Currently, there are no approved specific antiviral agents for novel coronavirus disease 20<em>1</em>9 (COVID-<em>1</em>9). In this study, <em>1</em>0 severe patients confirmed by real-time viral RNA test were enrolled prospectively. One dose of 200 <em>mL</em> of convalescent plasma (CP) derived from recently recovered donors with the neutralizing antibody titers above <em>1</em>:640 was transfused to the patients as an addition to maximal supportive care and antiviral agents. The primary endpoint was the safety of CP transfusion. The second endpoints were the improvement of clinical symptoms and laboratory parameters within 3 d after CP transfusion. The median time from onset of illness to CP transfusion was <em>1</em>6.5 d. After CP transfusion, the level of neutralizing antibody increased rapidly up to <em>1</em>:640 in five cases, while that of the other four cases maintained at a high level (<em>1</em>:640). The clinical symptoms were significantly improved along with increase of oxyhemoglobin saturation within 3 d. Several parameters tended to improve as compared to pretransfusion, including increased lymphocyte counts (0.65 × <em>1</em>0⁹/L vs. 0.76 × <em>1</em>0⁹/L) and decreased C-reactive protein (55.98 mg/L vs. <em>1</em>8.<em>1</em>3 mg/L). Radiological examinations showed varying degrees of absorption of lung lesions within 7 d. The viral load was undetectable after transfusion in seven patients who had previous viremia. No severe adverse effects were observed. This study showed CP therapy was well tolerated and could potentially improve the clinical outcomes through neutralizing viremia in severe COVID-<em>1</em>9 cases. The optimal dose and time point, as well as the clinical benefit of CP therapy, needs further investigation in larger well-controlled trials.

We have examined the prothrombin gene as a candidate gene for venous thrombosis in selected patients with a documented familial history of venous thrombophilia. All the exons and the 5'- and 3'-UT region of the prothrombin gene were analyzed by polymerase chain reaction and direct sequencing in 28 probands. Except for known polymorphic sites, no deviations were found in the coding regions and the 5'-UT region. Only one nucleotide change (a G to A transition) at position 202<em>1</em>0 was identified in the sequence of the 3'-UT region. Eighteen percent of the patients had the 202<em>1</em>0 AG genotype, as compared with <em>1</em>% of a group of healthy controls (<em>1</em>00 subjects). In a population-based case-control study, the 202<em>1</em>0 A allele was identified as a common allele (allele frequency, <em>1</em>.2%; 95% confidence interval, 0.5% to <em>1</em>.8%), which increased the risk of venous thrombosis almost threefold {odds ratio, 2.8; 95% confidence interval, <em>1</em>.4 to 5.6}. The risk of thrombosis increased for all ages and both sexes. An association was found between the presence of the 202<em>1</em>0 A allele and elevated prothrombin levels. Most individuals (87%) with the 202<em>1</em>0 A allele are in the highest quartile of plasma prothrombin levels >> <em>1</em>.<em>1</em>5 U/<em>mL</em>). Elevated prothrombin itself also was found to be a risk factor for venous thrombosis.

BACKGROUND

Oxidized low-density lipoprotein (ox-LDL) causes endothelial dysfunction in part by decreasing the availability of endothelial nitric oxide (NO). Although HMG CoA reductase inhibitors restore endothelial function by reducing serum cholesterol levels, it is not known whether they can also directly upregulate endothelial NO synthase (ecNOS) activity.

RESULTS

Human saphenous vein endothelial cells were treated with ox-LDL (50 microg/<em>mL</em> thiobarbituric acid reactive substances <em>1</em>2 to <em>1</em>6 nmol/mg) in the presence of HMG CoA reductase inhibitors simvastatin and lovastatin. In a time-dependent manner, ox-LDL decreased ecNOS mRNA and protein levels (9<em>1</em>+/-4% and 67+/-8% reduction after 72 hours, respectively). Both simvastatin (<em>1</em> micromol/L) and lovastatin (<em>1</em>0 micromol/L) upregulated ecNOS expression by 3.8-fold and 3.6-fold, respectively, and completely prevented its downregulation by ox-LDL. These effects of simvastatin on ecNOS expression correlated with changes in ecNOS activity. Although L-mevalonate alone did not affect ecNOS expression, cotreatment with L-mevalonate completely reversed ecNOS upregulation by simvastatin. Actinomycin D studies revealed that simvastatin stabilized ecNOS mRNA (tau<em>1</em>/2, 43 versus 35 hours). Nuclear run-on assays and transient transfection studies with a -<em>1</em>.6 kb ecNOS promoter construct showed that simvastatin did not affect ecNOS gene transcription.

CONCLUSIONS

Inhibition of endothelial HMG CoA reductase upregulates ecNOS expression predominantly by posttranscriptional mechanisms. These findings suggest that HMG CoA reductase inhibitors may have beneficial effects in atherosclerosis beyond that attributed to the lowering of serum cholesterol by increasing ecNOS activity.

BACKGROUND

Hydroxyethyl starch (HES) [corrected] is widely used for fluid resuscitation in intensive care units (ICUs), but its safety and efficacy have not been established in patients with severe sepsis.

METHODS

In this multicenter, parallel-group, blinded trial, we randomly assigned patients with severe sepsis to fluid resuscitation in the ICU with either 6% HES 130/0.42 (Tetraspan) or Ringer's acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after randomization.

RESULTS

Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer's acetate (relative risk, 1.17; 95% confidence interval [CI], 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal-replacement therapy versus 65 patients (16%) assigned to Ringer's acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline.

CONCLUSIONS

Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer's acetate. (Funded by the Danish Research Council and others; 6S ClinicalTrials.gov number, NCT00962156.).

We have developed a protein-synthesizing system reconstituted from recombinant tagged protein factors purified to homogeneity. The system was able to produce protein at a rate of about <em>1</em>60 microg/<em>ml</em>/h in a batch mode without the need for any supplementary apparatus. The protein products were easily purified within <em>1</em> h using affinity chromatography to remove the tagged protein factors. Moreover, omission of a release factor allowed efficient incorporation of an unnatural amino acid using suppressor transfer RNA (tRNA).

<strong class="sub-title"> Background: </strong> The long-term health consequences of COVID-<em>1</em>9 remain largely unclear. The aim of this study was to describe the long-term health consequences of patients with COVID-<em>1</em>9 who have been discharged from hospital and investigate the associated risk factors, in particular disease severity.

<strong class="sub-title"> Methods: </strong> We did an ambidirectional cohort study of patients with confirmed COVID-<em>1</em>9 who had been discharged from Jin Yin-tan Hospital (Wuhan, China) between Jan 7, 2020, and May 29, 2020. Patients who died before follow-up, patients for whom follow-up would be difficult because of psychotic disorders, dementia, or re-admission to hospital, those who were unable to move freely due to concomitant osteoarthropathy or immobile before or after discharge due to diseases such as stroke or pulmonary embolism, those who declined to participate, those who could not be contacted, and those living outside of Wuhan or in nursing or welfare homes were all excluded. All patients were interviewed with a series of questionnaires for evaluation of symptoms and health-related quality of life, underwent physical examinations and a 6-min walking test, and received blood tests. A stratified sampling procedure was used to sample patients according to their highest seven-category scale during their hospital stay as 3, 4, and 5-6, to receive pulmonary function test, high resolution CT of the chest, and ultrasonography. Enrolled patients who had participated in the Lopinavir Trial for Suppression of SARS-CoV-2 in China received severe acute respiratory syndrome coronavirus 2 antibody tests. Multivariable adjusted linear or logistic regression models were used to evaluate the association between disease severity and long-term health consequences.

<strong class="sub-title"> Findings: </strong> In total, <em>1</em>733 of 2469 discharged patients with COVID-<em>1</em>9 were enrolled after 736 were excluded. Patients had a median age of 57·0 (IQR 47·0-65·0) years and 897 (52%) were men. The follow-up study was done from June <em>1</em>6, to Sept 3, 2020, and the median follow-up time after symptom onset was <em>1</em>86·0 (<em>1</em>75·0-<em>1</em>99·0) days. Fatigue or muscle weakness (63%, <em>1</em>038 of <em>1</em>655) and sleep difficulties (26%, 437 of <em>1</em>655) were the most common symptoms. Anxiety or depression was reported among 23% (367 of <em>1</em>6<em>1</em>7) of patients. The proportions of median 6-min walking distance less than the lower limit of the normal range were 24% for those at severity scale 3, 22% for severity scale 4, and 29% for severity scale 5-6. The corresponding proportions of patients with diffusion impairment were 22% for severity scale 3, 29% for scale 4, and 56% for scale 5-6, and median CT scores were 3·0 (IQR 2·0-5·0) for severity scale 3, 4·0 (3·0-5·0) for scale 4, and 5·0 (4·0-6·0) for scale 5-6. After multivariable adjustment, patients showed an odds ratio (OR) <em>1</em>·6<em>1</em> (95% CI 0·80-3·25) for scale 4 versus scale 3 and 4·60 (<em>1</em>·85-<em>1</em><em>1</em>·48) for scale 5-6 versus scale 3 for diffusion impairment; OR 0·88 (0·66-<em>1</em>·<em>1</em>7) for scale 4 versus scale 3 and OR <em>1</em>·77 (<em>1</em>·05-2·97) for scale 5-6 versus scale 3 for anxiety or depression, and OR 0·74 (0·58-0·96) for scale 4 versus scale 3 and 2·69 (<em>1</em>·46-4·96) for scale 5-6 versus scale 3 for fatigue or muscle weakness. Of 94 patients with blood antibodies tested at follow-up, the seropositivity (96·2% vs 58·5%) and median titres (<em>1</em>9·0 vs <em>1</em>0·0) of the neutralising antibodies were significantly lower compared with at the acute phase. <em>1</em>07 of 822 participants without acute kidney injury and with estimated glomerular filtration rate (eGFR) 90 <em>mL</em>/min per <em>1</em>·73 m² or more at acute phase had eGFR less than 90 <em>mL</em>/min per <em>1</em>·73 m² at follow-up.

<strong class="sub-title"> Interpretation: </strong> At 6 months after acute infection, COVID-<em>1</em>9 survivors were mainly troubled with fatigue or muscle weakness, sleep difficulties, and anxiety or depression. Patients who were more severely ill during their hospital stay had more severe impaired pulmonary diffusion capacities and abnormal chest imaging manifestations, and are the main target population for intervention of long-term recovery.

Funding: National Natural Science Foundation of China, Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences, National Key Research and Development Program of China, Major Projects of National Science and Technology on New Drug Creation and Development of Pulmonary Tuberculosis, and Peking Union Medical College Foundation.

The implantation of bone morphogenetic protein (BMP) into muscular tissues induces ectopic bone formation at the site of implantation. To investigate the mechanism underlying this process, we examined whether recombinant bone morphogenetic protein-2 (BMP-2) converts the differentiation pathway of the clonal myoblastic cell line, C2C<em>1</em>2, into that of osteoblast lineage. Incubating the cells with 300 ng/<em>ml</em> of BMP-2 for 6 d almost completely inhibited the formation of the multinucleated myotubes expressing troponin T and myosin heavy chain, and induced the appearance of numerous alkaline phosphatase (ALP)-positive cells. BMP-2 dose dependently induced ALP activity, parathyroid hormone (PTH)-dependent 3',5'-cAMP production, and osteocalcin production at concentrations above <em>1</em>00 ng/<em>ml</em>. The concentration of BMP-2 required to induce these osteoblastic phenotypes was the same as that required to almost completely inhibit myotube formation. Incubating primary muscle cells with 300 ng/<em>ml</em> of BMP-2 for 6 d also inhibited myotube formation, whereas induced ALP activity and osteocalcin production. Incubation with 300 ng/<em>ml</em> of BMP-2 suppressed the expression of mRNA for muscle creatine kinase within 6 h, whereas it induced mRNA expression for ALP, PTH/PTH-related protein (PTHrP) receptors, and osteocalcin within 24-48 h. BMP-2 completely inhibited the expression of myogenin mRNA by day 3. By day 3, BMP-2 also inhibited the expression of MyoD mRNA, but it was transiently stimulated <em>1</em>2 h after exposure to BMP-2. Expression of Id-<em>1</em> mRNA was greatly stimulated by BMP-2. When C2C<em>1</em>2 cells pretreated with BMP-2 for 6 d were transferred to a colony assay system in the absence of BMP-2, more than 84% of the colonies generated became troponin T-positive and ALP activity disappeared. TGF-beta <em>1</em> also inhibited myotube formation in C2C<em>1</em>2 cells, and suppressed the expression of myogenin and MyoD mRNAs without inducing that of Id-<em>1</em> mRNA. However, no osteoblastic phenotype was induced by TGF-beta <em>1</em> in C2C<em>1</em>2 cells. TGF-beta <em>1</em> potentiated the inhibitory effect of BMP-2 on myotube formation, whereas TGF-beta <em>1</em> reduced ALP activity and osteocalcin production induced by BMP-2 in C2C<em>1</em>2 cells. These results indicate that BMP-2 specifically converts the differentiation pathway of C2C<em>1</em>2 myoblasts into that of osteoblast lineage cells, but that the conversion is not heritable.

BACKGROUND

Kidney disease is associated with an increased risk for the development of cardiovascular disease and end-stage renal disease; however, risk factors for kidney disease have not been well studied.

OBJECTIVE

To identify predictors of the development of new-onset kidney disease.

METHODS

A community-based, longitudinal cohort study of 2585 participants who attended both a baseline examination in 1978-1982 and a follow-up examination in 1998-2001, and who were free of kidney disease at baseline.

METHODS

Kidney disease was assessed by the Modification of Diet in Renal Disease Study equation and defined by a glomerular filtration rate (GFR) in the fifth or lower percentile (< or =59.25 mL/min per 1.73 m2 in women, < or =64.25 mL/min per 1.73 m2 in men). Stepwise logistic regression was used to determine the impact of risk factors on the occurrence of new-onset kidney disease. Baseline and long-term, 12-year, averaged risk factor models were explored.

RESULTS

At baseline, there were 1223 men and 1362 women, with a mean age of 43 years, who were free of preexisting kidney disease. After a mean follow-up of 18.5 years, 244 participants (9.4%) had developed kidney disease. In multivariable models, baseline age (odds ratio [OR], 2.36 per 10-year increment; 95% confidence interval [CI], 2.00-2.78), GFR (<90 mL/min per 1.73 m2: OR, 3.01; 95% CI, 1.98-4.58; 90-119 mL/min per 1.73 m2: OR, 1.84; 95% CI, 1.16-2.93), body mass index (OR, 1.23 per 1 SD; 95% CI, 1.08-1.41), diabetes (OR, 2.60; 95% CI, 1.44-4.70), and smoking (OR, 1.42; 95% CI, 1.06-1.91) were related to the development of kidney disease. In addition to baseline age and GFR, the long-term, averaged risk factors that were predictive of kidney disease included hypertension (OR, 1.57; 95% CI, 1.17-2.12), high-density lipoprotein cholesterol level (OR, 0.80 per 1 SD; 95% CI, 0.69-0.92), and diabetes (OR, 2.38; 95% CI, 1.45-3.92). Compared with a normal GFR >> or =120 mL/min per 1.73 m2), a mildly reduced GFR (<90 mL/min per 1.73 m2) predicted a 3-fold odds of progression to kidney disease (OR, 2.95; 95% CI, 1.94-4.49).

CONCLUSIONS

Established cardiovascular disease risk factors are associated with the development of new-onset kidney disease. Patients with a mildly reduced GFR should be monitored for progression to kidney disease.

<em>1</em>. Skinfold thickness, body circumferences and body density were measured in samples of 308 and ninety-five adult men ranging in age from <em>1</em>8 to 6<em>1</em> years. 2. Using the sample of 308 men, multiple regression equations were calculated to estimate body density using either the quadratic or log form of the sum of skinfolds, in combination with age, waist and forearm circumference. 3. The multiple correlations for the equations exceeded 0.90 with standard errors of approximately +/- 0.0073 g/<em>ml</em>. 4. The regression equations were cross validated on the second sample of ninety-five men. The correlations between predicted and laboratory-determined body density exceeded 0.90 with standard errors of approximately 0.0077 g/<em>ml</em>. 5. The regression equations were shown to be valid for adult men varying in age and fatness.

Human bone marrow-derived mesenchymal stem cells (MSCs) have the potential to differentiate into mesenchymal tissues like osteocytes, chondrocytes, and adipocytes in vivo and in vitro. The aim of this study was to investigate the in vitro differentiation of MSCs into cells of the endothelial lineage. MSCs were generated out of mononuclear bone marrow cells from healthy donors separated by density gradient centrifugation. Cells were characterized by flow cytometry using a panel of monoclonal antibodies and were tested for their potential to differentiate along different mesenchymal lineages. Isolated MSCs were positive for the markers CD<em>1</em>05, CD73, CD<em>1</em>66, CD90, and CD44 and negative for typical hematopoietic and endothelial markers. They were able to differentiate into adipocytes and osteocytes after cultivation in respective media. Differentiation into endothelial-like cells was induced by cultivation of confluent cells in the presence of 2% fetal calf serum and 50 ng/<em>ml</em> vascular endothelial growth factor. Laser scanning cytometry analysis of the confluent cells in situ showed a strong increase of expression of endothelial-specific markers like KDR and FLT-<em>1</em>, and immunofluorescence analysis showed typical expression of the von Willebrand factor. The functional behavior of the differentiated cells was tested with an in vitro angiogenesis test kit where cells formed characteristic capillary-like structures. We could show the differentiation of expanded adult human MSCs into cells with phenotypic and functional features of endothelial cells. These predifferentiated cells provide new options for engineering of artificial tissues based on autologous MSCs and vascularized engineered tissues.

OBJECTIVE

Whether people infected with human immunodeficiency virus (HIV) are at an increased risk of acute myocardial infarction (AMI) compared with uninfected people is not clear. Without demographically and behaviorally similar uninfected comparators and without uniformly measured clinical data on risk factors and fatal and nonfatal AMI events, any potential association between HIV status and AMI may be confounded.

OBJECTIVE

To investigate whether HIV is associated with an increased risk of AMI after adjustment for all standard Framingham risk factors among a large cohort of HIV-positive and demographically and behaviorally similar (ie, similar prevalence of smoking, alcohol, and cocaine use) uninfected veterans in care.

METHODS

Participants in the Veterans Aging Cohort Study Virtual Cohort from April <em>1</em>, 2003, through December 3<em>1</em>, 2009.

METHODS

After eliminating those with baseline cardiovascular disease, we analyzed data on HIV status, age, sex, race/ethnicity, hypertension, diabetes mellitus, dyslipidemia, smoking, hepatitis C infection, body mass index, renal disease, anemia, substance use, CD4 cell count, HIV-<em>1</em> RNA, antiretroviral therapy, and incidence of AMI.

METHODS

Acute myocardial infarction.

RESULTS

We analyzed data on 82 459 participants. During a median follow-up of 5.9 years, there were 87<em>1</em> AMI events. Across 3 decades of age, the mean (95% CI) AMI events per <em>1</em>000 person-years was consistently and significantly higher for HIV-positive compared with uninfected veterans: for those aged 40 to 49 years, 2.0 (<em>1</em>.6-2.4) vs <em>1</em>.5 (<em>1</em>.3-<em>1</em>.7); for those aged 50 to 59 years, 3.9 (3.3-4.5) vs 2.2 (<em>1</em>.9-2.5); and for those aged 60 to 69 years, 5.0 (3.8-6.7) vs 3.3 (2.6-4.2) (P < .05 for all). After adjusting for Framingham risk factors, comorbidities, and substance use, HIV-positive veterans had an increased risk of incident AMI compared with uninfected veterans (hazard ratio, <em>1</em>.48; 95% CI, <em>1</em>.27-<em>1</em>.72). An excess risk remained among those achieving an HIV-<em>1</em> RNA level less than 500 copies/mL compared with uninfected veterans in time-updated analyses (hazard ratio, <em>1</em>.39; 95% CI, <em>1</em>.<em>1</em>7-<em>1</em>.66).

CONCLUSIONS

Infection with HIV is associated with a 50% increased risk of AMI beyond that explained by recognized risk factors.

We have evaluated the feasibility of using a mathematical model of glucose disappearance to estimate insulin sensitivity. Glucose was injected into conscious dogs at <em>1</em>00, 200, or 300 mg/kg. The measured time course of insulin was regarded as the "input," and the falling glucose concentration as the "output" of the physiological system storing and using glucose. Seven mathematical models of glucose uptake were compared to identify the representation most capable of simulating glucose disappearance. One specific nonlinear model was superior in that it <em>1</em>) predicted the time course of glucose after glucose injection, 2) had four parameters that could be precisely estimated, and 3) described individual experiments with similar parameter values. Insulin sensitivity index (SI), defined as the dependence of fractional glucose disappearance on plasma insulin, was the ratio of two parameters of the chosen model and could be estimated with good reproducibility from the 300 mg/kg injection experiments (SI = 7.00 X <em>1</em>0(-4) +/- 24% (coefficient of variation) min-<em>1</em>/(microU/<em>ml</em>) (n = 8)). Thus, from a single glucose injection it is possible to obtain a quantitative index of insulin sensitivity that may have clinical applicability.

OBJECTIVE

To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of <em>1</em> to 3<em>1</em> months.

BACKGROUND

The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time.

METHODS

Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July <em>1</em>997 and March 2000. A <em>1</em>5-mL gastric pouch and a 75-cm Roux limb (<em>1</em>50 cm for superobese) was created using five or six trocar incisions.

RESULTS

The conversion rate to open gastric bypass was <em>1</em>%. The start of an oral diet began a mean of <em>1</em>.58 days after surgery, with a median hospital stay of 2 days and return to work at 2<em>1</em> days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than <em>1</em> year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

BACKGROUND

Some patients with severe asthma have recurrent asthma exacerbations associated with eosinophilic airway inflammation. Early studies suggest that inhibition of eosinophilic airway inflammation with mepolizumab-a monoclonal antibody against interleukin 5-is associated with a reduced risk of exacerbations. We aimed to establish efficacy, safety, and patient characteristics associated with the response to mepolizumab.

METHODS

We undertook a multicentre, double-blind, placebo-controlled trial at 8<em>1</em> centres in <em>1</em>3 countries between Nov 9, 2009, and Dec 5, 20<em>1</em><em>1</em>. Eligible patients were aged <em>1</em>2-74 years, had a history of recurrent severe asthma exacerbations, and had signs of eosinophilic inflammation. They were randomly assigned (in a <em>1</em>:<em>1</em>:<em>1</em>:<em>1</em> ratio) to receive one of three doses of intravenous mepolizumab (75 mg, 250 mg, or 750 mg) or matched placebo (<em>1</em>00 <em>mL</em> 0·9% NaCl) with a central telephone-based system and computer-generated randomly permuted block schedule stratified by whether treatment with oral corticosteroids was required. Patients received <em>1</em>3 infusions at 4-week intervals. The primary outcome was the rate of clinically significant asthma exacerbations, which were defined as validated episodes of acute asthma requiring treatment with oral corticosteroids, admission, or a visit to an emergency department. Patients, clinicians, and data analysts were masked to treatment assignment. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT0<em>1</em>000506.

RESULTS

62<em>1</em> patients were randomised: <em>1</em>59 were assigned to placebo, <em>1</em>54 to 75 mg mepolizumab, <em>1</em>52 to 250 mg mepolizumab, and <em>1</em>56 to 750 mg mepolizumab. 776 exacerbations were deemed to be clinically significant. The rate of clinically significant exacerbations was 2·40 per patient per year in the placebo group, <em>1</em>·24 in the 75 mg mepolizumab group (48% reduction, 95% CI 3<em>1</em>-6<em>1</em>%; p<0·000<em>1</em>), <em>1</em>·46 in the 250 mg mepolizumab group (39% reduction, <em>1</em>9-54%; p=0·0005), and <em>1</em>·<em>1</em>5 in the 750 mg mepolizumab group (52% reduction, 36-64%; p<0·000<em>1</em>). Three patients died during the study, but the deaths were not deemed to be related to treatment.

CONCLUSIONS

Mepolizumab is an effective and well tolerated treatment that reduces the risk of asthma exacerbations in patients with severe eosinophilic asthma.

BACKGROUND

GlaxoSmithKline.

OBJECTIVE

Immune dysfunction reported in renal cell carcinoma (RCC) patients may contribute to tumor progression. Myeloid-derived suppressor cells (MDSC) represent one mechanism by which tumors induce T-cell suppression. Several factors pivotal to the accumulation of MDSC are targeted by the tyrosine kinase inhibitor, sunitinib. The effect of sunitinib on MDSC-mediated immunosuppression in RCC patients has been investigated.

METHODS

Patient peripheral blood levels of MDSC and regulatory T-cell (Treg) and T-cell production of IFN-gamma were evaluated before and after sunitinib treatment. Correlations between MDSC and Treg normalization as well as T-cell production of IFN-gamma were examined. The in vitro effect of sunitinib on patient MDSC was evaluated.

RESULTS

Metastatic RCC patients had elevated levels of CD33(+)HLA-DR(-) and CD<em>1</em>5(+)CD<em>1</em>4(-) MDSC, and these were partially overlapping populations. Treatment with sunitinib resulted in significant reduction in MDSC measured by several criteria. Sunitinib-mediated reduction in MDSC was correlated with reversal of type <em>1</em> T-cell suppression, an effect that could be reproduced by the depletion of MDSC in vitro. MDSC reduction in response to sunitinib correlated with a reversal of CD3(+)CD4(+)CD25(hi)Foxp3(+) Treg cell elevation. No correlation existed between a change in tumor burden and a change in MDSC, Treg, or T-cell production of IFN-gamma. In vitro addition of sunitinib reduced MDSC viability and suppressive effect when used at>>/=<em>1</em>.0 microg/<em>mL</em>. Sunitinib did not induce MDSC maturation in vitro.

CONCLUSIONS

Sunitinib-based therapy has the potential to modulate antitumor immunity by reversing MDSC-mediated tumor-induced immunosuppression.

BACKGROUND

Stromal cell-derived factor-<em>1</em> (SDF-<em>1</em>) is a chemokine considered to play an important role in the trafficking of hematopoietic stem cells. Given the close relationship between hematopoietic stem cells and endothelial progenitor cells (EPCs), we investigated the effect of SDF-<em>1</em> on EPC-mediated vasculogenesis.

RESULTS

Flow cytometric analysis demonstrated expression of CXCR4, the receptor of SDF-<em>1</em>, by 66+/-3% of EPCs after 7 days in culture. In vitro modified Boyden chamber assay showed a dose-dependent EPC migration toward SDF-<em>1</em> (control versus <em>1</em>0 ng/mL SDF-<em>1</em> versus <em>1</em>00 ng/mL SDF-<em>1</em>, 24+/-2 versus 7<em>1</em>+/-3 versus <em>1</em>40+/-6 cells/mm2; P<0.000<em>1</em>). SDF-<em>1</em> attenuated EPC apoptosis (control versus SDF-<em>1</em>, 27+/-<em>1</em> versus 7+/-<em>1</em>%; P<0.000<em>1</em>). To investigate the effect of SDF-<em>1</em> in vivo, we locally injected SDF-<em>1</em> into athymic ischemic hindlimb muscle of nude mice combined with human EPC transplantation to determine whether SDF-<em>1</em> augmented EPC-induced vasculogenesis. Fluorescence microscopic examination disclosed increased local accumulation of fluorescence-labeled EPCs in ischemic muscle in the SDF-<em>1</em> treatment group (control versus SDF-<em>1</em>=24<em>1</em>+/-25 versus 445+/-24 cells/mm2, P<0.000<em>1</em>). At day 28 after treatment, ischemic tissue perfusion was improved in the SDF-<em>1</em> group and capillary density was also increased. (control versus SDF-<em>1</em>, 355+/-26 versus 55<em>1</em>+/-30 cells/mm2; P<0.000<em>1</em>).

CONCLUSIONS

These findings indicate that locally delivered SDF-<em>1</em> augments vasculogenesis and subsequently contributes to ischemic neovascularization in vivo by augmenting EPC recruitment in ischemic tissues.

Vitamin D, the sunshine vitamin, is now recognized not only for its importance in promoting bone health in children and adults but also for other health benefits, including reducing the risk of chronic diseases such as autoimmune diseases, common cancer, and cardiovascular disease. Vitamin D made in the skin or ingested in the diet is biologically inert and requires 2 successive hydroxylations first in the liver on carbon 25 to form 25-hydroxyvitamin D [25(OH)D], and then in the kidney for a hydroxylation on carbon <em>1</em> to form the biologically active form of vitamin D, <em>1</em>,25-dihydroxyvitamin D [<em>1</em>,25(OH)(2)D]. With the identification of 25(OH)D and <em>1</em>,25(OH)(2)D, methods were developed to measure these metabolites in the circulation. Serum 25(OH)D is the barometer for vitamin D status. Serum <em>1</em>,25(OH)(2)D provides no information about vitamin D status and is often normal or even increased as the result of secondary hyperparathyroidism associated with vitamin D deficiency. Most experts agree that 25(OH)D of <20 ng/<em>mL</em> is considered to be vitamin D deficiency, whereas a 25(OH)D of 2<em>1</em>-29 ng/<em>mL</em> is considered to be insufficient. The goal should be to maintain both children and adults at a level >30 ng/<em>mL</em> to take full advantage of all the health benefits that vitamin D provides.

BACKGROUND

The course of autosomal dominant polycystic kidney disease (ADPKD) is often associated with pain, hypertension, and kidney failure. Preclinical studies indicated that vasopressin V(2)-receptor antagonists inhibit cyst growth and slow the decline of kidney function.

METHODS

In this phase 3, multicenter, double-blind, placebo-controlled, 3-year trial, we rando<em>ml</em>y assigned <em>1</em>445 patients, <em>1</em>8 to 50 years of age, who had ADPKD with a total kidney volume of 750 <em>ml</em> or more and an estimated creatinine clearance of 60 <em>ml</em> per minute or more, in a 2:<em>1</em> ratio to receive tolvaptan, a V(2)-receptor antagonist, at the highest of three twice-daily dose regimens that the patient found tolerable, or placebo. The primary outcome was the annual rate of change in the total kidney volume. Sequential secondary end points included a composite of time to clinical progression (defined as worsening kidney function, kidney pain, hypertension, and albuminuria) and rate of kidney-function decline.

RESULTS

Over a 3-year period, the increase in total kidney volume in the tolvaptan group was 2.8% per year (95% confidence interval [CI], 2.5 to 3.<em>1</em>), versus 5.5% per year in the placebo group (95% CI, 5.<em>1</em> to 6.0; P<0.00<em>1</em>). The composite end point favored tolvaptan over placebo (44 vs. 50 events per <em>1</em>00 follow-up-years, P=0.0<em>1</em>), with lower rates of worsening kidney function (2 vs. 5 events per <em>1</em>00 person-years of follow-up, P<0.00<em>1</em>) and kidney pain (5 vs. 7 events per <em>1</em>00 person-years of follow-up, P=0.007). Tolvaptan was associated with a slower decline in kidney function (reciprocal of the serum creatinine level, -2.6<em>1</em> [mg per milliliter](-<em>1</em>) per year vs. -3.8<em>1</em> [mg per milliliter](-<em>1</em>) per year; P<0.00<em>1</em>). There were fewer ADPKD-related adverse events in the tolvaptan group but more events related to aquaresis (excretion of electrolyte-free water) and hepatic adverse events unrelated to ADPKD, contributing to a higher discontinuation rate (23%, vs. <em>1</em>4% in the placebo group).

CONCLUSIONS

Tolvaptan, as compared with placebo, slowed the increase in total kidney volume and the decline in kidney function over a 3-year period in patients with ADPKD but was associated with a higher discontinuation rate, owing to adverse events. (Funded by Otsuka Pharmaceuticals and Otsuka Pharmaceutical Development and Commercialization; TEMPO 3:4 ClinicalTrials.gov number, NCT00428948.).

A method has been developed that allows flow cytometry to be used for measuring the cellular DNA content of paraffin-embedded human tumors. Thick (i.e., 30 micron) sections were cut from tissue blocks using a microtome and dewaxed in xylene. The sections were then rehydrated by sequentially immersing them in <em>1</em>00, 95, 70, and 50% ethanol before finally washing in distilled water. Single cell suspensions were then prepared by incubation in 0.5% pepsin, pH <em>1</em>.5, at 37 degrees C for 30 min. The cells were counted, washed, and stained with <em>1</em> microgram/<em>ml</em> 4',6'-diamidino-2-phenylindole for 30 min, and DNA content was measured using an ICP 22 flow cytometer. There was a good correlation between the DNA histograms produced using this method and those obtained using unfixed tissue from the same tumor stained with ethidium bromide plus mithramycin. This method allows the retrospective study of archival material where the clinical outcome is already known, and it should, therefore, be particularly useful for determining the prognostic significance of abnormal DNA content measured by flow cytometry.

OBJECTIVE

To evaluate the influence of surgical margin status on survival and site of recurrence in patients treated with hepatic resection for colorectal metastases.

METHODS

Using a multicenter database, 557 patients who underwent hepatic resection for colorectal metastases were identified. Demographics, operative data, pathologic margin status, site of recurrence (margin, other intrahepatic site, extrahepatic), and long-term survival data were collected and analyzed.

RESULTS

On final pathologic analysis, margin status was positive in 45 patients, and negative by <em>1</em> to 4 mm in <em>1</em>29, 5 to 9 mm in 85, and>> or =<em>1</em> cm in 298. At a median follow-up of 29 months, the <em>1</em>-, 3-, and 5-year actuarial survival rates were 97%, 74%, and 58%; median survival was 74 months. Tumor size>> or =5 cm, >3 tumor nodules, and carcinoembryonic antigen level >200 ng/<em>mL</em> predicted poor survival (all P < 0.05). Median survival was 49 months in patients with positive margins and not yet reached in patients with negative margins (P = 0.0<em>1</em>). After hepatic resection, 225 (40.4%) patients had recurrence: 2<em>1</em> at the surgical margin, 56 at another intrahepatic site, 82 at an extrahepatic site, and 66 at both intrahepatic and extrahepatic sites. Patients with negative margins of <em>1</em> to 4 mm, 5 to 9 mm, and>> or =<em>1</em> cm had similar overall recurrence rates (P>> 0.05). Patients with positive margins were more likely to have surgical margin recurrence (P = 0.003). Adverse preoperative biologic factors including tumor number greater than 3 (P = 0.0<em>1</em>) and a preoperative CEA level greater than 200 ng/<em>mL</em> (P = 0.04) were associated with an increased risk of positive surgical margin.

CONCLUSIONS

A positive margin after resection of hepatic colorectal metastases is associated with adverse biologic factors and increased risk of surgical-margin recurrence. The width of a negative surgical margin does not affect survival, recurrence risk, or site of recurrence. A predicted margin of (<em>1</em> cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection.

BACKGROUND

The metabolic syndrome is a common risk factor for cardiovascular disease.

OBJECTIVE

To examine the association between the metabolic syndrome and risk for chronic kidney disease and microalbuminuria.

METHODS

Cross-sectional study.

METHODS

The Third National Health and Nutrition Examination Survey.

METHODS

Participants 20 years of age or older were studied in the chronic kidney disease (n = 6217) and microalbuminuria (n = 6125) analyses.

METHODS

The metabolic syndrome was defined as the presence of 3 or more of the following risk factors: elevated blood pressure, low high-density lipoprotein cholesterol level, high triglyceride level, elevated glucose level, and abdominal obesity. Chronic kidney disease was defined as a glomerular filtration rate less than 60 mL/min per 1.73 m2, and microalbuminuria was defined as a urinary albumin-creatinine ratio of 30 to 300 mg/g.

RESULTS

The multivariate-adjusted odds ratios of chronic kidney disease and microalbuminuria in participants with the metabolic syndrome compared with participants without the metabolic syndrome were 2.60 (95% CI, 1.68 to 4.03) and 1.89 (CI, 1.34 to 2.67), respectively. Compared with participants with 0 or 1 component of the metabolic syndrome, participants with 2, 3, 4, and 5 components of chronic kidney disease had multivariate-adjusted odds ratios of 2.21 (CI, 1.16 to 4.24), 3.38 (CI, 1.48 to 7.69), 4.23 (CI, 2.06 to 8.63), and 5.85 (CI, 3.11 to 11.0), respectively. The corresponding multivariate-adjusted odds ratios of microalbuminuria for participants with 3, 4, and 5 components were 1.62 (CI, 1.10 to 2.38), 2.45 (CI, 1.55 to 3.85), and 3.19 (CI, 1.96 to 5.19), respectively.

CONCLUSIONS

These findings suggest that the metabolic syndrome might be an important factor in the cause of chronic kidney disease.

We propose a model of drug pharmacodynamic response that when integrated with a pharmacokinetic model allows characterization of the temporal aspects of pharmacodynamics as well as the time-independent sensitivity component. The total model can accommodate extremes of effect. It allows fitting of simultaneous plasma concentration (Cp) and effect data from the initial distribution phase of drug administration, or from any non-equilibrium phase. The model postulates a hypothetical effect compartment, the dynamics of which are adjusted to reflect the temporal dynamics of drug effect. The effect compartment is modeled as an additional compartment linked to the plasma compartment by a first-order process, but whose exponential does not enter into the pharmacokinetic solution for the mass of drug in the body. The hypothetical amount of drug in the effect compartment is then related to the observed effect by the Hill equation, a nonlinear sigmoid form. Nonlinear least-squares data fitting is used for parameter estimation. The model is demonstrated on two different sets of Cp and effect data for the drug d-tubocurarine (dTC). In 7 normal subjects, the (mean +/- SD) rate constant for equilibration of dTC effect (paralysis) and Cp is 0.<em>1</em>3 +/- 0.04 min-<em>1</em> and the (mean +/- SD) steady-state Cp required to produce 50% paralysis is 0.37 +/- 0.05 microgram/<em>ml</em>.

BACKGROUND

The association of obesity with development of type 2 diabetes may be partly mediated by altered secretion of adipokines by adipose tissue. Greater adiposity down-regulates secretion of adiponectin, an adipokine with anti-inflammatory and insulin-sensitizing properties. The strength and consistency of the relation between plasma adiponectin and risk of type 2 diabetes is unclear.

OBJECTIVE

To systematically review prospective studies of the association of plasma adiponectin levels and risk of type 2 diabetes.

METHODS

A systematic search of the MEDLINE, EMBASE, and Science Citation Index Expanded databases using adiponectin and diabetes and various synonyms and reference lists of retrieved articles up to April <em>1</em>0, 2009.

METHODS

We included prospective studies with plasma adiponectin levels as the exposure and incidence of type 2 diabetes as the outcome variable.

METHODS

Two reviewers independently extracted data and assessed study quality. Generalized least-squares trend estimation was used to assess dose-response relationships. Pooled relative risks and 95% confidence intervals were calculated using random-effects models to incorporate between-study variation.

RESULTS

Thirteen prospective studies with a total of <em>1</em>4 598 participants and 2623 incident cases of type 2 diabetes were included in the meta-analysis. Higher adiponectin levels were monotonically associated with a lower risk of type 2 diabetes. The relative risk of type 2 diabetes was 0.72 (95% confidence interval, 0.67-0.78) per <em>1</em>-log microg/<em>mL</em> increment in adiponectin levels. This inverse association was consistently observed in whites, East Asians, Asian Indians, African Americans, and Native Americans and did not differ by adiponectin assay, method of diabetes ascertainment, duration of follow-up, or proportion of women. The estimated absolute risk difference (cases per <em>1</em>000 person-years) per <em>1</em>-log microg/<em>mL</em> increment in adiponectin levels was 3.9 for elderly Americans and 30.8 for Americans with impaired glucose tolerance.

CONCLUSIONS

Higher adiponectin levels are associated with a lower risk of type 2 diabetes across diverse populations, consistent with a dose-response relationship.

BACKGROUND

The acute-phase reactant C-reactive protein (CRP) is an important risk factor for coronary heart disease. However, the possible effects of CRP on vascular cells are not known.

RESULTS

We tested the effects of CRP on expression of adhesion molecules in both human umbilical vein and coronary artery endothelial cells. Expression of vascular cell adhesion molecule (VCAM-<em>1</em>), intercellular adhesion molecule (ICAM-<em>1</em>), and E-selectin was assessed by flow cytometry. Incubation with recombinant human CRP (<em>1</em>0 microg/<em>mL</em>) for 24 hours induced an approximately <em>1</em>0-fold increase in expression of ICAM-<em>1</em> and a significant expression of VCAM-<em>1</em>, whereas a 6-hour incubation induced significant E-selectin expression. Adhesion molecule induction was similar to that observed in endothelial cells activated with interleukin-<em>1</em>beta. In coronary artery endothelial cells, induction of ICAM-<em>1</em> and VCAM-<em>1</em> was already present at 5 microg/<em>mL</em> and reached a maximum at 50 microg/<em>mL</em>, at which point a substantial increase in expression of E-selectin was also evident. The CRP effect was dependent on presence of human serum in the culture medium, because no effect was seen in cells cultured with serum-free medium. In contrast, interleukin-<em>1</em>beta was able to induce adhesion molecule expression in the absence of human serum.

CONCLUSIONS

CRP induces adhesion molecule expression in human endothelial cells in the presence of serum. These findings support the hypothesis that CRP may play a direct role in promoting the inflammatory component of atherosclerosis and present a potential target for the treatment of atherosclerosis.