A Scoping Review of the Community Health Worker Model Used for Food Systems Interventions Within the United States

OBJECTIVE

To document and analyze the food systems interventions delivered by community health workers (CHW) serving as educators within the United States (U.S.).

DATA SOURCE

Ten databases (ie, Agricola, CAB Abstracts, CINAHL, ERIC, Proquest Social Science and Education, Proquest Theses and Dissertations, PubMed, Scopus, SocIndex, Web of Science) and gray-literature repositories were searched for publications between 2005-2020.

STUDY INCLUSION AND EXCLUSION CRITERIA

English-language and U.S. studies included with CHW as educators or facilitators for food systems interventions. Food systems defined as processes of production, processing, distribution, marketing, access, preparation, consumption, and disposal of food products. Studies excluded for clinical settings; non-adult CHWs; CHWs with medical or public health credentials; and programming guides, reviews, and commentaries.

DATA EXTRACTION

Variables included CHW and intervention description, priority population, food system processes, and targeted and unexpected outcomes.

DATA SYNTHESIS

Data were analyzed by the lead investigator and described narratively.

RESULTS

Of 43 records, CHWs educated for consumption (n = 38), preparation (n = 33), and food access (n = 22) to improve health of priority populations. Community health workers educated for the highest number of food system processes in garden-based interventions. Programs reached many underserved racial and socioeconomic populations.

CONCLUSIONS

The CHW model has been used to educate in interventions for all food systems processes and reached many diverse underserved audiences. Future work must explore garden-based food systems education and CHWs as community change agents.

Differentiation syndrome during ivosidenib treatment with immunohistochemistry showing isocitrate dehydrogenase R132H mutation

We report a case of differentiation syndrome in a patient receiving the IDH1 inhibitor ivosidenib, with skin biopsy showing isocitrate dehydrogenase (IDH) R132H-mutated leukemia cutis. A 72-year-old man with IDH1-mutated acute myeloid leukemia (AML), status-post allogeneic cell transplantation, on ivosidenib for 6 months, was admitted for culture-negative neutropenic fever, pink and purpuric plaques and patches on the legs, abdomen and back, edema, hypotension, and shortness of breath. Skin biopsy revealed an infiltrate of atypical, immature, myeloperoxidase-positive mononuclear cells compatible with leukemia cutis or Sweet syndrome. Although dermal edema and interstitial neutrophilic infiltrate with karyorrhexis characteristic of Sweet syndrome were not seen, the atypical cells lacked expression of CD117 and CD34, which were expressed in the original leukemia. Additional immunohistochemical staining of suspected blasts was strongly positive for IDH1 R132H, suggesting a diagnosis of leukemia cutis. As the immunophenotype of blasts in skin infiltrates can significantly differ from the immunophenotype seen in blood and bone marrow, this case shows that mutation-specific antibodies such as anti-IDH1 R132H may be useful to help distinguish malignant from non-malignant infiltrates in the skin. Furthermore, differentiation syndrome may show histopathologic features of leukemia cutis on skin biopsy.

Abstract TP112: Achieving 30 Minute Median Door to Needle Time at an Urban Center Using Telemedicine

Introduction: We constantly strive to improve outcomes for stroke patients. Current ASA Guidelines recommend a door to needle (DTN) time of 60 minutes or less, with a secondary goal DTN time of 45 minutes or less. Our goal was to decrease IV Alteplase (tPA) DTN times to 30 minutes or less using primarily Telemedicine.

Methods: In February of 2017, significant changes were made to our stroke alert process:Solidified process for direct neurology beam into the Telemedicine camera (rather than phoning first)Pharmacy responds to stroke alerts in person, and pre-mixes (if the neurologist deems appropriate) tPA at the bedsideThe Teleneurologist remains on the camera, which accompanies the patient to CAT Scan (CT). Through the camera, the neurologist reads the head CT in real timeIf no hemorrhage is confirmed on the CT scan, a verbal order to administer tPA is given while in the CT suite Challenges: Staff concern for patient safety, staff matrices, time constraints to implement these changes, our stroke committee collaborated with all affected departments. Resources were created including checklists and a Stroke Kit that contains tPA mixing guidelines, dosing charts, and blood pressure medications. The staff and physicians were educated on the new process via multiple venues including mock stroke alerts

Summary: From 2016 to 2017, there was a significant increase in the percentage of stroke patients who received tPA within 45 minutes or less, and within 30 minutes or less. There were no symptomatic hemorrhages post tPA administration in either 2016 or 2017.Our median DTN time decreased by 11 minutes 8 months after the implementations discussed (from 41 minutes in 2016 to 30 minutes in 2017). Many individual DTN times were under 30 minutes.Because of our success, these process changes were adapted by sister facilities within our division.Our stroke alert process is an excellent example of staff interdisciplinary collaboration, open mindedness, flexibility, enthusiasm and knowledge.

Abstract TP225: Predicting Large Vessel Occlusion in the Real World: Use of the Cincinnati Pre-hosptial Stroke Severity Score in Patients with Suspected Acute Ischemic Stroke

Background: The Colorado Stroke Advisory Board (COSAB) asked three Joint Commission (JC) comprehensive stroke centers (CSC) and one primary stroke center (PSC) to assist with determining the usefulness of the Cincinnati Pre-Hospital Stroke Severity Score (CPSSS) in predicting large vessel occlusion (LVO) in patients with acute stroke symptoms.

Purpose: The purpose of the study was to determine the real world applicability of the CPSSS in predicting LVO.

Methods: CPSSS and LVO data was collected by stroke coordinators at three CSCs and one PSC for all patients brought to their respective emergency departments via local emergency medical services (EMS) from June 2016 to July 2016 as stroke alerts. The CPSSS was calculated retrospectively using the initial documented neurological exam and LVO was determined by initial computed tomography (CT) imaging results or physician notes in the electronic medical record.

Results: Our study included 235 patients that were brought to 4 certified stroke centers in the Denver metropolitan area during a two month period in 2016. Eighty percent of patients (N=187/235) correctly screened negative on the CPSSS. Ten percent (N=23/235) of patients screened positive and were later determined to have LVO based on initial imaging. Four patients went on for endovascular treatment at a CSC that initially screened negative using the CPSSS. Nine percent (N=21/235) of patients screened false-positive for LVO. Top reasons for false positive CPSSS include intracerebral hemorrhage, altered mental status, seizure, and brain stem stroke.

Conclusion: CPSSS is a reasonable screening tool to assess for LVO. More study is recommended to determine how to avoid missing LVO in stroke patients with mild symptoms on initial presentation.

Abstract TP391: Working Within a Stroke System of Care to Decrease Door to Transfer Times From Spoke to Hub

Background: Best practice recommends that hospitals treating acute stroke patients have protocols in place to ensure rapid transfer to an advanced facility for a higher level of care, if needed. Our system of hospitals consists of five primary stroke centers (PSC) and one comprehensive stroke center (CSC) in a major metropolitan area. PSCs utilize telemedicine for acute stroke decision-making and patients are transferred to the CSC for consideration of advanced treatments when deemed appropriate by the care team.

Purpose: Our study objective was to streamline processes at our PSCs to decrease the door to transport time (DTT) to the CSC.

Methods: Stroke coordinators from the six sister hospitals meet quarterly to collaborate and share best practices in patient care. Our team of nurse leaders determined potential strategies to eliminate wasted time in the transfer process. Team members went back to their home facilities with the goal of generating buy-in from individual caregivers to decrease the time to transport out to the CSC. An overall attitude of urgency was encouraged during meetings with stroke councils and providers. Preliminary imaging results were used to guide decision to transfer, rather than waiting for final results. Some hospitals chose to notify the flight team of potential transport earlier in the emergency department stay, while others are still in the process of affecting change. We collected data on transferred patients with a diagnosis of acute stroke between the dates of 2/1/15-7/31/15 (n=23) and compared against the same time period in 2014 (n=11).

Results: A total of 34 patients were included in our retrospective chart review. The number of patients transferred for consideration of additional acute treatment increased from 11 in 2014 to 23 during the study period in 2015. When examining patients who transferred and actually received endovascular treatment for acute stroke (n=8 in 2014 versus n=11 in 2015), the mean DTT decreased from 84 minutes in 2014, to 77 minutes in 2015. We also noted that patient transfers were faster during day time hours when compared to night.

Conclusions: A system-wide, collaborative approach between PSCs and CSCs can decrease DTT when nurse leaders and providers streamline processes.

Performance of SAPS II and SAPS III scores in post-cardiac arrest

BACKGROUND

Cardiac arrest is a major public health issue affecting an estimated 300,000 patients in the United States each year. The American Heart Association has recommended the Simplified Acute Physiology Score II and III (SAPS) to assess severity of illness and to predict outcomes in the post-cardiac arrest population. Our objective was to determine if SAPS II and SAPS III scores predict outcomes in post-cardiac arrest patients.

METHODS

We performed an observational study of patients suffering cardiac arrest with return of spontaneous circulation. Data were collected prospectively and recorded in the Utstein style. SAPS II and SAPS III scores were calculated for each subject. Logistic regression was used to assess the relationship between the calculated severity of illness score and in-hospital mortality and poor neurologic outcome.

RESULTS

A total of 274 subjects were identified for analysis. SAPS II was a significant predictor of in-hospital mortality (OR: 1.05, 95% CI: 1.03-1.07) and poor-neurologic outcome (OR: 1.06, 95%CI: 1.04-1.08). SAPS III was a significant predictor of in-hospital mortality (OR: 1.04, 95%CI: 1.02-1.06) and poor neurologic outcome (OR: 1.04, 95%CI: 1.02-1.05). Both scores had moderate ability to discriminate survivors from non-survivors (SAPS II AUC: 0.70; SAPS III AUC: 0.66), and good neurologic outcome from poor neurologic outcome (SAPS II AUC: 0.71; SAPS III AUC: 0.65).

CONCLUSION

SAPS II and SAPS III scores have only moderate discrimination and are not clinically relevant tools to predict outcome in post-cardiac arrest patients. Further study is needed to identify a more reliable severity of illness score in the post-arrest population.

Proposed modifications to the conceptual model of coaching efficacy and additional validity evidence for the Coaching Efficacy Scale II-High School Teams

The purpose of this study was to determine whether theoretically relevant sources of coaching efficacy could predict the measures derived from the Coaching Efficacy Scale II-High School Teams (CES II-HST). Data were collected from head coaches of high school teams in the United States (N=799). The analytic framework was a multiple-group confirmatory factor analysis with ordered-categorical indicators and observed covariates. Applying this framework to the conceptual model of coaching efficacy (CMCE) resulted in a statistical model equivalent to a multiple-group multivariate regression with latent outcomes. Results provided evidence for the ability of measures derived from the CES II-HST to be predicted by theoretically relevant sources of coaching efficacy and suggested modifications to the CMCE.

Direct hypothalamic innervation of the trigeminal motor nucleus: a retrograde tracer study

It is currently thought that the hypothalamus influences motor output through connections with premotor structures which in turn project to motor nuclei. However, hypocretinergic/orexinergic projections to different motor pools have recently been demonstrated. The present study was undertaken to examine whether hypocretinergic/orexinergic neurons are the only source of projections from the hypothalamus to the trigeminal motor nucleus in the guinea-pig. Cholera toxin subunit b was injected into the trigeminal motor nucleus in order to retrogradely label premotor neurons. Two anatomically separated populations of labeled neurons were observed in the hypothalamus: one group was distributed along the dorsal zone of the lateral hypothalamic area, the lateral portion of the dorsomedial hypothalamic nucleus and the perifornical nucleus; the other was located within the periventricular portion of the dorsomedial hypothalamic nucleus. Numerous cholera toxin subunit b+ neurons in both populations displayed glutamate-like immunoreactivity. In addition, premotor neurons containing hypocretin/orexin were distributed throughout the lateral dorsomedial hypothalamic nucleus, perifornical nucleus and lateral hypothalamic area. Other premotor neurons were immunostained for melanin concentrating hormone; these cells, which were located within the lateral hypothalamic area and the perifornical nucleus, were intermingled with glutamatergic and hypocretinergic/orexinergic neurons. Nitrergic premotor neurons were located only in the periventricular zone of the dorsomedial hypothalamic nucleus. None of the hypothalamic premotor neurons were GABAergic, cholinergic or monoaminergic. The existence of diverse neurotransmitter systems projecting from the hypothalamus to the trigeminal motor pool indicates that this diencephalic structure may influence the numerous functions that are subserved by the trigeminal motor system.

Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation

BACKGROUND

Gastric outlet obstruction in patients with pancreatic cancer has a grim prognosis. Open surgical bypass is associated with high morbidity, whereas endoscopic duodenal stenting appears to provide better palliation.

METHODS

We reviewed the medical records of patients with gastric outlet obstruction secondary to pancreatic carcinoma who were admitted to our clinic between 1 October 1988, and 30 September 1998. The data included stage of disease, American Society of Anesthesiologists (ASA) class, surgical interventions, complications, and survival.

RESULTS

A total of 250 patients with pancreatic cancer were identified. Twenty-five of them (10%) had gastric outlet obstruction. Of these 25, 17 were treated with gastrojejunostomy, six had duodenal stenting (Wallstent), and two were resectable. There was no significant difference between the gastrojejunostomy group and the duodenal stenting group in ASA class or stage of disease. For the gastrojejunostomy group, median survival was 64 days (range, 15-167) and postoperative stay in hospital was 15 days (range, 8-39). For the duodenal stenting group, median survival was 110.5 days (range, 42-212) and postoperative stay was 4 days (range, 2-6). Ten patients (58.8%) in the gastrojejunostomy group had delayed gastric emptying. All of the patients in the duodenal stenting group were able to tolerate a soft diet the day after stent placement. Thirty-day mortality in the gastrojejunostomy group was 17.64%; in the duodenal stenting group, it was 0.

CONCLUSION

In pancreatic carcinoma patients with gastric outlet obstruction, duodenal stenting results in an earlier discharge from hospital and possibly improved survival.

Impact of infants born at the threshold of viability on the neonatal mortality rate in Colorado

OBJECTIVE

To determine the contribution of infants born at the threshold of viability (< 750 gm) on neonatal mortality in Colorado.

STUDY DESIGN

For the period of January 1991 to December 1996, all Colorado live births who expired were evaluated for gestational age, birth weight, gender, hospital level of care, age at time of death, delivery room resuscitation, mechanical ventilation, medical and surgical complications, and serious malformations.

RESULTS

Although infants weighing < 750 gm represent only 0.31% of all live births, they account for 46.3% of deaths. While those infants weighing < 500 gm and with a gestation of < 24 weeks almost always died (94.7%), the majority born in the 500- to 745-gm category (55.8%) survived. The vast majority (88.5%) of deaths occurred on the first day of life. A total of 38.4% of births in which the infant weighed < 750 gm occurred outside bona fide regional perinatal centers.

CONCLUSION

Future attempts to reduce the Colorado neonatal mortality rate would best focus on the 500- to 750-gm weight group through the re-regionalization of high-risk perinatal care.

Cholesteryl ester transfer protein corrects dysfunctional high density lipoproteins and reduces aortic atherosclerosis in lecithin cholesterol acyltransferase transgenic mice

Expression of human lecithin cholesterol acyltransferase (LCAT) in mice (LCAT-Tg) leads to increased high density lipoprotein (HDL) cholesterol levels but paradoxically, enhanced atherosclerosis. We have hypothesized that the absence of cholesteryl ester transfer protein (CETP) in LCAT-Tg mice facilitates the accumulation of dysfunctional HDL leading to impaired reverse cholesterol transport and the development of a pro-atherogenic state. To test this hypothesis we cross-bred LCAT-Tg with CETP-Tg mice. On both regular chow and high fat, high cholesterol diets, expression of CETP in LCAT-Tg mice reduced total cholesterol (-39% and -13%, respectively; p < 0.05), reflecting a decrease in HDL cholesterol levels. CETP normalized both the plasma clearance of [(3)H]cholesteryl esters ([(3)H]CE) from HDL (fractional catabolic rate in days(-1): LCAT-Tg = 3.7 +/- 0.34, LCATxCETP-Tg = 6.1 +/- 0.16, and controls = 6.4 +/- 0.16) as well as the liver uptake of [(3)H]CE from HDL (LCAT-Tg = 36%, LCATxCETP-Tg = 65%, and controls = 63%) in LCAT-Tg mice. On the pro-atherogenic diet the mean aortic lesion area was reduced by 41% in LCATxCETP-Tg (21.2 +/- 2.0 micrometer(2) x 10(3)) compared with LCAT-Tg mice (35.7 +/- 2.0 micrometer(2) x 10(3); p < 0.001). Adenovirus-mediated expression of scavenger receptor class B (SR-BI) failed to normalize the plasma clearance and liver uptake of [(3)H]CE from LCAT-Tg HDL. Thus, the ability of SR-BI to facilitate the selective uptake of CE from LCAT-Tg HDL is impaired, indicating a potential mechanism leading to impaired reverse cholesterol transport and atherosclerosis in these animals. We conclude that CETP expression reduces atherosclerosis in LCAT-Tg mice by restoring the functional properties of LCAT-Tg mouse HDL and promoting the hepatic uptake of HDL-CE. These findings provide definitive in vivo evidence supporting the proposed anti-atherogenic role of CETP in facilitating HDL-mediated reverse cholesterol transport and demonstrate that CETP expression is beneficial in pro-atherogenic states that result from impaired reverse cholesterol transport.

Selective delivery of herpes virus vectors to experimental brain tumors using RMP-7

RMP-7, a bradykinin analog, has been shown to selectively open the blood-tumor barrier for the delivery of chemotherapeutic drugs to brain tumors. In contrast to bradykinin, RMP-7 has no hypotensive effects and has been approved for human use. This study was initiated to determine whether RMP-7 would open the blood-tumor barrier to virus vectors encoding tumor-killing genes in an experimental model. The herpes virus vector used, hrR3, which encodes virus thymidine kinase gene and the lacZ reporter gene, is defective in a gene encoding ribonucleotide reductase, replicates selectively in dividing tumor cells and not in postmitotic neural cells. It was determined that an optimum dose of RMP-7 (1.5-3.0 microg/kg over 10-15 minutes) enhanced viral delivery to brain tumors in rats bearing intracranial 9 L gliosarcomas when infused through the carotid artery immediately prior to virus vector application. Maximum expression of the lacZ reporter gene occurred at 3 days after intracarotid infusion. By 8 days, transgene expression was largely confined to tumor foci away from the main tumor mass. Viral delivery was essentially specific to tumor cells, with little transgene expression elsewhere in the brain. Minimal uptake and pathology was noted in the kidney, spleen, and liver. These findings indicate that intracarotid delivery of RMP-7 can augment the selective delivery of virus vectors to brain tumors in an experimental rat model, with the potential for application to human brain tumors.

Hepatic lipase facilitates the selective uptake of cholesteryl esters from remnant lipoproteins in apoE-deficient mice

We have investigated the role of hepatic lipase (HL) in remnant lipoprotein metabolism independent of lipolysis by using recombinant adenovirus to express native and catalytically inactive HL (HL-145G) in apolipoprotein (apo)E-deficient mice characterized by increased plasma concentrations of apoB-48-containing remnants. In the absence of apoE, the mechanisms by which apoB-48-containing remnants are taken up by either low density lipoprotein (LDL)-receptor or LDL-receptor-related protein (LRP) remain unclear. Overexpression of either native or catalytically inactive HL in apoE-deficient mice led to similar reductions (P > 0.5) in the plasma concentrations of cholesterol (41% and 53%) and non high density lipoprotein (HDL)-cholesterol (41% and 56%) indicating that even in the absence of lipolysis, HL can partially compensate for the absence of apoE in this animal model. Although the clearance of [3H]cholesteryl ether from VLDL was significantly increased (approximately 2-fold; P < 0. 02) in mice expressing native or inactive HL compared to luciferase controls, the fractional catabolic rates (FCR) of [125I-labeled] apoB- very low density lipoprotein (VLDL) in all three groups of mice were similar (P > 0.4, all) indicating selective cholesterol uptake. Hepatic uptake of [3H]cholesteryl ether from VLDL was greater in mice expressing either native HL (87%) or inactive HL-145G (72%) compared to luciferase controls (56%). Our combined findings are consistent with a role for HL in mediating the selective uptake of cholesterol from remnant lipoproteins in apoE-deficient mice, independent of lipolysis. These studies support the concept that hepatic lipase (HL) may serve as a ligand that mediates the interaction between remnant lipoproteins and cell surface receptors and/or proteoglycans. We hypothesize that one of these pathways may involve the interaction of HL with cell surface receptors, such as scavenger receptor (SR)-BI, that mediate the selective uptake of cholesteryl esters.

Circumscription of the Malvales and relationships to other Rosidae: evidence from rbcL sequence data

The order Malvales remains poorly circumscribed, despite its seemingly indisputable core constituents: Bombacaceae, Malvaceae, Sterculiaceae, and Tiliaceae. We conducted a two-step parsimony analysis on 125 rbcL sequences to clarify the composition of Malvales, to determine the relationships of some controversial families, and to identify the placement of the Malvales within Rosidae. We sampled taxa that have been previously suggested to be within, or close to, Malvales (83 sequences), plus additional rosids (26 sequences) and nonrosid eudicots (16 sequences) to provide a broader framework for the analysis. The resulting trees strongly support the monophyly of the core malvalean families, listed above. In addition, these data serve to identify a broader group of taxa that are closely associated with the core families. This expanded malvalean clade is composed of four major subclades: (1) the core families (Bombacaceae, Malvaceae, Sterculiaceae, Tiliaceae); (2) Bixaceae, Cochlospermaceae, and Sphaerosepalaceae (Rhopalocarpaceae); (3) Thymelaeaceae sensu lato (s.l.); and (4) Cistaceae, Dipterocarpaceae s.l., Sarcolaenaceae (Chlaenaceae), and Muntingia. In addition, Neurada (Neuradaceae or Rosaceae) falls in the expanded malvalean clade but not clearly within any of the four major subclades. This expanded malvalean clade is sister to either the expanded capparalean clade of Rodman et al. or the sapindalean clade of Gadek et al. Members of Elaeocarpaceae, hypothesized by most authors as a sister group to the four core malvalean families, are shown to not fall close to these taxa. Also excluded as members of, or sister groups to, the expanded malvalean clade were the families Aextoxicaceae, Barbeyaceae, Cannabinaceae, Cecropiaceae, Dichapetalaceae, Elaeagnaceae, Euphorbiaceae s.l., Huaceae, Lecythidaceae, Moraceae s.l., Pandaceae, Plagiopteraceae, Rhamnaceae, Scytopetalaceae, Ulmaceae, and Urticaceae.

An oncolytic viral mutant that delivers the CYP2B1 transgene and augments cyclophosphamide chemotherapy

Herpes simplex viruses type 1 (HSV-1) with an inactivated viral ribonucleotide reductase (Hsrr, ICP6) were designed to target tumor cells with upregulated mammalian ribonucleotide reductase (mRR), an enzyme whose expression is regulated by the p16/pRB tumor suppressor pathway. A recombinant HSV-1 was generated by knock-out of Hsrr and insertion of the rat CYP2B1 transgene responsible for the bioactivation of the prodrugs, cyclophosphamide and ifosfamide. The mutant virus replicated selectively in rat and human tumor cells that express mRR. Addition of cyclophosphamide potentiated oncolytic effects against cultured tumor cells and subcutaneous tumor xenografts established in athymic mice.

Long-term survival in a rodent brain tumor model by bradykinin-enhanced intra-arterial delivery of a therapeutic herpes simplex virus vector

Recently, it was demonstrated that bradykinin (BK) enhances intracarotid delivery of herpes simplex virus type I (HSV) vectors to rat brain tumors, and that gene transfer takes place predominantly in the tumor periphery. The aim of the present study was to apply these findings to the treatment of experimental rat brain tumors. The HSV mutant, hrR3, which is disrupted in the ribonucleotide reductase gene, was injected intra-arterially with titers of 1 x 10(8), 1 X 10(9), and 1 x 10(10) plaque-forming units (pfu) both with and without BK into Fischer 344 rats with intracerebral, syngeneic 9L tumors. Starting on day 3 after vector administration, animals were treated by intraperitoneal injection of 60 mg/kg/day ganciclovir (GCV) or placebo. 1 x 10(10) pfu hrR3 in combination with BK and GCV treatment was able to eradicate tumors in 80% of the animals; 1 x 10(9) pfu cured 40% of the rats, and 1 x 10(8) pfu achieved an extension of survival time but no tumor cures. Control groups had 100% mortality within 30 days after injection of tumor cells, with the exception of the group with injection of 1 x 10(10) pfu of virus and GCV treatment, which had one long-term survivor. No apparent complications of this novel type of brain tumor gene therapy were encountered. In conclusion, intra-arterial injection of attenuated HSV vectors with blood-tumor barrier modification and subsequent systemic GCV application appears to be a promising approach for the treatment of malignant brain tumors.

Therapeutic efficiency and safety of a second-generation replication-conditional HSV1 vector for brain tumor gene therapy

A second-generation replication-conditional herpes simplex virus type 1 (HSV) vector defective for both ribonucleotide reductase (RR) and the neurovirulence factor gamma34.5 was generated and tested for therapeutic safety and efficiency in two different experimental brain tumor models. In culture, cytotoxic activity of this double mutant HSV vector, MGH-1, for 9L gliosarcoma cells was similar to that of the HSV mutant, R3616, which is defective only for gamma34.5, but was significantly weaker than that of the HSV mutant hrR3, which is defective only for RR. The diminished tumoricidal effect of the gamma34.5 mutants could be accounted for by their reduced ability to replicate in 9L cells. The MGH-1 vector did not achieve significant prolongation of survival in vivo in the syngeneic 9L rat gliosarcoma model for either single brain tumor focus or multiple intracerebral and leptomeningeal tumors, when the vector was applied intratumorally or intrathecally, respectively, and with or without subsequent ganciclovir (GCV) treatment. In identical 9L brain tumor models with single and multiple foci, application of hrR3 with or without GCV was previously shown to result in marked long-term survival. Contrary to the findings with intrathecal injection of hrR3, no vector-related mortality was observed in any animals treated with MGH-1. Thus, in these rat brain tumor models, the double mutant, replication-conditional HSV vector MGH-1 showed a higher therapeutic safety than the RR-minus vector, hrR3, but had clearly decreased therapeutic efficiency compared to hrR3. The development of new HSV vectors for brain tumor gene therapy will require a balance between maximizing therapeutic efficacy and minimizing toxicity to the brain. Standardized application in brain tumor models as presented here will help to screen new HSV vectors for these requirements.

The effect of ganciclovir on herpes simplex virus-mediated oncolysis

Entry of herpes simplex virus (HSV) into tumor cells results in viral gene expression followed by cellular lysis. Attenuated HSVs selectively destroy tumors with sparing of surrounding normal tissue. HSV encodes a thymidine kinase (TK) that converts ganciclovir to a toxic metabolite. This metabolite may be transferred between cells and lead to the death of neighboring uninfected cells, termed bystanders. We sought to determine if HSV-mediated oncolysis is enhanced by ganciclovir treatment. In addition, we examined bystander killing in cocultures of TK transfectants and parental cells. hrR3, an attenuated HSV, expresses TK. The 50% lethal dose of hrR3 for a rat gliosarcoma (9L) and three human colorectal carcinomas (HT29, KM12C6, and KM12L4) was determined. Cells were infected with a 50% lethal dose of hrR3, followed by treatment with ganciclovir, and then cell survival was quantitated. In separate experiments 9L and HT29 cells were transfected with TK. Parental cells and TK transfectants were cocultured in various ratios, in the presence of ganciclovir, and cell survival was quantitated. hrR3-mediated oncolysis was enhanced by ganciclovir in the gliosarcoma but not in the three colorectal carcinomas. Cocultures of both 9L and HT29 parental cells with their corresponding TK transfectants demonstrated bystander killing. The mortality of 9L cocultures was 54% greater than that predicted for exclusive killing of transfectants. HT29 mortality was 8% greater than predicted. The ability of ganciclovir to augment hrR3-mediated oncolysis varies significantly between tumor cells lines. The extent of ganciclovir-mediated killing of neighboring nontransduced parental cells similarly varies. Consideration should be given to these factors in the design of gene therapy strategies using HSV vectors as oncolytic agents.

Phylogenetic relationships of Lecythidaceae: a cladistic analysis using rbcL sequence and morphological data

This study examined in detail the rbcL sequence and morphological support for subfamilial relationships and monophyly of Lecythidaceae. Initially we needed to establish relationships of Lecythidaceae among other dicot families. To complete this we examined 47 rbcL sequences of 25 families along with molecular observations from several large analyses of rbcL data. All analyses strongly support the monophyly of the asterid III grouping. This analysis revealed Lecythidaceae to be paraphyletic and indicated potential outgroup relationships with Sapotaceae. Once relationships had been evaluated using molecular data we then concentrated on analyzing separate and combined morphological and molecular databases. The topology of the morphological data set was similar to the rbcL sequence and combined data sets except for the positioning of Napoleonaeoideae, Grias, Gustavia, and Oubanguia. According to the combined results, Planchonioideae, Lecythidoideae. and Foetidioideae are monophyletic, whereas the subfamily Napoleonaeoideae are paraphyletic. Nested within Napolconaeoideae, we found Asteronthos forms a strongly supported clade with Oubanguia (Scytopetalaceae). Foetidia, the only genus of Foetidioideae, is sister to Planchonioideae, and this clade is sister to Lecythidoideae. The [(Planchonioideae, Foetidioideae) Lecythidoideae are sister to Asteranthos/Oubanguia. Napoleonaeoideae are sister to the rest of Lecythidaceae.

A novel 'piggyback' packaging system for herpes simplex virus amplicon vectors

Recombinant and amplicon vectors derived from herpes simplex virus type 1 (HSV-1) have proven to be an efficient means of gene delivery to cells in culture and in vivo. In this study, a system was developed to make propagation of the amplicon vector and helper virus mutually dependent on each other, in a "piggyback' fashion. This combined system supports maintenance and enrichment of the amplicon vector when propagating stocks, while allowing the helper virus to serve as a recombinant vector in its own right. Amplicons bearing a gene essential for HSV-1 replication, IE3, as well as the Escherichia coli lacZ marker gene, were propagated using a mutant virus (d120) deleted in the same essential gene. Vector stocks could be propagated in Vero cells and other cultured cells not transfected with the IE3 gene with markedly delayed cytopathic effects, as compared to wild-type virus. Relatively high titers of amplicon vectors (6 x 10(7) infectious units/ml) were achieved with this piggyback system in Vero cells, with an apparent ratio of amplicon vector: helper virus of up of 5:1 under some conditions; however, recombinant wild-type virus was also generated. Injection of these stocks into experimental gliomas in rodent brain revealed gene delivery to tumor cells mediated by both amplicon vectors (lacZ) and helper virus (HSV-thymidine kinase), with no apparent neuropathology of normal brain. This basic piggyback vector model is amenable to modifications to promote conditional propagation of vectors in vivo and to allow incorporation of multiple transgene elements into both the amplicon and recombinant helper virus vectors.

Long-term survival in a rodent model of disseminated brain tumors by combined intrathecal delivery of herpes vectors and ganciclovir treatment

Brain tumors that have disseminated into cerebrospinal fluid (CSF) pathways are an unresolved therapeutic problem, especially in pediatric neurooncology. Here a gene therapy approach using the herpes simplex virus type 1 thymidine kinase (HSV-TK)/ganciclovir (GCV) paradigm was tested using an HSV vector in a rodent model of disseminated central nervous system tumors. 9L-gliosarcoma cells were implanted simultaneously into the brain and the CSF of syngeneic rats. Five days later, resulting intracerebral and leptomeningeal tumors were treated by intrathecal injection of a replication-conditional HSV vector. This vector was defective for the ribonucleotide reductase gene, but contained an intact HSV-tk gene. Systemic GCV treatment was started 2 days after vector application and continued for 14 days. Tumor-free, long-term survival (LTS) was achieved in 90% of the animals treated with this combined therapeutic approach, whereas only 30% LTS was found in animals that had received the vector alone and 10% LTS in untreated animals. This therapeutic response probably involves oncolytic, on-site replication of the vector, activation of GCV by a HSV-TK, and a strong immune response both to the vector and to 9L cells. Apparent vector-related mortality was observed in 20% of animals without subsequent GCV therapy, but no vector-related mortality was found when the animals were treated with GCV after vector application. Given the successful outcome of this experimental treatment and the apparent potential of GCV to control HSV-related toxicity, intrathecal application of HSV vectors combined with GCV treatment may be a promising approach for treatment of disseminated brain tumors.

Retrovirus-mediated gene therapy of experimental brain neoplasms using the herpes simplex virus-thymidine kinase/ganciclovir paradigm

Recent results in experimental brain tumors indicate that transfer of sensitizing genes to tumor cells in vivo with subsequent drug treatment can reduce tumor masses and prolong the survival of rodents. In the present study, the 9L rat gliosarcoma model was used to evaluate the therapeutic effectiveness of the herpes simplex virus-thymidine kinase (HSV-tk) gene, delivered by a retrovirus vector, against tumor cells in the rat brain after systemic application of the nucleoside analogue ganciclovir (GCV). The HSV-tk gene was inserted into a retroviral vector (pMFG), which was produced using the amphotropic packaging cell line CRIP-MFG-S-HSV-TK. Packaging cells were implanted into established 9L tumors in the brains of syngeneic rats to effect gene delivery to tumor cells, followed by intraperitoneal GCV injections. Treated animals survived significantly longer (more than twice as long) than did the control groups. Brains from GCV-treated and nontreated animals were examined immunohistochemically at different time intervals after grafting of CRIP-MFG-S-HSV-TK cells and GCV treatment. Tumors in GCV-treated animals were significantly smaller as compared with nontreated animals at all time points. Sections stained immunohistochemically for HSV-TK confirmed gene transfer to tumor cells, which could be distinguished from packaging cells by different morphology and immunohistochemical staining for the retroviral envelope protein gp70. Approximately 45% of the cells in tumors implanted with CRIP-MFG-S-HSV-TK cells, but not treated with GCV, showed immunocytochemical staining for HSV-TK, demonstrating a high-efficiency of retrovirus-mediated gene transfer. Tumors in rats treated with packaging cells and GCV showed only 9% HSV-TK-positive cells after treatment, indicating that most cells expressing the HSV-tk gene were killed. The success of this therapeutic modality in experimental animals depends in large parts on the high efficiency of gene delivery and on the immune response against tumor cells.

Herpes vector-mediated delivery of marker genes to disseminated central nervous system tumors

The present study investigated the ability of a recombinant herpes simplex virus type 1 (HSV) vector to deliver genes into disseminated brain tumor foci through intrathecal injection of the vector. The animal model was designed to simulate brain tumors with cerebrospinal fluid (CSF) metastases, which are found especially in the pediatric population. 9L gliosarcoma cells were injected both into the right frontal lobe and in through the cisterna magna of adult rats. The HSV vector, hrR3, was inoculated intrathecally 5 days later. This vector is defective in the gene for ribonucleotide reductase, and, therefore, replicates preferentially in dividing cells; it retains an intact HSV-thymidine kinase gene (HSV-tk). Two days after injection of the vector, immunohistochemical staining for HSV thymidine kinase (HSV-TK) revealed expression in frontal tumors, as well as in leptomeningeal tumor foci along the entire neuroaxis. HSV-TK-immunopositive cells were most frequent in small tumors contacting the CSF pathways. Frontal lobe tumors showed the highest density of HSV-TK-immunopositive cells around their periphery with little expression in central parts. Some paraventricular neurons temporarily showed HSV-TK-immunolabeling at this early time point. The number of HSV-TK-immunopositive tumor cells markedly decreased 5 days after injection of the HSV vector. In all animals, some toxicity was observed in the first 2-4 days after virus injection with extensive leptomeningeal inflammation. In conclusion, intrathecal application of HSV vectors can mediate widespread transfer of the therapeutic HSV-tk gene into disseminated tumors throughout the brain and CSF pathways. Although there was marked toxicity associated with intrathecal injection of this vector, this mode of gene delivery offers a promising approach for treatment of CSF-metastases in conjunction with development of less toxic vectors.

Selective uptake of viral and monocrystalline particles delivered intra-arterially to experimental brain neoplasms

In this study we investigated the intra-arterial delivery of viral and nonviral particles to experimental brain tumors. A herpes simplex virus (HSV) vector and monocrystalline iron oxide nanoparticles (MION) were injected into the internal carotid artery of Fisher 344 rats harboring intracerebral 9L gliosarcomas, using bradykinin to disrupt the blood-tumor barrier. Brain and internal organs were stained both for virus-mediated gene expression and for iron. Quantitative comparisons of gene expression and MION uptake with and without blood-tumor barrier disruption were performed in the center and at the periphery of the tumor mass, as well as in normal brain. In addition, MION distribution was traced in vivo by MR imaging. Delivery of HSV into 9L gliosarcoma cells was greatly enhanced by intra-carotid bradykinin infusion. Virus-mediated expression of the HSV-thymidine kinase (TK) and beta-galactosidase gene products was highest at the tumor periphery as compared to the tumor center. Selective HSV infection of multiple tumor foci was achieved in both hemispheres without affecting normal brain. MION uptake was high at the tumor periphery even without blood-tumor barrier disruption. Bradykinin increased MION uptake predominantly in the center of the tumor with virtually no effect at the periphery. These findings show that selective blood-tumor barrier disruption by bradykinin can be used to enhance HSV-mediated gene delivery to tumor cells in the periphery of brain tumors. A crucial aspect in the treatment of malignant brain tumors is the eradication of tumor cells infiltrating the brain; bradykinin may facilitate access of vectors to these areas by selective disruption of their neovasculature.

Transgene inheritance and retroviral infection contribute to the efficiency of gene expression in solid tumors inoculated with retroviral vector producer cells

One strategy to achieve efficient gene delivery into brain tumors employs the stereotactic implantation of fibroblasts that express a foreign gene and produce a retroviral vector bearing that gene. Another method involves the grafting of fibroblasts genetically engineered to produce a foreign gene product of interest. It is not clear to what extent retrovirus production in vivo provides an advantage over the grafting of genetically engineered cells for the purpose of achieving transgene expression. These two methods of gene delivery were compared in vivo by using the following cell lines: CRIP-MFG-LacZ cells, which express the lacZ gene and produce retrovirus vectors that bear this gene, and CRIP-LacZ cells, which express the lacZ gene, but do not produce retrovirus. Gene delivery was assessed in C6 gliomas established in the righ frontal lobe of athymic mice. CRIP-MFG-LacZ or CRIP-LacZ cells were inoculated stereotactically into these tumors. When CRIP-MFG-LacZ cells were used, a relatively elevated level of lacZ gene expression was present in cells scattered throughout the tumor. Using a computerized imaging system, this expression occurred in approximately 10% of the tumor area at 1 week, 42% at 2 weeks, and 32% at 3 weeks. In contrast, with CRIP-LacZ cells, lacZ gene expression was much weaker and occurred in a more focal area within the tumor. This expression occupied approximately 5% of the tumor area at 1 and 2 weeks and had almost disappeared at 3 weeks. In both cases there was no notable expression of the transgene in normal brain cells. In conclusion, transgene expression in brain tumors was achieved in more cells, at higher levels, and for longer time periods with retroviral vector-producing cells than with genetically engineered fibroblasts. This efficiency of gene delivery likely results from direct in situ delivery of the transgene to tumor cells with subsequent inheritance of the reporter gene to progeny tumor cells.

Long-term survival of rats harboring brain neoplasms treated with ganciclovir and a herpes simplex virus vector that retains an intact thymidine kinase gene

Survival of rats harboring cerebral 9L gliosarcomas can be significantly extended by an intratumoral inoculation with a herpes simplex virus vector, designated as hrR3. This vector, which bears the lacZ reporter gene, is defective in the gene encoding ribonucleotide reductase, allowing for replication in dividing tumor cells but not in postmitotic neural cells. It also possesses an intact viral thymidine kinase (TK) gene, which confers chemosensitivity to ganciclovir. In this study, the ability of ganciclovir to potentiate the antitumor effect of hrR3 was evaluated. In culture, there was a 23% decrease in the growth of 9L cells treated with hrR3 plus ganciclovir compared to hrR3 alone (P < 0.01). The combination of hrR3 plus ganciclovir led to the long-term survival of 48% of rats harboring intracerebral 9L gliosarcomas compared to 20% survival in the hrR3 group (P < 0.05). Ganciclovir treatment had no effect on the growth of tumor cells in vitro or in vivo when a herpes simplex virus vector with a defective TK gene was used. Immunocytochemistry confirmed selective expression of the TK gene in cells within the tumor. These findings indicate that the TK gene can potentiate the antitumor effect of the hrR3 herpes simplex virus vector and provide the basis for placing additional therapeutic genes in the genome of hrR3.

Antitumor activity and reporter gene transfer into rat brain neoplasms inoculated with herpes simplex virus vectors defective in thymidine kinase or ribonucleotide reductase

Herpes simplex virus (HSV) mutants or recombinant vectors might be useful oncolytic agents. Three general types of HSV vectors can be potentially used for this purpose: (1) mutants in viral transcription factors, such as ICP0 and ICP4; (2) mutants in enzymes involved in nucleic acid metabolism, such as thymidine kinase (TK) and ribonucleotide reductase (RR); and (3) mutants in neurovirulence factors, such as gamma 34.5. We tested the destructive ability of each type against rat 9L gliosarcoma cells in culture. We found that the HSV vectors defective in TK or RR were more efficient at tumor cell lysis in culture than the other types of HSV vectors. This increased efficiency provided the rationale for evaluating the TK and RR mutants in vivo following their stereotactic inoculation into 9L gliosarcomas implanted in rat brains. We employed the X-gal enzymatic histochemical assay to show that HSV-mediated lacZ gene expression was present in cells within the tumor mass in a relatively selective fashion. Immunoreactive HSV capsid and core antigens were present both in cells within the tumor, as well as in cells such as neurons and astrocytes, directly adjacent to the tumor mass. Long-term survival studies revealed that rats treated with either the TK or RR mutant lived significantly longer than control rats (p = 0.014, Kruskal-Wallis one-way analysis of variance). These results indicate that HSV vectors, defective in enzymes needed in nucleic acid metabolism, can preferentially mediate lacZ gene expression in cells within the tumor. (ABSTRACT TRUNCATED AT 250 WORDS)

Experimental tumor therapy in mice using the cyclophosphamide-activating cytochrome P450 2B1 gene

Most malignant tumors of the central nervous system do not respond well to chemotherapy. The anticancer drug cyclophosphamide (CPA) is largely ineffective against these neoplasms as its conversion to DNA-alkylating, cytotoxic metabolites is restricted primarily to the liver and these metabolites do not readily cross the blood-brain barrier. Here, we show that brain tumor cells can be sensitized to the cytotoxic effects of CPA, both in culture and in vivo, by introduction of the hepatic enzyme responsible for the activation of CPA, cytochrome P450 2B1. Stable transfection of rat C6 glioma cells with the P450 2B1 gene rendered the cultured tumor cells sensitive to CPA. Further, C6 cells bearing this gene were more sensitive than parental cells to the cytotoxic action of CPA when grown subcutaneously in the flanks of athymic mice. Murine fibroblasts producing a retrovirus vector encoding P450 2B1 and expressing this enzyme were then prepared and grafted into the brains of athymic mice seeded with rat C6 gliomas. Intrathecal administration of CPA prevented the development of meningeal neoplasia and led to partial regression of the parenchymal tumor mass. By contrast, C6 glioma-bearing mice receiving fibroblasts expressing the Escherichia coli lacZ gene and CPA exhibited extensive meningeal tumors and parenchymal solid brain tumors. The in situ activation of CPA by cytochrome P450 2B1 provides a novel approach not only for brain tumor gene therapy, but also for negative, drug-conditional selection of other defined cell populations.

Population synaptic potentials evoked in lumbar motoneurons following stimulation of the nucleus reticularis gigantocellularis during carbachol-induced atonia

The effect of electrical stimulation of the medullary nucleus reticularis gigantocellularis (NRGc) on lumbar spinal cord motoneurons was studied in the decerebrate cat using sucrose-gap recordings from ventral roots. The NRGc was stimulated ipsi- and contralaterally before and during atonia elicited by the microinjection of carbachol into the pontine reticular formation. Prior to carbachol administration, the NRGc-induced response recorded from the sucrose-gap consisted of two consecutive excitatory population synaptic potentials followed by a long-lasting, small amplitude inhibitory population synaptic potential. Following carbachol injection, the same NRGc stimulus evoked a distinct, large amplitude inhibitory population synaptic potential, whereas the excitatory population synaptic potentials decreased in amplitude. In addition, after carbachol administration, the amplitude of the monosynaptic excitatory population synaptic potential, which was evoked by stimulation of group Ia afferents in hindlimb nerves, was reduced by 18 to 43%. When evoked at the peak of the NRGc-induced inhibitory response, this potential was further decreased in amplitude. Systemic strychnine administration (0.07-0.1 mg/kg, i.v.) blocked the NRGc-induced inhibitory population synaptic potential and promoted an increase in the amplitude of the excitatory population synaptic potentials induced by stimulation of the NRGc and group Ia afferents. These data indicate that during the state of carbachol-induced atonia, the NRGc effects on ipsi- and contralateral spinal cord motoneurons are predominantly inhibitory and that glycine is likely to be involved in this inhibitory process. These results support the hypothesis that the nucleus reticularis gigantocellularis is part of the system responsible for state-dependent somatomotor inhibition that occurs during active sleep.

Gene transfer into experimental brain tumors mediated by adenovirus, herpes simplex virus, and retrovirus vectors

Three vectors derived from retrovirus, herpes simplex virus type 1 (HSV), and adenovirus were compared in cultured rat 9L gliosarcoma cells for gene transfer efficiency and in a 9L rat brain tumor model for histologic pattern and distribution of foreign gene delivery, as well as for associated tumor necrosis and inflammation. At a multiplicity of infection of 1, in vitro transfer of a foreign gene (lacZ from Escherichia coli) into cells was more efficient with either the replication-defective retrovirus vector or the replication-conditional thymidine kinase (TK)-deficient HSV vector than with the replication-defective adenovirus vector. In vivo, stereotactic injections of each vector into rat brain tumors revealed three main histopathologic findings: (i) retrovirus and HSV vector-mediated gene transfer was relatively selective for cells within the tumor, whereas adenovirus vector-mediated gene transfer occurred into several types of endogenous neural cells, as well as into cells within the tumor; (ii) gene transfer to multiple infiltrating tumor deposits without apparent gene transfer to intervening normal brain tissue occurred uniquely in one animal inoculated with the HSV vector, and (iii) extensive necrosis and selective inflammation in the tumor were evident with the HSV vector, whereas there was minimal evidence of tumor necrosis and inflammation with either the retrovirus or adenovirus vectors.

Isolated injury of the second tarsometatarsal joint. A case report

Injuries to tarsometatarsal (Lisfranc) joints are subtle, potentially disabling, and are still often overlooked. This case report of a rare isolated second Lisfranc joint dislocation (LJD) in a 46-year-old woman illustrates the typically subtle roentgenographic findings. A careful scrutiny of the base of the second metatarsal bone, especially on the lateral roentgenogram, shows alignment with the middle cuneiform. On an oblique view of the foot, the fourth metatarsal base should be aligned to the medial edge of the cuboid. Closed reduction of LJD is often unsuccessful and, if achieved, is often unstable. Soft-tissue or chondral fragment interposition impedes reduction. Open reduction and internal fixation are recommended.

Sugar "allergy" and children's behavior

Sixteen children whose behavior was said to become aggressive, overly active, loud, and noncompliant when ingesting sugar were tested. Sugar-free home diet was maintained and an "open" challenge to a large dose (3 g/kg) of candy bar sucrose was given. Subsequent behavior was noted by actometer, quantitative playroom observation using several standard behavioral tests, and ability to do maze drawings. No significant changes were found on the open challenge test. A slight change from baseline was noted in seven cases on three or four behavioral parameters. Five of these children agreed to a double-blind challenge test utilizing lemon-flavored slushes of sucrose, honey, tapioca starch, or aspartame, administered after a standard lunch free of sucrose. One child reacted to both sucrose and honey and another child reacted only to sucrose. These two children were challenged a second time. The child who reacted to honey again did so according to actometer readings, but this time not by Stony Brook test. To sugar, he reacted only at the 70-minute Stony Brook. The other child reacted to placebo instead of sucrose when rechallenged. The results indicate that high doses of sugar are not related to abnormal behavior. "Open" challenge was sufficient to rule out such a relationship in most instances. A repeated double-blind challenge confirmed the absence of a sugar effect in cases showing initial possibility of response.

Nursing Management of a Patient With a Subarachnoid Hemorrhage

Nursing care of the aneurysm patient is as demanding as any challenge the neuro unit can offer. Because these patients are extremely ill with major neurological deficits, close observation of their neurological status and its many physiologic parameters is demanded. Monitoring the patient's status and helping to prevent complications related to re-bleed and vasospasm are critical. Assisting the patient and his family to cope with the many problems presented during his hospitalization provides many stressors to the neurology staff nurse. A multi-disciplinary approach to the long-term care of this patient helps to reduce stress for the neurology nursing staff and optimizes the benefits for the cerebral aneurysm patient.