Safety and efficacy of oral anticoagulants in extreme weights.

BACKGROUND: The 2021 International Society on Thrombosis and Haemostasis' (ISTH) recommends standard doses of apixaban and rivaroxaban regardless of high body mass index (BMI) and weight, but had not compare DOACs head-to-head in obesity or address underweight patients. METHODS: Our aim is to evaluate the safety and efficacy of DOACs in underweight and obese patients compared to warfarin. The primary endpoints include incidence of thromboembolic and bleeding events. Descriptive statistics was used for continuous variables. The Kruskal-Wallis test was used to compare the four-groups for continuous measures and the chi-square test or Fisher's exact test was used to analyze categorical data. The chi-square test or Fisher's exact test, was used for categorical variables, and the Mann-Whitney test (the non-parametric counterpart to the two-sample t-test) for continuous data. RESULTS: Of 2940 patients receiving anticoagulation for venous thromboembolism (VTE) treatment or atrial fibrillation (AF), 492 met eligibility criteria. Within each group, 248 patients received warfarin, 101 received apixaban, 100 received rivaroxaban and 43 received dabigatran. Patients were characterized in 4 body mass index (BMI) categories, in which 80 were underweight and 412 were obese. CONCLUSIONS: When each DOAC was compared to warfarin in rates of VTE, apixaban showed statistically significant lower rate of VTE (p = 0.0149). However, no statistical significance was identified in the rate of VTE between DOACs combined vs. warfarin (p = 0.1529). When each DOAC was compared to warfarin, apixaban showed the lowest rate of overall bleeding (p = 0.0194). However, no statistical difference in the rate of bleeding was observed between DOACs combined vs. warfarin (p = 0.3284). Patients with extreme body weights requiring anticoagulation for VTE and AF may safety benefit from DOAC therapy. This evaluation showed apixaban with the lowest rate of VTE and bleeding compared to warfarin, rivaroxaban, and dabigatran. These results provide experience for the clinician to use DOACs, particularly apixaban, in underweight and obese populations.

Dam and granddam feeding during pregnancy in sheep affects milk supply in offspring and reproductive performance in grand-offspring.

In temperate climates, the cost of providing feed is greater in winter than in other seasons, causing ewes to be fed restricted rations during some periods of pregnancy. Epidemiological information indicates that undernutrition of the fetus may affect its health and performance in later life (i.e., fetal programming), and these effects may be passed between generations. The primary focus of the results presented in this paper is to examine the effects of feeding levels during pregnancy on a variety of traits from offspring at the fetal stage to 3.5 yr of age and also traits in the grand-offspring. Two studies are reported in which ewes were fed restricted diets during pregnancy, with a variety of fetal traits, offspring traits up to 3.5 yr of age, or grand-offspring traits up to 8 mo of age being measured. Study 2 also considered differences in dam size (heavy vs. light). In study 1, several fetal mammary gland measures indicated that milking ability may be enhanced in offspring from dams fed ad libitum during pregnancy. However, study 2 showed that mammary mass was greater in fetuses from dams fed at maintenance during pregnancy and that contemporaries of these fetuses produced greater protein and lactose yields in their first lactation. In the second lactation, the advantages in protein and lactose yields did not reoccur and ewes from ad libitum-fed dams produced greater fat yield. In study 2, grand-offspring whose granddams were fed at maintenance levels during pregnancy were lighter at birth in both the first and second parturitions than those whose granddams were fed ad libitum during pregnancy. First-parity grand-offspring whose granddams were fed maintenance levels during pregnancy achieved heavier BW by 40 to 50 d of age in the first lactation, which reflected the greater protein and lactose yields; however, no BW differences were present in second-parity lambs at the same age. A smaller proportion of first-parity ewe grand-offspring from heavy granddams that were fed ad libitum during pregnancy reached puberty at approximately 8 mo of age relative to the other granddam size and feeding groups. These results indicate that dam nutrition can affect the yield and composition of milk in their offspring and the BW and reproductive capability of their grand-offspring. Molecular and physiological mechanisms for these changes are being sought.

Exit learning outcomes for the PRHO year: an evidence base for informed decisions.

OBJECTIVE: To evaluate potential learning outcomes for pre-registration house officer (PRHO) training and develop an evidence base for informed decision making. DESIGN AND SETTING: A 2-stage Delphi process was employed to establish the opinions of Scottish stakeholders with regard to learning outcomes for the PRHO year. PARTICIPANTS: Doctors involved in the provision of PRHO training, including deans, postgraduate tutors and general practitioners (GPs) with trainees, were invited to participate in the study. MAIN OUTCOME MEASURES: Respondents rated a range of outcomes according to which they believed should be included or excluded from the PRHO training year. RESULTS: Learning outcomes identified for PRHOs were grouped under the 12-domain framework of the 3-circle model: 'What the doctor can do', 'How they approach their practice' and 'Their professionalism'. Based on the consensus opinions gained in the Delphi study, the ratings were classified into priority groupings. Priority 1 contained 45 of the original 81 learning outcomes, representing each area of the 3-circle model, with emphasis on the domains of clinical skills, patient investigation/management, communication, appropriate attitudes and personal development. Health promotion and disease prevention was the only domain not represented at priority 1. Priority 2 contained 24 outcomes with emphasis on the understanding of clinical skills, patient management and personal development. Priority 3 contained 12 outcomes indicating a lack of emphasis for some outcomes, particularly the role of the doctor and health promotion. CONCLUSION: Consensus on the learning outcomes for PRHO training has been achieved, providing an evidence base for curriculum planning. The relative priority assigned to these outcomes can facilitate the use of the evidence. This evidence base should be referred to when reviewing any PRHO training programme.

A novel fluorescent coronenyl-phospholipid analogue for investigations of submicrosecond lipid fluctuations.

A fluorescent phospholipid derivative, the 2'-(4-coronenylbutyric) ester of lyso-egg phosphatidylcholine, has been synthesized for use in studies of submicrosecond lipid dynamics. Synthesis of the phospholipid derivative involves Friedel-Crafts acylation of free coronene, followed by a Huang-Minlon reduction to yield the fatty-acyl derivative, 4-coronenylbutyric acid. Esterification of the carboxylic acid with lyso-phosphatidylcholine is achieved through a mixed anhydride intermediate. The resultant coronenyl-phospholipid adduct (Cor-PC) has been incorporated into sonicated unilamellar vesicles of dimyristoylphosphatidylcholine (DMPC) for dynamic lipid studies. Fluorescence quenching studies using potassium iodide, together with steady-state emission anisotropy (EA) measurements, confirm that the coronene moiety of the phospholipid adduct resides towards the head group interfacial region of the lipid bilayer. Unique properties of this new fluorescent phospholipid adduct are its long mean fluorescence lifetime (tau av approximately 112 ns at 14 degrees C), the planar symmetry of the fluorophore and its defined bilayer location. As a consequence, depolarizing motions of the coronene moiety target submicrosecond 'gel-fluid' lipid dynamics arising from a relatively narrow bilayer distribution. Our data suggest that the sensitivity of this new long-lived fluorescent phospholipid analogue to localized transverse submicrosecond lipid dynamics can provide important biological insights into varied processes including lipid-peptide interactions, bilayer fluidity gradients and passive ion transport.

Probing the binding domain of the Saccharomyces cerevisiae alpha-mating factor receptor with rluorescent ligands.

Three analogues of the alpha-mating factor pheromone of Saccharomyces cerevisiae containing the 7-nitrobenz-2-oxa-1,3-diazol-4-yl (NBD) group were synthesized that had high binding affinity to the receptor and retained biological activity. The fluorescence emission maximum of the NBD group in [K7(NBD),Nle(12)]-alpha-factor was blue shifted by 35 nm compared to buffer when the pheromone bound to its receptor. Fluorescence quenching experiments revealed that the NBD group in [K7(NBD),Nle(12)]-alpha-factor bound to the receptor was shielded from collision with iodide anion when in aqueous buffer. In contrast, the emission maximum of NBD in [K7(ahNBD),Nle(12)]-alpha-factor or [Orn7(NBD),Nle(12)]-alpha-factor was not significantly shifted and iodide anion efficiently quenched the fluorescence of these derivatives when they were bound to receptor. The fluorescence investigation suggests that when the alpha-factor is bound to its receptor, K7 resides in an environment that has both hydrophobic and hydrophilic groups within a few angstroms of each other.

The discovery of non-basic atrial natriuretic peptide clearance receptor antagonists. Part 1.

The cyclic peptide ANP 4-23 and the linear peptide analogue AP-811 have been shown to be selective ANP-CR antagonists. Via alanine scanning and truncation studies we sought to determine which residues in these molecules were important in their binding to the clearance receptor and the relationship between these two molecules. These studies show that several modifications to these compounds are possible which improve physical properties of these molecules while retaining high affinity for the ANP-CR.

Two new early bacteriophage T4 genes, repEA and repEB, that are important for DNA replication initiated from origin E.

Two new, small, early bacteriophage T4 genes, repEA and repEB, located within the origin E (oriE) region of T4 DNA replication, affect functioning of this origin. An important and unusual property of the oriE region is that it is transcribed at early and late periods after infection, but in opposite directions (from complementary DNA strands). The early transcripts are mRNAs for RepEA and RepEB proteins, and they can serve as primers for leading-strand DNA synthesis. The late transcripts, which are genuine antisense RNAs for the early transcripts, direct synthesis of virion components. Because the T4 genome contains several origins, and because recombination can bypass a primase requirement for retrograde synthesis, neither defects in a single origin nor primase deficiencies are lethal in T4 (Mosig et al., FEMS Microbiol. Rev. 17:83-98, 1995). Therefore, repEA and repEB were expected and found to be important for T4 DNA replication only when activities of other origins were reduced. To investigate the in vivo roles of the two repE genes, we constructed nonsense mutations in each of them and combined them with the motA mutation sip1 that greatly reduces initiation from other origins. As expected, T4 DNA synthesis and progeny production were severely reduced in the double mutants as compared with the single motA mutant, but early transcription of oriE was reduced neither in the motA nor in the repE mutants. Moreover, residual DNA replication and growth of the double mutants were different at different temperatures, suggesting different functions for repEA and repEB. We surmise that the different structures and protein requirements for functioning of the different origins enhance the flexibility of T4 to adapt to varied growth conditions, and we expect that different origins in other organisms with multiorigin chromosomes might differ in structure and function for similar reasons.

A direct method for the correction of pressure-induced scrambling of polarized fluorescence intensities.

A simple and direct method for the simultaneous correction of steady-state polarized fluorescence intensities, depolarized (or scrambled) by the effects of applied hydrostatic pressure, is described. In the method discussed here, it is not necessary to first determine the scrambling factors from a separate experiment with a dye immobilized in a rigid medium. Rather correction for depolarizing effects of the high-pressure spectroscopy cell windows is achieved by direct recalculation of the measured polarized data obtained for the sample of interest at the time of data collection. This method of correction is tested for common fluorescent dyes 1, 6-diphenyl-1,3,5-hexatriene (DPH) and 9,10-diphenylanthracene in glycerol where their rotational behavior is well understood. In addition, the pressure-induced "melt" profile for the more complicated biologically relevant system of DPH imbedded within dipalmitoylphosphatidylcholine small unilamellar vesicles has been reexamined. While the method discussed here is used for the correction of steady-state polarized data, it may be easily adapted for use in time-resolved polarized fluorescence measurements. Advantages and limitations of the new correction method are discussed.

The largest (70 kDa) product of the bacteriophage T4 DNA terminase gene 17 binds to single-stranded DNA segments and digests them towards junctions with double-stranded DNA.

Bacteriophage terminases are oligomeric multifunctional proteins that bind to vegetative DNA, cut it and, together with portal proteins, translocate the DNA into preformed heads. Most terminases are encoded by two partially overlapping genes. In phage T4 they are genes 16 and 17. We have shown before that the larger of these, gene 17, can yield, in addition to a full-length 70 kDa product, several shorter peptides. At least two of these, gene product (gp) 17' and gp17", are initiated in the same reading frame as the 70 kDa gp17 from internal ribosome binding sites. Most of the shorter gp17 s contain predicted ATPase motifs, but only the largest (70 kDa) peptide has a predicted single-stranded DNA binding domain. Here we describe the DNA binding and cutting properties of the purified 70 kDa protein, expressed from two different clones containing gene 17 but no other T4 gene. Epitope-specific antibodies, which recognize several different gene 17 products in extracts of induced clones or of T4-infected cells, precipitate the purified 70 kDa gp17. When Mg2+ is chelated by EDTA this 70 kDa protein binds to single-stranded DNA, preferentially to junctions of single- and double-stranded DNA segments. It does not bind to blunt-ended double-stranded DNA. When Mg2+ is present the purified 70 kDa gp17 digests single-stranded segments preferentially up to junctions with double-stranded DNA. A 70 kDa gp17 from a P379L temperature sensitive (ts) mutant, which has lost the nuclease and ATPase activities, retains the single-stranded DNA binding activity. Taken together with earlier findings these results support a model for packaging of T4 DNA from single-stranded regions in recombinational or replicative intermediates, which occur at nearly random positions of the genome. This mechanism may be an alternative to site-specific initiation of packaging proposed by other investigators.

A novel mechanism of virus-virus interactions: bacteriophage P2 Tin protein inhibits phage T4 DNA synthesis by poisoning the T4 single-stranded DNA binding protein, gp32.

P2 prophages have been known to inhibit DNA replication and growth of T-even phages. We show here that this inhibition is due to poisoning of the T-even single-stranded DNA binding protein gp32 by the product of the nonessential P2 tin gene. Synthesis of Tin protein from a gene cloned in a multicopy plasmid is necessary and sufficient to completely prevent de novo DNA replication and growth of wild-type T2 or T4 phage. We isolated more than 20 independent mutants that render T-even phages resistant to poisoning by the P2 Tin protein. In all of these mutants, which we call asp, Asp codon 163 of gene 32 is changed to a Gly or Asn codon. The mutant alleles are recessive; i.e., when wild-type and asp mutants coinfect the same host cells, most DNA replication is poisoned by P2 Tin protein. To explain our results, we propose that the P2 Tin protein interacts with T-even gp32 at position 163 and distorts the helical filament of gene 32 protein on single-stranded DNA. Thereby Tin protein inhibits either assembly or function, or both, of the T4 replisome. The inhibition of late gene expression by P2 Tin protein may be an indirect consequence of inhibition of DNA replication.

Submicrosecond phospholipid dynamics using a long-lived fluorescence emission anisotropy probe.

The use of the long-lived fluorescence probe coronene (mean value of tau(FL) approximately 200 ns) is described for investigating submicrosecond lipid dynamics in DPPC model bilayer systems occurring below the lipid phase transition. Time-resolved fluorescence emission anisotropy decay profiles, measures as a function of increasing temperature toward the lipid-phase transition temperature (T(C)), for coronene-labeled DPPC small unilamellar vesicles (SUVs), are best described in most cases by three rotational decay components (phi(i = 3)). We have interpreted these data using two dynamic lipid bilayer models. In the first, a compartmental model, the long correlation time (phi(N)) is assigned to immobilized coronene molecules located in "gel-like" or highly ordered lipid phases (S-->1) of the bilayer, whereas a second fast rotational time (phi(F) approximately 2-5 ns) is associated with probes residing in more "fluid-like" regions (with corresponding lower ordering, S-->0). Interests here have focused on the origins of an intermediate correlation time (50-100 ns), the associated amplitude (beta(G)) of which increases with increasing temperature. Such behavior suggests a changing rotational environment surrounding the coronene molecules, arising from fluidization of gel lipid. The observed effective correlation time (phi(EFF)) thus reflects a discrete gel-fluid lipid exchange rate (k(FG)). A refinement of the compartmental model invokes a distribution of gel-fluid exchange rates (d(S,T)) corresponding to a distribution of lipid order parameters and is based on an adapted Landau expression for describing "gated" packing fluctuations. A total of seven parameters (five thermodynamic quantities, defined by the free energy versus temperature expansion; one gating parameter (gamma) defining a cooperative "melting" requirement; one limiting diffusion rate (or frequency factor: d(infinity))) suffice to predict complete anisotropy decay curves measured for coronene at several temperatures below the phospholipid T(C). The thermodynamic quantities are associated with the particular lipid of interest (in this case DPPC) and have been determined previously from ultrasound studies, thus representing fixed constants. Hence resolved variables are r(O), temperature-dependent gate parameters (gamma), and limiting diffusion rates (d(infinity)). This alternative distribution model is attractive because it provides a general probe-independent expression for distributed lipid fluctuation-induced probe rotational rates occurring within bilayer membranes below the phospholipid phase transition on the submicrosecond time scale.

Novel and sensitive detection systems for the vitamin D receptor--in situ-reverse transcriptase-polymerase chain reaction and immunogold cytochemistry.

The receptor for the active metabolite of vitamin D, 1,25(OH)(2)D(3), known as the vitamin D receptor (VDR), belongs to the steroid hormone nuclear receptor superfamily. We have developed novel methods for detection of VDR mRNA and protein within a human promyelomonocytic cell line, HL-60. Using the newly developed technique of in situ-reverse transcriptase-polymerase chain reaction (IS-RT-PCR), low levels of VDR mRNA could be amplified and demonstrated unequivocally within these cells, and also within a human kidney proximal tubule cell line, CL-8. Use of a novel immunogold cytochemical technique has allowed clear and sensitive detection of VDR protein expression within the HL-60 cells. Further development of IS-RT-PCR has allowed us to apply this technique to tissue sections. We have shown clear amplification of VDR transcripts within sections of formalin-fixed paraffin-embedded human kidney and liver. These techniques will be useful to localise specifically the VDR within cell types that contain low levels of mRNA and protein, and will permit further investigation of the role played by 1,25(OH)(2)D(3) in cellular regulatory mechanisms.

Life-threatening situations: supporting the child survivor and the family.

Children encounter life-threatening situations through trauma as well as acute and chronic illnesses. These life-threatening situations are not only potentially physically incapacitating but also emotionally scarring. Using Jillings' model for life-threatening illnesses, nurses are able to assess and intervene with child survivors and their families to insure optimum psychological and emotional outcomes.

A novel Epstein-Barr virus glycoprotein gp150 expressed from the BDLF3 open reading frame.

Analysis of cDNAs mapping to the BamHI D fragment of the Epstein-Barr virus (EBV) genome indicates that the BDLF3 open reading frame, which is predicted to encode a type 1 membrane protein of 234 amino acids, is expressed as an unspliced message. Expression of the open reading frame as a recombinant protein in vaccinia virus reveals a glycoprotein that has both N- and O-linked sugars. Antibodies made to the recombinant protein immunoprecipitate a late glycoprotein with a mobility of approximately 150,000 Da from EBV-producing cells. The glycoprotein is associated with the virion. Antibodies to it appear to react primarily with carbohydrate and do not demonstrate neutralizing activity.

Preliminary in situ identification of estrogen target cells in bone.

Although estrogens profoundly influence skeletal growth and maturation, their mechanism of action is still unclear. To identify their target cells in bone, estrogen receptors were located by immunofluorescence using the H222 monoclonal antibody in cryosections (both undecalcified and briefly decalcified) of hyperplastic mandibular condyle (persistent asymmetric mandibular growth) from a 14-year-old girl and radius and ulna from an 18-month-old female pig (epiphyseal fusion) and from a 3-month-old guinea pig (epiphyses open). Bone was removed from the animals at the peak of estrus. The most striking feature in all three species was the high proportion (approximately 50%) of receptor positive osteocytes. Although all sections contained active bone-forming surfaces, we were unable to identify clearly osteoblasts or lining cells that were estrogen receptor positive. In pig bone only, distinctive groups of receptor positive chondrocytes, with a pericellular localization of collagen type 1, were detected above the growth plate but below secondary centers of ossification. This observation suggests that osteocytes are major skeletal estrogen target cells and may be involved in coordinating the response of surface bone cells to the hormone, and further that chondrocytes may be involved in estrogen-induced epiphyseal growth plate fusion.

Regulatory considerations in vaccine design.

To summarize, vaccines are regulated in the United States as biologics by CBER and must meet requirements for safety, purity, and potency (efficacy). Although general requirements exist for safety, purity, and potency, specific standards for each vaccine are agreed to by the manufacturer and CBER. The final standards for any vaccine are relevant to the technology used to produce the vaccine. Vaccine efficacy is demonstrated through conducting one or more Phase III trials. A single, definitive, well-controlled, double-blind, placebo-controlled Phase III trial often provides sufficient efficacy data for licensing a vaccine. Pivotal efficacy data may be derived from U.S. or outside the U.S. studies. Bridging studies may be required to link the efficacy data to the intended marketing target population. In the United States, approval for conducting clinical trials is obtained from the FDA through the mechanism of the IND application. Marketing approval is obtained through the mechanism of the PLA and ELA. Postmarketing Phase IV clinical trials are generally requested to develop large-scale field data for safety. Timely communication with the FDA throughout the development and approval process is the most efficient mechanism for meeting all regulatory requirements in the shortest possible time.

Long-lived fluorescence probes for studying lipid dynamics: A review.

A great many studies have focused on the heterogeneous packing of lipids in the bilayer matrix. However, less attention has been directed toward the temporal aspects of these lipid-lipid interactions. Studies of lipid packing fluctuations, or 'gel-fluid' exchange, using fluorescence probe methodologies have been limited. This limitation arises from thesubmicrosecond time scale over which the fluctuations are expected to occur. Traditionally, dynamic studies of lipid bilayers have been restricted to the nanosecond time regime, and the submicrosecond time 'window' has not been explored in any great depth by fluorescence methods, although persistent lipid dynamics has been evident. Probes with long fluorescence lifetimes (several hundred nanoseconds) have the potential to expand this important time 'window,' providing information on 'gel-fluid' exchange rates and insights into how important biological effectors such as proteins, cholesterol, and anesthetics affect or modulate these fluctuations. Using the long-lived fluorescence probe coronene, combined with time-resolved fluorescence methods geared toward microheterogeneity, we present a view of bilayer dynamics in an alternate time domain. Fluorescence probes are expected to inhabit an equilibrium between fluid and gel environments. Some probes remain in their respective environments throughout their excited-state lifetime, while others reside in surroundings that will change (i.e., 'melt'). Long-lived fluorescence membrane probes can provide direct estimates of submicrosecond lipid fluctuation or 'melt' rates. Simple Landau modeling leads to adistribution of 'melt' rates and provides an attractive alternative to a simplercompartmental model where a unique lipid fluctuation of gel-fluid exchange rate is measured. Thedistribution model is probe independent (defined by thermodynamic quantities) and can be applied generally to the rotational motions of fluorescence probes embedded in the lipid bilayer.