Gas Phase Ion Chemistry to Determine Isoaspartate in a Peptide Backbone.

Proof of concept evidence is presented for a new method for the determination of isoaspartate, an important post-translational modification. Chemical derivatization is performed using common reagents for the modification of carboxylic acids and shown to yield suitable diagnostic information with regard to isomerization at the aspartate residue. The diagnostic gas phase chemistry is probed by collision-induced dissociation mass spectrometry, on the timescale of the MS experiment and semi-quantitative calibration of the percentage of isoaspartate in a peptide sample is demonstrated. Graphical Abstract ᅟ.

Plasmonic ELISA for the detection of gp120 at ultralow concentrations with the naked eye.

The technique of plasmonic ELISA is utilised here to detect the HIV-1 protein gp120 with the ultralow limit of detection of 8 × 10(-20) M (10(-17) g mL(-1)) in an independent laboratory. It was corroborated that changes in the concentration of hydrogen peroxide as small as 0.05 µM could lead to nanoparticle solutions of completely different tonality.

Rural:urban inequalities in post 2015 targets and indicators for drinking-water.

Disparities in access to drinking water between rural and urban areas are pronounced. Although use of improved sources has increased more rapidly in rural areas, rising from 62% in 1990 to 81% in 2011, the proportion of the rural population using an improved water source remains substantially lower than in urban areas. Inequalities in coverage are compounded by disparities in other aspects of water service. Not all improved sources are safe and evidence from a systematic review demonstrates that water is more likely to contain detectable fecal indicator bacteria in rural areas. Piped water on premises is a service enjoyed primarily by those living in urban areas so differentiating amongst improved sources would exacerbate rural:urban disparities yet further. We argue that an urban bias may have resulted due to apparent stagnation in urban coverage and the inequity observed between urban and peri-urban areas. The apparent stagnation at around 95% coverage in urban areas stems in part from relative population growth - over the last two decades more people gained access to improved water in urban areas. There are calls for setting higher standards in urban areas which would exacerbate the already extreme rural disadvantage. Instead of setting different targets, health, economic, and human rights perspectives, We suggest that the focus should be kept on achieving universal access to safe water (primarily in rural areas) while monitoring progress towards higher service levels, including greater water safety (both in rural and urban areas and among different economic strata).

The radiologist as a palliative care subspecialist: providing symptom relief when cure is not possible.

OBJECTIVE: The purpose of this study was to determine the percentage of patients referred to an interventional radiology (IR) practice who need palliative care and to examine the training required for a diplomate of the American Board of Radiology (ABR) to qualify for the hospice and palliative medicine certifying examination. MATERIALS AND METHODS: This retrospective study reviewed all patient referrals to an academic vascular and IR practice during the month of August 2009. The demographics, underlying diagnosis, and the type of procedures performed were ascertained from the electronic medical record. The requirements for a diplomate of the ABR to obtain certification as a hospice and palliative medicine subspecialist were evaluated and summarized. RESULTS: Two-hundred eighty-two patients were referred to the IR service and underwent a total of 332 interventional procedures. Most of the patients (229 [81.2%]) had underlying diagnoses that would warrant consultation with a hospice and palliative medicine subspecialist; these patients were significantly older (58.5 vs 44.7 years; p < 0.01) and underwent more procedures (1.21 vs 1.02; p < 0.01). To obtain a subspecialty certification in hospice and palliative medicine, a radiologist needs certification by the ABR, an unrestricted medical license, 2 years of subspecialty training in hospice and palliative medicine, 100 hours of interdisciplinary hospice and palliative medicine team participation, active care of 50 terminally ill adult patients, and successful performance on the certification examination. CONCLUSION: Procedures related to palliative care currently compose the majority of our IR cases. Certification in hospice and palliative medicine can be achieved with a modest investment of time and clinical training.

Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track.

OBJECTIVE: To reduce the time between arrival at hospital of a patient with acute myocardial infarction and administration of thrombolytic therapy (door to needle time) by the introduction of nurse initiated thrombolysis in the accident and emergency department. METHODS: Two acute chest pain nurse specialists (ACPNS) based in A&E for 62.5 hours of the week were responsible for initiating thrombolysis in the A&E department. The service reverts to a "fast track" system outside of these hours, with the on call medical team prescribing thrombolysis on the coronary care unit. Prospectively gathered data were analysed for a nine month period and a head to head comparison made between the mean and median door to needle times for both systems of thrombolysis delivery. RESULTS: Data from 91 patients were analysed; 43 (47%) were thrombolysed in A&E by the ACPNS and 48 (53%) were thrombolysed in the coronary care unit by the on call medical team. The ACPNS achieved a median door to needle time of 23 minutes (IQR=17 to 32) compared with 56 minutes (IQR=34 to 79.5) for the fast track. The proportion of patients thrombolysed in 30 minutes by the ACPNS and fast track system was 72% (31 of 43) and 21% (10 of 48) respectively (difference=51%, 95% confidence intervals 34% to 69%, p<0.05). CONCLUSION: Diagnosis of acute myocardial infarction and administration of thrombolysis by experienced cardiology nurses in A&E is a safe and effective strategy for reducing door to needle times, even when compared with a conventional fast track system.

Epidemiology of parasitic gastrointestinal nematode infections of ruminants on smallholder farms in central Kenya.

In order to establish the infection pattern with gastrointestinal nematodes in ruminants in the central Kenya highlands, a study was carried out in 58 smallholder farms. The study involved monthly faecal examinations from sheep, goats and cattle and pasture sampling from eight communal grazing areas. Each month, six Dorper worm-free tracer lambs were introduced and four locally grazed cross-bred sheep were purchased for parasite recovery. The mean faecal egg counts (FEC) for cattle were low throughout the study period, whereas those for sheep and goats showed a seasonal pattern with high levels of infection occurring during the two main rainy seasons, especially in March, April and October. There were significant differences in egg counts over time and among farms. Haemonchus contortus was the most prevalent nematode in the tracer lambs whereas the previously exposed locally grazed sheep had significantly lower numbers of H contortus but significantly higher numbers of Trichostrongylus species The highest levels of infection in the tracer lambs occurred in November 1995 and January, May and June 1996. Based on this study, it is now possible to explore the possibility of using strategic treatments for the control of parasitic gastroenteritis in this area of Kenya.

A flexible stochastic curtailing procedure for the log-rank test.

For safety and ethical reasons, a data monitoring committee of a clinical trial may wish to assess the futility of continuing a trial if the currently available data at an interim look show no beneficial effect due to treatment, especially when accompanied by mounting evidence of treatment emergent adverse effects. Stochastic curtailing whereby conditional power is evaluated given currently observed data is one way of evaluating futility. In clinical trials that look at "time-to-event" as the primary outcome, difference between treatment groups with respect to the primary outcome is commonly evaluated using the log-rank test. Although the unconditional power function for the log-rank test has been described previously, its conditional power has not been widely investigated. We describe a method for evaluating conditional power when the log-rank test is used to assess the difference between the survival distributions of two treatment groups with respect to some failure-time outcome. The method is useful under a wide range of assumptions regarding the underlying survival distribution, patient entry distribution, losses to follow-up, and (if applicable) noncompliance, drop-ins, lag in treatment effect, and stratification. This level of applicability is attained by generalizing a flexible Markov chain approach to unconditional power computation, described previously, to compute conditional power.

Effect of intensive blood pressure control on the course of type 1 diabetic nephropathy. Collaborative Study Group.

Diabetic nephropathy is the most common cause of end-stage renal disease in the United States. We undertook a study to assess the impact of assignment to different levels of blood pressure control on the course of type 1 diabetic nephropathy in patients receiving angiotensin-converting enzyme (ACE) inhibitor therapy. We also examined the long-term course of this well-characterized cohort of patients receiving ACE inhibitor therapy. One hundred twenty-nine patients with type 1 diabetes and diabetic nephropathy who had previously participated in the Angiotensin-Converting Enzyme Inhibition in Diabetic Nephropathy Study who had a serum creatinine level less than 4.0 mg/dL were randomly assigned to a mean arterial blood pressure (MAP) goal of 92 mm Hg or less (group I) or 100 to 107 mm Hg (group II). Patients received varying doses of ramipril as the primary therapeutic antihypertensive agent. All patients were followed for a minimum of 2 years. Outcome measures included iothalamate clearance, 24-hour creatinine clearance, creatinine clearance estimated by the Cockcroft and Gault formula, and urinary protein excretion. The average difference in MAP between groups was 6 mm Hg over the 24-month follow-up. The median iothalamate clearance in group I was 62 mL/min/1.73 m(2) at baseline and 54 mL/min/1.73 m(2) at the end of the study compared with a baseline of 64 mL/min/1.73 m(2) and final 58 mL/min/1.73 m(2) in group II. There were no statistically significant differences in the rate of decline in renal function between groups. There was a significant difference in follow-up total urinary protein excretion between group I (535 mg/24 h) and group II (1,723 mg/24 h; P = 0.02). Thirty-two percent of 126 patients achieved a final total protein excretion less than 500 mg/24 h. Patients from groups I and II had equivalent rates of adverse events. In patients with type 1 diabetes mellitus and diabetic nephropathy, the MAP goal should be 92 mm Hg or less for optimal renoprotection, if defined as including decreased proteinuria. With the combination of ACE inhibition and intensive blood pressure control, many patients can achieve regression or apparent remission of clinical evidence of diabetic nephropathy.

Focal segmental glomerulosclerosis: prognostic implications of the cellular lesion.

The cellular lesion (CELL), seen in some patients with primary focal segmental glomerulosclerosis (FSGS), comprises proliferation, hypertrophy, and pathologic changes in the cells overlying the glomerular scar. The prognosis of the cellular lesion was retrospectively studied in 100 patients with FSGS (43 had FSGS-CELL and 57 had FSGS without the cellular lesion (classic segmental scar [CS]). Patients with the FSGS-CELL lesion were more often black and severely proteinuric and developed more end-stage renal disease (ESRD). Nephrotic patients with FSGS-CELL (n = 39) were more proteinuric at presentation than patients with FSGS-CS (n = 36). ESRD developed more frequently in patients with the FSGS-CELL (17 of 39, 44% versus 5 of 36, 14%, P = 0.005), and patients with extensive FSGS-CELL (> or = 20% glomeruli) were mainly black (94%), severely nephrotic (67%, >10 g/d), and had a poor response to treatment (23% remission). In nephrotic patients, initial serum creatinine, interstitial expansion > or = 20%, and CELL independently predicted ESRD. However, the rates of remission in treated nephrotic patients with FSGS-CELL and FSGS-CS were the same (9 of 17, 53% versus 17 of 39, 52%), and patients in both groups who achieved a remission had a 5-yr survival of 100%. Steroid treatment was the only variable that predicted remission. Patients with the FSGS-CELL have an increased prevalence of ESRD, but the improved prognosis associated with remission is so significant that a therapeutic trial is warranted in all nephrotic FSGS patients, regardless of the presence of the cellular lesion.

Design and baseline characteristics for the aminoguanidine Clinical Trial in Overt Type 2 Diabetic Nephropathy (ACTION II).

Advanced glycosylation endproduct (AGE) formation has been implicated in the development and progression of nephropathy in type 2 diabetes mellitus. In diabetic animals, aminoguanidine inhibits AGE-mediated cross-linking of proteins in vascular and renal tissue and slows the progression of renal disease. ACTION II is a randomized, double-blind, placebo-controlled trial comparing two dose levels of aminoguanidine with placebo on the progression of nephropathy in 599 type 2 diabetic patients with renal disease from 84 centers in the United States and Canada. The primary endpoint is time to doubling of serum creatinine concentration. Secondary endpoints include the effect of aminoguanidine on time to all-cause mortality, end-stage renal disease (ESRD), cardiovascular morbidity and mortality, rate of change in indices of renal function (iothalamate, Cockcroft and Gault [C&G] calculated creatinine and measured creatinine clearances), proteinuria, retinopathy, circulating and urinary AGE levels, and estimation of the relationship between plasma aminoguanidine concentrations and primary and secondary efficacy endpoints and adverse events. Progression of macrovascular disease was monitored and fundus photography performed. Type 2 diabetic patients aged 30 to 70 years were eligible for the trial if their blood pressure was < or =180 mm Hg systolic and < or =120 mm Hg diastolic, serum creatinine concentration > or =1.0 mg/dL (in women) or > or =1.2 mg/dL (in men), C&G clearance > or =40 mL/min, and proteinuria > or =500 mg/d with diabetic retinopathy or diabetic nephropathy on renal biopsy. Recruitment began in July 1995 and terminated in December 1996. The trial randomized a total of 599 subjects. At baseline, the mean (standard deviation [SD]) age was 58 (7.7) years, diabetes duration 16.5 (7.5) years, body mass index 32 kg/m2 (10-90% range 2642), arterial blood pressure 105 (12) mm Hg, C-peptide concentration 2.55 (1.71) ng/mL, serum glucose concentration 201 (89) mg/dL, hemoglobin A1c 8.7% (1.6), serum creatinine concentration 1.6 (0.5) mg/dL, iothalamate clearance 52 (25) mL/min/1.73 m2, proteinuria 4.1 (4.2) g/d, triglycerides 259 (214) mg/dL, and LDL cholesterol 144 (40) mg/dL. Patients are 72% male, 68% white, 16% black, and 16% Asian American and Native American. At baseline, 76% were receiving concomitant angiotensin-converting enzyme (ACE) inhibitors and 43% lipid-lowering agents. Follow-up in ACTION II was scheduled to continue through December 1998, so that follow-up was to be 2 years after the date of randomization of the final enrolled patient. The trial in fact ended in March 1998. This trial will contribute to our understanding of the natural history of type 2 diabetes mellitus-associated nephropathy and determine whether aminoguanidine will slow the progression of established diabetic renal disease.

Remission of nephrotic syndrome in type 1 diabetes: long-term follow-up of patients in the Captopril Study.

In 1994, we reported a 3.4 +/- 0.8 year follow-up of the eight patients who experienced remission of nephrotic syndrome during the Collaborative Study Group-sponsored, multicenter trial of captopril therapy in patients with type 1 diabetes with nephropathy (Captopril Study). Of the 409 patients randomized to treatment on the Captopril Study, 108 had nephrotic syndrome (24-hour proteinuria >/= 3.5 g of protein) at baseline. Of these 108 patients, 8 experienced remission of nephrotic syndrome (proteinuria

Report of a National Institutes of Health--Centers for Disease Control and Prevention workshop on the feasibility of conducting a randomized clinical trial to estimate the long-term health effects of intentional weight loss in obese persons.

A workshop was convened in 1997 by the National Institutes of Health and the Centers for Disease Control and Prevention to consider the need for and feasibility of conducting a randomized clinical trial to estimate the long-term health effects of intentional weight loss in obese persons. Although the benefits of weight loss in obese individuals may seem obvious, little information is available showing that intentional weight loss improves long-term health outcomes. Observational studies may be unable to provide convincing answers about the magnitude and direction of the health effects of intentional weight loss. Workshop participants agreed that a well-designed randomized clinical trial could answer several questions necessary for developing a rational clinical and public health policy for treating obesity. Such information will ultimately provide needed guidance on the risks and benefits of weight loss to health care providers and payers, as well as to millions of obese Americans.

Irradiated vaccines for helminth control in livestock.

For nearly 40 years, irradiated larval vaccines have been available for the control of parasitic bronchitis in cattle and sheep caused by Dictyocaulus spp. Despite research on a number of other host/parasite systems, no other vaccines have been commercially successful. Vaccination could provide a useful addition to other control methods in an integrated parasite management system where the criteria for vaccine success may not be complete control and sterile immunity, but a sufficient reduction in worm burden to decrease overall reinfection levels at the flock/herd level and, hence, prevent clinical disease and subclinical effects including production loss. Indeed, vaccination against Dictyocaulus spp. relies on continued natural infection to maintain levels of immunity. However, the difficulties of producing live larval vaccines are often cited as a reason why this line of research should not be pursued. This paper discusses some of the difficulties in vaccine production and offers some solutions and recommendations for those wishing to develop and register irradiated larval vaccines for other helminth diseases.

Pharmaceutical quality of anthelmintics sold in Kenya.

Nine anthelmintic products in pharmacies and from agricultural merchants in Kenya were tested for pharmaceutical quality. The concentration of active drug was compared with the claim on the label, and the variability of several products was tested between batches and between bottles within the same batch. All the products purchased claimed to contain levamisole but its mean (sd) concentration varied from 0 to 118.0 (13.3) per cent of the claimed. The concentration of levamisole in different batches of the same product ranged from 0 to 85.4 per cent of that claimed. One product consisting in part of mebendazole was found to contain 73.2 (9.4) per cent of the claimed concentration of this active component and two products consisting in part of oxyclozanide were found to contain 106.0 (14.4) and 120.6 (6.1) per cent of the expected concentration of oxyclozanide.

Availability of Haemonchus contortus L3 larvae on pasture at Kiboko: a semi-arid warm agro-climatic zone in Kenya.

A study was carried out to determine the availability of Haemonchus contortus L3 larvae on pasture in a semi-arid warm agro-climatic zone of Kenya. By means of tracer sheep, it was shown that no H. contortus L3 larvae were available on pasture during the dry periods of the year (July-October and February). They were only available on pasture during the rainy season (November-January and March-June). Sheep permanently grazed on the same pasture however, harboured adult H. contortus in their abomasa throughout the year indicating that the perpetuation of haemonchosis in livestock in this agro-climatic zone was greatly dependent on the ability of the parasite to survive in the host throughout all seasons.

Resistance of four sheep breeds to natural and subsequent artificial Haemonchus contortus infection.

The response of Red Maasai sheep to natural and artificial Haemonchus contortus infections was compared with sheep of Blackheaded Somali, Dorper and Romney Marsh breeds. Significant breed differences in egg count, packed cell volume (PCV), and mortality rates showed that the Red Maasai sheep were more resistant to natural H. contortus infection than sheep from the other three breeds. Of the initial groups of 15 wethers of each breed, two animals from each of the Dorper and Blackheaded Somali groups and nine from the Romney Marsh group died with haemonchosis during a 12 month field study. Following artificial infection of the Red Maasai, Dorpers and Blackheaded Somalis, with 10000 H. contortus L3, the Red Maasai sheep maintained a lower egg output and a higher PCV than animals of the other two breeds. The results clearly showed that breed substitution with the Red Maasai is a control option in areas where sheep are kept for meat and H. contortus is endemic.

Response to artificial and subsequent natural infection with Haemonchus contortus in red Maasai and Dorper ewes.

Maiden Red Maasai and Dorper ewes were kept indoors and artificially infected with a single oral dose of 5000 infective larvae of Haemonchus contortus. Their faecal egg counts (FEC) and packed red cell volumes (PCV) were monitored for 9 weeks. They were then treated with an anthelmintic and turned out to graze together on a pasture contaminated with H. contortus. They grazed this pasture for 14 months and were allowed to mate and lamb. While at pasture the ewes were monitored for FEC, PCV and peripheral eosinophilia. Red Maasai ewes had significantly lower FEC, and for certain periods, significantly higher PCV and peripheral eosinophilia. During the periparturient period, FEC were about twice as high in the Dorper breed as the Red Maasai. These results confirm and extend previous reports on the superiority of the Red Maasai breed in East Africa.

Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six prospective studies.

Risk factors associated with the progression from impaired glucose tolerance (IGT) to NIDDM were examined in data from six prospective studies. IGT and NIDDM were defined in all studies by World Health Organization (WHO) criteria, and baseline risk factors were measured at the time of first recognition of IGT. The studies varied in size from 177 to 693 participants with IGT, and included men and women followed from 2 to 27 years after the recognition of IGT. Across the six studies, the incidence rate of NIDDM was 57.2/1,000 person-years and ranged from 35.8/1,000 to 87.3/1,000 person-years. Although baseline measures of fasting and 2-h postchallenge glucose levels were both positively associated with NIDDM incidence, incidence rates were sharply higher for those in the top quartile of fasting plasma glucose levels, but increased linearly with increasing 2-h postchallenge glucose quartiles. Incidence rates were higher among the Hispanic, Mexican-American, Pima, and Nauruan populations than among Caucasians. The effect of baseline age on NIDDM incidence rates differed among the studies; the rates did not increase or rose only slightly with increasing baseline age in three of the studies and formed an inverted U in three studies. In all studies, estimates of obesity (including BMI, waist-to-hip ratio, and waist circumference) were positively associated with NIDDM incidence. BMI was associated with NIDDM incidence independently of fasting and 2-h post challenge glucose levels in the combined analysis of all six studies and in three cohorts separately, but not in the three studies with the highest NIDDM incidence rates. Sex and family history of diabetes were generally not related to NIDDM progression. This analysis indicates that persons with IGT are at high risk and that further refinement of risk can be made by other simple measurements. The ability to identify persons at high risk of NIDDM should facilitate clinical trials in diabetes prevention.

Response of Dorper and red Maasai lambs to trickle Haemonchus contortus infections.

Six-month-old red Maasai lambs were more resistant than Dorper lambs to repeated infections at one to two week intervals with 1000 Haemonchus contortus infective larvae. Resistance after infection was assessed by means of faecal egg counts, packed cell volumes, eosinophil counts, total serum protein concentrations and mortality rates. The weight gains of the infected animals were only marginally lower than those of their uninfected controls, most probably because of their significantly higher feed consumption, and evidently the infected lambs were not utilising all of the extra feed for growth. This absence of anorexia in spite of the infection was probably due to the palatability of the high protein diet fed to the lambs.

Predictors of the progression of renal insufficiency in patients with insulin-dependent diabetes and overt diabetic nephropathy. The Collaborative Study Group.

We designed a prospective, double-blind controlled trial to determine predictors of loss of renal function in patients with insulin dependent diabetes and established nephropathy. A total of 409 insulin-dependent diabetic patients with established nephropathy enrolled in a trial on the effect of Captopril on the rate of progression of renal disease. Baseline demographic, clinical (history and physical) and laboratory parameters were analyzed as risk factors for time to progression. Dichotomous characteristics were compared by Fisher's exact test and continuous characteristics with the Wilcoxon rank-sum test. Univariate proportional hazards regression analysis was used to estimate relative risk of nephropathy progression, and bivariate proportional hazard regression to identify interactions with the treatment group assignment. Multivariate proportional hazard regression was employed to determine which characteristics were independent risk factors. We found that a number of demographic and clinical characteristics were significantly associated with nephropathy progression even after adjustment for treatment group. However, after multivariate analysis, the risk factors that independently predicted progression were onset of IDDM later in life, parental diagnosis of IDDM, the presence of edema, increased mean arterial pressure, and an abnormal electrocardiogram. Likewise, a number of laboratory characteristics were also predictive of nephropathy progression. A low hematocrit, high blood sugar, and higher protein excretion predicted nephropathy progression as did a higher serum creatinine, particularly in the face of a normal serum albumin. In conclusion, this study identifies a number of clinical and laboratory risk factors that can predict which patients with insulin-dependent diabetes with established nephropathy are more likely to sustain a clinically important decrease in renal function over a median follow-up of three years.