Biomarker Predictors of Clinical Efficacy of the Anti-IgE Biologic, Omalizumab, in Severe Asthma in Adults: Results of the SoMOSA Study.

BACKGROUND: The anti-IgE monoclonal, omalizumab, is widely used for severe asthma. This study aimed to identify biomarkers that predict clinical improvement during one year of omalizumab treatment. METHODS: 1-year, open-label, Study of Mechanisms of action of Omalizumab in Severe Asthma (SoMOSA) involving 216 severe (GINA step 4/5) uncontrolled atopic asthmatics (≥2 severe exacerbations in previous year) on high-dose inhaled corticosteroids, long-acting ß-agonists, ± mOCS. It had two phases: 0-16 weeks, to assess early clinical improvement by Global Evaluation of Therapeutic Effectiveness (GETE), and 16-52 weeks, to assess late responses by ≥50% reduction in exacerbations or dose of maintenance oral corticosteroids (mOCS). All participants provided samples (exhaled breath, blood, sputum, urine) before and after 16 weeks of omalizumab treatment. RESULTS: 191 patients completed phase 1; 63% had early improvement. Of 173 who completed phase 2, 69% had reduced exacerbations by ≥50%, while 57% (37/65) on mOCS reduced their dose by ≥50%. The primary outcome 2, 3-dinor-11-ß-PGF2α, GETE and standard clinical biomarkers (blood and sputum eosinophils, exhaled nitric oxide, serum IgE) did not predict either clinical response. Five breathomics (GC-MS) and 5 plasma lipid biomarkers strongly predicted the ≥50% reduction in exacerbations (receiver operating characteristic area under the curve (AUC): 0.780 and 0.922, respectively) and early responses (AUC:0.835 and 0.949, respectively). In independent cohorts, the GC-MS biomarkers differentiated between severe and mild asthma. Conclusions This is the first discovery of omics biomarkers that predict improvement to a biologic for asthma. Their prospective validation and development for clinical use is justified. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Quantitative Proteomics of the Infectious and Replicative Forms of Chlamydia trachomatis.

The obligate intracellular developmental cycle of Chlamydia trachomatis presents significant challenges in defining its proteome. In this study we have applied quantitative proteomics to both the intracellular reticulate body (RB) and the extracellular elementary body (EB) from C. trachomatis. We used C. trachomatis L2 as a model chlamydial isolate for our study since it has a high infectivity:particle ratio and there is an excellent quality genome sequence. EBs and RBs (>99% pure) were quantified by chromosomal and plasmid copy number using PCR, from which the concentrations of chlamydial proteins per bacterial cell/genome were determined. RBs harvested at 15h post infection (PI) were purified by three successive rounds of gradient centrifugation. This is the earliest possible time to obtain purified RBs, free from host cell components in quantity, within the constraints of the technology. EBs were purified at 48h PI. We then used two-dimensional reverse phase UPLC to fractionate RB or EB peptides before mass spectroscopic analysis, providing absolute amount estimates of chlamydial proteins. The ability to express the data as molecules per cell gave ranking in both abundance and energy requirements for synthesis, allowing meaningful identification of rate-limiting components. The study assigned 562 proteins with high confidence and provided absolute estimates of protein concentration for 489 proteins. Interestingly, the data showed an increase in TTS capacity at 15h PI. Most of the enzymes involved in peptidoglycan biosynthesis were detected along with high levels of muramidase (in EBs) suggesting breakdown of peptidoglycan occurs in the non-dividing form of the microorganism. All the genome-encoded enzymes for glycolysis, pentose phosphate pathway and tricarboxylic acid cycle were identified and quantified; these data supported the observation that the EB is metabolically active. The availability of detailed, accurate quantitative proteomic data will be invaluable for investigations into gene regulation and function.

Electrophysiological correlates of looking at paintings and its association with art expertise.

This study investigated the electrocortical correlates of art expertise, as defined by a newly developed, content-valid and internally consistent 23-item art expertise questionnaire in N=27 participants that varied in their degree of art expertise. Participants viewed each 50 paintings, filtering-distorted versions of these paintings and plain colour stimuli under free-viewing conditions whilst the EEG was recorded from 64 channels. Results revealed P3b-/LPC-like bilateral posterior event-related potentials (ERP) that were larger over the right hemisphere than over the left hemisphere. Art expertise correlated negatively with the amplitude of the ERP responses to paintings and control stimuli. We conclude that art expertise is associated with reduced ERP responses to visual stimuli in general that can be considered to reflect increased neural efficiency due to extensive practice in the contemplation of visual art.

Epstein-Barr virus-positive mucocutaneous ulcer of the oral cavity: the importance of having a detailed clinical history to reach a correct diagnosis.

Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a recently recognized clinicopathological entity. It presents as an ulcerative lesion with lymphoma-like histologic features and is clinically associated with various types of immunosuppression. EBVMCU lesions respond well to conservative measures aimed at correcting the underlying immunosuppression. The case described clearly demonstrates the importance of appropriately completing biopsy submission forms with a detailed clinical history, thus aiding the histopathologist in reaching the correct diagnosis, particularly in pathologic conditions that have similar or overlapping histopathological features. Failure to do so may lead to incorrect diagnosis and management.

Voriconazole versus itraconazole for antifungal prophylaxis following allogeneic haematopoietic stem-cell transplantation.

Antifungal prophylaxis for allogeneic haematopoietic stem-cell transplant (alloHCT) recipients should prevent invasive mould and yeast infections (IFIs) and be well tolerated. This prospective, randomized, open-label, multicentre study compared the efficacy and safety of voriconazole (234 patients) versus itraconazole (255 patients) in alloHCT recipients. The primary composite endpoint, success of prophylaxis, incorporated ability to tolerate study drug for ≥ 100 d (with ≤ 14 d interruption) with survival to day 180 without proven/probable IFI. Success of prophylaxis was significantly higher with voriconazole than itraconazole (48·7% vs. 33·2%, P < 0·01); more voriconazole patients tolerated prophylaxis for 100 d (53·6% vs. 39·0%, P < 0·01; median total duration 96 vs. 68 d). The most common (>10%) treatment-related adverse events were vomiting (16·6%), nausea (15·8%) and diarrhoea (10·4%) for itraconazole, and hepatotoxicity/liver function abnormality (12·9%) for voriconazole. More itraconazole patients received other systemic antifungals (41·9% vs. 29·9%, P < 0·01). There was no difference in incidence of proven/probable IFI (1·3% vs. 2·1%) or survival to day 180 (81·9% vs. 80·9%) for voriconazole and itraconazole respectively. Voriconazole was superior to itraconazole as antifungal prophylaxis after alloHCT, based on differences in the primary composite endpoint. Voriconazole could be given for significantly longer durations, with less need for other systemic antifungals.

Investigation of the kinetics and order of tyrosine phosphorylation in the T-cell receptor zeta chain by the protein tyrosine kinase Lck.

We report experiments to investigate the role of the physiologically relevant protein tyrosine kinase Lck in the ordered phosphorylation of the T-cell receptor zeta chain. Six synthetic peptides were designed based on the sequences of the immunoreceptor tyrosine-based activation motifs (ITAMs) of the zeta chain. Preliminary 1H-NMR studies of recombinant zeta chain suggested that it is essentially unstructured and therefore that peptide mimics would serve as useful models for investigating individual ITAM tyrosines. Phosphorylation kinetics were determined for each tyrosine by assaying the transfer of 32P by recombinant Lck on to each of the peptides. The rates of phosphorylation were found to depend on the location of the tyrosine, leading to the proposal that Lck phosphorylates the six zeta chain ITAM tyrosines in the order 1N (first) > 3N > 3C > 2N > 1C > 2C (last) as a result of differences in the amino-acid sequence surrounding each tyrosine. This proposal was then tested on cytosolic, recombinant T-cell receptor zeta chain. After in vitro phosphorylation by Lck, the partially phosphorylated zeta chain was digested with trypsin. Separation and identification of the zeta chain fragments using LC-MS showed, as predicted by the peptide phosphorylation studies, that tyrosine 1N is indeed the first to be phosphorylated by Lck. We conclude that differences in the amino-acid context of the six zeta chain ITAM tyrosines affect the efficiency of their phosphorylation by the kinase Lck, which probably contributes to the distinct patterns of phosphorylation observed in vivo.

Coherence-weighted Wiener filtering of somatosensory evoked potentials.

In this paper, we present a Wiener filtering (WF) approach for extraction of somatosensory evoked potentials (SEPs) from the background electroencephalogram (EEG), with sweep-to-sweep variations in its signal power. To account for the EEG power variations, WF is modified by iteratively weighting the power spectrum using the coherence function. Coherence-weighted Wiener filtering (CWWF) is able to extract SEP waveforms, which have a greater level of detail as compared with conventional time-domain averaging (TDA). Using CWWF, the components of the SEP show significantly less variability. As such, CWWF should be useful as an important diagnostic tool able to detect minimal changes in the SEP. In an experimental study of cerebral hypoxia, CWWF is shown to be more responsive to detection of injury than WF or TDA.

Initial validation of the functional impairment scale for children and adolescents.

OBJECTIVE: Two studies assessed the validity of the Functional Impairment Scale for Children and Adolescents (FISCA), a multidimensional parent-report questionnaire. METHOD: In study 1, quasi-exploratory and confirmatory procedures tested whether FISCA data for 804 inpatients (mean age = 13.4, 456 boys), collected October 1994 through December 1995, fit a 3-factor model. Study 2 (n = 330) used survival and discriminant analyses to predict recidivism status at 3 and 6 months follow-up from FISCA scores at intake. RESULTS: The 8 FISCA scales reduced to 3 factors describing undercontrolled aggression, social role violations, and self-focused aspects of child functional impairment. Serious impairment on the Aggression and School scales each predicted a 3-fold increase in recidivism risk. Together, impairment scores for Aggression, School, Thinking, and Delinquency correctly identified 73% of the recidivists. However, 51% of the nonrecidivists also were classified as recidivists. CONCLUSIONS: Although these data initially support the FISCA's validity, they underscore the need for more effective strategies to identify severely impaired children whose problems will be sporadic or short-lived.

A transform domain SVD filter for suppression of muscle noise artefacts in exercise ECG's.

The proposed filter assumes the noisy electrocardiography (ECG) to be modeled as a signal of deterministic nature, corrupted by additive muscle noise artefact. The muscle noise component is treated to be stationary with known second-order characteristics. Since noise-free ECG is shown to possess a narrow-band structure in discrete cosine transform (DCT) domain and the second-order statistical properties of the additive noise component is preserved due to the orthogonality property of DCT, noise abatement is easily accomplished via subspace decomposition in the transform domain. The subspace decomposition is performed using singular value decomposition (SVD). The order of the transform domain SVD filter required to achieve the desired degree of noise abatement is compared to that of a suboptimal Wiener filter using DCT. Since the Wiener filter assumes both the signal and noise structures to be statistical, with a priori known second-order characteristics, it yields a biased estimate of the ECG beat as compared to the SVD filter for a given value of mean-square error (mse). The filter order required for performing the subspace smoothing is shown to exceed a certain minimal value for which the mse profile of the SVD filter follows the minimum-mean-quare error (mmse) performance warranted by the suboptimal Wiener filter. The effective filter order required for reproducing clinically significant features in the noisy ECG is then set by an upper bound derived by means of a finite precision linear perturbation model. A significant advantage resulting from the application of the proposed SVD filter lies in its ability to perform noise suppression independently on a single lead ECG record with only a limited number of data samples.

Daily behavior ratings among child and adolescent inpatients: the abbreviated Child Behavior Rating Form.

OBJECTIVE: Child and adolescent psychiatric inpatient facilities are in need of standardized behavior rating scales to assess continuous change in patient behaviors. This study used daily staff ratings to examine the factor structure and psychometric properties of an abbreviated version of the Child Behavior Rating Form (CBRF-A). METHOD: Three hundred eighty-seven inpatients, aged 3 to 17 years, were rated daily by unit staff. Subsamples of patients and/or their parents completed additional measures of behavior problems (Child Behavior Checklist, Functional Impairment Scale for Children and Adolescents) to assess the instrument's validity. RESULTS: Confirmatory factor analyses identified 5 behavior problem dimensions (Oppositionalism, Attention Problems, Overactivity, Withdrawal/Depression, and Anxiety), a second-order Externalizing dimension, and 2 positive behavior dimensions (Positive/Adaptive Social and Compliance/Self-Control). The scales were found to be internally consistent and showed expected age differences, and the scale factor structures were relatively stable over 1- and 2-week intervals. The scales correlated meaningfully with parent ratings of child behavior problems and functional impairment and were predictive of total hospital days. CONCLUSIONS: The psychometric properties of the CBRF-A appear adequate for daily inpatient rating; additional research is needed to determine the usefulness of the CBRF-A in assessing treatment and medication effects over the hospital stay.

Data processing of stress ECGs using discrete cosine transform.

The signal processing steps for the analysis of stress ECGs are aimed at improving the signal to noise ratio (SNR) of recordings in addition to eliminating artifacts due to respiration, movement of arms, etc. In this paper, we bring forth two important applications of the discrete cosine transform (DCT) for noise suppression and removal of baseline wander. The noise suppression algorithm has been framed on the basis of a two step procedure involving singular value decomposition (SVD) smoothing operation in transform domain followed by that in time domain. The mean square error (MSE) resulting from the first step is shown to effectively follow the trend obtained by using an ideal Wiener filter using DCT. In the second step, the degree of closeness to the minimum mean square error (MMSE) of the ideal Wiener filter is improved by subjecting the filtered outputs to a second SVD smoothing operation in time domain. Application of this scheme to noisy records has resulted in near perfect reproduction of the original noise free ECG without significant alterations in its morphological features.

Nuclear, biological and chemical warfare. Part I: Medical aspects of nuclear warfare.

Casualties in earlier wars were due much more to diseases than to weapons. Mention has been made in history of the use of biological agents in warfare, to deny the enemy food and water and to cause disease. In the first world war chemical agents were used to cause mass casualties. Nuclear weapons were introduced in the second world war. Several countries are now involved in developing nuclear, biological and chemical weapon systems, for the mass annihilation of human beings, animals and plants, and to destroy the economy of their enemies. Recently, natural calamities and accidents in nuclear, chemical and biological laboratories and industries have caused mass instantaneous deaths in civilian population. The effects of future wars will not be restricted to uniformed persons. It is time that physicians become aware of the destructive potential of these weapons. Awareness, immediate protective measures and first aid will save a large number of persons. This series of articles will outline the medical aspects of nuclear, biological and chemical weapon systems in three parts. Part I will deal with the biological effects of a nuclear explosion. The short and long term effects due to blast, heat and associated radiation are highlighted. In Part II, the role of biological agents which cause commoner or new disease patterns is mentioned. Some of the accidents from biological warfare laboratories are a testimony to its potential deleterious effects. Part III deals with medical aspects of chemical warfare agents, which in view of their mass effects can overwhelm the existing medical resources, both civilian and military.(ABSTRACT TRUNCATED AT 250 WORDS)

Advantages of hypothermic potassium cardioplegia and superiority of continuous versus intermittent aortic cross-clamping.

The relative effectivenss of hypothermic potassium (K) cardioplegia in conjunction with either continuous or intermittent aortic cross-clamping was evaluated in 20 mongrel dogs. Isovolumetric left ventricular (LV) contractions and myocardial biopsies were obtained before and after a total of 90 minutes of aortic cross-clamping. The dogs were randomly divided into four groups of five dogs each as follows: Group I, continuous 90 minute cross-clamping and multidose K at 4 degrees C (40 mEq/L); Group II, intermittent cross-clamping consisting of six 15 minute periods of cross-clamping separated by 5 minute reperfusion periods and K cardioplegia at 4 degrees C given at the start of each cross-clamping period; Group III, continuous 90 minute cross-clamping and multidose buffered saline at 4 degrees C; Group IV, intermittent cross-clamping, consisting of six 15 minute periods of cross-clamping separated by 5 minute reperfusion periods and buffered saline at 4 degrees C given at the initiation of each cross-clamp period. Group I dogs had the best myocardial performance, with no difference between control values of peak LV pressure and dP/dtmax and those recordings obtained 60 minutes after release of the aortic cross-clamp. Significant depression of LV function was noted in all other groups. Examination of force-velocity and length-tension relationships confirmed better myocardial performance in Groups I and II (multidose K at 4 degrees C) than in Groups III and IV (buffered saline at 4 degrees C). Groups I and III (continuous cross-clamping) had no de-rease in diastolic LV compliance after cross-clamping, whereas compliance was decreased in both Groups II and IV (intermittent cross-clamping) at higher preloads (p less than 0.05 and p less than 0.025, respectively). The wet weight/dry weight myocardial ratios were lower in Groups I and III (continuous cross-clamping) than in Groups II and IV (intermittent cross-clamping). Although creatine phosphate (CP) concentrations were rapidly restored by reperfusion in all groups, adenosine triphosphate (ATP) and glycogen myocardial stores were better preserved at the end of cross-clamping in Groups I and II (multidose K at 4 degrees C). Although LV diastolic compliance was decreased and myocardial water content was increased in Groups II and IV (intermittent cross-clamping), no differences in the minimal extent of subendocardial hemorrhage, edema, and contraction-band necrosis were observed among any of the groups examined electron microscopically. The present study identifies continuous aortic cross-clamping with multidose K at 4 degrees C as a superior method of myocardial protection.

Effects of Sulfite on Metabolism in Isolated Mesophyll Cells from Papaver somniferum.

Exposure (30 minutes) of leaf-free mesophyll cells from the C-3 plant, Papaver somniferum, to concentrations of sulfite (SO(2) + HSO(3) (-) + SO(3) (-)) up to 20 millimolar stimulated the rate of CO(2) incorporation as much as 30%. The sulfite rapidly affects the metabolism of newly incorporated CO(2). Ammonia incorporation into glutamine and subsequent transamination reactions were stimulated during the short term exposure periods while glycolate metabolism apparently was inhibited by bisulfite at two points in the pathway. The results further indicate that glycolate is the major precursor of glycine in these cells. Prolonged periods of exposure (24 hours) to sulfite had somewhat different effects on carbon metabolism: the high concentrations (10 to 20 millimolar) severely inhibited all aspects of cellular metabolism while lower concentrations (1 millimolar) appeared to inhibit ammonia incorporation but stimulated synthesis of sucrose and starch.

Effects of ammonia on carbon metabolism in photosynthesizing isolated mesophyll cells from Papaver somniferum L.

Addition of ammonia to a suspension of photosynthesizing isolated mesophyll cells from P. somniferum quantitatively alters the pattern of carbon metabolism by increasing rates of certain key ratelimiting steps leading to amino-acid synthesis and by decreasing rates of rate-limiting steps in alternative biosynthetic pathways. Of particular importance is the stimulation of reactions mediated by pyruvate kinase and phosphoenolpyruvate carboxylase. The increased rates of these two reactions, which result in an increased flow of carbon into the tricarboxylic-acid cycle, correlate with a rapid rise in glutamine (via glutamine synthetase) which draws carbon off the tricarboxylic-acid cycle as α-ketoglutarate. Increased flux of carbon in this direction appears to come mainly at the expense of sucrose synthesis. The net effect of addition of ammonia to mesophyll cells is thus a redistribution of newly fixed carbon away from carbohydrates and into amino acids.

Maintenance of High Photosynthetic Rates in Mesophyll Cells Isolated from Papaver somniferum.

The establishment and maintenance of high rates of photosynthetic CO(2) incorporation in mesophyll cells of Papaver somniferum (opium poppy) depend on a regime of dark and light periods immediately following isolation, as well as carefully adjusted conditions of isolation. Analysis of the incorporation pattern of (14)CO(2) by the isolated cells indicates an initial "stress-response" period of approximately 20 hours characterized by increased respiratory-type metabolism and diminished photosynthesis. Under the favorable regime, this period is followed by rapid recovery and the reinstatement of a metabolic state strikingly similar to that of intact leaves in which the initial rate of CO(2) incorporation is between 110 and 175 mumoles CO(2) fixed per mg chlorophyll per hour. The photosynthetic viability of these cells can be maintained for up to 80 hours.