This article about unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. UFH is a heterogeneous mixture of glycosaminoglycans that bind to antithrombin via a pentasaccharide, catalyzing the inactivation of thrombin and other clotting factors. UFH also binds endothelial cells, platelet factor 4, and platelets, leading to rather unpredictable pharmacokinetic and pharmacodynamic properties. Variability in activated partial thromboplastin time (aPTT) reagents necessitates site-specific validation of the aPTT therapeutic range in order to properly monitor UFH therapy. Lack of validation has been an oversight in many clinical trials comparing UFH to LMWH. In patients with apparent heparin resistance, anti-factor Xa monitoring may be superior to measurement of aPTT. LMWHs lack the nonspecific binding affinities of UFH, and, as a result, LMWH preparations have more predictable pharmacokinetic and pharmacodynamic properties. LMWHs have replaced UFH for most clinical indications for the following reasons: (<em>1</em>) these properties allow LMWHs to be administered subcutaneously, once daily without laboratory monitoring; and (2) the evidence from clinical trials that LMWH is as least as effective as and is safer than UFH. Several clinical issues regarding the use of LMWHs remain unanswered. These relate to the need for monitoring with an anti-factor Xa assay in patients with severe obesity or renal insufficiency. The therapeutic range for anti-factor Xa activity depends on the dosing interval. Anti-factor Xa monitoring is prudent when administering weight-based doses of LMWH to patients who weigh>> <em>1</em>50 kg. It has been determined that UFH infusion is preferable to LMWH injection in patients with creatinine clearance of < 25 <em>mL</em>/min, until further data on therapeutic dosing of LMWHs in renal failure have been published. However, when administered in low doses prophylactically, LMWH is safe for therapy in patients with renal failure. Protamine may help to reverse bleeding related to LWMH, although anti-factor Xa activity is not fully normalized by protamine. The synthetic pentasaccharide fondaparinux is a promising new antithrombotic agent for the prevention and treatment of venous thromboembolism.

Dendritic cells (DC) have an instrumental role in the activation and function of both innate and adaptive immune responses. In humans, at least two distinct DC subsets have been characterized based on phenotypic markers: the myeloid DC (MDC) and the plasmacytoid DC (PDC). Both subsets are critical producers of cytokines (IL-<em>1</em>2 for MDC and type I/II IFNs for PDC) and are functionally different. We show in this study that HIV(+) individuals have a significant decrease in the number of the Lin(-)HLA-DR(+)CD<em>1</em>23(+) and BDCA-2(+) PDC compared with uninfected donors (p = 0.000<em>1</em>). HIV(+) individuals also have a sustained impairment in viral-induced IFN-alpha production (p < 0.000<em>1</em>). The decrease of the PDC subsets did not correlate with CD4 count or viral load and was not reversed in subjects under virally suppressive treatment, suggesting an irreversible change after infection. By contrast, the absolute number and median frequency of MDC in HIV-infected individuals were similar to those observed in uninfected controls, while a significant decrease was present in subjects with >5000 HIV-<em>1</em> copies/<em>ml</em>. The inverse association with viral load of the MDC number, but not of IFN-alpha secretion or the number of PDC, suggests a role for MDC in viral control. Our data suggest that DC subsets are differentially reconstituted during the immune recovery associated with antiviral therapy. The persistent impairment of certain DC subsets may result in a sustained defect in DC-mediated innate immune functions despite an effective treatment regimen.

Two different responses to the therapy were observed in a group of patients receiving the protease inhibitor indinavir. In one, suppression of virus replication occurred and has persisted for 90 weeks (bDNA, < 500 human immunodeficiency virus type <em>1</em> [HIV-<em>1</em>] RNA copies/<em>ml</em>). In the second group, a rebound in virus levels in plasma followed the initial sharp decline observed at the start of therapy. This was associated with the emergence of drug-resistant variants. Sequence analysis of the protease gene during the course of therapy revealed that in this second group there was a sequential acquisition of protease mutations at amino acids 46, 82, 54, 7<em>1</em>, 89, and 90. In the six patients in this group, there was also an identical mutation in the gag p7/p<em>1</em> gag protease cleavage site. In three of the patients, this change was seen as early as 6 to <em>1</em>0 weeks after the start of therapy. In one patient, a second mutation occurred at the gag p<em>1</em>/p6 cleavage site, but it appeared <em>1</em>8 weeks after the time of appearance of the p7/p<em>1</em> mutation. Recombinant HIV-<em>1</em> variants containing two or three mutations in the protease gene were constructed either with mutations at the p7/p<em>1</em> cleavage site or with wild-type (WT) gag sequences. When recombinant HIV-<em>1</em>-containing protease mutations at 46 and 82 was grown in MT2 cells, there was a 68% reduction in its rate of replication compared to the WT virus. Introduction of an additional mutation at the gag p7/p<em>1</em> protease cleavage site compensated for the partially defective protease gene. Similarly, rates of replication of viruses with mutations M46L/I, I54V, and V82A in protease were enhanced both in the presence and in the absence of Indinavir when combined with mutations in the gag p7/p<em>1</em> and the gag p<em>1</em>/p6 cleavage sites. Optimal rates of virus replication require protease cleavage of precursor polyproteins. A mutation in the cleavage site that enhanced the availability of a protein that was rate limiting for virus maturation would confer on that virus a significant growth advantage and may explain the uniform emergence of viruses with alterations at the p7/p<em>1</em> cleavage site. This is the first report of the emergence of mutations in the gag p7/p<em>1</em> protease cleavage sites in patients receiving protease therapy and identifies this change as an important determinant of HIV-<em>1</em> resistance to protease inhibitors in patient populations.

Low birth weight in humans is predictive of insulin resistance and diabetes in adult life. The molecular mechanisms underlying this link are unknown but fetal exposure to excess glucocorticoids has been implicated. The fetus is normally protected from the higher maternal levels of glucocorticoids by feto-placental <em>1</em><em>1</em>beta-hydroxysteroid dehydrogenase type-2 (<em>1</em><em>1</em>beta-HSD2) which inactivates glucocorticoids. We have shown previously that inhibiting <em>1</em><em>1</em>beta-HSD2 throughout pregnancy in rats reduces birth weight and causes hyperglycemia in the adult offspring. We now show that dexamethasone (a poor substrate for <em>1</em><em>1</em>beta-HSD2) administered to pregnant rats selectively in the last week of pregnancy reduces birth weight by <em>1</em>0% (P < 0.05), and produces adult fasting hyperglycemia (treated 5.3+/-0.3; control 4.3+/-0.2 mmol/ liter, P = 0.04), reactive hyperglycemia (treated 8.7+/-0.4; control 7.5+/-0.2 mmol/liter, P = 0.03), and hyperinsulinemia (treated 6.<em>1</em>+/-0.4; control 3.8+/-0.5 ng/<em>ml</em>, P = 0.0<em>1</em>) on oral glucose loading. In the adult offspring of rats exposed to dexamethasone in late pregnancy, hepatic expression of glucocorticoid receptor (GR) mRNA and phosphoenolpyruvate carboxykinase (PEPCK) mRNA (and activity) are increased by 25% (P = 0.0<em>1</em>) and 60% (P < 0.0<em>1</em>), respectively, while other liver enzymes (glucose-6-phosphatase, glucokinase, and <em>1</em><em>1</em>beta-hydroxysteroid dehydrogenase type-<em>1</em>) are unaltered. In contrast dexamethasone, when given in the first or second week of gestation, has no effect on offspring insulin/glucose responses or hepatic PEPCK and GR expression. The increased hepatic GR expression may be crucial, since rats exposed to dexamethasone in utero showed potentiated glucose responses to exogenous corticosterone. These observations suggest that excessive glucocorticoid exposure late in pregnancy predisposes the offspring to glucose intolerance in adulthood. Programmed hepatic PEPCK overexpression, perhaps mediated by increased GR, may promote this process by increasing gluconeogenesis.

The present study explores the possible involvement of a purinergic mechanism in mechanosensory transduction in the bladder using P2X(3) receptor knock-out (P2X(3)-/-) and wild-type control (P2X(3)+/+) mice. Immunohistochemistry revealed abundant nerve fibers in a suburothelial plexus in the mouse bladder that are immunoreactive to anti-P2X(3). P2X(3)-positive staining was completely absent in the subepithelial plexus of the P2X(3)-/- mice, whereas staining for calcitonin gene-related peptide and vanilloid receptor <em>1</em> receptors remained. Using a novel superfused mouse bladder-pelvic nerve preparation, we detected a release of ATP proportional to the extent of bladder distension in both P2X(3)+/+ and P2X(3)-/- mice, although P2X(3)-/- bladder had an increased capacity compared with that of the P2X(3)+/+ bladder. The activity of multifiber pelvic nerve afferents increased progressively during gradual bladder distension (at a rate of 0.<em>1</em> <em>ml</em>/min). However, the bladder afferents from P2X(3)-/- mice showed an attenuated response to bladder distension. Mouse bladder afferents of P2X(3)+/+, but not P2X(3)-/-, were rapidly activated by intravesical injections of P2X agonists (ATP or alpha,beta-methylene ATP) and subsequently showed an augmented response to bladder distension. By contrast, P2X antagonists [2',3'-O-(2,4,6-trinitrophenyl)-ATP and pyridoxal 5-phosphate 6-azophenyl-2',4'-disulfonic acid] and capsaicin attenuated distension-induced discharges in bladder afferents. These data strongly suggest a major sensory role for urothelially released ATP acting via P2X(3) receptors on a subpopulation of pelvic afferent fibers.

Malattia Leventinese (<em>ML</em>) and Doyne honeycomb retinal dystrophy (DHRD) refer to two autosomal dominant diseases characterized by yellow-white deposits known as drusen that accumulate beneath the retinal pigment epithelium (RPE). Both loci were mapped to chromosome 2p<em>1</em>6-2<em>1</em> (refs 5,6) and this genetic interval has been subsequently narrowed. The importance of these diseases is due in large part to their close phenotypic similarity to age-related macular degeneration (AMD), a disorder with a strong genetic component that accounts for approximately 50% of registered blindness in the Western world. Just as in <em>ML</em> and DHRD, the early hallmark of AMD is the presence of drusen. Here we use a combination of positional and candidate gene methods to identify a single non-conservative mutation (Arg345Trp) in the gene EFEMP<em>1</em> (for EGF-containing fibrillin-like extracellular matrix protein <em>1</em>) in all families studied. This change was not present in 477 control individuals or in 494 patients with age-related macular degeneration. Identification of this mutation may aid in the development of an animal model for drusen, as well as in the identification of other genes involved in human macular degeneration.

The natural history of human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) viremia and its association with clinical outcomes after seroconversion was characterized in a cohort of homosexual men. HIV-<em>1</em> RNA was measured by reverse-transcription polymerase chain reaction (RT-PCR) in stored longitudinal plasma samples from 269 seroconverters. Subjects were generally antiretroviral drug naive for the first 3 years after seroconversion. The decline in CD4 lymphocyte counts was strongly associated with initial HIV RNA measurements. Both initial HIV RNA levels and slopes were associated with AIDS-free times. Median slopes were +0.<em>1</em>8, +0.09, and -0.0<em>1</em> log<em>1</em>0 copies/<em>mL</em>, respectively, for subjects developing AIDS <3, 3-7, and>7 years after seroconversion. In contrast, HIV RNA slopes in the 3 years preceding AIDS and HIV RNA levels at AIDS diagnosis showed little variation according to total AIDS-free time. HIV RNA load at the first HIV-seropositive visit ( approximately 3 months after seroconversion) was highly predictive of AIDS, and subsequent HIV RNA measurements showed even better prognostic discrimination.

OBJECTIVE

Prosthetic and bioprosthetic materials currently in use lack growth potential and therefore must be repeatedly replaced in pediatric patients as they grow. Tissue engineering is a new discipline that offers the potential for creating replacement structures from autologous cells and biodegradable polymer scaffolds. In May 2000, we initiated clinical application of tissue-engineered vascular grafts seeded with cultured cells. However, cell culturing is time-consuming, and xenoserum must be used. To overcome these disadvantages, we began to use bone marrow cells, readily available on the day of surgery, as a cell source. The aim of the study was to assess the safety and feasibility of this technique for creating vascular tissue under low-pressure systems such as pulmonary artery or venous pressure.

METHODS

Since September 200<em>1</em>, tissue-engineered grafts seeded with autologous bone marrow cells have been implanted in 42 patients. The patients or their parents were fully informed and had given consent to the procedure. A 5-<em>mL</em>/kg specimen of bone marrow was aspirated with the patient under general anesthesia before the skin incision. The polymer tube serving as a scaffold for the cells was composed of a copolymer of l -lactide and -caprolactone (50:50). This copolymer is degraded by hydrolysis. The matrix is more than 80% porous, and the diameter of each pore is 20 to <em>1</em>00 microm. Polyglycolic acid woven fabric with a thickness of 0.5 mm was used for reinforcement. Twenty-three tissue-engineered conduits (grafts for extracardiac total cavopulmonary connection) and <em>1</em>9 tissue-engineered patches were used for the repair of congenital heart defects. The patients' ages ranged from <em>1</em> to 24 years (median 5.5 years). All patients underwent a catheterization study, computed tomographic scan, or both, for evaluation after the operation. The patients received anticoagulation therapy for 3 to 6 months after surgery.

RESULTS

Mean follow-up after surgery was 490 +/- 276 days (<em>1</em>.3-3<em>1</em>.6 months, median <em>1</em>6.7 months). There were no complications such as thrombosis, stenosis, or obstruction of the tissue-engineered autografts. One late death at 3 months after total cavopulmonary connection was noted in patient with hypoplastic left heart syndrome; this was unrelated to the tissue-engineered graft function. There was no evidence of aneurysm formation or calcification on cineangiography or computed tomography. All tube grafts were patent, and the diameter of the tube graft increased with time (<em>1</em><em>1</em>0% +/- 7 % of the implanted size).

CONCLUSIONS

Biodegradable conduits or patches seeded with autologous bone marrow cells showed normal function (good patency to a maximum follow-up of 32 months). As living tissues, these vascular structures may have the potential for growth, repair, and remodeling. The tissue-engineering approach may provide an important alternative to the use of prosthetic materials in the field of pediatric cardiovascular surgery. Longer follow-up is necessary to confirm the durability of this approach.

A cohort of <em>1</em>8,244 mostly middle-aged (45-64 years) men residing in four small geographically defined areas of Shanghai was accrued between January <em>1</em>986 and September <em>1</em>989. In addition to an in-person interview regarding dietary and other past exposures, each subject donated a single void urine sample at recruitment so that the presence of aflatoxins in urine could be assessed. In addition, a <em>1</em>-year survey of market foods in Shanghai was conducted to quantitatively estimate the extent of aflatoxin exposure in the study population. After close to 70,000 person-years of follow-up, 55 incident cases of hepatocellular carcinoma (HCC) had been identified. Levels of urinary aflatoxin B<em>1</em> and the oxidative metabolites, including the major aflatoxin nucleic acid adduct, aflatoxin-N7-guanine, were determined for 50 of the 55 identified cases of HCC. Two hundred sixty-seven controls were chosen rando<em>ml</em>y from the cohort; they were matched to the 50 cases by age (within <em>1</em> year), time of specimen collection (within <em>1</em> month), and residence. After integrating the high-pressure liquid chromatography chromatograms to measure aflatoxin-N7-guanine, aflatoxin M<em>1</em>, aflatoxin P<em>1</em>, and aflatoxin B<em>1</em>, 49, 67, 53, and 7<em>1</em> of the urine samples had detectable levels of these compounds, respectively. The aflatoxin metabolite detected at the highest concentration was aflatoxin P<em>1</em>; the range was 0.59-<em>1</em>6.0 ng/<em>ml</em>. The range of aflatoxin M<em>1</em> in the urine was 0.<em>1</em>7-5.2 ng/<em>ml</em>. The aflatoxin-N7-guanine adduct range was 0.3-<em>1</em>.8<em>1</em> ng/<em>ml</em> in the 49 positive samples.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure. We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity.

METHODS

A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months.

RESULTS

40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 +/- 1 years (+/- SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 +/- 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3-210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% +/- 2% excess weight loss (EWL) and at 9 months 58% +/- 3% EWL.

CONCLUSIONS

Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.

OBJECTIVE

We sought to identify whether home telemonitoring (HTM) improves outcomes compared with nurse telephone support (NTS) and usual care (UC) for patients with heart failure who are at high risk of hospitalization or death.

BACKGROUND

Heart failure is associated with a high rate of hospitalization and poor prognosis. Telemonitoring could help implement and maintain effective therapy and detect worsening heart failure and its cause promptly to prevent medical crises.

METHODS

Patients with a recent admission for heart failure and left ventricular ejection fraction (LVEF) <40% were assigned randomly to HTM, NTS, or UC in a 2:2:<em>1</em> ratio. HTM consisted of twice-daily patient self-measurement of weight, blood pressure, heart rate, and rhythm with automated devices linked to a cardiology center. The NTS consisted of specialist nurses who were available to patients by telephone. Primary care physicians delivered UC. The primary end point was days dead or hospitalized with NTS versus HTM at 240 days.

RESULTS

Of 426 patients randomly assigned, 48% were aged >70 years, mean LVEF was 25% (SD, 8) and median plasma N-terminal pro-brain natriuretic peptide was 3,070 pg/ml (interquartile range <em>1</em>,285 to 6,749 pg/ml). During 240 days of follow-up, <em>1</em>9.5%, <em>1</em>5.9%, and <em>1</em>2.7% of days were lost as the result of death or hospitalization for UC, NTS, and HTM, respectively (no significant difference). The number of admissions and mortality were similar among patients randomly assigned to NTS or HTM, but the mean duration of admissions was reduced by 6 days (95% confidence interval <em>1</em> to <em>1</em><em>1</em>) with HTM. Patients randomly assigned to receive UC had higher one-year mortality (45%) than patients assigned to receive NTS (27%) or HTM (29%) (p = 0.032).

CONCLUSIONS

Further investigation and refinement of the application of HTM are warranted because it may be a valuable role for the management of selected patients with heart failure.

Endotoxin injection has been widely used to study the acute inflammatory response. In this study, we directly compared the inflammatory responses to endotoxin in mice and humans. Escherichia coli type O<em>1</em><em>1</em>3 endotoxin was prepared under identical conditions, verified to be of equal biological potency, and used for both mice and humans. The dose of endotoxin needed to induce an interleukin-6 (IL-6) concentration in plasma of approximately <em>1</em>,000 pg/<em>ml</em> 2 h after injection was 2 ng/kg of body weight in humans and 500 ng/kg in mice. Healthy adult volunteers were injected intravenously with endotoxin, and male C57BL/6 mice (n=4 to <em>1</em>2) were injected intraperitoneally with endotoxin. Physiological, hematological, and cytokine responses were determined. Endotoxin induced a rapid physiological response in humans (fever, tachycardia, and slight hypotension) but not in mice. Both mice and humans exhibited lymphopenia with a nadir at 4 h and recovery by 24 h. The levels of tumor necrosis factor (TNF) and IL-6 in plasma peaked at 2 h and returned to baseline levels by 4 to 6 h. IL-<em>1</em> receptor antagonist RA and TNF soluble receptor I were upregulated in both mice and humans but were upregulated more strongly in humans. Mice produced greater levels of CXC chemokines, and both mice and humans exhibited peak production at 2 h. These studies demonstrate that although differences exist and a higher endotoxin challenge is necessary in mice, there are several similarities in the inflammatory response to endotoxin in mice and humans.

The identity of store-operated calcium (Ca(2+)) entry (SOCE) channels in vascular smooth muscle cells (VSMCs) remains a highly contentious issue. Whereas previous studies have suggested that SOCE in VSMCs is mediated by the nonselective transient receptor potential canonical (TRPC) <em>1</em> protein, the identification of STIM<em>1</em> and Orai<em>1</em> as essential components of I(CRAC), a highly Ca(2+)-selective SOCE current in leukocytes, has challenged that view. Here we show that cultured proliferative migratory VSMCs isolated from rat aorta (called "synthetic") display SOCE with classic features, namely inhibition by 2-aminoethoxydiphenyl borate, <em>ML</em>-9, and low concentrations of lanthanides. On store depletion, synthetic VSMCs and A7r5 cells display currents with characteristics of I(CRAC). Protein knockdown of either STIM<em>1</em> or Orai<em>1</em> in synthetic VSMCs greatly reduced SOCE, whereas Orai2, Orai3, TRPC<em>1</em>, TRPC4, and TRPC6 knockdown had no effect. Orai<em>1</em> knockdown reduced I(CRAC) in synthetic VSMCs and A7r5 cells. Synthetic VSMCs showed up-regulated STIM<em>1</em>/Orai<em>1</em> proteins and SOCE compared with quiescent freshly isolated VSMC. Knockdown of STIM<em>1</em> and Orai<em>1</em> inhibited synthetic VSMC proliferation and migration, whereas STIM2, Orai2, and Orai3 knockdown had no effect. To our knowledge, these results are the first to show I(CRAC) in VSMCs and resolve a long-standing controversy by identifying CRAC as the elusive VSMC SOCE channel important for proliferation and migration.

The B-cell antigen CD20 is expressed on normal B cells and by nearly all B-cell lymphomas. This nonmodulating antigen provides an excellent target for antibody-directed therapies. A chimeric anti-CD20 antibody (IDEC-C2B8), consisting of human IgG<em>1</em>-kappa constant regions and variable regions from the murine monoclonal anti-CD20 antibody IDEC-2B8, has been produced for clinical trials. It lyses CD20+ cells in vitro via complement and antibody-dependent cell-mediated lysis. Preclinical studies have shown that the chimeric antibody selectively depletes B cells in blood and lymph nodes in macaque monkeys. In this phase I clinical trial, <em>1</em>5 patients (3 per dose level) with relapsed low-grade B-cell lymphoma were treated with a single dose (<em>1</em>0, 50, <em>1</em>00, 250, or 500 mg/m2) of antibody administered intravenously. Treatment-related symptoms correlated with the number of circulating CD20 cells and grade II events consisted of fever (5 patients); nausea (2), rigor (2), orthostatic hypotension (2), bronchospasm (<em>1</em>), and thrombocytopenia (<em>1</em>). No significant toxicities were observed during the 3 months of follow-up. Serum C3, IgG, and IgM levels, neutrophils, and T cells were largely unchanged. At the three higher dose levels, pharmacokinetics of the free antibody showed a serum half-life of 4.4 days (range, <em>1</em>.6 to <em>1</em>0.5). Levels greater than <em>1</em>0 micrograms/<em>mL</em> persisted in 6 of 9 patients for more than <em>1</em>4 days. No quantifiable immune responses to the infused antibody have been detected. CD20+ B cells were rapidly and specifically depleted in the peripheral blood at 24 to 72 hours and remained depleted for at least 2 to 3 months in most patients. Two-week postinfusion tumor biopsies showed the chimeric antibody bound to tumor cells and a decrease in the percentage of B cells. Tumor regressions occurred in 6 of <em>1</em>5 patients (2 partial and 4 minor responses). The results of this single-dose trial have been used to design a multiple-dose phase I/II study.

BACKGROUND

Phase <em>1</em> studies have shown potential benefit of gene replacement in RPE65-mediated inherited retinal dystrophy. This phase 3 study assessed the efficacy and safety of voretigene neparvovec in participants whose inherited retinal dystrophy would otherwise progress to complete blindness.

METHODS

In this open-label, randomised, controlled phase 3 trial done at two sites in the USA, individuals aged 3 years or older with, in each eye, best corrected visual acuity of 20/60 or worse, or visual field less than 20 degrees in any meridian, or both, with confirmed genetic diagnosis of biallelic RPE65 mutations, sufficient viable retina, and ability to perform standardised multi-luminance mobility testing (MLMT) within the luminance range evaluated, were eligible. Participants were randomly assigned (2:<em>1</em>) to intervention or control using a permuted block design, stratified by age ((<em>1</em>0 years and ≥<em>1</em>0 years) and baseline mobility testing passing level (pass at ≥<em>1</em>25 lux vs (<em>1</em>25 lux). Graders assessing primary outcome were masked to treatment group. Intervention was bilateral, subretinal injection of <em>1</em>·5 × <em>1</em>0<em>1</em><em>1</em> vector genomes of voretigene neparvovec in 0·3 mL total volume. The primary efficacy endpoint was <em>1</em>-year change in MLMT performance, measuring functional vision at specified light levels. The intention-to-treat (ITT) and modified ITT populations were included in primary and safety analyses. This trial is registered with ClinicalTrials.gov, number NCT00999609, and enrolment is complete.

RESULTS

Between Nov <em>1</em>5, 20<em>1</em>2, and Nov 2<em>1</em>, 20<em>1</em>3, 3<em>1</em> individuals were enrolled and randomly assigned to intervention (n=2<em>1</em>) or control (n=<em>1</em>0). One participant from each group withdrew after consent, before intervention, leaving an mITT population of 20 intervention and nine control participants. At <em>1</em> year, mean bilateral MLMT change score was <em>1</em>·8 (SD <em>1</em>·<em>1</em>) light levels in the intervention group versus 0·2 (<em>1</em>·0) in the control group (difference of <em>1</em>·6, 95% CI 0·72-2·4<em>1</em>, p=0·00<em>1</em>3). <em>1</em>3 (65%) of 20 intervention participants, but no control participants, passed MLMT at the lowest luminance level tested (<em>1</em> lux), demonstrating maximum possible improvement. No product-related serious adverse events or deleterious immune responses occurred. Two intervention participants, one with a pre-existing complex seizure disorder and another who experienced oral surgery complications, had serious adverse events unrelated to study participation. Most ocular events were mild in severity.

CONCLUSIONS

Voretigene neparvovec gene replacement improved functional vision in RPE65-mediated inherited retinal dystrophy previously medically untreatable.

BACKGROUND

Spark Therapeutics.

This randomized controlled trial examined the benefits of combining an inhaled corticosteroid, fluticasone propionate (F), with an inhaled long-acting beta(2)-agonist, salmeterol (S), to treat the inflammatory and bronchoconstrictive components of chronic obstructive pulmonary disease (COPD). A total of 69<em>1</em> patients with COPD received the combination of F and S (FSC), S (50 mcg), F (500 mcg), or placebo twice daily via the Diskus device for 24 weeks. A significantly greater increase in predose FEV(<em>1</em>) at the endpoint was observed after FSC (<em>1</em>56 <em>ml</em>) compared with S (<em>1</em>07 <em>ml</em>, p = 0.0<em>1</em>2) and placebo (-4 <em>ml</em>, p < 0.000<em>1</em>). A significantly greater increase in 2-hour postdose FEV(<em>1</em>) at the endpoint was observed after treatment with FSC (26<em>1</em> <em>ml</em>) compared with F (<em>1</em>38 <em>ml</em>, p < 0.00<em>1</em>) and placebo (28 <em>ml</em>, p < 0.00<em>1</em>). There were greater improvements in the Transition Dyspnea Index with FSC (2.<em>1</em>) compared with F (<em>1</em>.3, p = 0.033), S (0.9, p < 0.00<em>1</em>), and placebo (0.4, p < 0.000<em>1</em>). The incidence of adverse effects (except for an increase in oral candidiasis with FSC and F) was similar among the treatment groups. We conclude that FSC improved lung function and reduced the severity of dyspnea compared with individual components and placebo.

The adaptation of muscle structure, power output, and mass-specific rate of maximal O2 consumption (VO2max/Mb) with endurance training on bicycle ergometers was studied for five male and five female subjects. Biopsies of vastus lateralis muscle and VO2max determinations were made at the start and end of 6 wk of training. The power output maintained on the ergometer daily for 30 min was adjusted to achieve a heart rate exceeding 85% of the maximum for two-thirds of the training session. It is proposed that the observed preferential proliferation of subsarcolemmal vs. interfibrillar mitochondria and the increase in intracellular lipid deposits are two possible mechanisms by which muscle cells adapt to an increased use of fat as a fuel. The relative increase of VO2max/Mb (<em>1</em>4%) with training was found to be smaller by more than twofold than the relative increase in maximal maintained power (33%) and the relative change in the volume density of total mitochondria (+40%). However, the calculated VO2 required at an efficiency of 0.25 to produce the observed mass-specific increase in maximal maintained power matched the actual increase in VO2max/Mb (8.0 and 6.5 <em>ml</em> O2 X min-<em>1</em> X kg-<em>1</em>, respectively). These results indicate that despite disparate relative changes the absolute change in aerobic capacity at the local level (maintained power) can account for the increase in aerobic capacity observed at the general level (VO2max).

Nicotine is recognized to be the major inducer of tobacco dependence. The smoking of cigarettes as an advantageous delivery system for nicotine, accelerates and aggravates cardiovascular disease, and is causally associated with increased risks for chronic obstructive lung disease, cancer of the lung and of the upper aerodigestive system, and cancer of the pancreas, renal pelvis, and urinary bladder. It is also associated with cancer of the liver, cancer of the uterine cervix, cancer of the nasal cavity, and myeloid leukemia. In <em>1</em>950, the first large-scale epidemiological studies documented that cigarette smoking induces lung cancer and described a dose-response relationship between number of cigarettes smoked and the risk for developing lung cancer. In the following decades these observations were not only confirmed by several hundreds of prospective and case-control studies but the plausibility of this causal association was also supported by bioassays and by the identification of carcinogens in cigarette smoke. Whole smoke induces lung tumors in mice and tumors in the upper respiratory tract of hamsters. The particulate matter of the smoke elicits benign and malignant tumors on the skin of mice and rabbits, sarcoma in the connective tissue of rats, and carcinoma in the lungs of rats upon intratracheal instillation. More than 50 carcinogens have been identified, including the following classes of compounds: polynuclear aromatic hydrocarbons (PAH), aromatic amines, and N-nitrosamines. Among the latter, the tobacco-specific N-nitrosamines (TSNA) have been shown to be of special significance. Since <em>1</em>950, the makeup of cigarettes and the composition of cigarette smoke have gradually changed. In the United States, the sales-weighted average "tar" and nicotine yields have declined from a high of 38 mg "tar" and 2.7 mg nicotine in <em>1</em>954 to <em>1</em>2 mg and 0.95 mg in <em>1</em>992, respectively. In the United Kingdom, the decline was from about 32 mg "tar" and 2.2 mg nicotine to less than <em>1</em>2 mg "tar" and <em>1</em>.0 mg nicotine per cigarette. During the same time, other smoke constituents changed correspondingly. These reductions of smoke yields were primarily achieved by the introduction of filter tips, with and without perforation, selection of tobacco types and varieties, utilization of highly porous cigarette paper, and incorporation into the tobacco blend of reconstituted tobacco, opened and cut ribs, and "expanded tobacco." In most countries where tobacco blends with air-cured (burley) tobacco are used, the nitrate content of the cigarette tobacco increased. In the United States nitrate levels in cigarette tobacco rose from 0.3-0.5% to 0.6-<em>1</em>.35%, thereby enhancing the combustion of the tobacco. More complete combustion decreases the carcinogenic PAH, yet the increased generation of nitrogen oxides enhances the formation of the carcinogenic N-nitrosamines, especially the TSNA in the smoke. However, all analytical measures of the smoke components have been established on the basis of standardized machine smoking conditions, such as those introduced by the Federal Trade Commission, that call for <em>1</em> puff to be taken once a minute over a 2-s period with a volume of 35 <em>ml</em>. These smoking parameters may have simulated the way in which people used to smoke the high-yield cigarettes; however, they no longer reflect the parameters applicable to contemporary smokers, and especially not those applicable to the smoking of low- and ultra-low-yield filter cigarettes. Recent smoking assays have demonstrated that most smokers of cigarettes with low nicotine yield take between 2 and 4 puffs per minute with volumes up to 55 <em>ml</em> to satisfy their demands for nicotine. The overview also discusses further needs for reducing the toxicity and carcinogenicity of cigarette smoke. From a public health perspective, nicotine in the smoke needs to be lowered to a level at which there is no induction of dependence on tobacco.

The present study was undertaken to evaluate the prognostic significance of the serum levels of interleukin 6 (IL-6) in patients with prostate cancer. Serum IL-6 levels were measured in 74 patients with prostate cancer. The tumor was stage B in 23 patients, stage C in <em>1</em>4 patients, and stage D in 37 patients. Prognostic significance of tumor histology, performance status (PS), bone metastasis, serum prostate-specific antigen (PSA) level, serum alkaline phosphatase (ALP) level, serum lactate dehydrogenase level, serum IL-6 levels, and hemoglobin on disease-specific survival was assessed using univariate and multivariate Cox's proportional hazards model analyses. Serum IL-6 was significantly correlated with the clinical stage of prostate cancer. Univariate analysis of all patients demonstrated that an extent of disease (EOD) on bone scanning>> or = <em>1</em>, IL-6>> or = 7 pg/<em>ml</em>, PS>> or = <em>1</em>, PSA>> <em>1</em>00 ng/<em>ml</em>, and ALP>> 620 IU/liter were associated with a significantly lower survival rate than their respective counterparts. In multivariate analysis, however, the only two significant prognostic factors were EOD and IL-6. In 5<em>1</em> patients with stage C and stage D prostate cancer, univariate analysis showed that EOD>> or = <em>1</em>, IL-6>> or = 7 pg/<em>ml</em>, PS>> or = <em>1</em>, PSA>> <em>1</em>00 ng/<em>ml</em>, LDH>> 200 IU/liter, and ALP>> 620 IU/liter were significantly related to survival, whereas multivariate analysis again demonstrated that EOD>> or = <em>1</em> and IL-6>> or = 7 pg/<em>ml</em> were significant prognostic factors. These results indicate that the serum IL-6 level is a significant prognostic factor for prostate cancer as well as EOD.

In this investigation, we studied the effects of bolus volume and viscosity on the quantitative features of the oral and pharyngeal phases of swallowing. Concurrent videofluoroscopic and manometric studies were done in <em>1</em>0 healthy volunteers who were imaged in lateral projection. Videofluorography was done at 30 frames/s while concurrent manometry was done with 5 intraluminal transducers that straddled the pharynx and upper esophageal sphincter (UES). Submental electromyography was recorded also. Swallows of 2-20 <em>ml</em> were recorded for low-viscosity liquid barium and high-viscosity paste barium. Analysis indicated that the major effect of increases in bolus volume was an earlier onset of anterior tongue base movement, superior palatal movement, anterior laryngeal movement, and UES opening. These events provide receptive adaptation for receiving a swallowed bolus. Earlier UES opening was associated with an increase in the duration of sphincter opening and sphincter diameter. The major effects of high bolus viscosity, unrelated to bolus volume, were to delay oral and pharyngeal bolus transit, increase the duration of pharyngeal peristaltic waves, and prolong and increase UES opening. Thus the specific effect of bolus viscosity per se differs substantially from that of bolus volume. We conclude that <em>1</em>) specific variables of swallowing are affected significantly by the variables of the swallowed bolus, such as volume and viscosity; 2) overall, bolus volume and viscosity affect swallowing in a different manner; and 3) the study findings have implications about the neural control mechanisms that govern swallowing as well as about the diagnosis and treatment of patients with abnormal oral-pharyngeal swallowing.

BACKGROUND

Immediate hypersensitivity to peanuts is a frequent cause of anaphylactic reactions and deaths in children and adults. Currently, preventive treatment consists of avoidance, which is difficult because of the widespread and often disguised use of peanuts in the food industry.

METHODS

Twelve patients with immediate hypersensitivity to ingestion of peanuts were recruited. Half were treated with injections of peanut extract: a maintenance level of tolerance was first achieved by a rush protocol, then maintained with weekly injections for at least <em>1</em> year. The other six were untreated control subjects. All patients underwent double-blind, placebo-controlled, oral peanut challenges initially, after approximately 6 weeks, and after <em>1</em> year.

RESULTS

All treated patients achieved the maintenance dose of 0.5 ml of <em>1</em>:<em>1</em>00 wt/vol peanut extract by the rush injection protocol. All experienced increased tolerance to double-blind, placebo-controlled peanut challenge and decreased sensitivity on titrated skin prick testing with peanut extract, whereas the threshold to oral peanut challenge and cutaneous reactivity to peanut extract were unchanged in the untreated control subjects. Systemic reactions were common in the treated group both during rush immunotherapy and with maintenance injections. Only three patients remained tolerant of the full maintenance dose. The increased tolerance to oral peanut challenge was maintained in the three subjects who received full maintenance doses, but there was partial (n = 2) or complete (n = <em>1</em>) loss of protection in the patients who required dose reduction because of systemic reactions.

CONCLUSIONS

Injections of peanut extract increase the tolerance of patients with peanut allergy to oral ingestion of peanuts. Injections result in repeated systemic reactions in most patients, even during maintenance injections. For clinical application of this method of treatment, a modified peanut extract is needed.

BACKGROUND

Dolutegravir (GSK<em>1</em>349572), a once-daily HIV integrase inhibitor, has shown potent antiviral response and a favourable safety profile. We evaluated safety, efficacy, and emergent resistance in antiretroviral-experienced, integrase-inhibitor-naive adults with HIV-<em>1</em> with at least two-class drug resistance.

METHODS

ING<em>1</em><em>1</em><em>1</em>762 (SAILING) is a 48 week, phase 3, randomised, double-blind, active-controlled, non-inferiority study that began in October, 20<em>1</em>0. Eligible patients had two consecutive plasma HIV-<em>1</em> RNA assessments of 400 copies per mL or higher (unless>><em>1</em>000 copies per mL at screening), resistance to two or more classes of antiretroviral drugs, and had one to two fully active drugs for background therapy. Participants were randomly assigned (<em>1</em>:<em>1</em>) to once-daily dolutegravir 50 mg or twice-daily raltegravir 400 mg, with investigator-selected background therapy. Matching placebo was given, and study sites were masked to treatment assignment. The primary endpoint was the proportion of patients with plasma HIV-<em>1</em> RNA less than 50 copies per mL at week 48, evaluated in all participants randomly assigned to treatment groups who received at least one dose of study drug, excluding participants at one site with violations of good clinical practice. Non-inferiority was prespecified with a <em>1</em>2% margin; if non-inferiority was established, then superiority would be tested per a prespecified sequential testing procedure. A key prespecified secondary endpoint was the proportion of patients with treatment-emergent integrase-inhibitor resistance. The trial is registered at ClinicalTrials.gov, NCT0<em>1</em>23<em>1</em>5<em>1</em>6.

RESULTS

Analysis included 7<em>1</em>5 patients (354 dolutegravir; 36<em>1</em> raltegravir). At week 48, 25<em>1</em> (7<em>1</em>%) patients on dolutegravir had HIV-<em>1</em> RNA less than 50 copies per mL versus 230 (64%) patients on raltegravir (adjusted difference 7·4%, 95% CI 0·7 to <em>1</em>4·2); superiority of dolutegravir versus raltegravir was then concluded (p=0·03). Significantly fewer patients had virological failure with treatment-emergent integrase-inhibitor resistance on dolutegravir (four vs <em>1</em>7 patients; adjusted difference -3·7%, 95% CI -6·<em>1</em> to -<em>1</em>·2; p=0·003). Adverse event frequencies were similar across groups; the most commonly reported events for dolutegravir versus raltegravir were diarrhoea (7<em>1</em> [20%] vs 64 [<em>1</em>8%] patients), upper respiratory tract infection (38 [<em>1</em><em>1</em>%] vs 29 [8%]), and headache (33 [9%] vs 3<em>1</em> [9%]). Safety events leading to discontinuation were infrequent in both groups (nine [3%] dolutegravir, <em>1</em>4 [4%] raltegravir).

CONCLUSIONS

Once-daily dolutegravir, in combination with up to two other antiretroviral drugs, is well tolerated with greater virological effect compared with twice-daily raltegravir in this treatment-experienced patient group.

BACKGROUND

ViiV Healthcare.

OBJECTIVE

We sought to study the relationship between survival and right ventricular ejection fraction (RVEF) in a subgroup of patients with moderate congestive heart failure (CHF).

BACKGROUND

It has been demonstrated that RVEF is an independent predictor of survival in patients with advanced CHF.

METHODS

Cardiopulmonary exercise testing and radionuclide angiography (to determine right and left ventricular ejection fraction) were prospectively performed in 205 consecutive patients with moderate CHF (<em>1</em>40 patients in New York Heart Association [NYHA] class II, 65 in class III).

RESULTS

Left ventricular ejection fraction was 29.3%+/-<em>1</em>0.<em>1</em>%, RVEF was 37.5%+/-<em>1</em>4.6% and peak oxygen consumption (VO2) was <em>1</em>6.2+/-5.4 <em>ml</em>/min/kg (60.2%+/-<em>1</em>9% of maximal predicted VO2). After a median follow-up period of 755 days, there were 44 cardiac-related deaths, 3 deaths from noncardiac causes and <em>1</em>5 transplantations of whom 2 were urgent; <em>1</em> patient was lost to follow-up. Multivariate analysis showed that three variables-NYHA classification, percent of maximal predicted VO2 and RVEF-were independent predictors of both survival and event-free cardiac survival. Left ventricular ejection fraction and peak VO2 normalized to body weight had no predictive value. The event-free survival rates from cardiovascular mortality and urgent transplantation at <em>1</em> year were 80%, 90% and 95% in patients with an RVEF <25%, with a RVEF>> or =25% and <35% and with a RVEF>> or =35%, respectively. At 2 years, survival rates were 59%, 77% and 93% in the same subgroups, respectively.

CONCLUSIONS

In addition to the NYHA classification and to the percent of maximal predicted VO2, RVEF is an independent predictor of survival in patients with moderate CHF.

The emergence of cytotoxic T-lymphocyte (CTL) escape mutations in human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) proteins has been anecdotally associated with progression to AIDS, but it has been difficult to determine whether viral mutation is the cause or the result of increased viral replication. Here we describe a perinatally HIV-infected child who maintained a plasma viral load of <400 copies/<em>ml</em> for almost a decade until a nonbinding escape mutation emerged within the immunodominant CTL epitope. The child subsequently experienced a reemergence of HIV-<em>1</em> viremia accompanied by a marked increase in the number of CTL epitopes targeted. This temporal pattern suggests that CD8 escape can play a causal role in the loss of immune control.