OBJECTIVE

The diagnosis of infection in critically ill patients is challenging because traditional markers of infection are often misleading. For example, serum concentrations of calcitonin precursors are increased in patients with infections. However, their predictive accuracy for the diagnosis of sepsis in unselected patients in a medical intensive care unit (ICU) is unknown. Therefore, we compared the usefulness of serum concentrations of calcitonin precursors, C-reactive protein, interleukin-6, and lactate for the diagnosis of sepsis in consecutive patients suffering from a broad range of diseases with an anticipated stay of>> or =24 hrs in a medical ICU.

METHODS

Prospective cohort study.

METHODS

Medical intensive care unit in a university medical center.

METHODS

<em>1</em>0<em>1</em> consecutive critically ill patients.

METHODS

None.

RESULTS

Blood samples were collected at various time points during the course of the disease. Systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock were diagnosed according to standardized criteria, and patients were reclassified daily without prior knowledge of the serum concentrations of calcitonin precursors or interleukin-6. At admission, 99% of the patients had systemic inflammatory response syndrome, 53% had sepsis, and 5% developed sepsis during their stay in the ICU. Calcitonin precursors, C-reactive protein, interleukin-6, and lactate levels increased with the severity of infection (p < .0<em>1</em>, one-way analysis of variance). In a receiver operating characteristic curve analysis, calcitonin precursors were found to be the most reliable laboratory variable for the diagnosis of sepsis as compared with C-reactive protein, interleukin-6, and lactate (p < .0<em>1</em>, for each comparison). Calcitonin precursor concentrations of>><em>1</em> ng/<em>mL</em> had sensitivity of 89% and specificity of 94% for the diagnosis of sepsis. High serum concentrations of calcitonin precursors were associated with poor prognosis (p = .0<em>1</em>).

CONCLUSIONS

In a medical ICU, serum calcitonin precursor concentrations are more sensitive and are specific markers of sepsis as compared with serum C-reactive protein, interleukin-6, and lactate levels.

OBJECTIVE

It has been suggested that overall dietary patterns and not single nutrients should be studied, since food items might have a synergistic and antagonistic effect on health. The Mediterranean diet has long been associated with lower incidence of cardiovascular disease and cancer. Therefore, we developed a diet score that incorporates the inherent characteristics of this dietary pattern.

RESULTS

We used <em>1</em><em>1</em> main components of the Mediterranean diet (non-refined cereals, fruits, vegetables, potatoes, legumes, olive oil, fish, red meat, poultry, full fat dairy products and alcohol). For the consumption of items presumed to be close to this pattern we assigned scores 0, <em>1</em>, 2, 3, 4 and 5 when a participant reported no consumption, rare, frequent, very frequent, weekly and daily, respectively. For the consumption of foods presumed to be away from this pattern we assigned the scores on a reverse scale. Especially for alcohol, we assigned score 5 for consumption of less than 300 <em>ml</em>/day, score 0 for consumption of more than 700 <em>ml</em>/day or none and scores <em>1</em>-4 for consumption of 300-400, 400-500, 500-600, and 600-700 <em>ml</em>/day (<em>1</em>00 <em>ml</em> = <em>1</em>2 g ethanol), respectively. Then a total score ranging from 0 to 55 was calculated. After having applied this diet score in the participants of the ATTICA study we observed a significant positive association with monounsaturated fat and monounsaturated-to-saturated fat intake. We also observed, an inverse association with serum lipids, blood pressures, inflammation and coagulation markers related to cardiovascular disease. The application of that score in a case-control study (CARDIO2000) suggested that the score was inversely associated with the odds of having acute coronary syndromes.

CONCLUSIONS

The Mediterranean diet score proposed above may be useful in assessing the nutritional status of an individual and investigating the relationship of the Mediterranean diet with various health outcomes.

BACKGROUND

C-reactive protein (CRP) induces adhesion molecule expression by endothelial cells. However, the effects of CRP on chemokine expression by endothelial cells are not known.

RESULTS

We tested the effects of CRP on the production of the chemokines monocyte chemoattractant protein-<em>1</em> (MCP-<em>1</em>) and RANTES in cultured human umbilical vein endothelial cells. The secretion of chemokines was assessed by ELISA. Incubation with <em>1</em>00 microgram/<em>mL</em> recombinant human CRP induced a 7-fold increase in MCP-<em>1</em> but no change in RANTES secretion. We showed that the effect of CRP on MCP-<em>1</em> was present even at 5 microgram/<em>mL</em> CRP, with stepwise increases as the CRP concentration was increased to <em>1</em>0, 50, and <em>1</em>00 microgram/<em>mL</em>. The effect of CRP on MCP-<em>1</em> induction was not influenced by aspirin (at concentrations up to <em>1</em> mmol/L), but it was significantly inhibited by 5 micromol/L simvastatin. The peroxisome proliferator-activated receptor-alpha activators fenofibrate (<em>1</em>00 micromol/L) and Wy-<em>1</em>4649 (<em>1</em>00 micromol/L) almost completely abolished the induction of MCP-<em>1</em>, but the peroxisome proliferator-activated receptor-gamma activator ciglitazone had only a moderate effect.

CONCLUSIONS

These results further strengthen the role of CRP in the pathogenesis of vascular inflammation and, likely, atherosclerosis and provide a crucial insight into a novel mechanism of action of anti-atherosclerosis drugs such as simvastatin and fenofibrate.

Interleukin-6 (IL-6) is a multifunctional cytokine produced by macrophages, T cells, B cells, endothelial cells and tumour cells. Interleukin-6 is able to promote tumour growth by upregulating anti-apoptotic and angiogenic proteins in tumour cells. In murine models it has been demonstrated that antibodies against IL-6 diminish tumour growth. Several reports have highlighted the prognostic importance of IL-6 in e.g., prostate and colon cancer. We addressed prospectively the prognostic significance of serum IL-6 (sIL-6), measured at diagnosis of metastasis, in 96 unselected and consecutive patients with progressive metastatic breast cancer before the initiation of systemic therapy. The median sIL-6 value for the breast cancer population was 6.6 +/- 2.<em>1</em> pg/<em>ml</em>. Patients with 2 or more metastatic sites had higher sIL-6 values compared to those with only <em>1</em> metastatic site (respectively 8.<em>1</em>5 +/- <em>1</em>.7 pg/<em>ml</em> and 3.06 +/- 6.6 pg/<em>ml</em>; p < 0.00<em>1</em>). Patients with liver metastasis (8.3 +/- 2.4 pg/<em>ml</em>), with pleural effusions (<em>1</em>0.65 +/- 9.9 pg/<em>ml</em>) and with dominant visceral disease (8.<em>1</em>5 +/- 3.3 pg/<em>ml</em>) had significantly higher values compared to those without liver metastases (4.5 +/- 3.4 pg/<em>ml</em>; p = 0.00<em>1</em>), without pleural effusions (5.45 +/- <em>1</em>.5 pg/<em>ml</em>; p = 0.0077) and with dominant bone disease (4.5 +/- <em>1</em>.4 pg/<em>ml</em>; p = 0.007) respectively. No correlation between sIL-6 and age, menopausal status, performance status, tumour grade, body-mass index, histology and hormone receptor status was found. Multivariate analysis showed that high levels of serum IL-6 have independent prognostic value. We conclude that circulating IL-6 is associated with worse survival in patients with metastatic breast cancer and is correlated with the extent of disease.

BACKGROUND

We recently found evidence of tubular epithelial-myofibroblast transdifferentiation (TEMT) during the development of tubulointerstitial fibrosis in the rat remnant kidney. This study investigated the mechanisms that induce TEMT in vitro.

METHODS

The normal rat kidney tubular epithelial cell line (NRK52E) was cultured for six days on plastic or collagen type I-coated plates in the presence or absence of recombinant transforming growth factor-beta<em>1</em> (TGF-beta<em>1</em>). Transdifferentiation of tubular cells into myofibroblasts was assessed by electron microscopy and by expression of alpha-smooth muscle actin (alpha-SMA) and E-cadherin.

RESULTS

NRK52E cells cultured on plastic or collagen-coated plates showed a classic cobblestone morphology. Culture in <em>1</em> ng/<em>ml</em> TGF-beta caused only very minor changes in morphology, but culture in <em>1</em>0 or 50 ng/<em>ml</em> TGF-beta<em>1</em> caused profound changes. This involved hypertrophy, a loss of apical-basal polarity and microvilli, with cells becoming elongated and invasive, the formation of a new front-end back-end polarity, and the appearance of actin microfilaments and dense bodies. These morphological changes were accompanied by phenotypic changes. Double immunohistochemistry staining showed that the addition of TGF-beta<em>1</em> to confluent cell cultures caused a loss of the epithelial marker E-cadherin and de novo expression of alpha-SMA. An intermediate stage in transdifferentiation could be seen with hypertrophic cells expressing both E-cadherin and alpha-SMA. De novo alpha-SMA expression was confirmed by Northern blotting, Western blotting, and flow cytometry. In particular, cells with a transformed morphology showed strong alpha-SMA immunostaining of characteristic microfilament structures along the cell axis. There was a dose-dependent increase in the percentage of cells expressing alpha-SMA with increasing concentrations of TGF-beta<em>1</em>, which was completely inhibited by the addition of a neutralizing anti-TGF-beta<em>1</em> antibody. Compared with growth on plastic, cell culture on collagen-coated plates showed a threefold increase in the percentage of cells expressing alpha-SMA in response to TGF-beta<em>1</em>.

CONCLUSIONS

TGF-beta<em>1</em> is a key mediator that regulates, in a dose-dependent fashion, transdifferentiation of tubular epithelial cells into alpha-SMA+ myofibroblasts. This transdifferentiation is markedly enhanced by growth on collagen type I. These findings have identified a novel pathway that may contribute to renal fibrosis associated with overexpression of TGF-beta<em>1</em> within the diseased kidney.

BACKGROUND

Adherence to prescribed medications is a central feature of good clinical HIV care, but little is known about the factors associated with multidrug antiretroviral adherence, or about how such adherence is related to plasma HIV suppression.

METHODS

We collected data from <em>1</em>33 HIV-infected adults receiving antiretroviral therapy. Study subjects completed customized adherence self-report instruments and provided blood samples to measure plasma HIV-<em>1</em> RNA concentrations and CD4+ lymphocyte counts. Regression models were used to determine the independent predictors of antiretroviral adherence and plasma HIV concentration, and the relationships between the two.

RESULTS

Adherence was poor (average, <80% antiretrovirals/day) in 28% (95% confidence interval [CI], 20%-36%), fair (80%-99% per day) in 23% (95% CI, <em>1</em>5%-30%), and excellent (<em>1</em>00% per day) in 50% (95% CI, 4<em>1</em>%-58%) of study subjects. Mean decreases in HIV-<em>1</em> concentration from highest-ever levels were <em>1</em>.3, <em>1</em>.6, and 2.0 log<em>1</em>0 copies/ml in these three groups, respectively (chi2; p < .02). Two-stage least squares regression demonstrated a -<em>1</em>.3 log difference in viral load associated with each category improvement in adherence. In multivariate models, confidence in medication-taking ability, or perceived self-efficacy, and convenience of the medication regimen, or "fit" with routine and daily activities, were also associated with greater medication adherence (odds ratios [OR] 5.3; 95% CI, 2.4-<em>1</em><em>1</em>.8, and 9.0; 95% CI, <em>1</em>.8-45.3, respectively). The latter was also independently associated with a lower plasma HIV concentration (p < .02).

CONCLUSIONS

Nonadherence to combination antiretroviral medications is common and is associated with increased levels of plasma HIV. Programs and clinical efforts to improve medication taking should strive to integrate medications better into patients' daily routines and to improve patients' confidence in their ability to take medications correctly.

Thrombospondin (TSP) forms specific complexes with transforming growth factor-beta (TGF-beta) in the alpha granule releasate of platelets and these TSP-TGF-beta complexes inhibit the growth of bovine aortic endothelial cells (BAE). In these studies, we report that TSP stripped of associated TGF-beta (sTSP) retained growth inhibitory activity which was partially reversed by a neutralizing antibody specific for TGF-beta. Since BAE cells secrete latent TGF-beta, we determined whether sTSP activates the latent TGF-beta secreted by BAE cells. Cells were cultured with or without sTSP and then the conditioned medium was tested for the ability to support TGF-beta-dependent normal rat kidney (NRK) colony formation in soft agar. Medium conditioned with sTSP showed a dose- and time-dependent ability to stimulate BAE-secreted TGF-beta activity, reaching maximal activation by <em>1</em>-2 h with 0.4 micrograms/<em>ml</em> (0.9 nM) sTSP. The sTSP-mediated stimulation of TGF-beta activity is not dependent on serum factors and is not a general property of extracellular matrix molecules. The sTSP-mediated stimulation of TGF-beta activity was blocked by a mAb specific for sTSP and by neutralizing antibodies to TGF-beta. Activation of BAE cell secreted latent TGF-beta by sTSP can occur in the absence of cells and apparently does not require interactions with cell surface molecules, since in conditioned medium removed from cells and then incubated with sTSP, activation occurs with kinetics and at levels similar to what is seen when sTSP is incubated in the presence of cells. Serine proteases such as plasmin are not involved in sTSP-mediated activation of TGF-beta. Factors that regulate the conversion of latent to active TGF-beta are keys to controlling TGF-beta activity. These data suggest that TSP is a potent physiologic regulator of TGF-beta activation.

An estimated 650,000 Americans will have ESRD by 20<em>1</em>0. Young adults with kidney failure often develop progressive chronic kidney disease (CKD) in childhood and adolescence. The Chronic Kidney Disease in Children (CKiD) prospective cohort study of 540 children aged <em>1</em> to <em>1</em>6 yr and have estimated GFR between 30 and 75 <em>ml</em>/min per <em>1</em>.73 m2 was established to identify novel risk factors for CKD progression; the impact of kidney function decline on growth, cognition, and behavior; and the evolution of cardiovascular disease risk factors. Annually, a physical examination documenting height, weight, Tanner stage, and standardized BP is conducted, and cognitive function, quality of life, nutritional, and behavioral questionnaires are completed by the parent or the child. Samples of serum, plasma, urine, hair, and fingernail clippings are stored in biosamples and genetics repositories. GFR is measured annually for 2 yr, then every other year using iohexol, HPLC creatinine, and cystatin C. Using age, gender, and serial measurements of Tanner stage, height, and creatinine, compared with iohexol GFR, a formula to estimate GFR that will improve on traditional pediatric GFR estimating equations when applied longitudinally is expected to be developed. Every other year, echocardiography and ambulatory BP monitoring will assess risk for cardiovascular disease. The primary outcome is the rate of decline of GFR. The CKiD study will be the largest North American multicenter study of pediatric CKD.

In thalassemia and other iron loading anemias, ineffective erythropoiesis and erythroid signaling molecules are thought to cause inappropriate suppression of a small peptide produced by hepatocytes named hepcidin. Previously, it was reported that the erythrokine GDF<em>1</em>5 is expressed at very high levels in thalassemia and suppresses hepcidin expression. In this study, erythroblast expression of a second molecule named twisted gastrulation (TWSG<em>1</em>) was explored as a potential erythroid regulator of hepcidin. Transcriptome analyses suggest TWSG<em>1</em> is produced during the earlier stages of erythropoiesis. Hepcidin suppression assays demonstrated inhibition by TWSG<em>1</em> as measured by quantitative polymerase chain reaction (PCR) in dosed assays (<em>1</em>-<em>1</em>000 ng/<em>mL</em> TWSG<em>1</em>). In human cells, TWSG<em>1</em> suppressed hepcidin indirectly by inhibiting the signaling effects and associated hepcidin up-regulation by bone morphogenic proteins 2 and 4 (BMP2/BMP4). In murine hepatocytes, hepcidin expression was inhibited by murine Twsg<em>1</em> in the absence of additional BMP. In vivo studies of Twsg<em>1</em> expression were performed in healthy and thalassemic mice. Twsg<em>1</em> expression was significantly increased in the spleen, bone marrow, and liver of the thalassemic animals. These data demonstrate that twisted gastrulation protein interferes with BMP-mediated hepcidin expression and may act with GDF<em>1</em>5 to dysregulate iron homeostasis in thalassemia syndromes.

OBJECTIVE

To assess whether intraoperative intravascular volume optimisation improves outcome and shortens hospital stay after repair of proximal femoral fracture.

METHODS

Prospective, randomised controlled trial comparing conventional intraoperative fluid management with repeated colloid fluid challenges monitored by oesophageal Doppler ultrasonography to maintain maximal stroke volume throughout the operative period.

METHODS

Teaching hospital, London.

METHODS

40 patients undergoing repair of proximal femoral fracture under general anaesthesia.

METHODS

Patients were randomly assigned to receive either conventional intraoperative fluid management (control patients) or additional repeated colloid fluid challenges with oesophageal Doppler ultrasonography used to maintain maximal stroke volume throughout the operative period (protocol patients).

METHODS

Time declared medically fit for hospital discharge, duration of hospital stay (in acute bed; in acute plus long stay bed), mortality, perioperative haemodynamic changes.

RESULTS

Intraoperative intravascular fluid loading produced significantly greater changes in stroke volume (median <em>1</em>5 <em>ml</em> (95% confidence interval <em>1</em>0 to 2<em>1</em> <em>ml</em>)) and cardiac output (<em>1</em>.2 l/min (0.<em>1</em> to 2.3 l/min)) than in the conventionally managed group (-5 <em>ml</em> (-<em>1</em>0 to <em>1</em> <em>ml</em>) and -0.4 l/min (-<em>1</em>.0 to 0.2 l/min)) (P < 0.00<em>1</em> and P < 0.05, respectively). One protocol patient and two control patients died in hospital. In the survivors, postoperative recovery was significantly faster in the protocol patients, with shorter times to being declared medically fit for discharge (median <em>1</em>0 (9 to <em>1</em>5) days v <em>1</em>5 (<em>1</em><em>1</em> to 40) days, P < 0.05) and a 39% reduction in hospital stay (<em>1</em>2 (8 to <em>1</em>3) days v 20 (<em>1</em>0 to 6<em>1</em>) days, P < 0.05).

CONCLUSIONS

Proximal femoral fracture repair constitutes surgery in a high risk population. Intraoperative intravascular volume loading to optimal stroke volume resulted in a more rapid postoperative recovery and a significantly reduced hospital stay.

OBJECTIVE

Different prognostic factors stratify patients with pancreatic adenocarcinoma. The purpose of this study was to determine whether preoperative CA<em>1</em>9-9 levels can predict stage of disease or survival and whether a change in preoperative to postoperative CA<em>1</em>9-9 or the postoperative CA<em>1</em>9-9 predicts overall survival.

METHODS

Four hundred twenty-four consecutive patients with pancreatic adenocarcinoma underwent resection between January <em>1</em>, <em>1</em>985 and January <em>1</em>, 2004. Of the patients with a bilirubin less than 2 mg/dL, <em>1</em>76 had preoperative CA<em>1</em>9-9 values, and <em>1</em><em>1</em><em>1</em> had pre- and postoperative CA<em>1</em>9-9 values. Survival was measured from the first postoperative CA<em>1</em>9-9 level measured (median, 39 days) until death or last follow-up. A multivariate failure time model was fit using clinical, operative, pathologic, and adjuvant treatment characteristics, and a categorization was defined by the values and changes in CA<em>1</em>9-9 before and after surgery.

RESULTS

Of the <em>1</em>76 patients, <em>1</em>28 (73%) had T3 lesions, and 99 (56%) had N<em>1</em> disease; <em>1</em>38 patients (78%) underwent pancreaticoduodenectomy. Median preoperative CA<em>1</em>9-9 levels were lower in N0 patients compared with patients with positive nodes (nine v <em>1</em>64 U/mL, respectively; nonparametric P = .06) and in T<em>1</em>/T2 patients versus T3 patients (4<em>1</em> v <em>1</em>62 U/mL, respectively; P = .03). Median follow-up time (n = <em>1</em><em>1</em><em>1</em>) was <em>1</em>.8 years (range, <em>1</em> to <em>1</em>2.9 years), with overall actuarial <em>1</em>-, 3-, and 5-year survival rates of 70%, 36%, and 30%, respectively. Significant predictors of survival on multivariate analysis included a decrease in CA<em>1</em>9-9 (P = .0005), negative lymph nodes (P = .00<em>1</em>), lower T stage (P = .0008), and postoperative CA<em>1</em>9-9 less than 200 U/mL (P = .0007).

CONCLUSIONS

In patients with pancreatic adenocarcinoma, preoperative CA<em>1</em>9-9 correlates with stage of disease. Both a postoperative decrease in CA<em>1</em>9-9 and a postoperative CA<em>1</em>9-9 value of less than 200 U/mL are strong independent predictors of survival, even after adjusting for stage. CA<em>1</em>9-9 levels should be included in a patient's perioperative care and should be considered for prognostic nomograms.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is thought to result from an accelerated decline in forced expiratory volume in <em>1</em> second (FEV<em>1</em>) over time. Yet it is possible that a normal decline in FEV<em>1</em> could also lead to COPD in persons whose maximally attained FEV<em>1</em> is less than population norms.

METHODS

We stratified participants in three independent cohorts (the Framingham Offspring Cohort, the Copenhagen City Heart Study, and the Lovelace Smokers Cohort) according to lung function (FEV<em>1</em> ≥80% or <80% of the predicted value) at cohort inception (mean age of patients, approximately 40 years) and the presence or absence of COPD at the last study visit. We then determined the rate of decline in FEV<em>1</em> over time among the participants according to their FEV<em>1</em> at cohort inception and COPD status at study end.

RESULTS

Among 657 persons who had an FEV<em>1</em> of less than 80% of the predicted value before 40 years of age, <em>1</em>74 (26%) had COPD after 22 years of observation, whereas among 2207 persons who had a baseline FEV<em>1</em> of at least 80% of the predicted value before 40 years of age, <em>1</em>58 (7%) had COPD after 22 years of observation (P<0.00<em>1</em>). Approximately half the 332 persons with COPD at the end of the observation period had had a normal FEV<em>1</em> before 40 years of age and had a rapid decline in FEV<em>1</em> thereafter, with a mean (±SD) decline of 53±2<em>1</em> ml per year. The remaining half had had a low FEV<em>1</em> in early adulthood and a subsequent mean decline in FEV<em>1</em> of 27±<em>1</em>8 ml per year (P<0.00<em>1</em>), despite similar smoking exposure.

CONCLUSIONS

Our study suggests that low FEV<em>1</em> in early adulthood is important in the genesis of COPD and that accelerated decline in FEV<em>1</em> is not an obligate feature of COPD. (Funded by an unrestricted grant from GlaxoSmithKline and others.).

BACKGROUND

Many patients infected with human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) and receiving highly active antiretroviral therapy experience intermittent episodes of detectable viremia ("blips"), which may raise concerns about drug resistance, lead to costly repeat measurements of viral RNA, and sometimes trigger alterations in therapy.

OBJECTIVE

To test the hypothesis that blips represent random biological and statistical variation around mean steady-state HIV-<em>1</em> RNA levels slightly below 50 copies/mL rather than biologically significant elevations in viremia.

METHODS

Between June <em>1</em>9, 2003, and February 9, 2004, patients receiving therapy underwent intensive sampling (every 2-3 days) over 3 to 4 months to define the frequency, magnitude, and duration of blips and their association with drug levels and other clinical variables. Blips were defined as HIV-<em>1</em> RNA measurements greater than or equal to 50 copies/mL preceded and followed by measurements less than 50 copies/mL without a change in treatment. To determine whether blips result from or lead to drug resistance, an ultrasensitive genotyping assay was used to detect drug resistance mutations before, during, and after blips. Patients were <em>1</em>0 HIV-<em>1</em>-infected asymptomatic adults recruited by clinicians and followed up in the Moore Clinic at the Johns Hopkins Hospital. Patients had suppression of viremia to below 50 copies/mL while receiving a stable antiretroviral regimen for 6 months or longer.

METHODS

At each time point, plasma HIV-<em>1</em> RNA levels were measured in 2 independent laboratories and drug resistance mutations were analyzed by clonal sequencing.

RESULTS

With the intensive sampling, blips were detected in 9 of <em>1</em>0 patients. Statistical analysis was consistent with random assay variation around a mean viral load below 50 copies/mL. Blips were not concordant on independent testing and had a short duration (median, <3 days) and low magnitude (median, 79 copies/mL). Blip frequency was not associated with demographic, clinical, or treatment variables. Blips did not occur in relation to illness, vaccination, or directly measured antiretroviral drug concentrations. Blips were marginally associated (P = .08) with reported episodes of nonadherence. Most importantly, in approximately <em>1</em>000 independent clones sequenced for both protease and reverse transcriptase, no new resistance mutations were seen before, during, or shortly after blips.

CONCLUSIONS

Most blips in this population appear to represent random biological and statistical variation around mean HIV-<em>1</em> levels below 50 copies/mL rather than clinically significant elevations in viremia.

BACKGROUND

The aim of this study was to measure the circulating levels of glucagon-like peptide-<em>1</em> (GLP-<em>1</em>), glucose-dependent insulinotropic peptide (GIP), and glucagon in patients who had undergone adjustable gastric banding (BND) or Roux-en-Y gastric bypass (RYGB) to understand the differences in glucose and insulin regulation after these procedures.

METHODS

This was a cross-sectional study of 3 groups of women matched for age and body mass index: group <em>1</em>, overweight controls (n = <em>1</em>3); group 2, BND (n = <em>1</em>0); and group 3, RYGB (n = <em>1</em>3). Venous blood was drawn with the patient in the fasted state and throughout a 3-hour period after a liquid meal.

RESULTS

The fasting glucose level was similar between the 2 surgery groups; however, the fasting insulin concentrations were greater in the BND (<em>1</em>0.0 microU/mL) than in the RYGB (6.2 microU/mL; P <0.05) group. The glucose level at 60 minutes was significantly lower in the RYGB group (70 mg/dL, range 38-82) than in the BND group (83 mg/dL, range 63-98). The GLP-<em>1</em> levels at 30 minutes were more than threefold greater in the RYGB group (96 pmol/L) compared with the BND and overweight control (28 pmol/L) groups. The GLP-<em>1</em> and insulin concentrations correlated at 30 minutes only in the RYGB group (r = .66; P = .0<em>1</em>3). The glucose-dependent insulinotropic peptide levels at 30 minutes were lower in the RYGB group (20 pmol/L) than in the BND group (3<em>1</em> pmol/L) or overweight control group (33 pmol/L). The peak glucagon levels were similar among the 3 groups.

CONCLUSIONS

Exaggerated postprandial GLP-<em>1</em> and blunted glucose-dependent insulinotropic peptide secretion after RYGB might contribute to the greater weight loss and improved glucose homeostasis compared with BND.

We recently described a novel population of blood-borne cells, termed fibrocytes, that display a distinct cell surface phenotype (collagen+/CD<em>1</em>3+/CD34+/CD45+), rapidly enter sites of tissue injury, and contribute to scar formation. To further characterize the role of these cells in vivo, we examined the expression of type I collagen and cytokine mRNAs by cells isolated from wound chambers implanted into mice. Five days after chamber implantation, CD34+ fibrocytes but not CD<em>1</em>4+ monocytes or CD90+ T cells expressed mRNA for type I collagen. Fibrocytes purified from wound chambers also were found to express mRNA for IL-<em>1</em>beta, IL-<em>1</em>0, TNF-alpha, JE/MCP, MIP-<em>1</em>alpha, MIP-<em>1</em>beta, MIP-2, PDGF-A, TGF-beta<em>1</em>, and M-CSF. The addition of IL-<em>1</em>beta (<em>1</em>-<em>1</em>00 ng/<em>ml</em>), a critical mediator in wound healing, to fibrocytes isolated from human peripheral blood induced the secretion of chemokines (MIP-<em>1</em>alpha, MIP-<em>1</em>beta, MCP-<em>1</em>, IL-8, and GRO alpha), hemopoietic growth factors (IL-6, IL-<em>1</em>0, and macrophage-CSF), and the fibrogenic cytokine TNF-alpha. By contrast, IL-<em>1</em>beta decreased the constitutive secretion of type I collagen as measured by ELISA. Additional evidence for a role for fibrocytes in collagen production in vivo was obtained in studies of livers obtained from Schistosoma japonicum-infected mice. Mouse fibrocytes localized to areas of granuloma formation and connective matrix deposition. We conclude that fibrocytes are an important source of cytokines and type I collagen during both the inflammatory and the repair phase of the wound healing response. Furthermore, IL-<em>1</em>beta may act on fibrocytes to effect a phenotypic transition between a repair/remodeling and a proinflammatory mode.

Monoclonal antibody <em>1</em>9-9, produced by a hybridoma prepared from spleen cells of a mouse immunized with a human colon carcinoma cell line, detects an antigen in the serum from most patients with gastrointestinal and pancreatic cancer (M. Herlyn, H.F. Sears, Z. Steplewski, and H. Koprowski, J. Clin. Immunol., 2: <em>1</em>35-<em>1</em>40, <em>1</em>982). The epitope of this antibody is a carbohydrate with the sugar sequence (formula; see text) in which NeuNAc is N-acetylneuraminic acid, Gal is galactose, GlcNAc is N-acetylglucosamine, and Fuc is fucose. In the colon carcinoma cell line and many gastrointestinal and pancreatic cancers, this sequence occurs in a monosialoganglioside containing a sialylated Lea-active pentasaccharide (sialylated lacto-N-fucopentaose II, IV3-alpha-NeuNAc-III4-alpha-Fuc-LcOse4, in which LcOse4 is Gal beta <em>1</em>-3GlcNAc beta <em>1</em>-3Gal beta <em>1</em>-4Glc) (J. L. Magnani et al. J. Biol. Chem., 257: <em>1</em>4365-<em>1</em>4369, <em>1</em>982). However, the antigen in the sera of patients occurs mainly as a mucin, not a ganglioside, based on the following evidence. Little antigen is extracted by organic solvents from sera, and that which is extracted remains at the origin under conditions of thin-layer chromatography where the ganglioside antigen migrates up the plate. Upon gel filtration of serum on Sephacryl S-400, the antigen is eluted in the void volume, indicating a molecular weight of greater than or equal to 5 X <em>1</em>0(6). Incubation for 5 hr at 37 degrees in 0.<em>1</em> N NaOH destroys the serum antigen but does not affect the ganglioside antigen. The density of the serum antigen as determined in a CsCl gradient is <em>1</em>.50 g/<em>ml</em>, while in 4 M guanidine. HCl its density is <em>1</em>.43 g/<em>ml</em>. Finally, antigen affinity purified by antibody <em>1</em>9-9 from the serum of a cancer patient belonging to the Le(a-b+) blood group contains Leb antigen, consistent with the multiple antigenic specificities exhibited by mucins.

When the unicellular green soil alga Chlamydomonas reinhardtii is deprived of nitrogen after entering stationary phase in liquid culture, the cells produce abundant cytoplasmic lipid bodies (LBs), as well as abundant starch, via a pathway that accompanies a regulated autophagy program. After 48 h of N starvation in the presence of acetate, the wild-type LB content has increased <em>1</em>5-fold. When starch biosynthesis is blocked in the sta6 mutant, the LB content increases 30-fold, demonstrating that genetic manipulation can enhance LB production. The use of cell wall-less strains permitted development of a rapid "popped-cell" microscopic assay to quantitate the LB content per cell and permitted gentle cell breakage and LB isolation. The highly purified LBs contain 90% triacylglycerol (TAG) and <em>1</em>0% free fatty acids (FFA). The fatty acids associated with the TAGs are approximately 50% saturated (C(<em>1</em>6) and C(<em>1</em>8)) fatty acids and approximately 50% unsaturated fatty acids, half of which are in the form of oleic acid (C(<em>1</em>8:<em>1</em>)). The FFA are approximately 50% C(<em>1</em>6) and approximately 50% C(<em>1</em>8). The LB-derived TAG yield from a liter of sta6 cells at <em>1</em>0(7) cells/<em>ml</em> after starvation for 48 h is calculated to approach 400 mg. The LB fraction also contains low levels of charged glycerolipids, with the same profile as whole-cell charged glycerolipids, that presumably form LB membranes; chloroplast-specific neutral glycerolipids (galactolipids) are absent. Very low levels of protein are also present, but all matrix-assisted laser desorption ionization-identified species are apparent contaminants. Nitrogen stress-induced LB production in C. reinhardtii has the hallmarks of a discrete pathway that should be amenable to additional genetic and culture condition manipulation.

BACKGROUND

We have developed and tested a method for printing protein microarrays and using these microarrays in a comparative fluorescence assay to measure the abundance of many specific proteins in complex solutions. A robotic device was used to print hundreds of specific antibody or antigen solutions in an array on the surface of derivatized microscope slides. Two complex protein samples, one serving as a standard for comparative quantitation, the other representing an experimental sample in which the protein quantities were to be measured, were labeled by covalent attachment of spectrally resolvable fluorescent dyes.

RESULTS

Specific antibody-antigen interactions localized specific components of the complex mixtures to defined cognate spots in the array, where the relative intensity of the fluorescent signal representing the experimental sample and the reference standard provided a measure of each protein's abundance in the experimental sample. To test the specificity, sensitivity and accuracy of this assay, we analyzed the performance of <em>1</em><em>1</em>5 antibody/antigen pairs. 50% of the arrayed antigens and 20% of the arrayed antibodies provided specific and accurate measurements of their cognate ligands at or below concentrations of 0.34 microg/<em>ml</em> and <em>1</em>.6 microg/<em>ml</em>, respectively. Some of the antibody/antigen pairs allowed detection of the cognate ligands at absolute concentrations below <em>1</em> ng/<em>ml</em>, and partial concentrations of <em>1</em> part in <em>1</em>06, sensitivities sufficient for measurement of many clinically important proteins in patient blood samples.

CONCLUSIONS

These results suggest that protein microarrays can provide a practical means to characterize patterns of variation in hundreds of thousands of different proteins in clinical or research applications.

BACKGROUND

Cotinine, a metabolite of nicotine, is a marker of exposure to tobacco smoke. Previous studies suggest that non-Hispanic blacks have higher levels of serum cotinine than non-Hispanic whites who report similar levels of cigarette smoking.

OBJECTIVE

To investigate differences in levels of serum cotinine in black, white, and Mexican American cigarette smokers in the US adult population.

METHODS

Third National Health and Nutrition Examination Survey, <em>1</em>988-<em>1</em>99<em>1</em>.

METHODS

A nationally representative sample of persons aged <em>1</em>7 years or older who participated in the survey.

METHODS

Serum cotinine levels by reported number of cigarettes smoked per day and by race and ethnicity.

RESULTS

A total of 7<em>1</em>82 subjects were involved in the study; 2<em>1</em>36 subjects reported smoking at least <em>1</em> cigarette in the last 5 days. Black smokers had cotinine concentrations substantially higher at all levels of cigarette smoking than did white or Mexican American smokers (P<.00<em>1</em>). Serum cotinine levels for blacks were <em>1</em>25 nmol/L (22 ng/<em>mL</em>) (95% confidence interval [CI], 79-<em>1</em>76 nmol/L [<em>1</em>4-3<em>1</em> ng/<em>mL</em>]) to 539 nmol/L (95 ng/<em>mL</em>) (95% CI, 289-630 nmol/L [5<em>1</em>-<em>1</em><em>1</em><em>1</em> ng/<em>mL</em>]) higher than for whites and <em>1</em>36 nmol/L (24 ng/<em>mL</em>) (95% CI, 85-<em>1</em>82 nmol/L [<em>1</em>5-32 ng/<em>mL</em>]) to 64<em>1</em> nmol/L (<em>1</em><em>1</em>3 ng/<em>mL</em>) (95% CI, 386-897 nmol/L [68-<em>1</em>58 ng/<em>mL</em>]) higher than for Mexican Americans. These differences do not appear to be attributable to differences in environmental tobacco smoke exposure or in number of cigarettes smoked.

CONCLUSIONS

To our knowledge, this study provides the first evidence from a national study that serum cotinine levels are higher among black smokers than among white or Mexican American smokers. If higher cotinine levels among blacks indicate higher nicotine intake or differential pharmacokinetics and possibly serve as a marker of higher exposure to cigarette carcinogenic components, they may help explain why blacks find it harder to quit and are more likely to experience higher rates of lung cancer than white smokers.

BACKGROUND

Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear.

OBJECTIVE

To estimate whether mortality in mechanically ventilated patients has changed over time.

METHODS

Prospective cohort studies conducted in <em>1</em>998, 2004, and 20<em>1</em>0, including patients receiving mechanical ventilation for more than <em>1</em>2 hours in a <em>1</em>-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models.

RESULTS

We included <em>1</em>8,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.00<em>1</em>), with increased use of noninvasive positive-pressure ventilation (5% in <em>1</em>998 to <em>1</em>4% in 20<em>1</em>0), a decrease in tidal volume (mean 8.8 ml/kg actual body weight [SD = 2.<em>1</em>] in <em>1</em>998 to 6.9 ml/kg [SD = <em>1</em>.9] in 20<em>1</em>0), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O [SD = 3.8] in <em>1</em>998 to 7.0 cm of H2O [SD = 3.0] in 20<em>1</em>0). Crude mortality in the intensive care unit decreased in 20<em>1</em>0 compared with <em>1</em>998 (28 versus 3<em>1</em>%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92).

CONCLUSIONS

Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT0<em>1</em>093482).

We report here that the bacterial lipopolysaccharide endotoxin induces human blood monocytes in a time- and dose-dependent manner to release prodigious amounts of prostaglandins with thromboxane A2, the major metabolite formed. Cells responded to as little as <em>1</em> ng/<em>ml</em> lipopolysaccharide to release prostaglandin E2 and thromboxane A2 with maximal stimulation at <em>1</em>0 micrograms/<em>ml</em>. Lipopolysaccharide was found to induce increased activity of cyclooxygenase enzyme without affecting the activities of phospholipase and thromboxane synthase or the formation of 5-lipoxygenase products (e.g. leukotriene B4). The glucocorticoid dexamethasone completely blocked the lipopolysaccharide-induced prostanoid release by inhibiting the activity of monocyte cyclooxygenase. Dexamethasone did not affect phospholipase and thromboxane synthase activities or leukotriene formation. Immunoprecipitation of [35S]methionine-labeled cyclooxygenase confirmed that the effect of lipopolysaccharide and dexamethasone on the monocyte prostanoid production could be attributed to an increase or decrease, respectively, in cellular cyclooxygenase de novo synthesis.

Autism is characterized by impairments in reciprocal social interaction and communication, and restricted and sterotyped patterns of interests and activities. Developmental difficulties are apparent before 3 years of age and there is evidence for strong genetic influences most likely involving more than one susceptibility gene. A two-stage genome search for susceptibility loci in autism was performed on 87 affected sib pairs plus <em>1</em>2 non-sib affected relative-pairs, from a total of 99 families identified by an international consortium. Regions on six chromosomes (4, 7, <em>1</em>0, <em>1</em>6, <em>1</em>9 and 22) were identified which generated a multipoint maximum lod score (<em>MLS</em>)>> <em>1</em>. A region on chromosome 7q was the most significant with an <em>MLS</em> of 3.55 near markers D7S530 and D7S684 in the subset of 56 UK affected sib-pair families, and an <em>MLS</em> of 2.53 in all 87 affected sib-pair families. An area on chromosome <em>1</em>6p near the telomere was the next most significant, with an <em>MLS</em> of <em>1</em>.97 in the UK families, and <em>1</em>.5<em>1</em> in all families. These results are an important step towards identifying genes predisposing to autism; establishing their general applicability requires further study.

OBJECTIVE

This study was undertaken to determine which exercise and radionuclide ventriculographic variables predict prognosis in advanced heart failure.

BACKGROUND

Although cardiopulmonary exercise testing is frequently used to predict prognosis in patients with advanced heart failure, little is known about the prognostic significance of ventriculographic variables.

METHODS

The results of maximal symptom-limited cardiopulmonary exercise testing and first-pass radionuclide ventriculography in patients with advanced heart failure referred for evaluation for cardiac transplantation were analyzed.

RESULTS

Sixty-seven patients with advanced heart failure (mean [+/- SD]; age 51 +/- 10 years, New York Heart Association functional classes III (58%) and IV (18%); mean left ventricular ejection fraction 0.22 +/- 0.07) underwent simultaneous upright bicycle ergometric cardiopulmonary exercise testing and first-pass rest/exercise radionuclide ventriculography. Mean peak oxygen consumption (VO2) was 11.8 +/- 4.2 ml/kg per min, and mean peak age- and gender-adjusted percent predicted oxygen consumption (%VO2) was 38 +/- 11.9%. Univariate predictors of overall survival included right ventricular ejection fraction>> or = 0.35 at rest and>> or = 0.35 at exercise and %VO2>> or = 45% (all p < 0.05). In a multivariate proportional hazards survival model, right ventricular ejection fraction>> or = 0.35 at exercise (p < 0.01) and %VO2>> or = 45% (p = 0.01) were selected as independent predictors of overall survival. Univariate predictors of event-free survival included right ventricular ejection fraction>> or = 0.35 at rest (p = 0.01) and>> or = 0.35 at exercise (p < 0.01), functional class II (p < 0.05) and %VO2>> or = 45% (p = 0.05). Right ventricular ejection fraction>> or = 0.35 at exercise (p = 0.01) was the only independent predictor of event-free survival in a multivariate proportional hazards model. Cardiac index at rest, VO2, left ventricular ejection fraction at rest, and exercise-related increase or decrease>> 0.05 in left or right ventricular ejection fraction were not predictive of overall or event-free survival in any univariate or multivariate analysis.

CONCLUSIONS

1) Right ventricular ejection fraction>> or = 0.35 at rest and exercise is a more potent predictor of survival in advanced heart failure than VO2 or %VO2; 2) %VO2 rather than VO2 predicts survival in advanced heart failure; 3) neither %VO2 nor VO2 predicts survival to the combined end point of death or admission for inotropic or mechanical support in patients with advanced heart failure.

OBJECTIVE

To determine adherence to and effectiveness of antiretroviral therapy (ART) in adolescents vs. adults in southern Africa.

METHODS

Observational cohort study.

METHODS

Aid for AIDS, a private sector disease management program in southern Africa.

METHODS

Adolescents (age <em>1</em><em>1</em>-<em>1</em>9 years; n = <em>1</em>54) and adults (n = 7622) initiating ART between <em>1</em>999 and 2006 and having a viral load measurement within <em>1</em> year after ART initiation.

METHODS

Primary: virologic suppression (HIV viral load < or = 400 copies/mL), viral rebound, and CD4 T-cell count at 6, <em>1</em>2, <em>1</em>8, and 24 months after ART initiation. Secondary: adherence assessed by pharmacy refills at 6, <em>1</em>2, and 24 months. Multivariate analyses: loglinear regression and Cox proportional hazards.

RESULTS

A significantly smaller proportion of adolescents achieved <em>1</em>00% adherence at each time point (adolescents: 20.7% at 6 months, <em>1</em>4.3% at <em>1</em>2 months, and 6.6% at 24 months; adults: 40.5%, 27.9%, and 20.6% at each time point, respectively; P < 0.0<em>1</em>). Patients achieving <em>1</em>00% <em>1</em>2-month adherence were significantly more likely to exhibit virologic suppression at <em>1</em>2 months, regardless of age. However, adolescents achieving virologic suppression had significantly shorter time to viral rebound (adjusted hazard ratio 2.03; 95% confidence interval: <em>1</em>.3<em>1</em> to 3.<em>1</em>3; P < 0.003). Adolescents were less likely to experience long-term immunologic recovery despite initial CD4 T-cell counts comparable to adults.

CONCLUSIONS

Compared with adults, adolescents in southern Africa are less adherent to ART and have lower rates of virologic suppression and immunologic recovery and a higher rate of virologic rebound after initial suppression. Studies must determine specific barriers to adherence in this population and develop appropriate interventions.