Applying a Phase-Separation Parameterization in Modeling Secondary Organic Aerosol Formation from Acid-Driven Reactive Uptake of Isoprene Epoxydiols under Humid Conditions.

Secondary organic aerosol (SOA) from acid-driven reactive uptake of isoprene epoxydiols (IEPOX) contributes up to 40% of organic aerosol (OA) mass in fine particulate matter. Previous work showed that IEPOX substantially converts particulate inorganic sulfates to surface-active organosulfates (OSs). This decreases aerosol acidity and creates a viscous organic-rich shell that poses as a diffusion barrier, inhibiting additional reactive uptake of IEPOX. To account for this "self-limiting" effect, we developed a phase-separation box model to evaluate parameterizations of IEPOX reactive uptake against time-resolved chamber measurements of IEPOX-SOA tracers, including 2-methyltetrols (2-MT) and methyltetrol sulfates (MTS), at ~ 50% relative humidity. The phase-separation model was most sensitive to the mass accommodation coefficient, IEPOX diffusivity in the organic shell, and ratio of the third-order reaction rate constants forming 2-MT and MTS ( k M T / k M T S ). In particular, k M T / k M T S had to be lower than 0.1 to bring model predictions of 2-MT and MTS in closer agreement with chamber measurements; prior studies reported values larger than 0.71. The model-derived rate constants favor more particulate MTS formation due to 2-MT likely off-gassing at ambient-relevant OA loadings. Incorporating this parametrization into chemical transport models is expected to predict lower IEPOX-SOA mass and volatility due to the predominance of OSs.

Aerosolized Cyanobacterial Harmful Algal Bloom Toxins: Microcystin Congeners Quantified in the Atmosphere.

Cyanobacterial harmful algal blooms (cHABs) have the potential to adversely affect public health through the production of toxins such as microcystins, which consist of numerous molecularly distinct congeners. Microcystins have been observed in the atmosphere after emission from freshwater lakes, but little is known about the health effects of inhaling microcystins and the factors contributing to microcystin aerosolization. This study quantified total microcystin concentrations in water and aerosol samples collected around Grand Lake St. Marys (GLSM), Ohio. Microcystin concentrations in water samples collected on the same day ranged from 13 to 23 µg/L, dominated by the d-Asp3-MC-RR congener. In particulate matter <2.5 µm (PM2.5), microcystin concentrations up to 156 pg/m3 were detected; the microcystins were composed primarily of d-Asp3-MC-RR, with additional congeners (d-Asp3-MC-HtyR and d-Asp3-MC-LR) observed in a sample collected prior to a storm event. The PM size fraction containing the highest aerosolized MC concentration ranged from 0.44 to 2.5 µm. Analysis of total bacteria by qPCR targeting 16S rDNA revealed concentrations up to 9.4 × 104 gc/m3 in aerosol samples (≤3 µm), while a marker specific to cyanobacteria was not detected in any aerosol samples. Concentrations of aerosolized microcystins varied even when concentrations in water were relatively constant, demonstrating the importance of meteorological conditions (wind speed and direction) and aerosol generation mechanism(s) (wave breaking, spillway, and aeration systems) when evaluating inhalation exposure to microcystins and subsequent impacts on human health.

Wildfires Increase Concentrations of Hazardous Air Pollutants in Downwind Communities.

Due in part to climate change, wildfire activity is increasing, with the potential for greater public health impact from smoke in downwind communities. Studies examining the health effects of wildfire smoke have focused primarily on fine particulate matter (PM2.5), but there is a need to better characterize other constituents, such as hazardous air pollutants (HAPs). HAPs are chemicals known or suspected to cause cancer or other serious health effects that are regulated by the United States (US) Environmental Protection Agency. Here, we analyzed concentrations of 21 HAPs in wildfire smoke from 2006 to 2020 at 309 monitors across the western US. Additionally, we examined HAP concentrations measured in a major population center (San Jose, CA) affected by multiple fires from 2017 to 2020. We found that concentrations of select HAPs, namely acetaldehyde, acrolein, chloroform, formaldehyde, manganese, and tetrachloroethylene, were all significantly elevated on smoke-impacted versus nonsmoke days (P < 0.05). The largest median increase on smoke-impacted days was observed for formaldehyde, 1.3 µg/m3 (43%) higher than that on nonsmoke days. Acetaldehyde increased 0.73 µg/m3 (36%), and acrolein increased 0.14 µg/m3 (34%). By better characterizing these chemicals in wildfire smoke, we anticipate that this research will aid efforts to reduce exposures in downwind communities.

Wildfires in the western United States are mobilizing PM2.5-associated nutrients and may be contributing to downwind cyanobacteria blooms.

Wildfire activity is increasing in the continental U.S. and can be linked to climate change effects, including rising temperatures and more frequent drought conditions. Wildfire emissions and large fire frequency have increased in the western U.S., impacting human health and ecosystems. We linked 15 years (2006-2020) of particulate matter (PM2.5) chemical speciation data with smoke plume analysis to identify PM2.5-associated nutrients elevated in air samples on smoke-impacted days. Most macro- and micro-nutrients analyzed (phosphorus, calcium, potassium, sodium, silicon, aluminum, iron, manganese, and magnesium) were significantly elevated on smoke days across all years analyzed. The largest percent increase was observed for phosphorus. With the exception of ammonium, all other nutrients (nitrate, copper, and zinc), although not statistically significant, had higher median values across all years on smoke vs. non-smoke days. Not surprisingly, there was high variation between smoke impacted days, with some nutrients episodically elevated >10 000% during select fire events. Beyond nutrients, we also explored instances where algal blooms occurred in multiple lakes downwind from high-nutrient fires. In these cases, remotely sensed cyanobacteria indices in downwind lakes increased two to seven days following the occurrence of wildfire smoke above the lake. This suggests that elevated nutrients in wildfire smoke may contribute to downwind algal blooms. Since cyanobacteria blooms can be associated with the production of cyanotoxins and wildfire activity is increasing due to climate change, this finding has implications for drinking water reservoirs in the western United States, and for lake ecology, particularly alpine lakes with otherwise limited nutrient inputs.

Initial pH Governs Secondary Organic Aerosol Phase State and Morphology after Uptake of Isoprene Epoxydiols (IEPOX).

Aerosol acidity increases secondary organic aerosol (SOA) formed from the reactive uptake of isoprene-derived epoxydiols (IEPOX) by enhancing condensed-phase reactions within sulfate-containing submicron particles, leading to low-volatility organic products. However, the link between the initial aerosol acidity and the resulting physicochemical properties of IEPOX-derived SOA remains uncertain. Herein, we show distinct differences in the morphology, phase state, and chemical composition of individual organic-inorganic mixed particles after IEPOX uptake to ammonium sulfate particles with different initial atmospherically relevant acidities (pH = 1, 3, and 5). Physicochemical properties were characterized via atomic force microscopy coupled with photothermal infrared spectroscopy (AFM-PTIR) and Raman microspectroscopy. Compared to less acidic particles (pH 3 and 5), reactive uptake of IEPOX to the most acidic particles (pH 1) resulted in 50% more organosulfate formation, clearer phase separation (core-shell), and more irregularly shaped morphologies, suggesting that the organic phase transitioned to semisolid or solid. This study highlights that initial aerosol acidity may govern the subsequent aerosol physicochemical properties, such as viscosity and morphology, following the multiphase chemical reactions of IEPOX. These results can be used in future studies to improve model parameterizations of SOA formation from IEPOX and its properties, toward the goal of bridging predictions and atmospheric observations.

Wildfire Smoke Influence on Cloud Water Chemical Composition at Whiteface Mountain, New York.

Wildfires significantly impact air quality and climate, including through the production of aerosols that can nucleate cloud droplets and participate in aqueous-phase reactions. Cloud water was collected during the summer months (June-September) of 2010-2017 at Whiteface Mountain, New York and examined for biomass burning influence. Cloud water samples were classified by their smoke influence based on backward air mass trajectories and satellite-detected smoke. A total of 1,338 cloud water samples collected over 485 days were classified by their probability of smoke influence, with 49% of these days categorized as having moderate to high probability of smoke influence. Carbon monoxide and ozone levels were enhanced during smoke influenced days at the summit of Whiteface Mountain. Smoke-influenced cloud water samples were characterized by enhanced concentrations of potassium, sulfate, ammonium, and total organic carbon, compared to samples lacking identified influence. Five cloud water samples were examined further for the presence of dissolved organic compounds, insoluble particles, and light-absorbing components. The five selected cloud water samples contained the biomass burning tracer levoglucosan at 0.02-0.09 µM. Samples influenced by air masses that remained aloft, above the boundary layer during transport, had lower insoluble particle concentrations, larger insoluble particle diameters, and larger oxalate:sulfate ratios, suggesting cloud processing had occurred. These findings highlight the influence that local and long-range transported smoke have on cloud water composition.

Simultaneous Optical Photothermal Infrared (O-PTIR) and Raman Spectroscopy of Submicrometer Atmospheric Particles.

Physicochemical analysis of individual atmospheric aerosols at the most abundant sizes in the atmosphere (<1 µm) is analytically challenging, as hundreds to thousands of species are often present in femtoliter volumes. Vibrational spectroscopies, such as infrared (IR) and Raman, have great potential for probing functional groups in single particles at ambient pressure and temperature. However, the diffraction limit of IR radiation limits traditional IR microscopy to particles > ∼10 µm, which have less relevance to aerosol health and climate impacts. Optical photothermal infrared (O-PTIR) spectroscopy is a contactless method that circumvents diffraction limitations by using changes in the scattering intensity of a continuous wave visible laser (532 nm) to detect the photothermal expansion when a vibrational mode is excited by a tunable IR laser (QCL: 800-1800 cm-1 or OPO: 2600-3600 cm-1). Herein, we simultaneously collect O-PTIR spectra with Raman spectra at a single point for individual particles with aerodynamic diameters <400 nm (prior to impaction and spreading) at ambient temperature and pressure, by also collecting the inelastically scattered visible photons for Raman spectra. O-PTIR and Raman spectra were collected for submicrometer particles with different substrates, particle chemical compositions, and morphologies (i.e., core-shell), as well as IR mapping with submicron spatial resolution. Initial O-PTIR analysis of ambient atmospheric particles identified both inorganic and organic modes in individual sub- and supermicrometer particles. The simultaneous IR and Raman microscopy with submicrometer spatial resolution described herein has considerable potential both in atmospheric chemistry and numerous others fields (e.g., materials and biological research).

Aerosol Acidity Sensing via Polymer Degradation.

The acidity of atmospheric aerosols is a critical property that affects the chemistry and composition of the atmosphere. Many key multiphase chemical reactions are pH-dependent, impacting processes like secondary organic aerosol formation, and need to be understood at a single particle level due to differences in particle-to-particle composition that impact both climate and health. However, the analytical challenge of measuring aerosol acidity in individual particles has limited pH measurements for fine (<2.5 µm) and coarse (2.5-10 µm) particles. This has led to a reliance on indirect methods or thermodynamic modeling, which focus on average, not individual, particle pH. Thus, new approaches are needed to probe single particle pH. In this study, a novel method for pH measurement was explored using degradation of a pH-sensitive polymer, poly(ε-caprolactone), to determine the acidity of individual submicron particles. Submicron particles of known pH (0 or 6) were deposited on a polymer film (21-25 nm thick) and allowed to react. Particles were then rinsed off, and the degradation of the polymer was characterized using atomic force microscopy and Raman microspectroscopy. After degradation, holes in the PCL films exposed to pH 0 were observed, and the loss of the carbonyl stretch was monitored at 1723 cm-1. As particle size decreased, polymer degradation increased, indicating an increase in aerosol acidity at smaller particle diameters. This study describes a new approach to determine individual particle acidity and is a step toward addressing a key measurement gap related to our understanding of atmospheric aerosol impacts on climate and health.

Harmful Algal Bloom Toxins in Aerosol Generated from Inland Lake Water.

Harmful algal blooms (HABs) caused by cyanobacteria in freshwater environments produce toxins (e.g., microcystin) that are harmful to human and animal health. HAB frequency and intensity are increasing with greater nutrient runoff and a warming climate. Lake spray aerosol (LSA) released from freshwater lakes has been identified on lakeshores and after transport inland, including from lakes with HABs, but little is known about the potential for HAB toxins to be incorporated into LSA. In this study, freshwater samples were collected from two lakes in Michigan: Mona Lake during a severe HAB with microcystin concentrations (>200 µg/L) well above the Environmental Protection Agency (EPA) recommended "do not drink" level (1.6 µg/L) and Muskegon Lake without a HAB (<1 µg/L microcystin). Microcystin toxins were identified in freshwater, as well as aerosol particles generated in the laboratory from Mona Lake water by liquid chromatography-tandem mass spectrometry (LC-MS/MS) at atmospheric concentrations up to 50 ± 20 ng/m3. Enrichment of hydrophobic microcystin congeners (e.g., microcystin-LR) was observed in aerosol particles relative to bulk freshwater, while enrichment of hydrophilic microcystin (e.g., microcystin-RR) was lower. As HABs increase in a warming climate, understanding and quantifying the emissions of toxins into the atmosphere is crucial for evaluating the health consequences of HABs.

Increasing Isoprene Epoxydiol-to-Inorganic Sulfate Aerosol Ratio Results in Extensive Conversion of Inorganic Sulfate to Organosulfur Forms: Implications for Aerosol Physicochemical Properties.

Acid-driven multiphase chemistry of isoprene epoxydiols (IEPOX), key isoprene oxidation products, with inorganic sulfate aerosol yields substantial amounts of secondary organic aerosol (SOA) through the formation of organosulfur compounds. The extent and implications of inorganic-to-organic sulfate conversion, however, are unknown. In this article, we demonstrate that extensive consumption of inorganic sulfate occurs, which increases with the IEPOX-to-inorganic sulfate concentration ratio (IEPOX/Sulfinorg), as determined by laboratory measurements. Characterization of the total sulfur aerosol observed at Look Rock, Tennessee, from 2007 to 2016 shows that organosulfur mass fractions will likely continue to increase with ongoing declines in anthropogenic Sulfinorg, consistent with our laboratory findings. We further demonstrate that organosulfur compounds greatly modify critical aerosol properties, such as acidity, morphology, viscosity, and phase state. These new mechanistic insights demonstrate that changes in SO2 emissions, especially in isoprene-dominated environments, will significantly alter biogenic SOA physicochemical properties. Consequently, IEPOX/Sulfinorg will play an important role in understanding the historical climate and determining future impacts of biogenic SOA on the global climate and air quality.

Bouncier Particles at Night: Biogenic Secondary Organic Aerosol Chemistry and Sulfate Drive Diel Variations in the Aerosol Phase in a Mixed Forest.

Aerosol phase state is critical for quantifying aerosol effects on climate and air quality. However, significant challenges remain in our ability to predict and quantify phase state during its evolution in the atmosphere. Herein, we demonstrate that aerosol phase (liquid, semisolid, solid) exhibits a diel cycle in a mixed forest environment, oscillating between a viscous, semisolid phase state at night and liquid phase state with phase separation during the day. The viscous nighttime particles existed despite higher relative humidity and were independently confirmed by bounce factor measurements and atomic force microscopy. High-resolution mass spectrometry shows the more viscous phase state at night is impacted by the formation of terpene-derived and higher molecular weight secondary organic aerosol (SOA) and smaller inorganic sulfate mass fractions. Larger daytime particulate sulfate mass fractions, as well as a predominance of lower molecular weight isoprene-derived SOA, lead to the liquid state of the daytime particles and phase separation after greater uptake of liquid water, despite the lower daytime relative humidity. The observed diel cycle of aerosol phase should provoke rethinking of the SOA atmospheric lifecycle, as it suggests diurnal variability in gas-particle partitioning and mixing time scales, which influence aerosol multiphase chemistry, lifetime, and climate impacts.

Low to Intermediate Dose Atropine Administration During Dobutamine Stress Echocardiography in the Pre-Liver Transplant Population.

INTRODUCTION: Dobutamine stress echocardiography (DSE) is frequently used to screen for obstructive coronary artery disease in the pre-liver transplant evaluation. Although atropine is a commonly used adjunctive medication, no study has evaluated its side effect profile in patients with end-stage liver disease (ESLD). RESEARCH QUESTION: What is the safety of atropine in candidates undergoing pre-liver transplant evaluation when atropine is used in stress testing? DESIGN: This multicenter, prospective study enrolled patients over a 6-month period undergoing pre-liver transplant evaluation. Each patient completed a questionnaire assessing anticholinergic-related symptoms within 24 hours of testing and 48 hours following. Comparisons were made among patients receiving any atropine dose versus those who did not and among patients receiving at least 1 mg atropine and those receiving less/none. RESULTS: Forty patients were evaluated, and 32 (80%) had adjunctive atropine administered. No differences in clinical characteristics were noted. In comparisons among patients receiving any dose of atropine with those who did not, questionnaire results indicated a higher rate of nausea prior to testing and higher overall symptom severity following testing in patients not receiving atropine. In comparisons among patients receiving less than 1 mg atropine with those receiving at least 1 mg atropine, no difference in pre- or posttesting questionnaire responses was present. No patient in the study required reversal agents or hospitalization within 7 days of testing. CONCLUSIONS: Atropine, a hepatically metabolized medication, did not predispose patients with ESLD to an increased symptom burden, and clinical outcomes related to DSE were unaffected.

Extending surface enhanced Raman spectroscopy (SERS) of atmospheric aerosol particles to the accumulation mode (150-800 nm).

Due to their small size, measurements of the complex composition of atmospheric aerosol particles and their surfaces are analytically challenging. This is particularly true for microspectroscopic methods, where it can be difficult to optically identify individual particles smaller than the diffraction limit of visible light (∼350 nm) and measure their vibrational modes. Recently, surface enhanced Raman spectroscopy (SERS) has been applied to the study of aerosol particles, allowing for detection and characterization of previously undistinguishable vibrational modes. However, atmospheric particles analyzed via SERS have primarily been >1 µm to date, much larger than the diameter of the most abundant atmospheric aerosols (∼100 nm). To push SERS towards more relevant particle sizes, a simplified approach involving Ag foil substrates was developed. Both ambient particles and several laboratory-generated model aerosol systems (polystyrene latex spheres (PSLs), ammonium sulfate, and sodium nitrate) were investigated to determine SERS enhancements. SERS spectra of monodisperse, model aerosols between 400-800 nm were compared with non-SERS enhanced spectra, yielding average enhancement factors of 102 for both inorganic and organic vibrational modes. Additionally, SERS-enabled detection of 150 nm size-selected ambient particles represent the smallest individual aerosol particles analyzed by Raman microspectroscopy to date, and the first time atmospheric particles have been measured at sizes approaching the atmospheric number size distribution mode. SERS-enabled detection and identification of vibrational modes in smaller, more atmospherically-relevant particles has the potential to improve understanding of aerosol composition and surface properties, as well as their impact on heterogeneous and multiphase reactions involving aerosol surfaces.

Aerosol Emissions from Great Lakes Harmful Algal Blooms.

In freshwater lakes, harmful algal blooms (HABs) of Cyanobacteria (blue-green algae) produce toxins that impact human health. However, little is known about the lake spray aerosol (LSA) produced from wave-breaking in freshwater HABs. In this study, LSA were produced in the laboratory from freshwater samples collected from Lake Michigan and Lake Erie during HAB and nonbloom conditions. The incorporation of biological material within the individual HAB-influenced LSA particles was examined by single-particle mass spectrometry, scanning electron microscopy with energy-dispersive X-ray spectroscopy, and fluorescence microscopy. Freshwater with higher blue-green algae content produced higher number fractions of individual LSA particles that contained biological material, showing that organic molecules of biological origin are incorporated in LSA from HABs. The number fraction of individual LSA particles containing biological material also increased with particle diameter (greater than 0.5 µm), a size dependence that is consistent with previous studies of sea spray aerosol impacted by phytoplankton blooms. Similar to sea spray aerosol, organic carbon markers were most frequently observed in individual LSA particles less than 0.5 µm in diameter. Understanding the transfer of biological material from freshwater to the atmosphere via LSA is crucial for determining health and climate effects of HABs.

Reevaluating Reports of Defensive Medicine.

There is ongoing policy debate about the potential for malpractice liability reform to reduce the use of defensive medicine and slow the growth of health care spending. The effectiveness of such policy levers hinges on the degree to which physicians respond to liability pressures by prescribing medically unnecessary care. Many estimates of this relationship are based on physician reports. We present new survey evidence on physician assessment of their own use of medically unnecessary care in response to medical liability and other pressures, including a randomized evaluation of the sensitivity of those responses to survey framing. We find that while use of such care is potentially quite prevalent, responses vary substantially based on survey framing, with the way the question is phrased driving differences in responses that are often as great as those driven by physician specialty or whether the physician has personally been named in a lawsuit. These results suggest that self-reported use of medically unnecessary care ought to be used with caution in the formulation of malpractice liability system reform.

Variation in adherence to the treatment guidelines for Neisseria gonorrhoeae by clinical practice setting, California, 2009 to 2011.

BACKGROUND: Declining susceptibility of Neisseria gonorrhoeae to available antimicrobial agents has prompted repeated updates of the Centers for Disease Control and Prevention (CDC) treatment guidelines. The only regimen currently recommended as first-line treatment is dual therapy consisting of an intramuscular dose of ceftriaxone together with azithromycin or doxycycline. The objective of this analysis is to identify how adherence to the CDC guidelines varies by clinical practice setting. METHODS: A geographically representative random sample of N. gonorrhoeae cases reported from 2009 to 2011 was analyzed. Weighted generalized linear models were fit to calculate cumulative incidence ratios for receipt of non-recommended treatment regimen in relation to clinical practice setting, adjusted for age, race, and whether or not the participant was a man who has sex with men. RESULTS: Data from 3178 participants were available for analysis. Overall, 14.9% (weighted) of participants received non-recommended treatment. Among participants with gonorrhea identified by surveillance data as having received non-recommended treatment, the largest proportions were treated at private physicians' offices or health maintenance organizations (34.7% of participants receiving non-recommended treatment), family planning facilities (22.3%), and emergency departments/urgent care centers (12.8%). CONCLUSIONS: Barriers to adherence to the CDC treatment guidelines for gonorrhea seem to be experienced in a variety of clinical practice settings. Despite only moderate rates of nonadherence, interventions targeting private physicians/health maintenance organizations and family planning facilities may produce the largest absolute reductions in guideline-discordant treatment.

Exploring health plan perspectives in collecting and using data on race, ethnicity, and language.

OBJECTIVES: To explore why health plans collect or forgo data collection efforts on race, ethnicity, and language (REL), and the challenges encountered in collecting and using data for quality improvement. STUDY DESIGN: In-depth interviews with 15 health plans were conducted between June and August 2009. METHODS: Fifteen health plans participated and were divided into 2 groups: Plans that collect and use REL data (n = 10), and plans that do not collect REL data (n = 5). A structured interview guide was developed that included questions about REL data collection efforts, leadership support, collaboration with external partners, and challenges and opportunities in the collection and use of REL information. For plans not collecting REL data, questions were also asked regarding reasons to forgo data collection and existing health equity efforts. A summary report, based on audiotapes, interview notes, and input from the research team, was developed and analyzed. RESULTS: The interviews highlight the need for new partnerships and coordinated efforts to improve healthcare equity through disseminating best practices and tools that help expand such activities. Barriers noted include the costs associated with adapting information technology systems to accommodate new functions, such as new data fields, appropriate software and analytical tools, and the lack of standard codes for race and ethnicity. CONCLUSIONS: Health plans are eager to collaborate with new partners and share strategies to collect REL data as a foundation to reduce disparities. Opportunities exist to collaborate with employers and purchasers to improve the extent and quality of REL data and can ultimately lead to designing and implementing culturally appropriate programs in the workforce.

A national study of socioeconomic status and tuberculosis rates by country of birth, United States, 1996-2005.

BACKGROUND: Tuberculosis (TB) in developed countries has historically been associated with poverty and low socioeconomic status (SES). In the past quarter century, TB in the United States has changed from primarily a disease of native-born to primarily a disease of foreign-born persons, who accounted for more than 60% of newly-diagnosed TB cases in 2010. The purpose of this study was to assess the association of SES with rates of TB in U.S.-born and foreign-born persons in the United States, overall and for the five most common foreign countries of origin. METHODS: National TB surveillance data for 1996-2005 was linked with ZIP Code-level measures of SES (crowding, unemployment, education, and income) from U.S. Census 2000. ZIP Codes were grouped into quartiles from low SES to high SES and TB rates were calculated for foreign-born and U.S.-born populations in each quartile. RESULTS: TB rates were highest in the quartiles with low SES for both U.S.-born and foreign-born populations. However, while TB rates increased five-fold or more from the two highest to the two lowest SES quartiles among the U.S.-born, they increased only by a factor of 1.3 among the foreign-born. CONCLUSIONS: Low SES is only weakly associated with TB among foreign-born persons in the United States. The traditional associations of TB with poverty are not sufficient to explain the epidemiology of TB among foreign-born persons in this country and perhaps in other developed countries. TB outreach and research efforts that focus only on low SES will miss an important segment of the foreign-born population.

Alzheimer's disease amyloid ß-protein mutations and deletions that define neuronal binding/internalization as early stage nonfibrillar/fibrillar aggregates and late stage fibrils.

Accumulation of amyloid ß-protein (Aß) in neurons has been demonstrated to precede its formation as amyloid plaques in the extracellular space in Alzheimer's disease (AD) patients. Consequently, intraneuronal Aß accumulation is thought to be a critical first step in the fatal cascade of events that leads to neuronal degeneration in AD. Understanding the structural basis of neuronal binding and uptake of Aß might lead to potential therapeutic targets that could block this binding and the subsequent neurodegeneration that leads to the pathogenesis of AD. Previously, we demonstrated that mutation of the two adjacent histidine residues of Aß40 (H13,14G) resulted in a significant decrease in its level of binding to PC12 cells and mouse cortical/hippocampal neurons. We now demonstrate that the weakened neuronal binding follows the mutation order of H13G < H14G < H13,14G, which suggests that the primary domain for neuronal binding of Aß40 involves histidine at position 13. A novel APP mutation (E693Δ) that produced a variant Aß lacking glutamate 22 (E22Δ) in Japanese pedigrees was recently identified to have AD-type dementia without amyloid plaque formation but with extensive intraneuronal Aß in transfected cells and transgenic mice expressing this deletion. Deletion of glutamate 22 of Aß40 resulted in a 6-fold enhancement of PC12 neuronal binding that was not decreased by the H13G mutation. The dose-dependent enhanced binding of E22Δ explains the high level of intraneuronal Aß seen in this pedigree. Fluorescence anisotropy experiments at room temperature showed very rapid aggregation with increased tyrosine rigidity of Aß39E22Δ, Aß41E22Δ, and Aß42 but not Aß40. This rigidity was decreased but not eliminated by prior treatment with dimethyl sulfoxide. Surprisingly, all peptides showed an aggregated state when evaluated by transmission electron microscopy, with Aß39E22Δ having early stage fibrils, which was also verified by atomic force microscopy. This aggregation was not affected by centrifugation or pretreatment with organic solvents. The enhanced neuronal binding of Aß, therefore, results from aggregate binding to neurons, which requires H13 for Aß40 but not for E22Δ or Aß42. These latter proteins display increased tyrosine rigidity that likely masks the H13 residue, or alternatively, the H13 residue is not required for neuronal binding of these proteins as it is for Aß40. Late state fibrils also showed enhanced neuronal binding for E22Δ but not Aß40 with subsequent intraneuronal accumulation in lysosomes. This suggests that there are multiple pathways of binding/internalization for the different Aß proteins and their aggregation states or fibrillar structure.

Plasma renin activity-guided strategy for the management of hypertension.

Despite the wide array of antihypertensive agents and the availability of national guidelines regarding treatment for hypertension, the disease remains uncontrolled in nearly 50% of affected patients. Furthermore, the number of patients with resistant hypertension continues to increase. For patients with resistant hypertension, the American Heart Association has advocated for clinical studies to determine appropriate pharmacologic treatment strategies. One proposed strategy involves ambulatory measurement of plasma renin activity (PRA) to guide the selection of antihypertensive therapy. Patients with low PRA would be prescribed natriuretic volume-mediated therapies (e.g., diuretics and calcium channel blockers), whereas those with high PRA would receive antirenin system therapies (e.g., ß-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers). This review focuses on the principles of PRA-guided therapy, its historical development, alternative approaches to classifying patients into categories of response to antihypertensive agents, and recent data supporting the use of plasma renin activity-guided hypertension management.