Barriers and facilitators to implementing evidence-based integrated HIV and behavioral health care: perspectives from seven federal ending the HIV epidemic jurisdictions

The federal Ending the HIV Epidemic (EHE) initiative was created to reduce new US HIV infections, largely through pre-exposure prophylaxis and HIV treatments that reduce HIV transmissibility to zero. Behavioral health disorders (mental health and substance use) remain significant barriers to achieving EHE goals. Addressing behavioral health (BH) disorders within HIV primary care settings has been promoted as a critical EHE strategy. Implementation of efficacious HIV-BH care integration and its impact on HIV-related health outcomes is not well documented. In a federally-funded, exploratory phase implementation science study, we used the Collective Impact Framework to engage partners in seven EHE jurisdictions about the feasibility, acceptability, and sustainability of implementing HIV-BH integration interventions within local HIV settings. Partners concluded that full integration will remain the exception unless health systems invest in collaborative practice, professional training, appropriate health technology, and inter-system communication. Partners supported smaller incremental improvements including transdiagnostic approaches to reinforce each team member's sense of value in the shared endeavor. This early phase implementation science study identified research and implementation gaps that are critical to fill to end the HIV epidemic. Both the Collective Impact Framework and implementation science show promise for guiding future implementation of evidence-based HIV-BH intervention integration.

Interventions for Integrating Behavioral Health into HIV Settings for US Adults: A Narrative Review of Systematic Reviews and Meta-analyses, 2010-2020

Mental health and substance use disorders can negatively affect physical health, illness management, care access, and quality of life. These behavioral health conditions are prevalent and undertreated among people with HIV and may worsen outcomes along the entire HIV Care Continuum. This narrative review of tested interventions for integrating care for HIV and behavioral health disorders summarizes and contextualizes findings from systematic reviews and meta-analyses conducted in the past decade. We sought to identify gaps in research that hinder implementing evidence-based integrated care approaches. Using terms from the Substance Abuse and Mental Health Services Administration-Health Resources & Services Administration standard framework for integrated health care, we searched PubMed and PsycInfo to identify peer-reviewed systematic reviews or meta-analyses of intervention studies to integrate behavioral health and HIV published between 2010 and 2020. Among 23 studies identified, only reviews and meta-analyses that described interventions from the United States designed to integrate BH services into HIV settings for adults were retained, leaving six studies for narrative review by the study team. Demonstrated benefits from the relatively small literature on integrated care interventions include improved patient- and service-level outcomes, particularly for in-person case management and outreach interventions. Needed are systems-level integration interventions with assessments of long-term outcomes on behavioral health symptoms, HIV viral suppression, HIV transmission rates, and mortality. HIV, primary care, and other providers must include behavioral health as a part of overall healthcare and must play a central role in behavioral health care delivery. Research is needed to guide their way.

Durable Viral Suppression Among Young Adults Living with HIV Receiving Ryan White Services in New York City

Identifying factors associated with durable viral suppression (DVS) can inform interventions to support young adults living with HIV (YALWH) in sustaining optimal health. We examined associations between client characteristics and DVS among YALWH aged 18-29 who completed an intake assessment and received ≥ 1 Ryan White Part A service in New York City from 1/2017 to 12/2019. Individuals were classified as achieving DVS at least once if they had ≥ 2 suppressed viral load test results ≥ 90 days apart with: (a) no intervening unsuppressed viral load test results in a 12-month period; and (b) no unsuppressed viral load test results after achieving DVS in that 12-month period. Of 2208 YALWH, 92.1% (n = 2034) had sufficient data in the New York City HIV Surveillance Registry to ascertain DVS status. Of these, 68% achieved DVS at least once. Controlling for ART prescription status at intake, YALWH with higher incomes were significantly more likely to achieve DVS at least once. YALWH with lifetime and recent histories of incarceration and/or drug use were significantly less likely to achieve DVS. Our findings underscore the potential role of tailored harm reduction and post-incarceration programs in reducing health inequities among YALWH.

Efficacy of influenza vaccine (Fluvax) in cancer patients on treatment: a prospective single arm, open-label study

PURPOSE

Influenza virus infection has significant morbidity and mortality in patients with medical co-morbidities who are also immunosuppressed. The efficacy of the seasonal influenza vaccine has not been well studied in patients receiving chemotherapy. We assessed the efficacy of seasonal influenza vaccine in patients with non-haematological malignancy on active treatment (chemotherapy and targeted therapy).

METHODS

A prospective single arm, open label study with 53 patients with non-haematological cancers recruited during the 2011 and 2012 influenza seasons. Participants had one dose of 2011/2012 trivalent vaccine containing strains A/California/7/2009(H1N1), A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008 (Fluvax) prior to or in-between treatment cycles. Haemagglutination inhibition antibody (HIA) titres in serum were measured at baseline 3, 6 and 24 weeks. Primary endpoint: seroconversion rate (SCR) at 3 weeks. Secondary endpoints: late SCR at 6 weeks. rate of sustained sero-protection titres (SPR) at 24 weeks. Seroconversion was defined as postvaccination ≥ 4-fold increase in HIA titre and sero-protection defined as a HIA ≥ 1:40.

RESULTS

The SCR at 3 weeks were 35%, 30% and 22.5% to the H1N1, H3N2 and B/Bris strains, respectively. There were no new cases of late SC at 6 weeks or 24 weeks. The SPR at 3 weeks were 72.5%, 65% and 40%, respectively, to H1N1, H3N2 and B/Bris. The SPR at 24 weeks to H1N1, H3N2 and B/Bris were 40%, 52.5% and 17.5%, respectively.

CONCLUSIONS

Patients on various solid tumour treatments achieve sero-protection rate congruent with the general population. The sero-protection HIA titres were not sustained at 24 weeks postvaccination.

Effect of pericardial effusion on outcomes in children admitted with systemic lupus erythematosus: a multicenter retrospective cohort study from the United States

OBJECTIVE

We sought to describe characteristics of children admitted with pericardial effusion (PCE) and systemic lupus erythematosus (SLE) and determine the association between PCE and outcomes of interest.

METHODS

We performed a retrospective cohort study of the Pediatric Health Information System (PHIS). Patients were included if they were admitted to a PHIS participating hospital from 2004 to 2015 with a diagnosis of SLE and age ≤18 years. Children with congenital heart disease or who had undergone heart surgery were excluded. PCE was the primary predictor variable; multivariable analysis was used to evaluate the effect of PCE on the following outcomes: mortality, length of stay (LOS), and readmission within 30 days.

RESULTS

There were 5679 admissions, of which 705 (12.4%) had PCE. Median age at admission was 15 years (interquartile range: 13-17). There were no significant differences for age or sex between patients admitted either with or without PCE. A significantly higher percentage of children in the PCE group were black compared with those without PCE (43% vs. 31%, p < 0.001). In multivariable analysis, the odds of a black patient having PCE were 1.7 higher than non-black patients ( p < 0.001). In-hospital mortality was 2.5 times higher in children with PCE compared with those without PCE ( p = 0.027). Those with PCE also had 1.5 greater odds of readmission within 30 days ( p < 0.001). PCE was not associated with increased LOS (0.99, p = 0.753).

CONCLUSION

PCE is common in admissions of children with SLE. There are disproportionately more black patients with SLE affected by PCE than non-black. PCE is associated with significantly higher mortality and rates of readmission.

Successful delayed-interval delivery in the presence of clinical chorioamnionitis in the leading twin: A report of two cases

We present two cases of diamniotic, dichorionic twin pregnancies in which after the loss of the first foetus in the setting of clinical chorioamnionitis, both pregnancies were successfully managed by delayed-interval delivery. A fourstage protocol including aspects of management in this specific setting is proposed. We consider the importance of a selection process when managing conservatively, measures to promote latency and decisions regarding delivery of the foetuses. Whilst we report successful case studies of conservative management with delayed-interval delivery, we support a cautious approach and understand that in the setting of clinical chorioamnionitis of the remaining foetus, delivery is necessary.

1162. Epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa Identified Through the Emerging Infections Program (EIP), United States, 2016–2017

Background

Pseudomonas aeruginosa is intrinsically resistant to many commonly used antimicrobials and carbapenems are often required to treat infections. We describe the epidemiology and crude incidence of carbapenem-resistant P. aeruginosa(CRPA) in the EIP catchment area.

Methods

From August 1, 2016 through July 31, 2017, we conducted laboratory- and population-based surveillance for CRPA in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. We defined an incident case as the first isolate of P. aeruginosa-resistant to imipenem, meropenem, or doripenem from the lower respiratory tract, urine, wounds, or normally sterile sites identified from a resident of the EIP catchment area in a 30-day period. Patient charts were reviewed. A random sample of isolates was screened at CDC for carbapenemases using the modified carbapenem inactivation method (mCIM) and real-time PCR.

Results

During the 12-month period, we identified 3,042 incident cases among 2,154 patients. The crude incidence rate was 21.2 (95% CI, 20.4–21.9) per 100,000 persons and varied by site (range: 7.7 in Oregon to 31.1 in Maryland). The median age of patients was 64 years (range: <1–101) and 41.2% were female. Nearly all (97.1%) had at least one underlying condition and 10.2% had cystic fibrosis (CF); 17.8% of cases were from CF patients. For most cases, isolates were from the lower respiratory tract (49.2%) or urine (35.3%) and occurred in patients with recent hospitalization (87.2%) or indwelling devices (70.3%); 8.7% died. At the clinical laboratory, 84.7% of isolates were susceptible to an aminoglycoside and 66.4% to ceftazidime or cefepime. Among the 391 isolates tested, nine (2.3%) were mCIM-positive; one had a carbapenemase detected by PCR (bla_VIM-4).

Conclusion

The burden of CRPA varied by EIP site. Most cases occurred in persons with healthcare exposures and underlying conditions. The majority of isolates were susceptible to at least one first-line antimicrobial. Carbapenemase producers were rare; a more specific phenotypic definition would greatly facilitate surveillance for these isolates.

Disclosures

All authors: No reported disclosures.

Abstract P3-05-07: Improving CAR T cell function by reversing the immunosuppressive tumor environment of breast cancer

Adoptive transfer of T cells redirected to tumor-associated antigens (TAAs) by expression of chimeric antigen receptors (CARs) can produce tumor responses, even in patients with resistant malignancies. To target breast cancer, we generated T cells expressing a CAR directed to the TAA mucin-1 (MUC1). T cells expressing this CAR (86±1.9%, n=5) specifically killed MUC1-expressing cells (MDA-MB-468 – 45.9±7.3%, MCF-7 – 36.8±3.6) but not MUC1(-) 293T cells (3.7±1.6% specific lysis, 20:1 E:T, n=3). Although these CAR T cells had potent anti-tumor activity against breast cancer cells, when exposed to the Th2-polarizing cytokine IL4 [which is upregulated in tumor samples (Oncomine, p&lt;0.05)] we observed a dramatic reduction in their cytolytic potential [IL2 - 45.9±7.3% vs IL4 - 11.3±3.7% specific lysis, 20:1 E:T ratio, n=4]. Thus, to protect our CAR.MUC1 T cells from the negative influences of IL4, we generated an inverted cytokine receptor (ICR) in which the IL4 receptor exodomain was fused to the IL7 receptor endodomain (4/7 ICR). Transgenic expression of this molecule in CAR.MUC1 T cells (55±4.8% double positive cells, n=5), restored the cytolytic function of CAR T cells (30.9±8.1% specific lysis, 20:1 E:T, n=3). Next, to determine the long term effects of this modification we co-cultured transgenic T cells with MUC1+ tumor cells and measured tumor and T cells numbers. In the presence of IL4, only double positive (CAR.MUC1-4/7) T cells expanded and eliminated the tumors in vitro and in vivo. However, upon tumor elimination, transgenic T cells rapidly contracted, demonstrating the antigen- and cytokine-dependence of the product. In conclusion, CAR.MUC1-4/7 T cells can effectively target breast cancer cells and retain their cytotoxic function even in the IL4-rich tumor microenvironment.

Citation Format: Bajgain P, Tawinwung S, Watanabe N, Sukumaran S, Anurathapan U, Heslop HE, Rooney CM, Brenner M, Leen AM, Vera JF. Improving CAR T cell function by reversing the immunosuppressive tumor environment of breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-07.

Impact of obstructive sleep apnea on neurological recovery after ischemic stroke: A prospective study

OBJECTIVES

The presence of obstructive sleep apnea (OSA) has been found to adversely affect the neurological recovery after acute ischemic stroke (AIS) in previous observational studies. However, in most of these studies, diagnosis of OSA was based on oximetry data alone, raising concern in the accuracy of diagnosis as well as estimation of severity. Purpose of our study was to determine the prevalence and severity of OSA (based on polysomnography and American Association of Sleep Medicine [AASM] criteria) in patients with AIS and to compare the post-stroke neurological and functional outcome, in those with and without OSA.

MATERIALS AND METHODS

A prospective single-centre study was conducted over a period of eighteen months from January 2013. The demographic and clinical data were collected, and the etiology of stroke was classified according to TOAST classification. Subsequently, all selected patients (N=99) underwent premorbid sleep status assessment by Epworth Sleepiness Scale followed by polysomnography using Resmed ApneaLink polysomnograph. Data were analyzed to find out the prevalence and severity of OSA as well as its impact on neurological recovery as assessed by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) at different time points, starting from admission.

RESULTS

There was a high prevalence of OSA (~60%) with a quarter of them having severe OSA. The OSA group had a significantly higher mean NIHSS score at discharge (P=.002) and significantly higher mRS score (irrespective of severity of OSA) at all points of evaluation.

CONCLUSION

Ischemic stroke patients with OSA tend to have poor neurological and functional recovery, across all segments of stroke and OSA severity.

Comparison of 30- and 90-Day Mortality Rates in Patients with Cultures Positive for Carbapenem-resistant Enterobacteriaceae and Acinetobacter in Atlanta, 2011–2015

Background

Carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (CRAB) pose a threat to public health, but comparisons of disease burden are limited. We compared survival in patients following cultures positive for CRE or CRAB.

Methods

The Georgia Emerging Infections Program performs active population-based and laboratory-based surveillance for CRE and CRAB in metropolitan Atlanta, GA. Using standard CDC definitions, we included patients who had incident carbapenem-nonsusceptible E. coli, Klebsiella spp., Enterobacter spp., or Acinetobacter baumannii isolated from urine only (noninvasive infection) or a sterile site (invasive infection) between 8/2011 and 12/2015. Death dates, verified by Georgia Vital Statistics records, were used to calculate 30- and 90-day mortality rates. We used the chi-square test for mortality rates and the log-rank test for survival analysis to 90 days to compare patients with invasive CRAB, noninvasive CRAB, invasive CRE, and noninvasive CRE.

Results

There were 535 patients with CRE (87 invasive, 448 noninvasive) and 279 (78 invasive, 201 noninvasive) with CRAB. Nearly all patients with CRE and CRAB had healthcare exposures (97.2% vs. 100%) and most were immunosuppressed (62.6% vs. 56.3%). Both 30-day (24.4% vs. 18.3%, p = 0.04) and 90-day (37.6% vs. 30.5%, p = 0.04) mortality were higher in patients with CRAB than CRE. Patients with invasive infections were more likely to die at 90 days than those with noninvasive infections (53.3% vs. 38.4%, p < 0.0001). Overall mortality rates for invasive infection were similar between CRAB and CRE at 30 (44.9% vs. 34.5% p = 0.2) and 90 days (59.0% vs. 48.3%, p = 0.2). Using survival analysis at 90 days, invasive CRAB had the worst outcomes, followed by invasive CRE, noninvasive CRAB and noninvasive CRE 
(p < 0.0001, see Figure).

Conclusion

Ninety-day mortality for invasive infections with CRE and CRAB was ~50%, and patients with CRAB had lower survival than those with CRE, suggesting that prevention efforts may need to prioritize CRAB as highly as CRE in facilities with endemic CRAB. With the high proportion of healthcare exposures and immunosuppression, these infections may signify poor prognosis or directly contribute to mortality.

Disclosures

All authors: No reported disclosures.

Pregnancy screening prior to chemotherapy administration

A retrospective case notes review was performed to determine compliance with screening for undetected pregnancy prior to commencement of chemotherapy at Flinders Medical Centre. All female patients aged 18-55 who commenced chemotherapy between January and December 2014 were included. During the first 12 months, for women identified as having childbearing potential, pre-chemotherapy pregnancy screening was performed only in 40% of patients under 40 years and in 20.5% of the entire age range.

Delayed onset of benign pleural effusion following concurrent chemoradiotherapy for inoperable non-small-cell lung cancer

Chronic benign pleural effusion (BPE) is a rare complication of concurrent chemoradiotherapy (CRT) for inoperable stage IIIA non-small-cell lung cancer (NSCLC). This report presents three cases of BPE, the workup to differentiate this benign condition from recurrence of cancer and recommends a pleural biopsy as part of the diagnostic process. These inflammatory exudates often remain indolent, and may not require drainage or surgical intervention. In the absence of clinical, radiological and pathological evidence of recurrent disease, we recommend clinicians manage these patients expectantly, using regular clinical assessment and imaging.

Genetic characterization of the wheat association mapping initiative (WAMI) panel for dissection of complex traits in spring wheat

The wheat association mapping initiative is appropriate for gene discovery without the confounding effects of phenology and plant height. The wheat association mapping initiative (WAMI) population is a set of 287 diverse advanced wheat lines with a narrow range of variation for days to heading (DH) and plant height (PH). This study aimed to characterize the WAMI and showed that this diverse panel has a favorable genetic background in which stress adaptive traits and their alleles contributing to final yield can be identified with reduced confounding major gene effects through genome-wide association studies (GWAS). Using single nucleotide polymorphism (SNP) markers, we observed lower gene diversity on the D genome, compared with the other genomes. Population structure was primarily related to the distribution of the 1B.1R rye translocation. The narrow range of variation for DH and PH in the WAMI population still entailed segregation for a few markers associated with the former traits, while Rht genes were associated with grain yield (GY). Genotype by environment (G × E) interaction for GY was primarily explained by Rht-B1, Vrn-A1 and markers on chromosomes 2D and 3A when running GWAS with genotype scores from the G × E biplot. The use of PC scores from the G × E biplot seems a promising tool to determine genes and markers associated with complex interactions across environments. The WAMI panel lends itself to GWAS for complex trait dissection by avoiding the confounding effects of DH and PH which were reduced to a minimum (using Rht-B1 and Vrn-A1 scores as covariables), with significant associations with GY on chromosomes 2D, 3A and 3B.

Screening, diagnosis and management of gestational diabetes mellitus: A national survey

BACKGROUND AND METHODS

We conducted a National survey between February and June 2012 to evaluate the practices concerning screening, diagnosis and management of Gestational Diabetes (GDM) in England.

RESULTS

A total of 102/126 (80%) maternity units responded. The National Institute of Health and Clinical Excellence (NICE) recommended screening criteria were used by 83% of units. All the units performed 2 h 75 g oral glucose tolerance test (OGTT) between 24 and 28 weeks. There was a wide variation in the diagnostic blood glucose values used by different units. About 86% of units used a 2 h blood glucose value of ≥7.8 mmol/l and 45% of units used fasting value ≥6.1 mmol/l to diagnose GDM. Only 26% of units advised self-monitoring of blood glucose pre meal and 1 h post-meal, whereas 64% of units advised monitoring 2 h after the meal. Metformin was started when women did not respond to dietary measures in 101 units (99%). Regular growth scans every four weeks from 28 weeks onwards were performed by 99 units (97%). Women on metformin with no complications were offered induction of labour at 38 completed weeks in 97 units (95%). 84 maternity units (82.3%) offered OGTT six weeks postnatally.

CONCLUSION

Our survey has shown consistency in screening using the NICE criteria, use of 2 h 75 g OGTT at 24-28 weeks, in providing dietary support, use of metformin and ultrasound for fetal growth. But there is wide variation in the criteria used to diagnose GDM, self-monitoring of blood glucose, induction of labour and six weeks postnatal testing.

Phytochemical constituents and antibacterial efficacy of the flowers of Peltophorum pterocarpum (DC.) Baker ex Heyne

OBJECTIVE

To investigate the preliminary phytochemistry and antibacterial activity of the flower extract of Peltophorum pterocarpum .

METHODS

Phytochemical analysis was done by using the standard methods given by Harbone. The methanolic flower extract were tested against Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus cereus, Salmonella typhi, Serratia marsecens, Acinetobacter baumannii, Enterobacter sp., Proteus mirabilis, Enterococcus faecalis and Streptococcus pyogenes by the agar disc diffusion method.

RESULTS

Preliminary phytochemical screening of flower extract showed the presence of phenolic compounds, flavonoids, saponins, steroids, tannins, xanthoproteins, carboxylic acids, coumarins and carbohydrates. The flower extract of Peltophorum pterocarpum showed significant activity against four gram positive (Staphylococcus aureus, Bacillus cereus, Enterococcus faecalis and Streptococcus pyogenes) and three gram negative bacteria (Proteus mirabilis, Acinetobacter baumannii and Serratia marsecens), out of 12 pathogenic bacteria studied.

CONCLUSIONS

The findings of the present study confirm the presence of significant antibacterial activity against human pathogens in the flowers of Peltophorum pterocarpum.

Capecitabine and irinotecan (XELIRI) in first-line treatment of metastatic colorectal cancer (mCRC): A systematic review of controlled clinical trials

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Background: Irinotecan and 5-Fluorouracil based combination is an effective regimen for mCRC. Capecitabine, an oral fluoropyrimidine, is a convenient alternative to intravenous 5- Fluorouracil. This study aims to systematically review all published and unpublished controlled phase II and III trials of XELIRI combination, used in first line treatment of mCRC, reported from 2000–2008, to describe its efficacy and safety. Methods: A literature search of MEDLINE, EMBASE, CINAHL and proceedings from ASCO, ESMO and WGIC was conducted. The primary end point was response rate (RR), secondary endpoints include: time to progression (TTP), overall survival (OS) and toxicity. Results: Thirty non-randomised phase II trials (n = 1380) along with 6 randomised phase II and 3 phase III trials, were included (pooled n = 1478). The daily dose of capecitabine ranged from 1,800 mg/m2 to 2,500 mg/m2 for 7 to 14 days per cycle and the dose of irinotecan varied from 180mg/m2 to 350 mg/m2, over a 3 week period per cycle. Amongst the non-randomised studies, the median patient age was 61 years (53–72).The median RR was 46.75% (25–78%). The median reported TTP was 7.9 months (mo) (5- 9.9 mo) and the median OS was 15.6 months (7–24.8 mo). Grade 3–4 toxicity incidence was: diarrhoea (21.5%), neutropenia (12%), vomiting (12.5%), fatigue (6%) and Hand-foot syndrome (6%). The pooled incidence of febrile neutropenia was 2.5%. Amongst the randomised trials, the comparator regimens were XELOX or FOLFIRI. Median age was 65 years (61–74). RR for XELIRI was 39% (34–56%) compared to 47% (27–61.8%) for the non XELIRI comparator arms. Median reported TTP was 8.2 mo (5.7–12.5 mo) for the XELIRI arms and 9.2 mo for the comparator arms. Conclusions: XELIRI is an effective and feasible regime in the first line management of mCRC. However the optimal role of this combination remains to be established.

No significant financial relationships to disclose.

Structure-function correlation of outer membrane protein porin from Paracoccus denitrificans

Porins from outer membrane of Gram-negative bacteria have a highly stable structure. Our previous studies on porin from Paracoccus denitrificans showed that the outer membrane protein porin is extremely stable toward heat, pH, and chemical denaturants. The major question we have addressed in this paper is whether the high stability of porin is a consequence of the beta-barrel structure and whether it is required for its function. To explain this we have analyzed two cases: first, we used porin wild-type and mutants and compared their structure and function; second, we compared the activity of porin preheated to different temperatures. Structural changes were monitored by infrared spectroscopy. We observed that the structural stability of porin is not equivalent to functional activity as minor alteration in the structure can result in drastic differences in the activity of porins.

Safety of newer generation anti-epileptic drugs in non-accidental overdose: an Irish population study

Seven new anti-epileptic drugs (AEDs) have become available in Ireland over the last 10 years; data from animal models and clinical trials suggest that they have a superior safety profile to older AEDs. A specific relationship between epilepsy and psychiatric co-morbidity has long been recognised, including the relationship between epilepsy and suicide. AEDs are common agents taken in intentional drug overdoses. We undertook a study to review the frequency and outcome of non-accidental overdose with seven new AEDS in an Irish population from 1996 to 2000.

METHOD

All reported cases of drug overdoses with AEDs from 1996 to 2000 were reviewed. Data was provided by the National Poisons Information Centre, Beaumont Hospital and the Central Statistics Office. Medical records from Beaumont Hospital were reviewed in specific cases of serious drug toxicities. An extensive review of published literature reviewing the safety profile of these AEDs was performed and medical literature retrieved from the databases of the pharmaceutical industry was similarly reviewed.

RESULTS

Of the 164 reported cases of newer AEDs, there were no fatalities among the cases followed up.

CONCLUSION

The absence of mortalities and serious consequences from deliberate self-poisoning with the newer agents is supportive evidence for the superior safety profile of the newer AEDs.

Prehospital trauma management: a national study of paramedic activities

OBJECTIVES

The benefits of prehospital trauma management remain controversial. This study aimed to compare the processes of care and outcomes of trauma patients treated by paramedics, who are trained in advanced prehospital trauma care, with those treated by ambulance technicians.

METHODS

A six year prospective study was conducted of adult trauma patients attended to by the Scottish Ambulance Service and subsequently admitted to hospital. Prehospital times, interventions, triage, and outcomes were compared between patients treated by paramedics and those treated by technicians.

RESULTS

Paramedics attended more severely injured patients (16.5% versus 13.9%, p<0.001); they attended a higher proportion of patients with penetrating trauma (6.6% versus 5.7%, p = 0.014) and had longer prehospital times. Patients managed by paramedics were more likely to be taken to the intensive care unit, operating theatre or mortuary, (11.2% versus 7.8%, p<0.001) and had higher crude mortality rates (5.3% versus 4.5%, p = 0.07). However, no difference in mortality between the two groups was noted when corrected for age, Glasgow coma score and injury severity score.

CONCLUSIONS

This large scale national study shows that paramedics show good triage skills and clinical judgement when managing trauma patients. However, the value of the individual interventions they perform could not be ascertained. Further controlled trials are necessary to determine the true benefits of advanced prehospital trauma life support.

Investigation of the thermal stability of porin fromParacoccus denitrificansby site-directed mutagenesis and Fourier transform infrared spectroscopy

The folding of membrane proteins was addressed using outer membrane protein porin from the soil bacterium Paracoccus denitrificans (P. den.). IR spectroscopy and sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) analysis were used to probe the effect of mutagenesis on the thermal stability of the protein. Secondary structure analysis by amide I ir spectroscopy showed that the wild-type protein was predominantly composed of beta-sheet, which supports the x-ray crystal structure information (A. Hirsch, J. Breed, K. Saxena, O.-M. H. Richter, B. Ludwig, K. Diederichs, and W. Welte, FEBS Letters, 1997, Vol. 404, pp. 208-210). The mutants E81Q, W74C, and E81Q/D148N were shown to have similar secondary structure composition as the wild type. Wild-type protein and the mutants in detergent micelles underwent irreversible denaturation as a result of heating. Transition temperature calculated from the amide I analysis revealed that mutant porins were slightly less stable compared to the wild type. The protein in micelles showed complete monomerization of the trimer above 85 degrees C. In native-like conditions (provided by liposomes), no change was observed in the secondary structure of the protein until 95 degrees C. This is supported by SDS-PAGE as no change in quaternary structure was observed, proving that the proteins are structurally thermostable in liposomes as compared to micelles. Our studies demonstrated that porins resistant to detergents and proteases are highly thermostable as well.

Influence of shear flow on vesicles near a wall: A numerical study

We describe the dynamics of three-dimensional fluid vesicles in steady shear flow in the vicinity of a wall. This is analyzed numerically at low Reynolds numbers using a boundary element method. The area-incompressible vesicle exhibits bending elasticity. Forces due to adhesion or gravity oppose the hydrodynamic lift force driving the vesicle away from a wall. We investigate three cases. First, a neutrally buoyant vesicle is placed in the vicinity of a wall that acts only as a geometrical constraint. We find that the lift velocity is linearly proportional to shear rate and decreases with increasing distance between the vesicle and the wall. Second, with a vesicle filled with a denser fluid, we find a stationary hovering state. We present an estimate of the viscous lift force that seems to agree with recent experiments of Lorz et al. [Europhys. Lett. 51, 468 (2000)]. Third, if the wall exerts an additional adhesive force, we investigate the dynamical unbinding transition that occurs at an adhesion strength linearly proportional to the shear rate.

Unusual substrate specificity of a chimeric hypoxanthine-guanine phosphoribosyltransferase containing segments from the Plasmodium falciparum and human enzymes

Hypoxanthine-guanine phosphoribosyltransferase (HGPRT) catalyzes the phosphoribosylation of hypoxanthine and guanine by transferring the phosphoribosyl moiety from phosphoribosylpyrophosphate (PRPP) on to N9 in the purine base, resulting in the formation of inosine monophosphate (IMP) and guanosine monophosphate (GMP). Xanthine is an additional substrate for the Plasmodium falciparum HGXPRT. Our aim has been to elucidate structural features in HGPRT that govern substrate specificity. We have addressed this problem by engineering chimeric HGPRTs, which contain segments from both the parasite and human enzymes. Four chimeric enzymes were engineered (DS1-DS4), of which the chimeric enzyme, DS1, in which the first 49 residues of human HGPRT were replaced with the corresponding residues from the P. falciparum enzyme, exhibited additional specificity for xanthine. None of the switched residues forms a part of the purine or PRPP binding region in the available crystal structures of HG(X)PRTs. Our data on the chimeric enzyme DS1 provide the first evidence that the N-terminal approximately 50 amino acids, although not proximal to the active site in the crystal structure, can in fact modulate substrate specificity. DS1 exhibits a reduced k(cat) for hypoxanthine and guanine, while its K(m) for these oxopurine bases remains largely unchanged. Its specific activity for xanthine is comparable with hypoxanthine but five times more than that for guanine.

The Dictyostelium LIM domain-containing protein LIM2 is essential for proper chemotaxis and morphogenesis

We have identified limB, a gene encoding a novel LIM domain-containing protein, LIM2, in a screen for genes required for morphogenesis. limB null cells aggregate, although poorly, but they are unable to undergo morphogenesis, and the aggregates arrest at the mound stage. limB null cells exhibit an aberrant actin cytoskeleton and have numerous F-actin-enriched microspikes. The cells exhibit poor adhesion to a substratum and do not form tight cell-cell agglomerates in suspension. Furthermore, limB null cells are unable to properly polarize in chemoattractant gradients and move very poorly. Expression of limB from a prestalk-specific but not a prespore-specific promoter complements the morphogenetic defects of the limB null strain, suggesting that the limB null cell developmental defect results from an inability to properly sort prestalk cells. LIM2 protein is enriched in the cortex of wild-type cells, although it does not colocalize with the actin cytoskeleton. Our analysis indicates that LIM2 is a new regulatory protein that functions to control rearrangements of the actin cytoskeleton and is required for cell motility and chemotaxis. Our findings may be generally applicable to understanding pathways that control cell movement and morphogenesis in all multicellular organisms. Structure function studies on the LIM domains are presented.

lagC-null and gbf-null cells define key steps in the morphogenesis of Dictyostelium mounds

The transition to multicellularity is a key feature of the Dictyostelium life cycle, and two genes, gbf and lagC, are known to play pivotal roles in regulating this developmental switch. lagC-null and gbf-null cells fail to induce cell-type-specific genes ordinarily expressed during multicellular development. The null mutants also share a similar morphological phenotype: mutant cells repeatedly aggregate to form a loose mound, disperse, and reform a mound, rather than proceeding to form a tip. To characterize defects in morphogenesis in these mutants, we examined cell motion in the mutant mounds. In analogy with the failed transition in gene expression, we found that lagC-null and gbf-null mounds failed to make a morphogenetic transition from random to rotational motion normally observed in the parent strain. One reason for this was the inability of the mutant mounds to establish a single, dominant signaling-wave center. This defect of lagC-null or gbf-null cells could be overcome by the addition of adenosine, which alters cAMP signaling, but then even in the presence of apparently normal signaling waves, cell motility was still aberrant. This motility defect, as well as the signaling-wave defect, could be overcome in lagC-null cells by overexpression of GBF, suggesting that lagC is dispensable if GBF protein levels are high enough. This set of morphogenetic defects that we have observed helps define key steps in mound morphogenesis. These include the establishment of a dominant signaling-wave center and the capacity of cells to move directionally within the cell mass in response to guidance cues.

Differential expression of the arabidopsis nia1 and nia2 genes. cytokinin-induced nitrate reductase activity is correlated with increased nia1 transcription and mrna levels

Nitrate reductase (NR) activity increased up to 14-fold in response to treatment of Arabidopsis thaliana seedlings with the cytokinin benzyladenine. NR induction was observed in seedlings germinated directly on cytokinin-containing medium, seedlings transferred to cytokinin medium, and seedlings grown in soil in which cytokinin was applied directly to the leaves. About the same level of induction was seen in both wild-type and Nia2-deletion mutants, indicating that increased NR activity is related to the expression of the minor NR gene, Nia1. The steady-state Nia1 mRNA level was increased severalfold in both wild-type and mutant seedlings after benzyladenine treatment. Transcript levels of the Nia2 gene, which is responsible for 90% of the NR activity in developing wild-type seedlings, did not show any changes upon cytokinin treatment. Nuclear run-on assays demonstrated that Nia1 gene transcription increased dramatically after cytokinin treatment.

The effects of thyroxine treatment on slow- and fast-contracting skeletal muscle contractions of the cat and their cyclic AMP level

1. The effects of thyroxine treatment on soleus and extensor digitorum longus (EDL) muscle contractions and their cyclic adenosine 3',5'-monophosphate (cyclic AMP) levels were examined in anaesthetized cats. 2. Thyroxine treatment decreased the tension of incomplete tetanic contractions of the soleus as well as the EDL muscles. The effect on tension of these muscles was not associated with an increase in the cyclic AMP level of the muscle as is the case with a beta 2-adrenoceptor agonist effect. 3. The results do not support the involvement of cyclic AMP in the tension depressant effect of thyroxine on contractions of skeletal muscle. 4. It is suggested that the muscle weakness and tremor observed in thyrotoxicosis and during administration of beta 2-adrenoceptor agonists are mediated by different mechanisms.