BACKGROUND

Hypertension is associated with impaired glucose metabolism and insulin resistance. Chronic activation of the sympathetic nervous system may contribute to either condition. We investigated the effect of catheter-based renal sympathetic denervation on glucose metabolism and blood pressure control in patients with resistant hypertension.

RESULTS

We enrolled 50 patients with therapy-resistant hypertension. Thirty-seven patients underwent bilateral catheter-based renal denervation, and <em>1</em>3 patients were assigned to a control group. Systolic and diastolic blood pressures, fasting glucose, insulin, C peptide, hemoglobin A(<em>1</em>c), calculated insulin sensitivity (homeostasis model assessment-insulin resistance), and glucose levels during oral glucose tolerance test were measured before and <em>1</em> and 3 months after treatment. Mean office blood pressure at baseline was <em>1</em>78/96±3/2 mm Hg. At <em>1</em> and 3 months, office blood pressure was reduced by -28/-<em>1</em>0 mm Hg (P<0.00<em>1</em>) and -32/-<em>1</em>2 mm Hg (P<0.00<em>1</em>), respectively, in the treatment group, without changes in concurrent antihypertensive treatment. Three months after renal denervation, fasting glucose was reduced from <em>1</em><em>1</em>8±3.4 to <em>1</em>08±3.8 mg/dL (P=0.039). Insulin levels were decreased from 20.8±3.0 to 9.3±2.5 μIU/<em>mL</em> (P=0.006) and C-peptide levels from 5.3±0.6 to 3.0±0.9 ng/<em>mL</em> (P=0.002). After 3 months, homeostasis model assessment-insulin resistance decreased from 6.0±0.9 to 2.4±0.8 (P=0.00<em>1</em>). Additionally, mean 2-hour glucose levels during oral glucose tolerance test were reduced significantly by 27 mg/dL (P=0.0<em>1</em>2). There were no significant changes in blood pressure or metabolic markers in the control group.

CONCLUSIONS

Renal denervation improves glucose metabolism and insulin sensitivity in addition to a significantly reducing blood pressure. However, this improvement appeared to be unrelated to changes in drug treatment. This novel procedure may therefore provide protection in patients with resistant hypertension and metabolic disorders at high cardiovascular risk.

BACKGROUND

URL: http://www.ClinicalTrials.gov. Unique identifiers: NCT00664638 and NCT00888433.

We applied PCR to the rapid detection of the metallo-beta-lactamase gene, blaIMP, in clinically isolated gram-negative rods. A total of 54 high-level ceftazidime-resistant strains (MICs,>> <em>1</em>28 micrograms/<em>ml</em>) were subjected to PCR analyses with the blaIMP-specific primers, since the blaIMP-bearing clinical isolates tested in our previous study always demonstrated high-level resistance to ceftazidime. Twenty-two blaIMP-positive strains including 9 Pseudomonas aeruginosa, 9 Serratia marcescens, 2 Alcaligenes xylosoxidans, <em>1</em> Pseudomonas putida, and <em>1</em> Klebsiella pneumoniae strains were newly identified from <em>1</em>8 different hospitals in Japan. These strains were mostly isolated from urine samples and showed high-level resistance to almost every cephem, while their levels of resistance to carbapenems were diverse. The PCR analyses with novel integrase gene-specific (intI3) and acc(6')-Ib gene-specific primers suggested that the integron structure found in a large plasmid harbored by S. marcescens AK9373 was also well conserved among blaIMP-positive strains. These results imply that the blaIMP gene cassettes have been dispersing into various gram-negative rods with the help of the newly identified integron element. Thus, the PCR-aided rapid detection will be helpful for the early recognition of emerging blaIMP-positive clinical isolates which demonstrate consistent resistance to beta-lactams.

Infection of adherent primary monocytes with HIV-<em>1</em>Ba-L is significantly suppressed in the presence of human saliva. By reverse transcriptase (RT) levels, saliva, although present for only <em>1</em> h during monocyte viral exposure, inhibited HIV-<em>1</em> infectivity for 3 wk after infection, whereas human plasma and synovial fluid failed to inhibit HIV-<em>1</em> infectivity. Antiviral activity was identified in the saliva soluble fraction, and to determine the factor(s) responsible, individual saliva proteins were examined. Of those proteins examined, only secretory leukocyte protease inhibitor (SLPI) was found to possess anti-HIV-<em>1</em> activity at physiological concentrations. SLPI anti-HIV-<em>1</em> activity was dose dependent, with maximal inhibition at <em>1</em>-<em>1</em>0 micrograms/<em>ml</em> >> 90% inhibition of RT activity). SLPI also partially inhibited HIV-<em>1</em>IIIB infection in proliferating human T cells. SLPI appears to target a host cell-associated molecule, since no interaction with viral proteins could be demonstrated. However, SLPI anti-HIV-<em>1</em> activity was not due to direct interaction with or downregulation of the CD4 antigen. Partial depletion of SLPI in whole saliva resulted in decreased anti-HIV-<em>1</em> activity of saliva. These data indicate that SLPI has antiretroviral activity and may contribute to the important antiviral activity of saliva associated with the infrequent oral transmission of HIV-<em>1</em>.

Skeletal muscle atrophy and weakness are thought to be stimulated by tumor necrosis factor alpha (TNF-alpha) in a variety of chronic diseases. However, little is known about the direct effects of TNF-alpha on differentiated skeletal muscle cells or the signaling mechanisms involved. We have tested the effects of TNF-alpha on the mouse-derived C2C<em>1</em>2 muscle cell line and on primary cultures from rat skeletal muscle. TNF-alpha treatment of differentiated myotubes stimulated time- and concentration-dependent reductions in total protein content and loss of adult myosin heavy chain (MHCf) content; these changes were evident at low TNF-alpha concentrations (<em>1</em>-3 ng/<em>ml</em>) that did not alter muscle DNA content and were not associated with a decrease in MHCf synthesis. TNF-alpha activated binding of nuclear factor kappaB (NF-kappaB) to its targeted DNA sequence and stimulated degradation of I-kappaBalpha, an NF-kappaB inhibitory protein. TNF-alpha stimulated total ubiquitin conjugation whereas a 26S proteasome inhibitor (MG<em>1</em>32 <em>1</em>0-40 microM) blocked TNF-alpha activation of NF-kappaB. Catalase <em>1</em> kU/<em>ml</em> inhibited NF-kappaB activation by TNF-alpha; exogenous hydrogen peroxide 200 microM activated NF-kappaB and stimulated I-kappaBalpha degradation. These data demonstrate that TNF-alpha directly induces skeletal muscle protein loss, that NF-kappaB is rapidly activated by TNF-alpha in differentiated skeletal muscle cells, and that TNF-alpha/NF-kappaB signaling in skeletal muscle is regulated by endogenous reactive oxygen species.

The Glucatell (<em>1</em>-->3)- beta-D-glucan (BG) detection assay (Associates of Cape Cod) was studied as a diagnostic adjunct for invasive fungal infections (IFIs). On the basis of findings from a preliminary study of 30 candidemic subjects and 30 healthy adults, a serum BG level of>>or=60 pg/<em>mL</em> was chosen as the cutoff. Testing was performed with serial serum samples obtained from 283 subjects with acute myeloid leukemia or myelodysplastic syndrome who were receiving antifungal prophylaxis. At least <em>1</em> serum sample was positive for BG at a median of <em>1</em>0 days before the clinical diagnosis in <em>1</em>00% of subjects with a proven or probable IFI. IFIs included candidiasis, fusariosis, trichosporonosis, and aspergillosis. Absence of a positive BG finding had a <em>1</em>00% negative predictive value, and the specificity of the test was 90% for a single positive test result and>>or=96% for>>or=2 sequential positive results. The Glucatell serum BG detection assay is highly sensitive and specific as a diagnostic adjunct for IFI.

Liraglutide is a glucagon-like peptide-<em>1</em> (GLP-<em>1</em>) analog developed for type 2 diabetes. Long-term liraglutide exposure in rodents was associated with thyroid C-cell hyperplasia and tumors. Here, we report data supporting a GLP-<em>1</em> receptor-mediated mechanism for these changes in rodents. The GLP-<em>1</em> receptor was localized to rodent C-cells. GLP-<em>1</em> receptor agonists stimulated calcitonin release, up-regulation of calcitonin gene expression, and subsequently C-cell hyperplasia in rats and, to a lesser extent, in mice. In contrast, humans and/or cynomolgus monkeys had low GLP-<em>1</em> receptor expression in thyroid C-cells, and GLP-<em>1</em> receptor agonists did not activate adenylate cyclase or generate calcitonin release in primates. Moreover, 20 months of liraglutide treatment (at >60 times human exposure levels) did not lead to C-cell hyperplasia in monkeys. Mean calcitonin levels in patients exposed to liraglutide for 2 yr remained at the lower end of the normal range, and there was no difference in the proportion of patients with calcitonin levels increasing above the clinically relevant cutoff level of 20 pg/<em>ml</em>. Our findings delineate important species-specific differences in GLP-<em>1</em> receptor expression and action in the thyroid. Nevertheless, the long-term consequences of sustained GLP-<em>1</em> receptor activation in the human thyroid remain unknown and merit further investigation.

The stimulation of insulin vs. inhibition of glucagon secretion in relation to the antidiabetic action of glucagon-like peptide-<em>1</em> (GLP-<em>1</em>) is not established. Here, the influence of a 4-wk increase in circulating GLP-<em>1</em> by inhibition of dipeptidyl peptidase-4 (DPP-4) on 24-h glucose and insulin and glucagon responses to breakfast was studied in subjects with dietary controlled diabetes [age: 65 +/- 8 yr (SD), body mass index: 27.3 +/- 3.3 kg/m(2), fasting plasma glucose: 9.0 +/- <em>1</em>.3 mmol/liter]. Compared with placebo (n = <em>1</em>9), a specific DPP-4 inhibitor [(<em>1</em>-[[(3-hydroxy-<em>1</em>-adamantyl) amino] acetyl]-2-cyano-(S)-pyrrolidine) (LAF237); <em>1</em>00 mg daily, n = <em>1</em>8] reduced fasting glucose by 0.70 mmol/liter (P = 0.037), 4-h prandial glucose excursion by <em>1</em>.45 mmol/liter (P < 0.00<em>1</em>), and mean 24-h glucose by 0.93 mmol/liter (P < 0.00<em>1</em>). Baseline and postprandial active GLP-<em>1</em> were increased by LAF237. The glucagon response to breakfast was reduced by LAF237 (glucagon levels at 60 min were 88 +/- 8 pg/<em>ml</em> before treatment vs. 77 +/- 5 pg/<em>ml</em> after; P = 0.00<em>1</em>). In contrast, the overall insulin levels were not altered. The 4-wk reduction in glucagon correlated with the reduction in 2-h glucose (r = 0.6<em>1</em>; P = 0.008). No such association was observed for insulin. Thus, improved metabolic control by DPP-4 inhibition in type 2 diabetes is seen in association with reduced glucagon levels and, despite the lower glycemia, unaltered insulin levels.

One of the great challenges in science and engineering today is to develop technologies to improve the health of people in the poorest regions of the world. Here we integrated new procedures for manufacturing, fluid handling and signal detection in microfluidics into a single, easy-to-use point-of-care (POC) assay that faithfully replicates all steps of ELISA, at a lower total material cost. We performed this 'mChip' assay in Rwanda on hundreds of locally collected human samples. The chip had excellent performance in the diagnosis of HIV using only <em>1</em> <em>μl</em> of unprocessed whole blood and an ability to simultaneously diagnose HIV and syphilis with sensitivities and specificities that rival those of reference benchtop assays. Unlike most current rapid tests, the mChip test does not require user interpretation of the signal. Overall, we demonstrate an integrated strategy for miniaturizing complex laboratory assays using microfluidics and nanoparticles to enable POC diagnostics and early detection of infectious diseases in remote settings.

BACKGROUND

Transmission of multiclass drug-resistant human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) may increase with wider use of antiretroviral therapy.

OBJECTIVE

To determine trends in prevalence of HIV-<em>1</em> drug resistance among recently infected individuals in a geographic area with a high penetration of antiviral treatment.

METHODS

Consecutive case series of 225 patients referred to a San Francisco, Calif, hospital with recent HIV-<em>1</em> infection from June <em>1</em>996 through June 200<em>1</em>.

METHODS

Time trends in the prevalence of genotypic and phenotypic primary drug resistance.

RESULTS

Mutations associated with resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) steadily increased from 0% in <em>1</em>996-<em>1</em>997 to <em>1</em>2 (<em>1</em>3.2%) in 2000-200<em>1</em> (P =.0<em>1</em>). There was <em>1</em> mutation associated with protease inhibitor resistance in <em>1</em>996-<em>1</em>997 (2.5%) and there were 7 (7.7%) in 2000-200<em>1</em> (P =.25). Genotypic resistance to nucleoside reverse transcriptase inhibitors (NRTIs) initially decreased and then returned to prior levels (P =.007 for test of homogeneity). Genotypic resistance to 2 or more classes of drugs increased from <em>1</em> (2.5%) to <em>1</em>2 (<em>1</em>3.2%) (P =.004), but only <em>1</em> infection (<em>1</em>.2%) in the latter period was resistant to all 3 classes of agents (P =.58). Primary phenotypic resistance decreased for NRTIs from 2<em>1</em>% to 6.2% (P =.03) and increased for NNRTIs from 0 to 8 (9.9%) (P =.02). Phenotypic resistance increased for protease inhibitors from 2.6% to 6.2% (P =.32). Median time to virologic suppression (<500 copies/mL) during therapy was <em>1</em>2 weeks for patients with genotypic evidence of resistance compared with 5 weeks for patients with drug-sensitive infections (P =.02).

CONCLUSIONS

The frequency of primary resistance to NNRTIs is increasing, although resistance to all available classes of antiretroviral therapy remains rare. Genotypic resistance testing in recently infected persons predicts time to viral suppression during therapy.

Reports that interleukin-8 (IL-8) induces the infiltration of neutrophils followed by T-cells into injection sites led us to postulate that by stimulation of neutrophil degranulation IL-8 may cause the release of factors with chemoattractant activity for T-lymphocytes. Extracts of human neutrophil granules were chromatographed to isolate and purify T-lymphocyte chemoattractant factors. Two major peaks of T-cell chemotactic activity were purified by C<em>1</em>8 reversed phase high pressure liquid chromatography (HPLC). The first peak was resolved further by C4 reversed phase HPLC and yielded an active fraction shown by NH2-terminal amino acid sequence analysis to contain defensins HNP-<em>1</em>, HNP-2, and HNP-3. Purified defensins HNP-<em>1</em> and HNP-2 (kindly provided by Dr. R. I. Lehrer, UCLA) were also potent chemoattractants for human T-cells, while HNP-3 was inactive. The second peak of T-cell chemoattractant activity was also further purified to homogeneity by C4 reversed phase HPLC and identified by NH2-terminal sequence analysis as CAP37/azurocidin, a protein with sequence homology to serine proteases. 0.<em>1</em> <em>1</em>00 ng of defensins and <em>1</em>.0 <em>1</em>00 ng/<em>ml</em> CAP37 were able to stimulate in vitro T-cell chemotaxis. Neutrophil activating factors, i.e. IL-8, phorbol <em>1</em>2-myristate <em>1</em>3-acetate/ionomycin, and formylmethionylleucylphenylalanine each induced the release of CAP37 and defensins from neutrophil granules. Subcutaneous administration of defensins or CAP37/azurocidin into BALB/c mice resulted in a moderate neutrophil and mononuclear cell infiltrate by 4 h, which was greater by 24 h at the site of injection. Additionally, subcutaneous injection of defensins into chimeric huPBL-SCID mice resulted in significant infiltration by human CD3+ cells within 4 h. These results identify the antimicrobial proteins, CAP37/azurocidin and defensins HNP-<em>1</em> and HNP-2, as potent neutrophil-derived chemoattractants for T-cells. These proteins represent primordial antimicrobial peptides which may have evolved into acute inflammatory cell-derived signals that mobilize immunocompetent T-cells and other inflammatory cells.

BACKGROUND

Aging is associated with increased cardiovascular risk and endothelial dysfunction. Since exercise can improve endothelium-dependent vasodilation, in the present study we tested whether long-term physical activity could prevent aging-related endothelial dysfunction.

RESULTS

In <em>1</em>2 young and elderly (age 26.9+/-2.3 and 62.9+/-5.8 years, respectively) healthy sedentary subjects and <em>1</em><em>1</em> young and <em>1</em>4 elderly matched athletes (age 27.5+/-<em>1</em>.9 and 66.4+/-6.<em>1</em> years, respectively), we studied (with strain-gauge plethysmography) forearm blood flow modifications induced by intrabrachial acetylcholine (0.<em>1</em>5, 0.45, <em>1</em>.5, 4.5, and <em>1</em>5 microg/<em>1</em>00 <em>mL</em> per minute), an endothelium-dependent vasodilator, at baseline, during infusion of N(G)-monomethyl-L-arginine (L-NMMA) (<em>1</em>00 microg/<em>1</em>00 <em>mL</em> forearm tissue per minute), a nitric oxide-synthase inhibitor, vitamin C (8 mg/<em>1</em>00 <em>mL</em> forearm tissue per minute), an antioxidant, and finally under simultaneous infusion of L-NMMA and vitamin C. The response to sodium nitroprusside (<em>1</em>, 2, and 4 microg/<em>1</em>00 <em>mL</em> forearm tissue per minute) was also evaluated. In young athletes and sedentary subgroups, vasodilation to acetylcholine was inhibited by L-NMMA and was not changed by vitamin C. In elderly subjects, vasodilation to acetylcholine was blunted as compared with young subjects in both control subjects and athletes, whereas the response to sodium nitroprusside was similar. Moreover, in elderly athletes, vitamin C did not change the vasodilation to acetylcholine. In contrast, in elderly sedentary subjects, the response to acetylcholine was resistant to L-NMMA. In this subgroup, vitamin C increased the vasodilation to acetylcholine and restored the inhibiting effect of L-NMMA.

CONCLUSIONS

These results suggest that regular physical activity can at least in part prevent the age-induced endothelial dysfunction, probably the restoration of nitric oxide availability consequent to prevention of production of oxidative stress.

BACKGROUND

Together with smoking, the lung function attained in early adulthood is one of the strongest predictors of chronic obstructive pulmonary disease. We aimed to investigate whether lung function in early adulthood is, in turn, affected by airway function measured shortly after birth.

METHODS

Non-selected infants were enrolled at birth in the Tucson Children's Respiratory Study between <em>1</em>980 and <em>1</em>984. We measured maximal expiratory flows at functional residual capacity (Vmax(FRC)) in <em>1</em>69 of these infants by the chest compression technique at a mean of 2.3 months (SD <em>1</em>.9). We also obtained measurements of lung function for <em>1</em>23 of these participants at least once at ages <em>1</em><em>1</em>, <em>1</em>6, and 22 years. Indices were forced expiratory volume in <em>1</em> s (FEV<em>1</em>), forced vital capacity (FVC), and forced expiratory flow between 25% and 75% of FVC (FEF25-75), both before and after treatment with a bronchodilator (<em>1</em>80 microg of albuterol).

RESULTS

Participants who had infant Vmax(FRC) in the lowest quartile also had lower values for the FEV<em>1</em>/FVC ratio (-5.2%, p<0.000<em>1</em>), FEF25-75 (-663 mL/s, p<0.000<em>1</em>), and FEV<em>1</em> (-233 mL, p=0.00<em>1</em>) up to age 22, after adjustment for height, weight, age, and sex, than those in the upper three quartiles combined. The magnitude and significance of this effect did not change after additional adjustment for wheeze, smoking, atopy, or parental asthma.

CONCLUSIONS

Poor airway function shortly after birth should be recognised as a risk factor for airflow obstruction in young adults. Prevention of chronic obstructive pulmonary disease might need to start in fetal life.

The association of high levels of autoantibodies to glutamic acid decarboxylase (GAD-ab) and stiff-person syndrome (SPS) is well known. However, the full spectrum of neurological syndromes associated with GAD-ab is not well established. In addition, these patients usually present type <em>1</em> diabetes mellitus (DM<em>1</em>) that could justify the presence of high GAD-ab levels. To clarify these issues, we reviewed the clinical and immunological features of patients in whom high GAD-ab levels were detected in a reference centre for DM<em>1</em> and for the detection of antineuronal antibodies in suspected paraneoplastic neurological syndromes (PNS). High GAD-ab levels were defined as values>> or =2000 U/<em>ml</em> by radioimmunoassay. Intrathecal synthesis (IS) of GAD-ab was calculated in paired serum/CSF samples. Values higher than the IgG index were considered indicators for positive GAD-ab-specific IS. High GAD-ab levels were identified in 6<em>1</em> patients, 22 (36%) had SPS, <em>1</em>7 (28%) cerebellar ataxia, <em>1</em><em>1</em> (<em>1</em>8%) other neurological disorders (epilepsy -- four, PNS -- four; idiopathic limbic encephalitis -- two; myasthenia gravis -- one), and <em>1</em><em>1</em> (<em>1</em>8%) isolated DM<em>1</em>. Patients with SPS and cerebellar ataxia had the same frequency of female gender (86% vs 94%), DM<em>1</em> (59% vs 53%), CSF oligoclonal bands (35% vs 69%). Three of the four PNS patients, with paraneoplastic encephalomyelitis, a predominant gait cerebellar ataxia, and limbic encephalitis, had neuroendocrine carcinomas. GAD expression was confirmed in the two tumours in which the study was done. The fourth patient presented with paraneoplastic cerebellar degeneration antedating a lung adenocarcinoma. The frequency of increased IS of GAD-ab was 85% in SPS, <em>1</em>00% in cerebellar ataxia, and 86% in other neurological disorders. In conclusion, our study emphasizes that high GAD-ab levels associate with other neurological disorders besides SPS. Cerebellar ataxia, the second most common syndrome associated with high GAD-ab levels, shares with SPS the same demographic, clinical and immunological features. The demonstration of an increased IS of GAD-ab is important to confirm that the GAD autoimmunity is related to the neurological syndrome particularly when there is a concomitant DM<em>1</em> that could justify the presence of high GAD-ab levels. Lastly, in patients who develop neurological syndromes that suggest a PNS, the finding of GAD-ab does not rule out this possibility and appropriate studies should be done to confirm an underlying cancer.

BACKGROUND

There has been considerable interest in the hypothesis that low birth weight may be a marker of impaired nephrogenesis and that this is causally related to chronic kidney disease (CKD).

METHODS

Systematic review and meta-analysis of observational studies.

METHODS

Studies of the relationship between birth weight and CKD published before February <em>1</em>, 2008, were identified by using electronic searches.

METHODS

All studies that had collected data for birth weight and kidney function at greater than <em>1</em>2 months of age were eligible for inclusion, except for studies of extremely low-birth-weight infants, very premature infants, or toxic exposure in utero. STUDY FACTOR: Birth weight.

RESULTS

CKD defined as albuminuria, low estimated glomerular filtration rate (<60 mL/min/<em>1</em>.73 m(2) or < <em>1</em>0th centile for age/sex), or end-stage renal disease.

RESULTS

We analyzed 3<em>1</em> relevant cohort or case-control studies with data for 49,376 individuals and data for 2,<em>1</em>83,3<em>1</em>7 individuals from a single record-linkage study. Overall, <em>1</em>6 studies reported a significant association between low birth weight and risk of CKD and <em>1</em>6 observed a null result. The combination of weighted estimates from the <em>1</em>8 studies for which risk estimates were available (n = 46,249 plus 2,<em>1</em>83,3<em>1</em>7 from the record linkage study) gave an overall odds ratio (OR) of <em>1</em>.73 (95% confidence interval [CI], <em>1</em>.44 to 2.08). Combined ORs were consistent in magnitude and direction for risks of albuminuria (OR, <em>1</em>.8<em>1</em>; 95% CI, <em>1</em>.<em>1</em>9 to 2.77), end-stage renal disease (OR, <em>1</em>.58; 95% CI, <em>1</em>.33 to <em>1</em>.88), or low estimated glomerular filtration rate (OR, <em>1</em>.79; 95% CI, <em>1</em>.3<em>1</em> to 2.45).

CONCLUSIONS

A reliance on published estimates and estimates provided on request rather than individual patient data and the possibility of reporting bias.

CONCLUSIONS

Existing data indicate that low birth weight is associated with subsequent risk of CKD, although there is scope for additional well-designed population-based studies with accurate assessment of birth weight and kidney function and consideration of important confounders, including maternal and socioeconomic factors.

Certain respiratory tract infections are transmitted through air. Coughing and sneezing by an infected person can emit pathogen-containing particles with diameters less than <em>1</em>0 microm that can reach the alveolar region. Based on our analysis of the sparse literature on respiratory aerosols, we estimated that emitted particles quickly decrease in diameter due to water loss to one-half the initial values, and that in one cough the volume in particles with initial diameters less than 20 microm is 60 x <em>1</em>0(-8) <em>mL</em>. The pathogen emission rate from a source case depends on the frequency of expiratory events, the respirable particle volume, and the pathogen concentration in respiratory fluid. Viable airborne pathogens are removed by exhaust ventilation, particle settling, die-off, and air disinfection methods; each removal mechanism can be assigned a first-order rate constant. The pathogen concentration in well-mixed room air depends on the emission rate, the size distribution of respirable particles carrying pathogens, and the removal rate constants. The particle settling rate and the alveolar deposition fraction depend on particle size. Given these inputs plus a susceptible person's breathing rate and exposure duration to room air, an expected alveolar dosemicrois estimated. If the infectious dose is one organism, as appears to be true for tuberculosis, infection risk is estimated by the expression: R = <em>1</em>-exp(-micro). Using published tuberculosis data concerning cough frequency, bacilli concentration in respiratory fluid, and die-off rate, we illustrate the model via a plausible scenario for a person visiting the room of a pulmonary tuberculosis case. We suggest that patients termed "superspreaders" or "dangerous disseminators" are those infrequently encountered persons with high values of cough and/or sneeze frequency, elevated pathogen concentration in respiratory fluid, and/or increased respirable aerosol volume per expiratory event such that their pathogen emission rate is much higher than average.

Weight loss (WL) decreases regional depots of adipose tissue and improves insulin sensitivity, two parameters that correlate before WL. To examine the potential relation of WL-induced change in regional adiposity to improvement in insulin sensitivity, 32 obese sedentary women and men completed a 4-month WL program and had repeat determinations of body composition (dual-energy X-ray absorptiometry and computed tomography) and insulin sensitivity (euglycemic insulin infusion). There were <em>1</em>5 lean men and women who served as control subjects. VO2max was unaltered with WL (39.2 +/- 0.8 vs. 39.8 +/- <em>1</em>.<em>1</em> <em>ml</em> x fat-free mass [FFM](-<em>1</em>) x min(-<em>1</em>)). The WL intervention achieved significant decreases in weight (<em>1</em>00.2 +/- 2.6 to 85.5 +/- 2.<em>1</em> kg), BMI (34.3 +/- 0.6 to 29.3 +/- 0.6 kg/m2), total fat mass (FM) (36.9 +/- <em>1</em>.5 to 26.<em>1</em> +/- <em>1</em>.3 kg), percent body fat (37.7 +/- <em>1</em>.3 to 3<em>1</em>.0 +/- <em>1</em>.5%), and FFM (59.2 +/- 2.3 to 55.8 +/- 2.0 kg). Abdominal subcutaneous and visceral adipose tissue (SAT and VAT) were reduced (494 +/- <em>1</em>9 to 357 +/- <em>1</em>8 cm2 and <em>1</em>57 +/- <em>1</em>2 to 96 +/- 7 cm2, respectively). Cross-sectional area of low-density muscle (LDM) at the mid-thigh decreased from 67 +/- 5 to 55 +/- 4 cm2 after WL. Insulin sensitivity improved from 5.9 +/- 0.4 to 7.3 +/- 0.5 mg x FFM(-<em>1</em>) x min(-<em>1</em>) with WL. Rates of insulin-stimulated nonoxidative glucose disposal accounted for the majority of this improvement (3.00 +/- 0.3 to 4.3 +/- 0.4 mg x FFM(-<em>1</em>) x min(-<em>1</em>)). Serum leptin, triglycerides, cholesterol, and insulin all decreased after WL (P < 0.0<em>1</em>). After WL, insulin sensitivity continued to correlate with generalized and regional adiposity but, with the exception of the percent decrease in VAT, the magnitude of improvement in insulin sensitivity was not predicted by the various changes in body composition. These interventional weight loss data underscore the potential importance of visceral adiposity in relation to insulin resistance and otherwise suggest that above a certain threshold of weight loss, improvement in insulin sensitivity does not bear a linear relationship to the magnitude of weight loss.

Bacterial community composition, enzymatic activities, and carbon dynamics were examined during diatom blooms in four 200-liter laboratory seawater mesocosms. The objective was to determine whether the dramatic shifts in growth rates and ectoenzyme activities, which are commonly observed during the course of phytoplankton blooms and their subsequent demise, could result from shifts in bacterial community composition. Nutrient enrichment of metazoan-free seawater resulted in diatom blooms dominated by a Thalassiosira sp., which peaked 9 days after enrichment ( approximately 24 microg of chlorophyll a liter(-<em>1</em>)). At this time bacterial abundance abruptly decreased from 2.8 x <em>1</em>0(6) to 0.75 x <em>1</em>0(6) <em>ml</em>(-<em>1</em>), and an analysis of bacterial community composition, by denaturing gradient gel electrophoresis (DGGE) of PCR-amplified <em>1</em>6S rRNA gene fragments, revealed the disappearance of three dominant phylotypes. Increased viral and flagellate abundances suggested that both lysis and grazing could have played a role in the observed phylotype-specific mortality. Subsequently, new phylotypes appeared and bacterial production, abundance, and enzyme activities shifted from being predominantly associated with the (<em>1</em>.0-microm size fraction towards the>><em>1</em>.0-microm size fraction, indicating a pronounced microbial colonization of particles. Sequencing of DGGE bands suggested that the observed rapid and extensive colonization of particulate matter was mainly by specialized alpha-Proteobacteria- and Cytophagales-related phylotypes. These particle-associated bacteria had high growth rates as well as high cell-specific aminopeptidase, beta-glucosidase, and lipase activities. Rate measurements as well as bacterial population dynamics were almost identical among the mesocosms indicating that the observed bacterial community dynamics were systematic and repeatable responses to the manipulated conditions.

BACKGROUND

Dolutegravir (S/GSK<em>1</em>349572) is a once-daily HIV integrase inhibitor with potent antiviral activity and a favourable safety profile. We compared dolutegravir with HIV integrase inhibitor raltegravir, as initial treatment for adults with HIV-<em>1</em>.

METHODS

SPRING-2 is a 96 week, phase 3, randomised, double-blind, active-controlled, non-inferiority study that began on Oct <em>1</em>9, 20<em>1</em>0, at <em>1</em>00 sites in Canada, USA, Australia, and Europe. Treatment-naive adults (aged ≥ <em>1</em>8 years) with HIV-<em>1</em> infection and HIV-<em>1</em> RNA concentrations of <em>1</em>000 copies per mL or greater were randomly assigned (<em>1</em>:<em>1</em>) via a computer-generated randomisation sequence to receive either dolutegravir (50 mg once daily) or raltegravir (400 mg twice daily). Study drugs were given with coformulated tenofovir/emtricitabine or abacavir/lamivudine. Randomisation was stratified by screening HIV-<em>1</em> RNA (≤ <em>1</em>00,000 copies per mL or>><em>1</em>00,000 copies per mL) and nucleoside reverse transcriptase inhibitor backbone. Investigators were not masked to HIV-<em>1</em> RNA results before randomisation. The primary endpoint was the proportion of participants with HIV-<em>1</em> RNA less than 50 copies per mL at 48 weeks, with a <em>1</em>0% non-inferiority margin. Main secondary endpoints were changes from baseline in CD4 cell counts, incidence and severity of adverse events, changes in laboratory parameters, and genotypic or phenotypic evidence of resistance. Our primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT0<em>1</em>227824.

RESULTS

4<em>1</em><em>1</em> patients were randomly allocated to receive dolutegravir and 4<em>1</em><em>1</em> to receive raltegravir and received at least one dose of study drug. At 48 weeks, 36<em>1</em> (88%) patients in the dolutegravir group achieved an HIV-<em>1</em> RNA value of less than 50 copies per mL compared with 35<em>1</em> (85%) in the raltegravir group (adjusted difference 2·5%; 95% CI -2·2 to 7·<em>1</em>). Adverse events were similar between treatment groups. The most common events were nausea (59 [<em>1</em>4%] patients in the dolutegravir group vs 53 [<em>1</em>3%] in the raltegravir group), headache (5<em>1</em> [<em>1</em>2%] vs 48 [<em>1</em>2%]), nasopharyngitis (46 [<em>1</em><em>1</em>%] vs 48 [<em>1</em>2%]), and diarrhoea (47 [<em>1</em><em>1</em>%] in each group). Few patients had drug-related serious adverse events (three [(<em>1</em>%] vs five [<em>1</em>%]), and few had adverse events leading to discontinuation (ten [2%] vs seven [2%] in each group). CD4 cell counts increased from baseline to week 48 in both treatment groups by a median of 230 cells per μL. Rates of graded laboratory toxic effects were similar. We noted no evidence of treatment-emergent resistance in patients with virological failure on dolutegravir, whereas of the patients with virologic failure who received raltegravir, one (6%) had integrase treatment-emergent resistance and four (2<em>1</em>%) had nucleoside reverse transcriptase inhibitors treatment-emergent resistance.

CONCLUSIONS

The non-inferior efficacy and similar safety profile of dolutegravir compared with raltegravir means that if approved, combination treatment with once-daily dolutegravir and fixed-dose nucleoside reverse transcriptase inhibitors would be an effective new option for treatment of HIV-<em>1</em> in treatment-naive patients.

BACKGROUND

ViiV Healthcare.

Human bone cell cultures were established by maintaining collagenase-treated bone fragments in low Ca++ medium. The resulting cell cultures exhibited a high level of alkaline phosphatase activity and produced a significant increase in intracellular cAMP when exposed to the <em>1</em>-34 fragment of human parathyroid hormone. With continued culture, the cells formed a thick, extracellular matrix that mineralized when cultures were provided daily with normal levels of calcium, fresh ascorbic acid (50 micrograms/<em>ml</em>) and <em>1</em>0 mM beta-glycerol phosphate. Biosynthetically, these cells produced type I collagen (without any type III collagen), and the bone-specific protein, osteonectin. In addition, the cells produced sulfated macromolecules electrophoretically identical to those positively identified as the bone proteoglycan in parallel cultures of fetal bovine bone cells. This technique provides a useful system for the study of osteoblast metabolism in vitro.

OBJECTIVE

This study was conducted to compare viral dynamics in blood and semen between subjects with antibody negative, acute HIV-<em>1</em> infection and other subjects with later stages of infection.

METHODS

A prospective cohort study was embedded within a cross-sectional study of HIV screening in a Lilongwe, Malawi STD clinic.

METHODS

Blood samples from HIV antibody negative or indeterminate volunteers were used to detect HIV RNA in plasma using a pooling strategy. Blood and seminal plasma HIV-<em>1</em> RNA concentrations were measured over <em>1</em>6 weeks.

RESULTS

Sixteen men with acute HIV infection and 25 men with chronic HIV infection were studied. Blood viral load in subjects with acute HIV infection was highest about <em>1</em>7 days after infection (mean +/- SE, 6.9 +/- 0.5 log<em>1</em>0 copies/ml), while semen viral load peaked about 30 days after infection (4.5 +/- 0.4 log<em>1</em>0 copies/ml). Semen viral load declined by <em>1</em>.7 log<em>1</em>0 to a nadir by week <em>1</em>0 of HIV infection. Semen and blood viral loads were more stable in chronically infected subjects over <em>1</em>6 weeks. Higher semen levels of HIV RNA were noted in subjects with low CD4 cell counts.

CONCLUSIONS

These results provide a biological explanation for reported increases in HIV transmission during the very early (acute) and late stages of infection. Recognizing temporal differences in HIV shedding in the genital tract is important in the development of effective HIV prevention strategies.

Therapeutic strategies against free radicals have mostly focused on the augmentation of antioxidant defenses (eg, vitamins C and E). A novel approach is to prevent free radical generation by the enzyme system xanthine oxidase. We examined whether the inhibition of xanthine oxidase with allopurinol can improve endothelial function in subjects with type 2 diabetes and coexisting mild hypertension compared with control subjects of a similar age. We examined 23 subjects (<em>1</em><em>1</em> patients with type 2 diabetes and <em>1</em>2 healthy age-matched control subjects) in 2 parallel groups. The subjects were administered 300 mg allopurinol in a randomized, placebo-controlled study in which both therapies were administered for <em>1</em> month. Endothelial function was assessed with bilateral venous occlusion plethysmography, in which the forearm blood flow responses to intra-arterial infusions of endothelium-dependent and -independent vasodilators were measured. Allopurinol significantly increased the mean forearm blood flow response to acetylcholine by 30% (3.<em>1</em>6+/-<em>1</em>.2<em>1</em> versus 2.54+/-0.76 <em>mL</em>. <em>1</em>00 <em>mL</em>(-<em>1</em>). min(-<em>1</em>) allopurinol versus placebo; P=0.0<em>1</em>2, 95% CI 0.<em>1</em>4, <em>1</em>.30) but did not affect the nitroprusside response in patients with type 2 diabetes. There was no significant impact on either endothelium-dependent or -independent vascular responses in age-matched control subjects. Allopurinol improved endothelial function to near-normal levels. Regarding markers of free radical activity, the level of malondialdehyde was significantly reduced (0.30+/-0.04 versus 0. 34+/-0.05 micromol/L for allopurinol versus placebo, P=0.03) in patients with type 2 diabetes but not in control subjects. The xanthine oxidase inhibitor allopurinol improves endothelial dysfunction in patients with type 2 diabetes with mild hypertension but not in matched control subjects. In the former group, allopurinol restored endothelial function to near-normal levels.

BACKGROUND

In 2007, the effects of the autologous nonmyeloablative hematopoietic stem cell transplantation (HSCT) in <em>1</em>5 patients with type <em>1</em> diabetes mellitus (DM) were reported. Most patients became insulin free with normal levels of glycated hemoglobin A(<em>1</em>c) (HbA(<em>1</em>c)) during a mean <em>1</em>8.8-month follow-up. To investigate if this effect was due to preservation of beta-cell mass, continued monitoring was performed of C-peptide levels after stem cell transplantation in the <em>1</em>5 original and 8 additional patients.

OBJECTIVE

To determine C-peptide levels after autologous nonmyeloablative HSCT in patients with newly diagnosed type <em>1</em> DM during a longer follow-up.

METHODS

A prospective phase <em>1</em>/2 study of 23 patients with type <em>1</em> DM (aged <em>1</em>3-3<em>1</em> years) diagnosed in the previous 6 weeks by clinical findings with hyperglycemia and confirmed by measurement of serum levels of anti-glutamic acid decarboxylase antibodies. Enrollment was November 2003-April 2008, with follow-up until December 2008 at the Bone Marrow Transplantation Unit of the School of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil. Hematopoietic stem cells were mobilized via the 2007 protocol.

METHODS

C-peptide levels measured during the mixed-meal tolerance test, before, and at different times following HSCT. Secondary end points included morbidity and mortality from transplantation, temporal changes in exogenous insulin requirements, and serum levels of HbA(<em>1</em>c).

RESULTS

During a 7- to 58-month follow-up (mean, 29.8 months; median, 30 months), 20 patients without previous ketoacidosis and not receiving corticosteroids during the preparative regimen became insulin free. Twelve patients maintained this status for a mean 3<em>1</em> months (range, <em>1</em>4-52 months) and 8 patients relapsed and resumed insulin use at low dose (0.<em>1</em>-0.3 IU/kg). In the continuous insulin-independent group, HbA(<em>1</em>c) levels were less than 7.0% and mean (SE) area under the curve (AUC) of C-peptide levels increased significantly from 225.0 (75.2) ng/mL per 2 hours pretransplantation to 785.4 (90.3) ng/mL per 2 hours at 24 months posttransplantation (P < .00<em>1</em>) and to 728.<em>1</em> (<em>1</em>44.4) ng/mL per 2 hours at 36 months (P = .00<em>1</em>). In the transient insulin-independent group, mean (SE) AUC of C-peptide levels also increased from <em>1</em>48.9 (75.2) ng/mL per 2 hours pretransplantation to 546.8 (96.9) ng/mL per 2 hours at 36 months (P = .00<em>1</em>), which was sustained at 48 months. In this group, 2 patients regained insulin independence after treatment with sitagliptin, which was associated with increase in C-peptide levels. Two patients developed bilateral nosocomial pneumonia, 3 patients developed late endocrine dysfunction, and 9 patients developed oligospermia. There was no mortality.

CONCLUSIONS

After a mean follow-up of 29.8 months following autologous nonmyeloablative HSCT in patients with newly diagnosed type <em>1</em> DM, C-peptide levels increased significantly and the majority of patients achieved insulin independence with good glycemic control.

BACKGROUND

clinicaltrials.gov Identifier: NCT003<em>1</em>5<em>1</em>33.

Convection-enhanced delivery (CED) of cintredekin besudotox (CB) was compared with Gliadel wafers (GW) in adult patients with glioblastoma multiforme (GBM) at first recurrence. Patients were randomized 2:<em>1</em> to receive CB or GW. CB (0.5 microg/<em>mL</em>; total flow rate 0.75 <em>mL</em>/h) was administered over 96 hours via 2-4 intraparenchymal catheters placed after tumor resection. GW (3.85%/7.7 mg carmustine per wafer; maximum 8 wafers) were placed immediately after tumor resection. The primary endpoint was overall survival from the time of randomization. Prestated interim analyses were built into the study design. Secondary and tertiary endpoints were safety and health-related quality-of-life assessments. From March 2004 to December 2005, 296 patients were enrolled at 52 centers. Demographic and baseline characteristics were balanced between the 2 treatment arms. Median survival was 36.4 weeks (9.<em>1</em> months) for CB and 35.3 weeks (8.8 months) for GW (P = .476). For the efficacy evaluable population, the median survival was 45.3 weeks (<em>1</em><em>1</em>.3 months) for CB and 39.8 weeks (<em>1</em>0 months) for GW (P = .3<em>1</em>0). The adverse-events profile was similar in both arms, except that pulmonary embolism was higher in the CB arm (8% vs <em>1</em>%, P = .0<em>1</em>4). This is the first randomized phase III evaluation of an agent administered via CED and the first with an active comparator in GBM patients. There was no survival difference between CB administered via CED and GW. Drug distribution was not assessed and may be crucial for evaluating future CED-based therapeutics.

BACKGROUND

The diagnostic accuracy of sputum smear microscopy and routine chest radiology for HIV-associated tuberculosis is poor, and culture-based diagnosis is slow, expensive, and is unavailable in most resource-limited settings. We assessed the diagnostic accuracy of a urine antigen test Determine TB-LAM Ag (Determine TB-LAM; Alere, Waltham, MA, USA) for screening for HIV-associated pulmonary tuberculosis before antiretroviral therapy (ART).

METHODS

In this descriptive study, consecutive adults referred to a community-based ART clinic in Gugulethu township, South Africa, were all screened for tuberculosis by obtaining sputum samples for fluorescence microscopy, automated liquid culture (gold-standard test), and Xpert MTB/RIF assays (Cepheid, Sunnyvale, CA, USA) and urine samples for the Clearview TB-ELISA (TB-ELISA; Alere, Waltham, MA, USA) and Determine TB-LAM test. Patients with Mycobacterium tuberculosis cultured from one or more sputum samples were defined as cases of tuberculosis. The diagnostic accuracy of Determine TB-LAM used alone or combined with sputum smear microscopy was compared with that of sputum culture and the Xpert MTB/RIF assay for all patients and subgroups of patients stratified by CD4 cell count.

RESULTS

Patients were recruited between March <em>1</em>2, 20<em>1</em>0, and April 20, 20<em>1</em><em>1</em>. Of 602 patients enrolled, 542 were able to provide one or more sputum samples, and 94 had culture-positive tuberculosis (prevalence <em>1</em>7·4%, 95% CI <em>1</em>4·2-20·8). Complete results from all tests were available for 5<em>1</em>6 patients (median CD4 count, <em>1</em>69·5 cells per <em>μL</em>; IQR <em>1</em>00-233), including 85 culture-positive tuberculosis, 24 of whom (28·2%, 95% CI <em>1</em>9·0-39·0) had sputum smear-positive disease. Determine TB-LAM test strips provided results within 30 min. Agreement was very high between two independent readers of the test strips (κ=0·97) and between the test strips and TB-ELISA (κ=0·84). Determine TB-LAM had highest sensitivity at low CD4 cell counts: 66·7% (95% CI 4<em>1</em>·0-86·7) at <50 cells per <em>μL</em>, 5<em>1</em>·7% (32·5-70·6) at (<em>1</em>00 cells per <em>μL</em>, and 39·0% (26·5-52·6) at <200 cells per <em>μL</em>; specificity was greater than 98% for all strata. When combined with smear microscopy (either test positive), sensitivity was 72·2% (95% CI 46·5-90·3) at CD4 counts less than 50 cells per <em>μL</em>, 65·5% (45·7-82·<em>1</em>) at less than <em>1</em>00 cells per <em>μL</em>, and 52·5% (39·<em>1</em>-65·7) at less than 200 cells per <em>μL</em>, which did not differ statistically from the sensitivities obtained by testing a single sputum sample with the Xpert MTB/RIF assay.

CONCLUSIONS

Determine TB-LAM is a simple, low-cost, alternative to existing diagnostic assays for tuberculosis screening in HIV-infected patients with very low CD4 cell counts and provides important incremental yield when combined with sputum smear microscopy.

BACKGROUND

Wellcome Trust.