Vascular endothelial growth factor (VEGF) induces adhesion molecules on endothelial cells during inflammation. Here we examined the mechanisms underlying VEGF-stimulated expression of intercellular adhesion molecule <em>1</em> (ICAM-<em>1</em>), vascular cell adhesion molecule <em>1</em> (VCAM-<em>1</em>), and E-selectin in human umbilical vein endothelial cells. VEGF (20 ng/<em>ml</em>) increased expression of ICAM-<em>1</em>, VCAM-<em>1</em>, and E-selectin mRNAs in a time-dependent manner. These effects were significantly suppressed by Flk-<em>1</em>/kinase-insert domain containing receptor (KDR) antagonist and by inhibitors of phospholipase C, nuclear factor (NF)-kappaB, sphingosine kinase, and protein kinase C, but they were not affected by inhibitors of mitogen-activated protein/extracellular signal-regulated kinase kinase (MEK) <em>1</em>/2 or nitric-oxide synthase. Unexpectedly, the phosphatidylinositol (PI) 3'-kinase inhibitor wortmannin enhanced both basal and VEGF-stimulated adhesion molecule expression, whereas insulin, a PI 3'-kinase activator, suppressed both basal and VEGF-stimulated expression. Gel shift analysis revealed that VEGF stimulated NF-kappaB activity. This effect was inhibited by phospholipase C, NF-kappaB, or protein kinase C inhibitor. VEGF increased VCAM-<em>1</em> and ICAM-<em>1</em> protein levels and increased leukocyte adhesiveness in a NF-kappaB-dependent manner. These results suggest that VEGF-stimulated expression of ICAM-<em>1</em>, VCAM-<em>1</em>, and E-selectin mRNAs was mainly through NF-kappaB activation with PI 3'-kinase-mediated suppression, but was independent of nitric oxide and MEK. Thus, VEGF simultaneously activates two signal transduction pathways that have opposite functions in the induction of adhesion molecule expression. The existence of parallel inverse signaling implies that the induction of adhesion molecule expression by VEGF is very finely regulated.

BACKGROUND

Even though the strong association between physical inactivity and ill health is well documented, 60% of the population is inadequately active or completely inactive. Traditional methods of prescribing exercise have not proven effective for increasing and maintaining a program of regular physical activity.

OBJECTIVE

To compare the 24-month intervention effects of a lifestyle physical activity program with traditional structured exercise on improving physical activity, cardiorespiratory fitness, and cardiovascular disease risk factors.

METHODS

Randomized clinical trial conducted from August <em>1</em>, <em>1</em>993, through July 3<em>1</em>, <em>1</em>997.

METHODS

Sedentary men (n = <em>1</em><em>1</em>6) and women (n = <em>1</em><em>1</em>9) with self-reported physical activity of less than 36 and 34 kcal/kg per day, respectively.

METHODS

Six months of intensive and <em>1</em>8 months of maintenance intervention on either a lifestyle physical activity or a traditional structured exercise program.

METHODS

Primary outcomes were physical activity assessed by the 7-Day Physical Activity Recall and peak oxygen consumption (VO2peak) by a maximal exercise treadmill test. Secondary outcomes were plasma lipid and lipoprotein cholesterol concentrations, blood pressure, and body composition. All measures were obtained at baseline and at 6 and 24 months.

RESULTS

Both the lifestyle and structured activity groups had significant and comparable improvements in physical activity and cardiorespiratory fitness from baseline to 24 months. Adjusted mean changes (95% confidence intervals [CIs]) were 0.84 (95% CI, 0.42-<em>1</em>.25 kcal/kg per day; P<.00<em>1</em>) and 0.69 (95% CI, 0.25-<em>1</em>.<em>1</em>2 kcal/kg day; P = .002) for activity, and 0.77 (95% CI, 0.<em>1</em>8-<em>1</em>.36 mL/kg per minute; P = .0<em>1</em>) and <em>1</em>.34 (95% CI, 0.72-<em>1</em>.96 mL/kg per minute; P<.00<em>1</em>) for VO2peak for the lifestyle and structured activity groups, respectively. There were significant and comparable reductions in systolic blood pressure (-3.63 [95% CI, -5.54 to -<em>1</em>.72 mm Hg; P<.00<em>1</em>] and -3.26 [95% CI, -5.26 to -<em>1</em>.25 mm Hg; P = .002]) and diastolic blood pressure (-5.38 [95% CI, -6.90 to -3.86 mm Hg; P<.00<em>1</em>] and -5.<em>1</em>4 [95% CI, -6.73 to -3.54 mm Hg; P<.00<em>1</em>) for the lifestyle and structured activity groups, respectively. Neither group significantly changed their weight (-0.05 [95% CI, -<em>1</em>.05 to 0.96 kg; P = .93] and 0.69 [95% CI, -0.37 to <em>1</em>.74 kg; P = .20]), but each group significantly reduced their percentage of body fat (-2.39% [95% CI, -2.92% to -<em>1</em>.85%; P<.00<em>1</em>] and -<em>1</em>.85% [95% CI, -2.4<em>1</em> % to -<em>1</em>.28%; P<.00<em>1</em>]) in the lifestyle and structured activity groups, respectively.

CONCLUSIONS

In previously sedentary healthy adults, a lifestyle physical activity intervention is as effective as a structured exercise program in improving physical activity, cardiorespiratory fitness, and blood pressure.

<em>1</em>. Acetylcholine (ACh) noise and miniature end-plate potentials were recorded with focal external micro-electrodes.2. The effect of prostigmine on the time course of the ;molecular' and ;quantal' transmitter actions was studied. Prostigmine (<em>1</em>0(-6) g/<em>ml</em>.) has little or no effect on the duration of the molecular ;gating action', while it greatly prolongs the quantal conductance change.3. After inhibition of ACh hydrolysis, the removal of the transmitter from the synapse is generally too slow to be accounted for by free diffusion. It is suggested that diffusion is delayed by binding to post-synaptic receptors. This is consistent with the finding that receptor blockage by curare or alpha-bungarotoxin shortens as well as reduces quantal transmitter action.4. The correlated effects of the receptor-blocking agents, on size and time course of the miniature end-plate currents, were subjected to a simple analysis. Its result suggests that after inhibition of cholinesterase about two thrids of the quantal packet of ACh combines with post-synaptic receptors.5. During focal external recording the effect of prostigmine on the time course of miniature end-plate potentials can become exaggerated due to what appears to be a compression artifact which obstructs outward diffusion of the transmitter.

BACKGROUND

Vancomycin hydrochloride treatment failure for infections caused by susceptible methicillin-resistant Staphylococcus aureus (MRSA) strains with high minimum inhibitory concentration (MIC) has prompted recent guidelines to recommend a higher vancomycin target trough of 15 to 20 microg/mL.

METHODS

A prospective cohort study of adult patients infected with MRSA was performed to determine the distribution of vancomycin MIC and treatment outcomes with vancomycin doses targeting an unbound trough of at least 4 times the MIC. The microbiology laboratory computer records were used to identify all patients from whom MRSA was isolated from August 1, 2004, through June 30, 2005. Primary outcome measures were clinical response, mortality, and nephrotoxicity. Patients were placed into subgroups based on target trough attainment and high vs low vancomycin MIC >>/=2 vs <2 microg/mL) for efficacy and high vs low trough >>/=15 vs <15 microg/mL) for nephrotoxicity analyses.

RESULTS

Of the 95 patients in the study, 51 (54%) were infected with high-MIC strains and had pneumonia (77%) and/or bacteremia. An initial response rate of 74% was achieved if the target trough was attained irrespective of MIC. However, despite achieving the target trough, the high-MIC group had lower end-of-treatment responses (24/39 [62%] vs 34/40 [85%]; P = .02) and higher infection-related mortality (11/51 [24%] vs 4/44 [10%]; P=.16) compared with the low-MIC group. High MIC (P = .03) and Acute Physiology and Chronic Health Evaluation II score (P = .009) were independent predictors of poor response in multivariate analysis. Nephrotoxicity occurred only in the high-trough group (11/63 [12%]), significantly predicted by concomitant therapy with other nephrotoxic agents.

CONCLUSIONS

High prevalence of clinical MRSA strains with elevated vancomycin MIC (2 microg/mL) requires aggressive empirical vancomycin dosing to achieve a trough greater than 15 microg/mL. Combination or alternative therapy should be considered for invasive infections caused by these strains.

A murine monoclonal antibody (H4/<em>1</em>8) raised against cultured human endothelial cells (HEC) prestimulated by the monokine interleukin <em>1</em> (IL <em>1</em>) recognizes a cell surface molecule inducible by IL <em>1</em> or by the distinct monokine tumor necrosis factor (TNF) in primary or serially passaged HEC. H4/<em>1</em>8 binding is not basally expressed or inducible by IL <em>1</em> in an SV-40 transformed HEC line, in human dermal fibroblasts, or in blood leukocytes. Expression of this molecule by HEC in response to IL <em>1</em> can be blocked by protein and RNA synthesis inhibitors but not by cyclooxygenase inhibitors. In addition, H4/<em>1</em>8 can immunoprecipitate two biosynthetically labeled polypeptides (Mr <em>1</em>00,000 and <em>1</em>20,000) from HEC stimulated with IL <em>1</em> but not from control HEC. Thus, the H4/<em>1</em>8 binding site appears to be an inducible surface protein specific for HEC. The majority of HEC in a culture can be induced to express the H4/<em>1</em>8 binding protein, but expression is transient (peak 4 to 6 hr) and over the next 24 hr declines to near basal levels either in the continued presence of or upon removal of IL <em>1</em>. The magnitude of the peak response depends upon IL <em>1</em> concentration (peak 5 to <em>1</em>0 U/<em>ml</em>), and the response is optimized by the continued presence of IL <em>1</em> during the initial 4- to 6-hr induction period. The time of peak H4/<em>1</em>8 binding does not appear to be a function of IL <em>1</em> concentration. The decline of H4/<em>1</em>8 binding from peak levels is prevented by cycloheximide, a protein synthesis inhibitor. HEC maintained in the presence of IL <em>1</em> for 24 hr become refractory to restimulation by IL <em>1</em>; however, IL <em>1</em>-stimulated cells rested in the absence of IL <em>1</em> for 20 hr can be stimulated by fresh IL <em>1</em>. HEC expression of the H4/<em>1</em>8 binding protein is not induced by interleukin 2 or by interferon-alpha, -beta, or -gamma. Induction of H4/<em>1</em>8 binding by TNF is also concentration dependent, transient, and dependent upon protein and RNA synthesis. Several observations suggest that IL<em>1</em> and TNF act independently on HEC. Our TNF is a recombinant protein, expressed from a cloned cDNA and thus free of IL <em>1</em> contamination; it also has no activity in a highly sensitive IL <em>1</em> assay. Our standard IL <em>1</em> preparation is affinity purified and lacks TNF activity on L929 cells. Thus, our monokine preparations are not cross-contaminated. Most interestingly, HEC incubated with IL <em>1</em> and refractory to IL<em>1</em> restimulation can be restimulated by TNF to express H4/<em>1</em>8 binding and vice versa.(ABSTRACT TRUNCATED AT 400 WORDS)

BACKGROUND

Optimal timing of cardiac transplantation in ambulatory patients with severe left ventricular dysfunction is often difficult. To determine whether measurement of peak oxygen consumption (VO2) during maximal exercise testing can be used to identify patients in whom transplantation can be safely deferred, we prospectively performed exercise testing on all ambulatory patients referred for transplant between October <em>1</em>986 and December <em>1</em>989.

RESULTS

Patients were assigned into one of three groups on the basis of exercise data: Group <em>1</em> (n = 35) comprised patients accepted for transplant (VO2 less than or equal to <em>1</em>4 <em>ml</em>/kg/min); group 2 (n = 52) comprised patients considered too well for transplant (VO2 greater than <em>1</em>4 <em>ml</em>/kg/min); and group 3 (n = 27) comprised patients with low VO2 rejected for transplant due to noncardiac problems. All three groups were comparable in New York Heart Association functional class, ejection fraction, and cardiac index (p = NS). Pulmonary capillary wedge pressure was significantly lower in group 2 than in either group <em>1</em> or 3 (p less than 0.05), although there was wide overlap. Patients with preserved exercise capacity (group 2) had cumulative <em>1</em>- and 2-year survival rates of 94% and 84%, which are equal to survival levels after transplantation. In contrast, patients rejected for transplant (group 3) had survival rates of only 47% at <em>1</em> year and 32% at 2 years, whereas patients awaiting transplantation (group <em>1</em>) had a survival rate of 70% at <em>1</em> year (both p less than 0.005 versus patients with VO2 greater than <em>1</em>4 <em>ml</em>/kg/min). All deaths in group 2 were sudden. By univariate and multivariate analyses, peak VO2 was the best predictor of survival, with only pulmonary capillary wedge pressure providing additional prognostic information.

CONCLUSIONS

These data suggest that cardiac transplantation can be safely deferred in ambulatory patients with severe left ventricular dysfunction and peak exercise VO2 of more than <em>1</em>4 <em>ml</em>/min/kg.

A partially purified preparation of the heat-stable enterotoxin of Escherichia coli caused a rapid and persistent increase in electric potential difference and short-circuit current when added in vitro to the luminal surface of isolated rabbit ileal mucosa. As little as <em>1</em> ng/<em>ml</em> produced an easily detectable response. Under short-circuit condition, the enterotoxin abolished net Cl- absorption; this change was half that produced by theophylline, which stimulated net secretion. The enterotoxin did not change cyclic AMP concentration but caused large and persistent increases in cyclic GMP concentration. The electrical and nucleotide responses exhibited similar and unusually broad concentration-dependences and maximal effects could not be demonstrated. Theophylline elevated cyclic GMP concentration 3-fold both in the presence and absense of the enterotoxin, suggesting no effect of the toxin on cyclic GMP phosphodiesterase. Guanylate cyclase [GTP pyrophosphatelyase(cyclizing); EC 4.6.<em>1</em>.2] activity in a crude membrane fraction from intestinal epithelial cells was stimulated 7-fold by the enterotoxin. These results suggest that guanylate cyclase stimulation is the basis for the toxin's diarrheagenic effect.

OBJECTIVE

We retrospectively reviewed the clinical followup for a large series of men with clinically localized prostate cancer who underwent radical retropubic prostatectomy to identify clinical and/or pathological indicators of biochemical (prostate specific antigen [PSA]) recurrence. We then used those indicators to develop multivariate models for determination of recurrence probability following radical retropubic prostatectomy.

METHODS

From 1982 to 1999, 2,091 consecutive men underwent radical retropubic prostatectomy and pelvic lymphadenectomy for clinically localized adenocarcinoma of the prostate (clinical stage T1c or T2 disease with Gleason score 5 or greater). Actuarial analysis was performed comparing freedom from biochemical recurrence after radical retropubic prostatectomy (PSA 0.2 ng./ml. or greater.) using the Kaplan-Meier method. Event time distributions for the time to recurrence were compared using the log rank statistic or the Cox proportional hazards regression model. The first model was developed using preoperative variables only and the second model using all available variables. Observed and predicted recurrence-free survival curves for different models were compared to select a model for calculation of predicted recurrence-free probabilities and confidence intervals.

RESULTS

With a median followup of 5.9 years (range 1 to 17) 360 men (17%) had biochemical recurrence. Overall actuarial 5, 10 and 15-year biochemical recurrence-free survival rates were 84%, 72% and 61%, respectively. The relative risk of biochemical recurrence following surgery decreased with time, even after adjusted for other perioperative parameters. Variables identified for the preoperative model were biopsy Gleason score, clinical TNM stage and PSA. Variables identified for the postoperative model were prostatectomy Gleason score, PSA and pathological organ confinement status. Nomograms were generated and corrected for the decreasing relative risk of biochemical recurrence over time.

CONCLUSIONS

Using 3 preoperative or postoperative parameters, these nomograms can easily be used to determine the 3, 5, 7 and 10-year biochemical recurrence-free survival probabilities among men who undergo radical retropubic prostatectomy for clinically localized prostate cancer in the modern era.

OBJECTIVE

Efavirenz is an effective antiretroviral agent, but central nervous system side effects occur commonly, and population (racial) differences in pharmacokinetics and response have been reported. Efavirenz is metabolized by cytochrome P4502B6 (CYP2B6). We investigated whether polymorphisms in CYP2B6, CYP3A4, CYP3A5, and MDR<em>1</em> were associated with efavirenz central nervous system side effects and pharmacokinetics.

METHODS

Twenty-four week cohort from a randomized study.

METHODS

Adult AIDS Clinical Trials Group study A5097s examined relationships between central nervous system side effects and efavirenz plasma concentration-time profiles in HIV-infected subjects. Efavirenz plasma pharmacokinetics were estimated by a population-based method. Central nervous system symptoms were assessed by questionnaires and neuropsychological testing.

RESULTS

Study subjects included 89 (57%) European-Americans, 50 (32%) African-Americans, and <em>1</em>5 (<em>1</em>0%) Hispanics. The CYP2B6 T/T genotype at position 5<em>1</em>6 (GlnHis) was more common in African-Americans (20%) than in European-Americans (3%), and was associated with greater efavirenz plasma exposure (P < 0.000<em>1</em>). The median efavirenz [area-under-the-curve] (0-24 h) according to G/G, G/T, and T/T genotype was 44 (n = 78), 60 (n = 60), and <em>1</em>30 (n = <em>1</em>4) mug.h/<em>ml</em>, respectively (P < 0.000<em>1</em>). The CYP2B6 G5<em>1</em>6T genotype was also associated with central nervous system symptoms at week <em>1</em> (P = 0.036). Analysis of DNA from other subjects confirmed population differences in frequency of the G5<em>1</em>6T variant. No associations were apparent with the other polymorphisms studied.

CONCLUSIONS

A CYP2B6 allelic variant that is more common in African-Americans than in Europeans-Americans was associated with significantly greater efavirenz plasma exposure during HIV therapy. Inter-individual differences in metabolism may, in part, explain susceptibility to efavirenz central nervous system side effects.

In a recent study, immunoglobulin G in human plasma was identified as a major inhibitor of diagnostic PCR (W. Abu Al-Soud, L. J. Jönsson, and P. Rådström. J. Clin. Microbiol. 38:345-350, 2000). In this study, two major PCR inhibitors in human blood cells were purified using size exclusion and anion-exchange chromatographic procedures. Based on N-terminal amino acid sequencing and electrophoretic analysis of the purified polypeptides, hemoglobin and lactoferrin were identified as PCR-inhibitor components in erythrocytes and leukocytes, respectively. When different concentrations of hemoglobin or lactoferrin were added to PCR mixtures of 25 microl containing <em>1</em>0 different thermostable DNA polymerases and <em>1</em> ng of Listeria monocytogenes DNA as template DNA, AmpliTaq Gold, Pwo, and Ultma were inhibited in the presence of < or = <em>1</em>.3 microg of hemoglobin and < or = 25 ng of lactoferrin, while rTth and Tli were found to resist inhibition of at least <em>1</em>00 microg of hemoglobin. In addition, the quantitative effects of seven low-molecular-mass inhibitors, present in blood samples or degradation products of hemoglobin, on real-time DNA synthesis of rTth using the LightCycler Instrument were investigated. A reaction system based on a single-stranded poly(dA) template with an oligo(dT) primer annealed to the 3' end was used. It was found that the addition of 0.25 to 0.<em>1</em> mg of bile per <em>ml</em>, 2.5 mM CaCl2, 0.25 mM EDTA, 5 microM FeCl3, and 0.0<em>1</em> IU of heparin per <em>ml</em> reduced the fluorescence to approximately 76, 70, 46, <em>1</em>7, and 5<em>1</em>%, respectively. Finally, the effects of nine amplification facilitators were studied in the presence of hemoglobin and lactoferrin. Bovine serum albumin (BSA) was the most efficient amplification facilitator, so that the addition of 0.4% (wt/vol) BSA allowed AmpliTaq Gold to amplify DNA in the presence of 20 instead of <em>1</em> microg of hemoglobin and 500 instead of 5 ng of lactoferrin. Including 0.02% (wt/vol) gp32, a single-stranded-DNA binding protein, in the reaction mixture of AmpliTaq Gold was also found to reduce the inhibitory effects of hemoglobin and lactoferrin.

Infection with any <em>1</em> of 4 dengue viruses produces a spectrum of clinical illness ranging from a mild undifferentiated febrile illness to dengue fever (DF) to dengue hemorrhagic fever (DHF), a potentially life-threatening disease. The morbidity and mortality of DHF can be reduced by early hospitalization and careful supportive care. To determine its usefulness as a predictor of DHF, plasma levels of the secreted dengue virus nonstructural protein NS<em>1</em> (sNS<em>1</em>) were measured daily in 32 children with dengue-2 virus infections participating in a prospective, hospital-based study. Free sNS<em>1</em> levels in plasma correlated with viremia levels and were higher in patients with DHF than in those with DF. An elevated free sNS<em>1</em> level >> or =600 ng/<em>mL</em>) within 72 h of illness onset identified patients at risk for developing DHF.

Human neutrophils contain two structurally distinct types of antimicrobial peptides, beta-sheet defensins (HNP-<em>1</em> to HNP-4) and the alpha-helical peptide LL-37. We used radial diffusion assays and an improved National Committee for Clinical Laboratory Standards-type broth microdilution assay to compare the antimicrobial properties of LL-37, HNP-<em>1</em>, and protegrin (PG-<em>1</em>). Although generally less potent than PG-<em>1</em>, LL-37 showed considerable activity (MIC, (<em>1</em>0 microgram/<em>ml</em>) against Pseudomonas aeruginosa, Salmonella typhimurium, Escherichia coli, Listeria monocytogenes, Staphylococcus epidermidis, Staphylococcus aureus, and vancomycin-resistant enterococci, even in media that contained <em>1</em>00 mM NaCl. Certain organisms (methicillin-resistant S. aureus, Proteus mirabilis, and Candida albicans) were resistant to LL-37 in media that contained <em>1</em>00 mM NaCl but were susceptible in low-salt media. Burkholderia cepacia was resistant to LL-37, PG-<em>1</em>, and HNP-<em>1</em> in low- or high-salt media. LL-37 caused outer and inner membrane permeabilization of E. coli <em>ML</em>-35p. Chromogenic Limulus assays revealed that LL-37 bound to E. coli O<em>1</em><em>1</em><em>1</em>:B4 lipopolysaccharide (LPS) with a high affinity and that this binding showed positive cooperativity (Hill coefficient = 2.02). Circular dichroism spectrometry disclosed that LL-37 underwent conformational change in the presence of lipid A, transitioning from a random coil to an alpha-helical structure. The broad-spectrum antimicrobial properties of LL-37, its presence in neutrophils, and its inducibility in keratinocytes all suggest that this peptide and its precursor (hCAP-<em>1</em>8) may protect skin and other tissues from bacterial intrusions and LPS-induced toxicity. The potent activity of LL-37 against P. aeruginosa, including mucoid and antibiotic-resistant strains, suggests that it or related molecules might have utility as topical bronchopulmonary microbicides in cystic fibrosis.

Acute episodes of severe renal ischemia result in acute renal failure (ARF). These episodes are followed by a characteristic recovery and repair response, whereby tubular morphology and renal function appear completely restored within approximately <em>1</em> mo. However, the chronic effects of such an injury have not been well studied. Male rats were subjected to 60-min bilateral ischemia followed by reperfusion, yielding a characteristic injury. Postischemic animals manifested severe diuresis, peaking at <em>1</em> wk postinjury (volume: >45 <em>ml</em>/day, ARF vs. <em>1</em>8 <em>ml</em>/day, sham; P < 0.05). Urine flow subsequently declined but remained significantly elevated vs. sham animals for a 40-wk period. The prolonged alteration in urinary concentrating ability was attributable, in part, to a diminished capacity to generate a hypertonic medullary interstitium. By week <em>1</em>6, proteinuria developed in the post-ARF group and progressed for the duration of the study. Histological examination revealed essentially normal tubular morphology at 4 and 8 wk postinjury but the development of tubulointerstitial fibrosis at 40 wk. Transforming growth factor (TGF)-beta<em>1</em> expression was elevated at 40 wk, but not at 4 and 8 wk postinjury. Microfil analysis revealed an approximately 30-50% reduction in peritubular capillary density in the inner stripe of the outer medulla at 4, 8, and 40 wk in post-ARF groups vs. sham animals. In addition, post-ARF rats manifested a significant pressor response to a low dose of ANG II (<em>1</em>5 ng x kg(-<em>1</em>) x min(-<em>1</em>)). We hypothesize that severe ischemic injury results in a permanent alteration of renal capillary density, contributing to a urinary concentrating defect and the predisposition toward the development of renal fibrosis.

BACKGROUND

To further increase the efficacy of malaria vaccine RTS,S/AS02A, we tested the RTS,S antigen formulated using the AS0<em>1</em>B Adjuvant System (GlaxoSmithKline Biologicals).

METHODS

In a double-blind, randomized trial, <em>1</em>02 healthy volunteers were evenly allocated to receive RTS,S/AS0<em>1</em>B or RTS,S/AS02A vaccine at months 0, <em>1</em>, and 2 of the study, followed by malaria challenge. Protected vaccine recipients were rechallenged 5 months later.

RESULTS

RTS,S/AS0<em>1</em>B and RTS,S/AS02A were well tolerated and were safe. The efficacy of RTS,S/AS0<em>1</em>B and RTS,S/AS02A was 50% (95% confidence interval [CI], 32.9%-67.<em>1</em>%) and 32% (95% CI, <em>1</em>7.6%-47.6%), respectively. At the time of initial challenge, the RTS,S/AS0<em>1</em>B group had greater circumsporozoite protein (CSP)-specific immune responses, including higher immunoglobulin (Ig) G titers, higher numbers of CSP-specific CD4(+) T cells expressing 2 activation markers (interleukin-2, interferon [IFN]-gamma, tumor necrosis factor-alpha, or CD40L), and more ex vivo IFN-gamma enzyme-linked immunospots (ELISPOTs) than did the RTS,S/AS02A group. Protected vaccine recipients had a higher CSP-specific IgG titer (geometric mean titer, <em>1</em>88 vs 73 mug/mL; P < .00<em>1</em>), higher numbers of CSP-specific CD4(+) T cells per <em>1</em>0(6) CD4(+) T cells (median, 963 vs 308 CSP-specific CD4(+) T cells/<em>1</em>0(6) CD4(+) T cells; P < .00<em>1</em>), and higher numbers of ex vivo IFN-gamma ELISPOTs (mean, 2<em>1</em>2 vs 96 spots/million cells; P < .00<em>1</em>). At rechallenge, 4 of 9 vaccine recipients in each group were still completely protected.

CONCLUSIONS

The RTS,S/AS0<em>1</em>B malaria vaccine warrants comparative field trials with RTS,S/AS02A to determine the best formulation for the protection of children and infants. The association between complete protection and immune responses is a potential tool for further optimization of protection. Trial registration. ClinicalTrials.gov identifier NCT00075049.

Biomarkers are urgently needed for the diagnosis and monitoring of disease progression in Parkinson's disease. Both DJ-<em>1</em> and alpha-synuclein, two proteins critically involved in Parkinson's disease pathogenesis, have been tested as disease biomarkers in several recent studies with inconsistent results. These have been largely due to variation in the protein species detected by different antibodies, limited numbers of patients in some studies, or inadequate control of several important variables. In this study, the nature of DJ-<em>1</em> and alpha-synuclein in human cerebrospinal fluid was studied by a combination of western blotting, gel filtration and mass spectrometry. Sensitive and quantitative Luminex assays detecting most, if not all, species of DJ-<em>1</em> and alpha-synuclein in human cerebrospinal fluid were established. Cerebrospinal fluid concentrations of DJ-<em>1</em> and alpha-synuclein from <em>1</em><em>1</em>7 patients with Parkinson's disease, <em>1</em>32 healthy individuals and 50 patients with Alzheimer's disease were analysed using newly developed, highly sensitive Luminex technology while controlling for several major confounders. A total of 299 individuals and 389 samples were analysed. The results showed that cerebrospinal fluid DJ-<em>1</em> and alpha-synuclein levels were dependent on age and influenced by the extent of blood contamination in cerebrospinal fluid. Both DJ-<em>1</em> and alpha-synuclein levels were decreased in Parkinson's patients versus controls or Alzheimer's patients when blood contamination was controlled for. In the population aged>> or = 65 years, when cut-off values of 40 and 0.5 ng/<em>ml</em> were chosen for DJ-<em>1</em> and alpha-synuclein, respectively, the sensitivity and specificity for patients with Parkinson's disease versus controls were 90 and 70% for DJ-<em>1</em>, and 92 and 58% for alpha-synuclein. A combination of the two markers did not enhance the test performance. There was no association between DJ-<em>1</em> or alpha-synuclein and the severity of Parkinson's disease. Taken together, this represents the largest scale study for DJ-<em>1</em> or alpha-synuclein in human cerebrospinal fluid so far, while using newly established sensitive Luminex assays, with controls for multiple variables. We have demonstrated that total DJ-<em>1</em> and alpha-synuclein in human cerebrospinal fluid are helpful diagnostic markers for Parkinson's disease, if variables such as blood contamination and age are taken into consideration.

BACKGROUND

Clinical practice guidelines on the management of mineral and bone disorders due to chronic kidney disease recommend specific treatment target levels for serum phosphorus, parathyroid hormone, and calcium.

OBJECTIVE

To assess the quality of evidence for the association between levels of serum phosphorus, parathyroid hormone, and calcium and risks of death, cardiovascular mortality, and nonfatal cardiovascular events in individuals with chronic kidney disease.

METHODS

The databases of MEDLINE (<em>1</em>948 to December 20<em>1</em>0) and EMBASE (<em>1</em>947 to December 20<em>1</em>0) were searched without language restriction. Hand searches also were conducted of the reference lists of primary studies, review articles, and clinical guidelines along with full-text review of any citation that appeared relevant.

METHODS

Of 8380 citations identified in the original search, 47 cohort studies (N = 327,644 patients) met the inclusion criteria.

METHODS

The characteristics of study design, participants, exposures, and covariates together with the outcomes of all-cause mortality, cardiovascular mortality, and nonfatal cardiovascular events at different levels of serum phosphorus, parathyroid hormone, and calcium were analyzed within studies. Data were summarized across studies (when possible) using random-effects meta-regression.

RESULTS

The risk of death increased <em>1</em>8% for every <em>1</em>-mg/dL increase in serum phosphorus (relative risk [RR], <em>1</em>.<em>1</em>8 [95% confidence interval {CI}, <em>1</em>.<em>1</em>2-<em>1</em>.25]). There was no significant association between all-cause mortality and serum level of parathyroid hormone (RR per <em>1</em>00-pg/<em>mL</em> increase, <em>1</em>.0<em>1</em> [95% CI, <em>1</em>.00-<em>1</em>.02]) or serum level of calcium (RR per <em>1</em>-mg/dL increase, <em>1</em>.08 [95% CI, <em>1</em>.00-<em>1</em>.<em>1</em>6]). Data for the association between serum level of phosphorus, parathyroid hormone, and calcium and cardiovascular death were each available in only <em>1</em> adequately adjusted cohort study. Lack of adjustment for confounding variables was not a major limitation of the available studies.

CONCLUSIONS

The evidentiary basis for a strong, consistent, and independent association between serum levels of calcium and parathyroid hormone and the risk of death and cardiovascular events in chronic kidney disease is poor. There appears to be an association between higher serum levels of phosphorus and mortality in this population.

BACKGROUND

The intercellular adhesion molecule ICAM-<em>1</em> mediates adhesion and transmigration of leucocytes to the vascular endothelial wall, a step proposed to be critical in the initiation and progression of atherosclerosis. Whether concentrations of soluble ICAM-<em>1</em> (sICAM-<em>1</em>) are raised in apparently healthy individuals who later suffer acute myocardial infarction is unknown.

METHODS

We obtained baseline plasma samples from a prospective cohort of <em>1</em>4,9<em>1</em>6 healthy men enrolled in the Physicians' Health Study. With a nested case-control design, we measured sICAM-<em>1</em> concentrations for 474 participants who developed a first myocardial infarction, and 474 controls (participants who remained healthy throughout the 9-year follow-up). Cases were matched to controls according to age and smoking status at the time of myocardial infarction.

RESULTS

We found a significant association between increasing concentration of sICAM-<em>1</em> and risk of future myocardial infarction (p = 0.003), especially among participants with baseline sICAM-<em>1</em> concentrations in the highest quartile >> 260 ng/mL; relative risk <em>1</em>.6 [95% Cl <em>1</em>.<em>1</em>-2.4], p = 0.02). This association was present overall as well as among non-smokers, and persisted after control for lipid and non-lipid risk factors. In multivariate analyses, the risk of future myocardial infarction was 80% higher for participants with baseline sICAM-<em>1</em> concentrations in the highest quartile (relative risk <em>1</em>.8 [<em>1</em>.<em>1</em>-2.8], p = 0.02). Similar risk estimates were seen among non-smokers. We found slight but significant correlations between sICAM-<em>1</em> and fibrinogen, high-density-lipoprotein cholesterol, homocysteine, triglycerides, tissue-type plasminogen-activator antigen, and C-relative protein, but adjustment for these altered the risk little. The risk of myocardial infarction associated with raised concentrations of sICAM-<em>1</em> seemed to increase with length of follow-up.

CONCLUSIONS

Our data support the hypothesis that cellular mediators of inflammation have a role in atherogenesis and provide a clinical basis to consider antiadhesion therapies as a novel means of cardiovascular disease prevention.

The purpose of this investigation was to validate that in vivo measurement of skeletal muscle attenuation (MA) with computed tomography (CT) is associated with muscle lipid content. Single-slice CT scans performed on phantoms of varying lipid concentrations revealed good concordance between attenuation and lipid concentration (r(2) = 0.995); increasing the phantom's lipid concentration by <em>1</em> g/<em>1</em>00 <em>ml</em> decreased its attenuation by approximately <em>1</em> Hounsfield unit (HU). The test-retest coefficient of variation for two CT scans performed in six volunteers was 0.5<em>1</em>% for the midthigh and 0.85% for the midcalf, indicating that the methodological variability is low. Lean subjects had significantly higher (P < 0.0<em>1</em>) MA values (49.2 +/- 2.8 HU) than did obese nondiabetic (39.3 +/- 7.5 HU) and obese Type 2 diabetic (33.9 +/- 4. <em>1</em> HU) subjects, whereas obese Type 2 diabetic subjects had lower MA values that were not different from obese nondiabetic subjects. There was also good concordance between MA in midthigh and midcalf (r = 0.60, P < 0.0<em>1</em>), psoas (r = 0.65, P < 0.0<em>1</em>), and erector spinae (r = 0.77, P < 0.0<em>1</em>) in subsets of volunteers. In 45 men and women who ranged from lean to obese (body mass index = <em>1</em>8.5 to 35.9 kg/m(2)), including <em>1</em>0 patients with Type 2 diabetes mellitus, reduced MA was associated with increased muscle fiber lipid content determined with histological oil red O staining (P = -0.43, P < 0. 0<em>1</em>). In a subset of these volunteers (n = <em>1</em>9), triglyceride content in percutaneous biopsy specimens from vastus lateralis was also associated with MA (r = -0.58, P = 0.0<em>1</em>9). We conclude that the attenuation of skeletal muscle in vivo determined by CT is related to its lipid content and that this noninvasive method may provide additional information regarding the association between muscle composition and muscle function.

<strong class="sub-title"> Background: </strong> Older adults (aged ≥70 years) are at increased risk of severe disease and death if they develop COVID-<em>1</em>9 and are therefore a priority for immunisation should an efficacious vaccine be developed. Immunogenicity of vaccines is often worse in older adults as a result of immunosenescence. We have reported the immunogenicity of a novel chimpanzee adenovirus-vectored vaccine, ChAdOx<em>1</em> nCoV-<em>1</em>9, in young adults, and now describe the safety and immunogenicity of this vaccine in a wider range of participants, including adults aged 70 years and older.

<strong class="sub-title"> Methods: </strong> In this report of the phase 2 component of a single-blind, randomised, controlled, phase 2/3 trial (COV002), healthy adults aged <em>1</em>8 years and older were enrolled at two UK clinical research facilities, in an age-escalation manner, into <em>1</em>8-55 years, 56-69 years, and 70 years and older immunogenicity subgroups. Participants were eligible if they did not have severe or uncontrolled medical comorbidities or a high frailty score (if aged ≥65 years). First, participants were recruited to a low-dose cohort, and within each age group, participants were randomly assigned to receive either intramuscular ChAdOx<em>1</em> nCoV-<em>1</em>9 (2·2 × <em>1</em>0^<em>1</em>0 virus particles) or a control vaccine, MenACWY, using block randomisation and stratified by age and dose group and study site, using the following ratios: in the <em>1</em>8-55 years group, <em>1</em>:<em>1</em> to either two doses of ChAdOx<em>1</em> nCoV-<em>1</em>9 or two doses of MenACWY; in the 56-69 years group, 3:<em>1</em>:3:<em>1</em> to one dose of ChAdOx<em>1</em> nCoV-<em>1</em>9, one dose of MenACWY, two doses of ChAdOx<em>1</em> nCoV-<em>1</em>9, or two doses of MenACWY; and in the 70 years and older, 5:<em>1</em>:5:<em>1</em> to one dose of ChAdOx<em>1</em> nCoV-<em>1</em>9, one dose of MenACWY, two doses of ChAdOx<em>1</em> nCoV-<em>1</em>9, or two doses of MenACWY. Prime-booster regimens were given 28 days apart. Participants were then recruited to the standard-dose cohort (3·5-6·5 × <em>1</em>0^<em>1</em>0 virus particles of ChAdOx<em>1</em> nCoV-<em>1</em>9) and the same randomisation procedures were followed, except the <em>1</em>8-55 years group was assigned in a 5:<em>1</em> ratio to two doses of ChAdOx<em>1</em> nCoV-<em>1</em>9 or two doses of MenACWY. Participants and investigators, but not staff administering the vaccine, were masked to vaccine allocation. The specific objectives of this report were to assess the safety and humoral and cellular immunogenicity of a single-dose and two-dose schedule in adults older than 55 years. Humoral responses at baseline and after each vaccination until <em>1</em> year after the booster were assessed using an in-house standardised ELISA, a multiplex immunoassay, and a live severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) microneutralisation assay (MNA₈₀). Cellular responses were assessed using an ex-vivo IFN-γ enzyme-linked immunospot assay. The coprimary outcomes of the trial were efficacy, as measured by the number of cases of symptomatic, virologically confirmed COVID-<em>1</em>9, and safety, as measured by the occurrence of serious adverse events. Analyses were by group allocation in participants who received the vaccine. Here, we report the preliminary findings on safety, reactogenicity, and cellular and humoral immune responses. This study is ongoing and is registered with ClinicalTrials.gov, <a href="http://clinicaltrials.gov/show/NCT04400838" title="See in ClinicalTrials.gov">NCT04400838</a>, and ISRCTN, <em>1</em>528<em>1</em><em>1</em>37.

<strong class="sub-title"> Findings: </strong> Between May 30 and Aug 8, 2020, 560 participants were enrolled: <em>1</em>60 aged <em>1</em>8-55 years (<em>1</em>00 assigned to ChAdOx<em>1</em> nCoV-<em>1</em>9, 60 assigned to MenACWY), <em>1</em>60 aged 56-69 years (<em>1</em>20 assigned to ChAdOx<em>1</em> nCoV-<em>1</em>9: 40 assigned to MenACWY), and 240 aged 70 years and older (200 assigned to ChAdOx<em>1</em> nCoV-<em>1</em>9: 40 assigned to MenACWY). Seven participants did not receive the boost dose of their assigned two-dose regimen, one participant received the incorrect vaccine, and three were excluded from immunogenicity analyses due to incorrectly labelled samples. 280 (50%) of 552 analysable participants were female. Local and systemic reactions were more common in participants given ChAdOx<em>1</em> nCoV-<em>1</em>9 than in those given the control vaccine, and similar in nature to those previously reported (injection-site pain, feeling feverish, muscle ache, headache), but were less common in older adults (aged ≥56 years) than younger adults. In those receiving two standard doses of ChAdOx<em>1</em> nCoV-<em>1</em>9, after the prime vaccination local reactions were reported in 43 (88%) of 49 participants in the <em>1</em>8-55 years group, 22 (73%) of 30 in the 56-69 years group, and 30 (6<em>1</em>%) of 49 in the 70 years and older group, and systemic reactions in 42 (86%) participants in the <em>1</em>8-55 years group, 23 (77%) in the 56-69 years group, and 32 (65%) in the 70 years and older group. As of Oct 26, 2020, <em>1</em>3 serious adverse events occurred during the study period, none of which were considered to be related to either study vaccine. In participants who received two doses of vaccine, median anti-spike SARS-CoV-2 IgG responses 28 days after the boost dose were similar across the three age cohorts (standard-dose groups: <em>1</em>8-55 years, 20 7<em>1</em>3 arbitrary units [AU]/mL [IQR <em>1</em>3 898-33 550], n=39; 56-69 years, <em>1</em>6 <em>1</em>70 AU/mL [<em>1</em>0 233-40 353], n=26; and ≥70 years <em>1</em>7 56<em>1</em> AU/mL [9705-37 796], n=47; p=0·68). Neutralising antibody titres after a boost dose were similar across all age groups (median MNA₈₀ at day 42 in the standard-dose groups: <em>1</em>8-55 years, <em>1</em>93 [IQR <em>1</em><em>1</em>3-238], n=39; 56-69 years, <em>1</em>44 [<em>1</em><em>1</em>9-347], n=20; and ≥70 years, <em>1</em>6<em>1</em> [73-323], n=47; p=0·40). By <em>1</em>4 days after the boost dose, 208 (>99%) of 209 boosted participants had neutralising antibody responses. T-cell responses peaked at day <em>1</em>4 after a single standard dose of ChAdOx<em>1</em> nCoV-<em>1</em>9 (<em>1</em>8-55 years: median <em>1</em><em>1</em>87 spot-forming cells [SFCs] per million peripheral blood mononuclear cells [IQR 84<em>1</em>-2428], n=24; 56-69 years: 797 SFCs [383-<em>1</em>8<em>1</em>7], n=29; and ≥70 years: 977 SFCs [458-<em>1</em>9<em>1</em>4], n=48).

<strong class="sub-title"> Interpretation: </strong> ChAdOx<em>1</em> nCoV-<em>1</em>9 appears to be better tolerated in older adults than in younger adults and has similar immunogenicity across all age groups after a boost dose. Further assessment of the efficacy of this vaccine is warranted in all age groups and individuals with comorbidities.

Funding: UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midlands NIHR Clinical Research Network, and AstraZeneca.

OBJECTIVE

To investigate the relation between the quantity of human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) RNA in plasma and the risk for the acquired immunodeficiency syndrome (AIDS) or a decline in the CD4+ T-cell count after seroconversion.

METHODS

Prospective study.

METHODS

62 homosexual men with documented HIV-<em>1</em> seroconversion.

METHODS

University outpatient setting.

METHODS

Clinical status, CD4+ T-cell counts, and plasma and serum samples were obtained every 6 months. Human immunodeficiency virus RNA in plasma was quantitated with a branched-DNA (bDNA) assay. Serum samples were assayed for neopterin, beta 2-microglobulin, and immune complex dissociated HIV-<em>1</em> p24 antigen.

RESULTS

<em>1</em>8 of 62 (29%) men developed AIDS; 2<em>1</em> (34%) had a significant decline in the CD4+ T-cell count without AIDS; and 23 (37%) had a stable CD4+ T-cell count. For each participant, HIV-<em>1</em> RNA results were categorized into one of four groups: <em>1</em>) detection of HIV-<em>1</em> RNA >> <em>1</em> x <em>1</em>0(4) genome equivalents/mL [Eq/mL]) in all samples; 2) detection in most samples >> or = 50%); 3) detection in fewer than 50% of samples; and 4) detection in none of the samples. Detection of HIV-<em>1</em> RNA in all or most samples was strongly associated with AIDS (<em>1</em>6 of <em>1</em>8 patients) and a decline in the CD4+ T-cell count (<em>1</em>3 of 2<em>1</em> patients) compared with a stable CD4+ T-cell count (4 of 23 patients; P < 0.00<em>1</em>). Conversely, the absence of HIV-<em>1</em> RNA (< <em>1</em> x <em>1</em>0(4) Eq/mL) in all or most samples was associated with stable CD4+ T-cell counts (<em>1</em>9 of 23 patients) and a lower risk for AIDS or decline in the CD4+ T-cell count (<em>1</em>0 of 39 patients; P < 0.00<em>1</em>). In multivariate analysis of all laboratory values at the seroconversion visit, a plasma HIV-<em>1</em> RNA level greater than <em>1</em> x <em>1</em>0(5) Eq/mL was the most powerful predictor of AIDS (odds ratio, <em>1</em>0.8; P = 0.0<em>1</em>).

CONCLUSIONS

Plasma HIV-<em>1</em> RNA is a strong, CD4+ T-cell-independent predictor of a rapid progression to AIDS after HIV-<em>1</em> seroconversion.

PURPOSE To test the hypothesis that increasing radiation dose delivered to men with early-stage prostate cancer improves clinical outcomes. PATIENTS AND METHODS Men with T<em>1</em>b-T2b prostate cancer and prostate-specific antigen </= <em>1</em>5 ng/<em>mL</em> were randomly assigned to a total dose of either 70.2 Gray equivalents (GyE; conventional) or 79.2 GyE (high). No patient received androgen suppression therapy with radiation. Local failure (LF), biochemical failure (BF), and overall survival (OS) were outcomes. Results A total of 393 men were randomly assigned, and median follow-up was 8.9 years. Men receiving high-dose radiation therapy were significantly less likely to have LF, with a hazard ratio of 0.57. The <em>1</em>0-year American Society for Therapeutic Radiology and Oncology BF rates were 32.4% for conventional-dose and <em>1</em>6.7% for high-dose radiation therapy (P < .000<em>1</em>). This difference held when only those with low-risk disease (n = 227; 58% of total) were examined: 28.2% for conventional and 7.<em>1</em>% for high dose (P < .000<em>1</em>). There was a strong trend in the same direction for the intermediate-risk patients (n = <em>1</em>44; 37% of total; 42.<em>1</em>% v 30.4%, P = .06). Eleven percent of patients subsequently required androgen deprivation for recurrence after conventional dose compared with 6% after high dose (P = .047). There remains no difference in OS rates between the treatment arms (78.4% v 83.4%; P = .4<em>1</em>). Two percent of patients in both arms experienced late grade>>/= 3 genitourinary toxicity, and <em>1</em>% of patients in the high-dose arm experienced late grade>>/= 3 GI toxicity. CONCLUSION This randomized controlled trial shows superior long-term cancer control for men with localized prostate cancer receiving high-dose versus conventional-dose radiation. This was achieved without an increase in grade>>/= 3 late urinary or rectal morbidity.

In its normal state, the eye lens is transparent despite the presence in the cell cytoplasm of high concentrations of proteins, the crystallins, which, a priori, could be expected to scatter an important part of the incident light. Early on, an explanation was sought in the spatial correlations between individual scatterers. Trokel first proposed that the "high concentration of proteins in the lens must be accompanied by a degree of local order approaching a paracrystalline state"; Benedek subsequently suggested that a dense, noncrystalline packing of the proteins would sufficiently reduce the scattered intensity. However, in spite of an improved understanding of the molecular structure of crystallins, their spatial order remained unknown. We present here a small-angle X-ray scattering study of the problem, performed with calf lens cytoplasm both in intact lenses and in cytoplasmic extracts where the crystallin concentration was varied from 3 to 5<em>1</em>0 mg <em>ml</em>-<em>1</em>. All our experimental data are consistent with short-range spatial order, as in dense liquids or glasses, and this provides a simple explanation for lens transparency. In addition, we detected no conformational change or reorganization of the crystallin proteins throughout the investigated concentration range.

OBJECTIVE

To determine whether plasma tumor necrosis factor-alpha (TNF-alpha), interleukin-<em>1</em> beta (IL-<em>1</em> beta), interleukin-6 (IL-6), and lipopolysaccharide are detectable in patients when they first present with the sepsis syndrome and to determine whether levels correlate with patient survival.

METHODS

Prospective study comparing patients with the sepsis syndrome, critically ill patients without sepsis, and normal healthy volunteers.

METHODS

Tertiary care hospital affiliated with a medical school.

METHODS

The study included 97 consecutive patients on a medical service who met the criteria for the sepsis syndrome; 20 critically ill patients without sepsis who were in the medical intensive care unit; and 20 healthy volunteers who served as comparison groups.

METHODS

Plasma tumor necrosis factor-alpha, IL-<em>1</em> beta, interleukin-6, and endotoxin (lipopolysaccharide) levels were measured when a patient was first identified as having the sepsis syndrome. Survival was defined as being alive 30 days after the sepsis syndrome was diagnosed.

RESULTS

Fifty-four percent of patients with the sepsis syndrome had detectable levels of TNF-alpha (median, 26 pg/mL; range, nondetectable to <em>1</em>000 pg/mL); 37% had detectable levels of IL-<em>1</em> (median, 20 pg/mL; range, nondetectable to 2850 pg/mL); 80% had detectable levels of IL-6 (median, 4<em>1</em>5 pg/mL; range, nondetectable to 2380 pg/mL); and 89% had detectable levels of lipopolysaccharide (median, 2.6; range, nondetectable to <em>1</em>2.5 endotoxin units [EU]/mL). In all cases levels were higher than those in critically ill patients without sepsis and normal healthy controls (P < 0.00<em>1</em> for all comparisons). Plasma levels of TNF-alpha, IL-<em>1</em> beta, IL-6, and lipopolysaccharide were detectable in patients regardless of culture status. The IL-6 level was 69% (95% CI, 30% to <em>1</em>08%) higher in patients who died compared with those who survived. The scores for the individual levels of TNF-alpha, IL-<em>1</em> beta, IL-6, and lipopolysaccharide were summed to arrive at a total lipopolysaccharide-cytokine score, and mortality increased with lipopolysaccharide-cytokine score (P < 0.00<em>1</em>).

CONCLUSIONS

Patients with the sepsis syndrome have detectable levels of circulating TNF-alpha, IL-<em>1</em>, IL-6, and lipopolysaccharide independent of culture-documented infection. Lipopolysaccharide and cytokines may play a pathogenic role in sepsis, and the combination of several elevated factors may be important in determining patient survival.

This study investigates the separate effects of age and hepatocellular liver disease on the disposition and elimination of diazepam (Valium) in man. The drug was given either by rapid intravenous injection (0.<em>1</em> mg/kg) or orally (<em>1</em>0 mg) to 33 normal volunteers rnaging in age from <em>1</em>5 to 82 yr as well as to 9 individuals with alcoholic cirrhosis, 8 with acute viral hepatitis, and 4 with chronic active hepatitis. In the normal individuals, the terminal plasma half-life of diazepam, (t <em>1</em>/2 (B)) exhibited a striking age-dependence; at 20 yr the t <em>1</em>/2 (beta) was about 20 h, but it increased linearly with age to about 90 h at 80 yr. The plasma clearance of diazepam in the majority of the normal subjects was between 20 and 32 <em>ml</em>/min and showed no significant age-dependence. Cigarette smoking did not affect the half-life or the clearance. Additionally, neither the plasma binding (97.4 plus or minus <em>1</em>.2%, mean plus or minus SD) nor the blood/plasma concentration ratio (0.58 plus or minus 0.<em>1</em>6) of diazepam showed any age-related changes (P greater than 0.05). By contrast, analysis of the intravenous data according to a two-compartment open model indicated that both the initial distribution space (V<em>1</em>) and the volume of distribution at steady state [Vd(ss)] of diazepam increased linearly with age (P less than 0.005). The increase in Vd(ss) was secondary to the change in V<em>1</em>. It appears then that the prolongation of t <em>1</em>/2 (beta) of diazepam with age is primarily dependent on an increase in the initial distribution volume of the drug. The plasma concentration/time course of the metabolite, desmethyldiazepam, was also affected by age. In older individuals, the initial presence and the peak values of desmethyldiazepam were observed later and the metabolite was present in lower concentrations. Despite the profound prolongation of t <em>1</em>/2 (theta) with age, the constancy of diazepam clearance indicates that drug plasma concentrations will not accumulate any more in the old than the young, and chronic dosage more in the old than the young, and chronic dosage modifications based on pharmacokinetic considerations are unnecessary. Data obtained in patients with liver disease were compared with those found in age-matched control groups. Patients with cirrhosis showed a more than twofold prolongation in the half-life of diazepam (<em>1</em>05.6 plus or minus <em>1</em>5.2 vs. 46.6 plus or minus <em>1</em>4.2 h, P less than 0.00<em>1</em>).