A Phase 2 Trial of Peresolimab for Adults with Rheumatoid Arthritis

BACKGROUND

Peresolimab is a humanized IgG1 monoclonal antibody designed to stimulate the endogenous programmed cell death protein 1 (PD-1) inhibitory pathway. Stimulation of this pathway would be a novel approach to the treatment of patients with autoimmune or autoinflammatory diseases.

METHODS

In this phase 2a, double-blind, randomized, placebo-controlled trial, we assigned, in a 2:1:1 ratio, adult patients with moderate-to-severe rheumatoid arthritis who had had an inadequate response to, a loss of response to, or unacceptable side effects with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) or to biologic or targeted synthetic DMARDs to receive 700 mg of peresolimab, 300 mg of peresolimab, or placebo intravenously once every 4 weeks. The primary outcome was the change from baseline to week 12 in the Disease Activity Score for 28 joints based on the C-reactive protein level (DAS28-CRP). The DAS28-CRP ranges from 0 to 9.4, with higher scores indicating more severe disease. The primary comparison was between the 700-mg group and the placebo group. Secondary outcomes included the percentages of patients with American College of Rheumatology 20 (ACR20), ACR50, and ACR70 responses - defined as improvements from baseline of 20%, 50%, and 70% or more, respectively, in the numbers of tender and swollen joints and in at least three of five important domains - at week 12.

RESULTS

At week 12, the change from baseline in the DAS28-CRP was significantly greater in the 700-mg peresolimab group than in the placebo group (least-squares mean change [±SE], -2.09±0.18 vs. -0.99±0.26; difference in change, -1.09 [95% confidence interval, -1.73 to -0.46]; P<0.001). The results of the analyses of secondary outcomes favored the 700-mg dose over placebo with respect to the ACR20 response but not with respect to the ACR50 and ACR70 responses. Adverse events were similar in the peresolimab and placebo groups.

CONCLUSIONS

Peresolimab showed efficacy in a phase 2a trial in patients with rheumatoid arthritis. These results provide evidence that stimulation of the PD-1 receptor has potential efficacy in the treatment of rheumatoid arthritis. (Funded by Eli Lilly; ClinicalTrials.gov number, NCT04634253.).

Changes in health-related quality of life and associations with improvements in clinical efficacy: a Phase 2 study of mirikizumab in patients with ulcerative colitis

OBJECTIVE

Mirikizumab, a monoclonal antibody targeting the interleukin-23 p19 subunit, was effective in a Phase 2 study (NCT02589665) of moderately-to-severely active ulcerative colitis (UC). We studied mirikizumab's impact on health-related quality of life (HRQoL).

DESIGN

HRQoL was evaluated using the Inflammatory Bowel Disease Questionnaire (IBDQ) and 36-Item Short Form Health Survey (SF-36) Physical Component Score (PCS) and Mental Component Score (MCS). Mixed effects models for repeated measures compared score changes between mirikizumab and placebo groups. Additional analyses evaluated associations between HRQoL score changes and achievement of efficacy endpoints at weeks 12 and 52.

RESULTS

At week 12, IBDQ improved compared with placebo for all mirikizumab groups except mirikizumab 50 mg (50 mg, p=0.073; 200 mg, p<0.001; 600 mg, p<0.001). SF-36 PCS was significantly higher in all mirikizumab groups at week 12 (50 mg, p=0.011; 200 mg, p=0.022; 600 mg, p=0.002); MCS was significantly higher in mirikizumab 200 and 600 mg groups compared with placebo (50 mg, p=0.429; 200 mg, p=0.028; 600 mg, p<0.001). Achievement of clinical response and remission were associated with greater HRQoL improvements at week 12. Improvements in HRQoL scores were sustained through week 52. Of the clinical symptoms evaluated, reduction in rectal bleeding was associated with greater improvements in IBDQ and SF-36 scores.

CONCLUSION

Mirikizumab improved HRQoL in patients with moderately-to-severely active UC.

A-04 Acute Sports-Related Concussion Associations Between Cognitive Symptoms, Memory Performance, and Default Mode Network Hub Connectivity

Purpose: Disruptions in cognitive performance are commonly reported after a sports-related concussion (SRC) and may be related to brain network changes, particularly within the default mode network (DMN). Since well-connected brain regions across networks (hubs) play an important role in network organization, we hypothesize that DMN hubs will be disrupted after a SRC and associated with cognitive symptoms and cognitive performance. Methods: We collected resting-state fMRI, symptoms, and cognitive performance data from 44 student-athletes at baseline, after a SRC, and at recovery. Participation coefficient defined hubs for each athlete. We compared changes in functional connectivity between hubs and non-hubs within the DMN and between DMN hubs and non-hubs in the remaining networks. We used linear regression to examine the relationship between functional connectivity, cognitive symptoms, and cognitive performance while controlling for concussion history. Results: Functional connectivity between hubs and non-hubs within the DMN increased from baseline to post-injury and decreased from post-injury to recovery, but not to baseline connectivity levels. Post-injury functional connectivity was related to increased cognitive symptoms and decreased visual memory performance. Functional connectivity decreased between hubs in the DMN and non-hubs in the cingulo-opercular, salience, somatomotor, and visual networks from baseline to post-injury. Cognitive symptoms and visual memory performance were related to functional connectivity between DMN hubs and visual network non-hubs. Conclusions: Self-reported cognitive symptoms and cognitive performance were associated with changes in DMN hub connectivity. This relationship may suggest a decrease in efficiency between brain networks after a SRC and may provide insight into post-injury compensation during task performance.

Correlates of e-cigarette use among active duty US military personnel: implications for cessation policy

BACKGROUND

Electronic cigarette (or e-cigarette) use has grown substantially since its US market introduction in 2007. Although marketed as a safer alternative to traditional cigarettes, studies have shown they can also be a gateway to their use. The purpose of this investigation is to identify factors associated with different patterns of tobacco use among active duty military personnel.

METHODS

A secondary analysis was conducted using the 2014 Defense Health Agency Health Related Behaviors survey data. Results are based on 45 986 US military respondents, weighted to 1 251 606. Both univariate and regression analyses were conducted to identify correlates.

RESULTS

In 2014, approximately 7.8% of respondents reported using e-cigarettes at least once in the past year. Among e-cigarette users, 49% reported exclusive e-cigarette use. Prevalence of exclusive use is highest among white people (58%), Navy (33%), men (83%) and persons with income ≤$45 000 (65%). Regression comparing exclusive cigarette with exclusive e-cigarette users revealed higher odds of being Air Force (OR=2.19; CI 1.18 to 4.06) or Navy (OR=2.25; CI 1.14 to 4.41) personnel and being male (OR=1.72; CI 1.12 to 2.64), and more likely to not receive smoking cessation messaging from healthcare providers in the last 12 months (OR=2.88; CI 1.80 to 4.62). When comparing exclusive e-cigarette users with poly-tobacco users, e-cigarette users had higher odds of being Hispanic (OR=2.20; CI 1.02 to 4.78), college educated (OR=4.25; CI 1.22 to 14.84) and not receiving tobacco prevention/cessation messaging (OR=4.80; CI 2.79 to 8.27).

CONCLUSION

The results demonstrate that exclusive e-cigarette users in the military have unique characteristics when compared with groups of other/mixed tobacco users. Findings can inform cessation and prevention efforts to improve both the overall health and combat readiness of active duty military personnel.

A First-in-Human Phase I Study of a Bivalent MET Antibody, Emibetuzumab (LY2875358), as Monotherapy and in Combination with Erlotinib in Advanced Cancer

Purpose: The MET/HGF pathway regulates cell proliferation and survival and is dysregulated in multiple tumors. Emibetuzumab (LY2875358) is a bivalent antibody that inhibits HGF-dependent and HGF-independent MET signaling. Here, we report dose escalation results from the first-in-human phase I trial of emibetuzumab.Experimental Design: The study comprised a 3+3 dose escalation for emibetuzumab monotherapy (Part A) and in combination with erlotinib (Part A2). Emibetuzumab was administered i.v. every 2 weeks (Q2W) using a flat dosing scheme. The primary objective was to determine a recommended phase II dose (RPTD) range; secondary endpoints included tolerability, pharmacokinetics (PK), pharmacodynamics (PD), and antitumor activity.Results: Twenty-three patients with solid tumors received emibetuzumab monotherapy at 20, 70, 210, 700, 1,400, and 2,000 mg and 14 non-small cell lung cancer (NSCLC) patients at 700, 1,400, and 2,000 mg in combination with erlotinib 150 mg daily. No dose-limiting toxicities and related serious or ≥ grade 3 adverse events were observed. The most common emibetuzumab-related adverse events included mild diarrhea, nausea, and vomiting, and mild to moderate fatigue, anorexia, and hypocalcemia in combination with erlotinib. Emibetuzumab showed linear PK at doses >210 mg. Three durable partial responses were observed, one for emibetuzumab (700 mg) and two for emibetuzumab + erlotinib (700 mg and 2,000 mg). Both of the responders to emibetuzumab + erlotinib had progressed to prior erlotinib and were positive for MET protein tumor expression.Conclusions: Based on tolerability, PK/PD analysis, and preliminary clinical activity, the RPTD range for emibetuzumab single agent and in combination with erlotinib is 700 to 2,000 mg i.v. Q2W. Clin Cancer Res; 23(8); 1910-9. ©2016 AACR.

First-in-human dose escalation study of LY2875358 (LY), a bivalent MET antibody, as monotherapy and in combination with erlotinib (E) in patients with advanced cancer

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Background: Activation of the hepatocyte growth factor (HGF)/MET receptor pathway promotes tumor growth, invasion and dissemination. LY is a humanized IgG4 monoclonal bivalent antibody against MET which inhibits ligand dependent- and ligand independent activation of MET. Based on preclinical results, we examined LY alone in patients with advanced solid tumors and LY+E in advanced NSCLC patients. Methods: LY monotherapy was administered 20-2,000 mg Q2W IV to 23 patients with advanced solid tumors. Combination therapy with 700-2,000 mg Q2W IV of LY and E (150 mg QD) was completed in 14 patients with advanced NSCLC. The primary objective was to determine a recommended phase II dose (RPTD) for LY and LY+E. Secondary objectives included assessment of toxicity, PK, PD (including MET extracelluar domain and HGF), and antitumor activity. Results: LY and LY+E were well tolerated. No dose-limiting toxicities, serious adverse events, or ≥ Grade 3 adverse events (AEs) possibly related to LY have been observed. The most frequent (≥5% of patients) AEs possibly related to LY2875358 monotherapy were nausea (8.7 %), vomiting (8.7%), and diarrhea (8.7%). The most frequent (≥10% of patient) grade 1 or 2 adverse event possibly related to LY2875358 in patients treated with LY+E were fatigue (21.4%) and anorexia (14.3%). Durable PR according to RECIST were observed for LY (n=1) and LY+E (n=2 out of 13 evaluable patients; both PR patients positive for MET protein expression). Conclusions: LY appears to be safe when administered as single agent and in combination with E up to 2,000 mg Q2W IV. The RPTD of LY is 750 mg Q2W IV for monotherapy and in combination with E based on PK/PD data. Clinical trial information: NTC 01287546.

Search for long-lived doubly charged Higgs bosons in pp collisions at sqrt[s] = 1.96 TeV

We present a search for long-lived doubly charged Higgs bosons (H(+/- +/-)), with signatures of high ionization energy loss and muonlike penetration. We use 292 pb(-1) of data collected in pp collisions at sqrt[s] = 1.96 TeV by the CDF II detector at the Fermilab Tevatron. Observing no evidence of long-lived doubly charged particle production, we exclude H(+/- +/-)(L) and H(+/- +/-)(R) bosons with masses below 133 GeV/c(2) and 109 GeV/c(2), respectively. In the degenerate case we exclude H(+/- +/-) mass below 146 GeV/c(2). All limits are quoted at the 95% confidence level.

Reduced perivascular PO2 increases nitric oxide release from endothelial cells

Many studies have suggested that endothelial cells can act as "oxygen sensors" to large reductions in oxygen availability by increasing nitric oxide (NO) production. This study determined whether small reductions in oxygen availability enhanced NO production from in vivo intestinal arterioles, venules, and parenchymal cells. In vivo measurements of perivascular NO concentration ([NO]) were made with NO-sensitive microelectrodes during normoxic and reduced oxygen availability. During normoxia, intestinal first-order arteriolar [NO] was 397 +/- 26 nM (n = 5), paired venular [NO] was 298 +/- 34 nM (n = 5), and parenchymal cell [NO] was 138 +/- 36 nM (n = 3). During reduced oxygen availability, arteriolar and venular [NO] significantly increased to 695 +/- 79 nM (n = 5) and 534 +/- 66 nM (n = 5), respectively, whereas parenchymal [NO] remained unchanged at 144 +/- 34 nM (n = 4). During reduced oxygenation, arteriolar and venular diameters increased by 15 +/- 3% and 14 +/- 5%, respectively: NG-nitro-L-arginine methyl ester strongly suppressed the dilation to lower periarteriolar Po2. Micropipette injection of a CO2 embolus into arterioles significantly attenuated arteriolar dilation and suppressed NO release in response to reduced oxygen availability. These results indicated that in rat intestine, reduced oxygen availability increased both arteriolar and venular NO and that the main site of NO release under these conditions was from endothelial cells.

Teen Club: a nursing intervention for reducing risk-taking behavior and improving well-being in female African American adolescents

This article describes a nursing intervention called Teen Club that was designed to reduce risk-taking behavior and improve well-being in female African American adolescents. Participants were referred to Teen Club by their nurse practitioners, physicians, and a community health nurse who were working at an urban neighborhood health center's teen clinic. Referrals were based on factors such as parental substance abuse, lack of social and family support, and other characteristics thought to increase vulnerability to risk-taking behavior. The 2-year intervention included weekly group meetings co-led by a European American female community health nurse and a Latino American male community worker, supplemented by case management and home visits by both these persons. Findings from a retrospective group interview conducted with 11 of the 12 original participants are presented. This is the first step in a series of pilot studies designed to refine the Teen Club intervention in anticipation of a future prospective, randomized investigation of this health promotion and disease prevention model of nursing care.

Family connectedness and women's sexual risk behaviors: implications for the prevention/intervention of STD/HIV infection

The present study explores the relationship between connectedness with the intergenerational family and women's sexual risk-taking as a guide to the development of family-focused prevention and intervention. Cross-sectional interview data from a pilot study were analyzed for correlations between a number of self-reported, risky sexual practices, the range of extended family members with whom the respondent was in contact, and awareness of stories pertaining to intergenerational family history. Structured interviews were administered by female interviewers to 56 women from two contexts: a STD (sexually transmitted disease) Clinic (N = 26), and an inner-city, Hispanic Community Organization (N = 30). Knowledge of stories about grandparents or great-grandparents was a robust predictor of lower sexual risk-taking in the STD Clinic sample. This relationship persisted, but only at the trend level in the Community Organization sample. In both the total sample and the STD subsample, the number of categories of extended family members with whom a respondent was in at least monthly contact was correlated with less sexual risk-taking. Given the fundamental importance of the family system as the primary social unit, these findings argue for further family theory-based research and for its potential application in the development of health prevention and intervention. Implications for practice and future research are discussed.

Peer education project with persons who have experienced homelessness

This paper describes an unconventional health education project implemented by nurse practitioners in a nurse-managed clinic serving persons who are homeless. The nurse practitioners perceived that there were a number of potential barriers to providing health education to the homeless patients. These barriers included the fact that this patient population is part of a marginalized subculture affected by a variety of overwhelming social problems. An additional barrier was that the nurses often differed from their homeless patients in terms of race, gender, socioeconomic status, formal education, culture, and life experience. The nurse practitioners designed the Peer Health Education Project (PHEP) to try to overcome some of these barriers. The purpose of the PHEP was to increase the health education knowledge and empowerment of persons who had experienced homelessness so that they could serve as peer health educators with others who were living on the streets. The project model was based on the philosophy of Paulo Freire (1973). The peer health educators served as both leaders and participants in each education session. The educators set the agenda and the nurses acted as facilitators. The project was successful in preparing peer educators. Other indicators of the success of the project included increased empowerment, self-esteem, dignity, hope self-confidence, and community participation of the peer educators.

Clinical efficacy and safety of tolterodine compared to placebo in detrusor overactivity

PURPOSE

We evaluated the efficacy, patient acceptability and side effect profile of tolterodine, a new antimuscarinic agent for treating bladder overactivity.

MATERIALS AND METHODS

In our randomized, placebo controlled, parallel group study 123, 129 and 64 patients 18 years old or older with proved detrusor overactivity (idiopathic detrusor instability or detrusor hyperreflexia) were randomized to receive 1 or 2 mg. tolterodine, or placebo, respectively, twice daily for 12 weeks. Main outcome measures were number of voids per 24 hours, urine volume per void and episodes of urge incontinence per 24 hours on a frequency-volume chart with detailed recording of side effects.

RESULTS

After 12 weeks of treatment mean number of voids per 24 hours plus or minus standard deviation decreased from 11.2 +/- 3.1 to 9.0 +/- 2.6 with the 2 mg. dosage (p = 0.0045 versus placebo). At this dose mean urine volume per void increased from 155 +/- 52 to 190 +/- 70 ml. (p <0.0001 versus placebo), while mean number of incontinence episodes per 24 hours decreased from 3.6 +/- 4.0 to 1.8 +/- 3.1 (p = 0.19 versus placebo). Similar efficacy was observed in patients receiving the 1 mg. dose. Severe dry mouth was reported by only 2, 1 and 2% of patients given the 1 and 2 mg. dose, and placebo, respectively. There was no clinical or electrocardiographic evidence of significant cardiac adverse events.

CONCLUSIONS

Tolterodine administration resulted in a significant decrease in the frequency of voiding and improved voided volume but it was seldom associated with troublesome or severe side effects.

Lessons from a large outbreak of Escherichia coli O157:H7 infections: insights into the infectious dose and method of widespread contamination of hamburger patties

Between November 1992 and February 1993, a large outbreak of Escherichia coli O157:H7 infections occurred in the western USA and was associated with eating ground beef patties at restaurants of one fast-food chain. Restaurants that were epidemiologically linked with cases served patties produced on two consecutive dates; cultures of recalled ground beef patties produced on those dates yielded E. coli O157:H7 strains indistinguishable from those isolated from patients, confirming the vehicle of illness. Seventy-six ground beef patty samples were cultured quantitatively for E. coli O157:H7. The median most probable number of organisms was 1.5 per gram (range, < 0.3-15) or 67.5 organisms per patty (range, < 13.5-675). Correlation of the presence of E. coli O157:H7 with other bacterial indicators yielded a significant association between coliform count and the presence of E. coli O157:H7 (P = 0.04). A meat traceback to investigate possible sources of contamination revealed cattle were probably initially colonized with E. coli O157:H7, and that their slaughter caused surface contamination of meat, which once combined with meat from other sources, resulted in a large number of contaminated ground beef patties. Microbiological testing of meat from lots consumed by persons who became ill was suggestive of an infectious dose for E. coli O157:H7 of fewer than 700 organisms. These findings present a strong argument for enforcing zero tolerance for this organism in processed food and for markedly decreasing contamination of raw ground beef. Process controls that incorporate microbiological testing of meat may assist these efforts.

Results of a multicenter trial of the CapSure (Re/Stor) Continence shield on women with stress urinary incontinence

OBJECTIVES

To prospectively study the impact of the CapSure (Re/Stor) Continence shield for the treatment of stress urinary incontinence.

METHODS

One hundred women with pure stress urinary incontinence were enrolled in a 6-month study. Objective measures of urine loss included pad weight test (PdWt) and provocative stress test (PST). Subjective measures included incontinence diaries documenting the number of incontinence episodes per day (IEPD), quality of life questionnaires, and satisfaction surveys. Objective and subjective measures were performed prior to enrollment, during use of the CapSure shield, and after discontinuation of the device.

RESULTS

During the 12-week device utilization period, PdWt measurements demonstrated a 96% reduction in urine loss by week 1 and 97% by week 12. Eighty-two percent of subjects were completely dry by week 12. PST demonstrated 100% reduction in urine loss at each visit, with 91% of subjects completely dry by week 12. IEPD also demonstrated a 91% reduction in incontinence episodes by week 12. Quality of life scores and patient satisfaction surveys demonstrated significant improvement. During the 6-week post device utilization period (PUP), subjects continued to demonstrate a reduction in urine loss compared to pre-enrollment data, despite discontinuation of use. PdWt measurements demonstrated a 73% and 79% reduction in urine loss at weeks 14 and 18, respectively. Measurements of PST and IEPD demonstrated significant reductions in urine loss at weeks 14 and 18. A 1.5% prevalence of positive urine cultures was noted during device use. Bothersome vaginal or urethral irritation occurred in 12% of patients. Adverse events were few and required no therapeutic intervention.

CONCLUSIONS

The CapSure shield is a safe and efficacious method of managing stress urinary incontinence in women.

The risk of Guillain-Barré syndrome after tetanus-toxoid-containing vaccines in adults and children in the United States

OBJECTIVES

This study examined whether there is a risk that tetanus-toxoid-containing vaccines could cause Guillain-Barré syndrome and, if so, how large the risk is.

METHODS

This study was based on previous active surveillance epidemiological studies of Guillain-Barré syndrome and vaccination history.

RESULTS

A background rate of 0.3 cases of Guillain-Barré syndrome per million person-weeks has been estimated. By chance, 2.2 people with the syndrome would have received tetanus-toxoid-containing vaccine within the 6 weeks before onset, yet only 1 person had done so. Data on children show similar results.

CONCLUSIONS

If an association exists, it must be extremely rare and not of public health significance.

Hamburger-associated Escherichia coli O157:H7 infection in Las Vegas: a hidden epidemic

OBJECTIVES

This study sought to determine whether a multistate fast food hamburger-associated outbreak of Escherichia coli O157:H7 infection involved Las Vegas residents as well and, if so, why public health officials had not detected it.

METHODS

A matched case-control study was conducted among persons with bloody diarrhea and their healthy meal companions. Hamburger production, distribution, and cooking methods were reviewed. Unused hamburger patties were cultured, and E. coli O157:H7 isolates were characterized. Local laboratory stool culture practices were reviewed.

RESULTS

Fifty-eight cases of bloody diarrhea were identified. Illness was associated with eating regular hamburgers (matched odds ratio [OR] = 9.0, 95% confidence interval [CI] = 1.02,433.4), but 25% of ill persons reported eating only jumbo hamburgers. Regular and jumbo hamburger patties yielded E. coli O157:H7 indistinguishable from the lone clinical isolate. No local laboratory cultured routinely for E. coli O157:H7 until after the outbreak.

CONCLUSIONS

A large outbreak of E. coli O157:H7 infections escaped timely notice in Las Vegas because local laboratories did not culture for this pathogen. Health officials should encourage laboratories to screen at least all bloody stools on sorbitol-MacConkey medium.

Risk factors for fecal shedding of Escherichia coli O157:H7 in dairy calves

A case-control study was conducted to determine risk factors for fecal shedding of Escherichia coli O157:H7 (ECO) in dairy calves. Three herds previously found to lack calves that shed ECO in their feces were selected for each herd previously found to have calves that shed ECO. Fecal samples from 965 calves on 64 farms were tested for ECO by microbial culture. Sample prevalence of ECO in calves less than 8 weeks old was 1.4% and in calves 8 weeks or older was 4.8%. Calves were 3 times more likely to shed ECO after weaning than before weaning. Shedding of ECO was associated with grouping calves before weaning; feeding whole cottonseed was negatively associated with ECO shedding. The change in results between testing periods illustrated that an individual herd's status cannot be defined by a single testing of a small sample of cattle.

Antimicrobial-resistant epidemic Shigella dysenteriae type 1 in Zambia: modes of transmission

To determine the modes of transmission of an epidemic caused by Shigella dysenteriae type I (Sd1) in Zambia, a case-control study was conducted. Case-patients were more likely to have recent contact with a person with dysentery (P = .03) and to have a family member with preceding dysentery (P = .01). Case households were more likely to share their latrine (P = .06). Stored drinking water was obtained by hand-dipping a cup into wide-mouthed vessels or by pouring from narrow-mouthed vessels; case households were more likely to obtain drinking water only by hand-dipping (P = .03). Case-patients were more likely to have eaten relish (a cooked meat or vegetable dish; P = .03) purchased from a vendor. Evidence from this study suggests that Sd1 was transmitted by person-to-person spread, by water stored in vessels that permitted hand-dipping, and by prepared foods sold by vendors. Preventive measures should be directed at these risk factors.

Sequential 1H, 13C, and 15N NMR assignments and solution conformation of apokedarcidin

Kedarcidin is a recently discovered antitumor antibiotic chromoprotein. The solution conformation of the kedarcidin apoprotein (114 residues) has been characterized by heteronuclear multidimensional NMR spectroscopy. Sequence-specific backbone atom resonance assignments were obtained for a uniformly 13C/15N-enriched sample of apokedarcidin via a semiautomated analysis of 3D HNCACB, 3D CBCA-(CO)NH, 4D HNCAHA, 4D HN(CO)CAHA, 3D HBHA(CO)NH, and 3D HNHA(Gly) spectra. Side-chain assignments were subsequently obtained by analysis of (primarily) 3D HCCH-TOCSY and HCCH-COSY spectra. A qualitative analysis of the secondary structure is presented on the basis of 3J alpha NH coupling constants, deviations of 13C alpha and 13C beta chemical shifts from random coil values, and NOEs observed in 3D 15N- and 13C-edited NOESY-HSQC spectra. This analysis revealed a four-stranded antiparallel beta-sheet, a three-stranded antiparallel beta-sheet, and two two-standed antiparallel beta-sheets. The assignments of cross-peaks in the 3D NOESY spectra were assisted by reference to a preliminary model of apokedarcidin built using the program CONGEN starting from the X-ray structure of the homologous protein aponeocarzinostatin. An ensemble of 15 apokedarcidin solution structures has been generated by variable target function minimization (DIANA program) and refined by simulated annealing (X-PLOR program). The average backbone atom root-mean-square difference between the individual structures and the mean coordinates is 0.68 +/- 0.08 A. The overall fold of apokedarcidin is well-defined; it is composed of an immunoglobulin-like seven-stranded antiparallel beta-barrel and a subdomain containing two antiparallel beta-ribbons. Highly similar tertiary structures have been previously reported for the related proteins neocarzinostatin, macromomycin, and actinoxanthin. Important structural features are revealed, including the dimensions of the chromophore-binding pocket and the locations of side chains that are likely to be involved in chromophore stabilization.

Adolescent substance abuse: psychosocial factors

The prevention and management of adolescent substance abuse requires an understanding of the psychosocial context in which such a problem develops. This article reviews literature from the health and behavioral sciences and provides information about the prevalence of substance abuse, family and other psychosocial factors associated with substance abuse, and signs and symptoms of various kinds of substance abuse. Implications for school nursing practice are discussed and suggestions for implementation made.

An outbreak of cholera in Maryland associated with imported commercial frozen fresh coconut milk

In August 1991, the first outbreak of cholera associated with an imported commercial food product occurred among persons attending a private picnic. An epidemiologic investigation showed infection with toxigenic Vibrio cholerae O1, biotype El Tor, serotype Ogawa, in 4 of 6 persons who had consumed coconut milk imported from Thailand. In addition, the US Food and Drug Administration recovered toxigenic V. cholerae O1, biotype El Tor, serotype Ogawa, from 1 of 6 unopened bags of the same brand (but different shipment) of coconut milk as that consumed by infected persons. Investigation in Thailand of the manufacturing process of the implicated coconut milk showed several sanitary violations, suggesting that contamination had occurred during production. This outbreak suggests a model of entrance of V. cholerae into a population and shows the need to evaluate current methods of maintaining the safety of imported foods in the United States.

Overview of contemporary families

Perceptions and definitions of the term family have always been varied and complex. Hence, an overview of contemporary families is presented here from several perspectives. First, families as they have been perceived by nursing and social science theorists are reviewed. Demographic changes in the family over the last two decades are then presented, followed by an examination of issues faced by families as they change over time. Finally, families as they exist within varying cultural and social contexts are discussed. Emphasis is placed on the need for health care providers to be flexible in defining and working with individual patients and their families.

Lymphoma models for B-cell activation and tolerance. II. Growth inhibition by anti-mu of WEHI-231 and the selection and properties of resistant mutants

Regulation of the growth of murine B-cell lymphomas has been used as a model for tolerance induction. The inhibition by anti-immunoglobulin reagents of the growth of WEHI-231 and several variant clones has now been studied. The parental line is exquisitely sensitive to growth inhibition by heterologous or monoclonal anti-mu or anti-k reagents and ceases to incorporate thymidine within 24-48 hr of exposure to anti-immunoglobulin reagents. Growth inhibition is initially reversible, but prolonged exposure to anti-mu results in cell death. This inhibition is specific for immunoglobulin light and heavy chains since growth is not inhibited by antibodies directed at either class I or class II histocompatibility antigens. In order to study the mechanism of growth inhibition, we have mutagenized WEHI-231 with ethylmethane sulfonate and cloned the surviving colonies in the presence of anti-mu. Such variants, which have been repeatedly recloned, are able to grow normally in the presence of anti-mu up to 100 micrograms/ml. These "resistant" clones, while expressing amounts of surface IgM similar to that observed on WEHI-231, do not differ markedly in their ability to cap their immunoglobulin receptors compared to the parental line but appear to have lost class II antigens. Cell cycle analysis revealed that anti-mu causes a block in the transition of WEHI-231 from G1 to S phase. The relevance of these processes to models of B-cell tolerance induction are discussed.

Attitudes about death in the nursing home: a research note

An increasing percentage of the U.S. population dies in nursing homes. Despite the increased attention given to the topic of death, most nursing homes practice a covert approach. A total of 86 residents and staff members from 2 nursing homes support this finding; yet many expressed an interest in modifying the policy. A majority believed that others should be told about the death of a resident. Respondents reported the interview process to be satisfying.

Functional maturation of motor nerve terminals in the avian iris: ultrastructure, transmitter metabolism and synaptic reliability

1. The transformation of easily fatigued embryonic neuromuscular junctions into highly reliable mature terminals was examined by studying functional and morphological changes during development of the avian iris. The mature ability to follow repetitive electrical nerve stimulation was correlated with the rate of acetylcholine (ACh) synthesis and choline uptake, and with the fine structure of the nerve terminals and the post-synaptic elements.2. The terminals of the ciliary nerve of the chick initially form functional synaptic contacts with the iris muscle at embryonic St. 34-40. At the onset of this period, no Na(+)-dependent high affinity choline uptake can be demonstrated, and the low level of ACh synthesis present is sensitive to Na(+) removal. At St. 36 [(3)H]ACh synthesis begins to increase, the increment being Na(+)-dependent.3. ACh synthesis in the embryonic iris was insensitive to a conditioning [K(+)](o) depolarization even as late as St. 43. Just before hatching, depolarization elicits some augmentation in synthesis, but by 2 days ex ovo this release-induced response has increased by an order of magnitude.4. Concurrently with the acquisition of the ability to respond to depolarization with accelerated synthesis, neuromuscular transmission in the iris becomes reliable and secure during stimulation at 20 Hz. Embryonic junctions rapidly block during such stimulation, and the failure is shown to be presynaptic in origin, resulting most probably from failure to sustain adequate levels of transmitter release.5. Ultrastructural examination of the developing ciliary terminals revealed few synaptic vesicles at early stages, and a dearth of other specializations. The sequence of development from these small structurally undistinguished endings to large en plaque junctions completely filled with vesicles was reconstructed and compared to other neuromuscular junctions. Morphological maturation appears progressive with little evidence of discontinuity signalling functional status, but it is only after the terminals enlarge and become closely packed with vesicles that mature synaptic reliability is found.6. The temporal correlation between responsiveness of transmitter synthesis to depolarization and reliable neuromuscular transmission suggests that modulation of neurotransmitter metabolism in response to demand signals the achievement of junctional maturity.