BACKGROUND

There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking.

METHODS

A retrospective analysis using the German Trauma Registry database including <em>1</em>7,200 multiple injured patients was conducted to determine (a) to what extent clinically relevant coagulopathy has already been established upon ER admission, and whether its presence was associated (b) with the amount of intravenous fluids (i.v.) administered pre-clinically, (c) with the magnitude of injury, and (d) with impaired outcome and mortality. Eight thousand seven hundred and twenty-four patients with complete data sets were screened.

RESULTS

Coagulopathy upon ER admission as defined by prothrombin time test (Quick's value) <70% and/or platelets (<em>1</em>00,000 microl(-<em>1</em>), was present in 34.2% of all patients. There was an increasing incidence for coagulopathy with increasing amounts of i.v. fluids administered pre-clinically. Coagulopathy was observed in >40% of patients with >2000 <em>ml</em>, in >50% with >3000 <em>ml</em>, and in >70% with >4000 <em>ml</em> administered. Ten percentage of patients presented with clotting disorders although pre-clinical resuscitation was limited to 500 <em>ml</em> of i.v. fluids maximum. The mean ISS score in the coagulopathy group was 30 (S.D. <em>1</em>5) versus 2<em>1</em> (S.D. <em>1</em>2) (p<0.00<em>1</em>). Twenty-nine percentage of patients with coagulopathy developed multi organ failure (p<0.00<em>1</em>). Early in-hospital mortality (<24h) was <em>1</em>3% in patients with coagulopathy (p<0.00<em>1</em>) and overall in-hospital mortality totalled 28% (p<0.00<em>1</em>).

CONCLUSIONS

There is a high frequency of established coagulopathy in multiple injury upon ER admission. The presence of early traumatic coagulopathy was associated with the amount of intravenous fluids administered pre-clinically, magnitude of injury, and impaired outcome.

BACKGROUND

We aimed to assess the clinical validity of circulating tumour cell (CTC) quantification for prognostication of patients with metastatic breast cancer by undertaking a pooled analysis of individual patient data.

METHODS

We contacted 5<em>1</em> European centres and asked them to provide reported and unreported anonymised data for individual patients with metastatic breast cancer who participated in studies between January, 2003, and July, 20<em>1</em>2. Eligible studies had participants starting a new line of therapy, data for progression-free survival or overall survival, or both, and CTC quantification by the CellSearch method at baseline (before start of new treatment). We used Cox regression models, stratified by study, to establish the association between CTC count and progression-free survival and overall survival. We used the landmark method to assess the prognostic value of CTC and serum marker changes during treatment. We assessed the added value of CTCs or serum markers to prognostic clinicopathological models in a resampling procedure using likelihood ratio (LR) χ(2) statistics.

RESULTS

<em>1</em>7 centres provided data for <em>1</em>944 eligible patients from 20 studies. 9<em>1</em><em>1</em> patients (46·9%) had a CTC count of 5 per 7·5 <em>mL</em> or higher at baseline, which was associated with decreased progression-free survival (hazard ratio [HR] <em>1</em>·92, 95% CI <em>1</em>·73-2·<em>1</em>4, p<0·000<em>1</em>) and overall survival (HR 2·78, 95% CI 2·42-3·<em>1</em>9, p<0·000<em>1</em>) compared with patients with a CTC count of less than 5 per 7·5 <em>mL</em> at baseline. Increased CTC counts 3-5 weeks after start of treatment, adjusted for CTC count at baseline, were associated with shortened progression-free survival (HR <em>1</em>·85, 95% CI <em>1</em>·48-2·32, p<0·000<em>1</em>) and overall survival (HR 2·26, 95% CI <em>1</em>·68-3·03) as were increased CTC counts after 6-8 weeks (progression-free survival HR 2·20, 95% CI <em>1</em>·66-2·90, p<0·000<em>1</em>; overall survival HR 2·9<em>1</em>, 95% CI 2·0<em>1</em>-4·23, p<0·000<em>1</em>). Survival prediction was significantly improved by addition of baseline CTC count to the clinicopathological models (progression-free survival LR 38·4, 95% CI 2<em>1</em>·9-60·3, p<0·000<em>1</em>; overall survival LR 64·9, 95% CI 4<em>1</em>·3-93·4, p<0·000<em>1</em>). This model was further improved by addition of CTC change at 3-5 weeks (progression-free survival LR 8·2, 95% CI 0·78-20·4, p=0·004; overall survival LR <em>1</em><em>1</em>·5, 95% CI 2·6-25·<em>1</em>, p=0·0007) and at 6-8 weeks (progression-free survival LR <em>1</em>5·3, 95% CI 5·2-28·3; overall survival LR <em>1</em>4·6, 95% CI 4·0-30·6; both p<0·000<em>1</em>). Carcinoembryonic antigen and cancer antigen <em>1</em>5-3 concentrations at baseline and during therapy did not add significant information to the best baseline model.

CONCLUSIONS

These data confirm the independent prognostic effect of CTC count on progression-free survival and overall survival. CTC count also improves the prognostication of metastatic breast cancer when added to full clinicopathological predictive models, whereas serum tumour markers do not.

BACKGROUND

Janssen Diagnostics, the Nuovo-Soldati foundation for cancer research.

OBJECTIVE

The mechanisms for clinical deterioration in patients with ischemic stroke are not completely understood. Several proinflammatory cytokines are released early after the onset of brain ischemia, but it is unknown whether inflammation predisposes to neurological deterioration. We assessed the implication of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha in early neurological worsening in ischemic stroke.

METHODS

Two hundred thirty-one patients consecutively admitted with first-ever ischemic cerebral infarction within the first 24 hours from onset were included. Neurological worsening was defined when the Canadian Stroke Scale (CSS) score fell at least <em>1</em> point during the first 48 hours after admission. IL-6 and TNF-alpha were determined in plasma and cerebrospinal fluid (CSF; n=8<em>1</em>) obtained on admission.

RESULTS

Eighty-three patients (35.9%) deteriorated within the first 48 hours. IL-6 in plasma (>2<em>1</em>.5 pg/mL; OR 37.7, CI <em>1</em><em>1</em>.9 to <em>1</em><em>1</em>8.8) or in CSF (>6.3 pg/mL; OR <em>1</em>3.<em>1</em>, CI 2.2 to 77.3) were independent factors for early clinical worsening, with multiple logistic regression. The association was statistically significant in all ischemic stroke subtypes as well as in subjects with cortical or subcortical infarctions. IL-6 in plasma was highly correlated with body temperature, glucose, fibrinogen, and infarct volume. CSF and plasma concentrations of TNF-alpha were also higher in patients who deteriorated, but the differences observed did not remain significant on multivariate analysis.

CONCLUSIONS

In addition to participating in the acute-phase response that follows focal cerebral ischemia, IL-6 levels on admission are associated with early clinical deterioration. The association between IL-6 and early neurological worsening prevails without regard to the initial size, topography, or mechanism of the ischemic infarction.

Circulating tumor cells (CTC) released into blood from primary cancers and metastases reflect the current status of tumor genotypes, which are prone to changes. Here, we conducted the first comprehensive genomic profiling of CTCs using array-comparative genomic hybridization (CGH) and next-generation sequencing. We used the U.S. Food and Drug Administration-cleared CellSearch system, which detected CTCs in 2<em>1</em> of 37 patients (range, <em>1</em>-202/7.5 <em>mL</em> sample) with stage IV colorectal carcinoma. In total, we were able to isolate 37 intact CTCs from six patients and identified in those multiple colorectal cancer-associated copy number changes, many of which were also present in the respective primary tumor. We then used massive parallel sequencing of a panel of 68 colorectal cancer-associated genes to compare the mutation spectrum in the primary tumors, metastases, and the corresponding CTCs from two of these patients. Mutations in known driver genes [e.g., adenomatous polyposis coli (APC), KRAS, or PIK3CA] found in the primary tumor and metastasis were also detected in corresponding CTCs. However, we also observed mutations exclusively in CTCs. To address whether these mutations were derived from a small subclone in the primary tumor or represented new variants of metastatic cells, we conducted additional deep sequencing of the primary tumor and metastasis and applied a customized statistical algorithm for analysis. We found that most mutations initially found only in CTCs were also present at subclonal level in the primary tumors and metastases from the same patient. This study paves the way to use CTCs as a liquid biopsy in patients with cancer, providing more effective options to monitor tumor genomes that are prone to change during progression, treatment, and relapse.

Twenty-nine drugs of disparate structures and physicochemical properties were used in an examination of the capability of human liver microsomal lability data ("in vitro T(<em>1</em>/2)" approach) to be useful in the prediction of human clearance. Additionally, the potential importance of nonspecific binding to microsomes in the in vitro incubation milieu for the accurate prediction of human clearance was investigated. The compounds examined demonstrated a wide range of microsomal metabolic labilities with scaled intrinsic clearance values ranging from less than 0.5 <em>ml</em>/min/kg to <em>1</em>89 <em>ml</em>/min/kg. Microsomal binding was determined at microsomal protein concentrations used in the lability incubations. For the 29 compounds studied, unbound fractions in microsomes ranged from 0.<em>1</em><em>1</em> to <em>1</em>.0. Generally, basic compounds demonstrated the greatest extent of binding and neutral and acidic compounds the least extent of binding. In the projection of human clearance values, basic and neutral compounds were well predicted when all binding considerations (blood and microsome) were disregarded, however, including both binding considerations also yielded reasonable predictions. Including only blood binding yielded very poor projections of human clearance for these two types of compounds. However, for acidic compounds, disregarding all binding considerations yielded poor predictions of human clearance. It was generally most difficult to accurately predict clearance for this class of compounds; however the accuracy was best when all binding considerations were included. Overall, inclusion of both blood and microsome binding values gave the best agreement between in vivo clearance values and clearance values projected from in vitro intrinsic clearance data.

BACKGROUND

Seroprevalence data suggest that a third of the world's population has been infected with the hepatitis E virus. Our aim was to assess efficacy and safety of a recombinant hepatitis E vaccine, HEV 239 (Hecolin; Xiamen Innovax Biotech, Xiamen, China) in a randomised, double-blind, placebo-controlled, phase 3 trial.

METHODS

Healthy adults aged <em>1</em>6-65 years in, Jiangsu Province, China were randomly assigned in a <em>1</em>:<em>1</em> ratio to receive three doses of HEV 239 (30 microg of purified recombinant hepatitis E antigen adsorbed to 0.8 mg aluminium hydroxide suspended in 0.5 <em>mL</em> buffered saline) or placebo (hepatitis B vaccine) given intramuscularly at 0, <em>1</em>, and 6 months. Randomisation was done by computer-generated permuted blocks and stratified by age and sex. Participants were followed up for <em>1</em>9 months. The primary endpoint was prevention of hepatitis E during <em>1</em>2 months from the 3<em>1</em>st day after the third dose. Analysis was based on participants who received all three doses per protocol. Study participants, care givers, and investigators were all masked to group and vaccine assignments. This trial is registered with ClinicalTrials.gov, number NCT0<em>1</em>0<em>1</em>4845.

RESULTS

<em>1</em><em>1</em>,<em>1</em>65 of the trial participants were tested for hepatitis E virus IgG, of which 5285 (47%) were seropositive for hepatitis E virus. Participants were randomly assigned to vaccine (n=56,302) or placebo (n=56,302). 48,693 (86%) participants in the vaccine group and 48,663 participants (86%) in the placebo group received three vaccine doses and were included in the primary efficacy analysis. During the <em>1</em>2 months after 30 days from receipt of the third dose <em>1</em>5 per-protocol participants in the placebo group developed hepatitis E compared with none in the vaccine group. Vaccine efficacy after three doses was <em>1</em>00.0% (95% CI 72.<em>1</em>-<em>1</em>00.0). Adverse effects attributable to the vaccine were few and mild. No vaccination-related serious adverse event was noted.

CONCLUSIONS

HEV 239 is well tolerated and effective in the prevention of hepatitis E in the general population in China, including both men and women age <em>1</em>6-65 years.

BACKGROUND

Chinese National High-tech R&D Programme (863 programme), Chinese National Key Technologies R&D Programme, Chinese National Science Fund for Distinguished Young Scholars, Fujian Provincial Department of Sciences and Technology, Xiamen Science and Technology Bureau, and Fujian Provincial Science Fund for Distinguished Young Scholars.

BACKGROUND

Circulating tumour cells (CTCs) have shown prognostic relevance in metastatic breast, prostate, colon and pancreatic cancer. For further development of CTCs as a biomarker, we compared the performance of different protocols for CTC detection in murine breast cancer xenograft models (MDA-MB-23<em>1</em>, MDA-MB-468 and KPL-4). Blood samples were taken from tumour bearing animals (20 to 200 mm2) and analysed for CTCs using <em>1</em>. an epithelial marker based enrichment method (AdnaTest), 2. an antibody independent technique, targeting human gene transcripts (qualitative PCR), and 3. an antibody-independent approach, targeting human DNA-sequences (quantitative PCR). Further, gene expression changes associated with epithelial-to-mesenchymal transition (EMT) were determined with an EMT-specific PCR assay.

METHODS

We used the commercially available Adna Test, RT-PCR on human housekeeping genes and a PCR on AluJ sequences to detect CTCs in xenografts models. Phenotypic changes in CTCs were tested with the commercially available "Human Epithelial to Mesenchymal Transition RT-Profiler PCR Array".

RESULTS

Although the AdnaTest detects as few as <em>1</em> tumour cell in <em>1</em> ml of mouse blood spiking experiments, no CTCs were detectable with this approach in vivo despite visible metastasis formation. The presence of CTCs could, however, be demonstrated by PCR targeting human transcripts or DNA-sequences - without epithelial pre-enrichment. The failure of CTC detection by the AdnaTest resulted from downregulation of EpCAM, whereas mesenchymal markers like Twist and EGFR were upregulated on CTCs. Such a change in the expression profile during metastatic spread of tumour cells has already been reported and was linked to a biological program termed epithelial-mesenchymal transition (EMT).

CONCLUSIONS

The use of EpCAM-based enrichment techniques leads to the failure to detect CTC populations that have undergone EMT. Our findings may explain clinical results where low CTC numbers have been reported even in patients with late metastatic cancers. These results are a starting point for the identification of new markers for detection or capture of CTCs, including the mesenchymal-like subpopulations.

Elucidating virus-host interactions responsible for HIV-<em>1</em> transmission is important for advancing HIV-<em>1</em> prevention strategies. To this end, single genome amplification (SGA) and sequencing of HIV-<em>1</em> within the context of a model of random virus evolution has made possible for the first time an unambiguous identification of transmitted/founder viruses and a precise estimation of their numbers. Here, we applied this approach to HIV-<em>1</em> env analyses in a cohort of acutely infected men who have sex with men (MSM) and found that a high proportion (<em>1</em>0 of 28; 36%) had been productively infected by more than one virus. In subjects with multivariant transmission, the minimum number of transmitted viruses ranged from 2 to <em>1</em>0 with viral recombination leading to rapid and extensive genetic shuffling among virus lineages. A combined analysis of these results, together with recently published findings based on identical SGA methods in largely heterosexual (HSX) cohorts, revealed a significantly higher frequency of multivariant transmission in MSM than in HSX [<em>1</em>9 of 50 subjects (38%) versus 34 of <em>1</em>75 subjects (<em>1</em>9%); Fisher's exact p = 0.008]. To further evaluate the SGA strategy for identifying transmitted/founder viruses, we analyzed 239 overlapping 5' and 3' half genome or env-only sequences from plasma viral RNA (vRNA) and blood mononuclear cell DNA in an MSM subject who had a particularly well-documented virus exposure history 3-6 days before symptom onset and <em>1</em>4-<em>1</em>7 days before peak plasma viremia (47,600,000 vRNA molecules/<em>ml</em>). All 239 sequences coalesced to a single transmitted/founder virus genome in a time frame consistent with the clinical history, and a molecular clone of this genome encoded replication competent virus in accord with model predictions. Higher multiplicity of HIV-<em>1</em> infection in MSM compared with HSX is consistent with the demonstrably higher epidemiological risk of virus acquisition in MSM and could indicate a greater challenge for HIV-<em>1</em> vaccines than previously recognized.

BACKGROUND

In patients with severe heart failure, prolonged unloading of the myocardium with the use of a left ventricular assist device has been reported to lead to myocardial recovery in small numbers of patients for varying periods of time. Increasing the frequency and durability of myocardial recovery could reduce or postpone the need for subsequent heart transplantation.

METHODS

We enrolled <em>1</em>5 patients with severe heart failure due to nonischemic cardiomyopathy and with no histologic evidence of active myocarditis. All had markedly reduced cardiac output and were receiving inotropes. The patients underwent implantation of left ventricular assist devices and were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse remodeling. Once regression of left ventricular enlargement had been achieved, the beta2-adrenergic-receptor agonist clenbuterol was administered to prevent myocardial atrophy.

RESULTS

Eleven of the <em>1</em>5 patients had sufficient myocardial recovery to undergo explantation of the left ventricular assist device a mean (+/-SD) of 320+/-<em>1</em>86 days after implantation of the device. One patient died of intractable arrhythmias 24 hours after explantation; another died of carcinoma of the lung 27 months after explantation. The cumulative rate of freedom from recurrent heart failure among the surviving patients was <em>1</em>00% and 88.9% <em>1</em> and 4 years after explantation, respectively. The quality of life as assessed by the Minnesota Living with Heart Failure Questionnaire score at 3 years was nearly normal. Fifty-nine months after explantation, the mean left ventricular ejection fraction was 64+/-<em>1</em>2%, the mean left ventricular end-diastolic diameter was 59.4+/-<em>1</em>2.<em>1</em> mm, the mean left ventricular end-systolic diameter was 42.5+/-<em>1</em>3.2 mm, and the mean maximal oxygen uptake with exercise was 26.3+/-6.0 <em>ml</em> per kilogram of body weight per minute.

CONCLUSIONS

In this single-center study, we found that sustained reversal of severe heart failure secondary to nonischemic cardiomyopathy could be achieved in selected patients with the use of a left ventricular assist device and a specific pharmacologic regimen.

The cell line described here was established for a 50-year-old male patient with rapidly progressive non-Hodgkin's lymphoma whose marrow was diffusely infiltrated with large granular lymphocytes (LGL). Immunophenotyping of marrow blasts and peripheral lymphocytes was positive for CD56, CD2 and CD7, and negative for CD3. Cytotoxicity of peripheral blood mononuclear cells at an effector: target (E:T) cell ratio of 50:<em>1</em> was 79% against K562 cells and 48% against Daudi cells. To establish the line, cells from the peripheral blood were placed into enriched alpha medium containing <em>1</em>2.5% fetal calf serum, <em>1</em>2.5% horse serum, <em>1</em>0(-4) M beta-mercaptoethanol and <em>1</em>0(-6) M hydrocortisone. Growth of the line (termed NK-92) is dependent on the presence of recombinant IL-2 and a dose as low as <em>1</em>0 U/<em>ml</em> is sufficient to maintain proliferation. Conversely, cells die within 72 h when deprived of IL-2; IL-7 and IL-<em>1</em>2 do not maintain long-term growth, although IL-7 induces short-term proliferation measured by 3H-thymidine incorporation. None of the other cytokines tested (IL-<em>1</em> alpha, IL-6, TNF-alpha, IFN-alpha, IFN-gamma) supported growth of NK-92 cells which have the following characteristics: surface marker positive for CD2, CD7, CD<em>1</em><em>1</em>a, CD28, CD45, CD54, CD56bright; surface marker negative for CD<em>1</em>, CD3, CD4, CD5, CD8, CD<em>1</em>0, CD<em>1</em>4, CD<em>1</em>6, CD<em>1</em>9, CD20, CD23, CD34, HLA-DR. DNA analysis showed ger<em>ml</em>ine configuration for T-cell receptor beta and gamma genes. CD25 (p55 IL-2 receptor) is expressed on about 50% of all cells when tested at <em>1</em>00 U/<em>ml</em> of IL-2 and its expression correlates inversely with the IL-2 concentration. The p75 IL-2 receptor is expressed on about half of the cells at low density irrespective of the IL-2 concentration. NK-92 cells kill both K562 and Daudi cells very effectively in a 4 h5<em>1</em>-chromium release assay (84 and 86% respectively, at an E:T cell ratio of 5:<em>1</em>). The cell line described here thus displays characteristics of activated NK-cells and could be a valuable tool to study their biology.

Natural products, either as pure compounds or as standardized plant extracts, provide unlimited opportunities for new drug leads because of the unmatched availability of chemical diversity. To secure this, a number of pivotal quality standards need to be set at the level of extract processing and primary evaluation in pharmacological screening models. This review provides a number of recommendations that will help to define a more sound 'proof-of-concept' for antibacterial, antifungal, antiviral and antiparasitic potential in natural products. An integrated panel of pathogens is proposed for antimicrobial profiling, using accessible standard in vitro experimental procedures, endpoint parameters and efficacy criteria. Primary requirements include: (<em>1</em>) use of reference strains or fully characterized clinical isolates, (2) in vitro models on the whole organism and if possible cell-based, (3) evaluation of selectivity by parallel cytotoxicity testing and/or integrated profiling against unrelated micro-organisms, (4) adequately broad dose range, enabling dose-response curves, (5) stringent endpoint criteria with IC(50)-values generally below <em>1</em>00microug/<em>ml</em> for extracts and below 25microM for pure compounds, (6) proper preparation, storage and in-test processing of extracts, (7) inclusion of appropriate controls in each in vitro test replicate (blanks, infected and reference controls) and (8) follow-up of in vitro activity ('hit'-status) in matching animal models ('lead'-status).

Epithelial-mesenchymal transition (EMT) plays an important role in renal tubulointerstitial fibrosis and TGF-beta<em>1</em> is the key inducer of EMT. Phosphorylation of Smad proteins and/or mitogen-activated protein kinases (MAPK) is required for TGF-beta<em>1</em>-induced EMT. Because reactive oxygen species (ROS) are involved in TGF-beta<em>1</em> signaling and are upstream signaling molecules to MAPK, this study examined the role of ROS in TGF-beta<em>1</em>-induced MAPK activation and EMT in rat proximal tubular epithelial cells. Growth-arrested and synchronized NRK-52E cells were stimulated with TGF-beta<em>1</em> (0.2 to 20 ng/<em>ml</em>) or H(2)O(2) (<em>1</em> to 500 microM) in the presence or absence of antioxidants (N-acetylcysteine or catalase), inhibitors of NADPH oxidase (diphenyleneiodonium and apocynin), mitochondrial electron transfer chain subunit I (rotenone), and MAPK (PD 98059, an MEK [MAP kinase/ERK kinase] inhibitor, or p38 MAPK inhibitor) for up to 96 h. TGF-beta<em>1</em> increased dichlorofluorescein-sensitive cellular ROS, phosphorylated Smad 2, p38 MAPK, extracellular signal-regulated kinases (ERK)<em>1</em>/2, alpha-smooth muscle actin (alpha-SMA) expression, and fibronectin secretion and decreased E-cadherin expression. Antioxidants effectively inhibited TGF-beta<em>1</em>-induced cellular ROS, phosphorylation of Smad 2, p38 MAPK, and ERK, and EMT. H(2)O(2) reproduced all of the effects of TGF-beta<em>1</em> with the exception of Smad 2 phosphorylation. Chemical inhibition of ERK but not p38 MAPK inhibited TGF-beta<em>1</em>-induced Smad 2 phosphorylation, and both MAPK inhibitors inhibited TGF-beta<em>1</em>- and H(2)O(2)-induced EMT. Diphenyleneiodonium, apocynin, and rotenone also significantly inhibited TGF-beta<em>1</em>-induced ROS. Thus, this data suggest that ROS play an important role in TGF-beta<em>1</em>-induced EMT primarily through activation of MAPK and subsequently through ERK-directed activation of Smad pathway in proximal tubular epithelial cells.

BACKGROUND

Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery.

METHODS

This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 <em>ml</em> min(-<em>1</em>) m(-2) or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days.

RESULTS

Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (<em>1</em>,907 SD +/- 878 <em>ml</em> versus <em>1</em>,204 SD +/- 898 <em>ml</em>; p < 0.000<em>1</em>) and dopexamine (55 patients (89%) versus <em>1</em> patient (2%); p < 0.000<em>1</em>). Fewer GDT patients developed complications (27 patients (44%) versus 4<em>1</em> patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD +/- 0.9 per patient versus <em>1</em>.5 SD +/- <em>1</em>.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (<em>1</em><em>1</em> days (IQR 7 to <em>1</em>5) versus <em>1</em>4 days (IQR <em>1</em><em>1</em> to 27); p = 0.00<em>1</em>). There was no significant difference in mortality (seven patients (<em>1</em><em>1</em>.3%) versus nine patients (<em>1</em>5%); p = 0.59).

CONCLUSIONS

Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.

OBJECTIVE

To examine the relation between plasma HIV-<em>1</em> RNA concentrations in the community and HIV incidence among injecting drug users.

METHODS

Prospective cohort study.

METHODS

Inner city community in Vancouver, Canada.

METHODS

Injecting drug users, with and without HIV, followed up every six months between <em>1</em> May <em>1</em>996 and 30 June 2007.

METHODS

Estimated community plasma HIV-<em>1</em> RNA in the six months before each HIV negative participant's follow-up visit. Associated HIV incidence.

RESULTS

Among 622 injecting drug users with HIV, <em>1</em>2 435 measurements of plasma HIV-<em>1</em> RNA were obtained. Among <em>1</em>429 injecting drug users without HIV, there were <em>1</em>55 HIV seroconversions, resulting in an incidence density of 2.49 (95% confidence interval 2.09 to 2.88) per <em>1</em>00 person years. In a Cox model that adjusted for unsafe sexual behaviours and sharing used syringes, the estimated community plasma HIV-<em>1</em> RNA concentration remained independently associated with the time to HIV seroconversion (hazard ratio 3.32 (<em>1</em>.82 to 6.08, P<0.00<em>1</em>), per log(<em>1</em>0) increase). When the follow-up period was limited to observations after <em>1</em> January <em>1</em>988 (when the median plasma HIV RNA concentration was <20 000 copies/ml), the median viral load was no longer statistically associated with HIV incidence (<em>1</em>.70 (0.79 to 3.67, P=0.<em>1</em>75), per log(<em>1</em>0) increase).

CONCLUSIONS

A longitudinal measure of community plasma HIV-<em>1</em> RNA concentration was correlated with the community HIV incidence rate and predicted HIV incidence independent of unsafe sexual behaviours and sharing used syringes. If these findings are confirmed, they could help to inform both HIV prevention and treatment interventions.

BACKGROUND

An impaired glomerular filtration rate (GFR) leads to end-stage renal disease and increases the risks of cardiovascular disease and death. Persons with type <em>1</em> diabetes are at high risk for kidney disease, but there are no interventions that have been proved to prevent impairment of the GFR in this population.

METHODS

In the Diabetes Control and Complications Trial (DCCT), <em>1</em>44<em>1</em> persons with type <em>1</em> diabetes were randomly assigned to 6.5 years of intensive diabetes therapy aimed at achieving near-normal glucose concentrations or to conventional diabetes therapy aimed at preventing hyperglycemic symptoms. Subsequently, <em>1</em>375 participants were followed in the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study. Serum creatinine levels were measured annually throughout the course of the two studies. The GFR was estimated with the use of the Chronic Kidney Disease Epidemiology Collaboration formula. We analyzed data from the two studies to determine the long-term effects of intensive diabetes therapy on the risk of impairment of the GFR, which was defined as an incident estimated GFR of less than 60 ml per minute per <em>1</em>.73 m(2) of body-surface area at two consecutive study visits.

RESULTS

Over a median follow-up period of 22 years in the combined studies, impairment of the GFR developed in 24 participants assigned to intensive therapy and in 46 assigned to conventional therapy (risk reduction with intensive therapy, 50%; 95% confidence interval, <em>1</em>8 to 69; P=0.006). Among these participants, end-stage renal disease developed in 8 participants in the intensive-therapy group and in <em>1</em>6 in the conventional-therapy group. As compared with conventional therapy, intensive therapy was associated with a reduction in the mean estimated GFR of <em>1</em>.7 ml per minute per <em>1</em>.73 m(2) during the DCCT study but during the EDIC study was associated with a slower rate of reduction in the GFR and an increase in the mean estimated GFR of 2.5 ml per minute per <em>1</em>.73 m(2) (P<0.00<em>1</em> for both comparisons). The beneficial effect of intensive therapy on the risk of an impaired GFR was fully attenuated after adjustment for glycated hemoglobin levels or albumin excretion rates.

CONCLUSIONS

The long-term risk of an impaired GFR was significantly lower among persons treated early in the course of type <em>1</em> diabetes with intensive diabetes therapy than among those treated with conventional diabetes therapy. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT003608<em>1</em>5 and NCT00360893.).

We applied the polymerase chain reaction to detection of the pathogenic protozoan Toxoplasma gondii based on our identification of a 35-fold-repetitive gene (the B<em>1</em> gene) as a target. Using this procedure, we were able to amplify and detect the DNA of a single organism directly from a crude cell lysate. This level of sensitivity also allowed us to detect the B<em>1</em> gene from purified DNA samples containing as few as <em>1</em>0 parasites in the presence of <em>1</em>00,000 human leukocytes. This is representative of the maximal cellular infiltration (<em>1</em>0(5)/<em>ml</em>) in <em>1</em> <em>ml</em> of cerebrospinal fluid obtained from patients with toxoplasmic encephalitis. The B<em>1</em> gene is present and conserved in all six T. gondii strains tested to date, including two isolates from patients with acquired immunodeficiency syndrome. No signal was detected by using this assay and DNAs from a variety of other organisms, including several which might be found in the central nervous system of an immunocompromised host. This combination of sensitivity and specificity should make detection of the B<em>1</em> gene based on polymerase chain reaction amplification a very useful method for diagnosis of toxoplasmosis both in immunocompromised hosts and in congenitally infected fetuses.

Prochlorococcus is the numerically dominant phototroph in the tropical and subtropical oceans, accounting for half of the photosynthetic biomass in some areas. Here we report the isolation of cyanophages that infect Prochlorococcus, and show that although some are host-strain-specific, others cross-infect with closely related marine Synechococcus as well as between high-light- and low-light-adapted Prochlorococcus isolates, suggesting a mechanism for horizontal gene transfer. High-light-adapted Prochlorococcus hosts yielded Podoviridae exclusively, which were extremely host-specific, whereas low-light-adapted Prochlorococcus and all strains of Synechococcus yielded primarily Myoviridae, which has a broad host range. Finally, both Prochlorococcus and Synechococcus strain-specific cyanophage titres were low (< <em>1</em>0(3) <em>ml</em>(-<em>1</em>)) in stratified oligotrophic waters even where total cyanobacterial abundances were high >> <em>1</em>0(5) cells x <em>ml</em>(-<em>1</em>)). These low titres in areas of high total host cell abundance seem to be a feature of open ocean ecosystems. We hypothesize that gradients in cyanobacterial population diversity, growth rates, and/or the incidence of lysogeny underlie these trends.

OBJECTIVE

This study investigated the relationship between right ventricular (RV) structure and function and survival in idiopathic pulmonary arterial hypertension (IPAH).

RESULTS

In 64 patients, cardiac magnetic resonance, right heart catheterization, and the six-minute walk test (6MWT) were performed at baseline and after <em>1</em>-year follow-up. RV structure and function were analysed as predictors of mortality. During a mean follow-up of 32 months, <em>1</em>9 patients died. A low stroke volume (SV), RV dilatation, and impaired left ventricular (LV) filling independently predicted mortality. In addition, a further decrease in SV, progressive RV dilatation, and further decrease in LV end-diastolic volume (LVEDV) at <em>1</em>-year follow-up were the strongest predictors of mortality. According to Kaplan-Meier survival curves, survival was lower in patients with an inframedian SV index <or= 25 <em>mL</em>/m(2), a supramedian RV end-diastolic volume index>>or= 84 <em>mL</em>/m(2), and an inframedian LVEDV<or=40 <em>mL</em>/m(2).

CONCLUSIONS

The RV contains prognostic information in IPAH. A large RV volume, low SV, and a reduced LV volume are strong independent predictors of mortality and treatment failure.

BACKGROUND

Rotavirus vaccine has proved effective for prevention of severe rotavirus gastroenteritis in infants in developed countries, but no efficacy studies have been done in developing countries in Asia. We assessed the clinical efficacy of live oral pentavalent rotavirus vaccine for prevention of severe rotavirus gastroenteritis in infants in Bangladesh and Vietnam.

METHODS

In this multicentre, double-blind, placebo-controlled trial, undertaken in rural Matlab, Bangladesh, and urban and periurban Nha Trang, Vietnam, infants aged 4-<em>1</em>2 weeks without symptoms of gastrointestinal disorders were randomly assigned (<em>1</em>:<em>1</em>) to receive three oral doses of pentavalent rotavirus vaccine 2 <em>mL</em> or placebo at around 6 weeks, <em>1</em>0 weeks, and <em>1</em>4 weeks of age, in conjunction with routine infant vaccines including oral poliovirus vaccine. Randomisation was done by computer-generated randomisation sequence in blocks of six. Episodes of gastroenteritis in infants who presented to study medical facilities were reported by clinical staff and from parent recollection. The primary endpoint was severe rotavirus gastroenteritis (Vesikari score>>or=<em>1</em><em>1</em>) arising <em>1</em>4 days or more after the third dose of placebo or vaccine to end of study (March 3<em>1</em>, 2009; around 2<em>1</em> months of age). Analysis was per protocol; infants who received scheduled doses of vaccine or placebo without intervening laboratory-confirmed naturally occurring rotavirus disease earlier than <em>1</em>4 days after the third dose and had complete clinical and laboratory results were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT00362648.

RESULTS

2036 infants were randomly assigned to receive pentavalent rotavirus vaccine (n=<em>1</em>0<em>1</em>8) or placebo (n=<em>1</em>0<em>1</em>8). 99<em>1</em> infants assigned to pentavalent rotavirus vaccine and 978 assigned to placebo were included in the per-protocol analysis. Median follow up from <em>1</em>4 days after the third dose of placebo or vaccine until final disposition was 498 days (IQR 480-575). 38 cases of severe rotavirus gastroenteritis (Vesikari score>>or=<em>1</em><em>1</em>) were reported during more than <em>1</em><em>1</em>97 person-years of follow up in the vaccine group, compared with 7<em>1</em> cases in more than <em>1</em><em>1</em>56 person years in the placebo group, resulting in a vaccine efficacy of 48.3% (95% CI 22.3-66.<em>1</em>) against severe disease (p=0.0005 for efficacy >0%) during nearly 2 years of follow-up. 25 (2.5%) of <em>1</em>0<em>1</em>7 infants assigned to receive vaccine and 20 (2.0%) of <em>1</em>0<em>1</em>8 assigned to receive placebo had a serious adverse event within <em>1</em>4 days of any dose. The most frequent serious adverse event was pneumonia (vaccine <em>1</em>2 [<em>1</em>.2%]; placebo <em>1</em>5 [<em>1</em>.5%]).

CONCLUSIONS

In infants in developing countries in Asia, pentavalent rotavirus vaccine is safe and efficacious against severe rotavirus gastroenteritis, and our results support expanded WHO recommendations to promote its global use.

BACKGROUND

PATH (GAVI Alliance grant) and Merck.

The recently released Biograph mMR is the first commercially available integrated whole-body PET/MR scanner. There are considerable advantages to integrating both modalities in a single scanner that enables truly simultaneous acquisition. However, there are also concerns about the possible degradation of both PET and MR performance in an integrated system. This paper evaluates the performance of the Biograph mMR during independent and simultaneous acquisition of PET and morphologic MR data.

METHODS

The NEMA NU 2-2007 protocol was followed for studying the PET performance. The following measurements were performed: spatial resolution; scatter fraction, count losses, and randoms; sensitivity; accuracy of the correction for count losses and randoms; and image quality. The quality control manual of the American College of Radiology was followed for studying the MR performance. The following measurements were performed: geometric accuracy, spatial resolution, low-contrast detectability, signal-to-noise ratio, static field (B(0)) homogeneity, radiofrequency field (B(<em>1</em>)) homogeneity, and radiofrequency noise.

RESULTS

An average spatial resolution of 4.3 mm in full width at half maximum was measured at <em>1</em> cm offset from the center of the field of view. The system sensitivity was <em>1</em>5.0 kcps/MBq along the center of the scanner. The scatter fraction was 37.9%, and the peak noise-equivalent count rate was <em>1</em>84 kcps at 23.<em>1</em> kBq/mL. The maximum absolute value of the relative count rate error due to dead-time losses and randoms was 5.5%. The average residual error in scatter and attenuation correction was <em>1</em>2.<em>1</em>%. All MR parameters were within the tolerances defined by the American College of Radiology. B(0) inhomogeneities below <em>1</em> ppm were measured in a <em>1</em>20-mm radius. B(<em>1</em>) homogeneity and signal-to-noise ratio were equivalent to those of a standard MR scanner. No radiofrequency interference was detected.

CONCLUSIONS

These results compare favorably with other state-of-the-art PET/CT and PET/MR scanners, indicating that the integration of the PET detectors in the MR scanner and their operation within the magnetic field do not have a perceptible impact on the overall performance. The MR subsystem performs essentially like a standalone system. However, further work is necessary to evaluate the more advanced MR applications, such as functional imaging and spectroscopy.

OBJECTIVE

Multivariate prognostic instruments aim to predict risk of recurrence among patients with localized prostate cancer. We devised a novel risk assessment tool which would be a strong predictor of outcome across various levels of risk, and which could be easily applied and intuitively understood.

METHODS

We studied 1,439 men diagnosed between 1992 and 2001 who had undergone radical prostatectomy and were followed in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database, a longitudinal, community based disease registry of patients with prostate cancer. Disease recurrence was defined as prostate specific antigen (PSA) 0.2 ng/ml or greater on 2 consecutive occasions following prostatectomy or a second cancer treatment more than 6 months after surgery. The University of California, San Francisco-Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score was developed using preoperative PSA, Gleason score, clinical T stage, biopsy results and age. The index was developed and validated using Cox proportional hazards and life table analyses.

RESULTS

A total of 210 patients (15%) had recurrence, 145 by PSA criteria and 65 by second treatment. Based on the results of the Cox analysis, points were assigned based on PSA (0 to 4 points), Gleason score (0 to 3), T stage (0 to 1), age (0 to 1) and percent of biopsy positive cores (0 to 1). The UCSF-CAPRA score range is 0 to 10, with roughly double the risk of recurrence for each 2-point increase in score. Recurrence-free survival at 5 years ranged from 85% for a UCSF-CAPRA score of 0 to 1 (95% CI 73%-92%) to 8% for a score of 7 to 10 (95% CI 0%-28%). The concordance index for the UCSF-CAPRA score was 0.66.

CONCLUSIONS

The UCSF-CAPRA score is a straightforward yet powerful preoperative risk assessment tool. It must be externally validated in future studies.

OBJECTIVE

We define the role of urine volume as a stone risk factor in idiopathic calcium stone disease and test the actual preventive effectiveness of a high water intake.

METHODS

We studied <em>1</em>0<em>1</em> controls and <em>1</em>99 patients from the first idiopathic calcium stone episode. After a baseline study period the stone formers were divided by randomization into 2 groups (<em>1</em> and 2) and they were followed prospectively for 5 years. Followup in group <em>1</em> only involved a high intake of water without any dietetic change, while followup in group 2 did not involve any treatment. Each year clinical, laboratory and radiological evaluation was obtained to determine urinary stone risk profile (including relative supersaturations of calcium oxalate, brushite and uric acid by Equil 2), recurrence rate and mean time to relapse.

RESULTS

The original urine volume was lower in male and female stone formers compared to controls (men with calcium oxalate stones <em>1</em>,057 +/- 238 ml./24 hours versus normal men <em>1</em>,40<em>1</em> +/- 562 ml./24 hours, p < 0.000<em>1</em> and women calcium oxalate stones 990 +/- 230 ml./24 hours versus normal women <em>1</em>,239 +/- 440 ml./24 hours, p < 0.00<em>1</em>). During followup recurrences were noted within 5 years in <em>1</em>2 of 99 group <em>1</em> patients and in 27 of <em>1</em>00 group 2 patients (p = 0.008). The average interval for recurrences was 38.7 +/- <em>1</em>3.2 months in group <em>1</em> and 25.<em>1</em> +/- <em>1</em>6.4 months in group 2 (p = 0.0<em>1</em>6). The relative supersaturations for calcium oxalate, brushite and uric acid were much greater in baseline urine of the stone patients in both groups compared to controls. During followup, baseline values decreased sharply only in group <em>1</em>. Finally the baseline urine in patients with recurrences was characterized by a higher calcium excretion compared to urine of the patients without recurrences in both groups.

CONCLUSIONS

We conclude that urine volume is a real stone risk factor in nephrolithiasis and that a large intake of water is the initial therapy for prevention of stone recurrences. In cases of hypercalciuria it is suitable to prescribe adjuvant specific diets or drug therapy.

BACKGROUND

Use of raltegravir with optimum background therapy is effective and well tolerated in treatment-experienced patients with multidrug-resistant HIV-<em>1</em> infection. We compared the safety and efficacy of raltegravir with efavirenz as part of combination antiretroviral therapy for treatment-naive patients.

METHODS

Patients from 67 study centres on five continents were enrolled between Sept <em>1</em>4, 2006, and June 5, 2008. Eligible patients were infected with HIV-<em>1</em>, had viral RNA (vRNA) concentration of more than 5000 copies per mL, and no baseline resistance to efavirenz, tenofovir, or emtricitabine. Patients were randomly allocated by interactive voice response system in a <em>1</em>:<em>1</em> ratio (double-blind) to receive 400 mg oral raltegravir twice daily or 600 mg oral efavirenz once daily, in combination with tenofovir and emtricitabine. The primary efficacy endpoint was achievement of a vRNA concentration of less than 50 copies per mL at week 48. The primary analysis was per protocol. The margin of non-inferiority was <em>1</em>2%. This study is registered with ClinicalTrials.gov, number NCT0036994<em>1</em>.

RESULTS

566 patients were enrolled and randomly allocated to treatment, of whom 28<em>1</em> received raltegravir, 282 received efavirenz, and three were never treated. At baseline, 297 (53%) patients had more than <em>1</em>00 000 vRNA copies per mL and 267 (47%) had CD4 counts of 200 cells per microL or less. The main analysis (with non-completion counted as failure) showed that 86.<em>1</em>% (n=24<em>1</em> patients) of the raltegravir group and 8<em>1</em>.9% (n=230) of the efavirenz group achieved the primary endpoint (difference 4.2%, 95% CI -<em>1</em>.9 to <em>1</em>0.3). The time to achieve such viral suppression was shorter for patients on raltegravir than on efavirenz (log-rank test p<0.000<em>1</em>). Significantly fewer drug-related clinical adverse events occurred in patients on raltegravir (n=<em>1</em>24 [44.<em>1</em>%]) than those on efavirenz (n=2<em>1</em>7 [77.0%]; difference -32.8%, 95% CI -40.2 to -25.0, p<0.000<em>1</em>). Serious drug-related clinical adverse events occurred in less than 2% of patients in each drug group.

CONCLUSIONS

Raltegravir-based combination treatment had rapid and potent antiretroviral activity, which was non-inferior to that of efavirenz at week 48. Raltegravir is a well tolerated alternative to efavirenz as part of a combination regimen against HIV-<em>1</em> in treatment-naive patients.

BACKGROUND

Merck.

OBJECTIVE

To improve clinical outcome and to determine new treatment options, we studied the pathophysiologic response postburn in a large prospective, single center, clinical trial.

BACKGROUND

A severe burn injury leads to marked hypermetabolism and catabolism, which are associated with morbidity and mortality. The underlying pathophysiology and the correlations between humoral changes and organ function have not been well delineated.

METHODS

Two hundred forty-two severely burned pediatric patients [>30% total body surface area (TBSA)], who received no anabolic drugs, were enrolled in this study. Demographics, clinical data, serum hormones, serum cytokine expression profile, organ function, hypermetabolism, muscle protein synthesis, incidence of wound infection sepsis, and body composition were obtained throughout acute hospital course.

RESULTS

Average age was 8 +/- 0.2 years, and average burn size was 56 +/- <em>1</em>% TBSA with 43 +/- <em>1</em>% third-degree TBSA. All patients were markedly hypermetabolic throughout acute hospital stay and had significant muscle protein loss as demonstrated by a negative muscle protein net balance (-0.05% +/- 0.007 nmol/<em>1</em>00 <em>mL</em> leg/min) and loss of lean body mass (LBM) (-4.<em>1</em>% +/- <em>1</em>.9%); P < 0.05. Patients lost 3% +/- <em>1</em>% of their bone mineral content (BMC) and 2 +/- <em>1</em>% of their bone mineral density (BMD). Serum proteome analysis demonstrated profound alterations immediately postburn, which remained abnormal throughout acute hospital stay; P < 0.05. Cardiac function was compromised immediately after burn and remained abnormal up to discharge; P < 0.05. Insulin resistance appeared during the first week postburn and persisted until discharge. Patients were hyperinflammatory with marked changes in IL-8, MCP-<em>1</em>, and IL-6, which were associated with 2.5 +/- 0.2 infections and <em>1</em>7% sepsis.

CONCLUSIONS

In this large prospective clinical trial, we delineated the complexity of the postburn pathophysiologic response and conclude that the postburn response is profound, occurring in a timely manner, with derangements that are greater and more protracted than previously thought.