Avanti 3: A Randomized, Double-Blind Trial to Compare the Efficacy and Safety of Lamivudine plus Zidovudine versus Lamivudine plus Zidovudine plus Nelfinavir in HIV-1-Infected Antiretroviral-Naive Patients

The objective of our randomized, multicentre, double-blind, placebo-controlled study was to investigate the safety, tolerability, and antiretroviral and immunological effect of double and triple combination therapy regimens. A total of 105 antiretroviral therapy-naive patients were randomized to receive either zidovudine (300 mg twice per day) plus lamivudine (150 mg twice per day) plus nelfinavir placebo (three times per day) ( n=52), or zidovudine/lamivudine (dose as before) plus nelfinavir (750 mg three times per day) ( n=53) for 28 weeks. After this time, patients were allowed to switch to open-label zidovudine/lamivudine/nelfinavir. The overall log10 reduction from baseline in plasma HIV-1 RNA was significantly greater in the zidovudine/lamivudine/nelfinavir group than the zidovudine/lamivudine group ( P=0.001; median treatment difference, –1.01 log10 copies/ml; 95% confidence interval –1.23 to –0.79), as measured by the average area under the curve minus baseline over 28weeks. Increases from baseline in CD4 cell counts were statistically significantly greater in the zidovudine/lamivudine/nelfinavir group (101.5 cells/ml) than the zidovudine/lamivudine group (47.0 cells/ml; P=0.027) at week 28.

Of note, the addition of nelfinavir from weeks 28–52 led to an increase in the proportion of subjects with plasma HIV-1 RNA <400 copies/ml from 17% (9/52 patients on zidovudine/lamivudine) to 50% (13/26 patients who switched to zidovudine/lamivudine/nelfinavir). Incidence of drug-related adverse events was similar in the two groups, except for nausea (more common in zidovudine/lamivudine group; 40 versus 17%) and diarrhoea (more common in zidovudine/lamivudine/nelfinavir group; 45 versus 14%). In conclusion, our study confirms the efficacy of triple combination therapy with two nucleoside analogues and a protease inhibitor compared with double-nucleoside therapy. Interestingly, the addition of nelfinavir to zidovudine/lamivudine, even after 6 months of double nucleoside therapy, led to a substantial virological benefit that was sustained over 24weeks in a subset of patients.

Pitch and timing abilities in inherited speech and language impairment

Members of the KE family who suffer from an inherited developmental speech-and-language disorder and normal, age-matched, controls were tested on musical abilities, including perception and production of pitch and rhythm. Affected family members were not deficient in either the perception or production of pitch, whether this involved either single notes or familiar melodies. However, they were deficient in both the perception and production of rhythm in both vocal and manual modalities. It is concluded that intonation abilities are not impaired in the affected family members, whereas their timing abilities are impaired. Neither their linguistic nor oral praxic deficits can be at the root of their impairment in timing; rather, the reverse may be true.

Comparison of progenitor cell content in sequential peripheral blood progenitor collections after mobilization with chemotherapy and granulocyte macrophage colony-stimulating factor

Optimal timing of peripheral blood progenitor cell (PBPC) harvest to collect maximal stem cell numbers is unknown. We assessed the progenitor cell content in 128 PBPC harvests from 21 patients primed with chemotherapy and granulocyte macrophage-colony stimulating factor (GM-CSF) in relation to absolute neutrophil count (ANC) at collection time. Samples were obtained by leukapheresis during rebound from chemotherapy-induced neutropenia while receiving GM-CSF, and assayed by flow cytometry for CD34+ and by colony assays for CFU-GM and BFU-E. The CD34+ cell concentrations per sample tended to be greater at an ANC < 1,000 mm3 and decreased with rising ANC (p = 0.001). The CFU-GM and BFU-E concentrations per sample remained relatively constant with rising ANC (p = 0.72, p = 0.90, respectively). Total CD34+ cell number per harvest per kg slightly increased with ANC levels (p = 0.044) whereas the total CFU-GM and the total BFU-E per kilogram increased more modestly with rising ANC (p < 0.001, p < 0.001, respectively). We conclude that after priming with chemotherapy and GM-CSF, PBPC could be collected at different absolute neutrophil counts without greatly affecting total CD34+ cell numbers. The greater concentration of CD34+ progenitor cells at a lower ANC together with the CFU-GM and BFU-E peaking with higher ANC suggest a less mature progenitor cell population at lower ANC levels.

Laser removal of oxides and particles from copper surfaces for microelectronic fabrication

Laser removal of surface oxides and small particles from copper surfaces was carried out using a Q-switched Nd:YAG laser. Oxide layers and small particles on copper surfaces should be removed for the improvement of solder quality on printed circuit boards (PCBs) and for the prevention of circuit failure or loss of production yield during the fabrication of microelectronic devices. A selective removal of surface oxides from a copper surface was achieved by the laser treatment, which was confirmed by on-line acoustic monitoring of the process. An angular laser cleaning technique in which the laser irradiates the surface at a glancing angle was used for effective removal of the particles from the surface. The unique characteristics of this technique and the cleaning mechanism are discussed.

Examination of factor structure of the cognitive representations of hypertension scale for ethnic equivalence

The major purpose of this analysis was to examine the factor structure of separate interpretive dimensions of the Cognitive Representation of Hypertension Scales (CRHTN) for ethnic equivalence. The CRHTN is a theoretically derived measurement of individualized experience of hypertension assessed along three cognitive interpretive dimensions: perceptions, preferences and possibilities. The sample for this study was recruited from a university-based hypertension clinic, a Veterans Administration ambulatory service, and a large urban-based HMO. Analysis of data through confirmatory factor analysis techniques across both samples provided evidence for construct validity of a five-factor model along three dimensions: perceptions, preferences and possibilities. However, multigroup analyses suggest the model may not equally describe cognitive representations of hypertension for different ethnic groups. Differences in fit of the theoretical model to data from two different ethnic groups is discussed. Findings from this study provide a basis for development of culturally sensitive and appropriate cognitive strengthening strategies to influence behavioral outcomes for hypertension management.

Centriacinar remodeling and sustained procollagen gene expression after exposure to ozone and nitrogen dioxide

Sprague-Dawley rats were exposed to 0.8 ppm ozone (O3), to 14.4 ppm nitrogen dioxide (NO2), or to both gases simultaneously for 6 h per day for up to 90 d. The extent of histopathologic changes within the central acinus of the lungs was compared after 7 or 78 to 90 d of exposure using morphometric analysis by placement of concentric arcs radiating outward from a single reference point at the level of the bronchiole- alveolar duct junction. Lesions in the lungs of rats exposed to the mixture of gases extended approximately twice as far into the acinus as in those exposed to each individual gas. The extent of tissue involvement was the same at 78 to 90 d as noted at 7 d in all exposure groups. At the end of exposure, in situ hybridization for procollagen types I and III demonstrated high levels of messenger RNA within central acini in the lungs of animals exposed to the combination of O3 and NO2. In contrast, animals exposed to each individual gas had a similar pattern of message expression compared with that seen in control animals, although centriacinar histologic changes were still significantly different from control animals. We conclude that the progressive pulmonary fibrosis that occurs in rats exposed to the combination of O3 and NO2 is due to sustained, elevated expression of the genes for procollagen types I and III. This effect at the gene level is correlated with the more severe histologic lesions seen in animals exposed to both O3 and NO2 compared with those exposed to each individual gas. In contrast, the sustained expression of the procollagen genes is not associated with a shift in the distribution of the lesions because the area of change in each group after 7 d of exposure was the same as after 78 to 90 d of exposure.

Fournier's gangrene with an unusual urologic etiology

Fournier's gangrene is a necrotizing infection affecting the male genitalia and perineum, caused by synergistic aerobic and anaerobic organisms. We report on a previously undescribed upper urinary tract etiology for this life-threatening infection.

Supplemental Security Income (SSI), Disability Insurance (DI), and substance abusers

Federal legislation repealed Supplemental Security Income (SSI) and Disability Insurance (DI) for alcohol and drug abusers as of January 1997. This article outlines the context in which the legislation was passed and summarizes concerns resulting from the legislation. We discuss the effects of the legislation on treatment participation, financing, and availability, and the legislation's impact on individuals with dual mental health and substance abuse problems. We also consider the individual and societal implications of substance abusers' loss of monthly income and health insurance.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy

PURPOSE/OBJECTIVE

1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response.

METHODS AND MATERIALS

Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression.

RESULTS

Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010).

CONCLUSION

The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

Evaluation of the efficacy of Eimeria maxima oocyst immunization with different strains of day-old broiler and roaster chickens

The performances of three different strains of male and female broiler or roaster chickens immunized at 1 day of age with a drug-resistant field isolate of Eimeria maxima were evaluated in battery and floorpen immunization trials. No difference in immunization potential was seen between these strains or sexes of day-old chickens immunized with 2500 oocysts/bird of E. maxima and challenged at 10 days of age with 25,000 oocysts/bird of the same isolate in two separate battery trials. All immunized birds showed significant protection for the parameters of weight gain and midintestinal lesion scores at 7 days post challenge (PC) when compared with nonimmunized challenged controls. In two separate floorpen trials, one broiler bird strain (designated strain 2) immunized by the same procedure and challenged at 21 days of age with the equivalent of 25,000 oocysts/bird of the same isolate showed significant protection for weight gain and lesion scores at 7 days PC when compared with nonimmunized controls. Birds in these same floorpen experiments immunized with E. maxima and then fed three different anticoccidial shuttle diets (narasin and nicarbazin 90 grams/ton (g/t) in starter feed and narasin 72 g/t + roxarsone 45.4 g/t in grower feed; nicarbazin 113 g/t in starter feed and narasin 72 g/t + roxarsone 45.4 g/t in grower feed; and monensin 100 g/t in starter and grower feed) showed no interference with elicited immunity with E. maxima challenge for the same parameters measured. No significant difference was seen between any floorpen immunized bird groups for total weight gain at trial terminations (49 days of age).

The impact of the Women, Infants and Children Food Supplement Program on birth outcome

OBJECTIVE

Our purpose was to compare the birth outcomes of pregnant women in the Women, Infants and Children Food Supplement Program with women not in the program.

STUDY DESIGN

The vital records of 4713 women, 2895 enrolled in the Women, Infants and Children Food Supplement Program and 1812 not enrolled in the program, whose infants were delivered at Wishard Memorial Hospital over 18 months were reviewed with respect to age, education, race, substance habits, trimester of entry into prenatal care, maternal weight gain, and status in the program. The primary outcome variables evaluated were low birth weight, as defined by the delivery of an infant < 2500 gm, and infant mortality. The primary predictor was program participation versus nonparticipation. Analysis was by t test, chi2, and logistic regression models.

RESULTS

Black women, women with no prenatal care, and women who smoke were more likely to deliver a low-birth-weight infant. The incidence of low birth weight was 13.1% for nonparticipants versus 10.2% for program participants (p < 0.05). Univariate analysis confirmed program participants to be at significantly less risk for a low-birth-weight delivery (odds ratio = 0.75, p < 0.05). This relation, however, was not significant in the multivariate model (odds ratio = 0.88), indicating that the effect of participating in the program is being confounded by race, entry into prenatal care, and smoking. The overall infant mortality rate was 12.4 per 1000 for participants and 16 per 1000 for nonparticipants (p = not significant).

CONCLUSION

Nutritional and nonnutritional benefits to participation in the Women, Infants and Children Food Supplement Program were confirmed. Women enrolled in the program were less likely to deliver a low-birth-weight infant. Multiple variables likely contribute to the poorer outcome for nonparticipants.

Increased incidence of central venous catheter-related infections in bone marrow transplant patients

In view of an apparent increase of central venous catheter-related infections among our bone marrow transplant (BMT) patients, a retrospective study of infectious complications of central venous catheters was conducted. During 1992, 147 central venous catheters were placed in 133 patients. The overall infection rate of all catheters was 3.3 per thousand catheter-days (bacteremia 1.8, site infection 1.5). Patients scheduled for BMT had the highest infection rate of 11.5 (bacteremia 6.7, site infection 4.8). HIV patients had an infection rate of 6.6 per thousand catheter-days (bacteremia 3.8 and site infection 2.8) and patients with other diagnoses had a rate of 2.4 (bacteremia 1.3 and site infection 1.1). The difference of infection risk among the three groups is statistically significant (logrank p < .0001). In analyzing the 11 BMT patients more carefully, 14 catheters were placed. Of these, 9 catheters were removed, 8 (89%) of which were secondary to infection. Multivariate analysis showed that patients under 50 and BMT patients were more likely to develop catheter-related infection. While the cause of this complication is not known at present, the possible association with PBSC harvest is of much concern.

Praxic and nonverbal cognitive deficits in a large family with a genetically transmitted speech and language disorder

A pronounced speech and language disorder affecting half of the 30 members of the four-generational KE family has been attributed by some researchers to a specific defect in the generation of morphosyntactic rules. The reported selectivity of the impairment has led to the view that the affected members suffer from a grammar-specific disorder. Our investigations of the same KE family indicate that the inherited disorder has a broad phenotype which transcends impaired generation of syntactical rules and includes a striking articulatory impairment as well as defects in intellectual, linguistic, and orofacial praxic functions generally. Although the evidence from this family thus provides no support for the existence of "grammar genes," their linguistic difficulties do constitute a prominent part of their phenotype. Investigations of the neural and genetic correlates of their disorder could therefore uncover important clues to some of the bases of the primary human faculties of speech and language.

Cyclo-oxygenase blockade abrogates the endotoxin-induced increase in Na(+)-dependent hepatic amino acid transport

BACKGROUND

Endotoxemia is characterized by a marked increase in the uptake of amino acids by the liver, but the regulation of this response has not been fully elucidated. In the current study, we investigated the potential role of prostaglandins as mediators of this response. We examined the in vivo effects of the anti-inflammatory agent ketorolac, a cyclo-oxygenase inhibitor that blocks prostaglandin synthesis, on hepatic amino acid transport activity in endotoxin-treated rats.

METHODS

We assayed the activities of the Na(+)-dependent transport systems A and N in hepatic plasma membrane vesicles prepared from endotoxemic rats that were pretreated with ketorolac or vehicle. Hepatic plasma membrane vesicles were prepared by differential centrifugation, and the transport of [3H]glutamine (system N) and [3H]2-methylamino-isobutyric acid (system A) was assayed. Hepatic plasma membrane vesicles were also prepared from normal rats that received prostaglandin E2, and glutamine and MeAIB transport were measured.

RESULTS

Endotoxin treatment resulted in a twofold to threefold increase in Na(+)-dependent amino acid transport activity in hepatic plasma membrane vesicles secondary to an increase in the transport Vmax, which was consistent with the appearance of increased numbers of corresponding transporter proteins in the hepatocyte plasma membrane. Pretreatment with ketorolac almost completely abrogated the endotoxin-induced increase in hepatic amino acid transport. Administration of prostaglandin E2 to normal rats resulted in a statistically significant increase in glutamine and alanine transport by hepatic plasma membrane vesicles prepared from these animals.

CONCLUSIONS

Prostaglandins play a key role in mediating the accelerated hepatic amino acid transport that occurs during endotoxemia.

Collagen mRNA content and distribution in the lungs of rats exposed to ozone

cDNAs, synthesized by the polymerase chain reaction (PCR) technique, were used to quantify mRNA concentrations for the alpha 1 (I) and alpha 1 (III) chains of collagen types I and III and for beta-actin in the lungs of rats exposed to either filtered air or to 1.2 ppm of ozone. The alpha 1 (I) procollagen mRNA concentration was increased by about 30% in the lungs of rats exposed to ozone, while the concentrations of the mRNAs for alpha 1 (III) procollagen and for beta-actin were the same in the lungs of control and ozone-exposed animals. The lungs from the rats exposed to 1.2 ppm of ozone preferentially synthesized type I collagen as compared with controls. Sites of increased expression of the alpha 1 (I) procollagen mRNA were detected by in situ hybridization in lung sections embedded in paraffin prepared from rats exposed either to filtered air or to ozone. The lungs from rats treated with ozone focally expressed increased amounts of alpha 1 (I) procollagen mRNA in the lung parenchyma at the septal tips and the bronchiole-alveolar duct junctions. They also showed an apparent diffuse increase in alpha 1 (III) procollagen mRNA expression. We conclude that exposure of rats to high concentrations of ozone causes a specific increase in the lung content of mRNA for the major chain of type I collagen.

Comparative study of infectious complications of different types of chronic central venous access devices

BACKGROUND

Various devices for central venous access are widely used in patients with cancer. The authors studied the incidence of infectious complications affecting these different devices.

METHODS

A retrospective study of 111 central venous access devices (VAD) placed in 1992 was conducted.

RESULTS

Subcutaneous ports were placed in 42 patients, single lumen Groshong catheters in 45, single lumen Hickman catheters in 15, double lumen Hickman catheters in 5, and double lumen Groshong catheters in 4. Prognostic factors analysis was performed with the log rank test and Cox's multivariate analysis. Different VAD types were compared with the likelihood ratio test. There was no significant difference in the risk of VAD-related infection between Hickman and Groshong catheters. Double lumen catheters were slightly more likely to cause infectious complications than single lumen catheters, although the difference was not statistically significant (P = 0.072 and 0.083 for bacteremia and site infection, respectively). No significant difference was observed in the risk of infection between subcutaneous ports and external catheters. Multivariate analysis using Cox's proportional hazards model demonstrated age younger than 50 years as the only significant risk factor, thus younger patients should be monitored more closely.

CONCLUSIONS

No significant difference was observed in the risk of infection between subcutaneous ports and external catheters. There was a slightly higher risk of infection in double lumen catheters than single lumen catheters, although the difference did not reach statistical significance. Considering the small sample size, the results should be confirmed in larger prospective studies.

Peripheral blood stem cells harvested during marrow recovery from disease-specific chemotherapy shorten duration of neutropenia in patients undergoing autologous bone marrow transplantation

A total of 41 patients who underwent autologous bone marrow transplantation without the use of granulocyte-macrophage colony-stimulating factor were retrospectively evaluated to determine whether the infusion of peripheral blood stem cells collected during the period of recovery of bone marrow from previous disease-specific chemotherapy could shorten the time to bone marrow engraftment after transplantation. Of the 41 patients, 24 patients received bone marrow only (group 1), 8 patients received bone marrow plus steady-state peripheral blood stem cells (group 2) and 9 patients received bone marrow plus rebound peripheral blood stem cells collected during the period of recovery from disease-specific chemotherapy (group 3). Infusion of rebound peripheral blood stem cells (group 3) accelerated recovery of white blood cells and neutrophils and resulted in a white blood cell count of > 10(9)/L by day 15 compared with day 25 in group 1 (P < 0.001), and a neutrophil count of > 0.5 x 10(9)/L by day 16 versus day 26 in group 1 (P = 0.0034). Addition of steady-state peripheral blood stem cells (group 2) did not hasten myeloid engraftment, and recovery of platelets was not improved in either group given peripheral blood stem cells. Compared with patients in group 1, patients in group 3 required 7 fewer days of parenteral antibiotics (25 days versus 18 days, respectively; P = 0.0072) and were discharged about 3 weeks earlier than patients in group 1 (day + 41 verus day +21; P = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)