OBJECTIVE

We analyzed the long-term progression-free probability after radical retropubic prostatectomy in a consecutive series of patients with localized prostate cancer.

METHODS

From <em>1</em>983 to <em>1</em>998, <em>1</em>,000 patients (median age 62.9 years, range 37.7 to 8<em>1</em>.4) with clinical stage T<em>1</em> to T2 prostate cancer were treated with radical retropubic prostatectomy and pelvic lymphadenectomy, without other cancer related therapy before recurrence. Mean followup was 53.2 months (median 46.9, range <em>1</em> to <em>1</em>70).

RESULTS

Ten years after radical retropubic prostatectomy the mean probability +/- 2 standard errors that patients remained free of progression and of any further treatment was 75.0% +/- 3.7% and of metastasis 84.2% +/- 4.4%. Mean actuarial cancer specific survival rate +/- 2 standard error was 97.6% +/- <em>1</em>.7%. In a multivariate analysis pretreatment prostate specific antigen level (p <0.000<em>1</em>), biopsy Gleason sum (p <0.000<em>1</em>) and clinical stage (p=0.007<em>1</em>) were independent prognostic factors for progression. After prostatectomy independent risk factors were Gleason sum in the prostatectomy specimen (p=0.0008), extracapsular extension (p=0.00<em>1</em>9), seminal vesical involvement (p <0.000<em>1</em>), lymph node metastasis (p <0.000<em>1</em>) and surgical margin status (p <0.000<em>1</em>). Margins were positive in <em>1</em>2.8% of cases. At <em>1</em>0 years postoperatively radical retropubic prostatectomy was effective for cancer confined to the prostate (92.2% progression-free probability) and also not confined (52.8%), including 7<em>1</em>.4% progression-free probability for patients with only extracapsular extension and 37.4% with seminal vesicle invasion without lymph node metastasis.

CONCLUSIONS

Radical retropubic prostatectomy provided long-term cancer control in 75% of patients with clinically localized prostate cancer and was effective in the majority of those with high risk cancer, including T2c or biopsy Gleason sum 8 to <em>1</em>0, or PSA greater than 20 ng./ml. Further research should address identifying patients who can safely avoid aggressive therapy.

BACKGROUND

The incremental prognostic value of post-stress left ventricular ejection fraction (EF) and volume over perfusion has not been investigated.

RESULTS

We identified <em>1</em>680 consecutive patients who underwent rest Tl-20<em>1</em>/stress Tc-99m sestamibi gated single photon emission computed tomography (SPECT) and who were followed-up for 569+/-<em>1</em>06 days. Receiver-operator characteristics analysis defined an EF<45%, an end-systolic volume (ESV) >70 <em>mL</em>, and an end-diastolic volume>><em>1</em>20 <em>mL</em> as optimal thresholds, yielding moderate sensitivity and high specificity in the prediction of cardiac death. Patients with an EF> or = 45% had mortality rates (<em>1</em>%/year, despite severe perfusion abnormalities, whereas patients with an EF<45% had high mortality rates, even with only mild/moderate perfusion abnormalities (9.2%/year; P<0.0000<em>1</em>). Similarly, an ESV< or = 70 <em>mL</em> was related to a low cardiac death rate ((<em>1</em>.2%/year), even for patients with severe perfusion abnormalities, whereas patients with an ESV>70 <em>mL</em> and only mild/moderate perfusion abnormalities had high death rates (8.2%/year; P<0.0000<em>1</em>). Patients with an EF<45% and an ESV< or = 70 <em>mL</em> had low cardiac death rates (<em>1</em>.7%/year); those with an EF<45% but an ESV>70 <em>mL</em> had high death rates (7.9%/year; P<0.02). Multivariate Cox proportional hazards regression showed that perfusion variables and ESV were independent predictors of overall coronary events, whereas EF and ESV demonstrated incremental prognostic values over prescan and perfusion information in predicting cardiac death and cardiac death or myocardial infarction.

CONCLUSIONS

Post-stress EF and ESV by gated-SPECT have incremental prognostic values over prescan and perfusion information in predicting cardiac death, and they provide clinically useful risk stratification.

Human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) elite controllers (EC) maintain viremia below the limit of commercial assay detection (<50 RNA copies/<em>ml</em>) in the absence of antiviral therapy, but the mechanisms of control remain unclear. HLA-B57 and the closely related allele B*580<em>1</em> are particularly associated with enhanced control and recognize the same Gag(240-249) TW<em>1</em>0 epitope. The typical escape mutation (T242N) within this epitope diminishes viral replication capacity in chronically infected persons; however, little is known about TW<em>1</em>0 epitope sequences in residual replicating viruses in B57/B*580<em>1</em> EC and the extent to which mutations within this epitope may influence steady-state viremia. Here we analyzed TW<em>1</em>0 in a total of 50 B57/B*580<em>1</em>-positive subjects (23 EC and 27 viremic subjects). Autologous plasma viral sequences from both EC and viremic subjects frequently harbored the typical cytotoxic T-lymphocyte (CTL)-selected mutation T242N (<em>1</em>5/23 sequences [65.2%] versus 23/27 sequences [85.<em>1</em>%], respectively; P = 0.<em>1</em>8). However, other unique mutants were identified in HIV controllers, both within and flanking TW<em>1</em>0, that were associated with an even greater reduction in viral replication capacity in vitro. In addition, strong CTL responses to many of these unique TW<em>1</em>0 variants were detected by gamma interferon-specific enzyme-linked immunospot assay. These data suggest a dual mechanism for durable control of HIV replication, consisting of viral fitness loss resulting from CTL escape mutations together with strong CD8 T-cell immune responses to the arising variant epitopes.

OBJECTIVE

While our understanding of the pathogenesis and management of acute respiratory distress syndrome (ARDS) has improved over the past decade, estimates of its incidence have been controversial. The goal of this study was to examine ARDS incidence and outcome under current lung protective ventilatory support practices before and after the diagnosis of ARDS.

METHODS

This was a <em>1</em>-year prospective, multicenter, observational study in <em>1</em>3 geographical areas of Spain (serving a population of 3.55 million at least <em>1</em>8 years of age) between November 2008 and October 2009. Subjects comprised all consecutive patients meeting American-European Consensus Criteria for ARDS. Data on ventilatory management, gas exchange, hemodynamics, and organ dysfunction were collected.

RESULTS

A total of 255 mechanically ventilated patients fulfilled the ARDS definition, representing an incidence of 7.2/<em>1</em>00,000 population/year. Pneumonia and sepsis were the most common causes of ARDS. At the time of meeting ARDS criteria, mean PaO(2)/FiO(2) was <em>1</em><em>1</em>4 ± 40 mmHg, mean tidal volume was 7.2 ± <em>1</em>.<em>1</em> ml/kg predicted body weight, mean plateau pressure was 26 ± 5 cmH(2)O, and mean positive end-expiratory pressure (PEEP) was 9.3 ± 2.4 cmH(2)O. Overall ARDS intensive care unit (ICU) and hospital mortality was 42.7% (95%CI 37.7-47.8) and 47.8% (95%CI 42.8-53.0), respectively.

CONCLUSIONS

This is the first study to prospectively estimate the ARDS incidence during the routine application of lung protective ventilation. Our findings support previous estimates in Europe and are an order of magnitude lower than those reported in the USA and Australia. Despite use of lung protective ventilation, overall ICU and hospital mortality of ARDS patients is still higher than 40%.

Human hepatocytes in primary culture were used as a model system to investigate the mechanism(s) involved in the induction of the acute-phase response in human liver. Hepatocytes were incubated with increasing amounts of recombinant human interleukin-<em>1</em> beta, recombinant interleukin-6 and tumor necrosis factor-alpha. Synthesis of C-reactive protein was studied at the mRNA and protein levels. Only recombinant interleukin-6 was capable of inducing C-reactive protein-mRNA and C-reactive protein-protein synthesis. Also, fibrinogen and alpha-<em>1</em>-antitrypsin synthesis measured by immunoprecipitation with specific antisera increased in a dose-dependent, time-dependent manner, whereas albumin synthesis decreased to about 50% of controls. Maximal effects were observed at <em>1</em>00 to 300 units of recombinant interleukin-6/<em>ml</em> culture medium after 20 hr of incubation. Although the synthetic glucocorticoid dexamethasone slightly modulated the effect of recombinant interleukin-6, it was not an absolute requirement for the induction of acute-phase protein synthesis in human hepatocytes. In pulse-chase experiments it was shown that the time course of the disappearance of the acute-phase proteins from the cells and their appearance in the medium is not influenced by recombinant interleukin-6. This finding suggests that recombinant interleukin-6 exerts its regulatory effect on acute-phase protein synthesis at the pretranslational level.

BACKGROUND

Although insulin secretion is severely decreased in most patients with type <em>1</em> diabetes, levels of residual insulin secretion often vary early in the disease. The significance of residual insulin secretion with regard to metabolic control and to long-term complications and ways to preserve such secretion are not well understood.

OBJECTIVE

To compare the effects of intensive and conventional therapy on residual insulin secretion in Diabetes Control and Complications Trial (DCCT) participants.

METHODS

Multicenter, randomized, controlled clinical trial.

METHODS

29 DCCT clinical centers.

METHODS

855 of the <em>1</em>44<em>1</em> DCCT participants had had type <em>1</em> diabetes for <em>1</em> to 5 years at baseline. Of these 855 patients, 303 were C-peptide responders (C-peptide level, 0.20 to 0.50 pmol/mL after ingestion of a standardized, mixed meal); <em>1</em>38 of these patients were randomly assigned to intensive therapy, and <em>1</em>65 were assigned to conventional therapy. Five hundred fifty-two patients were nonresponders (stimulated C-peptide level < 0.2 pmol/mL); 274 of these patients were assigned to intensive therapy, and 278 were assigned to conventional therapy.

METHODS

<em>1</em>) Intensive therapy with 3 or more insulin injections daily or continuous subcutaneous infusion of insulin, guided by 4 or more glucose tests per day or 2) conventional therapy with <em>1</em> or 2 insulin injections daily.

METHODS

Stimulated C-peptide level was measured annually in responders. Development of retinopathy and microalbuminuria was assessed annually, hemoglobin A<em>1</em>c levels were measured quarterly, and episodes of hypoglycemia were ascertained quarterly.

RESULTS

Responders receiving intensive therapy maintained a higher stimulated C-peptide level and a lower likelihood of becoming nonresponders than did responders receiving conventional therapy (risk reduction, 57% [95% CI, 39% to 7<em>1</em>%]; P < 0.00<em>1</em>). As in the entire DCCT cohort, intensively treated responders had a reduced risk for retinopathy progression and development of microalbuminuria and a higher risk for severe hypoglycemia compared with conventionally treated responders. Among intensively treated patients, responders had a lower hemoglobin A<em>1</em>c value (P < 0.0<em>1</em>), a 50% (95% CI, <em>1</em>2% to 72%) reduced risk for retinopathy progression, and a lower risk for severe hypoglycemia (risk reduction, 65% [CI, 53% to 74%]; P < 0.00<em>1</em>) compared with nonresponders.

CONCLUSIONS

Intensive therapy for type <em>1</em> diabetes helps sustain endogenous insulin secretion, which, in turn, is associated with better metabolic control and lower risk for hypoglycemia and chronic complications. These observations underscore the importance of initiating intensive diabetic management as early as safely possible after type <em>1</em> diabetes is diagnosed.

This study aims to determine the presence of the components of the metabolic syndrome in primary nonalcoholic steatohepatitis (NASH) and to assess the role of liver disease in the genesis of peripheral hyperinsulinemia. Nineteen patients (<em>1</em>8 men and <em>1</em> woman; mean age, +/- SD, 38 +/- <em>1</em>0 years; body mass index [BMI], 26 +/- 2 kg/m(2)) with histologic evidence of NASH were enrolled; <em>1</em>9 age- and sex-matched normal subjects were investigated as controls. Plasma glucose, insulin, and C-peptide levels were measured during an oral glucose tolerance test, and a frequently sampled intravenous glucose tolerance test (FSIGT), analyzed by minimal modeling technique, was performed. Compared with controls, the NASH group had lower insulin sensitivity (3.84 +/- 2.44 vs. 7.48 +/- 3.0<em>1</em> <em>1</em>0(-4) x min(-<em>1</em>)/microU/<em>mL</em>; P =.0003) and higher total insulin secretion (2<em>1</em> +/- <em>1</em>3 vs. <em>1</em>0 +/- 3 nmol/L in 240 minutes; P =.00<em>1</em>). Hepatic insulin extraction was similar in both groups (69.8% +/- <em>1</em>6.<em>1</em>% vs. 70.2% +/- <em>1</em>8.3%; P =.854). According to the results of the oral glucose tolerance test, no patient was classified as diabetic, 5 were classified as glucose intolerant, and <em>1</em> was classified as having impaired fasting glycemia. Nine patients (47%) had at least the 2 minimum criteria required to define the metabolic syndrome according to the European Group for the Study of Insulin Resistance (EGIR). In conclusion, hyperinsulinemia and insulin resistance occur frequently in patients with NASH; these conditions do not stem from a reduced hepatic insulin extraction but from an enhanced pancreatic insulin secretion compensatory to reduced insulin sensitivity. The derangement of insulin regulation, often associated with the metabolic syndrome, may play a causal role in the pathogenesis of NASH.

BACKGROUND

Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy are brain disorders characterised by intracellular α-synuclein deposits. We aimed to assess whether reduction of α-synuclein concentrations in CSF was a marker for α-synuclein deposition in the brain, and therefore diagnostic of synucleinopathies.

METHODS

We assessed potential extracellular-fluid markers of α-synuclein deposition in the brain (total α-synuclein and total tau in CSF, and total α-synuclein in serum) in three cohorts: a cross-sectional training cohort of people with Parkinson's disease, multiple system atrophy, dementia with Lewy bodies, Alzheimer's disease, or other neurological disorders; a group of patients with autopsy-confirmed dementia with Lewy bodies, Alzheimer's disease, or other neurological disorders (CSF specimens were drawn ante mortem during clinical investigations); and a validation cohort of patients who between January, 2003, and December, 2006, were referred to a specialised movement disorder hospital for routine inpatient admission under the working diagnosis of parkinsonism. CSF and serum samples were assessed by ELISA, and clinical diagnoses were made according to internationally established criteria. Mean differences in biomarkers between diagnostic groups were assessed with conventional parametric and non-parametric statistics.

RESULTS

In our training set, people with Parkinson's disease, multiple system atrophy, and dementia with Lewy bodies had lower CSF α-synuclein concentrations than patients with Alzheimer's disease and other neurological disorders. CSF α-synuclein and tau values separated participants with synucleinopathies well from those with other disorders (p<0·000<em>1</em>; area under the receiver operating characteristic curve [AUC]=0·908). In the autopsy-confirmed cases, CSF α-synuclein discriminated between dementia with Lewy bodies and Alzheimer's disease (p=0·0<em>1</em>90; AUC=0·687); in the validation cohort, CSF α-synuclein discriminated Parkinson's disease and dementia with Lewy bodies versus progressive supranuclear palsy, normal-pressure hydrocephalus, and other neurological disorders (p<0·000<em>1</em>; AUC=0·7<em>1</em><em>1</em>). Other predictor variables tested in this cohort included CSF tau (p=0·0798), serum α-synuclein (p=0·0502), and age (p=0·0335). CSF α-synuclein concentrations of <em>1</em>·6 pg/<em>μL</em> or lower showed 70·72% sensitivity (95% CI 65·3-76·<em>1</em>%) and 52·83% specificity (39·4-66·3%) for the diagnosis of Parkinson's disease. At this cutoff, the positive predictive value for any synucleinopathy was 90·7% (95% CI 87·3-94·2%) and the negative predictive value was 20·4% (<em>1</em>3·7-27·2%).

CONCLUSIONS

Mean CSF α-synuclein concentrations as measured by ELISA are significantly lower in Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy than in other neurological diseases. Although specificity was low, the high positive predictive value of CSF α-synuclein concentrations in patients presenting with synucleinopathy-type parkinsonism might be useful in stratification of patients in future clinical trials.

BACKGROUND

American Parkinson Disease Association, Stifterverband für die Deutsche Wissenschaft, Michael J Fox Foundation for Parkinson's Research, National Institutes of Health, Parkinson Research Consortium Ottawa, and the Government of Canada.

Pure cultures of three types of mononuclear phagocytes-mouse peritoneal macrophages, unstimulated or after thioglycollate stimulation, and human monocytes-synthesize and secrete large amounts of lysozyme in vitro. The macrophage lysozyme is indistinguishable from authentic lysozyme in its ability to lyse M. lysodeikticus, inhibition by specific antisera, a similar size of <em>1</em>4,000 and cationic charge. Lysozyme secretion in culture is characterized by a large net increase in total lysozyme, 4-20-fold in 3 h, 75-95% of which is in the medium, and its continued extracellular accumulation over at least 2 wk in culture. Lysozyme is the major (<em>1</em>4)C-labeled protein secreted into the medium by both unstimulated and thioglycollate-stimulated macrophages and the 0.75-<em>1</em> microg produced per <em>1</em> x <em>1</em>0(6) cells/day represents 0.5-2.5% of the total cell protein. Lysozyme is a cell-specific marker for mononuclear phagocytes and the PMN, which contains preformed enzyme, since it is absent in lymphoid cells and a variety of fibroblast and epithelioid cell lines. Lysozyme production is also a useful measure of mononuclear phagocyte cell number. The rate of lysozyme production and secretion is remarkably constant for all cell types under a variety of culture conditions. Production by the mouse macrophage increases threefold on the 2nd day in culture and then remains linear with time. Production is optimal at a relatively low serum concentration, but can be maintained, in the absence of serum, in lactalbumin hydrolysate or, at a reduced level in basal media. The production and secretion of lysozyme are independent of the production of macrophage acid hydrolases. Net increase and secretion of lysozyme occur under conditions where acid hydrolases like N-acetyl beta-glucosaminidase, beta-glucuronidase, beta-galactosidase, and cathepsin D are neither accumulated nor secreted. Massive phagocytosis of latex particles has no effect on lysozyme production and secretion. Lysozyme production can be rapidly inhibited by treatment with cycloheximide (0.4 microg/<em>ml</em>) whereas inhibition of its production by colchicine (<em>1</em>0(-6) M) occurs only after a lag period of more than 8 h, and is probably due to a secondary effect. These results show that mouse macrophages provide a simple in vitro system to measure lysozyme secretion and its control. These studies also indicate the possible importance of mononuclear phagocytes in the secretion of a variety of biologically active products and in the modification of their environment.

We prospectively studied long-term antiretroviral adherence patterns and their impact on biologic outcomes for human immunodeficiency virus (HIV)-infected participants in 2 randomized, multicenter clinical trials. For the period from baseline to month <em>1</em>2 of the study, participants who reported adherence levels of <em>1</em>00%, 80%-99%, and 0%-79% had plasma HIV RNA levels that decreased by 2.77, 2.33, and 0.67 log(<em>1</em>0) copies/<em>mL</em>, respectively (P<.00<em>1</em>), whereas their CD4 counts increased by <em>1</em>79, <em>1</em>59, and 53 cells/mm(3), respectively (P<.00<em>1</em>). Adherence predicted nondetectable HIV RNA levels (<50 copies/<em>mL</em>) at <em>1</em>2 months of follow-up (P<.00<em>1</em>). The HIV RNA level was nondetectable in 72% of participants who reported <em>1</em>00% adherence at all 4 follow-up visits, compared with 66%, 4<em>1</em>%, 35%, and <em>1</em>3% of participants who reported <em>1</em>00% adherence at 3, 2, <em>1</em>, or 0 follow-up visits, respectively (P<.00<em>1</em>). Nonwhite race was associated with poorer adherence (P<.00<em>1</em>), and older age was associated with better adherence (P<.00<em>1</em>).

Apolipoprotein E (apoE), particularly the e4 allele, is genetically linked to the incidence of Alzheimer's disease. ApoE is present in the extracellular senile plaques and intracellular neurofibrillary tangles associated with Alzheimer's disease. In vitro, apoE has been shown to bind beta-amyloid (A beta), an amyloidogenic proteolytic product of amyloid precursor protein. To analyze the interaction of A beta and apoE, we used Western immunoblotting of human A beta-(<em>1</em>-40)-peptide incubated with conditioned medium from HEK-293 cells transfected with either human apoE3 or apoE4 (products of the e3 and e4 alleles, respectively) cDNA. Nonreducing SDS-polyacrylamide gel electrophoresis revealed the presence of an approximately 45-kDa complex with both A beta and apoE immunoreactivity. The level of the apoE3.A beta complex was approximately 20-fold greater than that of the apoE4.A beta complex. This apoE isoform-specific binding pattern was maintained from pH 5.0 to 9.0, from 2 min to 24 h of peptide incubation, and at concentrations of apoE from 5 to <em>1</em>00 micrograms/<em>ml</em> and of A beta from <em>1</em>0 microM to <em>1</em> mM. The higher level of apoE3 binding to A beta is in contrast to previously published data using purified apoE (Strittmatter, W. J., Weisgraber, K.H., Huang, D. Y., Dong, L.-M., Salvesen, G. S., Pericak-Vance, M., Schmechel, D., Saunders, A. M., Goldgaber, D., and Roses, A.D. (<em>1</em>993) Proc. Natl. Acad. Sci. U. S. A. 90, 8098-8<em>1</em>02). Factors responsible for the isoform-specific interactions between apoE and A beta will require further study before the apparent discrepancy between these data can be reconciled.

BACKGROUND

We identified an interleukin-<em>1</em> receptor family member, ST2, as a gene markedly induced by mechanical strain in cardiac myocytes and hypothesized that ST2 participates in the acute myocardial response to stress and injury.

RESULTS

ST2 mRNA was induced in cardiac myocytes by mechanical strain (4.7+/-0.9-fold) and interleukin-<em>1</em>beta (2.0+/-0.2-fold). Promoter analysis revealed that the proximal and not the distal promoter of ST2 is responsible for transcriptional activation in cardiac myocytes by strain and interleukin-<em>1</em>beta. In mice subjected to coronary artery ligation, serum ST2 was transiently increased compared with unoperated controls (20.8+/-4.4 versus 0.8+/-0.8 ng/mL, P<0.05). Soluble ST2 levels were increased in the serum of human patients (N=69) <em>1</em> day after myocardial infarction and correlated positively with creatine kinase (r=0.4<em>1</em>, P<0.00<em>1</em>) and negatively with ejection fraction (P=0.02).

CONCLUSIONS

These data identify ST2 release in response to myocardial infarction and suggest a role for this innate immune receptor in myocardial injury.

Replication-competent HIV-<em>1</em> can be isolated from infected patients despite prolonged plasma virus suppression by anti-retroviral treatment. Recent studies have identified resting, memory CD4+ T lymphocytes as a long-lived latent reservoir of HIV-<em>1</em> (refs. 4,5). Cross-sectional analyses indicate that the reservoir is rather small, between <em>1</em>03 and <em>1</em>07 cells per patient. In individuals whose plasma viremia levels are well suppressed by anti-retroviral therapy, peripheral blood mononuclear cells containing replication-competent HIV-<em>1</em> were found to decay with a mean half-life of approximately 6 months, close to the decay characteristics of memory lymphocytes in humans and monkeys. In contrast, little decay was found in a less-selective patient population. We undertook this study to address this apparent discrepancy. Using a quantitative micro-culture assay, we demonstrate here that the latent reservoir decays with a mean half-life of 6.3 months in patients who consistently maintain plasma HIV-<em>1</em> RNA levels of fewer than 50 copies/<em>ml</em>. Slower decay rates occur in individuals who experience intermittent episodes of plasma viremia. Our findings indicate that the persistence of the latent reservoir of HIV-<em>1</em> despite prolonged treatment is due not only to its slow intrinsic decay characteristics but also to the inability of current drug regimens to completely block HIV-<em>1</em> replication.

Stimulated human monocytes/macrophages are a source of mediators such as tumor necrosis factor alpha (TNF-alpha), interleukin <em>1</em> (IL-<em>1</em>), and prostaglandin E2 (PGE2), which can modulate inflammatory and immune reactions. Therefore, the ability to control the production of such mediators by monocytes/macrophages may have therapeutic benefits, and it has been proposed that glucocorticoids may act in this way. Purified human monocytes, when stimulated in vitro with lipopolysaccharide (LPS) or with LPS and gamma interferon (IFN-gamma), produce TNF-alpha, IL-<em>1</em>, and PGE2. Cotreatment of stimulated cells with the purified human lymphokine, interleukin 4 (IL-4 greater than or equal to 0.<em>1</em>-0.5 unit/<em>ml</em>; <em>1</em>2-60 pM) dramatically blocked the increased levels of these three mediators; for TNF-alpha and IL-<em>1</em>, the inhibition was manifest at the level of mRNA. Thus, IL-4 can suppress some parameters of monocyte activation and, as for B cells, have opposite effects to IFN-gamma. The effects of IL-4 on human monocytes are similar to those obtained with the glucocorticoid dexamethasone (0.<em>1</em> microM).

OKT3, a monoclonal anti-human T cell antibody (IgG2), was found to induce DNA synthesis in human peripheral lymphocyte cultures. OKT3 induced maximal mitogenesis at a concentration of <em>1</em>0 to 20 ng/<em>ml</em> and was about 20-fold more potent than PHA as a mitogen. No high-dose inhibition of thymidine incorporation was noticed at concentrations up to 2.5 microgram OKT3/<em>ml</em>. The monovalent Fab fragment of OKT3 was also mitogenic but about <em>1</em>00 times less potent than the parent IgG. OKT3 appeared to be a T lymphocyte mitogen as only sheep red blood cell rosetting lymphocytes were responsive. Quantitative studies on the binding of <em>1</em>25I-labeled Fab fragment of OKT3 to human lymphocytes showed an average of 5.<em>1</em> x <em>1</em>0(4) receptor sites/cell with an association of about <em>1</em>0(8) M-<em>1</em> at 37 degrees C, with no heterogeneity of the cell binding sites. These data suggest a strong interaction of the monoclonal OKT3 with a limited number of identical T cell membrane receptors. As this interaction can trigger mitogenesis, the cell membrane determinant recognized by OKT3 could be described as a "T cell stimulation receptor." The mitogenecity of the lymphocytes is not solely dependent on cross-linking of these receptors.

BACKGROUND

Enumeration of extracellular vesicles has clinical potential as a biomarker for disease. In biological samples, the smallest and largest vesicles typically differ 25-fold in size, 300,000-fold in concentration, 20,000-fold in volume, and <em>1</em>0,000,000-fold in scattered light. Because of this heterogeneity, the currently employed techniques detect concentrations ranging from <em>1</em>0(4) to <em>1</em>0(<em>1</em>2) vesicles <em>mL</em>(-<em>1</em>) .

OBJECTIVE

To investigate whether the large variation in the detected concentration of vesicles is caused by the minimum detectable vesicle size of five widely used techniques.

METHODS

The size and concentration of vesicles and reference beads were measured with transmission electron microscopy (TEM), a conventional flow cytometer, a flow cytometer dedicated to detecting submicrometer particles, nanoparticle tracking analysis (NTA), and resistive pulse sensing (RPS).

RESULTS

Each technique gave a different size distribution and a different concentration for the same vesicle sample.

CONCLUSIONS

Differences between the detected vesicle concentrations are primarily caused by differences between the minimum detectable vesicle sizes. The minimum detectable vesicle sizes were 70-90 nm for NTA, 70-<em>1</em>00 nm for RPS, <em>1</em>50-<em>1</em>90 nm for dedicated flow cytometry, and 270-600 nm for conventional flow cytometry. TEM could detect the smallest vesicles present, albeit after adhesion on a surface. Dedicated flow cytometry was most accurate in determining the size of reference beads, but is expected to be less accurate on vesicles, owing to heterogeneity of the refractive index of vesicles. Nevertheless, dedicated flow cytometry is relatively fast and allows multiplex fluorescence detection, making it most applicable to clinical research.

BACKGROUND

Sickle-cell anaemia is associated with substantial morbidity from acute complications and organ dysfunction beginning in the first year of life. Hydroxycarbamide substantially reduces episodes of pain and acute chest syndrome, admissions to hospital, and transfusions in adults with sickle-cell anaemia. We assessed the effect of hydroxycarbamide therapy on organ dysfunction and clinical complications, and examined laboratory findings and toxic effects.

METHODS

This randomised trial was undertaken in <em>1</em>3 centres in the USA between October, 2003, and September, 2009. Eligible participants had haemoglobin SS (HbSS) or haemoglobin Sβ(0)thalassaemia, were aged 9-<em>1</em>8 months at randomisation, and were not selected for clinical severity. Participants received liquid hydroxycarbamide, 20 mg/kg per day, or placebo for 2 years. Randomisation assignments were generated by the medical coordinating centre by a pre-decided schedule. Identical appearing and tasting formulations were used for hydroxycarbamide and placebo. Patients, caregivers, and coordinating centre staff were masked to treatment allocation. Primary study endpoints were splenic function (qualitative uptake on (99)Tc spleen scan) and renal function (glomerular filtration rate by (99m)Tc-DTPA clearance). Additional assessments included blood counts, fetal haemoglobin concentration, chemistry profiles, spleen function biomarkers, urine osmolality, neurodevelopment, transcranial Doppler ultrasonography, growth, and mutagenicity. Study visits occurred every 2-4 weeks. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00006400.

RESULTS

96 patients received hydroxycarbamide and 97 placebo, of whom 83 patients in the hydroxycarbamide group and 84 in the placebo group completed the study. Significant differences were not seen between groups for the primary endpoints (<em>1</em>9 of 70 patients with decreased spleen function at exit in the hydroxycarbamide group vs 28 of 74 patients in the placebo group, p=0·2<em>1</em>; and a difference in the mean increase in DTPA glomerular filtration rate in the hydroxycarbamide group versus the placebo group of 2 <em>mL</em>/min per <em>1</em>·73 m(2), p=0·84). Hydroxycarbamide significantly decreased pain (<em>1</em>77 events in 62 patients vs 375 events in 75 patients in the placebo group, p=0·002) and dactylitis (24 events in <em>1</em>4 patients vs <em>1</em>23 events in 42 patients in the placebo group, p<0·000<em>1</em>), with some evidence for decreased acute chest syndrome, hospitalisation rates, and transfusion. Hydroxyurea increased haemoglobin and fetal haemoglobin, and decreased white blood-cell count. Toxicity was limited to mild-to-moderate neutropenia.

CONCLUSIONS

On the basis of the safety and efficacy data from this trial, hydroxycarbamide can now be considered for all very young children with sickle-cell anaemia.

BACKGROUND

The US National Heart, Lung, and Blood Institute; and the National Institute of Child Health and Human Development.

OBJECTIVE

Distal pancreatectomy is performed for a variety of benign and malignant conditions. In recent years, significant improvements in perioperative results have been observed at high-volume centers after pancreaticoduodenectomy. Little data, however, are available concerning the current indications and outcomes after distal pancreatectomy. This single-institution experience reviews the recent indications, complications, and outcomes after distal pancreatectomy.

METHODS

A retrospective analysis was performed of the hospital records of all patients undergoing distal pancreatectomy between January <em>1</em>994 and December <em>1</em>997, inclusive.

RESULTS

The patient population (n = 235) had a mean age of 5<em>1</em> years, (range <em>1</em> month to 82 years); 43% were male and 84% white. The final diagnoses included chronic pancreatitis (24%), benign pancreatic cystadenoma (22%), pancreatic adenocarcinoma (<em>1</em>8%), neuroendocrine tumor (<em>1</em>4%), pancreatic pseudocyst (6%), cystadenocarcinoma (3%), and miscellaneous (<em>1</em>3%). The level of resection was at or to the left of the superior mesenteric vein in 96% of patients. A splenectomy was performed in 84% and a cholecystectomy in <em>1</em>5% of patients. The median intraoperative blood loss was 450 <em>ml</em>, the median number of red blood cell units transfused was zero, and the median operative time was 4.3 hours. Two deaths occurred in the hospital or within 30 days of surgery for a perioperative mortality rate of 0.9%. The overall postoperative complication rate was 3<em>1</em>%; the most common complications were new-onset insulin-dependent diabetes (8%), pancreatic fistula (5%), intraabdominal abscess (4%), small bowel obstruction (4%), and postoperative hemorrhage (4%). Fourteen patients (6%) required a second surgical procedure; the most common indication was postoperative bleeding. The median length of postoperative hospital stay was <em>1</em>0 days. Patients who underwent a distal pancreatectomy with splenectomy (n = <em>1</em>98) had a similar complication rate (30% vs. 29%), operative time (4.6 vs. 5.<em>1</em> hours), and intraoperative blood loss (500 vs. 350 <em>ml</em>) and a shorter postoperative length of stay (<em>1</em>3 vs. 2<em>1</em> days) than the patients who had splenic preservation (n = 37).

CONCLUSIONS

This series represents the largest single-institution experience with distal pancreatectomy. These data demonstrate that elective distal pancreatectomy is associated with a mortality rate of (<em>1</em>%. These results demonstrate that, as with pancreaticoduodenectomy, distal pancreatectomy can be performed with minimal perioperative mortality and acceptable morbidity.

BACKGROUND

In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown.

OBJECTIVE

To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users.

METHODS

Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program.

METHODS

British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x <em>1</em>0(9)/L (500/microL) and/or HIV-<em>1</em> RNA levels higher than 5000 copies/<em>mL</em>.

METHODS

A total of <em>1</em>77 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May <em>1</em>996.

METHODS

Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection.

RESULTS

After a median of <em>1</em><em>1</em> months after first eligibility, only 7<em>1</em> (40%) of <em>1</em>77 patients had received any antiretroviral drugs, primarily double combinations (47/7<em>1</em> [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-<em>1</em> RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], <em>1</em>.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, <em>1</em>.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/<em>1</em>0-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-<em>1</em>2.37).

CONCLUSIONS

Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.

OBJECTIVE

We sought to investigate the relationship between increased central venous pressure (CVP), renal function, and mortality in a broad spectrum of cardiovascular patients.

BACKGROUND

The pathophysiology of impaired renal function in cardiovascular disease is multifactorial. The relative importance of increased CVP has not been addressed previously.

METHODS

A total of 2,557 patients who underwent right heart catheterization in the University Medical Center Groningen, the Netherlands, between January <em>1</em>, <em>1</em>989, and December 3<em>1</em>, 2006, were identified, and their data were extracted from electronic databases. Estimated glomerular filtration rate (eGFR) was assessed with the simplified modification of diet in renal disease formula.

RESULTS

Mean age was 59 +/- <em>1</em>5 years, and 57% were men. Mean eGFR was 65 +/- 24 ml/min/<em>1</em>.73 m(2), with a cardiac index of 2.9 +/- 0.8 l/min/m(2) and CVP of 5.9 +/- 4.3 mm Hg. We found that CVP was associated with cardiac index (r = -0.259, p < 0.000<em>1</em>) and eGFR (r = -0.<em>1</em>47, p < 0.000<em>1</em>). Also, cardiac index was associated with eGFR (r = 0.<em>1</em>23, p < 0.000<em>1</em>). In multivariate analysis CVP remained associated with eGFR (r = -0.<em>1</em>08, p < 0.000<em>1</em>). In a median follow-up time of <em>1</em>0.7 years, 74<em>1</em> (29%) patients died. We found that CVP was an independent predictor of reduced survival (hazard ratio: <em>1</em>.03 per mm Hg increase, 95% confidence interval: <em>1</em>.0<em>1</em> to <em>1</em>.05, p = 0.0032).

CONCLUSIONS

Increased CVP is associated with impaired renal function and independently related to all-cause mortality in a broad spectrum of patients with cardiovascular disease.

Results from a new PET/CT scanner using lutetium-yttrium oxyorthosilicate (LYSO) crystals for the PET component are presented. This scanner, which operates in a fully 3-dimensional mode, has a diameter of 90 cm and an axial field of view of <em>1</em>8 cm. It uses 4 x 4 x 22 mm(3) LYSO crystals arranged in a pixelated Anger-logic detector design. This scanner was designed to perform as a high-performance conventional PET scanner as well as provide good timing resolution to operate as a time-of-flight (TOF) PET scanner.

METHODS

Performance measurements on the scanner were made using the National Electrical Manufacturers Association (NEMA) NU2-200<em>1</em> procedures to benchmark its conventional imaging capabilities. The scatter fraction and noise equivalent count (NEC) measurements with the NEMA cylinder (20-cm diameter) were repeated for 2 larger cylinders (27-cm and 35-cm diameter), which better represent average and heavy patients. New measurements were designed to characterize its intrinsic timing resolution capability, which defines its TOF performance. Additional measurements to study the impact of pulse pileup at high counting rates on timing, as well as energy and spatial, resolution were also performed. Finally, to characterize the effect of TOF reconstruction on lesion contrast and noise, the standard NEMA/International Electrotechnical Commission torso phantom as well as a large 35-cm-diameter phantom with both hot and cold spheres were imaged for varying scan times.

RESULTS

The transverse and axial resolution near the center is 4.8 mm. The absolute sensitivity of this scanner measured with a 70-cm-long line source is 6.6 cps/kBq, whereas scatter fraction is 27% measured with a 70-cm-long line source in a 20-cm-diameter cylinder. For the same line source cylinder, the peak NEC rate is measured to be <em>1</em>25 kcps at an activity concentration of <em>1</em>7.4 kBq/<em>mL</em> (0.47 microCi/<em>mL</em>). The 2 larger cylinders showed a decrease in the peak NEC due to increased attenuation, scatter, and random coincidences, and the peak occurs at lower activity concentrations. The system coincidence timing resolution was measured to be 585 ps. The timing resolution changes as a function of the singles rate due to pulse pileup and could impact TOF image reconstruction. Image-quality measurements with the torso phantom show that very high quality images can be obtained with short scan times (<em>1</em>-2 min per bed position). However, the benefit of TOF is more apparent with the large 35-cm-diameter phantom, where small spheres are detectable only with TOF information for short scan times.

CONCLUSIONS

The Gemini TF whole-body scanner represents the first commercially available fully 3-dimensional PET scanner that achieves TOF capability as well as conventional imaging capabilities. The timing resolution is also stable over a long duration, indicating the practicality of this device. Excellent image quality is achieved for whole-body studies in <em>1</em>0-30 min, depending on patient size. The most significant improvement with TOF is seen for the heaviest patients.

Vascular endothelial growth factor (VEGF) is a mitogen for endothelial cells, and it promotes angiogenesis in vivo. Here we report that VEGF(<em>1</em>65) has neurotrophic actions on cultured adult mouse superior cervical ganglia (SCG) and dorsal root ganglia (DRG), measured as axonal outgrowth. Maximal effect was observed at <em>1</em>0-50 ng/<em>ml</em> for SCG and <em>1</em>00 ng/<em>ml</em> for DRG. VEGF-induced axonal outgrowth was inhibited by the mitogen-activated protein kinase kinase inhibitor PD 98059 but not by the protein kinase inhibitor K252a. VEGF also increased survival of both neurons and satellite cells and the number of proliferating Schwann cells. Immunocytochemistry and immunoblotting revealed that VEGF was expressed in virtually all nerve cells in the SCG but only in a population of small-diameter (<35 micrometers) neurons representing approximately 30% of the neurons in DRG. Immunostaining showed that the VEGF receptor fetal liver kinase receptor (flk-<em>1</em>) was found on nerve cell bodies in DRG and to a lesser extent on neurons in SCG. Growth cones of regenerating axons from both types of ganglia exhibited flk-<em>1</em> immunoreactivity, as did Schwann cells. We conclude that VEGF has both neurotrophic and mitogenic activity on cells in the peripheral nervous system.

BACKGROUND

The failing heart demonstrates a preference for glucose as its metabolic substrate. Whether enhancing myocardial glucose uptake favorably influences left ventricular (LV) contractile performance in heart failure remains uncertain. Glucagon-like peptide-<em>1</em> (GLP-<em>1</em>) is a naturally occurring incretin with potent insulinotropic effects the action of which is attenuated when glucose levels fall below 4 mmol. We examined the impact of recombinant GLP-<em>1</em> (rGLP-<em>1</em>) on LV and systemic hemodynamics and myocardial substrate uptake in conscious dogs with advanced dilated cardiomyopathy (DCM) as a mechanism for overcoming myocardial insulin resistance and enhancing myocardial glucose uptake.

RESULTS

Thirty-five dogs were instrumented and studied in the fully conscious state. Advanced DCM was induced by 28 days of rapid pacing. Sixteen dogs with advanced DCM received a 48-hour infusion of rGLP-<em>1</em> (<em>1</em>.5 pmol x kg(-<em>1</em>) x min(-<em>1</em>)). Eight dogs with DCM served as controls and received 48 hours of a saline infusion (3 mL/d). Infusion of rGLP-<em>1</em> was associated with significant (P<0.02) increases in LV dP/dt (98%), stroke volume (<em>1</em>02%), and cardiac output (57%) and significant decreases in LV end-diastolic pressure, heart rate, and systemic vascular resistance. rGLP-<em>1</em> increased myocardial insulin sensitivity and myocardial glucose uptake. There were no significant changes in the saline control group.

CONCLUSIONS

rGLP-<em>1</em> dramatically improved LV and systemic hemodynamics in conscious dogs with advanced DCM induced by rapid pacing. rGLP-<em>1</em> has insulinomimetic and glucagonostatic properties, with resultant increases in myocardial glucose uptake. rGLP-<em>1</em> may be a useful metabolic adjuvant in decompensated heart failure.

We have investigated the ability of dexamethasone to regulate interleukin-<em>1</em>beta (IL-<em>1</em>beta)-induced gene expression, histone acetyltransferase (HAT) and histone deacetylase (HDAC) activity. Low concentrations of dexamethasone (<em>1</em>0(-<em>1</em>0) M) repress IL-<em>1</em>beta-stimulated granulocyte-macrophage colony-stimulating factor (GM-CSF) expression and fail to stimulate secretory leukocyte proteinase inhibitor expression. Dexamethasone (<em>1</em>0(-7) M) and IL-<em>1</em>beta (<em>1</em> ng/<em>ml</em>) both stimulated HAT activity but showed a different pattern of histone H4 acetylation. Dexamethasone targeted lysines K5 and K<em>1</em>6, whereas IL-<em>1</em>beta targeted K8 and K<em>1</em>2. Low concentrations of dexamethasone (<em>1</em>0(-<em>1</em>0) M), which do not transactivate, repressed IL-<em>1</em>beta-stimulated K8 and K<em>1</em>2 acetylation. Using chromatin immunoprecipitation assays, we show that dexamethasone inhibits IL-<em>1</em>beta-enhanced acetylated K8-associated GM-CSF promoter enrichment in a concentration-dependent manner. Neither IL-<em>1</em>beta nor dexamethasone elicited any GM-CSF promoter association at acetylated K5 residues. Furthermore, we show that GR acts both as a direct inhibitor of CREB binding protein (CBP)-associated HAT activity and also by recruiting HDAC2 to the p65-CBP HAT complex. This action does not involve de novo synthesis of HDAC protein or altered expression of CBP or p300/CBP-associated factor. This mechanism for glucocorticoid repression is novel and establishes that inhibition of histone acetylation is an additional level of control of inflammatory gene expression. This further suggests that pharmacological manipulation of of specific histone acetylation status is a potentially useful approach for the treatment of inflammatory diseases.