Virginia Mason Bainbridge Island Medical Center

OBJECTIVES: The authors test the reliability and validity of the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) as a written, self-administered survey in outpatients with chronic schizophrenia. METHODS: Thirty-six schizophrenic outpatients completed a written and oral form of the SF-36. A psychiatrist rated the patients using the Brief Psychiatric Rating Scale to determine severity of psychopathology. Cognitive functioning and academic achievement were also assessed. Internal consistency, test-retest reliability, concurrent and discriminative validity of the oral and written versions were determined. RESULTS: The SF-36 in both forms was shown to have good internal consistency, stability, and concurrent validity. The mental health SF-36 subscales had poor discriminant validity, compared with the physical functioning scale that demonstrated good discriminant validity. CONCLUSIONS: The validity of using the written form of the SF-36 on a sample of patients with chronic mental illness was demonstrated. The SF-36 appears to be an appropriate outcome measure for changes in physical and role functioning in consumers of outpatient mental health programs.

Abstract Resource managers often need scientific information to match their decisions (typically short‐term and local) to complex, long‐term, large‐scale challenges such as adaptation to climate change. In such situations, the most reliable route to actionable science is coproduction, whereby managers, policy makers, scientists, and other stakeholders first identify specific decisions to be informed by science, and then jointly define the scope and context of the problem, research questions, methods, and outputs, make scientific inferences, and develop strategies for the appropriate use of science. Here, we present seven recommended practices intended to help scientists, managers, funders and other stakeholders carry out a coproduction project, one recommended practice to ensure that partners learn from attempts at coproduction, and two practices to promote coproduction at a programmatic level. The recommended practices focus research on decisions that need to be made, give priority to processes and outcomes over stand‐alone products, and allocate resources to organizations and individuals that engage in coproduction. Although this article focuses on the coproduction of actionable science for climate change adaptation and natural resource management, the approach is relevant to other complex natural‐human systems.

OBJECTIVE: To determine whether treatment with leflunomide (LEF), methotrexate (MTX), or sulfasalazine (SSZ) for 6-12 months retards progression of radiographic damage and to identify clinical variables that correlate with radiographic progression. METHODS: Radiographs of the hands and feet were performed at baseline and at the end of study or early exit in 3 randomized controlled trials. Protocol US301 was a 12-month controlled trial of LEF or MTX treatment compared with placebo in 482 patients randomized in a 3:3:2 ratio. Protocol MN301 compared 6 months of LEF or SSZ treatment with placebo in 358 patients, randomized in a 3:3:2 ratio, with continued blinded treatment in the active control arms for 12 months. Protocol MN302 compared 12 months of LEF treatment with MTX in 999 patients. Radiographs were blinded for sequence and treatment and were scored for erosions and joint space narrowing. All analyses were by intent-to-treat. Sensitivity analyses were performed to account for missing data. RESULTS: LEF, MTX, and SSZ treatment resulted in statistically significantly less radiographic progression compared with placebo at 6 and 12 months: for protocol US301, LEF versus placebo P = 0.0007 and MTX versus placebo P = 0.0196; for protocol MN301, LEF versus placebo P = 0.0004 and SSZ versus placebo P = 0.0484. The effect of LEF treatment was similar to that of MTX and SSZ. CONCLUSION: These are the first 6- and 12-month randomized placebo- and active drug-controlled trials to demonstrate retardation of radiographic progression by a new disease-modifying antirheumatic drug (DMARD), LEF, as well as 2 commonly used DMARDs, MTX and SSZ.

Selection of aptamers from nucleic acid libraries by in vitro evolution represents a powerful method of identifying high-affinity ligands for a broad range of molecular targets. Nevertheless, a sizeable fraction of proteins remain difficult targets due to inherently limited chemical diversity of nucleic acids. We have exploited synthetic nucleotide modifications that confer protein-like diversity on a nucleic acid scaffold, resulting in a new generation of binding reagents called SOMAmers (Slow Off-rate Modified Aptamers). Here we report a unique crystal structure of a SOMAmer bound to its target, platelet-derived growth factor B (PDGF-BB). The SOMAmer folds into a compact structure and exhibits a hydrophobic binding surface that mimics the interface between PDGF-BB and its receptor, contrasting sharply with mainly polar interactions seen in traditional protein-binding aptamers. The modified nucleotides circumvent the intrinsic diversity constraints of natural nucleic acids, thereby greatly expanding the structural vocabulary of nucleic acid ligands and considerably broadening the range of accessible protein targets.

Abstract Tumor-infiltrating myeloid cells promote tumor progression by mediating angiogenesis, tumor cell intravasation, and metastasis, which can offset the effects of chemotherapy, radiation, and antiangiogenic therapy. Here, we show that the kinase switch control inhibitor rebastinib inhibits Tie2, a tyrosine kinase receptor expressed on endothelial cells and protumoral Tie2-expressing macrophages in mouse models of metastatic cancer. Rebastinib reduces tumor growth and metastasis in an orthotopic mouse model of metastatic mammary carcinoma through reduction of Tie2+ myeloid cell infiltration, antiangiogenic effects, and blockade of tumor cell intravasation mediated by perivascular Tie2Hi/Vegf-AHi macrophages in the tumor microenvironment of metastasis (TMEM). The antitumor effects of rebastinib enhance the efficacy of microtubule inhibiting chemotherapeutic agents, either eribulin or paclitaxel, by reducing tumor volume, metastasis, and improving overall survival. Rebastinib inhibition of angiopoietin/Tie2 signaling impairs multiple pathways in tumor progression mediated by protumoral Tie2+ macrophages, including TMEM-dependent dissemination and angiopoietin/Tie2-dependent angiogenesis. Rebastinib is a promising therapy for achieving Tie2 inhibition in cancer patients. Mol Cancer Ther; 16(11); 2486–501. ©2017 AACR.

The management of rare species is a conservation priority worldwide, but this task is made difficult by detection errors in population surveys. Both false positive (misidentification) and false negative (missed detection) errors are prevalent in surveys for rare species and can affect resulting inferences about their population status or distribution. Environmental DNA (eDNA)—DNA shed from an organism in its environment—coupled with quantitative PCR (qPCR) analyses, has become a reliable and extremely sensitive mean for identifying rare species in aquatic systems. Due to the demonstrated effectiveness of these methods, we tested their efficacy in surveys for rare species in terrestrial settings to reduce detection errors for three rare forest carnivores of conservation concern: Canada lynx (Lynx canadensis), fisher (Pekania pennanti), and wolverine (Gulo gulo). We specifically investigated our ability to reliably: 1) identify species directly from snow samples collected within tracks; 2) identify species by collecting snow in locations where an animal had been photographed; and 3) identify species from hair samples collected during the summer after being deployed throughout the winter (i.e., overwinter surveys). Our findings indicated that qPCR assays can effectively detect DNA of all three species, including from snow-track surveys, snow collected at camera stations, and overwinter samples that failed to amplify with conventional PCR techniques. All results indicate that the sources of targeted DNA collection provided adequate quantities of DNA for robust species detection. We suggest that using qPCR methods to detect DNA has the potential to revolutionize winter surveys for rare species in terrestrial settings by reducing or eliminating misidentifications and missed detections.

Misfolding and degradation of CFTR is the cause of disease in patients with the most prevalent CFTR mutation, an in-frame deletion of phenylalanine (F508del), located in the first nucleotide-binding domain of human CFTR (hNBD1). Studies of (F508del)CFTR cellular folding suggest that both intra- and inter-domain folding is impaired. (F508del)CFTR is a temperature-sensitive mutant, that is, lowering growth temperature, improves both export, and plasma membrane residence times. Yet, paradoxically, F508del does not alter the fold of isolated hNBD1 nor did it seem to perturb its unfolding transition in previous isothermal chemical denaturation studies. We therefore studied the in vitro thermal unfolding of matched hNBD1 constructs ±F508del to shed light on the defective folding mechanism and the basis for the thermal instability of (F508del)CFTR. Using primarily differential scanning calorimetry (DSC) and circular dichroism, we show for all hNBD1 pairs studied, that F508del lowers the unfolding transition temperature (T(m)) by 6-7°C and that unfolding occurs via a kinetically-controlled, irreversible transition in isolated monomers. A thermal unfolding mechanism is derived from nonlinear least squares fitting of comprehensive DSC data sets. All data are consistent with a simple three-state thermal unfolding mechanism for hNBD1 ± F508del: N(±MgATP) <==> I(T)(±MgATP) → A(T) → (A(T))(n). The equilibrium unfolding to intermediate, I(T), is followed by the rate-determining, irreversible formation of a partially folded, aggregation-prone, monomeric state, A(T), for which aggregation to (A(T))(n) and further unfolding occur with no detectable heat change. Fitted parameters indicate that F508del thermodynamically destabilizes the native state, N, and accelerates the formation of A(T).

Computational fluid dynamics (CFD) is a rapidly emerging field in wastewater treatment (WWT), with application to almost all unit processes. This paper provides an overview of CFD applied to a wide range of unit processes in water and WWT from hydraulic elements like flow splitting to physical, chemical and biological processes like suspended growth nutrient removal and anaerobic digestion. The paper's focus is on articulating the state of practice and research and development needs. The level of CFD's capability varies between different process units, with a high frequency of application in the areas of final sedimentation, activated sludge basin modelling and disinfection, and greater needs in primary sedimentation and anaerobic digestion. While approaches are comprehensive, generally capable of incorporating non-Newtonian fluids, multiphase systems and biokinetics, they are not broad, and further work should be done to address the diversity of process designs. Many units have not been addressed to date. Further needs are identified throughout, but common requirements include improved particle aggregation and breakup (flocculation), and improved coupling of biology and hydraulics.

Calcineurin is important for fungal virulence and a potential antifungal target, but compounds targeting calcineurin, such as FK506, are immunosuppressive. Here we report the crystal structures of calcineurin catalytic (CnA) and regulatory (CnB) subunits complexed with FK506 and the FK506-binding protein (FKBP12) from human fungal pathogens (Aspergillus fumigatus, Candida albicans, Cryptococcus neoformans and Coccidioides immitis). Fungal calcineurin complexes are similar to the mammalian complex, but comparison of fungal and human FKBP12 (hFKBP12) reveals conformational differences in the 40s and 80s loops. NMR analysis, molecular dynamic simulations, and mutations of the A. fumigatus CnA/CnB-FK506-FKBP12-complex identify a Phe88 residue, not conserved in hFKBP12, as critical for binding and inhibition of fungal calcineurin. These differences enable us to develop a less immunosuppressive FK506 analog, APX879, with an acetohydrazine substitution of the C22-carbonyl of FK506. APX879 exhibits reduced immunosuppressive activity and retains broad-spectrum antifungal activity and efficacy in a murine model of invasive fungal infection.

We describe a novel fragment library termed fragments of life (FOL) for structure-based drug discovery. The FOL library includes natural small molecules of life, derivatives thereof, and biaryl protein architecture mimetics. The choice of fragments facilitates the interrogation of protein active sites, allosteric binding sites, and protein-protein interaction surfaces for fragment binding. We screened the FOL library against leukotriene A4 hydrolase (LTA4H) by X-ray crystallography. A diverse set of fragments including derivatives of resveratrol, nicotinamide, and indole were identified as efficient ligands for LTA4H. These fragments were elaborated in a small number of synthetic cycles into potent inhibitors of LTA4H representing multiple novel chemotypes for modulating leukotriene biosynthesis. Analysis of the fragment-bound structures also showed that the fragments comprehensively recapitulated key chemical features and binding modes of several reported LTA4H inhibitors.

BACKGROUND AND OBJECTIVE: Cryolipolysis provides a method of non-invasive fat reduction that significantly reduces subcutaneous fat without injury to adjacent tissues. Preliminary animal and human data have suggested that cryolipolysis has no effect on serum lipid profiles or liver tests. This study was intended to more fully document any effect of this procedure on lipid and liver-related blood tests. STUDY DESIGN/MATERIALS AND METHODS: Forty subjects with fat bulges on their flanks ("love handles") were treated bilaterally with a non-invasive device (Zeltiq Aesthetics, Pleasanton, CA) that precisely cools tissue to achieve a reduction in the fat layer. Serum lipid levels and liver tests were measured prior to treatment, and at 1 day and 1, 4, 8, and 12 weeks post-treatment. RESULTS: No meaningful changes in mean values were observed for any blood lipid level or liver test at any point over the 12-week follow-up period. CONCLUSION: Cryolipolysis, when used for reduction of subcutaneous flank fat, is not associated with changes in serum lipids or liver test results.

The continuing efforts in biomedical research to develop new therapies for cancer are entering an exciting new phase. Research over the past two to three decades has yielded a much more detailed understanding of the complexities of the cellular and molecular interactions involved in the generation and regulation of immune responses. We are also gaining insights into the mechanisms by which tumors evade or escape immune recognition and by which they become resistant to various existing chemotherapeutic and/or radiotherapeutic strategies. A clear conclusion that can be drawn from these studies is that effective treatments of cancer will become much more multifaceted and will include immunotherapeutic approaches. The identification and molecular cloning of genes encoding the receptors and ligands that play crucial roles in the generation and regulation of immune responses provides exciting new opportunities to induce and enhance effective endogenous immune responses to cancer. In this regard, the genes that comprise the tumor necrosis factor and tumor necrosis factor receptor superfamilies show particular promise. One receptor:ligand pair (4-1BB/CD137 and 4-1BBL/CD137L) is emerging as a target with important potential in its ability to enhance the generation of effective tumor-specific immune responses in situ. The results of the studies cited in this review highlight the potentials of 4-1BB-mediated immunotherapy.

Following the Exxon Valdez oil spill of March 24, 1989, in Prince William Sound, Alaska, Exxon conducted comprehensive, systematic shoreline surveys in cooperation with federal and state authorities to obtain information on the distribution and magnitude of shoreline oiling and to identify natural and cultural resources requiring special protection. Similar joint surveys were performed during the springs of 1990, 1991, and 1992 on all Prince William Sound and Gulf of Alaska shorelines that were suspected of having remnants of weathered oil and that would benefit from further cleanup. The extent of oiling declined substantially between 1989 and 1992: in 1989, survey teams found oil on about 16% (783 km) of the approximately 5 000 km of shoreline in Prince William Sound; in the spring of 1991, they found oil on about 96 km; and, in May 1992, on only about 10 km of shoreline in the sound. During this period, most of the oil was located in the biologically least productive upper intertidal and supratidal zones. In the springs of 1990, 1991, and 1992, isolated pockets of subsurface oil were found, chiefly in small scattered zones in coarse cobble/boulder sediments in the upper intertidal or supratidal zones. In 1991, about one-third of the subdivisions in Prince William Sound with surface oil also contained some subsurface oil. The areal extent of this subsurface oil declined by nearly 70% between 1991 and 1992, from about 37 000m2 to about 12 000m2. Moreover, where subsurface oil remained in 1992, it was present in lesser amounts. Rates of oil removal were greatest on coastal sections treated early in the spring and summer of 1989. Where shoreline treatment was delayed, the subsequent rate of removal of oil from the shore by natural processes was slower.

The AAP’s Committee on Children With Disabilities published a statement on developmental surveillance and screening.1 In doing so, they have appropriately called attention to the need for continuous developmental surveillance using procedures that are simple, valid, standardized, and reliable, as well as culturally sensitive and appropriate to the population. This recommendation could be applied as well to the surveillance of growth, which is an essential aspect health maintenance. Where the recommendations on developmental surveillance differ is in the recommendation that the procedures be “sensitive” and “specific” in the identification of “developmental delays.” Sensitivity and specificity apply to specific disease entities and not to the broad concept of general development, which encompasses skills in such diverse areas as language, motor, intellectual, social, self help, etc.2 It, therefore, is not surprising that there is no single universally agreed on definition of “developmental delay” (J. Shakelford, personal communication, April 10, 1992). Rather, developmental delay, like growth delay, is a subjective term based on many factors such as the child’s previous developmental pattern, the degree of delay, and the expectations of the parent and/or provider. In summary, screening should be valid, but sensitivity and specificity are not relevant to … Address correspondence to William K. Frankenburg, MD, MSPH, Box 10247, Bainbridge Island, WA 98110. E-mail: wkfwilliamaol.com

Targeted inhibitors to oncogenic kinases demonstrate encouraging clinical responses early in the treatment course; however, most patients will relapse because of target-dependent mechanisms that mitigate enzyme-inhibitor binding or through target-independent mechanisms, such as alternate activation of survival and proliferation pathways, known as adaptive resistance. Here, we describe mechanisms of adaptive resistance in FMS-like receptor tyrosine kinase (FLT3)-mutant acute myeloid leukemia (AML) by examining integrative in-cell kinase and gene regulatory network responses after oncogenic signaling blockade by FLT3 inhibitors (FLT3i). We identified activation of innate immune stress response pathways after treatment of FLT3-mutant AML cells with FLT3i and showed that innate immune pathway activation via the interleukin-1 receptor-associated kinase 1 and 4 (IRAK1/4) complex contributes to adaptive resistance in FLT3-mutant AML cells. To overcome this adaptive resistance mechanism, we developed a small molecule that simultaneously inhibits FLT3 and IRAK1/4 kinases. The multikinase FLT3-IRAK1/4 inhibitor eliminated adaptively resistant FLT3-mutant AML cells in vitro and in vivo and displayed superior efficacy as compared to current targeted FLT3 therapies. These findings uncover a polypharmacologic strategy for overcoming adaptive resistance to therapy in AML by targeting immune stress response pathways.

In Brief In an effort to diffuse mounting tensions between veteran and new nursing staff, consider some practical solutions to reduce horizontal violence in the workplace.

Data on the population dynamics and threats to large carnivores are vital to conservation efforts, but these are hampered by a paucity of studies. For some species, such as the leopard ( Panthera pardus ), there is such uncertainty in population trends that leopard trophy hunting has been banned in South Africa since 2016 while further data on leopard abundance are collected. We present one of the first assessments of leopard population dynamics, and identify the key threats to a population of leopards outside of protected areas in South Africa. We conducted a long-term trap survey between 2012 and 2016 in the Soutpansberg Mountains, and drew on a previous estimate of leopard population density for the region from 2008. In 24 sampling periods, we estimated the population density and assessed population structure. We fitted eight leopards with GPS collars to assess threats to the population. Leopard population density declined by 66%, from 10.73 to 3.65 leopards per 100 km 2 in 2008 and 2016, respectively. Collared leopards had a high mortality rate, which appeared to be due to illegal human activity. While improving the management of trophy hunting is important, we suggest that mitigating human–wildlife conflict could have a bigger impact on carnivore conservation.

Computational fluid dynamics (CFD) modelling in the wastewater treatment (WWT) field is continuing to grow and be used to solve increasingly complex problems. However, the future of CFD models and their value to the wastewater field are a function of their proper application and knowledge of their limits. As has been established for other types of wastewater modelling (i.e. biokinetic models), it is timely to define a good modelling practice (GMP) for wastewater CFD applications. An International Water Association (IWA) working group has been formed to investigate a variety of issues and challenges related to CFD modelling in water and WWT. This paper summarizes the recommendations for GMP of the IWA working group on CFD. The paper provides an overview of GMP and, though it is written for the wastewater application, is based on general CFD procedures. A forthcoming companion paper to provide specific details on modelling of individual wastewater components forms the next step of the working group.

Altiratinib (DCC-2701) was designed based on the rationale of engineering a single therapeutic agent able to address multiple hallmarks of cancer (1). Specifically, altiratinib inhibits not only mechanisms of tumor initiation and progression, but also drug resistance mechanisms in the tumor and microenvironment through balanced inhibition of MET, TIE2 (TEK), and VEGFR2 (KDR) kinases. This profile was achieved by optimizing binding into the switch control pocket of all three kinases, inducing type II inactive conformations. Altiratinib durably inhibits MET, both wild-type and mutated forms, in vitro and in vivo. Through its balanced inhibitory potency versus MET, TIE2, and VEGFR2, altiratinib provides an agent that inhibits three major evasive (re)vascularization and resistance pathways (HGF, ANG, and VEGF) and blocks tumor invasion and metastasis. Altiratinib exhibits properties amenable to oral administration and exhibits substantial blood-brain barrier penetration, an attribute of significance for eventual treatment of brain cancers and brain metastases.

OBJECTIVES: The purpose of this study was to explore the reasons that cancer patients with pain find it difficult to adhere to analgesic therapy. MATERIALS AND METHODS: Twenty-one patients with advanced cancer with pain were interviewed using a semistructured schedule of questions. Participants were asked to describe their decision making regarding analgesics and the factors that made it difficult for them to take analgesics prescribed for their pain. They also were asked to describe their relationships with their healthcare providers. Themes were identified and refined using qualitative analytic techniques. Two investigators independently coded all data to ensure that findings accurately reflected participants' experiences. RESULTS: Findings reveal several factors that hindered analgesic use and the specific ways in which patients evaluated these factors in making decisions about taking pain medication. The provider-patient factors that impeded analgesic use also were described. Finally, the common use of nonpharmacologic methods of pain control offers insight into the role of these therapeutic strategies in achieving pain relief and decreasing analgesic use. CONCLUSIONS: The findings underscore the importance of early intervention to address barriers to analgesic use. Some barriers may be overcome through educational efforts. The findings suggest, however, that consistent, repeated patient education often may not be sufficient to subdue patients' negative thoughts about taking the medication. Other approaches, such as changing medications or assisting the patient to use nonpharmacologic pain strategies, may prove more successful.