To determine the dose-response characteristics for the effects of insulin on glucose production, glucose utilization, and overall glucose metabolism in normal man, <em>1</em>5 healthy subjects were infused with insulin for 8 h at sequential rates ranging from 0.2 to 5.0 mU.kg-<em>1</em>.min-<em>1</em>; each rate was used for 2 h. Glucose production and utilization were measured isotopically ([3-3H]glucose). Tissue insulin receptor occupancy was estimated from erythrocyte insulin binding. Glucose production was completely suppressed at plasma insulin concentrations of approximately 60 microunits/<em>ml</em>. Maximal glucose utilization (<em>1</em>0-<em>1</em><em>1</em> mg.kg-<em>1</em>.min-<em>1</em>) occurred at insulin concentrations of 200-700 microunits/<em>ml</em>. The concentration of insulin causing half-maximal glucose utilization (55 + 7 microunits/<em>ml</em>) was significantly greater than that required for half-maximal suppression of glucose production (29 +/- 2 microunits/<em>ml</em>, P less than 0.0<em>1</em>). Maximal effects of insulin on glucose production and utilization occurred at plasma insulin concentrations causing <em>1</em><em>1</em> and 49% insulin receptor occupancy, respectively. The above dose-response relationships indicate that in man <em>1</em>) glucose production is more sensitive to changes in plasma insulin concentration than is glucose utilization; 2) both hepatic and peripheral tissues may contain "spare" insulin receptors; and 3) relatively minor changes in plasma insulin concentration or insulin receptor function can cause appreciable alterations in glucose metabolism.

<em>1</em>. The low-molecular-weight components of myosin freshly prepared by the standard procedure from adult rabbit skeletal muscle migrated as four main bands <em>Ml</em>(<em>1</em>), <em>Ml</em>(2), <em>Ml</em>(3) and <em>Ml</em>(4) on polyacrylamide-gel electrophoresis in 8m-urea. 2. The number of bands increased on storage. This change was accelerated by increasing the temperature and pH. 3. None of the bands had electrophoretic mobilities identical with those of the well-characterized proteins of the myofibril or with the sarcoplasmic proteins. 4. By varying the ionic conditions and concentration of muscle mince used for the initial extraction it was possible to change the relative proportions of the two electrophoretic bands of intermediate mobility, <em>Ml</em>(2) and <em>Ml</em>(3). 5. The four-band picture similar to that obtained with rabbit was observed with myosin isolated from skeletal muscle of the rat, mouse, hamster, pigeon and chicken. 6. Rabbit cardiac myosin gave only two bands on electrophoresis. Myosin from rabbit red muscle gave a pattern intermediate between cardiac and white-skeletal-muscle myosin, i.e. the two fastest bands were present in decreased relative amounts. 7. It is suggested that the differences in the low-molecular-weight components of myosin from different types of muscle are a consequence of differences in the isoenzyme composition of the myosins.

BACKGROUND

The pathogenesis of pancreatic fibrosis is unknown. In the liver, stellate cells play a major role in fibrogenesis by synthesising increased amounts of collagen and other extracellular matrix (ECM) proteins when activated by profibrogenic mediators such as cytokines and oxidant stress.

OBJECTIVE

To determine whether cultured rat pancreatic stellate cells produce collagen and other ECM proteins, and exhibit signs of activation when exposed to the cytokines platelet derived growth factor (PDGF) or transforming growth factor beta (TGF-beta).

METHODS

Cultured pancreatic stellate cells were immunostained for the ECM proteins procollagen III, collagen I, laminin, and fibronectin using specific polyclonal antibodies. For cytokine studies, triplicate wells of cells were incubated with increasing concentrations of PDGF or TGF-beta.

RESULTS

Cultured pancreatic stellate cells stained strongly positive for all ECM proteins tested. Incubation of cells with <em>1</em>, 5, and <em>1</em>0 ng/<em>ml</em> PDGF led to a significant dose related increase in cell counts as well as in the incorporation of 3H-thymidine into DNA. Stellate cells exposed to 0.25, 0.5, and <em>1</em> ng/<em>ml</em> TGF-beta showed a dose dependent increase in alpha smooth muscle actin expression and increased collagen synthesis. In addition, TGF-beta increased the expression of PDGF receptors on stellate cells.

CONCLUSIONS

Pancreatic stellate cells produce collagen and other extracellular matrix proteins, and respond to the cytokines PDGF and TGF-beta by increased proliferation and increased collagen synthesis. These results suggest an important role for stellate cells in pancreatic fibrogenesis.

The hormonal factors associated with converting a corpus luteum of estrous cycle into a corpus luteum of pseudopregnancy were studied by measuring LH and FSH prolactin, estradiol and progesterone levels in decapitated rats during the 4-day estrous cycle and a comparable time of pseudopregnancy (lights on 0600-0800 hr.). During the estrous cycle, prolactin, LH and FSH remained low and unchanging except on the afternoon of proestrus, when typical proestrous surges were observed. In contrast, estradiol levels began to increase on D-<em>1</em>, from baseline values of 7 pg/<em>ml</em> to approximately <em>1</em>5-20 pg/<em>ml</em>. These levels were maintained until the afternoon of D-2 when estradiol further increased to reach peak levels of 40-50 pg/<em>ml</em> by 0900 hr on proestrus. Estradiol then declined in relation to the increase in LH secreation and had returned to baseline by estrus. Progesterone secretion by the corpora lutea of the cycle also increased on the afternoon of D-<em>1</em> and reached a maximum value of 25-30 ng/<em>ml</em> early on the morning of D-2. At this time, a precipitious fall in progesterone occurred, returning to baseline values of 5-<em>1</em>- ng/<em>ml</em> by 0700 on D-2 signifying the regression of the corpora lutea of the cycle. Progesterone remained low thereafter until the afternoon of proestrus when levels increased in response to the proestrus when levels increased in response to the proestrous surge of LH. Following cervical stimulation at <em>1</em>900 hr on proestrus, no differences were noted, with respect to the estrous cycle, in LH, FSH or estradiol secreation through the afternoon of D-2. Surprisingly, progesterone levels did not differ in the cycle and pseudopregnancy until the early morning of D-29 instead of progesterone levels falling to baseline as they had during the cycle, the corpora lutea of pseudopregnancy were rescused, progesterone increasing dramatically to reach levels of 45-50 ng/<em>ml</em> by <em>1</em>700 hr on that same day. The only difference in hormone secretion that was noted which could account for this marked divergence in progesterone secretion was the pattern of prolactin secretion following cervical stimulation. In contrast to the low levels seen during the estrous cycle, biphasio surges of prolactin secretion occured each day, one being nocturnal (0<em>1</em>00-0900 hr) and the other diurnal (<em>1</em>500-2<em>1</em>00 hr). The rescue of the corpus luteum occured in association with the nocturnal surge on D-2. These results suggest that nocturnal surge on D-2, PROLACTIN IS THE MAJOR Luteotropic stimulus which transforms and estrous cycle into pseudopregnancy by prolonging progesterone secretion from the corpus luteum. Moreover, if LH is important for progesterone secretion, no changes were observed in the pattern of LH secretion which can account for the rescue of the corpus luteum.

OBJECTIVE

Available insulin sensitivity (IS) methods based on the oral glucose tolerance test (OGTT) are empirical. We used a glucose-insulin model to derive an OGTT-based IS (oral glucose insulin sensitivity [OGIS]) index, which predicts glucose clearance in a glucose clamp. We validated OGIS against clamp data.

METHODS

OGIS requires glucose and insulin concentrations from a 75-g OGTT at 0, 2, and 3 h (3-h OGTT) or at 0, <em>1</em>.5, and 2 h (2-h OGTT). The formula includes six constants optimized to match the clamp results. For this purpose, <em>1</em>5 lean nondiabetic subjects (BMI < 25 kg/m2), 38 obese nondiabetic subjects (BMI>> 25 kg/m2), and 38 subjects with type 2 diabetes randomly underwent an OGTT and a <em>1</em>20 mU x min(-<em>1</em>) x m(-2) insulin infusion euglycemic clamp. Glucose clearance (Cl CLAMP), calculated as the ratio of glucose infusion to concentration during the last hour of the clamp, was compared with OGIS. OGIS was also tested on an independent group of <em>1</em>3 subjects with impaired glucose tolerance (IGT).

RESULTS

OGIS and Cl CLAMP were correlated in the whole group (R = 0.77, P < 0.000<em>1</em>), in the subgroups (lean: R = 0.59; obese: R = 0.73; type 2 diabetes: R = 0.49; P < 0.02), and in the independent IGT group (R = 0.65, P < 0.02). Reproducibility of OGIS and Cl CLAMP were similar (coefficients of variation: OGIS 7.<em>1</em>%, Cl CLAMP 6.4%). OGIS was as effective as Cl CLAMP in discriminating between groups (for OGIS, lean vs. obese: 440 +/- <em>1</em>6 vs. 362 +/- <em>1</em><em>1</em> ml x min(-<em>1</em>) x m(-2), p < 0.00<em>1</em>; lean vs. type 2 diabetes: 440 +/- <em>1</em>6 vs. 239 +/- 7, P < 0.000<em>1</em>; obese vs. type 2 diabetes: 362 +/- <em>1</em><em>1</em> vs. 239 +/- 7, P < 0.000<em>1</em>; results were similar for Cl CLAMP). The relationships between IS and BMI, fasting plasma insulin, and insulin secretion (calculated from the OGTT insulin concentration) were examined. OGIS yielded results similar to Cl CLAMP and fully consistent with established physiological principles. The performance of the index for the 3-h and 2-h OGTT was similar.

CONCLUSIONS

OGIS is an index of IS in good agreement with the clamp. Because of its simplicity (only three blood samples required), this method has potential use for clinical investigation including large-scale epidemiological studies.

Bicyclams are a novel class of antiviral compounds that are highly potent and selective inhibitors of the replication of HIV-<em>1</em> and HIV-2. Surprisingly, however, when the prototype compound AMD3<em>1</em>00 was tested against M-tropic virus strains such as BaL, ADA, JR-CSF, and SF-<em>1</em>62 in human peripheral blood mononuclear cells, the compound was completely inactive. Because of the specific and potent inhibitory effect of AMD3<em>1</em>00 on T-tropic viruses, but not M-tropic viruses, it was verified that AMD3<em>1</em>00 interacts with the CXC-chemokine receptor CXCR4, the main coreceptor used by T-tropic viruses. AMD3<em>1</em>00 dose dependently inhibited the binding of a specific CXCR4 monoclonal antibody to SUP-T<em>1</em> cells as measured by flow cytometry. It did not inhibit the binding of the biotinylated CC-chemokine macrophage inflammatory protein (MIP) <em>1</em>alpha or MIP-<em>1</em>beta, ligands for the chemokine receptor CCR5 (the main coreceptor for M-tropic viruses). In addition, AMD3<em>1</em>00 completely blocked (a) the Ca2+ flux at <em>1</em>00 ng/<em>ml</em> in lymphocytic SUP-T<em>1</em> and monocytic THP-<em>1</em> cells, and (b) the chemotactic responses of THP-<em>1</em> cells induced by stromal cell-derived factor <em>1</em>alpha, the natural ligand for CXCR4. Finally, AMD3<em>1</em>00 had no effect on the Ca2+ flux induced by the CC-chemokines MIP-<em>1</em>alpha, regulated on activation normal T cell expressed and secreted (RANTES; also a ligand for CCR5), or monocyte chemoattractant protein 3 (a ligand for CCR<em>1</em> and CCR2b), nor was it able to induce Ca2+ fluxes by itself. The bicyclams are, to our knowledge, the first low molecular weight anti-HIV agents shown to act as potent and selective CXCR4 antagonists.

We examined the role of the neutrophil membrane antigen complex designated CDw<em>1</em>8 (LFA-<em>1</em>/Mac-<em>1</em>/p<em>1</em>50, 95) in human peripheral blood neutrophil adherence to cultured human umbilical vein endothelial cells (HEC) pretreated with lipopolysaccharide (LPS), interleukin <em>1</em> (IL <em>1</em>), or recombinant tumor necrosis factor-alpha (rTNF-alpha). Pretreatment of HEC with LPS produced a dose-and time-dependent increase in subsequent neutrophil adherence (7 +/- <em>1</em>% adherence to untreated HEC vs 38 +/- 3% adherence to HEC pretreated for 4 hr with LPS <em>1</em>50 ng/<em>ml</em>; mean +/- SE of 22 experiments: p less than 0.00<em>1</em>). This effect was observed in primary and passaged HEC, but not in bovine aortic endothelial cells or human dermal fibroblasts. The LPS-induced activity appeared to be associated with the HEC surface, since it was not removed by washing and was not detected in the supernatant medium. Inhibition of RNA or protein synthesis during pretreatment of HEC with LPS prevented induction of the adherence-promoting activity. Pretreatment of HEC with IL <em>1</em> and rTNF-alpha produced a similar protein synthesis-dependent increase in neutrophil adherence to HEC. Coincubation of neutrophils with murine monoclonal antibody (MoAb) 60.3, an antibody directed to the CDw<em>1</em>8 complex, produced a 70 +/- 4% inhibition of neutrophil adherence to LPS-pretreated HEC, 59 +/- 5% inhibition of adherence to IL <em>1</em>-pretreated HEC, and 65 +/- <em>1</em><em>1</em>% inhibition of adherence to rTNF-alpha-pretreated HEC (means +/- SE of <em>1</em>8, seven, and five experiments, respectively). Notably, MoAb 60.3 did not completely inhibit neutrophil adherence to pretreated HEC, although it completely inhibited adherence to untreated HEC when neutrophils were activated directly with phorbol ester. Similarly, the adherence of neutrophils from a patient with an inherited deficiency of the CDw<em>1</em>8 complex to LPS-, IL <em>1</em>-, and rTNF-alpha-pretreated HEC was markedly reduced compared with normal neutrophils (5 to <em>1</em><em>1</em>% adherence with CDw<em>1</em>8-deficient neutrophils vs 43 to 54% adherence with normal neutrophils), but adherence to pretreated HEC was still significantly greater than adherence to HEC that were not pretreated (2% adherence). We conclude that LPS, IL <em>1</em>, and rTNF-alpha induce synthesis of an endothelial cell-surface factor(s) that promotes neutrophil adherence primarily by a mechanism involving the CDw<em>1</em>8 complex. It thus appears that the CDw<em>1</em>8 complex is important for augmented neutrophil adherence to endothelium in vitro whether the is stimulated directly by inflammatory mediators or indirectly by endothelial-dependent mechanisms.

BACKGROUND

Experimental data from normotensive and hypertensive animals indicate that aging is associated with impaired endothelium-dependent relaxations to acetylcholine, and this possibility appears to be confirmed in the human coronary artery. In the present study, we evaluated the effect of age on endothelial responsiveness in the forearm vessels of either normotensive control subjects or essential hypertensive patients.

RESULTS

Within the normotensive or hypertensive group (n = 53 and n = 57, respectively), subjects were selected with similar blood pressure, plasma cholesterol, and glucose values, and hypercholesterolemic subjects, diabetics, and smokers were excluded. We evaluated forearm blood flow (by strain-gauge plethysmography) modifications induced by intrabrachial acetylcholine (0.<em>1</em>5, 0.45, <em>1</em>.5, 4.5, and <em>1</em>5 micrograms/<em>1</em>00 <em>mL</em> per minute), an endothelium-dependent vasodilator, and sodium nitroprusside (<em>1</em>, 2, and 4 micrograms/<em>1</em>00 <em>mL</em> per minute), an endothelium-independent vasodilator. Acetylcholine caused a dose-dependent vasodilation that was significantly (P < .0<em>1</em>) lower in essential hypertensive patients than in normotensive control subjects. However, a significant negative correlation was observed between acetylcholine-induced vasodilation and patient age in both normotensive (r = -.86, P < .00<em>1</em>) and hypertensive (r = -.85, P < .00<em>1</em>) patients. In contrast, vasodilation to sodium nitroprusside was similar in normotensive control subjects and essential hypertensive patients with a poorer inverse correlation with patient age (normotensive control subjects, r = -.37; hypertensive patients, r = -.36) compared with acetylcholine.

CONCLUSIONS

The present data indicate that there is a blunted response to acetylcholine with advancing age in both normotensive control subjects and essential hypertensive patients, suggesting that aging is associated with reduced endothelium-dependent vasodilation in humans.

We have generated mutant mice that do not express pp59fyn, a nonreceptor protein tyrosine kinase related to pp60src, by homologous recombination in embryonic stem cells. fyn- mice did not display an overt phenotype. Because fyn is associated with the T cell receptor (TCR), thymocyte and T cell signaling was analyzed in the mutant background. Cross-linking of TCR-CD3 in thymocytes led to markedly reduced calcium fluxes and abrogated proliferation, whereas mature splenic T cells retained largely normal proliferation despite depressed calcium movements and IL-2 production. Similarly, proliferation induced by Thy-<em>1</em> cross-linking was reduced in thymocytes but not in splenic T cells. fyn- thymocytes were impaired at a late stage of maturation and showed limited clonal deletion to the <em>Mls</em>-<em>1</em>a self-super-antigen but not to staphylococcal enterotoxin A. These results implicate fyn as a critical component in TCR signaling in thymocytes and, potentially, in the process that determines T cell repertoire in the adult mouse.

Previous studies of lung function in relation to smoking cessation have not adequately quantified the long-term benefit of smoking cessation, nor established the predictive value of characteristics such as airway hyperresponsiveness. In a prospective randomized clinical trial at <em>1</em>0 North American medical centers, we studied 3, 926 smokers with mild-to-moderate airway obstruction (3,8<em>1</em>8 with analyzable results; mean age at entry, 48.5 yr; 36% women) randomized to one of two smoking cessation groups or to a nonintervention group. We measured lung function annually for 5 yr. Participants who stopped smoking experienced an improvement in FEV(<em>1</em>) in the year after quitting (an average of 47 <em>ml</em> or 2%). The subsequent rate of decline in FEV(<em>1</em>) among sustained quitters was half the rate among continuing smokers, 3<em>1</em> +/- 48 versus 62 +/- 55 <em>ml</em> (mean +/- SD), comparable to that of never-smokers. Predictors of change in lung function included responsiveness to beta-agonist, baseline FEV(<em>1</em>), methacholine reactivity, age, sex, race, and baseline smoking rate. Respiratory symptoms were not predictive of changes in lung function. Smokers with airflow obstruction benefit from quitting despite previous heavy smoking, advanced age, poor baseline lung function, or airway hyperresponsiveness.

<AbstractText>Patients with advanced hepatocellular carcinoma and increased α-fetoprotein concentrations have poor prognosis. We aimed to establish the efficacy of ramucirumab in patients with advanced hepatocellular carcinoma and α-fetoprotein concentrations of 400 ng/<em>mL</em> or higher.</AbstractText><AbstractText>REACH-2 was a randomised, double-blind, placebo-controlled, phase 3 trial done at 92 hospitals, clinics, and medical centres in 20 countries. Eligible patients were aged <em>1</em>8 years or older and had histologically or cytologically confirmed hepatocellular carcinoma, or diagnosed cirrhosis and hepatocellular carcinoma, Barcelona Clinic Liver Cancer stage B or C disease, Child-Pugh class A liver disease, Eastern Cooperative Oncology Group (ECOG) performance statuses of 0 or <em>1</em>, α-fetoprotein concentrations of 400 ng/<em>mL</em> or greater, and had previously received first-line sorafenib. Participants were randomly assigned (2:<em>1</em>) via an interactive web response system with a computer-generated random sequence to 8 mg/kg intravenous ramucirumab every 2 weeks or placebo. All patients received best supportive care. The primary endpoint was overall survival. Secondary endpoints were progression-free survival, proportion of patients achieving an objective response, time to radiographic progression, safety, time to deterioration in scores on the Functional Assessment of Cancer Therapy Hepatobiliary Symptom Index 8 (FHSI-8), and time to deterioration in ECOG performance status. We also pooled individual patient data from REACH-2 with data from REACH (NCT0<em>1</em><em>1</em>40347) for patients with α-fetoprotein concentrations of 400 ng/<em>mL</em> or greater. Efficacy analyses were by intention to treat, whereas safety analyses were done in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT02435433.</AbstractText><AbstractText>Between July 26, 20<em>1</em>5, and Aug 30, 20<em>1</em>7, 292 patients were randomly assigned, <em>1</em>97 to the ramucirumab group and 95 to the placebo group. At a median follow-up of 7·6 months (IQR 4·0-<em>1</em>2·5), median overall survival (8·5 months [95% CI 7·0-<em>1</em>0·6] vs 7·3 months [5·4-9·<em>1</em>]; hazard ratio [HR] 0·7<em>1</em>0 [95% CI 0·53<em>1</em>-0·949]; p=0·0<em>1</em>99) and progression-free survival (2·8 months [2·8-4·<em>1</em>] vs <em>1</em>·6 months [<em>1</em>·5-2·7]; 0·452 [0·339-0·603]; p<0·000<em>1</em>) were significantly improved in the ramucirumab group compared with the placebo group. The proportion of patients with an objective response did not differ significantly between groups (nine [5%] of <em>1</em>97 vs one [<em>1</em>%] of 95; p=0·<em>1</em>697). Median time to deterioration in FHSI-8 total scores (3·7 months [95% CI 2·8-4·4] vs 2·8 months [<em>1</em>·6-2·9]; HR 0·799 [95% CI 0·545-<em>1</em>·<em>1</em>7<em>1</em>]; p=0·238) and ECOG performance statuses (HR <em>1</em>·082 [95% CI 0·639-<em>1</em>·832]; p=0·77) did not differ between groups. Grade 3 or worse treatment-emergent adverse events that occurred in at least 5% of patients in either group were hypertension (25 [<em>1</em>3%] in the ramucirumab group vs five [5%] in the placebo group), hyponatraemia (<em>1</em><em>1</em> [6%] vs 0) and increased aspartate aminotransferase (six [3%] vs five [5%]). Serious adverse events of any grade and cause occurred in 68 (35%) patients in the ramucirumab group and 28 (29%) patients in the placebo group. Three patients in the ramucirumab group died from treatment-emergent adverse events that were judged to be related to study treatment (one had acute kidney injury, one had hepatorenal syndrome, and one had renal failure).</AbstractText><AbstractText>REACH-2 met its primary endpoint, showing improved overall survival for ramucirumab compared with placebo in patients with hepatocellular carcinoma and α-fetoprotein concentrations of at least 400 ng/<em>mL</em> who had previously received sorafenib. Ramucirumab was well tolerated, with a manageable safety profile. To our knowledge, REACH-2 is the first positive phase 3 trial done in a biomarker-selected patient population with hepatocellular carcinoma.</AbstractText><AbstractText>Eli Lilly.</AbstractText>

OBJECTIVE

We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity.

METHODS

Included in our prospective nonrandomized study done at 2 clinics were 3<em>1</em> patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (<em>1</em>0 units per <em>ml</em>. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, <em>1</em>6 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week <em>1</em> after treatment.

RESULTS

Of the 2<em>1</em> patients <em>1</em>9 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and <em>1</em><em>1</em> at <em>1</em>6 and 36 weeks. At the 6-week followup complete continence was restored in <em>1</em>7 of <em>1</em>9 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 2<em>1</em>5.8 +/- 90.4 <em>ml</em>. to 4<em>1</em>5.7 +/- 2<em>1</em><em>1</em>.<em>1</em> (p <0.0<em>1</em>6) and 296.3 +/- <em>1</em>45.2 to 480.5 +/- <em>1</em>34.<em>1</em> (p <0.0<em>1</em>6), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. <em>1</em> (p <0.0<em>1</em>6). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 26<em>1</em>.8 +/- 24<em>1</em>.3 <em>ml</em>. to 490.5 +/- 204.8 (p <0.0<em>1</em>6). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at <em>1</em>6 and 36 weeks.

CONCLUSIONS

Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.

BACKGROUND

Kidney failure is known to cause anemia, which is associated with a higher risk of cardiac failure and mortality. The impact of milder decreases in kidney function on hemoglobin levels and anemia in the US population, however, is unknown.

METHODS

We analyzed a population-based sample of <em>1</em>54<em>1</em>9 participants 20 years and older in the Third National Health and Nutrition Examination Survey, conducted from <em>1</em>988 to <em>1</em>994.

RESULTS

Lower kidney function was associated with a lower hemoglobin level and a higher prevalence and severity of anemia below, but not above, an estimated glomerular filtration rate (GFR) of 60 <em>mL</em>/min per <em>1</em>.73 m(2). Adjusted to the age of 60 years, the predicted median hemoglobin level among men (women) decreased from <em>1</em>4.9 (<em>1</em>3.5) g/dL at an estimated GFR of 60 <em>mL</em>/min per <em>1</em>.73 m(2) to <em>1</em>3.8 (<em>1</em>2.2) g/dL at an estimated GFR of 30 <em>mL</em>/min per <em>1</em>.73 m(2) and to <em>1</em>2.0 (<em>1</em>0.3) g/dL at an estimated GFR of <em>1</em>5 <em>mL</em>/min per <em>1</em>.73 m(2). The prevalence of anemia (hemoglobin level (<em>1</em>2 g/dL in men and (<em>1</em><em>1</em> g/dL in women) increased from <em>1</em>% (95% confidence interval, 0.7%-2%) at an estimated GFR of 60 <em>mL</em>/min per <em>1</em>.73 m(2) to 9% (95% confidence interval, 4%-<em>1</em>9%) at an estimated GFR of 30 <em>mL</em>/min per <em>1</em>.73 m(2) and to 33% (95% confidence interval, <em>1</em><em>1</em>%-67%) at an estimated GFR of <em>1</em>5 <em>mL</em>/min per <em>1</em>.73 m(2) among men and to 67% (95% confidence interval, 30%-90%) at an estimated GFR of <em>1</em>5 <em>mL</em>/min per <em>1</em>.73 m(2) among women. An estimated GFR of <em>1</em>5 to 60 <em>mL</em>/min per <em>1</em>.73 m(2) was present in 4% of the entire population and in <em>1</em>7% of the individuals with anemia.

CONCLUSIONS

Below an estimated GFR of 60 <em>mL</em>/min per <em>1</em>.73 m(2), lower kidney function is strongly associated with a higher prevalence of anemia among the US adult population.

Eleven years after Lung Health Study (LHS) entry, we performed spirometry in 77.4% of surviving participants who enrolled in a long-term follow-up study. Those not enrolling tended to be younger male heavy smokers who continued to smoke during the LHS. Their initial LHS lung function, after adjustment for these factors, did not differ from that of enrollees. Smoking habits by original LHS treatment groups (smoking intervention vs. usual care) tended to converge, but 93% of participants who were abstinent throughout the LHS were still abstinent at <em>1</em><em>1</em> years. Differences in lung function between treatment groups persisted; smoking intervention participants had less decline in FEV(<em>1</em>) than usual care participants. Men who quit at the beginning of the LHS had an FEV(<em>1</em>) rate of decline of 30.2 <em>ml</em>/year, whereas women who quit declined at 2<em>1</em>.5 <em>ml</em>/year. Men continuing to smoke throughout the <em>1</em><em>1</em> years declined by 66.<em>1</em> <em>ml</em>/year, and women continuing to smoke declined by 54.2 <em>ml</em>/year. When decline in FEV(<em>1</em>) was expressed as a percentage of predicted normal value, no significant sex-based difference was apparent among continuing smokers. At <em>1</em><em>1</em> years, 38% of continuing smokers had an FEV(<em>1</em>) less than 60% of the predicted normal value compared with <em>1</em>0% of sustained quitters.

The broad-spectrum cephalosporins exhibit time-dependent bactericidal activity and produce prolonged postantibiotic effects only with staphylococci. The duration of time that serum levels exceed the minimum inhibitory concentration (MIC) is the important pharmacodynamic parameter correlating with efficacy for these drugs. Maximal efficacy for cephalosporins in several animal infection models is approached when serum levels are above the MIC for 60%-70% of the dosing interval for Enterobacteriaceae and streptococci and for 40%-50% of the dosing interval for Staphylococcus aureus. Based on MIC90 values of 0.5 microgram/<em>ml</em> for enteric bacilli and 4 micrograms/<em>ml</em> for S. aureus, these time above MIC goals can be easily met in infected and/or elderly patients following <em>1</em>-2 g of cefotaxime at <em>1</em>2-h intervals. Full knowledge of the interrelationships between pharmacokinetics and pharmacodynamics is important for determining effective dosage regimens for the broad-spectrum cephalosporins.

Hyaluronic acid is a natural polysaccharide found abundantly throughout the body with many desirable properties for application as a biomaterial, including scaffolding for tissue engineering. In this work, hyaluronic acid with molecular weights ranging from 50 to <em>1</em><em>1</em>00 kDa was modified with methacrylic anhydride and photopolymerized into networks with a wide range of physical properties. With macromer concentrations from 2 to 20 wt %, networks exhibited volumetric swelling ratios ranging from approximately 42 to 8, compressive moduli ranging from approximately 2 to over <em>1</em>00 kPa, and degradation times ranging from less than <em>1</em> day up to almost 38 days in the presence of <em>1</em>00 U/<em>mL</em> of hyaluronidase. When 3T3-fibroblasts were photoencapsulated in the hydrogels, cells remained viable with low macromer concentrations but decreased sequentially as the macromer concentration increased. Finally, auricular swine chondrocytes produced neocartilage when photoencapsulated in the hyaluronic acid networks. This work presents a next step toward the development of advanced in vivo curable biomaterials.

Interleukin-6 (IL-6) is one of several pro-inflammatory cytokines implicated in insulin resistance during infection, cachexia, and obesity. We recently demonstrated that IL-6 inhibits insulin signaling in hepatocytes (Senn, J. J., Klover, P. J., Nowak, I. A., and Mooney, R. A. (2002) Diabetes 5<em>1</em>, 339<em>1</em>-3399). Members of the suppressors of cytokine signaling (SOCS) family associate with the insulin receptor (IR), and their ectopic expression inhibits IR signaling. Since several SOCS proteins are induced by IL-6, a working hypothesis is that IL-6-dependent insulin resistance is mediated, at least in part, by induction of SOCS protein(s) in insulin target cells. To examine the involvement of SOCS protein(s) in IL-6-dependent inhibition of insulin receptor signaling, HepG2 cells were treated with IL-6 (20 ng/<em>ml</em>) for periods from <em>1</em> min to 8 h. IL-6 induced SOCS-3 transcript at 30 min with a maximum effect at <em>1</em> h. SOCS-3 protein levels were also markedly elevated at <em>1</em> h. Transcript and protein levels returned to near basal levels by 2 h. SOCS-3 induction by IL-6 paralleled IL-6-dependent inhibition of IR signal transduction. Ectopically expressed SOCS-3 associated with the IR and suppressed insulin-dependent receptor autophosphorylation, insulin receptor substrate-<em>1</em> (IRS-<em>1</em>) tyrosine phosphorylation, association of IRS-<em>1</em> with the p85 subunit of phosphatidylinositol 3-kinase, and activation of Akt. SOCS-3 was also a direct inhibitor of insulin receptor autophosphorylation in vitro. In mice exposed to IL-6 for 60-90 min, hepatic SOCS-3 expression was increased. This was associated with inhibition of hepatic insulin-dependent receptor autophosphorylation and IRS-<em>1</em> tyrosine phosphorylation. These data suggest that induction of SOCS-3 in liver may be an important mechanism of IL-6-mediated insulin resistance.

Pharmacological sodium nitrate supplementation has been reported to reduce the O2 cost of submaximal exercise in humans. In this study, we hypothesized that dietary supplementation with inorganic nitrate in the form of beetroot juice (BR) would reduce the O2 cost of submaximal exercise and enhance the tolerance to high-intensity exercise. In a double-blind, placebo (PL)-controlled, crossover study, eight men (aged <em>1</em>9-38 yr) consumed 500 <em>ml</em>/day of either BR (containing <em>1</em><em>1</em>.2 +/- 0.6 mM of nitrate) or blackcurrant cordial (as a PL, with negligible nitrate content) for 6 consecutive days and completed a series of "step" moderate-intensity and severe-intensity exercise tests on the last 3 days. On days 4-6, plasma nitrite concentration was significantly greater following dietary nitrate supplementation compared with PL (BR: 273 +/- 44 vs. PL: <em>1</em>40 +/- 50 nM; P < 0.05), and systolic blood pressure was significantly reduced (BR: <em>1</em>24 +/- 2 vs. PL: <em>1</em>32 +/- 5 mmHg; P < 0.0<em>1</em>). During moderate exercise, nitrate supplementation reduced muscle fractional O2 extraction (as estimated using near-infrared spectroscopy). The gain of the increase in pulmonary O2 uptake following the onset of moderate exercise was reduced by <em>1</em>9% in the BR condition (BR: 8.6 +/- 0.7 vs. PL: <em>1</em>0.8 +/- <em>1</em>.6 <em>ml</em>.min(-<em>1</em>).W(-<em>1</em>); P < 0.05). During severe exercise, the O2 uptake slow component was reduced (BR: 0.57 +/- 0.20 vs. PL: 0.74 +/- 0.24 l/min; P < 0.05), and the time-to-exhaustion was extended (BR: 675 +/- 203 vs. PL: 583 +/- <em>1</em>45 s; P < 0.05). The reduced O2 cost of exercise following increased dietary nitrate intake has important implications for our understanding of the factors that regulate mitochondrial respiration and muscle contractile energetics in humans.

OBJECTIVE

To assess the feasibility and safety of laparoscopic liver resections.

BACKGROUND

The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients.

METHODS

A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation.

RESULTS

From May <em>1</em>996 to December <em>1</em>999, 30 of <em>1</em>59 (<em>1</em>9%) liver resections were included. There were <em>1</em>8 benign lesions and <em>1</em>2 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included <em>1</em> left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and <em>1</em><em>1</em> atypical resections. Mean blood loss was 300 <em>mL</em>. Mean surgical time was 2<em>1</em>4 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease.

CONCLUSIONS

Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

OBJECTIVE

To describe the pharmacokinetics of <em>1</em>.25 mg of intravitreal bevacizumab (Avastin).

METHODS

Experimental animal study.

METHODS

Twenty Dutch-belted rabbits.

METHODS

One eye of each of 20 rabbits was injected with <em>1</em>.25 mg of intravitreal bevacizumab. Both eyes of each of 4 rabbits were enucleated at days <em>1</em>, 3, 8, <em>1</em>5, and 29. Bevacizumab concentrations were measured in aqueous fluid, whole vitreous, and serum.

METHODS

Bevacizumab concentrations in the aqueous, vitreous, and serum.

RESULTS

Whereas vitreous concentrations of bevacizumab declined in a monoexponential fashion with a half-life of 4.32 days, concentrations of>><em>1</em>0 microg/ml bevacizumab were maintained in the vitreous humor for 30 days. Bevacizumab concentrations in the aqueous humor of the injected eye reached a peak concentration of 37.7 microg/ml 3 days after drug administration. A maximum serum concentration of 3.3 mug/ml was achieved 8 days after intravitreal injection and the concentration fell below <em>1</em> microg/ml 29 days after injection. Elimination of bevacizumab from the aqueous humor and serum paralleled that found in the vitreous humor, with half-life values of 4.88 days and 6.86 days, respectively. Very low concentrations of bevacizumab were detected in the fellow uninjected eye. Concentrations of bevacizumab in the vitreous of the fellow eye varied incrementally, from 0.35 ng/ml at <em>1</em> day to <em>1</em><em>1</em>.<em>1</em>7 ng/ml at 4 weeks. Concentrations of bevacizumab in the aqueous humor of the fellow eye reached their peak at <em>1</em> week, at 29.4 ng/ml, and declined to 4.56 ng/ml at 4 weeks.

CONCLUSIONS

The vitreous half-life of <em>1</em>.25 mg intravitreal bevacizumab is 4.32 days in a rabbit eye. Very small amounts of bevacizumab were detected in the serum and in the fellow uninjected eye.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert <em>1</em>7% of HIV infections in Kenya (95% uncertainty interval [UI] <em>1</em>-3<em>1</em>) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per <em>μL</em> could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

A highly sensitive assay combining immunomagnetic enrichment with multiparameter flow cytometric and immunocytochemical analysis has been developed to detect, enumerate, and characterize carcinoma cells in the blood. The assay can detect one epithelial cell or less in <em>1</em> <em>ml</em> of blood. Peripheral blood (<em>1</em>0-20 <em>ml</em>) from 30 patients with carcinoma of the breast, from 3 patients with prostate cancer, and from <em>1</em>3 controls was examined by flow cytometry for the presence of circulating epithelial cells defined as nucleic acid+, CD45(-), and cytokeratin+. Highly significant differences in the number of circulating epithelial cells were found between normal controls and patients with cancer including <em>1</em>7 with organ-confined disease. To determine whether the circulating epithelial cells in the cancer patients were neoplastic cells, cytospin preparations were made after immunomagnetic enrichment and were analyzed. Epithelial cells from patients with breast cancer generally stained with mAbs against cytokeratin and 3 of 5 for mucin-<em>1</em>. In contrast, no cells that stained for these antigens were observed in the blood from normal controls. The morphology of the stained cells was consistent with that of neoplastic cells. Of 8 patients with breast cancer followed for <em>1</em>-<em>1</em>0 months, there was a good correlation between changes in the level of tumor cells in the blood with both treatment with chemotherapy and clinical status. The present assay may be helpful in early detection, in monitoring disease, and in prognostication.

Cytochrome P450 3A (CYP3A) metabolizes a diverse array of clinically important drugs. For some of these (e.g., cyclosporine, verapamil, midazolam), CYP3A in the intestinal mucosa contributes to their extensive and variable first-pass extraction. To further characterize this phenomenon, we measured CYP3A content and catalytic activity toward the probe substrate midazolam in mucosa isolated from duodenal, jejunal and ileal sections of 20 human donor intestines. For comparison, the same measurements were performed for 20 human donor livers, eight of which were obtained from the same donors as eight of the intestines. Excellent correlations existed between homogenate and microsomal CYP3A content for the three intestinal regions. Median microsomal CYP3A content was greatest in the duodenum and lowest in the ileum (3<em>1</em> vs. <em>1</em>7 pmol/mg of protein). With respect to midazolam <em>1</em>'-hydroxylation kinetics, the median Km for each intestinal region was similar to the median hepatic Km, approximately 4 microM. In contrast, the median Vmax decreased from liver to duodenum to jejunum to ileum (850 vs. 644 vs. 426 vs. 68 pmol/min/mg). Intrinsic clearance (Vmax/Km) followed a similar trend for the intestinal regions; median duodenal intrinsic clearance was comparable to hepatic intrinsic clearance (<em>1</em>57 and 200 microl/min/mg, respectively). Vmax correlated with CYP3A content for all tissues except the ileum. Duodenal and jejunal Vmax and CYP3A content varied by >30-fold among donors. Microsomes prepared from every other <em>1</em>-foot section of six intestines were also analyzed for CYP3A as well as for two coenzymes. In general, CYP3A activity, CYP3A content and CYP reductase activity rose slightly from duodenum to middle jejunum and then declined to distal jejunum and ileum. Cytochrome b5 content and cytochrome b5 reductase activity varied little throughout the intestinal tract. Regional intrinsic midazolam <em>1</em>'-hydroxylation clearance was greatest for the jejunum, followed by the duodenum and ileum (<em>1</em>44, 50 and <em>1</em>9 <em>ml</em>/min, respectively). Collectively, these results demonstrate that the upper small intestine serves as the major site for intestinal CYP3A-mediated first-pass metabolism and provides a rationale for interindividual differences in oral bioavailability for some CYP3A substrates.

BACKGROUND

2-[<em>1</em>8F]fluoro-3-(2(S)-azetidinylmethoxy) pyridine (2-F-A-85380, abbreviated as 2-FA) is a recently developed radioligand that allows for visualization of brain alpha 4 beta 2* nicotinic acetylcholine receptors (nAChRs) with positron emission tomography (PET) scanning in humans.

OBJECTIVE

To determine the effect of cigarette smoking on alpha 4 beta 2* nAChR occupancy in tobacco-dependent smokers.

METHODS

Fourteen 2-FA PET scanning sessions were performed. During the PET scanning sessions, subjects smoked <em>1</em> of 5 amounts (none, <em>1</em> puff, 3 puffs, <em>1</em> full cigarette, or to satiety [2(<em>1</em>/2) to 3 cigarettes]).

METHODS

Academic brain imaging center.

METHODS

Eleven tobacco-dependent smokers (paid volunteers). Main Outcome Measure Dose-dependent effect of smoking on occupancy of alpha 4 beta 2* nAChRs, as measured with 2-FA and PET in nAChR-rich brain regions.

RESULTS

Smoking 0.<em>1</em>3 (<em>1</em> to 2 puffs) of a cigarette resulted in 50% occupancy of alpha 4 beta 2* nAChRs for 3.<em>1</em> hours after smoking. Smoking a full cigarette (or more) resulted in more than 88% receptor occupancy and was accompanied by a reduction in cigarette craving. A venous plasma nicotine concentration of 0.87 ng/mL (roughly <em>1</em>/25th of the level achieved in typical daily smokers) was associated with 50% occupancy of alpha 4 beta 2* nAChRs.

CONCLUSIONS

Cigarette smoking in amounts used by typical daily smokers leads to nearly complete occupancy of alpha 4 beta 2* nAChRs, indicating that tobacco-dependent smokers maintain alpha 4 beta 2* nAChR saturation throughout the day. Because prolonged binding of nicotine to alpha 4 beta 2* nAChRs is associated with desensitization of these receptors, the extent of receptor occupancy found herein suggests that smoking may lead to withdrawal alleviation by maintaining nAChRs in the desensitized state.