OBJECTIVE

Pancreatic cancer is almost always lethal, and the only U.S. Food and Drug Administration-approved therapies for it, gemcitabine and erlotinib, produce objective responses in (<em>1</em>0% of patients. We evaluated the clinical biological effects of curcumin (diferuloylmethane), a plant-derived dietary ingredient with potent nuclear factor-kappaB (NF-kappaB) and tumor inhibitory properties, against advanced pancreatic cancer.

METHODS

Patients received 8 g curcumin by mouth daily until disease progression, with restaging every 2 months. Serum cytokine levels for interleukin (IL)-6, IL-8, IL-<em>1</em>0, and IL-<em>1</em> receptor antagonists and peripheral blood mononuclear cell expression of NF-kappaB and cyclooxygenase-2 were monitored.

RESULTS

Twenty-five patients were enrolled, with 2<em>1</em> evaluable for response. Circulating curcumin was detectable as drug in glucuronide and sulfate conjugate forms, albeit at low steady-state levels, suggesting poor oral bioavailability. Two patients showed clinical biological activity. One had ongoing stable disease for>><em>1</em>8 months; interestingly, one additional patient had a brief, but marked, tumor regression (73%) accompanied by significant increases (4- to 35-fold) in serum cytokine levels (IL-6, IL-8, IL-<em>1</em>0, and IL-<em>1</em> receptor antagonists). No toxicities were observed. Curcumin down-regulated expression of NF-kappaB, cyclooxygenase-2, and phosphorylated signal transducer and activator of transcription 3 in peripheral blood mononuclear cells from patients (most of whom had baseline levels considerably higher than those found in healthy volunteers). Whereas there was considerable interpatient variation in plasma curcumin levels, drug levels peaked at 22 to 4<em>1</em> ng/mL and remained relatively constant over the first 4 weeks.

CONCLUSIONS

Oral curcumin is well tolerated and, despite its limited absorption, has biological activity in some patients with pancreatic cancer.

This study characterizes the high-fat diet-fed mouse as a model for impaired glucose tolerance (IGT) and type 2 diabetes. Female C57BL/6J mice were fed a high-fat diet (58% energy by fat) or a normal diet (<em>1</em><em>1</em>% fat). Body weight was higher in mice fed the high-fat diet already after the first week, due to higher dietary intake in combination with lower metabolic efficiency. Circulating glucose increased after <em>1</em> week on high-fat diet and remained elevated at a level of approximately <em>1</em> mmol/l throughout the <em>1</em>2-month study period. In contrast, circulating insulin increased progressively by time. Intravenous glucose challenge revealed a severely compromised insulin response in association with marked glucose intolerance already after <em>1</em> week. To illustrate the usefulness of this model for the development of new treatment, mice were fed an orally active inhibitor of dipeptidyl peptidase-IV (LAF237) in the drinking water (0.3 mg/<em>ml</em>) for 4 weeks. This normalized glucose tolerance, as judged by an oral glucose tolerance test, in association with augmented insulin secretion. We conclude that the high-fat diet-fed C57BL/6J mouse model is a robust model for IGT and early type 2 diabetes, which may be used for studies on pathophysiology and development of new treatment.

Biotin-labelled DNA probes, prepared by nick-translation in the presence of biotinylated analogs of TTP, are hybridized to DNA or RNA immobilized on nitrocellulose filters. After removal of residual probe, the filters are incubated for 2--5 min with a preformed complex made with avidin-DH (or streptavidin) and biotinylated polymers of intestinal alkaline phosphatase. The filters are then incubated with a mixture of 5-bromo-4-chloro-3-indolyl phosphate and nitro blue tetrazolium, which results in the deposition of a purple precipitate at the sites of hybridization. This procedure will detect target sequences in the <em>1</em>- to <em>1</em>0-pg range after enzyme incubation periods of <em>1</em> hr or less. The incubation period can be extended up to 24 hr, if required, to increase the color intensity of the hybridization signal. Furthermore, at high probe concentrations (250--7560 ng/<em>ml</em>), biotin-labeled DNA exhibits lower nonspecific binding to nitrocellulose than does radiolabeled DNA, so hybridization times required for the analysis of unique mammalian gene sequences can be decreased to <em>1</em>--2 hr. This nonradiographic method of probe detection should be of general utility for genetic studies using Southern, RNA, or dot-blot hybridization protocols.

Previous studies suggested that tetrodotoxin, a poison from the puffer fish, blocks conduction of nerve and muscle through its rather selective inhibition of the sodium-carrying mechanism. In order to verify this hypothesis, observations have been made of sodium and potassium currents in the lobster giant axons treated with tetrodotoxin by means of the sucrose-gap voltage-clamp technique. Tetrodotoxin at concentrations of <em>1</em> x <em>1</em>0(-7) to 5 x <em>1</em>0(-9) gm/<em>ml</em> blocked the action potential but had no effect on the resting potential. Partial or complete recovery might have occurred on washing with normal medium. The increase in sodium conductance normally occurring upon depolarization was very effectively suppressed when the action potential was blocked after tetrodotoxin, while the delayed increase in potassium conductance underwent no change. It is concluded that tetrodotoxin, at very low concentrations, blocks the action potential production through its selective inhibition of the sodium-carrying mechanism while keeping the potassium-carrying mechanism intact.

OBJECTIVE

Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients.

METHODS

The Acute Kidney Injury-Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge.

RESULTS

A total of <em>1</em>032 ICU patients out of <em>1</em>802 [57.3%; 95% confidence interval (CI) 55.0-59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage <em>1</em> = <em>1</em>.679 (95% CI 0.890-3.<em>1</em>69; p = 0.<em>1</em>09), stage 2 = 2.945 (95% CI <em>1</em>.382-6.276; p = 0.005), and stage 3 = 6.884 (95% CI 3.876-<em>1</em>2.228; p < 0.00<em>1</em>). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 <em>mL</em>/min/<em>1</em>.73 m(2) in 47.7% (95% CI 43.6-5<em>1</em>.7) versus <em>1</em>4.8% (95% CI <em>1</em><em>1</em>.9-<em>1</em>8.2) in those without AKI, p < 0.00<em>1</em>.

CONCLUSIONS

This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.

T-20, a synthetic peptide corresponding to a region of the transmembrane subunit of the HIV-<em>1</em> envelope protein, blocks cell fusion and viral entry at concentrations of less than 2 ng/<em>ml</em> in vitro. We administered intravenous T-20 (monotherapy) for <em>1</em>4 days to sixteen HIV-infected adults in four dose groups (3, <em>1</em>0, 30 and <em>1</em>00 mg twice daily). There were significant, dose-related declines in plasma HIV RNA in all subjects who received higher dose levels. All four subjects receiving <em>1</em>00 mg twice daily had a decline in plasma HIV RNA to less than 500 copies/<em>ml</em>, by bDNA assay. A sensitive RT-PCR assay (detection threshold 40 copies/<em>ml</em>) demonstrated that, although undetectable levels were not achieved in the <em>1</em>4-day dosing period, there was a <em>1</em>.96 log<em>1</em>0 median decline in plasma HIV RNA in these subjects. This study provides proof-of-concept that viral entry can be successfully blocked in vivo. Short-term administration of T-20 seems safe and provides potent inhibition of HIV replication comparable to anti-retroviral regimens approved at present.

More sensitive assays for human immunodeficiency virus type <em>1</em> (HIV-<em>1</em>) RNA are needed to detect, quantify, and characterize persistent viremia in patients who are receiving antiretroviral therapy and whose plasma HIV-<em>1</em> RNA levels are suppressed to less than 50 to 75 copies/<em>ml</em>. We therefore developed an internally controlled real-time reverse transcriptase-initiated PCR assay that quantifies HIV-<em>1</em> RNA concentrations down to <em>1</em> copy per <em>ml</em> of plasma. This assay with single-copy sensitivity (the single-copy assay) generates a reproducible linear regression plot of input copy number versus threshold cycle by using HIV-<em>1</em> RNA transcripts at copy numbers ranging from <em>1</em> to <em>1</em>0(6) per reaction mixture. The single-copy assay was compared to the ultrasensitive AMPLICOR HIV-<em>1</em> MONITOR assay and a more sensitive modification of the ultrasensitive assay by repeatedly testing a low-copy-number panel containing 200 to 0.78<em>1</em> copies of HIV-<em>1</em> RNA per <em>ml</em> of plasma. This comparison showed that the single-copy assay had a greater sensitivity than the other assays and was the only assay that detected HIV-<em>1</em> RNA at levels as low as 0.78<em>1</em> copies/<em>ml</em>. Testing of plasma samples from <em>1</em>5 patients who were receiving antiretroviral therapy and who had <75 HIV-<em>1</em> RNA copies/<em>ml</em> revealed persistent viremia in all <em>1</em>5 patients, with HIV-<em>1</em> RNA levels ranging from <em>1</em> to 32 copies/<em>ml</em> (median, <em>1</em>3 copies/<em>ml</em>). The greater sensitivity of the single-copy assay should allow better characterization of persistent viremia in patients who are receiving antiretroviral therapy and whose HIV-<em>1</em> RNA levels are suppressed to below the detection limits of present assays.

Serum samples from patients with meningococcal disease were examined for the presence of IL-6, TNF-alpha, and LPS. Median serum concentration of IL-6 was <em>1</em>,000 times higher in patients with septic shock (<em>1</em>89 ng/<em>ml</em>) than in patients with bacteriaemia, meningitis, or combined septic shock and meningitis. <em>1</em><em>1</em> of 2<em>1</em> patients with serum levels greater than 3.0 ng/<em>ml</em> died, whereas all 58 patients with serum levels at less than or equal to 3.0 ng/<em>ml</em>, survived. All four patients with serum IL-6 levels greater than 750 ng/<em>ml</em>, died. IL-<em>1</em> was detected in serum from three patients who also had high serum levels of IL-6, TNF-alpha, and LPS, and rapidly fatal courses. IL-6 appeared to be released into serum later than TNF-alpha, and was detected in serum for up to 36 h. The half-life of IL-6 and TNF-alpha was calculated to be <em>1</em>03 +/- 27 min and 70 +/- <em>1</em><em>1</em> min, respectively. These data indicate that a complex pattern of cytokines exists in serum from patients with meningococcal septic shock, and that the release of IL-6 and IL-<em>1</em>, in addition to TNF-alpha, is associated with fatal outcome.

BACKGROUND

Pilot studies indicate that probe-guided resection of radioactive sentinel nodes (the first nodes that receive drainage from tumors) can identify regional metastases in patients with breast cancer. To confirm this finding, we conducted a multicenter study of the method as used by <em>1</em><em>1</em> surgeons in a variety of practice settings.

METHODS

We enrolled 443 patients with breast cancer. The technique involved the injection of 4 <em>ml</em> of technetium-99m sulfur colloid (<em>1</em> mCi [37 MBq]) into the breast around the tumor or biopsy cavity. "Hot spots" representing underlying sentinel nodes were identified with a gamma probe. Sentinel nodes subjacent to hot spots were removed. All patients underwent a complete axillary lymphadenectomy.

RESULTS

The overall rate of identification of hot spots was 93 percent (in 4<em>1</em>3 of 443 patients). The pathological status of the sentinel nodes was compared with that of the remaining axillary nodes. The accuracy of the sentinel nodes with respect to the positive or negative status of the axillary nodes was 97 percent (392 of 405); the specificity of the method was <em>1</em>00 percent, the positive predictive value was <em>1</em>00 percent, the negative predictive value was 96 percent (29<em>1</em> of 304), and the sensitivity was 89 percent (<em>1</em>0<em>1</em> of <em>1</em><em>1</em>4). The sentinel nodes were outside the axilla in 8 percent of cases and outside of level <em>1</em> nodes in <em>1</em><em>1</em> percent of cases. Three percent of positive sentinel nodes were in nonaxillary locations.

CONCLUSIONS

Biopsy of sentinel nodes can predict the presence or absence of axillary-node metastases in patients with breast cancer. However, the procedure can be technically challenging, and the success rate varies according to the surgeon and the characteristics of the patient.

BACKGROUND

Chronic kidney disease (CKD) associated with type 2 diabetes is the leading cause of kidney failure, with both inflammation and oxidative stress contributing to disease progression. Bardoxolone methyl, an oral antioxidant inflammation modulator, has shown efficacy in patients with CKD and type 2 diabetes in short-term studies, but longer-term effects and dose response have not been determined.

METHODS

In this phase 2, double-blind, randomized, placebo-controlled trial, we assigned 227 adults with CKD (defined as an estimated glomerular filtration rate [GFR] of 20 to 45 <em>ml</em> per minute per <em>1</em>.73 m(2) of body-surface area) in a <em>1</em>:<em>1</em>:<em>1</em>:<em>1</em> ratio to receive placebo or bardoxolone methyl at a target dose of 25, 75, or <em>1</em>50 mg once daily. The primary outcome was the change from baseline in the estimated GFR with bardoxolone methyl, as compared with placebo, at 24 weeks; a secondary outcome was the change at 52 weeks.

RESULTS

Patients receiving bardoxolone methyl had significant increases in the mean (±SD) estimated GFR, as compared with placebo, at 24 weeks (with between-group differences per minute per <em>1</em>.73 m(2) of 8.2±<em>1</em>.5 <em>ml</em> in the 25-mg group, <em>1</em><em>1</em>.4±<em>1</em>.5 <em>ml</em> in the 75-mg group, and <em>1</em>0.4±<em>1</em>.5 <em>ml</em> in the <em>1</em>50-mg group; P<0.00<em>1</em>). The increases were maintained through week 52, with significant differences per minute per <em>1</em>.73 m(2) of 5.8±<em>1</em>.8 <em>ml</em>, <em>1</em>0.5±<em>1</em>.8 <em>ml</em>, and 9.3±<em>1</em>.9 <em>ml</em>, respectively. Muscle spasms, the most frequent adverse event in the bardoxolone methyl groups, were generally mild and dose-related. Hypomagnesemia, mild increases in alanine aminotransferase levels, and gastrointestinal effects were more common among patients receiving bardoxolone methyl.

CONCLUSIONS

Bardoxolone methyl was associated with improvement in the estimated GFR in patients with advanced CKD and type 2 diabetes at 24 weeks. The improvement persisted at 52 weeks, suggesting that bardoxolone methyl may have promise for the treatment of CKD. (Funded by Reata Pharmaceuticals; BEAM ClinicalTrials.gov number, NCT008<em>1</em><em>1</em>889.).

We report the purification from pig brain of a factor supporting the survival of, and fibre outgrowth from, cultured embryonic chick sensory neurons. The purified factor migrates as one single band, mol. wt. <em>1</em>2 300, on gel electrophoresis in the presence of sodium dodecylsulphate (SDS) and is a basic molecule (pI greater than or equal to <em>1</em>0.<em>1</em>). Approximately <em>1</em> microgram factor was isolated from <em>1</em>.5 kg brain. The final degree of purification was estimated to be <em>1</em>.4 X <em>1</em>0(6)-fold, and the specific activity 0.4 ng/<em>ml</em>/unit, which is similar to that of nerve growth factor (NGF) using the same assay system. This factor is the first neurotrophic factor to be purified since NGF, from which it is clearly distinguished because it has different antigenic and functional properties.

This first-in-man imaging study evaluated the safety and feasibility of hyperpolarized [<em>1</em>-¹³C]pyruvate as an agent for noninvasively characterizing alterations in tumor metabolism for patients with prostate cancer. Imaging living systems with hyperpolarized agents can result in more than <em>1</em>0,000-fold enhancement in signal relative to conventional magnetic resonance (MR) imaging. When combined with the rapid acquisition of in vivo ¹³C MR data, it is possible to evaluate the distribution of agents such as [<em>1</em>-¹³C]pyruvate and its metabolic products lactate, alanine, and bicarbonate in a matter of seconds. Preclinical studies in cancer models have detected elevated levels of hyperpolarized [<em>1</em>-¹³C]lactate in tumor, with the ratio of [<em>1</em>-¹³C]lactate/[<em>1</em>-¹³C]pyruvate being increased in high-grade tumors and decreased after successful treatment. Translation of this technology into humans was achieved by modifying the instrument that generates the hyperpolarized agent, constructing specialized radio frequency coils to detect ¹³C nuclei, and developing new pulse sequences to efficiently capture the signal. The study population comprised patients with biopsy-proven prostate cancer, with 3<em>1</em> subjects being injected with hyperpolarized [<em>1</em>-¹³C]pyruvate. The median time to deliver the agent was 66 s, and uptake was observed about 20 s after injection. No dose-limiting toxicities were observed, and the highest dose (0.43 <em>ml</em>/kg of 230 mM agent) gave the best signal-to-noise ratio for hyperpolarized [<em>1</em>-¹³C]pyruvate. The results were extremely promising in not only confirming the safety of the agent but also showing elevated [<em>1</em>-¹³C]lactate/[<em>1</em>-¹³C]pyruvate in regions of biopsy-proven cancer. These findings will be valuable for noninvasive cancer diagnosis and treatment monitoring in future clinical trials.

Hyperinsulinemia secondary to a poorly characterized disorder of insulin action is a feature of the polycystic ovary syndrome (PCO). However, controversy exists as to whether insulin resistance results from PCO or the obesity that is frequently associated with it. Thus, we determined in vivo insulin action on peripheral glucose utilization (M) and hepatic glucose production (HGP) with the euglycemic glucose-clamp technique in obese (n = <em>1</em>9) and nonobese (n = <em>1</em>0) PCO women and age- and body-composition-matched normal ovulatory women (n = <em>1</em><em>1</em> obese and n = 8 nonobese women). None had fasting hyperglycemia. Two obese PCO women had diabetes mellitus, established with an oral glucose tolerance test; no other women had impairment of glucose tolerance. However, the obese PCO women had significantly increased fasting and 2-h glucose levels after an oral glucose load and increased basal HGP compared with their body-composition-matched control group. There were statistically significant interactions between obesity and PCO in fasting glucose levels and basal HGP (P less than .05). Steady-state insulin levels of approximately <em>1</em>00 microU/<em>ml</em> were achieved during the clamp. Insulin-stimulated glucose utilization was significantly decreased in both PCO groups whether expressed per kilogram total weight (P less than .00<em>1</em>) or per kilogram fat free mass (P less than .00<em>1</em>) or when divided by the steady-state plasma insulin (l) level (M/l, P less than .00<em>1</em>). There was residual HGP in 4 of <em>1</em>5 obese PCO, 0 of <em>1</em><em>1</em> obese normal, 2 of <em>1</em>0 nonobese PCO, and 0 of 8 nonobese normal women. The metabolic clearance rate of insulin did not differ in the four groups. We conclude that <em>1</em>) PCO women have significant insulin resistance that is independent of obesity, changes in body composition, and impairment of glucose tolerance, 2) PCO and obesity have a synergistic deleterious effect on glucose tolerance, 3) hyperinsulinemia in PCO is not the result of decreased insulin clearance, and 4) PCO is associated with a unique disorder of insulin action.

BACKGROUND

Clinically localized prostate cancer is very prevalent among US men, but recurrence after treatment with conventional radiation therapy is common.

OBJECTIVE

To evaluate the hypothesis that increasing the radiation dose delivered to men with clinically localized prostate cancer improves disease outcome.

METHODS

Randomized controlled trial of 393 patients with stage T1b through T2b prostate cancer and prostate-specific antigen (PSA) levels less than 15 ng/mL randomized between January 1996 and December 1999 and treated at 2 US academic institutions. Median age was 67 years and median PSA level was 6.3 ng/mL. Median follow-up was 5.5 (range, 1.2-8.2) years.

METHODS

Patients were randomized to receive external beam radiation to a total dose of either 70.2 Gy (conventional dose) or 79.2 Gy (high dose). This was delivered using a combination of conformal photon and proton beams.

METHODS

Increasing PSA level (ie, biochemical failure) 5 years after treatment.

RESULTS

The proportions of men free from biochemical failure at 5 years were 78.8% [corrected] (95% confidence interval, 73.1%-84.6%) [corrected] for conventional-dose and 91.3% [corrected] (95% confidence interval, 87.2%-95.4%) [corrected] for high-dose therapy (P<.001), a 59% [corrected] reduction in the risk of failure. The advantage to high-dose therapy was statistically significant [corrected] in both the low-risk subgroup [corrected] (risk reduction, 84% [P<.001]) [corrected] There has been no significant difference in overall survival rates between the treatment groups. Only 1% of patients receiving conventional-dose and 2% receiving high-dose radiation experienced acute urinary or rectal morbidity of Radiation Therapy Oncology Group (RTOG) grade 3 or greater. So far, only 2% and 1%, respectively, have experienced late morbidity of RTOG grade 3 or greater.

CONCLUSIONS

Men with clinically localized prostate cancer have a lower risk of biochemical failure if they receive high-dose rather than conventional-dose conformal radiation. This advantage was achieved without any associated increase in RTOG grade 3 acute or late urinary or rectal morbidity.

OBJECTIVE

It is not known why some people with Helicobacter pylori infection develop gastric cancer whereas others do not. Whether the CagA phenotype of H pylori infection affected risk for cancer independently of other posited risk factors was evaluated.

METHODS

242 persons who participated in a previous nested case-control study of gastric cancer. <em>1</em>79 (90 cases and 89 controls) were infected with H pylori as determined by enzyme linked immunosorbent assay (ELISA) in serum and 63 (<em>1</em>3 cases and 50 controls) were uninfected.

METHODS

Serum samples from cases and controls, obtained a mean of <em>1</em>4.2 years before diagnosis of cancer in the cases, were tested by ELISA for IgG antibodies against the CagA gene product of H pylori. They had previously been tested for pepsinogen I. Using logistic regression analysis, risk for cancer was compared among infected persons with CagA antibodies, infected persons without CagA antibodies, and uninfected persons.

RESULTS

Subjects infected with H pylori who had CagA antibodies were 5.8-fold more likely than uninfected subjects to develop gastric cancer (95% confidence interval (95% CI) = 2.6-<em>1</em>3.0). This was true for both intestinal (odds ratio (OR) 5.<em>1</em>, 95% CI = 2.<em>1</em>-<em>1</em>2.2) and diffuse type (OR <em>1</em>0.<em>1</em>, 95% CI = 2.2-47.4) cancers. By contrast, H pylori infected subjects without CagA antibodies were only slightly, and not significantly, at increased risk for cancer (OR 2.2, 95% CI = 0.9-5.4) and any possible association was restricted to diffuse type carcinoma (OR 9.0, 95% CI = <em>1</em>.2-65.8). Pepsinogen <em>1</em> < 50 ng/<em>ml</em> significantly increased risk for both cancer types in H pylori infected persons and lessened the magnitude of association between CagA and cancer. Educational attainment, cigarette smoking, and ABO blood group were not associated with malignancy.

CONCLUSIONS

When compared with uninfected subjects, persons infected with CagA positive H pylori are at considerably increased risk of gastric cancer. CagA negative H pylori are less strongly linked to malignancy and may only be associated with diffuse type disease.

BACKGROUND

Individuals with the metabolic syndrome are 3 times more likely to die of heart disease than healthy counterparts. Exercise training reduces several of the symptoms of the syndrome, but the exercise intensity that yields the maximal beneficial adaptations is in dispute. We compared moderate and high exercise intensity with regard to variables associated with cardiovascular function and prognosis in patients with the metabolic syndrome.

RESULTS

Thirty-two metabolic syndrome patients (age, 52.3+/-3.7 years; maximal oxygen uptake [o(2)max], 34 <em>mL</em> x kg(-<em>1</em>) x min(-<em>1</em>)) were randomized to equal volumes of either moderate continuous moderate exercise (CME; 70% of highest measured heart rate [Hfmax]) or aerobic interval training (AIT; 90% of Hfmax) 3 times a week for <em>1</em>6 weeks or to a control group. o(2)max increased more after AIT than CME (35% versus <em>1</em>6%; P<0.0<em>1</em>) and was associated with removal of more risk factors that constitute the metabolic syndrome (number of factors: AIT, 5.9 before versus 4.0 after; P<0.0<em>1</em>; CME, 5.7 before versus 5.0 after; group difference, P<0.05). AIT was superior to CME in enhancing endothelial function (9% versus 5%; P<0.00<em>1</em>), insulin signaling in fat and skeletal muscle, skeletal muscle biogenesis, and excitation-contraction coupling and in reducing blood glucose and lipogenesis in adipose tissue. The 2 exercise programs were equally effective at lowering mean arterial blood pressure and reducing body weight (-2.3 and -3.6 kg in AIT and CME, respectively) and fat.

CONCLUSIONS

Exercise intensity was an important factor for improving aerobic capacity and reversing the risk factors of the metabolic syndrome. These findings may have important implications for exercise training in rehabilitation programs and future studies.

BACKGROUND

Cardiac resynchronization therapy (CRT) through biventricular pacing is an effective treatment for heart failure (HF) with a wide QRS; however, the outcomes of patients requiring CRT and implantable cardioverter defibrillator (ICD) therapy are unknown.

OBJECTIVE

To examine the efficacy and safety of combined CRT and ICD therapy in patients with New York Heart Association (NYHA) class III or IV congestive HF despite appropriate medical management.

METHODS

Randomized, double-blind, parallel-controlled trial conducted from October <em>1</em>, <em>1</em>999, to August 3<em>1</em>, 200<em>1</em>, of 369 patients with left ventricular ejection fraction of 35% or less, QRS duration of <em>1</em>30 ms, at high risk of life-threatening ventricular arrhythmias, and in NYHA class III (n = 328) or IV (n = 4<em>1</em>) despite optimized medical treatment.

METHODS

Of 369 randomized patients who received devices with combined CRT and ICD capabilities, <em>1</em>82 were controls (ICD activated, CRT off) and <em>1</em>87 were in the CRT group (ICD activated, CRT on).

METHODS

The primary double-blind study end points were changes between baseline and 6 months in quality of life, functional class, and distance covered during a 6-minute walk. Additional outcome measures included changes in exercise capacity, plasma neurohormones, left ventricular function, and overall HF status. Survival, incidence of ventricular arrhythmias, and rates of hospitalization were also compared.

RESULTS

At 6 months, patients assigned to CRT had a greater improvement in median (95% confidence interval) quality of life score (-<em>1</em>7.5 [-2<em>1</em> to -<em>1</em>4] vs -<em>1</em><em>1</em>.0 [-<em>1</em>6 to -7], P =.02) and functional class (-<em>1</em> [-<em>1</em> to -<em>1</em>] vs 0 [-<em>1</em> to 0], P =.007) than controls but were no different in the change in distance walked in 6 minutes (55 m [44-79] vs 53 m [43-75], P =.36). Peak oxygen consumption increased by <em>1</em>.<em>1</em> mL/kg per minute (0.7-<em>1</em>.6) in the CRT group vs 0.<em>1</em> mL/kg per minute (-0.<em>1</em> to 0.8) in controls (P =.04), although treadmill exercise duration increased by 56 seconds (30-79) in the CRT group and decreased by <em>1</em><em>1</em> seconds (-55 to <em>1</em>2) in controls (P<.00<em>1</em>). No significant differences were observed in changes in left ventricular size or function, overall HF status, survival, and rates of hospitalization. No proarrhythmia was observed and arrhythmia termination capabilities were not impaired.

CONCLUSIONS

Cardiac resynchronization improved quality of life, functional status, and exercise capacity in patients with moderate to severe HF, a wide QRS interval, and life-threatening arrhythmias. These improvements occurred in the context of underlying appropriate medical management without proarrhythmia or compromised ICD function.

Increased leukocyte adhesion to the endothelial lining of blood vessels is an essential event in inflammation and the pathogenesis of certain vascular diseases. We have studied the effect of interleukin <em>1</em> (IL-<em>1</em>), an inflammatory/immune mediator, on endothelial-leukocyte adhesion using quantitative in vitro assays. Selective pretreatment of cultured human umbilical vein endothelial monolayers with IL-<em>1</em> (5 U/<em>ml</em>, 4 h) resulted in an <em>1</em>8.3 +/- 2.6-fold increase in human peripheral blood polymorphonuclear leukocyte (PMN) adhesion (mean +/- SEM, n = <em>1</em>6) and a 2.6 +/- 0.3-fold increase in monocyte adhesion (n = 7) over basal levels. IL-<em>1</em>-treated endothelial monolayers also supported increased adhesion of the promyelocytic cell line HL-60 and the monocytelike cell line U937 (33.0 +/- 6.0-fold, n = 6 and 4.9 +/- 0.5-fold, n = <em>1</em>5, respectively). In contrast, selective IL-<em>1</em> pretreatment of leukocytes, or the addition of IL-<em>1</em> during the adhesion assay, did not alter endothelial-leukocyte adhesion. Conditioned medium from IL-<em>1</em>-treated endothelial cultures also did not promote leukocyte adhesion to untreated monolayers. IL-<em>1</em> induction of endothelial adhesivity was concentration dependent (maximum, <em>1</em>0 U/<em>ml</em>), time dependent (peak, 4-6 h), and reversible, was blocked by cycloheximide (<em>1</em>0 micrograms/<em>ml</em>) or actinomycin D (5 micrograms/<em>ml</em>) but not by acetylsalicylic acid (<em>1</em>00 microM), and occurred without detectable endothelial cell damage. IL-<em>1</em> treatment of SV40-transformed human endothelial cells and dermal fibroblasts did not increase their adhesivity for leukocytes. These data suggest that IL-<em>1</em> can act selectively on human vascular endothelium to increase its adhesivity for circulating blood leukocytes, and thus to localize leukocyte-vessel wall interactions at sites of inflammation in vivo.

The availability of compactin (<em>ML</em>-236B), a potent competitive inhibitor of 3-hydroxy-3-methylglutaryl Coenzyme A reductase, has permitted the demonstration of a hitherto unsuspected aspect of mevalonate metabolism and isoprenoid synthesis in cultured mammalian cells. 3-Hydroxy-3-methylglutaryl Coenzyme A reductase, the enzyme that synthesizes mevalonate, appears to be regulated through a multivalent feedback mechanism. Full suppression of the reductase requires the presence of at least two regulators: <em>1</em>) cholesterol, which is normally derived exogenously from plasma low density lipoprotein (LDL), and 2) a nonsterol product, which is normally synthesized endogenously from mevalonate. Evidence indicates that both of these regulators of the reductase may be essential for the growth of mammalian cells in culture. The multivalent feedback regulation of 3-hydroxy-3-methylglutaryl Coenzyme A reductase, together with secondary regulatory changes in other enzymes of the sterol synthetic pathway, coordinates the branched pathway of mevalonate metabolism so as to assure a constant supply of cholesterol and nonsterol products. These new findings have important implications for the understanding of isoprenoid metabolism and its relation to cell growth.

Virus-specific T-helper cells are considered critical for the control of chronic viral infections. Successful treatment of acute HIV-<em>1</em> infection leads to augmentation of these responses, but whether this enhances immune control has not been determined. We administered one or two supervised treatment interruptions to eight subjects with treated acute infection, with the plan to restart therapy if viral load exceeded 5,000 copies of HIV-<em>1</em> RNA per millilitre of plasma (the level at which therapy has been typically recommended) for three consecutive weeks, or 50,000 RNA copies per <em>ml</em> at one time. Here we show that, despite rebound in viraemia, all subjects were able to achieve at least a transient steady state off therapy with viral load below 5,000 RNA copies per <em>ml</em>. At present, five out of eight subjects remain off therapy with viral loads of less than 500 RNA copies per <em>ml</em> plasma after a median 6.5 months (range 5-8.7 months). We observed increased virus-specific cytotoxic T lymphocytes and maintained T-helper-cell responses in all. Our data indicate that functional immune responses can be augmented in a chronic viral infection, and provide rationale for immunotherapy in HIV-<em>1</em> infection.

Highly purified functional cytotrophoblasts have been prepared from human term placentae by adding a Percoll gradient centrifugation step to a standard trypsin-DNase dispersion method. The isolated mononuclear trophoblasts averaged <em>1</em>0 microns in diameter, with occasional cells measuring up to 20-30 microns. Viability was greater than 90%. Transmission electron microscopy revealed that the cells had fine structural features typical of trophoblasts. In contrast to syncytial trophoblasts of intact term placentae, these cells did not stain for hCG, human placental lactogen, pregnancy-specific beta <em>1</em>-glycoprotein or low mol wt cytokeratins by immunoperoxidase methods. Endothelial cells, fibroblasts, or macrophages did not contaminate the purified cytotrophoblasts, as evidenced by the lack of immunoperoxidase staining with antibodies against vimentin or alpha <em>1</em>-antichymotrypsin. The cells produced progesterone (<em>1</em> ng/<em>1</em>0(6) cells . 4 h), and progesterone synthesis was stimulated up to 8-fold in the presence of 25-hydroxycholesterol (20 micrograms/<em>ml</em>). They also produced estrogens (<em>1</em>360 pg/<em>1</em>0(6) cells . 4 h) when supplied with androstenedione (<em>1</em> ng/<em>ml</em>) as a precursor. When placed in culture, the cytotrophoblasts consistently formed aggregates, which subsequently transformed into syncytia within 24-48 h after plating. Time lapse cinematography revealed that this process occurred by cell fusion. The presumptive syncytial groups were proven to be true syncytia by microinjection of fluorescently labeled alpha-actinin, which diffused completely throughout the syncytial cytoplasm within 30 min. Immunoperoxidase staining of cultured trophoblasts between 3.5 and 72 h after plating revealed a progressive increase in cytoplasmic pregnancy-specific beta <em>1</em>-glycoprotein, hCG, and human placental lactogen concomitant with increasing numbers of aggregates and syncytia. At all time points examined, occasional single cells positive for these markers were identified. RIA of the spent culture media for hCG revealed a significant increase in secreted hCG, paralleling the increase in hCG-positive cells and syncytia identified by immunoperoxidase methods. We conclude that human cytotrophoblasts differentiate in culture and fuse to form functional syncytiotrophoblasts.

The lack of a standardized, statistically reliable method for in vitro determinations of the minimal lethal or bactericidal concentrations of antibiotics has complicated analyses of isolates of Staphylococcus aureus which appear to be inhibited but not killed by the usual concentrations of cell wall-active antibiotics. We describe a method which identifies some of the covariants involved in determinations of minimal lethal concentrations. Lethality was defined as a 99.9% reduction in the initial inoculum of bacteria after 24 h of incubation. We limited the sample volume to 0.0<em>1</em> <em>ml</em> to minimize the inhibitory effect of antibiotic and corresponding rejection values, which detected lethality with a high degree of sensitivity and specificity. When the number of colonies on subculture was equal to or less than the rejection value, the antibiotic was considered lethal for the test organism. Rejection values encompassed initial inocula from <em>1</em>0(5) to <em>1</em>0(7) colony-forming units per <em>ml</em> for single and duplicate samples and allowed for <em>1</em> or 5% variability in pipette volumes and errors in initial inoculum determinations. This method was used to determine the minimal lethal concentrations of semi-synthetic penicillins for S. aureau isolates, one of which was tolerant to the killing action of penicillin.

OBJECTIVE

This study set out to define the incidence, predictors, and mortality related to acute renal failure (ARF) and acute renal failure requiring dialysis (ARFD) after coronary intervention.

METHODS

Derivation-validation set methods were used in 1,826 consecutive patients undergoing coronary intervention with evaluation of baseline creatinine clearance (CrCl), diabetic status, contrast exposure, postprocedure creatinine, ARF, ARFD, in-hospital mortality, and long-term survival (derivation set). Multiple logistic regression was used to derive the prior probability of ARFD in a second set of 1,869 consecutive patients (validation set).

RESULTS

The incidence of ARF and ARFD was 144.6/1,000 and 7.7/1,000 cases respectively. The cutoff dose of contrast below which there was no ARFD was 100 mL. No patient with a CrCl>> 47 mL/min developed ARFD. These thresholds were confirmed in the validation set. Multivariate analysis found CrCl [odds ratio (OR) = 0.83, 95% confidence interval (CI) 0.77 to 0.89, P <0.00001], diabetes (OR = 5.47, 95% CI 1.40 to 21.32, P = 0.01), and contrast dose (OR = 1.008, 95% CI 1.002 to 1.013, P = 0.01) to be independent predictors of ARFD. Patients in the validation set who underwent dialysis had a predicted prior probability of ARFD of between 0.07 and 0.73. The in-hospital mortality for those who developed ARFD was 35.7% and the 2-year survival was 18.8%.

CONCLUSIONS

The occurrence of ARFD after coronary intervention is rare (<1%) but is associated with high in-hospital mortality and poor long-term survival. Individual patient risk can be estimated from calculated CrCl, diabetic status, and expected contrast dose prior to a proposed coronary intervention.

Total sleep restriction in humans is associated with increased daytime sleepiness, decreased performance, and hormonal/metabolic disturbances. The effects of mild chronic sleep restriction that mimic real life are not known. To assess the effects of modest sleep restriction from 8 to 6 h/night for <em>1</em> wk, 25 young, healthy, normal sleepers (<em>1</em>2 men and <em>1</em>3 women) were studied for <em>1</em>2 consecutive nights in the sleep laboratory. After <em>1</em> wk of sleep restriction, although subjects' nighttime sleep was deeper, subjects were significantly sleepier (multiple sleep latency test) and performed worse in four primary variables of psychomotor vigilance test (both P < 0.0<em>1</em>). Furthermore, 24-h secretion of IL-6 was increased by 0.8 +/- 0.3 pg/<em>ml</em> (P < 0.05) in both sexes, whereas TNFalpha was increased only in men. Also, the peak cortisol secretion was lower after sleep restriction than at baseline, and this difference was stronger in men (55.<em>1</em>8 +/- 24.83 nmol/liter; P < 0.05) than in women (35.87 +/- 24.83 nmol/liter; P < 0.<em>1</em>6). We conclude that in young men and women, modest sleep loss is associated with significant sleepiness, impairment of psychomotor performance, and increased secretion of proinflammatory cytokines. Given the potential association of these behavioral and physical alterations with health, well-being, and public safety, the idea that sleep or parts of it are optional should be regarded with caution.