Expansion of electronic health record-based screening, prevention, and management of diabetes in New York City.

To address the increasing burden of diabetes in New York City, we designed 2 electronic health records (EHRs)-facilitated diabetes management systems to be implemented in 6 primary care practices on the West Side of Manhattan, a standard system and an enhanced system. The standard system includes screening for diabetes. The enhanced system includes screening and ensures close patient follow-up; it applies principles of the chronic care model, including community-clinic linkages, to the management of patients newly diagnosed with diabetes and prediabetes through screening. We will stagger implementation of the enhanced system across the 6 clinics allowing comparison, through a quasi-experimental design (pre-post difference with a control group), of patients treated in the enhanced system with similar patients treated in the standard system. The findings could inform health system practices at multiple levels and influence the integration of community resources into routine diabetes care.

Exploiting Overlapping Advantages of In Vitro and In Cellulo Selection Systems to Isolate a Novel High-Affinity cJun Antagonist.

We have combined two peptide library-screening systems, exploiting the benefits offered by both to select novel antagonistic agents of cJun. CIS display is an in vitro cell-free system that allows very large libraries (≤1014) to be interrogated. However, affinity-based screening conditions can poorly reflect those relevant to therapeutic application, particularly for difficult intracellular targets, and can lead to false positives. In contrast, an in cellulo screening system such as the Protein-fragment Complementation Assay (PCA) selects peptides with high target affinity while additionally profiling for target specificity, protease resistance, solubility, and lack of toxicity in a more relevant context. A disadvantage is the necessity to transform cells, limiting library sizes that can be screened to ≤106. However, by combining both cell-free and cell-based systems, we isolated a peptide (CPW) from a ∼1010 member library, which forms a highly stable interaction with cJun (Tm = 63 °C, Kd = 750 nM, ΔG = -8.2 kcal/mol) using the oncogenic transcriptional regulator Activator Protein-1 (AP-1) as our exemplar target. In contrast, CIS display alone selected a peptide with low affinity for cJun (Tm = 34 °C, Kd = 25 µM, ΔG = -6.2 kcal/mol), highlighting the benefit of CIS → PCA. Furthermore, increased library size with CIS → PCA vs PCA alone allows the freedom to introduce noncanonical options, such as interfacial aromatics, and solvent exposed options that may allow the molecule to explore alternative structures and interact with greater affinity and efficacy with the target. CIS → PCA therefore offers significant potential as a peptide-library screening platform by synergistically combining the relative attributes of both assays to generate therapeutically interesting compounds that may otherwise not be identified.

Downsizing Proto-oncogene cFos to Short Helix-Constrained Peptides That Bind Jun.

The oncogenic transcription factor activator protein-1 (AP-1) is a DNA-binding protein that assembles through dimerization of Fos and Jun protein subunits, their leucine-rich helical sequences entwining into a coiled-coil structure. This study reports on downsizing the proto-oncogene cFos protein (380 residues) to shorter peptides (37-25 residues) modified with helix-inducing constraints to enhance binding to Jun. A crystal structure is reported for a 37-residue Fos-derived peptide (FosW) bound to Jun. This guided iterative downsizing of FosW to shorter peptide sequences that were constrained into stable water-soluble α-helices by connecting amino acid side chains to form cyclic pentapeptide components. Structural integrity in the presence and absence of Jun was assessed by circular dichroism spectroscopy, while the thermodynamics of binding to cFos was measured by isothermal titration calorimetry. A 25-residue constrained peptide, one-third shorter yet 25% more helical than the structurally characterized 37-residue Fos-derived peptide, retained 80% of the binding free energy as a result of preorganization in a Jun-binding helix conformation, with the entropy gain (TΔS = +3.2 kcal/mol) compensating for the enthalpy loss. Attaching a cell-penetrating peptide (TAT48-57) and a nuclear localization signal (SV40) promoted cell uptake, localization to the nucleus, and inhibition of the proliferation of two breast cancer cell lines.

Deriving Heterospecific Self-Assembling Protein-Protein Interactions Using a Computational Interactome Screen.

Interactions between naturally occurring proteins are highly specific, with protein-network imbalances associated with numerous diseases. For designed protein-protein interactions (PPIs), required specificity can be notoriously difficult to engineer. To accelerate this process, we have derived peptides that form heterospecific PPIs when combined. This is achieved using software that generates large virtual libraries of peptide sequences and searches within the resulting interactome for preferentially interacting peptides. To demonstrate feasibility, we have (i) generated 1536 peptide sequences based on the parallel dimeric coiled-coil motif and varied residues known to be important for stability and specificity, (ii) screened the 1,180,416 member interactome for predicted Tm values and (iii) used predicted Tm cutoff points to isolate eight peptides that form four heterospecific PPIs when combined. This required that all 32 hypothetical off-target interactions within the eight-peptide interactome be disfavoured and that the four desired interactions pair correctly. Lastly, we have verified the approach by characterising all 36 pairs within the interactome. In analysing the output, we hypothesised that several sequences are capable of adopting antiparallel orientations. We subsequently improved the software by removing sequences where doing so led to fully complementary electrostatic pairings. Our approach can be used to derive increasingly large and therefore complex sets of heterospecific PPIs with a wide range of potential downstream applications from disease modulation to the design of biomaterials and peptides in synthetic biology.

Library construction, selection and modification strategies to generate therapeutic peptide-based modulators of protein-protein interactions.

In the modern age of proteomics, vast numbers of protein-protein interactions (PPIs) are being identified as causative agents in pathogenesis, and are thus attractive therapeutic targets for intervention. Although traditionally regarded unfavorably as druggable agents relative to small molecules, peptides in recent years have gained considerable attention. Their previous dismissal had been largely due to the susceptibility of unmodified peptides to the barriers and pressures exerted by the circulation, immune system, proteases, membranes and other stresses. However, recent advances in high-throughput peptide isolation techniques, as well as a huge variety of direct modification options and approaches to allow targeted delivery, mean that peptides and their mimetics can now be designed to circumvent many of these traditional barriers. As a result, an increasing number of peptide-based drugs are reaching clinical trials and patients beyond.

Cost-effectiveness of fingolimod versus interferon beta-1a for relapsing remitting multiple sclerosis in the United States.

OBJECTIVE: Fingolimod has been shown to be more efficacious than interferon (IFN) beta-1a, but at a higher drug acquisition cost. The aim of this study was to assess the cost-effectiveness of fingolimod compared to IFN beta-1a in patients diagnosed with relapsing-remitting multiple sclerosis (RRMS) in the US. METHODS: A Markov model comparing fingolimod to intramuscular IFN beta-1a using a US societal perspective and a 10-year time horizon was developed. A cohort of 37-year-old patients with RRMS and a Kurtzke Expanded Disability Status Scale score of 0-2.5 were assumed. Data sources included the Trial Assessing Injectable Interferon vs FTY720 Oral in Relapsing-Remitting Multiple Sclerosis (TRANSFORMS) and other published studies of MS. Outcomes included costs in 2011 US dollars, quality-adjusted life years (QALYs), number of relapses avoided, and incremental cost-effectiveness ratios (ICERs). RESULTS: Compared to IFN beta-1a, fingolimod was associated with fewer relapses (0.41 vs 0.73 per patient per year) and more QALYs gained (6.7663 vs 5.9503), but at a higher cost ($565,598 vs $505,234). This resulted in an ICER of $73,975 per QALY. Results were most sensitive to changes in drug costs and the disutility of receiving IFN beta-1a. Monte Carlo simulation demonstrated fingolimod was cost-effective in 35% and 70% of 10,000 iterations, assuming willingness-to-pay thresholds of $50,000 and $100,000 per QALY, respectively. LIMITATIONS: Event rates were primarily derived from a single randomized clinical trial with 1-year duration of follow-up and extrapolated to a 10-year time horizon. Comparison was made to only one disease-modifying drug-intramuscular IFN beta-1a. CONCLUSION: Fingolimod use is not likely to be cost-effective compared to IFN beta-1a unless fingolimod cost falls below $3476 per month or a higher than normal willingness-to-pay threshold is accepted by decision-makers.

Congenital midface abnormalities.

There are a wide variety of congenital midface abnormalities that originate during transformation of the first pair of pharyngeal arches into adult structures. Computed tomography and magnetic resonance imaging are important components in the comprehensive evaluation of these lesions. A detailed understanding of midface embryogenesis and developmental anatomy is important in directing appropriate patient management.

Developmental maxillofacial anomalies.

There is a wide variety of developmental maxillofacial anomalies secondary to defective transformation of the first pair of pharyngeal arches into adult structures. Computed tomography and magnetic resonance imaging are essential to precisely define aberrant maxillofacial anatomy and guide appropriate management. This review article provides an overview of maxillofacial embryogenesis, clinical symptoms, and characteristic imaging features of several anomalies, including choanal atresia, congenital nasal piriform aperture stenosis, dacryocystoceles, nasolacrimal duct stenosis, cleft lip and palate, micrognathia, and midline nasal masses. Finally the major features of common first pharyngeal arch syndromes are discussed.

Strengthening healthcare capacity through a responsive, country-specific, training standard: the KITSO AIDS training program's support of Botswana's national antiretroviral therapy rollout.

In parallel with the rollout of Botswana's national antiretroviral therapy (ART) program, the Botswana Ministry of Health established the KITSO AIDS Training Program by entering into long-term partnerships with the Botswana-Harvard AIDS Institute Partnership for HIV Research and Education and others to provide standardized, country-specific training in HIV/AIDS care. The KITSO training model has strengthened human capacity within Botswana's health sector and been indispensable to successful ART rollout. Through core and advanced training courses and clinical mentoring, different cadres of health care workers have been trained to provide high-quality HIV/AIDS care at all ART sites in the country. Continuous and standardized clinical education will be crucial to sustain the present level of care and successfully address future treatment challenges.

A regional comparison of mold spore concentrations outdoors and inside "clean" and "mold contaminated" Southern California buildings.

A total of 625 buildings and outdoor locations in the San Diego, California, area were monitored using the Allergenco Sampl-Air MK-3 impaction sampler or the Zefon Air-O-Cell slit bioaerosol cassette. Locations were classified by rigid criteria as clean commercial, commercial with mold growth, clean residential, residential with water staining, and residential with mold growth. In addition, coastal and inland outdoor locations were measured. Seven categories (total spores, Ascospores/Basidiospores, Cladosporium, Smut/Myxomycetes-like, Aspergillus/Penicillium (AS/PE), Alternaria, and Unidentified/Other) were detected frequently enough that maximum likelihood estimate techniques could be used to determine distribution parameters and, thus, treat these as continuous variables. For total counts (no nondetectables) an analysis of variance was used to examine differences in location means. For the other categories Land's confidence limits were generated and visually compared for differences among locations. For 12 other categories (Curvularia, Dreschlera, Epicoccum, Fusarium, Mildew-like, Pithomyces, Rusts, Stachybotrys, Stemphyllium, Torula, Ulocladium, and Zygomycetes-like), detection generally occurred in less than 10% of samples. These genera were treated as dichotomous (detect/nondetect) data, and Chi-square analyses differentiated between locations. For total counts, values were significantly different on the order of clean < outdoor < moldy. There was a large difference between the moldy and other location classes. For AS/PE, moldy location means were clearly higher than those for clean buildings and outdoors, although the clean and outdoor means could not be differentiated. For all other genera the results tend to indicate little or no ability to discriminate location. For example, there were no differences in the probabilities of detecting Stachybotrys among the various locations. In our study only total counts, usually driven by AS/PE concentrations, had value in determining whether a building is mold contaminated employing our set of rigorous location classification criteria.