Addiction and Sleep Disorders

Shared neurophysiology of addiction and sleep disorders results in a bidirectional interplay. Diagnosing and treating primary sleep disorders, particularly in adolescents, can prevent the development of addiction in susceptible individuals. Addressing sleep issues in early recovery, and throughout maintenance, can prevent relapse. Cannabis use for insomnia shows mixed results; assisting with onset sleep latency in early use, this subsides with chronic use and holds addiction risk. Insomnia is a primary complaint of cannabis withdrawal syndrome and a primary cause of relapse in cannabis use disorder. An ideal sleep aid would prevent relapse and have low abuse potential. Pharmaceutical and behavioral options include suvorexant, mirtazapine, trazodone, and aerobic exercise, but clinical trials are lacking to demonstrate efficacy.

Abstract B4: High-dose ascorbic acid synergizes with anti-PD1 in a lymphoma mouse model

Major efforts are under way to identify agents that can potentiate effects of immune checkpoint inhibition. Ascorbic acid (AA) has been previously shown to cause DNA demethylation and corresponding increase in hydroxymethylation in multiple malignancies by enhancing the activity of the Ten-Eleven Translocation (TET) enzymes (Shenoy et al., BCJ 2017; Shenoy et al., JCI 2019; Cimmino et al., Cancer Cell 2017; Agathocleous et al., Nature 2017). Furthermore, AA has re-emerged as a promising anticancer agent based on recent knowledge of pharmacokinetics, discovery of unexpected mechanisms of action, and early phase trials with IV AA (Shenoy et al., Cancer Cell 2018). Here, we report that AA treatment caused genome-wide demethylation and enhanced expression of endogenous retroviral elements in lymphoma cells. AA also increased 5-hydroxymethylcytosine (5hmC) levels of CD8+ T cells and enhanced their cytotoxic activity in a lymphoma coculture system. High-dose AA treatment synergized with anti-PD1 therapy in a syngeneic lymphoma mouse model, resulting in marked inhibition of tumor growth compared with either agent alone. Analysis of the intratumoral epigenome revealed increased 5hmC with AA treatment, consistent with in vitro findings. Analysis of the tumor immune microenvironment revealed that AA strikingly increased intratumoral infiltration of CD8+ T cells and macrophages, suggesting enhanced tumor immune recognition. The combination treatment markedly enhanced intratumoral infiltration of macrophages and CD8+ T lymphocytes, granzyme B production by cytotoxic cells (cytotoxic T cells and natural killer cells), and IL-12 production by antigen-presenting cells compared with single-agent anti-PD1. These data strongly indicate that AA potentiates anti-PD1 checkpoint inhibition through synergistic mechanisms. The study provides a compelling rationale for testing combinations of AA and anti-PD1 agents in lymphoma patients as well as in preclinical models of other malignancies.

Citation Format: Rebecca Luchtel, Tushar Bhagat, Kith Pradhan, William Jacobs, Mark Levine, Amit Verma, Niraj Shenoy. High-dose ascorbic acid synergizes with anti-PD1 in a lymphoma mouse model [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr B4.

High-throughput phenotyping reveals expansive genetic and structural underpinnings of immune variation

By developing a high-density murine immunophenotyping platform compatible with high-throughput genetic screening, we have established profound contributions of genetics and structure to immune variation (http://www.immunophenotype.org). Specifically, high-throughput phenotyping of 530 unique mouse gene knockouts identified 140 monogenic 'hits', of which most had no previous immunologic association. Furthermore, hits were collectively enriched in genes for which humans show poor tolerance to loss of function. The immunophenotyping platform also exposed dense correlation networks linking immune parameters with each other and with specific physiologic traits. Such linkages limit freedom of movement for individual immune parameters, thereby imposing genetically regulated 'immunologic structures', the integrity of which was associated with immunocompetence. Hence, we provide an expanded genetic resource and structural perspective for understanding and monitoring immune variation in health and disease.

2165. Helicobacter pylori Infections in the Bronx, New York: Whole-Genome Sequencing for Rapid Genotypic Susceptibility Testing

Background

Susceptibility-guided treatment of H. pylori is superior to empiric therapy. We determined the accuracy of whole-genome sequencing (WGS) compared with phenotypic testing using CLSI/EUCAST breakpoints.

Methods

Thirty-three clinical isolates of H. pylori cultured from gastric biopsies were sequenced with a coverage range between 40x and 80x using Illumina Miseq platform and the reads were assembled and annotated with PATRIC. Phenotypic susceptibility tests were performed using E-test strips under microaerophilic conditions for 72 hours. Mutations associated with amoxicillin, tetracycline, clarithromycin, levofloxacin, metronidazole and rifampin resistance were examined.

Results

Of the 33 isolates, two were phenotypically resistant to amoxicillin: one carried a β-lactamase gene (blaTEM-116) and the other exhibited a point mutation pbp2 (A541T). All isolates were tetracycline susceptible phenotypically, but three isolates had point mutations in 16S rRNA that are associated with resistance (A926G). Clarithromycin results showed a good correlation between methods. Nine clarithromycin-resistant isolates demonstrated point mutations in 23S rRNA (A2142G/A2143G). Fifteen isolates were phenotypically resistant to levofloxacin, but resistance mutations were found in only 14 strains (N87I/N87K/D91Y/D91N/D91G/D99N in gyrA). We analyzed our strains for the presence of intact genes rdxA and frxA, either of which convert the prodrug form of metronidazole into the active form. Twenty-four of 33 isolates were tested phenotypically. We found 3 isolates with truncations in both genes. These isolates had metronidazole MICs >256. The presence of one or both intact genes did not always result in low MICs, indicating that there may be significant point mutations that contribute to resistance. Rifampin was not tested phenotypically, but no mutations in rpoB were found. In summary, the correlation of WGS and phenotypic testing was 100% for amoxicillin and clarithromycin, 97% for levofloxacin, 91% for tetracycline (n = 33), and 67% for metronidazole (n = 24).

Conclusion

WGS provides a detailed analysis of H. pylori resistance and a broader analysis of antimicrobials that may be of clinical value. Additional studies are needed for genotypic prediction of metronidazole resistance.

Disclosures

All authors: No reported disclosures.

Estudo comparativo entre layouts sob a ótica da teoria das restrições com apoio de simulação de eventos discretos em empresa de alimentos

O layout tem interferência direta nos sistemas produtivos das empresas. Contudo não é tarefa fácil prever todas as variáveis em seu rearranjo, e se ao final atenderá às metas globais da empresa. Buscando contribuir com esta questão o presente estudo propôs uma nova abordagem para análise de layout, empregando a simulação de eventos discretos e os indicadores operacionais da Teoria das Restrições (TOC), para avaliar qual o arranjo físico mais adequado – celular ou funcional - a ser utilizado em um setor de misturas de uma empresa de alimentos. Esta análise foi realizada sob a perspectiva dos seguintes indicadores operacionais da TOC: ganho, investimentos e despesas operacionais. Inicialmente foram identificados os produtos mais vendidos em um período de 12 meses, por meio da curva ABC. Em seguida foram realizados os projetos de layout: funcional, através do método de planejamento computadorizado de relação de layout (CORELAP); celular, através da análise de fluxo de produção (FPA).  Depois de realizada a modelagem dos layouts com os dados coletados, as simulações foram rodadas e posteriormente analisadas com base nos indicadores operacionais da TOC, apontando ao final o layout mais adequado. Os resultados mostraram que o layout funcional apresentou o melhor desempenho sob a perspectiva dos indicadores operacionais da TOC, proporcionando o aumento no ganho (+12,34%), redução nos investimentos (-11,47%) e redução nas despesas operacionais (-18,71%). Este estudo demonstrou que o layout funcional, no contexto estudado, ofereceu maior flexibilidade produtiva, impactando de forma positiva nos indicadores operacionais da TOC e que tais indicadores podem ser ferramentas efetivas na comparação de layouts.

Insurance Companies Fighting the Peer Review Empire without any Validity: the Case for Addiction and Pain Modalities in the face of an American Drug Epidemic

The United States are amid an opioid overdose epidemic; we are challenged to provide non-addicting/non-pharmacological alternatives to assist in pain attenuation. There are proven strategies available to manage chronic pain effectively without opioids. Utilization review providers for insurance companies often ignore medicine based scientific peer-reviewed studies that warn against the chronic use of opioid medications, as well as the lack of evidence to support long-term use of opioids for pain. This paradigm must change if we are to indeed change the drug-embracing culture in American chronic pain management. A barrier to treatment is pushback on the part of insurance companies especially as it relates to fighting against pain relief alternatives compared to classical analgesic agents. Pain specialists in the U.S., are compelled to find alternative solutions to help pain victims without promoting unwanted tolerance to analgesics and subsequent biological induction of the "addictive brain." It is noteworthy that reward center of the brain plays a crucial role in the modulation of nociception, and that adaptations in dopaminergic circuitry may affect several sensory and affective components of chronic pain syndromes. Possibly knowing a patient's genetic addiction risk score (GARS™) could eliminate guessing as it relates to becoming addicted.

A Systematic, Intensive Statistical Investigation of Data from the Comprehensive Analysis of Reported Drugs (CARD) for Compliance and Illicit Opioid Abstinence in Substance Addiction Treatment with Buprenorphine/naloxone

BACKGROUND

Buprenorphine and naloxone (bup/nal), a combination partial mu receptor agonist and low-dose delta mu antagonist, is presently recommended and used to treat opioid-use disorder. However, a literature review revealed a paucity of research involving data from urine drug tests that looked at compliance and abstinence in one sample.

METHOD

Statistical analysis of data from the Comprehensive Analysis of Reported Drugs (CARD) was used to assess compliance and abstinence during treatment in a large cohort of bup/nal patients attending chemical-dependency programs from eastern USA in 2010 and 2011.

RESULTS

Part 1: Bup/nal was present in 93.4% of first (n = 1,282; p <.0001) and 92.4% of last (n = 1,268; p <.0001) urine samples. Concomitantly, unreported illicit drugs were present in 47.7% (n = 655, p =.0261) of samples. Patients who were compliant to the bup/nal prescription were more likely than noncompliant patients to be abstinent during treatment (p =.0012; odds ratio = 1.69 with 95% confidence interval (1.210, 2.354). Part 2: An analysis of all samples collected in 2011 revealed a significant improvement in both compliance (p < 2.2 × 10^-16) and abstinence (p < 2.2 × 10^-16) during treatment. Conclusion/Importance: While significant use of illicit opioids during treatment with bup/nal is present, improvements in abstinence and high compliance during maintenance-assisted therapy programs may ameliorate fears of diversion in comprehensive programs. Expanded clinical datasets, the treatment modality, location, and year of sampling are important covariates, for further studies. The potential for long-term antireward effects from bup/nal use requires consideration in future investigations.

Establishing Models of Herpes Simplex Virus Type 2 Superinfection of Herpes Simplex Virus Type 1 Seropositive Mice to Test The Efficacy of a Novel Vaccine

Background

Multiple subunit vaccines that elicit neutralizing antibodies (nAbs) against the immunodominant HSV-2 glycoproteins D and/or B (gD and gB) were advanced into the clinic after demonstrating protection against disease in animal models. However, although the vaccines elicited nAbs in seronegative and boosted nAb titers in HSV-1 seropositive (HSV-1+) participants, none prevented HSV-2 infection suggesting that nAbs alone are not sufficient. The results also indicate that current animal models are not predictive of clinical trial outcomes. We recently engineered a candidate single cycle vaccine strain deleted in gD (ΔgD-2) and showed that it elicits high titer non-neutralizing Abs that provide complete protection against HSV-1 or HSV-2. The Abs passively protect naïve mice and activate the Fc receptor to induce antibody-dependent cell mediated cytotoxicity (ADCC). We hypothesize that ΔgD-2 will protect HSV-1+ individuals from HSV-2 because it elicits a different type of immune response. To test this hypothesis, we established a model of HSV-2 superinfection in HSV-1+ mice.

Methods

We infected mice by corneal scarification with serial dilutions of a clinical strain of HSV-1 (Bx31.1) to identify a sublethal dose associated with seroconversion. We then superinfected mice on the skin with HSV-2 and monitored for disease. The presence of virus in dorsal root ganglia (DRG), the site of HSV latency, was determined by quantitative PCR.

Results

Corneal infection with 10^4 PFU of HSV-1 resulted in disease in 18/29 (62%) mice and 13/18 survived. Seroconversion was documented in 9/13 survivors. Surviving mice were superinfected 2 weeks post-recovery with HSV-2. All of the mice developed signs of disease, but only 2/9 who were HSV-1+ died compared with 4/4 seronegative mice (P = 0.02, Fisher exact test). HSV-2 DNA was detected in the DRG of 12/13 mice.

Conclusion

Sublethal HSV-1 corneal disease provides partial protection against HSV-2 superinfection and provides a model to test vaccine efficacy. We speculate that superinfection boosts preexisting nAb titers, a response consistent with immune repertoire freeze, but that ΔgD-2, because it elicits ADCC Abs, will overcome repertoire freeze and provide greater protection against HSV-2 superinfection.

Disclosures

W. Jacobs, X-vax: Grant Investigator, Research grant and Research support. B. C. Herold, X-vax: Grant Investigator, Research grant and Research support.

Neurogenetics of acute and chronic opiate/opioid abstinence: treating symptoms and the cause

This review begins with a comprehensive history of opioid dependence and treatment in the United States. The focus is an evidence-based treatment model for opioid/opiate dependent individuals. The role of reward genetic polymorphisms and the epigenetic modifications that lead to vulnerability to use and misuse of opiates/opioid to treat pain are reviewed. The neurochemical mechanisms of acute opiate withdrawal and opiate/opioid reward mechanisms are explored with a goal of identifying specific treatment targets. Alterations in functional brain connectivity based on neurobiological mechanisms in heroin dependence and abstinence are also reviewed. A new clinical model an alternative to merely blocking acute withdrawal symptoms as identified in the DSM -5 is proposed. Genetic diagnosis at the onset of detoxification, to determine risk stratification, and identify polymorphic gene targets for pharmaceutical and nutraceutical interventions, followed by the simultaneous initiation of Medication Assisted Therapy (MAT), to enable psychological extinction, and steady pro-dopaminergic therapy with the goal of developing "dopamine homeostasis" is recommended. The objective of these interventions is to prevent future relapse by treating all "Reward Deficiency Syndrome" (RDS) behaviors and eventually make an addiction-free life possible.

Assessing the capability of the mycobacterial ribosome to elicit a CD4+ T cell response (APP5P.115)

Mycobacterium tuberculosis (Mtb) infects one third of the world’s population, and an effective vaccine is desperately needed to curb the spread of disease. We have identified that the CD4+ T cell response is critical in combating Mtb. Using an attenuated version of Mycobacterium smegmatis, IKEPLUS, our lab previously identified the mycobacterial ribosome as a potential target to enhance CD4+ T cell responses to Mtb in mice. To directly assess the CD4+ T cell response mounted against the individual mycobacterial ribosomal proteins, we used an E. coli expression system to express and purify all fifty-seven proteins that make up the Mtb ribosome. This Mtb ribosomal library was then used to identify which proteins of the mycobacterial ribosome elicited a CD4+ T cell response in IKEPLUS infected animals by IFN-γ ELISPOT. When CD4+T cells of infected animals were isolated and restimulated with the Mtb ribosomal protein library, twenty-five of the fifty-seven total proteins elicited significant CD4+ Tcell responses. These ELISPOT results indicate that the Mtb ribosome is a highly immunogenic structure with the ability to stimulate strong T cell responses in mice. Further studies will focus on the use of the mycobacterial ribosome and isolated ribosomal proteins as potential components of vaccination regimens for inducing protective immunity against Mycobacterium tuberculosis.

Identification of ribosomal proteins as targets for protective CD4+ T cell responses against mycobacteria (APP5P.114)

Mycobacterium tuberculosis (Mtb) infects one-third of the global population, and a more efficacious vaccine is urgently needed for control and prevention of disease caused by Mtb. We previously reported a genetically modified strain of Mycobacterium smegmatis called IKEPLUS, which is a promising vaccine candidate due to its ability to generate an unprecedented level of bactericidal immunity against Mtb in mice. Protective immunity induced by IKEPLUS is dependent on antigen-specific CD4+ T cell memory, and we hypothesized that specificity of the CD4+ T cell response was a critical feature of this protection. Using in vitro assays of IFNγ production by splenocytes from IKEPLUS-immunized mice, we identified an immunogenic peptide within the mycobacterial RplJ protein encoded by the Rv0651 gene. In a complementary approach, screening T cell hybridomas against Mtb ribosomal proteins identified as the RplA protein, a product of the Rv0641 gene in Mtb, as an additional specific target. Both RplJ and RplA are structural proteins of the 50S large subunit of the mycobacterial ribosome. Our results demonstrate that the CD4+ T cell response in IKEPLUS-immunized mice has multiple targets including components of the mycobacterial ribosome, among which RplA and RplJ represent novel specificities for protective responses against Mtb. Further studies to more fully define the CD4+ T cell responses to ribosomal targets should help to inform the design of effective vaccines against Mtb.

Aging-related changes in lymphatic collectors predispose to pathogen dissemination in tissues (INC4P.342)

Herein we analyze how the aging process affects the structure and functionality of the lymphatic collectors (LCs) with reference to their ability to maintain pathogen clearance. Ultrastructural, biochemical and proteomic analysis indicated a loss of extracellular matrix proteins, an increase in protein oxidative modifications as well as activation of nuclear factor-κB signaling as sign of “low grade” inflammation in aged LCs. This resulted in a decrease in contractile and pumping activity of LCs, as measured in vivo. Functionally, this impairment also translated into a reduced ability for in vivo bacterial transport as determined by time-lapse microscopy. Ultrastructural and proteomic analysis also indicated a decrease in the thickness of the endothelial cell glycocalyx and loss of gap-junction proteins in aged LCs. Redox proteomic analysis mapped an aging-related increase in the glycation and carboxylation of endothelial cell glycocalyx structural proteins. Functionally, these modifications translated into higher ability of the pathogen to escape from aged LCs into the surrounding tissue. Altogether, our analysis mapped the complexity of the aging-related anatomical, biochemical and functional changes in LCs. The decreased ability to transport bacteria to the draining nodes, associated with increased bacterial escape in the surrounding tissue can contribute to the decreased ability of the immune system to clear pathogens in the elderly, as observed in immunosenescence.

Buprenorphine Response as a Function of Neurogenetic Polymorphic Antecedents: Can Dopamine Genes Affect Clinical Outcomes in Reward Deficiency Syndrome (RDS)?

There is a plethora of research indicating the successful treatment of opioid dependence with either buprenorphine alone or in combination with naloxone (Suboxone®). However, we encourage caution in long-term maintenance with these drugs, albeit, lack of any other FDA approved opioid maintenance compound to date. Our concern has been supported by severe withdrawal (even with tapering of the dosage of for example Suboxone® which is 40 times more potent than morphine) from low dose of buprenorphine (alone or with naloxone). In addition our findings of a long-term flat affect in chronic Suboxone® patients amongst other unwanted side effects including diversion and suicide attempts provides impetus to reconsider long-term utilization. However, it seems prudent to embrace genetic testing to reveal reward circuitry gene polymorphisms especially those related to dopaminergic pathways as well as opioid receptor(s) as a way of improving treatment outcomes. Understanding the interaction of reward circuitry involvement in buprenorphine effects and respective genotypes provide a novel framework to augment a patient's clinical experience and benefits during opioid replacement therapy.

Correction: Priming with Recombinant Auxotrophic BCG Expressing HIV-1 Gag, RT and Gp120 and Boosting with Recombinant MVA Induces a Robust T Cell Response in Mice

[This corrects the article DOI: 10.1371/journal.pone.0071601.].

Priming with recombinant auxotrophic BCG expressing HIV-1 Gag, RT and Gp120 and boosting with recombinant MVA induces a robust T cell response in mice

In previous studies we have shown that a pantothenate auxotroph of Myocbacterium bovis BCG (BCGΔpanCD) expressing HIV-1 subtype C Gag induced Gag-specific immune responses in mice and Chacma baboons after prime-boost immunization in combination with matched rMVA and VLP vaccines respectively. In this study recombinant BCG (rBCG) expressing HIV-1 subtype C reverse transcriptase and a truncated envelope were constructed using both the wild type BCG Pasteur strain as a vector and the pantothenate auxotroph. Mice were primed with rBCG expressing Gag and RT and boosted with a recombinant MVA, expressing a polyprotein of Gag, RT, Tat and Nef (SAAVI MVA-C). Priming with rBCGΔpanCD expressing Gag or RT rather than the wild type rBCG expressing Gag or RT resulted in higher frequencies of total HIV-specific CD8⁺ T cells and increased numbers of T cells specific to the subdominant Gag and RT epitopes. Increasing the dose of rBCG from 10⁵ cfu to 10⁷ cfu also led to an increase in the frequency of responses to subdominant HIV epitopes. A mix of the individual rBCGΔpanCD vaccines expressing either Gag, RT or the truncated Env primed the immune system for a boost with SAAVI MVA-C and generated five-fold higher numbers of HIV-specific IFN-γ-spot forming cells than mice primed with rBCGΔpanCD containing an empty vector control. Priming with the individual rBCGΔpanCD vaccines or the mix and boosting with SAAVI MVA-C also resulted in the generation of HIV-specific CD4⁺ and CD8⁺ T cells producing IFN-γ and TNF-α and CD4⁺ cells producing IL-2. The rBCG vaccines tested in this study were able to prime the immune system for a boost with rMVA expressing matching antigens, inducing robust, HIV-specific T cell responses to both dominant and subdominant epitopes in the individual proteins when used as individual vaccines or in a mix.

Antigen specificity of tuberculosis-specific CD4+ T cells in IKEPLUS immunized mice (P3122)

Mycobacterium tuberculosis (Mtb) infects one-third of the global population. A more efficacious vaccine is urgently needed for control and prevention of disease. We recently reported a genetically modified strain of M. smegmatis, IKEPLUS, which is a promising vaccine candidate due to its ability to generate an unprecedented level of bactericidal immunity against Mtb in mice. Since protective immunity induced by IKEPLUS is dependent on antigen-specific CD4+ T cell memory, we hypothesized that specificity of the CD4+ T cell response was critical for protection. To determine CD4+ T cell specificity directly, we generated MHC class II (I-Ab) restricted T cell hybridomas from IKEPLUS-immunized mice. Screening of T cell hybridomas against anion exchange-fractionated IKEPLUS and Mtb proteins provided evidence for multiple specific targets, one of which was identified as the AtpA protein, a product of the Mtb Rv1308 gene. In a complementary approach, using in vitro assays of IFNγ production by splenocytes from IKEPLUS-immunized mice, we identified an immunogenic peptide within the Mtb RplJ protein encoded by the Rv0651 gene. Our results demonstrate the CD4+ T cell response in IKEPLUS-immunized mice has multiple targets, among which AtpA and RplJ represent novel specificities for protective responses against Mtb. Further studies to more fully define the range of specificities of CD4+ T cells in IKEPLUS-immunized mice should help to inform the design of effective vaccines against Mtb.

HSV activates Akt to trigger calcium release and promote viral entry: novel candidate target for treatment and suppression

HSV triggers intracellular calcium release to promote viral entry. We hypothesized that Akt signaling induces the calcium responses and contributes to HSV entry. Exposure of human cervical and primary genital tract epithelial, neuronal, or keratinocyte cells to HSV serotype 2 resulted in rapid phosphorylation of Akt. Silencing of Akt with small interfering RNA prevented the calcium responses, blocked viral entry, and inhibited plaque formation by 90% compared to control siRNA. Susceptibility to infection was partially restored if Akt was reintroduced into silenced cells with an Akt-expressing plasmid. HSV-2 variants deleted in glycoproteins B or D failed to induce Akt phosphorylation, and coimmunoprecipitation studies indicated that Akt interacts with glycoprotein B. Cell-surface expression of Akt was rapidly induced in response to HSV exposure. Miltefosine (50 μM), a licensed drug that blocks Akt phosphorylation, inhibited HSV-induced calcium release, viral entry, and plaque formation following infection with acyclovir-sensitive and resistant clinical isolates. Miltefosine blocked amplification of HSV from explanted ganglia to epithelial cells; viral yields were significantly less in miltefosine compared to control-treated cocultures (P<0.01). Together, these findings identify a novel role for Akt in viral entry, link Akt and calcium signaling, and suggest a new target for HSV treatment and suppression.

Priming with a recombinant pantothenate auxotroph of Mycobacterium bovis BCG and boosting with MVA elicits HIV-1 Gag specific CD8+ T cells

A safe and effective HIV vaccine is required to significantly reduce the number of people becoming infected with HIV each year. In this study wild type Mycobacterium bovis BCG Pasteur and an attenuated pantothenate auxotroph strain (BCGΔpanCD) that is safe in SCID mice, have been compared as vaccine vectors for HIV-1 subtype C Gag. Genetically stable vaccines BCG[pHS400] (BCG-Gag) and BCGΔpanCD[pHS400] (BCGpan-Gag) were generated using the Pasteur strain of BCG, and a panothenate auxotroph of Pasteur respectively. Stability was achieved by the use of a codon optimised gag gene and deletion of the hsp60-lysA promoter-gene cassette from the episomal vector pCB119. In this vector expression of gag is driven by the mtrA promoter and the Gag protein is fused to the Mycobacterium tuberculosis 19 kDa signal sequence. Both BCG-Gag and BCGpan-Gag primed the immune system of BALB/c mice for a boost with a recombinant modified vaccinia virus Ankara expressing Gag (MVA-Gag). After the boost high frequencies of predominantly Gag-specific CD8(+) T cells were detected when BCGpan-Gag was the prime in contrast to induction of predominantly Gag-specific CD4(+) T cells when priming with BCG-Gag. The differing Gag-specific T-cell phenotype elicited by the prime-boost regimens may be related to the reduced inflammation observed with the pantothenate auxotroph strain compared to the parent strain. These features make BCGpan-Gag a more desirable HIV vaccine candidate than BCG-Gag. Although no Gag-specific cells could be detected after vaccination of BALB/c mice with either recombinant BCG vaccine alone, BCGpan-Gag protected mice against a surrogate vaccinia virus challenge.

Perceptions of clients regarding family planning service delivery in a clinic of the Greater Johannesburg Metropolitan Council

Unwanted pregnancies with their negative impact on both women and children occur on an ongoing basis in Gauteng, South Africa. One way to prevent unwanted pregnancies is to use areliable contraceptive method available free of charge from primary health care clinics providing family planning services throughout Gauteng Province. A literature review was completed on women and access to family planning services and an interview schedule (questionnaire) was developed. The purpose of this study was to describe guidelines to meet the expectations of clients accessing family planning services provided by a clinic in Region F, Area 28 of the Greater Johannesburg metropolitan council. This quantitative, exploratory, descriptive and comparative study measured the gaps between the expectations of participants on service delivery and the extent to which these expectations were met. A convenience sample was conducted and consisted of 50 women of reproductive age (ages 15 to 49) attending the family planning clinic. Pre-testing of the instrument was conducted. Structured interviews with a interview schedule were conducted before and after women attended a family planning service. Inferential statistics indicated that there was a significant gap between the client expectations of family planning service delivery and the extent to which these expectations were met. Of the sixty-four items where women indicated the extent of their expectations the findings on only three items were not statistically significant. These gaps were addressed by proposing managerial guidelines to be implemented by the nurse manager in charge of the facility, on which this article will focus. Validity and reliability principles were ensured in the study. Ethical principles were adhered to during the research process.

Inhibition through PD-1 is crucial for protection against M. tuberculosis infection (58.1)

With over one-third of the world's population currently infected with M. tuberculosis, there is an increasing need to develop novel vaccines and immunotherapies. Better understanding of the early immune responses in the lung is crucial for this purpose. We have shown that Programmed Death-1 (PD-1), a co-inhibitory receptor that is known to negatively regulate adaptive immune responses, is crucial for the development of a protective host response against M. tuberculosis. PD-1 deficient mice are extremely sensitive to tuberculosis, show uncontrolled bacterial proliferation in the lung and develop severe necrotic pneumonia, with dramatically reduced survival. Cytokine responses in the lungs of PD-1-/- and wild-type mice were profoundly different, indicating a significantly altered inflammatory response in the absence of PD-1. PD-1 blockade in wild-type mice after M. tuberculosis infection resulted in decreased survival, suggesting that immunotherapeutic approaches targeting PD-1 blockade should be considered cautiously. By studying genetically modified mouse models that have altered PD-1 or PD-L expression, our data show differential contributions of PD-L1 and PD-L2 to the immune regulatory role of PD-1 observed in tuberculosis. By providing the mechanism on the immune regulatory role of PD-1 in tuberculosis, our data will allow for the identification of novel therapeutic targets, which can be of great value for future immunotherapy.

Acute kidney injury after use of oral Fleet Phospho Soda as bowel preparation for colonoscopy

We present a case of a 64-year old woman who developed acute kidney injury (AKI) finally resulting in stage 4 chronic kidney disease after ingestion of a high phosphate containing solution (oral Fleet Phospho Soda) as bowel cleansing for colonoscopy.

Hypereosinophilic syndrome with cardiac involvement in a pregnant patient with multiple sclerosis

In hypereosinophilic syndrome, the sustained overproduction of eosinophils leads to the dysfunction of one or more organs. Symptoms vary in accordance with which organ is affected. Cardiac involvement leads to substantial morbidity and to most of the deaths that are associated with hypereosinophilic syndrome.Herein, we present the case of a 31-year-old woman, pregnant for 12 weeks and with a history of multiple sclerosis, who presented with transient vision loss and splinter hemorrhages in her fingernail beds. The diagnosis was hypereosinophilic syndrome with cardiac involvement. Echocardiography revealed 2 echodense structures: one that obliterated the left ventricular apex, and another in the basal lateral wall. The patient underwent therapy with prednisone and heparin but developed heparin-induced thrombocytopenia. This condition resolved when argatroban was substituted for heparin. Two weeks after the patient's release from the hospital, echocardiography revealed improvement in the echodense ventricular structures. The transient vision loss and the splinter hemorrhages were attributed to the hypereosinophilic syndrome.We believe that this is the 1st report of a pregnant patient with hypereosinophilic syndrome and cardiac involvement.

The role of Programmed Death-1 (PD-1) in pulmonary M. tuberculosis infection: friend or foe? (40.10)

The programmed death-1 (PD-1) co-inhibitory receptor attenuates T and B cell responses and plays a crucial role in peripheral tolerance. Recently, PD-1 has been shown to inhibit T cell responses during chronic viral infections such as LCMV and HIV, and blockade of PD-1 restored anti-viral effector T cell responses. In this study, we examined the role of PD-1 in infection with Mycobacterium tuberculosis, a common co-infection with HIV. Surprisingly and paradoxically, PD-1 deficient mice showed dramatically reduced survival compared to wild-type mice. Moreover, lungs of the PD-1-/- mice showed uncontrolled bacterial proliferation, and focal necrotic areas with predominantly neutrophilic infiltrates, but a lower number of infiltrating T and B cells. Pro-inflammatory cytokines, such as TNF-α, IL-1, and especially IL-6 were significantly increased in the lung and sera of infected PD-1-/- mice, consistent with an excessive inflammation. Microarray analysis of the lungs infected with M. tuberculosis showed dramatic differences between PD-1-/- and control mice: 297 genes were differentially expressed, resulting in profoundly altered inflammatory responses, with implications in both innate and adaptive immunity. Our studies demonstrate that M. tuberculosis infection in the absence of PD-1 results in fatal inflammation with increased bacterial load; therefore we suggest that the PD-1 pathway is involved in controlling inflammatory responses after M. tuberculosis infection in the lungs.

Renal failure and abdominal pain as the presenting symptoms of a rare tumor of the aorta masquerading as a calcified plaque

Vascular obstructive causes must be considered in chronic renal failure with no obvious cause. We present the case of a 74-year-old woman with smoldering renal failure who undergoes a renal biopsy that did not undercover a cause. As her symptoms persisted and renal function worsened, her nephrologist proposed magnetic resonance angiography with gadolinium and prophylactic initiation of hemodialysis. Imaging uncovered an occlusive aortic mass, which was removed surgically with improvement in renal function. The case discusses the nature of the mass and the need to weigh the risks and benefits of MR imaging with gadolinium and initiation of hemodialysis against the risk of nephrogenic systemic fibrosis.

[Two patients with a rare manifestation of amyloidosis in the respiratory system]

Amyloidosis of the respiratory tract was diagnosed in 2 patients. The patients were men, 62 and 55 years ofage. The first patient presented with dyspnoea and diffuse parenchymal lung abnormalities. There was a rapidly progressive obstructive lung function disorder and a severe diffusion impairment. The second patient had haemoptysis due to tracheobronchial amyloidosis. Amyloidosis of the respiratory system is rarely diagnosed. Nearly all cases ofclinically relevant respiratory amyloidosis are due to light chain amyloid (AL amyloidosis). The described diffuse lung parenchymal abnormalities are a manifestation of systemic AL amyloidosis. On the other hand, tracheobronchial amyloidosis is a disorder which usually remains localised in the airways. Systemic AL amyloidosis may be treated with chemotherapy or stem cell transplantation. It is unknown whether this treatment leads to a decrease of pulmonary function abnormalities. Tracheobronchial amyloidosis can be treated by endobronchial therapy. Often this treatment is required repeatedly. The first patient died 2 months after diagnosis due to pneumonia. The second patient was treated with endobronchial argon plasma coagulation and diathermy and has been symptom-free for 3 years since.

Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: an echocardiographic study

STUDY DESIGN

Prospective randomized study of patients undergoing spine surgery.

OBJECTIVE

To compare changes in hemodynamic and cardiac function after prone positioning using different prone positioners.

SUMMARY OF BACKGROUND DATA

Prone positioning decreases blood pressure and cardiac function. Several studies have evaluated changes in cardiac function after prone positioning, and linked them to reduced venous return and ventricular compliance. This study compares different prone positioners using transesophageal echocardiography, and determines their effect on cardiac function and hemodynamics.

METHODS

After correction of fluid deficits with the patient under stable anesthesia, hemodynamic and cardiac performance was measured using transesophageal echocardiography. After prone positioning, repeat measurements were performed, and comparisons were made between prone and supine positions.

RESULTS

No intergroup differences in demographics, fluid deficit, baseline hemodynamics, or differences from supine to prone position were noted. Cardiac output decreased with the Wilson (Union City, CA) and Siemens AG (Munich, Germany) frames, while cardiac index and stroke volume decreased with the Andrews (Hollywood, CA), Wilson, and Siemens systems. Cardiac preload decreased using the Andrews frame. The Jackson spine table (Hollywood, CA) and bolsters had the least effect on cardiac performance.

CONCLUSION

Adequate fluid replacement reduced hypotension and hemodynamic instability after prone positioning. The Jackson spine table and longitudinal bolsters had minimal effects on cardiac function, and should be considered in patients with limited cardiac reserve.

The TB structural genomics consortium: a resource for Mycobacterium tuberculosis biology

The TB Structural Genomics Consortium is an organization devoted to encouraging, coordinating, and facilitating the determination and analysis of structures of proteins from Mycobacterium tuberculosis. The Consortium members hope to work together with other M. tuberculosis researchers to identify M. tuberculosis proteins for which structural information could provide important biological information, to analyze and interpret structures of M. tuberculosis proteins, and to work collaboratively to test ideas about M. tuberculosis protein function that are suggested by structure or related to structural information. This review describes the TB Structural Genomics Consortium and some of the proteins for which the Consortium is in the progress of determining three-dimensional structures.

Mobile bearing vs fixed bearing prostheses for total knee arthroplasty for post-operative functional status in patients with osteoarthritis and rheumatoid arthritis

BACKGROUND

The polyethylene insert in a total knee replacement (TKR) can be fixed to the tibial plateau or it can have freedom of rotation and / or translation. It is not yet clear whether there are differences in functional or clinical results between the two prosthesis types.

OBJECTIVES

The goal of this review is to assess if a mobile bearing total knee prosthesis provides a better range of motion (ROM) and a better functional outcome than a fixed bearing prosthesis in patients with rheumatoid arthritis or osteoarthritis after total knee arthroplasty.

SEARCH STRATEGY

We searched the Cochrane Library (issue 2002-3), Current contents (1996 to September 2002), and MEDLINE (1966 to September 2002). Reference lists of selected articles were also included.

SELECTION CRITERIA

Randomised controlled trials or controlled clinical trials were selected which used a functional or clinical outcome measure comparing mobile (rotating and/or sliding) with fixed bearing types.

DATA COLLECTION AND ANALYSIS

Data was collected on relevant demographic data and functional outcome measures like Range of Motion, specific measures of activities with daily tasks, and composite knee scores such as Knee Society Score, Hospital for Special Surgery score and similar scores. Only controlled studies comparing a fixed bearing with a mobile bearing type of TKP were considered.

MAIN RESULTS

Two randomised studies were encountered evaluating the difference in functional or clinical outcome of the two prosthesis types. The methodological quality of the studies was low. The study with the best quality found no difference in ROM, but found a superiority of the mobile bearing on Knee Society Score and Oxford Knee Score and the pain sub scores of these clinical measures. The second study found no differences.

REVIEWERS' CONCLUSIONS

We could find no evidence of superiority for one of the two prosthesis types with regard to ROM or functional performance of the patients. The majority (96%) of patients in the 2 included studies had OA. Therefore, the results reflect primarily results in OA patients.

Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogastrostomy

BACKGROUND

Since 1968, there have been three published reports in the United States literature of 41, 118, and 145 consecutive patients undergoing pancreaticoduodenectomy without mortality. In all of these series, the pancreatic remnant was anastomosed to the jejunum.

STUDY DESIGN

This study was designed to review 152 consecutive patients who underwent pancreaticoduodenectomy in whom the pancreatic remnant was anastomosed to the stomach (pancreaticogastrostomy).

RESULTS

A total of 152 patients underwent pancreaticoduodenectomy with pancreaticogastrostomy between July 1992 and May 2002. There were 85 men and 67 women with a mean age of 65.7 years (range 31 to 90 years). Of the patients, 87 were less than 69 years of age and 65 were more than 69 years. A total of 114 patients had a malignant neoplasm and the remaining 38 had either cystic neoplasms or benign disease. When the two groups were compared, the patients who were more than 69 years of age had a significantly high incidence of hypertension, previous cancer, atrial fibrillation, and coronary artery disease. In addition, patients more than 69 years of age had a significantly high incidence of jaundice and placement of preoperative stents. Patients more than 69 years of age had significantly less operative time but there was no between-group difference in estimated blood loss, transfusion, number of units transfused, and postoperative length of stay. There was no postoperative mortality [corrected] in this series. Pancreatic leak and fistulae were the most common complications, followed by intraabdominal abscess, wound infection, and delayed gastric emptying.

CONCLUSIONS

In this study, 152 consecutive patients underwent pancreaticoduodenectomy with pancreaticogastrostomy without postoperative mortality. Morbidity was mostly because of pancreatic leaks and fistulae, which were successfully treated nonoperatively. With proper selection, careful preoperative preparation, and proper intraoperative conduct of operation, the Whipple procedure can be performed without postoperative mortality.

Teardrop-femoral head distance after shelf acetabuloplasty for Perthes' disease

Shelf acetabuloplasty is an accepted treatment for Perthes' disease. Favourable outcomes have been reported. This study aimed at determining whether changes in femoral head subluxation after shelf acetabuloplasty occur and whether they predict outcome. We assumed that reduction of subluxation after shelf acetabuloplasty would improve the long-term outcome. During follow-up, growth presented as a source of error when comparing the amount of absolute subluxation. Correction for growth was achieved by calculating a subluxation index. This index showed a significant reduction during follow-up. There was no correlation between clinical and radiological outcome, but the fact that the subluxation index showed a decreasing trend could be promising regarding outcome. This might be one of the reasons why shelf acetabuloplasty produces its effect. Following shelf acetabuloplasty the enlarged acetabulum could possibly direct the growth of the femoral head to a better-contained joint. This could result in better joint congruity and lesser tendency to degenerative arthritis.

Ejection fraction: subjective visual echocardiographic estimation versus radionuclide angiography

OBJECTIVES

The aim of this study was to validate the correlation of left ventricular ejection fraction (LVEF) between two-dimensional (2D) echocardiography with harmonic imaging modality and radionuclide angiography (RNA) in a large number of patients.

BACKGROUND

Subjective visual estimation of LVEF is the most prevalent method in evaluating left ventricular systolic function. Previous published reports demonstrated that visual estimation from 2D was superior to other mathematical calculations, however the studies contained less than 50 patients.

METHODS

Retrospective review of 377 consecutive medical records containing LVEF from both 2D echocardiography and RNA obtained from the same patient within 15 days from January 1998 to September 1999.

RESULTS

Correlation coefficient value (r) between 2D echocardiography subjective visual estimation and RNA was 0.84. The r value was further increased to 0.87 when heart transplant recipients excluded. The agreement of LVEF between 2D echocardiography and RNA are higher in normal or severely depressed LV.

CONCLUSION

Excellent correlation of LVEF exists between 2D echocardiography subjective visual estimation and RNA, especially in normal or severely depressed LV.

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.

The TB structural genomics consortium: providing a structural foundation for drug discovery

Structural genomics, the large-scale determination of protein structures, promises to provide a broad structural foundation for drug discovery. The tuberculosis (TB) Structural Genomics Consortium is devoted to encouraging, coordinating, and facilitating the determination of structures of proteins from Mycobacterium tuberculosis and hopes to determine 400 TB protein structures over 5 years. The Consortium has determined structures of 28 proteins from TB to date. These protein structures are already providing a basis for drug discovery efforts.