Long-term safety and efficacy of anacetrapib in patients with atherosclerotic vascular disease.

AIMS: REVEAL was the first randomized controlled trial to demonstrate that adding cholesteryl ester transfer protein inhibitor therapy to intensive statin therapy reduced the risk of major coronary events. We now report results from extended follow-up beyond the scheduled study treatment period. METHODS AND RESULTS: A total of 30 449 adults with prior atherosclerotic vascular disease were randomly allocated to anacetrapib 100 mg daily or matching placebo, in addition to open-label atorvastatin therapy. After stopping the randomly allocated treatment, 26 129 survivors entered a post-trial follow-up period, blind to their original treatment allocation. The primary outcome was first post-randomization major coronary event (i.e. coronary death, myocardial infarction, or coronary revascularization) during the in-trial and post-trial treatment periods, with analysis by intention-to-treat. Allocation to anacetrapib conferred a 9% [95% confidence interval (CI) 3-15%; P = 0.004] proportional reduction in the incidence of major coronary events during the study treatment period (median 4.1 years). During extended follow-up (median 2.2 years), there was a further 20% (95% CI 10-29%; P < 0.001) reduction. Overall, there was a 12% (95% CI 7-17%, P < 0.001) proportional reduction in major coronary events during the overall follow-up period (median 6.3 years), corresponding to a 1.8% (95% CI 1.0-2.6%) absolute reduction. There were no significant effects on non-vascular mortality, site-specific cancer, or other serious adverse events. Morbidity follow-up was obtained for 25 784 (99%) participants. CONCLUSION: The beneficial effects of anacetrapib on major coronary events increased with longer follow-up, and no adverse effects emerged on non-vascular mortality or morbidity. These findings illustrate the importance of sufficiently long treatment and follow-up duration in randomized trials of lipid-modifying agents to assess their full benefits and potential harms. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 48678192; ClinicalTrials.gov No. NCT01252953; EudraCT No. 2010-023467-18.

Recommendations for breast cancer education for African American women below screening age.

Although statistically unlikely, early-onset breast cancer tends to be more aggressive and leads to greater mortality than breast cancer among women of screening age. Young African American women are disproportionately impacted by early-onset breast cancer compared to women of other races. Given the racial disparities and because young women are typically not the primary audience for breast cancer educational messaging, there is a need to identify recommendations for age-appropriate breast cancer education for African American women below mammogram eligibility. Through N = 30 key informant interviews with young African American breast cancer survivors, family members of young survivors, community organization leaders and healthcare providers, we identified breast cancer educational message content and communication channels relevant for these women. Participants recommended that message content should emphasize the need to address family cancer history and self-advocacy in healthcare encounters in addition to concerns about loss of womanhood, financial costs and opportunity costs associated with preventive healthcare visits. Breast cancer messages for this audience should consider the influences of earlier life stage, culture and race. Recommended communication channels highlighted use of social media and videos. Findings will inform future age-appropriate educational messaging aimed at eliminating early-onset breast cancer disparities disproportionately impacting young African American women.

Mitigating emotional responses to stressors: coping strategies, modifiers and support.

OBJECTIVE: The stressful nature of the intensive care unit (ICU) environment is increasingly well characterised. The aim of this paper was to explore modifiers, coping strategies and support pathways identified by experienced Intensivists, in response to these stressors. METHOD: Prospective qualitative study employing interviews with Intensivists in two countries. Participants were asked how they mitigated their emotional responses to the stressors of the ICU. Audio-recordings were transcribed and analysed by all researchers who agreed upon emerging themes and subthemes. RESULTS: A wide range of strategies were reported. Although several participants had sought professional help and all supported its utility, few disclosed accessing such help to others indicating stigma. Many felt a sense of responsibility for the well-being of other staff but identified barriers that suggest alternate support pathways are required. Further implications of these findings to training considerations are described. CONCLUSIONS: Several approaches were described as regularly employed by Intensivists to mitigate ICU environmental stressors. Intensivists perceive themselves to have limited training to provide support to others; they also perceive stigma in seeking professional help.

Behavioural responses of Intensivists to stressors in Intensive Care.

BACKGROUND: The hospital intensive care unit (ICU) environment encompasses sick patients who present for care in health crisis. Healthcare in this setting is complex, often involving the co-ordination of multiple professional teams, all under significant time pressures. The sequelae for staff interacting in this dynamic and often volatile setting are variable, depending upon their coping skillset and their familiarity with the stressors. AIMS: The primary aim of this study was to describe and in doing so, normalize the behavioural responses expressed by ICU doctors (Intensivists) in response to stressful workplace events. The secondary aim was to identify those responses that contributed to resilience. METHODS: A prospective qualitative study of senior Intensivists using a semi-scripted iterative interview. Data were transcribed and thematically analysed with verbatim quotations selected to support coding choices. RESULTS: Nineteen experienced Intensivists from three sites in Australia and Israel participated. Clinicians described conscious, physiological and professional responses to stressors, including sense-making and taking time to process information with appropriate support. Two of the most important mitigation processes revealed were the use of reflective learning and preventative practice changes to prevent future errors. These were overlaid with the importance of disclosure and transparency in clinical work. CONCLUSIONS: Repeated exposure to stressful events potentiates burnout, wherein staff no longer experience satisfaction and enjoyment in what they do. This paper presents the behavioural responses that experienced Intensivists described in relation to stressful events in the ICU, including steps taken to mitigate the effects of these events on their personal well-being.

First Report of Rust Disease Caused by Puccinia sparganioides on Spartina alterniflora in Louisiana.

Spartina alterniflora Loisel. (smooth cordgrass) is the dominant plant species of intertidal salt marshes in the Atlantic and Gulf Coast regions of the United States. It is a perennial deciduous grass that can reduce and reverse coastal erosion by buffering wave energy and storm surges and by accumulating suspended solids from intertidal waters. Therefore, smooth cordgrass is utilized extensively in coastal restoration projects in Louisiana. In July 2009, smooth cordgrass leaf samples with signs and symptoms of a rust disease were collected from plant material grown at the Aquaculture Research Station near Baton Rouge, LA. Numerous hypophyllous, narrow, linear lesions were observed in which the uredinia were pale orange, erumpent, and arranged seriately. Urediniospores were yellowish to orange, obovoid to oblong, echinulate with a thickened apical wall and obscure germ pores, and measured 27.5 to 44.9 (-48.3) × 17.3 to 27.6 (-31.05) µm. Telia and teliospores were not observed. The pathogen was identified as Puccinia sparganioides Ellis & Tracy based on the DNA sequence of nuclear ribosomal large subunit (28S) and internal transcribed spacer region 2 (ITS-2) amplified with rust-specific primers (1). The sequence (deposited in GenBank as No. GU327649) was found to share 99.8% identity (1,077/1,079 bp) with sequence No. GU058027 of P. sparganioides from S. patens (Aiton) Muhl. and did not match any other species of Puccinia in GenBank. P. sparganioides has previously been reported on S. alterniflora in Connecticut, Delaware, Florida, Maine, Massachusetts, Mississippi, North Carolina, New Hampshire, Rhode Island, Vermont, and Virginia (2). To the best of our knowledge, this is the first report of P. sparganioides on S. alterniflora from Louisiana. Efforts to screen for rust-resistant lines for use in coastal restoration projects are underway to prevent land loss that could occur due to smooth cordgrass stress from infection. Voucher material (LSU00121657) has been deposited in the Bernard Lowy Mycological Herbarium (LSUM). References: (1) M. C. Aime. Mycoscience 47:112, 2006. (2) D. F. Farr and A. Y. Rossman. Fungal Databases. Systematic Mycology and Microbiology Laboratory, Online publication. ARS, USDA, October, 2009.

Neoplasia in Three Aye-Ayes (Daubentonia madagascariensis).

Tumours diagnosed in three aged captive aye-ayes (Daubentonia madagascariensis), held in two different institutions, are described. A cerebral glioblastoma was diagnosed based on histological and immunohistochemical findings in one of the animals following initial presentation with bilateral mydriasis, absent pupillary reflex, head tilt and ataxia. A second animal was humanely destroyed due to impaired locomotion associated with spondylosis and a post-mortem diagnosis of cholangiocarcinoma was made based on histology with further confirmation with immunohistochemical labelling for cytokeratin 7. A third aye-aye suffering from dental disease was diagnosed with an oral squamous cell carcinoma following an excisional biopsy from a non-healing wound in the lip. Due to progression of the neoplasia the animal was humanely destroyed and post-mortem examination revealed the presence on an additional unilateral phaeochromocytoma.

BRCA1 partially reverses the transforming activity of the ras oncogene.

The BRCA1 gene is associated with hereditary breast and ovarian cancers. BRCA1 fits the model of a classic tumor suppressor gene, a hypothesis supported by recent work demonstrating that expression of BRCA1 inhibits growth of breast and ovarian cancer cell lines. The present study was designed to test the potential of BRCA1 to reverse the transforming activity of the ras oncogene. The v-Ha ras oncogene was cloned downstream of the retrovirus LTR and stably expressed in Rat-1 cells (Rat-1/ras). Rat-1/ras (R/R) cells were fully transformed as indicated by change in morphology, colony formation in soft-agarose and tumor induction in nude mice. BRCA1 was stably expressed in R/R cells under the CMV promoter (R/R-BRCA1). The expression of ras and BRCA1 was confirmed by Western blot using monoclonal antibodies (mAbs) specific to ras and BRCA1, respectively. R/R-BRCA1 cells grew slower than the negative control, which was R/R cells transfected with vector alone (R/R-pCEP4). R/R-BRCA1 cells generated approximately 5 to 10 times less colonies in a soft-agarose assay compared to the negative control. When injected into nude mice, R/R-BRCA1 cells exhibited a delayed onset of tumorigenesis and generated smaller tumors compared to R/R or R/R-pCEP4 cells. These data strongly suggest that BRCA1 partially reverses the transforming activity of the v-Ha ras oncogene indicating that BRCA1 can bypass the effects of the v-Ha ras oncogene on cell growth. BRCA1, therefore, may be used in therapy of tumors arising due to activation of v-Ha ras oncogene.

Regional effects of pertussis toxin in vivo and in vitro on GABAB receptor binding in rat brain.

Agonist binding to GABAB receptors modulates the activity of the guanine nucleotide binding proteins, Go and Gi. These G proteins are ADP-ribosylated by pertussis toxin and this prevents them from coupling to the GABAB receptor resulting in a reduction in high-affinity GABAB binding. GTP, which binds to a different site on the G protein alpha subunit, also reduces the affinity of the receptor for the G protein, and this can be used as a "marker" for G protein-GABAB receptor linkage. We have examined GABAB binding site distribution in rat brain after unilateral intrahippocampal pertussis toxin injection in vivo, and after incubating brain slices in pertussis toxin in vitro, using the technique of receptor autoradiography. The effect of pertussis toxin was compared with that of GTP gamma S on GABAB binding. Intrahippocampal pertussis toxin administration reduced GABAB but not GABAA receptor binding and the effects appeared to be limited by pertussis toxin diffusion. More widespread reductions in GABAB binding were seen after incubation of brain slices in vitro but the extent varied in different brain regions. No reduction was detected in the corpus striatum. GABAB binding was also reduced in membranes prepared from cerebral cortex, hippocampus and cerebellum but there was no significant reduction in the corpus striatum after pertussis toxin treatment. GTP gamma S reduced GABAB binding to a similar extent in all areas studied irrespective of their sensitivity to pertussis toxin suggesting that while GABAB binding sites are linked to G proteins throughout the rat brain, those in the corpus striatum may be predominantly pertussis toxin insensitive.

Placental transfer of anticonvulsants in the rabbit: the effect of maternal protein binding and fetal flow.

The fetal-to-maternal ratios of carbamazepine, antipyrine and phenytoin are principally determined by maternal protein binding, though greater lipid solubility may enhance the transfer of valproate compared to that of other drugs at high flows. Placental clearance of all anticonvulsants showed flow-dependent characteristics. This is in line with our findings for basic drugs.

Neurologic function among termiticide applicators exposed to chlorpyrifos.

Chlorpyrifos is a moderately toxic organophosphate pesticide. Houses and lawns in the United States receive a total of approximately 20 million annual chlorpyrifos treatments, and 82% of U.S. adults have detectable levels of a chlorpyrifos metabolite (3,5, 6-trichloro-2-pyridinol; TCP) in the urine. The U.S. Environmental Protection Agency has estimated that there are 5,000 yearly reported cases of accidental chlorpyrifos poisoning, and approximately one-fourth of these cases exhibit symptoms. Organophosphates affect the nervous system, but there are few epidemiologic data on chlorpyrifos neurotoxicity. We studied neurologic function in 191 current and former termiticide applicators who had an average of 2.4 years applying chlorpyrifos and 2.5 years applying other pesticides, and we compared them to 189 nonexposed controls. The average urinary TCP level for 65 recently exposed applicators was 629.5 microg/L, as compared to 4.5 microg/L for the general U.S. population. The exposed group did not differ significantly from the nonexposed group for any test in the clinical examination. Few significant differences were found in nerve conduction velocity, arm/hand tremor, vibrotactile sensitivity, vision, smell, visual/motor skills, or neurobehavioral skills. The exposed group did not perform as well as the nonexposed group in pegboard turning tests and some postural sway tests. The exposed subjects also reported significantly more symptoms, including memory problems, emotional states, fatigue, and loss of muscle strength; our more quantitative tests may not have been adequate to detect these symptoms. Eight men who reported past chlorpyrifos poisoning had a pattern of low performance on a number of tests, which is consistent with prior reports of chronic effects of organophosphate poisoning. Overall, the lack of exposure effects on the clinical examination was reassuring. The findings for self-reported symptoms raise some concern, as does the finding of low performance for those reporting prior poisoning. Although this was a relatively large study based on a well-defined target population, the workers we studied may not be representative of all exposed workers, and caution should be exercised in generalizing our results.

Human IL-6 enhances human lymphocyte engraftment and activation but not human antibody production in SCIDhu PBL mice.

The SCIDhu PBL model of human Ig production was modified by using human interleukin-6 (hIL-6) secreting tumors for continuous hIL-6 production, in vivo. On day one, SCID mice were injected subcutaneously with 200 microliters PBS (control mice), 10(4) SP2/0-Ag14 cells (IL-6+ mice) or 10(4) hIL-6 secreting SP2/0-hIL6.17 cells (IL-6- mice). The mice were reconstituted with human PBMC on day two and immunized with 100 micrograms of tetanus toxoid (TT) on days two and fifteen. Serum hIL-6 concentrations in IL-6+ mice ranged between 2.9 and 38.1 ng/ml by days 26-33. IL-6+ mice had enlarged spleens and lymph nodes (LN). Flow cytometry and histology showed that SCIDhu PBL mouse spleen, LN and peritoneal exudate cells (PEC) contained mostly murine myeloid lineage cells. In addition, many more human B cells, T cells and IL-2R(+)-activated lymphocytes were present in spleen, LN and PEC of IL-6+ mice. Despite enhanced lymphocyte engraftment and activation, by day 14 IL-6+ mice produced up to 6-fold less TT-specific IgG relative to total IgG than either control group. TT-specific and total Ig sera concentrations were equivalent in all three groups on days 26-33. Our results suggest that sustained circulating hIL-6 enhanced human delayed-type hypersensitivity (DTH)-like inflammatory responses with consequential inhibition of TT-specific IgG production in SCIDhu PBL mice.

Therapy of streptozotocin induced diabetes with a bifunctional antibody that delivers vinca alkaloids to IL-2 receptor positive cells.

IVA039.1 is a bifunctional antibody with specificity for the murine IL-2 receptor and vinca alkaloids. Biodistribution studies show that IVA039.1 can target and deliver vinca alkaloids to tissues that contain IL-2 receptor positive cells. Vinca alkaloids are lymphocytotoxic. Therapy of diabetic mice with IVA039.1 plus vincristine results in a significant decrease in the glucose levels of diabetic compared to untreated mice. The therapeutic effect of IVA039.1 plus vincristine therapy was additive but surprisingly not synergistic. The binding of IVA039.1 to vincristine has moderate affinity with a slow off rate. In vitro studies suggest that, when bound to IVA039.1, the vincristine is inactivated. We attribute the lack of an enhanced therapeutic response to bifunctional antibody therapy using IVA039.1 plus vincristine to the inaccessibility of the drug to the target cells.

Age-related regional sensitivity to pertussis toxin-mediated reduction in GABAB receptor binding in rat brain.

GABAB binding was performed in rat brain membranes incubated with pertussis toxin (PTX; 7-15 micrograms/mg protein) or vehicle during postnatal development. In peripubertal rats, GABAB binding was reduced by PTX in corpus striatum and hippocampus but not in cortex or cerebellum, while in sexually mature adults binding was reduced in all areas except the corpus striatum. These data may indicate regional differences in the postnatal development of GABAB receptor-G protein linkage.

Signal processing technique to extract neuronal activity from noise.

A method of extracting extracellularly recorded action potentials from background electronic noise is described. Segments of traces containing stimulus-induced activity are Fourier transformed and the increase in the total power density over that of control noise segments is used as a measure of stimulus-induced neuronal activity. We show first, with observations from the amphibian visual system and mammalian auditory system, that our technique yields similar quantitative information to that obtained from the conventional spike counting method when the recording arrangement is optimal. Moreover, the size and centre of a visual receptive field can be determined even when the evoked action potentials are buried in the background noise. To investigate the potential of this technique further, we have used it to study the auditory responses in the amphibian midbrain. The power spectral density, we demonstrate here, is proportional to the stimulus intensity over a wide range, and varies systematically with stimulus frequency and the direction of sound source. Other possible applications of this technique, together with the theoretical basis for it, are discussed.

Tetanus toxin produces neuronal loss and a reduction in GABAA but not GABAB binding sites in rat hippocampus.

The neuropathological effects of tetanus toxin, microinjected in the rat CA1 hippocampal area, were studied by using a microscopical and autoradiographical approach. Tetanus toxin produced a dose- and time-dependent neuronal loss in the CA1 area accompanied by a reduction in the binding of gamma-[3H]aminobutyric acid ([3H]GABA) to GABAA but not GABAB sites in the pyramidal cell layer.

Astrocytes and microglia in the substantia nigra and caudate-putamen in Parkinson's disease.

There is evidence that astrocytes and microglia can release agents which might have a protective effect on damaged neurons. However the associations of glia with dopaminergic neurons in Parkinson's disease are not defined. Our studies showed that in post mortem parkinsonian nigra healthy neuronal somata were enveloped by astrocyte processes but these withdrew from fragmenting neurons and amoeboid microglia occupied the vacated peri-somal space. Thus, during the course of the disease both classes of glia are appropriately sited to release protective molecules onto failing neurons, but this may be inadequate for their long-term survival.

Elevated glial brain-derived neurotrophic factor in Parkinson's diseased nigra.

We show the cellular distribution of immunoreactivity (IR) for brain-derived-neurotrophic-factor (BDNF), neurotrophin-3 (NT-3) and tyrosine kinase receptors TRKB and TRKC in idiopathic Parkinson's disease (IPD) and controls at post-mortem. In both groups, nigral neurons, astrocytes, ramified and amoeboid microglia expressed all antigens. Caudate-putamen neurons expressed all antigens except BDNF with similar distribution between groups. In IPD nigra, increased numbers of BDNF-IR and, less frequently, NT-3-IR ramified glia surrounded fragmented neurons, accompanied by BDNF-IR in surrounding neuropil. Amoeboid microglia were abundant only in IPD nigral scars. In IPD, glia might up-regulate neurotrophins in response to signals released from failing nigral neurons.

Vigabatrin in the treatment of complex partial seizures.

We report the effect of vigabatrin on seizure frequency in 13 severely drug-resistant patients with intractable complex partial seizures (CPS) with or without secondary generalization. Patients were followed for a 3-month period before vigabatrin administration to establish a 'baseline'. Six patients became seizure free for 2-3 weeks immediately after starting vigabatrin. In seven patients a transient (4-6 weeks) increase in seizures above baseline occurred, which was attenuated by vigabatrin dose increments. After 3 months, the mean baseline CPS frequency was reduced from 7.75 +/- 1.18 (median 8, range 2.6-16) to 2.77 +/- 0.7 (median 1, range 0-7). At 6 months a > 50% improvement remained in seven patients. After 12 or more months CPS frequency returned to baseline in four patients, improved (by 25-62.5%) in four and deteriorated in three. One patient who was seizure free lost control at 16 months. Other effects were drowsiness (3), weight increase (3), diarrhoea (1), depression (2) and mood elevation (2). Four patients discontinued vigabatrin; one because of severe depression, three owing to lack of efficacy. Three patients have undergone and two are awaiting neurosurgery for their epilepsy. Thus, CPS frequency progressively deteriorated toward baseline in all patients, however, secondary generalizations were abolished in four and reduced in two.

Isolation of hybridoma forming cells from immune spleens by unit gravity sedimentation.

In 1975 a method for the production of hybridomas that secrete monoclonal antibodies was first described (1). Since that time, surprisingly little information has emerged on the identity of the fusible spleen cell. In this report we describe the isolation of hybridoma forming cells from immune spleens and the enrichment of B cell populations in different states of activation. The B cells that reside in immune spleens are comprised of heterogeneous populations that differ in their states of activation. These populations have been difficult to separate and, therefore, difficult to characterize. Two factors that discriminate B cells in different states of activation are cell size and density. Unit gravity sedimentation is a simple, reliable and reproducible method for separating cells based on their size and density. Immune B cells were fractionated on a 10 to 25% serum gradient at unit gravity. Cells were collected and pooled, when necessary, to perform functional assays. Fractionated B cells were assayed for hybridoma formation, PFC response, Ig secretion and proliferation. The cells that exhibited hybridoma formation, PFC activity and Ig secretion were all found in the large cell fractions that comprised less than 10% of the cells recovered from the gradient. Proliferating B cells were found primarily in smaller cell fractions compared to antibody forming cells. Resting B cells were located in the smallest cell fractions recovered from the gradient. Data show that separation of immune B cells by unit gravity sedimentation is an effective means to isolate hybridoma forming cells and enrich for B cell subpopulations in different states of activation.

Evaluation of Bcl-2/B cell transgenic mice (B6) for hybridoma production.

Bcl-2 is an oncogene associated with prevention of apoptosis in a variety of cell types. Bcl-2 expression in B lymphoid cells prolongs antibody production, in vitro and in vivo. A line of transgenic mice (B6) has been developed that expresses human Bcl-2 in the B cells of SWR/SJL mice. B6 transgenic, nontransgenic littermates, and BALB/c mice were immunized with beta-galactosidase (B-gal) or sheep red blood cells (SRBC). The number of spleen cells recovered from immunized B6 mice was 3-4 times greater than syngeneic, nontransgenic littermates or BALB/c mice. Spleen cells from B-gal or SRBC immune B6, SWR/SJL, and BALB/c mice were fused with P3 myeloma cells to produce hybridomas. Forty-eight percent of the wells plated with fused B6 spleen cells produced B-gal-specific antibodies compared to 14% from BALB/c and 12% from SWR/SJL. Antibody-specific wells were subcloned, resulting in enhanced recovery of antigen-specific subclones with B6-derived fusions compared to controls. In the SRBC fusions, 17% of the wells plated with fused B6 spleen cells produced SRBC-specific antibodies compared to 6% for BALB/c and SWR/SJL spleens. After subcloning, B6-derived clones produced 8% positive subclones compared to 9.5% from SWR/SJL and 3.5% from BALB/c. Comparison of the isotype distribution of subclones showed a higher ratio of IgG antibodies compared to IgM from B6 mice in the B-gal fusions. IgA antibodies were recovered only from B6 mice. These data indicate that B6 transgenic mice that overexpress Bcl-2 in their B cells may be superior to other mouse strains for production of antigen-specific hybridomas.