A new quinoline-based chemical probe inhibits the autophagy-related cysteine protease ATG4B.

The cysteine protease ATG4B is a key component of the autophagy machinery, acting to proteolytically prime and recycle its substrate MAP1LC3B. The roles of ATG4B in cancer and other diseases appear to be context dependent but are still not well understood. To help further explore ATG4B functions and potential therapeutic applications, we employed a chemical biology approach to identify ATG4B inhibitors. Here, we describe the discovery of 4-28, a styrylquinoline identified by a combined computational modeling, in silico screening, high content cell-based screening and biochemical assay approach. A structure-activity relationship study led to the development of a more stable and potent compound LV-320. We demonstrated that LV-320 inhibits ATG4B enzymatic activity, blocks autophagic flux in cells, and is stable, non-toxic and active in vivo. These findings suggest that LV-320 will serve as a relevant chemical tool to study the various roles of ATG4B in cancer and other contexts.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system.

BACKGROUND: Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE: The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN: This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS: The study included 55,438 stroke patients. MEASURES: Study measures were LOS, functional status at discharge, and community discharge. RESULTS: The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS: While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.

Effectiveness of specific immunotherapy in the treatment of allergic rhinitis: an analysis of randomized, prospective, single- or double-blind, placebo-controlled studies.

BACKGROUND: The effectiveness of specific immunotherapy (SIT) in the treatment of allergic rhinitis has been supported by empirical evidence and clinical experience. OBJECTIVE: This report is an analysis of multiple studies involving patients with documented allergic rhinitis. METHODS: All studies of the effectiveness of SIT in the treatment of allergic rhinitis published in English between the years 1966 and 1996 were identified through a MEDLINE search. All prospective, single- or double-blind, placebo-controlled studies were included in the analysis. One author (R.N.R.) extracted data from the studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model for a variety of clinical measures in studies that permitted the extraction of numbers of patients with positive and negative outcomes. RESULTS: Data were extracted from 16 studies of the clinical effectiveness of SIT in the treatment of allergic rhinitis, involving 759 patients (546 adults, 53 children, 160 all ages). In 15 (94%) of the studies, investigators concluded that SIT was effective. In the remaining study (the only one conducted in children), investigators concluded that SIT was not effective. Symptoms of allergic rhinitis were more likely to improve in patients receiving SIT than in the comparison patients (OR 1.81, 95% CI 1.48 to 2.23). Symptom-medication scores were significantly lower in patients receiving SIT than in the comparison patients in all studies using such measures (P < 0.05). CONCLUSION: Results of this analysis support the conclusion that SIT is effective in the treatment of allergic rhinitis.

Effectiveness of specific immunotherapy in the treatment of asthma: a meta-analysis of prospective, randomized, double-blind, placebo-controlled studies.

BACKGROUND: Despite decades of positive experience with specific immunotherapy (SIT) in the treatment of asthma, outcomes associated with SIT have not been evaluated. OBJECTIVE: This meta-analysis was conducted to compare the effects of SIT plus medical treatment with those of SIT without medical treatment in patients with asthma. METHODS: All studies of SIT in patients with asthma published in English between the years 1966 and 1998 were identified through a MEDLINE search. All prospective, randomized, double-blind, placebo-controlled studies of SIT identified by the search were included in the meta-analysis. One author (R.N.R.) extracted data from these studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. RESULTS: Data were extracted from 24 identified studies of the clinical effectiveness of SIT in the treatment of asthma, involving 962 asthmatic patients with documented allergy. Immunotherapy was judged effective in 17 (71%) of the 24 studies, ineffective in 4 (17%), and equivocal in 3 (12%) (chi2 = 15.25, df = 2, P = 0.0005). Symptoms of asthma were more likely to improve in patients who received SIT than in patients who received placebo (OR 2.76, 95% CI 2.22 to 3.42). Results also favored the immunotherapy group for improvement in pulmonary function (OR 2.87, 95% CI 1.82 to 4.52), protection against bronchial challenge (OR 1.81, 95% CI 1.32 to 2.49), and reduced need for medications (OR 2.00, 95% CI 1.46 to 2.72). CONCLUSION: The findings of this meta-analysis support the conclusion that SIT is effective in a population of patients with allergen-triggered asthma.

Effectiveness of specific immunotherapy in the treatment of hymenoptera venom hypersensitivity: a meta-analysis.

BACKGROUND: For most people, Hymenoptera stings produce a transient, local inflammatory reaction (pain, redness, swelling). However, for those who are allergic to components of this venom, the reactions can be severe, frightening, and sometimes fatal. Specific immunotherapy (SIT) has been the only means of desensitizing patients who have experienced a systemic reaction to this venom. OBJECTIVE: This meta-analysis was conducted to compare the effects of SIT in the treatment of Hymenoptera venom hypersensitivity. METHODS: All studies of SIT in the treatment of Hymenoptera venom hypersensitivity published in English between the years 1966 and 1996 were identified through a MEDLINE search. Because of the ethical difficulties involved in designing a double-blind, placebo-controlled study in this patient population, most of the studies were open and not placebo-controlled. One author (R.N.R.) extracted data from the studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. RESULTS: Data were extracted from 8 studies involving 453 patients; 1 study was conducted in adults (n = 20), 2 in children (n = 188), and 5 in all ages (n = 245). The symptoms of Hymenoptera venom hypersensitivity were prevented in 80 (79%) of the 101 patients receiving SIT versus 49 (36%) of 136 comparison patients. The symptoms were not prevented in 21 (21%) of the patients receiving SIT versus 87 (64%) of the comparison patients (OR 2.20, 95% CI 1.72 to 2.81). CONCLUSION: The findings of this meta-analysis support the conclusion that SIT is effective in the treatment of Hymenoptera venom hypersensitivity.

A functional diagnostic complexity index for rehabilitation medicine: measuring the influence of many diagnoses on functional independence and resource use.

OBJECTIVE: To develop an index that weights diagnostic information (International Classification of Diseases, 9th revision, Clinical Modification, or ICD-9-CM codes) by the extent to which it is expected to affect functional status and inpatient rehabilitation length of stay (LOS). DESIGN: Eleven nationally prominent physiatrists assigned ICD-9-CM codes to ordinal categories by expected effect on functional recovery. A resulting functional diagnostic complexity index score was calculated for each patient by combining the ranked values of each ICD-9-CM code in the discharge record. Analyses were stratified across the 20 rehabilitation impairment categories (RICs) of the Functional Independence Measure-Function Related Groups. DATA: Patients (182,254) discharged from 465 inpatient rehabilitation units in larger hospitals and free-standing rehabilitation hospitals in 1995. RESULTS: High degrees of diagnostic complexity were associated with low levels of functional independence at admission within each of 20 RICs (Spearman R = .06 to .25). Depending on RIC, patients in the highest (compared with the lowest) complexity category had up to a 35% increase in rehabilitation LOS after accounting for the primary medical reason for rehabilitation and severity of disabilities at admission. CONCLUSION: This prototype index of medical complexity offers a promising approach for analyzing the cumulative effects of diagnoses on patients' initial functional status and rehabilitation LOS.

The relationship between choice of outcome measure and hospital rank in general surgical procedures: implications for quality assessment.

OBJECTIVE: Institutional complication rates are often used to assess hospital quality of care, particularly for conditions and procedures where mortality rates are not useful because deaths are rare. The objective of this study was to assess the correlation among hospital quality assessment rankings based on adjusted mortality, complication and failure-to-rescue rates. DESIGN: This study used a clinically detailed administrative data set to compare severity and case-mix adjusted hospital outcome rankings for three different measures of quality of care: in-hospital death, complication and failure-to-rescue (in-hospital death following a complication). SETTING AND PATIENTS: Analysis of 74,647 patients who underwent general surgical procedures included in the 1991 and 1992 MedisGroups National Comparative Data Base. MEASUREMENTS: Adjusted outcomes of death, complication and failure to rescue based on multivariable logistic regression models. RESULTS: For 142 hospitals, the correlation between hospital rankings based on the death rate and those ranked by the complication rate was only 0.208 (P = 0.013). A similarly low correlation was present between the complication and failure rate rankings, r = -0.090 (P = 0.287). A higher correlation was observed between the death and failure rate rankings, r = 0.90 (P < 0.001). CONCLUSIONS: For general surgical procedures, hospital rank using the complication rate is poorly correlated with rankings using the death or failure rate. Complication rates should be used with great caution and should not be used in isolation when assessing hospital quality of care.

Loss of bronchodilator medication in priming a conventional metered dose inhaler: a cost of treating asthma.

The direct and indirect costs of lost medication resulting from the required "test dose" to reestablish the prime of active drug in the conventional metered-dose inhaler (MDI) valve and the uncertainties associated with "tail-off" increase the cost of using a conventional chlorofluorocarbon driven MDI to deliver aerosolized bronchodilator in the management of asthma. In this article, the author establishes a basis for estimating the cost of wasted medication.

Urinary nuclear matrix protein as a marker for transitional cell carcinoma of the urinary tract.

PURPOSE: The purpose of this trial was to evaluate an immunoassay for urinary nuclear matrix protein, NMP22, as an indicator for transitional cell carcinoma of the urinary tract. MATERIALS AND METHODS: Three groups of subjects participated in this trial of NMP22: 1-175 with transitional cell carcinoma, 2-117 with benign urinary tract conditions and 3-375 healthy volunteers. Each subject provided a single (3 voids) urine sample for analysis at the time of study entry. Each sample was assayed for the level of NMP22. RESULTS: In normal healthy volunteers and in subjects with benign conditions median NMP22 levels were 2.9 and 3.3 units per ml., respectively. Median urinary NMP22 levels in patients with transitional cell carcinoma were significantly greater than in comparison subjects. Patients with active transitional cell carcinoma had significantly greater median urinary NMP22 levels than those with no evidence of disease (6.04 versus 4.11 units per ml., p = 0.027, 1-tailed Mann-Whitney U test). We noted no effect of tumor grade, extent of disease or exposure to intravesical therapy on urinary NMP22 levels. CONCLUSIONS: NMP22 is a promising urinary tumor marker for monitoring transitional cell carcinoma. Nuclear matrix proteins are a new class of tumor markers that represent the basis for the development of assays with increased efficacy for the detection and treatment of cancer.

A retrospective assessment of cost avoidance associated with the use of nedocromil sodium metered-dose inhaler in the treatment of patients with asthma.

A retrospective analysis of patient charts was performed for a single, multioffice pulmonary practice in Toronto, Ontario. Canada, to assess hospital care utilization and associated cost reductions after asthma prophylaxis with nedocromil sodium inhalation aerosol. Data were obtained from 310 adult patients with mild, moderate, or severe asthma who were treated in the practice between January 1988 and June 1994 and who had been placed on nedocromil sodium for at least 1 year. The number of office visits increased with nedocromil sodium therapy due to initial surveillance of the new medication, but no other changes were made in the usual protocol for each visit. After initiation of nedocromil sodium therapy, patients showed better asthma control as measured by improvements in pulmonary function scores and by reduced hospital utilization (both emergency department visits and hospital admissions). It is likely that the improvements in asthma control could result in cost savings, and savings projections for the Canadian health care system were made using the retrospective data collected for asthma-related hospital services. Prospective data are needed to confirm our findings.

Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery.

OBJECTIVE: To determine whether hospital rankings based on complication rates provide the same information as hospital rankings based on mortality rates. DESIGN: A retrospective study of in-hospital death, complication, and death following complication (failure to rescue). Hospitals were ranked using residuals based on the difference between the observed and the expected number of events (from logistic regression models); rankings were compared using Spearman rank correlations. SETTING: Hospitals performing coronary artery bypass graft (CABG) surgery in the 1991 and 1992 MedisGroups National Comparative Data Bases. PATIENTS AND DATA SETS: Record abstraction data for 16,673 patients who underwent CABG procedures at 57 hospitals, linked with data from the 1991 American Hospital Association Annual Survey. RESULTS: After adjusting for patient admission severity of illness, there were low correlations between hospital rankings based on death or failure to rescue and those rankings based on complication (death vs complication, r = 0.07, P = .58; failure to rescue vs complication, r = -0.22, P = .11). In addition, many hospital characteristics that are generally associated with a higher quality of care were associated with higher complication rates but with expected or lower-than-expected mortality rates. CONCLUSIONS: Hospital rankings based on complication rates provide different information than those based on mortality rates. Until more is known about these differences, complication rates should not be used to judge hospital quality of care in CABG surgery.

Environmental survey of RCMP detachment building in Powell River, B.C., implicated in a cancer cluster.

The rationale and approach are presented that were used to investigate the Powell River RCMP detachment building, perceived to have a higher than normal cancer incidence and whose occupants demanded to know whether the building was safe to work in. On the basis of the history of the building and the cancers observed, a set of carcinogens were looked for in areas where the worst conditions were expected. A positive result would initiate a second more in-depth survey. This was done for Fyrol-PCF, which was shown to be a contaminant of the charcoal adsorption tubes used. The results of the survey indicated a safe work environment. The chemical analyses, complemented by the bioassay and comparison with a recognizable control site, were found to be most effective in the acceptance of the results by the public. The conclusions from this survey were confirmed by the findings of an epidemiological survey.

Twenty questions for tanning facility operators: a survey of operator knowledge.

A two-page questionnaire was administered to 37 tanning operators in five municipalities in BC's lower mainland. The results were analyzed to determine the knowledge base of the participants as it related to ultraviolet radiation (UVR), tanning equipment, biological effects of exposure and the advice given to clients. Only 19% of the participants scored high enough to meet Alberta's criteria for adequate knowledge to operate a tanning facility. Participants seemed knowledgeable about skin type, premature skin aging effects, skin cancer, cataracts and skin and eye irritation. The greatest knowledge deficiencies identified were 1) the definition of UVA and UVB; 2) the biological role of UVA and UVB as it relates to tanning; 3) the degree to which UVA and UVB is emitted by sunbeds; and 4) knowledge of common drugs and medications that cause photosensitivity. Follow-up activity is briefly described.

Race and prognosis after myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) phase II trial.

BACKGROUND: To better understand the role of race/ethnicity in survival after acute myocardial infarction, we compared clinical and laboratory data, response to thrombolytic therapy, and clinical outcome in 2885 patients participating in the Thrombolysis in Myocardial Infarction Phase II (TIMI II) Trial among three groups of patients (2564 whites, 174 blacks, and 147 Hispanics). METHODS AND RESULTS: Differences were found in baseline characteristics among the three groups including (1) age (mean age for whites, 57.2 years; blacks, 54.8 years; Hispanics, 52.8 years; P < .001), (2) sex (percentage of women for whites, 17.6; blacks, 28.7; Hispanics, 14.3; P < .001), and (3) risk factor prevalence: current smoking (percent for whites, 49.4; blacks, 62.1; Hispanics, 55.1; P < .003), history of hypertension (percent for whites, 36.6; blacks, 55.7; Hispanics, 39.5; P < .001), and diabetes mellitus (percent for whites, 11.9; blacks, 22.4; Hispanics, 19.7; P < .001). Changes in hemostatic factors 5 hours after infusion of recombinant tissue plasminogen activator (rt-PA) revealed a more profound fall in fibrinogen levels in black patients compared with the response seen in Hispanic or white patients (mean change in fibrinogen +/- SD, mg/dL: 151.3 +/- 107.4, 112.2 +/- 97.0, 109.4 +/- 98.6; P < .001, respectively) without more frequent infarct-related artery patency or hemorrhagic complications. Mortality was similar in the white, black, and Hispanic patients through the first year after adjustment for baseline variables. CONCLUSIONS: TIMI II data yield evidence that (1) corroborates published reports of a high prevalence of classic cardiovascular risk factors among minority patients with acute myocardial infarction, (2) there is a greater decrease in fibrinogen levels 5 hours after the start of rt-PA infusion among black patients than in white and Hispanic patients without evidence of more frequent infarct-related artery patency or hemorrhagic complications, and (3) thrombolytic therapy with appropriate supplemental measures is associated with comparable 1-year mortality in white, black, and Hispanic patients.

A masked quantitative cytologic study of the safety of a multipurpose contact lens solution applied to the in vivo rabbit eye.

The purpose of this study was to challenge the cornea in vivo with a lens care solution (ReNu Multi-Purpose Solution, Bausch & Lomb) formulated with polyaminopropyl biguanide at a higher than standard concentration of 1.0 ppm (1.0 x 10(-6) percent) rather than the marketed 0.5 ppm (0.5 x 10(-6) percent) and to evaluate any cytotoxic epithelial response. Test solutions included the modified formulation of Bausch & Lomb ReNu Multi-Purpose Solution (poloxamine, EDTA, borate buffer, and polyaminopropyl biguanide) and Bausch & Lomb Hypo-Clear unpreserved, isotonic saline. A dose of 50 microL of each solution was administered to the superior limbus of 10 pigmented rabbits free of anterior segment disease. Neither the unpreserved saline solution nor the more highly concentrated multipurpose solution produced significant toxic effects on the corneal epithelial cells and compared favorably with previously reported incidences of desquamating cells in the normal corneal epithelium.

Determination of the interval during which one application of compound 48/80 to the rat conjunctiva influences the response to a second application.

We studied the effect of one application of compound 48/80 to the conjunctiva of the rat on the response to a subsequent challenge. Rats treated once showed conjunctival edema and marked degranulation of conjunctival mast cells. A second exposure to compound 48/80, applied after an interval of 24 h, produced slight clinical effects but had marked effects on conjunctival mast cells. Approximately 90% of the mast cells could no longer be observed by light microscopy. As the interval between initial challenge and rechallenge was increased, the clinical response returned, mast cells were again observable in normal numbers, and the extent of degranulation returned to approximately 50%. After an interval of 7 days, rats responded clinically as they had to the first application of compound 48/80. Although the number of mast cells in the conjunctiva was normal and extensive degranulation occurred, exocytosis was not observed. Thus some effects of the first application of compound 48/80 persisted for at least 1 week. Whether the effects observed depend upon the continued presence of compound 48/80 in the mast cell or granule membrane remains to be determined.

Response of rat conjunctival mast cells to multiple versus single applications of compound 48/80.

A single application of the mast cell secretagogue compound 48/80 to the surface of the rat eye induces significant histologic changes. Ocular anaphylaxis is usually the result of repeated, not single, exposures to allergenic substances. The response of conjunctival mast cells to repeated daily applications of compound 48/80 was, therefore, evaluated. Ninety rats received one dose of compound 48/80 or phosphate-buffered saline almost daily for 17 days. The frequency and degree of mast cell degranulation and the number of mast cells and other inflammatory cells in the subepithelial conjunctiva were determined histologically. The clinical response was most marked after one application of compound 48/80; repeated daily applications markedly reduced the clinical response. In eyes treated with multiple applications, 75% fewer mast cells were observable in the conjunctiva by light microscopy compared with phosphate-buffered saline treated eyes. Most mast cells were granulated; a few showed mild to moderate degranulation. Except for epithelial damage, no tissue injury was associated with multiple applications of compound 48/80. In contrast to conjunctivae subjected to a single application of compound 48/80, conjunctivae receiving multiple applications resembled that of phosphate-buffered saline controls.

Ocular anaphylaxis induced in the rat by topical application of compound 48/80. Dose response and time course study.

In the present study we sought to develop a model of ocular anaphylaxis based on the topical application of compound 48/80 to the surface of the rat eye. Doses ranging from 50 to 1000 micrograms were found to produce graded edema of the conjunctiva and swelling of the lid. On histologic examination, 50 microns compound 48/80 produced no changes distinguishable from those in PBS-treated controls, 150 microns produced mild alterations, and 250, 500, and 1000 micrograms compound 48/80 produced a marked increase in degranulated mast cells and a mild influx of neutrophils. The time course of the response to 250 micrograms and 1000 micrograms of compound 48/80 was evaluated over a 72-h period. Both doses elicited epithelial damage. A mild reduction in the number of mast cell was seen at 6 h in rats receiving 250 or 1000 micrograms. The reduction persisted to 72 h in rats receiving 1000 micrograms. The number of neutrophils was increased at 1 and 6 h in eyes treated with 250 micrograms and at 1, 6, and 24 h in eyes treated with 1000 micrograms compound 48/80. The clinical and histologic changes induced by application of 250 micrograms compound 48/80 resemble those seen in patients with allergic conjunctivitis suggesting that a model of ocular anaphylaxis based on the topical application compound 48/80 will be clinically relevant and experimentally practical.