastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after breast-conserving surgery (BCS) are controversial. In this analysis, we evaluate the impact of these radiotherapy (RT) approaches for women with clinically node-positive breast cancer treated with NAC in the National Cancer Database (NCDB).

PATIENTS AND METHODS

Women with cT1-3 cN1 M0 breast cancer treated with NAC were divided into four cohorts by surgery [Mastectomy (Mast) versus BCS] and post-chemotherapy pathologic nodal status (ypN0 versus ypN+). Overall survival (OS) was estimated using the Kaplan-Meier method and RT approaches were analyzed using the log-rank test, multivariate Cox models, and propensity score-matched analyses.

RESULTS

From 2003 to 2011, 15 315 cases were identified including 3040 Mast-ypN0, 7243 Mast-ypN+, 2070 BCS-ypN0, and 2962 BCS-ypN+ patients. On univariate analysis, PMRT was associated with improved OS for both Mast-ypN0 (P = 0.019) and Mast-ypN+ (P < 0.001) patients. On multivariate analyses adjusted for factors including age, comorbidity score, cT stage, in-breast pathologic complete response, axillary surgery, ypN stage, estrogen receptor status and hormone therapy, PMRT remained independently associated with improved OS among Mast-ypN0 [hazard ratio (HR) = 0.729, 95% confidence interval (CI) 0.566-0.939, P = 0.015] and Mast-ypN+ patients (HR = 0.772, 95% CI 0.689-0.866, P < 0.001). No differences in OS were observed with the addition of RNI to breast RT for BCS-ypN0 or BCS-ypN+ patients. Propensity score-matched analyses demonstrated identical patterns of significance. On subset analysis, OS was improved with PMRT in each pathologic nodal subgroup (ypN0, ypN1, and ypN2-3) (all P < 0.05).

CONCLUSIONS

In the largest reported analysis of RT for cN1 patients treated with NAC, PMRT was associated with improved OS for all pathologic nodal subgroups. No OS differences were observed with the addition of RNI to breast RT.

Economic evaluation of treatment for MRSA complicated skin and soft tissue infections in Glasgow hospitals

In the UK, methicillin-resistant Staphylococcus aureus (MRSA)-associated skin and soft tissue infections (SSTIs) are predominantly managed in the hospital using intravenous (IV) glycopeptides. We set out to explore the potential for and relative healthcare costs of earlier hospital discharge through switch to oral antibiotic therapy (linezolid or rifampicin and doxycycline) or continuation of IV therapy (teicoplanin) via an outpatient parenteral antimicrobial therapy (OPAT) service. Over 16 months, 173 patients were retrospectively identified with MRSA SSTI, of whom 82.8 % were treated with IV therapy. Thirty-seven patients were potentially suitable for earlier discharge with outpatient therapy. The model assumed 3 days of inpatient management and a maximum of 14 days of outpatient therapy. For the status quo, where patients received only inpatient care with IV therapy, hospital costs were calculated at £12,316 per patient, with 97 % of costs accounted for by direct bed day costs. The mean total cost savings achievable through OPAT or oral therapy was estimated to be £6,136 and £6,159 per patient treated, respectively. A significant proportion of patients with MRSA SSTI may be suitable for outpatient management with either oral therapy or via OPAT, with the potential for significant reduction in healthcare costs.

Cow and herd variation in milk urea nitrogen concentrations in lactating dairy cattle

Milk urea nitrogen (MUN) is correlated with N balance, N intake, and dietary N content, and thus is a good indicator of proper feeding management with respect to protein. It is commonly used to monitor feeding programs to achieve environmental goals; however, genetic diversity also exists among cows. It was hypothesized that phenotypic diversity among cows could bias feed management decisions when monitoring tools do not consider genetic diversity associated with MUN. The objective of the work was to evaluate the effect of cow and herd variation on MUN. Data from 2 previously published research trials and a field trial were subjected to multivariate regression analyses using a mixed model. Analyses of the research trial data showed that MUN concentrations could be predicted equally well from diet composition, milk yield, and milk components regardless of whether dry matter intake was included in the regression model. This indicated that cow and herd variation could be accurately estimated from field trial data when feed intake was not known. Milk urea N was correlated with dietary protein and neutral detergent fiber content, milk yield, milk protein content, and days in milk for both data sets. Cow was a highly significant determinant of MUN regardless of the data set used, and herd trended to significance for the field trial data. When all other variables were held constant, a percentage unit change in dietary protein concentration resulted in a 1.1mg/dL change in MUN. Least squares means estimates of MUN concentrations across herds ranged from a low of 13.6 mg/dL to a high of 17.3 mg/dL. If the observed MUN for the high herd were caused solely by high crude protein feeding, then the herd would have to reduce dietary protein to a concentration of 12.8% of dry matter to achieve a MUN concentration of 12 mg/dL, likely resulting in lost milk production. If the observed phenotypic variation is due to genetic differences among cows, genetic choices could result in herds that exceed target values for MUN when adhering to best management practices, which is consistent with the trend for differences in MUN among herds.

Trajectories of alcohol consumption following liver transplantation

Any use of alcohol in the years following liver transplantation (LTX) approaches 50% of patients transplanted for alcoholic liver disease (ALD). We collected detailed prospective data on alcohol consumption following LTX for ALD to investigate ongoing patterns of use. Using trajectory modeling we identified four distinct alcohol use trajectories. One group had minimal use over time. Two other groups developed early onset moderate-to-heavy consumption and one group developed late onset moderate use. These trajectories demonstrate that alcohol use varies based on timing of onset, quantity and duration. Using discriminant function analysis, we examine characteristics of recipient's pre-LTX alcohol histories and early post-LTX psychological stressors to identify the profile of those at risk for these specific trajectories. We discuss the relevance of these findings to clinical care and preliminarily to outcomes.

Sex-specific effects of chronic anabolic androgenic steroid treatment on GABA(A) receptor expression and function in adolescent mice

Anabolic androgenic steroids are synthetic derivatives of testosterone designed for therapeutic uses, but now taken as drugs of abuse. Potential health risks associated with anabolic androgenic steroid abuse are believed to be higher in adolescents than in adults, but few studies have tested anabolic androgenic steroid effects in adolescent subjects or determined if effects of these steroids differ between females and males. We have studied GABA(A) receptor expression and function in the medial preoptic nucleus of mice chronically treated during adolescence with the anabolic androgenic steroid, 17alpha-methyltestosterone. Three-week treatment did not elicit significant differences the expression of alpha1, alpha2 or alpha5 subunit mRNAs in animals of either sex, although there was a trend toward decreases in all three subunit mRNAs in female mice, which was augmented and attained significance for the alpha2 subunit mRNA in females treated for six weeks. Immunocytochemical analysis revealed that treatment with 17alpha-methyltestosterone for 6 weeks also elicited a significant decrease in the number of alpha2-immunopositive neurons in female subjects. To test if anabolic androgenic steroid treatment also promoted changes in GABA(A) receptor function, spontaneous inhibitory synaptic currents were analyzed in adolescent animals treated for 3-4 weeks. This treatment regimen promoted a significant decrease in spontaneous inhibitory synaptic current frequency in female, but not male mice. Finally, anabolic androgenic steroid treatment was found to have no effect on the numbers of interneurons within the medial preoptic nucleus, as assessed by immunoreactivity for calcium binding proteins, suggesting that the decrease in the frequency of spontaneous inhibitory synaptic currents in female mice does not arise from an anabolic androgenic steroid-induced loss of interneurons. Taken together, our results indicate that chronic exposure to 17alpha-methyltestosterone elicits significant changes in GABAergic transmission in the medial preoptic nucleus of female, but not male, mice effectively enhancing the sexually dimorphic nature of GABAergic transmission in a forebrain region crucial for the expression of aggression and sexual behaviors.

Anabolic androgenic steroids and forebrain GABAergic transmission

Anabolic androgenic steroids are synthetic derivatives of testosterone designed for therapeutic purposes, but now taken predominantly as drugs of abuse. The most common behavioral effects associated with anabolic androgenic steroid use are changes in anxiety, aggression and reproductive behaviors, including the onset of puberty and sexual receptivity. GABAergic circuits in the forebrain underlie these behaviors and are regulated by gonadal steroids. Work from our laboratories has shown that the expression and function of GABA(A) receptors in the rat and mouse forebrain varies between the sexes and across the estrous cycle. We have also shown that there are significant changes in GABA(A) receptor expression that occur with the progression through puberty to adulthood. Because GABAergic systems are both steroid-sensitive and critical for the expression of behaviors altered with anabolic androgenic steroid use, forebrain GABA(A) receptors are an attractive candidate to assess how molecular actions of anabolic androgenic steroids may be translated to known behavioral outcomes. Our studies demonstrate that anabolic androgenic steroids elicit both acute modulation of GABA(A) receptor-mediated currents, as well as chronic regulation of GABA(A) receptor expression and forebrain GABAergic transmission. Because anabolic androgenic steroid use has now become prevalent not only among adolescent boys, but in an increasing number of adolescent girls, we have also been particularly interested in determining age- and sex-specific effects of anabolic androgenic steroids. Our data show that the effects of chronic anabolic androgenic steroid exposure can be greater for adolescent than adult animals and are more marked in females than in males. These data have particularly important implications with respect to studies we have done demonstrating that chronic anabolic androgenic steroid exposure alters the onset of puberty, estrous cyclicity and sexual receptivity.

A prospective study of real-time panfungal PCR for the early diagnosis of invasive fungal infection in haemato-oncology patients

A blinded prospective study was performed to determine whether screening of whole blood using a real-time, panfungal polymerase chain reaction (PCR) technique could predict the development of invasive fungal infection (IFI) in immunocompromised haemato-oncology patients. In all, 78 patients (125 treatment episodes) were screened twice weekly by real-time panfungal PCR using LightCyclertrade mark technology. IFI was documented in 19 treatment episodes (five proven, three probable and 11 possible), and in 12, PCR was sequentially positive. PCR positivity occurred in: 4/5 proven; 2/3 probable; 6/11 possible; and 29/106 with no IFI. In 8/12 with IFI and sequentially positive PCR results, PCR positivity occurred before (median 19.5 days) and in 4/12 (median 10.5 days) after the initiation of empirical antifungal therapy. Based on sequential positive results for proven/probable IFI sensitivity, specificity, positive predictive value and negative predictive value were 75, 70, 15 and 98%, respectively. Real-time panfungal PCR is a sensitive tool for the early diagnosis of IFI in immunocompromised haemato-oncology patients. It may be most useful as a screening method in high-risk patients, either to direct early pre-emptive antifungal therapy or to determine when empirical antifungal therapy can be withheld in patients with antibiotic--resistant neutropenic fever. However, these strategies require further assessment in comparative clinical trials.

Fine mapping of a malting-quality QTL complex near the chromosome 4H S telomere in barley

Malting quality has long been an active objective in barley (Hordeum vulgare L.) breeding programs.However, it is difficult for breeders to manipulate malting-quality traits because of inheritance complexity and difficulty in evaluation of these quantitative traits. Quantitative trait locus (QTL) mapping provides breeders a promising basis with which to manipulate quantitative trait genes. A malting-quality QTL complex, QTL2, was mapped previously to a 30-cM interval in the short-arm telomere region of barley chromosome 4H in a "Step-toe"/"Morex" doubled haploid population by the North American Barley Genome Project, using an interval mapping method with a relatively low-resolution genetic map. The QTL2 complex has moderate effects on several malting-quality traits, including malt extract percentage(ME), a-amylase activity (AA), diastatic power (DP), malt 13-glucan content (BG), and seed dormancy, which makes it a promising candidate gene source in malting barley-cultivar development. Fine mapping QTL2 is desirable for precisely studying barley malting-quality trait inheritance and for efficiently manipulating QTL2 in breeding. A reciprocal-substitution mapping method was employed to fine map QTL2. Molecular marker-assisted backcrossing was used to facilitate the generation of isolines. Fourteen different types of "Steptoe" isolines, including regenerated "Steptoe" and 13 different types of "Morex" isolines,including regenerated "Morex", were made within a 41.5-cM interval between MWG634 and BCD265B on chromosome 4H. Duplicates were identified for 12 "Steptoe" and 12 "Morex" isoline types. The isolines together with "Steptoe" and "Morex" were grown variously at three locations in 2 years for a total of five field environments.Four malting-quality traits were measured: ME, DP, AA,and BG. Few significant differences were found between duplicate isolines for these traits. A total of 15 putative QTLs were mapped; three for ME, four for DP, six for AA,and two for BG. Background genotype seemed to make a difference in expression/detection of QTLs. Of the 15 QTLs identified, ten were from the "Morex" and only five from the "Steptoe" background. By combining the results from different years, field environments, and genetic backgrounds and taking into account overlapping QTLsegments, six QTLs can be conservatively estimated: two each for ME and AA and one each for DP and BG with chromosome segments ranging from 0.7 cM to 27.9 cM. A segment of 15.8 cM from the telomere (MWG634-CDO669) includes all or a portion of all QTLs identified. Further study and marker-assisted breeding should focus on this 15.8-cM chromosome region.

Interactions of malt and barley (Hordeum vulgare L.) endoproteinases with their endogenous inhibitors

For producing worts that are optimal for beer production, some, but not all, of the barley proteins must be degraded during malting and mashing. This protein hydrolysis is controlled by endoproteinases, and, in turn, is partially regulated by the presence of low-molecular-weight (LMW) proteinaceous inhibitors. This paper reports studies of the interactions between the proteinases and inhibitors and an "affinity" method for concentrating the inhibitors. The malt inhibitors (I) and proteinases (E) quickly formed strong (E-I) complexes when dissolved together, and all of the I was complexed. Heating at 100 degrees C, but not 70 degrees C, dissociated the complex, even though the enzyme activities were destroyed at 70 degrees C. The released I readily recomplexed with fresh E. Barley, however, contained insufficient E to complex all of its I complement. The E-I complex was treated with salts, detergents, and reducing agents to release active E molecules, but none disrupted the complex. By removing the LMW proteins from a malt E-I extract and dissociating the complex by heating, the concentration of I molecules was greatly increased. This "affinity" method can thus be used to concentrate the I molecules for further purification.

Study of metallopeptidase isozymes from malted barley (Hordeum vulgare cv. Morex)

It has been reported that germinated barley contains peptidases that are sensitive to metal-chelating agents; however, none of these enzymes have been isolated, nor have their roles in germinated barley been investigated. Anion-exchange chromatography and chromatofocusing have been used to isolate a group of peptidases from barley (Hordeum vulgare cv. Morex) green malt that are sensitive to metal-chelating agents. Their activities were studied using one- and two-dimensional polyacrylamide gel electrophoresis. When analyzed on two-dimensional PAGE gels that contained gelatin as substrate, the enzymes separated into three major and approximately six minor activity spots with acidic pI values. The enzymes were optimally active against the gelatin substrate at pH 8.0 and were completely inhibited by 1,10-phenanthroline and EDTA, indicating that they belonged to the metallopeptidase class (EC 3.4.24.x). After the enzymes were inhibited with EDTA, the activities were recovered in the presence of low concentrations of metal ions. The hydrolysis of gelatin substrate was also impaired by the presence of reducing agents. The metallopeptidases readily digested, in vitro, the barley prolamine D hordein, indicating that they may be involved in degrading storage proteins during barley germination.

An outbreak of Serratia marcescens in two neonatal intensive care units

Outbreaks of infection in neonatal intensive care units (NICUs) due to Serratia marcescens are well recognized. In some outbreaks no point source has been found, whereas in others cross-infection has been associated with contaminated ventilator equipment, disinfectants, hands and breast pumps. We report an outbreak due to S. marcescens that involved two geographically distinct NICUs. The outbreak occurred over a six week period; 17 babies were colonized, 12 at Glasgow Royal Maternity Hospital (GRMH) and five at the Queen Mothers Hospital (QMH). At GRMH three babies developed septicaemia, of whom two died. The outbreak isolates were of the same serotype and phage type and were indistinguishable on the basis of restriction fragment length polymorphism analysis. During the outbreak, two babies shown consistently to be negative on screening, were transferred between the two units. In addition, two members of medical staff attended both units. In QMH no means of cross infection was identified. However, in GRMH the outbreak strain of S. marcescens was isolated from a laryngoscope blade and a sample of expressed breast milk.

Quantitative study of the formation of endoproteolytic activities during malting and their stabilities to kilning

The proteinases of germinating barley (Hordeum vulgare L.) hydrolyze storage proteins into amino acids and small peptides that can be used by the growing plant or, during brewing, by yeast. They are critical for the malting and brewing processes because several aspects of brewing are affected by the amounts of protein, peptide, and amino acids that are in the wort. This study was carried out to quantitatively measure when endoproteinases form in green malt and whether they are inactivated at the high temperatures that occur during malt kilning. Little endoproteolytic activity was present in ungerminated barley, but the activities began forming 1 day into the "germination" phase of malting, and they were nearly maximal by the third germination day. Quantitative studies with azogelatin "in solution" assays showed that the green malt endoproteolytic activities were not inactivated under commercial kilning conditions that use temperatures as high as 85 degrees C but that some actually increased during the final kilning step. Qualitative (2-D, IEF x PAGE) analyses, which allow the study of individual proteases, showed that some of the enzymes were affected by heating at 68 and 85 degrees C, during the final stages of kilning. These changes obviously did not, however, decrease the overall proteolytic activity.

Learning disabilities: diagnostic considerations from an educational perspective

This article reviews the current definitions of specific learning disability (LD). It describes the multiple causes among the specific learning disability (SLD) population, citing cognitive, neuroanatomical, cellular, and genetic research trends. Emphasis is placed on assessment components and processes, including typically used academic, cognitive, and neuropsychological measures and newly introduced dynamic or domain-based approaches. Researchers and practitioners now acknowledge that SLD represents a life-long condition, manifesting differently at each developmental stage. The impact of LD on adult adjustment and independence is described as the newest challenge in the field of LD research.

Purification and partial characterization of a second cysteine proteinase inhibitor from ungerminated barley (Hordeum vulgare L.)

It was previously shown that ungerminated barley contains inhibitors that suppress the activities of green malt cysteine proteinases. This paper reports the purification and partial characterization of a second barley cysteine endoproteinase inhibitor, a protein called lipid transfer protein 2 (LTP2). The chromatographically purified inhibitor had a molecular mass of 7112. The amino acid composition and sequence data of the purified inhibitor indicated that it was a protein whose gene, but not the protein itself, was isolated earlier from barley aleurone tissue. The purified protein inhibited the activities of electrophoretically separated green malt cysteine proteinases but not the activities of the serine- or metalloproteinases. The purified LTP2 inhibited the same proteases as the LTP1 that was characterized previously but was present in the mature seed in much smaller amounts. Neither LTP1 nor LTP2 has been proven to transport lipids in vivo, and it seems possible that both serve to keep cysteine endoproteinases that are synthesized during barley seed development inactive until the plant needs them. The small amount of LTP2 in the seed made it impossible to determine whether it, like LTP1, is involved in beer foam formation. Because of its proteinase-inhibiting ability and its resistance to heat inactivation, some of the LTP2 may persist in beer.

Control of an outbreak of respiratory syncytial virus infection in immunocompromised adults

Respiratory syncytial virus (RSV) is increasingly recognized as an important pathogen in immunocompromised adults, particularly those receiving bone marrow transplants, and, given the ease with which it spreads, represents a significant nosocomial problem. We describe an outbreak of RSV infection involving eight patients on a haematology/oncology ward which was controlled by early screening of patients and staff. Positive patients were cohort nursed on a separate ward and basic infection control measures including use of gowns and gloves were enforced. Children under age 12 were denied ward access. All patients with lower respiratory tract infection, and bone marrow transplant recipients with upper respiratory symptoms, were treated with nebulized ribavirin. There were no deaths. We conclude that awareness of the risk of RSV infection in immunocompromised patients coupled with rapid diagnosis and treatment, screening of symptomatic patients and staff, cohort nursing of cases and basic infection control procedures can prevent spread of RSV infection and reduce morbidity.

Separation and characterization of barley (Hordeum vulgare L.) hordeins by free zone capillary electrophoresis

Extraction conditions, separation conditions, and capillary rinsing protocols were optimized for the separation of barley hordeins by free zone capillary electrophoresis. Stable hordein extracts were obtained with a single 5 min extraction after the albumins and globulins were removed. Hordeins had to be reduced for optimal resolution. Optimum separation conditions for hordein separations were 100 mM phosphate-glycine buffer containing 20% acetonitrile and 0.05% hydroxypropylmethylcellulose. The addition of zwitterionic sulfobetaine detergents containing hydrocarbon tails of eight and ten carbons slightly improved the resolution of the separations, but not enough to warrant their use on a routine basis. The migration positions of the hordein subclasses were determined by two- dimensional reversed-phase high-performance liquid chromatography x free zone capillary electrophoresis mapping. The hordein subclasses formed clusters similar to those of wheat gliadins. Separation-to-separation repeatability was good, with migration time relative standard deviations < 1% for a 15-run period. For routine discrimination of cultivars, a 2 min post-separation rinse with 500 mM acetic acid was necessary to prevent protein build-up on the capillary walls. An example of successfully differentiating barley cultivars using this technique is shown.

Conversion of acetaldehyde-protein adduct epitopes from a nonreduced to a reduced phenotype by antigen processing cells

Many investigators have suggested that an immune reaction to acetaldehyde-protein adducts may be involved in the development and/or progression of alcohol liver disease. The most often reported acetaldehyde adduct is the reduced adduct prepared in vitro in the presence of strong reducing agents. However, the production of this adduct in vivo has been difficult to prove. Nevertheless, the detection of serum antibodies to this reduced adduct following alcohol exposure in animals and humans has been used to support the formation of this adduct in vivo. We have recently observed that when acetaldehyde-protein adducts prepared under nonreducing conditions are used to immunize animals, antibody to the reduced protein adduct is detected. Therefore, it was the purpose of this study to demonstrate that nonreduced (NR) adduct epitopes can be modified by intact cells to express reduced (R) adduct epitopes. This was accomplished using the monoclonal antibody RT1.1 that has been previously characterized by this laboratory and has been shown to recognize only R and not NR acetaldehyde adducts. In these studies, Balb/c mice were injected intraperitoneally (500 microg/animal) with either keyhole limpet hemocyanin (KLH)-NR or KLH-R adducted proteins. Immunization with KLH-NR produced significant amounts of antibodies that recognized both NR and R epitopes. In contrast, immunization with KLH-R produced antibodies to only R and not NR epitopes. Isolated peritoneal macrophages from nonimmunized mice were incubated in vitro with either KLH-NR, KLH-R, or unmodified KLH proteins, and the cell surface expression of the reduced epitope (RT1.1) and the activated macrophage marker (MAC-3) determined by double immunofluorescent staining. Activated macrophages incubated with KLH-NR expressed the R adduct on 11.5% of the cells, compared with 3.8% following incubation with unmodified KLH, and 19.4% following incubation with KLH-R. These data suggest that the NR adduct and/or the carrier protein are modified by peritoneal macrophages in vivo and present an epitope that is detected as a reduced adduct (RT1.1 positive). These observations may explain the presence of circulating antibodies to the reduced adduct that has been reported in human and animal studies.

Simplified endoproteinase assays using gelatin or azogelatin

Endoproteinase assays with gels containing incorporated gelatin have shown that gelatin is an exceptional substrate for studying enzymes from different sources. However, due to its solubility in trichloroacetic acid, gelatin is not suited to "in-solution" assays carried out in the classic manner (by reading the absorbance of supernatants of hydrolysis reactions after the substrate has been precipitated with trichloroacetic acid). In this paper we demonstrate that gelatin can be used for such analyses by using isopropanol as precipitating reagent. Alternatively, azogelatin, which is precipitated by trichloroacetic acid, can be used. Azogelatin also serves as a very good substrate. One problem with using gelatin (or any nonderivatized protein) as substrate for measuring the activity of crude enzyme preparations is that protein contaminants in the enzyme preparation are hydrolyzed. The resulting peptides are impossible to differentiate from those released from the gelatin substrate. This problem is obviated when azogelatin is used, since its peptides are detected at 440 nm, where nonderivatized peptides do not absorb. Unlike some azo-derivatized proteins, azogelatin is soluble from pH 3.0 to 9.0. This, together with the fact that it is hydrolyzed by many different endoproteinases, makes it suitable for many applications.

Subdural empyema due to Enterococcus faecalis

Central nervous system infections due to Enterococcus species are uncommon. We report the first case of subdural empyema due to Enterococcus faecalis. Following partial treatment of a middle ear infection due to Enterococcus species and mixed coliforms, the patient developed signs of meningeal involvement. A lumbar puncture showed a raised polymorph cell count, but was sterile on culture; broad-spectrum antimicrobial therapy with cefotaxime, flucloxacillin and metronidazole was commenced. Following development of focal neurological signs, a CT scan revealed a subdural collection. Drainage and culture of the pus yielded a pure growth of Enterococcus faecalis. This case demonstrates the need to remain aware of the ability of the Enterococcus to cause serious infections and to direct specific antimicrobial therapy accordingly.

Effect of 12 atmospheres helium-oxygen on the response of mice to convulsant drugs

The mechanism by which 12 atm abs of a helium-oxygen gas mixture (heliox) antagonizes behavioral effects of ethanol is unknown. Although the threshold for pressure-reversal of general anesthesia and expression of the high pressure neurologic syndrome (HPNS) is well above 12 atm abs in mice, the ethanol antagonism by 12 atm abs heliox could result from similar underlying excitatory effects. To investigate this possibility, the behavior of water-injected control mice and the latency to convulsions in drug-injected mice were determined in 1 atm abs air and 12 atm abs heliox. Four convulsant drugs were tested: picrotoxin (2 mg/kg), dl-allylglycine (300 mg/kg), isoniazid (300 mg/kg), and l-methionine-dl-sulfoximine (170 mg/kg). Responses were videotaped to observe behavior and to measure latency to the onset of myoclonus and clonus. Results indicated no observable excitatory effects of 12 atm abs in control mice. The latency to myoclonus was significantly reduced by pressure in allylglycine-treated mice but not in mice treated with the other convulsants. Latency to clonus was not significantly altered by pressure, relative to latency at 1 atm abs heliox, for any drug tested. In conclusion, the present findings indicate that exposure to 12 atm abs heliox is not proconvulsant and, thus, the findings do not support the hypothesis that 12 atm abs heliox antagonizes ethanol indirectly via an increase in central nervous system excitability.

Purification and partial characterization of a 31-kDa cysteine endopeptidase from germinated barley

Proteolytic enzymes hydrolyze cereal seed storage proteins into small peptides and amino acids, which are very important for seed germination and the malting process. A cysteine-class endopeptidase was purified from 4-d-germinated barley (Hordeum vulgare L. cv. Morex). Four purification steps were used, carboxymethyl cellulose cation-exchange chromatography, chromatofocusing, size-exclusion chromatography, and electroelution from a polyacrylamide gel. The endopeptidase was most active at pH 4.5. It's isoelectric point (pI) was 4.4, as determined by isoelectric focusing, and it's SDS-PAGE molecular size was 31 kDa. The enzyme specifically hydrolyzed peptide bonds when the S2 site contained relatively large hydrophobic amino acids. The N-terminal amino acid sequence residues (1-9) of the 31-kDa endopeptidase had high homology to those of the EP-A and EP-B cysteine proteinases reported previously. The 31-kDa endopeptidase had a hydrolytic specificity similar to that of the Morex green malt 30-kDa endopeptidase we characterized previously, and also reacted with the antibody raised against the purified 30-kDa proteinase, but the two had different mobilities on non-denaturing PAGE. The hydrolytic specificities of both 30- and 31-kDa endopeptidases are such that both would very quickly cleave hordein (barley storage) proteins to small glutamine- and proline-rich peptides that could be quickly degraded to amino acids by barley exopeptidases.

Mapping of β-glucan content and β-glucanase activity loci in barley grain and malt

Genetic study of β-glucan content and β-glucanase activity has been facilitated by recent developments in quantitative trait loci (QTL) analysis. QTL for barley and malt β-glucan content and for green and finished malt β-glucanase activity were mapped using a 123-point molecular marker linkage map from the cross of Steptoe/Morex. Three QTL for barley β-glucan, 6 QTL for malt β-glucan, 3 QTL for β-glucanase in green malt and 5 QTL for β-glucanase in finished malt were detected by interval mapping procedures. The QTL with the largest effects on barley β-glucan, malt βglucan, green malt β-glucanase and finished malt βglucanase were identified on chromosomes 2,1,4 and 7, respectively. A genome map-based approach allows for dissection of relationships among barley and malt βglucan content, green and finished malt β-glucanase activity, and other malting quality parameters.

Aeromonas infections and their treatment

With advances in the identification and molecular taxonomy of Aeromonas spp., these organisms, which are widely distributed in the environment, are increasingly being recognised as human pathogens. Clinical infections include gastroenteritis, skin and soft tissue infections and bacteraemia. Antibiotic resistance poses a potential problem in the antimicrobial therapy of infections cased by Aeromonas spp. While most strains are susceptible to chloramphenicol, ciprofloxacin, co-trimoxazole and the aminoglycosides, the activity of amoxycillin/clavulanate and the acylureidopenicillins is inconsistent. Addition of a beta-lactamase inhibitor does not significantly enhance the activity of the acylureidopenicillins. Aztreonam and the carbapenems, imipenem and meropenem remain highly active. Although resistance to the first and second generation cephalosporins is variable, more than 90% of Aeromonas spp. are susceptible to the third generation agents. Of potential significance is the identification of chromosomally-encoded inducible beta-lactamases, associated with resistance to extended spectrum penicillins, cephalosporins, monobactams and carbapenems, in clinical isolates of Aeromonas spp. Two distinct enzymes are produced: the A1 enzyme, a serine beta-lactamase behaving as a group 1 cephalosporinase, and the A2 enzyme, a metallo beta-lactamase which hydrolyses a wide range of beta-lactam agents including the carbapenems. The clinical relevance of these enzymes in Aeromonas spp. is unclear.

Linkage of vancomycin and high-level gentamicin resistance genes on the same plasmid in a clinical isolate of Enterococcus faecalis

A transferable 55-MDa plasmid which encoded resistance to both vancomycin and high concentrations of gentamicin was identified in a clinical isolate of Enterococcus faecalis. The plasmid hybridized with probes for the vanB and aac6'aph2" resistance genes. This is the first report of linkage of glycopeptide and high-level aminoglycoside resistance genes in an Enterococcus sp.

Low-level hyperbaric antagonism of ethanol's anticonvulsant property in C57BL/6J mice

This study investigated the ability of hyperbaric exposure to antagonize ethanol's anticonvulsant effect on isoniazid (INH)-induced seizures. Drug-naive, male C57BL/6 mice were injected intraperitoneally with saline, 1.5, 2.0, or 2.5 g/kg ethanol followed immediately by an intramuscular injection of 300 mg/kg of INH. The mice were then exposed to either 1 atmosphere absolute (1 ATA) air, 1 ATA helium-oxygen gas mixture (heliox), or 12 ATA heliox at temperatures that offset the hypothermic effects of helium. Ethanol increased the latency to onset of myoclonus in a dose-dependent manner. Exposure to 12 ATA heliox antagonized ethanol's anticonvulsant effect at 2.0 and 2.5 g/kg, but not at 1.5 g/kg. Ethanol also increased the latency to onset of clonus in a dose-dependent manner beginning at 2.0 g/kg. Exposure to 12 ATA heliox antagonized this anticonvulsant effect. When exposed to 12 ATA heliox, the blood ethanol concentrations at time to onset of myoclonus were significantly higher in mice treated with 2.5 g/kg of ethanol as compared with blood ethanol concentrations of mice exposed to 1 ATA air. These findings extend the acute behavioral effects of ethanol known to be antagonized by hyperbaric exposure and support the hypothesis that low-level hyperbaric exposure blocks or reverses the initial action(s) of ethanol leading to its acute behavioral effects.

Temperature dependence of ethanol depression in mice: dose response

Manipulation of body temperature during intoxication significantly alters brain sensitivity to ethanol. The current study tested the generality of this effect within the hypnotic dose range. Drug naive, male C57BL/6J mice were injected with 3.2, 3.6, or 4.0 g/kg ethanol (20% w/v) and were exposed to 1 of 7 designated temperatures from 13 degrees to 34 degrees C to manipulate body temperature during intoxication. Rectal temperature at return of righting reflex (RORR) was significantly, positively correlated with loss of righting reflex (LORR) duration and significantly, negatively correlated with blood ethanol concentration (BEC) at RORR at all three doses. These results indicate that increasing body temperature during intoxication increased ethanol sensitivity in C57 mice at all three doses tested and demonstrate the generality of temperature dependence across hypnotic doses in these animals. Interestingly, the LORR duration was dose-dependent at each ambient temperature, but the degree of body temperature change and the BEC at RORR were not dose-dependent. Overall, these results emphasize the importance of body temperature as a variable in ethanol research.

Use of monoclonal antibodies to study the structure and function of eukaryotic protein synthesis initiation factor eIF-2B

The eukaryotic protein synthesis initiation factor, eIF-2B, is a multimeric protein of five different subunits termed alpha, beta, gamma, delta and epsilon, which facilitates recycling of a further factor, eIF-2, and is an important control point in the initiation process. In order to investigate the structure and function of eIF-2B, monoclonal antibodies have been prepared to the beta, delta and epsilon subunits of the factor from rabbit reticulocytes. All three antibodies are active in Western blotting, ELISA and immunoprecipitation. The anti-epsilon antibody inhibits both the guanine nucleotide exchange activity of eIF-2B and protein synthesis in the rabbit reticulocyte lysate at the level of initiation. The other two antibodies do not inhibit either guanine nucleotide exchange or protein synthesis. The monoclonal antibodies and a polyclonal anti-(rabbit reticulocyte eIF-2B) serum were used to investigate the subunit size and the antigenic structure of eIF-2B from a variety of rabbit tissues and from a variety of mammalian species. eIF-2B from all rabbit tissues tested was indistinguishable from that prepared from rabbit reticulocytes. Quantitative studies showed substantial variation in the relative concentrations of eIF-2 and eIF-2B between different rabbit tissues. Marked variation in both the sizes of the subunits and their reaction with the antibodies was observed between eIF-2B from rabbit, rat, guinea pig and man.

Morphine-6-glucuronide: a potent stimulator of locomotor activity in mice

The present study tested the hypothesis that morphine glucuronides have stimulant properties by studying their effects on locomotor activity in mice. Drug-naive C57BL/6J male mice were injected with saline, morphine, morphine-6-glucuronide (M6G) or morphine-3-glucuronide (M3G). In some experiments, mice were injected with saline or naloxone 5 min prior to drug treatment. Injection of 40 mg/kg morphine or M6G, but not M3G, significantly increased activity versus saline. The extent of activation induced by M6G was markedly higher than for morphine. Subsequent dose-response studies across a somewhat lower dose range using equimolar doses of morphine and M6G (3-80 mumoles/kg) found that both drugs significantly increased locomotor activity beginning at 20 mumoles/kg. M6G increased locomotor activity from 1.3 to 2.1 times more than for equimolar doses of morphine. Pretreatment with naloxone (10 mg/kg) completely abolished the locomotor stimulation induced by 32 mumoles/kg morphine and M6G. These findings present evidence that M6G is an active metabolite of morphine which has behaviorally stimulating effects and may play an important role in mediating the reinforcing properties of morphine in humans.