In Retrospect: Root-Cause Analysis of Structure-Activity Relationships in IRAK4 Inhibitor Zimlovisertib (PF-06650833)

In this paper, we disclose insights on the root causes of three structure-activity relationship (SAR) observations encountered in the discovery of the IRAK4 inhibitor Zimlovisertib (PF-06650833). The first is a nonlinear potency SAR encountered with the isoquinoline ether substituent, the second is a potency enhancement introduced by fluorine substitution on the lactam, and the third is a slight potency preference for all-syn (2S,3S,4S) stereochemistry in the fluorine-substituted lactam. We present new data that help to inform us of the origins of these unexpected SAR trends.

Synthesis of Deuterated Enaminones with High Isotopic Fidelity

The unexpected oxidation of nitrogenous heterocycles by aldehyde oxidase (AO) may be addressed by the substitution of deuterium for hydrogen adjacent to the heterocycle nitrogen atom. Enaminones are versatile intermediates in the synthesis of nitrogenous heterocycles. We report that heretofore inaccessible monodeuterated enaminones of the general structure RC(=O)CH=CDNMe2 may be synthesized from methyl ketones and DCO2Me with high isotopic fidelity and efficient utilization of deuterium.

Small Change, Big Impact: Reversal of Diastereoselection in Cuprate Conjugate Additions to α,β-Unsaturated Lactams and Identification of a Competing Mechanism

A seemingly minor change to a reactant is shown to cause a change in reaction mechanisms. Conjugate addition of organocopper reagents to bicyclic α,β-unsaturated lactams derived from pyroglutaminol is determined by the nature of the aminal group. Aminals derived from aldehydes give anti addition; those from ketones give syn addition. Divergence in diastereoselection occurs because the substrates react by different mechanisms, ultimately due to a small but significant difference in pyramidalization of the aminal nitrogen.

Synthesis of Deuterated Heterocycles with Me2NCD(OMe)2 and Evaluation of the Products for Metabolism by Aldehyde Oxidase

The metabolic oxidation of drug-like small molecules by aldehyde oxidase (AO) has commonly been mitigated through the incorporation of deuterium at the oxidation site. We report that dimethylformamide dimethyl acetal and related compounds undergo rapid CH to CD isotopic exchange upon exposure to methanol-d and similar deuterated alcohols. This isotopic exchange process can be used to synthesize Me₂NCD(OMe)₂ and has significant implications for the use of Me₂NCD(OMe)₂ in the synthesis of specifically deuterium-labeled compounds. The application of Me₂NCD(OMe)₂ to the synthesis of various heterocycles that have been associated with AO metabolism is described, and we report the impact of deuteration on the rate of in vitro AO-mediated metabolism.

Discovery of a Series of Pyrimidine Carboxamides as Inhibitors of Vanin-1

A diaryl ketone series was identified as vanin-1 inhibitors from a high-throughput screening campaign. While this novel scaffold provided valuable probe 2 that was used to build target confidence, concerns over the ketone moiety led to the replacement of this group. The successful replacement of this moiety was achieved with pyrimidine carboxamides derived from cyclic secondary amines that were extensively characterized using biophysical and crystallographic methods as competitive inhibitors of vanin-1. Through optimization of potency and physicochemical and ADME properties, and guided by co-crystal structures with vanin-1, 3 was identified with a suitable profile for advancement into preclinical development.

Prevention and partial reversion of the lupus phenotype in ABIN1[D485N] mice by an IRAK4 inhibitor

Objective

We have reported previously that the IRAK4 inhibitor PF06426779 given to ubiquitin-binding-defective ABIN1[D485N] mice at 6 weeks of age prevents the major facets of lupus that develop 10 weeks later. The present study was undertaken to investigate whether PF06426779 could reverse the lupus phenotype when administered to 13-week-old ABIN1[D485N] mice that had already developed symptoms of lupus.

Methods

Splenomegaly, the number of splenic neutrophils, T_FH and Germinal Centre B (GCB) cells, serum levels of immunoglobulins, the extent of kidney, liver and lung pathology, and glomerular IgA and IgM were measured after feeding 13-week-old ABIN1[D485N] and wild-type mice for another 10 weeks with R&M3 diet with and without PF06426779 (4 g/kg).

Results

Following drug treatment, spleen size and weight, splenic neutrophil numbers, and serum IgA and glomerular IgA levels of ABIN1[D485N] mice returned to those seen in wild-type mice. The rise in splenic T_FH and GCB numbers, the increase in kidney and liver pathology, and the concentrations of serum IgG1, IgG2A and IgE between 13 and 23 weeks were suppressed. There was no reduction in the level of anti-self double-stranded DNA, anti-self nuclear antigens or IgM during the drug treatment.

Conclusions

The results demonstrate the therapeutic potential of IRAK4 inhibitors for the treatment of lupus and raise the possibility of monitoring efficacy by measuring decreases in the serum levels of IgA. Our results support the view that there may be a closer connection between lupus and IgA nephropathy than realised previously.

Elucidation of a Sequential Iminium Ion Cascade Reaction Triggered by a Silica Gel-Promoted Aza-Peterson Reaction

In a recent methodological study investigating the synthesis of N-alkoxyazomethine ylides, an unexpected aminal byproduct was generated during our attempt to isolate O-benzyl-N-((trimethylsilyl)methyl)hydroxylamine. After a strategic investigation, silica gel was discovered to be the cause of the byproduct formation. Through the mechanistic insight from control and trapping experiments, we propose the formation of a methaniminium ion via a novel aza-Peterson reaction, which ultimately triggers a sequential iminium ion cascade sequence. Herein, we discuss the elucidation of this cascade reaction mechanism and the constraints for the byproduct formation.

Discovery of Tyrosine Kinase 2 (TYK2) Inhibitor (PF-06826647) for the Treatment of Autoimmune Diseases

Tyrosine kinase 2 (TYK2) is a member of the JAK kinase family that regulates signal transduction downstream of receptors for the IL-23/IL-12 pathways and type I interferon family, where it pairs with JAK2 or JAK1, respectively. On the basis of human genetic and emerging clinical data, a selective TYK2 inhibitor provides an opportunity to treat autoimmune diseases delivering a potentially differentiated clinical profile compared to currently approved JAK inhibitors. The discovery of an ATP-competitive pyrazolopyrazinyl series of TYK2 inhibitors was accomplished through computational and structurally enabled design starting from a known kinase hinge binding motif. With understanding of PK/PD relationships, a target profile balancing TYK2 potency and selectivity over off-target JAK2 was established. Lead optimization involved modulating potency, selectivity, and ADME properties which led to the identification of the clinical candidate PF-06826647 (22).

Longitudinal profiling of plasma cytokines in melioidosis and their association with mortality: a prospective cohort study

OBJECTIVES

To characterize plasma cytokine responses in melioidosis and analyse their association with mortality.

METHODS

A prospective longitudinal study was conducted in two hospitals in Northeast Thailand to enrol 161 individuals with melioidosis, plus 13 uninfected healthy individuals and 11 uninfected individuals with diabetes to act as controls. Blood was obtained from all individuals at enrolment (day 0), and at days 5, 12 and 28 from surviving melioidosis patients. Interferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IL-23, and tumour necrosis factor-α (TNF-α) were assayed in plasma. The association of each cytokine and its dynamics with 28-day mortality was determined.

RESULTS

Of the individuals with melioidosis, 131/161 (81%) were bacteraemic, and 68/161 (42%) died. On enrolment, median levels of IFN-γ, IL-6, IL-8, IL-10, IL-23 and TNF-α were higher in individuals with melioidosis compared with uninfected healthy individuals and all but IFN-γ were positively associated with 28-day mortality. Interleukin-8 provided the best discrimination of mortality (area under the receiver operating characteristic curve 0.78, 95% CI 0.71-0.85). Over time, non-survivors had increasing IL-6, IL-8 and IL-17A levels, in contrast to survivors. In joint modelling, temporal trajectories of IFN-γ, IL-6, IL-8, IL-10 and TNF-α predicted survival.

CONCLUSIONS

In a severely ill cohort of individuals with melioidosis, specific pro- and anti-inflammatory and T helper type 17 cytokines were associated with survival from melioidosis, at enrolment and over time. Persistent inflammation preceded death. These findings support further evaluation of these mediators as prognostic biomarkers and to guide targeted immunotherapeutic development for severe melioidosis.

Distinct signals and immune cells drive liver pathology and glomerulonephritis in ABIN1[D485N] mice

This article shows that liver and kidney damage in a lupus-prone mouse line occurs by different mechanisms and that only drugs targeting core components of signaling pathway, such as IRAK4, are able to suppress all facets of the disease.

We report that TLR7, IL-6, and the adaptive immune system are essential for autoimmunity and glomerulonephritis but not for liver pathology in mice expressing the ubiquitin-binding–defective ABIN1[D485N] mutant. The blood and organs of ABIN1[D485N] mice have exceptionally high numbers of patrolling monocytes (pMo), which develop independently of IL-6 and the adaptive immune system. They are detectable in the blood months before autoimmunity and organ pathology are seen and may have diagnostic potential. The splenic pMo, inflammatory monocytes (iMo), and neutrophils of ABIN1[D485N] mice expressed high levels of mRNAs encoding proteins released during NETosis, which together with the high numbers of monocyte-derived dendritic cells (MoDCs) may drive the liver pathology in ABIN1[D485N] mice, and contribute to the pathology of other organs. The splenic iMo of ABIN1[D485N] mice displayed high expression of mRNAs encoding proteins controlling cell division and were actively dividing; this may underlie the increased pMo and MoDC numbers, which are derived from iMo. An orally active IRAK4 inhibitor suppressed all facets of the disease phenotype and prevented the increase in pMo numbers.

Identification of Morpholino-2H-pyrido[3,2-b][1,4]oxazin-3(4H)-ones as Nonsteroidal Mineralocorticoid Antagonists

A novel series of morpholine-based nonsteroidal mineralocorticoid receptor antagonists is reported. Starting from a pyrrolidine HTS hit 9 that possessed modest potency but excellect selectivity versus related nuclear hormone receptors, a series of libraries led to identification of morpholine lead 10. After further optimization, cis disubstituted morpholine 22 was discovered, which showed a 45-fold boost in binding affinity and corresponding functional potency compared to 13. While 22 had high clearance in rat, it provided sufficient exposure at high doses to favorably assess in vivo efficacy (increased urinary Na⁺/K⁺ ratio) and safety. In contrast to rat, the dog and human MetID and PK profiles of 22 were adequate, suggesting that it could be suitable as a potential clinical asset.

Discovery of Clinical Candidate 1-{[(2S,3S,4S)-3-Ethyl-4-fluoro-5-oxopyrrolidin-2-yl]methoxy}-7-methoxyisoquinoline-6-carboxamide (PF-06650833), a Potent, Selective Inhibitor of Interleukin-1 Receptor Associated Kinase 4 (IRAK4), by Fragment-Based Drug Design

Through fragment-based drug design focused on engaging the active site of IRAK4 and leveraging three-dimensional topology in a ligand-efficient manner, a micromolar hit identified from a screen of a Pfizer fragment library was optimized to afford IRAK4 inhibitors with nanomolar potency in cellular assays. The medicinal chemistry effort featured the judicious placement of lipophilicity, informed by co-crystal structures with IRAK4 and optimization of ADME properties to deliver clinical candidate PF-06650833 (compound 40). This compound displays a 5-unit increase in lipophilic efficiency from the fragment hit, excellent kinase selectivity, and pharmacokinetic properties suitable for oral administration.

Acoustic power delivery to pipeline monitoring wireless sensors

The use of energy harvesting for powering wireless sensors is made more challenging in most applications by the requirement for customization to each specific application environment because of specificities of the available energy form, such as precise location, direction and motion frequency, as well as the temporal variation and unpredictability of the energy source. Wireless power transfer from dedicated sources can overcome these difficulties, and in this work, the use of targeted ultrasonic power transfer as a possible method for remote powering of sensor nodes is investigated. A powering system for pipeline monitoring sensors is described and studied experimentally, with a pair of identical, non-inertial piezoelectric transducers used at the transmitter and receiver. Power transmission of 18mW (Root-Mean-Square) through 1m of a118mm diameter cast iron pipe, with 8mm wall thickness is demonstrated. By analysis of the delay between transmission and reception, including reflections from the pipeline edges, a transmission speed of 1000m/s is observed, corresponding to the phase velocity of the L(0,1) axial and F(1,1) radial modes of the pipe structure. A reduction of power delivery with water-filling is observed, yet over 4mW of delivered power through a fully-filled pipe is demonstrated. The transmitted power and voltage levels exceed the requirements for efficient power management, including rectification at cold-starting conditions, and for the operation of low-power sensor nodes. The proposed powering technique may allow the implementation of energy autonomous wireless sensor systems for monitoring industrial and network pipeline infrastructure.

Lithium Enolates Derived from Pyroglutaminol: Mechanism and Stereoselectivity of an Azaaldol Addition

A lithium enolate derived from an acetonide-protected pyroglutaminol undergoes a highly selective azaaldol addition with (E)-N-phenyl-1-[2-(trifluoromethyl)phenyl]methanimine. The selectivity is sensitive to tetrahydrofuran (THF) concentration, temperature, and the presence of excess lithium diisopropylamide base. Rate studies show that the observable tetrasolvated dimeric enolate undergoes reversible deaggregation, with the reaction proceeding via a disolvated-monomer-based transition structure. Limited stereochemical erosion stems from the intervention of a trisolvated-monomer-based pathway, which is suppressed at low THF concentrations and elevated temperature. Endofacial selectivity observed with excess lithium diisopropylamide (LDA) is traced to an intermediate dianion formed by subsequent lithiation of the monomeric azaaldol adduct, which is characterized as both a dilithio form and a trilithio dianion-LDA mixed aggregate.

Lithium Enolates Derived from Pyroglutaminol: Aggregation, Solvation, and Atropisomerism

Lithium enolates derived from protected pyroglutaminols were characterized by using (6)Li, (13)C, and (19)F NMR spectroscopies in conjunction with the method of continuous variations. Mixtures of tetrasolvated dimers and tetrasolvated tetramers in different proportions depend on the steric demands of the hemiaminal protecting group, tetrahydrofuran concentration, and the presence or absence of an α-fluoro moiety. The high steric demands of the substituted bicyclo[3.3.0] ring system promote dimers to an unusual extent and allow solvents and atropisomers in cubic tetramers to be observed in the slow-exchange limit. Pyridine used as a (6)Li chemical shift reagent proved useful in assigning solvation numbers.

Correction: Design and chemoproteomic functional characterization of a chemical probe targeted to bromodomains of BET family proteins

Correction for ‘Design and chemoproteomic functional characterization of a chemical probe targeted to bromodomains of BET family proteins’ by Jiang Wu et al., Med. Chem. Commun., 2014, 5, 1871–1878.

Design and chemoproteomic functional characterization of a chemical probe targeted to bromodomains of BET family proteins

Selectivity of a PFI-1 based BET bromodomain probe was demonstrated using affinity capture in nuclear extracts from human cells.

(3R,4S)-4-(2,4,5-Trifluorophenyl)-pyrrolidin-3-ylamine inhibitors of dipeptidyl peptidase IV: Synthesis, in vitro, in vivo, and X-ray crystallographic characterization

A series of pyrrolidine based inhibitors of dipeptidyl peptidase IV were developed from a high throughput screening hit for the treatment of type 2 diabetes. Potency, selectivity, and pharmacokinetic properties were optimized resulting in the identification of a pre-clinical candidate for further profiling.

A convenient preparation of heteroaryl sulfonamides and sulfonyl fluorides from heteroaryl thiols

Heteroaromatic thiols may be oxidized to the sulfonyl chloride at low temperature (-25 degrees C) by using 3.3 equiv of aqueous sodium hypochlorite. The reaction is rapid, avoids the use of chlorine gas, and succeeds with substrates that have previously been found to afford little or none of the sulfonamide product with other procedures. The method allows the preparation of the sulfonyl fluorides, which are stable enough to be purified and stored, making them potentially useful monomers in parallel chemistry efforts.

cis-2,5-Dicyanopyrrolidine Inhibitors of Dipeptidyl Peptidase IV: Synthesis and in Vitro, in Vivo, and X-ray Crystallographic Characterization

Inhibitors of the glucagon-like peptide-1 (GLP-1) degrading enzyme dipeptidyl peptidase IV (DPP-IV) have been shown to be effective treatments for type 2 diabetes in animal models and in human subjects. A novel series of cis-2,5-dicyanopyrrolidine alpha-amino amides were synthesized and evaluated as inhibitors of dipeptidyl peptidase IV (DPP-IV) for the treatment of type 2 diabetes. 1-({[1-(Hydroxymethyl)cyclopentyl]amino}acetyl)pyrrolidine-2,5-cis-dicarbonitrile (1c) is an achiral, slow-binding (time-dependent) inhibitor of DPP-IV that is selective for DPP-IV over other DPP isozymes and proline specific serine proteases, and which has oral bioavailability in preclinical species and in vivo efficacy in animal models. The mode of binding of the cis-2,5-dicyanopyrrolidine moiety was determined by X-ray crystallography. The hydrochloride salt of 1c was further profiled for development as a potential new treatment for type 2 diabetes.

A convenient preparation of heteroaryl sulfonamides and sulfonyl fluorides from heteroaryl thiols

Heteroaromatic thiols may be oxidized to the sulfonyl chloride at low temperature (-25 degrees C) by using 3.3 equiv of aqueous sodium hypochlorite. The reaction is rapid, avoids the use of chlorine gas, and succeeds with substrates that have previously been found to afford little or none of the sulfonamide product with other procedures. The method allows the preparation of the sulfonyl fluorides, which are stable enough to be purified and stored, making them potentially useful monomers in parallel chemistry efforts.

5-Chloroindoloyl glycine amide inhibitors of glycogen phosphorylase: synthesis, in vitro, in vivo, and X-ray crystallographic characterization

The synthesis, in vitro, and in vivo biological characterization of a series of achiral 5-chloroindoloyl glycine amide inhibitors of human liver glycogen phosphorylase A are described. Improved potency over previously reported compounds in cellular and in vivo assays was observed. The allosteric binding site of these compounds was shown by X-ray crystallography to be the same as that reported previously for 5-chloroindoloyl norstatine amides.

3-(2-carboxyethyl)-4,6-dichloro-1H-indole-2-carboxylic acid: an allosteric inhibitor of fructose-1,6-bisphosphatase at the AMP site

3-(2-Carboxyethyl)-4,6-dichloro-1H-indole-2-carboxylic acid (MDL-29951), an antagonist of the glycine site of the NMDA receptor, has been found to be an allosteric inhibitor of the enzyme fructose 1,6-bisphosphatase. The compound binds at the AMP regulatory site by X-ray crystallography. This represents a new approach to inhibition of fructose 1,6-bisphosphatase and serves as a lead for further drug design.

Anilinoquinazoline inhibitors of fructose 1,6-bisphosphatase bind at a novel allosteric site: synthesis, in vitro characterization, and X-ray crystallography

The synthesis and in vitro structure-activity relationships (SAR) of a novel series of anilinoquinazolines as allosteric inhibitors of fructose-1,6-bisphosphatase (F16Bpase) are reported. The compounds have a different SAR as inhibitors of F16Bpase than anilinoquinazolines previously reported. Selective inhibition of F16Bpase can be attained through the addition of appropriate polar functional groups at the quinazoline 2-position, thus separating the F16Bpase inhibitory activity from the epidermal growth factor receptor tyrosine kinase inhibitory activity previously observed with similar structures. The compounds have been found to bind at a symmetry-repeated novel allosteric site at the subunit interface of the enzyme. Inhibition is brought about by binding to a loop comprised of residues 52-72, preventing the necessary participation of these residues in the assembly of the catalytic site. Mutagenesis studies have identified the key amino acid residues in the loop that are required for inhibitor recognition and binding.

Allosteric inhibition of fructose-1,6-bisphosphatase by anilinoquinazolines

Anilinoquinazolines currently of interest as inhibitors of tyrosine kinases have been found to be allosteric inhibitors of the enzyme fructose 1,6-bisphosphatase. These represent a new approach to inhibition of F16BPase and serve as leads for further drug design. Enzyme inhibition is achieved by binding at an unidentified allosteric site.

Emergency medicine in Ukraine: challenges in the post-Soviet era

The practice of emergency medicine in Ukraine is markedly different from the practice in North America. The emergency physician counterpart in Ukraine attends 6 years of medical school then 18 months of prehospital physician training at an EMS base station. Once trained, prehospital physicians work 160 hours/month in 24-hour shifts at the base station as part of a physician-nurse team which answers ambulance requests. Most patients are seen and treated on site of the ambulance call. Patients are transported to the hospital only 20% of the time. Prehospital physicians can expect to earn $35 to $65 per month. Nearly all prehospital physicians are government employees. Since becoming an independent democratic republic, Ukraine's turbulent economy has negatively affected health care. Deaths from infectious diseases, including vaccine-preventable illnesses are 10-fold to that of Western countries. A 90% income tax discourages the private practice of medicine. Medical care is provided free of charge, however, if a patient wants a higher standard of care, they may have to pay an attending physician up to $200. Most medications used to treat emergencies are free, but if thrombolytics are required, the patient will have to pay for them before they are administered. Budgetary constraints limit equipment and technology. The disparity between urban and rural resources is striking as even the most basic equipment is antiquated and in need of repair. Despite the economic challenges facing Ukranian physicians, they are enthusiastic about the care and services they provide. EMS is well organized and offers services not seen in the United States. Prehospital physicians in Ukraine are viewed as an integral part of the health care system by their hospital-based colleagues.

Metal detectors in the pediatric emergency department: patron attitudes and national prevalence

OBJECTIVES

The purpose of this study was to investigate patron attitudes toward a walk through a metal detector that was used for universal weapon screening in a pediatric emergency department. Additionally, we conducted a telephone survey to determine the nationwide prevalence of metal detectors in pediatric emergency departments.

METHODS

A convenience sample of family and acquaintances of patients seen in the pediatric emergency department was selected, and members were interviewed using scripted questions. Members of the National Association of Children's Hospitals and Related Institutions were interviewed for the nationwide survey.

RESULTS

The vast majority of patrons responded favorably to the presence of the arch-style walk through a metal detector. The metal detector was felt to be appropriate in a pediatric emergency department by a large majority of patrons and was protective for both patrons and employees. Handbag searches were felt to be an invasion of privacy by 14%. Nationwide, the prevalence of arch-style metal detectors for security purposes in pediatric emergency departments was only 6%.

CONCLUSIONS

The public has a strong perception that a metal detector protects both patrons and employees in a pediatric emergency department. Fear that patrons will be disturbed or that the presence of a metal detector will reflect negatively upon the institution appear to be unfounded. Nationwide use of metal detectors in pediatric emergency departments remains uncommon but is apparently increasing.

Prevalence and risk factors for multidrug resistant uropathogens in ED patients

The purpose of this study was to describe resistance patterns of infecting organisms and determine risk factors for multidrug resistance in patients with urinary tract infections. Retrospective case series of 435 patients age > or =16 with urinary tract infection. Multidrug resistance was defined as resistance to > or = two classes of antibiotics. Demographic, historical, and microbiological data were collected. Univariate analysis and multivariate logistic regression were used to determine risk factors for multidrug resistance. Multidrug resistance was seen in 37% of isolates. Univariate analysis revealed numerous associations with resistance. Multivariate analysis found three independent factors associated with multidrug resistance: urinary catheter use (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.4 to 4.8), age > or = 65 years (OR 3.0, 95% CI 1.7 to 5.4) and antibiotic use (OR 4.6, 95% CI 2.8 to 7.5). Diabetes was also a risk factor when patients with urinary catheters were excluded (OR 2.4, 95% CI 1.1 to 5.3). Resistance was seen in all groups of patients, but was particularly common in older patients and those who used a urinary catheter. Antibiotic use was highly associated with multidrug resistance.

Trimethoprim-sulfamethoxazole resistance among urinary coliform isolates

OBJECTIVE

A large majority of urinary tract infections are caused by coliform organisms. Trimethoprim-sulfamethoxazole (TMP-SMX) resistance among uropathogens is increasing in many areas. The objective of this study was to determine risk factors for TMP-SMX-resistant coliforms in patients with urinary tract infections.

DESIGN

Retrospective case-control study.

SETTING

Emergency department of a tertiary care university hospital.

PATIENTS

We studied 448 emergency department patients aged 14 years or older with a urinary tract infection caused by a coliform organism. Cases consisted of all patients with a culture-documented urinary tract infection caused by a TMP-SMX-resistant coliform, while control patients were those with a TMP-SMX-sensitive organism.

MEASUREMENTS AND MAIN RESULTS

A univariate analysis of clinical variables associated with TMP-SMX resistance was performed. Multiple logistic regression was performed to determine independent predictors of TMP-SMX resistance. Resistance to TMP-SMX was seen in 15% of isolates. Numerous variables were associated with TMP-SMX resistance on the univariate screen. Independent predictors of resistance were diabetes (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.2, 8.4), recent hospitalization (OR 2.5; 95% CI 1.1, 5.7), current use of antibiotics (OR 4.5; 95% CI 2.0, 10.2), and recent use of TMP-SMX (OR 5.1; 95% CI 2.2, 11.5). When those with recent hospitalization were excluded from analysis, independent predictors were current use of any antibiotic (OR 3.5; 95% CI 1.4, 8. 4) and recent use of TMP-SMX (OR 5.9; 95% CI 2.4, 14.3).

CONCLUSIONS

Coliforms resistant to TMP-SMX are common in our emergency department. Diabetes, recent hospitalization, and the use of antibiotics, particularly the use of TMP-SMX, are independent risk factors for TMP-SMX resistance. Clinicians should consider these findings when deciding on antimicrobial therapy for patients with urinary tract infections.

Anxiety levels in EMS providers: effects of violence and shifts schedules

We tried to measure anxiety levels in emergency medical service (EMS) providers to determine the effects of (1) having had a violent encounter during a shift and (2) different shift schedules, conducting a prospective observational study over 3 months in an urban EMS system setting. A convenience sample of 23 EMTs and 40 EMT-Ps was observed. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory. A total of 99 inventories were completed by 63 EMS providers. The mean state (32.6+/-8) and trait (31.7+/-7.1) scores were less than normative scores (35.7+/-10.4 and 34.9+/-9.2 respectively) for working adult males (P = .004 and .007, respectively). Paramedics had lower anxiety scores than basic EMTs (P = .015 and .039) and years of experience also decreased anxiety scores (P < .0001). There was no significant difference in state scores between those EMS providers who had encountered violence during the preceding 12 hours and those providers who had not. Comparisons of state scores of providers assessed at hour 12 of a 12 hour shift, hour 12 of a 24 hour shift, and hour 24 of a 24 hour shift failed to show any significant differences. Although the working environment of the EMS provider contains numerous stressors and uncertainties, this population of providers were no more anxious than the general working public. Advanced training and years of experience decreased anxiety. Violent encounters during a shift did not appear to affect anxiety levels. There was no difference in anxiety levels in providers who worked 12 and 24 hour shifts.