Essential data dimensions for prospective international data collection in older age bipolar disorder (OABD): Recommendations from the GAGE-BD group

BACKGROUND

By 2030, over 50% of individuals living with bipolar disorder (BD) are expected to be aged ≥50 years. However, older age bipolar disorder (OABD) remains understudied. There are limited large-scale prospectively collected data organized in key dimensions capable of addressing several fundamental questions about BD affecting this subgroup of patients.

METHODS

We developed initial recommendations for the essential dimensions for OABD data collection, based on (1) a systematic review of measures used in OABD studies, (2) a Delphi consensus of international OABD experts, (3) experience with harmonizing OABD data in the Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD, n ≥ 4500 participants), and (4) critical feedback from 34 global experts in geriatric mental health.

RESULTS

We identified 15 key dimensions and variables within each that are relevant for the investigation of OABD: (1) demographics, (2) core symptoms of depression and (3) mania, (4) cognition screening and subjective cognitive function, (5) elements for BD diagnosis, (6) descriptors of course of illness, (7) treatment, (8) suicidality, (9) current medication, (10) psychiatric comorbidity, (11) psychotic symptoms, (12) general medical comorbidities, (13) functioning, (14) family history, and (15) other. We also recommend particular instruments for capturing some of the dimensions and variables.

CONCLUSION

The essential data dimensions we present should be of use to guide future international data collection in OABD and clinical practice. In the longer term, we aim to establish a prospective consortium using this core set of dimensions and associated variables to answer research questions relevant to OABD.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Simulated Electroconvulsive Therapy: A Novel Approach to a Control Group in Clinical Trials

OBJECTIVES

Agitation is the most common behavioral symptom of Alzheimer disease (AD) affecting approximately 40% to 60% of the AD population, yet there are no Food and Drug Administration-approved therapies for the myriad of behavioral or psychological symptoms of dementia. There is growing evidence from naturalistic studies that electroconvulsive therapy (ECT) is a safe and effective treatment for agitation in AD patients who are refractory to pharmacotherapy and behavioral interventions. Despite the existing evidence, ECT remains underused because of stigma, lack of education, and concerns regarding adverse cognitive effects. Randomized controlled clinical trials of ECT are an opportunity to provide high-quality evidence of ECT as a safe and efficacious treatment for agitation in the AD population. We describe the methods for the Electroconvulsive Therapy in Alzheimer's Dementia study, which uses a novel, simulated ECT (S-ECT) control group to conduct a single-blind efficacy study of ECT for the treatment of agitation and aggression in individuals with moderate to severe AD.

METHODS

We discuss the rationale, study design, methodology, ethical and practical challenges, and management strategies in using an S-ECT group as the comparator arm in this randomized controlled trial of ECT in AD-related treatment refractory agitation and aggression.

CONCLUSIONS

Validation of the safety and efficacy of ECT in patients with advanced AD with refractory agitation and aggression is necessary. This can be accomplished through creative formulation of S-ECT groups that effectively maintain the blind while providing scientific integrity.

Developing a New Suicide Risk Assessment for Virtual Encounters with Non-Clinicians

Introduction

The COVID-19 pandemic has necessitated that many research encounters be conducted virtually. Non clinician staff (e.g. research assistants (RAs), study coordinators, or research trainees) with varying levels of clinical training and experience are typically the primary point of contact for research participants. Consequently, they are often the first to encounter suicidality. This highlights the need for robust virtual suicide risk assessment procedures that are at an appropriate level for research staff and optimized for remote clinical research visits. The current procedures for in-person visits conducted by the Geriatric Psychiatry Program at McLean Hospital require non-clinician staff to complete the full Columbia Suicide Severity Rating Scale (CSSRS) in situations of active suicidal ideation (SI) before requiring clinician notification and intervention. However, staff and clinicians both reported that the virtual visit format limited the quality of the assessment and the ability to respond rapidly in situations of passive suicidal ideation, especially when this ideation did not meet the threshold for clinician notification specified in the in-person protocol.  Thus, we established the need for a specific virtual suicide risk assessment protocol. Here we present our process for needs assessment and its findings, which in turn have shaped our revised protocol.

Methods

We surveyed clinicians and social workers affiliated with the Geriatric Psychiatry Research Program at McLean Hospital. The first goal of this survey was to collect information on how clinicians respond to situations of suicidality during telehealth assessments, and how clinicians recommend that staff navigate these situations in a virtual research setting. The second goal was to gather qualitative data that would guide preparatory safety planning (PSP) that non-clinician staff could complete prior to research visits. Because there are no standardized instruments for the information we wanted to collect, we developed a survey based on consensus among research staff.

Results

Of the 19 clinicians surveyed, 11 completed the brief survey. Nine (81.8%) of the eleven clinicians that responded had needed to deal with a patient at imminent risk of suicide in any setting. Only three (27.27%) clinicians were fully comfortable using the in-person SI protocol for virtual encounters. All 11 (100%) of responding clinicians conveyed that PSP should include information on (a) the exact location of the patient's home,  (b) contact information for friends and family, and (c) an assessment of firearm access. The PSP should be completed as early as feasible in the research process, prior to formal enrollment, even if there was no reason to suspect SI at the time. Additional qualitative feedback included recommendations for lowering the threshold for enacting the SOP from subjects expressing active SI to passive SI to facilitate earlier intervention.  Clinicians also recommended training staff on formal assessment measures such as the combined SAFE-T (Suicide Assessment Five-step Evaluation and Triage) and CSSRS protocol in a structured interview so that they could conduct a more systematic assessment if passive SI was reported.

Conclusions

As more research encounters are conducted virtually, protocols designed for in-person assessment of suicide risk must be adapted. We found that the most useful addition to a virtual SI protocol  may be to lower the threshold for action from active to passive SI and inclusion of PSP. Our findings also indicate that staff should be trained in standardized suicide assessment and that there should be a low threshold for conducting these assessments (i.e. passive ideation) and notifying clinicians. Our findings may be broadly generalizable to all mental health research settings that involve virtual assessment by non-clinician staff.

This research was funded by

This work was supported in part by an unrestricted philanthropic gift from Eric Warren Goldman to the Technology and Aging Lab at McLean Hospital

Les inhibiteurs du système rénine-angiotensine et la mortalité par COVID-19 : une cohorte prospective de 1160 patients hypertendus, et revue de littérature

Introduction

L’influence d’un traitement chronique par inhibiteurs du système rénine-angiotensine (ISRA) chez les patients infectés par la COVID-19 a fait l’objet de nombreuses études en 2020 avec des résultats controversés, suggérant tantôt l’interruption du traitement au long cours, ou au contraire un effet protecteur du traitement. Nos objectifs étaient :

– d’étudier la mortalité associée à un traitement chronique par ISRA chez des patients hospitalisés pour une infection par le SARS-CoV-2 en France ;

– les raisons expliquant les résultats discordants dans la littérature.

Méthodes

Nous avons sélectionné les sujets hypertendus inclus dans l’étude nationale prospective de 3512 patients hospitalisés avec COVID-19 (cohorte French-COVID) jusqu’au 30 juin 2020. L’exposition était définie par la prescription d’inhibiteurs de l’enzyme de conversion ou antagonistes des récepteurs de l’angiotensine II avant hospitalisation. Des modèles de Cox avec pondérations basées sur le score de propension ont permis d’estimer des hazard ratios (HR) de mortalité à 30 jours du diagnostic de COVID-19 chez les sujets exposés aux ISRA par rapport aux non exposés. Notre revue de la littérature s’est intéressée aux méthodes (plan expérimental, population, exposition, critères de jugement, méthodes statistiques) et aux résultats des études observationnelles publiées étudiant le rôle pronostique des ISRA dans la COVID-19.

Résultats

Nous avons analysé 1160 patients hypertendus ; 719 (62 %) hommes, 777 (67 %) âgés de plus de 65 ans. Les principales comorbidités étaient le diabète (n = 416, 36 %), les maladies cardiaques (n = 401, 35 %) et l’obésité (n = 340, 29 %) ; 705 (61 %) patients étaient sous oxygène dans les deux jours suivant l’admission. Nous avons enregistré 135 (11,6 %) décès dans les 30 jours. Aucune association entre l’exposition chronique aux ISRA et la mortalité (HR non ajusté = 1,13, IC95 % [0,8–1,6] ; HR pondéré sur l’IPT = 1,09 [0,86–1,39] ; HR pondéré sur le SMR = 1,08 [0,79–1,47]) n’a été mise en évidence. Notre revue de littérature a retrouvé 51 études individuelles : 31 chez des patients hypertendus, et 39 chez des patients hospitalisés. Parmi ces dernières, 25/39 ont étudié l’effet du traitement chronique par ISRA avant l’hospitalisation, 11/39 ont étudié l’effet de l’exposition aux ISRA pendant le séjour, et pour 4/39 la temporalité de l’exposition était indéfinie. Un risque augmenté de mortalité associé à l’exposition aux ISRA était fréquemment rapporté dans les études menées dans des populations peu sélectionnées (non restreintes aux hypertendus) ou avec un ajustement inapproprié, généralement expliqué par un biais d’indication. A contrario, une diminution significative de la mortalité associée à l’exposition aux ISRA était le plus souvent rapportée dans des études où l’exposition était définie par le traitement ISRA au cours de l’hospitalisation, expliquée par un biais de causalité inverse et un biais d’immortalité.

Conclusion

Nos résultats ne montrent pas d’association significative entre la prise chronique d’ISRA et la mortalité chez des patients hypertendus hospitalisés pour COVID-19, en accord avec les recommandations des sociétés savantes qui recommandent la poursuite de ces traitements malgré la pandémie. La question d’introduire ces traitements en cours d’hospitalisation est en cours d’évaluation dans des essais randomisés.

OS1.6 Peripheral blood immune profiles at first recurrence of IDH wild type glioblastoma after standard chemoradiotherapy predict overall survival: secondary analyses of the phase II DIRECTOR trial

BACKGROUND

Isocitrate dehydrogenase (IDH) wildtype glioblastoma is associated with distinctive peripheral blood immune cell profiles that evolve under first line chemoirradiation with temozolomide. Whether peripheral blood immune cell profiles at recurrence are associated with survival of IDH wildtype glioblastoma has not been studied in detail.

PATIENTS AND METHODS

Peripheral blood mononuclear cells (PBMC) of 21 healthy donors and of 52 clinically well-annotated patients with IDH wildtype glioblastoma were analyzed by 11-color flow cytometry at 1st recurrence after standard chemoirradiation with temozolomide and at 2nd recurrence after dose-intensified temozolomide re-challenge. Patients were treated within the randomized phase II trial DIRECTOR, which explored the efficacy of dose-intensified temozolomide at first recurrence of glioblastoma. Patients were classified based on unsupervised analyses of PBMC profiles at 1stand 2ndrecurrence. Associations with survival were explored in multivariate Cox models controlling for established prognostic and predictive factors.

RESULTS

At 1strecurrence, two patient clusters were identified which differed in CD4+ T-cell fractions, but not with respect to CD8+ T-cells, CD4+;CD25+;FoxP3+ regulatory T-cells, B-cells or monocytes. The composition of CD4+, CD8+ or regulatory T-cell fractions was similar in both clusters. All control samples clustered with the CD4high cluster. Patients in both clusters did not differ by established prognostic factors, including age, O6-methylguanine-DNA-methyl-transferase (MGMT) gene promoter methylation, tumor volume, Karfnosky performance score or steroid use. Progression-free survival was similar (CD4high vsCD4low 2.1 vs 2.4 months, p=0.19), whereas post-recurrence overall survival was longer among the CD4highcluster (12.7 vs 8.7 months, p= 0.004). At 2nd recurrence, monocyte fractions increased, whereas memory CD4+ T-cell fractions decreased. Unsupervised segregation of patients by CD4+ subpopulations yielded two clusters characterized by the abundance of memory T-cell fractions and higher memory CD4+ fractions were associated with longer overall survival at 2nd recurrence (p=0.004). The reported prognostic associations were retained in multivariate Cox models controlling for established prognostic factors.

CONCLUSION

We conclude that temozolomide-associated memory CD4+ T-cell depletion may have deteriorating effects on the survival of glioblastoma patients.

Acid lakes from natural and anthropogenic causes

Lakes may be acid because of natural ecological conditions or because of anthropogenic activities. Apparently there has been a recent increase in acidity of many lakes in the northeastern United States. Factors that may be contributing to this increase include the use by utilities of precipitators, sulfur scrubbers, and tall stacks; the use of petroleum; and methods of combustion of fossil fuels.

Temperature and manganese as determining factors in the presence of diatom or blue-green algal floras in streams

Diatoms are usually the major component of the algal flora in many streams, although green and blue-green algae may be present. These experiments were designed to determine if high temperature or a shift in the chemical composition of the water might bring about a dominance of blue-green algae and/or green algae rather than a dominance of diatoms in the algal flora.The results of these experiments indicate that an average temperature of 34 degrees to 38 degrees C results in a shift of dominance in the algal flora from diatoms to blue-green algae. Furthermore, a blue-green and green algal flora of species typically found in organically polluted water in favored if the manganese content is a few parts per billion. If the manganese content averaged 0.02-0.043 mg/liter in the natural stream to 0.04-0.28 mg/liter in the recycled water experiment, a diatom flora remained dominant.

Primary gynecological neoplasms and clinical outcomes in patients diagnosed with breast carcinoma

The purpose of this study was to quantify and describe nonmammary neoplasms (n-MN), particularly gynecological neoplasms, in a patient population previously diagnosed with breast cancer. Data were collected prospectively in our institutional review board-approved registry for patients diagnosed with infiltrating breast cancer or ductal carcinoma in situ. Patients who developed a second, n-MN were identified; neoplastic site, time to development after breast cancer, and clinical outcomes were recorded. FIGO stage was recorded for patients who developed a gynecological neoplasm. Synchronous bilateral breast cancer was defined as a second, contralateral diagnosis made within 12 months of the first and, similarly, synchronous n-MN were defined as those identified within 1 year of a breast cancer diagnosis. Outcome curves were generated using the method of Kaplan and Meier, and compared using the log-rank test. Of 4126 patients diagnosed with breast cancer, 3% developed a n-MN, the majority of which were nongynecological and asynchronous to the initial breast cancer diagnosis. Three percent of patients diagnosed with breast cancer were diagnosed with a second, n-MN. Among patients who developed a n-MN, most developed a nongynecological cancer more than 1 year after the initial breast cancer diagnosis, and their outcomes were significantly worse than those patients who did not develop a n-MN.

Primary gynecological neoplasms and clinical outcomes in patients diagnosed with breast carcinoma

The purpose of this study was to quantify and describe nonmammary neoplasms (n-MN), particularly gynecological neoplasms, in a patient population previously diagnosed with breast cancer. Data were collected prospectively in our institutional review board–approved registry for patients diagnosed with infiltrating breast cancer or ductal carcinoma in situ. Patients who developed a second, n-MN were identified; neoplastic site, time to development after breast cancer, and clinical outcomes were recorded. FIGO stage was recorded for patients who developed a gynecological neoplasm. Synchronous bilateral breast cancer was defined as a second, contralateral diagnosis made within 12 months of the first and, similarly, synchronous n-MN were defined as those identified within 1 year of a breast cancer diagnosis. Outcome curves were generated using the method of Kaplan and Meier, and compared using the log-rank test. Of 4126 patients diagnosed with breast cancer, 3% developed a n-MN, the majority of which were nongynecological and asynchronous to the initial breast cancer diagnosis. Three percent of patients diagnosed with breast cancer were diagnosed with a second, n-MN. Among patients who developed a n-MN, most developed a nongynecological cancer more than 1 year after the initial breast cancer diagnosis, and their outcomes were significantly worse than those patients who did not develop a n-MN.

Breath isoprene in patients with heart failure

BACKGROUND

Chronic heart failure (CHF) is characterised by increased vascular resistance. This increased after load on the left ventricle contributes to the vicious cycle that leads to progression of myocardial failure, multiple organ failure and death. There is evidence for increased oxidative stress in heart failure, which will influence the myocardium but also peripheral vasculature endothelium.

AIMS

The aim of the present study was to examine the production of isoprene, reputed to reflect oxidative stress, in patients with CHF compared to control subjects.

METHODS

Twelve patients with CHF and thirty-one healthy control subjects free from heart disease were studied. Breath was collected via a two-way non-re-breathing valve into a 60-l gas collection bag. A sample of ambient air was collected at the same time. A measured aliquot of patient breath and ambient air (approx. 1.5 l) was adsorbed onto a gas adsorption tube packed with poropak-Q. Isoprene was measured using GC/MS and the production rate calculated. All samples of breath were collected at 10.00 h after subjects had been sitting at rest for 15 min.

RESULTS

Breath isoprene production in subjects with CHF was significantly reduced compared to controls 83(23) vs. 168(20) pmol min(-1) kg(-1).

CONCLUSION

Breath isoprene does not directly reflect oxidative stress in CHF.

Breath isoprene during acute respiratory exacerbation in cystic fibrosis

Patients with cystic fibrosis (CF) experience a combination of chronic systemic oxidative stress, generation of free radicals in the lungs due to a hyperimmune response and a diminished ability to scavenge free radicals secondary to malabsorption and increased consumption. The authors asked the question, "Does breath isoprene content reflect systemic oxidative stress?" The study involved 12 CF patients and 12 matched healthy controls. The patients were sampled during acute respiratory exacerbation (increased respiratory symptoms, reduction in forced expiratory volume (FEV1) of >10%, and a decision to treat with intravenous antibiotics) and after two weeks of antibiotic treatment. Blood samples were examined for markers of oxidative stress. Breath samples were analysed for isoprene content. Malondialdehyde (MDA), erythrocyte membrane polyunsaturated fatty acids, protein sulphydryls and protein carbonyls all showed evidence of increased oxidative stress which was moderated by antibiotic treatment. Breath isoprene production rate was significantly lower in patients during exacerbation than in controls with a mean difference of-39 (95% confidence interval (CI) -11-57) pmol.min.kg(-1) and increased to normal values following treatment (mean change 63 (95% CI 42-84) pmol.min.kg(-1)). In conclusion, breath isoprene cannot be considered a reliable marker of oxidative stress.

Oxygen contamination of the nitrous oxide pipeline supply

Midogas (CIG Australia) nitrous oxide/oxygen blenders are commonly used in delivery wards in Australia. In this case report we describe an incident where a small hole in the diaphragm of the oxygen failure alarm in a Midogas nitrous oxide/oxygen blender led to retrograde flow of oxygen contaminating the nitrous oxide pipeline supply to the operating theatres and the delivery ward. This caused a reduced level of nitrous oxide to the patient in theatre, but there was no adverse outcome. However, if the oxygen pipeline pressure had been lower than the nitrous oxide pipeline pressure, the contamination would have been reversed, potentially resulting in a hypoxic mixture being delivered to many patients. Suggestions are made as to a method of prevention of this problem.

The oral dose-effect relationship for fluvoxamine: a fixed-dose comparison against placebo in depressed outpatients

This 7- to 8-week, multicenter, randomized, double-blind, placebo-controlled study was performed to determine the dose-effect relationship and minimum effective dose for fluvoxamine maleate in a titrated fixed-dose study of major depressive disorder. Gradual titration over 2 weeks to fixed maintenance doses was employed to minimize dropout due to initial side effects. The study enrolled 600 outpatients, male and female, age 18-65, meeting DSM-III-R criteria for major depressive disorder. A 13-item subscore of the standard 21-Item Hamilton Depression Scale was used to minimize the possible contribution of known side effects from serotonin reuptake inhibitors to the overall HAM-D score. Secondary efficacy assessments included the HAM-D retardation factor, HAM-D depressed mood item, CGI-severity of illness item, and SCL depression factor. Fluvoxamine (50-150 mg/day) was therapeutically effective and well tolerated during 6 weeks of therapy. Based on the HAM-D depressed mood item, efficacy was dose dependent. The minimum effective dose was 50 mg/day. Fluvoxamine maleate shows dose-related effectiveness in the acute treatment of major depressive disorder.

Long-term safety and clinical acceptability of venlafaxine and imipramine in outpatients with major depression

The antidepressant efficacy and safety of venlafaxine was shown previously in 6-week, placebo-controlled trials. We evaluated the long-term safety and clinical acceptability of venlafaxine and imipramine in a double-blind, parallel-group, comparative study. Two hundred ninety depressed outpatients were treated with venlafaxine, and an additional 91 received imipramine for as long as clinically necessary, up to 1 year. The total daily dose of each drug could vary from 75 to 225 mg. The Clinical Global Impressions Scale and a therapeutic response rate that was based on Clinical Global Impressions Scale-Improvement and incorporated discontinuation information were used to evaluate efficacy. Safety determinations and patient subjective ratings were used to evaluate safety and clinical acceptability. During the study, the adverse events were generally mild to moderate and most subsided with continued treatment; the most frequent were nausea for venlafaxine and dry mouth for imipramine. The anticholinergic side effect burden was significantly higher in the imipramine group than in the venlafaxine group. Venlafaxine was judged significantly more acceptable than imipramine, on the basis of the subjective ratings by patients. Fewer venlafaxine-treated patients than imipramine-treated patients withdrew because of adverse events and unsatisfactory response. There was a consistent trend in the therapeutic response rates in favor of venlafaxine that reached statistical significance at months 2, 6, and 12. In this long-term study, patient acceptability was greater for venlafaxine than for imipramine, suggesting therapeutic advantages for venlafaxine in the long-term treatment of depression. Additional studies with other active comparators are underway to confirm and extend these encouraging results.

Ground water contamination in the United States

Ground water contamination is of increasing concern in the United States because about 50 percent of our drinking water comes from well water. The causes of contamination stem from both point sources and nonpoint sources. Since ground water moves slowly, the contaminant may affect only a small portion of an aquifer for a considerable period of time. Deleterious effects on human health have resulted from pathogenic organisms in ground water and from its toxic chemical composition. It is difficult to estimate the extent of contamination on a national basis as the frequency of instances of contamination is very variable. Remedial actions to clean up aquifers are difficult, expensive, and sometimes not feasible. Many of the laws and regulations that control ground water contamination are designed with other main objectives.

Active chronic hepatitis after chlorpromazine ingestion

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A population of lymphocytes bearing a membrane receptor for antigen-antibody-complement complexes. I. Separation and characterization

A population of lymphoid cells from several animal species, including man, was identified through a membrane receptor which binds sheep red blood cells treated with antibody and complement. When cells from different lymphoid organs were incubated with EAC at 37 degrees C, only part of the lymphocytes (named CRL) bound EAC and formed rosettes, and this interaction was shown to be C3-dependent. Mouse lymphoid cells could be specifically depleted of CRL by allowing them first to interact with EAC and then submitting the mixture to ultracentrifugation in a gradient of BSA. After ultracentrifugation, a population of cells containing 95% or more of non-CRL were recovered from the upper layers of the gradient. In addition to their different abilities to bind EAC, CRL and non-CRL from mouse lymphoid organs could be distinguished by the following properties: (a) CRL adhered preferentially to nylon wool at 37 degrees C in the presence of mouse serum. (b) After differential flotation in a gradient of BSA, a significantly higher proportion of CRL were recovered from the upper layers of the gradient. (c) The population of CRL contained most of the lymphocytes bearing immunoglobulin determinants on their membranes. (d) The distribution of CRL was quite different among lymphocytes obtained from various lymphoid organs, and they were never found in the thymus. (e) The membrane receptor for EAC was not detected in plaque-forming cells of mice which had been previously immunized with burro red cells. CRL and non-CRL could not be distinguished by their life span, as they were found in similar proportions among long-lived and short-lived lymphocytes from mouse peripheral lymph nodes. The function of this receptor on the membrane of certain lymphoid cells may be related to (a) the trapping and localization of antigen in lymphoid organs or (b) the localization of lymphoid cells in inflammatory sites.

Production of 2,3-butylene glycol from citrus wastes. II. The Bacillus polymyxa fermentation

The conditions required for production of levo 2,3-butylene glycol by Bacillus polymyxa from citrus molasses were studied. Starter cultures required acclimatization to the substrate prior to inoculation of the fermentation medium. Maximal production of butylene glycol with minimal residual sugar was obtained with a medium consisting of molasses, diluted to 20 degrees Brix, and 0.4% urea. Optimal environmental conditions included aeration at 0.11 volumes of air per volume of medium per minute, maintenance of pH at 6.0 to 6.2, a fermentation temperature of 30 C, and a stirring rate of 420 rev/min. The concentration of butylene glycol obtained in the fermentation beer ranged from 2.3 to 4.4%. The optical rotation of the glycol ranged from [alpha](D) (23 degrees ) = -1.01 degrees to -10.45 degrees . The variation in rotation was probably due to the presence of contaminating substances in the distillate.