Racial Differences in Accepting Pegfilgrastim Onpro Kit (On-Body Injector) Use Among Cancer Patients.

Background: 1.1.Neulasta Onpro kit eliminates need for additional clinic visit after chemotherapy. Given the racially diverse population in our institution, we investigated acceptance of Onpro kit among patients on chemotherapy. Research Design and Methods: 1.2.Single-institution, retrospective review conducted in patients with GI tumors who received Onpro kit within 1 hour of completion of systemic chemotherapy from Jan 2014 through Jan 2018. Clinic/nursing notes and pharmacy records were reviewed to identify patients who refused Onpro kit and to discern reasons for refusal, including racial reason. Results: 1.3.Total 238 orders for kit were voided amongst 68 patients (Caucasian 41; African American 7; Spanish 3; Asian 17). Overall, 15/68 patients refused kit (22%) of these 87% were Asian. The reasons for refusal included dislike of bulky attachment to skin, request to place kit on stomach instead of arm, trepidation over unwitnessed administration of drug, fear of reaction, disposal at home, fear of pain, lack of confirmation of proper dose administration, and need for MRI. Conclusions: 1.4.While Onpro kit is an attractive alternative, 22% of patients with voided orders, mainly of Asian race, declined its application. We believe the current study represents the first look at important racial differences in accepting Onpro kit. Consideration of patients' cultural heritage, race, ethnicity and education may facilitate communication between physicians and patients to achieve optimal cancer care.

Effect of heparin and heparin fractions on platelet aggregation.

Porcine intestinal mucosal heparin induced aggregation of platelets in citrated platelet-rich plasma and enhanced platelet aggregation and serotonin secretion induced by other agents. This action of heparin was blocked by substances that elevate platelet cyclic AMP and by EDTA but not by inhibitors of platelet cyclooxygenase. The effect was not inhibited by apyrase or by N-amylthio-5'-AMP and therefore did not require the action of ADP, nor was there activation of platelet phospholipase. Platelet aggregation by heparin required a plasma cofactor different from the cofactor required for ristocetin. Fractionation of heparin yielded preparations that varied in molecular weight and, within a given molecular weight fraction, in affinity for antithrombin III. Fractions of high molecular weight (average 20,000) were more reactive with platelets than were fractions of low molecular weight (7,000). Anticoagulant activity did not parallel the platelet reactivity of heparin fractions. Among high molecular weight fractions, preparations of high or low antithrombin affinity were equally active in induction of platelet aggregation. In low molecular weight fractions, there was an inverse relationship between platelet reactivity and anticoagulant activity in normal platelet-rich plasma, but, in platelet-rich plasma depleted of antithrombin, low molecular weight fractions of high and low antithrombin affinity reacted equally with platelets. These results suggest that formation of an antithrombin-heparin complex protected platelets from aggregation by heparin. Selection of heparin fractions of low molecular weight and high antithrombin affinity may improve anticoagulant therapy and development of thromboresistant heparin-coated artificial materials.

In vitro analysis of mutant LexA proteins with an increased rate of specific cleavage.

Specific cleavage of LexA repressor plays a crucial role in the SOS response of Escherichia coli. In vivo, cleavage requires an activated form of RecA protein. However, previous work has shown that the mechanism of cleavage is unusual, in that the chemistry of cleavage is probably carried out by residues in the repressor, and not those in RecA; RecA appears to facilitate this reaction, acting as a coprotease. We recently described a new type of lexA mutation, a class termed lexA (IndS) and here called IndS, that confers an increased rate of in vivo cleavage. Here, we have characterized the in vitro cleavage of these IndS mutant proteins, and of several double mutant proteins containing an IndS mutation and one of several mutations, termed Ind-, that decrease the rate of cleavage. We found, first, that the autodigestion reaction for the IndS mutant proteins had a higher maximum rate and a lower apparent pKa than wild-type LexA. Second, the IndS mutations had little or no effect on the rate of RecA-mediated cleavage, measured at low protein concentrations, implying that the value of Kcat/Km was unaffected. Third, the rate of autodigestion for the double-mutant proteins, relative to wild-type, was about that rate predicted from the product of the effects of the two single mutations. Finally, by contrast, these proteins displayed the same rate of RecA-mediated cleavage as did the single Ind- mutant protein. We interpret these data to mean that the IndS mutations mimic to some extent the effect of RecA on cleavage, perhaps by favoring a conformational change in LexA. We present and analyze a model that embodies these conclusions.

Health, homelessness, and poverty. A study of clinic users.

When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems.

The conformational flexibility of class I H-2 molecules as revealed by anti-peptide antibodies specific for intracytoplasmic determinants: differential reactivity of beta 2-microglobulin "bound" and "free" H-2Kb heavy chains.

Immunoprecipitation experiments using anti-peptide antisera prepared against exon 6, exon 7 and exon 8-encoded intracytoplasmic regions of the H-2Kb gene product indicated that approximately 1/3 of the H-2Kb heavy chains in a cell surface-labelled glycoprotein fraction from EL-4 cells, or H-2b spleen cells, is not associated with beta 2-microglobulin (beta 2-m). This population of "free" H-2Kb heavy chains failed to react with alloantisera or monoclonal antibodies specific for conventional H-2Kb serological determinants, suggesting that significant conformational alterations were induced in the extracellular domains upon dissociation of beta 2-m. In addition, although antibodies to intracytoplasmic peptide 8 were able to react with both "free" and beta 2-m "bound" heavy chains, the determinants seen by anti-peptide 6 and anti-peptide 7 were only recognized in the "free" heavy chain. These data suggest that the conformational perturbation of the extracellular domains induced by beta 2-m dissociation can be "transmitted" to the intracytoplasmic region of the heavy chain. These results indicate the potential for a class I heavy chain-mediated transmembrane signalling event, and suggest that the "free" class I heavy chain might have a role to play in the major histocompatibility complex (MHC)-restricted presentation of T-cell determinants to cytotoxic T-lymphocytes.

Peptide sequences binding to MHC class I proteins.

Motifs for peptides which bind specifically to the human class I major histocompatibility complex molecules HLA-A2 and B7 were determined by sequence analysis of class I-bound peptides selected from a random synthetic library of nonamers. Thirteen individual peptides were sequenced for HLA-A2, twelve individual and nine pooled peptides were sequenced for HLA-B7. Analysis of sequence alignment implicated four peptide positions in potential contact with the class I HLA-A2 molecule and three positions for the HLA-B7 molecule. The results demonstrate that a synthetic peptide library can be used to identify allele-specific motifs for class I molecules, providing information comparable to the results obtained from sequencing endogenous peptides. This method utilizes denatured class I heavy chains, and similar results were obtained using a class I protein purified from mammalian cells or by expression in Escherichia coli. This method has the potential to detect peptides which may not be generated physiologically, but due to their binding properties, may be valuable to predict or engineer immunomodulatory T cell epitopes.

The preparation and characterization of anti-peptide heteroantisera recognizing subregions of the intracytoplasmic domain of class I H-2 antigens.

Peptides corresponding to each of the three intracytoplasmic exons (i.e. exons 6, 7 and 8) of the murine class I H-2Kb gene were synthesized, coupled to bovine serum albumin and used as immunogens in rabbits. In each case the antisera were found to react with the immunizing peptide coupled to a heterologous carrier, and recognized class I heavy chains electrophoretically transferred from SDS-polyacrylamide gels to nitrocellulose. Immunoprecipitation of class I antigens from Nonidet P-40 (NP-40) solubilized EL-4 (H-2b) tumour cells by each of the antisera reflected their ability to recognize the corresponding determinants in non-denatured class I molecules. The same sera were also able to immunoprecipitate class I molecules from NP-40 solubilized RDM-4 (H-2k) and P815 (H-2d) tumour cells, indicating the cross-reactive nature of these antisera for different class I alleles. In addition to reacting with the class I heavy chain in its conventional form as a dimer with beta 2-microglobulin, the antiserum specific for the exon 8 peptide was able to react with "free" (i.e. non-beta 2-microglobulin-associated) class I heavy chains. Thus, a unique set of immunological reagents has been prepared which offer a new approach to studying the structural and functional features of the cytoplasmic domain of class I H-2 antigens.

Baculoviral expressed HLA class I heavy chains used to screen a synthetic peptide library for allele-specific peptide binding motifs.

Recombinant baculoviruses encoding truncated HLA-A*0101 and HLA-A*0201 class I heavy chains have been isolated and used to infect lepidopteran cells. Proteins overexpressed in this system were glycosylated, and consisted of 282 amino acid residues after signal sequence cleavage. These class I heavy chains could fold into their native conformation in the presence of recombinant human beta2-microglobulin expressed in Escherichia coli and a synthetic peptide library of nonamers bound to resin-support beads. Reconstitution into native ternary complexes was detected using a conformation specific monoclonal antibody followed by isolation and sequencing of the bound peptides. The motifs obtained for HLA-A1.1 and HLA-A2.1 peptides are similar although more extensive than those derived from sequencing endogenous peptides. This approach selects peptides which form very stable complexes regardless of whether these peptides are generated under physiological conditions, thereby providing unique supplementary data for predicting and designing CTL epitopes. This method is based solely on peptide binding to the class I molecule and is therefore independent of any constraints imposed by endogenous intracellular processing or transport systems. A comparison of the two motifs provides an opportunity to distinguish between the requirements of binding from those arising as a function of intracellular processing or transport. Our findings are not consistent with a recent report suggesting that constraints on the COOH termini of these peptides can be attributed to the effects of either intracellular processing or transport. We find that the carboxy termini in the class I peptides analyzed to date mimic the endogenous data, suggesting that residues in this position contribute to binding affinity.

A randomized, controlled, safety study using imiquimod for the topical treatment of anogenital warts in HIV-infected patients. Imiquimod Study Group.

OBJECTIVE: To assess the safety of imiquimod, an immune response modifier, in the topical treatment of external anogenital warts in HIV-infected patients. SETTING: Clinical sites in the United Kingdom (eight) and the United States (five). DESIGN: A prospective, randomized, double-blind, vehicle-controlled study of imiquimod 5% cream or vehicle applied for 8+/-2 h three times per week for a maximum of 16 weeks in HIV-seropositive males (n = 97) and females (n = 3) aged 18 years or more with clinically diagnosed external anogenital warts, CD4 T lymphocyte count of > or = 100 x 10(6) cells/l and Karnofsky score > or = 70. MAIN OUTCOME MEASURES: Safety was assessed through the incidence and severity of local skin reactions and other adverse events, and through clinical laboratory tests. Wart clearance was documented by two-dimensional measurements of warts and by photography. RESULTS: Among the patients treated with imiquimod (n = 65) and vehicle (n = 35), the most common local skin reaction was erythema, (41.9 and 26.7%, respectively) and the incidence of patients reporting at least one adverse event was 69.2 and 65.7%, respectively. No clinically meaningful differences or changes in laboratory values were observed between treatment groups, nor were drug-related adverse effects observed in regard to HIV disease. While there was no significant difference between treatment groups in the number of patients who totally cleared their baseline warts (imiquimod 11% versus vehicle 6%, P = 0.488), more imiquimod-treated patients experienced a > or = 50% reduction in baseline wart area (38% versus 14%, P = 0.013). CONCLUSION: Most local skin reactions were mild and no adverse effects on HIV disease were observed. Topically applied imiquimod 5% cream reduced wart area and may have clinical utility in treating external anogenital warts in some HIV-infected patients.

Alterations in osmotic but not pressor responses to ACTH by optic recess lesions in sheep.

This study examines whether neural structures in the region of the optic recess of the third ventricle may be involved in the genesis of adrenocorticotrophic hormone (ACTH)-induced hypertension in sheep. Five sheep were prepared with lesions in an area of the forebrain that included the organum vasculosum of the lamina terminalis (OVLT) and surrounding periventricular tissue. In these animals the dipsogenic response to systemically infused hypertonic sodium chloride (NaCl) was abolished. ACTH treatment (20 micrograms/kg/day) for 5 days caused an increase in mean arterial pressure (MAP) of 19 mm Hg, a response identical to that seen in normal sheep. With ACTH treatment, increases in plasma osmolality were greater than normal, but polydipsia did not occur in the lesioned sheep. In six other sheep with lesions either lateral or anterior to the optic recess of the third ventricle, the dipsogenic response to hypertonic NaCl and pressor response to ACTH were normal. These studies establish that in ACTH-treated sheep the integrity of the anterior ventral part of the third ventricle is not essential for the development of the hypertension. This is in contrast to the finding in other models of experimental hypertension in the rat.

Statistical methods for the blood beryllium lymphocyte proliferation test.

The blood beryllium lymphocyte proliferation test (BeLPT) is a modification of the standard lymphocyte proliferation test that is used to identify persons who may have chronic beryllium disease. A major problem in the interpretation of BeLPT test results is outlying data values among the replicate well counts (approximately 7%). A long-linear regression model is used to describe the expected well counts for each set of Be exposure conditions, and the variance of the well counts is proportional to the square of the expected count. Two outlier-resistant regression methods are used to estimate stimulation indices (SIs) and the coefficient of variation. The first approach uses least absolute values (LAV) on the log of the well counts as a method for estimation; the second approach uses a resistant regression version of maximum quasi-likelihood estimation. A major advantage of these resistant methods is that they make it unnecessary to identify and delete outliers. These two new methods for the statistical analysis of the BeLPT data and the current outlier rejection method are applied to 173 BeLPT assays. We strongly recommend the LAV method for routine analysis of the BeLPT. Outliers are important when trying to identify individuals with beryllium hypersensitivity, since these individuals typically have large positive SI values. A new method for identifying large Sls using combined data from the nonexposed group and the beryllium workers is proposed. The log(SI)s are described with a Gaussian distribution with location and scale parameters estimated using resistant methods. This approach is applied to the test data and results are compared with those obtained from the current method.

Standard therapy for tuberculosis 1985.

PIP: Numerous clinical trials of chemotherapy for tuberculosis conducted throughout the world over the past 4 decades have established 2 basic principles of treatment: effective treatment requires the initial concomitant administration of at least 2 drugs to which the patient's organisms are susceptible; and cure of tuberculosis requires that treatment continue beyond the time of sputum conversion and amelioration of symptoms. The treatment of tuberculosis was revolutionized in the late 1960s with the introduction of rifampin. Shorter regimens of 6-9 months in duration became possible. Scores of trials of short-course chemotherapy have been conducted, and more are planned. The goals of the new treatment regimens are to achieve effective sterilization of the tuberculous lesion in the shortest time possible. A table lists drugs now in use in the US and Canada and gives the usual doses, common side effects, and important interactions among drugs. Chemotherapeutic regimens acceptable for use in the US and Canada are well-defined combinations of drugs which must be regularly administered in the recommended dosages and rhythm for a specific time period. Regimens should be highly effective, i.e., a relapse rate of less than 5%, and have a low risk of toxic effects. Regimens also should be acceptable to patients and applicable on a community-wide basis. The regimens recommended meet these criteria and are backed by well-conducted clinical trails. A 9-month regimen consisting of isoniazid and rifampin throughout, usually supplemented in the initial phase by ethambutol, streptomycin, or pyrazinamide, is a well-tolerated regimen which will cure virtually all patients with susceptible organisms. The initial daily phase may last 2-8 weeks; the continuation phase may be administered daily or twice weekly. These regimens have an overall bacteriologic relapse rate of between zero and 4%. When 4 drugs -- isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin -- are given under close during supervision during the initial 2 months of daily or "induction" therapy, followed by an additional 4 months of isoniazid and rifampin, the results have been excellent. Where primary resistance to isoniazid or streptomycin is suspected, the patient should be placed on 1 of the following 3 regimens: isoniazid, rifampin, and ethambutol; isoniazid, rifampin, pyrazinamide, and streptomycin; or isoniazid, rifampin, pyrazinamide, and ethambutol. Short-course chemotherapy for extrapulmonary tuberculosis and chemotherapy of tuberculosis in children are reviewed along with several conditions which affect therapy -- tuberculosis during pregnancy, renal and hepatic disease, cancer and other conditions associated with immunosuppression, and drug interaction.^ieng

Enhancement of the innate and cellular immune response in patients with genital warts treated with topical imiquimod cream 5%.

The mechanism of action of imiquimod 5% cream applied topically to patients with genital warts was evaluated in a double-blind, placebo-controlled study. Imiquimod (16 patients) or placebo (three patients) was applied three times per week for up to 16 weeks. All imiquimod-treated patients had a > or =75% reduction in total wart area while only one of three placebo-treated patients had a similar reduction. Wart biopsies were taken at prestudy, week 6, and end of treatment. Polymerase chain reaction (PCR) for human papillomavirus (HPV) DNA and reverse transcriptase (RT)-PCR for messenger (m)RNAs were used to identify cytokines, cellular markers, viral gene products, and cell cycle markers in these biopsies. Treatment with imiquimod, an immune response modifier, stimulated significant increases in mRNA for interferon (IFN)-alpha, IFN-gamma and 2',5' oligoadenylate synthetase (2',5'-AS) as well as a tendency towards increases in tumor necrosis factor (TNF)-alpha and interleukin-12 p40. Significant increases in mRNA for CD4 and a trend toward increases in CD8 were also observed in imiquimod-treated patients, suggesting activation of a cell mediated immune response. Imiquimod administration was also associated with a significant decrease in viral load as measured by HPV DNA and L1 mRNA. The effects on HPV markers were accompanied by an apparent decrease in mRNA expression for markers of cell proliferation and an increase in mRNA for markers of keratinocyte differentiation and tumor suppressors.

Modeling the impact of treatment options in genital warts: patient-applied versus physician-administered therapies.

With the availability of new patient-applied treatments for genital and perianal warts, medical providers, physician groups, and health systems are reassessing the role of physician-administered therapies. Two key questions are: how cost-effective are physician- versus patient-administered therapies and, given patient preferences for the convenience and privacy associated with the latter therapies, which of the 2 presently available treatments-imiquimod and podofilox-is most appropriate? The purpose of this article is to examine, from the perspective of the health care purchaser, these questions and to undertake a pharmacoeconomic analysis of the direct cost-effectiveness of therapy options, given targets being set for the outcomes of genital warts therapy. The analysis employs a synthetic, decision-modeling framework in which data on sustained clearance and the direct costs of treatment are drawn from both clinical studies and previous studies on the resources used to support treatment. Once targets are set-and it is proposed here that physicians should aim for at least a 50% sustained clearance rate for genital warts--it becomes clear that in cost per sustained clearance terms, imiquimod, as first-line therapy, is the most cost-effective intervention. If we compare imiquimod with podofilox as first-line therapy (with cryotherapy as the second-line option), the cost per sustained clearance for the imiquimod treatment sequence is $1367 compared with the podofilox-initiated sequence of $1508.

Osmoregulatory thirst in sheep is disrupted by ablation of the anterior wall of the optic recess.

Ablation of the organum vasculosum of the lamina terminalis (OVLT) and adjacent midline tissue in the anterior wall of the optic recess of the third ventricle resulted in greatly reduced water drinking to intracarotid infusion of hypertonic NaCl in sheep. Daily food and water intake and angiotensin II drinking were not consistently reduced by these lesions. Tissue in or close to the OVLT is probably involved in osmotically induced water-drinking.

Optical model of the blood in large retinal vessels.

Several optical techniques that investigate blood contained within the retinal vessels are available or under development. We present a mechanical model that simulates the optical properties of the eye, the retinal vessels, and the ocular fundus. A micropipette is chosen as the retinal vessel model, and a mechanical housing is constructed to simulate the eyeball. Spectralon is used to simulate the retinal layers. Filling the eye with fluid index matched to the glass pipette eliminates reflection and refraction effects from the pipette. An apparatus is constructed and used to set the oxygen, nitrogen, and carbon dioxide concentrations in whole human blood. These whole blood samples are pumped through the pipette at 34 microL/min. Measurements made in the model eye closely resemble measurements made in the human eye. This apparatus is useful for developing the science and testing the systems that optically investigate blood and blood flow in the large retinal vessels.

Oxygen Saturation Measurements of Blood in Retinal Vessels during Blood Loss.

We describe a noninvasive technique and instrumentation for measuring the oxygen saturation of blood in retinal arteries and veins. The measurements are made by shining low-power lasers into the eye, and scanning the beams across a retinal blood vessel. The light reflected and scattered back out of the eye is collected and measured. The oxygen saturation of blood within the vessel is determined by analyzing the vessel absorption profiles at two wavelengths. A complete saturation measurement can be made in less than 1 s, allowing real-time measurement during physiologic changes. The sensitivity of this measurement technique to changes in retinal saturation has been demonstrated through a series of pilot studies in anesthetized swine. We present data indicating that retinal venous oxygen saturation decreases during ongoing blood loss, demonstrating a potential application of an eye oximeter to noninvasively monitor blood loss. © 1998 Society of Photo-Optical Instrumentation Engineers.

Tuberculosis in children and adolescents.

The epidemiology, pathogenesis, and clinical picture of primary tuberculosis are presented as they are seen today in the United States in children and adolescents. Diagnosis, treatment, and prevention of the disease are discussed in detail.

Retinal imaging techniques in diabetes.

Diabetic retinopathy is progressive, and detection early is essential for the prevention of blindness. Doppler flowmetry, retinal photography, scanning laser ophthalmoscopy, and retinal oximetry measurements may identify proliferative disease early. Drawbacks of these methods include lack of compliance, failure to refer, and failure to identify disease early. As a result, diabetic retinopathy is a leading cause of blindness. Our retinal oximeter measures the blood oxygen saturation in the large vessels of the retina near the optic disc. Retinal vessel oxygen saturations measured with our instrument are sensitive indicators of blood loss and hypoxia in swine. We are generating scientific data that suggests that retinal vessel oxygen saturations may be used to identify retinal hypoxia prior to changes in retinal vessel architecture. We expect to study humans within the next two years, and a clinically useful eye oximeter should be available in the near future.

Estimation of imprecision in immunoassay quality assessment programmes.

A computer was used to produce and store a large body of simulated thyroxine and thyrotropin radioimmunoassay results over wide concentration ranges. Sets of 24 results, designed to represent results returned to an external quality assessment survey, were randomly drawn from the stored results in order to compare limited data survey estimates of imprecision with the 'true' values obtained from the population data. Results show that estimation of an imprecision profile has advantages over the usual index of imprecision, but that neither form of estimate is particularly reliable when the available data is limited. Results suggest that survey organisers should place considerably less emphasis on results from any one survey and greater emphasis on analysing cumulative data and method comparison data.