OBJECTIVE

The purpose of this study was to assess trends in endothelial coverage and recovery among leading polymer-based drug-eluting stents (DES).

BACKGROUND

Autopsy studies of human U.S. Food and Drug Administration (FDA)-approved DES implanted coronary arteries suggest that complications of late stent thrombosis are associated with incomplete endothelial coverage of struts.

METHODS

Rabbits received sirolimus-eluting stents (SES), paclitaxel-eluting stents (PES), zotarolimus-eluting stents (ZES), and everolimus-eluting stents (EES) for <em>1</em>4 or 28 days along with MULTI-LINK (<em>ML</em>) Vision control stents. Endothelial coverage above and between struts was measured by morphometric analysis of images acquired through en face scanning electron microscopy. Dual fluorescent immunolabeling was performed for platelet-endothelial cell adhesion molecule (PECAM)-<em>1</em> and thrombomodulin (TM), factors involved in cell-to-cell contact and thrombogenicity, respectively. In a separate analysis, the endothelial mitogen, vascular endothelial growth factor (VEGF), was also assessed.

RESULTS

Varying rates of endothelialization among comparator DES were most notable at <em>1</em>4 days, where coverage above struts remained poor in SES, PES, and ZES (<or=30%) relative to EES and <em>ML</em> Vision controls >>or=70%), whereas no significant differences were observed at 28 days. Select DES with poor endothelialization showed a further reduced expression of PECAM-<em>1</em>. All DES showed an absence or weak expression of the antithrombotic cofactor TM. Incomplete endothelialization in select DES was further associated with increased VEGF secretion and messenger ribonucleic acid levels at <em>1</em>4 days, providing evidence of a transitional healing surface.

CONCLUSIONS

The present study marks the first comparator analysis of endothelial coverage in leading polymeric DES, supporting disparities in arterial healing based on endothelial regrowth and recovery, favoring newer designs over the current generation of FDA-approved stents.

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was <em>1</em>2%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses>> <em>1</em>5 cm.

OBJECTIVE

The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders.

BACKGROUND

Since the first laparoscopic adrenalectomy was performed in <em>1</em>992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations.

METHODS

One hundred consecutive laparoscopic adrenal procedures from January <em>1</em>992 until November <em>1</em>996 were reviewed and followed for adequacy of resection.

RESULTS

Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, <em>1</em>7-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 2<em>1</em>), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = <em>1</em>3), Cushing's disease (n = 8), and others (n = <em>1</em>3). Fifty-five patients had previous abdominal surgery. Mean operative time was <em>1</em>23 minutes (range, 80-360 minutes), and estimated blood loss was 70 <em>mL</em> (range, 20-<em>1</em>300 <em>mL</em>). There was no mortality, and morbidity was encountered in <em>1</em>2% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-<em>1</em>9 days) in the first 3 years to 2.4 days (range, <em>1</em>-6 days) over the past <em>1</em>6 months. During follow-up (range, <em>1</em>-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess.

CONCLUSIONS

Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses>> <em>1</em>5 cm.

Several cytokines, in particular tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma), have been shown to be responsible for pathological reactions which may lead to shock and death observed in infection with Gram-negative bacteria and in response to endotoxins (lipopolysaccharides, LPS). Priming of mice with the avirulent Bacille Calmette Guérin (BCG) vaccine strain of Mycobacterium bovis increases the sensitivity of mice to the lethal effect of LPS and results in an efficient priming for cytokine production. In response to low doses (<em>1</em> microgram/mouse) of LPS, BCG-primed mice produce interleukin-<em>1</em>2 (IL-<em>1</em>2) which controls IFN-gamma production, as demonstrated by the ability of neutralizing anti-IL-<em>1</em>2 antibodies to suppress IFN-gamma production. However, the concentration of the biologically active IL-<em>1</em>2 p70 heterodimer is similar in the serum of both BCG-primed or unprimed mice, reaching levels of <em>1</em>-3 ng/<em>ml</em> at 3-6 h after LPS injection, whereas IFN-gamma production was observed only in BCG-primed mice. The priming effect of BCG on IFN-gamma production appears to be mostly due to its ability to increase TNF-alpha production, which acts as cofactor with LPS-induced IL-<em>1</em>2 in inducing IFN-gamma production, as shown by the ability of injection of TNF-alpha and LPS (<em>1</em> microgram/mouse), but not LPS alone, to induce IFN-gamma production. However, in addition to TNF-alpha, other LPS-induced cofactor(s) are required in cooperation with IL-<em>1</em>2 to induce optimal IFN-gamma production, because co-injection of TNF-alpha and IL-<em>1</em>2, sufficient to induce serum concentrations of both cytokines higher and more persistent than those obtained by injection of LPS, was not sufficient to induce IFN-gamma production in vivo. Neutralizing anti-IL-<em>1</em>2 antibodies, in addition to inhibiting the in vivo LPS-induced IFN-gamma production, also completely protect BCG-primed mice injected with up to <em>1</em>0 micrograms of LPS from shock-induced death. Thus, IL-<em>1</em>2 is required for IFN-gamma production and lethality in an endotoxic shock model in mice.

Recruitment of activated T cells to mucosal surfaces, such as the airway epithelium, is important in host defense and for the development of inflammatory diseases at these sites. We therefore asked whether the CXC chemokines IFN-induced protein of <em>1</em>0 kDa (IP-<em>1</em>0), monokine induced by IFN-gamma (Mig), and IFN-inducible T-cell alpha-chemoattractant (I-TAC), which specifically chemoattract activated T cells by signaling through the chemokine receptor CXCR3, were inducible in respiratory epithelial cells. The effects of proinflammatory cytokines, including IFN-gamma (Th<em>1</em>-type cytokine), Th2-type cytokines (IL-4, IL-<em>1</em>0, and IL-<em>1</em>3), and dexamethasone were studied in normal human bronchial epithelial cells (NHBEC) and in two human respiratory epithelial cell lines, A549 and BEAS-2B. We found that IFN-gamma, but not TNF-alpha or IL-<em>1</em> beta, strongly induced IP-<em>1</em>0, Mig, and I-TAC mRNA accumulation mainly in NHBEC and that TNF-alpha and IL-<em>1</em> beta synergized with IFN-gamma induction in all three cell types. High levels of IP-<em>1</em>0 protein >> 800 ng/<em>ml</em>) were detected in supernatants of IFN-gamma/TNF-alpha-stimulated NHBEC. Neither dexamethasone nor Th2 cytokines modulated IP-<em>1</em>0, Mig, or I-TAC expression. Since IFN-gamma is up-regulated in tuberculosis (TB), using in situ hybridization we studied the expression of IP-<em>1</em>0 in the airways of TB patients and found that IP-<em>1</em>0 mRNA was expressed in the bronchial epithelium. In addition, IP-<em>1</em>0-positive cells obtained by bronchoalveolar lavage were significantly increased in TB patients compared with normal controls. These results show that activated bronchial epithelium is an important source of IP-<em>1</em>0, Mig, and I-TAC, which may, in pulmonary diseases such as TB (in which IFN-gamma is highly expressed) play an important role in the recruitment of activated T cells.

BACKGROUND

Whether hepatitis B (HBV) coinfection affects outcome in HIV-<em>1</em>-infected patients remains unclear.

OBJECTIVE

To assess the prevalence of HBV (assessed as HBsAg) coinfection and its possible impact on progression to AIDS, all-cause deaths, liver-related deaths and response to highly active antiretroviral therapy (HAART) in the EuroSIDA cohort.

METHODS

Data on 9802 patients in 72 European HIV centres were analysed. Incidence rates of AIDS, global mortality and liver-related mortality, time to 25% CD4 cell count increase and time to viral load < 400 copies/ml after starting HAART were calculated and compared between HBsAg-positive and HBsAg-negative patients.

RESULTS

HBsAg was found in 498 (8.7%) patients. The incidence of new AIDS diagnosis was similar in HBsAg-positive and HBsAg-negative patients (3.3 and 3.4/<em>1</em>00 person-years, respectively) even after adjustment for potential confounders: the incidence rate ratio (IRR) was 0.94 [95% confidence interval (CI), 0.74-<em>1</em>.<em>1</em>9; P = 0.6<em>1</em>]. The incidences of all-cause and liver-related mortalities were significantly higher in HBsAg-positive subjects (3.7 and 0.7/<em>1</em>00 person-years, respectively) compared with HBsAg-negative subjects (2.6 and 0.2/<em>1</em>00 person-years, respectively). The adjusted IRR values were <em>1</em>.53 for global (95% CI, <em>1</em>.23-<em>1</em>.90; P = 0.000<em>1</em>) and 3.58 for liver-related (95% CI, 2.09-6.<em>1</em>6; P < 0.000<em>1</em>) mortality. HBsAg status did not influence viral or immunological responses among the <em>1</em>679 patients starting HAART.

CONCLUSIONS

The prevalence of HBV coinfection was 9% in the EuroSIDA cohort. Chronic HBV infection significantly increased liver-related mortality in HIV-<em>1</em>-infected patients but did not impact on progression to AIDS or on viral and immunological responses to HAART.

The echinocandins are being used increasingly as therapy for invasive candidiasis. Prospective sentinel surveillance for the emergence of in vitro resistance to the echinocandins among invasive Candida sp. isolates is indicated. We determined the in vitro activities of anidulafungin, caspofungin, and micafungin against 5,346 invasive (bloodstream or sterile-site) isolates of Candida spp. collected from over 90 medical centers worldwide from <em>1</em> January 200<em>1</em> to 3<em>1</em> December 2006. We performed susceptibility testing according to the CLSI M27-A2 method and used RPMI <em>1</em>640 broth, 24-h incubation, and a prominent inhibition endpoint for determination of the MICs. Of 5,346 invasive Candida sp. isolates, species distribution was 54% C. albicans, <em>1</em>4% C. parapsilosis, <em>1</em>4% C. glabrata, <em>1</em>2% C. tropicalis, 3% C. krusei, <em>1</em>% C. guilliermondii, and 2% other Candida spp. Overall, all three echinocandins were very active against Candida: anidulafungin (MIC50, 0.06 microg/<em>ml</em>; MIC90, 2 microg/<em>ml</em>), caspofungin (MIC50, 0.03 microg/<em>ml</em>; MIC90, 0.25 microg/<em>ml</em>), micafungin (MIC50, 0.0<em>1</em>5 microg/<em>ml</em>; MIC90, <em>1</em> microg/<em>ml</em>). More than 99% of isolates were inhibited by < or = 2 microg/<em>ml</em> of all three agents. Results by species (expressed as the percentages of isolates inhibited by < or = 2 microg/<em>ml</em> of anidulafungin, caspofungin, and micafungin, respectively) were as follows: for C. albicans, 99.6%, <em>1</em>00%, and <em>1</em>00%; for C. parapsilosis, 92.5%, 99.9%, and <em>1</em>00%; for C. glabrata, 99.9%, 99.9%, and <em>1</em>00%; for C. tropicalis, <em>1</em>00%, 99.8%, and <em>1</em>00%; for C. krusei, <em>1</em>00%, <em>1</em>00%, and <em>1</em>00%; and for C. guilliermondii, 90.2%, 95.<em>1</em>%, and <em>1</em>00%. There was no significant change in the activities of the three echinocandins over the 6-year study period and no difference in activity by geographic region. All three echinocandins have excellent in vitro activities against invasive strains of Candida isolated from centers worldwide. Our prospective sentinel surveillance reveals no evidence of emerging echinocandin resistance among invasive clinical isolates of Candida spp.

OBJECTIVE

To establish whether absolute prostate-specific antigen (PSA) value after androgen deprivation (AD) is prognostic in metastatic (D2) prostate cancer (PCa).

METHODS

D2 PCa patients with baseline PSA of at least 5 ng/<em>mL</em> received 7 months induction AD. Patients achieving PSA of 4.0 ng/<em>mL</em> or less on months 6 and 7 are randomly assigned to continuous versus intermittent AD on month 8. Eligibility for this analysis required a prestudy PSA with at least two subsequent PSAs and that patients be registered at least <em>1</em> year before analysis date. Survival was defined as time to death after 7 months of AD. Associations were evaluated by proportional hazards regression models.

RESULTS

One thousand one hundred thirty four of <em>1</em>,345 eligible patients achieved a PSA of 4 ng/<em>mL</em> or less. At end of induction, 965 patients maintained PSA of 4 or less and 604 had a PSA of 0.2 ng/<em>mL</em> or less. After controlling for prognostic factors, patients with a PSA of 4 or less to more than 0.2 ng/<em>mL</em> had less than one third the risk of death (ROD) as those with a PSA of more than 4 ng/<em>mL</em> (P < .00<em>1</em>). Patients with PSA of 0.2 ng/<em>mL</em> or less had less than one fifth the ROD as patients with a PSA of more than 4 ng/<em>mL</em> (P < .00<em>1</em>) and had significantly better survival than those with PSA of more than 0.2 to 4 ng/<em>mL</em> or less (P < .00<em>1</em>). Median survival was <em>1</em>3 months for patients with a PSA of more than 4 ng/<em>mL</em>, 44 months for patients with PSA of more than 0.2 to 4 ng/<em>mL</em> or less, and 75 months for patients with PSA of 0.2 ng/<em>mL</em> or less.

CONCLUSIONS

A PSA of 4 ng/mL or less after 7 months of AD is a strong predictor of survival. This data should be used to tailor future trial design for D2 prostate cancer.

OBJECTIVE

We report data on <em>1</em><em>1</em> patients with neurological symptoms and human immunodeficiency virus (HIV) cerebrospinal fluid (CSF) viremia contrasting with suppressed plasma HIV RNA during receipt of combined antiretroviral therapy.

METHODS

We retrospectively identified instances of central nervous system (CNS) symptoms in patients who had been receiving stable combination antiretroviral therapy. Discordance between plasma and CSF HIV RNA levels was defined by any detectable CSF HIV RNA level >200 copies/<em>mL</em> while plasma levels were <50 copies/<em>mL</em> or by a CSF HIV RNA level that was <em>1</em> log greater than the plasma HIV RNA level.

RESULTS

Eleven patients had experienced acute or subacute neurological symptoms. All but one patient had CSF pleocytosis and/or elevated protein levels. The median CSF HIV RNA level was 880 copies/<em>mL</em> (range, 558-<em>1</em>2,885 copies/<em>mL</em>). Patients had been receiving stable combination antiretroviral therapy for a median of <em>1</em>3 months (range, <em>1</em>0-32 months). Eight of <em>1</em><em>1</em> patients had a plasma HIV RNA level <50 copies/<em>mL</em>, and 3 had plasma HIV RNA blips with their CSF HIV RNA level>><em>1</em> log higher than their plasma HIV RNA level. Resistance-associated mutations were detected in 7 of 8 CSF HIV RNA genotypic strains. The median number of resistance-associated mutations was 6 (range, 2-8) to nucleoside reverse-transcriptase inhibitors and 3 (range, <em>1</em>-9) to protease inhibitors. One patient had a virus harboring nonnucleoside reverse-transcriptase inhibitor mutations. The median central nervous system penetration-effectiveness (CPE) rank was 2 (range, <em>1</em>-3), and 5 patients had a CPE <em>1</em>.5. After antiretroviral therapy optimization based on genotypes and CPE, all patients clinically improved, with normalization of CSF.

CONCLUSIONS

Despite successful suppression of plasma viremia with antiretroviral therapy, HIV may replicate in CSF, with development of CSF HIV resistance resulting in acute or subacute neurological manifestations.

We determined the incidence of exercise-induced arterial hypoxaemia and its determinants in sixteen highly trained, healthy runners who were capable of achieving and sustaining very high metabolic rates (maximal O2 uptake = 72 +/- 2 <em>ml</em> kg-<em>1</em> min-<em>1</em> or 4.8<em>1</em> +/- 0.<em>1</em>3 l min-<em>1</em>). Arterial blood gases and acid-base status were determined at each load of a progressive short-term exercise test and repeatedly during constant-load treadmill running while breathing air and during inhalation of mildly hypoxic, hyperoxic, and helium-enriched gases. Three types of responses to heavy and maximum exercise were evident and highly reproducible within subjects. Four runners maintained arterial PO2 (Pa, O2) within <em>1</em>0 mmHg of resting values, another four showed <em>1</em>0-<em>1</em>5 mmHg reductions in Pa, O2, and the remaining eight showed reductions of 2<em>1</em>-35 mmHg, i.e. in all cases to a Pa, O2 of less than 75 mmHg and to less than 60 mmHg in two cases. During constant-load exercise, Pa, O2 was often maintained during the initial 30 s when hyperventilation was greatest; then hypoxaemia occurred and in most cases was either maintained or worsened over the ensuing 3-4 min. The most severe hypoxaemia during heavy exercise was associated with no or little alveolar hyperventilation (Pa, CO2 greater than 35 mmHg and PA, O2 less than <em>1</em><em>1</em>0 mmHg) and an alveolar to arterial PO2 difference [(A-a)DO2] in excess of 40 mmHg. During 3-4 min of heavy exercise alveolar PO2 (PA, O2) decreased by 20 mmHg in mild hypoxia (0.<em>1</em>7 FI, O2; inspired % O2) and increased by 20 mmHg during mild hyperoxia (0.24 FI, O2) and <em>1</em>0 mmHg during the hyperventilation which accompanied normoxic helium breathing. In all cases Pa, O2 changed in proportion to PA, O2 with no consistent change in the alveolar to arterial PO2 difference [(A-a)DO2]. In view of the correction of hypoxaemia with mild hyperoxia and the very high ratios of alveolar ventilation to pulmonary blood flow (VA/QC = 4-6) achieved during heavy exercise, we think it unlikely that non-uniformity of the VA/QC distribution or veno-arterial shunt could explain the hypoxaemia observed in most of our subjects. By exclusion, we suggest that hypoxaemia may be attributed to a diffusion limitation secondary to very short red cell transit times in at least a portion of the pulmonary circulation.(ABSTRACT TRUNCATED AT 400 WORDS)

BACKGROUND

An open-irrigated radiofrequency (RF) ablation catheter was developed to measure contact force (CF). Three optical fibers measure microdeformation of the catheter tip. The purpose of this study was to (<em>1</em>) validate the accuracy of CF sensor (CFS) (bench test); and (2) determine the relationship between CF and tissue temperatures, lesion size, steam pop, and thrombus during RF ablation using a canine thigh muscle preparation.

RESULTS

CFS measurements (total <em>1</em>409) from 2 catheters in 3 angles (perpendicular, parallel, and 45 degrees ) were compared with a certified balance (range, 0 to 50 g). CFS measurements correlated highly (R(2)>> or =0.988; mean error, < or =<em>1</em>.0 g). In <em>1</em>0 anesthetized dogs, a skin cradle over the thigh muscle was superfused with heparinized blood at 37 degrees C. A 7F catheter with 3.5-mm saline-irrigated electrode and CFS (Endosense) was held perpendicular to the muscle at CF of 2, <em>1</em>0, 20, 30, and 40 g. RF was delivered (n=<em>1</em>00) for 60 seconds at 30 or 50 W (irrigation <em>1</em>7 or 30 mL/min). Tissue temperature (3 and 7 mm depths), lesion size, thrombus, and steam pop increased significantly with increasing CF at each RF power. Lesion size was greater with applications of lower power (30 W) and greater CF (30 to 40 g) than at high power (50 W) with lower CF (2 to <em>1</em>0 g).

CONCLUSIONS

This novel ablation catheter, which accurately measures CF, confirmed CF is a major determinant of RF lesion size. Steam pop and thrombus incidence also increases with CF. CFS in an open-irrigated ablation catheter that may optimize the selection of RF power and application time to maximize lesion formation and reduce the risk of steam pop and thrombus.

OBJECTIVE

The differentiation of THP-<em>1</em> monocytes into macrophages is mainly conducted at a phorbol <em>1</em>2-myristate <em>1</em>3-acetate (PMA) concentration of <em>1</em>0-400 ng/<em>ml</em>. However, this concentration might be high enough to upregulate the expressions of some genes in differentiated macrophages, which could overwhelm gene expression increases induced by other stimuli. The present study was performed to optimize the PMA concentration required to differentiate monocytes whilst minimizing gene upregulation.

METHODS

THP-<em>1</em> cells were treated with 2.5-<em>1</em>00 ng/<em>ml</em> PMA and analyzed for the extent of cell adherence, the surface marker of macrophages, and stable differentiation without undesirable gene upregulation. The stably differentiated THP-<em>1</em> cells at the minimum PMA concentration were treated with <em>1</em>0 ng/<em>ml</em> LPS or <em>1</em>25 nM amyloid beta (Abeta(<em>1</em>-42)).

RESULTS

The treatment of THP-<em>1</em> with 5 ng/<em>ml</em> PMA was found to be sufficient to induce stable differentiation without undesirable gene upregulation. These macrophages differentiated at 5 ng/<em>ml</em> responded well to secondary weak stimuli like <em>1</em>0 ng/<em>ml</em> LPS or <em>1</em>25 nM of amyloid beta (Abeta(<em>1</em>-42)).

CONCLUSIONS

This finding suggests that THP-<em>1</em> cells are well differentiated by 5 ng/<em>ml</em> PMA, and that the resulting differentiated macrophages respond well to secondary weak stimuli without being overwhelmed by undesirable gene upregulation induced by PMA.

BACKGROUND

Sugar-sweetened beverages are risk factors for type 2 diabetes; however, the role of artificially sweetened beverages is unclear.

OBJECTIVE

The objective was to examine the associations of sugar- and artificially sweetened beverages with incident type 2 diabetes.

METHODS

An analysis of healthy men (n = 40,389) from the Health Professionals Follow-Up Study, a prospective cohort study, was performed. Cumulatively averaged intakes of sugar-sweetened (sodas, fruit punches, lemonades, fruit drinks) and artificially sweetened (diet sodas, diet drinks) beverages from food-frequency questionnaires were tested for associations with type 2 diabetes by using Cox regression.

RESULTS

There were 2680 cases over 20 y of follow-up. After age adjustment, the hazard ratio (HR) for the comparison of the top with the bottom quartile of sugar-sweetened beverage intake was <em>1</em>.25 (95% CI: <em>1</em>.<em>1</em><em>1</em>, <em>1</em>.39; P for trend < 0.0<em>1</em>). After adjustment for confounders, including multivitamins, family history, high triglycerides at baseline, high blood pressure, diuretics, pre-enrollment weight change, dieting, total energy, and body mass index, the HR was <em>1</em>.24 (95% CI: <em>1</em>.09, <em>1</em>.40; P for trend < 0.0<em>1</em>). Intake of artificially sweetened beverages was significantly associated with type 2 diabetes in the age-adjusted analysis (HR: <em>1</em>.9<em>1</em>; 95% CI: <em>1</em>.72, 2.<em>1</em><em>1</em>; P for trend < 0.0<em>1</em>) but not in the multivariate-adjusted analysis (HR: <em>1</em>.09; 95% CI: 0.98, <em>1</em>.2<em>1</em>; P for trend = 0.<em>1</em>3). The replacement of one serving of sugar-sweetened beverage with <em>1</em> cup (≈237 <em>mL</em>) of coffee was associated with a risk reduction of <em>1</em>7%.

CONCLUSIONS

Sugar-sweetened beverage consumption is associated with a significantly elevated risk of type 2 diabetes, whereas the association between artificially sweetened beverages and type 2 diabetes was largely explained by health status, pre-enrollment weight change, dieting, and body mass index.

BACKGROUND

The CD4 T cell count recovery in human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>)-infected individuals receiving potent antiretroviral therapy (ART) shows high variability. We studied the determinants and the clinical relevance of incomplete CD4 T cell restoration.

METHODS

Longitudinal CD4 T cell count was analyzed in 293 participants of the Swiss HIV Cohort Study who had had a plasma HIV-<em>1</em> RNA load (<em>1</em>000 copies/mL for>> or =5 years. CD4 T cell recovery was stratified by CD4 T cell count 5 years after initiation of ART >> or =500 cells/microL was defined as a complete response, and <500 cells/microL was defined as an incomplete response). Determinants of incomplete responses and clinical events were evaluated using logistic regression and survival analyses.

RESULTS

The median CD4 T cell count increased from <em>1</em>80 cells/microL at baseline to 576 cells/microL 5 years after ART initiation. A total of 35.8% of patients were incomplete responders, of whom 47.6% reached a CD4 T cell plateau <500 cells/microL. Centers for Disease Control and Prevention HIV-<em>1</em> disease category B and/or C events occurred in 2<em>1</em>% of incomplete responders and in <em>1</em>4.4% of complete responders (P>.05). Older age (adjusted odds ratio [aOR], <em>1</em>.7<em>1</em> per <em>1</em>0-year increase; 95% confidence interval [CI], <em>1</em>.2<em>1</em>-2.43), lower baseline CD4 T cell count (aOR, 0.37 per <em>1</em>00-cell increase; 95% CI, 0.28-0.49), and longer duration of HIV infection (aOR, 2.39 per <em>1</em>0-year increase; 95% CI, <em>1</em>.<em>1</em>9-4.8<em>1</em>) were significantly associated with a CD4 T cell count <500 cells/microL at 5 years. The median increases in CD4 T cell count after 3-6 months of ART were smaller in incomplete responders (P<.00<em>1</em>) and predicted, in conjunction with baseline CD4 T cell count and age, incomplete response with 80% sensitivity and 72% specificity.

CONCLUSIONS

Individuals with incomplete CD4 T cell recovery to <500 cells/microL had more advanced HIV-<em>1</em> infection at baseline. CD4 T cell changes during the first 3-6 months of ART already reflect the capacity of the immune system to replenish depleted CD4 T lymphocytes.

BACKGROUND

Growing evidence has linked HIV-<em>1</em> resistance mutations and drug failure. The use of genotypic-resistance analysis to assist therapeutic decision-making in patients failing therapy has not been investigated. We assessed the virological and immunological impact of genotypic-resistance testing.

METHODS

We did a prospective, open, randomised, controlled study of HIV-<em>1</em>-infected patients in whom combination therapy was not successful. We randomly assigned patients standard care (control, n=43) or treatment according to the resistance mutations in protease and reverse-transcriptase genes (genotypic group, n=65). The major endpoint was the change in HIV-<em>1</em> RNA viral load. Analysis was by intention to treat.

RESULTS

<em>1</em>08 patients were enrolled. All patients were similar for risk factors, age, sex, previous treatment, CD4-cell count (2<em>1</em>4/microL [SD<em>1</em>4]) and log HIV-<em>1</em> RNA viral load at baseline (4.7 copies/mL [0.<em>1</em>]). At month 3, the mean change in HIV-<em>1</em> RNA was -<em>1</em>.04 log (0.<em>1</em>4) in the study group compared with -0.46 log (0.<em>1</em>7) in the control group (mean difference 0.58 log [95% CI 0.<em>1</em>4-<em>1</em>.02], p=0.0<em>1</em>). At month 6, changes were -<em>1</em>.<em>1</em>5 (0.<em>1</em>5) log copies/mL, and -0.67 (0.<em>1</em>9) log copies/mL in the genotypic group and the control group, respectively (mean difference 0.48 log [0.0<em>1</em>-0.97], p=0.05). Difference in the drop in viral load combined at 3 months and 6 months was significant (p=0.0<em>1</em>5). At month 3, HIV-<em>1</em> RNA was lower than detection level (200 copies/mL) in 29% (<em>1</em>9/65) of patients in the genotypic group versus <em>1</em>4% (6/43) in the control group (p=0.0<em>1</em>7). At month 6, the values were 32% (2<em>1</em>/65) and <em>1</em>4% (6/43) (p=0.067) for the genotypic group and the control group, respectively. Therapy was generally well tolerated, with ten patients (six in the genotypic group, four in the control group) requiring toxic-effect-related drug modification.

CONCLUSIONS

We found genotypic-resistance testing to have a significant benefit on the virological response when choosing a therapeutic alternative. Further study of the use of genotypic-resistance testing in assisting clinical decision-making is warranted.

We have monitored fusion between cell pairs consisting of a single human immunodeficiency virus-<em>1</em> (HIV-<em>1</em>) envelope glycoprotein-expressing cell and a CD4+ target cell, which had been labeled with both a fluorescent lipid in the membrane and a fluorescent solute in the cytosol. We developed a new three-color assay to keep track of the cell into which fluorescent lipids and/or solutes are redistributed. Lipid and solute redistribution occur as a result of opening a lipid-permissive fusion pore and a solute-permissive fusion pore (FPS), respectively. A synthetic peptide (DP<em>1</em>78) corresponding to residues 643-678 of the HIV-<em>1</em>LAI gp<em>1</em>20-gp4<em>1</em> sequence (Wild, C.T., D.C. Shugars, T.K. Greenwell, C.B. McDanal, and T.J. Matthews. <em>1</em>994. Proc. Natl. Acad. Sci. USA. 9<em>1</em>:<em>1</em>2676-<em>1</em>2680) completely inhibited FPS at 50 ng/<em>ml</em>, whereas at that concentration there was 20-30% fusion activity measured by the lipid redistribution. The differences detected in lipid mixing versus contents mixing are maintained up to 6 h of coculture of gp<em>1</em>20-4<em>1</em>-expressing cells with target cells, indicating that DP<em>1</em>78 can "clamp" the fusion complex in the lipid mixing intermediate for very long time periods. A peptide from the NH2-terminal of gp4<em>1</em>, DP<em>1</em>07, inhibited HIV-<em>1</em>LAI gp<em>1</em>20-gp4<em>1</em>-mediated cell fusion at higher concentrations, but with no differences between lipid and aqueous dye redistribution at the different inhibitor concentrations. The inhibition of solute redistribution by DP<em>1</em>78 was complete when the peptide was added to the fusion reaction mixture during the first <em>1</em>5 min of coculture. We have analyzed the inhibition data in terms of a fusion pore dilation model that incorporates the recently determined high resolution structure of the gp4<em>1</em> core.

The macrolide antibiotic azithromycin (CP-62,993; 9-deoxo-9a-methyl-9a-aza-9a-homoerythromycin A; also designated XZ-450 [Pliva Pharmaceuticals, Zagreb, Yugoslavia]) showed a significant improvement in potency against gram-negative organisms compared with erythromycin while retaining the classic erythromycin spectrum. It was up to four times more potent than erythromycin against Haemophilus influenzae and Neisseria gonorrhoeae and twofold more potent against Branhamella catarrhalis, Campylobacter species, and Legionella species. It had activity similar to that of erythromycin against Chlamydia spp. Azithromycin was significantly more potent versus many genera of the family Enterobacteriaceae; its MIC for 90% of strains of Escherichia, Salmonella, Shigella, and Yersinia was less than or equal to 4 micrograms/<em>ml</em>, compared with <em>1</em>6 to <em>1</em>28 micrograms/<em>ml</em> for erythromycin. Azithromycin inhibited the majority of gram-positive organisms at less than or equal to <em>1</em> micrograms/<em>ml</em>. It displayed cross-resistance to erythromycin-resistant Staphylococcus and Streptococcus isolates. It had moderate activity against Bacteroides fragilis and was comparable to erythromycin against other anaerobic species. Azithromycin also demonstrated improved bactericidal activity in comparison with erythromycin. The mechanism of action of azithromycin was similar to that of erythromycin since azithromycin competed effectively for [<em>1</em>4C]erythromycin ribosomebinding sites.

We performed a numerical taxonomy analysis of 38 Mycobacterium paratuberculosis and related mycobacterial strains, including wood pigeon mycobacteria; this analysis was based on 22 tests, which were selected for their potential discriminative value from a total of 5<em>1</em> tests studied and produced four well-defined clusters. Cluster <em>1</em> contained the M. paratuberculosis strains, including two strains isolated from Crohn's disease patients; cluster 2 contained Mycobacterium avium and Mycobacterium intracellulare reference strains; cluster 3 consisted of the wood pigeon mycobacteria; and the only strain in cluster 4 was M. paratuberculosis 3<em>1</em>6F, which is used for antigen and vaccine production. Strains in cluster <em>1</em> were mycobactin dependent even when they were subcultured, whereas strains in cluster 3 were unable to grow on egg medium and their growth was stimulated by pH 5.5. Growth stimulation by pyruvate, resistance to D-cycloserine (50 micrograms/<em>ml</em>), and alkaline phosphatase activity also were characteristics that were useful for discriminating between clusters <em>1</em> and 3. The results of previous DNA-DNA hybridization studies have demonstrated that M. avium Chester <em>1</em>90<em>1</em>, M. paratuberculosis Bergey et al. <em>1</em>923, and the wood pigeon mycobacteria belong to a single genomic species, and we propose that the name of this species should be M. avium. On the basis of the results of previous genomic analyses based on restriction fragment length, the results of polymorphism studies, and DNA patterns determined by field inversion gel electrophoresis as well as the results of our phenotypic study, we propose that the species should be divided into subspecies which correspond to pathogenicity and host range characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)

To isolate a stable tumor cell line capable of producing human interleukin 2 (IL-2; formerly referred to as T cell growth factor), <em>1</em>6 human T and B leukemia cell lines were screened for constitutive and mitogen-stimulated IL-2 production. We found that the T cell leukemia line designated Jurkat-FHCRC produced>> 200 U/<em>ml</em> of IL-2 activity after a 24-h stimulation with T cell mitogens. Peak mitogen-induced IL-2 activity was found in supernates harvested from 24-h Jurkat-FHCRC cell cultures stimulated with either <em>1</em>% phytohemagglutinin or 20 microgram/<em>ml</em> concanavalin A. Addition of the fatty acid derivative phorbol myristate acetate to mitogen-stimulated cultures increased Jurkat-FHCRC IL-2 production to concentrations>> 400 U/<em>ml</em>. IL-2 activity observed in such cases represented between <em>1</em>00--300 times that produced in conventional cultures of mitogen- or alloantigen-stimulated normal human peripheral blood or splenic lymphocytes. Jurkat-FHCRC-derived conditioned medium demonstrated equal capacity to promote the sustained in vitro proliferation of either murine or human activated T cell lines confirming the ability of Jurkat-FHCRC cells to produce human IL-2. These studies identify a new source of human IL-2 and establish a valuable reagent for the isolation and further molecular characterization of this immunoregulatory molecule.

OBJECTIVE

Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons.

METHODS

We performed a retrospective chart review, evaluating <em>1</em><em>1</em>8 consecutive laparoscopic partial nephrectomies and <em>1</em>29 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes.

RESULTS

The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (<em>1</em>89 vs <em>1</em>74 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs <em>1</em>%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (<em>1</em>55 vs <em>1</em>96 <em>ml</em>, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.000<em>1</em>). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (<em>1</em>9.7 vs 28.4 minutes, p <0.000<em>1</em>). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (<em>1</em>5.3 vs 25.2 minutes for simple, p <0.000<em>1</em>; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs <em>1</em> complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs <em>1</em>0.2%).

CONCLUSIONS

Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

OBJECTIVE

It has been proposed that skeletal muscle insulin resistance arises from the accumulation of intramyocellular lipid metabolites that impede insulin signaling, including diacylglycerol and ceramide. We determined the role of de novo ceramide synthesis in mediating muscle insulin resistance.

METHODS

Mice were subjected to <em>1</em>2 weeks of diet-induced obesity (DIO), and then treated for 4 weeks with myriocin, an inhibitor of serine palmitoyl transferase-<em>1</em> (SPT<em>1</em>), the rate-limiting enzyme of de novo ceramide synthesis.

RESULTS

After <em>1</em>2 weeks of DIO, C57BL/6 mice demonstrated a doubling in gastrocnemius ceramide content, which was completely reversed (<em>1</em>4<em>1</em>.5 ± <em>1</em>5.8 vs. 94.6 ± <em>1</em>0.2 nmol/g dry wt) via treatment with myriocin, whereas hepatic ceramide content was unaffected by DIO. Interestingly, myriocin treatment did not alter the DIO-associated increase in gastrocnemius diacyglycerol content, and the only correlation observed between lipid metabolite accumulation and glucose intolerance occurred with ceramide (R = 0.6<em>1</em>). DIO mice treated with myriocin showed a complete reversal of glucose intolerance and insulin resistance which was associated with enhanced insulin-stimulated Akt and glycogen synthase kinase 3β phosphorylation. Furthermore, myriocin treatment also decreased intramyocellular ceramide content and prevented insulin resistance development in db/db mice. Finally, myriocin-treated DIO mice displayed enhanced oxygen consumption rates (3,04<em>1</em> ± <em>1</em>24 vs. 2,407 ± <em>1</em>24 ml/kg/h) versus their control counterparts.

CONCLUSIONS

Our results demonstrate that the intramyocellular accumulation of ceramide correlates strongly with the development of insulin resistance, and suggests that inhibition of SPT<em>1</em> is a potentially promising target for the treatment of insulin resistance.

OBJECTIVE

There is no evidence for the participation of the human fetus in the mechanisms responsible for the onset of preterm labor. We propose that preterm labor in the setting of infection results from the actions of proinflammatory cytokines secreted as part of the fetal and/or maternal host response to microbial invasion. The objective of this study was to determine whether a systemic fetal inflammatory response, defined as an elevation of fetal plasma interleukin-6 concentrations, has a temporal relationship with the commencement of labor.

METHODS

After informed consent was obtained, amniocentesis and cordocentesis were performed in 4<em>1</em> patients with preterm premature rupture of membranes who were not in labor on admission. Amniotic fluid was cultured for both aerobic and anaerobic bacteria, as well as for mycoplasmas. Fetal plasma interleukin-6 was assayed by a sensitive and specific immunoassay. Statistical analyses included contingency tables and survival analysis with time-dependent Cox regression hazard modeling.

RESULTS

Microbial invasion of the amniotic cavity was present in 58.5% (24/4<em>1</em>) of patients. Fetuses with fetal plasma interleukin-6 concentrations>> <em>1</em><em>1</em> pg/<em>mL</em> had a higher rate of spontaneous preterm delivery within 48 and 72 hours of the procedure than those with fetal plasma interleukin-6 levels < or = <em>1</em><em>1</em> pg/<em>mL</em> (88% vs 29% and 88% vs 35%, respectively; P < .05 for all comparisons). Moreover, patients with initiation of labor and delivery within 48 hours of the procedure had a higher proportion of fetuses with plasma interleukin-6 values>> <em>1</em><em>1</em> pg/<em>mL</em> than patients delivered>> 48 hours (58% [7/<em>1</em>2] vs 8% [<em>1</em>/<em>1</em>3], respectively; P < .05). Survival analysis indicated that fetuses with elevated fetal plasma interleukin-6 levels had a shorter cordocentesis-to-delivery interval than those without elevated fetal plasma interleukin-6 concentrations (median 0.8 days [range 0.<em>1</em> to 5] vs median 6 days [range 0.2 to 33.6], respectively; P < .05). Time-dependent Cox regression hazard modeling indicated that fetal plasma interleukin-6 level was the only covariate significantly associated with the duration of pregnancy after we adjusted for gestational age, amniotic fluid interleukin-6 level, and the microbiologic state of the amniotic cavity (P < .0<em>1</em>).

CONCLUSIONS

A systemic fetal proinflammatory cytokine response is followed by the onset of spontaneous preterm parturition in patients with preterm premature rupture of membranes.

A procedure has been developed for electroporation-mediated transformation of Listeria monocytogenes with plasmid DNA. The method was optimized for intact cells of L. monocytogenes 23074 by determining the effects of field strength, cell density, and plasmid DNA topology. Transformation efficiencies were dramatically increased when cells were treated with penicillin. Optimum frequencies of transformation (4 x <em>1</em>0(6) transformants/microgram DNA) were obtained when cells were grown in <em>1</em>0 micrograms/<em>ml</em> of penicillin G and electroporated at a field strength of <em>1</em>0 kV/cm. Using this procedure, transformation of relaxed plasmid DNA from ligation reactions provided <em>1</em> x <em>1</em>0(4) transformants/microgram DNA, allowing direct molecular cloning of DNA into this organism.

OBJECTIVE

To estimate drug susceptibility patterns of Streptococcus pneumoniae in selected hospitals in the United States and to characterize the epidemiology of invasive drug-resistant pneumococcal infections.

METHODS

Minimum inhibitory concentrations (MICs) for a variety of commonly used antimicrobial drugs were determined for pneumococcal isolates submitted to the Centers for Disease Control and Prevention (CDC). Risk factors for drug-resistant pneumococcal infection were evaluated.

METHODS

Hospital laboratories in the United States submitting pneumococcal isolates to the CDC between October <em>1</em>, <em>1</em>99<em>1</em>, and September 30, <em>1</em>992.

METHODS

A total of 544 persons with pneumococci isolated from normally sterile sites.

RESULTS

A total of <em>1</em>3 hospitals in <em>1</em>2 states actively participated in an ongoing pneumococcal surveillance study. Resistance to penicillin was detected in 6.6% of isolates, including <em>1</em>.3% of isolates with MICs of 2.0 micrograms/mL or more (compared with < 0.02% of isolates with MIC>> or = 2.0 micrograms/mL identified by CDC surveillance from <em>1</em>979 to <em>1</em>987). A total of <em>1</em>6.4% were resistant to at least one of the following drugs or drug classes: penicillin, cephalosporins, macrolides, combination trimethoprim and sulfamethoxazole, and chloramphenicol. Six serotypes (6B, 23F, <em>1</em>4, 9V, <em>1</em>9A, and <em>1</em>9F) accounted for nearly 85% of strains resistant to at least one drug class. Children were more likely than adults to be infected with strains resistant to trimethoprim-sulfamethoxazole, erythromycin, or chloramphenicol.

CONCLUSIONS

Emergence of drug-resistant pneumococcal infections will present critical challenges to clinicians for treating patients with pneumococcal disease. Widened and intensified surveillance is needed. These data suggest that current recommendations for use of 23-valent pneumococcal capsular polysaccharide vaccines should be aggressively promoted and that development and evaluation of new conjugate pneumococcal vaccines may be a crucial part of strategies for prevention.

A <em>1</em>-d point-prevalence study was performed with the aim of describing the characteristics of conventional mechanical ventilation in intensive care units ICUs from North America, South America, Spain, and Portugal. The study involved 4<em>1</em>2 medical-surgical ICUs and <em>1</em>,638 patients receiving mechanical ventilation at the moment of the study. The main outcome measures were characterization of the indications for initiation of mechanical ventilation, the artificial airways used to deliver mechanical ventilation, the ventilator modes and settings, and the methods of weaning. The median age of the study patients was 6<em>1</em> yr, and the median duration of mechanical ventilation at the time of the study was 7 d. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic obstructive pulmonary disease (<em>1</em>3%), coma (<em>1</em>0%), and neuromuscular disorders (<em>1</em>0%). Mechanical ventilation was delivered via an endotracheal tube in 75% of patients, a tracheostomy in 24%, and a facial mask in <em>1</em>%. Ventilator modes consisted of assist/control ventilation in 47% of patients and 46% were ventilated with synchronized intermittent mandatory ventilation, pressure support, or the combination of both. The median tidal volume setting was 9 <em>ml</em>/kg in patients receiving assist/control and the median setting of pressure support was <em>1</em>8 cm H(2)O. Positive end-expiratory pressure was not employed in 3<em>1</em>% of patients. Method of weaning varied considerably from country to country, and even within a country several methods were in use. We conclude that the primary indications for mechanical ventilation and the ventilator settings were remarkably similar across countries, but the selection of modes of mechanical ventilation and methods of weaning varied considerably from country to country.