Vascular endothelial growth factor (VEGF) is an angiogenic protein with neurotrophic and neuroprotective effects. Because VEGF promotes the proliferation of vascular endothelial cells, we examined the possibility that it also stimulates the proliferation of neuronal precursors in murine cerebral cortical cultures and in adult rat brain in vivo. VEGF >><em>1</em>0 ng/<em>ml</em>) stimulated 5-bromo-2'-deoxyuridine (BrdUrd) incorporation into cells that expressed immature neuronal marker proteins and increased cell number in cultures by 20-30%. Cultured cells labeled by BrdUrd expressed VEGFR2/Flk-<em>1</em>, but not VEGFR<em>1</em>/Flt-<em>1</em> receptors, and the effect of VEGF was blocked by the VEGFR2/Flk-<em>1</em> receptor tyrosine kinase inhibitor SU<em>1</em>498. Intracerebroventricular administration of VEGF into rat brain increased BrdUrd labeling of cells in the subventricular zone (SVZ) and the subgranular zone (SGZ) of the hippocampal dentate gyrus (DG), where VEGFR2/Flk-<em>1</em> was colocalized with the immature neuronal marker, doublecortin (Dcx). The increase in BrdUrd labeling after the administration of VEGF was caused by an increase in cell proliferation, rather than a decrease in cell death, because VEGF did not reduce caspase-3 cleavage in SVZ or SGZ. Cells labeled with BrdUrd after VEGF treatment in vivo include immature and mature neurons, astroglia, and endothelial cells. These findings implicate the angiogenesis factor VEGF in neurogenesis as well.

BACKGROUND

The initial report of the Selenium and Vitamin E Cancer Prevention Trial (SELECT) found no reduction in risk of prostate cancer with either selenium or vitamin E supplements but a statistically nonsignificant increase in prostate cancer risk with vitamin E. Longer follow-up and more prostate cancer events provide further insight into the relationship of vitamin E and prostate cancer.

OBJECTIVE

To determine the long-term effect of vitamin E and selenium on risk of prostate cancer in relatively healthy men.

METHODS

A total of 35,533 men from 427 study sites in the United States, Canada, and Puerto Rico were randomized between August 22, 200<em>1</em>, and June 24, 2004. Eligibility criteria included a prostate-specific antigen (PSA) of 4.0 ng/<em>mL</em> or less, a digital rectal examination not suspicious for prostate cancer, and age 50 years or older for black men and 55 years or older for all others. The primary analysis included 34,887 men who were randomly assigned to <em>1</em> of 4 treatment groups: 8752 to receive selenium; 8737, vitamin E; 8702, both agents, and 8696, placebo. Analysis reflect the final data collected by the study sites on their participants through July 5, 20<em>1</em><em>1</em>.

METHODS

Oral selenium (200 μg/d from L-selenomethionine) with matched vitamin E placebo, vitamin E (400 IU/d of all rac-α-tocopheryl acetate) with matched selenium placebo, both agents, or both matched placebos for a planned follow-up of a minimum of 7 and maximum of <em>1</em>2 years.

METHODS

Prostate cancer incidence.

RESULTS

This report includes 54,464 additional person-years of follow-up and 52<em>1</em> additional cases of prostate cancer since the primary report. Compared with the placebo (referent group) in which 529 men developed prostate cancer, 620 men in the vitamin E group developed prostate cancer (hazard ratio [HR], <em>1</em>.<em>1</em>7; 99% CI, <em>1</em>.004-<em>1</em>.36, P = .008); as did 575 in the selenium group (HR, <em>1</em>.09; 99% CI, 0.93-<em>1</em>.27; P = .<em>1</em>8), and 555 in the selenium plus vitamin E group (HR, <em>1</em>.05; 99% CI, 0.89-<em>1</em>.22, P = .46). Compared with placebo, the absolute increase in risk of prostate cancer per <em>1</em>000 person-years was <em>1</em>.6 for vitamin E, 0.8 for selenium, and 0.4 for the combination.

CONCLUSIONS

Dietary supplementation with vitamin E significantly increased the risk of prostate cancer among healthy men.

BACKGROUND

Clinicaltrials.gov Identifier: NCT00006392.

BACKGROUND

Tenofovir disoproxil fumarate (DF) is a once-daily nucleotide analogue reverse transcriptase inhibitor.

OBJECTIVE

To evaluate the efficacy and safety of tenofovir DF compared with stavudine in antiretroviral-naive patients.

METHODS

A prospective, randomized, double-blind study conducted at 81 centers in the United States, South America, and Europe from June 9, 2000, to January 30, 2004. A total of 753 patients infected with HIV who were antiretroviral naive were screened and 602 patients entered the study.

METHODS

Patients were randomized to receive either tenofovir DF (n = 299) or stavudine (n = 303), with placebo, in combination with lamivudine and efavirenz.

METHODS

Proportion of patients with HIV RNA levels of less than 400 copies/mL at week 48.

RESULTS

In the primary intent-to-treat analysis in which patients with missing data or who added or switched antiretroviral medications before week 48 were considered as failures, the proportion of patients with HIV RNA of less than 400 copies/mL at week 48 was 239 (80%) of 299 in patients receiving tenofovir DF and 253 (84%) of 301 in patients receiving stavudine (95% confidence interval, -10.4% to 1.5%), exceeding the predefined -10% limit for equivalence. However, equivalence was demonstrated in the secondary analyses (HIV RNA <50 copies/mL) at week 48 and through 144 weeks. Virologic failure was associated most frequently with efavirenz and lamivudine resistance. Through 144 weeks, the K65R mutation emerged in 8 and 2 patients in the tenofovir DF and stavudine groups, respectively (P =.06). A more favorable mean change from baseline in fasting lipid profile was noted in the tenofovir DF group at week 144: for triglyceride levels (+1 mg/dL for tenofovir DF [n = 170] vs +134 mg/dL for stavudine [n = 162], P<.001), total cholesterol (+30 mg/dL [n = 170] vs +58 mg/dL [n = 162], P<.001), direct low-density lipoprotein cholesterol (+14 mg/dL [n = 169] vs +26 mg/dL [n = 161], P<.001), and high-density lipoprotein cholesterol (+9 mg/dL [n = 168] vs +6 mg/dL [n = 154], P =.003). Investigator-reported lipodystrophy was less common in the tenofovir DF group compared with the stavudine group (9 [3%] of 299 vs 58 [19%] of 301, P<.001). The number of bone fractures and the renal safety profile were similar between the 2 groups.

CONCLUSIONS

Through 144 weeks, the combination of tenofovir DF, lamivudine, and efavirenz was highly effective and comparable with stavudine, lamivudine, and efavirenz in antiretroviral-naive patients. However, tenofovir DF appeared to be associated with better lipid profiles and less lipodystrophy.

BACKGROUND

Restricting protein intake and controlling hypertension delay the progression of renal disease in animals. We tested these interventions in 840 patients with various chronic renal diseases.

METHODS

In study <em>1</em>, 585 patients with glomerular filtration rates of 25 to 55 <em>ml</em> per minute per <em>1</em>.73 m2 of body-surface area were rando<em>ml</em>y assigned to a usual-protein diet or a low-protein diet (<em>1</em>.3 or 0.58 g of protein per kilogram of body weight per day) and to a usual- or a low-blood-pressure group (mean arterial pressure, <em>1</em>07 or 92 mm Hg). In study 2, 255 patients with glomerular filtration rates of <em>1</em>3 to 24 <em>ml</em> per minute per <em>1</em>.73 m2 were rando<em>ml</em>y assigned to the low-protein diet (0.58 g per kilogram per day) or a very-low-protein diet (0.28 g per kilogram per day) with a keto acid-amino acid supplement, and a usual- or a low-blood-pressure group (same values as those in study <em>1</em>). An <em>1</em>8-to-45-month follow-up was planned, with monthly evaluations of the patients.

RESULTS

The mean follow-up was 2.2 years. In study <em>1</em>, the projected mean decline in the glomerular filtration rate at three years did not differ significantly between the diet groups or between the blood-pressure groups. As compared with the usual-protein group and the usual-blood-pressure group, the low-protein group and the low-blood-pressure group had a more rapid decline in the glomerular filtration rate during the first four months after randomization and a slower decline thereafter. In study 2, the very-low-protein group had a marginally slower decline in the glomerular filtration rate than did the low-protein group (P = 0.07). There was no delay in the time to the occurrence of end-stage renal disease or death. In both studies, patients in the low-blood-pressure group who had more pronounced proteinuria at base line had a significantly slower rate of decline in the glomerular filtration rate.

CONCLUSIONS

Among patients with moderate renal insufficiency, the slower decline in renal function that started four months after the introduction of a low-protein diet suggests a small benefit of this dietary intervention. Among patients with more severe renal insufficiency, a very-low-protein diet, as compared with a low-protein diet, did not significantly slow the progression of renal disease.

BACKGROUND

High plasma HIV-<em>1</em> RNA concentrations are associated with increased risk of HIV-<em>1</em> transmission. Initiation of antiretroviral therapy (ART) reduces plasma HIV-<em>1</em> concentrations. We aimed to assess the effect of ART use by patients infected with HIV-<em>1</em> on risk of transmission to their uninfected partners.

METHODS

Participants in our prospective cohort analysis were from a randomised placebo-controlled trial that enrolled heterosexual African adults who were seropositive for both HIV-<em>1</em> and herpes simplex virus type 2, and their HIV-<em>1</em> seronegative partners. At enrolment, HIV-<em>1</em> infected participants had CD4 counts of 250 cells per microL or greater and did not meet national guidelines for ART initiation; during 24 months of follow-up, CD4 counts were measured every 6 months and ART was initiated in accordance with national guidelines. Uninfected partners were tested for HIV-<em>1</em> every 3 months. The primary outcome was genetically-linked HIV-<em>1</em> transmission within the study partnership. We assessed rates of HIV-<em>1</em> transmission by ART status of infected participants.

RESULTS

338<em>1</em> couples were eligible for analysis. 349 (<em>1</em>0%) participants with HIV-<em>1</em> initiated ART during the study, at a median CD4 cell count of <em>1</em>98 (IQR <em>1</em>6<em>1</em>-265) cells per microL. Only one of <em>1</em>03 genetically-linked HIV-<em>1</em> transmissions was from an infected participant who had started ART, corresponding to transmission rates of 0.37 (95% CI 0.09-2.04) per <em>1</em>00 person-years in those who had initiated treatment and 2.24 (<em>1</em>.84-2.72) per <em>1</em>00 person-years in those who had not-a 92% reduction (adjusted incidence rate ratio 0.08, 95% CI 0.00-0.57, p=0.004). In participants not on ART, the highest HIV-<em>1</em> transmission rate (8.79 per <em>1</em>00 person-years) was from those with CD4 cell counts lower than 200 cells per microL. In couples in whom the untreated HIV-<em>1</em> infected partner had a CD4 cell count greater than 200 cells per microL, 66 (70%) of 94 transmissions occurred when plasma HIV-<em>1</em> concentrations exceeded 50 000 copies per mL.

CONCLUSIONS

Low CD4 cell counts and high plasma HIV-<em>1</em> concentrations might guide use of ART to achieve an HIV-<em>1</em> prevention benefit. Provision of ART to HIV-<em>1</em> infected patients could be an effective strategy to achieve population-level reductions in HIV-<em>1</em> transmission.

BACKGROUND

Bill & Melinda Gates Foundation; US National Institutes of Health.

BACKGROUND

Only <em>1</em>5-20% of patients with chronic hepatitis C achieve a sustained virological response with interferon therapy. The aim of this study was to compare the efficacy and safety of interferon alpha2b in combination with oral ribavirin with interferon alone, for treatment of chronic infection with hepatitis C virus (HCV).

METHODS

832 patients aged <em>1</em>8 years or more with chronic HCV who had not been treated with interferon or ribavirin, were enrolled and randomly allocated one of three regimens: 3 mega units (MU) interferon alpha2b three times a week plus <em>1</em>000-<em>1</em>200 mg ribavirin per day for 48 weeks; 3 MU interferon alpha2b three times a week plus <em>1</em>000-<em>1</em>200 mg ribavirin per day for 24 weeks; or 3 MU interferon alpha2b three times a week and placebo for 48 weeks. All patients were assessed for safety, tolerance, and efficacy at the end of weeks <em>1</em>, 2, 4, 6, and 8, and every 4 weeks during treatment. After treatment was completed patients were followed up on weeks 4, 8, <em>1</em>2, and 24. The primary endpoint was loss of detectable HCV-RNA (serum HCV-RNA (<em>1</em>00 copies/<em>mL</em>) at week 24 after treatment.

RESULTS

Sustained virological response at 24 weeks after treatment, was found in <em>1</em><em>1</em>9 (43%) of the 277 patients treated for 48 weeks with the combination regimen, 97 (35%) of the 277 patients treated for 24 weeks with the combination regimen (p=O.055), and 53 (<em>1</em>9%) of the 278 patients treated for 48 weeks with interferon alone (p<0.00<em>1</em> vs both combination regimens, intention-to-treat analysis). Logistic regression identified five independent factors significantly associated with response: genotype 2 or 3, viral load less than 2 million copies/<em>mL</em>, age 40 years or less, minimal fibrosis stage, and female sex. Among patients with fewer than three of these factors the odds ratio of sustained response was 2.6 (95% Cl <em>1</em>.4-4.8; p=0.002) for the 48 week combination regimen compared with 24 weeks of the combination regimen. Discontinuation of therapy for adverse events was more frequent with combination (<em>1</em>9%) and monotherapy (<em>1</em>3%) given for 48 weeks than combination therapy given for 24 weeks (8%).

CONCLUSIONS

An interferon alpha2b plus ribavirin combination is more effective than 48 weeks of interferon alpha2b monotherapy and has an acceptable safety profile. Patients with few favourable factors benefit more from extending the duration of combination therapy to 48 weeks.

BACKGROUND

Exercise training reduces the symptoms of chronic heart failure. Which exercise intensity yields maximal beneficial adaptations is controversial. Furthermore, the incidence of chronic heart failure increases with advanced age; it has been reported that 88% and 49% of patients with a first diagnosis of chronic heart failure are >65 and >80 years old, respectively. Despite this, most previous studies have excluded patients with an age >70 years. Our objective was to compare training programs with moderate versus high exercise intensity with regard to variables associated with cardiovascular function and prognosis in patients with postinfarction heart failure.

RESULTS

Twenty-seven patients with stable postinfarction heart failure who were undergoing optimal medical treatment, including beta-blockers and angiotensin-converting enzyme inhibitors (aged 75.5+/-<em>1</em><em>1</em>.<em>1</em> years; left ventricular [LV] ejection fraction 29%; VO2peak <em>1</em>3 <em>mL</em> x kg(-<em>1</em>) x min(-<em>1</em>)) were randomized to either moderate continuous training (70% of highest measured heart rate, ie, peak heart rate) or aerobic interval training (95% of peak heart rate) 3 times per week for <em>1</em>2 weeks or to a control group that received standard advice regarding physical activity. VO2peak increased more with aerobic interval training than moderate continuous training (46% versus <em>1</em>4%, P<0.00<em>1</em>) and was associated with reverse LV remodeling. LV end-diastolic and end-systolic volumes declined with aerobic interval training only, by <em>1</em>8% and 25%, respectively; LV ejection fraction increased 35%, and pro-brain natriuretic peptide decreased 40%. Improvement in brachial artery flow-mediated dilation (endothelial function) was greater with aerobic interval training, and mitochondrial function in lateral vastus muscle increased with aerobic interval training only. The MacNew global score for quality of life in cardiovascular disease increased in both exercise groups. No changes occurred in the control group.

CONCLUSIONS

Exercise intensity was an important factor for reversing LV remodeling and improving aerobic capacity, endothelial function, and quality of life in patients with postinfarction heart failure. These findings may have important implications for exercise training in rehabilitation programs and future studies.

BACKGROUND

Angiomyolipomas in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis are associated with mutations in tuberous sclerosis genes resulting in constitutive activation of the mammalian target of rapamycin (mTOR). The drug sirolimus suppresses mTOR signaling.

METHODS

We conducted a 24-month, nonrandomized, open-label trial to determine whether sirolimus reduces the angiomyolipoma volume in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis. Sirolimus was administered for the first <em>1</em>2 months only. Serial magnetic resonance imaging of angiomyolipomas and brain lesions, computed tomography of lung cysts, and pulmonary-function tests were performed.

RESULTS

Of the 25 patients enrolled, 20 completed the <em>1</em>2-month evaluation, and <em>1</em>8 completed the 24-month evaluation. The mean (+/-SD) angiomyolipoma volume at <em>1</em>2 months was 53.2+/-26.6% of the baseline value (P<0.00<em>1</em>) and at 24 months was 85.9+/-28.5% of the baseline value (P=0.005). At 24 months, five patients had a persistent reduction in the angiomyolipoma volume of 30% or more. During the period of sirolimus therapy, among patients with lymphangioleiomyomatosis, the mean forced expiratory volume in <em>1</em> second (FEV<em>1</em>) increased by <em>1</em><em>1</em>8+/-330 <em>ml</em> (P=0.06), the forced vital capacity (FVC) increased by 390+/-570 <em>ml</em> (P<0.00<em>1</em>), and the residual volume decreased by 439+/-493 <em>ml</em> (P=0.02), as compared with baseline values. One year after sirolimus was discontinued, the FEV<em>1</em> was 62+/-4<em>1</em><em>1</em> <em>ml</em> above the baseline value, the FVC was 346+/-7<em>1</em>2 <em>ml</em> above the baseline value, and the residual volume was 333+/-570 <em>ml</em> below the baseline value; cerebral lesions were unchanged. Five patients had six serious adverse events while receiving sirolimus, including diarrhea, pyelonephritis, stomatitis, and respiratory infections.

CONCLUSIONS

Angiomyolipomas regressed somewhat during sirolimus therapy but tended to increase in volume after the therapy was stopped. Some patients with lymphangioleiomyomatosis had improvement in spirometric measurements and gas trapping that persisted after treatment. Suppression of mTOR signaling might constitute an ameliorative treatment in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis. (ClinicalTrials.gov number, NCT00457808.)

OBJECTIVE

Preclinical studies indicate that gefitinib (Iressa, ZD<em>1</em>839; AstraZeneca, Wilmington, DE), an orally active epidermal growth factor receptor tyrosine kinase inhibitor, may enhance antitumor efficacy of cytotoxics, and combination with paclitaxel and carboplatin had acceptable tolerability in a phase I trial. Gefitinib monotherapy demonstrated unparalleled antitumor activity for a biologic agent, with less toxicity than docetaxel, in phase II trials in refractory, advanced non-small-cell lung cancer (NSCLC). This phase III, randomized, placebo-controlled, double-blind trial evaluated gefitinib plus paclitaxel and carboplatin in chemotherapy-naive patients with advanced NSCLC.

METHODS

Patients received paclitaxel 225 mg/m(2) and carboplatin area under concentration/time curve of 6 mg/min/<em>mL</em> (day <em>1</em> every 3 weeks) plus gefitinib 500 mg/d, gefitinib 250 mg/d, or placebo. After a maximum of six cycles, daily gefitinib or placebo continued until disease progression. End points included overall survival, time to progression (TTP), response rate (RR), and safety evaluation. Results A total of <em>1</em>,037 patients were recruited. Baseline demographic characteristics were well balanced. There was no difference in overall survival (median, 8.7, 9.8, and 9.9 months for gefitinib 500 mg/d, 250 mg/d, and placebo, respectively; P =.64), TTP, or RR between arms. Expected dose-related diarrhea and skin toxicity were observed in gefitinib-treated patients, with no new significant/unexpected safety findings from combination with chemotherapy. Subset analysis of patients with adenocarcinoma who received>> or = 90 days' chemotherapy demonstrated statistically significant prolonged survival, suggesting a gefitinib maintenance effect.

CONCLUSIONS

Gefitinib showed no added benefit in survival, TTP, or RR compared with standard chemotherapy alone. This large, placebo-controlled trial confirmed the favorable gefitinib safety profile observed in phase I and II monotherapy trials.

OBJECTIVE

To determine if photodynamic therapy with verteporfin (Visudyne; CIBA Vision Corp, Duluth, Ga) can safely reduce the risk of vision loss in patients with subfoveal choroidal neovascularization (CNV) caused by age-related macular degeneration (AMD).

METHODS

Two multicenter, double-masked, placebo-controlled, randomized clinical trials.

METHODS

Twenty-two ophthalmology practices in Europe and North America.

METHODS

Patients with subfoveal CNV lesions caused by AMD measuring 5400 microm or less in greatest linear dimension with evidence of classic CNV and best-corrected visual acuity of approximately 20/40 to 20/200.

METHODS

Six hundred nine patients were randomly assigned (2: <em>1</em>) to verteporfin (6 mg per square meter of body surface area) or placebo (5% dextrose in water) administered via intravenous infusion of 30 <em>mL</em> over <em>1</em>0 minutes. Fifteen minutes after the start of the infusion, a laser light at 689 nm delivered 50J/cm2 at an intensity of 600 mW/cm2 over 83 seconds using a spot size with a diameter <em>1</em>000 microm larger than the greatest linear dimension of the CNV lesion. At follow-up examinations every 3 months, retreatment with the same regimen was applied if angiography showed fuorescein leakage. The primary outcome was the proportion of eyes with fewer than <em>1</em>5 letters lost (approximately <3 lines of loss), adhering to an intent-to-treat analysis.

RESULTS

In each group, 94% of patients completed the month <em>1</em>2 examination. Visual acuity, contrast sensitivity, and fluorescein angiographic outcomes were better in the verteporfin-treated eyes than in the placebo-treated eyes at every follow-up examination through the month <em>1</em>2 examination. At the month-<em>1</em>2 examination, 246 (6<em>1</em>%) of 402 eyes assigned to verteporfin compared with 96 (46%) of 207 eyes assigned to placebo had lost fewer than <em>1</em>5 letters of visual acuity from baseline (P<.00<em>1</em>). In subgroup analyses, the visual acuity benefit (< <em>1</em>5 letters lost) of verteporfin therapy was clearly demonstrated (67% vs 39%; P<.00<em>1</em>) when the area of classic CNV occupied 50% or more of the area of the entire lesion (termed predominantly classic CNV lesions), especially when there was no occult CNV. No statistically significant differences in visual acuity were noted when the area of classic CNV was more than 0% but less than 50% of the area of the entire lesion. Few ocular or other systemic adverse events were associated with verteporfin treatment, compared with placebo, including transient visual disturbances (<em>1</em>8% vs <em>1</em>2%), injection-site adverse events (<em>1</em>3% vs 3%), transient photosensitivity reactions (3% vs 0%), and infusion-related low back pain (2% vs 0%).

CONCLUSIONS

Since verteporfin therapy of subfoveal CNV from AMD can safely reduce the risk of vision loss, we recommend verteporfin therapy for treatment of patients with predominantly classic CNV from AMD.

Recombinant human tumor necrosis factor (rTNF alpha) injected intravenously into rabbits produces a rapid-onset, monophasic fever indistinguishable from the fever produced by rIL-<em>1</em>. On a weight basis (<em>1</em> microgram/kg) rTNF alpha and rIL-<em>1</em> produce the same amount of fever and induce comparable levels of PGE2 in rabbit hypothalamic cells in vitro; like IL-<em>1</em>, TNF fever is blocked by drugs that inhibit cyclooxygenase. At higher doses (<em>1</em>0 micrograms/kg) rTNF alpha produces biphasic fevers. The first fever reaches peak elevation 45-55 min after bolus injection and likely represents a direct action on the thermoregulatory center. During the second fever peak (3 h later), a circulating endogenous pyrogen can be shown present using passive transfer of plasma into fresh rabbits. This likely represents the in vivo induction of IL-<em>1</em>. In vitro, rTNF alpha induces the release of IL-<em>1</em> activity from human mononuclear cells with maximal production observed at 50-<em>1</em>00 ng/<em>ml</em> of rTNF alpha. In addition, rTNF alpha and rIFN-gamma have a synergistic effect on IL-<em>1</em> production. The biological activity of rTNF alpha could be distinguished from IL-<em>1</em> in three ways: the monophasic pyrogenic activity of rIL-<em>1</em> was destroyed at 70 degrees C, whereas rTNF alpha remained active; anti-IL-<em>1</em> neutralized IL-<em>1</em> but did recognize rTNF alpha or natural cachectin nor neutralize its cytotoxic effect; and unlike IL-<em>1</em>, rTNF alpha was not active in the mitogen-stimulated T cell proliferation assay. The possibility that endotoxin was responsible for rTNF alpha fever and/or the induction of IL-<em>1</em> was ruled-out in several studies: rTNF alpha produced fever in the endotoxin-resistant C3H/HeJ mice; the IL-<em>1</em>-inducing property of rTNF alpha was destroyed either by heat (70 degrees C) or trypsinization, and was unaffected by polymyxin B; pyrogenic tolerance to daily injections of rTNF alpha did not occur; levels of endotoxin, as determined in the Limulus amebocyte lysate, were below the minimum rabbit pyrogen dose; and these levels of endotoxin were confirmed by gas chromatography/mass spectrometry analysis for the presence of beta-hydroxymyristic acid. Although rTNF alpha is not active in T cell proliferation assays, it may mimic IL-<em>1</em> in a T cell assay, since high concentrations of rTNF alpha induced IL-<em>1</em> from epithelial or macrophagic cells in the thymocyte preparations. These studies show that TNF (cachectin) is another endogenous pyrogen which, like IL-<em>1</em> and IFN-alpha, directly stimulate hypothalamic PGE2 synthesis. In addition, rTNF alpha is an endogenous inducer of IL-<em>1</em>.(ABSTRACT TRUNCATED AT 400 WORDS)

Fibrocytes are a distinct population of blood-borne cells that display a unique cell surface phenotype (collagen I+/CD<em>1</em><em>1</em>b+/CD<em>1</em>3+/CD34+/CD45RO+/MHC class II+/CD86+) and exhibit potent immunostimulatory activities. Circulating fibrocytes rapidly enter sites of tissue injury, suggesting an important role for these cells in wound repair. However, the regulatory processes that govern the differentiation of blood-borne fibrocytes and the mechanisms that underlie the migration of these cells to wound sites are currently not known. We report herein that ex vivo cultured fibrocytes can differentiate from a CD<em>1</em>4+-enriched mononuclear cell population and that this process requires contact with T cells. Furthermore, we demonstrate that TGF-beta<em>1</em> (<em>1</em>-<em>1</em>0 ng/<em>ml</em>), an important fibrogenic and growth-regulating cytokine involved in wound healing, increases the differentiation and functional activity of cultured fibrocytes. Because fibrocytes home to sites of tissue injury, we examined the role of chemokine/chemokine receptor interactions in fibrocyte trafficking. We show that secondary lymphoid chemokine, a ligand of the CCR7 chemokine receptor, acts as a potent stimulus for fibrocyte chemotaxis in vitro and for the homing of injected fibrocytes to sites of cutaneous tissue injury in vivo. Finally, we demonstrate that differentiated, cultured fibrocytes express alpha smooth muscle actin and contract collagen gels in vitro, two characteristic features of wound-healing myofibroblasts. These data provide important insight into the control of fibrocyte differentiation and trafficking during tissue repair and significantly expand their potential role during wound healing.

A rapid spectrophotometric procedure is described for the estimation of sulfated glycosaminoglycans in cartilage cultures. Papain digestion of tissue or culture medium provides glycosaminoglycans in solution for assay; an aliquot of the digest is mixed with the dye <em>1</em>,9-dimethylmethylene blue. The assay is based on the metachromatic shift in absorption maximum which occurs when the dye is complexed with sulfated glycosaminoglycans. The reagent is stable, and the method is substantially free from interference, is sensitive to less than <em>1</em> microgram (4 micrograms/<em>ml</em>) of chondroitin sulfate, and provides a simple alternative to the traditional methods for glycosaminoglycan determinations.

To define the role of the human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) envelope proteins in virus infection, a series of peptides were synthesized based on various regions of the HIV-<em>1</em> transmembrane protein gp4<em>1</em>. One of these peptides, DP-<em>1</em>78, corresponding to a region predictive of alpha-helical secondary structure (residues 643-678 of the HIV-<em>1</em>LAI isolate), has been identified as a potent antiviral agent. This peptide consistently blocked <em>1</em>00% of virus-mediated cell-cell fusion at < 5 ng/<em>ml</em> (IC90 approximately <em>1</em>.5 ng/<em>ml</em>) and gave an approximately <em>1</em>0 times reduction in infectious titer of cell-free virus at approximately 80 ng/<em>ml</em>. The inhibitory activity was observed at peptide concentrations approximately <em>1</em>0(4) to <em>1</em>0(5) times lower than those at which cytotoxicity and cytostasis were detected. Peptide-mediated inhibition is HIV-<em>1</em> specific in that approximately <em>1</em>0(2) to <em>1</em>0(3) times more peptide was required for inhibition of a human immunodeficiency virus type 2 isolate. Further experiments showed that DP-<em>1</em>78 exhibited antiviral activity against both prototypic and primary HIV-<em>1</em> isolates. As shown by PCR analysis of newly synthesized proviral DNA, DP-<em>1</em>78 blocks an early step in the virus life cycle prior to reverse transcription. Finally, we discuss possible mechanisms by which DP-<em>1</em>78 may exert its inhibitory activity.

Although T cell activation is associated with disease progression in untreated human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) infection, its significance in antiretroviral-treated patients is unknown. Activated (CD38(+)HLA-DR(+)) T cell counts were measured in 99 HIV-infected adults who had maintained a plasma HIV RNA level <or=<em>1</em>000 copies/<em>mL</em> for a median of 2<em>1</em> months while receiving antiretroviral therapy. Patients with sustained viral suppression had lower levels of T cell activation than untreated patients but higher levels than HIV-uninfected control subjects. Persistent T cell activation was associated with decreased CD4(+) T cell gains during therapy. For every 5% increase in the proportion of activated CD8(+) T cells, 35 fewer CD4(+) T cells/mm(3) were gained. Increased T cell activation was associated with shorter duration of viral suppression, hepatitis C virus coinfection, frequent low-level viremia, and lower nadir CD4(+) T cell counts. Interventions that directly target T cell activation or the determinants of activation may prove to be useful adjuvants to antiretroviral therapy.

BACKGROUND

Studies have shown that an inflammatory response may be elicited by mechanical ventilation used for recruitment or derecruitment of collapsed lung units or to overdistend alveolar regions, and that a lung-protective strategy may reduce this response.

OBJECTIVE

To test the hypothesis that mechanical ventilation induces a pulmonary and systemic cytokine response that can be minimized by limiting recruitment or derecruitment and overdistention.

METHODS

Randomized controlled trial in the intensive care units of 2 European hospitals from November <em>1</em>995 to February <em>1</em>998, with a 28-day follow-up.

METHODS

Forty-four patients (mean [SD] age, 50 [<em>1</em>8] years) with acute respiratory distress syndrome were enrolled, 7 of whom were withdrawn due to adverse events.

METHODS

After admission, volume-pressure curves were measured and bronchoalveolar lavage and blood samples were obtained. Patients were randomized to either the control group (n = <em>1</em>9): tidal volume to obtain normal values of arterial carbon dioxide tension (35-40 mm Hg) and positive end-expiratory pressure (PEEP) producing the greatest improvement in arterial oxygen saturation without worsening hemodynamics; or the lung-protective strategy group (n = <em>1</em>8): tidal volume and PEEP based on the volume-pressure curve. Measurements were repeated 24 to 30 and 36 to 40 hours after randomization.

METHODS

Pulmonary and systemic concentrations of inflammatory mediators approximately 36 hours after randomization.

RESULTS

Physiological characteristics and cytokine concentrations were similar in both groups at randomization. There were significant differences (mean [SD]) between the control and lung-protective strategy groups in tidal volume (<em>1</em><em>1</em>.<em>1</em> [<em>1</em>.3] vs 7.6 [<em>1</em>.<em>1</em>] <em>mL</em>/kg), end-inspiratory plateau pressures (3<em>1</em>.0 [4.5] vs 24.6 [2.4] cm H2O), and PEEP (6.5 [<em>1</em>.7] vs <em>1</em>4.8 [2.7] cm H2O) (P<.00<em>1</em>). Patients in the control group had an increase in bronchoalveolar lavage concentrations of interleukin (IL) <em>1</em>beta, IL-6, and IL-<em>1</em> receptor agonist and in both bronchoalveolar lavage and plasma concentrations of tumor necrosis factor (TNF) alpha, IL-6, and TNF-alpha, receptors over 36 hours (P<.05 for all). Patients in the lung-protective strategy group had a reduction in bronchoalveolar lavage concentrations of polymorphonuclear cells, TNF-alpha, IL-<em>1</em>beta, soluble TNF-alpha receptor 55, and IL-8, and in plasma and bronchoalveolar lavage concentrations of IL-6, soluble TNF-alpha receptor 75, and IL-<em>1</em> receptor antagonist (P<.05). The concentration of the inflammatory mediators 36 hours after randomization was significantly lower in the lung-protective strategy group than in the control group (P<.05).

CONCLUSIONS

Mechanical ventilation can induce a cytokine response that may be attenuated by a strategy to minimize overdistention and recruitment/derecruitment of the lung. Whether these physiological improvements are associated with improvements in clinical end points should be determined in future studies.

BACKGROUND

In cross-sectional studies, low serum levels of 25-hydroxyvitamin D are associated with higher prevalence of cardiovascular risk factors and disease. This study aimed to determine whether endogenous 25-hydroxyvitamin D and <em>1</em>,25-dihydroxyvitamin D levels are related to all-cause and cardiovascular mortality.

METHODS

Prospective cohort study of 3258 consecutive male and female patients (mean [SD] age, 62 [<em>1</em>0] years) scheduled for coronary angiography at a single tertiary center. We formed quartiles according to 25-hydroxyvitamin D and <em>1</em>,25-dihydroxyvitamin D levels within each month of blood drawings. The main outcome measures were all-cause and cardiovascular deaths.

RESULTS

During a median follow-up period of 7.7 years, 737 patients (22.6%) died, including 463 deaths from cardiovascular causes. Multivariate-adjusted hazard ratios (HRs) for patients in the lower two 25-hydroxyvitamin D quartiles (median, 7.6 and <em>1</em>3.3 ng/<em>mL</em> [to convert 25-hydroxyvitamin D levels to nanomoles per liter, multiply by 2.496]) were higher for all-cause mortality (HR, 2.08; 95% confidence interval [CI], <em>1</em>.60-2.70; and HR, <em>1</em>.53; 95% CI, <em>1</em>.<em>1</em>7-2.0<em>1</em>; respectively) and for cardiovascular mortality (HR, 2.22; 95% CI, <em>1</em>.57-3.<em>1</em>3; and HR, <em>1</em>.82; 95% CI, <em>1</em>.29-2.58; respectively) compared with patients in the highest 25-hydroxyvitamin D quartile (median, 28.4 ng/<em>mL</em>). Similar results were obtained for patients in the lowest <em>1</em>,25-dihydroxyvitamin D quartile. These effects were independent of coronary artery disease, physical activity level, Charlson Comorbidity Index, variables of mineral metabolism, and New York Heart Association functional class. Low 25-hydroxyvitamin D levels were significantly correlated with variables of inflammation (C-reactive protein and interleukin 6 levels), oxidative burden (serum phospholipid and glutathione levels), and cell adhesion (vascular cell adhesion molecule <em>1</em> and intercellular adhesion molecule <em>1</em> levels).

CONCLUSIONS

Low 25-hydroxyvitamin D and <em>1</em>,25-dihydroxyvitamin D levels are independently associated with all-cause and cardiovascular mortality. A causal relationship has yet to be proved by intervention trials using vitamin D.

OBJECTIVE

We conducted a retrospective cohort study to investigate factors to early and late phase recurrence of hepatocellular carcinoma (HCC).

METHODS

The study population consisted of 249 patients including <em>1</em>57 with cirrhosis who underwent hepatectomy for HCC. The endpoint was time-to-recurrence. Using a Cox regression model, factors to early and late phase recurrences were investigated censoring recurrence-free patients at the 2-year time point and in patients without recurrence at 2 years.

RESULTS

Actuarial probability of overall recurrence at <em>1</em>, 3, and 5 years were 0.30<em>1</em>, 0.623, and 0.790, respectively, with a median follow-up of 624 days. Early recurrence was observed in <em>1</em>23 out of 249 patients; while late recurrence was found in 6<em>1</em> out of <em>1</em><em>1</em>3 patients. Factors to early recurrence were as follows: non-anatomical resection, presence of microscopic vascular invasion, and serum alpha-fetoprotein level>>or=32 ng/<em>ml</em>. Those contributing to late phase recurrence were higher grade of hepatitis activity, multiple tumors, and gross tumor classification.

CONCLUSIONS

Variables associated with metastatic recurrence were factors to early phase recurrence; whereas those related with elevated carcinogenesis contributed to late phase recurrence, thus providing an epidemiological evidence that different mechanisms, i.e. metastasis and de novo, are involved in intrahepatic recurrence after hepatectomy for HCC.

OBJECTIVE

Increased intra-abdominal fat is associated with insulin resistance and an atherogenic lipoprotein profile. Circulating concentrations of adiponectin, an adipocyte-derived protein, are decreased with insulin resistance. We investigated the relationships between adiponectin and leptin, body fat distribution, insulin sensitivity and lipoproteins.

METHODS

We measured plasma adiponectin, leptin and lipid concentrations, intra-abdominal and subcutaneous fat areas by CT scan, and insulin sensitivity index (S(I)) in <em>1</em>82 subjects (76 M/<em>1</em>06F).

RESULTS

Adiponectin concentrations were higher in women than in men (7.4+/-2.9 vs 5.4+/-2.3 micro g/<em>ml</em>, p<0.000<em>1</em>) as were leptin concentrations (<em>1</em>9.<em>1</em>+/-<em>1</em>3.7 vs 6.9+/-5.<em>1</em> ng/<em>ml</em>, p<0.000<em>1</em>). Women were more insulin sensitive (S(I): 6.8+/-3.9 vs 5.9+/-4.4 x <em>1</em>0(-5) min(-<em>1</em>)/(pmol/l), p<0.0<em>1</em>) and had more subcutaneous (240+/-<em>1</em>33 vs <em>1</em>87+/-90 cm(2), p<0.0<em>1</em>), but less intra-abdominal fat (82+/-57 vs <em>1</em>24+/-68 cm(2), p<0.000<em>1</em>). By simple regression, adiponectin was positively correlated with age ( r=0.227, p<0.0<em>1</em>) and S(I) ( r=0.375, p<0.000<em>1</em>), and negatively correlated with BMI ( r=-0.333, p<0.000<em>1</em>), subcutaneous ( r=-0.<em>1</em>68, p<0.05) and intra-abdominal fat ( r=-0.35, p<0.000<em>1</em>). Adiponectin was negatively correlated with triglycerides ( r=-0.28<em>1</em>, p<0.00<em>1</em>) and positively correlated with HDL cholesterol ( r=0.605, p<0.000<em>1</em>) and Rf, a measure of LDL particle buoyancy ( r=0.474, p<0.000<em>1</em>). By multiple regression analysis, adiponectin was related to age ( p<0.000<em>1</em>), sex ( p<0.005) and intra-abdominal fat ( p<0.0<em>1</em>). S(I) was related to intra-abdominal fat ( p<0.000<em>1</em>) and adiponectin ( p<0.0005). Both intra-abdominal fat and adiponectin contributed independently to triglycerides, HDL cholesterol and Rf.

CONCLUSIONS

These data suggest that adiponectin concentrations are determined by intra-abdominal fat mass, with additional independent effects of age and sex. Adiponectin could link intra-abdominal fat with insulin resistance and an atherogenic lipoprotein profile.

BACKGROUND

Vitamin D deficiency may be involved in the development of atherosclerosis and coronary heart disease in humans.

METHODS

We assessed prospectively whether plasma 25-hydroxyvitamin D (25[OH]D) concentrations are associated with risk of coronary heart disease. A nested case-control study was conducted in <em>1</em>8,225 men in the Health Professionals Follow-up Study; the men were aged 40 to 75 years and were free of diagnosed cardiovascular disease at blood collection. The blood samples were returned between April <em>1</em>, <em>1</em>993, and November 30, <em>1</em>999; 99% were received between April <em>1</em>, <em>1</em>993, and November 30, <em>1</em>995. During <em>1</em>0 years of follow-up, 454 men developed nonfatal myocardial infarction or fatal coronary heart disease. Using risk set sampling, controls (n = 900) were selected in a 2:<em>1</em> ratio and matched for age, date of blood collection, and smoking status.

RESULTS

After adjustment for matched variables, men deficient in 25(OH)D (<or=<em>1</em>5 ng/mL [to convert to nanomoles per liter, multiply by 2.496]) were at increased risk for MI compared with those considered to be sufficient in 25(OH)D >>or=30 ng/mL) (relative risk [RR], 2.42; 95% confidence interval [CI], <em>1</em>.53-3.84; P < .00<em>1</em> for trend). After additional adjustment for family history of myocardial infarction, body mass index, alcohol consumption, physical activity, history of diabetes mellitus and hypertension, ethnicity, region, marine omega-3 intake, low- and high-density lipoprotein cholesterol levels, and triglyceride levels, this relationship remained significant (RR, 2.09; 95% CI, <em>1</em>.24-3.54; P = .02 for trend). Even men with intermediate 25(OH)D levels were at elevated risk relative to those with sufficient 25(OH)D levels (22.6-29.9 ng/mL: RR, <em>1</em>.60 [95% CI, <em>1</em>.<em>1</em>0-2.32]; and <em>1</em>5.0-22.5 ng/mL: RR, <em>1</em>.43 [95% CI, 0.96-2.<em>1</em>3], respectively).

CONCLUSIONS

Low levels of 25(OH)D are associated with higher risk of myocardial infarction in a graded manner, even after controlling for factors known to be associated with coronary artery disease.

A maximal multistage 20 m shuttle run test was designed to determine the maximal aerobic power of schoolchildren, healthy adults attending fitness class and athletes performing in sports with frequent stops and starts (e.g. basketball, fencing and so on). Subjects run back and forth on a 20 m course and must touch the 20 m line; at the same time a sound signal is emitted from a prerecorded tape. Frequency of the sound signals is increased 0.5 km h-<em>1</em> each minute from a starting speed of 8.5 km h-<em>1</em>. When the subject can no longer follow the pace, the last stage number announced is used to predict maximal oxygen uptake (VO2max) (Y, <em>ml</em> kg-<em>1</em> min-<em>1</em>) from the speed (X, km h-<em>1</em>) corresponding to that stage (speed = 8 + 0.5 stage no.) and age (A, year): Y = 3<em>1</em>.025 + 3.238 X - 3.248A + 0.<em>1</em>536AX, r = 0.7<em>1</em> with <em>1</em>88 boys and girls aged 8-<em>1</em>9 years. To obtain this regression, the test was performed individually. Right upon termination VO2 was measured with four 20 s samples and VO2max was estimated by retroextrapolating the O2 recovery curve at time zero of recovery. For adults, similar measurements indicated that the same equation could be used keeping age constant at <em>1</em>8 (r = 0.90, n = 77 men and women <em>1</em>8-50 years old). Test-retest reliability coefficients were 0.89 for children (<em>1</em>39 boys and girls 6-<em>1</em>6 years old) and 0.95 for adults (8<em>1</em> men and women, 20-45 years old).(ABSTRACT TRUNCATED AT 250 WORDS)

DNA shuffling is a method for in vitro homologous recombination of pools of selected mutant genes by random fragmentation and polymerase chain reaction (PCR) reassembly. Computer simulations called genetic algorithms have demonstrated the importance of iterative homologous recombination for sequence evolution. Oligonucleotide cassette mutagenesis and error-prone PCR are not combinatorial and thus are limited in searching sequence space. We have tested mutagenic DNA shuffling for molecular evolution in a beta-lactamase model system. Three cycles of shuffling and two cycles of backcrossing with wild-type DNA, to eliminate non-essential mutations, were each followed by selection on increasing concentrations of the antibiotic cefotaxime. We report here that selected mutants had a minimum inhibitory concentration of 640 micrograms <em>ml</em>-<em>1</em>, a 32,000-fold increase and 64-fold greater than any published TEM-<em>1</em> derived enzyme. Cassette mutagenesis and error-prone PCR resulted in only a <em>1</em>6-fold increase.

Blood stream forms (BSF) of Trypanosoma brucei brucei GUT at 3.<em>1</em> were propagated in vitro in the absence of feeder layer cells at 37 C, using a modified Iscove's medium (HMI-<em>1</em>8). The medium was supplemented with 0.05 mM bathocuproine sulfonate, <em>1</em>.5 mM L-cysteine, <em>1</em> mM hypoxanthine, 0.2 mM 2-mercaptoethanol, <em>1</em> mM sodium pyruvate. 0.<em>1</em>6 mM thymidine, and 20% (v/v) Serum Plus (SP) (Hazleton Biologics, Lenexa, Kansas). The latter contained a low level of serum proteins (<em>1</em>3 micrograms/<em>ml</em>). Each primary culture was initiated by placing 3.5-4 x <em>1</em>0(6) BSFs isolated from infected mice in a flask containing 5 <em>ml</em> of the medium (HMI-9) supplemented with <em>1</em>0% fetal bovine serum (FBS) and <em>1</em>0% SP. The cultures were maintained by replacing the medium every 24 hr for 5-7 days. During this period, many BSFs died. However, from day 4 onward, long slender BSFs increased in number. On days 5-7, trypanosome suspensions were pooled and cell debris was removed by means of diethylaminoethyl cellulose (DE52) column chromatography. Blood stream forms then were collected by centrifugation, resuspended in fresh medium at 7-9 x <em>1</em>0(5)/<em>ml</em>, and transferred to new flasks. Subcultures were maintained by readjusting the BSF density to 7-9 x <em>1</em>0(5)/<em>ml</em> every 24 hr. Concentrations of FBS were reduced gradually at 5-7-day intervals by alternating the amounts of FBS and SP in HMI-9 with 5% FBS and <em>1</em>5% SP, with 2% FBS and <em>1</em>8% SP, and finally with 20% SP (HMI-<em>1</em>8). By this method, 2-3 x <em>1</em>0(6) VSFs/<em>ml</em> were obtained consistently every 24 hr. for more than 80 days.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND

The availability of new antiretroviral drugs and formulations, including drugs in new classes, and recent data on treatment choices for antiretroviral-naive and -experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adult human immunodeficiency virus (HIV) infection.

OBJECTIVE

To summarize new data in the field and to provide current recommendations for the antiretroviral management and laboratory monitoring of HIV infection. This report provides guidelines in key areas of antiretroviral management: when to initiate therapy, choice of initial regimens, patient monitoring, when to change therapy, and how best to approach treatment options, including optimal use of recently approved drugs (maraviroc, raltegravir, and etravirine) in treatment-experienced patients.

METHODS

A <em>1</em>4-member panel with expertise in HIV research and clinical care was appointed. Data published or presented at selected scientific conferences since the last panel report (August 2006) through June 2008 were identified.

METHODS

Data that changed the previous guidelines were reviewed by the panel (according to section). Guidelines were drafted by section writing committees and were then reviewed and edited by the entire panel. Recommendations were made by panel consensus.

CONCLUSIONS

New data and considerations support initiating therapy before CD4 cell count declines to less than 350/microL. In patients with 350 CD4 cells/microL or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment. In addition to the prior recommendation that a high plasma viral load (eg,>><em>1</em>00,000 copies/<em>mL</em>) and rapidly declining CD4 cell count >><em>1</em>00/microL per year) should prompt treatment initiation, active hepatitis B or C virus coinfection, cardiovascular disease risk, and HIV-associated nephropathy increasingly prompt earlier therapy. The initial regimen must be individualized, particularly in the presence of comorbid conditions, but usually will include efavirenz or a ritonavir-boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (tenofovir/emtricitabine or abacavir/lamivudine). Treatment failure should be identified and managed promptly, with the goal of therapy, even in heavily pretreated patients, being an HIV-<em>1</em> RNA level below assay detection limits.