PIP4K2C inhibition reverses autophagic flux impairment induced by SARS-CoV-2

In search for broad-spectrum antivirals, we discovered a small molecule inhibitor, RMC-113, that potently suppresses the replication of multiple RNA viruses including SARS-CoV-2 in human lung organoids. We demonstrated selective dual inhibition of the lipid kinases PIP4K2C and PIKfyve by RMC-113 and target engagement by its clickable analog. Advanced lipidomics revealed alteration of SARS-CoV-2-induced phosphoinositide signature by RMC-113 and linked its antiviral effect with functional PIP4K2C and PIKfyve inhibition. We discovered PIP4K2C's roles in SARS-CoV-2 entry, RNA replication, and assembly/egress, validating it as a druggable antiviral target. Integrating proteomics, single-cell transcriptomics, and functional assays revealed that PIP4K2C binds SARS-CoV-2 nonstructural protein 6 and regulates virus-induced impairment of autophagic flux. Reversing this autophagic flux impairment is a mechanism of antiviral action of RMC-113. These findings reveal virus-induced autophagy regulation via PIP4K2C, an understudied kinase, and propose dual inhibition of PIP4K2C and PIKfyve as a candidate strategy to combat emerging viruses.

Anticancer pan-ErbB inhibitors reduce inflammation and tissue injury and exert broad-spectrum antiviral effects

Targeting host factors exploited by multiple viruses could offer broad-spectrum solutions for pandemic preparedness. Seventeen candidates targeting diverse functions emerged in a screen of 4,413 compounds for SARS-CoV-2 inhibitors. We demonstrated that lapatinib and other approved inhibitors of the ErbB family of receptor tyrosine kinases suppress replication of SARS-CoV-2, Venezuelan equine encephalitis virus (VEEV), and other emerging viruses with a high barrier to resistance. Lapatinib suppressed SARS-CoV-2 entry and later stages of the viral life cycle and showed synergistic effect with the direct-acting antiviral nirmatrelvir. We discovered that ErbB1, ErbB2, and ErbB4 bind SARS-CoV-2 S1 protein and regulate viral and ACE2 internalization, and they are required for VEEV infection. In human lung organoids, lapatinib protected from SARS-CoV-2-induced activation of ErbB-regulated pathways implicated in non-infectious lung injury, proinflammatory cytokine production, and epithelial barrier injury. Lapatinib suppressed VEEV replication, cytokine production, and disruption of blood-brain barrier integrity in microfluidics-based human neurovascular units, and reduced mortality in a lethal infection murine model. We validated lapatinib-mediated inhibition of ErbB activity as an important mechanism of antiviral action. These findings reveal regulation of viral replication, inflammation, and tissue injury via ErbBs and establish a proof of principle for a repurposed, ErbB-targeted approach to combat emerging viruses.

Anticancer pan-ErbB inhibitors reduce inflammation and tissue injury and exert broad-spectrum antiviral effects

Targeting host factors exploited by multiple viruses could offer broad-spectrum solutions for pandemic preparedness. Seventeen candidates targeting diverse functions emerged in a screen of 4,413 compounds for SARS-CoV-2 inhibitors. We demonstrated that lapatinib and other approved inhibitors of the ErbB family receptor tyrosine kinases suppress replication of SARS-CoV-2, Venezuelan equine encephalitis virus (VEEV), and other emerging viruses with a high barrier to resistance. Lapatinib suppressed SARS-CoV-2 entry and later stages of the viral life cycle and showed synergistic effect with the direct-acting antiviral nirmatrelvir. We discovered that ErbB1, 2 and 4 bind SARS-CoV-2 S1 protein and regulate viral and ACE2 internalization, and they are required for VEEV infection. In human lung organoids, lapatinib protected from SARS-CoV-2-induced activation of ErbB-regulated pathways implicated in non-infectious lung injury, pro-inflammatory cytokine production, and epithelial barrier injury. Lapatinib suppressed VEEV replication, cytokine production and disruption of the blood-brain barrier integrity in microfluidic-based human neurovascular units, and reduced mortality in a lethal infection murine model. We validated lapatinib-mediated inhibition of ErbB activity as an important mechanism of antiviral action. These findings reveal regulation of viral replication, inflammation, and tissue injury via ErbBs and establish a proof-of-principle for a repurposed, ErbB-targeted approach to combat emerging viruses.

Egg-Derived Anti-SARS-CoV-2 Immunoglobulin Y (IgY) With Broad Variant Activity as Intranasal Prophylaxis Against COVID-19

COVID-19 emergency use authorizations and approvals for vaccines were achieved in record time. However, there remains a need to develop additional safe, effective, easy-to-produce, and inexpensive prevention to reduce the risk of acquiring SARS-CoV-2 infection. This need is due to difficulties in vaccine manufacturing and distribution, vaccine hesitancy, and, critically, the increased prevalence of SARS-CoV-2 variants with greater contagiousness or reduced sensitivity to immunity. Antibodies from eggs of hens (immunoglobulin Y; IgY) that were administered the receptor-binding domain (RBD) of the SARS-CoV-2 spike protein were developed for use as nasal drops to capture the virus on the nasal mucosa. Although initially raised against the 2019 novel coronavirus index strain (2019-nCoV), these anti-SARS-CoV-2 RBD IgY surprisingly had indistinguishable enzyme-linked immunosorbent assay binding against variants of concern that have emerged, including Alpha (B.1.1.7), Beta (B.1.351), Delta (B.1.617.2), and Omicron (B.1.1.529). This is different from sera of immunized or convalescent patients. Culture neutralization titers against available Alpha, Beta, and Delta were also indistinguishable from the index SARS-CoV-2 strain. Efforts to develop these IgY for clinical use demonstrated that the intranasal anti-SARS-CoV-2 RBD IgY preparation showed no binding (cross-reactivity) to a variety of human tissues and had an excellent safety profile in rats following 28-day intranasal delivery of the formulated IgY. A double-blind, randomized, placebo-controlled phase 1 study evaluating single-ascending and multiple doses of anti-SARS-CoV-2 RBD IgY administered intranasally for 14 days in 48 healthy adults also demonstrated an excellent safety and tolerability profile, and no evidence of systemic absorption. As these antiviral IgY have broad selectivity against many variants of concern, are fast to produce, and are a low-cost product, their use as prophylaxis to reduce SARS-CoV-2 viral transmission warrants further evaluation.

Clinical Trial Registration

https://www.clinicaltrials.gov/ct2/show/NCT04567810, identifier NCT04567810.

LY-CoV1404 (bebtelovimab) potently neutralizes SARS-CoV-2 variants

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-neutralizing monoclonal antibodies (mAbs) can reduce the risk of hospitalization from coronavirus disease 2019 (COVID-19) when administered early. However, SARS-CoV-2 variants of concern (VOCs) have negatively affected therapeutic use of some authorized mAbs. Using a high-throughput B cell screening pipeline, we isolated LY-CoV1404 (bebtelovimab), a highly potent SARS-CoV-2 spike glycoprotein receptor binding domain (RBD)-specific antibody. LY-CoV1404 potently neutralizes authentic SARS-CoV-2, B.1.1.7, B.1.351, and B.1.617.2. In pseudovirus neutralization studies, LY-CoV1404 potently neutralizes variants, including B.1.1.7, B.1.351, B.1.617.2, B.1.427/B.1.429, P.1, B.1.526, B.1.1.529, and the BA.2 subvariant. Structural analysis reveals that the contact residues of the LY-CoV1404 epitope are highly conserved, except for N439 and N501. The binding and neutralizing activity of LY-CoV1404 is unaffected by the most common mutations at these positions (N439K and N501Y). The broad and potent neutralization activity and the relatively conserved epitope suggest that LY-CoV1404 has the potential to be an effective therapeutic agent to treat all known variants.

Antibody Response to SARS-CoV-2 Infection and Vaccination in COVID-19-naïve and Experienced Individuals

Understanding the magnitude of responses to vaccination during the ongoing SARS-CoV-2 pandemic is essential for ultimate mitigation of the disease. Here, we describe a cohort of 102 subjects (70 COVID-19-naïve, 32 COVID-19-experienced) who received two doses of one of the mRNA vaccines (BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna)). We document that a single exposure to antigen via infection or vaccination induces a variable antibody response which is affected by age, gender, race, and co-morbidities. In response to a second antigen dose, both COVID-19-naïve and experienced subjects exhibited elevated levels of anti-spike and SARS-CoV-2 neutralizing activity; however, COVID-19-experienced individuals achieved higher antibody levels and neutralization activity as a group. The COVID-19-experienced subjects exhibited no significant increase in antibody or neutralization titer in response to the second vaccine dose (i.e., third antigen exposure). Finally, we found that COVID-19-naïve individuals who received the Moderna vaccine exhibited a more robust boost response to the second vaccine dose (p = 0.004) as compared to the response to Pfizer-BioNTech. Ongoing studies with this cohort will continue to contribute to our understanding of the range and durability of responses to SARS-CoV-2 mRNA vaccines.

Toll-like receptor 4 mediates blood-brain barrier permeability and disease in C3H mice during Venezuelan equine encephalitis virus infection

Venezuelan equine encephalitis virus (VEEV) is an encephalitic alphavirus that can cause debilitating, acute febrile illness and potentially result in encephalitis. Currently, there are no FDA-licensed vaccines or specific therapeutics for VEEV. Previous studies have demonstrated that VEEV infection results in increased blood-brain barrier (BBB) permeability that is mediated by matrix metalloproteinases (MMPs). Furthermore, after subarachnoid hemorrhage in mice, MMP-9 is upregulated in the brain and mediates BBB permeability in a toll-like receptor 4 (TLR4)-dependent manner. Here, we demonstrate that disease in C3H mice during VEEV TC-83 infection is dependent on TLR4 because intranasal infection of C3H/HeN (TLR4^WT) mice with VEEV TC-83 resulted in mortality as opposed to survival of TLR4-defective C3H/HeJ (TLR4^mut) mice. In addition, BBB permeability was induced to a lesser extent in TLR4^mut mice compared with TLR4^WT mice during VEEV TC-83 infection as determined by sodium fluorescein and fluorescently-conjugated dextran extravasation. Moreover, MMP-9, MMP-2, ICAM-1, CCL2 and IFN-γ were all induced to significantly lower levels in the brains of infected TLR4^mut mice compared with infected TLR4^WT mice despite the absence of significantly different viral titers or immune cell populations in the brains of infected TLR4^WT and TLR4^mut mice. These data demonstrate the critical role of TLR4 in mediating BBB permeability and disease in C3H mice during VEEV TC-83 infection, which suggests that TLR4 is a potential target for the development of therapeutics for VEEV.

Human monoclonal antibodies against chikungunya virus target multiple distinct epitopes in the E1 and E2 glycoproteins

Chikungunya virus (CHIKV) is a mosquito-transmitted alphavirus that causes persistent arthritis in a subset of human patients. We report the isolation and functional characterization of monoclonal antibodies (mAbs) from two patients infected with CHIKV in the Dominican Republic. Single B cell sorting yielded a panel of 46 human mAbs of diverse germline lineages that targeted epitopes within the E1 or E2 glycoproteins. MAbs that recognized either E1 or E2 proteins exhibited neutralizing activity. Viral escape mutations localized the binding epitopes for two E1 mAbs to sites within domain I or the linker between domains I and III; and for two E2 mAbs between the β-connector region and the B-domain. Two of the E2-specific mAbs conferred protection in vivo in a stringent lethal challenge mouse model of CHIKV infection, whereas the E1 mAbs did not. These results provide insight into human antibody response to CHIKV and identify candidate mAbs for therapeutic intervention.

A trivalent alphavirus virus-like replicon particle vaccine induces cell-mediated responses against conserved glycoprotein regions

Venezuelan (VEEV), eastern (EEEV) and western (WEEV) equine encephalitis viruses are highly infectious and neuroinvasive when aerosolized, making them threats for weaponization. In contrast to subcutaneous infection, studies suggest that protection from aerosol challenge is partially cell-mediated, albeit poorly understood. A trivalent (VEEV/EEEV/WEEV) virus-like replicon particle (triVRP) vaccine is protective against aerosol challenge in mice, yet the correlates of protection are unclear. To investigate, mice were vaccinated (day 0 and 28; PBS or triVRP) and spleens were harvested for analysis. Using an ex vivo splenocyte expansion assay with peptides from VEEV, EEEV and WEEV glycoprotein libraries, IFNγ-producing memory CD8+ T cells were identified. T cell-specific epitopes were mapped, and the most immunodominant were found within regions of sequence homology between strains. Thus, ongoing studies evaluate potential monovalent vaccine cross-protection, which would greatly reduce manufacturing costs. Understanding vaccine-induced responses will inform rational design and clinical evaluation.

Interleukin-12 Immunomodulation Delays the Onset of Lethal Peritoneal Disease of Ovarian Cancer

The omental fat band (OFB) is the predominant site for metastatic seeding of ovarian cancer. Previously, we highlighted the influx and accumulation of neutrophils and macrophages in the OFB following syngeneic ovarian cancer cell seeding as an important factor in the development of a protumorigenic cascade. Here we investigated localized immunomodulation as a means of promoting a successful protective response. As an important TH1-type immunomodulator, interleukin (IL)-12 has previously been investigated clinically as an anticancer therapeutic. However, systemic IL-12 administration was associated with serious side effects, galvanizing the development of immune or accessory cells engineered to express secreted or membrane-bound IL-12 (mbIL-12). Using an mbIL-12-expressing cell variant, we demonstrate that localized IL-12 in the tumor microenvironment significantly delays disease development. The mbIL-12-mediated decrease in tumor burden was associated with a significant reduction in neutrophil and macrophage infiltration in the OFB, and correlated with a reduced expression of neutrophil and macrophage chemoattractants (CXCL1, -2, -3 and CCL2, -7). Vaccination with mitotically impaired tumor cells did not confer protection against subsequent tumor challenge, indicating that IL-12 did not impact the immunogenicity of the cancer cells. Our findings are in agreement with previous reports suggesting that IL-12 may hold promise when delivered in a targeted and sustained manner to the omental microenvironment. Furthermore, resident cells within the omental microenvironment may provide a reservoir that can be activated and mobilized to prevent metastatic seeding within the peritoneum and, therefore, may be targets for chemotherapeutics.

The parity-associated microenvironmental niche in the omental fat band is refractory to ovarian cancer metastasis

Ovarian cancer is an insidious and aggressive disease of older women, typically undiscovered before peritoneal metastasis due to its asymptomatic nature and lack of early detection tools. Epidemiologic studies suggest that child-bearing (parity) is associated with decreased ovarian cancer risk, although the molecular mechanisms responsible for this phenomenon have not been delineated. Ovarian cancer preferentially metastasizes to the omental fat band (OFB), a secondary lymphoid organ that aids in filtration of the peritoneal serous fluid (PSF) and helps combat peritoneal infections. In the present study, we assessed how parity and age impact the immune compositional profile in the OFB of mice, both in the homeostatic state and as a consequence of peritoneal implantation of ovarian cancer. Using fluorescence-activated cell sorting analysis and quantitative real-time PCR, we found that parity was associated with a significant reduction in omental monocytic subsets and B1-B lymphocytes, correlating with reduced homeostatic expression levels of key chemoattractants and polarization factors (Ccl1, Ccl2, Arg1, and Cxcl13). Of note, parous animals exhibited significantly reduced tumor burden following intraperitoneal implantation compared with nulliparous animals. This was associated with a reduction in tumor-associated neutrophils and macrophages, as well as in the expression levels of their chemoattractants (Cxcl1 and Cxcl5) in the OFB and PSF. These findings define a preexisting "parity-associated microenvironmental niche" in the OFB that is refractory to metastatic tumor seeding and outgrowth. Future studies designed to manipulate this niche may provide a novel means to mitigate peritoneal dissemination of ovarian cancer.

Abstract 1496: Changes in white adipose tissue progenitor populations with ovarian cancer

Ovarian cancer is the fourth leading cause of cancer death in women and has the highest mortality rate of all gynecological malignancies. Among the greatest risk factors are age, reproductive history, hormone therapy, and more recently suggested, obesity. Currently, the mechanism for how obesity contributes to ovarian cancer is unknown, but there is potential for adipose tissue-associated cells to be key players in this pathogenesis. The stromal vascular fraction (SVF) of white adipose tissue is a rich source of various stem and progenitor cell populations, which can be recruited by cancer cells to enhance cancer progression and metastatic potential. Studies have shown that there is an increase in progenitor populations within the adipose tissue with obesity and age, two risk factors for ovarian cancer. While it has been shown that SVF cells can contribute to cancer, it has not been determined what impact cancer progression has on adipose tissue. It is plausible that ovarian cancer has systemic effects, which may influence cell populations within adipose tissue to promote metastases. Our lab has developed a spontaneously transformed murine ovarian surface epithelial (MOSE) cell model that becomes increasingly more aggressive with repeated passaging. Late passage cells rapidly form tumors when injected into mice, while earlier passage cells do not. Using this model, we investigated the effects of ovarian cancer on systemic changes in progenitor populations. Firefly luciferase-expressing MOSE-L TICv cells, a highly aggressive, metastatic tumor-initiating cell variant were injected into the peritoneal cavity of C57BL/6 mice and stem/progenitor populations and various immune cell populations within the perigonadal white adipose tissue, blood, ascites, and omentum were immunophenotyped by flow cytometry. Changes in gene expression profiles were also analyzed using quantitative real-time PCR. Interestingly, peritoneal dissemination changed the profile and composition of progenitor populations in the various tissues, suggesting that ovarian cancer does have a more widespread impact, affecting the blood and perigonadal adipose tissue. Additionally, co-culture studies demonstrate that MOSE cells and SVF associated cells positively interact enhancing tumor spheroid growth and provide survival signals. This suggests a synergistic relationship between the MOSE and SVF cells. These discoveries may provide a mechanistic link for the detrimental impact of obesity on ovarian cancer progression.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1496. doi:1538-7445.AM2012-1496

Abstract 401: Early immune modulatory events during ovarian cancer outgrowth in the omental fat band

Ovarian cancer is the fourth most deadly cancer in women. Typically originating in the layer of epithelial cells surrounding the ovary, cancer cells exfoliate, disseminating throughout the peritoneal cavity. The omental fat band (OFB) has been described as a secondary lymphoid organ, composed of heavily vascularized fatty tissue interspersed with immune cell aggregates. The OFB is also the site of preferential tumor cell adhesion and invasion within the peritoneal cavity, and is removed at the time of surgical debulking in ovarian cancer patients as a preventative measure. Animal studies have shown that ovarian cancer cells home to the omentum as early as 20 minutes post-injection, however the early signaling events that contribute to immune evasion and neoplastic outgrowth have not been fully elucidated. Our lab has developed a spontaneously transformed murine ovarian surface epithelial (MOSE) cell model that, following long-term passaging mimics the progressive stages of ovarian cancer from non-tumorigenic MOSE-E (early) cells to MOSE-L (late) cells which readily disseminate and establish tumors throughout the peritoneum after injection. We have developed two cell variants of the MOSE-L cell line, which differ in their in vivo aggressiveness. The heterogeneous EGFP-expressing MOSE-L IVP2 cell line results in a slowly developing disease state with administration of 1 x 106 cells. In contrast, the MOSE-L firefly luciferase-expressing (FFL) TICv is a highly aggressive tumor-initiating cell variant that results in rapidly disseminating disease with as few as 100 implantable cells. Here we have utilized these cell lines to evaluate early and late changes within the OFB immune microenvironment in order to shed light on both beneficial anti-tumorigenic immune signals, as opposed to signals involved in immune evasion, tumor cell seeding/outgrowth and establishment of aggressive disease states. Specifically, MOSE-E, EGFP∼MOSE-L IVP2 and MOSE-L FFL TICv cells were injected intraperitoneally (IP) into C57BL/6 mice and at 24 h or 4 wks post-injection subsets of mice were euthanized and blood, peritoneal washings, OFB, spleens, perigonadal fat depots were collected for further analysis. Here we describe changes to the OFB and peritoneal serous exudate as a function of tumor cell dissemination using flow cytometry for immunophenotyping and quantitative real-time PCR for gene expression profiling. Preliminary results confirm that ovarian tumor initiating cells preferentially invade the omentum early during cancer metastasis, and are capable of escaping innate immune surveillance mechanisms. In contrast, MOSE-E cells readily home to the OFB early, but are cleared within 7 days. The completion of this study should provide new insights into the initial immunomodulatory events associated with early ovarian cancer seeding and outgrowth within the OFB, a tissue crucial in early ovarian cancer metastasis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 401. doi:1538-7445.AM2012-401

Predictors of high yield and purify of CD34(+) cell-selected PBPC, collected from patients with multiple myeloma

BACKGROUND

Wide ranges i n cell recovery and purity may be observed following CD34(+) cell selection of mobilized HPC componetns. Characteristics of the mobilized HPC, associated with isolation of a high CD34(+) cell yield and purity following cell selection, have yet to be defined.

METHODS

Cell number and purities were determined before and after 56 CD34(+) cell-selection procedures, performed using the CellPro Ceprate SC system from April 1997 to February 1998. HPC were collected from 28 patients with multiple myeloma, following cyclophosphamide (60mg/kg) and G-CSF (10microg/kg) mobilization.

RESULTS

A medium of 47.9% (range 1.5-109.6%) CD34(+) cells were recovered in the enriched (ENR) fraction. A linear correlation existed between total CD34(+) cells in the ENR fraction and total CD34(+) cells in the START fraction (R2=0.93); there was a logarithmic correlation between CD34 ENR fraction purity and START fraction purity (R2=0.73). A START CD34(+) cell purity > 0.42% improved purity in the ENR fraction. A median of one (range one to nine) procedure was required to isolate 2 x 10 6 CD34(+) cells/kg. Three patients pretreated with alkylating agents failed to mobilized adequate numbers of HPC.

DISCUSSION

Isolation of highly purified CD34(+) cell-selected components using the Ceprate SC system in dependent on the CD34(+) purity of the lekapheresis component collected. Mobilization regimens should be used to maximize CD34(+) cell purity in stem cell authografts if CD34(+) cell selection is to be performed. Similar strategies should be used to evaluate other cell-selection devices as they become available.

Radical nanomedicine

Nanotechnology has made significant advances in the reduction of free radical damage in the field of materials science. Cross-disciplinary interactions and the application of this technology to biological systems has led to the elucidation of novel nanoparticle antioxidants, which are the subject of this review. Recent reports suggest that cerium oxide and other nanoparticles are potent, and probably regenerative, free radical scavengers in vitro and in vivo. The neuroprotective, longevity-enhancing and anti-inflammatory properties of nanoparticles are summarized and hypotheses regarding their unique mechanism of action are presented. The chemical and physical properties of antioxidant nanoparticles are discussed in an interdisciplinary manner, with emphasis on biological properties and biomedical applications. Additionally, the need for alterations in traditional pharmacological parameters of dose and absorption, distribution, metabolism, and excretion are discussed and future directions necessary for bringing nanoparticle antioxidants into the realm of clinical reality are presented.

Dementia caregiving: the role of the primary care physician

BACKGROUND

Family and friends play an important role in caring for individuals with dementia living in the community. In preparation for the Canadian Consensus Conference on Dementia held in Montreal, Canada in February 1998, the subject of dementia caregiving was reviewed in order to provide primary care physicians with some guidelines for their practice. The review was updated in June 2000 in preparation for this article.

METHOD

Pertinent English-language publications and resources from the Alzheimer Society of Canada were reviewed from 1985 onwards. Findings related to the consequences of caregiving, services for caregivers and recommendations regarding the role of the primary care physician were reviewed.

FINDINGS

Dementia caregivers experience many positive and negative consequences of caregiving. Some comprehensive services for caregivers have been shown to delay institutionalization and reduce negative consequences of caregiving. The primary care physician has a role to play in working with families and should address the following issues: 1) education about dementia; 2) psychological support for caregivers; 3) assistance mobilizing caregiver social support networks.

CONCLUSION

Primary care physicians have an important role to play in acknowledging and supporting the caregiving provided by family and friends to individuals with dementia.

Lessons learned from a longitudinal study of dementia care

In a longitudinal study, the authors document the moves of dementia patients between different care settings, following up 103 individuals who had participated in an earlier study of the transition from home to institutional care. It was possible to document numerous moves between home, respite care, acute care hospital, and long-term care settings for these patients. The authors discuss the clinical implications of the many changes of residence for those suffering from dementia.

Caregivers for people with dementia. What is the family physician's role?

OBJECTIVE

To examine the role of family physicians in providing support and care to caregivers for people with dementia.

QUALITY OF EVIDENCE

Data were obtained from Alzheimer Society guidelines, published consensus statements, and guidelines for family physicians caring for people with dementia and their caregivers. Most of the reported findings and recommendations are based on information from expert consensus statements and opinion.

MAIN MESSAGE

Caring for people with dementia causes substantial psychological and physical morbidity. Services developed for caregivers (in-home respite and individual psychological interventions) and comprehensive support programs are helpful in relieving caregiver distress. There is a role for family physicians in following caregivers longitudinally to assess their physical and emotional health and coping skills, to provide information and assistance in dealing with problems as they arise, to assist caregivers in mobilizing family and friends, and to facilitate referrals to appropriate services and resources.

CONCLUSIONS

Family physicians have an important role in identifying caregiver problems and providing direct and ongoing support to caregivers in their day-to-day role.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians toward the recognition, assessment and management of dementing disorders and to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral, management of complications (especially behavioural problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations; neuroimaging and referrals; and appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to perform a literature search, discover additional relevant material, including references cited in retrieved articles, consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based on this evidence, consensus statements were developed by a group of experts, guided by a steering committee of 8 individuals, from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care, and are intended to support family physicians in their ongoing assessment and care of patients with dementia. BENEFITS HARM AND COSTS: Potential for improved clinical care of people with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

Forty-eight recommendations are offered that address the following aspects of dementia care: early recognition; importance of careful history and examination in making a positive diagnosis; essential laboratory tests; rules for neuroimaging and referral; disclosure of diagnosis; importance of monitoring and providing support to caregivers; cultural aspects; detection and treatment of depression; observation and management of behavioural disturbances; detection and reporting of unsafe motor vehicle driving; genetic factors and opportunities for preventing dementia; pharmacological treatment with particular emphasis on cognitive enhancing agents.

VALIDATION

Four other sets of consensus statement or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Ethical issues in Alzheimer disease: the experience of a national Alzheimer society task force

There has been increasing recognition of the ethical dilemmas that arise in the delivery of health care services and in planning and executing scientific research. Alzheimer disease (AD) and related dementias pose a particular challenge for families, care providers, and researchers because of the nature of the illness. Naturally, those at potential risk of developing the disease are eager for scientists to develop valid predictive tests for the disease. Alzheimer organizations have developed worldwide in response to the growing awareness and knowledge of the effects of dementia on individuals and their families. These organizations have played a role in advocating for research, increasing general awareness of the nature of the disease, and lobbying for more services for persons with dementia and their families. These organizations have also realized the increasing concern about the many ethical issues that arise in caring for those with AD and researching causes and cures. This paper describes a unique process one national Alzheimer society used to develop an Ethics Task Force to provide guidelines on ethical issues.

Ethical guidelines of the Alzheimer Society of Canada

Alzheimer's disease raises numerous ethical issues which vary and evolve over the course of the illness. In recognition of the need for ongoing discussion of these issues, the Alzheimer Society of Canada established a Task Force on Ethics in 1995. Through a process of "discourse ethics" and consultation on a national scale, the Task Force produced a series of guidelines dealing with the issues of: communicating the diagnosis, driving, respecting individual choice, quality of life, participation in research, genetic testing, the use of restraints, and end-of-life care. This manuscript presents a summary of these guidelines as well as a summary of the ideas on which they were based. It was the hope of the Society that the publication of these guidelines will serve to facilitate discussion of the ethics of care of those with Alzheimer's disease.

The SMARTT (Sunnybrook Memory Assessment Research Treatment and Training) Program: planning for dementia care

Dementia is being recognized as a major public health challenge. Caring for those with dementia poses a unique problem for family and health care providers in community and institutional settings. This article describes the development of the Sunnybrook Memory Assessment Research Treatment and Training (SMARTT) Program at an academic health science centre. This program serves as a model for an integrated health system to meet the needs of dementia patients and their families.

In vivo adsorption of isohemagglutinins with fresh frozen plasma in major ABO-incompatible bone marrow transplantation

Despite techniques to deplete red cells from major ABO-incompatible allogeneic bone marrow (BM) or to remove recipient isohemagglutinins (IHGs) before transplantation, delayed erythropoiesis and hemolysis, red cell aplasia, and increased red cell transfusion requirements may occur. Twenty-nine recipients of major ABO-incompatible allografts received donor-type frozen fresh plasma (FFP) infusions twice daily to adsorb IHGs in vivo. Engraftment and transfusion requirements were compared between the 29 FFP-treated major ABO-incompatible allograft recipients, 5 recipients of major ABO-incompatible BM who did not receive FFP infusions, 35 recipients of minor ABO-incompatible BM, and 172 recipients of ABO-compatible BM. No significant differences in either transfusion requirements or engraftment were seen in the FFP-treated major ABO-incompatible vs. minor ABO-incompatible or ABO-compatible groups (p values > or = 0.10). The infusion of donor-type FFP represents a simple, effective treatment strategy to neutralize IHGs and to prevent adverse consequences of major ABO incompatibility in the setting of allogeneic BM transplantation. The role of this strategy in the care of patients receiving ABO-incompatible solid organs remains to be defined.

Diagnosing and managing dementia patients. Practice patterns of family physicians

OBJECTIVE

To examine the practice patterns of family physicians in diagnosing and managing patients with dementia.

DESIGN

In-depth structured interviews.

SETTING

Metropolitan Toronto family practices.

PARTICIPANTS

Twenty family physicians who referred patients to a specialized community psychiatry service for the elderly in the previous year.

METHOD

Two vignettes focusing on diagnosis and management issues were developed for the study. Physicians were asked how they would handle the clinical problems presented in the vignettes. Their responses were compared to standardized diagnostic and management protocols.

MAIN FINDINGS

Participants were more comfortable with diagnosing dementia than with ongoing management issues, and most physicians were not using standardized cognitive screening protocols. Physicians were more oriented to immediate medical and psychiatric problems than to long-term psychosocial issues.

CONCLUSIONS

More attention should be paid to the ongoing educational needs of family physicians with respect to this patient population.

Creating community agency placements for undergraduate medical education: a program description

PROGRAM OBJECTIVE: To provide first- and second-year medical students with stimulating learning experiences in the community.

SETTING

Three hundred placements representing a broad array of urban community agencies providing both general and specialized health care services.

PARTICIPANTS

All first- and second-year medical students at the University of Toronto (n = 354). Other participants include staff of community agencies and tutors from the Faculty of Medicine and from the community.

PROGRAM

The Health, illness and the Community course is mandatory and consists of 3 components. The first, in the first semester of first year, emphasizes the provision of health care in the community for individuals and populations. The second, in the second semester of first year, introduces a health promotion paradigm. The third component, throughout second year, allows students to engage in an in-depth study of the interconnection between a health problem and a social issue in a community agency setting.

OUTCOMES

Students have expressed high levels of satisfaction with the community agency placements. The feedback from agencies has also been enthusiastic. Patients in the home care program have reported that visits by medical students are a positive experience.

CONCLUSION

It is possible to recruit and maintain large numbers of urban community agencies as learning sites for medical students. It is hoped that this approach will help to produce socially responsive medical practitioners.

Factors determining the decision to institutionalize dementing individuals: a prospective study

This longitudinal study of 196 caregiver/care receiver dyads was undertaken to determine the variables predictive of caregiver decision to institutionalize a dependent with dementia. Seven variables (use of services, enjoyment of caregiving, caregiver burden and health, caregiver rating and reaction to care receiver behavior and memory problems, and presence of troublesome behaviors) predicted the decision to institutionalize. Six variables (caregiver health and burden, use of services, care receiver cognitive function and troublesome behaviors, and caregiver reaction to behaviors) predicted actual institutionalization at 18 months.

Acute opiate withdrawal in rats undernourished during infancy: impact of the undernutrition method

Acute morphine withdrawal was assessed in adult rats following early postnatal undernutrition produced by two different methods (Large Litter procedure-20 pups/litter and Modified Slob procedure-rats cross-fostered on days 2, 4, and 6 to nonlactating dams for 24-hour periods). Response rates were first stabilized on a FR16 operant schedule. A single dose of morphine (20 mg/kg) was then administered, followed 4 h later by a single injection of naloxone (2.5 mg/kg). Males reared in large litters showed little behavioral disruption after morphine, suggesting either insensitivity to the opiate or the rapid development of tolerance. After naloxone. Modified Slob males displayed milder withdrawal than those in the well-nourished control or large litter groups. Thus the method of undernutrition influenced morphine's action and expression of withdrawal. A clear sex difference was also evident, females appearing to be generally less sensitive to the opiate- and naloxone-induced withdrawal than males. Body temperature underwent a characteristic elevation following morphine and a depression following naloxone across all groups, but undernutrition did not affect these responses. Hence, behavior proved to be the more sensitive measure for revealing differences in opiate dependence and withdrawal following early life undernutrition, under the test conditions employed.

Different methods for producing neonatal undernutrition in rats cause different brain changes in the face of equivalent somatic growth parameters

Similar degrees of undernutrition were induced in neonatal rat pups using a modified Slob technique and a large-litter manipulation. From birth, large litters and Slob litters were comprised of 20 and 10 pups, respectively. On days 2, 4 and 6, half of the pups in the Slob group were cross-fostered to nonlactating foster aunts, while the remaining half of each litter (controls), as well as the large-litter rats were cross-fostered to a lactating dam. On day 10, undernourished Slob and large-litter pups showed similar body weight and body length deficits compared with controls, but differences between the two undernourished groups emerged when regional brain weight and nucleic acids and proteins were examined. The acute intermittent undernutrition of the modified Slob technique had more severe consequences than the large-litter manipulation for brain growth and development. Therefore, two methods of inducing early postnatal undernutrition may yield equivalent somatic effects, but very different brain growth parameters.

Reversal of a trimethyltin-induced learning deficit by desglycinamide-8-arginine vasopressin

Trimethyltin (TMT) is an organometal neurotoxin which produces lesions primarily in the limbic system. Selectivity seems to depend upon the dose, but the hippocampus and related entorhinal cortical structures, of importance for learning and memory, are most often described as target sites. We have previously demonstrated that subjects treated with a moderate dose of TMT prior to acquisition sessions, are unable to learn a forward autoshaping task with a 6 sec delay of reinforcement, but are capable of acquiring the same task when no delay of reinforcement is used. These data suggested that the performance deficit is one of learning (i.e. consolidation) rather than of memory (i.e. storage), retrieval, or sensorimotor impairment. To more rigorously test this hypothesis, we determined if performance of a task already learned would be impaired by the neurotoxin. Adult male Long Evans rats were given 10 acquisition sessions of 24 trials, following which TMT (6.0 mg/kg, p.o.) was administered. One month later, these rats performed the lever-touching behavior as well as controls, despite the fact that the same dose of TMT interfered with learning if given one month prior to acquisition sessions, thus confirming our hypothesis. In a second experiment we determined if the peptide analog of vasopressin, desglycinamide-8-arginine vasopressin (DGAVP), could reverse a learning deficit in a population of non-learners. Rats were treated with TMT or water vehicle one month prior to autoshaping. TMT significantly retarded acquisition. After 10 sessions of 12 trials each, non-learners (i.e. rats treated with TMT that failed to associate the lever with delivery of a reinforcer) were administered saline or DGAVP (7.5 micrograms/kg, s.c.) 1 hr before sessions 11-13; treatment was discontinued prior to sessions 14 and 15. Peptide treated subjects showed evidence of acquisition and exhibited higher levels of lever-directed behavior than saline treated nonlearners. Performance was maintained after DGAVP treatment was discontinued, indicating that the learning-enhancing action of DGAVP was not transient or state-dependent.

Selective learning impairment of delayed reinforcement autoshaped behavior caused by low doses of trimethyltin

The organometal neurotoxin trimethyltin (TMT), induces impaired learning and memory for various tasks. However, administration is also associated with other "non-specific" behavioral changes which may be responsible for effects on conditioned behaviors. To determine if TMT treatment causes a specific learning impairment, three experiments were done using variations of a delay of reinforcement autoshaping task in which rats learn to associate the presentation and retraction of a lever with the delivery of a food pellet reinforcer. No significant effects of TMT treatment were found with a short (4 s) delay of reinforcement, indicating that rats were motivated and had the sensorimotor capacity for learning. When the delay was increased to 6 s, 3.0 or 6.0 mg TMT/kg produced dose-related reductions in behaviors directed towards the lever. Performance of a group given 7.5 mg TMT/kg, while still impaired relative to controls, appeared to be better than the performance of groups given lower doses. This paradoxical effect was investigated with a latent inhibition paradigm, in which rats were pre-exposed to the Skinner boxes for several sessions without delivery of food reinforcement. Control rats showed retardation of autoshaping when food reinforcement was subsequently introduced. Rats given 7.5 mg TMT/kg exhibited elevated levels of lever responding during pre-exposure and autoshaping sessions. The results indicate that 7.5 mg TMT/kg produces learning impairments which are confounded by hyperreactivity to the environment and an inability to suppress behavior toward irrelevant stimuli. In contrast, low doses of TMT cause learning impairments which are not confounded by hyperreactivity, and may prove to be useful models for studying specific associational dysfunctions.

Hydrogen peroxide contrast echocardiography: quantification in vivo of myocardial risk area during coronary occlusion and of the necrotic area remaining after myocardial reperfusion

During sustained coronary occlusion in canine preparations, the extent of regions that fail to show contrast enhancement when imaged by supra-aortic hydrogen peroxide contrast echocardiography (SHPCE) has been shown to correlate well for single cross sections with the extent of malperfused myocardium "at risk" of infarction. In the present study, SHPCE was investigated as a means of determining the fraction of total left ventricular mass at risk during occlusion. Since necrotic tissue has low blood flow even when reperfused, we also investigated the potential of quantitating the extent of infarcted myocardium by measuring the extent of contrast defects seen with SHPCE performed during reperfusion. In 20 dogs the fraction of the left ventricle showing a contrast defect during coronary occlusion correlated well with the fraction of the left ventricular mass "at risk" by an autoradiographic technique (autoradiography = 0.83 echocardiography + 8.6%; r = .89, SEE = 4.5%). SHPCE was also performed after 3 hr of reperfusion following occlusions varying in duration from 60 to 150 min. The fraction of the ventricle showing a contrast defect during reperfusion predicted the infarcted portion of the left ventricle as shown by triphenyl tetrazolium chloride staining (% left ventricle infarcted = 0.81 echocardiography + 3.3%; r = .84, SEE = 5.3%). Observer variability for the fraction of the ventricle showing a contrast defect was excellent during both occlusion and reperfusion. The ratio of the left ventricular extent of contrast-negative regions during reperfusion and occlusion was used to calculate a necrosis-to-risk index in vivo that correlated relatively well with the myocardial necrosis-to-risk ratio determined morphologically (r = .77, SEE = 16%).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical manifestations of inspiratory muscle fatigue

Twelve patients exhibiting difficulties during discontinuation of artificial ventilation permitted us to investigate physical examination techniques used in diagnosing inspiratory muscle fatigue. Diaphragmatic and intercostal electromyographic tracings, arterial blood gases, rate and depth of ventilation, and thoracoabdominal motion were monitored during spontaneous breathing. Six patients showed electromyographic evidence of inspiratory muscle fatigue. A sequence of events leading to respiratory acidemia emerged--namely electromyographic evidence of fatigue, accompanied or followed by an increased respiratory rate, in turn followed by alternation between abdominal and rib cage breathing (respiratory alternans), paradoxical inward abdominal motion during inspiration (abdominal paradox), and finally an increase in PaCO2 associated with a fall in minute ventilation and respiratory rate, and worsening of respiratory acidemia. The abnormalities of respiratory movements may be reliable clinical signs of inspiratory muscle fatigue, particularly when accompanied by tachypnea and hypercapnia.

HLA and alopecia areata in Jerusalem

A study of 46 patients with Alopecia areata in Jerusalem showed a significant increase in the frequency of HLA-B18 (23.9%) as compared to the control population (7.4%) with a relative risk of 3.9%. This association of HLA-B18 with AA was independent of the origin of patients, sex, age of onset and type of alopecia areata.

Scapulocostal syndrome: diagnosis and treatment

The scapulocostal syndrome is an often encountered yet infrequently diagnosed cause of back and/or shoulder pain. Results of examination and treatment in the three cases described point out the necessary differential diagnosis to effectively screen these groups of patients from among those with more complex diseases.

Chronic neck and back pain: a reassessment of usual surgical treatment

One hundred seventeen patients with chronic (noncancerous) back or neck pain had multidisciplinary evaluation in the Medical College of Virginia Pain Center and were followed up for one year. They ranged in age from 26 to 57 years. The 57 patients who had surgery had an average of 2.5 procedures (either laminectomies or back fusion) and only five of them returned to work. By contrast, 16 of 60 patients who had not had operation were able to secure employment after evaluation and treatment in the Pain Center.

Three-year follow-up study of stroke patients at the Medical College of Virginia

Thirty-two patients with recent stroke were followed up for a three-year period. Correlation of rehabilitation therapy, survival, and life-style integration is discussed. Problems related to physician-patient relationship are emphasized including impact of available facilities upon long-term prognosis.