Certolizumab pegol, abatacept, tocilizumab or active conventional treatment in early rheumatoid arthritis: 48-week clinical and radiographic results of the investigator-initiated randomised controlled NORD-STAR trial

BACKGROUND

The optimal first-line treatment in early rheumatoid arthritis (RA) is debated. We compared clinical and radiographic outcomes of active conventional therapy with each of three biological treatments with different modes of action.

METHODS

Investigator-initiated, randomised, blinded-assessor study. Patients with treatment-naïve early RA with moderate-severe disease activity were randomised 1:1:1:1 to methotrexate combined with (1) active conventional therapy: oral prednisolone (tapered quickly, discontinued at week 36) or sulfasalazine, hydroxychloroquine and intra-articular glucocorticoid injections in swollen joints; (2) certolizumab pegol; (3) abatacept or (4) tocilizumab. Coprimary endpoints were week 48 Clinical Disease Activity Index (CDAI) remission (CDAI ≤2.8) and change in radiographic van der Heijde-modified Sharp Score, estimated using logistic regression and analysis of covariance, adjusted for sex, anticitrullinated protein antibody status and country. Bonferroni's and Dunnet's procedures adjusted for multiple testing (significance level: 0.025).

RESULTS

Eight hundred and twelve patients were randomised. Adjusted CDAI remission rates at week 48 were: 59.3% (abatacept), 52.3% (certolizumab), 51.9% (tocilizumab) and 39.2% (active conventional therapy). Compared with active conventional therapy, CDAI remission rates were significantly higher for abatacept (adjusted difference +20.1%, p<0.001) and certolizumab (+13.1%, p=0.021), but not for tocilizumab (+12.7%, p=0.030). Key secondary clinical outcomes were consistently better in biological groups. Radiographic progression was low, without group differences.The proportions of patients with serious adverse events were abatacept, 8.3%; certolizumab, 12.4%; tocilizumab, 9.2%; and active conventional therapy, 10.7%.

CONCLUSIONS

Compared with active conventional therapy, clinical remission rates were superior for abatacept and certolizumab pegol, but not for tocilizumab. Radiographic progression was low and similar between treatments.

TRIAL REGISTRATION NUMBER

NCT01491815.

Electroencephalographic Changes in Sleep During Acute and Subacute Phases After Sports-Related Concussion

Purpose

Little is known about sleep after a concussion, a form of mild traumatic brain injury. Given the importance of sleep for both maintaining brain health and recovery from injury, we sought to examine sleep acutely and subacutely after concussion.

Methods

Athletes who experienced a sports-related concussion were invited to participate. Participants underwent overnight sleep studies within 7 days of the concussion (acute phase), and again eight-weeks after the concussion (subacute phase). Changes in sleep from both the acute and subacute phases were compared to population normative values. Additionally, changes in sleep from acute to subacute phase were analysed.

Results

When compared to normative data, the acute and subacute phases of concussion showed longer total sleep time (p < 0.005) and fewer arousals (p < 0.005). The acute phase showed longer rapid eye movement sleep latency (p = 0.014). The subacute phase showed greater total sleep spent in Stage N3% (p = 0.046), increased sleep efficiency (p < 0.001), shorter sleep onset latency (p = 0.013), and reduced wake after sleep onset (p = 0.013). Compared to the acute phase, the subacute phase experienced improved sleep efficiency (p = 0.003), reduced wake after sleep onset (p = 0.02), and reduced latencies for both stage N3 sleep (p = 0.014) and rapid eye movement sleep (p = 0.006).

Conclusion

This study indicated sleep during both the acute and subacute phases of SRC was characterised by longer and less disrupted sleep, along with improvements in sleep from the acute to subacute phases of SRC.

889Association of maternal smoking during pregnancy and early-childhood with adult insomnia symptoms

Background

Evidence regarding the association between perinatal smoking and insomnia symptoms in adulthood is limited. Using the UK 1970 Birth Cohort Study, we determined the association of maternal smoking during pregnancy and early-childhood with insomnia symptoms at 42 years.

Methods

Participants were followed from birth (1970; N = 9020; male, 48%) and age 5 (1975; N = 8050; male, 47.9%) to 42 years (2012). Data on maternal smoking was collected at birth and age 5; difficulties initiating or maintaining sleep (DIMS) and DIMS plus daytime symptoms (tiredness, irritability, depression and nervousness) [DIMS plus] at age 42. We used a direct acyclic graph to select confounders. A log-binomial logistic regression, adjusted for confounders, was used to estimate the association. Missing data were imputed via multiple imputation.

Results

The prevalence of DIMS and DIMS plus was 32% and 25%, respectively. There was a 25% [odds ratio (OR)=1.25; 95% confidence interval (CI): 1.12-1.38)] and 23% [OR = 1.23; 95% CI: 1.09-1.38] increase in odds of DIMS and DIMS plus among participants whose mothers smoked during pregnancy compared to those whose mother did not. A 24% [OR = 1.24; 95% CI: 1.12-1.37] and 18% [OR = 1.18; 95% CI: 1.05-1.33] increase in odds of DIMS and DIMS plus respectively, was observed among participants who had smoking mothers at age 5. Intensity and duration of smoking had a dose-response relationship with insomnia symptoms.

Conclusions

Maternal smoking during pregnancy and early-childhood is associated with increased risk of adult insomnia symptoms.

Key messages

This study suggests that reducing maternal smoking may reduce the risk of adult insomnia.

Syphilis with vision loss

BACKGROUND

Neurosyphilis is a rare cause of vision loss that can mimic the presentation of other diseases, including giant cell arteritis.

CASE PRESENTATION

A man in his sixties presented to the university hospital with a four-day history of right eye vision loss. He experienced a headache, myalgia and fatigue. Right eye vision was limited to finger counting at 2 metres and a relative afferent pupillary defect was present. He was tender over the right temporal area and had a decreased pulse in the right temporal artery. A pink maculopapular rash was present on the trunk. Laboratory testing showed elevated inflammatory parameters with ESR 50. Ischaemic optic neuropathy caused by giant cell arteritis was suspected, and treatment with high dose steroids was initiated. Expanded history revealed travel to Thailand five months prior to presentation and unprotected sex with multiple female partners. A non-painful sore had developed on his penis that resolved after 14 days.

INTERPRETATION

Neurosyphilis was suspected and the diagnosis was subsequently confirmed. The patient received appropriate antibiotic therapy, and four months later his vision had almost normalised.

Association Between Childhood Behavioral Problems and Insomnia Symptoms in Adulthood

Importance

Life-course determinants of insomnia, particularly the long-term association of childhood behavioral problems with insomnia later in life, are unknown. As childhood behaviors are measurable and potentially modifiable, understanding their associations with insomnia symptoms may provide novel insights into early intervention strategies to reduce the burden.

Objective

To investigate the association between behavioral problems at 5, 10, and 16 years of age and self-reported insomnia symptoms at 42 years of age.

Design, Setting, and Participants

This cohort study used data from the United Kingdom 1970 Birth Cohort Study, an ongoing large-scale follow-up study. Participants were followed up from birth (1970) to age 42 years (2012). Missing data were imputed via multiple imputation. Statistical analysis was performed from February 1 to July 15, 2019.

Exposures

Behavior measured at 5, 10, and 16 years of age using the Rutter Behavioral Scale (RBS). Children's behavior was classified as normal (≤80th percentile), moderate behavioral problems (>80th to ≤95th percentile), and severe behavioral problems (>95th percentile) based on their RBS score.

Main Outcomes and Measures

Self-reported difficulties initiating or maintaining sleep (DIMS) were collected using a self-administered questionnaire at 42 years of age. Log-binomial logistic regression, adjusted for several potential confounders, was used to estimate the association of childhood behavioral problems with insomnia symptoms in adulthood. Sensitivity analyses were conducted to check robustness of the findings.

Results

Participants were followed up from a baseline age of 5 years (n = 8050; 3854 boys and 4196 girls), 10 years (n = 9090; 4365 boys and 4725 girls), or 16 years (n = 7653; 3575 boys and 4078 girls) until age 42 years. There was a 39% higher risk of DIMS (odds ratio [OR], 1.39; 95% CI, 1.04-1.84; P = .06 for trend) for participants with severe behavioral problems at 5 years of age compared with those with a normal RBS score. The odds of DIMS plus not feeling rested on waking (DIMS plus) in participants with severe behavioral problems at 5 years of age were 29% higher (odds ratio, 1.29; 95% CI, 0.97-1.70; P = .14 for trend) than participants with a normal RBS score, although this result was not statistically significant. Moderate and severe behavioral problems at 16 years of age were positively associated with DIMS and DIMS plus (moderate: OR, 1.28; 95% CI, 1.07-1.52; severe: OR, 1.67; 95% CI, 1.22-2.30; P < .001 for trend) and DIMS plus (moderate: OR, 1.32; 95% CI, 1.11-1.56; severe: OR, 1.47; 95% CI, 1.09-1.98; P < .001 for trend). Externalizing behavioral problems at 5 and 10 years of age were positively associated with insomnia symptoms at 42 years of age.

Conclusions and Relevance

This study is the first to show associations of early-life behavioral problems, particularly early- and middle-childhood externalizing problems, with insomnia symptoms in adulthood. These findings underline the importance of addressing insomnia from a life-course perspective and considering the benefits of early behavioral intervention to sleep health.

Effect of 1 month of zopiclone on obstructive sleep apnoea severity and symptoms: a randomised controlled trial

Hypnotic use in obstructive sleep apnoea (OSA) is contraindicated due to safety concerns. Recent studies indicate that single-night hypnotic use worsens hypoxaemia in some and reduces OSA severity in others depending on differences in pathophysiology. However, longer clinical trial data are lacking. This study aimed to determine the effects of 1 month of zopiclone on OSA severity, sleepiness and alertness in patients with low-moderate respiratory arousal thresholds without major overnight hypoxaemia.69 participants completed a physiology screening night with an epiglottic catheter to quantify arousal threshold. 30 eligible patients (apnoea-hypopnoea index (AHI) 22±11 events·h^-1) then completed standard in-laboratory polysomnography (baseline) and returned for two additional overnight sleep studies (nights 1 and 30) after receiving either nightly zopiclone (7.5 mg) or placebo during a 1-month, double-blind, randomised, parallel trial (ANZCTR identifier ANZCTRN12613001106729).The change in AHI from baseline to night 30 was not different between zopiclone versus placebo groups (-5.9±10.2 versus -2.4±5.5 events·h^-1; p=0.24). Similarly, hypoxaemia, next-day sleepiness and driving simulator performance were not different.1 month of zopiclone does not worsen OSA severity, sleepiness or alertness in selected patients without major overnight hypoxaemia. As the first study to assess the effect of a hypnotic on OSA severity and sleepiness beyond single-night studies, these findings provide important safety data and insight into OSA pathophysiology.

A simple method for assessing muscle function in common marmosets

A novel method of assessing muscle function in the common marmoset was developed as part of a multidisciplinary long-term study. The method involved home cage presentation of a weight-pulling task. Over a 4–5 month period, 38 of 42 animals were successfully trained to displace weights of up to 920 g (mean 612±20 g). Performance, following initial training, was stable and independent of gender or body weight.

Statistical Learning Is Not Affected by a Prior Bout of Physical Exercise

This study examined the effect of a prior bout of exercise on implicit cognition. Specifically, we examined whether a prior bout of moderate intensity exercise affected performance on a statistical learning task in healthy adults. A total of 42 participants were allocated to one of three conditions-a control group, a group that exercised for 15 min prior to the statistical learning task, and a group that exercised for 30 min prior to the statistical learning task. The participants in the exercise groups cycled at 60% of their respective V˙O2 max. Each group demonstrated significant statistical learning, with similar levels of learning among the three groups. Contrary to previous research that has shown that a prior bout of exercise can affect performance on explicit cognitive tasks, the results of the current study suggest that the physiological stress induced by moderate-intensity exercise does not affect implicit cognition as measured by statistical learning.

Statistical learning under incidental versus intentional conditions

Statistical learning (SL) studies have shown that participants are able to extract regularities in input they are exposed to without any instruction to do so. This and other findings, such as the fact that participants are often unable to verbalize their acquired knowledge, suggest that SL can occur implicitly or incidentally. Interestingly, several studies using the related paradigms of artificial grammar learning and serial response time tasks have shown that explicit instructions can aid learning under certain conditions. Within the SL literature, however, very few studies have contrasted incidental and intentional learning conditions. The aim of the present study was to investigate the effect of having prior knowledge of the statistical regularities in the input when undertaking a task of visual sequential SL. Specifically, we compared the degree of SL exhibited by participants who were informed (intentional group) versus those who were uninformed (incidental group) about the presence of embedded triplets within a familiarization stream. Somewhat surprisingly, our results revealed that there were no statistically significant differences (and only a small effect size) in the amount of SL exhibited between the intentional versus the incidental groups. We discuss the ways in which this result can be interpreted and suggest that short presentation times for stimuli in the familiarization stream in our study may have limited the opportunity for explicit learning. This suggestion is in line with recent research revealing a statistically significant difference (and a large effect size) between intentional versus incidental groups using a very similar visual sequential SL task, but with longer presentation times. Finally, we outline a number of directions for future research.

Changes in the hemagglutinin of H5N1 viruses during human infection--influence on receptor binding

As avian influenza A(H5N1) viruses continue to circulate in Asia and Africa, global concerns of an imminent pandemic persist. Recent experimental studies suggest that efficient transmission between humans of current H5N1 viruses only requires a few genetic changes. An essential step is alteration of the virus hemagglutinin from preferential binding to avian receptors for the recognition of human receptors present in the upper airway. We have identified receptor-binding changes which emerged during H5N1 infection of humans, due to single amino acid substitutions, Ala134Val and Ile151Phe, in the hemagglutinin. Detailed biological, receptor-binding, and structural analyses revealed reduced binding of the mutated viruses to avian-like receptors, but without commensurate increased binding to the human-like receptors investigated, possibly reflecting a receptor-binding phenotype intermediate in adaptation to more human-like characteristics. These observations emphasize that evolution in nature of avian H5N1 viruses to efficient binding of human receptors is a complex multistep process.

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Changes in receptor binding of HA during H5N1 human infection were identified.

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Single A134V and L151F substitutions caused reduced affinity for avian receptors.

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Glycan array analyses were used to identify changes in receptor binding specificity.

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Structural basis for altered receptor binding was examined by X-ray crystallography.

Haemagglutinin mutations responsible for the binding of H5N1 influenza A viruses to human-type receptors

H5N1 influenza A viruses have spread to numerous countries in Asia, Europe and Africa, infecting not only large numbers of poultry, but also an increasing number of humans, often with lethal effects. Human and avian influenza A viruses differ in their recognition of host cell receptors: the former preferentially recognize receptors with saccharides terminating in sialic acid-alpha2,6-galactose (SAalpha2,6Gal), whereas the latter prefer those ending in SAalpha2,3Gal (refs 3-6). A conversion from SAalpha2,3Gal to SAalpha2,6Gal recognition is thought to be one of the changes that must occur before avian influenza viruses can replicate efficiently in humans and acquire the potential to cause a pandemic. By identifying mutations in the receptor-binding haemagglutinin (HA) molecule that would enable avian H5N1 viruses to recognize human-type host cell receptors, it may be possible to predict (and thus to increase preparedness for) the emergence of pandemic viruses. Here we show that some H5N1 viruses isolated from humans can bind to both human and avian receptors, in contrast to those isolated from chickens and ducks, which recognize the avian receptors exclusively. Mutations at positions 182 and 192 independently convert the HAs of H5N1 viruses known to recognize the avian receptor to ones that recognize the human receptor. Analysis of the crystal structure of the HA from an H5N1 virus used in our genetic experiments shows that the locations of these amino acids in the HA molecule are compatible with an effect on receptor binding. The amino acid changes that we identify might serve as molecular markers for assessing the pandemic potential of H5N1 field isolates.

Avian and human receptor binding by hemagglutinins of influenza A viruses

An understanding of the structural determinants and molecular mechanisms involved in influenza A virus binding to human cell receptors is central to the identification of viruses that pose a pandemic threat. To date, only a limited number of viruses are known to have infected humans even sporadically, and this has recently included the virulent H5 and H7 avian viruses. We compare here the 3-dimensional structures of H5 and H7 hemagglutinins (HA) complexed with avian and human receptor analogues, to highlight regions within the receptor binding domains of these HAs that might prevent strong binding to the human receptor.

The structure of H5N1 avian influenza neuraminidase suggests new opportunities for drug design

The worldwide spread of H5N1 avian influenza has raised concerns that this virus might acquire the ability to pass readily among humans and cause a pandemic. Two anti-influenza drugs currently being used to treat infected patients are oseltamivir (Tamiflu) and zanamivir (Relenza), both of which target the neuraminidase enzyme of the virus. Reports of the emergence of drug resistance make the development of new anti-influenza molecules a priority. Neuraminidases from influenza type A viruses form two genetically distinct groups: group-1 contains the N1 neuraminidase of the H5N1 avian virus and group-2 contains the N2 and N9 enzymes used for the structure-based design of current drugs. Here we show by X-ray crystallography that these two groups are structurally distinct. Group-1 neuraminidases contain a cavity adjacent to their active sites that closes on ligand binding. Our analysis suggests that it may be possible to exploit the size and location of the group-1 cavity to develop new anti-influenza drugs.

Studies into Using Manure in a Biorefinery Concept

Animal manure is an underutilized biomass resource containing a large amount of organic carbon that is often wasted with the existing manure disposal practices. A research project funded by the US Department of Energy explored the feasibility of using manure via the sugar platform in a biorefinery, converting the carbon from fiber to biochemicals. The results showed that (1) fiber was the major component of manure dry material making up approx 50%, 40%, and 36% of the dry dairy, swine, and poultry manure material, respectively; within dairy manure, more than 56% of the dry matter was in particles larger than 1.680 mm; (2) in addition to being a carbon source, manure could provide a variety of nutrient for fungi T. reesei and A. phoenicis to produce cellulase; (3) the hemicellulose component in the manure fiber could be readily converted to sugar through acid hydrolysis; while concentrated acid decrystallization treatment was most effective in manure cellulose hydrolysis; (4) purification and separation was necessary for further chemical conversion of the manure hydrolysate to polyols through hydrogenation; and (5) the manure utilization strategy studied in this work is currently not profitable.

Printed covalent glycan array for ligand profiling of diverse glycan binding proteins

Here we describe a glycan microarray constructed by using standard robotic microarray printing technology to couple amine functionalized glycans to an amino-reactive glass slide. The array comprises 200 synthetic and natural glycan sequences representing major glycan structures of glycoproteins and glycolipids. The array has remarkable utility for profiling the specificity of a diverse range of glycan binding proteins, including C-type lectins, siglecs, galectins, anticarbohydrate antibodies, lectins from plants and microbes, and intact viruses.

H1 and H7 influenza haemagglutinin structures extend a structural classification of haemagglutinin subtypes

Comparing the structures of H3, H5 and H9 subtype haemagglutinins, we deduced a structural basis for including all 15 influenza subtypes in four clades. H3, H5 and H9 represent three of these clades; we now report the structure of an H7 HA as a representative of the fourth clade. We confirm the structure of the turn at the N-terminus of the conserved central alpha-helix of HA2, and the combination of ionisable residues near the "fusion peptide" as clade-specific features. We compare the structures of three H1 HAs with H5 HA in the same clade, to refine our previous classification and we confirm the division of the clades into two groups of two. We also show the roles of carbohydrate side chains in the esterase-fusion domain boundaries in the formation of clade-specific structural markers.

The Structure and Receptor Binding Properties of the 1918 Influenza Hemagglutinin

The 1918 influenza pandemic resulted in about 20 million deaths. This enormous impact, coupled with renewed interest in emerging infections, makes characterization of the virus involved a priority. Receptor binding, the initial event in virus infection, is a major determinant of virus transmissibility that, for influenza viruses, is mediated by the hemagglutinin (HA) membrane glycoprotein. We have determined the crystal structures of the HA from the 1918 virus and two closely related HAs in complex with receptor analogs. They explain how the 1918 HA, while retaining receptor binding site amino acids characteristic of an avian precursor HA, is able to bind human receptors and how, as a consequence, the virus was able to spread in the human population.

Subtle manipulation of egg sex ratio in birds

Mothers are predicted to overproduce male or female eggs when the relative fitness gains from one sex are higher and outweigh the costs of manipulation. However, in birds such biases are often difficult to distinguish from differential embryo or chick mortality. Using a molecular technique to identify the sex of early embryos, we aim to determine the effect of maternal nutrition on zebra finch (Taeniopygia guttata) egg sex ratios after 2 days of incubation, which is as close to conception as is currently possible. We found no overall bias in the sex ratio of eggs laid and sex did not differ with relative laying order under any diet regime. However, mothers on a low-quality diet did produce a female bias in small clutches and a slight male bias in large clutches. On a high-quality diet, mothers produced a male bias in small clutches and a female bias in large clutches. Those on a standard diet produced a roughly even sex ratio, irrespective of clutch size. These observed biases in egg sex are partly in line with predictions that, in this species, daughters suffer disproportionately from poor rearing conditions. Thus, when relatively malnourished, mothers should only rear daughters in small broods and vice versa. Sex-ratio patterns in this species therefore appear to be subtle.

X-ray structure of the hemagglutinin of a potential H3 avian progenitor of the 1968 Hong Kong pandemic influenza virus

We have determined the structure of the HA of an avian influenza virus, A/duck/Ukraine/63, a member of the same antigenic subtype, H3, as the virus that caused the 1968 Hong Kong influenza pandemic, and a possible progenitor of the pandemic virus. We find that structurally significant differences between the avian and the human HAs are restricted to the receptor-binding site particularly the substitutions Q226L and G228S that cause the site to open and residues within it to rearrange, including the conserved residues Y98, W153, and H183. We have also analyzed complexes formed by the HA with sialopentasaccharides in which the terminal sialic acid is in either alpha2,3- or alpha2,6-linkage to galactose. Comparing the structures of complexes in which an alpha2,3-linked receptor analog is bound to the H3 avian HA or to an H5 avian HA leads to the suggestion that all avian influenza HAs bind to their preferred alpha2,3-linked receptors similarly, with the analog in a trans conformation about the glycosidic linkage. We find that alpha2,6-linked analogs are bound by both human and avian HAs in a cis conformation, and that the incompatibility of an alpha2,6-linked receptor with the alpha2,3-linkage-specific H3 avian HA-binding site is partially resolved by a small change in the position and orientation of the sialic acid. We discuss our results in relation to the mechanism of transfer of influenza viruses between species.

H5 avian and H9 swine influenza virus haemagglutinin structures: possible origin of influenza subtypes

There are 15 subtypes of influenza A virus (H1-H15), all of which are found in avian species. Three caused pandemics in the last century: H1 in 1918 (and 1977), H2 in 1957 and H3 in 1968. In 1997, an H5 avian virus and in 1999 an H9 virus caused outbreaks of respiratory disease in Hong Kong. We have determined the three-dimensional structures of the haemagglutinins (HAs) from H5 avian and H9 swine viruses closely related to the viruses isolated from humans in Hong Kong. We have compared them with known structures of the H3 HA from the virus that caused the 1968 H3 pandemic and of the HA--esterase--fusion (HEF) glycoprotein from an influenza C virus. Structure and sequence comparisons suggest that HA subtypes may have originated by diversification of properties that affected the metastability of HAs required for their membrane fusion activities in viral infection.

X-ray structures of H5 avian and H9 swine influenza virus hemagglutinins bound to avian and human receptor analogs

The three-dimensional structures of avian H5 and swine H9 influenza hemagglutinins (HAs) from viruses closely related to those that caused outbreaks of human disease in Hong Kong in 1997 and 1999 were determined bound to avian and human cell receptor analogs. Emerging influenza pandemics have been accompanied by the evolution of receptor-binding specificity from the preference of avian viruses for sialic acid receptors in alpha2,3 linkage to the preference of human viruses for alpha2,6 linkages. The four new structures show that HA binding sites specific for human receptors appear to be wider than those preferring avian receptors and how avian and human receptors are distinguished by atomic contacts at the glycosidic linkage. alpha2,3-Linked sialosides bind the avian HA in a trans conformation to form an alpha2,3 linkage-specific motif, made by the glycosidic oxygen and 4-OH of the penultimate galactose, that is complementary to the hydrogen-bonding capacity of Gln-226, an avian-specific residue. alpha2,6-Linked sialosides bind in a cis conformation, exposing the glycosidic oxygen to solution and nonpolar atoms of the receptor to Leu-226, a human-specific residue. The new structures are compared with previously reported crystal structures of HA/sialoside complexes of the H3 subtype that caused the 1968 Hong Kong Influenza virus pandemic and analyzed in relation to HA sequences of all 15 subtypes and to receptor affinity data to make clearer how receptor-binding sites of HAs from avian viruses evolve as the virus adapts to humans.

Biological consequences of multiple vaccine and pyridostigmine pretreatment in the guinea pig

An investigation of the possible interactions between combinations of vaccines and pyridostigmine bromide (PB) has been undertaken in the guinea pig. This study is part of a research programme funded by the UK Government to determine any effects of the pretreatment regimes given to UK Forces during the Persian Gulf conflict of 1990-1991. The study was designed to simulate PB administration and to model multiple vaccination protocols that were experienced by UK Forces, modelling a "worst case" situation in which all ten vaccines and PB were administered within a short period of time. Seven of the vaccines were health and hygiene (H+H) vaccines given to protect against endemic diseases and two vaccines to protect against the biological warfare agents anthrax and plague. In addition, pertussis vaccine was administered as an adjuvant to reduce the time to achieve immunity against anthrax. Four groups of eight animals were treated with 1/20th, 1/10th or 1/5th human doses of vaccines or vehicles, respectively. The PB or saline was delivered by implanted 28 day mini-osmotic pumps to achieve a mean red blood cell acetylcholinesterase (AChE) inhibition of around 30%. Body weight, temperature, immunological response, biochemical indices and spontaneous activity were monitored for 72 days. Although immunological responses to bacterial vaccines were observed, there were no remarkable findings in the parameters measured other than minor changes in body weight (4.9% decrease at the 1/5th human dose of vaccines) and temperature increases in response to vaccination. Animals in all groups remained generally healthy and active without visible adverse signs throughout the study. Reproduced with the permission of Her Majesty's Stationery Office. Published by John Wiley & Sons, Ltd.

Developmental trade-offs and life histories: strategic allocation of resources in caddis flies

Resource allocation trade-offs during development are potentially very important in the evolution of organism morphology and life-history strategy However, they have rarely been demonstrated empirically. To what extent the division of limited resources between growing organs is a consequence of particular developmental pathways or varies strategically in line with life-history predictions is unknown. It has been demonstrated in a number of holometabolous insects that altering the resources available at pupation changes the pattern of allocation to adult tissues, but this has not been examined in a life-history context. Using caddis flies (Trichoptera), we show here that the effect of depleted larval resources on the pattern of somatic and reproductive investment is not fixed but varies between species with different life-history patterns. In particular, we demonstrate that, in a long-lived species, thorax size is preserved, which contrasts with the pattern previously observed in a short-lived species. That the adult body can be differentially altered by the same resource depletion in the larvae demonstrates that the allocation of resources amongst body parts is not a consequence of fixed pathways during development. Rather, the allocation of resources during development can occur in a manner consistent with the minimization of the effects on adult fitness.

Structure of the hemagglutinin precursor cleavage site, a determinant of influenza pathogenicity and the origin of the labile conformation

The membrane fusion potential of influenza HA, like many viral membrane-fusion glycoproteins, is generated by proteolytic cleavage of a biosynthetic precursor. The three-dimensional structure of ectodomain of the precursor HA0 has been determined and compared with that of cleaved HA. The cleavage site is a prominent surface loop adjacent to a novel cavity; cleavage results in structural rearrangements in which the nonpolar amino acids near the new amino terminus bury ionizable residues in the cavity that are implicated in the low-pH-induced conformational change. Amino acid insertions at the cleavage site in HAs of virulent avian viruses and those of viruses isolated from the recent severe outbreak of influenza in humans in Hong Kong would extend this surface loop, facilitating intracellular cleavage.

Genomic structure and sequence of the Fugu rubripes glucose-6-phosphate dehydrogenase gene (G6PD)

To investigate the organization of the compact genome of the puffer fish Fugu rubripes at the level of an individual housekeeping gene, we have cloned and sequenced the glucose-6-phosphate dehydrogenase (G6PD) gene from this fish and compared it to the corresponding human gene. The intron/exon structure of the two genes is identical throughout the protein coding regions. The puffer fish gene is four times smaller than the human gene--the difference is accounted for by the fact that the puffer fish gene has smaller introns. Intron 2 is the largest intron in both species. We have constructed a molecular phylogeny for 10 G6PD protein sequences. The sequences fall in the expected arrangement based on established phylogenetic relationships, with the Plasmodium falciparum sequence the most widely diverged.

New glucose-6-phosphate dehydrogenase mutations associated with chronic anemia

We have identified the glucose-6-phosphate dehydrogenase mutations responsible for enzyme deficiency in nine individuals with chronic nonspherocytic hemolytic anemia. We found the variants Tokyo, Iowa, Shinshu, and Guadalajara in British subjects and Kobe in an Italian. In addition we have determined the variant Corum has the mutation 820 G-->A and have found in British subjects the mis-sense mutations 224 T-->C, 488 G-->A and 833 C-->T which have not been described before. Some, but not all, of the mutations involve amino acids located near putative substrate binding sites.

Carcinoma of the pharyngeal pouch

The condition of carcinoma arising in a pharyngeal pouch is rare. It has been described in relation to long standing pouches and in pouches previously treated by the Dohlman's operation. Three additional cases of carcinoma of the pharyngeal pouch are described.

Acinous cell carcinoma of the larynx

Acinous cell tumours of the larynx and trachea are extremely rare. A recent review of the literature has only found four reported cases. This short report describes such a patient and discusses her management in the light of previous articles. In view of its rarity in the laryngotracheal area and the uncertainty in the way in which the tumour should be managed, we thought the following case report and review of the literature would be of interest.

Papillary endothelial hyperplasia in the nose

Benign papillary endothelial hyperplasia is a very rare lesion of the nasal cavity; histologically, it may be mistaken for an angiosarcoma. An awareness of this and the ways in which it differs from angiosarcoma will prevent incorrect diagnosis and inappropriate treatment by surgery or radiotherapy. A case report of each condition involving the nasal cavity is presented.

Tracheostomy service for ITU patients

An account of experience of tracheostomy performed on patients in the intensive care unit situation is presented. Forty-seven operations were undertaken over a 5-year period and the advantages and disadvantages are discussed. The authors recommend tracheostomy under these circumstances as an acceptable alternative to the procedure performed in an operating theatre.

Neurofibromas of the paranasal sinuses

Two cases of neurofibroma of the paranasal sinuses are presented. The tumours presented as space-occupying lesions and were treated by local excision. Histologically one was a typical neurofibroma, whilst the other showed some features of a schwannoma. The patients show no evidence of tumour recurrence at 18 and 6 months respectively.

Cushing's syndrome due to the abuse of betamethasone nasal drops

Cushing's syndrome due to the abuse of Betamethasone nasal drops has not been described before. This report presents such a case and emphasises the care which one must take in prescribing topical steroids.

Antigenic and amino acid sequence analysis of the variants of H1N1 influenza virus in 1986

Since their reintroduction to human populations in 1977, influenza A viruses of the H1N1 subtype have undergone antigenic drift. Recently a distinct antigenic variant, A/Singapore/6/86, has been almost exclusively isolated internationally, and the antigenic properties and amino acid sequence of its haemagglutinin have been determined and compared with those of the haemagglutinins of other H1N1 viruses, in particular A/Chile/1/83. Fourteen amino acid sequence differences are detected between the HA1 components of these two viruses, ten of which are different from equivalent residues in the haemagglutinins of all H1N1 viruses isolated between 1982 and 1983, and seven of which are novel in the haemagglutinins of all H1N1 viruses sequenced to date. The results are discussed in relation to the three-dimensional structure of the haemagglutinin and the location of the previously defined antigenically important regions.

The relevance of physical signs in recurrent tonsillitis in children (a prospective study)

Tonsillar physical signs plus cervical lymphadenopathy are irrelevant factors in the assessment of children with recurrent tonsillitis. Tonsillar protrusion, but not size, is related to snoring.

A carbohydrate side chain on hemagglutinins of Hong Kong influenza viruses inhibits recognition by a monoclonal antibody

A single amino acid substitution, Asp-63 to Asn-63, was detected in the hemagglutinin of an antigenic variant of the 1968 Hong Kong (H3) influenza virus that was selected by growth of the wild-type virus in the presence of a monoclonal antibody. The mutation generates an oligosaccharide attachment site, Asn-Cys-Thr at residues 63-65, that is glycosylated. Immunoprecipitation experiments with extracts from variant virus-infected cells prepared in the presence or absence of tunicamycin, which inhibits glycosylation, demonstrate that addition of the new oligosaccharide side chain is required to prevent reaction with the monoclonal antibody. Similar experiments with the virus of the 1969 Hong Kong influenza epidemic, A/England/878/69, which also contains a hemagglutinin glycosylated at residue 63, support this conclusion and provide evidence for the epidemiological significance of carbohydrate-mediated modifications of hemagglutinin antigenicity.

Platelet lesion of collection

In the early stages of blood collection for transfusion, whole blood is subjected to trauma from the anticoagulant. The blood--anticoagulant mixture does not attain a pH at which platelets can remain functional (approximately pH 6.0) until about 25% of the unit has been collected. We have examined platelet ultrastructure and in vitro aggregation responses to adenosine diphosphate (ADP) and epinephrine (EPN), to assess the platelet trauma of collection into citrate-phosphate-dextrose. For comparison blood was collected by 2 methods: one was conventional (CC), the other metered anticoagulant into the blood as it was collected (MC). Platelets from CC blood showed disruption of organelles and depletion of the dense bodies, whereas platelets from MC blood showed no ultrastructural damage. In addition, biphasic aggregation in response to ADP or EPN was seen in MC platelets but not in CC platelets.

Studies on the quaternary structure of Escherichia coli pyruvate oxidase

Pyruvate oxidase is a peripheral membrane enzyme isolated from Escherichia coli. The enzyme catalyzes the oxidative decarboxylation of pyruvate to yield acetate plus CO2. The specific activity of the purified oxidase is stimulated 25-fold by lipids, and this lipid requirement has been the subject of previous studies. Since the enzyme is a tetramer at high protein concentrations (1 mg/ml) and is known to self-aggregate under certain conditions, the question arose as to whether the lipid stimulation observed in the steady state assay might be due to a change in the quaternary structure of the protein, either a dissociation or further association. This report is directed at determining the state of association of pyruvate oxidase under assay conditions by using fluorescence polarization. A photoreactive, nonspecific probe, 1-azidonaphthalene 5-sulfonate, was used to label the protein surface with an extrinsic fluorophore. It is concluded that under steady state assay conditions the oxidase remains tetrameric.