Risk factors for advancement of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome. Studies of Ocular Complications of AIDS Research Group

OBJECTIVE

To identify ocular and systemic factors that predict advancement of cytomegalovirus (CMV) retinitis during treatment.

METHODS

Patients with acquired immunodeficiency syndrome were enrolled in a multicenter clinical trial designed to evaluate foscarnet sodium and ganciclovir sodium as therapy for newly diagnosed CMV retinitis. Ocular characteristics at baseline and measurements of retinitis were assessed from fundus photographs by graders at a fundus photograph reading center. The following measures of advancement were assessed: (1) lesion border movement of at least 750 microm or development of a new lesion in involved eyes; (2) rate of increase in retinal area with CMV in involved eyes; and (3) development of retinitis in uninvolved eyes of patients with unilateral disease at baseline.

RESULTS

In eyes with retinitis, risk factors at baseline for advancement while receiving treatment included smaller area involved, active margins of retinitis, and posterior location. Risk factors for development of retinitis in uninvolved fellow eyes included blood and urine cultures positive for CMV and lower CD8(+) T-lymphocyte count.

CONCLUSIONS

Lesion characteristics can be used to predict advancement of preexisting disease, whereas only systemic factors are associated with development of bilateral disease. These analyses describe retinitis activity before the introduction of potent antiretroviral therapies but provide an important reference point for patients in whom CMV retinitis develops after failure or intolerance of antiretroviral agents. Arch Ophthalmol. 2000;118:1196-1204

Combination gene therapy with CD86 and the MHC class II transactivator in the control of lung tumor growth

Early reports suggest that the costimulatory molecule CD86 (B7-2) has sporadic efficacy in tumor immunity, whereas changes in cancer immunity mediated by the MHC class II transactivator (CIITA) have not been extensively investigated. CIITA activates MHC class II expression in most cells; however, in the Line 1 lung carcinoma model system, CIITA activates MHC class I and well as class II. Here we show that CD86 is very effective in inducing a primary immune response against Line 1. Tumor cells expressing CD86 grew in only 50% of the mice injected with live cells, and those mice that developed tumors did so with significantly delayed kinetics. Furthermore, irradiated CD86-expressing Line 1 cells served as an effective tumor vaccine, demonstrating that CD86 is effective in inducing tumor immunity in the Line 1 system. These data suggest that if CIITA and CD86 cooperate, enhanced tumor immunity could be achieved. CIITA alone was mildly beneficial in slowing primary tumor growth but only when expressed at low levels. Clones expressing high levels of class II MHC grew as fast as or faster than parental tumor, and CIITA expression in a tumor vaccine assay lacked efficacy. When CIITA and CD86 were coexpressed, there was no cooperative immune protection from tumor growth. Cells that coexpress both genes also failed as a cancer vaccine, suggesting a negative role for CIITA in this lung carcinoma. These data suggest that human cancer vaccine trials utilizing CIITA gene therapy alone or in combination with CD86 should be approached with caution.

Major histocompatibility complex class II-transfected tumor cells present endogenous antigen and are potent inducers of tumor-specific immunity

We have developed an immunotherapy in which tumor cells transfected with syngeneic major histocompatibility complex (MHC) class II genes are cell-based vaccines for the treatment of established tumor and metastatic disease. If this strategy is to be used clinically, convenient methods for generating class II+ tumor cells are necessary. Interferon-gamma treatment or transduction of the class II transactivator (CIITA) gene induces class II expression but also up-regulates the class II-associated accessory molecules, invariant chain (Ii) and DM. To determine if interferon-gamma treatment and CIITA transduction are potential immunotherapies, we assessed the tumorigenicity of sarcoma cells expressing combinations of class II, Ii, and DM. Since we hypothesized that class II-transfected tumor cells not coexpressing Ii and DM present endogenously encoded tumor peptides, we have assessed the transfectants for antigen presentation activity to MHC class II-restricted antigen-specific CD4(+) T cells. Tumor challenge studies demonstrate that tumor cells expressing class II without coexpression of Ii or Ii plus DM are highly immunogenic and preferentially present endogenous antigens, while tumors coexpressing class II with Ii or Ii plus DM are not effective immunogens. Because tumor rejection correlates with expression of class II without coexpression of Ii and DM, the most efficacious vaccines will express MHC class II without coexpression of Ii and DM and will preferentially present endogenous antigen.

Expression of the murine CD21 gene is regulated by promoter and intronic sequences

Murine CD21 gene products are expressed primarily on the surface of B lymphocytes and follicular dendritic cells. To identify the genetic elements that control the tissue-specific expression of the CD21 gene, we analyzed, via transient transfections, the 5' proximal promoter region of the CD21 gene (1272 bp 5' of the initiating ATG). This region possessed strong promoter activity, but it was not tissue specific, in that T cell expression was equivalent to that of B cells. These data suggested that the anticipated tissue-specific control element(s) lies 3' of the initiating ATG. Analysis of a novel minigene construct that possessed both the 5' promoter region and a large region (9 kb) of the CD21 gene 3' of the initiating ATG demonstrated the expected tissue-specific expression. Further analysis using the luciferase reporter system indicated that such control elements reside in the first intron (5.5 kb in size), which separates the exons encoding the signal sequence and the first extracellular short consensus repeat domain of the mature protein. Further dissection of intron 1 demonstrated that the sequences controlling the tissue-specific expression of the murine CD21 gene are contained in the 5' 1.6-kb region of this intron. This 1.6-kb fragment was fractionated into an 800-bp sequence at the 5' end that showed very significant inhibitory activity in both B and T cells and a 3' 800-bp sequence that demonstrated moderate repression in T cells, but enhancer activity in B cells. These data suggest this region of the CD21 gene possesses a number of functionally distinct sites that positively and negatively regulate CD21 gene transcription.

Expression of the murine CD21 gene is regulated by promoter and intronic sequences

Murine CD21 gene products are expressed primarily on the surface of B lymphocytes and follicular dendritic cells. To identify the genetic elements that control the tissue-specific expression of the CD21 gene, we analyzed, via transient transfections, the 5' proximal promoter region of the CD21 gene (1272 bp 5' of the initiating ATG). This region possessed strong promoter activity, but it was not tissue specific, in that T cell expression was equivalent to that of B cells. These data suggested that the anticipated tissue-specific control element(s) lies 3' of the initiating ATG. Analysis of a novel minigene construct that possessed both the 5' promoter region and a large region (9 kb) of the CD21 gene 3' of the initiating ATG demonstrated the expected tissue-specific expression. Further analysis using the luciferase reporter system indicated that such control elements reside in the first intron (5.5 kb in size), which separates the exons encoding the signal sequence and the first extracellular short consensus repeat domain of the mature protein. Further dissection of intron 1 demonstrated that the sequences controlling the tissue-specific expression of the murine CD21 gene are contained in the 5' 1.6-kb region of this intron. This 1.6-kb fragment was fractionated into an 800-bp sequence at the 5' end that showed very significant inhibitory activity in both B and T cells and a 3' 800-bp sequence that demonstrated moderate repression in T cells, but enhancer activity in B cells. These data suggest this region of the CD21 gene possesses a number of functionally distinct sites that positively and negatively regulate CD21 gene transcription.

Induction of MHC class I expression by the MHC class II transactivator CIITA

Major histocompatibility complex (MHC) class I-deficient cell lines were used to demonstrate that the MHC class II transactivator (CIITA) can induce surface expression of MHC class I molecules. CIITA induces the promoter of MHC class I heavy chain genes. The site alpha DNA element is the target for CIITA-induced transactivation of class I. In addition, interferon-gamma (IFNgamma)-induced MHC class I expression also requires an intact site alpha. The G3A cell line, which is defective in CIITA induction, does not induce MHC class I antigen and promoter in response to IFNgamma. Trans-dominant-negative forms of CIITA reduce class I MHC promoter function and surface antigen expression. Collectively, these data argue that CIITA has a role in class I MHC gene induction.

Taxol-dependent transcriptional activation of IL-8 expression in a subset of human ovarian cancer

Taxol is important in the treatment of both primary and drug-resistant ovarian cancer. Although Taxol is known to stabilize microtubules and block cell mitosis, the effectiveness of this drug exceeds that of other antimitotic agents, suggesting it may have an additional mode of action. Stimulated by murine macrophage studies indicating cytokine induction by Taxol, we have investigated proinflammatory cytokine expression in a series of cell lines and recent explants of human ovarian cancer. Taxol induced secretion of interleukin (IL) 8 but not IL-6, IL-1alpha, or IL-1beta in 4 of 10 samples. Induction was dependent on transcriptional activation, and, in contrast to murine macrophage studies, was apparently independent of an active lipopolysaccharide signaling pathway. Confluent cultures secreted as much IL-8 as proliferating cells. Taxol did not induce IL-8 in breast carcinoma, endometrial stromal, or T-lymphocyte or monocyte cultures. We propose that the local expression of this chemokine in vivo may elicit a host response similar in effectiveness to that of cytokine gene therapy. These data are the first to suggest that a chemotherapeutic agent may have a direct effect on transcription of cytokine and/or growth factor genes in ovarian cancer, and that this effect may not be restricted to proliferating tumor cells.

Murine macrophages lack expression of the Cr2-145 (CR2) and Cr2-190 (CR1) gene products

Murine macrophages have been described as possessing complement receptors for C3b and iC3b. These binding activities have been assumed to be due to the presence of the CR1 and CR3 proteins, respectively. The mouse Cr2 gene produces two distinct gene products of approximately 190,000 relative molecular mass (M(r)) (Cr2-190) and 145,000 M(r) (Cr2-145). Because of the similarity in size to human complement receptors, the Cr2-190 protein has been dubbed murine CR1 while the murine Cr2-145 product has been termed murine CR2. In order to define the complement receptor genes expressed by murine macrophages, we investigated the expression patterns of Cr2-190, Cr2-145 and another mouse complement receptor, Crry, in three different mouse macrophage populations: bone marrow-derived macrophages, thioglycollate-elicited peritoneal macrophages and the macrophage cell line, J774. Neither of the Cr2 gene transcripts encoding the Cr2-145 and Cr2-190 proteins could be detected in these populations by RT-RPCR analysis although Crry transcripts were evident. Cr2-145 and Cr2s-190 proteins could not be detected on the surface of thioglycollate-elicited macrophages using a monoclonal antibody that recognizes both proteins. Thus, contrary to previously published data, murine macrophages do not possess the Cr2 gene products.

Functional identification of transcription control sequences of the mouse Crry gene

The mouse C receptor-related gene Crry is expressed by a wide variety of cells. Those sequences required for the transcriptional control of this gene were identified by deletion analysis of regions 5' of the initiating ATG. Fusion of Crry promoter sequences to the reporter gene CAT identified a region approximately 1,500 bp upstream of the transcriptional start site that enhanced transcription of this gene construct. Gel shift and methylation interference assays were performed, and a specific protein-DNA complex was identified within this region. These assays defined a 16-bp sequence 1,642 bp 5' of the initiating ATG that bound a protein in nuclear extracts prepared from all murine cell lines and tissues examined. The methylation interference assay indicated that the core region of the DNA sequence recognized by the protein was GGAA, the common core binding site for the ets family of proto-oncogenes. Oligonucleotides prepared from this sequence with the GGAA sequence did inhibit the DNA/protein complex formation, whereas those with a mutant GGAA sites did not. The minimal site identified by methylation interference was able to up-regulate transcription when placed downstream of a heterologous promoter, whereas the same sequence with an altered GGAA site could not. Thus, this site functions as an enhancer.

Functional identification of transcription control sequences of the mouse Crry gene

The mouse C receptor-related gene Crry is expressed by a wide variety of cells. Those sequences required for the transcriptional control of this gene were identified by deletion analysis of regions 5' of the initiating ATG. Fusion of Crry promoter sequences to the reporter gene CAT identified a region approximately 1,500 bp upstream of the transcriptional start site that enhanced transcription of this gene construct. Gel shift and methylation interference assays were performed, and a specific protein-DNA complex was identified within this region. These assays defined a 16-bp sequence 1,642 bp 5' of the initiating ATG that bound a protein in nuclear extracts prepared from all murine cell lines and tissues examined. The methylation interference assay indicated that the core region of the DNA sequence recognized by the protein was GGAA, the common core binding site for the ets family of proto-oncogenes. Oligonucleotides prepared from this sequence with the GGAA sequence did inhibit the DNA/protein complex formation, whereas those with a mutant GGAA sites did not. The minimal site identified by methylation interference was able to up-regulate transcription when placed downstream of a heterologous promoter, whereas the same sequence with an altered GGAA site could not. Thus, this site functions as an enhancer.

Identification of sites for distinct DNA binding proteins including Oct-1 and Oct-2 in the Cr2 gene

The murine Cr2 gene produces two distinct products in a variety of murine cell types. Both of these transcripts appear to initiate from the same position within the gene but vary from one another via an alternative splicing event within the coding exons. An analysis of those gene sequences that might control the cell specific expression of the Cr2 gene has identified a region of Cr2 5' of the transcription start site that is conserved in both the murine Cr2 and human CR2 genes. When this region was examined using the gel shift assay with nuclear extracts from cells expressing Cr2 (B cells) and those that do not (T cells and fibroblasts), at least four distinct proteins were identified that bound to at least three distinct sites. The DNA sequence recognized by two of these proteins is the octamer sequence recognized by a family of transcriptional regulators including the B cell specific Oct-2 protein. During an acute bacterial infection, the levels of Oct-2 and Cr2 mRNA are both depressed. This suggests that the Oct-2 protein directly controls the transcriptional activity of the Cr2 gene and that during such an infection, the levels of Ag receptors on B cells (Ig and complement receptors) are diminished.

Identification of sites for distinct DNA binding proteins including Oct-1 and Oct-2 in the Cr2 gene

The murine Cr2 gene produces two distinct products in a variety of murine cell types. Both of these transcripts appear to initiate from the same position within the gene but vary from one another via an alternative splicing event within the coding exons. An analysis of those gene sequences that might control the cell specific expression of the Cr2 gene has identified a region of Cr2 5' of the transcription start site that is conserved in both the murine Cr2 and human CR2 genes. When this region was examined using the gel shift assay with nuclear extracts from cells expressing Cr2 (B cells) and those that do not (T cells and fibroblasts), at least four distinct proteins were identified that bound to at least three distinct sites. The DNA sequence recognized by two of these proteins is the octamer sequence recognized by a family of transcriptional regulators including the B cell specific Oct-2 protein. During an acute bacterial infection, the levels of Oct-2 and Cr2 mRNA are both depressed. This suggests that the Oct-2 protein directly controls the transcriptional activity of the Cr2 gene and that during such an infection, the levels of Ag receptors on B cells (Ig and complement receptors) are diminished.

Spironolactone metabolism: steady-state serum levels of the sulfur-containing metabolites

Metabolism of spironolactone in man is extensive and complex. For many years the dethioacetylated metabolite, canrenone, was assumed to be the major metabolite. However, recent studies using specific high performance liquid chromatography (HPLC) have demonstrated the presence of spironolactone and the sulfur-containing metabolites 7 alpha-thiomethylspirolactone (IV) and 6 beta-hydroxy-7 alpha-thiomethylspirolactone (V), in addition to canrenone, in the serum after a single oral dose of spironolactone. The importance of spironolactone and metabolites IV and V relative to canrenone at steady state remains unknown and was the subject of the present investigation. Twelve healthy males received 100 mg spironolactone, once daily, for 15 days. Repeated blood samples were taken on days 1, 8 and 15 for estimation of spironolactone and its metabolites. Peak serum levels [mean (SD)] of spironolactone, canrenone, and sulfur-containing metabolites IV and V were 72 (45), 155 (43), 359 (106) and 101 (26) ng/ml, respectively on day 1 and 80 (20), 181 (39), 391 (118) and 125 (24) ng/ml, respectively on day 15. The AUC (0-24) values of these compounds on day 15 were 231 (50), 2173 (312), 2804 (777) and 1727 (367) ng.hr/ml, respectively and the post-steady state elimination half-life (t1/2) values were 1.4 (0.5), 16.5 (6.3), 13.8 (6.4), and 15.0 (4.0) hours, respectively. It was concluded that unmetabolized spironolactone is present in the serum and that the sulfur-containing metabolite IV rather than canrenone is the major metabolite in serum following single or repeated doses of spironolactone.

Building a relational database for a physician document index

We show how three existing medical knowledge bases: Medical Subject Headings (MeSH), Standardized Nomenclature of Medicine (SNOMED) and Current Medical Information and Technology (CMIT) are mapped into a relational data model and stored on an Apollo workstation and an Intelligent Database Machine. Since two of these knowledge bases have been used in the indexing of medical literature and patient records, they can be useful not only as direct views on the organization of medical concepts but also as tools for the retrieval of documents. In order that the concepts from one knowledge base can be connected to those of the other knowledge base, a method has been developed for the semi-automatic merging of MeSH, SNOMED and CMIT. This method takes advantage of the relational model and the synonyms that are given in SNOMED and CMIT, in order to recommend concepts to be merged. An expert interacts with the system to accept or reject the recommendations of the computer. The method would apply equally well to other knowledge bases and is particularly well-suited for knowledge bases that contain tens of thousands of concepts.

A repeated dose pharmacokinetic study of a new hypnotic agent, zopiclone (Imovane)

Eleven volunteers were dosed once daily for 14 days with zopiclone (7.5 mg/day). The peak plasma zopiclone concentration (65 ng/ml) occurred at 1.4 h after dosing and thereafter declined by a biexponential process, with half-lives of 2.0 and 6.5 h, to 3 ng/ml by 24 h after dosing. Repeated once daily dosing did not markedly alter the peak plasma zopiclone concentration or the pharmacokinetic parameters of absorption or elimination.

Comparison of occult blood loss caused by pirazolac and diclofenac sodium: a double-blind crossover study

A study was carried out in 10 healthy subjects to compare the faecal blood loss caused by pirazolac, a new non-steroidal anti-inflammatory drug, and diclofenac sodium, using chromium51-labelled red blood cells. After 1 week on placebo, subjects received at random either 200 mg pirazolac 3-times daily or 50 mg diclofenac sodium 3-times daily for 7 days. They were then crossed over to the alternative medication for a further 7 days, preceded and followed by 1 week on placebo. Stool samples were collected and bulked for each day and total blood loss over 14 days (7 days on treatment and 7 days immediately after) was calculated for each period. The results showed that both drugs caused a greater blood loss than that measured in the placebo run-in period, and diclofenac sodium caused significantly greater blood loss than did pirazolac. Three subjects reported gastro-intestinal side-effects during diclofenac sodium treatment but there were no reports of any side-effects whilst subjects were receiving pirazolac.

Comparative bioavailability of two furosemide formulations in humans

Twelve healthy male volunteers participated in a balanced crossover comparison of a brand-name and generic furosemide formulations. Each treatment was given as a single 40-mg tablet following an overnight fast. Furosemide concentrations in plasma and urine were determined up to 24 h after treatment; urine output and urinary sodium excretion were also measured. In comparison with the brand-name tablets, generic furosemide was significantly less bioavailable. Using a 95% confidence interval approach, generic furosemide gave up to 66% lower maximum furosemide plasma levels, up to 52% less area under the plasma level curve to infinite time, and up to 37% less urinary recovery of furosemide. Comparison of the effect of the two treatments was a less sensitive measurement of bioequivalence. Confidence intervals for differences in urinary output and sodium excretion over the period of maximum effect (0-4 h) were, however, asymmetrical, and pharmacodynamic differences between treatments were significant at the 10% level.

Trazodone--a new assay procedure and some pharmacokinetic parameters

1 A simple and specific procedure is described for the determination of the new anti-depressant trazodone in human plasma utilising reverse-phase HPLC which is sensitive to 20 ng ml-1. 2 Following oral administration of single 50 mg doses of two formulations of trazodone on separate occasions to healthy fasted volunteers, the peak plasma concentration, time to peak concentration, area under the curve, elimination rate constant and half-life were determined. 3 The two formulations are closely similar and they are considered to have comparable bioavailability.

Gas-liquid chromatography of methylpentynol carbamate and its metabolite 3-methylpentyne-3,4-diol

Procedures are described for the determination of methylpentynol carbamate in serum, either by injection into the chromatograph of diluted serum or extraction of the drug into chloroform and injection of an aliquot of the concentrated organic phase; a 4% CDMS column is used. Similar assays for measuring the metabolite 3-methylpentyne-3,4-diol in urine are reported. The methods have been used for measuring methylpentynol carbamate and its metabolite in samples from rats and dogs.

The kinetics of elimination of salicylic acid and the formation of gentisic acid

1. A method for the estimation of gentisic acid in urine has been devised which is based on thin-layer chromatography and fluorimetry.2. In man the urinary excretion of gentisic acid accounted for 0.6% of a 0.32 g dose of aspirin and 1.1% of a 1.28 g dose. The increase in the percentage of the dose excreted as gentisic acid provides further evidence that the elimination of salicylic acid cannot be entirely described by first order kinetics.3. Equations are presented which describe the amount of gentisic acid formed from various doses of salicylic acid in a model system, when elimination proceeds partly by simultaneous first order and zero order kinetics. The close agreement of the experimental and theoretical results indicates that the model provides an acceptable interpretation of salicylic acid elimination in man.