Alleviation of monocyte exhaustion by BCG derivative mycolic acid

Monocyte exhaustion with sustained pathogenic inflammation and immune-suppression, a hallmark of sepsis resulting from systemic infections, presents a challenge with limited therapeutic solutions. This study identified Methoxy-Mycolic Acid (M-MA), a branched mycolic acid derived from Mycobacterium bovis Bacillus Calmette-Guérin (BCG), as a potent agent in alleviating monocyte exhaustion and restoring immune homeostasis. Co-treatment of monocytes with M-MA effectively blocked the expansion of Ly6Chi/CD38hi/PD-L1hi monocytes induced by LPS challenges and restored the expression of immune-enhancing CD86. M-MA treatment restored mitochondrial functions of exhausted monocytes and alleviated their suppressive activities on co-cultured T cells. Independent of TREM2, M-MA blocks Src-STAT1-mediated inflammatory polarization and reduces the production of immune suppressors TAX1BP1 and PLAC8. Whole genome methylation analyses revealed M-MA's ability to erase the methylation memory of exhausted monocytes, particularly restoring Plac8 methylation. Together, our data suggest M-MA as an effective agent in restoring monocyte homeostasis with a therapeutic potential for treating sepsis.

Monocytes reprogrammed by 4-PBA potently contribute to the resolution of inflammation and atherosclerosis

Background

Chronic inflammation initiated by inflammatory monocytes underlies the pathogenesis of atherosclerosis. However, approaches that can effectively resolve chronic low-grade inflammation targeting monocytes are not readily available. The small chemical compound 4-phenylbutyric acid (4-PBA) exhibits broad anti-inflammatory effects in reducing atherosclerosis. Selective delivery of 4-PBA reprogrammed monocytes may hold novel potential in providing targeted and precision therapeutics for the treatment of atherosclerosis.

Methods

Systems analyses integrating single-cell RNA-sequencing and complementary immunological approaches characterized key resolving characteristics as well as defining markers of reprogrammed monocytes trained by 4-PBA. Molecular mechanisms responsible for monocyte reprogramming was assessed by integrated biochemical and genetic approaches. The inter-cellular propagation of homeostasis resolution was evaluated by co-culture assays with donor monocytes trained by 4-PBA and recipient naïve monocytes. The in vivo effects of monocyte resolution and atherosclerosis prevention by 4-PBA were assessed with the high fat diet-fed ApoE -/- mouse model with i.p. 4-PBA administration. Furthermore, the selective efficacy of 4-PBA trained monocytes were examined by i.v. transfusion of ex vivo trained monocytes by 4-PBA into recipient high fat diet-fed ApoE -/- mice.

Results

In this study, we found that monocytes can be potently reprogrammed by 4-PBA into an immune-resolving state characterized by reduced adhesion and enhanced expression of anti-inflammatory mediator CD24. Mechanistically, 4-PBA reduced the expression of ICAM-1 via reducing peroxisome stress and attenuating SYK-mTOR signaling. Concurrently, 4-PBA enhanced the expression of resolving mediator CD24 through promoting PPARγ neddylation mediated by TOLLIP. 4-PBA trained monocytes can effectively propagate anti-inflammation activity to neighboring monocytes through CD24. Our data further demonstrated that 4-PBA trained monocytes effectively reduce atherosclerosis pathogenesis when administered in vivo .

Conclusion

Our study describes a robust and effective approach to generate resolving monocytes, characterizes novel mechanisms for targeted monocyte reprogramming, and offers a precision-therapeutics for atherosclerosis based on delivering reprogrammed resolving monocytes.

Abstract PR006: Multi-modal single-cell profiling of sarcomas from archival tissue reveals mechanisms of resistance to immune checkpoint inhibitors

Single-cell genomics is an enabling technology that may inform the molecular underpinnings of drug response and resistance in patient biopsies. These methods are difficult to implement in the study of rare diseases such as sarcomas due to specimen requirements and technical limitations. Here, we evolved novel methods that we recently reported in melanoma (Wang, Fan, et al., bioRxiv, 2022) which enable single-nucleus RNA, T cell receptor (snRNA/TCR-seq), and pool-matched whole-genome sequencing (WGS) from archival frozen sarcoma tissue. This enabled profiling of 75,716 cells and 788 matched TCR clonotypes from six patients with intimal sarcoma (INS) and undifferentiated pleomorphic sarcoma (UPS), including two matched pair samples from pre/post-immune checkpoint inhibitor (ICI). Our analysis revealed substantial transcriptional cancer cell heterogeneity driven by varying copy number alterations (CNAs). In one patient with INS with a complete response to ICI followed by an isolated recurrence, we identified a rare cancer cell clone defined by CNA (confirmed with WGS) and resulting transcriptional outputs that pre-existed and emerged during resistance. Furthermore, in a UPS patient with intrinsic resistance to ICI, we find adequate T cell clonal expansion, activation, and differentiation, suggesting appropriate T cell response to ICI dampened by intrinsic mechanisms of ICI resistance within the cancer cells. Non-negative matrix factorization (NMF) analysis identified cell states associated with either intrinsic or adaptive resistance to ICI that was distinct from resistance to doxorubicin. These observations are consistent with those previously reported from sequential biopsies obtained from KEYNOTE-001 in metastatic melanoma (Wang, Fan, et al., bioRxiv, 2022), which also revealed emergence of pre-existing populations of resistant clones defined by their underlying aneuploidy patterns. Together, these results demonstrate feasibility of implementing single-cell genomics from archival tissue to study sarcoma and propel our understanding of drug resistance. Conceptually, this work suggests that large-scale CNAs may allow us to identify cell sub-populations associated with ICI resistance in sarcoma and in other diseases.

Citation Format: Sminu Bose, Blake Caldwell, Amit Dipak Amin, Johannes Melms, Somnath Tagore, Matthew Ingham, Benjamin Izar, Gary K. Schwartz. Multi-modal single-cell profiling of sarcomas from archival tissue reveals mechanisms of resistance to immune checkpoint inhibitors [abstract]. In: Proceedings of the AACR Special Conference: Sarcomas; 2022 May 9-12; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2022;28(18_Suppl):Abstract nr PR006.

Dissecting the treatment-naive ecosystem of human melanoma brain metastasis

Melanoma brain metastasis (MBM) frequently occurs in patients with advanced melanoma; yet, our understanding of the underlying salient biology is rudimentary. Here, we performed single-cell/nucleus RNA-seq in 22 treatment-naive MBMs and 10 extracranial melanoma metastases (ECMs) and matched spatial single-cell transcriptomics and T cell receptor (TCR)-seq. Cancer cells from MBM were more chromosomally unstable, adopted a neuronal-like cell state, and enriched for spatially variably expressed metabolic pathways. Key observations were validated in independent patient cohorts, patient-derived MBM/ECM xenograft models, RNA/ATAC-seq, proteomics, and multiplexed imaging. Integrated spatial analyses revealed distinct geography of putative cancer immune evasion and evidence for more abundant intra-tumoral B to plasma cell differentiation in lymphoid aggregates in MBM. MBM harbored larger fractions of monocyte-derived macrophages and dysfunctional TOX+CD8+ T cells with distinct expression of immune checkpoints. This work provides comprehensive insights into MBM biology and serves as a foundational resource for further discovery and therapeutic exploration.

Abstract 984: Dissecting the ecosystem of treatment-naïve melanoma brain metastasis using multi-modal single-cell analysis

Brain metastases are the most frequent malignancies in the brain and are associated with significant morbidity and mortality. Melanoma brain metastases (MBM) occur in most patients with advanced melanoma and are challenging to treat. Our understanding of the treatment-naïve landscape of MBM is still rudimentary, and there are no site-specific molecular therapies available. To gain comprehensive insights into the niche-specific biology of MBM, we performed multi-modal profiling of fresh and frozen samples using single-cell RNA-seq, single-cell TCR-seq, single-nuclei RNA-seq, and spatial transcriptional profiling. We evolved single-nucleus RNA-seq processing methods to enable profiling of minute amounts of archival, frozen specimens and compared data quality and structure between matched fresh and frozen MBM. We curated a treatment-naïve single-transcriptome atlas of MBM, collected either fresh samples over 1 year or profiled frozen samples dating back more than 15 years, and compared these samples to extracranial melanoma metastases (ECMM). In total, we profiled 25 samples with more than 114,000 transcriptomes. We identified more than 20 different cell types, including diverse tumor-infiltrating T-cell subsets and rare dendritic cell types, and tissue-specific cell types, such as activated microglia. Tumor cells in MBM showed an increase in copy number alterations (CNAs) compared to ECMM, which we validated using an external dataset of whole exome sequencing (WES) data including both MBM and ECMM. MBM-derived tumor cells show enrichment of genes involved in neuronal development and function, and site-specific metabolic programs (e.g., oxidative phosphorylation). Comparison with an external bulk RNA-seq dataset validated enriched key genes in MBM and ECMM as putative dependencies. We recovered cell-cell interactions between tumor and brain-resident cells involved in brain development, homeostasis, and disease. Similar to ECMM, the tumor microenvironment of MBM contained CD8+ T cells across a spectrum of differentiation, exhaustion and expansion, which was associated with loss of TCF7 expression and adoption of a TOX+ cell state. CD4+ T cells included T regulatory, T helper and T follicular-helper-like expression profiles. Plasma cells showed spatially localized expansion and limited heterogeneity. Myeloid cells largely adopted pro-tumorigenic cell states, including microglia, the brain-resident myeloid cells, which showed an activation trajectory characterized by expression of SPP1 (osteopontin). Spatial transcriptional analysis revealed restricted expression of antigen presentation genes with only a subset of these locations showing a type I interferon response. In summary, this work presents a multi-modal single-cell approach to dissect and compare the landscape of treatment-naïve MBM and ECMM.

Citation Format: Johannes C. Melms, Jana Biermann, Amit Dipak Amin, Yiping Wang, Somnath Tagore, Massimo Andreatta, Ajay Nair, Meri Rogava, Patricia Ho, Lindsay A. Caprio, Zachary H. Walsh, Shivem Shah, Daniel H. Vacarro, Blake Caldwell, Adrienne M. Luoma, Joseph Driver, Matthew Ingham, Suthee Rapisuwon, Jennifer Wargo, Craig L. Slinguff, Evan Z. Macosco, Fei Chen, Richard Carvajal, Michael B. Atkins, Michael A. Davies, Elham Azizi, Santiago J. Carmona, Hanina Hibshoosh, Peter D. Canoll, Jeffrey N. Bruce, Wenya L. Bi, Gary K. Schwartz, Benjamin Izar. Dissecting the ecosystem of treatment-naïve melanoma brain metastasis using multi-modal single-cell analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 984.

Multi-modal single-cell profiling of sarcomas from archival tissue reveals mechanisms of resistance to immune checkpoint inhibitors

e23518

Background: Single-cell RNA-seq is an enabling technology that may inform the molecular underpinnings of drug response and resistance in patient biopsies. This method is difficult to implement in the study of rare diseases such as sarcomas due to specimen requirements and technical limitations. Methods: Here, we evolved novel methods that we recently reported in melanoma ( Wang, Fan, et al., bioRxiv, 2022), which enable single-nucleus RNA, T cell receptor (snRNA/TCR)-seq, and pool-matched whole-genome sequencing (WGS) from archival, frozen sarcoma tissue. Results: This enabled profiling of 75,716 cells and 788 matched TCR clonotypes from six patients with intimal sarcoma (INS) and undifferentiated pleomorphic sarcomas (UPS), including two matched pair samples from pre/post-immune checkpoint inhibitor (ICI). Our analysis revealed substantial transcriptional cancer cell heterogeneity driven by varying copy number alterations (CNAs). In one patient with INS with a complete response to ICI followed by an isolated recurrence, we identified a rare cancer cell clone defined by CNA (confirmed with WGS) and resulting transcriptional outputs that pre-existed and emerged during resistance. Furthermore, in a patient with UPS with intrinsic resistance to ICI, we find adequate T cell clonal expansion and activation, suggesting appropriate T cell response to ICI dampened by intrinsic mechanisms of ICI resistance within the cancer cells. Non-negative matrix factorization (NMF) analysis identified cell states associated with either intrinsic or adaptive resistance to ICI that was distinct from resistance to doxorubicin. These observations are consistent with those previously reported from sequential biopsies obtained from KEYNOTE-001 in metastatic melanoma ( Wang, Fan, et al., bioRxiv, 2022), which also revealed emergence of pre-existing populations of resistant clones defined by their underlying aneuploidy patterns. Conclusions: Together, these results demonstrate feasibility of implementing single-cell genomics from archival tissue to study sarcoma and propel our understanding of drug resistance. Conceptually, this work suggests that large-scale CNAs may drive cell sub-populations associated with ICI resistance in sarcoma and in other diseases.

Human Neocortical Neurosolver (HNN), a new software tool for interpreting the cellular and network origin of human MEG/EEG data

Magneto- and electro-encephalography (MEG/EEG) non-invasively record human brain activity with millisecond resolution providing reliable markers of healthy and disease states. Relating these macroscopic signals to underlying cellular- and circuit-level generators is a limitation that constrains using MEG/EEG to reveal novel principles of information processing or to translate findings into new therapies for neuropathology. To address this problem, we built Human Neocortical Neurosolver (HNN, https://hnn.brown.edu) software. HNN has a graphical user interface designed to help researchers and clinicians interpret the neural origins of MEG/EEG. HNN’s core is a neocortical circuit model that accounts for biophysical origins of electrical currents generating MEG/EEG. Data can be directly compared to simulated signals and parameters easily manipulated to develop/test hypotheses on a signal’s origin. Tutorials teach users to simulate commonly measured signals, including event related potentials and brain rhythms. HNN’s ability to associate signals across scales makes it a unique tool for translational neuroscience research.

Neurons carry information in the form of electrical signals. Each of these signals is too weak to detect on its own. But the combined signals from large groups of neurons can be detected using techniques called EEG and MEG. Sensors on or near the scalp detect changes in the electrical activity of groups of neurons from one millisecond to the next. These recordings can also reveal changes in brain activity due to disease.

But how do EEG/MEG signals relate to the activity of neural circuits? While neuroscientists can rarely record electrical activity from inside the human brain, it is much easier to do so in other animals. Computer models can then compare these recordings from animals to the signals in human EEG/MEG to infer how the activity of neural circuits is changing. But building and interpreting these models requires advanced skills in mathematics and programming, which not all researchers possess.

Neymotin et al. have therefore developed a user-friendly software platform that can help translate human EEG/MEG recordings into circuit-level activity. Known as the Human Neocortical Neurosolver, or HNN for short, the open-source tool enables users to develop and test hypotheses on the neural origin of EEG/MEG signals. The model simulates the electrical activity of cells in the outer layers of the human brain, the neocortex. By feeding human EEG/MEG data into the model, researchers can predict patterns of circuit-level activity that might have given rise to the EEG/MEG data. The HNN software includes tutorials and example datasets for commonly measured signals, including brain rhythms. It is free to use and can be installed on all major computer platforms or run online.

HNN will help researchers and clinicians who wish to identify the neural origins of EEG/MEG signals in the healthy or diseased brain. Likewise, it will be useful to researchers studying brain activity in animals, who want to know how their findings might relate to human EEG/MEG signals. As HNN is suitable for users without training in computational neuroscience, it offers an accessible tool for discoveries in translational neuroscience.

Non-accidental harms (‘abuse’) in athletes with impairment (‘para athletes’): a state-of-the-art review

Objective

Para athletes reap significant health benefits from sport but are vulnerable to non-accidental harms. Little is known about the types and impacts of non-accidental harms Para athletes face. In this literature review, we summarise current knowledge and suggest priorities for future research related to non-accidental harms in Para athletes.

Design

Six electronic databases were searched between August and September 2017. 2245 articles were identified in the initial title/abstract review, and 202 records were selected for full-text review following preliminary screening. Two independent examiners evaluated each full text, and eight citations were selected based on inclusion/exclusion criteria.

Data sources

MEDLINE, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Scopus and Academic Search Premier.

Eligibility criteria for selecting studies

Inclusion criteria: (A) human participants; (B) written in English; (C) descriptive, cohort and case series, case–control, qualitative, mixed methods studies and all clinical trials; and (D) data pertain to harassment/abuse of youth, recreational, collegiate, national-level and/or elite-level athletes with a physical and/or intellectual impairment.

Results

Most studies focused on young, visually impaired athletes and approximately half of all studies described high rates of bullying and its social implications. One study confirmed remarkably high rates of psychological, physical and sexual harms in Para athletes, compared with able-bodied peers.

Conclusions

Bullying in young, visually impaired athletes is described most commonly in the available literature. Due to the limited amount of data, the prevalence of non-accidental harms in Para athletes remains unclear and information on trends over time is similarly unavailable.

Evaluating feasibility of an automated 3-dimensional scanner using Raman spectroscopy for intraoperative breast margin assessment

Breast conserving surgery is the preferred treatment for women diagnosed with early stage invasive breast cancer. To ensure successful breast conserving surgeries, efficient tumour margin resection is required for minimizing tumour recurrence. Currently surgeons rely on touch preparation cytology or frozen section analysis to assess tumour margin status intraoperatively. These techniques have suboptimal accuracy and are time-consuming. Tumour margin status is eventually confirmed using postoperative histopathology that takes several days. Thus, there is a need for a real-time, accurate, automated guidance tool that can be used during tumour resection intraoperatively to assure complete tumour removal in a single procedure. In this paper, we evaluate feasibility of a 3-dimensional scanner that relies on Raman Spectroscopy to assess the entire margins of a resected specimen within clinically feasible time. We initially tested this device on a phantom sample that simulated positive tumour margins. This device first scans the margins of the sample and then depicts the margin status in relation to an automatically reconstructed image of the phantom sample. The device was further investigated on breast tissues excised from prophylactic mastectomy specimens. Our findings demonstrate immense potential of this device for automated breast tumour margin assessment to minimise repeat invasive surgeries.

Thermally Stable Poled Polymers: Highly Efficient Heteroaromatic Chromophores In High Temperature Polyimides

In this paper, we report our recent developments in achieving thermally stable polyimides that possess large second order nonlinear optical activity. We have developed several classes of novel chromophores based on the combination of efficient thiophene conjugating units and novel electron-donating and electron-accepting functional groups. Through these developments, we have synthesized chromophores that possess non-resonant βμ values as high as 9,100 × 10−48 esu measured at 1.9 μm. These chromophores also possess improved thermal and chemical stabilities. The incorporation of these chromophores in high temperature polyimides produces E-O Materials with high linear electro-optic coefficients (in excess of 15 pm/V at 1.3 μm) and long-term temporal stability at an elevated temperature of 150°C for more than 800 hours.

Randomised double-blind, placebo-controlled trial of the effects of the 'party pills' BZP/TFMPP alone and in combination with alcohol

The objective of this study was to determine the clinical effects of party pills containing benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP) when taken alone and in combination with alcohol. The study was a randomised, double-blind, placebo-controlled trial conducted in a hospital-based clinic in Wellington, New Zealand. Thirty-five volunteers who had previously used party pills containing BZP were included in this trial. Participants received one of the following four treatments: 300 mg/74 mg BZP/TFMPP and placebo, 300 mg/74 mg BZP/TFMPP and 57.6 g (6 units) alcohol, placebo and 57.6 g (6 units) alcohol and double placebo. The primary outcome variable was a measure of driving performance, the standard deviation of lateral position (SDLP) measured at 6.5 h. Secondary measures included adverse events, cardiovascular effects, psychological function and delayed effects on sleep. The study was stopped early, after 35 of the planned 64 subjects had undertaken testing, because of severe adverse events that occurred in four of 10 BZP/TFMPP-only subjects, three of seven combined BZP/TFMPP and alcohol subjects, none of the 6 placebo subjects, and none of the 12 alcohol-only subjects. The overall rate of severe adverse events (defined as causing considerable interference with usual activity and/or rated by subject as severe) in those receiving BZP/TFMPP was seven of 17 (41.2%, 95% CI 18.4-67.1). The severe events included agitation, anxiety, hallucinations, vomiting, insomnia and migraine. BZP/TFMPP significantly improved the driving performance, decreasing SDLP at -4.2 cm (95% CI -6.8 to -1.6, P = 0.002). The effect of alcohol was to increase SDLP: 2.3 cm (95% CI -0.3 to 4.9, P = 0.08). BZP/TFMPP also resulted in increased heart rate and blood pressure and in difficulty in getting to sleep. BZP/TFMPP alone or with alcohol carries a significant risk of severe adverse events when taken in similar doses to those recommended by manufacturers.

National Bioterrorism Syndromic Surveillance Demonstration Program

The National Bioterrorism Syndromic Surveillance Demonstration Program identifies new cases of illness from electronic ambulatory patient records. Its goals are to use data from health plans and practice groups to detect localized outbreaks and to facilitate rapid public health follow-up. Data are extracted nightly on patient encounters occurring during the previous 24 hours. Visits or calls with diagnostic codes corresponding to syndromes of interest are counted; repeat encounters are excluded. Daily counts of syndromes by zip code are sent to a central data repository, where they are statistically analyzed for unusual clustering by using a model-adjusted SaTScan approach. The results and raw data are displayed on a restricted website. Patient-level information stays at the originating health-care organization unless required by public health authorities. If a cluster surpasses a threshold of statistical aberration chosen by the corresponding public health department, an electronic alert can be sent to that department. The health department might then call a clinical responder, who has electronic access to records of cases contributing to clusters. The system is flexible, allowing for changes in participating organizations, syndrome definitions, and alert thresholds. It is transparent to clinicians and has been accepted by the health-care organizations that provide the data. The system's data are usable by local and national health agencies. Its software is compatible with commonly used systems and software and is mostly open-source. Ongoing activities include evaluating the system's ability to detect naturally occurring outbreaks and simulated terrorism events, automating and testing alerts and response capability, and evaluating alternative data sources.

Syndromic surveillance using minimum transfer of identifiable data: the example of the National Bioterrorism Syndromic Surveillance Demonstration Program

Several health plans and other organizations are collaborating with the Centers for Disease Control and Prevention to develop a syndromic surveillance system with national coverage that includes more than 20 million people. A principal design feature of this system is reliance on daily reporting of counts of individuals with syndromes of interest in specified geographic regions rather than reporting of individual encounter-level information. On request from public health agencies, health plans and telephone triage services provide additional information regarding individuals who are part of apparent clusters of illness. This reporting framework has several advantages, including less sharing of protected health information, less risk that confidential information will be distributed inappropriately, the prospect of better public acceptance, greater acceptance by health plans, and less effort and cost for both health plans and public health agencies. If successful, this system will allow any organization with appropriate data to contribute vital information to public health syndromic surveillance systems while preserving individuals' privacy to the greatest extent possible.

"Silent" transverse patellar fracture following anterior cruciate ligament reconstruction

Patellar fracture is a rare but specific complication of anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft. When this complication occurs, early internal fixation is recommended and need not compromise the outcome. We report 2 cases of displaced transverse patellar fracture occurring after reconstruction but which were not diagnosed and presented with late sequelae.

Can managed health care help manage health care-associated infections?

Managed-care organizations have a unique opportunity, still largely unrealized, to collaborate with health-care providers and epidemiologists to prevent health care-associated infections. Several attributes make these organizations logical collaborators for infection control programs: they have responsibility for defined populations of enrollees and for their overall health, including preventive care; they possess unique data resources about their members and their care; and they are able to make systemwide changes in care. Health care-associated infections merit the attention and effort of managed-care organizations because these infections are common, incur substantial illness and costs, and can be effectively prevented by using methods that are unevenly applied in different health-care settings. Both national and local discussions will be required to enable the most effective and efficient collaborations between managed care organizations and health-care epidemiologists. It will be important to articulate clear goals and standards that can be readily understood and widely adopted.

The first generation to control family size: a microstudy of the causes of fertility decline in a rural area of Bangladesh

In Bangladesh, the total fertility rate declined from more than six children per woman of reproductive age in 1980 to 3.3 children per woman in 1996. Much discussion has ensued about the circumstances responsible for this decline and, in particular, about the contribution made by the national family planning program. For this study, qualitative interviews were conducted with 67 women concerning the factors influencing their reproductive behavior. The participants, residents of a rural area in southwestern Bangladesh, consisted of two groups: women who were currently practicing family planning and women who had never practiced or had not done so for at least four years. The findings suggest that the family planning program has played an important role in reducing family size, but also indicate that economic and social changes, and especially growing aspirations (particularly for a life outside agriculture) have combined with changes in the nature of family decision making to make couples more receptive to the idea of family planning.

Summary of research issues in personal, interpersonal, and group dynamics

People working on space missions, whether they are crewmembers or Mission Control personnel, must interact in groups. Consequently, it is important to consider interpersonal and group dynamic issues to assure that mission goals are accomplished. Simulation studies on Earth and anecdotal reports from space have described a number of such issues that include crew heterogeneity, culture and language variations, leadership roles, and personality differences. Problems that can result include increased group tension, decreased cohesion, subgrouping, scapegoating, miscommunication, role confusion, and displacement of tension and dysphoria from one group to another. The three papers by Drs. Caldwell, Kanas, and Stuster that are presented in this session address some of these issues at the group level. They suggest three critical questions related to: 1) improving communication between space crews and Mission Control personnel; 2) dealing with emotional and interpersonal decrements during the second half of space missions; and 3) minimizing the effects of culture and language differences. These questions in turn lead to six research strategies related to: 1) developing and testing new technologies to enhance crew-ground communication; 2) developing tools to recognize important communication themes and the factors that affect them over time; 3) studying the ability of voice analysis technology to detect on-board interpersonal stress; 4) developing and testing countermeasures to deal with second half emotional and interpersonal decrements; 5) studying the effects of cultural and language differences on crew tension, cohesion, and performance; and 6) studying the effects of crew heterogeneity and size on crew tension, cohesion, and performance.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

Detection of hepatitis C core antigen in the antibody negative 'window' phase of hepatitis C infection

BACKGROUND AND OBJECTIVES

Despite improvements in assays for anti-HCV, there remains a significant delay before the appearance of antibodies following infection, during which, circulating viral RNA is present. We have evaluated a prototype assay for the serological detection of hepatitis C virus (HCV) core antigen with specimens derived from the early phase of HCV infection.

MATERIALS AND METHODS

Serial specimens from 24 individuals undergoing HCV seroconversion were tested for the presence of anti-HCV, HCV RNA and HCV core antigen.

RESULTS

HCV antigen was detected at the same time as HCV RNA in 83% (20/24) cases. The mean time to the first detection of HCV antigen was approximately 1 day later than HCV RNA. Overall, 87% of HCV-RNA-positive specimens contained detectable HCV core antigen.

CONCLUSION

These results indicate that HCV core antigen can be identified by routine serological ELISA in specimens from the early antibody-negative phase of HCV infection. A test for HCV core antigen may be a useful test for identifying window phase blood donations from antibody negative donors infected with HCV.

Trends in perinatal transmission of HIV/AIDS in the United States

CONTEXT

Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission.

OBJECTIVE

To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998.

MAIN OUTCOME MEASURES

Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states.

RESULTS

Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%.

CONCLUSIONS

According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.

Effect of price and access on contraceptive use

The Family Planning Program in Bangladesh has been very successful. The contraceptive prevalence rate (CPR) has increased from 13% in 1979 to 49% in 1996. Now that the program has matured and demand for family planning has been created, the Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh is concerned with increasing its financial sustainability. Options to increase financial sustainability include cost sharing and a gradual transition from doorstep to static clinic delivery of contraceptives. Many of these alternatives would involve additional travel time or charges for consumers, and it is important to estimate the effect that these additional prices would have on the use of contraception. The effect of economic constraints, such as cash price and access to services on contraceptive method use, the choice of contraceptive method and provider choice, has been analyzed, taking into account the socioeconomic factors that influence decision-making for individual family members. Two data sources have been used for this analysis: (1) a survey on use of contraception and (2) two baseline surveys of 1993 and 1994 in the two field sites of the MCH-FP Extension Project (Rural) of International Center for Diarrhoeal Disease Research, Bangladesh. No effect of cash prices was found on the probability of use of any contraceptive method, but clients were to a limited extent responsive to price in making choices about contraceptive methods and providers. In addition, couples were less likely to use contraception or choose methods if the travel time to fixed clinics was greater than 30 min.

The role of resource allocation models in selecting clinical preventive services

OBJECTIVE

To demonstrate the potential value and current limitations of using resource allocation models for selecting health services.

DESIGN

To identify the most efficient mix of preventive services that could be offered by a managed care organization (MCO) for a fixed budget, an optimization model (greatest number of life years saved) and a cost-effectiveness model (rank order of most to least cost effective) were developed. Because of the lack of cost-effectiveness analyses that met the study criteria, only 9 preventive services were selected to demonstrate each model.

PATIENTS AND METHODS

The 2 models were applied to a hypothetical managed care population of 100,000 enrollees with age, sex, and risk distribution similar to that of the US population. Data for the input variables were obtained from cost-effectiveness studies of 9 preventive services. Model variables included the target population, percent of enrollees who received the preventive service, the cost of the preventive service, life years saved, and cost-effectiveness ratios.

RESULTS

The models demonstrated that efficient allocation of finite resources can be achieved. When budgets are limited, different premises between the 2 models may yield different health consequences. However, as the budgets were increased, results from the 2 models were more closely aligned.

CONCLUSIONS

Resource allocation models have the potential for assisting MCOs in selecting a set of preventive services that will maximize population health. Before this potential can be fully realized, additional methodological development and cost-effectiveness studies are needed. The use of resource allocation should be examined for selecting all healthcare services.

Sexual regimes and sexual networking: the risk of an HIV/AIDS epidemic in Bangladesh

Bangladesh adjoins the Asian region with the severest AIDS epidemic and has common borders with two of the most affected areas, the Indian Hill States and northern Burma. There has been disagreement about the danger to Bangladesh, one view citing the likelihood of transmission from neighbouring infected populations and the other claiming that the country's predominantly Muslim culture protects it. This paper reports on a 1995-1997 research project. Preliminary research was carried out in Dhaka in 1995-1996 which suggested that the poor squatter areas might well sustain an epidemic. The experience also showed that more accurate measures of sexual networking could be obtained from males than females. The 1997 field research reported here investigated 983 males, 52% single and 48% married in Chittagong city and two more rural areas of Chittagong Division in southeast Bangladesh. It was found that around half of all males and probably a somewhat lower proportion of females, experience premarital sexual relations, with males having a lower level of extramarital than premarital relations. The factor heightening Bangladesh's risk of an epidemic is that one-quarter of single males and a significant but lower level of married males have had relations with prostitutes. This is one explanation for quite high levels of STDs in Bangladesh. The factors restricting the chances of a major national epidemic are the small number of premarital sexual episodes per person and the low level of intravenous drug use.

Coitus-dependent family planning methods: observations from Bangladesh

Some coitus-dependent methods of family planning, such as withdrawal, periodic abstinence, and the condom, require male involvement for their use, and using these methods in combination has proved to be sensible. An investigation of why male and female respondents in a survey conducted in Bangladesh often gave conflicting answers about which methods they were currently using, particularly about "traditional" methods and condoms, showed that inconsistency in their reports arose because these methods are used in combination to such an extent that they are difficult to distinguish. In order to obtain reliable responses about these methods, a survey approach different from the long-established one is required.

Assessment of health risk behaviors. A tool to inform consumers, providers, health care organizations, and purchasers

INTRODUCTION

Tobacco use, diet and physical activity patterns, and alcohol use are the leading causes of death in the United States. To make major improvements in the health status of the population, behavioral risk factors for disease must be addressed.

METHODS

We propose a brief survey of behavioral risk factors for enrollees of health care organizations, employer groups, or other adult populations that can be used to profile the health risk behaviors of a population, assess performance of prevention and risk reduction programs, or make comparisons with other populations. The survey contains questions about tobacco, diet, physical activity, alcohol, firearms, motor vehicle safety, sexual behavior, and drugs.

RESULTS

Recommendations for survey items, implementation, and calculation of performance measures are given.

CONCLUSIONS

Widespread adoption of this type of survey would be a major step forward in acknowledging the impact that behavior has on health and in furthering individual and organizational accountability for improving health risk behaviors.

Lack of evidence of transmission of HIV-1 to family contacts of HIV-1 infected children

Although a number of studies have documented that casual household contact does not result in the transmission of HIV, isolated cases of person-to-person transmission have been reported. We report a study of household transmission in which the families were unaware the children were infected with HIV and thus took no precautions to prevent transmission. Twenty-two family members of nine transfusion-associated HIV-infected children were studied for transmission of HIV in households. There was a total of 174 person-year of household exposure; 76 of these exposure years were before the diagnosis of HIV infection in the index child. All family members tested negative for HIV by ELISA. Sharing household facilities, and interactions with the infected child including kissing, bathing, sleeping with, and helping to bathe, dress, and eat, did not result in transmission. Interactions that could theoretically result in person-to-person transmission occurred in these households such as caring for nose bleeds, biting, and home health care procedures. The findings of this and other studies support the participation of HIV-infected infants and children in out-of-home care programs. It remains prudent, however, to observe current recommendations for prevention of HIV-1 for all individuals regardless of whether HIV status is known.

Designing HeartCare: custom computerized home care for patients recovering from CABG surgery

With the current trend toward discharge of cardiac artery bypass graft (CABG) patients from the hospital after 5 days, clinicians must make effective use of existing computer technology to provide more efficiently the services once available during the patient's lengthier hospital stay. This paper describes the design of the HeartCare initiative, a computerized cardiac recovery service designed to provide home-care support for patients in the first three months following CABG surgery. Capitalizing on the expansion in health resources on the Internet, and building on the lessons from the ComputerLink projects, HeartCare will employ the World Wide Web platform in the generation of personalized in-home computerized access to recovery resources. Key implementation decisions include selection of WebTV/ as the home-based device, and application of Metadata to organizing health-related knowledge resources on the WWW.

The complete genome sequence of the gram-positive bacterium Bacillus subtilis

Bacillus subtilis is the best-characterized member of the Gram-positive bacteria. Its genome of 4,214,810 base pairs comprises 4,100 protein-coding genes. Of these protein-coding genes, 53% are represented once, while a quarter of the genome corresponds to several gene families that have been greatly expanded by gene duplication, the largest family containing 77 putative ATP-binding transport proteins. In addition, a large proportion of the genetic capacity is devoted to the utilization of a variety of carbon sources, including many plant-derived molecules. The identification of five signal peptidase genes, as well as several genes for components of the secretion apparatus, is important given the capacity of Bacillus strains to secrete large amounts of industrially important enzymes. Many of the genes are involved in the synthesis of secondary metabolites, including antibiotics, that are more typically associated with Streptomyces species. The genome contains at least ten prophages or remnants of prophages, indicating that bacteriophage infection has played an important evolutionary role in horizontal gene transfer, in particular in the propagation of bacterial pathogenesis.

Comparison of hiking stick use on lateral stability while balancing with and without a load

To compare hiking stick use on lateral stability while balancing with or without a load (15-kg internal frame backpack) under conditions of no stick, 1 stick, and 2 sticks for six trials 15 volunteers ages 19 to 23 years (M = 21.7 yr.) were tested six separate times on a stability platform. During randomly ordered, 1-min. trials, the length of time (sec.) the subject maintained balance (+/-10 degrees of horizontal) and the number of deviations beyond 10 degrees were recorded simultaneously. Backpack and hiking sticks were individually adjusted for each subject. A 2 x 3 repeated factor analysis of variance indicated that subjects balanced significantly longer both with and without a load while using 2 hiking sticks than 1 or 0 sticks. Significantly fewer deviations beyond 10 degrees were found when subjects were without a load and using 1 or 2 sticks versus when they used none, and no significant difference in the number of deviations were found between 1 and 2 hiking sticks. When subjects were equipped with a load, significantly improved balance was found only between the 2 sticks and no sticks. Balance was significantly enhanced by using hiking sticks, and two sticks were more effective than one while carrying a load. An increase in maintenance of static balance may reduce the possibility of falling and injury while standing on loose alpine terrain.

Trends in age at the first medical evaluation of human immunodeficiency virus infection among infants born to infected mothers. New York City Pediatric Spectrum of HIV Disease Clinical Consortium

OBJECTIVE

To evaluate the trends in age at the first medical evaluation of human immunodeficiency virus (HIV) infection among infants enrolled in the Pediatric Spectrum of Disease study born to mothers infected with HIV.

DESIGN

Retrospective study based on medical chart review.

SETTING

Nine pediatric centers in New York City.

PARTICIPANTS

Infants (N = 925) born between January 1988 and December 1991 to mothers infected with HIV; the infants were examined for HIV infection by age 2 years and were receiving medical care.

RESULTS

In each successive birth cohort, an increasing proportion of infants was examined by 3 months of age (from 35% in 1988 to 76% in 1991, chi 2 = 38.1, P < .001). The median age at the first evaluation persistently declined among the cohort evaluated by 24 months. The median age decreased from 6 months in 1988 to less than 1 month in 1991. The proportion of infants who were examined because of HIV-related symptoms decreased in each successive birth cohort (1988, 65%; 1989, 59%; 1990, 42%; and 1991, 25%).

CONCLUSIONS

An increasing proportion of newborns exposed to HIV are being examined within the first 3 months of life in 9 leading pediatric HIV centers in New York City. Prenatal HIV counseling and testing of mothers are optimal procedures because they benefit mothers, they allow the use of zidovudine to reduce the chance of HIV infection in the infants, and they allow mothers with HIV to be counseled about the potential risks of breast-feeding. The family and the pediatrician must have knowledge of the infants' HIV status as early in life as possible to allow the necessary postnatal interventions, including Pneumocystis carinii pneumonia prophylaxis, which reduces morbidity and may prolong survival.

Invasive pneumococcal infections in human immunodeficiency virus-infected children

Invasive pneumococcal infection (IPI) is the most common serious bacterial infection in human immunodeficiency virus (HIV)-infected children. Data from a population-based pediatric HIV surveillance project were used to determine the incidence of IPI in HIV-infected children and to conduct a case-control study assessing potential risk factors for IPI in HIV-infected children. There were 50 episodes of IPI and a cumulative incidence of 6.1 cases/100 patient-years through age 7 years. Children with IPI were more likely to have a prior AIDS diagnosis (odds ratio, 4.2; 95% confidence interval, 1.2-15.1) and higher levels of IgG and IgM (P=.01) than were controls. In a separate case-control study, the manifestations of IPI in HIV-infected children were compared with those in HIV-negative controls. Focal complication rates in the 2 groups did not differ; however, HIV-infected children were less likely than controls to have leukocytosis (P<.001) and more likely to have isolates with penicillin resistance (P=.03).

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention

OBJECTIVE

To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections.

METHOD

The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost.

RESULTS

Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million.

CONCLUSION

Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

The family and demographic change in Sri Lanka

Sri Lanka has almost completed the demographic transition with low mortality rates and fertility rates approaching replacement levels. Sri Lanka shares these characteristics with the South Indian states of Kerala and Tamil Nadu in contrast to elsewhere in South Asia where mortality and especially fertility rates remain much higher. A key part of the explanation for these differences lies in the nature of the family. The Sri Lankan family is essentially the conjugal unit of husband, wife and dependent children whereas in northern South Asia agnatic relations between son and parents are central to family structure. Related to this family system the position of women in Sri Lankan society was relatively high in South Asian terms. Consequently women had a strong say in health and fertility behaviour. When required, for example, mothers take the initiative in seeking health care for themselves and their children. Importantly family structure has facilitated female education which is associated with both mortality and fertility decline. There are few concerns that the values imparted by secular education are contrary to the values of the family or to women's roles within it. The egalitarian family structure has also contributed to fertility decline by raising the costs of children and reducing the long-run benefits to be gained from them. Sri Lanka is particularly distinctive in the contribution of changes in female age at marriage to its fertility decline, marriage age having risen six years this century. This change has been accompanied in recent times by a shift from family-arranged to self-selected (love) marriage. The explanation lies in changes in the socio-economic system which have reduced the centrality of the family in wider social and economic relations, and placed a greater premium on an individual's own abilities and attributes.

Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group

BACKGROUND

Pneumocystis carinii pneumonia (PCP) remains a common and often fatal opportunistic infection among children infected with the human immunodeficiency virus (HIV). HIV-infected infants between three and six months of age are particularly vulnerable. Current guidelines recommend prophylaxis in children from birth to 11 months old who have CD4+ counts below 1500 cells per cubic millimeter.

METHODS

We used national surveillance data to estimate the annual incidence of PCP among children less than one year old. We reviewed the medical records of 300 children given a diagnosis of PCP between January 1991 and June 1993 to determine why treatment according to the 1991 guidelines for prophylaxis against PCP either was not given or failed to prevent the disease.

RESULTS

In our study the incidence of PCP in the first year of life among infants born to HIV-infected mothers changed little between 1989 and 1992. Among 7080 children born to HIV-infected mothers in 1992, PCP developed in 2.4 percent. Of 300 children with PCP diagnosed from January 1991 through June 1993, 199 (66 percent) had never received prophylaxis, and for 118 of those children (59 percent) exposure to HIV was first identified 30 days or less before the diagnosis of PCP. Among 129 children less than one year old, the CD4+ count declined by an estimated 967 cells per cubic millimeter (95 percent confidence interval, 724 to 1210 cells per cubic millimeter) during the three months before the diagnosis of PCP. Among infants in whom CD4+ counts were determined within one month of the diagnosis of PCP, 18 percent (20 of 113) had at least 1500 cells per cubic millimeter, a level higher than the currently recommended threshold for prophylaxis.

CONCLUSIONS

In the United States the incidence of PCP among HIV-infected infants has not declined. If this infection is to be prevented, infants exposed to HIV must be identified earlier, and prophylaxis must be offered to more children than the guidelines currently recommend.

Factors associated with early clinical recognition of children with perinatal human immunodeficiency virus infection. Northern California Pediatric HIV Consortium

Surveillance of children born to women with human immunodeficiency virus (HIV) infection at five pediatric regional centers assessed times and patterns of clinical recognition in these children. Regional HIV seroprevalences among childbearing women were used to assess the proportion of identified children born to HIV-infected women. In total, 415 children with perinatal HIV exposure were identified. Early age at first HIV evaluation was significantly associated with maternal intravenous drug use (3.2 vs. 7.2 months for other or unknown maternal risk, P = .01), birth county with population > 500,000 (3.5 vs. 8.2 months for population < or = 500,000, P = .003), and hospital with routine HIV screening of pregnant women (0.1 vs. 8.8 months for no screening, P = .006). Race did not correlate with age at first evaluation. Using maternal HIV seroprevalence rates for 1988-1991, 34%-50% of the expected number of infants born to HIV-infected women were in clinical care. Perception of increased maternal risk for HIV infection was associated with early clinical recognition of infants of HIV-infected women.

Perinatally acquired human immunodeficiency virus infection: extent of clinical recognition in a population-based cohort. Massachusetts Pediatric HIV Surveillance Working Group

To evaluate factors that may affect the timely diagnosis of children with human immunodeficiency virus (HIV) infection, we compared data derived from two population-based pediatric HIV studies. Data from anonymous newborn HIV serosurveys were used to estimate the number of children born to HIV-seropositive mothers. A statewide active surveillance project determined the number of HIV-exposed children who had been clinically recognized. Of 88,732 Massachusetts newborn specimens tested anonymously for HIV antibodies during a 12-month period (November, 1987, to October, 1988), 223 were positive. As of October, 1991, 78 of these children (35%) had been identified by a statewide network of infectious disease physicians. HIV-exposed children born in inner city hospitals were more likely to have come to medical attention than those born in suburban hospitals (47% vs. 17%). Among the 29 children with confirmed HIV infection (13% of 223), the initial evaluation for HIV occurred at an earlier age among children born in inner city hospitals than among children born in other areas. HIV testing practices that rely heavily on risk assessment may result in delayed diagnosis of HIV infection in children whose mothers are not perceived to be at risk.