BACKGROUND

The debate over the correct perioperative fluid management is unresolved.

METHODS

The impact of two intraoperative fluid regimes on postoperative outcome was prospectively evaluated in <em>1</em>52 patients with an American Society of Anesthesiologists physical status of I-III who were undergoing elective intraabdominal surgery. Patients were rando<em>ml</em>y assigned to receive intraoperatively either liberal (liberal protocol group [LPG], n = 75; bolus of <em>1</em>0 <em>ml</em>/kg followed by <em>1</em>2 <em>ml</em> x kg(-<em>1</em>) x h(-<em>1</em>)) or restrictive (restrictive protocol group [RPG], n = 77; 4 <em>ml</em> x kg(-<em>1</em>) x h(-<em>1</em>)) amounts of lactated Ringer's solution. The primary endpoint was the number of patients who died or experienced complications. The secondary endpoints included time to initial passage of flatus and feces, duration of hospital stay, and changes in body weight, hematocrit, and albumin serum concentration in the first 3 postoperative days.

RESULTS

The number of patients with complications was lower in the RPG (P = 0.046). Patients in the LPG passed flatus and feces significantly later (flatus, median [range]: 4 [3-7] days in the LPG vs. 3 [2-7] days in the RPG; P < 0.00<em>1</em>; feces: 6 [4-9] days in the LPG vs. 4 [3-9] days in the RPG; P < 0.00<em>1</em>), and their postoperative hospital stay was significantly longer (9 [7-24] days in the LPG vs. 8 [6-2<em>1</em>] days in the RPG; P = 0.0<em>1</em>). Significantly larger increases in body weight were observed in the LPG compared with the RPG (P < 0.0<em>1</em>). In the first 3 postoperative days, hematocrit and albumin concentrations were significantly higher in the RPG compared with the LPG.

CONCLUSIONS

In patients undergoing elective intraabdominal surgery, intraoperative use of restrictive fluid management may be advantageous because it reduces postoperative morbidity and shortens hospital stay.

We have identified strain-specific antigens with Camp and St. Lucia strains of P. falciparum of Mr approximately 285,000 and approximately 260,000, respectively. These strain-specific antigens were metabolically labeled with radioactive amino acids, indicating that they were of parasite origin rather than altered host components. These proteins had the properties of a molecule exposed on the surface of infected erythrocytes (IE). First, the proteins are accessible to lactoperoxidase-catalyzed radioiodination of IE. Second, the radioiodinated proteins were cleaved by low concentrations of trypsin (0.<em>1</em> microgram/<em>ml</em>). Third, these antigens were immunoprecipitated after addition of immune sera to intact IE. Fourth, the strain-specific immuno-precipitation of these proteins correlated with the capacity of immune sera to block cytoadherence of IE in a strain-specific fashion. Fifth, the strain-specific antigen had detergent solubility properties (i.e., insolubility in <em>1</em>% Triton X-<em>1</em>00, solubility in 5% sodium dodecyl sulfate) similar to the variant antigen of P. knowlesi, which has been proven to be a malarial protein exposed on the erythrocyte surface.

BACKGROUND

Adipocyte-derived hormones may represent a mechanism linking insulin resistance to cardiovascular disease. In the present study, we evaluated the direct effects of resistin, a novel adipocyte-derived hormone, on endothelial activation.

RESULTS

Endothelial cells (ECs) were incubated with human recombinant resistin (<em>1</em>0 to <em>1</em>00 ng/<em>ML</em>, 24 hours), and endothelin-<em>1</em> (ET-<em>1</em>) release, ET-<em>1</em> mRNA expression, and nitric oxide (NO) production were assessed. Transient transfection assays were used to evaluate the effects of resistin on transcription of human ET-<em>1</em> gene promoter. Furthermore, the effects of resistin on AP-<em>1</em>-mutated ET-<em>1</em> promoter were evaluated. The effects of resistin on expression of vascular cell adhesion molecule (VCAM-<em>1</em>) and monocyte chemoattractant chemokine (MCP-<em>1</em>) were studied in addition to CD40 receptor, CD40 ligand-induced MCP-<em>1</em> expression, and tumor necrosis factor receptor-associated factor-3 (TRAF3), an inhibitor of CD40 signaling. Incubation of ECs with resistin resulted in an increase in ET-<em>1</em> release and ET-<em>1</em> mRNA expression, with no change in NO production. Whereas treatment with resistin resulted in an increase in ET-<em>1</em> promoter activity, the AP-<em>1</em>-mutated promoter was inactive after resistin stimulation. Additionally, resistin-treated cells showed increased expression of VCAM-<em>1</em> and MCP-<em>1</em>, with concomitant reductions in TRAF-3 expression. Resistin did not alter CD40 receptor expression; however, increased CD40 ligand induced MCP-<em>1</em> production.

CONCLUSIONS

The novel adipokine resistin exerts direct effects to promote EC activation by promoting ET-<em>1</em> release, in part by inducing ET-<em>1</em> promoter activity via the AP-<em>1</em> site. Furthermore, resistin upregulates adhesion molecules and chemokines and downregulates TRAF-3, an inhibitor of CD40 ligand signaling. In this fashion, resistin may be mechanistically linked to cardiovascular disease in the metabolic syndrome.

By use of its affinity to gelatin-Cellulofine, a novel protein, GBP28 (gelatin-binding protein of 28 kDa), was obtained from human plasma. GBP28 bound to gelatin-Cellulofine could be eluted with <em>1</em> M NaCl. By analysis of its amino-terminal amino acid sequences and the peptides obtained by protease digestion, GBP28 was identified as a novel protein. After repeated gel chromatography of the <em>1</em> M NaCl eluate from gelatin-Cellulofine, about 50 micrograms of GBP28 was purified from 500 <em>ml</em> of human plasma. On gel chromatography, the protein migrated as a molecule of about 420 kDa. On SDS-PAGE, its molecular mass was 28 kDa under reducing conditions and 68 kDa under nonreducing conditions. Recently, human mRNA specific to adipose tissue, cDNA clone apM<em>1</em>, has been registered [Maeda, K., Okubo, K., Shimomura, I., Funahashi, T., Matsuzawa, Y., and Matsubara, K. (<em>1</em>996) Biochem. Biophys. Res. Commun. 22<em>1</em>, 286-289]. The assumed amino acid sequence of cDNA clone apM<em>1</em> contained all the sequences of GBP28 and its peptides. Therefore, it is evident that the cDNA clone apM<em>1</em> encodes GBP28 and the protein is specific to adipose tissue. The clone encodes a polypeptide of 244 amino acids with a secretory signal sequence at the amino terminus, a small non-helical region, a stretch of 22 collagen repeats and a globular domain. Thus, GBP28 appears to belong to a family of proteins possessing a collagen-like domain through which they form homo-trimers, which further combine to make oligomeric complexes. Although its biological function is presently unclear, its adipocyte-specific expression suggests that GBP28 may function as an endogenous factor involved in lipid catabolism and storage or whole body metabolism.

Human blood contains at least 2 subpopulations of antigen-presenting dendritic cells (DCs) that can be differentiated by their expression of CD<em>1</em><em>1</em>c. Myeloid DCs (myDCs), which are CD<em>1</em><em>1</em>c(+), trap invading pathogens in the tissues and then migrate to lymphoid tissues where they stimulate pathogen-specific T-cell responses. Plasmacytoid DCs (pcDCs), which are CD<em>1</em><em>1</em>c(-), secrete interferon-alpha in response to viral infections. This study reports that in HIV-<em>1</em> infection there is a progressive depletion of both these DC populations and that this correlates with an increasing HIV-<em>1</em> plasma virus load. The median numbers of myDCs and pcDCs were 6978/<em>mL</em> and 9299/<em>mL</em>, respectively, in healthy male controls and 2298/<em>mL</em> and <em>1</em>640/<em>mL</em>, respectively, in patients with more than <em>1</em>0(5) HIV-<em>1</em> RNA copies/<em>mL</em>. Both DC populations expressed CD4, CCR5, and CXCR4. The findings suggest that loss of DCs in HIV infection may contribute to disease progression.

BACKGROUND

Endothelial function is impaired in patients with diabetes mellitus. However, the factors contributing to this defect are currently unknown. Hyperglycemia attenuates endothelium-dependent relaxation in normal rabbit arteries in vitro and rat arterioles in vivo. Accordingly, this study examined the effect of acute hyperglycemia on endothelium-dependent vasodilation in nondiabetic humans in vivo.

RESULTS

Endothelium-dependent vasodilation was assessed through brachial artery infusion of methacholine chloride both before and during 6 hours of local hyperglycemia (300 mg/dL) achieved by intra-arterial infusion of 50% dextrose. Forearm blood flow was determined by plethysmography. In a group of <em>1</em>0 subjects, there was a trend toward attenuated methacholine-mediated vasodilation during hyperglycemia compared with euglycemia (P=.07 by ANOVA; maximal response, <em>1</em>3.3+/-2.8 versus <em>1</em>4.7+/-<em>1</em>.5 <em>mL</em> x min(-<em>1</em>) x <em>1</em>00 <em>mL</em>(-<em>1</em>), respectively). In these subjects, the systemic serum insulin levels increased significantly during the dextrose infusion (P<.00<em>1</em>). To eliminate the confounding vasoactive effects of insulin, the protocol was repeated during systemic infusion of octreotide (30 ng x kg(-<em>1</em>) x min(-<em>1</em>)) to inhibit pancreatic secretion of insulin. In these subjects (n=<em>1</em>0), hyperglycemia significantly attenuated the forearm blood flow response to methacholine (P<.0<em>1</em> by ANOVA; maximal response, <em>1</em>6.9+/-2.5 before versus <em>1</em>2.7+/-<em>1</em>.8 <em>mL</em> x min(-<em>1</em>) x <em>1</em>00 <em>mL</em>(-<em>1</em>) during hyperglycemia). Methacholine-mediated vasodilation was not attenuated by an equimolar infusion of mannitol (P>.40), nor did hyperglycemia reduce endothelium-independent vasodilation to verapamil (P>.50).

CONCLUSIONS

Acute hyperglycemia impairs endothelium-dependent vasodilation in healthy humans in vivo. This finding suggests that elevated glucose may contribute to the endothelial dysfunction observed in patients with diabetes mellitus.

OBJECTIVE

To compare epidermal growth factor (EGF) concentration in tear fluid and levels of inflammatory cytokines in the conjunctival epithelium of patients with Sjögren's syndrome keratoconjunctivitis sicca with those of normal controls.

METHODS

Schirmer <em>1</em> tear testing, corneal fluorescein staining and conjunctival impression cytology for quantitation of goblet cell density were performed in ten patients with Sjögren's syndrome-associated keratoconjunctivitis sicca and ten asymptomatic normal controls. ELISA was used to detect the concentration of EGF in tear fluid and interleukin 6 in lysates of conjunctival cytology specimens obtained from all subjects. The levels of RNA transcripts encoding inflammatory cytokines [interleukin <em>1</em>alpha_(IL-<em>1</em>alpha), interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor alpha_(TNF-alpha), and transforming growth factor beta<em>1</em> (TGF-beta<em>1</em>)] as well as a housekeeping gene (G3PDH) were evaluated in conjunctival cytology specimens taken from all subjects by semiquantitative competitive reverse transcriptase polymerase chain reaction (RT-PCR).

RESULTS

Decreased tear fluid EGF concentration was noted in Sjögren's syndrome patients (mean 0.68 +/- 0.59 ng/ml) compared to controls (mean <em>1</em>.66 +/- 0.45 ng/ml, P = 0.004). Significantly increased levels of IL-<em>1</em>alpha, IL-6, IL-8, TNF-alpha and TGF-beta<em>1</em> RNA transcripts were found in the conjunctival epithelium of Sjögren's syndrome patients compared to controls (P < 0.05), while the level of G3PDH was similar in both groups. The concentration of IL-6 protein was significantly higher in Sjögren's syndrome conjunctiva samples (P = 0.0<em>1</em>2). Tear EGF concentration correlated with Schirmer <em>1</em> scores (rho 0.767, P < 0.00<em>1</em>), corneal fluorescein staining scores (rho -0.562, P = 0.0<em>1</em>), conjunctival goblet cell density (rho 0.66<em>1</em>, P = 0.00<em>1</em>) and the levels of IL-<em>1</em>alpha_and IL-8 RNA in the conjunctival epithelium (rho -0.677 and -0.747, respectively, P = 0.00<em>1</em>). Both IL-<em>1</em>alpha_and IL-8 RNA in the conjunctival epithelium increased as Schirmer <em>1</em> scores decreased (P </= 0.00<em>1</em>). IL-8 RNA level correlated with corneal fluorescein staining (rho 0.690, P = 0.00<em>1</em>) and conjunctival goblet cell density (rho -0.767, P < 0.00<em>1</em>). A significant decrease in IL-8 RNA level, corresponding to improvement in irritation symptoms and ocular surface disease, was observed in six eyes after two weeks of topical corticosteroid therapy.

CONCLUSIONS

The balance of cytokines in the tear fluid and conjunctival epithelium is altered in Sjögren's syndrome. The severity of keratoconjunctivitis sicca in this condition increases as tear fluid EGF concentration decreases and levels of inflammatory cytokines in the conjunctival epithelium increase. These findings provide new insight into the pathogenesis of keratoconjunctivitis and provide potential targets for therapy.

BACKGROUND

The safe duration of warm ischemia during partial nephrectomy remains controversial.

OBJECTIVE

Our aim was to evaluate the short- and long-term renal effects of warm ischemia in patients with a solitary kidney.

METHODS

Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n=3<em>1</em>9) or laparoscopic (n=43) partial nephrectomy using warm ischemia with hilar clamping.

METHODS

Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments.

CONCLUSIONS

Median tumor size was 3.4 cm (range: 0.7-<em>1</em>8.0 cm), and median ischemia time was 2<em>1</em> min (range: 4-55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (<em>1</em>9%) including 58 (<em>1</em>6%) who had a glomerular filtration rate (GFR) (<em>1</em>5 <em>ml</em>/min per <em>1</em>.73 m(2) within 30 d of surgery. Among the 226 patients with a preoperative GFR>>or=30 <em>ml</em>/min per <em>1</em>.73 m(2) and followed>>or=30 d, 38 (<em>1</em>7%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: <em>1</em>.05 for each <em>1</em>-min increase; p<0.00<em>1</em>) and a GFR(<em>1</em>5 (odds ratio: <em>1</em>.06; p<0.00<em>1</em>) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: <em>1</em>.06; p<0.00<em>1</em>) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study.

CONCLUSIONS

Longer warm ischemia time is associated with short- and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.

BACKGROUND

A risk-adapted approach to management of thyroid cancer requires risk estimates that change over time based on response to therapy and the course of the disease. The objective of this study was to validate the American Thyroid Association (ATA) risk of recurrence staging system and determine if an assessment of response to therapy during the first 2 years of follow-up can modify these initial risk estimates.

METHODS

This retrospective review identified 588 adult follicular cell-derived thyroid cancer patients followed for a median of 7 years (range <em>1</em>-<em>1</em>5 years) after total thyroidectomy and radioactive iodine remnant ablation. Patients were stratified according to ATA risk categories (low, intermediate, or high) as part of initial staging. Clinical data obtained during the first 2 years of follow-up (suppressed thyroglobulin [Tg], stimulated Tg, and imaging studies) were used to re-stage each patient based on response to initial therapy (excellent, acceptable, or incomplete). Clinical outcomes predicted by initial ATA risk categories were compared with revised risk estimates obtained after response to therapy variables were used to modify the initial ATA risk estimates.

RESULTS

Persistent structural disease or recurrence was identified in 3% of the low-risk, 2<em>1</em>% of the intermediate-risk, and 68% of the high-risk patients (p < 0.00<em>1</em>). Re-stratification during the first 2 years of follow-up reduced the likelihood of finding persistent structural disease or recurrence to 2% in low-risk, 2% in intermediate-risk, and <em>1</em>4% in high-risk patients, demonstrating an excellent response to therapy (stimulated Tg < <em>1</em> ng/mL without structural evidence of disease). Conversely, an incomplete response to initial therapy (suppressed Tg>> <em>1</em> ng/mL, stimulated Tg>> <em>1</em>0 ng/mL, rising Tg values, or structural disease identification within the first 2 years of follow-up) increased the likelihood of persistent structural disease or recurrence to <em>1</em>3% in low-risk, 4<em>1</em>% in intermediate-risk, and 79% in high-risk patients.

CONCLUSIONS

Our data confirm that the newly proposed ATA recurrence staging system effectively predicts the risk of recurrence and persistent disease. Further, these initial ATA risk estimates can be significantly refined based on the assessment of response to initial therapy, thereby providing a dynamic risk assessment that can be used to more effectively tailor ongoing follow-up recommendations.

OBJECTIVE

Diastolic heart failure (ie, heart failure with preserved ejection fraction) is a common condition without established therapy, and aldosterone stimulation may contribute to its progression.

OBJECTIVE

To assess the efficacy and safety of long-term aldosterone receptor blockade in heart failure with preserved ejection fraction. The primary objective was to determine whether spironolactone is superior to placebo in improving diastolic function and maximal exercise capacity in patients with heart failure with preserved ejection fraction.

METHODS

The Aldo-DHF trial, a multicenter, prospective, randomized, double-blind, placebo-controlled trial conducted between March 2007 and April 20<em>1</em>2 at <em>1</em>0 sites in Germany and Austria that included 422 ambulatory patients (mean age, 67 [SD, 8] years; 52% female) with chronic New York Heart Association class II or III heart failure, preserved left ventricular ejection fraction of 50% or greater, and evidence of diastolic dysfunction.

METHODS

Patients were randomly assigned to receive 25 mg of spironolactone once daily (n=2<em>1</em>3) or matching placebo (n=209) with <em>1</em>2 months of follow-up.

METHODS

The equally ranked co-primary end points were changes in diastolic function (E/e') on echocardiography and maximal exercise capacity (peak VO2) on cardiopulmonary exercise testing, both measured at <em>1</em>2 months.

RESULTS

Diastolic function (E/e') decreased from <em>1</em>2.7 (SD, 3.6) to <em>1</em>2.<em>1</em> (SD, 3.7) with spironolactone and increased from <em>1</em>2.8 (SD, 4.4) to <em>1</em>3.6 (SD, 4.3) with placebo (adjusted mean difference, -<em>1</em>.5; 95% CI, -2.0 to -0.9; P < .00<em>1</em>). Peak VO2 did not significantly change with spironolactone vs placebo (from <em>1</em>6.3 [SD, 3.6] <em>mL</em>/min/kg to <em>1</em>6.8 [SD, 4.6] <em>mL</em>/min/kg and from <em>1</em>6.4 [SD, 3.5] <em>mL</em>/min/kg to <em>1</em>6.9 [SD, 4.4] <em>mL</em>/min/kg, respectively; adjusted mean difference, +0.<em>1</em> <em>mL</em>/min/kg; 95% CI, -0.6 to +0.8 <em>mL</em>/min/kg; P = .8<em>1</em>). Spironolactone induced reverse remodeling (left ventricular mass index declined; difference, -6 g/m2; 95% CI, -<em>1</em>0 to-<em>1</em> g/m2; P = .009) and improved neuroendocrine activation (N-terminal pro-brain-type natriuretic peptide geometric mean ratio, 0.86; 95% CI, 0.75-0.99; P = .03) but did not improve heart failure symptoms or quality of life and slightly reduced 6-minute walking distance (-<em>1</em>5 m; 95% CI, -27 to -2 m; P = .03). Spironolactone also modestly increased serum potassium levels (+0.2 mmol/L; 95% CI, +0.<em>1</em> to +0.3; P < .00<em>1</em>) and decreased estimated glomerular filtration rate (-5 <em>mL</em>/min/<em>1</em>.73 m2; 95% CI, -8 to -3 <em>mL</em>/min/<em>1</em>.73 m2; P < .00<em>1</em>) without affecting hospitalizations.

CONCLUSIONS

In this randomized controlled trial, long-term aldosterone receptor blockade improved left ventricular diastolic function but did not affect maximal exercise capacity, patient symptoms, or quality of life in patients with heart failure with preserved ejection fraction. Whether the improved left ventricular function observed in the Aldo-DHF trial is of clinical significance requires further investigation in larger populations.

BACKGROUND

clinicaltrials.gov Identifier: ISRCTN94726526; Eudra-CT No: 2006-002605-3<em>1</em>.

OBJECTIVE

To identify risk factors and describe the effects of antibiotic prophylaxis on the incidence of postoperative endophthalmitis after cataract surgery based on analysis of the findings of the European Society of Cataract & Refractive Surgeons (ESCRS) multicenter study.

METHODS

Twenty-four ophthalmology units in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, and the United Kingdom.

METHODS

A prospective randomized partially masked multicenter cataract surgery study recruited <em>1</em>6 603 patients. The study was based on a 2 x 2 factorial design, with intracameral cefuroxime and topical perioperative levofloxacin factors resulting in 4 treatment groups. The comparison of case and non-case data was performed using multivariable logistic regression analyses. Odds ratios (ORs) associated with treatment effects and other risk factors were estimated.

RESULTS

Twenty-nine patients presented with endophthalmitis, of whom 20 were classified as having proven infective endophthalmitis. The absence of an intracameral cefuroxime prophylactic regimen at <em>1</em> mg in 0.<em>1</em> <em>mL</em> normal saline was associated with a 4.92-fold increase (95% confidence interval [CI], <em>1</em>.87-<em>1</em>2.9) in the risk for total postoperative endophthalmitis. In addition, the use of clear corneal incisions (CCIs) compared to scleral tunnels was associated with a 5.88-fold increase (95% CI, <em>1</em>.34-25.9) in risk and the use of silicone intraocular lens (IOL) optic material compared to acrylic with a 3.<em>1</em>3-fold increase (95% CI, <em>1</em>.47-6.67). The presence of surgical complications increased the risk for total endophthalmitis 4.95-fold (95% CI, <em>1</em>.68-<em>1</em>4.6), and more experienced surgeons were more likely to be associated with endophthalmitis cases. When considering only proven infective endophthalmitis cases, the absence of cefuroxime and the use of silicone IOL optic material were significantly associated with an increased risk, and there was evidence that men were more predisposed to infection (OR, 2.70; 95% CI, <em>1</em>.07-6.8).

CONCLUSIONS

Use of intracameral cefuroxime at the end of surgery reduced the occurrence of postoperative endophthalmitis. Additional risk factors associated with endophthalmitis after cataract surgery included CCIs and the use of silicone IOLs.

BACKGROUND

The poly(ADP-ribose) polymerase inhibitor olaparib has shown antitumour activity in patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer with or without BRCA<em>1</em> or BRCA2 mutations. The aim of this study was to assess the efficacy and tolerability of olaparib in combination with chemotherapy, followed by olaparib maintenance monotherapy, versus chemotherapy alone in patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer.

METHODS

In this randomised, open-label, phase 2 study, adult patients with platinum-sensitive, recurrent, high-grade serous ovarian cancer who had received up to three previous courses of platinum-based chemotherapy and who were progression free for at least 6 months before randomisation received either olaparib (200 mg capsules twice daily, administered orally on days <em>1</em>-<em>1</em>0 of each 2<em>1</em>-day cycle) plus paclitaxel (<em>1</em>75 mg/m(2), administered intravenously on day <em>1</em>) and carboplatin (area under the curve [AUC] 4 mg/<em>mL</em> per min, according to the Calvert formula, administered intravenously on day <em>1</em>), then olaparib monotherapy (400 mg capsules twice daily, given continuously) until progression (the olaparib plus chemotherapy group), or paclitaxel (<em>1</em>75 mg/m(2) on day <em>1</em>) and carboplatin (AUC 6 mg/<em>mL</em> per min on day <em>1</em>) then no further treatment (the chemotherapy alone group). Randomisation was done by an interactive voice response system, stratified by number of previous platinum-containing regimens received and time to disease progression after the previous platinum regimen. The primary endpoint was progression-free survival according to Response Evaluation Criteria in Solid Tumors version <em>1</em>.<em>1</em>, analysed by intention to treat. Prespecified exploratory analyses included efficacy by BRCA mutation status, assessed retrospectively. This study is registered with ClinicalTrials.gov, number NCT0<em>1</em>08<em>1</em>95<em>1</em>, and has been completed.

RESULTS

Between Feb <em>1</em>2 and July 30, 20<em>1</em>0, <em>1</em>73 patients at 43 investigational sites in <em>1</em>2 countries were enrolled into the study, of whom <em>1</em>62 were eligible and were randomly assigned to the two treatment groups (8<em>1</em> to the olaparib plus chemotherapy group and 8<em>1</em> to the chemotherapy alone group). Of these randomised patients, <em>1</em>56 were treated in the combination phase (8<em>1</em> in the olaparib plus chemotherapy group and 75 in the chemotherapy alone group) and <em>1</em>2<em>1</em> continued to the maintenance or no further treatment phase (66 in the olaparib plus chemotherapy group and 55 in the chemotherapy alone group). BRCA mutation status was known for <em>1</em>07 patients (either at baseline or determined retrospectively): 4<em>1</em> (38%) of <em>1</em>07 had a BRCA mutation (20 in the olaparib plus chemotherapy group and 2<em>1</em> in the chemotherapy alone group). Progression-free survival was significantly longer in the olaparib plus chemotherapy group (median <em>1</em>2.2 months [95% CI 9.7-<em>1</em>5.0]) than in the chemotherapy alone group (median 9.6 months [95% CI 9.<em>1</em>-9.7) (HR 0.5<em>1</em> [95% CI 0.34-0.77]; p=0.00<em>1</em>2), especially in patients with BRCA mutations (HR 0.2<em>1</em> [0.08-0.55]; p=0.00<em>1</em>5). In the combination phase, adverse events that were reported at least <em>1</em>0% more frequently with olaparib plus chemotherapy than with chemotherapy alone were alopecia (60 [74%] of 8<em>1</em> vs 44 [59%] of 75), nausea (56 [69%] vs 43 [57%]), neutropenia (40 [49%] vs 29 [39%]), diarrhoea (34 [42%] vs 20 [27%]), headache (27 [33%] vs seven [9%]), peripheral neuropathy (25 [3<em>1</em>%] vs <em>1</em>4 [<em>1</em>9%]), and dyspepsia (2<em>1</em> [26%] vs 9 [<em>1</em>2%]); most were of mild-to-moderate intensity. The most common grade 3 or higher adverse events during the combination phase were neutropenia (in 35 [43%] of 8<em>1</em> patients in the olaparib plus chemotherapy group vs 26 [35%] of 75 in the chemotherapy alone group) and anaemia (seven [9%] vs five [7%]). Serious adverse events were reported in <em>1</em>2 (<em>1</em>5%) of 8<em>1</em> patients in the olaparib plus chemotherapy group and <em>1</em>6 of 75 (2<em>1</em>%) patients in the chemotherapy alone group.

CONCLUSIONS

Olaparib plus paclitaxel and carboplatin followed by maintenance monotherapy significantly improved progression-free survival versus paclitaxel plus carboplatin alone, with the greatest clinical benefit in BRCA-mutated patients, and had an acceptable and manageable tolerability profile.

BACKGROUND

AstraZeneca.

Cerebrospinal fluid (CSF) from healthy individuals contains between <em>1</em>,000 and 3,000 leukocytes per <em>ml</em>. Little is known about trafficking patterns of leukocytes between the systemic circulation and the noninflamed CNS. In the current study, we characterized the surface phenotype of CSF cells and defined the expression of selected adhesion molecules on vasculature in the choroid plexus, the subarachnoid space surrounding the cerebral cortex, and the cerebral parenchyma. Using multicolor flow cytometry, we found that CSF cells predominantly consisted of CD4+/CD45RA-/CD27+/CD69+-activated central memory T cells expressing high levels of CCR7 and L-selectin. CD3+ T cells were present in the choroid plexus stroma in autopsy CNS tissue sections from individuals who died without known neurological disorders. P- and E-selectin immunoreactivity was detected in large venules in the choroid plexus and subarachnoid space, but not in parenchymal microvessels. CD4+ T cells in the CSF expressed high levels of P-selectin glycoprotein ligand <em>1</em>, and a subpopulation of circulating CD4+ T cells displayed P-selectin binding activity. Intercellular adhesion molecule <em>1</em>, but not vascular cell adhesion molecule <em>1</em> or mucosal addressin cell adhesion molecule <em>1</em>, was expressed in choroid plexus and subarachnoid space vessels. Based on these findings, we propose that T cells are recruited to the CSF through interactions between P-selectin/P-selectin ligands and intercellular adhesion molecule <em>1</em>/lymphocyte function-associated antigen <em>1</em> in choroid plexus and subarachnoid space venules. These results support the overall hypothesis that activated memory T cells enter CSF directly from the systemic circulation and monitor the subarachnoid space, retaining the capacity to either initiate local immune reactions or return to secondary lymphoid organs.

BACKGROUND

Fabry disease (alpha-galactosidase A deficiency) is a rare, X-linked lysosomal storage disorder that can cause early death from renal, cardiac, and cerebrovascular involvement.

OBJECTIVE

To see whether agalsidase beta delays the onset of a composite clinical outcome of renal, cardiovascular, and cerebrovascular events and death in patients with advanced Fabry disease.

METHODS

Randomized (2:<em>1</em> treatment-to-placebo randomization), double-blind, placebo-controlled trial.

METHODS

4<em>1</em> referral centers in 9 countries.

METHODS

82 adults with mild to moderate kidney disease; 74 of whom were protocol-adherent.

METHODS

Intravenous infusion of agalsidase beta (<em>1</em> mg per kg of body weight) or placebo every 2 weeks for up to 35 months (median, <em>1</em>8.5 months).

METHODS

The primary end point was the time to first clinical event (renal, cardiac, or cerebrovascular event or death). Six patients withdrew before reaching an end point: 3 to receive commercial therapy and 3 due to positive or inconclusive serum IgE or skin test results. Three patients assigned to agalsidase beta elected to transition to open-label treatment before reaching an end point.

RESULTS

Thirteen (42%) of the 3<em>1</em> patients in the placebo group and <em>1</em>4 (27%) of the 5<em>1</em> patients in the agalsidase-beta group experienced clinical events. Primary intention-to-treat analysis that adjusted for an imbalance in baseline proteinuria showed that, compared with placebo, agalsidase beta delayed the time to first clinical event (hazard ratio, 0.47 [95% CI, 0.2<em>1</em> to <em>1</em>.03]; P = 0.06). Secondary analyses of protocol-adherent patients showed similar results (hazard ratio, 0.39 [CI, 0.<em>1</em>6 to 0.93]; P = 0.034). Ancillary subgroup analyses found larger treatment effects in patients with baseline estimated glomerular filtration rates greater than 55 mL/min per <em>1</em>.73 m2 (hazard ratio, 0.<em>1</em>9 [CI, 0.05 to 0.82]; P = 0.025) compared with 55 mL/min per <em>1</em>.73 m2 or less (hazard ratio, 0.85 [CI, 0.32 to 2.3]; P = 0.75) (formal test for interaction, P = 0.09). Most treatment-related adverse events were mild or moderate infusion-associated reactions, reported by 55% of patients in the agalsidase-beta group and 23% of patients in the placebo group.

CONCLUSIONS

The study sample was small. Only one third of the patients experienced clinical events, and some patients withdrew before experiencing any event.

CONCLUSIONS

Agalsidase-beta therapy slowed progression to the composite clinical outcome of renal, cardiac, and cerebrovascular complications and death compared with placebo in patients with advanced Fabry disease. Therapeutic intervention before irreversible organ damage may provide greater clinical benefit.

BACKGROUND

Although several studies compare surgical results of laparoscopic and open colonic resections, there is no study of laparoscopic gastrectomy compared with open gastrectomy.

OBJECTIVE

When compared with conventional open gastrectomy, laparoscopy-assisted Billroth I gastrectomy is less invasive in patients with early-stage gastric cancer.

METHODS

Retrospective review of operative data, blood analyses, and postoperative clinical course after Billroth I gastrectomy.

METHODS

University hospital in Japan.

METHODS

The study included <em>1</em>02 patients who were treated with Billroth I gastrectomy for early-stage gastric cancer from January <em>1</em>993 to July <em>1</em>999: 49 with laparoscopy-assisted gastrectomy and 53 with conventional open gastrectomy.

METHODS

Demographic features examined were operation time; blood loss; blood cell counts of leukocytes, granulocytes, and lymphocytes; serum levels of C-reactive protein, interleukin 6, total protein, and albumin; body temperature; weight loss; analgesic requirements; time to first flatus; time to liquid diet; length of postoperative hospital stay; complications; proximal margin of the resected stomach; and number of harvested lymph nodes.

RESULTS

Significant differences (P<.05) were present between laparoscopy-assisted and conventional open gastrectomy when the following features were compared: blood loss (<em>1</em>58 vs 302 <em>mL</em>), leukocyte count on day <em>1</em> (9.42 vs <em>1</em><em>1</em>.<em>1</em>4 x <em>1</em>0(9)/L) and day 3 (6.99 vs 8.22 x <em>1</em>0(9)/L), granulocyte count on day <em>1</em> (7.28 vs 8.90 x <em>1</em>0(9)/L), C-reactive protein level on day 7 (2.9<em>1</em> vs 5.<em>1</em>9 mg/dL), interleukin 6 level on day 3 (4.2 vs 26.0 U/<em>mL</em>), serum albumin level on day 7 (35.6 vs 33.9 g/L), number of times analgesics given (3.3 vs 6.2), time to first flatus (3.9 vs 4.5 days), time to liquid diet (5.0 vs 5.7 days), postoperative hospital stay (<em>1</em>7.6 vs 22.5 days), and weight loss on day <em>1</em>4 (5.5% vs 7.<em>1</em>%). There was no significant difference between laparoscopy-assisted and conventional open gastrectomy with regard to operation time (246 vs 228 minutes), proximal margin (6.2 vs 6.0 cm), number of harvested lymph nodes (<em>1</em>8.4 vs 22.<em>1</em>), and complication rate (8% vs 2<em>1</em>%).

CONCLUSIONS

Laparoscopy-assisted Billroth I gastrectomy, when compared with conventional open gastrectomy, has several advantages, including less surgical trauma, less impaired nutrition, less pain, rapid return of gastrointestinal function, and shorter hospital stay, with no decrease in operative curability. When performed by a skilled surgeon, laparoscopy-assisted Billroth I gastrectomy is a safe and useful technique for patients with early-stage gastric cancer.

Nonadherence to highly active antiretroviral therapy (HAART) is a major cause of human immunodeficiency virus (HIV) drug resistance; however the level of nonadherence associated with the greatest risk of resistance is unknown. Beginning in February 2000, <em>1</em>95 patients at the Johns Hopkins Outpatient Center (Baltimore, MD) who were receiving HAART and who had HIV loads of <500 copies/<em>mL</em> were recruited into a cohort study and observed for <em>1</em> year. At each visit, adherence to HAART was assessed and plasma samples were obtained and stored for resistance testing, if indicated. The overall incidence of viral rebound with clinically significant resistance was <em>1</em>4.5 cases per <em>1</em>00 person-years. By multivariate Cox proportional hazards regression, a cumulative adherence of 70%-89%, a CD4 cell nadir of <200 cells/microL, and the missing of a scheduled clinic visit in the past month were independently associated with an increased hazard of viral rebound with clinically significant resistance. Clinicians and patients must set high adherence goals to avoid the development of resistance.

Proteinuria has been shown to be an adverse prognostic factor in IgA nephropathy. The benefit of achieving a partial remission of proteinuria, however, has not been well described. We studied 542 patients with biopsy-proven primary IgA nephropathy in the Toronto Glomerulonephritis Registry and found that glomerular filtration rate (GFR) declined at -0.38 +/- 0.6<em>1</em> <em>ml</em>/min per <em>1</em>.73 m2/mo overall, with 30% of subjects reaching end-stage renal disease. Multivariate analysis revealed that proteinuria during follow-up was the most important predictor of the rate of GFR decline. Among the <em>1</em>7<em>1</em> patients with (<em>1</em> g/d of sustained proteinuria, the rate of decline was 90% slower than the mean rate. The rate of decline increased with the amount of proteinuria, such that those with sustained proteinuria >3 g/d (n = <em>1</em>2<em>1</em>) lost renal function 25-fold faster than those with (<em>1</em> g/d. Patients who presented with>> or =3 g/d who achieved a partial remission ((<em>1</em> g/d) had a similar course to patients who had < or =<em>1</em> g/d throughout, and fared far better than patients who never achieved remission. These results underscore the relationship between proteinuria and prognosis in IgA nephropathy and establish the importance of remission.

OBJECTIVE

It has been shown in a two-center study that high positive end-expiratory pressure (PEEP) and low tidal volume (LTV) improved outcome in ARDS. However, that study involved patients with underlying diseases unique to the study area, was conducted at only two centers, and enrolled a small number of patients. We similarly hypothesized that a ventilatory strategy based on PEEP above the lower inflection point of the pressure volume curve of the respiratory system (Pflex) set on day <em>1</em> with a low tidal volume would result in improved outcome in patients with severe and persistent acute respiratory distress syndrome (ARDS).

METHODS

Randomized, controlled clinical trial.

METHODS

Network of eight Spanish multidisciplinary intensive care units (ICUs) under the acronym of ARIES (Acute Respiratory Insufficiency: España Study).

METHODS

All consecutive patients admitted into participating Spanish ICUs from March <em>1</em>999 to March 200<em>1</em> with a diagnosis of ARDS were considered for the study. If 24 hrs after meeting ARDS criteria, the Pao2/Fio2 remained < or =200 mm Hg on standard ventilator settings, patients were randomized into two groups: control and Pflex/LTV.

METHODS

In the control group, tidal volume was 9-<em>1</em><em>1</em> mL/kg of predicted body weight (PBW) and PEEP>> or =5 cm H2O. In the Pflex/LTV group, tidal volume was 5-8 mL/kg PBW and PEEP was set on day <em>1</em> at Pflex + 2 cm H2O. In both groups, Fio2 was set to maintain arterial oxygen saturation >90% and Pao2 70-<em>1</em>00 mm Hg, and respiratory rate was adjusted to maintain Paco2 between 35 and 50 mm Hg.

RESULTS

The study was stopped early based on an efficacy stopping rule as described in the methods. Of <em>1</em>03 patients who were enrolled (50 control and 53 Pflex), eight patients (five in control, three in Pflex) were excluded from the final evaluation because the random group assignment was not performed in one center according to protocol. Main outcome measures were ICU and hospital mortality, ventilator-free days, and nonpulmonary organ dysfunction. ICU mortality (24 of 45 [53.3%] vs. <em>1</em>6 of 50 [32%], p = .040), hospital mortality (25 of 45 [55.5%] vs. <em>1</em>7 of 50 [34%], p = .04<em>1</em>), and ventilator-free days at day 28 (6.02 +/- 7.95 in control and <em>1</em>0.90 +/- 9.45 in Pflex/LTV, p = .008) all favored Pflex/LTV. The mean difference in the number of additional organ failures postrandomization was higher in the control group (p < .00<em>1</em>).

CONCLUSIONS

A mechanical ventilation strategy with a PEEP level set on day <em>1</em> above Pflex and a low tidal volume compared with a strategy with a higher tidal volume and relatively low PEEP has a beneficial impact on outcome in patients with severe and persistent ARDS.

BACKGROUND

Previous evidence suggests that aging in healthy persons does not result in decreased incorporation of muscle proteins after a bolus ingestion of <em>1</em>5 g essential amino acids (EAAs).

OBJECTIVE

We sought to examine whether ingestion of a smaller bolus of EAAs is associated with diminished accretion of muscle proteins in the elderly when compared with the young.

METHODS

Eleven elderly subjects (mean +/- SEM: 68 +/- 2 y) and 8 young control subjects (mean +/- SEM: 3<em>1</em> +/- 2 y) were studied in the postabsorptive state and for 3.5 h after a bolus ingestion of approximately 7 g EAAs. Muscle protein accretion and synthesis were measured with the femoral arteriovenous phenylalanine net balance technique during a constant infusion of L-[ring-(2)H5]phenylalanine.

RESULTS

Similar to previous observations, no significant differences in the postabsorptive phenylalanine net balance were observed between the groups. However, the mean (+/-SEM) net phenylalanine uptake after EAA ingestion was significantly less in the elderly (9.9 +/- 3.7 mg/leg) than in the young (25.<em>1</em> +/- 3.7 mg/leg; P < 0.05). The mean (+/-SEM) rate of disappearance of phenylalanine during the same period significantly increased above basal rates in the young (36 +/- 3 compared with 30 +/- 3 nmol x min(-<em>1</em>) x <em>1</em>00 <em>mL</em> leg volume(-<em>1</em>); P < 0.05) but not in the elderly (30 +/- 3 compared with 28 +/- 5 nmol x min(-<em>1</em>) x <em>1</em>00 <em>mL</em> leg volume(-<em>1</em>); P>> 0.05).

CONCLUSIONS

These data indicate that aging results in a diminished accretion of muscle proteins after ingestion of a small dose of EAAs. These findings may have practical implications with respect to the amount of protein contained in supplements given to the elderly for enhancing the stimulation of muscle protein synthesis.

Trimetazidine is a clinically effective antianginal agent that has no negative inotropic or vasodilator properties. Although it is thought to have direct cytoprotective actions on the myocardium, the mechanism(s) by which this occurs is as yet undefined. In this study, we determined what effects trimetazidine has on both fatty acid and glucose metabolism in isolated working rat hearts and on the activities of various enzymes involved in fatty acid oxidation. Hearts were perfused with Krebs-Henseleit solution containing <em>1</em>00 microU/<em>mL</em> insulin, 3% albumin, 5 mmol/L glucose, and fatty acids of different chain lengths. Both glucose and fatty acids were appropriately radiolabeled with either (3)H or (<em>1</em>4)C for measurement of glycolysis, glucose oxidation, and fatty acid oxidation. Trimetazidine had no effect on myocardial oxygen consumption or cardiac work under any aerobic perfusion condition used. In hearts perfused with 5 mmol/L glucose and 0.4 mmol/L palmitate, trimetazidine decreased the rate of palmitate oxidation from 488+/-24 to 408+/-<em>1</em>5 nmol x g dry weight(-<em>1</em>) x minute(-<em>1</em>) (P<0.05), whereas it increased rates of glucose oxidation from <em>1</em>889+/-<em>1</em><em>1</em>9 to 2378+/-<em>1</em>66 nmol x g dry weight(-<em>1</em>) x minute(-<em>1</em>) (P<0.05). In hearts subjected to low-flow ischemia, trimetazidine resulted in a 2<em>1</em>0% increase in glucose oxidation rates. In both aerobic and ischemic hearts, glycolytic rates were unaltered by trimetazidine. The effects of trimetazidine on glucose oxidation were accompanied by a 37% increase in the active form of pyruvate dehydrogenase, the rate-limiting enzyme for glucose oxidation. No effect of trimetazidine was observed on glycolysis, glucose oxidation, fatty acid oxidation, or active pyruvate dehydrogenase when palmitate was substituted with 0.8 mmol/L octanoate or <em>1</em>.6 mmol/L butyrate, suggesting that trimetazidine directly inhibits long-chain fatty acid oxidation. This reduction in fatty acid oxidation was accompanied by a significant decrease in the activity of the long-chain isoform of the last enzyme involved in fatty acid beta-oxidation, 3-ketoacyl coenzyme A (CoA) thiolase activity (IC(50) of 75 nmol/L). In contrast, concentrations of trimetazidine in excess of <em>1</em>0 and <em>1</em>00 micromol/L were needed to inhibit the medium- and short-chain forms of 3-ketoacyl CoA thiolase, respectively. Previous studies have shown that inhibition of fatty acid oxidation and stimulation of glucose oxidation can protect the ischemic heart. Therefore, our data suggest that the antianginal effects of trimetazidine may occur because of an inhibition of long-chain 3-ketoacyl CoA thiolase activity, which results in a reduction in fatty acid oxidation and a stimulation of glucose oxidation.

BACKGROUND

Most HIV-<em>1</em>-infected patients on effective antiretroviral therapy (ART) with plasma HIV-<em>1</em> RNA levels below the detection limits of commercial assays have residual viremia measurable by more sensitive methods. We assessed whether adding raltegravir lowered the level of residual viremia in such patients.

RESULTS

Patients receiving ART who had plasma HIV-<em>1</em> RNA levels below 50 copies/mL but detectable viremia by single copy assay (SCA) were randomized to add either raltegravir or placebo to their ART regimen for <em>1</em>2 weeks; patients then crossed-over to the other therapy for an additional <em>1</em>2 weeks while continuing pre-study ART. The primary endpoint was the plasma HIV-<em>1</em> RNA by SCA averaged between weeks <em>1</em>0 and <em>1</em>2 (<em>1</em>0/<em>1</em>2) compared between treatment groups. Fifty-three patients were enrolled. The median screening HIV-<em>1</em> RNA was <em>1</em>.7 copies/mL. The HIV-<em>1</em> RNA level at weeks <em>1</em>0/<em>1</em>2 did not differ significantly between the raltegravir-intensified (n = 25) and the placebo (n = 24) groups (median <em>1</em>.2 versus <em>1</em>.7 copies/mL, p = 0.55, Wilcoxon rank sum test), nor did the change in HIV-<em>1</em> RNA level from baseline to week <em>1</em>0/<em>1</em>2 (median -0.2 and -0.<em>1</em> copies/mL, p = 0.7<em>1</em>, Wilcoxon rank sum test). There was also no significant change in HIV-<em>1</em> RNA level from weeks <em>1</em>0/<em>1</em>2 to weeks 22/24 after patients crossed-over. There was a greater CD4 cell count increase from baseline to week <em>1</em>2 in the raltegravir-intensified group compared with the placebo group (+42 versus -44 cells/mm(3), p = 0.082, Wilcoxon rank sum test), which reversed after the cross-over. This CD4 cell count change was not associated with an effect of raltegravir intensification on markers of CD4 or CD8 cell activation in blood.

CONCLUSIONS

In this randomized, double-blind cross-over study, <em>1</em>2 weeks of raltegravir intensification did not demonstrably reduce low-level plasma viremia in patients on currently recommended ART. This finding suggests that residual viremia does not arise from ongoing cycles of HIV-<em>1</em> replication and infection of new cells. New therapeutic strategies to eliminate reservoirs that produce residual viremia will be required to eradicate HIV-<em>1</em> infection.

BACKGROUND

ClinicalTrials.gov NCT005<em>1</em>5827

Most human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) strains require either the CXCR4 or CCR5 chemokine receptor to efficiently enter cells. Blocking viral binding to these coreceptors is an attractive therapeutic target. Currently, several coreceptor antagonists are being evaluated in clinical trials that require characterization of coreceptor tropism for enrollment. In this report, we describe the development of an automated and accurate procedure for determining HIV-<em>1</em> coreceptor tropism (Trofile) and its validation for routine laboratory testing. HIV-<em>1</em> pseudoviruses are generated using full-length env genes derived from patient virus populations. Coreceptor tropism is determined by measuring the abilities of these pseudovirus populations to efficiently infect CD4+/U87 cells expressing either the CXCR4 or CCR5 coreceptor. Viruses exclusively and efficiently infecting CXCR4+/CD4+/U87 cells are designated X4-tropic. Conversely, viruses exclusively and efficiently infecting CCR5+/CD4+/U87 cells are designated R5-tropic. Viruses capable of infecting both CXCR4+/CD4+/U87 and CCR5+/CD4+/U87 cells are designated dual/mixed-tropic. Assay accuracy and reproducibility were established by evaluating the tropisms of well-characterized viruses and the variability among replicate results from samples tested repeatedly. The viral subtype, hepatitis B virus or hepatitis C virus coinfection, and the plasma viral load did not affect assay performance. Minority subpopulations with alternate tropisms were reliably detected when present at 5 to <em>1</em>0%. The plasma viral load above which samples can be amplified efficiently in the Trofile assay is <em>1</em>,000 copies per <em>ml</em> of plasma. Trofile has been automated for high-throughput use; it can be used to identify patients most likely to benefit from treatment regimens that include a coreceptor inhibitor and to monitor patients on treatment for the emergence of resistant virus populations that switch coreceptor tropism.

Invasive aspergillosis is an increasingly frequent opportunistic infection in immunocompromised patients. Only two agents, amphotericin B and itraconazole, are licensed for therapy. Itraconazole acts through inhibition of a P-450 enzyme undertaking sterol <em>1</em>4alpha demethylation. In vitro resistance in Aspergillus fumigatus to itraconazole correlated with in vivo outcome has not been previously described. For three isolates (AF72, AF90, and AF9<em>1</em>) of A. fumigatus from two patients with invasive aspergillosis itraconazole MICs were elevated. A neutropenic murine model was used to establish the validity of the MICs. The isolates were typed by random amplification of polymorphic DNA. Analysis of sterols, inhibition of cell-free sterol biosynthesis from [<em>1</em>4C] mevalonate, quantitation of P-450 content, and [3H]itraconazole concentration in mycelial pellets were used to determine the mechanisms of resistance. The MICs for the three resistant isolates were>><em>1</em>6 microg/<em>ml</em>. In vitro resistance was confirmed in vivo for all three isolates. Molecular typing showed the isolates from the two patients to be genetically distinct. Compared to the susceptible isolate from patient <em>1</em>, AF72 had a reduced ergosterol content, greater quantities of sterol intermediates, a similar susceptibility to itraconazole in cell-free ergosterol biosynthesis, and a reduced intracellular [3H]itraconazole concentration. In contrast, AF9<em>1</em> and AF92 had slightly higher ergosterol and lower intermediate sterol concentrations, fivefold increased resistance in cell-free systems to the effect of itraconazole on sterol <em>1</em>4alpha demethylation, and intracellular [3H] itraconazole concentrations found in susceptible isolates. Resistance to itraconazole in A. fumigatus is detectable in vitro and is present in wild-type isolates, and at least two mechanisms of resistance are responsible.

Lymphocyte trafficking is an essential process in immune and inflammatory functions which can be thought to contain at least two main components: adhesion and migration. Whereas adhesion molecules such as the selections are known to mediate the homing of leukocytes from the blood to the endothelium, the chemoattractant substances responsible for the migration of specific subsets of lymphocytes to sites of infection or inflammation are largely unknown. Here we show that two molecules in the chemokine (for chemoattractant cytokine) superfamily, human macrophage inflammatory protein <em>1</em> alpha (MIP-<em>1</em> alpha) and MIP-<em>1</em> beta, do not share identical attractant activities for lymphocyte subpopulations. When analyzed in vitro in microchemotaxis experiments, HuMIP-<em>1</em> beta tends to attract CD4+ T lymphocytes, with some preference for T cells of the naive (CD45RA) phenotype. HuMIP-<em>1</em> alpha, when tested in parallel with HuMIP-<em>1</em> beta, is a more potent lymphocyte chemoattractant with a broader range of concentration-dependent chemoattractant specificities. HuMIP-<em>1</em> alpha at a concentration of <em>1</em>00 pg/<em>ml</em> attracts B cells and cytotoxic T cells, whereas at higher concentrations (<em>1</em>0 ng/<em>ml</em>), the migration of these cells appears diminished, and the migration of CD4+ T cells is enhanced. Thus, in this assay system, HuMIP-<em>1</em> alpha and -<em>1</em> beta have differential attractant activities for subsets of immune effector cells, with HuMIP-<em>1</em> alpha having greater effects than HuMIP-<em>1</em> beta, particularly on B cells.