Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Signatures of Interactions in the Andreev Spectrum of Nanowire Josephson Junctions

We performed microwave spectroscopy of an InAs nanowire between superconducting contacts implementing a finite-length, multichannel Josephson weak link. Certain features in the spectra, such as the splitting by spin-orbit interactions of the transition lines among Andreev states, have been already understood in terms of noninteracting models. However, we identify here additional transitions, which evidence the presence of Coulomb interactions. By combining experimental measurements and model calculations, we reach a qualitative understanding of these very rich Andreev spectra.

From Adiabatic to Dispersive Readout of Quantum Circuits

Spectral properties of a quantum circuit are efficiently read out by monitoring the resonance frequency shift it induces in a microwave resonator coupled to it. When the two systems are strongly detuned, theory attributes the shift to an effective resonator capacitance or inductance that depends on the quantum circuit state. At small detuning, the shift arises from the exchange of virtual photons, as described by the Jaynes-Cummings model. Here we present a theory bridging these two limits and illustrate, with several examples, its necessity for a general description of quantum circuits readout.

Efecto del uso de hidrolizado enzimático de proteína de levadura sobre la fermentación y el perfil sensorial del vino

Se evaluó el uso de proteínas de levaduras como fuente de nitrógeno orgánica para la fermentación en reemplazo del diaminofosfato (DAP). Se utilizaron Saccharomyces cerevisiae autoclavadas y posteriormente hidrolizadas con 6.75 mAU/g de subtilisina a pH 8.0 y 50 ∘C hasta grados de hidrólisis de 5% y 15%. Se fermentó mosto de Cabernet sauvignon con Saccharomyces cerevisiae a 28 ∘C y pH 3.5, utilizando como fuente de nitrógeno DAP (control) e hidrolizados proteicos de levadura (tratamientos). Se realizó un seguimiento de las fermentaciones midiendo ∘Brix, azúcares reductores y grado alcohólico final. El grado alcohólico resultó en promedio 12 ∘, mientras que los azúcares residuales fueron menores a 2 [g/L]. No se observaron diferencias significativas entre el control y los tratamientos, lo cual implica que durante las fermentaciones con hidrolizado proteico de levaduras no hubo deficiencia de nitrógeno, por lo que se infiere que los péptidos del hidrolizado fueron metabolizados por las levaduras. Se realizaron análisis sensoriales y de compuestos volátiles de diferentes vinos elaborados con DAP e hidrolizado proteico de levaduras como fuente de nitrógeno. El uso de hidrolizado proteico de levaduras generó cambios significativos en el perfil de alcoholes superiores y ésteres del vino en comparación con el uso de DAP. El panel organoléptico detectó un mayor dulzor y menor acidez en los vinos que usaron hidrolizado en comparación con los producidos con DAP. La utilización de hidrolizado enzimático de proteínas de levadura como fuente de nitrógeno orgánica en la fermentación del vino es técnicamente factible y además beneficiosa para las propiedades organolépticas del vino.

Superconducting atomic contacts inductively coupled to a microwave resonator

We describe and characterize a microwave setup to probe the Andreev levels of a superconducting atomic contact. The contact is part of a superconducting loop inductively coupled to a superconducting coplanar resonator. By monitoring the resonator reflection coefficient close to its resonance frequency as a function of both flux through the loop and frequency of a second tone we perform spectroscopy of the transition between two Andreev levels of highly transmitting channels of the contact. The results indicate how to perform coherent manipulation of these states.

Agenesis of the Corpus Callosum Due to Defective Glial Wedge Formation in Lhx2 Mutant Mice

Establishment of the corpus callosum involves coordination between callosal projection neurons and multiple midline structures, including the glial wedge (GW) rostrally and hippocampal commissure caudally. GW defects have been associated with agenesis of the corpus callosum (ACC). Here we show that conditional Lhx2 inactivation in cortical radial glia using Emx1-Cre or Nestin-Cre drivers results in ACC. The ACC phenotype was characterized by aberrant ventrally projecting callosal axons rather than Probst bundles, and was 100% penetrant on 2 different mouse strain backgrounds. Lhx2 inactivation in postmitotic cortical neurons using Nex-Cre mice did not result in ACC, suggesting that the mutant phenotype was not autonomous to the callosal projection neurons. Instead, ACC was associated with an absent hippocampal commissure and a markedly reduced to absent GW. Expression studies demonstrated strong Lhx2 expression in the normal GW and in its radial glial progenitors, with absence of Lhx2 resulting in normal Emx1 and Sox2 expression, but premature exit from the cell cycle based on EdU-Ki67 double labeling. These studies define essential roles for Lhx2 in GW, hippocampal commissure, and corpus callosum formation, and suggest that defects in radial GW progenitors can give rise to ACC.

Evidence for long-lived quasiparticles trapped in superconducting point contacts

We have observed that the supercurrent across phase-biased, highly transmitting atomic size contacts is strongly reduced within a broad phase interval around π. We attribute this effect to quasiparticle trapping in one of the discrete subgap Andreev bound states formed at the contact. Trapping occurs essentially when the Andreev energy is smaller than half the superconducting gap Δ, a situation in which the lifetime of trapped quasiparticles is found to exceed 100 μs. The origin of this sharp energy threshold is presently not understood.

Asymmetric noise probed with a josephson junction

Fluctuations of the current through a tunnel junction are measured using a Josephson junction. The current noise adds to the bias current of the Josephson junction and affects its switching out of the supercurrent branch. The experiment is carried out in a regime where switching is determined by thermal activation. The variance of the noise results in an elevated effective temperature, whereas the third cumulant, related to its asymmetric character, leads to a difference in the switching rates observed for opposite signs of the current through the tunnel junction. Measurements are compared quantitatively with recent theoretical predictions.

Phase controlled superconducting proximity effect probed by tunneling spectroscopy

Using a dual-mode STM-AFM microscope operating below 50 mK we measured the local density of states along small normal wires connected at both ends to superconductors with different phases. We observe that a uniform minigap can develop in the whole normal wire and in the superconductors near the interfaces. The minigap depends periodically on the phase difference. The quasiclassical theory of superconductivity applied to a simplified 1D model geometry accounts well for the data.

Mechanism of nicotinic acid transport in human liver cells: experiments with HepG2 cells and primary hepatocytes

This study reports on the functional expression of a specific, high-affinity carrier-mediated mechanism for the transport of niacin (nicotinic acid) in human liver cells. Both human-derived liver HepG2 cells and human primary hepatocytes were used as models in these investigations. The initial rate of transport of nicotinic acid into HepG2 cells was found to be acidic pH, temperature, and energy dependent; it was, however, Na(+) independent in nature. Evidence for the existence of a carrier-mediated system that is specific for [(3)H]nicotinic acid transport was found and included the following: 1) saturability as a function of concentration with an apparent K(m) of 0.73 +/- 0.16 microM and V(max) of 25.02 +/- 1.45 pmol.mg protein(-1).3 min(-1), 2) cis-inhibition by unlabeled nicotinic acid and nicotinamide but not by unrelated organic anions (lactate, acetate, butyrate, succinate, citrate, and valproate), and 3) trans-stimulation of [(3)H]nicotinic acid efflux by unlabeled nicotinic acid. Transport of the vitamin into human primary hepatocytes occurs similarly via an acidic pH-dependent and specific carrier-mediated process. Inhibitors of the Ca(2+)-calmodulin-mediated pathway (but not modulators of the PKC-, PKA-, and protein tyrosine kinase-mediated pathways) inhibited nicotinic acid transport into both HepG2 cells and human primary hepatocytes. Maintenance of HepG2 cells (for 48 h) in growth medium oversupplemented with nicotinic acid (or nicotinamide) did not affect the subsequent transport of [(3)H]nicotinic acid into HepG2 cells. These results show, for the first time, the existence of a specific and regulated membrane carrier-mediated system for nicotinic acid transport in human liver cells.

Measurement of the current-phase relation of superconducting atomic contacts

We have probed the current-phase relation of an atomic contact placed with a tunnel junction in a small superconducting loop. The measurements are in quantitative agreement with the predictions of a resistively shunted SQUID model in which the Josephson coupling of the contact is calculated using the independently determined transmissions of its conduction channels.

Crossover from Josephson to multiple Andreev reflection currents in atomic contacts

The basic current-carrying mechanism through a superconducting weak link embedded in a resistive environment undergoes a continuous crossover, as the voltage increases, from Josephson Cooper pair transfer exciting electromagnetic modes in the environment to multiple Andreev reflections leading to the creation of quasiparticles. We corroborate these ideas through measurements of the dc current-voltage characteristics of superconducting atomic contacts containing channels of arbitrary and adjustable transmission. We present a simple model, in the spirit of the classical resistively shunted junction model, that accounts well for the observed characteristics.

Recruitment pharmacophore for interleukin 5 receptor alpha antagonism

Interleukin-5 receptor alpha is a therapeutic target for hypereosinophilic diseases including allergic inflammations and asthma. The cyclic peptide AF17121 (Ac-VDE[CWRIIASHTWFC]AEE-CONH(2)) has been identified as a submicromolar inhibitor of interleukin 5 (IL5)-interleukin 5 receptor alpha (IL5Ralpha) interaction from a random peptide screen. However, this inhibitor has limitations as a drug lead because of its relatively large size. We used chemical synthesis of peptides with natural and non-natural amino acids along with kinetic binding and cell proliferation competition assays to expand definition of structural elements in the peptide that are important for receptor antagonism and to elucidate the underlying pharmacophore. We found that the specific steric array of hydrogen bonding groups in the Arg 6 guanido side chain is critical for receptor inhibition. We also investigated noncharged structural elements in AF17121. Screening a set of five hydrophobic residues showed that peptide function is strongly sensitive to variations in several of these residues, most prominently Ile 7 and Trp 13. We postulate that presentation of charged, hydrogen bonding and hydrophobic structural elements within the disulfide-constrained peptide drives IL5Ralpha recruitment by AF17121. We hypothesize from these results and previous receptor mutagenesis studies that Arg 6 recruitment of IL5Ralpha occurs through hydrogen bonding as well as charge-charge interactions with Asp 55 in site one of domain 1 of IL5Ralpha, and that this interaction is complemented by additional charged and hydrophobic interactions around the Asp 55 locus. Scaffolding a limited set of structural elements in the inhibitor pharmacophore may be useful for small molecule antagonist design inspired by the peptide.

Superconducting atomic contacts under microwave irradiation

We have measured the effect of microwave irradiation on the dc current-voltage characteristics of superconducting atomic contacts. The interaction of the external field with the ac supercurrents leads to replicas of the supercurrent peak, the well-known Shapiro resonances. The observation of supplementary fractional resonances for contacts containing highly transmitting conduction channels reveals their nonsinusoidal current-phase relation. The resonances sit on a background current which is itself deeply modified, as a result of photon-assisted multiple Andreev reflections. The results provide firm support for the full quantum theory of transport between two superconductors based on the concept of Andreev bound states.

Asymmetric usage of antagonist charged residues drives interleukin-5 receptor recruitment but is insufficient for receptor activation

The cyclic peptide AF17121 (VDECWRIIASHTWFCAEE) is a library-derived antagonist for human Interleukin-5 receptor alpha (IL5Ralpha). We have previously demonstrated that AF17121 mimics Interleukin-5 (IL5) by binding in a region of IL5Ralpha that overlaps the IL5 binding epitope. In the present study, to explore the functional importance of the amino acid residues of AF17121 required for effective binding to, and antagonism of, IL5Ralpha, each charged residue was subjected to site-directed mutagenesis and examined for IL5Ralpha interaction by using a surface plasmon resonance biosensor. One residue, Arg(6), was found to be essential for receptor antagonism; its replacement with either alanine or lysine completely abolished the interaction between AF17121 and IL5Ralpha. Other charged residues play modulatory roles. One class consists of the N-terminal acidic cluster (Asp(2) and Glu(3)) for which alanine replacement decreased the association rate. A second class consists of His(11) and the C-terminal acidic cluster (Glu(17) and Glu(18)) for which alanine replacement increased the dissociation rate. Binding model analysis of the mutants of the latter class of residues indicated the existence of conformational rearrangement during the interaction. On the basis of these results, we propose a model in which Arg(6) and N-terminal acidic residues drive the encounter complex, while Arg(6), His(11), and C-terminal acidic residues are involved in stabilizing the final complex. These data argue that the charged residues of AF17121 are utilized asymmetrically in the pathway of inhibitor-receptor complex formation to deactivate the receptor function. The results also help focus emerging models for the mechanism by which IL5 activates the IL5Ralpha-betac receptor system.

Receptor Epitope Usage by an Interleukin-5 Mimetic Peptide

The cyclic peptide AF17121 is a library-derived antagonist for human interleukin-5 (IL5) receptor alpha (IL5Ralpha) and inhibits IL5 activity. Our previous results have demonstrated that the sixth arginine residue of the peptide is crucial for the inhibitory effect and that several acidic residues in the N- and C-terminal regions also make a contribution, although to a lesser extent (Ruchala, P., Varadi, G., Ishino, T., Scibek, J., Bhattacharya, M., Urbina, C., Van Ryk, D., Uings, I., and Chaiken, I. (2004) Biopolymers 73, 556-568). However, the recognition mechanism of the receptor has remained unresolved. In this study, AF17121 was fused to thioredoxin by recombinant DNA techniques and examined for IL5Ralpha interaction using a surface plasmon resonance biosensor method. Kinetic analysis revealed that the dissociation rate of the peptide.receptor complex is comparable with that of the cytokine.receptor complex. The fusion peptide competed with IL5 for both biological function and interaction with IL5Ralpha, indicating that the binding sites on the receptor are shared by AF17121 and IL5. To define the epitope residues for AF17121, we defined its binding footprint on IL5Ralpha by alanine substitution of Asp(55), Asp(56), Glu(58), Lys(186), Arg(188), and Arg(297) of the receptor. Marked effects on the interaction were observed in all three fibronectin type III domains of IL5Ralpha, in particular Asp(55), Arg(188), and Arg(297) in the D1, D2, and D3 domains, respectively. This footprint represents a significant subset of that for IL5 binding. The fact that AF17121 mimics the receptor binding capability of IL5 but antagonizes biological function evokes several models for how IL5 induces activation of the multisubunit receptor system.

Cyclic peptide interleukin 5 antagonists mimic CD turn recognition epitope for receptor ?

The cyclic peptide AF17121 (Ac-VDECWRIIASHTWFCAEE) that inhibits interleukin 5 (IL-5) function and IL-5 receptor alpha-chain (IL-5Ralpha) binding has been derived from recombinant random peptide library screening and follow-up synthetic variation. To better understand the structural basis of its antagonist activity, AF17121 and a series of analogs of the parent peptide were prepared by solid phase peptide synthesis. Sequence variation was focused on the charged residues Asp(2), Glu(3), Arg(6), Glu(17), and Glu(18). Two of those residues, Glu(3) and Arg(6), form an EXXR motif that was found to be common among library-derived IL-5 antagonists. The E and R in the EXXR motif have a proximity similar to charged residues in a previously identified receptor alpha binding region, the beta-strand between the C- and D-helices of human IL-5. Optical biosensor interaction kinetics and cell proliferation assays were used to evaluate the antagonist activities of the purified synthetic peptides, by measuring competition with the highly active single chain IL-5. Analogs in which acidic residues (Asp(2), Glu(3), Glu(17), and Glu(18)) were replaced individually by Ala retained substantial competition activity, with multiple replacements in these residues leading to fractional loss of potency at most. In contrast, R6A analogs had strongly reduced competition activity. The results reveal that the arginine residue is crucial for the IL-5Ralpha binding of AF17121, while the acidic residues are not essential though likely complex-stabilizing particularly in the Asp(2)-Glu(3) region. By CD, AF17121 exhibited mostly disordered structure with evidence for a small beta-sheet content, and replacement of the arginine had no influence on the observed secondary structure of the peptides. The dominance of Arg(6) in AF17121 activity corresponds to previous findings of dominance of the positive charge balance in the antiparallel beta-sheet of IL-5 composed of (88)EERRR(92) in one strand of the CD turn region of IL-5 and with Arg(32) in the neighboring beta-strand. These results argue that AF17121 and related library-derived peptides function by mimicking the CD turn receptor alpha recognition epitope in IL-5 and open the way to small molecule antagonist design.

Rabi oscillations in a large Josephson-junction qubit

We have designed and operated a circuit based on a large-area current-biased Josephson junction whose two lowest energy quantum levels are used to implement a solid-state qubit. The circuit allows measurement of the qubit states with a fidelity of 85% while providing sufficient decoupling from external sources of relaxation and decoherence to allow coherent manipulation of the qubit state, as demonstrated by the observation of Rabi oscillations. This qubit circuit is the basis of a scalable quantum computer.

Manipulating the quantum state of an electrical circuit

We have designed and operated a superconducting tunnel junction circuit that behaves as a two-level atom: the "quantronium." An arbitrary evolution of its quantum state can be programmed with a series of microwave pulses, and a projective measurement of the state can be performed by a pulsed readout subcircuit. The measured quality factor of quantum coherence Qphi approximately 25,000 is sufficiently high that a solid-state quantum processor based on this type of circuit can be envisioned.

Direct link between Coulomb blockade and shot noise in a quantum-coherent structure

We analyze the current-voltage characteristic of a quantum conduction channel coupled to an electromagnetic environment with arbitrary frequency-dependent impedance. In the weak blockade regime the correction to the Ohmic behavior is directly related to the channel current fluctuations, vanishing at perfect transmission in the same way as shot noise. This relation can be generalized to describe the environmental Coulomb blockade in a generic mesoscopic conductor coupled to an external impedance, as the response of the latter to the current fluctuations in the former.

Multiple-charge-quanta shot noise in superconducting atomic contacts

We have measured shot noise in aluminum atomic point contacts containing a small number of conduction channels of known transmissions. In the normal state, we find that the noise power is reduced from its Poissonian value and reaches the partition limit, as calculated from the transmissions. In the superconducting state, the noise reveals the large effective charge associated with each elementary transfer process, in excellent agreement with the predictions of the quantum theory of multiple Andreev reflections.

Multiple Andreev reflections revealed by the energy distribution of quasiparticles

We have performed the tunnel spectroscopy of the energy distribution function of quasiparticles in 5-microm-long silver wires connected to superconducting reservoirs biased at different potentials. The distribution function f(E) presents several steps, which are manifestations of multiple Andreev reflections at the NS interfaces. The rounding of the steps is well explained by electron-electron interactions.

Proximity effect and multiple Andreev reflections in gold atomic contacts

We investigate the electronic transport properties of gold point contacts with superconducting aluminum leads. The modifications induced by the proximity effect in the quasiparticle density of states at the contact region are measured by tunnel spectroscopy. The theory of transport through multiple Andreev reflections is extended to incorporate these effects and used to determine the number and transmission coefficients of the conduction channels in the contact regime. We find that the smallest contacts, formed by one gold atom between the electrodes, contribute one single channel to the transport with variable transmission T between 0.1 and 1.

Supercurrent in atomic point contacts and andreev states

We have measured the supercurrent in aluminum atomic point contacts containing a small number of well characterized conduction channels. For most contacts, the measured supercurrent is adequately described by the opposite contributions of two thermally populated Andreev bound states per conduction channel. However, for contacts containing an almost perfectly transmitted channel 0.9</=tau</=1 the measured supercurrent is higher than expected, a fact that we attribute to nonadiabatic transitions between bound states.

Interdisciplinary ambulatory education and service in primary care at the University of New Mexico

To compete and survive in a managed care market, academic health centers must develop integrated delivery systems in general and an integrated primary care system in particular. However, the departmental-based structure at most academic health centers is ill-suited to this purpose. Service and education are usually segregated by department, and the professional activities of primary care faculty in different departments are fragmented, leaving them weakened as a political force within the institution. The University of New Mexico established a model of integrated primary care education and service by creating three interdisciplinary primary care clinics staffed by primary care residents and faculty. The clinics attracted a substantial portion of each department's faculty and residents. The clinics united primary care providers from different departments as a stronger, more unified voice in negotiating with the hospital and in fostering needed changes for primary care in the institution. Interdisciplinary teams require considerable time and labor both in planning (because of joint decision making) and in operation. Better staff structures and staff development must be learned through trial and error because there are not established benchmarks for interdisciplinary teams. Governance presents problems, primarily because loyalties to departments may supersede those to the clinic practice, and sometimes the departments' teaching priorities are challenged by clinic directors' need to ensure filling their interdisciplinary staff needs. These obstacles to collaboration can be addressed creatively, and ultimately the comprehensiveness and quality of care convinces providers and the institution.

Synthesis and Characterization of Molybdenum Based Colloidal Particles

The synthesis and characterization of molybdenum colloidal particles were evaluated using thermal and sonochemical methods and starting from different metal precursors, Mo(CO)6 and (NH4)2MoS4. The products were characterized by elemental analysis, spectroscopic (UV, FTIR), and surface analysis (XPS) techniques, as well as by transmission electron microscopy (TEM) for determining the particle sizes. Using Mo(CO)6 as metal source, particle sizes with an average diameter of 1.5 nm can be obtained using tert-amyl alcohol as solvent and tetrahydrothiophene as sulfurating ligand. The characterization of these particles showed that they are composed of molybdenum oxide MoO3. Using (NH4)2MoS4 as metal precursor, particles with average diameters of 4.7 and 2.5 nm were synthesized using thermal and sonochemical methods, respectively. The characterization of these particles showed them to be composed of molybdenum sulfide, MoS2. The sonochemical method proved to be the fastest and most convenient synthetic pathway of obtaining small colloidal particles at low temperatures and with control of the average size. Copyright 1998 Academic Press.

Fostering the health of communities: a unifying mission for the University of New Mexico Health Sciences Center

Fostering the health of communities can serve as a unifying mission of the academic health center (AHC), which can set the AHC apart from other health providers in the community. To achieve this mission, the University of New Mexico's AHC is increasingly focusing education, research, and service upon the identified health and service needs of communities in its state. Since major health problems in our society have social, behavioral, and economic roots, New Mexico's AHC has tapped into the broad expertise of its different components as well as that of its state and community partners to adequately address health problems in the community. Its hospitals offer financing and management resources, its colleges offer innovative approaches to community-based education, and the state department of health offers expertise in health policy development. To adequately respond to the complexity of community health needs, the different colleges and departments at New Mexico's AHC are increasingly merging into integrated governance units. Measures of community outreach success include evidence of strengthened community development, increased health care access, and improved indices of community health. New Mexico's AHC formed an interdisciplinary rural outreach task force, which has demonstrated its ability to form partnerships with state and local agencies and to mobilize institutional resources in education, research, and service from the AHC's different departments, colleges, and hospitals to respond promptly to unique community health needs. Evidence shows that such an integrated, coordinated AHC intervention can generate strong and lasting AHC-community alliances, improve the quality and economic viability of community health systems, and enhance the financial resources of the AHC.

Innovative generalist programs: academic health care centers respond to the shortage of generalist physicians

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.

Comparison of reactogenicity and antigenicity of M37 rotavirus vaccine and rhesus-rotavirus-based quadrivalent vaccine

90 Venezuelan infants aged 10-20 weeks were randomly allocated to four groups which received one of the following: the M37 vaccine (1 x 10(4) pfu [plaque-forming units]); quadrivalent rotavirus vaccine (1 x 10(4) pfu each of serotype 3 rhesus rotavirus [RRV] and human rotavirus-RRV reassortants of serotypes 1, 2, and 4); balanced quadrivalent vaccine consisting of 1 x 10(4) pfu of serotype 1 and 3 components but 5 x 10(4) pfu of serotype 2 and 4 components; or placebo. The frequencies of transient febrile responses in these four groups were 20%, 27%, 30%, and 9%. 50% of 22 infants tested who received M37 vaccine showed a serum rotavirus IgA antibody response, compared with 74% of the 23 quadrivalent and 86% of the 22 balanced-quadrivalent recipients. 64% of the M37 recipients showed a neutralising antibody response to M37; 27% showed such responses to human serotype 1 Wa strain and 27% to serotype 4 neonatal strain ST3. 17-39% of the quadrivalent recipients and 27-41% of the balanced-quadrivalent recipients showed neutralising antibody responses to serotypes 1-4. 70-73% of the quadrivalent and balanced quadrivalent groups also showed neutralising antibody responses to RRV.

Changes in cytoskeleton-associated molecules in cells with different degrees of proliferation and metastatic ability

An antiserum prepared against the Triton-insoluble cytoskeleton of in vivo grown B16 melanoma tumor has been used to analyze the differential expression of cytoskeleton-associated molecules in cells with different degrees of proliferation and metastatic ability. This antiserum identified a major 97 kd molecule associated with the cytoskeletal fraction in B16 melanoma tumors, mouse embryo and in proliferating lymphocytes, with no reactivity with the 97 kd species in non proliferating lymphocytes. The antiserum revealed immune reactivity with a 180 kd Triton-insoluble species in normal adult mouse liver and kidney. A comparison of tumor cells with differing metastatic ability also showed a minor 180 kd component in poorly metastatic cells which appeared decreased and partly degraded in its more invasive counterpart. The differential recognition of a 97 kd species in resting and proliferating lymphocytes, as well as the different cleavage of a 180 kd species in tumor cells of differing metastatic ability, implies a role for these molecules in cell proliferation. The fact that these differences can be detected with an antiserum to tumor cell cytoskeleton suggests that this Triton-insoluble fraction may be a good source of molecules involved in growth control.

Differential response of adherent and unanchored melanoma cells to bromodeoxyuridine evidenced by specific lectin-binding protein changes

The possible differential response of adherent and nonadherent cells of the same tumor type to pyrimidine analogues has been investigated. We show that bromodeoxyuridine (BUdR) increases interactions of attached cells with their substrate without markedly affecting the cell adhesion properties of the same cells when these are not anchored. However, evidence for an adhesion-independent response of both cell types to BUdR has been obtained with lectin binding assays using 125I-labelled Lens culinaris agglutinin (LCA). This revealed a greatly increased binding of LCA to a large glycoconjugate in all cultures exposed to the halogenated pyrimidine. Attachment-dependent effects of BUdR were manifested in flattened cells by a greater LCA-binding to a 240-kDa protein and by increased interaction of 125I-labelled wheat-germ agglutinin (WGA) with a 200-kDa protein and a large glycoconjugate sharply defined in electrophoresis. Although both tumor cell aggregates and anchored cells exhibit detectable responses to pyrimidine analogues such as BUdR, the corresponding effects are thus manifested unequally in cells with different adhesion properties.

DNA on membrane receptors: a target for monoclonal anti-DNA antibody induced by a nucleoprotein shed in systemic lupus erythematosus

Antibodies to double stranded (ds) DNA correlate with clinical evolution in systemic lupus erythematosus (SLE) although little is known about the immunogen and target for these antibodies, since ds DNA is poorly immunogenic. We now show that monoclonal anti DNA antibodies similar to those detected in human SLE can be produced by immunization of genetically non-autoimmune mice with a human circulating DNA-protein complex increased in the circulation of SLE patients. One such monoclonal antibody showed antinuclear reactivity, interacting with a 74 kd DNA-binding membrane protein, in reactions prevented by absorption with ds DNA cellulose. Our data suggests that anti ds DNA antibody reactions in SLE may be triggered by circulating nucleoproteins and directed toward membrane receptors capable of interacting with extracellular DNA.

Decrease in tumor-cell attachment and in a 140-kDa fibronectin receptor correlate with greater expression of multiple 34-kDa surface proteins and cytoplasmic 54-kDa components

B16 melanoma cells attach to matrix-bound fibronectin but fail to adhere to albumin-coated surfaces supplemented with soluble fibronectin. Attachment to substratum is also decreased in the presence of an adhesion-disrupting antibody, or when cells are seeded on substrates poorly adhesive for these cells, such as collagen gels. We have now investigated some of the more general adhesion-related alterations that occur between flattened and poorly attached cells. Immune blots of octylglucoside extracts with the adhesion-disrupting IgG revealed a 140-kDa component in flattened cells, in contrast to the increased detection of a 54-kDa species in a comparable assay with rounded cells. Surface iodination also showed a decreased external exposure of a 140-kDa fibronectin binding species and an increased labelling in multiple 34-kDa protein species, in cells with decreased attachment to substratum. Analysis of 35S-methionine-labelled cell aggregates cultured on collagen gels also revealed a decrease in the 140-kDa region and a greater labelling of multiple 54-kDa components, compared to the same cells flattened on fibronectin. A change in 54- and 34-kDa species was also seen in matrix-associated components of rounded cells that failed to attach with soluble fibronectin. Since the 34-kDa species increase in poorly adherent cells is mainly detected by iodination, and the 54-kDa species increase in the same cells is partly associated with the corresponding detergent-insoluble matrices, we propose that these 2 novel proteins may relate to cell rounding, through a transmembrane modulation involving both surface membrane and cytoskeletal structures.

120 and 80 kd detergent-insoluble glycoproteins as markers of differentiation and adhesion in B16 melanoma

Surface glycoproteins correlating with cell adhesion and differentiation have now been studied in pigmented and amelanotic B16 melanoma cell monolayers and aggregates, labelled with 3H-glucosamine. Solubilization with the non-ionic detergent octyl glucoside revealed mostly adhesion-related changes, which involved a decrease in 140 and 110 kd glycoproteins in both pigmented and amelanotic cell aggregates. Nevertheless, differentiation-regulated changes were preferentially evident in the remaining detergent-insoluble glycoproteins. Pigmented cell monolayers showed a preferential increase in glycoprotein species of about 120 kd and 80 kd, which were not detected in amelanotic monolayers or in pigmented or amelanotic cell aggregates. Our findings suggest the relevance of these cytoskeleton associated glycoproteins as markers of differentiation and adhesion in melanoma cells.

Substrate-dependent effect of epidermal growth factor on intercellular adhesion and synthesis of triton-insoluble proteins in human carcinoma A431 cells

Human epidermoid carcinoma A431 cells attach more rapidly to collagen type-I and -IV substrates than to surfaces coated with laminin or fibronectin. The diminished intercellular interaction and rounding up manifested when these cells are exposed to epidermal growth factor (EGF) in tissue culture plastic or collagen films is not shown when the assay is performed on 3-dimensional collagen. In the latter substrate, cells exposed to EGF reveal greater cell cohesion with interdigitations and desmosomal junctions, compared to the limited intercellular interaction detected in similarly treated cells assayed in tissue culture substrate. Although the protein synthesis inhibitor, cycloheximide, did not prevent these EGF-mediated changes, metabolic labelling indicated a substrate-dependent effect of EGF on the synthesis of proteins associated with the Triton-insoluble cytoskeletal matrix. The involvement of cytoskeleton components in the EGF effects on intercellular adhesion was shown by its susceptibility to cytochalasin B, known to disorganize actin-containing microfilaments. Some of the mechanisms of epithelial morphogenesis and the influence of extracellular matrix components on cell-receptor/growth-factor interactions may now be suitably analyzed by examining the EGF effects on A431 cells grown on different substrata.