Genetic and epigenetic profiling of CLL disease progression reveals limited somatic evolution and suggests a relationship to memory-cell development.

We examined genetic and epigenetic changes that occur during disease progression from indolent to aggressive forms of chronic lymphocytic leukemia (CLL) using serial samples from 27 patients. Analysis of DNA mutations grouped the leukemia cases into three categories: evolving (26%), expanding (26%) and static (47%). Thus, approximately three-quarters of the CLL cases had little to no genetic subclonal evolution. However, we identified significant recurrent DNA methylation changes during progression at 4752 CpGs enriched for regions near Polycomb 2 repressive complex (PRC2) targets. Progression-associated CpGs near the PRC2 targets undergo methylation changes in the same direction during disease progression as during normal development from naive to memory B cells. Our study shows that CLL progression does not typically occur via subclonal evolution, but that certain CpG sites undergo recurrent methylation changes. Our results suggest CLL progression may involve developmental processes shared in common with the generation of normal memory B cells.

[Quality management in acute pain therapy: results from a survey of certified hospitals]. / Qualitätsmanagement in der Akutschmerztherapie : Ergebnisse einer Befragung TÜV-zertifizierter Kliniken.

AIM: Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept "quality management acute pain therapy" of the TÜV Rheinland® (TÜV) after a 5-year project period. MATERIAL AND METHODS: General characteristics of the participating hospitals, number of departments certified by the TÜV and implementation of structures and processes according to the TÜV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals' representatives of certification. RESULTS: A total of 36 questionnaires were returned. Since 2006 the number of certified hospitals (2011: n = 48) and surgical departments (2011: n = 202) has increased continuously. The number of certified medical departments is low (2011: n = 39); however, in the last 3 years, it has increased by about 200-300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15). CONCLUSION: Certification by the TÜV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients' outcome.

Obesity is an independent predictor of poor survival in metastatic breast cancer: retrospective analysis of a patient cohort whose treatment included high-dose chemotherapy and autologous stem cell support.

The purpose of the study was to identify predictors of long-term survival in metastatic breast cancer (MBC). A cohort of 96 patients, who received high-dose chemotherapy with autologous stem cell support (HD-ASCT) as part of their treatment, was analyzed. Percent long-term survival at 10 years was 24.5% (CI 17.2-34.9%) when metastasis was diagnosed and 14.4% (CI 8.7-23.9%) when MBC was diagnosed. Survival was impacted significantly by body mass index (BMI). Median overall survival from initial diagnosis or from time of metastasis for patients with BMIs ≤30 and >30 (obese) was 7.1 (CI 4.4-8.7) and 3.2 years (2.41-6.75), respectively, or 3.2 or 2.3 years (all P = 0.02). Also, obesity was the only independent patient-related predictor of time to metastasis and of survival. While obesity is linked with poor outcomes in earlier stages of breast cancer, this has not been previously reported for MBC.

Acridizinium salts as a novel class of DNA-binding and site-selective DNA-photodamaging chromophores.

It was demonstrated that the interaction of the aminoacridizinium salts 2a-2d with DNA depends on the substitution pattern of the chromophore. Spectrophotometric and fluorometric titrations of the acridizinium salts 2a-2d with natural and synthetic polynucleotides reveal that the degree of interaction of the acridizinium salts 2a-2d with the nucleic acid differs significantly. The binding mode of the dyes with DNA was evaluated by circular dichroism and linear dichroism spectroscopy and compared with the parent system 2c. Whereas the 9-aminoacridizinium (2a) mainly intercalates into DNA, the salts 2b-c show a higher degree of association to the DNA backbone. The intercalated aminoacridizinium 2a caused few strand breaks upon UVA exposure, whereas the salts 2b-2d exhibit relatively efficient DNA-damaging properties. All acridizinium salts showed a sequence-selective strand cleavage for guanine-rich DNA regions.

Murrastifoline-F: first total synthesis, atropo-enantiomer resolution, and stereoanalysis of an axially chiral N,C-coupled biaryl alkaloid.

The first total synthesis of the Murraya alkaloid murrastifoline-F (3), an unsymmetric, N,C-bonded heterobiarylic biscarbazole, is described. Starting from the likewise naturally occurring-but here synthetically prepared-"monomer" murrayafoline-A (6), lead tetraacetate-mediated oxidative non-phenolic biaryl coupling gives 3 as the main regioisomer. The existence of this natural product as a pair of stable atropo-enantiomers was demonstrated analytically through LC-CD investigations. Preparatively, the racemate resolution succeeded by O-demethylation, derivatization with Mosher's reagent, and chromatographic separation of the resulting diastereomers. The absolute configurations of the atropisomers were assigned by CD spectroscopy in combination with quantum chemical CD calculations at the stage of the alkaloid 3 and by ROESY experiments of the diastereomeric Mosher derivatives. In the root extract of the curry leaf plant Murraya koenigii (Rutaceae), murrastifoline-F (3) was found to exist as a 56:44 mixture in favor of the M-enantiomer, by LC-CD coupling.

The absolute configuration of (+)-isoshinanolone and in situ LC-CD analysis of its stereoisomers from crude extracts.

The absolute configuration of (+)-isoshinanolone, a wide-spread acetogenic metabolite from higher plants, has been determined by X-ray structure analysis of its new dibromide; accordingly, this natural tetralone is 3R,4R-configured, in agreement with previous degradative results. In addition, a first chiroptical on-line stereoanalysis for isoshinanolones is presented, i.a. by HPLC on a chiral phase coupled to CD spectroscopy, giving pure CD spectra of all of the four stereoisomers of isoshinanolone directly from stereoisomeric mixtures.

Vaccine-specific antibody responses induced by HIV-1 envelope subunit vaccines.

The first generation of candidate vaccines to prevent HIV infection consisted of recombinant envelope proteins (Env, gp120, and gp160) derived from a single laboratory strain of HIV, designated IIIB/LAV, but produced with different expression systems. In this study we examined the fine specificity of the human Ab response to each vaccine and compared them to the responses of laboratory workers infected with the same strain of HIV. The best responders from each vaccine protocol were studied and compared. Detailed comparisons of the fine specificity of the Ab response were possible because all immunologic assays were performed using homologous recombinant proteins, peptides, and virus stocks. Although the total amounts of anti-Env Ab were comparable, the groups exhibited significant differences in epitope specificity, avidity, and functional capacity of the Ab response. The data demonstrate that the form of the immunogen (e.g., live virus or recombinant protein) is important in determining the quality of the Ab response. Conclusions are also drawn regarding characteristics of the anti-HIV-neutralizing Ab response. These studies represent one of the most detailed analyses of the human Ab response to any Ag and have implications for the development of vaccines for HIV as well as for other microbial pathogens.

Characteristics associated with pregnant women's utilization of substance abuse treatment services.

There is a dearth of substance abuse treatment programs available to pregnant substance-using women. However, even when specialized substance abuse treatment programs are offered to these high-risk women, some women will choose not to enter treatment. To gain a better understanding concerning the characteristics of pregnant substance-using women related to their decisions regarding treatment utilization, this study compares two groups of substance users: 93 pregnant women who accepted offered substance-related treatment services, and 89 pregnant women who declined the same services. All women were interviewed and information was gathered concerning their sociodemographic characteristics, their types and levels of substance use, substance use by their family members, and their experiences of being victims of violence. Bivariate analyses found that, compared to women who declined treatment, women who accepted treatment were more likely to be African-American, to be single (never married), and to have a significantly greater number of children. Bivariate analyses also showed that, compared to women who declined treatment, women who accepted treatment had more severe substance abuse problems and were more likely to have previously undergone treatment for a substance problem. Women who accepted treatment were twice as likely to have partners who used alcohol and were three times more likely to have experienced physical and/or sexual violence during pregnancy. When logistic regression procedures were used to simultaneously examine the relative impact of all of the variables on treatment utilization, the four strongest independent predictors positively associated with treatment utilization were the women's race (being African-American), the women's use of illegal drugs during pregnancy, the women's past treatment for substance abuse, and the women's use of cigarettes before pregnancy.

Improving patient quality of life with feedback to physicians about functional status.

OBJECTIVE: To improve functional status among primary care patients. INTERVENTION: 1) Computer-generated feedback to physicians about the patient's functional status, the patient's self-reported "chief complaint," and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians. DESIGN: Randomized controlled trial. SETTING: University primary care clinic. PARTICIPANTS: All 73 internal medicine house officers and 557 of their new primary care patients. MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems. RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p < 0.03). Limitations in social activities indicated as "due to health" decreased among the elderly (> or = 70 years of age) individuals in the experimental group compared with the control group (p < 0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p < 0.001) and took more actions recommended by the feedback form (p < 0.02). CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients.

Temporal analysis of the antibody response to HIV envelope protein in HIV-infected laboratory workers.

Three laboratory workers have been infected with the IIIB strain of HIV; their antibody response to HIV has been studied in serial serum specimens. Because the infecting virus is known, the fine specificity of the antibody response was studied on the homologous strain of HIV. Anti-p17, anti-p24, anti-gp160, CD4/gp120 blocking and neutralizing antibodies developed in parallel. Epitope mapping of the anti-gp160 response indicated several regions that consistently induced an antibody response. Serum contained antibody which reacted with V3-specific peptides corresponding to the very tip of the loop and crossreactivity was seen with V3 loop peptides from other sequence divergent strains of HIV. Antibody to the V1 loop was produced at levels comparable with that seen for the V3-loop. Anti-V1 neutralized HIV with a titration curve equivalent to an anti-V3 monoclonal antibody. Because the infecting virus is known and serial reisolates have been obtained, we explored the relationship between production of antibody to a given epitope and mutation in the virus. The data suggest that an association exists, but do not clearly indicate that antibody drives the selection for mutant viruses. The findings presented here provide a fine specificity analysis of the evolution of the antibody response to HIV in greater detail than has previously been performed.

Effect of nonprotective vaccination on antibody response to subsequent human immunodeficiency virus infection.

We have investigated the systemic anti-HIV antibody response in chimpanzees who were immunized with live vaccinia containing either the HIV envelope glycoprotein (gp160IIIB) or a control antigen (herpes simplex virus glycoprotein D) and then challenged with either a high dose (300,000 TCID50) or low dose (100 TCID50) of HIVIIIB. HIV was subsequently isolated from all animals, indicating failure of the vaccination to protect against HIV infection. Serum antibody responses were evaluated before immunization, at the time of challenge with HIV, and at multiple time points in the 9 mo after challenge. Immunization resulted in a more rapid rise of antibody to gp160 in both high and low dose animals. Antibodies to the V3 loop induced upon infection were unaffected by immunization. In low dose animals, neutralizing antibody rose more rapidly and to higher levels in the immunized animals as compared with the control. There was no difference in neutralizing antibodies between immunized and control chimpanzees in the high dose group. Epitope mapping of the anti-gp 160 response indicated that immunization with gp160 vaccinia induced a postinfection antibody response to a region of gp41 (amino acids 718-743) that was not immunogenic in control-vaccinated animals. These data indicate that failed vaccination with the HIV envelope can alter both the timing and epitope specificity of the subsequent anti-HIV antibody response. These studies also define the evolution and fine specificity of the antibody response during the critical period immediately postinfection.

Differences in the antibody response to human immunodeficiency virus-1 envelope glycoprotein (gp160) in infected laboratory workers and vaccinees.

Studies of the immune response to the human immunodeficiency virus (HIV) have been hampered by the antigenic diversity of the HIV envelope protein. In an effort to predict the efficacy of vaccination we have compared the systemic anti-envelope antibody response in seronegative volunteers immunized with recombinant gp160 (either in vaccinia or as soluble protein produced in baculovirus) derived from the HTLV-IIIB strain of HIV-1 and in two laboratory workers accidentally infected with the same strain. 11 of 14 vaccinees responded to immunization by producing anti-gp160 of similar titer and the same isotype as that seen in the laboratory workers. Four vaccinees also had antibody to the principal neutralizing domain (V3 loop) that was comparable in titer with that seen in the laboratory workers, but the fine specificity of anti-V3 antibody was qualitatively different in the two groups. Antibody that can block the interaction between CD4 and gp120 was present at comparable levels in three vaccines and the lab workers. Neutralizing antibody titers were markedly lower in the vaccinees than in the laboratory workers. In seven of the vaccinees, an immunodominant epitope was at amino acid 720-740. Analyses of monoclonal antibodies to this region indicate that they do not neutralize, bind to infected cells, nor function as immunotoxins. Although the anti-gp160 antibody response was of similar magnitude in both infected and vaccinated individuals, there were important qualitative differences.

On the binding of aminoalkyl adenylates to isoleucyl-tRNA synthetase from Escherichia coli MRE 600.

The binding of nine aminoalkyl adenylates to isoleucyl-tRNA synthetase from Escherichia coli MRE 600 was measured and compared with the binding of the cognate amino acids. It was found that they bind rather tightly to the enzyme, the Kd's ranging from 3.1.10(-4) M with glycinol-AMP ester to 3.7.10(-9) M with L-isoleucinol-AMP ester. The binding is not affected by magnesium. It is shown that the free energies of binding of the esters can be calculated adding a constant contribution of the AMP-moiety of about - 4.1 (- 17) kcal/mole (kJ/mole) to the free energies of binding of the cognate amino acids, which we have reported earlier (19, 25, 26).

[Neo-natal hyperbilirubinemia and G-6-PD Ankara deficiency, a new enzymatic variant discovered in a Turkish family (author's transl)]. / Ictère néo-natal et déficit en G-6-PD Ankara, une nouvelle variante enzymatique découverte dans une famille turque

A G-6-PD deficiency has been found in a Turkish male premature with neo-natal hyperbilirubinemia. His parents have no hemolytic antecedents. The propositus has a severe enzym deficiency in erythrocytes, a very decreased activity in leukocytes and platelets. His mother was heterozygous for this variant and his father had no abnormality. The deficient enzym was a new variant: G-6-PD Ankara. The main characteristics of this variant were the following: 1 degree severe enzym deficiency in erythrocytes (8% of normal); 2 degrees fast starch gel electrophoretic mobility (110% of normal); 3 degrees enzym instability in vivo and in vitro; 4 degrees increased KiNADPH; 5 degrees decreased molecular specific activity (58% of normal). Only variant B(-) G-6-PD deficiency have hitherto been described in Turkey. In contrast, G-6-PD Ankara is a fast variant and is unlike any other known variants.