An Industry Proposal for a Cell and Gene Therapy Safety Data Sheet

Introduction

A safety data sheet (SDS) is an established hazard communication tool for chemicals, for which no comparable document exists in the biotherapeutics industry. As the cell and gene therapy (CGT) field expands, industry leaders have identified a growing need to address this gap in communication of the unique occupational health and safety risks posed by CGT materials and products.

Methods

Following the sections of a traditional chemical SDS, information was modified by industry subject matter experts, relevant to CGT biological materials. This guide was developed based on assumptions of a maximum biosafety level 2, and any chemical components present in the material were excluded from the hazard classification.

Results

The guide contains necessary information to conduct a workplace risk assessment and communicate the unique workplace hazards posed by potential exposures to the material. The target audience is intended to be entities handling and producing these materials, plus collaborators, contractors, or operations sites receiving and handling the CGT material. An example of a CGT SDS is provided in Table 1.

Discussion

The CGT SDS provides industry with a best practice to address an existing gap in hazard communication for CGT. We expect that, as the field evolves, so may the contents. The CGT SDS can be used as a reference for other biological modalities in the field.

Conclusions

This initial CGT SDS communicates workplace hazards and assesses the unique risks posed by these biological materials and can assist in creating exposure control plans specific to the workplace hazards.

Analysis of Zika Virus Sequence Data Associated with a School Cohort in Haiti

Zika virus (ZIKV) infections occurred in epidemic form in the Americas in 2014-2016, with some of the earliest isolates in the region coming from Haiti. We isolated ZIKV from 20 children with acute undifferentiated febrile illness who were part of a cohort of children seen at a school clinic in the Gressier region of Haiti. The virus was also isolated from three pools of Aedes aegypti mosquitoes collected at the same location. On phylogenetic analysis, three distinct ZIKV clades were identified. Strains from all three clades were present in Haiti in 2014, making them among the earliest isolates identified in the Western Hemisphere. Strains from all three clades were also isolated in 2016, indicative of their persistence across the time period of the epidemic. Mosquito isolates were collected in 2016 and included representatives from two of the three clades; in one instance, ZIKV was isolated from a pool of male mosquitoes, suggestive of vertical transmission of the virus. The identification of multiple ZIKV clades in Haiti at the beginning of the epidemic suggests that Haiti served as a nidus for transmission within the Caribbean.

Isolation of a Novel Recombinant Canine Coronavirus From a Visitor to Haiti: Further Evidence of Transmission of Coronaviruses of Zoonotic Origin to Humans

We isolated a novel coronavirus from a medical team member presenting with fever and malaise after travel to Haiti. The virus showed 99.4% similarity with a recombinant canine coronavirus recently identified in a pneumonia patient in Malaysia, suggesting that infection with this virus and/or recombinant variants occurs in multiple locations.

Orthobunyaviruses in the Caribbean: Melao and Oropouche virus infections in school children in Haiti in 2014

We report the identification of two orthobunyaviruses, Melao virus (MELV) and Oropouche virus (OROV), in plasma specimens from Haitian children with acute febrile illness who presented during outbreaks caused by alpha- and flaviviruses in 2014. Heretofore not described as a human pathogen, MELV was isolated in cell culture from the plasma of five case patients. OROV RNA was detected in the plasma of an additional child, using an unbiased sequencing approach, with phylogenetic inference suggesting a close relationship with strains from Brazil. Abdominal pain was reported by four case patients with MELV infections, with lymphadenopathy noted in two cases. Our findings document the occurrence of these orthobunyaviruses within the Caribbean region and highlight the critical importance of surveillance with viral genome sequence analyses to identify outbreaks caused by these and other emerging viruses.

Melao and Oropuche virus infections were detected in Haitian children who developed acute febrile illnesses in year 2014. As these viruses were not previously known to circulate in Haiti, our findings highlight the critical importance of surveillance to identify outbreaks caused by these and other emerging viruses.

Emergence of porcine delta-coronavirus pathogenic infections among children in Haiti through independent zoonoses and convergent evolution

Coronaviruses have caused three major epidemics since 2003, including the ongoing SARS-CoV-2 pandemic. In each case, coronavirus emergence in our species has been associated with zoonotic transmissions from animal reservoirs^1,2, underscoring how prone such pathogens are to spill over and adapt to new species. Among the four recognized genera of the family Coronaviridae – Alphacoronavirus, Betacoronavirus, Deltacoronavirus, Gammacoronavirus, – human infections reported to date have been limited to alpha- and betacoronaviruses³. We identify, for the first time, porcine deltacoronavirus (PDCoV) strains in plasma samples of three Haitian children with acute undifferentiated febrile illness. Genomic and evolutionary analyses reveal that human infections were the result of at least two independent zoonoses of distinct viral lineages that acquired the same mutational signature in the nsp15 and the spike glycoprotein genes by convergent evolution. In particular, structural analysis predicts that one of the changes in the Spike S1 subunit, which contains the receptor-binding domain, may affect protein’s flexibility and binding to the host cell receptor. Our findings not only underscore the ability of deltacoronaviruses to adapt and potentially lead to human-to-human transmission, but also raise questions about the role of such transmissions in development of pre-existing immunity to other coronaviruses, such as SARS-CoV-2.

Independent infections of porcine deltacoronavirus among Haitian children

Coronaviruses have caused three major epidemics since 2003, including the ongoing SARS-CoV-2 pandemic. In each case, the emergence of coronavirus in our species has been associated with zoonotic transmissions from animal reservoirs^1,2, underscoring how prone such pathogens are to spill over and adapt to new species. Among the four recognized genera of the family Coronaviridae, human infections reported so far have been limited to alphacoronaviruses and betacoronaviruses^3-5. Here we identify porcine deltacoronavirus strains in plasma samples of three Haitian children with acute undifferentiated febrile illness. Genomic and evolutionary analyses reveal that human infections were the result of at least two independent zoonoses of distinct viral lineages that acquired the same mutational signature in the genes encoding Nsp15 and the spike glycoprotein. In particular, structural analysis predicts that one of the changes in the spike S1 subunit, which contains the receptor-binding domain, may affect the flexibility of the protein and its binding to the host cell receptor. Our findings highlight the potential for evolutionary change and adaptation leading to human infections by coronaviruses outside of the previously recognized human-associated coronavirus groups, particularly in settings where there may be close human-animal contact.

Keystone Virus Isolated From a Florida Teenager With Rash and Subjective Fever: Another Endemic Arbovirus in the Southeastern United States?

Keystone virus, a California-serogroup orthobunyavirus, was first isolated in 1964 from mosquitoes in Keystone, Florida. There were no prior reports of isolation from humans, despite studies suggesting that ~20% of persons living in the region are seropositive. We report virus isolation from a Florida teenager with a rash and fever.

Madariaga Virus: Identification of a Lineage III Strain in a Venezuelan Child With Acute Undifferentiated Febrile Illness, in the Setting of a Possible Equine Epizootic

We report identification of Madariaga virus (MADV) in plasma and urine samples from a child with acute undifferentiated febrile illness in Venezuela. Our data document the occurrence of milder MADV infections (ie, without encephalitis), with a symptom complex that resembles that seen with other arboviral infections, including dengue and zika.

Spondweni Virus in Field-Caught Culex quinquefasciatus Mosquitoes, Haiti, 2016

Spondweni virus (SPONV) and Zika virus cause similar diseases in humans. We detected SPONV outside of Africa from a pool of Culex mosquitoes collected in Haiti in 2016. This finding raises questions about the role of SPONV as a human pathogen in Haiti and other Caribbean countries.

Clinical and Epidemiologic Patterns of Chikungunya Virus Infection and Coincident Arboviral Disease in a School Cohort in Haiti, 2014-2015

BACKGROUND

Beginning in December 2013, an epidemic of chikungunya virus (CHIKV) infection spread across the Caribbean and into virtually all countries in the Western hemisphere, with >2.4 million cases reported through the end of 2017.

METHODS

We monitored a cohort of school children in rural Haiti from May 2014, through February 2015, for occurrence of acute undifferentiated febrile illness, with clinical and laboratory data available for 252 illness episodes.

RESULTS

Our findings document passage of the major CHIKV epidemic between May and July 2014, with 82 laboratory-confirmed cases. Subsequent peaks of febrile illness were found to incorporate smaller outbreaks of dengue virus serotypes 1 and 4 and Zika virus, with identification of additional infections with Mayaro virus, enterovirus D68, and coronavirus NL63. CHIKV and dengue virus serotype 1 infections were more common in older children, with a complaint of arthralgia serving as a significant predictor for infection with CHIKV (odds ratio, 16.2; 95% confidence interval, 8.0-34.4; positive predictive value, 66%; negative predictive value, 80%).

CONCLUSIONS

Viral/arboviral infections were characterized by a pattern of recurrent outbreaks and case clusters, with the CHIKV epidemic representing just one of several arboviral agents moving through the population. Although clinical presentations of these agents are similar, arthralgias are highly suggestive of CHIKV infection.

Emergence of Madariaga virus as a cause of acute febrile illness in children, Haiti, 2015-2016

Madariaga virus (MADV), also known as South American eastern equine encephalitis virus, has been identified in animals and humans in South and Central America, but not previously in Hispaniola or the northern Caribbean. MADV was isolated from virus cultures of plasma from an 8-year-old child in a school cohort in the Gressier/Leogane region of Haiti, who was seen in April, 2015, with acute febrile illness (AFI). The virus was subsequently cultured from an additional seven AFI case patients from this same cohort in February, April, and May 2016. Symptoms most closely resembled those seen with confirmed dengue virus infection. Sequence data were available for four isolates: all were within the same clade, with phylogenetic and molecular clock data suggesting recent introduction of the virus into Haiti from Panama sometime in the period from October 2012-January 2015. Our data document the movement of MADV into Haiti, and raise questions about the potential for further spread in the Caribbean or North America.

Madariaga virus (MADV) is the name given to what used to be called South American eastern equine encephalitis virus (EEEV), based on recent studies suggesting that MADV is distinct genetically from the EEEV circulating in North America. Until now, MADV has been found primarily in animals in South and Central America, with a limited number of human cases reported (most of whom had encephalitis). Our group has been responsible for a series of studies assessing the etiology of acute febrile illness (AFI) among children in a school cohort in Haiti. Unexpectedly, in April, 2015, we identified MADV on viral culture of plasma from a student with AFI in this cohort; an additional seven cases were identified on culture of samples from children with AFI in this same cohort in February, April, and May 2016. On sequence analysis, all strains were very similar genetically, and appear to have come from a strain introduced into Haiti from Panama sometime in the period from October 2012- January 2015. Symptoms of children were similar to those seen with dengue; none had encephalitis. Our data indicate that this virus, which has the potential for causing serious illness, has been recently introduced into Haiti, and raises the possibility that it might move into other parts of the Caribbean or North America.

Detection and phylogenetic characterization of arbovirus dual-infections among persons during a chikungunya fever outbreak, Haiti 2014

In the context of recent arbovirus epidemics, questions about the frequency of simultaneous infection of patients with different arbovirus species have been raised. In 2014, a major Chikungunya virus (CHIKV) epidemic impacted the Caribbean and South America. As part of ongoing screening of schoolchildren presenting with acute undifferentiated febrile illness in rural Haiti, we used RT-PCR to identify CHIKV infections in 82 of 100 children with this diagnosis during May-August 2014. Among these, eight were infected with a second arbovirus: six with Zika virus (ZIKV), one with Dengue virus serotype 2, and one with Mayaro virus (MAYV). These dual infections were only detected following culture of the specimen, suggesting low viral loads of the co-infecting species. Phylogenetic analyses indicated that the ZIKV and MAYV strains differ from those detected later in 2014 and 2015, respectively. Moreover, CHIKV and ZIKV strains from co-infected patients clustered monophyletically in their respective phylogeny, and clock calibration traced back the common ancestor of each clade to an overlapping timeframe of introduction of these arboviruses onto the island.

Evidence for Mother-to-Child Transmission of Zika Virus Through Breast Milk

Zikavirus (ZIKV) is an emerging viral pathogen that continues to spread throughout different regions of the world. Herein we report a case that provides further evidence that ZIKV transmission can occur through breastfeeding by providing a detailed clinical, genomic, and virological case-based description.

Bacteria in a water-damaged building: associations of actinomycetes and non-tuberculous mycobacteria with respiratory health in occupants

We examined microbial correlates of health outcomes in building occupants with a sarcoidosis cluster and excess asthma. We offered employees a questionnaire and pulmonary function testing and collected floor dust and liquid/sludge from drain tubing traps of heat pumps that were analyzed for various microbial agents. Forty-nine percent of participants reported any symptom reflecting possible granulomatous disease (shortness of breath on exertion, flu-like achiness, or fever and chills) weekly in the last 4 weeks. In multivariate regressions, thermophilic actinomycetes (median = 529 CFU/m² ) in dust were associated with FEV₁ /FVC [coefficient = -2.8 per interquartile range change, P = 0.02], percent predicted FEF_25-75% (coefficient = -12.9, P = 0.01), and any granulomatous disease-like symptom [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 1.45-6.73]. Mycobacteria (median = 658 CFU/m² ) were positively associated with asthma symptoms (OR = 1.5, 95% CI = 0.97-2.43). Composite score (median = 11.5) of total bacteria from heat pumps was negatively associated with asthma (0.8, 0.71-1.00) and positively associated with FEV₁ /FVC (coefficient = 0.44, P = 0.095). Endotoxin (median score = 12.0) was negatively associated with two or more granulomatous disease-like symptoms (OR = 0.8, 95% CI = 0.67-0.98) and asthma (0.8, 0.67-0.96). Fungi or (1→3)-β-D-glucan in dust or heat pump traps was not associated with any health outcomes. Thermophilic actinomycetes and non-tuberculous mycobacteria may have played a role in the occupants' respiratory outcomes in this water-damaged building.

Zika and Chikungunya virus co-infection in a traveller returning from Colombia, 2016: virus isolation and genetic analysis

Introduction:

Zikavirus (ZIKV) and Chikungunyavirus (CHIKV) can share the same mosquito vector, and co-infections by these viruses can occur in humans. While infections with these viruses share commonalities, CHIKV is unique in causing arthritis and arthralgias that may persist for a year or more. These infections are commonly diagnosed by RT–PCR-based methods during the acute phase of infection. Even with the high specificity and sensitivity characteristic of PCR, false negatives can occur, highlighting the need for additional diagnostic methods for confirmation.

Case presentation:

On her return to the USA, a traveller to Colombia, South America developed an illness consistent with Zika, Chikungunya and/or Dengue. RT-PCR of her samples was positive only for ZIKV. However, arthralgias persisted for months, raising concerns about co-infection with CHIKV or Mayaro viruses. Cell cultures inoculated with her original clinical samples demonstrated two types of cytopathic effects, and both ZIKV and CHIKV were identified in the supernatants. On phylogenetic analyses, both viruses were found to be related to strains found in Colombia.

Conclusion:

These findings highlight the need to consider CHIKV co-infection in patients with prolonged rheumatological symptoms after diagnosis with ZIKV, and the usefulness of cell culture as an amplification step for low-viremia blood and other samples.

Coinfection With Zika and Dengue-2 Viruses in a Traveler Returning From Haiti, 2016: Clinical Presentation and Genetic Analysis

Zika virus and dengue virus serotype 2 were isolated from a patient with travel to Haiti who developed fever, rash, arthralgias, and conjunctivitis. The infecting Zika virus was related to Venezuelan and Brazilian strains but evolved along a lineage originating from strains isolated in 2014 in the same region of Haiti.

Serologic evidence of exposure to influenza D virus among persons with occupational contact with cattle

BACKGROUND

Influenza D virus (IDV), a novel influenza virus with proposed classification: family Orthomyxoviridae, genus Influenzavirus D, species Influenza D virus, has been associated with influenza-like illness in cattle and swine. More recently, anti-IDV antibodies have also been detected in small ruminants. A seroprevalence of approximately 1.3% has been estimated for the general human population.

OBJECTIVES

To gain insights on the zoonotic potential of IDV to human adults with occupational exposure to cattle in north central Florida.

STUDY

A cross-sectional serological study was performed on human serum samples from 35 cattle-exposed and 11 non-cattle-exposed adults to screen for IDV antibodies using hemagglutination inhibition (HI) and microneutralization (MN) assays.

RESULTS

A seroprevalence of 91% was detected via HI assay, and 97% by MN assay among individuals working with cattle in Florida. Among non-cattle-exposed individuals, seropositivity determined via MN assay (only) was lower (18%).

CONCLUSIONS

IDV poses a zoonotic risk to cattle-exposed workers, based on detection of high seroprevalence (94-97%). Whereas it is still unknown whether IDV causes disease in humans, our studies indicate that the virus may be an emerging pathogen among cattle-workers.

Live poultry market workers are susceptible to both avian and swine influenza viruses, Guangdong Province, China

•

This cross-sectional study analyzed previous zoonotic infections among animal workers.

•

We examined 3 avian, 2 swine, 1 canine and 1 human influenza A viruses

•

Swine and poultry farm workers can easier be infected by respective species’ virus subtypes.

•

LPM workers were facing significant higher infectious risk both from avian and swine viruses.

•

H5N1, H7N9 previously infected cases were detected in this study.

Guangdong Province is recognized for dense populations of humans, pigs, poultry and pets. In order to evaluate the threat of viral infection faced by those working with animals, a cross-sectional, sero-epidemiological study was conducted in Guangdong between December 2013 and January 2014. Individuals working with swine, at poultry farms, or live poultry markets (LPM), and veterinarians, and controls not exposed to animals were enrolled in this study and 11 (4 human, 3 swine, 3 avian, and 1 canine) influenza A viruses were used in hemagglutination inhibition (HI) assays (7 strains) and the cross-reactivity test (9 strains) in which 5 strains were used in both tests. Univariate analysis was performed to identify which variables were significantly associated with seropositivity. Odds ratios (OR) revealed that swine workers had a significantly higher risk of elevated antibodies against A/swine/Guangdong/L6/2009(H1N1), a classical swine virus, and A/swine/Guangdong/SS1/2012(H1N1), a Eurasian avian-like swine virus than non-exposed controls. Poultry farm workers were at a higher risk of infection with avian influenza H7N9 and H9N2. LPM workers were at a higher risk of infection with 3 subtypes of avian influenza, H5N1, H7N9, and H9N2. Interestingly, the OR also indicated that LPM workers were at risk of H1N1 swine influenza virus infection, perhaps due to the presence of pigs in the LPM. While partial confounding by cross-reactive antibodies against human viruses or vaccines cannot be ruled out, our data suggests that animal exposed people as are more likely to have antibodies against animal influenza viruses.

Equine influenza A(H3N8) virus isolated from Bactrian camel, Mongolia

Because little is known about the ecology of influenza viruses in camels, 460 nasal swab specimens were collected from healthy (no overt illness) Bactrian camels in Mongolia during 2012. One specimen was positive for influenza A virus (A/camel/Mongolia/335/2012[H3N8]), which is phylogenetically related to equine influenza A(H3N8) viruses and probably represents natural horse-to-camel transmission.

Evidence for subclinical H5N1 avian influenza infections among Nigerian poultry workers

In recent years Nigeria has experienced sporadic incursions of highly pathogenic H5N1 avian influenza among poultry. In 2008, 316 poultry-exposed agricultural workers, and 54 age-group matched non-poultry exposed adults living in the Enugu or Ebonyi States of Nigeria were enrolled and then contacted monthly for 24 months to identify acute influenza-like-illnesses. Annual follow-up sera and questionnaire data were collected at 12 and 24 months. Participants reporting influenza-like illness completed additional questionnaires, and provided nasal and pharyngeal swabs and acute and convalescent sera. Swab and sera specimens were studied for evidence of influenza A virus infection. Sera were examined for elevated antibodies against 12 avian influenza viruses by microneutralization and 3 human viruses by hemagglutination inhibition. Four (3.2%) of the 124 acute influenza-like-illness investigations yielded molecular evidence of influenza, but virus could not be cultured. Serial serum samples from five poultry-exposed subjects had a ≥4-fold change in microneutralization titers against A/CK/Nigeria/07/1132123(H5N1), with three of those having titers ≥1:80 (maximum 1:1,280). Three of the five subjects (60%) reported a preceding influenza-like illness. Hemagglutination inhibition titers were ≥4-fold increases against one of the human viruses in 260 participants. While cross-reactivity from antibodies against other influenza viruses cannot be ruled out as a partial confounder, over the course of the 2-year follow-up, at least 3 of 316 (0.9%) poultry-exposed subjects had evidence for subclinical HPAI H5N1 infections. If these data represent true infections, it seems imperative to increase monitoring for avian influenza among Nigeria's poultry and poultry workers.

Myocardial Tissue Characterization: Histological and Pathophysiological Correlation

Cardiovascular magnetic resonance imaging (CMR) has become the gold standard not only for cardiac volume and function quantification, but for a key unique strength: non-invasive myocardial tissue characterization. Several different techniques, separately or in combination, can detect and quantify early and established myocardial pathological processes permitting better diagnosis, prognostication and tracking of therapy. The authors will focus on the histological and pathophysiological evidence of these imaging parameters in the characterization of edema, infarction, scar and fibrosis. In addition to laying out the strengths and weaknesses of each modality, the reader will be introduced to rapid developments in T1 and T2 mapping as well as the use of contrast-derived extracellular volume for quantification of diffuse fibrosis.

Little evidence of human infection with equine influenza during the 2007 epizootic, Queensland, Australia

BACKGROUND

Equine influenza virus (EIV) is considered enzootic in Europe (except Iceland), Asia, North Africa, and North and South America. When EIV outbreaks occur they may severely impact the equine and tourist industries. Australia faced its first EIV outbreak beginning in August of 2007. The outbreak was concentrated in New South Wales and Queensland, with more than 1400 confirmed EIV infections in horses during the first month. Rapid response from the equine industry and the federal government was successful and Australia was declared free from EIV by the end of 2007.

OBJECTIVES

This cross-sectional study was designed to examine associations between exposure to EIV-infected horses and evidence of EIV infection in humans.

STUDY DESIGN

Employing informed consent, between October 2007 and April 2008, 100 subjects (89 with horse exposures and 11 non-exposed) were enrolled during equine events and at the University of the Sunshine Coast. All subjects provided a blood sample and were asked to complete an online questionnaire including health history, animal exposure and demographic information. Sera samples were tested for the presence of antibodies against two H3N8 EIV strains using microneutralization, hemagglutination inhibition, and enzyme-linked lectin assays.

RESULTS

Evidence for H3N8 infection was sparse, with only 9 study participants having any indication of H3N8 infection and the seroreactivity seen was low and easily explained by cross-reactions against human influenza strains or vaccines.

CONCLUSIONS

These data provide little evidence to support the premise that EIV infections occurred among humans exposed to EIV-infected horses during the 2007 Australian epizootic.

Work-related peak flow and asthma symptoms in a damp building

BACKGROUND

Working in damp conditions is associated with asthma, but few studies have used objective testing to document work-related patterns.

AIMS

To describe the relationship of peak flow measurements to work-related asthma (WRA) symptoms and WRA among occupants in a damp office building.

METHODS

At the beginning of the study, all workers were offered a questionnaire and methacholine challenge testing. Participants were then instructed to perform serial spirometry using handheld spirometers five times per day over a 3 week period. Peak flow data were analysed using OASYS-2 software. We calculated the area between the curves (ABC score) using hours from waking. We considered a score >5.6 L/min/h to be indicative of a work-related pattern.

RESULTS

All 24 employees participated in the questionnaire. Seven participants (29%) reported physician-diagnosed asthma with onset after starting work in the building. Almost two-thirds (63%) of participants reported at least one lower respiratory symptom (LRS) occurring one or more times per week in the last 4 weeks. Twenty-two (92%) consented to participate in serial spirometry. Fourteen participants had adequate quality of serial spirometry, five of whom had ABC scores >5.6, ranging from 5.9-23.0. Of these five, two had airways responsiveness, three had current post-hire onset physician-diagnosed asthma and four reported work-related LRS.

CONCLUSIONS

We found evidence of work-related changes in serial peak flows among some occupants of an office building with a history of dampness. Serial peak flows may be a useful measure to determine WRA in office settings.

16alpha-Bromoepiandrosterone (HE2000) limits non-productive inflammation and stimulates immunity in lungs

16alpha-Bromoepiandrosterone (HE2000) is a synthetic steroid that limits non-productive inflammation, enhances protective immunity and improves survival in clinical studies of patients with human immunodeficiency virus (HIV), malaria and tuberculosis infections. We now show that HE2000 decreased nitric oxide production by lipopolysaccharide (LPS)-stimulated RAW264.7 cells. Treatment with HE2000 also reduced non-productive inflammation associated with carrageenan-induced pleurisy and LPS-induced lung injury in mice. In the hapten-carrier reporter antigen popliteal lymph node assay, HE2000 increased absolute numbers of lymphocytes, antigen-presenting cells, hapten-specific immunoglobulin (Ig)M antibody-forming cells and shifted the interferon (IFN)-gamma/interleukin (IL)-4 balance towards IFN-gamma production. In the cystic fibrosis transmembrane conductance regulator (CFTR(-/-)) mouse model of acute Pseudomonas aeruginosa infection, treatment with HE2000 consistently reduced bacterial burden in lungs. All HE2000 effects were dose-dependent. In H1N1 infection in mice, HE2000 was safe but not effective as a monotherapy, as treatment did not effect survival. HE2000 reduced mortality related to excessive inflammation and opportunistic lung infections in animals and patients, and this might extend to those with H1N1 influenza infection.

Respiratory inflammatory responses among occupants of a water-damaged office building

The National Institute for Occupational Safety and Health (NIOSH) received a request for evaluation of a water-damaged office building which housed approximately 1300 employees. Workers reported respiratory conditions that they perceived to be building related. We hypothesized that these symptoms were associated with airways inflammation. To test this hypothesis, we assessed airways inflammation in employees using exhaled breath condensate (EBC) and the fraction of exhaled nitric oxide (FENO). In September 2001, a health questionnaire was offered to all employees. Based on this questionnaire, NIOSH invited 356 symptomatic and asymptomatic employees to participate in a medical survey. In June 2002, these employees were offered questionnaire, spirometry, methacholine challenge test, allergen skin prick testing, EBC and FENO. FENO or EBC were completed by 239 participants. As smoking is highly related to the measurements that we used in this study, we included only the 207 current non-smokers in the analyses. EBC interleukin-8 (IL-8) levels, but not nitrite, were significantly higher among workers with respiratory symptoms and in the physician-diagnosed asthmatic group. Of the analyses assessed, EBC IL-8 showed the most significant relationship with a number of symptoms and physician-diagnosed asthma.

PRACTICAL IMPLICATIONS

Implementation of exhaled breath condensate and exhaled nitric oxide in indoor air quality problems.

Synthesis of C-11 methyl-substituted benzocycloheptapyridine inhibitors of farnesyl protein transferase

[formula: see text] Synthesis of C-11 methyl-substituted benzocycloheptylpyridine tricyclic compounds has been achieved via two different methods. Methylation of C-11 has been effected by treatment of amine 4 with BuLi followed by Mel quenching. In a similar procedure, introduction of a C-11 substituent with concomitant rearrangement of the exocyclic double bond has been carried out. Potent farnesyl protein transferase inhibitors have been synthesized using the above methodologies.

Arrhythmia detection and response in a monitoring technician and pocket paging system

Technologically advanced telemetry systems have begun to produce alternatives to the need for continuous visual observation of the electrocardiogram (ECG). Few studies have been conducted to determine the efficacy of these systems in the clinical setting. The purpose of this study was to describe two different approaches to communication of arrhythmia events and corresponding nurse response. One approach, on a cardiac medical unit, utilized a monitoring technician to continuously observe ECGs at a central monitoring technician station (MTS) and notify the nurse of changes. The other approach, on a general medical unit, eliminated the use of the monitoring technician and utilized a pocket paging system (PPS). The PPS interfaced with the computerized arrhythmia detection system from the ECG monitor, which directly alerted the nurse to arrhythmia events. A quasi-experimental comparative post-test design was used. The sample consisted of 50 randomly selected, 2-hour observation periods on each unit during a 3-month period. Data collectors recorded the interaction of the monitoring technician with the arrhythmia detection system and the nurse on the MTS unit, or the nurse using the PPS. Results of this study revealed all arrhythmia events activated an alarm by the computerized arrhythmia detection system. Length of time to notify the nurse was within 0 to 1 minute for both systems. This study demonstrated that the PPS is a viable approach to arrhythmia detection and communication in the medical/cardiac patient population.

The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

Hyperthermic intraoperative intraperitoneal chemotherapy safety considerations

Perioperative staff members encounter many occupational exposure hazards in the workplace. Cytotoxic agent exposure is a relatively new hazard that perioperative staff members are experiencing as more surgeons use hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) to treat patients with abdominopelvic cavity malignancies. Routes of exposure include inhalation, ingestion, injection, and skin contact. The National Cancer Institute, the Occupational Safety and Health Administration, and the Joint Commission on Accreditation of Healthcare Organizations provide guidelines for the safe administration and handling of cytotoxic agents. Institutions in which cytotoxic agents are administered should use these guidelines to develop policies, procedures, and educational programs to protect surgical patients and perioperative staff members.

Safety constiderations in the use of intraoperative intraperitoneal chemotherapy

The clinical significance of occupational exposure to antineoplastic agents is controversial. Accrued evidence does not seem to indicate mutagenicity, carcinogenicity, and tertogenicity when exposure is limited by proper precautions. However, medical surveillance of personnel continually exposed to these cytotoxic agents will aid in early detection of any problems should they occur. Because the current fiscal milieu constantly emphasizes cost containment, true prevention means an intense worker education program. Personnel continually exposed to these cytotoxic agents should have scheduled health checkups twice a year, and exposure frequency should be reported to the employee's personal physician.

Supporting nursing innovations in a cost-conscious environment

Our rapidly changing health care environment requires critical care nurses to develop creative and innovative approaches to patient care. Empowering and enabling these nurses are the only ways that health care institutions will be able to meet the challenges of the future. This article describes two examples of innovations that have contributed to cost containment within a coronary care unit.

Synthesis and structure-activity relationships of novel retinoid X receptor-selective retinoids

Two series of potent retinoid X receptor (RXR)-selective compounds were designed and synthesized based upon recent observation that (E)-4-[2-(5,5,8,8-tetramethyl-5,6,7,8-tetrahydro-2-naphthalenyl)-1- propenyl]benzoic acid (TTNBP) binds and transactivates only the retinoic acid receptor (RAR) subtypes whereas (E)-4-[2-(3,5,5,8,8-pentamethyl-5,6,7,8- tetrahydro-2-naphthalenyl)-1-propenyl]benzoic acid (3-methyl TTNPB) binds and transactivates both the RAR and RXR subfamilies. Addition of functional groups such as methyl, chloro, bromo, or ethyl to the 3 position of the tetrahydronaphthalene moiety of 4-[(5,5,8,8-tetramethyl-5,6,7,8-tetrahydro-2-naphthyl)carbonyl]benzoic acid (5a) and 4-[1-(5,5,8,8-tetramethyl-5,6,7,8-tetrahydro-2- naphthyl)ethenyl]benzoic acid (6a) results in compounds which elicit potent and selective activation of the RXR class. Such RXR-selective compounds offer pharmacological tools for elucidating the biological role of the individual retinoid receptors with which they interact. Activation profiles in cotransfection and competitive binding assays as well as molecular modeling calculations demonstrate critical structural determinants that confer selectivity for members of the RXR subfamily. The most potent compound of these series, 4-[1-(3,5,5,8,8-pentamethyl-5,6,7,8-tetrahydro-2-naphthyl)ethenyl]ben zoi c acid (6b), is the first RXR-selective retinoid (designated as LGD1069) to enter clinical trials for cancer indications.

Synthesis of high specific activity [3H]-9-cis-retinoic acid and its application for identifying retinoids with unusual binding properties

all-trans-Retinoic acid is known to bind to the retinoic acid receptors (RARs) resulting in an increase in their transcriptional activity. In contrast, recently identified 9-cis-retinoic acid (9-cis-RA), which is an additional endogenous RA isomer, is capable of binding to both RARs and retinoid X receptors (RXRs). These distinct properties have raised questions as to the biological role governed by these two retinoic acid isomers and the set of target genes that they regulate. Herein, we report the synthesis of high specific activity [3H]-9-cis-RA and its application to study the ligand-binding properties of the various retinoid receptor subtypes. We examined the binding properties of RARs and RXRs for a series of synthetic retinoids and compared the ligand-binding properties of these arotinoid analogs with their ability to regulate gene expression via the retinoid receptors in a cotransfection assay. The utilization of the [3H]-9-cis-RA competitive binding assay and the cotransfection assay has made it possible to rapidly identify important structural features of retinoids leading to increased selectivity for either the RAR or RXR receptor subtypes.

Transactivation properties of retinoic acid and retinoid X receptors in mammalian cells and yeast. Correlation with hormone binding and effects of metabolism

The binding affinities of 9-cis-retinoic acid (9-cis-RA) and all-trans-retinoic acid (t-RA) for retinoic acid receptors (RAR) alpha, beta, and gamma and for retinoid X receptors (RXR) alpha, beta, and gamma were determined using the recombinant receptor proteins and were compared with each hormone's ability to activate transcription through the receptors in mammalian and yeast cell systems. 9-cis-RA bound to both the RXRs (Kd values = 1.4-2.4 nM) and the RARs (Kd values = 0.2-0.8 nM). The ability of 9-cis-RA to bind to the RARs and RXRs correlated with its ability to produce similar transactivation profiles with these receptors in mammalian and yeast cell assays. t-RA bound to the RARs (Kd values = 0.2-0.4 nM) and activated transcription through the RARs in mammalian and yeast cells. In contrast, while t-RA did not bind to the RXRs, it did activate the RXRs, albeit less potently than 9-cis-RA, in mammalian cells. In yeast, however, the RXRs activated transcription only in the presence of 9-cis-RA, not with t-RA. While RAR gamma is activated in yeast by either t-RA or 9-cis-RA, the overall level of transcription was increased upon the addition of hormone-occupied RXR. Metabolism studies suggest that while there was no cell-dependent interconversion between t-RA and 9-cis-RA in yeast, there was cell-dependent conversion of 9-cis-RA to t-RA in mammalian cells [corrected].

Neuroaxonal dystrophy with neuromelanin deposition, neurofibrillary tangles, and neuronal loss. Light- and electron-microscopic changes in a 45-year-old woman with progressive psychomotor deterioration

Neuroaxonal spheroids became evident microscopically after the autopsy of a 45-year-old woman with pigmentation of the globus pallidus suggesting Hallervorden-Spatz disease. In our opinion the fine floccular pigment seen electron-microscopically in many of the axonal spheroids is melanin, an end product of catecholamine metabolism. Neurofibrillary degeneration, senile plaques, and granulovacuolar degeneration in the hippocampus produced a picture of Alzheimer's disease. Pontocerebellar degeneration and motor neuron disease were also observed.