Cardiac Amyloid Detection by PET/CT Imaging of Iodine (124I) Evuzamitide (124I-p5+14): A Phase 1/2 Study

BACKGROUND

The noninvasive detection of cardiac amyloid, as well as deposits in other vital organs, is critical for early diagnosis and quantitative disease monitoring. Positron emission tomography is an intrinsically quantitative imaging modality suitable for high-resolution amyloid detection.

OBJECTIVES

This study sought to evaluate the safety and efficacy of a novel amyloid-reactive peptide, designated p5+14, labeled with iodine-124 (124I), in patients with diverse types of systemic amyloidosis.

METHODS

In a single-site, open label phase 1/2 study (NCT03678259), the safety, biodistribution, and sensitivity of a single intravenous infusion of 124I-evuzamitide was assessed in patients with systemic amyloidosis (n = 50), asymptomatic transthyretin sequence variant carriers (n = 2), and healthy volunteers (n = 5). Subjects were administered 1.4 ± 0.2 mg of 124I-evuzamitide (71.5 ± 12.4 MBq) and positron emission tomography/x-ray computed tomography images acquired at 5.2 hours (Q25-Q75: 4.9-5.4 hours) postinfusion. Images were assessed visually and semi-quantitatively for positive uptake of radiotracer in the heart and other major organs.

RESULTS

Uptake of 124I-evuzamitide in the heart and other abdominothoracic organs was consistent with the patient's clinical presentation and the type of amyloidosis. The patient- and cardiac-associated sensitivity for imaging and clinical observations was 93.6% (95% CI: 82.8%-97.8%) and 96.2% (95% CI: 81.8%-99.8%), respectively. Semi-quantitative uptake of the radiotracer correlated significantly with serum N-terminal pro-B-type natriuretic peptide measurements in patients with light chain-associated amyloidosis. Cardiac uptake was not observed in any healthy volunteers. The agent was well tolerated, with 1 drug-related adverse event and no deaths.

CONCLUSIONS

124I-evuzamitide is an amyloid-binding radiotracer capable of detecting cardiac amyloid in patients with high sensitivity.

Development and characterization of a prototypic pan-amyloid clearing agent - a novel murine peptide-immunoglobulin fusion

Introduction

Systemic amyloidosis is a progressive disorder characterized by the extracellular deposition of amyloid fibrils and accessory proteins in visceral organs and tissues. Amyloid accumulation causes organ dysfunction and is not generally cleared by the immune system. Current treatment focuses on reducing amyloid precursor protein synthesis and slowing amyloid deposition. However, curative interventions will likely also require removal of preexisting amyloid deposits to restore organ function. Here we describe a prototypic pan-amyloid binding peptide-antibody fusion molecule (mIgp5) that enhances macrophage uptake of amyloid.

Methods

The murine IgG1-IgG2a hybrid immunoglobulin with a pan amyloid-reactive peptide, p5, fused genetically to the N-terminal of the immunoglobulin light chain was synthesized in HEK293T/17 cells. The binding of the p5 peptide moiety was assayed using synthetic amyloid-like fibrils, human amyloid extracts and amyloid-laden tissues as substrates. Binding of radioiodinated mIgp5 with amyloid deposits in vivo was evaluated in a murine model of AA amyloidosis using small animal imaging and microautoradiography. The bioactivity of mIgp5 was assessed in complement fixation and in vitro phagocytosis assays in the presence of patient-derived amyloid extracts and synthetic amyloid fibrils as substrates and in the presence or absence of human serum.

Results

Murine Igp5 exhibited highly potent binding to AL and ATTR amyloid extracts and diverse types of amyloid in formalin-fixed tissue sections. In the murine model of systemic AA amyloidosis, 125I-mIgp5 bound rapidly and specifically to amyloid deposits in all organs, including the heart, with no evidence of non-specific uptake in healthy tissues. The bioactivity of the immunoglobulin Fc domain was uncompromised in the context of mIgp5 and served as an effective opsonin. Macrophage-mediated uptake of amyloid extract and purified amyloid fibrils was enhanced by the addition of mIgp5. This effect was exaggerated in the presence of human serum coincident with deposition of complement C5b9.

Conclusion

Immunostimulatory, amyloid-clearing therapeutics can be developed by incorporating pan-amyloid-reactive peptides, such as p5, as a targeting moiety. The immunologic functionality of the IgG remains intact in the context of the fusion protein. These data highlight the potential use of peptide-antibody fusions as therapeutics for all types of systemic amyloidosis.

Collagen inhibits phagocytosis of amyloid in vitro and in vivo and may act as a 'don't eat me' signal

BACKGROUND

Systemic amyloidosis refers to a group of protein misfolding disorders characterized by the extracellular deposition of amyloid fibrils in organs and tissues. For reasons heretofore unknown, amyloid deposits are not recognized by the immune system, and progressive deposition leads to organ dysfunction.

METHODS

In vitro and in vivo phagocytosis assays were performed to elucidate the impact of collagen and other amyloid associated proteins (eg serum amyloid p component and apolipoprotein E) had on amyloid phagocytosis. Immunohistochemical and histopathological staining regimens were employed to analyze collagen-amyloid interactions and immune responses.

RESULTS

Histological analysis of amyloid-laden tissue indicated that collagen is intimately associated with amyloid deposits. We report that collagen inhibits phagocytosis of amyloid fibrils by macrophages. Treatment of 15 patient-derived amyloid extracts with collagenase significantly enhanced amyloid phagocytosis. Preclinical mouse studies indicated that collagenase treatment of amyloid extracts significantly enhanced clearance as compared to controls, coincident with increased immune cell infiltration of the subcutaneous amyloid lesion.

CONCLUSIONS

These data suggest that amyloid-associated collagen serves as a 'don't eat me' signal, thereby hindering clearance of amyloid. Targeted degradation of amyloid-associated collagen could result in innate immune cell recognition and clearance of pathologic amyloid deposits.

First in Human Evaluation and Dosimetry Calculations for Peptide 124I-p5+14-a Novel Radiotracer for the Detection of Systemic Amyloidosis Using PET/CT Imaging

PURPOSE

Accurate diagnosis of amyloidosis remains a significant clinical challenge and unmet need for patients. The amyloid-reactive peptide p5+14 radiolabeled with iodine-124 has been developed for the detection of amyloid by PET/CT imaging. In a first-in-human evaluation, the dosimetry and tissue distribution of ¹²⁴I-p5+14 peptide in patients with systemic amyloidosis. Herein, we report the dosimetry and dynamic distribution in the first three enrolled patients with light chain-associated (AL) amyloidosis.

PROCEDURES

The radiotracer was assessed in a single-site, open-label phase 1 study (NCT03678259). The first three patients received a single intravenous infusion of ¹²⁴I-p5+14 peptide (≤37 MBq). Serial PET/CT imaging was performed during the 48 h post-infusion. Dosimetry was determined as a primary endpoint for each patient and gender-averaged mean values were calculated. Pharmacokinetic parameters were estimated from whole blood radioactivity measurements and organ-based time activity data. Lastly, the biodistribution of radiotracer in major organs was assessed visually and compared to clinically appreciated organ involvement.

RESULTS

Infusion of the ¹²⁴I-p5+14 was well tolerated with rapid uptake in the heart, kidneys, liver, spleen, pancreas, and lung. The gender-averaged whole-body effective radiation dose was estimated to be 0.23 (± 0.02) mSv/MBq with elimination of the radioactivity via renal and gastrointestinal routes. The whole blood elimination t_1/2 of 21.9 ± 7.6 h. Organ-based activity concentration measurements indicated that AUC_last tissue:blood ratios generally correlated with the anticipated presence of amyloid. Peptide uptake was observed in 4/5 clinically suspected organs, as noted in the medical record, as well as six anatomic sites generally associated with amyloidosis in this population.

CONCLUSION

Peptide ¹²⁴I-p5+14 rapidly distributes to anatomic sites consistent with the presence of amyloid in patients with systemic AL. The dosimetry estimates established in this cohort are acceptable for whole-body PET/CT imaging. Pharmacokinetic parameters are heterogeneous and consistent with uptake of the tracer in an amyloid compartment. PET/CT imaging of ¹²⁴I-p5+14 may facilitate non-invasive detection of amyloid in multiple organ systems.

Macrophage-Mediated Phagocytosis and Dissolution of Amyloid-Like Fibrils in Mice, Monitored by Optical Imaging

Light chain-associated amyloidosis is characterized by the extracellular deposition of amyloid fibrils in abdominothoracic organs, skin, soft tissue, and peripheral nerves. Phagocytic cells of the innate immune system appear to be ineffective at clearing the material; however, human light chain amyloid extract, injected subcutaneously into mice, is rapidly cleared in a process that requires neutrophil activity. To better elucidate the phagocytosis of light chain fibrils, a potential method of cell-mediated dissolution, amyloid-like fibrils were labeled with the pH-sensitive dye pHrodo red and a near infrared fluorophore. After injecting this material subcutaneously in mice, optical imaging was used to quantitatively monitor phagocytosis and dissolution of fibrils concurrently. Histologic evaluation of the residual fibril masses revealed the presence of CD68⁺, F4/80⁺, ionized calcium binding adaptor molecule 1^- macrophages containing Congo red-stained fibrils as well as neutrophil-associated proteins with no evidence of intact neutrophils. These data suggest an early infiltration of neutrophils, followed by extensive phagocytosis of the light chain fibrils by macrophages, leading to dissolution of the mass. Optical imaging of this novel murine model, coupled with histologic evaluation, can be used to study the cellular mechanisms underlying dissolution of synthetic amyloid-like fibrils and human amyloid extracts. In addition, it may serve as a test bed to evaluate investigational opsonizing agents that might serve as therapeutic agents for light chain-associated amyloidosis.

A functional assay to identify amyloidogenic light chains

INTRODUCTION

Multiple myeloma (MM) and light chain monoclonal gammopathy of undetermined significance (LCMGUS) are plasma cell disorders associated with the secretion of monoclonal free light-chain (LC) proteins. Due to the high concentrations of LC in circulation, both of these populations are at risk for developing LC-associated amyloidosis (AL) - a protein misfolding disease characterized by the deposition of LC protein fibrils in organs and tissues, leading to dysfunction and significant morbidity. At present, accurate identification of subjects at risk for developing amyloidosis is not possible, but with the advent of novel, amyloid-targeted therapies, identification of pre-symptomatic individuals is of clinical import.

METHODS

To address this, a competition assay has been developed to discern LC proteins with enhanced amyloidogenic potential. Numerous factors that may influence the efficacy of the assay have been evaluated to yield optimal conditions.

RESULTS

Using a panel of nine patient-derived LC, we have demonstrated that amyloid-associated LC inhibited the recruitment of a biotinyl-λ6 variable domain by homologous amyloid-like fibrils significantly more than MM LC (p < .01).

CONCLUSION

The assay accurately discriminated AL from MM patient populations, suggesting that it may aid in the identification of patients with monoclonal gammopathies who have an increased risk of developing amyloidosis.

Strain and Bond Length Dynamics upon Growth and Transfer of Graphene by NEXAFS Spectroscopy from First-Principles and Experiment

As the quest toward novel materials proceeds, improved characterization technologies are needed. In particular, the atomic thickness in graphene and other 2D materials renders some conventional technologies obsolete. Characterization technologies at wafer level are needed with enough sensitivity to detect strain in order to inform fabrication. In this work, NEXAFS spectroscopy was combined with simulations to predict lattice parameters of graphene grown on copper and further transferred to a variety of substrates. The strains associated with the predicted lattice parameters are in agreement with experimental findings. The approach presented here holds promise to effectively measure strain in graphene and other 2D systems at wafer levels to inform manufacturing environments.

A Peptide-Fc Opsonin with Pan-Amyloid Reactivity

There is a continuing need for therapeutic interventions for patients with the protein misfolding disorders that result in systemic amyloidosis. Recently, specific antibodies have been employed to treat AL amyloidosis by opsonizing tissue amyloid deposits thereby inducing cell-mediated dissolution and organ improvement. To develop a pan-amyloid therapeutic agent, we have produced an Fc-fusion product incorporating a peptide, p5, which binds many if not all forms of amyloid. This protein, designated Fcp5, expressed in mammalian cells, forms the desired bivalent dimer structure and retains pan-amyloid reactivity similar to the p5 peptide as measured by immunosorbent assays, immunohistochemistry, surface plasmon resonance, and pulldown assays using radioiodinated Fcp5. Additionally, Fcp5 was capable of opsonizing amyloid fibrils in vitro using a pH-sensitive fluorescence assay of phagocytosis. In mice,¹²⁵ I-labeled Fcp5 exhibited an extended serum circulation time, relative to the p5 peptide. It specifically bound AA amyloid deposits in diseased mice, as evidenced by biodistribution and microautoradiographic methods, which coincided with an increase in active, Iba-1-positive macrophages in the liver at 48 h postinjection of Fcp5. In healthy mice, no specific tissue accumulation was observed. The data indicate that polybasic, pan-amyloid-targeting peptides, in the context of an Fc fusion, can yield amyloid reactive, opsonizing reagents that may serve as next-generation immunotherapeutics.

Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) have the highest co-morbidity rates within the internalizing disorders cluster, yet no Internet-based cognitive behavioural therapy (iCBT) programme exists for their combined treatment.

METHOD

We designed a six-lesson therapist-assisted iCBT programme for mixed anxiety and depression. Study 1 was a randomized controlled trial (RCT) comparing the iCBT programme (n = 46) versus wait-list control (WLC; n = 53) for patients diagnosed by structured clinical interview with MDD, GAD or co-morbid GAD/MDD. Primary outcome measures were the Patient Health Questionnaire nine-item scale (depression), Generalized Anxiety Disorder seven-item scale (generalized anxiety), Kessler 10-item Psychological Distress scale (distress) and 12-item World Health Organization Disability Assessment Schedule II (disability). The iCBT group was followed up at 3 months post-treatment. In study 2, we investigated the adherence to, and efficacy of the same programme in a primary care setting, where patients (n = 136) completed the programme under the supervision of primary care clinicians.

RESULTS

The RCT showed that the iCBT programme was more effective than WLC, with large within- and between-groups effect sizes found (>0.8). Adherence was also high (89%), and gains were maintained at 3-month follow-up. In study 2 in primary care, adherence to the iCBT programme was low (41%), yet effect sizes were large (>0.8). Of the non-completers, 30% experienced benefit.

CONCLUSIONS

Together, the results show that iCBT is effective and adherence is high in research settings, but there is a problem of adherence when translated into the 'real world'. Future efforts need to be placed on developing improved adherence to iCBT in primary care settings.

Human anti-Aβ IgGs target conformational epitopes on synthetic dimer assemblies and the AD brain-derived peptide

Soluble non-fibrillar assemblies of amyloid-beta (Aβ) and aggregated tau protein are the proximate synaptotoxic species associated with Alzheimer's disease (AD). Anti-Aβ immunotherapy is a promising and advanced therapeutic strategy, but the precise Aβ species to target is not yet known. Previously, we and others have shown that natural human IgGs (NAbs) target diverse Aβ conformers and have therapeutic potential. We now demonstrate that these antibodies bound with nM avidity to conformational epitopes on plate-immobilized synthetic Aβ dimer assemblies, including synaptotoxic protofibrils, and targeted these conformers in solution. Importantly, NAbs also recognized Aβ extracted from the water-soluble phase of human AD brain, including species that migrated on denaturing PAGE as SDS-stable dimers. The critical reliance on Aβ's conformational state for NAb binding, and not a linear sequence epitope, was confirmed by the antibody's nM reactivity with plate-immobilized protofibrills, and weak uM binding to synthetic Aβ monomers and peptide fragments. The antibody's lack of reactivity against a linear sequence epitope was confirmed by our ability to isolate anti-Aβ NAbs from intravenous immunoglobulin using affinity matrices, immunoglobulin light chain fibrils and Cibacron blue, which had no sequence similarity with the peptide. These findings suggest that further investigations on the molecular basis and the therapeutic/diagnostic potential of anti-Aβ NAbs are warranted.

Anti-amyloidogenic activity of IgGs contained in normal plasma

INTRODUCTION

We have previously shown that a subpopulation of naturally occurring human IgGs has therapeutic potential for the amyloid-associated disorders. These molecules cross-react with conformational epitopes on amyloidogenic assemblies, including amyloid beta (Abeta) protein fibrils that are a pathological hallmark of Alzheimer's disease.

MATERIALS AND METHODS

Using our europium-linked immunosorbant assay, we established that approximately 95% of 260 screened donor plasma samples had amyloid fibril-reactive IgGs and Abeta conformer-reactive IgGs with minimal binding to Abeta monomers. Anti-amyloidogenic reactivity was diverse and attributed to Abeta targeting multiple fibril-related binding sites and/or variations in multidentate binding.

RESULTS AND DISCUSSION

There was no correlation between anti-fibril and anti-oligomer reactivity and donor age (19 to 60 years old) or gender. These findings demonstrate the inherent but diverse anti-amyloidogenic activity of natural IgGs contained in normal plasma.

CONCLUSION

Our studies provide support for investigating the clinical significance and physiological function of this novel class of antibodies.

Phagocytosis and bactericidal activity of leukocytes in hemorrhagic shock

Polymorphonuclear leukocytes from dogs in hemorrhagic shock did not demonstrate impairment in phagocytosis or killing of Staphylococcus aureus or Escherichia coli in vitro.

Abeta(1-40) forms five distinct amyloid structures whose beta-sheet contents and fibril stabilities are correlated

The ability of a single polypeptide sequence to grow into multiple stable amyloid fibrils sets these aggregates apart from most native globular proteins. The existence of multiple amyloid forms is the basis for strain effects in yeast prion biology, and might contribute to variations in Alzheimer's disease pathology. However, the structural basis for amyloid polymorphism is poorly understood. We report here five structurally distinct fibrillar aggregates of the Alzheimer's plaque peptide Abeta(1-40), as well as a non-fibrillar aggregate induced by Zn(2+). Each of these conformational forms exhibits a unique profile of physical properties, and all the fibrillar forms breed true in elongation reactions under a common set of growth conditions. Consistent with their defining cross-beta structure, we find that in this series the amyloid fibrils containing more extensive beta-sheet exhibit greater stability. At the same time, side chain packing outside of the beta-sheet regions contributes to stability, and to differences of stability between polymorphic forms. Stability comparison is facilitated by the unique feature that the free energy of the monomer (equivalent to the unfolded state in a protein folding reaction) does not vary, and hence can be ignored, in the comparison of DeltaG degrees of elongation values for each polymorphic fibril obtained under a single set of conditions.

Plasticity of amyloid fibrils

In experiments designed to characterize the basis of amyloid fibril stability through mutational analysis of the Abeta (1-40) molecule, fibrils exhibit consistent, significant structural malleability. In these results, and in other properties, amyloid fibrils appear to more resemble plastic materials generated from synthetic polymers than globular proteins. Thus, like synthetic polymers and plastics, amyloid fibrils exhibit both polymorphism, the ability of one polypeptide to form aggregates of different morphologies, and isomorphism, the ability of different polypeptides to grow into a fibrillar amyloid morphology. This view links amyloid with the prehistorical and 20th century use of proteins as starting materials to make films, fibers, and plastics, and with the classic protein fiber stretching experiments of the Astbury group. Viewing amyloids from the point of view of the polymer chemist may shed new light on a number of issues, such as the role of protofibrils in the mechanism of amyloid formation, the biological potency of fibrils, and the prospects for discovering inhibitors of amyloid fibril formation.

Distinct thymidine kinases encoded by cowpox virus and herpes simplex virus contribute significantly to the differential antiviral activity of nucleoside analogs

Orthopoxviruses and herpesviruses are both large enveloped DNA viruses, yet these virus families exhibit very different susceptibilities to antiviral drugs. We investigated the activation of nucleoside analogs by the types I and II thymidine kinase (TK) homologs expressed by herpes simplex virus type 1 (HSV-1) and cowpox virus (CV). Antiviral activity against TK(-) and TK(+) strains of HSV-1 and CV was determined, and the ratio of the EC(50) values was used as a measurement of TK dependence. As to HSV-1, most of the selected compounds were markedly less effective against the TK(-) strains, suggesting that this enzyme was required for the activation of these nucleoside analogs. This differs from the results for CV where only idoxuridine and bromodeoxyuridine appeared to be activated, putatively by the type II TK expressed by this virus. These data confirm that the type II TK encoded by CV exhibits a more limited substrate specificity than the type I TK encoded by HSV-1. These data suggest that the inefficient activation of nucleoside analogs by the orthopoxvirus TK significantly limits their activity. Additional screening against orthopoxviruses will be required to identify nucleoside analogs that are efficiently activated by their type II TK.

Alanine scanning mutagenesis of Abeta(1-40) amyloid fibril stability

We describe here an alanine scanning mutational analysis of the Abeta(1-40) amyloid fibril monitored by fibril elongation thermodynamics derived from critical concentration values for fibril growth. Alanine replacement of most residues in the amyloid core region, residues 15-36, leads to destabilization of the elongation step, compared to wild-type, by about 1kcal/mol, consistent with a major role for hydrophobic packing in Abeta(1-40) fibril assembly. Where comparisons are possible, the destabilizing effects of Ala replacements are generally in very good agreement with the effects of Ala replacements of the same amino acid residues in an element of parallel beta-sheet in the small, globular protein Gbeta1. We utilize these Ala-WT DeltaDeltaG values to filter previously described Pro-WT DeltaDeltaG values, creating Pro-Ala DeltaDeltaG values that specifically assess the sensitivity of a sequence position, in the structural context of the Abeta fibril, to replacement by proline. The results provide a conservative view of the energetics of Abeta(1-40) fibril structure, indicating that positions 18-21, 25-26, and 32-33 within amyloid structure are particularly sensitive to the main-chain disrupting effects of Pro replacements. In contrast, residues 14-17, 22, 24, 27-31, and 34-39 are relatively insensitive to Pro replacements; most N-terminal residues were not tested. The results are discussed in terms of amyloid fibril structure and folding energetics, in particular focusing on how the data compare to those from other structural studies of Abeta(1-40) amyloid fibrils grown in phosphate-buffered saline at 37 degrees C under unstirred ("quiescent") conditions.

Kinetics and Thermodynamics of Amyloid Assembly Using a High‐Performance Liquid Chromatography–Based Sedimentation Assay

Nonnative protein aggregation has been classically treated as an amorphous process occurring by colloidal coagulation kinetics and proceeding to an essentially irreversible endpoint often ascribed to a chaotic tangle of unfolded chains. However, some nonnative aggregates, particularly amyloid fibrils, exhibit ordered structures that appear to assemble according to ordered mechanisms. Some of these fibrils, as illustrated here with the Alzheimer's plaque peptide amyloid beta, assemble to an endpoint that is a dynamic equilibrium between monomers and fibrils exhibiting a characteristic equilibrium constant with an associated free energy of formation. Some fibrils, as illustrated here with the polyglutamine repeat sequences associated with Huntington's disease, assemble via highly regular mechanisms exhibiting nucleated growth polymerization kinetics. Here, we describe a series of linked methods for quantitative analysis of such aggregation kinetics and thermodynamics, focusing on a robust high-performance liquid chromatography (HPLC)-based sedimentation assay. An integrated group of protocols is provided for peptide disaggregation, setting up the HPLC sedimentation assay, the preparation of fibril seed stocks and determination of the average functional molecular weight of the fibrils, elongation and nucleation kinetics analysis, and the determination of the critical concentration describing the thermodynamic endpoint of fibril elongation.

Oligoproline effects on polyglutamine conformation and aggregation

There are nine known expanded CAG repeat neurological diseases, including Huntington's disease (HD), each involving the repeat expansion of polyglutamine (polyGln) in a different protein. Similar conditions can be induced in animal models by expression of the polyGln sequence alone or in other protein contexts. Besides the polyGln sequence, the cellular context of the disease protein, and the sequence context of the polyGln within the disease protein, are both likely to contribute to polyGln physical behavior and to pathology. In HD, the N-terminal, exon-1 segment of the protein huntingtin contains the polyGln sequence immediately followed by an oligoproline region. We show here that introduction of a P10 sequence C-terminal to polyGln in synthetic peptides decreases both the rate of formation and the apparent stability of the amyloid-like aggregates associated with this family of diseases. The sequence can be trimmed to P6 without altering the suppression, but a P3 sequence is ineffective. Spacers up to at least three amino acid residues in length can be inserted between polyGln and P10 without altering this effect. There is no suppression, however, when the P10 sequence is either placed on the N-terminal side of polyGln or attached to polyGln via a side-chain tether. The nucleation mechanism of a Q40 sequence is unchanged upon addition of a P10 C-terminal extension, yielding a critical nucleus of one. The effects of oligoPro length and structural context on polyGln aggregation are correlated strongly with alterations in the circular dichroism spectra of the monomeric peptides. For example, the P10 sequence eliminates the small amount of alpha helical content otherwise exhibited by the Q40 sequence. The P10 sequence may suppress aggregation by stabilizing an aggregation-incompetent conformation of the monomer. The effect is transportable: a P10 sequence fixed to the C terminus of the sequence Abeta similarly modulates amyloid fibril formation.

Hydrogen-deuterium (H/D) exchange mapping of Abeta 1-40 amyloid fibril secondary structure using nuclear magnetic resonance spectroscopy

We describe here details of the hydrogen-deuterium (H/D) exchange behavior of the Alzheimer's peptide Abeta(1)(-)(40), while it is a resident in the amyloid fibril, as determined by high-resolution solution NMR. Kinetics of H/D exchange in Abeta(1)(-)(40) fibrils show that about half the backbone amide protons exchange during the first 25 h, while the other half remain unexchanged because of solvent inaccessibility and/or hydrogen-bonded structure. After such a treatment for 25 h with D(2)O, fibrils of (15)N-enriched Abeta were dissolved in a mixture of 95% dimethyl sulfoxide (DMSO) and 5% dichloroacetic acid (DCA) and successive heteronuclear (1)H-(15)N HSQC spectra were collected to identify the backbone amides that did not exchange in the fibril. These studies showed that the N and C termini of the peptide are accessible to the solvent in the fibril state and the backbone amides of these residues are readily exchanged with bulk deuterium. In contrast, the residues in the middle of the peptide (residues 16-36) are mostly protected, suggesting that that many of the residues in this segment of the peptide are involved in a beta structure in the fibril. Two residues, G25 and S26, exhibit readily exchangeable backbone amide protons and therefore may be located on a turn or a flexible part of the peptide. Overall, the data substantially supports current models for how the Abeta peptide folds when it engages in the amyloid fibril structure, while also addressing some discrepancies between models.

Structural properties of Abeta protofibrils stabilized by a small molecule

Metastable oligomeric and protofibrillar forms of amyloidogenic proteins have been implicated as on-pathway assembly intermediates in amyloid formation and as the major toxic species in a number of amyloid diseases including Alzheimer's disease. We describe here a chemical biology approach to structural analysis of Abeta protofibrils. Library screening yielded several molecules that stimulate Abeta aggregation. One of these compounds, calmidazolium chloride (CLC), rapidly and efficiently converts Abeta(1-40) monomers into clusters of protofibrils. As monitored by electron microscopy, these protofibrils persist for days when incubated in PBS at 37 degrees C, with a slow transition to fibrillar structures apparent only after several weeks. Like normal protofibrils, the CLC-Abeta aggregates exhibit a low thioflavin T response. Like Abeta fibrils, the clustered protofibrils bind the anti-amyloid Ab WO1. The CLC-Abeta aggregates exhibit the same protection from hydrogen-deuterium exchange as do protofibrils isolated from a spontaneous Abeta fibril formation reaction: approximately 12 of the 39 Abeta(1-40) backbone amide protons are protected from exchange in the protofibril, compared with approximately twice that number in amyloid fibrils. Scanning proline mutagenesis analysis shows that the Abeta molecule in these protofibrillar assemblies exhibits the same flexible N and C termini as do mature amyloid fibrils. The major difference in Abeta conformation between fibrils and protofibrils is added structural definition in the 22-29 segment in the fibril. Besides aiding structural analysis, compounds capable of facilitating oligomer and protofibril formation might have therapeutic potential, if they act to sequester Abeta in a form and/or location that cannot engage the toxic pathway.

Kinetic analysis of beta-amyloid fibril elongation

We used surface plasmon resonance biosensors to evaluate the kinetics associated with the initial events of beta-amyloid (Abeta) fibril elongation. Fibrils were immobilized on the sensor chip surface and extended by exposure to soluble Abeta(1-40) peptide. The fibril surfaces bound Congo red, a marker for beta sheet structures, and exhibited a slow linear background decay that is consistent with fibril depolymerization. Sonicated fibrils supported elongation better than unsonicated fibrils, which is consistent with fibril extension reactions. The kinetic data revealed that peptide association and dissociation occurred in multiple steps. Kinetic rate constants for fibril extension were determined by globally fitting the response data with a three-step polymerization model. In the first step, the soluble peptide binds to the growing fibril tip in a readily reversible reaction. The subsequent steps likely allow bound peptide to be stabilized into the growing fiber through postbinding transitional events. Using a mutant peptide, F19P Abeta(1-40), we illustrate how the biosensor assay can be used to probe structure/function relationships of fibril elongation.

Mapping abeta amyloid fibril secondary structure using scanning proline mutagenesis

Although the amyloid fibrils formed from the Alzheimer's disease amyloid peptide Abeta are rich in cross-beta sheet, the peptide likely also exhibits turn and unstructured regions when it becomes incorporated into amyloid. We generated a series of single-proline replacement mutants of Abeta(1-40) and determined the thermodynamic stabilities of amyloid fibrils formed from these mutants to characterize the susceptibility of different residue positions of the Abeta sequence to proline substitution. The results suggest that the Abeta peptide, when engaged in the amyloid fibril, folds into a conformation containing three highly structured segments, consisting of contiguous sequence elements 15-21, 24-28, and 31-36, that are sensitive to proline replacement and likely to include the beta-sheet portions of the fibrils. Residues relatively insensitive to proline replacement fall into two groups: (a) residues 1-14 and 37-40 are likely to exist in relatively unstructured, flexible elements extruded from the beta-sheet-rich amyloid core; (b) residues 22, 23, 29 and 30 are likely to occupy turn positions between these three structured elements. Although destabilized, fibrils formed from Abeta(1-40) proline mutants are very similar in structure to wild-type fibrils, as indicated by hydrogen-deuterium exchange and other analysis. Interestingly, however, some proline mutations destabilize fibrils while at the same time increasing the number of amide protons protected from hydrogen exchange. This suggests that the stability of amyloid fibrils, rather than being driven exclusively by the formation of H-bonded beta-sheet, is achieved, as in globular proteins, through a balance of stabilizing and destabilizing forces. The proline scanning data are most compatible with a model for amyloid protofilament structure loosely resembling the parallel beta-helix folding motif, such that each Abeta(15-36) core region occupies a single layer of a prismatic, H-bonded stack of peptides.

Seeding specificity in amyloid growth induced by heterologous fibrils

Over residues 15-36, which comprise the H-bonded core of the amyloid fibrils it forms, the Alzheimer's disease plaque peptide amyloid beta (Abeta) possesses a very similar sequence to that of another short, amyloidogenic peptide, islet amyloid polypeptide (IAPP). Using elongation rates to quantify seeding efficiency, we inquired into the relationship between primary sequence similarity and seeding efficiency between Abeta-(1-40) and amyloid fibrils produced from IAPP as well as other proteins. In both a solution phase and a microtiter plate elongation assay, IAPP fibrils are poor seeds for Abeta-(1-40) elongation, exhibiting weight-normalized efficiencies of only 1-2% compared with Abeta-(1-40) fibrils. Amyloid fibrils of peptides with sequences completely unrelated to Abeta also exhibit poor to negligible seeding ability for Abeta elongation. Fibrils from a number of point mutants of Abeta-(1-40) exhibit intermediate seeding abilities for wild-type Abeta elongation, with differing efficiencies depending on whether or not the mutation is in the amyloid core region. The results suggest that amyloid fibrils from different proteins exhibit structural differences that control seeding efficiencies. Preliminary results also suggest that identical sequences can grow into different conformations of amyloid fibrils as detected by seeding efficiencies. The results have a number of implications for amyloid structure and biology.

Evaluation of dysfunction following reconstruction of an anorectal anomaly

To evaluate the utility of anorectal manometry (ARM) and magnetic resonance imaging (MRI) with an endocoil in the assessment of dysfunction in children with repaired anorectal anomalies (ARA), 15 patients aged 1 to 15 years with repaired ARAs and chronic faecal incontinence or constipation were prospectively recruited. They underwent clinical assessment using a modified Wingfield score (MWS). ARM and MRI with an endocoil and conventional external coil were carried out. The results of ARM alone, MRI alone, and a combination of ARM and MRI were correlated with the MWS. Manometric internal anal sphincter (IAS) scores determined from sphincter length and activity correlated with MWS (r = 0.56, P = 0.02); manometric scores of rectal peristaltic activity did not. Overall manometric score (IAS and rectal scores combined) showed a correlation with MWS (r = 0.55, P = 0.02). Endoanal MRI sphincter scores did not correlate with MWS, but the presence of a megarectum on MRI did (r = 0.44, P = 0.05). Overall MRI score did not correlate with MWS. Minor neurosacral anomalies were shown on MRI in 3 children who had poor functional scores. Combined manometric and MRI scores showed a correlation with MWS (r = 0.58, P = 0.01). ARM and MRI are potentially useful in the assessment of dysfunction of children with repaired ARAs. Both modalities require refinement and further assessment in the context of directing management.

Psychometric concerns in neuropsychological testing

This article describes measurement and norming problems with commonly used neuropsychological tests. Test standards regarding differential diagnoses, validity and reliability, the need for manuals, standardized administration, screening, and research versions are discussed. Further development of reliability, validity, sensitivity and specificity is needed for many tests.

Detection of pelvic lymph node metastases in gynecologic malignancy: a comparison of CT, MR imaging, and positron emission tomography

OBJECTIVE

Accurate assessment of lymph node status before treatment is critical in the treatment of gynecologic cancers because the 5-year survival and treatment of women is influenced by lymph node involvement. The aims of this study were to investigate the ability of X-ray CT, MR imaging, and (18)F-FDG positron emission tomography (PET) to detect pelvic lymph node metastases by comparing imaging with histopathologic findings after lymph node dissection.

MATERIALS AND METHODS

Eighteen patients with gynecologic cancers were studied by all three imaging methods before surgery. The images were initially reviewed with routine diagnostic conditions and then, subsequently, by two observers who were unaware of the clinical and histopathologic findings of the patients. The nodal sites were split into upper (aortic to common iliac bifurcations) and lower (common iliac bifurcations to inguinal ligament) iliac chains. All observers' results were statistically analyzed with specificity, sensitivity, positive and negative predictive values, Fisher's exact test (individual observers) or chi-square test (combined observers), and Cohen's kappa test.

RESULTS

Eight of 18 patients had lymph node metastases at histology. Findings of all three modalities agreed in full in only one patient. CT correctly revealed 10 node-negative patients, whereas MR imaging was correct in eight of these patients. (18)F-FDG PET correctly depicted one patient with lymph nodes negative for tumor. CT was the most specific imaging modality (97.0%), with MR imaging and PET rendering values of 90.7% and 77.3%, respectively, but sensitivity of all modalities was low (CT, 48.1%; MR imaging, 53.7%; PET, 24.5%). Observer agreement for each modality was good; kappa values among all observers were 0.88 for CT, 0.85 for MR imaging, and 0.72 for PET.

CONCLUSION

CT is the most specific modality for detecting lymph nodes positive for tumor in gynecologic cancers, whereas MR imaging is the most sensitive. The poor results of PET in the pelvis are attributed to urinary (18)F-FDG in the ureters or bladder, which may mask or imitate lymph node metastases.

Catheter tracking for MR fluoroscopy: design of a transmit/receive coil for use with a nasogastric tube

A coil tuned to 21.3 MHz was incorporated into a nasogastric tube and used as a marker of tube position during magnetic resonance (MR) imaging in a 0.5-T scanner. Catheter tracking was investigated with the coil used in both transmit/receive and in receive-only modes. Data acquired from this coil were overlaid on images obtained using the body coil of the scanner. Visualization of the full length of the catheter with local high signal at the tip was achieved with a temporal resolution of approximately 1 second. J. Magn. Reson. Imaging 2001;13:127-130.

Magnetic resonance imaging of the primary site in stage I cervical carcinoma: A comparison of endovaginal coil with external phased array coil techniques at 0.5T

OBJECTIVE

To compare endovaginal with pelvic phased array coil magnetic resonance imaging (MRI) in detection of Stage I cervical carcinoma by correlating the findings with histopathology.

PATIENTS AND METHODS

Forty consecutive patients with Stage I cervical carcinoma confirmed histologically were studied using an endovaginal coil alone immediately followed by a pelvic phased array coil. T1-W transverse and T2-W FSE sagittal images made with each coil were analyzed independently by two radiologists noting the presence and size of a mass within the cervix and any parametrial extension or involvement of adjacent organs. Tumor volumes were measured using the electronic calliper to compute tumor area on each slice and multiplying by the slice thickness. Thirty patients underwent radical hysterectomy, one a trachylectomy, one simple hysterectomy and four extended cone biopsies. Four patients had radiotherapy to the primary tumor. Following surgery, histopathologic findings were recorded and tumor volumes measured.

RESULTS

Tumor volumes ranged from 0-106 cm(3)(median 1.4 cm(3), mean 9 +/- 19.4 cm(3)). Thirty-six patients had correlation of the primary site with the surgical specimen. Agreement between observers was excellent for both endovaginal (k = 0.90) and pelvic phased array (k = 0.96) techniques. Combined sensitivity and specificity for both observers of endovaginal MR imaging for detection of tumor was 96% and 70%, respectively; for pelvic phased array imaging sensitivity was substantially less at 54%. Specificity was higher at 83.7%, probably because small abnormalities were seldom visible. In patients treated surgically, early parametrial involvement in four women on endovaginal MRI was confirmed histologically in two. Pelvic phased array imaging showed early parametrial involvement in four women and was confirmed in one.

CONCLUSION

Endovaginal MRI adds substantially to information from pelvic phased array images in the preoperative assessment of patients with early cervical cancer. J. Magn. Reson. Imaging 2000;12:1020-1026.

Chronic myelogenous leukemia primitive hematopoietic progenitors demonstrate increased sensitivity to growth factor-induced proliferation and maturation

We investigated whether primary chronic myelogenous leukemia (CML) hematopoietic progenitors demonstrated altered proliferation and maturation in response to growth factor (GF) stimulation. The effect of GF stimulation on proliferation and expansion of committed and primitive progenitors (colony forming cells [CFC]) was evaluated. Culture of CML and normal CD34(+) cells with different GF for 7 days resulted in similar expansion of committed progenitors (CFC). In contrast, GF culture conditions that expanded normal primitive progenitors (week-6 long-term culture-initiating cells (LTC-IC)] led to depletion of CML LTC-IC numbers. GF culture also resulted in increased depletion of week-10 extended LTC-IC, which represent an even more primitive progenitor population, from CML compared with normal CD34(+) cells. CML CD34(+) cells enter into cycle more quickly than normal CD34(+) cells and CML CFC expansion was accelerated compared to normal CFC. Evaluation of primitive progenitor proliferation using PKH-26 and single-cell LTC-IC analysis demonstrated that the majority of CML LTC-IC remaining after GF culture originated from divided CD34(+) cells, whereas GF-cultured normal LTC-IC were derived mainly from undivided cells. Depletion of CML primitive progenitor numbers in association with increased proliferation suggests increased sensitivity to GF-induced maturation. These studies indicate that CML primitive progenitors have enhanced sensitivity to GF-induced cell division and maturation. Altered GF responsiveness may contribute to abnormal expansion of malignant myeloid cells in CML. These findings may also be applied toward the development of novel approaches to select benign stem cells in CML.

Design and use of internal receiver coils for magnetic resonance imaging

This review describes coils for MRI that are inserted into the body through natural orifices. It covers the design and implementation of small internal receiver coils for use in the pelvis and gastrointestinal tract. Normal anatomy delineated by the high resolution obtained by using these coils and the appearances in a number of disease states for each clinical application are described.

Pre-polarized saline: an in vivo feasibility study of a potential contrast agent

The potential for using pre-polarized liquids as contrast agents in vivo is investigated and the feasibility of the method demonstrated. In this study we show the enhancement obtained following intravenous delivery of pre-polarized saline into the antecubital vein of a volunteer. This form of contrast agent provides signal gain on time scales commensurate with its T(1) and allows repeated doses to be administered, thus making alternate acquisitions of data with and without enhancement practicable.

Transanal MR imaging after repair of anorectal anomalies in children: appearances in pull-through versus posterior sagittal reconstructions

OBJECTIVE

Our objective was to use transanal MR imaging to compare the anatomic appearance of the components of the anal sphincter and the pattern of scarring after a pull-through perineoplasty versus a posterior sagittal anorectoplasty.

SUBJECTS AND METHODS

Sixteen children ranging in age from 10 months to 15 years (mean, 10 years) were imaged using transanal receiver coils appropriate to the size of the child. Five had low, four intermediate, and seven high anomalies. Seven had undergone a transanal pull-through procedure, and nine had undergone posterior sagittal reconstruction. The integrity of the muscles was assessed on T1-weighted and short inversion time inversion recovery transverse and coronal images using a qualitative MR imaging score. The pattern of scarring was also assessed.

RESULTS

In the transanal pull-through group, four of seven patients showed external sphincter deficiency. A circumferential low-signal-intensity band was seen inferior to the sphincter in six patients. All posterior sagittal reconstructions had a long posterior midline scar. Five of nine patients showed external sphincter deficiency, whereas a further two had internal sphincter deficiency. No differences were seen in MR imaging scores for each operative procedure for all grades of severity of anorectal anomaly. However, a comparison between high and intermediate anomalies showed a small improvement in MR imaging score using the transanal pull-through procedure (Mann-Whitney U test = 3, p < .03). Manometric pressures obtained in 13 patients were poor.

CONCLUSION

Transanal MR imaging identifies focal defects and patterns of scarring of the anal sphincter complex in infants and children and provides valuable information about individual muscle components.

High-resolution magnetic resonance imaging of the anal sphincter using a dedicated endoanal receiver coil

The use of a surface coil in MR imaging improves signal-to-noise ratio of adjacent tissues of interest. We therefore devised an endoanal receiver coil for imaging the anal sphincter. The probe is solid and re-usable: it comprises a saddle geometry receiver with integral tuning, matching and decoupling. It is placed in the anal canal and immobilised externally. Both in vitro and in vivo normal anatomy is identified. The mucosa is high signal intensity, the submucosa low signal intensity, the internal sphincter uniformly high signal intensity and the external sphincter low signal intensity on T1- and T2-weighted images. In females, the transverse perineal muscle bridges the inferior part of the external sphincter anteriorly. In perianal sepsis, collections and the site of the endoanal opening are identified. In early-onset fecal incontinence following obstetric trauma/surgery, focal sphincter defects are demonstrated; in late-onset fecal incontinence external sphincter atrophy is seen. In fecally incontinent patients with scleroderma, forward deviation of the anterior sphincter musculature with descent of rectal air and feces into the anal canal is noted. The extent of sphincter invasion is assessed in low rectal tumours. In children with congenital anorectal anomalies, abnormalities of the muscle components are defined using smaller-diameter coils. Such information is invaluable in the assessment and surgical planning of patients with a variety of anorectal pathologies.

Effect of 3 weeks of detraining on the resting metabolic rate and body composition of trained males

OBJECTIVE

To examine the hypothesis that detraining decreases the resting metabolic rate (RMR) of long-term exercisers.

DESIGN

Eight pairs of subjects were matched for age, mass and training volume. They were then randomly allocated to either a control group (continue normal training) or detraining group (stop normal training but continue activities of daily living).

SETTING

Exercise Physiology Laboratory, The Flinders University of South Australia.

SUBJECTS

Sixteen male subjects (age 23.1 +/- 4.7 y (s.d.); mass 73.73 +/- 8.9 kg; VO2max 60.2 +/- 6.3 ml. kg-1.min-1; height 180.3 +/- 5.0 cm; body fat 14.6 +/- 5.4%) were selected from a pool of respondents to our advertisements.

INTERVENTIONS

Each pair of subjects was measured before and after a 3-week experimental period.

RESULTS

Two (groups) x 3 (2-, 3-and 4-compartment body composition models) ANOVAs were conducted on the difference between the pre- and post-treatment scores for percentage body fat, fat-free mass (FFM) and relative RMR (kJ.kg FFM-1.h-1). No significant between-group differences were identified except for the detraining group's small decrease in FFM (0.7 kg, P = 0.05). The main effects for body composition model were all significant; but the overall differences between the multicompartment models and the 2-compartment one were less than their technical errors of measurement. No significant interaction (P = 0.51) resulted from a 2 x 2 ANOVA on the pre- and post-treatment absolute RMR data for the control (315.2 and 311.9 kJ/h) and detraining groups (325.4 and 325.5 kJ/h).

CONCLUSIONS

3-weeks detraining is not associated with a decrease in RMR (kJ/h, kJ.kg FFM-1.h-1) in trained males; hence, our data do not support a potentiation of the RMR via exercise training. The greater sensitivity of the multicompartment models to detect changes in body composition was of marginal value.

Fecal incontinence in scleroderma: assessment of the anal sphincter with thin-section endoanal MR imaging

PURPOSE

To compare the magnetic resonance (MR) imaging appearance of the anal sphincter in patients with fecal incontinence and scleroderma with that in patients with fecal incontinence alone, scleroderma alone, or neither.

MATERIALS AND METHODS

The study population comprised 14 patients with fecal incontinence and scleroderma, four with scleroderma alone, 13 with incontinence alone, and six with neither. T1- and T2-weighted spin-echo, magnetization transfer contrast-weighted, and dynamic gadolinium-enhanced images were obtained and analyzed for the integrity, thickness, and length of sphincter components. Magnetization transfer contrast ratios and T2 were calculated to assess fibrosis of the internal sphincter. The percentage enhancement above baseline was calculated at 30-second intervals for the internal and the external sphincter.

RESULTS

Eleven patients with incontinence and scleroderma showed descent of rectal air and feces into the anterior anal canal, with forward deviation of the significantly (P < .05) atrophied internal sphincter, which showed a slower gadolinium-enhancement pattern compared with that in other groups. Patients with incontinence alone showed no evidence of internal sphincter deviation or altered vascularity but had a significant reduction (P < .05) in deep external sphincter bulk.

CONCLUSION

In patients with fecal incontinence and scleroderma, endoanal MR imaging helps delineate the anterior sphincter deformity and shows the slower gadolinium-enhancement pattern on dynamic studies of the internal sphincter.

Platinum coil-mediated implantation of growth factor-secreting endovascular tissue grafts: an in vivo study

PURPOSE

To demonstrate in vivo that platinum embolic coils can be used to deliver genetically modified, growth factor-secreting fibroblast grafts into the endovascular space with the long-term goal of improving fibrosis within coil-embolized cerebral aneurysms.

MATERIALS AND METHODS

Murine fibroblasts that contained multiple inserts of the DNA for human basic fibroblast growth factor were grown in culture onto 10-mm-long segments of Guglielmi detachable coils. Control (n = 4) and fibroblast-bearing (n = 4) coils were implanted into the common carotid artery in nude rats. The arterial segments that contained the coil were harvested after 14 or 35 days. Cellular content and collagen formation in the treated vessels were assessed histologically.

RESULTS

At both 14 and 35 days, samples with control coils showed primarily involuting blood elements with minimal fibroblast proliferation or collagen formation. At 14 days, samples with fibroblast-bearing coils showed extensive fibroblast proliferation. At 35 days, samples with fibroblast-bearing coils showed marked interval fibroblast proliferation and collagen formation.

CONCLUSION

Platinum coils can be used as a cell delivery device. Direct intravascular implantation of growth factor-secreting fibroblast grafts leads to improved intravascular scar formation, therefore theoretically reducing the potential for aneurysm regrowth or coil compaction.

Impulse response of a dental implant in bone by numerical analysis

The osseointegration process of titanium dental implants in bone has been simulated previously using natural frequency and impulse excitation. However, the impulse strength was arbitrarily chosen and may not have yielded the correct frequencies and displacements to be compared with those measured in a clinical situation. In this work the range of impulse excitation strengths applied to a dental implant osseointegrated in bone and the corresponding response have been examined using the finite element method. Both conditions of a dental pin only and a dental pin with attached cantilever integrated in the mandible have been examined. The dynamic analysis indicated that the frequency and displacement responses are indeed sensitive to impulse duration and direction but independent of impulse load. The analysis summarizes the proper impulse excitation values for a correct interpretation of clinically measured frequency response data.

Apparent life-threatening events in presumed healthy neonates during the first three days of life

OBJECTIVE

To study the historical, clinical and pneumographic correlates of apparent life-threatening events (ALTEs) in a term newborn nursery population during the first 3 days of life in a maternity hospital.

METHODS

Twenty newborns with ALTEs during the first 3 days of life were studied. Family, antenatal, and intrapartum histories were reviewed. Diagnostic and therapeutic data surrounding the ALTEs were documented. Multichannel recordings performed after the ALTEs occurred were analyzed. Hospital discharge dispositions and postdischarge outcomes were reviewed.

RESULTS

Of approximately 15 000 deliveries during a three-year period, 20 infants had ALTEs. Apnea was the most common presenting symptom, and cyanosis usually accompanied the event. Tactile stimulation and oxygen were the most frequent acute treatments, with airway clearance, intermittent positive pressure ventilation, and cardiac massage less common. Forty percent of the events had potentially identifiable causes, including central nervous system abnormality, airway obstruction, or a persistent fetal cardiovascular shunt. Of the initial nultichannel recordings, 11 had desaturation oor less the 85%, 10 had apneic pauses of greater than 15 seconds, and 4 had bradycardia of less than 80 beats per minute. Eighteen infants were discharged and received home monitors; 4 received medication. ALTEs recurred in 4 infants before discharge and in 1 after discharge. No deaths occurred.

CONCLUSIONS

(1) ALTEs do occur in the early newborn period in a low-risk term group; (2) causes are unknown in the majority of cases; (3) multichannel recordings may have abnormalities; and (4) the likelihood of recurrent ALTEs is greater during the first week than during the next 2 months.

Identifying nursing outcome indicators

Patient outcomes...indicators..measurement. What do these concepts mean to you? More importantly, what do they mean to our customers, the patients? The department of nursing at the University of Maryland Medical System (UMMS) embarked on a 6-month initiative to begin to identify the major outcome indicators of nursing practice. This article will discuss the outcome indicator project from its inception to the identification of the actual outcome indicators. The rationale for undertaking this project and the process of selecting the indicators also will be addressed.

A computer simulation for learning about the physiological response to exercise

An interactive computer program written for IBM-compatible microcomputers, which simulates the physiological response to graded exercise in healthy individuals, is described. The program presents high-resolution graphic data (heart rate, pulmonary ventilation, oxygen consumption, and blood lactate concentration) in a form comparable to that of a chart recorder display. Data are derived from an empirical model that allows users to select certain parameters of the subject they wish to investigate, including sex, age, height, weight, and level of training. Measurements may be taken directly from the monitor screen by use of the cross-hair cursor facility provided. The program has been positively evaluated in use by undergraduate students and shown to be an effective teaching aid. The potential use of the software in light of these findings is discussed.

Hyperlipidaemia and atherogenesis

Hyperlipidaemia has become generally accepted as a cause of coronary artery atherosclerosis, arterial occlusion and subsequent myocardial infarction. This may be true in a few people with lipid intolerance, but for the majority, hyperlipidaemia represents a normal physiological response to another pathological process. One such disease process involves the vessel wall, which appears to suffer injury. The cause of the injury may be associated with abnormal movement in the wall and this in turn can be provoked by stress. A hypothesis encompassing these observations is proposed. It would therefore appear that hyperlipidaemia is not a cause of arterial disease, but as part of normal homeostasis, it can be a risk indicator. It is dangerous to consider hyperlipidaemia as a cause of myocardial infarction as this leads to inappropriate treatment. The lowering of cholesterol and low density lipoproteins (LDL) by any means other than sensible dieting may be likened to attempts to lower elevated white blood cell counts in cases of bacterial pneumonia, without treating the pneumonia.

Nursing management of the child with AIDS

Children with HIV infection have highly specialized physical and psychosocial needs. Appropriately applied, standard and creative nursing interventions can greatly improve the quality of life.

Heterogeneity of the rabbit collecting tubule: localization of mineralocorticoid hormone action to the cortical portion

This study was designed to examine the sodium, potassium, and chloride transport rates across the cortical and outer medullary collecting tubule and to localize the action of mineralocorticoid hormone. Rabbit collecting tubules were dissected from the cortex (CCT), the outer stripe of the outer medulla (OMCT0), or the inner stripe of the outer medulla (OMCTi). From normal rabbits, the transepithelial voltage was -20.8 +/- 2.7 mV in CCT, -4.2 +/- 1.4 mV in OMCT0, and +10.6 +/- 2.3 mV in OMCTi. From DOCA-treated rabbits, only the CCT voltage was different (-42.9 mV). Net sodium absorption across the CCT increased ith DOCA-treatment from 23 +/- 5 to 54 +/- 8 pEq . mm-1 . min-1, whereas net potassium secretion increased from 15 +/- 2 to 43 +/- 5 pEq . min-1 . min-1. Net chloride absorption was significant only in DOCA-treated rabbits. The OMCTi, in contrast, displayed no net transport of sodium, potassium, or chloride and had a lower rate coefficient for sodium efflux than did the CCT. DOCA treatment had no effect on any transport rate measured in this segment. The OMCT0 has small potassium secretion, which did not increase with DOCA treatment. The collecting tubule is heterogeneous along its length with respect to ion transport. Mineralocorticoid-hormone-sensitive sodium absorption is present predominantly, if not exclusively, in the cortical collecting tubule.

Echinobothrium bonasum sp. n., a new cestode from the cownose ray, rhinoptera bonasus (Mitchill 1815), in the western North Atlantic

Echinobothrium bonasum sp. n. is described from the cownose ray, Rhinoptera bonasus (Mitchill), taken in Atlantic coastal waters of Chesapeake Bay, Virginia, and off Sakonnet Point, Rhode Island. This species can be distinguished from all others by the following combination of characters: 14 hooklets armature of 11 large hooks, six in the anterior row and five in the posterior row, flanked by 12 to 14 hooklets per side; 24 to 25 spines per row on the cephalic peduncle; 24 to 31 testes per segment, and, wide vitelline bands that overlap the testicular field.