Maternal and neonatal outcomes associated with illness severity of maternal COVID-19

BACKGROUND

Several reports demonstrated that perinatal SARS-CoV-2 has significant impact on maternal and neonatal health outcomes. However, the relationship between severity of maternal illness with outcomes remains less clear.

METHODS

This is a single-center retrospective cohort study of mother/infant dyads with positive maternal test for SARS-CoV-2 between 14 days prior and 3 days after delivery from 3/30/2020 to 12/28/2021.

RESULTS

Among 538 mothers, those with moderate/severe/critical illness were more likely to undergo induction, receive oxygen, mechanical ventilation or ECMO. Mortality was significantly higher among the mothers with severe illness than asymptomatic and those with mild illness (6% vs 0% and 0%, respectively, P < 0.05). Neonates born to mothers with moderate/severe/critical illness were more likely to be preterm with lower birth weight, and to be admitted to the NICU (P < 0.05) but not to be small for gestational age. Mild maternal illness was only associated with NICU admission for isolation precaution and decreased rate of breastfeeding.

CONCLUSIONS

Maternal illness severity was significantly associated with prematurity and several adverse maternal and neonatal outcomes.

Antibiotic duration and gastric dysmotility in preterm neonates

OBJECTIVES

Prolonged antibiotic use after birth is associated with neonatal feeding intolerance and functional gastrointestinal disorders (FGIDs). A gastric dysrhythmia (tachygastria) with frequencies >4-9 cycles per minute, measured by electrogastrography (EGG), is associated with FGIDs. The relationship between prolonged antibiotic use and % time spent in tachygastria is unknown in preterm infants. We aimed to compare weekly changes in % tachygastria between preterm infants receiving long (>48 h) versus short (≤48 h) courses of antibiotics for early onset sepsis evaluation (initiated at <3 days of life).

METHODS

This was a longitudinal, prospective cohort study of 88 preterm infants (<34 weeks' gestation) with weekly EGG recordings from the first week of life until 40 weeks' post-menstrual age, discharge, or death. We calculated % of EGG recording time in tachygastria and determined the mean across weekly sessions. A mixed effects model assessed variance in % tachygastria between the short- and long-antibiotic exposure groups across all weeks.

RESULTS

Baseline characteristics were similar between the two groups. There was no difference in % tachygastria between short and long antibiotic exposure groups across nine postnatal weeks (p = 0.08).

CONCLUSIONS

Early, prolonged antibiotic exposure among preterm infants may not lead to significant gastric dysrhythmia. Future studies including larger sample sizes and a "no antibiotic" exposure arm are essential in elucidating this potential relationship.

Impact of a clinical pharmacist within an HIV PrEP program for patients experiencing homelessness

BACKGROUND

Human immunodeficiency virus (HIV) continues to be a concern in the United States despite pre-exposure prophylaxis (PrEP) being a highly recommended preventative option. Homeless populations have a significantly increased risk of HIV acquisition, and recent literature found attrition to PrEP care being concentrated in demographics common to these populations. Pharmacist-led PrEP programs may be a feasible option to combat this attrition, as they have shown high rates of patient satisfaction and pharmacist comfortability in other populations.

OBJECTIVES

To evaluate PrEP uptake and the continuum of care before and after a Clinical Pharmacy Specialist (CPS) expanded HIV prevention services within a primary care setting for persons experiencing homelessness.

METHODS

We compared a retrospective cohort of patients experiencing homelessness who received an initial PrEP prescription during a pre-CPS period and those with an initial PrEP prescription after CPS. Charts were reviewed through the surrounding time period of a 3-month and a 6-month PrEP follow-up appointment. Outcomes evaluated included number of initial PrEP prescriptions, dispensations of PrEP, PrEP discontinuations, patient retention in PrEP care, and new HIV diagnoses.

RESULTS

A total of 40 patients were included, with 10 initial PrEP prescriptions in the pre-CPS population and 30 in the post-CPS one. Both groups largely represented those disproportionately impacted by HIV. After CPS, more patients were enrolled in patient assistance programs (100% vs. 44%; P < 0.01), and more patients picked up the first PrEP dispensation (80% vs. 40%; P = 0.04). The overall population had low dispensation rates and retention to care. Having no CPS management and a lack of medical appointment attendance trended toward attrition of care, and having no patient assistance program enrollment significantly led to attrition of care.

CONCLUSION

These findings may prompt further studies and adaptations to PrEP care among persons experiencing homelessness, including the utilization of pharmacists to improve patient outcomes.

Tachygastria in Preterm Infants: A Longitudinal Cohort Study

OBJECTIVES

Tachygastria is a gastric dysrhythmia (>4 to ≤9 cycles per minute, cpm) associated with gastric hypomotility and gastrointestinal disorders. Healthy preterm infants spend more time in tachygastria than adults; however, normative values are not defined. We sought to determine the percent of time preterm infants spend in tachygastria.

METHODS

We conducted a longitudinal, prospective cohort study with weekly electrogastrography (EGG) recordings in 51 preterm <34 weeks' gestation and 5 term (reference) infants. We calculated percentage recording time in tachygastria (% tachygastria) and determined the mean ± standard deviation (SD) across EGG sessions. Mixed effects model was performed to test weekly variance in % tachygastria and gestational age effect. Successive pre- and post-prandial measurements were obtained to assess reproducibility of % tachygastria. We compared time to achieve full feeds between subjects with % tachygastria within 1 SD from the mean versus % tachygastria >1 SD from mean.

RESULTS

Three hundred seventy-six EGG sessions were completed (N = 56). Mean % tachygastria was 40% with SD ±5%. We demonstrated no change in % tachygastria across 9 postnatal weeks (P = 0.70) and no gestational age effect. No difference was demonstrated between successive pre- (P = 0.91) and post-prandial (P = 0.96) % tachygastria. Infants with 35%-45% tachygastria (within 1 SD from mean) had higher gestational age and less time to achieve full feeds than infants with <35% or >45% tachygastria.

CONCLUSIONS

EGG is a reproducible tool to assess % tachygastria in preterm infants. Clinical significance of increased or decreased % tachygastria needs further investigation to validate if 35%-45% tachygastria is safe for feeding.

Linguistic Differences by Gender in Letters of Recommendation for Minimally Invasive Gynecologic Surgery Fellowship Applicants

OBJECTIVE

Various surgical specialties have reported gender bias in letters of recommendation (LOR). We aimed to determine if linguistic differences exist in LOR for female and male physicians applying to Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS).

DESIGN

Retrospective cohort study including application cycles 2019 and 2020.

SETTING

Academic university hospital.

PARTICIPANTS

FMIGS applicants.

RESULTS

Applicant demographic and baseline data included age, race, gender, geographical region of residency training, Step 1 and 2 scores, number of research and volunteer activities, Alpha Omega Alpha and Gold Humanism status and number of LOR, as well as the gender and academic rank of the letter writer. The Linguistic Inquiry and Word Count software, a validated text analysis program, was used to characterize LOR linguistic content. A total of 118 applications, including 391 letters, were analyzed. Seventy-six (64.4%) applicants were female and 42 (35.6%) were male. Most female applicants were white (46% vs. 36%, p = 0.04), had Alpha Omega Alpha status (13% vs. 0%, p = 0.01), higher Step 2 scores (239.7 vs. 230.4, p < 0.01), and more service activities (7.7 vs. 4.7, p < 0.01), compared to male applicants. Male applicants were more likely to graduate from international medical schools (45% vs. 16%, p < 0.01). Female authors wrote 159 LOR, and male authors wrote 232. Following multivariable analysis controlling for race, Step 1 score and letter writer gender, no significant differences in average LOR word count for female and male applicants (406.7 ± 24.2 words vs. 340.1 ± 35.4 words), or differences in Linguistic Inquiry and Word Count linguistic categories existed.

CONCLUSIONS

Although Baseline differences were noted between female and male FMIGS applicants, no differences in LOR length or linguistic categories were noted. These results likely reflect the impact of female predominance and increased efforts to address gender bias within Obstetrics and Gynecology.

A Review of the Effectiveness of Audio-Only Telemedicine for Chronic Disease Management

Background: The clinical effectiveness of audio-only telemedicine has not been fully quantified. The pandemic afforded a unique situation to retrospectively observe clinical outcomes of care for three disease cohorts within three care models, including audio-only telemedicine. Methods: Patients were classified into three care models: audio-only telemedicine, in-person, and hybrid. Each model was compared with an aggregate group before the onset of the pandemic and within each group during the pandemic. Each disease cohort was evaluated in cross-sectional and paired analyses. Results: Patients (n = 52,720) were grouped within one of three care models. A majority (n = 48,335) of patients qualified for the "pre" group comparison. The audio-only telemedicine care model showed similar control of renal disease, hypertension control, and diabetes management than in-person and hybrid care models. Conclusions: Audio-only telemedicine appears to be noninferior to in-person or hybrid models for chronic disease management for the diseases studied. In all instances, it had similar control compared with the in-person care model. We acknowledge the limitations of this study, including convenience sampling and a limited observation timeframe. Audio-only telemedicine should be considered a viable care model modality that can be integrated into options for patient care. Further study and investment are warranted, as it provides efficacy and convenience to health systems (Clinical Registration Number # 32449).

Peripherally inserted central cathether migration in neonates: Incidence, timing and risk factors

BACKGROUND

PICC line use is a common practice in neonatal units, but it is associated with various complications. Catheter migration is the most common complication in neonates. Periodic imaging is recommended to monitor the tip position of the PICCs, but the optimal frequency is undetermined. The incidence, timing and risk factors that are associated with PICC migration have not been fully investigated beyond 24 hrs in neonates. The aim of the study was to determine the incidence, timing and risk factors that are associated with peripherally inserted central venous catheter (PICC) migration in neonates.

METHODS

This was a single center, retrospective study of 168 PICCs placed in 141 neonates in the neonatal intensive care unit (NICU) between 2015 and 2016. The incidence of catheter migration was determined radiographically at 12-24 hrs and every third day after insertion until it was removed.

RESULTS

Overall incidence of PICC migration was 28%and most commonly was detected within the first three days after PICC placement (83%). The incidence of PICC migration was higher in males. The PICC migration was associated with difficulty advancing the PICC at the time of insertion and PICC dressing change.

CONCLUSION

Serial evaluation of PICC placement in neonates is required to maintain proper position. Based on our experience in our unit, we recommend periodic imaging at 12-24 hrs and on the third day after PICC placement as most migration occurred within three days after insertion.

Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry

BACKGROUND

Cardiopulmonary resuscitation (CPR) in the delivery room (DR) after birth is rare. We hypothesized that factors related to maternal, delivery, infant and resuscitation event characteristics associated with outcomes could be identified. We also hypothesized there would be substantial variation from the Neonatal Resuscitation Program (NRP) algorithm.

METHODS

Retrospective review of all neonates receiving chest compressions in the DR from the AHA Get With The Guidelines-Resuscitation registry from 2001 to 2014. The primary outcome was return of spontaneous circulation (ROSC) in the DR. Secondary outcome was survival to hospital discharge. Descriptive statistics were used to characterize data. Odds ratios with confidence intervals were calculated as appropriate to compare survivors and non-survivors.

RESULTS

There were 1153 neonates who received chest compressions in the DR. ROSC was achieved in 968 (84%) newborns and 761 (66%) survived to hospital discharge. Fifty-one percent of the cohort received chest compressions without medications. Cardiac compressions were initiated within the first minute of life in 76% of the events, and prior to endotracheal intubation in 79% of the events. In univariate analysis, factors such as prematurity, number of endotracheal intubation attempts, increased time to first adrenaline dose, and CPR duration were associated with decreased odds of ROSC in the DR. Longer CPR duration was associated with decreased odds of ROSC in multivariate analysis.

CONCLUSION

In this cohort of infants receiving chest compressions following delivery, recognizable pre-birth risk factors as well as resuscitation interventions associated with increased and decreased odds of achieving ROSC were identified. Chest compressions were frequently initiated in the first minute of the event and often prior to endotracheal intubation. Further investigations should focus on methods to decrease time to critical resuscitation interventions, such as successful endotracheal intubation and administration of the first dose of adrenaline, in order to improve DR-CPR outcomes.

Proton transport mechanism of bacteriorhodopsin as revealed by site-specific mutagenesis and protein sequence variability

A large share of the current ideas about the mechanism of proton transport by bacteriorhodopsin has emerged from studies of site-specific mutants. This review is an attempt to check some of these ideas against the natural variability in the primary structure of the protein.

Coupling of the reisomerization of the retinal, proton uptake, and reprotonation of Asp-96 in the N photointermediate of bacteriorhodopsin

In the N to O reaction of the bacteriorhodopsin photocycle, Asp-96 is protonated from the cytoplasmic surface, and coupled to this, the retinal isomerizes from 13-cis,15-anti back to the initial all-trans configuration. To dissect the two steps, and to better understand how and why they occur, we describe the properties of two groups of site-specific mutants in which the N intermediate has greatly increased lifetime. In the first group, with the mutations near the retinal, an unusual N state is produced in which the retinal is 13-cis,15-anti but Asp-96 has a protonated carboxyl group. The apparent pK(a) for the protonation is 7.5, as in the wild-type. It is likely that here the interference with N decay is the result of steric conflict of side-chains with the retinal or with the side-chain of Lys-216 connected to the retinal, which delays the reisomerization after protonation of Asp-96. In the second group, with the mutations located near Asp-96 or between Asp-96 and the cytoplasmic surface, reprotonation of Asp-96 is strongly perturbed. The reisomerization of the retinal occurs only after recovery from a long-living protein conformation in which reprotonation of Asp-96 is either entirely blocked or blocked at low pH.

The validity of the interviewer severity ratings in groups of ASI interviewers with varying training

AIMS

This study evaluated the hypothesis that the subjective interviewer severity rating (ISR) summary indices of the intake Addiction Severity Index (ASI) of less trained interviewers are less valid than those of more highly trained interviewers.

DESIGN

Baseline ASIs from three completed studies whose interviewers varied in degree of initial ASI training and subsequent quality assurance monitoring were examined. Associations between baseline ISRs and three other sets of ASI summary indices not based on interviewer ratings-composite scores, clinical indices and evaluation indices-were compared for three groups of interviewers with varying amounts of training. The assumption underlying these analyses was that more reliable ISRs, found in more trained interviewers, would be more highly associated with the other more objective indices.

SETTING

Methadone maintenance patients in the Philadelphia and New York City areas.

PARTICIPANTS

Thirty-five interviewers with the most intense training who administered 295 interviews; 10 interviewers with an intermediate level of training who administered 763 interviews; and eight identified (and other unidentified) least trained interviewers who administered a total of 276 interviews. Measurements and methods. Four sets of summary indices from the above ASIs. Both bivariate and multivariate analyses were performed.

FINDINGS

The study found that the validity of the validity of ISRs was greater in more trained interviewers.

CONCLUSIONS

Greater training and subsequent monitoring of ASI interviewers generally appears to be associated with increased ISR validity.

Photochemical reaction cycle and proton transfers in Neurospora rhodopsin

It was recently found that NOP-1, a membrane protein of Neurospora crassa, shows homology to haloarchaeal rhodopsins and binds retinal after heterologous expression in Pichia pastoris. We report on spectroscopic properties of the Neurospora rhodopsin (NR). The photocycle was studied with flash photolysis and time-resolved Fourier-transform infrared spectroscopy in the pH range 5-8. Proton release and uptake during the photocycle were monitored with the pH-sensitive dye, pyranine. Kinetic and spectral analysis revealed six distinct states in the NR photocycle, and we describe their spectral properties and pH-dependent kinetics in the visible and infrared ranges. The phenotypes of the mutant NR proteins, D131E and E142Q, in which the homologues of the key carboxylic acids of the light-driven proton pump bacteriorhodopsin, Asp-85 and Asp-96, were replaced, show that Glu-142 is not involved in reprotonation of the Schiff base but Asp-131 may be. This implies that, if the NR photocycle is associated with proton transport, it has a low efficiency, similar to that of haloarchaeal sensory rhodopsin II. Fourier-transform Raman spectroscopy revealed unexpected differences between NR and bacteriorhodopsin in the configuration of the retinal chromophore, which may contribute to the less effective reprotonation switch of NR.

Feelings in context: countertransference and the real world in feminist therapy

The concept of countertransference has been seen as problematic by feminist therapists. However, feminist therapy theory is intensely interested in the symbolic levels of the relationships between therapists and clients, with an emphasis on how the here and now social context informs and transforms those symbols. This article describes a feminist perspective on the therapist's symbolic relationships to clients, and the positive and challenging ramifications of those symbolic encounters.

Light-induced rotation of a transmembrane alpha-helix in bacteriorhodopsin

Spin labeling EPR spectroscopy has been used to characterize light-induced conformational changes of bacteriorhodopsin (bR). Pairs of nitroxide spin labels were attached to engineered cysteine residues at strategic positions near the cytoplasmic ends of transmembrane alpha-helices B, F, and G in order to monitor distance changes upon light activation. The EPR analysis of six doubly labeled bR mutants indicates that the cytoplasmic end of helix F not only tilts outwards, but also rotates counter-clockwise during the photocycle. The direction of the rotation of helix F is the opposite of the clockwise rotation previously reported for bovine rhodopsin. The opposite chirality of the F helix rotation in the two systems is perhaps related to the differences in the cis-trans photoisomerization of the retinal in the two proteins. Using time-resolved EPR, we monitored the rotation of helix F also in real time, and found that the signal from the rotation arises concurrently with the reprotonation of the retinal Schiff base.

Reconciling crystallography and mutagenesis: a synthetic approach to the creation of a comprehensive model for proton pumping by bacteriorhodopsin

As a result of the number of new high-resolution structures of the pigment and some of its photointermediates, a realistic model for the functioning of bacteriorhodopsin seems to be finally emerging. However, lack of structural information for some of the key functional states, and contradictions between some published structural models, argue for the use of the synthetic approach, one that includes use of data from both crystallographic and mutagenesis studies. The role of mutagenesis in this synthetic approach falls into two categories. First, to provide additional structural information, and second, to test the predictions of structural models by studying mutant phenotypes. This review urges critical comparisons of the structural and mutagenesis data, as there are problems with their selective and indiscriminate use.

Origins of deuterium kinetic isotope effects on the proton transfers of the bacteriorhodopsin photocycle

Deuterium kinetic isotope effects (KIE) were measured, and proton inventory plots were constructed, for the rates of reactions in the photocycles of wild-type bacteriorhodopsin and several site-specific mutants. Consistent with earlier reports from many groups, very large KIEs were observed for the third (and largest) rise component for the M state and for the decay of the O state, processes both linked to proton transfers in the extracellular region. The proton inventory plots (ratio of reaction rates in mixtures of H(2)O and D(2)O to that in H(2)O vs mole fraction of D(2)O) were approximately linear for the first and second M rise components and for M decay, as well as for O decay, indicating that the rates of these reactions are limited by simple proton transfer. Uniquely, the third rise component of M (and in the D96N mutant also a fourth rise component) exhibited a strongly curved proton inventory plot, suggesting that its rate, which largely accounts for the rate of deprotonation of the retinal Schiff base, depends on a complex multiproton process. This curvature is observed also in the E194Q, E204Q, and Y57F mutants but not in the R82A mutant. From these findings, and from the locations of bound water in the extracellular region in the crystal structure of the protein [Luecke, Schobert, Richter, Cartailler, and Lanyi (1999) J. Mol. Biol. 291, 899-911], we suspect that the effects of deuterium substitution on the formation of the M state originate from cooperative rearrangements of the extensively hydrogen-bonded water molecules 401, 402, and 406 near Asp-85 and Arg-82.

Fourier transform infrared spectra of a late intermediate of the bacteriorhodopsin photocycle suggest transient protonation of Asp-212

We measured time-resolved difference spectra, in the visible and the infrared, for the Glu-194 and Glu-204 mutants of bacteriorhodopsin and detected an anomalous O state, labeled O', in addition to the authentic O intermediate, before recovery of the initial state in the photocycle. The O' intermediate exhibits prominent bands at 1712 cm(-1) (positive) and 1387 cm(-1) (negative). These bands arise with the same time constant as the deprotonation of Asp-85. Both bands are shifted to lower frequency upon labeling of the protein with [4-(13)C]aspartic acid. The former band, but not the latter, is shifted in D2O. These shifts identify the two bands as the carboxyl stretch of a protonated aspartic acid and the symmetric carbonyl stretch of an unprotonated aspartate, respectively, and suggest that in O' an initially anionic aspartate enters into protonation equilibrium with Asp-85. Elimination of the few other candidates, on various grounds, identifies Asp-212 as the unknown residue. It is possible, therefore, that in the last step of the photocycle of the mutants studied the proton released from Asp-85 is conducted to the extracellular surface via Asp-212. An earlier report of a weak band at 1712 cm(-1) late in the wild-type photocycle [Zscherp and Heberle (1997) J. Phys. Chem. B 101, 10542-10547] suggests that Asp-212 might play this role in the wild-type protein also.

Binding of calcium ions to bacteriorhodopsin

Adding Ca2+ or other cations to deionized bacteriorhodopsin causes a blue to purple color shift, a result of deprotonation of Asp85. It has been proposed by different groups that the protonation state of Asp85 responds to the binding of Ca2+ either 1) directly at a specific site in the protein or 2) indirectly through the rise of the surface pH. We tested the idea of specific binding of Ca2+ and found that the surface pH, as determined from the ionization state of eosin covalently linked to engineered cysteine residues, rises about equally at both extracellular and cytoplasmic surfaces when only one Ca2+ is added. This precludes binding to a specific site and suggests that rather than decreasing the pKa of Asp85 by direct interaction, Ca2+ increases the surface pH by binding to anionic lipid groups. As Ca2+ is added the surface pH rises, but deprotonation of Asp85 occurs only when the surface pH approaches its pKa. The nonlinear relationship between Ca2+ binding and deprotonation of Asp85 from this effect is different in the wild-type protein and in various mutants and explains the observed complex and varied spectral titration curves.

Functional roles of aspartic acid residues at the cytoplasmic surface of bacteriorhodopsin

The functions of the four aspartic acid residues in interhelical loops at the cytoplasmic surface of bacteriorhodopsin, Asp-36, Asp-38, Asp-102, and Asp-104, were investigated by studying single and multiple aspartic acid to asparagine mutants. The same mutants were examined also with the additional D96N residue replacement. The kinetics of the M and N intermediates of the photochemical cycles of these recombinant proteins were affected only in a minor, although self-consistent, way. When residue 38 is an aspartate and anionic, it makes the internal proton exchange between the retinal Schiff base and Asp-96 about 3 times more rapid, and events associated with the reisomerization of retinal to all-trans about 3 times slower. Asp-36 has the opposite effect on these processes, but to a smaller extent. Asp-102 and Asp-104 have even less or none of these effects. Of the four aspartates, only Asp-36 could play a direct role in proton uptake at the cytoplasmic surface. In the 13 bacterioopsin sequences now available, only this surface aspartate is conserved.

Methadone-maintenance outcomes for Hispanic and African-American men and women

Six-month methadone-maintenance response and outcome were examined for African-American and Hispanic men and women in a large urban sample. A consistent pattern of improvement was indicated for both races and genders on the addiction severity index (ASI). There were virtually no statistically significant differences in ASI outcomes between Hispanics and African-Americans and men and women using conventional analysis of variance (ANOVA) procedures. Results from an additional equivalence analysis, however, indicated that baseline to 6-month changes for the different groups were generally not similar enough to consider them equivalent. Urine toxicologies obtained during the 6-month treatment period were also not statistically equivalent by race and gender. Evaluating outcomes by gender and race are discussed, as are the implications of using equivalence tests when examining group differences.

Rates of tuberculosis infection in healthcare workers providing services to HIV-infected populations. Terry Beirn Community Programs for Clinical Research on AIDS

OBJECTIVE

To assess the prevalence of tuberculosis (TB) or a positive skin test in healthcare workers (HCWs) providing services to human immunodeficiency virus (HIV)-infected individuals and to determine prospectively the incidence of new infections in this population.

DESIGN

This prospective cohort study enrolled 1,014 HCWs working with HIV-infected populations from 10 metropolitan areas. Purified protein derivative (PPD) tuberculin skin tests were placed at baseline and every 6 months afterwards on those without a history of TB or a positive PPD. Demographic, occupational, and TB exposure data also were collected.

SETTING

Outpatient clinics, hospitals, private practice offices, and drug treatment programs providing HIV-related healthcare and research programs.

PARTICIPANTS

A voluntary sample of staff and volunteers from 16 Community Programs for Clinical Research on AIDS units.

RESULTS

Factors related to prior TB or a positive skin test at baseline included being foreign-born, increased length of time in health care, living in New York City, or previous bacille Calmette-Guerin vaccination. The rate of PPD conversion was 1.8 per 100 person years of follow-up. No independent relation was found between the amount or type of contact with HIV-infected populations and the risk of TB infection.

CONCLUSION

These data provide some reassurance that caring for HIV-infected patients is not related to an increased rate of TB infection among HCWs in these settings.

Connectivity of the retinal Schiff base to Asp85 and Asp96 during the bacteriorhodopsin photocycle: the local-access model

In the recently proposed local-access model for proton transfers in the bacteriorhodopsin transport cycle (Brown et al. 1998. Biochemistry. 37:3982-3993), connection between the retinal Schiff base and Asp85 (in the extracellular direction) and Asp96 (in the cytoplasmic direction)is maintained as long as the retinal is in its photoisomerized state. The directionality of the proton translocation is determined by influences in the protein that make Asp85 a proton acceptor and, subsequently, Asp96 a proton donor. The idea of concurrent local access of the Schiff base in the two directions is now put to a test in the photocycle of the D115N/D96N mutant. The kinetics had suggested that there is a single sequence of intermediates, L<-->M1<-->M2<-->N, and the M2-->M1 reaction depends on whether a proton is released to the extracellular surface. This is now confirmed. We find that at pH 5, where proton release does not occur, but not at higher pH, the photostationary state created by illumination with yellow light contains not only the M1 and M2 states, but also the L and the N intermediates. Because the L and M1 states decay rapidly, they can be present only if they are in equilibrium with later intermediates of the photocycle. Perturbation of this mixture with a blue flash caused depletion of the M intermediate, followed by its partial recovery at the expense of the L state. The change in the amplitude of the C=O stretch band at 1759 cm-1 demonstrated protonation of Asp85 in this process. Thus, during the reequilibration the Schiff base lost its proton to Asp85. Because the N state, also present in the mixture, arises by protonation of the Schiff base from the cytoplasmic surface, these results fulfill the expectation that under the conditions tested the extracellular access of the Schiff base would not be lost at the time when there is access in the cytoplasmic direction. Instead, the connectivity of the Schiff base flickers rapidly (with the time constant of the M1<-->M2 equilibration) between the two directions during the entire L-to-N segment of the photocycle.

Partitioning of free energy gain between the photoisomerized retinal and the protein in bacteriorhodopsin

Photoisomerization of the all-trans-retinal of bacteriorhodopsin to 13-cis,15-anti initiates a sequence of thermal reactions in which relaxation of the polyene chain back to all-trans is coupled to various changes in the protein and the translocation of a proton across the membrane. We investigated the nature of this high-energy state in a genetically modified bacteriorhodopsin. When the electric charges of residues 85 and 96, the two aspartic acids critical for proton transport, are both changed to what they become after photoexcitation of the wild-type protein, i.e., neutral and anionic, respectively, the retinal assumes a thermally stable 13-cis,15-anti configuration. Thus, we have reversed cause and effect in the photocycle. It follows that when the 13-cis,15-anti isomeric state is produced by illumination, in the wild type it is unstable initially only because of conflicts with the retinal binding pocket. Later in the photocycle, the free energy gain is transferred from the chromophore to the protein. Before recovery of the initial state, it will come to be represented entirely by the free energy of the changed protonation states of aspartic acids 85 and 96.

The effect of fluconazole on the clinical pharmacokinetics of methadone

A randomized, double-blinded, placebo-controlled pharmacokinetic and safety trial was conducted to determine the effect of fluconazole on methadone disposition. Volunteers receiving methadone maintenance therapy were randomized to receive either 200 mg/day oral fluconazole (n = 13) or placebo (n = 12). After 14 days there was a 35% average increase in serum methadone area under the curve relative to baseline among patients receiving fluconazole (p = 0.0008). At the same time, mean serum methadone peak and trough concentrations increased by 27% (p = 0.0076) and 48% (p = 0.0023), respectively, and oral clearance of methadone was reduced by 24% (p = 0.0007). In contrast, the pharmacokinetics of methadone were unaltered in the placebo group. Renal clearance of methadone was not significantly affected by fluconazole or placebo therapy. Although exposed to increased concentrations of methadone, patients treated with fluconazole did not exhibit signs or symptoms of significant narcotic overdose.

Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial

AIMS

To evaluate the safety and efficacy of an 8 mg/day sublingual dose of buprenorphine in the maintenance treatment of heroin addicts by comparison with a 1 mg/day dose over a 16-week treatment period. As a secondary objective, outcomes were determined concurrently for patients treated with two other dose levels.

DESIGN

Patients were randomized to four dosage groups and treated double-blind.

SETTING

Twelve outpatient opiate maintenance treatment centers throughout the United States.

PARTICIPANTS

Two hundred and thirty-nine women and 497 men who met the DSM-III-R criteria for opioid dependence and were seeking treatment.

INTERVENTION

Patients received either 1, 4, 8 or 16 mg/day of buprenorphine and were treated in the usual clinical context, including a 1-hour weekly clinical counseling session.

MEASUREMENT

Retention in treatment, illicit opioid use as determined by urine toxicology, opioid craving and global ratings by patient and staff. Safety outcome measures were provided by clinical monitoring and by analysis of the reported adverse events.

FINDINGS

Outcomes in the 8 mg group were significantly better than in the 1 mg group in all four efficacy domains. No deaths occurred in either group. The 8 mg group did not show an increase in the frequency of adverse events. Most reported adverse effects were those commonly seen in patients treated with opioids.

CONCLUSIONS

The findings support the safety and efficacy of buprenorphine and suggest that an adequate dose of buprenorphine will be a useful addition to pharmacotherapy.

Local-access model for proton transfer in bacteriorhodopsin

The accessibility of the retinal Schiff base in bacteriorhodopsin was studied in the D85N/D96N mutant where the proton acceptor and donor are absent. Protonation and deprotonation of the Schiff base after pH jump without illumination and in the photocycle of the unprotonated Schiff base were measured in the visible and the infrared. Whether access is extracellular (EC) or cytoplasmic (CP) was decided from the effect of millimolar concentrations of azide on the rates of proton transfers. The results, together with earlier work on the wild-type protein, suggest a new hypothesis for the proton-transfer switch: (i) In the metastable 13-cis, 15-anti and all-trans, 15-syn photoproducts, but not in the stable isomeric states, access flickers between the EC and CP directions. (ii) The direction of proton transfer is decided both by this local access and by the presence of a suitable donor or acceptor group (in the wild type), or the proton conductivity in the EC and CP half-channels (in D85N/D96N). (iii) Thermal reisomerization of the retinal can occur only when the Schiff base is protonated, as is well-known. In the wild-type transport cycle, the concurrent local EC and CP access during the lifetime of the metastable 13-cis, 15-anti state enables the changing pKa's of the proton acceptor and donor to determine the direction of proton transfer. Proton transfer from the Schiff base to Asp-85 in the EC direction is followed by reprotonation by Asp-96 from the CP direction because proton release to the EC surface raises the pKa of Asp-85 and a large-scale protein conformation change lowers the pKa of Asp-96. The unexpected finding we report here for D85N/D96N, that when the retinal is in the stable all-trans, 15-anti and 13-cis, 15-syn isomeric forms access of the Schiff base is locked (in the EC and CP directions, respectively), suggests that in this protein reisomerization, rather than changes in the proton conductivities of the EC and CP half-channels, provides the switch function. With this mechanism, the various modes of transport reported for Asp-85 mutants (CP to EC direction with blue light, and EC to CP direction with blue plus green light) are understood also in terms of rules i-iii.

Existence of a proton transfer chain in bacteriorhodopsin: participation of Glu-194 in the release of protons to the extracellular surface

Glu-194 near the extracellular surface of bacteriorhodopsin is indispensable for proton release to the medium upon protonation of Asp-85 during light-driven transport. As for Glu-204, its replacement with glutamine (but not aspartate) abolishes both proton release and the anomalous titration of Asp-85 that originates from coupling between the pKa of this buried aspartate and those of the other acidic groups. Unlike the case of Glu-204, however, replacement of Glu-194 with aspartate raises the pKa for proton release. In Fourier transform infrared spectra of the E194D mutant a prominent positive band is observed at 1720 cm-1. It can be assigned from [4-13C]aspartate and D2O isotope shifts to the C&dbd;O stretch of protonated Asp-194. Its rise correlates with proton transfer from the retinal Schiff base to Asp-85. Its decay coincides with the appearance of a proton at the surface, detected under similar conditions with fluorescein covalently bound to Lys-129 and with pyranine. Its amplitude decreases with increasing pH, with a pKa of about 9. We show that this pKa is likely to be that of the internal proton donor to Asp-194, the Glu-204 site, before photoexcitation, while 13C NMR titration indicates that Asp-194 has an initial pKa of about 3. We propose that there is a chain of interacting residues between the retinal Schiff base and the extracellular surface. After photoisomerization of the retinal the pKa's change so as to allow (i) Asp-85 to become protonated by the Schiff base, (ii) the Glu-204 site to transfer its proton to Asp-194 in E194D, and therefore to Glu-194 in the wild type, and (iii) residue 194 to release the proton to the medium.

Sexual risk behaviour among subgroups of heterosexual HIV infected patients in an urban setting

OBJECTIVE

To determine the frequency of characteristics associated with unprotected heterosexual intercourse in HIV infected adults in an urban area.

DESIGN

Retrospective comparison of sexual risk transmission behaviour between HIV infected men and women from a drug treatment site and between women from the drug site and HIV infected women from an urban medical centre.

METHODS

HIV infected women and men were asked questions on sexual behaviour for a 1 year period before enrollment. The outcome variable was heterosexual risk behaviour (HRB) defined as having vaginal sex at least once in the previous year and not always using condoms.

RESULTS

73% of the drug clinic females, 72% of the drug clinic males, and 42% of the medical centre female engaged in HRB. Using logistic regression analysis, women and men in drug treatment engaged in similar rates of HRB; however, women in drug treatment were four times (95% CI = 2.0-8.3) more likely to engage in HRB risk behaviour than women from the medical centre.

CONCLUSION

The data suggest that a surprisingly large portion of HIV infected patients under treatment engaged in HRB, especially former drug users. Without specifically targeted interventions, the heterosexual spread of HIV in urban areas will continue to be a serious problem.

Transient channel-opening in bacteriorhodopsin: an EPR study

Active translocation of ions across membranes requires alternating access of the ion binding site inside the pump to the two membrane surfaces. Proton translocation by bacteriorhodopsin (bR), the light-driven proton pump in Halobacterium salinarium, involves this kind of a change in the accessibility of the centrally located retinal Schiff base. This key event in bR's photocycle ensures that proton release occurs to the extracellular side and proton uptake from the cytoplasmic side. To study the role of protein conformational changes in this reprotonation switch, spin labels were attached to pairs of engineered cysteine residues in the cytoplasmic interhelical loops of bR. Light-induced changes in the distance between a spin label on the EF interhelical loop and a label on either the AB or the CD interhelical loop were observed, and the changes were monitored following photoactivation with time-resolved electron paramagnetic resonance (EPR) spectroscopy. Both distances increase transiently by about 5 A during the photocycle. This opening occurs between proton release and uptake, and may be the conformational switch that changes the accessibility of the retinal Schiff base to the cytoplasmic surface after proton release to the extracellular side.

Guanidinium restores the chromophore but not rapid proton release in bacteriorhodopsin mutant R82Q

Replacement of the Arg residue at position 82 in bacteriorhodopsin by Gln or Ala was previously shown to slow the rate of proton release and raise the pK of Asp 85, indicating that R82 is involved both in the proton release reaction and in stabilizing the purple form of the chromophore. We now find that guanidinium chloride lowers the pK of D85, as monitored by the shift of the 587-nm absorbance maximum to 570 nm (blue to purple transition) and increased yield of photointermediate M. The absorbance shift follows a simple binding curve, with an apparent dissociation constant of 20 mM. When membrane surface charge is taken into account, an intrinsic dissociation constant of 0.3 M fits the data over a range of 0.2-1.0 M cation concentration (Na+ plus guanidinium) and pH 5.4-6.7. A chloride counterion is not involved in the observed spectral changes, as chloride up to 0.2 M has little effect on the R82Q chromophore at pH 6, whereas guanidinium sulfate has a similar effect to guanidinium chloride. Furthermore, guanidinium does not affect the chromophore of the double mutant R82Q/D85N. Taken together, these observations suggest that guanidinium binds to a specific site near D85 and restores the purple chromophore. Surprisingly, guanidinium does not restore rapid proton release in the photocycle of R82Q. This result suggests either that guanidinium dissociates during the pump cycle or that it binds with a different hydrogen-bonding geometry than the Arg side chain of the wild type.

A controlled trial of isoniazid in persons with anergy and human immunodeficiency virus infection who are at high risk for tuberculosis. Terry Beirn Community Programs for Clinical Research on AIDS

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection and latent tuberculosis are at substantial risk for the development of active tuberculosis. As a public health measure, prophylactic treatment with isoniazid has been suggested for HIV-infected persons who have anergy and are in groups with a high prevalence of tuberculosis.

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial of six months of prophylactic isoniazid treatment in HIV-infected patients with anergy who have risk factors for tuberculosis infection. The primary end point was culture-confirmed tuberculosis.

RESULTS

The study was conducted from November 1991 through June 1996. Over 90 percent of the patients had two or more risk factors for tuberculosis infection, and nearly 75 percent of patients were from greater New York City. After a mean follow-up of 33 months, tuberculosis was diagnosed in only 6 of 257 patients in the placebo group and 3 of 260 patients in the isoniazid group (risk ratio, 0.48; 95 percent confidence interval, 0.12 to 1.91; P=0.30). There were no significant differences between the two groups with regard to death, death or the progression of HIV disease, or adverse events.

CONCLUSIONS

Even in HIV-infected patients with anergy and multiple risk factors for latent tuberculosis infection, the rate of development of active tuberculosis is low. This finding does not support the use of isoniazid prophylaxis in high-risk patients with HIV infection and anergy unless they have been exposed to active tuberculosis.

A local electrostatic change is the cause of the large-scale protein conformation shift in bacteriorhodopsin

During light-driven proton transport bacteriorhodopsin shuttles between two protein conformations. A large-scale structural change similar to that in the photochemical cycle is produced in the D85N mutant upon raising the pH, even without illumination. We report here that (i) the pKa values for the change in crystallographic parameters and for deprotonation of the retinal Schiff base are the same, (ii) the retinal isomeric configuration is nearly unaffected by the protein conformation, and (iii) preventing rotation of the C13-C14 double bond by replacing the retinal with an all-trans locked analogue makes little difference to the Schiff base pKa. We conclude that the direct cause of the conformational shift is destabilization of the structure upon loss of interaction of the positively charged Schiff base with anionic residues that form its counter-ion.

Time-resolved fourier transform infrared study of structural changes in the last steps of the photocycles of Glu-204 and Leu-93 mutants of bacteriorhodopsin

The last intermediate in the photocycle of the light-driven proton pump bacteriorhodopsin is the red-shifted O state. The structure and dynamics of the last step in the photocycle were characterized with time-resolved Fourier transform infrared spectroscopy of the mutants of Glu-204 and Leu-93, which accumulate this intermediate in much larger amounts than the wild type. The results show that E204Q and E204D give distorted all-trans-retinal chromophore like the O intermediate of the wild type. This is simply due to the perturbation of the proton acceptor function of Glu-204 in the O-to-BR transition in the Glu-204 mutants. The corresponding red-shifted intermediates of L93M, L93T, and L93S have a 13-cis chromophore like the N intermediate of the wild type, as reported from analysis of extracted retinal [Delaney, J. K., Schweiger, U., & Subramaniam, S. (1995) Proc. Natl. Acad. Sci. U.S.A. 92, 11120-11124]. In spite of their different chromophore structures from the O intermediate, the red-shifted intermediates are similar to the O intermediate but not to the N intermediate of the wild type with respect to structural changes in the peptide carbonyls. The structural changes around Asp-96 in the N intermediate are completely restored also in the red-shifted intermediates of the Leu-93 mutants like in the O intermediate. These results imply that the protein structural changes in the last step proceed regardless of thermal isomerization of the chromophore. Time-resolved Fourier transform infrared spectroscopy with the Glu-204 mutants suggests that the response of Asp-204 (Glu-204 in the wild type) to the protonation of Asp-85 during formation of the M intermediate, which results in proton release, is slow and may occur through structural changes.

Interaction of proton and chloride transfer pathways in recombinant bacteriorhodopsin with chloride transport activity: implications for the chloride translocation mechanism

When the protonated retinal Schiff base dissociates in the photocycle of the proton pump bacteriorhodopsin, asp-85 is the proton acceptor. Replacing this residue with threonine confers halorhodopsin-like properties on the protein, including chloride transport [Sasaki, J., Brown, L.S., Chon, Y.-S., Kandori, H., Maeda, A., Needleman, R., & Lanyi, J.K. (1995) Science 269, 73-75]. However, the electrostatic interaction between the vicinity of residue 85 and glu-204, a residue located about 10 A away near the extracellular surface, that is a part of the proton transport mechanism, should still exist. We find that in the D85T mutant glu-204 becomes protonated when chloride is added. This indicates that the binding of chloride at thr-85 must be equivalent to deprotonation of asp-85. The protonation state of glu-204 reports therefore on the presence or absence of chloride bound at thr-85. During the chloride-transport cycle of D85T, but not D85T/E204Q, fluorescein and pyranine detect the transient release of protons from the protein to the surface and the bulk. The release and the subsequent uptake of the protons occur during the rise and decay of a red-shifted photointermediate, respectively, and confirm the earlier suggestion that this state has the same role in the chloride transport as the M intermediate in the proton transport. Consistent with the red-shift of the absorption maximum, the chloride bound near the Schiff base had already moved away, presumably to be released at the cytoplasmic surface, but another chloride ion has not yet been taken up from the extracellular surface. The switch of the connectivity of the chloride binding site from the cytoplasmic to the extracellular membrane surface must occur therefore during the lifetime of this photointermediate.

Lack of a pharmacologic interaction between rifabutin and methadone in HIV-infected former injecting drug users

Rifampin, an agent known to decrease the half-life of methadone, and rifabutin are two rifamycins that are structurally similar and share mechanisms of action. Hence the possibility of a drug-drug interaction between rifabutin and methadone was evaluated in 24 methadone-maintained, former injecting drug users infected with the human immunodeficiency virus. The study was an open-label, drug-drug interaction and safety trial in which patients were followed for 15 days. Each patient received rifabutin 300 mg as a single dose concomitantly with their individualized methadone dosage. No significant differences in methadone peak plasma concentration, time to peak plasma concentration, area under the plasma concentration-time curve, systemic clearance or renal clearance was observed in the presence of rifabutin. Seventy-five percent of the patients reported at least one symptom of narcotic withdrawal during the study, however, these symptoms were mild. A relationship between the development of narcotic withdrawal and methadone systemic exposure could not be established. Concurrent administration of rifabutin and methadone appeared to be safe in human immunodeficiency virus-infected injecting drug users maintained on stable doses of methadone and is not expected to produce any significant changes in the pharmacokinetics of methadone in these patients.

Nicotine dependence and depression among methadone maintenance patients

There recently has been increasing interest at substance abuse treatment centers in smoking cessation treatment. Because a history of depression has been shown in other populations to complicate cessation efforts, the relationship between depression and nicotine dependence was tested in 726 methadone patients. Elevated odds of nicotine dependence given depression were found with three of four depression measures. Additional research is recommended to determine whether smoking cessation treatment will be more successful for methadone patients with a history of depression if it also addresses depression.

Hydration of the counterion of the Schiff base in the chloride-transporting mutant of bacteriorhodopsin: FTIR and FT-raman studies of the effects of anion binding when Asp85 is replaced with a neutral residue

The chromophores of the D85T and D85N mutants of bacteriorhodopsin are blue but become purple like the wild type when chloride or bromide binds near the Schiff base. In D85T this occurs near neutral pH, but in D85N only at pH < 4. The structures of the L and the unphotolyzed states of these proteins were examined with Fourier transform infrared spectroscopy. The difference spectra of the purple forms, but not the blue forms in the absence of these anions, resembled the spectrum of the wild-type protein. Shift of the ethylenic band toward lower frequency upon replacing chloride by bromide confirmed the contribution of the negative charge of the anions to the Schiff base counterion. These anions restored the change of water, which is bound near the protonated Schiff base but is absent in the blue form of the D85N mutant, though with stronger H-bonding than in the wild type. The C = N stretching vibration of the Schiff base in H2O and 2H2O was detected by Fourier transform Raman spectroscopy. The H-bonding strength of the Schiff base in the unphotolyzed state was weaker when chloride or bromide was bound to the mutants than with Asp85 as the counterion in the wild type. Thus, although the geometry of the environment is different, there is at least one water molecule coordinated to the bound halide in these mutants, in a way similar to water bound to Asp85 in the wild type.

Steric interaction between the 9-methyl group of the retinal and tryptophan 182 controls 13-cis to all-trans reisomerization and proton uptake in the bacteriorhodopsin photocycle

The hypothesis was tested whether in bacteriorhodopsin (BR) the reduction of the steric interaction between the 9-methyl group of the chromophore all-trans-retinal and the tryptophan at position 182 causes the same changes as observed in the photocycle of 9-demethyl-BR. For this, the photocycle of the mutant W182F was investigated by time-resolved UV-vis and pH measurements and by static and time-resolved FT-IR difference spectroscopy. We found that the second half of the photocycle was similarly distorted in the two modified systems: based on the amide-I band, the protonation state of D96, and the kinetics of proton uptake, four N intermediates could be identified, the last one having a lifetime of several seconds; no O intermediate could be detected; the proton uptake showed a pronounced biphasic time course; and the pKa of group(s) on the cytoplasmic side in N was reduced from 11 in wild type BR to around 7.5. In contrast to 9-demethyl-BR, in the W182F mutant the first part of the photocycle does not drastically deviate from that of wild type BR. The results demonstrate the importance of the steric interaction between W182 and the 9-methyl group of the retinal in providing tight coupling between chromophore isomerization and the late proton transfer steps.

Evidence for response set effects in structured research interviews

The Addiction Severity Index and NIMH Diagnostic Interview Schedule data of 20 methadone-maintained subjects with "fake bad" invalid profiles on the Personality Assessment Inventory, 15 methadone-maintained subjects with "fake good" invalid profiles, and 158 methadone-maintained subjects with valid profiles were compared. The findings revealed a number of significant group differences on both measures with the highest scores for the fake bad subjects and lowest scores for the fake good subjects. These findings suggest that the response sets exhibited in response to the Personality Assessment Inventory questionnaire extended to performance during the two semi-structured interviews. There was no indication that interviewers were aware of misrepresentation. The limitations of the findings and alternative interpretations of the data are considered.

Proton transport by halorhodopsin

In halorhodopsin from Natronobacterium pharaonis, a light-driven chloride pump, the chloride binding site also binds azide. When azide is bound at this location the retinal Schiff base transiently deprotonates after photoexcitation with light > 530 nm, like in the light-driven proton pump bacteriorhodopsin. As in the photocycle of bacteriorhodopsin, pyranine detects the release of protons to the bulk. The subsequent reprotonation of the Schiff base is also dependent on azide, but with different kinetics that suggest a shuttling of protons from the surface as described earlier for halorhodopsin from Halobacterium salinarium. This azide-dependent, bacteriorhodopsin-like photocycle results in active electrogenic proton transport in the cytoplasmic to extracellular direction, detected in cell envelope vesicle suspensions both with a potential-sensitive electrode and by measuring light-dependent pH change. We conclude that in halorhodopsin an azide bound to the extracellular side of the Schiff base, and another azide shuttling between the Schiff base and the cytoplasmic surface, fulfill the functions of Asp-85 and Asp-96, respectively, in bacteriorhodopsin. Thus, although halorhodopsin is normally a chloride ion pump, it evidently contains all structural requirements, except an internal proton acceptor and a donor, of a proton pump. This observation complements our earlier finding that when a chloride binding site was created in bacteriorhodopsin through replacement of Asp-85 with a threonine, that protein became a chloride ion pump.

A linkage of the pKa's of asp-85 and glu-204 forms part of the reprotonation switch of bacteriorhodopsin

Because asp-85 is the acceptor of the retinal Schiff base proton during light-driven proton transport by bacteriorhodopsin, modulation of its pKa in the photocycle is to be expected. The complex titration of asp-85 in the unphotolyzed protein was suggested [Balashov, S. P., Govindjee, R., Imasheva, E. S., Misra, S., Ebrey, T. G., Feng, Y., Crouch, R. K., & Menick, D. R (1995) Biochemistry 34, 8820-8834] to reflect the dependence of this residue on the protonation state of another, unidentified group. From the pH dependencies of the rate constant for the thermal equilibration of retinal isomeric states (dark adaptation) and the deprotonation kinetics of the Schiff base during the photocycle in the E204Q and E204D mutants, we identify the residue as glu-204. The nature of its interaction with asp-85 is that at neutral pH either residue can be anionic but not both. This is consistent with our recent finding that glu-204 is the origin of the proton released to the extracellular surface upon protonation of asp-85 during the transport. We propose, therefore, that the following series of events occur in the photocycle. Protonation of asp-85 in the proton equilibrium with the Schiff base of the photoisomerized retinal results in the dissociation of glu-204 and proton release to the extracellular surface. The deprotonation of glu-204, in turn, raises the pK(a) of asp-85, and the equilibrium with the Schiff base shifts toward complete proton transfer. This constitutes the first phase of the reprotonation switch because it excludes asp-85 as a donor in the reprotonation of the Schiff base that follows. The sequential structural changes of the protein that ensue, detected earlier by diffraction, are suggested to facilitate the change of the access of the Schiff base toward the cytoplasmic side as the second phase of the switch, and the lowering the pKa of asp-96, so as to make it a proton donor, as the third phase.

Determination of the transiently lowered pKa of the retinal Schiff base during the photocycle of bacteriorhodopsin

Reprotonation of the transiently deprotonated retinal Schiff base in the bacteriorhodopsin photocycle is greatly slowed when the proton donor Asp-96 is removed with site-specific mutagenesis, but its rate is restored upon adding azide or other weak acids such as formate and cyanate. As expected, between pH 3 and 7 the rate of Schiff base protonation in the photocycle of the D96N mutant correlates with the concentrations of the acid forms of these agents. Dissection of the rates in the biexponential reprotonation kinetics of the Schiff base between pH 7 and 9 yielded calculated rate constants for the protonation equilibrium. Their dependencies on pH and azide or cyanate concentrations are consistent with both earlier suggested mechanisms: (i) azide and other weak acids may function as proton carriers in the protonation equilibrium of the Schiff base, or (ii) the binding of their anionic forms may catalyze proton conduction to and from the Schiff base. The measured rate constants allow the calculation of the pKa of the Schiff base during its reprotonation in the photocycle of D96N. It is 8.2-8.3, a value much below the pKa determined earlier in unphotolyzed bacteriorhodopsin.

Natural history of HIV-1 infection and predictors of survival in a cohort of HIV-1 seropositive injecting drug users

Injecting drug users represent a pivotal and increasing component of acquired immunodeficiency syndrome (AIDS) case reporting in the United States. This article describes the natural history of human immunodeficiency virus (HIV) disease in a New York City cohort of 328 HIV-infected injecting drug users. The study sample of nearly two-thirds men (predominately African Americans and Latino Americans) underwent follow-up from December 1988 through December 1993. Male injecting drug users reported a longer injecting drug use history and were more likely to share needles/works than female injecting drug users. Eighty-nine of 328 study subjects died during the 5 years of observation. Comparing African Americans and Latinos, race/ethnicity was not related to survival. Survival was related to baseline CD4 count and hemoglobin level. Zidovudine use and PCP prophylaxis did not predict survival. Because of the continuing and increasing impact of HIV disease on injecting drug users and communities of color, there remains an unquestionable need to develop effective prevention programs, to understand the natural history of HIV disease, and to develop appropriate therapeutic interventions to treat those with HIV disease.

Glutamic acid 204 is the terminal proton release group at the extracellular surface of bacteriorhodopsin

We have measured proton release into the medium after proton transfer from the retinal Schiff base to Asp85 in the photocycle and the C = O stretch bands of carboxylic acids in wild type bacteriorhodopsin and the E204Q and E204D mutants. In E204Q, but not in E204D, the normal proton release is absent. Consistent with this, a negative band in the Fourier transform infrared difference spectra at 1700 cm-1 in the wild type, which we now attribute to depletion of the protonated E204, is also absent in E204Q. In E204D, this band is shifted to 1714 cm-1, as expected from the higher frequency for a protonated aspartic than for a glutamic acid. Consistent with their origin from protonated carboxyls, the depletion bands in the wild type and E204D shift in D2O to 1690 and 1703 cm-1, respectively. In the protein structure, Glu204 seems to be connected to the Schiff base region by a chain of hydrogen-bonded water. As with other residues closer to the Schiff base, replacement of Glu204 with glutamine changes the O-H stretch frequency of the bound water molecule near Asp85 that undergoes hydrogen-bonding change in the photocycle. The results therefore identify Glu204 as XH, the earlier postulated residue that is the source of the released proton during the transport, and suggest that its deprotonation is triggered by the protonation of Asp85 through a network that contains water dipoles.