Beyond Words: A Case of Pure Alexia Following Posterior Cerebral Artery Occlusion

Alexia is an acquired reading disorder known as pure alexia or alexia without agraphia when unaccompanied by other higher-level deficits. We present the case of a 40-year-old man experiencing a sudden-onset headache and blurred vision. Despite an absence of known medical history, the patient exhibited a distinctive difficulty in reading without impairing other language aspects accompanied by a right superior homonymous quadrantanopia. Through comprehensive ophthalmological and neurological evaluations, a diagnosis of pure alexia was established. An imaging scan uncovered a left posterior cerebral artery occlusion as the underlying cause. Meticulous assessments of visual acuity, perimetry, and non-visual functions played a pivotal role in decisively diagnosing this condition. This case emphasizes the indispensable role of ophthalmologists in recognizing urgent clinical conditions that extend beyond ophthalmic concerns.

Cytomegalovirus-Induced Hypertensive Anterior Uveitis: Diagnostic Challenge in an Immunocompetent Patient

Hypertensive anterior uveitis poses diagnostic challenges owing to its multiple potential etiologies. Cytomegalovirus (CMV) infection is an under-recognized cause that exhibits diverse clinical presentations. This case report focuses on the intricate diagnostic challenge encountered in a 66-year-old immunocompetent patient with CMV-induced hypertensive anterior uveitis. The patient's history, encompassing angle closure glaucoma and topiramate use, contributed to the hypertensive crisis. Initial management included intraocular pressure (IOP)-lowering medication, topiramate discontinuation, and bilateral phacoemulsification, successfully normalizing IOP. However, a subsequent recurrence prompted a detailed investigation. The identification of keratic precipitates and a synechial closed angle led to aqueous humor sampling and polymerase chain reaction (PCR) testing, unveiling the presence of CMV-DNA. Treatment led to a favorable response, resolving ocular inflammation and effectively controlling IOP. This case underscores the complexity of diagnosing and managing CMV-induced hypertensive anterior uveitis, emphasizing the critical role of a comprehensive approach in achieving successful outcomes.

Case Report: Alternaria alternata keratitis

Background

Alternaria spp are ubiquitous pigmented filamentous fungi that can cause opportunistic human infections. These molds can be found in healthy individuals and the most frequently observed clinical manifestations are skin infections, ocular mycosis, rhinosinusitis, among others. Immunosuppression (both local and systemic) as well as contact or trauma with contaminated matter are important risk and predisposing factors for ocular mycosis. Accurate diagnosis with microscopy and culture is crucial since infections by filamentous fungi are sight-threatening, and clinically indistinguishable from bacterial disease. In general terms, conventional antifungal drugs are effective.

Case Presentation

We report a case of Alternaria alternata keratitis after ocular trauma with biological material in a 44-year-old man's functional single eye, which had a good clinical and functional evolution after topical therapy with voriconazole.

Conclusion

This case accounts the importance of thinking about other etiological diagnoses in infectious keratitis refractory to the established therapy and with a history of trauma with biological material.

Presence of Chromosomal crpP-like Genes Is Not Always Associated with Ciprofloxacin Resistance in Pseudomonas aeruginosa Clinical Isolates Recovered in ICU Patients from Portugal and Spain

CrpP enzymes have been recently described as a novel ciprofloxacin-resistance mechanism. We investigated by whole genome sequencing the presence of crpP-genes and other mechanisms involved in quinolone resistance in MDR/XDR-Pseudomonas aeruginosa isolates (n = 55) with both ceftolozane-tazobactam susceptible or resistant profiles recovered from intensive care unit patients during the STEP (Portugal) and SUPERIOR (Spain) surveillance studies. Ciprofloxacin resistance was associated with mutations in the gyrA and parC genes. Additionally, plasmid-mediated genes (qnrS2 and aac(6')-Ib-cr) were eventually detected. Ten chromosomal crpP-like genes contained in related pathogenicity genomic islands and 6 different CrpP (CrpP1-CrpP6) proteins were found in 65% (36/55) of the isolates. Dissemination of CrpP variants was observed among non-related clones of both countries, including the CC175 (Spain) high-risk clone and CC348 (Portugal) clone. Interestingly, 5 of 6 variants (CrpP1-CrpP5) carried missense mutations in an amino acid position (Gly7) previously defined as essential conferring ciprofloxacin resistance, and decreased ciprofloxacin susceptibility was only associated with the novel CrpP6 protein. In our collection, ciprofloxacin resistance was mainly due to chromosomal mutations in the gyrA and parC genes. However, crpP genes carrying mutations essential for protein function (G7, I26) and associated with a restored ciprofloxacin susceptibility were predominant. Despite the presence of crpP genes is not always associated with ciprofloxacin resistance, the risk of emergence of novel CrpP variants with a higher ability to affect quinolones is increasing. Furthermore, the spread of crpP genes in highly mobilizable genomic islands among related and non-related P. aeruginosa clones alert the dispersion of MDR pathogens in hospital settings.

Distinct epidemiology and resistance mechanisms affecting ceftolozane/tazobactam in Pseudomonas aeruginosa isolates recovered from ICU patients in Spain and Portugal depicted by WGS

Objectives

To analyse the epidemiology, the resistome and the virulome of ceftolozane/tazobactam-susceptible or -resistant Pseudomonas aeruginosa clinical isolates recovered from surveillance studies in Portugal (STEP, 2017–18) and Spain (SUPERIOR, 2016–17).

Methods

P. aeruginosa isolates were recovered from intra-abdominal, urinary tract and lower respiratory tract infections in ICU patients admitted to 11 Portuguese and 8 Spanish hospitals. MICs were determined (ISO-standard broth microdilution, EUCAST 2020 breakpoints). A subset of 28 ceftolozane/tazobactam-resistant P. aeruginosa isolates were analysed and compared with 28 ceftolozane/tazobactam-susceptible P. aeruginosa strains by WGS.

Results

Clonal complex (CC) 235 (27%) and CC175 (18%) were the most frequent, followed by CC244 (13%), CC348 (9%), CC253 (5%) and CC309 (5%). Inter-hospital clonal dissemination was observed, limited to a geographical region (CC235, CC244, CC348 and CC253 in Portugal and CC175 and CC309 in Spain). Carbapenemases were detected in 25 isolates (45%): GES-13 (13/25); VIM type (10/25) [VIM-2 (4/10), VIM-20 (3/10), VIM-1 (2/10) and VIM-36 (1/10)]; and KPC-3 (2/25). GES-13-CC235 (13/15) and VIM type-CC175 (5/10) associations were observed. Interestingly, KPC-3 and VIM-36 producers showed ceftolozane/tazobactam-susceptible phenotypes. However, ceftolozane/tazobactam resistance was significantly associated with GES-13 and VIM-type carbapenemase production. Six non-carbapenemase producers also displayed ceftolozane/tazobactam resistance, three of them showing known ceftolozane/tazobactam resistance-associated mutations in the PBP3 gene, ftsI (R504C and F533L). Overall, an extensive virulome was identified in all P. aeruginosa isolates, particularly in carbapenemase-producing strains.

Conclusions

GES-13-CC235 and VIM type-CC175 were the most frequent MDR/XDR P. aeruginosa clones causing infections in Portuguese and Spanish ICU patients, respectively. Ceftolozane/tazobactam resistance was mainly due to carbapenemase production, although mutations in PBP-encoding genes may additionally be involved.

Predicting lung nodules malignancy

BACKGROUND

It is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting.

METHODS

The authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy.

RESULTS

From a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573.

CONCLUSIONS

The prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.

HASHIMOTO'S ENCEPHALOPATHY AS A RARE MANIFESTATION OF HYPOTHYROIDISM

Hashimoto's Encephalopathy (HE) is a rare syndrome of steroid-responsive encephalopathy associated with elevated serum antithyroid antibody concentrations. The presentation of HE is highly variable making it difficult to recognize.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

[Metformin-associated lactic acidosis: incidence, diagnosis, prognostic factors and treatment]

We describe the case of a patient with severe lactic acidosis, as well as presenting some data on its incidence, diagnosis, prognostic factors, and the most appropriate treatment. A 76 year-old male patient with diabetes on treatment with metformin, hypertension, dyslipaemia, and with mild cognitive impairment, was admitted to the Intensive Care Unit in a state of circulatory shock, requiring aggressive treatment with vasopressors and volume. The patient had acute kidney injury with an anuria of 3 days, probably secondary to dehydration to vomiting and to NSAIDs. As a result of the acute renal damage, the patient suffered a severe metformin-associated lactic acidosis. The rest of the causes of metabolic acidosis with an increased anion gap were ruled out, as well as a possible sepsis or rhabdomyolysis. Metformin-associated lactic acidosis is an uncommon metabolic condition, but with a high mortality. To reduce the mortality of these patients, it is important to make an early diagnosis using the clinical records, physical examination, and laboratory tests, with an early resuscitation with volume, vasopressors, bicarbonate, and renal replacement therapy.

[Extracorporeal membrane oxygenation in acute respiratory distress syndrome after a liver transplant]

Extracorporeal membrane oxygenation (ECMO) is used in the treatment of severe respiratory failure that is potentially reversible. This mode of therapy reduces ventilator-associated lung injury. Although ECMO is costly and not free of complications, its early application by experienced multidisciplinary teams can improve survival. We report a case of acute respiratory distress syndrome in a patient who had received a liver transplant. Respiratory failure was unresponsive to conventional treatment and the patient required ECMO until recovery.

Exploring pharmacists' communication with customers through screening services

OBJECTIVE

To describe pharmacist-customer communication, during blood pressure and capillary cholesterol services, in a community pharmacy setting.

METHODS

Participants were purposively selected and data collected by audio-recording. The encounters' verbal content was transcribed verbatim, utterances identified, time stamped, and classified according to a coding scheme of 15 categories. Four dialogue structures were analyzed: speaker turn, interactivity, turn density and turn duration.

RESULTS

Eighty-three episodes were registered (51 blood pressure, 32 cholesterol). The average blood pressure episode lasted 5:35 min, with 81.2 utterances (55.3% customers), and an interactivity rate of 7 turns/min. The average cholesterol episode took 7:05 min, with 135.3 utterances (52.7% pharmacists), and an interactivity rate of 13.3 turns/min. In both cases, pharmacists asked more questions (mainly closed ones), while customers gave more information. An increased number of speaker turns and closed questions were associated to higher systolic pressure. No correlations were identified with cholesterol values.

CONCLUSION

It would seem that pharmacists tend to control the exchange and its content through closed questioning. Although talk dominance is balanced, hypertensive episodes induce a higher information search.

PRACTICE IMPLICATIONS

Educational interventions, focusing on pharmacists' communication competencies, should be available to favor interaction skills resulting in a customer's augment of proactive information seeking behaviour.

Safety and availability of dapivirine (TMC120) delivered from an intravaginal ring

Vaginal delivery of 200 mg or 25 mg dapivirine from intravaginal rings (IVRs) was evaluated over a 7-day period in two phase 1 safety trials (IPM001 and IPM008, respectively) in a total of 25 healthy women 19 to 46 years of age. The IVR was generally safe and well tolerated with similar adverse events observed in the placebo and dapivirine groups. Across both studies, dapivirine concentrations in vaginal fluids measured at the introitus, cervix, and ring area were within the mean range of 0.7-7.1 microg/ml. Mean dapivirine concentrations in vaginal and cervical tissues on day 7 were 0.3-0.7 microg/g in IPM001 and 1.5-3.5 microg/g in IPM008. Mean plasma concentrations of dapivirine were <50 pg/ml. Dapivirine from both IVRs was successfully distributed throughout the lower genital tract at concentrations >1000x the EC(50) against wild-type HIV-1 (LAI) in MT4 cells suggesting that IVR delivery of microbicides is a viable option meriting further study.

A poorly-differentiated squamous cell thymoma in a chicken with lymphoma

Thymic carcinomas are rare in birds. A poorly-differentiated squamous cell thymoma was found in a chicken in association with a lymphoma caused by Marek's disease. Immunohistochemical techniques with different tumour markers were applied in order to determine the histogenesis of the thymic tumour cells. A positive immunoreaction of the tumour cells to cytokeratin, considered a specific marker for epithelial tumours, confirmed the diagnosis of a thymoma.

Diffuse basal ganglia or thalamus hyperechogenicity in preterm infants

OBJECTIVE

To determine the incidence and factors associated with diffuse basal ganglia or thalamus hyperechogenicity (BGTH) in preterm infants.

STUDY DESIGN

(1) Review of serial neurosonograms among neonates with gestational age (GA) <34 weeks born at Weiler Hospital during a 21-month period; (2) Color Doppler flow imaging; (3) Case-control study using GA group-matched controls; and (4) Blind reading of CT scans or MRIs in patients with BGTH.

RESULTS

Among 289 infants, 24 (8.3%) had diffuse BGTH. Color Doppler flow imaging was normal in nine patients. The incidence of diffuse BGTH was inversely related to GA (P<0.01). Logistic regression (n=96) showed that diffuse BGTH was significantly associated with requirement of high-frequency oscillation (HFO) (P=0.031), severe intraventricular hemorrhage (IVH) (P=0.004), hypotension requiring vasopressors (P=0.040), hypoglycemia (P=0.031) and male gender (P=0.014). Most patients with diffuse BGTH had normal basal ganglia and thalamus on CT/MRI, one had a hemorrhage, and one had an ischemic infarction.

CONCLUSIONS

In our series, diffuse BGTH occurred in 8.3%, and was associated with factors similar to those previously reported. In contrast, several series have reported almost exclusively linear or punctuate hyperechoic foci, corresponding to hyperechogenicity of the lenticulostriate vessels. Our data provide further evidence to suggest that diffuse BGTH and hyperechogenicity of the lenticulostriate vessels are two different entities. Additional studies are required to determine the long-term significance of diffuse BGTH.

Survival Outcome After Hepatic Retransplantation for Hepatitis C Virus–Positive and –Negative Recipients

INTRODUCTION

Hepatitis C virus (HCV)-related liver disease is the most common indication for liver transplantation in the United States. Recurrence of HCV infection in these recipients is almost uniform. The currently available antiviral treatment is known to cause significant side effects, and the rate of sustained viral response is low. There is still controversy about whether such patients should undergo subsequent transplantations for HCV disease. This study compared outcomes for hepatic retransplantation performed in HCV(+) and HCV(-) recipients at a single center.

PATIENTS AND METHODS

From December 1994 through November 2003, 68 patients at our institution received a second liver allograft. Nineteen of the recipients were HCV(+) (group A) and 49 were HCV(-) (group B). All patients were followed until January 2004. The mean follow-up time after initial retransplantation was 37 +/- 29 months. Patient and graft survival for the two groups were compared.

RESULTS

Seven recipients in group A (36.8%) and 22 recipients in group B (44.9%) died during follow-up. The actuarial 3-year patient survival after initial retransplantation for groups A and B were 61.7% and 51.6%, respectively. Nine patients required a second retransplantation, 3 (15.8%) in group A and 6 (12.2%) in group B. The actuarial 3-year graft survival from initial retransplantation for groups A and B were 56.3% and 45.7%, respectively.

CONCLUSION

We observed slightly better patient and graft survivals at 3 years from initial retransplantation in HCV(+) recipients compared to HCV(-) recipients. This may be due to younger donor age and better selection of HCV(+) recipients in this series.

124CRYOPRESERVATION OF WHITE-TAILED DEER (ODOCOILEUS VIRGINIANUS) SEMEN

The methods for collecting and freezing deer semen have been, for the most part, limited to two species; red deer ( Cervus elaphus) and fallow deer ( Dama dama) (Asher et al., 2000 Anim. Reprod. Sci. 62, 195–211). The object of this study was to evaluate the progressive motility and effects of a thermal stress test on white-tailed deer (WTD) semen frozen in Biladyl extender (Mini Tube, Verona, WI, USA). Semen was collected by electroejaculation from WTD bucks (n=7, ages 1.5–2.5 years) during the breeding season. This trial was the second collection for one buck (#0025) and the third collection for the other 6 bucks. The bucks were immobilized with a xylazine/ketamine mixture i.m. (2mgkg−1 Vedco, Inc., St. Joseph, MO, 2.2mgkg−1 ketamine HCl, Fort Dodge Animal Health, Fort Dodge, IA, USA) and electroejaculated with a Pulsator IV unit (Lane Manufacturing, Denver, Co). Semen was extended 1:1 with Biladyl A, and then slowly cooled to 4°C. Once cooled, semen was extended with equal amounts of Biladyl part A, then part B, to a final concentration of 160×106cells/mL. The extended semen was then loaded into 0.25-cc straws, placed over liquid nitrogen (LN2) in vapors (−80°C) for 10min, and then plunged into LN2. Straws were stored in a LN2 tank for 3 months. Semen was thawed in a 38.5°C water bath for 45s, then placed in a warm test tube and incubated at 38.5°C for 5min before progressive motility was evaluated using a computer program (Sperm Vision, Mini Tube). A thermal stress test was performed by incubating thawed samples at 38.5°C for 1h. Results of the stress test were graded as either passed (progressive motility ≥50%) or failed (progressive motility&lt;50%). Results are shown in the table below. Our results show that the protocol described above is suitable for the cryopreservation of white-tailed deer semen. These data suggest that the initial post-thaw progressive motility may not accurately represent the potential progressive motility of the spermatozoa (e.g. WTD s 0038 &amp; 0103). Table 1 Volume collected and post thaw evaluation of white-tailed deer semen

Early diagnosis of carpal tunnel syndrome: comparison of digit 1 with wrist and distoproximal ratio

Our objective in this study was to compare the sensitivity and specificity of the median sensory nerve conduction velocity (SNCV) from digit 1 to wrist with those of the distoproximal (D/P) ratio of the median SNCV from palm to digit 3/palm to wrist in the diagnosis of mild carpal tunnel syndrome (CTS) by using a receiver operating characteristic (ROC) curve. To achieve this objective, we studied prospectively (January 1997-October 1998) 370 patients referred for CTS. One hundred forty-two patients (38.4%) with moderate to severe CTS and 15 patients (4.1%) with multiple (> or = 3) compressive neuropathies in upper limbs with subclinical peripheral neuropathy were excluded. The remaining 213 patients (302 hands with mild CTS; 167 women; mean age, 50 y +/- 12 y) and 38 controls (71 hands; 25 women; mean age, 47 y +/- 13 y) had median and ulnar nerve conduction studies. ROC curves were constructed for median SNCV digit 1 to wrist and median SNCV D/P ratio from the patients' and controls' data. The median SNCV at < or = 45.9 m/s, corresponding to an optimal cutoff point on ROC curve, discriminated 89.5% of mild CTS from controls with specificity of 98.6%. The median D/P ratio at > or = 1.12, corresponding to an optimal cutoff point on ROC curve, discriminated 67.2% of mild CTS from controls with specificity of 97.2%. Of the 10.3% (31/302) of hands in which digit 1 to wrist was within normal limits at the selected optimal cutoff value (< or = 45.9 ms), 7% (21/302) had an abnormal D/P ratio (> or = 1.12), and 3.3% (10/302) had a normal electrophysiologic examination. The likelihood ratio (true-positive ratio to false-positive ratio, assessing the discriminative power of a test) of the median SNCV digit 1 to wrist, at an optimal point on ROC curve (63.9), was higher than that of the median SNCV D/P ratio (23.9, chi2 = 36.9, P < .001). These findings suggest that the median SNCV digit 1 to wrist is more sensitive than the median SNCV D/P ratio in the diagnosis of mild CTS.

Relationships between CD4 independence, neutralization sensitivity, and exposure of a CD4-induced epitope in a human immunodeficiency virus type 1 envelope protein

A CD4-independent version of the X4 human immunodeficiency virus type 1 (HIV-1) HXBc2 envelope (Env) protein, termed 8x, mediates infection of CD4-negative, CXCR4-positive cells, binds directly to CXCR4 in the absence of CD4 due to constitutive exposure of a conserved coreceptor binding site in the gp120 subunit, and is more sensitive to antibody-mediated neutralization. To study the relationships between CD4 independence, neutralization sensitivity, and exposure of CD4-induced epitopes associated with the coreceptor binding site, we generated a large panel of Env mutants and chimeras between 8x and its CD4-dependent parent, HXBc2. We found that a frameshift mutation just proximal to the gp41 cytoplasmic domain in 8x Env was necessary but not sufficient for CD4 independence and led to increased exposure of the coreceptor binding site. In the presence of this altered cytoplasmic domain, single amino acid changes in either the 8x V3 (V320I) or V4/C4 (N386K) regions imparted CD4 independence, with other changes playing a modulatory role. The N386K mutation resulted in loss of an N-linked glycosylation site, but additional mutagenesis showed that it was the presence of a lysine rather than loss of the glycosylation site that contributed to CD4 independence. However, loss of the glycosylation site alone was sufficient to render Env neutralization sensitive, providing additional evidence that carbohydrate structures shield important neutralization determinants. Exposure of the CD4-induced epitope recognized by monoclonal antibody 17b and which overlaps the coreceptor binding site was highly sensitive to an R298K mutation at the base of the V3 loop and was often but not always associated with CD4 independence. Finally, while not all neutralization-sensitive Envs were CD4 independent, all CD4-independent Envs exhibited enhanced sensitivity to neutralization by HIV-1-positive human sera, indicating that the humoral immune response can exert strong selective pressure against the CD4-independent phenotype in vivo. Whether this can be used to advantage in designing more effective immunogens remains to be seen.

The simian immunodeficiency virus envelope glycoprotein contains multiple signals that regulate its cell surface expression and endocytosis

The cell surface expression of the envelope glycoproteins (Envs) of primate immunodeficiency viruses is, at least in part, regulated by endocytosis signal(s) located in the Env cytoplasmic domain. Here, we show that a membrane proximal signal that directs the simian immunodeficiency virus (SIV) Env to clathrin-coated pits, and is conserved in all SIV and human immunodeficiency virus Envs, conforms to a YxxØ motif (where x can be any amino acid and Ø represents a large hydrophobic residue). This motif is similar to that described for a number of cellular membrane proteins. By surface plasmon resonance we detected a high affinity interaction between peptides containing this membrane proximal signal and both AP1 and AP2 clathrin adaptor complexes. Mutation of the tyrosine in this membrane proximal motif in a SIV Env with a prematurely truncated cytoplasmic domain leads to a > or = 25-fold increase in Env expression on infected cells. By contrast, the same mutation in an Env with a full-length cytoplasmic domain increases cell surface expression only 4-fold. We show that this effect results from the presence of additional endocytosis signals in the full-length cytoplasmic domain. Chimeras containing CD4 ecto- and membrane spanning domains and a full-length SIV Env cytoplasmic domain showed rapid endocytosis even when the membrane proximal tyrosine-based signal was disrupted. Mapping experiments indicated that at least some of the additional endocytosis information is located between residues 743 and 812 of Env from the SIVmac239 molecular clone. Together, our findings indicate that the cytoplasmic domain of SIV Env contains multiple endocytosis and/or trafficking signals that modulate its surface expression on infected cells, and suggest an important role for this function in pathogenesis.

Determinants of CD4 independence for a human immunodeficiency virus type 1 variant map outside regions required for coreceptor specificity

Although infection by human immunodeficiency virus (HIV) typically requires an interaction between the viral envelope glycoprotein (Env), CD4, and a chemokine receptor, CD4-independent isolates of HIV and simian immunodeficiency virus have been described. The structural basis and underlying mechanisms for this phenotype are unknown. We have derived a variant of HIV-1/IIIB, termed IIIBx, that acquired the ability to utilize CXCR4 without CD4. This virus infected CD4-negative T and B cells and fused with murine 3T3 cells that expressed human CXCR4 alone. A functional IIIBx env clone exhibited several mutations compared to the CD4-dependent HXBc2 env, including the striking loss of five glycosylation sites. By constructing env chimeras with HXBc2, the determinants for CD4 independence were shown to map outside the V1/V2 and V3 hypervariable loops, which determine chemokine receptor specificity, and at least partly within an area on the gp120 core that has been implicated in forming a conserved chemokine receptor binding site. We also identified a point mutation in the C4 domain that could render the IIIBx env clone completely CD4 dependent. Mutations in the transmembrane protein (TM) were also required for CD4 independence. Remarkably, when the V3 loop of a CCR5-tropic Env was substituted for the IIIBx Env, the resulting chimera was found to utilize CCR5 but remained CD4 independent. These findings show that Env determinants for chemokine receptor specificity are distinct from those that mediate CD4-independent use of that receptor for cell fusion and provide functional evidence for multiple steps in the interaction of Env with chemokine receptors. Combined with our observation that the conserved chemokine receptor binding site on gp120 is more exposed on the IIIBx gp120 (T. L. Hoffman, C. C. LaBranche, W. Zhang, G. Canziani, J. Robinson, I. Chaiken, J. A. Hoxie, and R. W. Doms, Proc. Natl. Acad. Sci. USA 96:6359-6364, 1999), the findings from this study suggest novel approaches to derive and design Envs with exposed chemokine receptor binding sites for vaccine purposes.

The acute diagnosis of Takayasu's arteritis based on helical CT angiography of the chest and neck in the emergency room

Recently, a young woman presented acutely with a left hemispheric stroke and differing blood pressures in the arms as her initial manifestation of Takayasu's arteritis. Helical CT angiography, performed to rule out aortic dissection, revealed a thickened wall of the aortic arch with stenoses and occlusions of the great vessels, suggesting the diagnosis. The sequence of imaging studies and findings in this unusually catastrophic presentation of a typically insidious disease are highlighted.

Neuregulin-4: a novel growth factor that acts through the ErbB-4 receptor tyrosine kinase

The ErbB/HER family of receptor tyrosine kinases consists of four receptors that bind a large number of growth factor ligands sharing an epidermal growth factor- (EGF)-like motif. Whereas ErbB-1 binds seven different ligands whose prototype is EGF, the three families of neuregulins (NRGs) activate ErbB-3 and/or ErbB-4. Here we characterize a fourth neuregulin, NRG-4, that acts through ErbB-4. The predicted pro-NRG-4 is a transmembrane protein carrying a unique EGF-like motif and a short cytoplasmic domain. A synthetic peptide encompassing the full-length EGF-like domain can induce growth of interleukin-dependent cells ectopically expressing ErbB-4, but not cells expressing the other three ErbB proteins or their combinations. Consistent with specificity to ErbB-4, NRG-4 can displace an ErbB-4-bound NRG-1 and can activate signaling downstream of this receptor. Expression of NRG-4 mRNA was detected in the adult pancreas and weakly in muscle; other tissues displayed no detectable NRG-4 mRNA. The primary structure and the pattern of expression of NRG-4, together with the strict specificity of this growth factor to ErbB-4, suggest a physiological role distinct from that of the known ErbB ligands.

CD8+ lymphocyte antiviral activity in monkeys immunized with SIV recombinant poxvirus vaccines: potential role in vaccine efficacy

Protection against intravenous simian immunodeficiency virus (SIV) challenge was assessed in rhesus macaques after immunization with a highly attenuated vaccinia (NYVAC)-SIV recombinant. One-third of vaccinated animals controlled viral infection and progressed to disease more slowly than control animals (Benson J, et al.: J Virol 1998;72:4170). However, this protection was not associated with neutralizing antibodies, cytotoxic T lymphocytes, or helper T cell responses. To explore other potential correlates of protection, we examined CD8+ T cell antiviral activity in macaques vaccinated with NYVAC-SIV, with or without added cytokine adjuvants, and in controls receiving only IL-12 or IL-12 plus IL-2. Before immunization, naive macaques exhibited a broad range of CD8+ T cell antiviral activity. Nevertheless, in the course of immunization, the vaccinated macaques as a group developed increased CD8+ T cell antiviral activity while the controls remained stable. Infectious SIV exposure also increased antiviral activity. Prechallenge antiviral activity levels of vaccinated macaques were not sufficient to prevent SIV transmission or control viral replication during acute infection. However, vaccinated animals consistently exhibited reduced viral loads postchallenge compared with controls. Moreover, high suppressive activity 8 weeks postchallenge, at which time the viremia set point was established, was significantly correlated with reduced viral load and slow disease progression. Prechallenge antiviral activity influenced this result, as decreased viremia and slow progressor status were more apparent in macaques with high suppressive activity both pre- and postchallenge. Our data demonstrate the impact of CD8+ antiviral activity on viral replication and disease progression, and suggest that vaccine designs able to elicit high levels of this activity will contribute significantly to protective efficacy.

Study of atmospheric ozone formation by means of a neural network-based model

The occurrence of high ozone levels in the atmosphere of urban areas has become a serious pollution problem in a number of large cities in the world. Although mathematical models have been proposed for predicting ozone concentrations as a function of a number of gas components, sometimes there are uncertainties due to lack of the combined effects of meteorological factors and the complex chemical reaction system involved. The application of neural network models, based on measured values of air pollutants and meteorological factors at different locations within the São Paulo Metropolitan Area, combine chemical and meteorological information. This has shown to be a promising tool for predicting ozone concentration. Simulations carried out with the model indicate the sensitivity of ozone in relation to different air pollution and weather conditions. Predictions using this model have shown good agreement with measured values of ozone concentrations.

Mammalian prenylcysteine carboxyl methyltransferase is in the endoplasmic reticulum

Prenylcysteine carboxyl methyltransferase (pcCMT) is the third of three enzymes that posttranslationally modify C-terminal CAAX motifs and thereby target CAAX proteins to the plasma membrane. Here we report the molecular characterization and subcellular localization of the first mammalian (human myeloid) pcCMT. The deduced amino acid sequence of mammalian pcCMT predicts a multiple membrane-spanning protein with homologies to the yeast pcCMT, STE14, and the mammalian band 3 anion transporter. The human gene complemented a ste14 mutant. pcCMT mRNAs were ubiquitously expressed in human tissues. An anti-pcCMT antiserum detected a 33-kDa protein in myeloid cell membranes. Ectopically expressed recombinant pcCMT had enzymatic activity identical to that observed in neutrophil membranes. Mammalian pcCMT was not expressed at the plasma membrane but rather restricted to the endoplasmic reticulum. Thus, the final enzyme in the sequence that modifies CAAX motifs is located in membranes topologically removed from the CAAX protein target membrane.

Plasma virus load evaluation in relation to disease progression in HIV-infected children

The objective of this study was to investigate the relationship of plasma HIV RNA load with survival and disease progression in HIV-infected children and to determine its correlation with cellular HIV DNA. Virus load (VL, HIV RNA copies/ml) was determined retrospectively by nucleic acid sequence-based amplification (NASBA) assay in 144 stored plasma samples between birth and 48 months in 50 children of whom 40 are alive (age range, 2-13 years). On the basis of clinical and immunologic status children were classified as rapid progressors (RPs), or nonrapid progressors (NRPs). Proviral HIV DNA quantitated by QC-PCR (quantitative competitive polymerase chain reaction) in 24 children was compared with plasma HIV RNA. At age <3 months, plasma VL <750,000 copies/ml was associated with significantly higher survival to age >2 years (p < or =0.01) compared with a VL of > or =750,000 copies/ml. Increasing mortality was observed with increasing plasma HIV RNA levels at ages 3-24 months and baseline VL of infants who died before age 24 months was significantly higher (p = 0.004) than baseline VL of those who survived beyond 24 months. Although baseline VL in infants classified as RPs was higher than that of NRPs, the difference was not statistically significant. Among surviving children 2-13 years of age, the baseline VL obtained at <24 months of age was not predictive of disease severity. Although no significant correlation was noted between plasma HIV RNA and proviral DNA, the concurrence of positive and negative results was >80%. We conclude that high plasma HIV RNA in infancy is associated with increased mortality.

São Paulo aerosol characterization study

The São Paulo Metropolitan area (SPMA) is characterized as having one of the worst air pollution problems in Brazil, with frequent violations of air quality standards for particulate matter. This paper presents the results of a receptor model source apportionment study carried out to develop a quantitative database on which a control strategy could be developed. The study was conducted in four sites with distinct land uses. Fine, coarse (CP), and total suspended particles (TSP) samples were collected on Teflon and glass filters and analyzed by x-ray fluorescence (XRF), ion chromatography, and thermal evolution. The sources were characterized by similar methodology. Chemical mass balance (CMB) receptor modeling indicated that carbonaceous material plays an important role in the aerosol composition; that the three major source categories contributing to the fine particles are vehicles, secondary carbon, and sulfates; and that the main contributors to CP and TSP are road dust and vehicles. All sampling sites presented the same general pattern in terms of source contribution, although this contribution varied from site to site.

Didanosine but not high doses of hydroxyurea rescue pigtail macaque from a lethal dose of SIV(smmpbj14)

It has been previously reported that hydroxyurea (HU) displays anti-HIV-1 activity and potentiates the antiviral effects of didanosine (ddI) in vitro. To assess the antiviral efficacy of HU in an animal model, the effects of HU and ddI, either individually or as combination therapy, were tested in a model using infection of pigtail macaque with the acutely fatal variant SIV(smpbj14). At the high dosage used (100 mg/kg/day), HU monotherapy failed to protect the exposed animals from viral infection and death, which occurred within 10 days postinoculation. However, both of the ddI-treated animals (5 mg/kg/day) survived the SIV(smmpbj14) lethal dose and displayed a reduction in viral load (undetectable SIV RNA or p27gag) in the primary phase of infection. Of the animals treated with the combination of drugs, one died at day 18 after infection and failed to seroconvert to viral antigens. These data suggest that a high dose of HU monotherapy does not protect against death induced by SIV(mmpbj14). However, lower doses of HU as monotherapy or combination therapy deserve further evaluation for their therapeutic effects.

Upregulation of human immunodeficiency virus (HIV) replication by CD4 cross-linking in peripheral blood mononuclear cells of HIV-infected adults

This study was conducted with peripheral blood mononuclear cells from 67 human immunodeficiency virus (HIV)-infected adults. It supports the hypothesis that cross-linking of CD4 molecules by HIV gp120 can result in HIV upregulation and spread of infection. Underlying mechanisms include activation of latent infection by factors in addition to, or other than, tumor necrosis factor alpha.

Cytokine pattern in relation to disease progression in human immunodeficiency virus-infected children

Cytokine mRNA expression and stimulus-induced cytokines were examined in peripheral blood mononuclear cells in 62 human immunodeficiency virus (HIV)-infected children and uninfected controls. Compared with that in controls, constitutive mRNA expression in patients was increased for tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma, and interleukin (IL)-10 and decreased for IL-12; it was undetectable for IL-2 and IL-4 in both patients and controls. Stimulus-induced secretion of TNF-alpha, IFN-gamma, IL-12, and IL-4 was less than that in controls; IL-10 secretion was similar. There was no increase in stimulus-induced or constitutive IL-4 or IL-10 in children with severe immunologic deficit compared with controls. A higher stimulus-induced IL-10 secretion and a lower constitutive TNF-alpha mRNA were associated with a slower rate of disease progression, and TNF-alpha mRNA expression correlated with lower plasma HIV RNA. Thus, constitutive cytokine mRNA expression differs from stimulus-induced cytokine responses. The dominant defect in HIV-infected children appears to be one of reduced type 1 cytokines, predominantly IL-2.

Embryological origin for autism: developmental anomalies of the cranial nerve motor nuclei

The underlying brain injury that leads to autism has been difficult to identify. The diagnostic criteria of the disease are not readily associated with any brain region or system, nor are they mimicked by vascular accidents, tumors, or degenerative neurological diseases occurring in adults. Fortuitously, a recent report of autism induced by thalidomide exposure provides evidence that the disease originates by an injury at the time of closure of the neural tube. The human data suggest that the initiating lesion includes the motor cranial nerve nuclei. To test this hypothesis, we first examined motor nuclei in the brainstem of a human autistic case. The autopsy brain exhibited near-complete absence of the facial nucleus and superior olive along with shortening of the brainstem between the trapezoid body and the inferior olive. A similar deficit has been reported in Hoxa-1 gene knockout mice in which pattern formation of the hindbrain is disrupted during neurulation. Alternatively, exposure to antimitotic agents just after neural tube closure could produce the observed pattern of deficits. Thus, the lesions observed in the autopsy case appear to match those predicted by the thalidomide cases in both time of origin and central nervous system (CNS) location. To produce similar brain lesions experimentally, we exposed rat embryos to valproic acid, a second teratogen newly linked to autism. Dams received 350 mg/kg of valproic acid (VPA) on day 11.5 (the day of neural tube closure), day 12, or day 12.5 gestation. Each treatment significantly reduced the number of motor neurons counted in matched sections of the earliest-forming motor nuclei (V, XII), and progressively later exposures affected the VIth and IIIrd cranial nerve nuclei. All treatments spared the facial nucleus, which forms still later. Counts from the mesencephalic nucleus of trigeminal, the dorsal motor nucleus of the vagus, and the locus ceruleus were not affected by exposure to VPA, even though these nuclei form during the period when exposure occurred. Despite its effects on the motor nuclei, valproic acid exposure did not alter the further development of the brain in any obvious way. Treated animals were robust and had no external malformations. The autopsy data and experimental data from rats confirm that CNS injuries occurring during or just after neural tube closure can lead to a selective loss of neurons derived from the basal plate of the rhombencephalon. The results add two new lines of evidence that place the initiating injury for autism around the time of neural tube closure.