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BackgroundThe clinical severity of sickle cell disease (SCD) is strongly influenced by the level of fetal haemoglobin (HbF) persistent in each patient. Three major HbF loci (BCL11A,HBS1L-MYB, andXmn1-HBG2) have been reported, but a considerable hidden heritability remains.AimBuilding on the power of a large and genetically diverse patient pool present in Nigeria, we conducted a genome-wide association study for HbF levels in patients from three regions of the country with a diverse ethnic make-up.MethodsWe analysed genome-wide trait association in 1006 Nigerian patients with SCD (HbSS/HbSβ0), followed by a replication and meta-analysis exercise in four independent SCD cohorts (3,582 patients). To dissect association signals at the major loci, we performed stepwise conditional analysis, haplotype association analysis and included public functional annotation data (fGCTA).ResultsAssociation signals were detected forBCL11A(lead SNP rs6706648, β=- 0.39,P=4.96 x 10-34) andHBS1L-MYB(lead SNP rs61028892, β=0.73,P=1.18 x 10-9), whereas the variant allele forXmn1-HBG2was found to be very rare. Genetically dissecting the two major loci, we defined trait-boosting haplotypes containing suspected or so-far unidentified causal variants. AtBCL11A, one such haplotype (trait increaseP< 0.0001) contains the putative functional variant rs1427407-‘T’ and a second haplotype (P< 0.0001) is tagged by the rs7565301-‘A’ allele, with no obvious candidate causal variant. AtHBS1L- MYB, one haplotype (trait increaseP< 0.0001) contains the likely functional rs66650371 (Δ3-bp), and a second (P< 0.0001) is tagged by the ‘C’ allele of rs6102889. Together, variants atBCL11AandHBS1L-MYBSNPs explained 24.1% of the trait variance.We detected three novel association signals:SLC28A3on chromosome 9 (rs115555854: β=- 0.73,P=2.52 x 10-8),TICRRon chromosome 15 (rs140496989: β=-0.43,P=3.34 x 10-8), andPIEZO2on chromosome 18 (rs58817161: β= −0.63,P= 8.04 x 10-8). These appeared to be restricted to the Nigerian patient cohort and were not confirmed in the replication cohorts.ConclusionsStudying a diverse cohort of Nigerian patients with sickle cell disease, we genetically dissected the known fetal-haemoglobin lociBCL11AandHBS1L-MYBand detected putative new trait-associated regions.

Background: A large proportion of genetic risk remains unexplained for structural heart disease involving the interventricular septum (IVS) including hypertrophic cardiomyopathy and ventricular septal defects. This study sought to develop a reproducible proxy of IVS structure from standard medical imaging, discover novel genetic determinants of IVS structure, and relate these loci to diseases of the IVS, hypertrophic cardiomyopathy, and ventricular septal defect. Methods: We estimated the cross-sectional area of the IVS from the 4-chamber view of cardiac magnetic resonance imaging in 32 219 individuals from the UK Biobank which was used as the basis of genome wide association studies and Mendelian randomization. Results: Measures of IVS cross-sectional area at diastole were a strong proxy for the 3-dimensional volume of the IVS (Pearson r =0.814, P =0.004), and correlated with anthropometric measures, blood pressure, and diagnostic codes related to cardiovascular physiology. Seven loci with clear genomic consequence and relevance to cardiovascular biology were uncovered by genome wide association studies, most notably a single nucleotide polymorphism in an intron of CDKN1A (rs2376620; β, 7.7 mm 2 [95% CI, 5.8–11.0]; P =6.0×10 − 10 ), and a common inversion incorporating KANSL1 predicted to disrupt local chromatin structure (β, 8.4 mm 2 [95% CI, 6.3–10.9]; P =4.2×10 − 14 ). Mendelian randomization suggested that inheritance of larger IVS cross-sectional area at diastole was strongly associated with hypertrophic cardiomyopathy risk (p IVW =4.6×10 − 10 ) while inheritance of smaller IVS cross-sectional area at diastole was associated with risk for ventricular septal defect (p IVW =0.007). Conclusions: Automated estimates of cross-sectional area of the IVS supports discovery of novel loci related to cardiac development and Mendelian disease. Inheritance of genetic liability for either small or large IVS, appears to confer risk for ventricular septal defect or hypertrophic cardiomyopathy, respectively. These data suggest that a proportion of risk for structural and congenital heart disease can be localized to the common genetic determinants of size and shape of cardiovascular anatomy.

Background: A large proportion of genetic risk remains unexplained for structural heart disease involving the interventricular septum (IVS) including hypertrophic cardiomyopathy (HCM) and ventricular septal defects (VSD). Methods: We performed machine learning to estimate the cross-sectional area of the interventricular septum (IVS.csad) from the 4-chamber view of cardiac MRI in 32,219 individuals from the UK Biobank. We related IVS.csad to relevant clinical phenotypes, and performed genome-wide association studies and Mendelian Randomization. Results: Automated measures of IVS.csad were highly accurate, and strongly correlated with anthropometric measures, blood pressure, and diagnostic codes related to cardiovascular physiology. A single nucleotide polymorphism in an intron of CDKN1A was associated with IVS.csad (rs2376620, Beta 8.4 mm2, 95% confidence intervals (CI) 5.8 to 11.0, p=2.0e-10), and a common inversion incorporating KANSL1 predicted to disrupt local chromatin structure was associated with an increase in IVS.csad (Beta 8.6 mm2, 95% CI 6.3-10.9, p=1.3e-13). Mendelian Randomization suggested that inheritance of larger IVS.csad was causal for HCM (Beta 2.45 log odds ratio (OR) HCM per increase in SD of IVS.csad, standard error (SE) 0.48, pIVW = 2.8e-7) while inheritance of smaller IVS.csad was causal for VSD (Beta -2.06 log odds ratio (OR) VSD per decrease in SD of IVS.csad, SE 0.75, pIVW = 0.006) Conclusion: Automated derivation of the cross sectional area of the IVS allowed discovery of loci related to cardiac development and Mendelian disease. Inheritance of genetic liability for either large or small interventricular septum, appears to confer risk for HCM or VSD respectively, suggesting that a proportion of risk for structural and congenital heart disease may localize to the common genetic determinants of cardiovascular anatomy.

Type 2 diabetes (T2D) is an important heritable risk factor for coronary artery disease (CAD), the risk of both diseases being increased by metabolic syndrome (MS). With the availability of large-scale genome-wide association data, we aimed to elucidate the genetic burden of CAD risk in T2D predisposed individuals within the context of MS and their shared genetic architecture. Mendelian randomization (MR) analyses supported a causal relationship between T2D and CAD [odds ratio (OR) = 1.13 per log-odds unit 95% confidence interval (CI): 1.10-1.16; p = 1.59 × 10-17 ]. Simultaneously adjusting MR analyses for the effects of the T2D instrument including blood pressure, dyslipidaemia, and obesity attenuated the association between T2D and CAD (OR = 1.07, 95% CI: 1.04-1.11). Bayesian locus-overlap analysis identified 44 regions with the same causal variant underlying T2D and CAD genetic signals (FDR 0.7; five (MHC, LPL, ABO, RAI1 and MC4R) of these regions contain genome-wide significant (p

Rapid progress of the discovery of genetic loci associated with common, complex diseases has outpaced the elucidation of mechanisms pertinent to disease pathogenesis. To address relevant barriers for coronary artery disease (CAD), we combined genetic discovery analyses with downstream characterization of likely causal variants, genes, and biological pathways. Specifically, we conducted a genome-wide association study (GWAS) comprising 181,522 cases of CAD among 1,165,690 participants. We detected 241 associations, including 54 associations and 30 loci not previously linked to CAD. Next, we prioritized likely causal variants using functionally-informed fine-mapping, yielding 42 associations with fewer than five variants in the 95% credible set. Combining eight complementary predictors, we prioritized 185 candidate causal genes, including 94 genes supported by three or more predictors. Similarity-based clustering underscored a role for early developmental processes, cell cycle signaling, and vascular proliferation in the pathogenesis of CAD. Our analysis identifies and systematically characterizes risk loci for CAD to inform experimental interrogation of putative causal mechanisms for CAD.

Background: \ud Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes (ACS) afflicting predominantly younger to middle-aged women. Observational studies have reported a high prevalence of extracoronary vascular anomalies, especially fibromuscular dysplasia (FMD) and a low prevalence of coincidental cases of atherosclerosis. PHACTR1/EDN1 is a genetic risk locus for several vascular diseases, including FMD and coronary artery disease, with the putative causal noncoding variant at the rs9349379 locus acting as a potential enhancer for the endothelin-1 (EDN1) gene.\ud \ud Objectives: \ud This study sought to test the association between the rs9349379 genotype and SCAD.\ud \ud Methods: \ud Results from case control studies from France, United Kingdom, United States, and Australia were analyzed to test the association with SCAD risk, including age at first event, pregnancy-associated SCAD (P-SCAD), and recurrent SCAD.\ud \ud Results: \ud The previously reported risk allele for FMD (rs9349379-A) was associated with a higher risk of SCAD in all studies. In a meta-analysis of 1,055 SCAD patients and 7,190 controls, the odds ratio (OR) was 1.67 (95% confidence interval [CI]: 1.50 to 1.86) per copy of rs9349379-A. In a subset of 491 SCAD patients, the OR estimate was found to be higher for the association with SCAD in patients without FMD (OR: 1.89; 95% CI: 1.53 to 2.33) than in SCAD cases with FMD (OR: 1.60; 95% CI: 1.28 to 1.99). There was no effect of genotype on age at first event, P-SCAD, or recurrence.\ud \ud Conclusions: \ud The first genetic risk factor for SCAD was identified in the largest study conducted to date for this condition. This genetic link may contribute to the clinical overlap between SCAD and FMD.

The discovery of genetic loci associated with complex diseases has outpaced the elucidation of mechanisms of disease pathogenesis. Here we conducted a genome-wide association study (GWAS) for coronary artery disease (CAD) comprising 181,522 cases among 1,165,690 participants of predominantly European ancestry. We detected 241 associations, including 30 new loci. Cross-ancestry meta-analysis with a Japanese GWAS yielded 38 additional new loci. We prioritized likely causal variants using functionally informed fine-mapping, yielding 42 associations with less than five variants in the 95% credible set. Similarity-based clustering suggested roles for early developmental processes, cell cycle signaling and vascular cell migration and proliferation in the pathogenesis of CAD. We prioritized 220 candidate causal genes, combining eight complementary approaches, including 123 supported by three or more approaches. Using CRISPR–Cas9, we experimentally validated the effect of an enhancer in MYO9B, which appears to mediate CAD risk by regulating vascular cell motility. Our analysis identifies and systematically characterizes >250 risk loci for CAD to inform experimental interrogation of putative causal mechanisms for CAD.

Background Over the last 10 years, there have been over 3300 genome-wide association studies (GWAS). Almost every GWAS study provides a Manhattan plot either as a main figure or in the supplement. Several software packages can generate a Manhattan plot, but they are all limited in the extent to which they can annotate gene-names, allele frequencies, and variants having high impact on gene function or provide any other added information or flexibility. Furthermore, in a conventional Manhattan plot, there is no way of distinguishing a locus identified due to a single variant with very significant p-value from a locus with multiple variants which appear to be in a haplotype block having very similar p-values. Results Here we present a software tool written in R, which generates a transposed Manhattan plot along with additional features like variant consequence and minor allele frequency to annotate the plot and addresses these limitations. The software also gives flexibility on how and where the user wants to display the annotations. The software can be downloaded from CRAN repository and also from the GitHub project page. Conclusions We present a major step up to the existing conventional Manhattan plot generation tools. We hope this form of display along with the added annotations will bring more insight to the reader from this new Manhattan++ plot.

Genome-wide association studies (GWAS) in coronary artery disease (CAD) had identified 66 loci at 'genome-wide significance' (P < 5 × 10(-8)) at the time of this analysis, but a much larger number of putative loci at a false discovery rate (FDR) of 5% (refs. 1,2,3,4). Here we leverage an interim release of UK Biobank (UKBB) data to evaluate the validity of the FDR approach. We tested a CAD phenotype inclusive of angina (SOFT; ncases = 10,801) as well as a stricter definition without angina (HARD; ncases = 6,482) and selected cases with the former phenotype to conduct a meta-analysis using the two most recent CAD GWAS. This approach identified 13 new loci at genome-wide significance, 12 of which were on our previous list of loci meeting the 5% FDR threshold, thus providing strong support that the remaining loci identified by FDR represent genuine signals. The 304 independent variants associated at 5% FDR in this study explain 21.2% of CAD heritability and identify 243 loci that implicate pathways in blood vessel morphogenesis as well as lipid metabolism, nitric oxide signaling and inflammation.

Nerve growth factor (NGF) is a neurotrophin that is implicated in the modulation of pain perception. Tanezumab, a humanized monoclonal antibody (mAb) specific for NGF, is highly potent in sequestering NGF and has demonstrated efficacy for treatment of chronic pain in clinical trials. We describe a novel, sensitive immunoaffinity liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for quantitative determination of human serum NGF levels at baseline and after tanezumab treatment. The assay combines magnetic bead-based NGF immunoaffinity enrichment using a non-neutralizing polyclonal antibody followed by digestion and quantitation of a NGF-derived tryptic peptide via high-flow peptide immunoaffinity enrichment and nanoflow LC-MS/MS. Following validation, the assay was employed to measure total NGF concentrations in samples from clinical studies. The assay had a10% interassay relative error and15% interassay coefficient of variation across a range from 7.03 to 450 pg/mL human NGF. Generally, human basal serum NGF concentrations were between 20 and 30 pg/mL which, upon treatment with tanezumab, elevated in a dose-dependent manner into the high pg/mL to low ng/mL range. This is the first report of clinical trial implementation of a MS-based assay that uses sequential protein and peptide immunoaffinity capture for protein target quantitation. The use of robotic sample preparation and a robust chromatography configuration enabled this technology to advance into the routine clinical analysis and now provides a bioanalytical platform for the development of similar assays for other protein targets.

Advances in recombinant antibody technology and protein engineering have provided the opportunity to reduce antibodies to their smallest binding domain components and have concomitantly driven the requirement for devising strategies to increase serum half-life to optimise drug exposure, thereby increasing therapeutic efficacy. In this study, we adopted an immunization route to raise picomolar affinity shark immunoglobulin new antigen receptors (IgNARs) to target human serum albumin (HSA). From our model shark species, Squalus acanthias, a phage display library encompassing the variable binding domain of IgNAR (VNAR) was constructed, screened against target, and positive clones were characterized for affinity and specificity. N-terminal and C-terminal molecular fusions of our lead hit in complex with a naïve VNAR domain were expressed, purified and exhibited the retention of high affinity binding to HSA, but also cross-selectivity to mouse, rat and monkey serum albumin both in vitro and in vivo. Furthermore, the naïve VNAR had enhanced pharmacokinetic (PK) characteristics in both N- and C-terminal orientations and when tested as a three domain construct with naïve VNAR flanking the HSA binding domain at both the N and C termini. Molecules derived from this platform technology also demonstrated the potential for clinical utility by being available via the subcutaneous route of delivery. This study thus demonstrates the first in vivo functional efficacy of a VNAR binding domain with the ability to enhance PK properties and support delivery of multifunctional therapies.

As part of a 2010 conference entitled “Patients and Populations: Public Health in Medical Education,” faculty from four U.S. medical schools (Case Western Reserve University, Harvard Medical School, the University of Colorado School of Medicine, and the University of Vermont College of Medicine), collaborated on a workshop to help other medical educators develop scenario-based learning experiences as practical, engaging, and effective mechanisms for teaching public health principles to medical school students. This paper describes and compares four different medical schools' experiences using a similar pandemic exercise scenario, discusses lessons learned, and suggests a curricular framework for medical schools adding such exercises to their population health curriculum. Different strategies to create realistic scenarios and engage students, including use of professionals and stakeholders from the community, are described.

Background. Curbside consultations are common in clinical practice. The complexity, relative value, and revenue loss associated with curbside consultations are not well defined. Methods. Curbside consultations performed during a 1-year period were studied. Each curbside consultation was assigned a Current Procedural Terminology (CPT) code on the basis of the inpatient versus outpatient status of the patient, initial versus subsequent care, and clinical complexity. On the basis of the CPT code, the physician work component of the relative value unit (wRVU) was assigned for each curbside consultation. The 2005 Centers for Medicaid and Medicare Services conversion factor of $37.89 per wRVU was used for cost estimates. Comparisons were made with formal consultations performed during the same time period. Results. A total of 1001 curbside consultations were fielded: 66% involved outpatients, and 97% were coded as initial consultations. A total of 78% of curbside consultations were considered complex in nature, being assigned a CPT code of level 4-5, including 84% of the inpatient and 75% of the outpatient curbside consultations. These curbside consultations would have generated 2480 wRVUs. During the same period, formal consultations generated 12,121 wRVUs. Thus, curbside consultations represented 17% (2480/14,601) of the clinical work value of the infectious diseases unit. If the infectious diseases unit had performed these curbside consultations as formal consultations, an additional $93,979 in revenue would have been generated. Conclusions. Curbside consultations are common and complex. The curbside consultation should be incorporated into measures of infectious diseases providers' productivity and compensation.

Existing knowledge of genetic variants affecting risk of coronary artery disease (CAD) is largely based on genome-wide association study (GWAS) analysis of common SNPs. Leveraging phased haplotypes from the 1000 Genomes Project, we report a GWAS meta-analysis of ∼185,000 CAD cases and controls, interrogating 6.7 million common (minor allele frequency (MAF) > 0.05) and 2.7 million low-frequency (0.005 < MAF < 0.05) variants. In addition to confirming most known CAD-associated loci, we identified ten new loci (eight additive and two recessive) that contain candidate causal genes newly implicating biological processes in vessel walls. We observed intralocus allelic heterogeneity but little evidence of low-frequency variants with larger effects and no evidence of synthetic association. Our analysis provides a comprehensive survey of the fine genetic architecture of CAD, showing that genetic susceptibility to this common disease is largely determined by common SNPs of small effect size.

Background Biomarkers of inflammation and altered coagulation are of increasing interest as predictors of chronic disease and mortality in HIV patients, as well as the use of risk stratification scores such as the Framingham index and the Veterans Aging Cohort Study (VACS) score. Methods Demographic and laboratory data for 252 HIV patients were assessed for their relationship with 5 biomarkers: hsCRP, D-dimer, Cystatin C, IL-6 and TNF-alpha. Analysis of variance was used to model the association between the number of elevated biomarkers patients had and their Framingham 10 year cardiovascular risk and VACS scores. Results 87% of patients were male and 75.7% were virally suppressed (HIV RNA 75th percentile, while 18.6% had three or more elevated biomarkers. Increased age, cigarette smoking, CD4 counts of

We conducted a retrospective study to determine the yield of blood samples drawn for culture during the initial 72 h of antibiotic therapy given to 139 patients who were admitted to the hospital for community-acquired infections or fever. The yield of these blood cultures was predictable and rarely (in only 1 patient [0.72%]) isolated new pathogens.

SUMMARY The epidemic of HIV infection is spreading into rural areas of the United States. Injection drug use (IDU) is contributing to this spread in a manner similar to that of larger urban areas. The purpose of this paper is to assess the extent that IDU contributes to the HIV epidemic in Vermont and to compare this group of patients to others infected by HIV by non-IDU means. Twenty-three percent of 119 HIV-positive patients attending rural clinics in Vermont identified IDU as the most likely route of their HIV infection. Another 25% were infected by heterosexual contact with someone at risk for HIV. The majority of patients reported that they became infected with HIV outside of Vermont. Over 40% of IDU patients were first diagnosed with HIV after moving to Vermont. Proportionately more women and minorities were HIV infected by IDU when compared to men and white non-Hispanic patients. The great majority of IDUs were unemployed and depended on welfare or disability for financial support. All IDUs had eit...

While myriad molecular formats for bispecific antibodies have been examined to date, the simplest structures are often based on the scFv. Issues with stability and manufacturability in scFv-based bispecific molecules, however, have been a significant hindrance to their development, particularly for high-concentration, stable formulations that allow subcutaneous delivery. Our aim was to generate a tetravalent bispecific molecule targeting two inflammatory mediators for synergistic immune modulation. We focused on an scFv-Fc-scFv format, with a flexible (A4T)3 linker coupling an additional scFv to the C-terminus of an scFv-Fc. While one of the lead scFvs isolated directly from a naive library was well-behaved and sufficiently potent, the parental anti-CXCL13 scFv 3B4 required optimization for affinity, stability, and cynomolgus ortholog cross-reactivity. To achieve this, we eschewed framework-based stabilizing mutations in favor of complementarity-determining region (CDR) mutagenesis and re-selection for simultaneous improvements in both affinity and thermal stability. Phage-displayed 3B4 CDR-mutant libraries were used in an aggressive “hammer-hug” selection strategy that incorporated thermal challenge, functional, and biophysical screening. This approach identified leads with improved stability and >18-fold, and 4,100-fold higher affinity for both human and cynomolgus CXCL13, respectively. Improvements were exclusively mediated through only 4 mutations in VL-CDR3. Lead scFvs were reformatted into scFv-Fc-scFvs and their biophysical properties ranked. Our final candidate could be formulated in a standard biopharmaceutical platform buffer at 100 mg/ml with

In a clinical trial involving asymptomatic, HIV-seropositive subjects treated with either the HIV-1 immunogen (an inactivated, gp120-depleted HIV-1 virus in incomplete Freund's adjuvant) or an adjuvant control, we examined the relationship between changes in the percentage of CD4 cells over time and early clinical markers of HIV disease progression. Subjects who had an early clinical event were more likely to have a greater decline in the percentage of CD4 cells than those subjects who did not have a clinical event (p = 0.054). The greatest decline in CD4 percentage occurred within 10 weeks prior to a clinical event (mean 11% decrease from baseline). Subjects from the quartile with the greatest decline in CD4 percentage had a fivefold greater risk of having a clinical event than subjects from the quartile with the second largest decline (p = 0.045). These results demonstrate a relationship between changes in the percentage of CD4 cells and early clinical events. Further validation of this association may be useful in clinical monitoring and in evaluating therapies to treat HIV infection.

Liquid chromatography tandem mass spectrometry (LC-MS/MS) has been shown to be a viable tool for preclinical pharmacokinetic (PK) analysis of monoclonal antibody (mAb) therapeutics. This work describes free and total PK assays for the mAb PF-00547,659 in serum of ulcerative colitis patients in a First-In-Human study [Vermeire, S. et al. Gut2011, 60 (8), 1068-1075]. The assay to measure free PF-00547,659 used immuno-enrichment with a biotinylated anti-idiotypic antibody and streptavidin magnetic beads. The total assay used enrichment by protein G magnetic beads. Following elution of PF-00547,659 from the beads, addition of an extended sequence stable isotope labeled peptide and trypsin digestion, a proteotypic peptide derived from the CDR region of the light chain of PF-00547,659 was quantified by LC-MS/MS. The free assay had a calibration range from 7.03 ng/mL to 450 ng/mL. The assay was precise and accurate with interbatch imprecision16.5%, and interbatch inaccuracy13.7% at all concentrations investigated during assay qualification. Results from LC-MS/MS methodologies are compared with historical immunoassay data originally acquired during the course of the clinical study. PK parameter estimates were highly correlated between the two analytical approaches. This work provides precedence that immunoaffinity LC-MS/MS can effectively be used to measure the serum concentrations of mAb therapeutics in clinical studies.

PURPOSE To determine the toxicity, response, and survival rate of 72-hour continuous infusion bleomycin administered to patients with AIDS-related Kaposi's sarcoma. PATIENTS AND METHODS Seventeen patients with biopsy-proven and measurable-disease AIDS-related Kaposi's sarcoma were treated with a continuous infusion of bleomycin at a dose of 20 mg/m2/d for 3 days every 3 weeks. All patients were evaluated for toxicity, response, and survival using the National Cancer Institute common toxicity criteria, and both the Eastern Cooperative Oncology Group (ECOG) and AIDS Clinical Trials Group (ACTG) response criteria. Fourteen of 17 patients (82%) enrolled had at least two on-study poor-risk factors by ACTG staging criteria. RESULTS A total of 59 cycles of therapy were administered. Only one cycle (2%) was complicated by an absolute neutrophil count less than 500, and there were no episodes of febrile neutropenia. Fifty-four percent of cycles were associated with fever during the infusion, and five cycles (8%) were complicated by grade 3 rash. There were no other clinically significant (> or = grade 3) toxicities. There were seven partial remissions (41%) by ECOG criteria (95% confidence interval, 18% to 64%) and 11 partial remissions (65%) by ACTG criteria (95% confidence interval, 42% to 88%). Three of five (60%) previously treated patients had a partial remission with this schedule of bleomycin. The median survival duration was 7 months, with a range of 2.5 to 25 months. CONCLUSION This continuous infusion schedule of bleomycin is active in patients with advanced-stage AIDS-related Kaposi's sarcoma and has acceptable toxicity. This regimen should be further evaluated in patients with earlier stage Kaposi's sarcoma and as salvage therapy.

Context: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. Purpose: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. Methods: This was a retrospective cohort study. Findings: Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P = .38) or antiretroviral therapy (96.8% vs 97.5%, P = .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to

The administration of biological protein therapeutics can lead to an unwanted immune response resulting in the generation of anti-drug antibodies (ADA) with potentially harmful clinical consequences. Hence, to develop safe and efficacious biotherapeutics, the immunogenic potential needs to be examined during the development phase. Current assay technologies measuring ADAs are subject to interference by high circulating concentrations of the protein therapeutic, raising concerns about data reliability since protein therapeutic-free washout samples are not always available. Herein, we report the development and characterization of a magnetic bead based immunoprecipitation method followed by quantitative LC/MS to determine ADA in human and cynomolgus serum in the presence of high circulating concentrations of the protein therapeutic. Available ADA binding sites are saturated by the addition of excess therapeutic followed by magnetic bead based protein G isolation of IgG antibodies and their bound antigens before elution and digestion. Peptides of the target therapeutic proteins are then quantified by LC/MS using stable isotope labeled standards inferring the presence of total ADA. This approach complements established methodologies for the assessment of immunogenicity responses and currently supports clinical programs addressing the safety and tolerability of human growth hormone analogues.

This study was designed to determine the prevalence and risk factors for anal squamous intraepithelial lesions and human papillomavirus infection in a rural population of HIV-infected males. A cross-sectional study was performed. Risk factors were collected. Anal Papanicolaou smear and human papillomavirus screening for oncogenic types were performed. Of 211 eligible male patients, 149 (70.6 percent) participated. HIV transmission risk was predominantly males who have sex with males (82 percent). The mean duration of HIV infection was 9.9 years. Ninety (60 percent) males had abnormal anal cytology, including atypical cells of unknown significance 40 (26 percent), low-grade squamous intraepithelial lesions 28 (19 percent), and high-grade squamous intraepithelial lesions 22 (15 percent). Human papillomavirus was detected in 61 percent. Binary logistic regression adjusted risks for abnormal anal cytology included: males who have sex with males (P

Introduction: infectious disease emergencies - recognition and initial management, Robert E. Levitz commonly used oral antibiotics, Thomas D. Lamarre, William Maher, and Robert Fass pharmacokinetics and dynamics, John W. Ahern the clinician andthe microbiology laboratory, Daniel J. Diekema outpatient parenteral antibiotic therapy, Donald M. Poretz. Fever and: fever and rash, Mary Beth Ramundo non-infectious and cryptic fevers, Brad E. Robinson and Christopher J. Grace blood cultures, CherylA. Smith. Clinical syndromes: Respiratory tract upper respiratory tract infections, Kemper Alston and Kristen I. Fahrner infections of the oral cavity, H. Charles Hill, Susan M. Hill, and Thomas W. Connolly pneumonia and bronchitis, John G. Bartlettand Christopher J. Grace tuberculosis, C. Fordham von Reyn common cold and influenza, Sherif B. Mossad genito-urinary tract urinary tract infections, Kevin Diekhaus gyneacologic infections, Rebecca A. Clark male urogenital syndromes, Craig S.Conover and Mark Potter cardiac endocarditis, JoAnn Tufariello and Frank Lowey skin and soft tissue bacterial infections of the skin, Jeffrey Parsonnet non-bacterial infections of the skin, Anita L. Licata ocular infections, Martin Mayers, EsseneBell, and Michael Miller Gastrointestinal infectious diarrhoea, Beth D. Kirkpatrick hepatitis, Jayant A. Talwalkar and Michael R. Charlton intra-abdominal infections, Neil H. Hyman and Christopher Grace human immunodeficiency virus the patient withHIV infection - recognition, testing and initial assessment, Ken H. Mayer and Dan Cohen evaluation of the symptomatic HIV infected patient, Janine R. Maenza bone and joint septic arthritis and bursitis, Ellis H. Tobin and Eric Brescher osteomyelitis,Keith Collins diabetic foot infections, Christopher Grace and Michael Ricci geographic exposure tick-borne infections, Robert Smith endemic fungal and viral infections, Harold M. Henderson common manifestations of parasitic infections, Sampath Kumarand Gordon M. Trenholme. Infections in special hosts: the pregnant patient, Mary-Margaret Andrews the immune compromised patient, Robert W. Lyons infections in the injection drug user, Audrey L. French infections in the dialysis patient, MichaelBerkoben infections in the patient with animal contact, Anthony L. Esposito and George Abraham the patient with fatigue, Irving E. Salit the patient with Epstein Barr virus infection and infectious mononucleosis-like illnesses, Irving E. Salit evaluation of the international traveller, Beth D. Kirkpatrick the patient living in a nursing home, Henry S. Sacks. Health maintenance: post-exposure prophylaxis, Judith L. Steinberg adult immunizations, W. Kemper Alston bioterrorism, ChristopherGrace.