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The use of β-lactam (BL) and β-lactamase inhibitor combination to overcome BL antibiotic resistance has been validated through clinically approved drug products. However, unmet medical needs still exist for the treatment of infections caused by Gram-negative (GN) bacteria expressing metallo-β-lactamases. Previously, we reported our effort to discover pan inhibitors of three main families in this class: IMP, VIM, and NDM. Herein, we describe our work to improve the GN coverage spectrum in combination with imipenem and relebactam. This was achieved through structure- and property-based optimization to tackle the GN cell penetration and efflux challenges. A significant discovery was made that inhibition of both VIM alleles, VIM-1 and VIM-2, is essential for broad GN coverage, especially against VIM-producing P. aeruginosa . In addition, pharmacokinetics and nonclinical safety profiles were investigated for select compounds. Key findings from this drug discovery campaign laid the foundation for further lead optimization toward identification of preclinical candidates.

With the emergence and rapid spreading of NDM-1 and existence of clinically relevant VIM-1 and IMP-1, discovery of pan inhibitors targeting metallo-beta-lactamases (MBLs) became critical in our battle against bacterial infection. Concurrent with our fragment and high-throughput screenings, we performed a knowledge-based search of known metallo-beta-lactamase inhibitors (MBLIs) to identify starting points for early engagement of medicinal chemistry. A class of compounds exemplified by 11 , discovered earlier as B. fragilis metallo-beta-lactamase inhibitors, was selected for in silico virtual screening. From these efforts, compound 12 was identified with activity against NDM-1 only. Initial exploration on metal binding design followed by structure-guided optimization led to the discovery of a series of compounds represented by 23 with a pan MBL inhibition profile. In in vivo studies, compound 23 in combination with imipenem (IPM) robustly lowered the bacterial burden in a murine infection model and became the lead for the invention of MBLI clinical candidates.

Purpose: To report toxicity and early survival data for IDEAL-CRT, a trial of dose-escalated concurrent chemoradiotherapy (CRT) for non-small cell lung cancer., Patients and Methods: Patients received tumor doses of 63 to 73 Gy in 30 once-daily fractions over 6 weeks with 2 concurrent cycles of cisplatin and vinorelbine. They were assigned to 1 of 2 groups according to esophageal dose. In group 1, tumor doses were determined by an experimental constraint on maximum esophageal dose, which was escalated following a 6 + 6 design from 65 Gy through 68 Gy to 71 Gy, allowing an esophageal maximum tolerated dose to be determined from early and late toxicities. Tumor doses for group 2 patients were determined by other tissue constraints, often lung. Overall survival, progression-free survival, tumor response, and toxicity were evaluated for both groups combined., Results: Eight centers recruited 84 patients: 13, 12, and 10, respectively, in the 65-Gy, 68-Gy, and 71-Gy cohorts of group 1; and 49 in group 2. The mean prescribed tumor dose was 67.7 Gy. Five grade 3 esophagitis and 3 grade 3 pneumonitis events were observed across both groups. After 1 fatal esophageal perforation in the 71-Gy cohort, 68 Gy was declared the esophageal maximum tolerated dose. With a median follow-up of 35 months, median overall survival was 36.9 months, and overall survival and progression-free survival were 87.8% and 72.0%, respectively, at 1 year and 68.0% and 48.5% at 2 years., Conclusions: IDEAL-CRT achieved significant treatment intensification with acceptable toxicity and promising survival. The isotoxic design allowed the esophageal maximum tolerated dose to be identified from relatively few patients., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

The development of a convergent and highly stereoselective synthesis of an HCV NS3/4a protease inhibitor possessing a unique spirocyclic and macrocyclic architecture is described. A late-stage spirocyclization strategy both enabled rapid structure-activity relationship studies in the drug discovery phase and simultaneously served as the basis for the large scale drug candidate preparation for clinical use. Also reported is the discovery of a novel InCl3-catalyzed carbonyl reduction with household aluminum foil or zinc powder as the terminal reductant.

Copper (Cu) is a trace metal that readily gains and donates electrons, a property that renders it desirable as an enzyme cofactor but dangerous as a source of free radicals. To regulate cellular Cu metabolism, an elaborate system of chaperones and transporters has evolved, although no human Cu chaperone mutations have been described to date. We describe a child from a consanguineous family who inherited homozygous mutations in the SLC33A1, encoding an acetyl CoA transporter, and in CCS, encoding the Cu chaperone for superoxide dismutase. The CCS mutation, p.Arg163Trp, predicts substitution of a highly conserved arginine residue at position 163, with tryptophan in domain II of CCS, which interacts directly with superoxide dismutase 1 (SOD1). Biochemical analyses of the patient's fibroblasts, mammalian cell transfections, immunoprecipitation assays, and Lys7Δ (CCS homolog) yeast complementation support the pathogenicity of the mutation. Expression of CCS was reduced and binding of CCS to SOD1 impaired. As a result, this mutation causes reduced SOD1 activity and may impair other mechanisms important for normal Cu homeostasis. CCS-Arg163Trp represents the primary example of a human mutation in a gene coding for a Cu chaperone., (© 2012 Wiley Periodicals, Inc.)

ATP7A is a copper-transporting ATPase critical for central and peripheral nervous system function. Mutations in ATP7A cause Menkes disease and occipital horn syndrome (OHS), allelic X-linked recessive conditions that feature vascular abnormalities ascribed to low activity of lysyl oxidase, a copper-dependent enzyme. From a recently created Menkes disease/OHS patient registry, we identified four of 95 patients with major congenital heart defects (4.2%), a proportion exceeding the general population prevalence (≈1%). In conjunction with mouse models of Menkes disease, OHS, and lysyl oxidase deficiency (which feature aortic aneurysms, irregular attachment between vascular endothelium and mesoderm, and other defects of embryological development) our observation suggests an important role of copper metabolism in cardiac development. Congenital heart disease may be an under-appreciated abnormality in Menkes disease, and should be considered in a broad differential diagnosis of cardiac defects found prenatally in male fetuses. Conversely, newborn infants with suspected or confirmed Menkes disease should be evaluated for heart disease by careful clinical examination and echocardiography, if indicated.

Techniques for the diagnosis of copper transport disorders are increasingly important due to recent recognition of previously unappreciated clinical phenotypes and emerging advances in the treatment of these conditions. Here, we collate the diagnostic approaches and techniques currently employed for biochemical and molecular assessment of at-risk individuals in whom abnormal copper metabolism is suspected., (© 2011 by John Wiley & Sons, Inc.)

Epilepsy is a major feature of Menkes disease, an X-linked recessive infantile neurodegenerative disorder caused by mutations in ATP7A, which produces a copper-transporting ATPase. Three prior surveys indicated clinical seizures and electroencephalographic (EEG) abnormalities in a combined 27 of 29 (93%) symptomatic Menkes disease patients diagnosed at 2 months of age or older. To assess the influence of earlier, presymptomatic diagnosis and treatment on seizure semiology and brain electrical activity, we evaluated 71 EEGs in 24 Menkes disease patients who were diagnosed and treated with copper injections in early infancy (≤6 weeks of age), and whose ATP7A mutations we determined. Clinical seizures were observed in only 12.5% (3/24) of these patients, although 46% (11/24) had at least one abnormal EEG tracing, including 50% of patients with large deletions in ATP7A, 50% of those with small deletions, 60% of those with nonsense mutations, and 57% of those with canonical splice junction mutations. In contrast, five patients with mutations shown to retain partial function, either via some correct RNA splicing or residual copper transport capacity, had neither clinical seizures nor EEG abnormalities. Our findings suggest that early diagnosis and treatment improve brain electrical activity and decrease seizure occurrence in classical Menkes disease irrespective of the precise molecular defect. Subjects with ATP7A mutations that retain some function seem particularly well protected by early intervention against the possibility of epilepsy.

We report the efficient N-arylation of acyclic secondary amides and related nucleophiles with aryl nonaflates, triflates, and chlorides. This method allows for easy variation of the aromatic component in tertiary aryl amides. A new biaryl phosphine with P-bound 3,5-(bis)trifluoromethylphenyl groups was found to be uniquely effective for this amidation. The critical aspects of the ligand were explored through synthetic, mechanistic, and computational studies. Systematic variation of the ligand revealed the importance of (1) a methoxy group on the aromatic carbon of the "top ring" ortho to the phosphorus and (2) two highly electron-withdrawing P-bound 3,5-(bis)trifluoromethylphenyl groups. Computational studies suggest the electron-deficient nature of the ligand is important in facilitating amide binding to the LPd(II)(Ph)(X) intermediate.

The pyran-containing fragments 1 and 2 of AM3 have been synthesized from the common pyran intermediate 3. Careful orchestration of the alcohol protecting groups was necessary to facilitate deprotection of alcohol functionality in the presence of the chemically sensitive polyene chain.

Treatment of unsaturated 1,5-diols 2 with TES-Cl (1.1 equiv), imidazole, and catalytic DMAP in 1:1 CH2Cl2-DMF at -78 degrees C effects selective silylation of the allylic alcohol with >95:5 chemoselectivity when the allylic and homoallylic alcohols are in similar steric environments.

[reaction: see text] A synthesis of the C(43)-C(67) fragment of amphidinol 3 (AM3) has been accomplished by a route that features the use of a double allylboration reaction for synthesis of 1,5-diol 4b, which serves as a precursor to dihydropyran 11.

Aim: To compare serum analyses of vitamin B12 and methylmalonic acid (MMA) as indices of cobalt/vitamin B12 deficiency in lambs around weaning., Methods: Lambs on five properties, considered to be cobalt- deficient, were supplemented with either cobalt bullets, or short- or long-acting vitamin B12 preparations. Blood samples, and in some cases liver biopsies, and liveweights were obtained at monthly intervals. Serum samples were assayed for vitamin B12 and MMA and liver for vitamin B12 concentrations. Pasture cobalt concentrations were measured on three of the properties., Results: Pasture cobalt concentrations were generally maintained below 0.07 microg/g dry matter (DM) on the properties sampled. Growth responses to supplementation were observed on only 2/5 properties, despite serum vitamin B12 concentrations being within the currently used 'marginal' reference range (336-499 pmol/L) for at least 3 months on all properties and in the deficient reference range (0-335 pmol/L) for at least 2 months on all farms except one. Serum MMA concentrations in supplemented lambs were <2 micromol/L, except in those animals sampled 1 month after receiving treatment with a short-acting vitamin B12 injection. Serum MMA concentrations in unsupplemented animals on properties on which no growth response to supplementation occurred generally reached peak levels of between 4 and 7 micromol/L at the nadir of serum vitamin B12 concentration. When a growth response was observed, differences in weight gain between supplemented and unsupplemented lambs occurred as mean serum MMA concentrations increased from 9 to 14 micromol/L. On one property where supplementation commenced before weaning, normal growth rates were maintained despite serum vitamin B12 concentrations of 140 pmol/L and serum MMA concentrations in excess of 40 micromol/L serum., Conclusions: The possibility that current serum vitamin B12 references ranges for diagnosis of cobalt deficiency are set too high and lead to over-diagnosis of responsiveness to cobalt/ vitamin B12 supplementation is discussed. The suggestion is made that serum MMA concentrations in excess of 9-14 micromol/L will provide a more reliable diagnostic test for cobalt deficiency. However, there was sufficient variation between properties in the relationships between cobalt concentrations of pasture and serum vitamin B12 or MMA concentrations to require more rigorous testing of the reliability of using serum MMA concentration for this purpose. The possibility that differences in rumen fermentation and therefore propionate and vitamin B12 production could be involved is discussed. The measurement of serum MMA and vitamin B12 appears to be of little value whilst the lamb is still suckling., Clinical Significance: Serum MMA concentration may offer advantages over serum vitamin B12 concentrations in the diagnosis of a cobalt/vitamin B12 responsiveness in weaned lambs.

This study describes size of constituent deciduous tooth crown components (enamel, dentine, and pulp) to address the manner in which males characteristically have larger teeth than females, and the observation that teeth of American blacks are larger than those of American whites. Measurements were collected (n = 333 individuals) from bitewing radiographs using computer-aided image analysis. Tissue thicknesses (enamel, dentine, pulp) were measured at the crown's mesial and distal heights of contour. Deciduous mesiodistal molar crown length is composed of about 1/7 enamel, 1/3 dentine, and 1/2 pulp. Details differ by tooth type, but males typically have significantly larger dentine and pulp dimensions than females; there is no sexual dimorphism in marginal enamel thickness. Males scale isometrically with females for all variables tested here. Blacks significantly exceed whites in size of all tissues, but tissue types scale isometrically with blacks and whites with one exception: enamel thickness is disproportionately thick in blacks. While the absolute difference is small (5.56 mm of enamel in blacks summed over all four deciduous molar tooth types vs. 5.04 mm in whites), the statistical difference is considerable (P < 0.001). Aside from enamel, crown size in blacks is increased proportionately vis-à-vis whites. Principal components analysis confirmed these univariate relationships and emphasizes the statistical independence of crown component thicknesses, which is in keeping with the sequential growth and separate embryonic origins of the tissues contributing to a tooth crown. Results direct attention to the rates of enamel and dentine deposition (of which little is known), since the literature suggests that blacks (with larger crowns and thicker enamel) spend less time in tooth formation than whites., (Copyright 2001 Wiley-Liss, Inc.)

Crown sizes of human teeth are sexually dimorphic, with male larger than female. This holds for most human groups, though the extent of dimorphism varies among populations. It is not known whether size dimorphism is due to differences in enamel thickness, dentine differences, or some combination of the two. This study examined the pattern of variation in enamel thickness on the mesial and distal margins of the four maxillary permanent incisors. Standardized periapical radiographs of the incisors of 115 adolescent American whites were measured. Enamel was significantly thicker on the distal than the mesial margins of both the lateral and central incisors, with a mean difference of 0.1 mm. There was no sexual dimorphism in the maximum mesial or distal enamel thicknesses. In contrast, the widths of the dentine of the crowns were significantly greater in males, by an average of 6.5%. Sexual dimorphism in mesiodistal diameters of the incisors seems, then, to be due to the dentine component, which is the size attained at the end of the bell stage of tooth formation. Sex-specific correlations between enamel thickness and crown width of the dentine were low (and lower for males), indicating considerable independence between regulatory mechanisms of dentine and enamel development.

In 1992, Forces Command had 42 Child Development Centers on 22 installations. We evaluated program compliance in the areas of health, sanitation, and nutrition using inspection findings from April 1991 through June 1992. Each program was rated on 20 items, using inspection checklists developed for this evaluation. We also surveyed Haemophilus influenza type b (Hib) vaccination records among enrolled children. Most programs and facilities were fully or partially compliant in most areas. By quantifying the inspection findings, we were able to identify compliance items that needed further attention. The most frequent problem area across all programs was documentation of child immunization and health records. For children between 13 and 60 months of age, 77.7% had records indicating appropriate vaccination against Hib. Comparisons with the prior year's findings indicated a trend toward improvement.

Comparison was made of the value of information obtained from imprints and from histological sections of lymph nodes from 100 biopsies on patients with mainly haematological disorders and 55 spleens removed surgically. The sections provided the definitive diagnosis. It was seldom possible to make a definite diagnosis from imprints, but they provide additional information useful in interpreting the histology of sections.

The clinical and pathological features of histiocytic medullary reticulosis (HMR) are described in five patients. Treatment by splenectomy and the MOPP routine resulted in a transient improvement in platelet and neutrophil counts and resolution of anaemia and apparent prolongation of survival in two of the five patients. The relationship of HMR to other histiocytic disorders is discussed. HMR is defined as a unique malignant histiocytosis in which malignant histiocytes engage in phagocytosis of eryrhrocytes, leucocytes and platelets.

Mice chronically infected with 3 metazoan and 1 protozoan parasite contain in their circulation levels of IgG1 which are increased over the levels in uninfected mice by at least 10x. In the case of infection with the larval cestode, Mesocestoides corti, the serum IgG1 concentration can reach greater than 50 mg/ml and, with a half-life of less than 2 days, the number of cells engaged in IgG1 production is approximately 2 x 10(8). The IgG1 hypergammaglobulinaemia is not seen in infected hypothymic nude mice. Biosynthetic labelling studies with organ and tissue cultures established that in two of the chronic infections the organs principally involved in IgG1 synthesis were those pathologically involved or those "in line" for antigen capture: i.e. liver and spleen in the case of M. corti which is located in the liver and the peritoneal cavity, and various intestinal lymph nodes in the case of the gut-dwelling nematode, Nematospiroides dubius. This apparently exaggerated response to chronic parasitic infection is of interest simply because of the potential magnitude of the effect and the fact that it involves an Ig isotype with very poorly defined biological function.

Patients who have received marrow transplants and total body irradiation with different forms of chemotherapy should be routinely watched by an ophthalmology service because of the high incidence of dry eye syndrome, viral keratitis, and trophic disturbances of the cornea. Herpes simplex keratitis must be strongly suspected in bizarre corneal findings associated with geographic epithelial denudement accompanying acute GVHD. Acute GVH ocular syndrome warrants clinical recognition when, in the course of severe GVHD, the eyes reveal keratoconjunctivitis with associated herpes simplex infections of the cornea, later to show chronic problems of severe drying conjunctival and corneal scarring compatible with Stevens-Johnson syndrome.

The necropsy findings of a large cell lymphoma involving only the pericardium and myocardium in a 62-year-old woman are reported. The initial presenting symptoms were heart failure followed by rapidly progressive heart block. The diagnosis of cardiac lymphoma was suggested by gallium and blood pool isotope studies, and was subsequently confirmed by operative myocardial biopsy. The clinical course was abrupt, and the patient died before therapy was instituted. While primary cardiac lymphoma is an extremely rare condition, experience in this case suggests that noninvasive isotope studies, particularly gallium and blood pool, are helpful in the diagnosis of atypical cardiomyopathy.