Defensins are small, cysteine-rich antimicrobial peptides that are abundant in human, rabbit, and guinea pig neutrophils (PMN). Three defensins (human neutrophil peptide defensin [HNP]-<em>1</em>, HNP-2, and HNP-3) constitute between 30 and 50% of the total protein in azurophil granules of human PMN. We examined the mechanism of HNP-mediated bactericidal activity against Escherichia coli <em>ML</em>-35 (i-, y-, z+) and its pBR322-transformed derivative, E. coli <em>ML</em>-35p. Under conditions that supported bactericidal activity, HNP-<em>1</em> sequentially permeabilized the outer membrane (OM) and inner membrane (IM) of E. coli. Coincident with these events, bacterial synthesis of DNA, RNA, and protein ceased and the colony count fell. Although these events were closely coupled under standard assay conditions, OM permeabilization was partially dissociated from IM permeabilization when experiments were performed with E. coli that had been plasmolyzed by mannitol. Under such conditions, the rate and extent of bacterial death more closely paralled loss of IM integrity than OM permeabilization. Electron microscopy of E. coli that had been killed by defensins revealed the presence of striking electron-dense deposits in the periplasmic space and affixed to the OM. Overall, these studies show that HNP-mediated bactericidal activity against E. coli <em>ML</em>-35 is associated with sequential permeabilization of the OM and IM, and that inner membrane permeabilization appears to be the lethal event.

OBJECTIVE

This randomized, double-masked, placebo-controlled clinical trial tested whether oral insulin administration could delay or prevent type <em>1</em> diabetes in nondiabetic relatives at risk for diabetes.

METHODS

We screened <em>1</em>03,39<em>1</em> first- and second-degree relatives of patients with type <em>1</em> diabetes and analyzed 97,273 samples for islet cell antibodies. A total of 3,483 were antibody positive; 2,523 underwent genetic, immunological, and metabolic staging to quantify risk of developing diabetes; 388 had a 5-year risk projection of 26-50%; and 372 (median age <em>1</em>0.25 years) were randomly assigned to oral insulin (7.5 mg/day) or placebo. Oral glucose tolerance tests were performed every 6 months. The median follow-up was 4.3 years, and the primary end point was diagnosis of diabetes.

RESULTS

Diabetes was diagnosed in 44 oral insulin and 53 placebo subjects. Annualized rate of diabetes was similar in both groups: 6.4% with oral insulin and 8.2% with placebo (hazard ratio 0.764, P = 0.<em>1</em>89). In a hypothesis-generating analysis of a subgroup with insulin autoantibody (IAA) levels confirmed (on two occasions)>> or =80 nU/ml (n = 263), there was the suggestion of benefit: annualized diabetes rate 6.2% with oral insulin and <em>1</em>0.4% with placebo (0.566, P = 0.0<em>1</em>5).

CONCLUSIONS

It is possible to identify individuals at high risk for type <em>1</em> diabetes and to enroll them in a large, multisite, randomized, controlled clinical trial. However, oral insulin did not delay or prevent type <em>1</em> diabetes. Further studies are needed to explore the potential role of oral insulin in delaying diabetes in relatives similar to those in the subgroup with higher IAA levels.

Two methods to generate human dendritic cells from hematopoietic precursor cells in peripheral blood have recently been published. One approach utilizes the rare CD34+ precursors and GM-CSF plus TNF-alpha. The other method makes use of the more abundant CD34- precursor population and GM-CSF plus IL-4. Here we report a method that is based on the latter approach. However, the GM-CSF and IL-4 treated cells are not stable mature dendritic cells, e.g., the characteristic morphology and nonadherence of dendritic cells is lost if the cytokines are removed. We describe the need for a monocyte-conditioned medium to generate fully mature and stable dendritic cells. This is achieved by adding a 3 day 'maturation culture' to the initial 6-7 day culture in the presence of GM-CSF and IL-4. Macrophage-conditioned medium contains the critical maturation factors. Mature dendritic cells are defined by their pronounced display of motile cytoplasmic processes ('veils'), their high capacity to induce proliferative responses in resting T cells, particularly in naive umbilical cord T cells, their down-regulated antigen processing ability, and their characteristic phenotype: expression of CD83, high levels of MHC molecules and CD86, lack of CD<em>1</em><em>1</em>5 and perinuclear dot-like CD68 staining. These features are stable for at least 3 days upon withdrawal of cytokines and conditioned media. IL-4 can be replaced by IL-<em>1</em>3. When CD34+ progenitors are depleted from blood, there is only a minor reduction in the yield of dendritic cells by this method. We have adapted the method to consider several variables that are pertinent to clinical use, including a change from fetal calf serum to human plasma and to media approved for clinical use like X-VIVO or AIM-V. <em>1</em>% plasma and RPMI <em>1</em>640 are currently optimal. Additional reagents used for cell culture (Ig. cytokines) and cell separation (immunomagnetic beads) are approved for or already used in clinical applications. For 40 <em>ml</em> blood, the yield is 0.8-3.3 x <em>1</em>0(6) mature dendritic cells as defined by the expression of the new dendritic cell-restricted marker CD83. CD83+ cells constitute between 30 and 80% of all cells recovered at the end of the culture period. Yields can be enhanced up to six-fold if the blood donors are pretreated with G-CSF. Stable, mature dendritic cells generated by this method should be a powerful tool for active immunotherapy.

BACKGROUND

Heart failure with preserved ejection fraction is associated with substantial morbidity and mortality, but effective treatments are lacking. We assessed the efficacy and safety of LCZ696, a first-in-class angiotensin receptor neprilysin inhibitor (ARNI), in patients with this disorder.

METHODS

PARAMOUNT was a phase 2, randomised, parallel-group, double-blind multicentre trial in patients with New York Heart Association (NYHA) class II-III heart failure, left ventricular ejection fraction 45% or higher, and NT-proBNP greater than 400 pg/<em>mL</em>. Participants were randomly assigned (<em>1</em>:<em>1</em>) by central interactive voice response system to LCZ696 titrated to 200 mg twice daily or valsartan titrated to <em>1</em>60 mg twice daily, and treated for 36 weeks. Investigators and participants were masked to treatment assignment. The primary endpoint was change in NT-proBNP, a marker of left ventricular wall stress, from baseline to <em>1</em>2 weeks; analysis included all patients randomly assigned to treatment groups who had a baseline and at least one postbaseline assessment. This trial is registered at Clinicaltrials.gov, number NCT00887588.

RESULTS

<em>1</em>49 patients were randomly assigned to LCZ696 and <em>1</em>52 to valsartan; <em>1</em>34 in the LCZ696 group and <em>1</em>32 in the valsartan group were included in analysis of the primary endpoint. NT-proBNP was significantly reduced at <em>1</em>2 weeks in the LCZ696 group compared with the valsartan group (LCZ696: baseline, 783 pg/<em>mL</em> [95% CI 670-9<em>1</em>4], <em>1</em>2 weeks, 605 pg/<em>mL</em> [5<em>1</em>2-7<em>1</em>4]; valsartan: baseline, 862 pg/<em>mL</em> [733-<em>1</em>0<em>1</em>2], <em>1</em>2 weeks, 835 [7<em>1</em>0-98<em>1</em>]; ratio LCZ696/valsartan, 0·77, 95% CI 0·64-0·92, p=0·005). LCZ696 was well tolerated with adverse effects similar to those of valsartan; 22 patients (<em>1</em>5%) on LCZ696 and 30 (20%) on valsartan had one or more serious adverse event.

CONCLUSIONS

In patients with heart failure with preserved ejection fraction, LCZ696 reduced NT-proBNP to a greater extent than did valsartan at <em>1</em>2 weeks and was well tolerated. Whether these effects would translate into improved outcomes needs to be tested prospectively.

BACKGROUND

Novartis.

OBJECTIVE

The aim of this randomized multicenter trial was to assess the rate of symptomatic anastomotic leakage in patients operated on with low anterior resection for rectal cancer and who were intraoperatively randomized to a defunctioning stoma or not.

BACKGROUND

The introduction of total mesorectal excision surgery as the surgical technique of choice for carcinoma in the lower and mid rectum has led to decreased local recurrence and improved oncological results. Despite these advances, perioperative morbidity remains a major issue, and the most feared complication is symptomatic anastomotic leakage. The role of the defunctioning stoma in regard to anastomotic leakage is controversial and has not been assessed in any randomized trial of sufficient size.

METHODS

From December <em>1</em>999 to June 2005, a total of 234 patients were randomized to a defunctioning loop stoma or no loop stoma. Loop ileostomy or loop transverse colostomy was at the choice of the surgeon. Inclusion criteria for randomization were expected survival >6 months, informed consent, anastomosis < or =7 cm above the anal verge, negative air leakage test, intact anastomotic rings, and absence of major intraoperative adverse events.

RESULTS

The overall rate of symptomatic leakage was <em>1</em>9.2% (45 of 234). Patients randomized to a defunctioning stoma (n = <em>1</em><em>1</em>6) had leakage in <em>1</em>0.3% (<em>1</em>2 of <em>1</em><em>1</em>6) and those without stoma (n = <em>1</em><em>1</em>8) in 28.0% (33 of <em>1</em><em>1</em>8) (odds ratio = 3.4; 95% confidence interval, <em>1</em>.6-6.9; P < 0.00<em>1</em>). The need for urgent abdominal reoperation was 8.6% (<em>1</em>0 of <em>1</em><em>1</em>6) in those randomized to stoma and 25.4% (30 of <em>1</em><em>1</em>8) in those without (P < 0.00<em>1</em>). After a follow-up of median 42 months (range, 6-72 months), <em>1</em>3.8% (<em>1</em>6 of <em>1</em><em>1</em>6) of the initially defunctioned patients still had a stoma of any kind, compared with <em>1</em>6.9% (20 of <em>1</em><em>1</em>8) those not defunctioned (not significant). The 30-day mortality after anterior resection was 0.4% (<em>1</em> of 234) and after elective reversal a defunctioning stoma 0.9% (<em>1</em> of <em>1</em><em>1</em><em>1</em>). Median age was 68 years (range, 32-86 years), 45.3% (<em>1</em>06 of 234) were females, 79.<em>1</em>% (<em>1</em>85 of 234) had preoperative radiotherapy, the level of anastomosis was median 5 cm, and intraoperative blood loss 550 <em>mL</em>, without differences between the groups.

CONCLUSIONS

Defunctioning loop stoma decreased the rate of symptomatic anastomotic leakage and is therefore recommended in low anterior resection for rectal cancer.

One year of treatment with entecavir (0.5 mg daily) in nucleoside-naive patients with hepatitis B e antigen (HBeAg)-positive or HBeAg-negative chronic hepatitis B (CHB) resulted in significantly improved liver histology and virological and biochemical endpoints in comparison with lamivudine. Patients who received at least 3 years of cumulative entecavir therapy in phase 3 studies and a long-term rollover study and underwent long-term liver biopsy were evaluated for improvements in histological appearance. Sixty-nine patients [50 HBeAg-positive and <em>1</em>9 HBeAg-negative] receiving entecavir therapy underwent long-term liver biopsy (median time of biopsy = 6 years, range = 3-7 years). Histological improvement was analyzed for 57 patients who had adequate baseline biopsy samples, baseline Knodell necroinflammatory scores>> or =2, and adequate long-term biopsy samples. At the time of long-term biopsy, all patients in the cohort had a hepatitis B virus DNA level <300 copies/<em>mL</em>, and 86% had a normalized alanine aminotransferase level. Histological improvement >> or =2-point decrease in the Knodell necroinflammatory score and no worsening of the Knodell fibrosis score) was observed in 96% of patients, and a>> or =<em>1</em>-point improvement in the Ishak fibrosis score was found in 88% of patients, including all <em>1</em>0 patients with advanced fibrosis or cirrhosis at the phase 3 baseline.

CONCLUSIONS

The majority of nucleoside-naive patients with CHB who were treated with entecavir in this long-term cohort achieved substantial histological improvement and regression of fibrosis or cirrhosis.

Thalidomide selectively inhibits the production of human monocyte tumor necrosis factor alpha (TNF-alpha) when these cells are triggered with lipopolysaccharide and other agonists in culture. 40% inhibition occurs at the clinically achievable dose of the drug of <em>1</em> micrograms/<em>ml</em>. In contrast, the amount of total protein and individual proteins labeled with [35S]methionine and expressed on SDS-PAGE are not influenced. The amounts of interleukin <em>1</em> beta (IL-<em>1</em> beta), IL-6, and granulocyte/macrophage colony-stimulating factor produced by monocytes remain unaltered. The selectivity of this drug may be useful in determining the role of TNF-alpha in vivo and modulating its toxic effects in a clinical setting.

BACKGROUND

We aimed to examine whether stereotactic radiosurgery without whole-brain radiotherapy (WBRT) as the initial treatment for patients with five to ten brain metastases is non-inferior to that for patients with two to four brain metastases in terms of overall survival.

METHODS

This prospective observational study enrolled patients with one to ten newly diagnosed brain metastases (largest tumour (<em>1</em>0 <em>mL</em> in volume and <3 cm in longest diameter; total cumulative volume ≤<em>1</em>5 <em>mL</em>) and a Karnofsky performance status score of 70 or higher from 23 facilities in Japan. Standard stereotactic radiosurgery procedures were used in all patients; tumour volumes smaller than 4 <em>mL</em> were irradiated with 22 Gy at the lesion periphery and those that were 4-<em>1</em>0 <em>mL</em> with 20 Gy. The primary endpoint was overall survival, for which the non-inferiority margin for the comparison of outcomes in patients with two to four brain metastases with those of patients with five to ten brain metastases was set as the value of the upper 95% CI for a hazard ratio (HR) of <em>1</em>·30, and all data were analysed by intention to treat. The study was finalised on Dec 3<em>1</em>, 20<em>1</em>2, for analysis of the primary endpoint; however, monitoring of stereotactic radiosurgery-induced complications and neurocognitive function assessment will continue for the censored subset until the end of 20<em>1</em>4. This study is registered with the University Medical Information Network Clinical Trial Registry, number 00000<em>1</em>8<em>1</em>2.

RESULTS

We enrolled <em>1</em><em>1</em>94 eligible patients between March <em>1</em>, 2009, and Feb <em>1</em>5, 20<em>1</em>2. Median overall survival after stereotactic radiosurgery was <em>1</em>3·9 months [95% CI <em>1</em>2·0-<em>1</em>5·6] in the 455 patients with one tumour, <em>1</em>0·8 months [9·4-<em>1</em>2·4] in the 53<em>1</em> patients with two to four tumours, and <em>1</em>0·8 months [9·<em>1</em>-<em>1</em>2·7] in the 208 patients with five to ten tumours. Overall survival did not differ between the patients with two to four tumours and those with five to ten (HR 0·97, 95% CI 0·8<em>1</em>-<em>1</em>·<em>1</em>8 [less than non-inferiority margin], p=0·78; pnon-inferiority<0·000<em>1</em>). Stereotactic radiosurgery-induced adverse events occurred in <em>1</em>0<em>1</em> (8%) patients; nine (2%) patients with one tumour had one or more grade 3-4 event compared with <em>1</em>3 (2%) patients with two to four tumours and six (3%) patients with five to ten tumours. The proportion of patients who had one or more treatment-related adverse event of any grade did not differ significantly between the two groups of patients with multiple tumours (50 [9%] patients with two to four tumours vs <em>1</em>8 [9%] with five to ten; p=0·89). Four patients died, mainly of complications relating to stereotactic radiosurgery (two with one tumour and one each in the other two groups).

CONCLUSIONS

Our results suggest that stereotactic radiosurgery without WBRT in patients with five to ten brain metastases is non-inferior to that in patients with two to four brain metastases. Considering the minimal invasiveness of stereotactic radiosurgery and the fewer side-effects than with WBRT, stereotactic radiosurgery might be a suitable alternative for patients with up to ten brain metastases.

BACKGROUND

Japan Brain Foundation.

Human neutrophils were isolated from peripheral blood by four methods: <em>1</em>) Ficoll-Hypaque gradients and erythrocyte lysis, 2) plasma-Percoll gradients, 3) a "lipopolysaccharide (LPS)-free" method yielding 85% neutrophils, and 4) by centrifugation of cells prepared by Method 3 through a plasma-Percoll gradient to produce pure neutrophils. The use of the Ficoll-Hypaque method resulted in spontaneous change of cell shape, enhanced formyl-methionyl-leucyl-phenylalanine (FMLP)-stimulated release of superoxide anion, increased release of lysosomal enzymes upon subsequent FMLP stimulation, and reduced chemotactic responsiveness, by comparison with the other methods. These effects were not due to erythrocyte lysis by NH4C<em>1</em> but were reproduced by exposure of neutrophils prepared by the "LPS-free" method or the use of plasma-Percoll gradients to <em>1</em>0-<em>1</em>00 ng/<em>ml</em> LPS. Neutrophil change of shape and stimulated O-2 production were particularly sensitive markers of these effects. The effects of trace concentrations of LPS in the modulation of neutrophil function may have relevance to the pathophysiology of endotoxemia and its resultant tissue injury.

The respective volumes of hepatic tumors and nontumorous parenchyma of 50 patients requiring hepatectomy of more than one segment of Healey for tumor removal were measured using computed tomography (Vol-CT). The volume estimated by Vol-CT was found to correlate with the real weight resected (P < .000<em>1</em>) with a mean absolute error of 64.9 <em>mL</em>. The ratio of the nontumorous parenchymal volume of the resected liver to that of the whole liver (R2) in <em>1</em>5 patients who underwent right or extended right hepatic lobectomy was 43% +/- <em>1</em>5%. Eight of <em>1</em>5 patients with R2s < 60% underwent the procedures without right portal vein embolization (PE). The other seven with R2s exceeding 60% or an indocyanine green retention rate after <em>1</em>5 minutes (ICG<em>1</em>5) of <em>1</em>0% to 20% underwent PE: in six of seven, the nontumorous parenchyma of the right hepatic lobe became atrophic and in all seven, the volume of the remaining left hepatic lobe increased with a decrease in the mean R2 from 62% +/- <em>1</em>4% to 55% +/- 8% (P = .0006). In the remaining 35 who underwent other hepatectomy procedures, R2s also remained <60%. Overall, at surgery, in 27 with normal liver function (ICG<em>1</em>5 < <em>1</em>0%), R2s exceeded 60% in one, remained at 50% to 60% in five, and <50% in 2<em>1</em>, whereas 23 patients except for one with an ICG<em>1</em>5 exceeding <em>1</em>0%, had R2s of <50%. The postoperative serum total bilirubin levels in 84% of the patients remained within the normal range and there was no surgery-related mortality. In conclusion, <em>1</em>) Vol-CT can accurately assess the extent of liver resection, 2) individuals with normal liver function can undergo resection of up to 60% of the nontumorous parenchyma without the need for PE, and 3) PE can be used to reduce the size of the resected tissue and increase the volume of the remnant liver to approximate the target limits in individuals with large tumors or minimally abnormal liver function.

GLP-<em>1</em> stimulates insulin secretion, suppresses glucagon secretion, delays gastric emptying, and inhibits small bowel motility, all actions contributing to the anti-diabetogenic peptide effect. Endothelial dysfunction is strongly associated with insulin resistance and type 2 diabetes mellitus and may cause the angiopathy typifying this debilitating disease. Therefore, interventions affecting both endothelial dysfunction and insulin resistance may prove useful in improving survival in type 2 diabetes patients. We investigated GLP-<em>1</em>'s effect on endothelial function and insulin sensitivity (S(I)) in two groups: <em>1</em>) <em>1</em>2 type 2 diabetes patients with stable coronary artery disease and 2) <em>1</em>0 healthy subjects with normal endothelial function and S(I). Subjects underwent infusion of recombinant GLP-<em>1</em> or saline in a random crossover study. Endothelial function was measured by postischemic FMD of brachial artery, using ultrasonography. S(I) [in (<em>1</em>0(-4) dl.kg(-<em>1</em>).min(-<em>1</em>))/(muU/<em>ml</em>)] was measured by hyperinsulinemic isoglycemic clamp technique. In type 2 diabetic subjects, GLP-<em>1</em> infusion significantly increased relative changes in brachial artery diameter from baseline FMD(%) (3.<em>1</em> +/- 0.6 vs. 6.6 +/- <em>1</em>.0%, P < 0.05), with no significant effects on S(I) (4.5 +/- 0.8 vs. 5.2 +/- 0.9, P = NS). In healthy subjects, GLP-<em>1</em> infusion affected neither FMD(%) (<em>1</em><em>1</em>.9 +/- 0.9 vs. <em>1</em>0.3 +/- <em>1</em>.0%, P = NS) nor S(I) (<em>1</em>4.8 +/- <em>1</em>.8 vs. <em>1</em><em>1</em>.6 +/- 2.0, P = NS). We conclude that GLP-<em>1</em> improves endothelial dysfunction but not insulin resistance in type 2 diabetic patients with coronary heart disease. This beneficial vascular effect of GLP-<em>1</em> adds yet another salutary property of the peptide useful in diabetes treatment.

OBJECTIVE

The present study compared the effects of aerobic endurance training at different intensities and with different methods matched for total work and frequency. Responses in maximal oxygen uptake (VO2max), stroke volume of the heart (SV), blood volume, lactate threshold (LT), and running economy (CR) were examined.

METHODS

Forty healthy, nonsmoking, moderately trained male subjects were randomly assigned to one of four groups:<em>1</em>) long slow distance (70% maximal heart rate; HRmax); 2)lactate threshold (85% HRmax); 3) <em>1</em>5/<em>1</em>5 interval running (<em>1</em>5 s of running at 90-95% HRmax followed by <em>1</em>5 s of active resting at 70% HRmax); and 4) 4 x 4 min of interval running (4 min of running at 90-95% HRmax followed by 3 min of active resting at 70%HRmax). All four training protocols resulted in similar total oxygen consumption and were performed 3 d.wk for 8 wk.

RESULTS

High-intensity aerobic interval training resulted in significantly increased VO2max compared with long slow distance and lactate-threshold training intensities (P<0.0<em>1</em>). The percentage increases for the <em>1</em>5/<em>1</em>5 and 4 x 4 min groups were 5.5 and 7.2%, respectively, reflecting increases in V O2max from 60.5 to 64.4 mL x kg(-<em>1</em>) x min(-<em>1</em>) and 55.5 to 60.4 mL x kg(-<em>1</em>) x min(-<em>1</em>). SV increased significantly by approximately <em>1</em>0% after interval training (P<0.05).

CONCLUSIONS

: High-aerobic intensity endurance interval training is significantly more effective than performing the same total work at either lactate threshold or at 70% HRmax, in improving VO2max. The changes in VO2max correspond with changes in SV, indicating a close link between the two.

BACKGROUND

Long-term studies of the outcome of very prematurely born infants have clearly documented that the majority of such infants have significant motor, cognitive, and behavioral deficits. However, there is a limited understanding of the nature of the cerebral abnormality underlying these adverse neurologic outcomes.

OBJECTIVE

The overall aim of this study was to define quantitatively the alterations in cerebral tissue volumes at term equivalent in a large longitudinal cohort study of very low birth weight premature infants in comparison to term-born infants by using advanced volumetric 3-dimensional magnetic resonance imaging (MRI) techniques. We also aimed to define any relationship of such perinatal lesions as white matter (WM) injury or other potentially adverse factors to the quantitative structural alterations. Additionally, we wished to identify the relationship of the structural alterations to short-term neurodevelopmental outcome.

METHODS

From November <em>1</em>998 to December 2000, <em>1</em><em>1</em>9 consecutive premature infants admitted to the neonatal intensive care units at Christchurch Women's Hospital (Christchurch, New Zealand) and the Royal Women's Hospital (Melbourne, Australia) were recruited (88% of eligible) after informed parental consent to undergo an MRI scan at term equivalent. Twenty-one term-born infants across both sites were recruited also. Postacquisition advanced 3-dimensional tissue segmentation with 3-dimensional reconstruction was undertaken to estimate volumes of cerebral tissues: gray matter (GM; cortical and deep nuclear structures), WM (myelinated and unmyelinated), and cerebrospinal fluid (CSF).

RESULTS

In comparison to the term-born infants, the premature infants at term demonstrated prominent reductions in cerebral cortical GM volume (premature infants [mean +/- SD]: <em>1</em>78 +/- 4<em>1</em> <em>mL</em>; term infants: 227 +/- 26 <em>mL</em>) and in deep nuclear GM volume (premature infants: <em>1</em>0.8 +/- 4.<em>1</em> <em>mL</em>; term infants: <em>1</em>3.8 +/- 5.2 <em>mL</em>) and an increase in CSF volume (premature infants: 45.6 +/- 22.<em>1</em> <em>mL</em>; term infants: 28.9 +/- <em>1</em>6 <em>mL</em>). The major predictors of altered cerebral volumes were gestational age at birth and the presence of cerebral WM injury. Infants with significantly reduced cortical GM and deep nuclear GM volumes and increased CSF volume volumes exhibited moderate to severe neurodevelopmental disability at <em>1</em> year of age.

CONCLUSIONS

This MRI study of prematurely born infants further defines the nature of quantitative cerebral structural abnormalities present as early as term equivalent. The abnormalities particularly involve cerebral neuronal regions including both cortex and deep nuclear structures. The pattern of cerebral alterations is related most significantly to the degree of immaturity at birth and to concomitant WM injury. The alterations are followed by abnormal short-term neurodevelopmental outcome.

Belatacept, a costimulation blocker, may preserve renal function and improve long-term outcomes versus calcineurin inhibitors in kidney transplantation. This Phase III study (Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial) assessed a more intensive (MI) or less intensive (LI) regimen of belatacept versus cyclosporine in adults receiving a kidney transplant from living or standard criteria deceased donors. The co-primary endpoints at <em>1</em>2 months were patient/graft survival, a composite renal impairment endpoint (percent with a measured glomerular filtration rate (mGFR) <60 <em>mL</em>/min/<em>1</em>.73 m(2) at Month <em>1</em>2 or a decrease in mGFR>> or =<em>1</em>0 <em>mL</em>/min/<em>1</em>.73 m(2) Month 3-Month <em>1</em>2) and the incidence of acute rejection. At Month <em>1</em>2, both belatacept regimens had similar patient/graft survival versus cyclosporine (MI: 95%, LI: 97% and cyclosporine: 93%), and were associated with superior renal function as measured by the composite renal impairment endpoint (MI: 55%; LI: 54% and cyclosporine: 78%; p < or = 0.00<em>1</em> MI or LI versus cyclosporine) and by the mGFR (65, 63 and 50 <em>mL</em>/min for MI, LI and cyclosporine; p < or = 0.00<em>1</em> MI or LI versus cyclosporine). Belatacept patients experienced a higher incidence (MI: 22%, LI: <em>1</em>7% and cyclosporine: 7%) and grade of acute rejection episodes. Safety was generally similar between groups, but posttransplant lymphoproliferative disorder was more common in the belatacept groups. Belatacept was associated with superior renal function and similar patient/graft survival versus cyclosporine at <em>1</em> year posttransplant, despite a higher rate of early acute rejection.

OBJECTIVE

The objective of this study was to determine the frequency and clinical significance of a systemic inflammatory response as defined by an elevated plasma interleukin-6 concentration in fetuses with preterm labor or preterm premature rupture of membranes.

METHODS

Amniocenteses and cordocenteses were performed in <em>1</em>57 patients with preterm labor and preterm premature rupture of membranes. Written informed consent and multi-institutional review board approvals were obtained. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as mycoplasmas. Amniotic fluid and fetal plasma interleukin-6 concentrations were measured with a sensitive and specific immunoassay. Statistical analyses included contingency tables, receiver operating characteristic curve analysis, and multiple logistic regression.

RESULTS

One hundred five patients with preterm labor and 52 patients with preterm premature rupture of membranes were included in this study. The overall prevalence of severe neonatal morbidity (defined as the presence of respiratory distress syndrome, suspected or proved neonatal sepsis, pneumonia, bronchopulmonary dysplasia. intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis) among survivors was 34.8% (54/<em>1</em>55). Neonates in whom severe neonatal morbidity developed had higher concentrations of fetal plasma interleukin-6 than fetuses without development of severe neonatal morbidity (median <em>1</em>4.0 pg/<em>mL</em>, range 0.5 to 900 vs median 5.2 pg/<em>mL</em>, range 0.3 to 900, respectively; P < .005). Multivariate analysis was performed to explore the relationship between the presence of a systemic fetal inflammatory response and subsequent neonatal outcome. To preserve a meaningful temporal relationship between the results of fetal plasma interleukin-6 concentrations and the occurrence of severe neonatal morbidity, the analysis was restricted to 73 fetuses delivered within 7 days of cordocentesis who survived. The prevalence of severe neonatal morbidity in this subset of patients was 53.4% (39/73). A fetal plasma interleukin-6 cutoff value of <em>1</em><em>1</em> pg/<em>mL</em> was used to define the presence of a systemic inflammatory response. The prevalence of a fetal plasma interleukin-6 level>> <em>1</em><em>1</em> pg/<em>mL</em> was 49.3% (36/73). Fetuses with fetal plasma interleukin-6 concentrations>> <em>1</em><em>1</em> pg/<em>mL</em> had a higher rate of severe neonatal morbidity than did those with fetal plasma interleukin-6 levels < or = <em>1</em><em>1</em> pg/<em>mL</em> (77.8% [28/36] vs 29.7% [<em>1</em><em>1</em>/37], respectively; P < .00<em>1</em>). Stepwise logistic regression analysis demonstrated that the fetal plasma interleukin-6 concentration was an independent predictor of the occurrence of severe neonatal morbidity (odds ratio 4.3, 95% confidence interval <em>1</em> to <em>1</em>8.5) when adjusted for gestational age at delivery, the cause of preterm delivery (preterm labor or preterm premature rupture of membranes), clinical chorioamnionitis, the cordocentesis-to-delivery interval, amniotic fluid culture, and amniotic fluid interleukin-6 results.

CONCLUSIONS

A systemic fetal inflammatory response, as determined by an elevated fetal plasma interleukin-6 value, is an independent risk factor for the occurrence of severe neonatal morbidity.

Coronavirus disease 20<em>1</em>9 (COVID-<em>1</em>9) is a newly emerging human infectious disease caused by acute respiratory syndrome coronavirus 2 (SARS-CoV-2, previously called 20<em>1</em>9-nCoV). Based on the rapid increase in the rate of human infection, the World Health Organization (WHO) has classified the COVID-<em>1</em>9 outbreak as a pandemic. Because no specific drugs or vaccines for COVID-<em>1</em>9 are yet available, early diagnosis and management are crucial for containing the outbreak. Here, we report a field-effect transistor (FET)-based biosensing device for detecting SARS-CoV-2 in clinical samples. The sensor was produced by coating graphene sheets of FET with a specific antibody against SARS-CoV-2 spike protein. The performance of the sensor was determined using antigen protein, cultured virus, and nasopharyngeal swab specimens from COVID-<em>1</em>9 patients. Our FET device could detect SARS-CoV-2 spike protein at concentrations of <em>1</em> fg/<em>ml</em> in PBS and <em>1</em>00 fg/<em>ml</em> clinical transport medium. In addition, the FET sensor successfully detected SARS-CoV-2 in culture medium (limit of detection [LOD]: <em>1</em>.6 x <em>1</em>0^<em>1</em> pfu/<em>ml</em>) and clinical samples (LOD: 2.42 x <em>1</em>0² copies/<em>ml</em>). Thus, we have successfully fabricated a promising FET biosensor for SARS-CoV-2; our device is a highly sensitive immunological diagnostic method for COVID-<em>1</em>9 that requires no sample pretreatment or labeling.

BACKGROUND

Guidelines for antiretroviral therapy are important for clinicians worldwide given the complexity of the field and the varied clinical situations in which these agents are used. The International AIDS Society-USA panel has updated its recommendations as warranted by new developments in the field.

OBJECTIVE

To provide physicians and other human immunodeficiency virus (HIV) clinicians with current recommendations for the use of antiretroviral therapy in HIV-infected adults in circumstances for which there is relatively unrestricted access to drugs and monitoring tools. The recommendations are centered on 4 key issues: when to start antiretroviral therapy; what to start; when to change; and what to change. Antiretroviral therapy in special circumstances is also described.

METHODS

A <em>1</em>6-member noncompensated panel was appointed, based on expertise in HIV research and patient care internationally. Data published or presented at selected scientific conferences from mid 2004 through May 2006 were identified and reviewed by all members of the panel.

METHODS

Data that might change previous guidelines were identified and reviewed. New guidelines were drafted by a writing committee and reviewed by the entire panel.

CONCLUSIONS

Antiretroviral therapy in adults continues to evolve rapidly, making delivery of state-of-the-art care challenging. Initiation of therapy continues to be recommended in all symptomatic persons and in asymptomatic persons after the CD4 cell count falls below 350/microL and before it declines to 200/microL. A nonnucleoside reverse transcriptase inhibitor or a protease inhibitor boosted with low-dose ritonavir each combined with 2 nucleoside (or nucleotide) reverse transcriptase inhibitors is recommended with choice being based on the individual patient profile. Therapy should be changed when toxicity or intolerance mandate it or when treatment failure is documented. The virologic target for patients with treatment failure is now a plasma HIV-<em>1</em> RNA level below 50 copies/<em>mL</em>. Adherence to antiretroviral therapy in the short-term and the long-term is crucial for treatment success and must be continually reinforced.

BACKGROUND

Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion.

METHODS

This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients.

RESULTS

Patients who underwent LSG (n=<em>1</em>0) showed a significant decrease of plasma ghrelin at day <em>1</em> compared to preoperative values (35.8 +/- <em>1</em>2.3 fmol/<em>ml</em> vs <em>1</em>09.6 +/- 32.6 fmol/<em>ml</em>, P=0.005). Plasma ghrelin remained low and stable at <em>1</em> and 6 months postoperatively. In contrast, no change of plasma ghrelin at day <em>1</em> (7<em>1</em>.8 +/- 35.3 fmol/<em>ml</em> vs 73.7 +/- 24.8 fmol/<em>ml</em>, P=0.44<em>1</em>) was found in patients after LAGB (n=<em>1</em>0). Increased plasma ghrelin levels compared with the preoperative levels at <em>1</em> (<em>1</em>0<em>1</em>.9 +/- 30.3 fmol/<em>ml</em> vs 73.7 +/- 24.8 fmol/<em>ml</em>, P=0.028) and 6 months (<em>1</em>04.9 +/- 5<em>1</em>.<em>1</em> fmol/<em>ml</em> vs 73.7 +/- 24.8 fmol/<em>ml</em>, P=0.0<em>1</em>2) after surgery were observed. Mean excess weight loss was higher in the LSG group at <em>1</em> (30 +/- <em>1</em>3% vs <em>1</em>7 +/- 7%, P=0.005) and 6 months (6<em>1</em> +/- <em>1</em>6% vs 29 +/- <em>1</em><em>1</em>%, P=0.00<em>1</em>) compared with the LAGB group.

CONCLUSIONS

As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.

OBJECTIVE

Chiari malformations are regarded as a pathological continuum of hindbrain maldevelopments characterized by downward herniation of the cerebellar tonsils. The Chiari I malformation (CMI) is defined as tonsillar herniation of at least 3 to 5 mm below the foramen magnum. Increased detection of CMI has emphasized the need for more information regarding the clinical features of the disorder.

METHODS

We examined a prospective cohort of 364 symptomatic patients. All patients underwent magnetic resonance imaging of the head and spine, and some were evaluated using CINE-magnetic resonance imaging and other neurodiagnostic tests. For 50 patients and 50 age- and gender-matched control subjects, the volume of the posterior cranial fossa was calculated by the Cavalieri method. The families of 2<em>1</em> patients participated in a study of familial aggregation.

RESULTS

There were 275 female and 89 male patients. The age of onset was 24.9+/-<em>1</em>5.8 years (mean +/- standard deviation), and 89 patients (24%) cited trauma as the precipitating event. Common associated problems included syringomyelia (65%), scoliosis (42%), and basilar invagination (<em>1</em>2%). Forty-three patients (<em>1</em>2%) reported positive family histories of CMI or syringomyelia. Pedigrees for 2<em>1</em> families showed patterns consistent with autosomal dominant or recessive inheritance. The clinical syndrome of CMI was found to consist of the following: <em>1</em>) headaches, 2) pseudotumor-like episodes, 3) a Meniere's disease-like syndrome, 4) lower cranial nerve signs, and 5) spinal cord disturbances in the absence of syringomyelia. The most consistent magnetic resonance imaging findings were obliteration of the retrocerebellar cerebrospinal fluid spaces (364 patients), tonsillar herniation of at least 5 mm (332 patients), and varying degrees of cranial base dysplasia. Volumetric calculations for the posterior cranial fossa revealed a significant reduction of total volume (mean, <em>1</em>3.4 <em>ml</em>) and a 40% reduction of cerebrospinal fluid volume (mean, <em>1</em>0.8 <em>ml</em>), with normal brain volume.

CONCLUSIONS

These data support accumulating evidence that CMI is a disorder of the para-axial mesoderm that is characterized by underdevelopment of the posterior cranial fossa and overcrowding of the normally developed hindbrain. Tonsillar herniation of less than 5 mm does not exclude the diagnosis. Clinical manifestations of CMI seem to be related to cerebrospinal fluid disturbances (which are responsible for headaches, pseudotumor-like episodes, endolymphatic hydrops, syringomyelia, and hydrocephalus) and direct compression of nervous tissue. The demonstration of familial aggregation suggests a genetic component of transmission.

BACKGROUND

Chronic kidney disease is characterised by low estimated glomerular filtration rate (eGFR) and high albuminuria, and is associated with adverse outcomes. Whether these risks are modified by diabetes is unknown.

METHODS

We did a meta-analysis of studies selected according to Chronic Kidney Disease Prognosis Consortium criteria. Data transfer and analyses were done between March, 20<em>1</em><em>1</em>, and June, 20<em>1</em>2. We used Cox proportional hazards models to estimate the hazard ratios (HR) of mortality and end-stage renal disease (ESRD) associated with eGFR and albuminuria in individuals with and without diabetes.

RESULTS

We analysed data for <em>1</em>,024,977 participants (<em>1</em>28,505 with diabetes) from 30 general population and high-risk cardiovascular cohorts and <em>1</em>3 chronic kidney disease cohorts. In the combined general population and high-risk cohorts with data for all-cause mortality, 75,306 deaths occurred during a mean follow-up of 8·5 years (SD 5·0). In the 23 studies with data for cardiovascular mortality, 2<em>1</em>,237 deaths occurred from cardiovascular disease during a mean follow-up of 9·2 years (SD 4·9). In the general and high-risk cohorts, mortality risks were <em>1</em>·2-<em>1</em>·9 times higher for participants with diabetes than for those without diabetes across the ranges of eGFR and albumin-to-creatinine ratio (ACR). With fixed eGFR and ACR reference points in the diabetes and no diabetes groups, HR of mortality outcomes according to lower eGFR and higher ACR were much the same in participants with and without diabetes (eg, for all-cause mortality at eGFR 45 <em>mL</em>/min per <em>1</em>·73 m(2) [vs 95 <em>mL</em>/min per <em>1</em>·73 m(2)], HR <em>1</em>·35; 95% CI <em>1</em>·<em>1</em>8-<em>1</em>·55; vs <em>1</em>·33; <em>1</em>·<em>1</em>9-<em>1</em>·48 and at ACR 30 mg/g [vs 5 mg/g], <em>1</em>·50; <em>1</em>·35-<em>1</em>·65 vs <em>1</em>·52; <em>1</em>·38-<em>1</em>·67). The overall interactions were not significant. We identified much the same findings for ESRD in the chronic kidney disease cohorts.

CONCLUSIONS

Despite higher risks for mortality and ESRD in diabetes, the relative risks of these outcomes by eGFR and ACR are much the same irrespective of the presence or absence of diabetes, emphasising the importance of kidney disease as a predictor of clinical outcomes.

BACKGROUND

US National Kidney Foundation.

We have shown previously that dendritic cells (DC) produce IL-<em>1</em>2 upon interaction with CD4+ T cells. Here we ask how this IL-<em>1</em>2 production is induced and regulated. Quantitative PCR and in situ hybridization for IL-<em>1</em>2 p40 and an ELISA specific for the p70 heterodimer were used to determine IL-<em>1</em>2 production. We demonstrate that ligation of either CD40 or MHC class II molecules independently trigger IL-<em>1</em>2 production in DC, and that IL-<em>1</em>2 production is downregulated by IL-4 and IL-<em>1</em>0. The levels of bioactive IL-<em>1</em>2 that can be released by triggering with an anti-CD40 mAb or with a T cell hybridoma are high (range 260-4700 pg/<em>ml</em> from <em>1</em> X <em>1</em>0(6) DC in 72 h). The CD40-mediated pathway indicates that IL-<em>1</em>2 production is induced in DC upon interaction with activated, CD40 ligand-expressing helper T cells, even in the absence of cognate antigen recognition. Side-by-side comparison of IL-<em>1</em>2 production, and blocking experiments employing an anti-CD40 ligand mAb, suggest that the CD40-mediated pathway is quantitatively more significant than induction via the MHC class II molecule. The importance of the CD40/CD40 ligand interaction for IL-<em>1</em>2 induction in DC likely contributes to the recent finding that mice lacking the CD40 ligand are impaired in mounting Th<em>1</em> type cell-mediated immune responses.

BACKGROUND

Although inhibitors of the renin-angiotensin-aldosterone system can slow the progression of diabetic kidney disease, the residual risk is high. Whether nuclear <em>1</em> factor (erythroid-derived 2)-related factor 2 activators further reduce this risk is unknown.

METHODS

We randomly assigned 2<em>1</em>85 patients with type 2 diabetes mellitus and stage 4 chronic kidney disease (estimated glomerular filtration rate [GFR], <em>1</em>5 to <30 ml per minute per <em>1</em>.73 m(2) of body-surface area) to bardoxolone methyl, at a daily dose of 20 mg, or placebo. The primary composite outcome was end-stage renal disease (ESRD) or death from cardiovascular causes.

RESULTS

The sponsor and the steering committee terminated the trial on the recommendation of the independent data and safety monitoring committee; the median follow-up was 9 months. A total of 69 of <em>1</em>088 patients (6%) randomly assigned to bardoxolone methyl and 69 of <em>1</em>097 (6%) randomly assigned to placebo had a primary composite outcome (hazard ratio in the bardoxolone methyl group vs. the placebo group, 0.98; 95% confidence interval [CI], 0.70 to <em>1</em>.37; P=0.92). In the bardoxolone methyl group, ESRD developed in 43 patients, and 27 patients died from cardiovascular causes; in the placebo group, ESRD developed in 5<em>1</em> patients, and <em>1</em>9 patients died from cardiovascular causes. A total of 96 patients in the bardoxolone methyl group were hospitalized for heart failure or died from heart failure, as compared with 55 in the placebo group (hazard ratio, <em>1</em>.83; 95% CI, <em>1</em>.32 to 2.55; P<0.00<em>1</em>). Estimated GFR, blood pressure, and the urinary albumin-to-creatinine ratio increased significantly and body weight decreased significantly in the bardoxolone methyl group, as compared with the placebo group.

CONCLUSIONS

Among patients with type 2 diabetes mellitus and stage 4 chronic kidney disease, bardoxolone methyl did not reduce the risk of ESRD or death from cardiovascular causes. A higher rate of cardiovascular events with bardoxolone methyl than with placebo prompted termination of the trial. (Funded by Reata Pharmaceuticals; BEACON ClinicalTrials.gov number, NCT0<em>1</em>35<em>1</em>675.).

BACKGROUND

Vancomycin treatment failure in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is not uncommon, even when MRSA is susceptible to vancomycin. The aim of our study was to evaluate whether vancomycin minimum inhibitory concentration has any influence on the mortality associated with MRSA bacteremia.

METHODS

A total of 4<em>1</em>4 episodes of MRSA bacteremia were prospectively followed-up from <em>1</em>99<em>1</em> through 2005. MIC of vancomycin for the first isolate was determined by E-test. Clinical variables recorded were age, comorbidity, prior administration of vancomycin, use of corticosteroids, prognosis of underlying disease, source of bacteremia, the need for mechanical ventilation, shock, and mortality. A "treatment group" variable was created and defined as follows: (<em>1</em>) receipt of empirical vancomycin and an isolate with a vancomycin MIC of <em>1</em> microg/<em>mL</em> (38 episodes), (2) receipt of empirical vancomycin and an isolate with a vancomycin MIC of <em>1</em>.5 microg/<em>mL</em> (90 episodes), (3) receipt of empirical vancomycin and an isolate with a vancomycin MIC of 2 microg/<em>mL</em> (40 episodes), and (4) receipt of inappropriate empirical therapy (246 episodes). Univariate and multivariate analyses were performed.

RESULTS

Episodes caused by strains with a vancomycin MIC of 2 microg/<em>mL</em> were independently associated with a lower risk of shock (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.<em>1</em>5-0.75). Multivariate analysis selected receipt of empirical vancomycin and an isolate with a vancomycin MIC of 2 microg/<em>mL</em> (OR, 6.39; 95% CI, <em>1</em>.68-24.3), receipt of inappropriate empirical therapy (OR, 3.62; 95% CI, <em>1</em>.20-<em>1</em>0.9), increasing age (OR, <em>1</em>.02; 95% CI, <em>1</em>.00-<em>1</em>.04), use of corticosteroids (OR, <em>1</em>.85; 95% CI, <em>1</em>.04-3.29), an ultimately (OR, <em>1</em>0.2; 95% CI, 2.85-36.8) or rapidly (OR, <em>1</em>.8<em>1</em>; 95% CI, <em>1</em>.06-3.<em>1</em>0) fatal underlying disease, high-risk (OR, 3.60; 95% CI, <em>1</em>.89-6.88) and intermediate-risk (OR, 2.<em>1</em>8; 95% CI, <em>1</em>.<em>1</em>7-4.04) sources of bacteremia, and shock (OR, 7.38; 95% CI, 4.<em>1</em><em>1</em>-<em>1</em>3.3) as the best predictors of mortality.

CONCLUSIONS

Mortality associated with MRSA bacteremia was significantly higher when the empirical antibiotic was inappropriate and when vancomycin was empirically used for treatment of infection with strains with a high vancomycin MIC >><em>1</em> microg/<em>mL</em>).

OBJECTIVE

Prostate-specific membrane antigen (PSMA) is a cell surface protein with high expression in prostate carcinoma (PC) cells. Recently, procedures have been developed to label PSMA ligands with (68)Ga, (99m)Tc and (<em>1</em>23/<em>1</em>24/<em>1</em>3<em>1</em>)I. Our initial experience with Glu-NH-CO-NH-Lys-(Ahx)-[(68)Ga(HBED-CC)]((68)Ga-PSMA) suggests that this novel tracer can detect PC relapses and metastases with high contrast. The aim of this study was to investigate its biodistribution in normal tissues and tumour lesions.

METHODS

A total of 37 patients with PC and rising prostate-specific antigen (PSA) levels were subjected to (68)Ga-PSMA positron emission tomography (PET)/CT. Quantitative assessment of tracer uptake was performed <em>1</em> and 3 h post-injection (p.i.) by analysis of mean and maximum standardized uptake values (SUVmean/max) of several organs and 65 tumour lesions. Subsequently, tumour to background ratios were calculated.

RESULTS

The PET/CT images showed intense tracer uptake in both kidneys and salivary glands. Moderate uptake was seen in lacrimal glands, liver, spleen and in small and large bowel. Quantitative assessment revealed excellent contrast between tumour lesions and most normal tissues. Of 37 patients, 3<em>1</em> (83.8 %) showed at least one lesion suspicious for cancer at a detection rate of 60 % at PSA <2.2 ng/ml and <em>1</em>00 % at PSA >2.2 ng/ml. Median tumour to background ratios were <em>1</em>8.8 (2.4-<em>1</em>58.3) in early images and 28.3 (2.9-224.0) in late images.

CONCLUSIONS

The biodistribution of the novel (68)Ga-PSMA tracer and its ability to detect PC lesions was analysed in 37 patients. Within healthy organs, kidneys and salivary glands demonstrated the highest radiotracer uptake. Lesions suspicious for PC presented with excellent contrast as early as <em>1</em> h p.i. with high detection rates even at low PSA levels.