Risdiplam in Patients Previously Treated with Other Therapies for Spinal Muscular Atrophy: An Interim Analysis from the JEWELFISH Study

INTRODUCTION

Risdiplam is a survival of motor neuron 2 (SMN2) splicing modifier for the treatment of patients with spinal muscular atrophy (SMA). The JEWELFISH study (NCT03032172) was designed to assess the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of risdiplam in previously treated pediatric and adult patients with types 1-3 SMA. Here, an analysis was performed after all patients had received at least 1 year of treatment with risdiplam.

METHODS

Patients with a confirmed diagnosis of 5q-autosomal recessive SMA between the ages of 6 months and 60 years were eligible for enrollment. Patients were previously enrolled in the MOONFISH study (NCT02240355) with splicing modifier RG7800 or treated with olesoxime, nusinersen, or onasemnogene abeparvovec. The primary objectives of the JEWELFISH study were to evaluate the safety and tolerability of risdiplam and investigate the PK after 2 years of treatment.

RESULTS

A total of 174 patients enrolled: MOONFISH study (n = 13), olesoxime (n = 71 patients), nusinersen (n = 76), onasemnogene abeparvovec (n = 14). Most patients (78%) had three SMN2 copies. The median age and weight of patients at enrollment was 14.0 years (1-60 years) and 39.1 kg (9.2-108.9 kg), respectively. About 63% of patients aged 2-60 years had a baseline total score of less than 10 on the Hammersmith Functional Motor Scale-Expanded and 83% had scoliosis. The most common adverse event (AE) was upper respiratory tract infection and pyrexia (30 patients each; 17%). Pneumonia (four patients; 2%) was the most frequently reported serious AE (SAE). The rates of AEs and SAEs per 100 patient-years were lower in the second 6-month period compared with the first. An increase in SMN protein was observed in blood after risdiplam treatment and was comparable across all ages and body weight quartiles.

CONCLUSIONS

The safety and PD of risdiplam in patients who were previously treated were consistent with those of treatment-naïve patients.

Workforce predictive risk modelling: development of a model to identify general practices at risk of a supply-demand imbalance

OBJECTIVE

This study aimed to develop a risk prediction model identifying general practices at risk of workforce supply-demand imbalance.

DESIGN

This is a secondary analysis of routine data on general practice workforce, patient experience and registered populations (2012 to 2016), combined with a census of general practitioners' (GPs') career intentions (2016).

SETTING/PARTICIPANTS

A hybrid approach was used to develop a model to predict workforce supply-demand imbalance based on practice factors using historical data (2012-2016) on all general practices in England (with over 1000 registered patients n=6398). The model was applied to current data (2016) to explore future risk for practices in South West England (n=368).

PRIMARY OUTCOME MEASURE

The primary outcome was a practice being in a state of workforce supply-demand imbalance operationally defined as being in the lowest third nationally of access scores according to the General Practice Patient Survey and the highest third nationally according to list size per full-time equivalent GP (weighted to the demographic distribution of registered patients and adjusted for deprivation).

RESULTS

Based on historical data, the predictive model had fair to good discriminatory ability to predict which practices faced supply-demand imbalance (area under receiver operating characteristic curve=0.755). Predictions using current data suggested that, on average, practices at highest risk of future supply-demand imbalance are currently characterised by having larger patient lists, employing more nurses, serving more deprived and younger populations, and having considerably worse patient experience ratings when compared with other practices. Incorporating findings from a survey of GP's career intentions made little difference to predictions of future supply-demand risk status when compared with expected future workforce projections based only on routinely available data on GPs' gender and age.

CONCLUSIONS

It is possible to make reasonable predictions of an individual general practice's future risk of undersupply of GP workforce with respect to its patient population. However, the predictions are inherently limited by the data available.

Hair analysis to monitor adherence to prescribed chronic inhaler drug therapy in patients with asthma or COPD

BACKGROUND

Poor adherence to inhaled drug therapy in individuals with asthma and/or chronic obstructive pulmonary disease (COPD) may be associated with suboptimal therapeutic outcomes. Measurement of drug residues in hair samples has been employed to assess oral medication use over time. Here, we test the feasibility of analyzing hair samples from patients with asthma and/or COPD for assessing adherence to prescribed inhaled medication.

METHODS

In total, 200 male and female subjects, ≥ 18 years of age, with stable asthma and/or COPD who were receiving an acceptable standard of care daily inhaled product consistently, were recruited. Head hair samples were taken during a single visit to the clinical site and grouped by hair color according to the Fischer-Saller scale. Drug residues were extracted from milled hair samples using solid-phase extraction and analyzed using liquid chromatography-tandem mass spectrometry.

RESULTS

Inhaled drugs were detected in hair for 72% of subjects from whom it was possible to analyze hair samples (n = 157/200). Most hair samples obtained from subjects receiving formoterol or vilanterol had amounts of drug present that allowed determination of a quantifiable concentration, and demonstrated a dose response. Drugs were detected in all hair colors, with higher concentrations of formoterol observed in dark-haired versus light-haired individuals.

CONCLUSIONS

This is the first study to demonstrate that inhaled medication can be measured in hair samples from subjects with asthma and/or COPD. The results show that hair drug concentration data could potentially provide a record of historical adherence to inhaled therapeutics.

Systemic Exposures of Fluticasone Propionate and Salmeterol Following Inhalation via Metered Dose Inhaler with the Mini Spacer Compared with the Aerochamber Plus Spacer

BACKGROUND

The Mini Spacer has been developed for use with Ventolin(®) metered dose inhalers (MDIs) to improve accessibility to affordable spacers in developing countries. To ensure patient safety is not compromised if the Mini Spacer is used off-label with fluticasone propionate (FP) or salmeterol/FP combination (SFC) MDIs (currently not recommended), this study compared the systemic exposure of FP and salmeterol following delivery of FP and SFC MDIs with the Mini Spacer and the Aerochamber Plus(®) spacer (Aerochamber).

METHODS

This was an open-label, randomized, single dose, crossover study in healthy subjects that evaluated four treatments: i) FP 250 μg MDI with Mini Spacer; ii) FP 250 μg MDI with Aerochamber; iii) SFC 25/250 μg with Mini Spacer; iv) SFC 25/250 μg with Aerochamber. There was a minimum 7 day washout between treatments. Pharmacokinetic samples were collected over 24 hours post-dose. The co-primary endpoints were FP area under the concentration-time curve from time zero to 24 h [FP AUC(0-24)] and salmeterol maximum plasma concentration [Cmax].

RESULTS

FP systemic exposure in terms of AUC(0-24) was lower following inhalation with the Mini Spacer compared with the Aerochamber for both FP 250 μg (Mini Spacer/Aerochamber Ratio 0.76 [90% CI: 0.57-1.01]) and SFC 25/250 μg (Ratio 0.74 [90% CI: 0.56-0.99]). Salmeterol systemic exposure was also lower following SFC 25/250 μg with Mini Spacer compared with Aerochamber (Cmax Ratio 0.90 [90% CI 0.48-1.66]). The incidence of adverse events was low and similar with each treatment.

CONCLUSIONS

In the event of use of the Mini Spacer with FP and SFC MDIs, which is not recommended, FP and salmeterol systemic exposure is unlikely to be higher than if MDIs were to be used with the Aerochamber. However, these data do not indicate that the Mini Spacer and Aerochamber are interchangeable.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review

BACKGROUND

Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients.

DATA SOURCES

Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature.

REVIEW METHODS

A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin.

RESULTS

Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY.

LIMITATIONS

The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses.

CONCLUSION

The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Meta-analysis of mortality and cancer incidence among workers in the synthetic rubber-producing industry

Production of synthetic rubber involves exposure to several potentially harmful chemicals. The authors carried out a systematic review and meta-analysis of cohort studies of workers in the rubber-producing industry. Data were obtained from computerized literature searches of several databases from their inception through December 2003. The reference lists of identified articles were inspected for further relevant articles. The authors conducted random-effects meta-analyses of log standardized mortality ratios (SMRs)/standardized incidence ratios. Heterogeneity between study results was explored through subgroup analyses and meta-regression on cohort demographic factors and study quality indicators. The authors identified 36 published articles reporting information on 31 different cohort groups. The meta-SMR was 0.86 (95% confidence interval (CI): 0.82, 0.91) for all-cause mortality (28 cohorts) and 0.94 (95% CI: 0.89, 1.01) for all malignant neoplasms (27 cohorts). Heterogeneity was observed for these endpoints and for the majority of disease-specific outcomes. Statistically significant excesses were observed for diabetes (meta-SMR=1.36, 95% CI: 1.17, 1.59) (five cohorts) and leukemia (meta-SMR=1.21, 95% CI: 1.03, 1.43) (16 cohorts), the latter particularly for persons working exclusively in nontire manufacturing (meta-SMR=1.70, 95% CI: 1.14, 2.54) (four cohorts). Excesses highlighted in previous narrative reviews were not substantiated. Interpretation of these results is complicated by substantial unexplainable heterogeneity; small excesses in specific mortality outcomes may have been disguised by the healthy worker effect.

The possible effects on health, comfort and safety of aircraft cabin environments

A consultation was undertaken to investigate the views and concerns of stakeholders in the aircraft industry about the possible harmful effects on personal health, comfort and safety of aircraft cabin environments. Stakeholders were identified from a variety of sources including Government agencies, the Internet, House of Lords inquiry, and suggestions of interviewees. They represented: aircraft crews, aircraft constructors and engineers, government departments and authorities, holiday/flight companies, insurance companies, non-governmental organisations, occupational health physicians, passenger representatives, and independent researchers and consultants. Eighty-seven were contacted of which 57 were interviewed over the telephone using a semi-structured questionnaire. Their concerns were transcribed into a standard format and analysed qualitatively. Key stakeholders, along with Government officials, were invited to a workshop to discuss and prioritize the issues raised during the interviews. The main concerns expressed by the participants fell into five main areas: deep vein thrombosis, air quality, infection, cosmic radiation, and jet lag and work patterns. In addition, a number of safety concerns were raised as well as comments on the provision of appropriate advice to passengers. It was generally felt that further research was required on each of these subjects, as well as an improvement in the quality, quantity and availability of information provided for passengers prior to boarding a flight.

Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder

BACKGROUND

The view that severe personality disorder (SPD) is untreatable derives from poor-quality studies of treatment outcome which use indirect measures of SPD pathology. This study evaluates the impact of psychotherapeutic in-patient treatment on core personality disorder symptoms.

METHOD

137 SPD patients completed the Borderline Syndrome Index (BSI) on referral and one year post-treatment ('admitted', n = 70) or one year post-referral ('non-admitted', n = 67); 22 of the non-admitted group were refused extra-contractual referral funding for their treatment.

RESULTS

There was a significantly greater reduction in BSI scores in the treated than in the non-admitted group. Changes in BSI scores were significantly positively correlated with length of treatment. Assessment of the reliability and clinical significance of changes in individual subjects showed that the magnitude of this change was reliable and clinically significant in 42.9% of the admitted sample, compared with only 17.9% of the non-admitted sample (18.2% of the unfunded group).

CONCLUSIONS

Specialist in-patient treatment is effective in reducing core SPD psychopathology.

Beneficial effects of corticosteroids on ocular myasthenia gravis

OBJECTIVE

To determine if moderate-or low-dose corticosteroid therapy can reduce the diplopia and frequency of deterioration to generalized disease in ocular myasthenia gravis.

DESIGN

Retrospective record review.

SETTING

Two university-based neuro-ophthalmology services.

PATIENTS

All 32 patients with ocular myasthenia gravis, treated with prednisone, followed up for a minimum of 2 years were included. Patients were treated with 1 or more courses of daily prednisone (highest initial dose, 40-80 mg) gradually withdrawn over 4 to 6 weeks. Subsequently, in 6 patients, 2.5 to 20 mg of prednisone was given on alternate day.

OUTCOME MEASURES

Diplopia in the primary position or downgaze diplopia and generalized myasthenia gravis after 2 years of follow-up.

RESULTS

Diplopia, which was initially found in the primary position in 29 patients and in the downgaze position in 26 patients, was absent in 21 patients at 2 years. Generalized myasthenia gravis occurred in 3 patients at 2 years. Elevated serum acetylcholine receptor antibody levels and abnormal electromyography findings were not predictive of worsening. No patient experienced a major steroid complication.

CONCLUSIONS

Moderate-dose daily prednisone for 4 to 6 weeks, followed by low-dose alternate-day therapy as needed, can control the diplopia in patients with ocular myasthenia gravis. The frequency of deterioration to generalized myasthenia gravis at 2 years may be reduced; 9.4% in this study compared with more than 40% previously reported frequency. Corticosteroids may be useful even when ocular motor dysfunction is not normalized.

Venous obstruction as the cause of retinal/choroidal dysfunction associated with arteriovenous shunts in the cavernous sinus

OBJECTIVE

To determine the hemodynamic abnormalities that result in visual acuity loss because of retinal or choroidal dysfunction associated with arteriovenous shunts (AVS) that involve the cavernous sinus.

METHODS

Retrospective study of the records of 250 patients with either a carotid cavernous fistula or dural arteriovenous malformation revealed a total of 10 patients with vision loss secondary to retinopathy (group I) or choroidal effusion (group II). The cerebral angiograms of these 10 patients and 10 additional patients with visual dysfunction due to elevated intraocular pressure (group III) were evaluated to determine whether the three groups could be distinguished by a specific vasculopathic pattern. Particular attention was given to the extent of thrombosis in the ophthalmic venous system and cavernous sinus.

RESULTS

There were angiographic signs of severe thrombosis in the ophthalmic vein in nine patients and in the cavernous sinus in seven patients ipsilateral to the retinal or choroidal lesion. In contrast, in group III, severe thrombosis in the ipsilateral ophthalmic vein and in the cavernous sinus occurred in one and two patients, respectively. Closure of the AVS improved the visual acuity in 1 of 4 patients in group I and in 4 of 5 patients in group II, and normalized the intraocular pressure in all patients.

CONCLUSIONS

Ophthalmic vein thrombosis, rather than arterialization of the venous system or an arterial "steal, " is the principal cause of retinal or choroidal dysfunction associated with AVS to the cavernous sinus. Following AVS closure, visual recovery is more frequent with choroidal effusion or detachment rather than with retinopathy.

Medical applications of single-chain antibodies

A single-chain antibody or single-chain Fv (sFv) incorporates the complete antibody binding site in a single polypeptide chain of minimal size, with an approximate molecular weight of 26,000. In antibodies, the antigen combining site is part of the Fv region, which is composed of the VH and VL variable domains on separate heavy and light chains. Efforts over nearly two decades have indicated that Fv fragments can only rarely be prepared from IgG and IgA antibodies by proteolytic dissection. Beginning in 1988, single-chain analogues of Fv fragments and their fusion proteins have been reliably generated by antibody engineering methods. The first step involves obtaining the genes encoding VH and VL domains with desired binding properties; these V genes may be isolated from a specific hybridoma cell line, selected from a combinatorial V-gene library, or made by V gene synthesis. The single-chain Fv is formed by connecting the component V genes with an oligonucleotide that encodes an appropriately designed linker peptide, such as (Gly4-Ser)3. The linker bridges the C-terminus of the first V region and N-terminus of the second, ordered as either VH-linker-VL or VL-linker-VH. In principle, the sFv binding site can faithfully replicate both the affinity and specificity of its parent antibody combining site, as demonstrated in our model studies with the 26-10 anti-digoxin sFv. Furthermore, the sFv remains stable at low concentrations that promote VH and VL dissociation from the Fv heterodimer, resulting in loss of Fv binding. Intravenously administered sFv proteins exhibit accelerated biodistribution and exceptionally fast clearance compared to IgG or Fab. These pharmacokinetic properties allow rapid imaging by sFv, which therefore may be labeled with a short-lived isotope such as Tc-99m. Expression of a single gene product from fused sFv and effector genes facilitates immunotargeting of the effector protein, as shown for single-chain Fv toxin fusion proteins.

Maculopathy caused by intra-arterially administered cisplatin and intravenously administered carmustine

Eight patients with malignant gliomas were monitored with clinical examinations to study the effects of the combination of intravenous administration of carmustine and infraophthalmic intra-arterial administration of cisplatin on retinal and optic nerve function. Three patients developed a severe macular retinal pigment abnormality in the eye ipsilateral to the intra-arterial infusion. Electrophysiologic studies disclosed no evidence of a generalized disturbance in the photoreceptors, middle retinal layers, or retinal pigment epithelium. In contrast to previous studies involving patients whose visual loss was caused by vaso-occlusive lesions in the retina and optic nerve, our study involved patients with clinically significant maculopathy, that was not vascular in origin and that developed after treatment with carmustine and cisplatin. We suggest that the deficit may result from a localized retinal pigment disturbance in the macula.

Increasing gene expression in yeast by fusion to ubiquitin

Heterologous gene expression in yeast can be increased up to several hundred-fold by expressing a foreign gene as a fusion to the ubiquitin gene. An endogenous yeast endoprotease (Ub-Xase) removes the ubiquitin from the fusion product to produce the authentic protein. The utility of this technique has been demonstrated by expression of three different proteins in yeast as both unfused and ubiquitin-fused forms: 1) the alpha subunit of the mammalian stimulating G-protein of the adenylate cyclase complex (Gs alpha); 2) a soluble fragment of the T cell receptor protein (sCD4); and 3) the protease domain of human urokinase (UKP). The sequence specificity of the Ub-Xase was demonstrated by mutagenesis of the carboxyl-terminal glycine of ubiquitin to an alanine, which inhibited ubiquitin removal in vivo. Processing of the ubiquitin-Gs alpha fusion protein (ub-Gs alpha) in vivo resulted in Gs alpha which could be reconstituted in mammalian membrane preparations and had the same specific activity as the authentic Gs alpha expressed in yeast. The yeast Ub-Xase has also been shown to work in vitro by the processing of a ub-sCD4 fusion protein synthesized in Escherichia coli. This technology should greatly enhance the utility of yeast for heterologous protein production.

Management of nontraumatic vascular shunts involving the cavernous sinus

The authors managed 38 consecutive cases of nontraumatic vascular shunts involving the cavernous sinus. Selective angiography demonstrated 12 carotid cavernous fistulas (CCFs) and 26 dural arteriovenous shunts (DAVSs). Visual disability occurred from glaucoma, venous retinopathy, optic neuropathy, or diplopia. Ten patients with slow-flow shunts and minimal dysfunction were treated medically to lower intraocular pressure (IOP) and/or instructed in manual compression of the internal carotid artery, ipsilateral to the lesion, using the contralateral hand. Percutaneous intraarterial embolization using detachable balloons, isobutylcyanoacrylate, or polyvinyl alcohol particles was successful in 16/18 DAVSs and 9/10 CCFs. The neuro-ophthalmic signs resolved in these 25 cases. Complications occurred in five patients. These included a transient hemiparesis, twelfth nerve palsy, unilateral nasal field loss, a pseudoaneurysm causing a third-nerve paresis, and temporary cavernous sinus thrombosis. Conservative therapy in mild cases and embolization in cases with visual disability or progressive signs are warranted.

Regulation of NAD metabolism in Salmonella typhimurium: genetic analysis and cloning of the nadR repressor locus

The nadR locus (99 min) controls the transcription of several genes involved with either the biosynthesis (nadAB) or recycling (pncB) of NAD in Salmonella typhimurium. Point mutations in this locus were found to cause defects either in the transport of nicotinamide mononucleotide (PnuA-), the regulation of nadAB (NadR-) or both transport and regulation (PnuA-NadR-). Deletions or insertions into nadR always resulted in the PnuA- NadR- phenotypes. Merodiploids constructed with various combinations of PnuA-, NadR- or PnuA- NadR- strains indicate a single complementation group. The results suggest the NadR product is a bifunctional regulatory protein. Operon fusions to lacZ (nadR :: Mud1-8) were used to show that nadR is not autoregulated and is transcribed in a clockwise direction. The gene was also cloned and located within a 2 kb EcoR1-Bg/II fragment.

Oxygen-regulated stimulons of Salmonella typhimurium identified by Mu d(Ap lac) operon fusions

Using the technique of Mu d1(Ap lac)-directed lacZ operon fusions, several oxygen-regulated genetic loci were identified in Salmonella typhimurium. Thirteen anaerobically inducible and six aerobically inducible operon fusions were identified. Based on control by the oxrA and oxrB regulatory loci, the anti-lacZ fusions were grouped into three classes: class I loci were regulated by both oxr loci, class II genes were regulated by oxrA only, and class III loci were not affected by either regulatory locus. Several of the anti-lacZ fusions required growth in complex medium before they exhibited the inducible phenotype. While the expression of some of these loci was repressed when organisms were grown in nitrate, others were stimulated by nitrate. Fusions into the hyd and phs loci were identified among the isolated anti-lacZ fusions. Six oxygen-inducible (oxi) operon fusions were also identified. Two of the oxi loci mapped near oxygen-regulatory loci: oxiC near oxrA and oxiE near oxyR. However, neither fusion appeared to occur within the regulatory locus. The data presented serve to further define the aerobic and anaerobic stimulons of S. typhimurium but indicate additional regulatory circuits above those already defined.

Formation of termination-resistant transcription complex at phage lambda nut locus: effects of altered translation and a ribosomal mutation

Transcription antitermination by lambda N gene product is affected in a mutant Escherichia coli with altered ribosomal protein S10, caused by the nusE71 mutation. To study the role of translation in antitermination, we have fused the phage nutR locus, the site of action of N, with the lac regulatory region. We have monitored N action by measuring galactokinase, whose synthesis depends on suppression of terminators located between nutR and the galK cistron. We show that a deletion removing potential ribosome binding signals and AUG codons from the upstream region of nut site does not affect N action. Moreover, the lack of translation upstream of nutR does not overcome the antitermination defect caused by nusE mutation. When the upstream region is translated, however, N action is impaired if translation terminates 19 base pairs upstream of nutR . Termination of translation at further upstream sites, such as 23 or 97 base pairs upstream, does not interfere with N action. Our results suggest that the S10 ribosomal protein is required for N action without involving translation. These results also suggest that the nut site RNA itself plays an important role in the formation of a termination-resistant transcription complex.

Hallucinatory experiences of prelingually profoundly deaf schizophrenics

The communication difficulties of prelingually profoundly deaf patients render psychiatric diagnosis extremely difficult. A study of 12 prelingually profoundly deaf schizophrenic patients revealed that visual hallucinations occurred in 10, and 10 also had experiences analogous to auditory hallucinations although voices may not have been heard.

A psychiatric unit for the deaf

Lack of speech, i.e. dumbness, has long been equated with backwardness, and probably for this reason and because of success in teaching some hearing impaired children to speak, the terms ‘deaf and dumb’ and ‘deaf mute’ have fallen into disrepute. When deafness is profound and prelingual (i.e. congenital or acquired in early infancy), there is a formidable barrier to the development of language. Many deaf children still leave school with poor language, incomprehensible speech and little ability in lip reading and consequently come to rely upon manual communication methods (finger spelling and signing).