Long-term efficacy of combination therapy with interferon-alpha 2b and ribavirin for severe chronic hepatitis C in HIV-infected patients

BACKGROUND

We have assessed the long-term efficacy and safety of a combination therapy of interferon alpha-2b (IFN) and ribavirin (RBV) for the treatment of severe chronic hepatitis C in co-infected HIV-seropositive patients in an open prospective study.

METHODS

Fifty-one patients were treated for 12 months. Mean baseline CD4 cell count, alanine aminotransferase and aspartate aminotransferase were 412 +/- 232 x 106/l, 113 +/- 75 IU/l and 111 +/- 84 IU/l respectively. The mean Knodell score was 11.5 +/- 2.1 with 28 patients (55%) exhibiting histological evidence of active cirrhosis.

RESULTS

Fifteen (29%) patients discontinued the treatment prematurely because of adverse events. An end of treatment response (ETR) as defined by the lack of detectable hepatitis C virus (HCV) RNA in plasma at the end of treatment was achieved in 15 patients (29%). A sustained virological response (SVR), defined by the lack of detectable HCV RNA in plasma 6 months after completion of combination therapy, was achieved in 11 patients (21%). The HCV genotype 3a was associated with ETR and SVR (P = 0.002 and P = 0.003, respectively). HCV viraemia at baseline was lower in patients who achieved SVR and ETR than in those who did not (6.7 +/- 7.8 versus 24 +/- 26.7 x 10(6) genome equivalents/ml, P = 0.03 and 14.3 +/- 28.7 versus 22.5 +/- 23, P = 0.05, respectively).

CONCLUSION

Our results indicate that combination therapy with IFN and RBV is effective in approximately 20% of co-infected patients with severe liver disease.

[Chronic cough in children: signs of serious disease and investigations]

Only in some particular cases chronic cough requires special investigations. Respiratory diseases linked to environment are frequent in children. Cough is the most common symptom in child asthma and usually occurs during sleep or exercise. Environmental tobacco smoke exposure may concern up to 30% of families. Questioning should systematically check for parental smoking in children with chronic cough since avoidance is the only effective treatment. The incidence of whooping cough appears to be increasing and the diagnosis may be difficult among already immunized children in whom symptoms are often nonspecific. Nowadays Bordetella pertussis can easily be detected on nasal smears (ELISA, PCR, cultures). Swallowing dysfunction may cause productive cough in toddlers, most often related to functional dyspraxia, yet possibly due to aerodigestive tract malformation. Unrecognized bronchial foreign body is a well-known pitfall particularly between 9 and 36 months of age. Bronchiectasis and cystic fibrosis are responsible for chronic productive cough in toddlers and older children. In teenagers, psychogenic coughing is difficult to manage and usually requires psycho- and speech therapy.

Molecular basis of a selective C1s deficiency associated with early onset multiple autoimmune diseases

We have investigated the molecular basis of selective and complete C1s deficiency in 2-year-old girl with complex autoimmune diseases including lupus-like syndrome, Hashimoto's thyroiditis, and autoimmune hepatitis. This patient's complement profile was characterized by the absence of CH50 activity, C1 functional activity <10%, and undetectable levels of C1s Ag associated with normal levels of C1r and C1q Ags. Exon-specific amplification of genomic DNA by PCR followed by direct sequence analysis revealed a homozygous nonsense mutation in the C1s gene exon XII at codon 534, caused by a nucleotide substitution from C (CGA for arginine) to T (TGA for stop codon). Both parents were heterozygous for this mutation. We used the new restriction site for endonuclease Fok-1 created by the mutation to detect this mutation in the genomic DNA of seven healthy family members. Four additional heterozygotes for the mutation were identified in two generations. Our data characterize for the first time the genetic defect of a selective and complete C1s deficiency in a Caucasian patient.

[A structured pain interview for geriatric patients]

BACKGROUND

In old age, assessment of pain often is hampered by sensory and cognitive deficits that do not allow the patients to fill in standardized questionnaires without help from significant others. Therefore, as an alternative, we developed a structured pain interview, and examined its properties and acceptance in a sample of geriatric patients with pain.

METHODS

The interview covers site of pain, intensity of pain, its duration and persistency, pain related disability and, finally, emotional and cognitive variables. In addition, the interviewer addresses significant others to get information about medication, previous treatment, and residence, and administers the Mini-Mental-State-Examination (MMSE). The analysis includes 128 patients of pain centers older than 74 years, of whom 80% are female.

RESULTS

Forty percent of the subjects score below the critical MMSE value < or =23 indicative of cognitive impairment. These patients are responsible for 36 out of a total of 39 missing values. A significant increase of missing values is observed in patients with a MMSE score below 10. Cognitive impairment goes along with greater functional and social disability. On the other hand, cognitive impairment is unrelated to localization, intensity, and duration of pain. The memory item of the MMSE can be used as a screening tool for cognitive impairment. Patients, who are unable to recall any of the three objects, comprise 80% of the total of missing values and demonstrate a low MMSE score.

CONCLUSION

As long as geriatric patients are able to communicate verbally, they are most likely to profit from the structured pain interview in spite of existing cognitive impairment. A MMSE score <10 indicates that the interpretation of the data obtained may be difficult, especially due to a high frequency of missing values.

The immunomodulator Linomide: role in treatment and prevention of autoimmune diabetes mellitus

Insulin-dependent diabetes mellitus (IDDM) is considered to be an autoimmune disorder characterized by destruction of the pancreatic beta-cells by auto-reacting lymphocytes. An attractive therapeutic approach to this disease would be to abrogate the autoimmune process at an early stage, thus preserving a critical mass of pancreatic beta-cells necessary for maintenance of normal glucose tolerance. Linomide (quinoline-3-carboxamide, Roquinimex, LS 2616), is a novel, orally absorbed, immunomodulatory drug that has been shown to be effective in various models of autoimmunity without causing non-specific immunosuppression. In this review, we describe the efficacy of Linomide for ameliorating the autoimmune process and diabetes in the non-obese diabetic (NOD) model of IDDM when administered at early stages of the disease. We also show that advanced disease in the NOD mouse can be treated effectively by combining Linomide with therapeutic modalities designed to increase pancreatic beta-cell mass. Subsequent clinical studies have shown that Linomide preserves beta-cell function in individuals with new-onset IDDM. Based on these data, Linomide or derivatives thereof might be useful for treatment of human IDDM.

Plasma levels of immunoinflammatory markers in De Novo coronary atherosclerosis and coronary restenosis postangioplasty

OBJECTIVE

To compare circulating plasma levels of immunoinflammatory markers in patients with known de novo coronary artery disease and patients with postangioplasty restenosis.

METHODS

Using enzymatic immunoabsorbent assay, we measured plasma levels of soluble interleukin-2 receptosr, tumor necrosis factor alpha, and soluble tumor necrosis alpha receptors I and II in 11 patients with restenosis postcoronary angioplasty (restenosis group), in 10 patients with primary atherosclerosis (de novo group) who were referred for coronary angiography because of stable or unstable angina, and in 9 healthy volunteers (control group). Levels of soluble interleukin-2 receptors were significantly higher in the de novo group compared with that in the restenosis and control groups. Levels were also higher in the restenosis group compared with that in the control group. Plasma levels of tumor necrosis alpha and receptor levels were significantly higher in the de novo group compared to with that in the restenosis and control groups, but levels in the restenosis group were not different from that in the controls.

CONCLUSION

Coronary artery disease, either primary or secondary to restenosis, is associated with significant immunoinflammatory activity, which can be assessed by examining the extent of circulating plasma levels of inflammatory markers. Moreover, patients with de novo lesions appear to have increased inflammatory activity compared with patients with restenosis.

Long-term clinical outcome of human immunodeficiency virus-infected patients with discordant immunologic and virologic responses to a protease inhibitor-containing regimen

Within a prospective cohort of 150 human immunodeficiency virus (HIV)-infected patients who began first-line protease inhibitor therapy in 1996, the outcome of 42 patients with discrepant virologic and immunologic responses to antiretroviral treatment at 12 months was analyzed at 30 months of treatment. The incidence of AIDS-defining events and deaths (14%) in the group of patients with immunologic responses in the absence of a virologic response was higher than that in full-responder patients (2%); yet, the incidence in this group was lower than that in patients with no immunologic response, despite a virologic response (21%), and was lower than that in patients without an immunologic or virologic response (67%; P<.0001, log-rank test). Differences in outcome were significant (relative risk, 6.9; 95% confidence interval, 1.9-39.3) when factors for progression were compared with those of responder patients. The results support the relevance of the CD4 cell marker over plasma HIV load for predicting clinical outcome in patients who do not achieve full immunologic and virologic responses.

Do High-flux Dialysis Membranes Affect Renal Dyslipidemia?

High-flux hemodialysis has been reported to attenuate renal dyslipidemia. To evaluate the contribution of dialysis membrane composition per se, we compared the impact on the lipoprotein profile of hemodialysis (HD) with a conventional cellulose dialysis membrane with that of a synthetic high-flux dialysis membrane in standard hemodialysis mode. Forty-two patients (24 men, 18 women; mean age, 69 years; range, 39-85 years) on maintenance HD with cellulosic dialysis membranes were randomized and stratified for diabetes mellitus to 12 weeks of HD treatment with either a cellulose acetate (CA; n = 23) or polyacrylonitrile (AN69; n = 19) membrane. HD was performed in a conventional low-flux standard HD mode 4-6 hours/session. Plasma levels of lipids (TC, TG), apolipoproteins (A-I, B, C-III, E), lipoprotein (a) (Ip(a)), and individual apoA and apoB containing lipoproteins (LP-A-I, LP-A-I:A-II, LP-B, LP-Bc) were determined. At baseline, the AN69 group had slightly higher plasma concentrations of apoC-III and C-III/HS, but there were no other differences at entry in study variables between the treatment groups. Twelve week treatment with an AN69 membrane did not result in any significant changes in lipoprotein profile compared with treatment with a cellulose acetate membrane. HD with AN69 dialysis membranes in the conventional low-flux standard hemodialysis mode does not affect the lipoprotein profile.

Variations of dose and electrode spacing for rat breast cancer electrochemical treatment

Electrochemical treatment (EChT) with direct current delivered through implanted electrodes has been used for local control of solid tumors in humans. This study tested the hypothesis that rat breast cancer responses to EChT are dependent on electrode spacing and dose, and explored suitable parameters for treating breast cancers with EChT. Rat breast cancers were initiated by injecting 1 x 10(6) MTF-7 cells to the right mammary gland fat pad of Fisher 344 female rats. The rats were randomly divided into designated experimental groups when the tumors grew to approximately 2 x 2 x 2 cm. One hundred and thirty rats were used for a survival study and 129 for a pathology study. A 4-channel EChT machine was used to administer coulometric doses. The survival study indicated that local tumor control rate is less than 40% in the 40 coulomb (C) and 60 C groups and more than 70% in the 80 and 100 C groups. Sixty six rats died of primary tumors, including all 10 rats in the control group. Once a rat's primary tumor was controlled, no recurrence was found. The main reason for terminating the primary tumor-free rats (51) was lymph node metastasis. Thirteen tumor-free rats survived for more than 6 months. The pathology study showed a significant dose effect on EChT induced tumor necrosis. At 10, 20, 40, and 80 C, the fraction showing necrosis were 39.7, 52.3, 62, and 77.7%, respectively (P </= 0.001). Electrodes spacing was not an important factor within a given range. At 5, 10, and 15 mm spacing, the fraction showing the necrosis were 54.1, 60.4, and 59.2%, respectively (P = 0.552). The overlap rate of necroses was similar in the 5 and 10 mm groups (82.5 and 85%) and lower in the 15 mm group (65%). We conclude that the tumor responses to EChT, local control, survival rates, and necrosis percentages were significantly increased with increasing dose. The changes in electrode spacing (3, 5, and 10 mm) did not significantly affect the tumor responses to EChT within the same dose. For a diameter of 2.0-2.5 cm rat breast cancer, EChT should be applied with 5-10 mm spacing and a minimum dosage of 80 C.

Cryptogenetic multifocal ulcerous stenosing enteritis: an atypical type of vasculitis or a disease mimicking vasculitis

BACKGROUND/AIMS

Cryptogenetic multifocal ulcerous stenosing enteritis (CMUSE) is a rare disease whose origin is unknown. The aim of this study was to describe the clinical spectrum of CMUSE, to determine the origin and pathophysiology of the disease, and to propose a treatment strategy.

METHODS

A total of 220 French gastroenterology departments were contacted to review patients with unexplained small bowel strictures. Of 17 responses, 12 corresponded to a diagnosis of CMUSE. These patients were hospitalised between 1965 and 1993 and their medical records were reviewed.

RESULTS

All patients (mean age 42.1 (4.4) years) had intestinal and five had extraintestinal symptoms (peripheral neuropathy, buccal aphthae, sicca syndrome, polyarthralgia, Raynaud's phenomenon, arterial hypertension). One patient had heterozygous type I C2 deficiency (28 base pair gene deletion). Two to 25 (mean 8.3 (1.9)) small intestine strictures were found. Stenoses of the large jejunoileal arteries were observed on two and aneurysms on three of five mesenteric angiograms. Despite surgery, symptoms recurred in seven of 10 patients and strictures in four. Steroid therapy was effective but caused dependence. One untreated patient died. Small bowel pathology showed superficial ulceration of the mucosae and submucosae, and an inflammatory infiltrate made of neutrophils and eosinophils.

CONCLUSIONS

CMUSE is an independent entity characterised by steroid sensitive inflammation of the small bowel which often recurs after surgery. CMUSE may be related to a particular form of polyarteritis nodosa with mainly intestinal expression or with an as yet unclassified vasculitis.

Labeling effects of a controversial psychiatric diagnosis: a vignette experiment of late luteal phase dysphoric disorder

During the 1990s debate arose about the inclusion of Late Luteal Phase Dysphoric Disorder in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual. Opponents argued that the inclusion of this category would increase stigma and be used as a legal defense for child abuse and other violent crimes. Proponents argued that it would decrease stigma and enhance treatment seeking. Using an experimental vignette design, we tested these propositions in a study of 307 men and women living in Putnam County, New York. In general, the results do not indicate a pervasive negative impact of this label. On the other hand, labeling the disorder a "psychiatric condition" did increase recommendations for psychiatric help.

Lack of evidence of a specific role for C4A gene deficiency in determining disease susceptibility among C4-deficient patients with systemic lupus erythematosus (SLE)

The aim of the present study was to investigate the prevalence of C4 and C2 deficiencies and to characterize genomic alterations in C4 genes in a large cohort of 125 unselected patients with SLE. We determined the protein concentration and functional activity of C2 and C4, as well as the C4 phenotype. C4 genotyping included Taq 1 restricted fragment lengh polymorphism (RFLP) analysis and polymerase chain reaction using sequence-specific primers (SSP-PCR). Type I C2 deficiency was diagnosed by PCR. Overall, 79.2% of the patients exhibited abnormalities of the C4 genes including deletion, non-expression, gene conversion and duplication. Among C4-deficient patients (n = 66, 52.8% prevalence), 41.0% of the patients exhibited a C4A deficiency and 59.0% a C4B deficiency. Half of the C4 deficiencies were due to a gene deletion. There was a strong association between C4A and C4B gene deletion and the presence of the DRB1*03 allele. Among the silent C4A genes, only two cases were related to a 2-bp insertion in exon 29 of the C4A gene. A gene conversion was demonstrated in eight patients (6.4%). One patient had a homozygous C4A deficiency. Three (2.4%) patients presented with a heterozygous type I C2 deficiency and none with homozygous deficiency. Our results argue against a specific role for C4A gene deficiency in determining disease susceptibility among patients with SLE that are C4-deficient.

Long-term clinical effects of a peritoneal dialysis fluid with less glucose degradation products

BACKGROUND

Glucose degradation products (GDPs) are cytotoxic in vitro and potentially toxic in vivo during peritoneal dialysis (PD). We are presenting the results of a two-year randomized clinical trial of a new PD fluid, produced in a two-compartment bag and designed to minimize heat-induced glucose degradation while producing a near neutral pH. The effects of the new fluid over two years of treatment on membrane transport characteristics, ultrafiltration (UF) capacity, and effluent markers of peritoneal membrane integrity were investigated and compared with those obtained during treatment with a standard solution.

DESIGN

A two-group parallel design with 80 continuous ambulatory peritoneal dialysis patients was used. The patients were randomly assigned to either the new fluid (N = 40) or to a conventional one (N = 40), and were stratified with respect to age, diabetes, and time on PD. Peritoneal transport characteristics were assessed by the Personal Dialysis Capacity (PDCtrade mark) test at 1, 6, 12, 18, and 24 months after inclusion and by weighing the overnight bag daily. Infusion pain and handling were evaluated using a questionnaire. Peritoneal mesothelial and interstitial integrity were evaluated by analyzing overnight effluent dialysate concentrations of CA 125, hyaluronan (HA), procollagen-1-C-terminal peptide (PICP), and procollagen-3-N-terminal peptide (PIIINP) at 1, 6, 12, 18, and 24 months.

RESULTS

The handling of the new two-compartment bag was considered easy, and there were no indications of increased discomfort with the new system. Furthermore, no changes in peritoneal fluid or solute transport characteristics were observed during the study period for either fluid, and neither were there any differences with regard to peritonitis incidence. However, significantly higher dialysate CA 125 (73 +/- 41 vs. 25 +/- 18 U/mL), PICP (387 +/- 163 vs. 244 +/- 81 ng/mL), and PIIINP (50 +/- 24 vs. 29 +/- 13 ng/mL) and significantly lower concentrations of HA (395 +/- 185 vs. 530 +/- 298 ng/mL) were observed in the overnight effluent during treatment with the new fluid.

CONCLUSIONS

We conclude that the new fluid with a higher pH and less GDPs is safe and easy to use and has no negative effects on either the frequency of peritonitis or peritoneal transport characteristics as compared with conventional ones. Our results indicate that the new solution causes less mesothelial and interstitial damage than conventional ones; that is, it may be considered more biocompatible than a number of conventional PD solutions currently in use.

Isolation and characterization of West Nile virus from the blood of viremic patients during the 2000 outbreak in Israel

We report the isolation of West Nile (WN) virus from four patient serum samples submitted for diagnosis during an outbreak of WN fever in Israel in 2000. Sequencing and phylogenetic analysis revealed two lineages, one closely related to a 1999 New York isolate and the other to a 1999 Russian isolate.

Survival of patients with synchronous brain metastases: an epidemiological study in southeastern Michigan

OBJECT

It has been suggested that synchronous brain metastases (that is, those occurring within 2 months of primary cancer diagnosis) are associated with a shorter survival time compared with metachronous lesions (those occurring more than 2 months after primary cancer diagnosis). In this study the authors used data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the incidence of synchronous brain metastases and length of survival of patients in a defined population of southeastern Michigan residents.

METHODS

Data obtained in 2682 patients with synchronous brain metastases treated between 1973 and 1995 were reviewed. Study criteria included patients in whom at least one brain metastasis was diagnosed within 2 months of the diagnosis of primary cancer and those with an unknown primary source. The incidence per 100,000 population increased fivefold, from 0.69 in 1973 to 3.83 in 1995. The most frequent site for the primary cancer was the lung (75.4%). The second largest group (10.7%) consisted of patients in whom the primary site was unknown. The median length of survival was 3.2 months. There was no significant difference in the median survival of patients with primary lung/bronchus and those with an unknown primary site (3.3 months and 3.2 months, respectively).

CONCLUSIONS

Patients who present with synchronous lesions have a poor prognosis, and the predominant cause of death, in more than 90% of cases, is related to systemic disease; however, despite poor median survival times, certain patients will experience prolonged survival.

Sulfated glycans induce rapid hematopoietic progenitor cell mobilization: evidence for selectin-dependent and independent mechanisms

The adhesive mechanisms leading to the mobilization of hematopoietic progenitor cells (HPCs) from the bone marrow into the blood are poorly understood. We report on a role for selectins and fucoidan in progenitor mobilization. Baseline levels of circulating HPCs are increased in endothelial selectin-deficient (P/E-/-) mice. Similar levels are observed when E-selectin null (E-/-) mice are treated with anti-P-selectin antibody or with fucoidan (which inhibits P- and L-selectin function). In particular, administration of 2 doses of fucoidan (25 mg/kg) over 6 hours produces profound mobilization of progenitors in wild-type mice and the response is greatly enhanced in E-/- and P/E-/- mice. Competitive reconstitution experiments reveal that fucoidan also elicits long-term (more than 6 months) repopulating stem cells. Mobilization assays using chimeric mice harboring L-selectin-deficient progenitors and wild-type progenitors expressing the green fluorescence protein suggest that L-selectin expression is not required but confers an advantage for fucoidan-induced mobilization. Sulfation is critical as desulfated fucoidan is ineffective. In addition, sulphogalactosylceramide (sulfatide) but not heparin can induce HPC mobilization. Our results indicate that administration of sulfated glycans, especially with concurrent inhibition of E-selectin function, represents a powerful novel method for rapid mobilization of long-term-repopulating stem cells. These findings may help elucidate the mechanisms of HPC trafficking during development and adult life.

An experimental evaluation of theory-based mother and mother-child programs for children of divorce

This study evaluated the efficacy of 2 theory-based preventive interventions for divorced families: a program for mothers and a dual component mother-child program. The mother program targeted mother-child relationship quality, discipline, interparental conflict, and the father-child relationship. The child program targeted active coping, avoidant coping, appraisals of divorce stressors, and mother-child relationship quality. Families with a 9- to 12-year-old child (N = 240) were randomly assigned to the mother, dual-component, or self-study program. Postintervention comparisons showed significant positive program effects of the mother program versus self-study condition on relationship quality, discipline, attitude toward father-child contact, and adjustment problems. For several outcomes, more positive effects occurred in families with poorer initial functioning. Program effects on externalizing problems were maintained at 6-month follow-up. A few additive effects of the dual-component program occurred for the putative mediators; none occurred for adjustment problems.

Clinical outcome of patients with HIV-1 infection according to immunologic and virologic response after 6 months of highly active antiretroviral therapy

BACKGROUND

The prognostic value of discordant immunologic (CD4 cell increase) and virologic (plasma HIV RNA level decrease) responses to antiretroviral treatment is not known.

OBJECTIVE

To study the relation between clinical outcome of HIV-infected patients receiving highly active antiretroviral therapy (HAART) and early immunologic and virologic responses to such therapy.

DESIGN

Prospective cohort study.

SETTING

68 hospitals in France.

PATIENTS

2236 protease inhibitor-naive patients.

INTERVENTION

Initiation of HAART with one protease inhibitor and two nucleoside analogues between July 1996 and March 1997.

MEASUREMENTS

Immunologic and virologic response at 6 months. Multivariate Cox models were used to assess the relation between these responses and progression to a new AIDS-defining event or death.

RESULTS

On the basis of 6-month immunologic and virologic responses, patients were classified into four groups: complete response (47.5%), complete nonresponse (16.2%), immunologic response only (19.0%), and virologic response only (17.3%). After month 6 and within a median of 18 months, 69 patients died and 123 experienced a new AIDS-defining event. After adjustment, complete nonresponders and those with only a virologic response had significantly higher risks for clinical progression at 6 months (relative risk, 3.38 [95% CI, 2.28 to 5.02] and 1.98 [CI, 1.26 to 3.10], respectively) than complete responders. The difference between complete responders and those with only an immunologic response at 6 months was weaker and nonsignificant (relative risk, 1.55 [CI, 0.96 to 2.50]).

CONCLUSIONS

Immunologic response after 6 months of HAART indicates a favorable clinical outcome in HIV-infected patients regardless of virologic response. This suggests that both immunologic and virologic markers should be used in clinical practice to evaluate treatment response.

CD14+CD16++ cells derived in vitro from peripheral blood monocytes exhibit phenotypic and functional dendritic cell-like characteristics

We previously reported an increased percentage of CD14+CD16++ monocytes in the peripheral blood of HIV-infected patients but the physiopathological role of this monocyte subset remains unclear. Cells with a CD14+CD16++ phenotype may be obtained in vitro by culturing human peripheral blood monocytes in the presence of GM-CSF, IL-4 and IL-10. In the present study, we compared the phenotypic and functional characteristics of monocytes-derived CD14+CD16++ cells with those of macrophages and dendritic cells. We show that the CD14+CD16++ cells express dendritic cell markers: CD40, CD80, CD86, HLA-DR, CD11b, CD11c, CD18, CD1a, and CD83. Using RNase protection assay, we demonstrate that CD14+CD16++ cell subset expresses a low ratio of IL-1beta/IL-1ra mRNA and expresses IL-6, MIP-1alpha, MIP-1beta, MCP-1, IL-8, RANTES and I-309 transcripts, similar to dendritic cells. CD14+CD16++ cells produce IL-12, MCP-1 and IL-8, as assessed by flow cytometry. Moreover, CD14+CD16++ cells pulsed with different recall antigens induce a potent autologous T cell proliferation. Altogether, these results provide evidence that CD14+CD16++ cells differentiated in vitro from peripheral blood monocytes exhibit dendritic cell characteristics.

Non-Hodgkin's lymphoma: an analysis of the Metropolitan Detroit SEER database

We evaluated incidence and survival trends of non-Hodgkin's lymphoma (NHL) in a large population-based cancer registry. Data regarding demographics, histology, incidence, and survival were obtained on all patients with NHL registered in the Metropolitan Detroit Cancer Surveillance System, a participant in the Surveillance Epidemiology and End Results (SEER) Program of the National Cancer Institute. Incidence and survival trends from 1973 through 1995 were evaluated and stratified based on age at diagnosis, sex, race, and tumor grade. There were 11,978 patients diagnosed with NHL and recorded in the Metropolitan Detroit SEER registry from 1973 to 1995. The age-adjusted incidence rate increased from 8.6 to 15.8 per 100,000, leading to an overall increase in incidence of 83% and an average annual increase of 3.2% per year. Incidence increased significantly (p < 0.05) over time in all age groups except the youngest (ages 0-19) and in all demographic groups studied. Incidence was highest in white men and lowest in black women. The incidence of both low-grade and intermediate/high-grade NHL increased significantly for each age group (p < 0.05) except the youngest (ages 0-19). In the oldest patients (70+ years), the incidence of intermediate/high-grade NHL was almost double that of low-grade NHL. Five-year relative survival increased from 64% (1973-1983) to 68% (1984-1991) for patients with low-grade NHL and from 40% to 44% for those with intermediate/high-grade NHL. The increase in relative survival was only seen in whites, however, with 5-year relative survival in blacks decreased from 53% (1973-1983) to 45% (1984-1991). In metropolitan Detroit, the current NHL epidemic affects all age groups except the very young (ages 0-19), both sexes, and both whites and blacks and is due to increases in the incidence of both low-grade and intermediate/high-grade NHL. Five-year survival rates have increased for whites but not for blacks.

Efficacy and safety of combination therapy with interferon-alpha2b and ribavirin for chronic hepatitis C in HIV-infected patients

OBJECTIVES

To evaluate the efficacy and safety of a combination therapy of interferon-alpha2b (IFN) and ribavirin for the treatment of chronic hepatitis C in HIV-seropositive patients.

DESIGN

Open prospective trial.

METHODS

Twenty patients co-infected with hepatitis C virus (HCV) and HIV, with a mean CD4 cell count of 350 +/- 153 x 10(6)/l were treated with IFN (3 MU three times per week) in combination with ribavirin (500 mg or 600 mg twice a day) for 6 months. Tolerance and efficacy were monitored at weeks 12 (month 3) and 24 (month 6). The primary endpoint was a complete virological response, as defined by the lack of detectable HCV RNA in serum.

RESULTS

Baseline values of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were 121 +/- 72 IU/l and 75 +/- 67 IU/l, respectively. The total Knodell score was 10.4 +/- 2.4, with nine patients showing histological evidence of active cirrhosis (45%). All patients exhibited circulating HCV RNA. The treatment was well tolerated, with no impact on the course of HIV infection. After 6 months of combination therapy with IFN and ribavirin, 10 patients (50%) exhibited no further detectable HCV RNA viraemia, seven of whom achieved undetectable viraemia at month 3. Levels of ALT and AST decreased after 6 months of treatment from a mean of 121 +/- 72 to 51 +/- 40 IU/l and from a mean of 129 +/- 58 IU/l to 68 +/- 61 IU/l, respectively (P < 0.0002 and P < 0.0001).

CONCLUSION

Our results indicate that combination therapy with IFN and ribavirin is effective in 50% of cases in clearing serum HCV RNA and may thus provide effective means of therapy in HIV-HCV-coinfected patients as initial treatment or in patients who have previously failed IFN monotherapy.

High levels of drug-resistant human immunodeficiency virus variants in patients exhibiting increasing CD4+ T cell counts despite virologic failure of protease inhibitor-containing antiretroviral combination therapy

The genotypic mutations associated with indinavir resistance were analyzed in 27 patients who exhibited sustained CD4+ T cell responses to highly active antiretroviral therapy (HAART), despite virologic failure of treatment. After 12 months of HAART, 1 or 2 primary resistance mutations had occurred in 18 (66%) of the patients, and secondary mutations had accumulated in 22 (88%) of the patients. The number and patterns of mutations in the patients who exhibited discrepant responses to HAART did not differ from those observed in patients who exhibited immunologic and virologic failure to therapy. Results indicate that many patients have prolonged immunologic benefits, despite the development of virologic failure and protease inhibitor mutations. The clinical course of this group of patients calls into question the relevance of genotypic resistance and plasma human immunodeficiency virus RNA level as surrogate markers in patients receiving HAART.

Assessing body composition and changes in body composition. Another look at dual-energy X-ray absorptiometry

Dual-energy X-ray absorptiometry (DXA) is selected with increasing frequency as a method for both assessing body composition and measuring the changes in body composition. Issues have been raised about hydration, software version, hardware (fan beam vs. pencil beam), and the subject population in relation to the validity of DXA-derived estimates of body composition. This paper reviews validation studies of DXA to assess the impact of recent developments in its technology. Studies by Prior et al., Kohrt et al., Salamone et al., Going et al., and Pietrobelli et al. demonstrate the effectiveness of DXA estimates of changes in body composition. By contrast, Clasey et al., Nelson et al., and Friedl et al. found limitations in DXA estimates of body composition and its changes. These contradictory conclusions were explored for threats to internal validity in each research study. From this analysis, two validation guidelines are recommended for use when evaluating estimates of body composition. When multicomponent models are used, it is essential that estimates of body water as a fraction of fat-free mass fall in the expected range (71 to 75%) and have a relatively small standard deviation (2 to 3%). For measuring changes in body composition, DXA estimates of total body mass must accurately reflect both baseline and posttreatment scale body weight estimates. Failure to meet these guidelines threatens the internal validity of the study and raises the likelihood of methodological discrepancies. Applying these criteria to DXA studies of body composition under review accounts for much of the contradictory conclusions among investigations.

P-Selectin glycoprotein ligand 1 (PSGL-1) is expressed on platelets and can mediate platelet-endothelial interactions in vivo

The platelet plays a pivotal role in maintaining vascular integrity. In a manner similar to leukocytes, platelets interact with selectins expressed on activated endothelium. P-selectin glycoprotein ligand 1 (PSGL-1) is the main P-selectin ligand expressed on leukocytes. Searching for platelet ligand(s), we used a P-selectin-immunoglobulin G (IgG) chimera to affinity purify surface-biotinylated proteins from platelet lysates. P-selectin-bound ligands were eluted with ethylenediaminetetraacetic acid. An approximately 210-kD biotinylated protein was isolated from both human neutrophil and platelet preparations. A band of the same size was also immunopurified from human platelets using a monoclonal anti-human PSGL-1 antibody and could be blotted with P-selectin-IgG. Under reducing conditions, both the predicted PSGL-1 approximately 210-kD dimer and the approximately 120-kD monomer were isolated from platelets. Comparative immunoelectron microscopy and Western blotting experiments suggested that platelet PSGL-1 expression is 25-100-fold lower than that of leukocytes. However, patients with chronic idiopathic thrombocytopenic purpura who harbor predominantly young platelets displayed greater expression, indicating that PSGL-1 expression may be decreased during platelet aging. By flow cytometry, thrombin-activated platelets from normal individuals exhibited greater expression than those unstimulated. An inhibitory anti-PSGL-1 antibody significantly reduced platelet rolling in mesenteric venules, as observed by intravital microscopy. Our results indicate that functional PSGL-1 is expressed on platelets, and suggest an additional mechanism by which selectins and their ligands participate in inflammatory and/or hemostatic responses.

Conference highlight: do T cells care about the mitogen-activated protein kinase signalling pathways?

Mitogen-activated protein (MAP) kinases, which include the extracellular response kinases, p38 and c-Jun amino terminal kinases (JNK), play a significant role in mediating signals triggered by cytokines, growth factors and environmental stress. The JNK and p38 MAP kinases have been involved in growth, differentiation and cell death in different cell types. In the present paper, we describe how the JNK and p38 MAP kinase signalling pathways are regulated and their role during thymocyte development and the activation and differentiation of T cells in the peripheral immune system. The results from these studies demonstrate that the JNK and p38 MAP kinase signalling pathways regulate different aspects of T-cell mediated immune responses.

Angiotensin I-converting enzyme gene polymorphism in non-diabetic renal disease

BACKGROUND

The insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene determines the concentration of ACE in serum and local tissues. The role of this polymorphism in progressive chronic renal disease is still not fully clear.

METHODS

We analysed the impact of the D/D polymorphism on the rate of decline in renal function in patients with non-diabetic, chronic progressive renal insufficiency. Seventy non-diabetic patients, aged 21-69 years at baseline, with moderately advanced renal insufficiency due to primary chronic renal disease were followed for an average of 3 years with repeated measurements of their glomerular filtration rate (GFR). Their mean GFR at baseline was 41 ml/min/1.73 m(2) body surface area (BSA). The polymerase chain reaction (PCR) amplification method was used to detect the I/D polymorphism of the ACE gene. GFR was measured as the clearance of (51)Cr-EDTA and the individual rate of progression was calculated using linear regression.

RESULTS

The distributions of the genotypes were: D/D 30%, I/D 49%, and I/I 21%. The rates of progression in the three ACE genotype groups were an annual decline in renal function of -4.2 (SD 4.6) ml/minx1.73 m(2) BSA in the D/D group, -2.7 (SD 3. 4) in the I/D group and -1.7 (SD 3.4) in the I/I group (ANOVA P=0. 12). In patients with proteinuria below 3.5 g/24 h, the D/D group had a significantly higher rate of progression than patients with the I allele. The same was found in a separate analysis when only patients with normal apoliprotein B (below 155 mg/dl) levels were analysed. Furthermore, the D/D genotype was a significant predictor of a more rapid decline in renal function in male, but not female, patients.

CONCLUSION

The results in this study in non-diabetic patients with chronic renal disease indicate that the presence of the D allele in the ACE genotype may be of particular importance as a predictor of a high rate of progression in male patients who otherwise do not have a major burden of documented and important prognostic factors for progressive renal insufficiency.

[Tracheobronchial foreign bodies]

Forty cases of children with an inhaled foreign body (FB) are reviewed over a three-year period. Clinical data, radiologic findings and complications are detailed. The nature and size of FBs are also reported. Diagnosis and management are discussed according to the most recent studies in the literature. Diagnostic flexible bronchoscopy is a useful first step when the diagnosis is unclear (i.e., choking history, unexplained respiratory symptoms), but FB removal is usually not possible during this procedure. Extraction is performed via the rigid bronchoscope under general anesthesia. However, FB could be removed with the flexible bronchoscope in five children in our study. Diagnosis and removal of an inhaled FB are required as quickly as possible in order to prevent respiratory sequelae (bronchiectasis). Prevention is based upon information to be given to families, but to the medical community as well, which often minimizes the seriousness of inhalation hazards.

The prophylactic potential of fludarabine monophosphate in graft-versus-host disease after bone marrow transplantation in murine models

Fludarabine phosphate, a purine analogue currently used in the therapy of hematological malignancies, is known to cause immunosuppression and long-lasting T cell lymphopenia. In this study, the effect of fludarabine on murine graft-versus-host disease occurring after marrow transplantation across major and minor histocompatibility barriers was evaluated. Survival of (BALB/c x C57BL/6)F1 mice irradiated and transplanted across the major histocompatibility barrier with C57BL/6 spleen cells, and subsequently treated with fludarabine was significantly longer than that of the control animals (P < 0.0001). On the other hand, fludarabine had no effect on the graft-versus-host disease and survival of CBA mice transplanted by B10.BR and of BALB/c mice transplanted by B10.D2 spleen cells across the minor histocompatability barrier. The results indicate that in certain murine models, particularly a major mismatch, fludarabine has the potential to induce bilateral tolerance and stable chimerism after marrow transplantation. Bone Marrow Transplantation (2000) 25, 263-266.

Induction of resistance to diabetes in non-obese diabetic mice by targeting CD44 with a specific monoclonal antibody

Inflammatory destruction of insulin-producing beta cells in the pancreatic islets is the hallmark of insulin-dependent diabetes mellitus, a spontaneous autoimmune disease of non-obese diabetic mice resembling human juvenile (type I) diabetes. Histochemical analysis of diabetic pancreata revealed that mononuclear cells infiltrating the islets and causing autoimmune insulitis, as well as local islet cells, express the CD44 receptor; hyaluronic acid, the principal ligand of CD44, is detected in the islet periphery and islet endothelium. Injection of anti-CD44 mAb 1 hr before cell transfer of diabetogenic splenocytes and subsequently on alternate days for 4 weeks induced considerable resistance to diabetes in recipient mice, reflected by reduced insulitis. Contact sensitivity to oxazolone was not influenced by this treatment. A similar antidiabetic effect was observed even when the anti-CD44 mAb administration was initiated at the time of disease onset: i.e., 4-7 weeks after cell transfer. Administration of the enzyme hyaluronidase also induced appreciable resistance to insulin-dependent diabetes mellitus, suggesting that the CD44-hyaluronic acid interaction is involved in the development of the disease. These findings demonstrate that CD44-positive inflammatory cells may be a potential therapeutic target in insulin-dependent diabetes.

Variation in microdeletions of the cyclic AMP-responsive element-binding protein gene at chromosome band 16p13.3 in the Rubinstein-Taybi syndrome

Most reported microdeletions of the CREB-binding protein (CBP) gene in the Rubinstein-Taybi syndrome (RTS) were detected by fluorescence in situ hybridization (FISH) with a single cosmid probe specific to the 3' region of the gene. In order to test the hypothesis that the rate of microdeletion-positive cases would be greater if the entire gene was evaluated, we performed FISH on 66 patients with an established diagnosis of RTS, using a panel of five cosmids that span the CBP gene. Five of 66 patients had deletions by FISH (9%), consistent with those rates reported in various series that ranged between 3-25%. Among our cases, different deletions were observed; one was deleted for the 5' but not the 3' region of the CBP gene (case 055). Other deletions included a total CBP deletion extending from the 5' through the 3' region (case 017), a deletion of all but the 5' region (cases 006 and 060), and an interstitial deletion in the 3' region (case 028). Fine breakpoint mapping with additional cosmid and yeast artificial chromosome (YAC) constructs was performed on these patients. The findings of a partial 5' deletion and of interstitial deletions of the CBP gene add to the known spectrum of mutations of this gene in RTS and demonstrate the need for evaluation of the entire CBP gene region for deletions rather than only the 3' region in RTS patients. These results further suggest that the true rate of microdeletion across the CBP gene detectable by FISH has yet to be established firmly. No phenotypic differences between partial deletion, complete deletion, and nondeletion patients were observed, supporting a haploinsufficiency model for RSTS.

Familial aggregation of breast cancer with early onset lung cancer

Site-specific familial aggregation and evidence supporting Mendelian codominant inheritance have been shown in lung cancer. In characterizing lung cancer families, a number of other cancers have been observed. The current study evaluates whether first-degree relatives of early onset lung cancer cases are at increased risk of breast cancer. Families were identified through population-based lung cancer cases and controls under 40 years of age. Cases were ascertained through the Metropolitan Detroit SEER registry; controls through random-digit dialing. Data were available for 384 female relatives of 118 cases and 465 female relatives of 161 controls. Breast cancer in relatives was evaluated after adjusting for age, race, sex, and smoking status of each family member and the sex and age of the probands. A positive family history of early onset lung cancer increased breast cancer risk among first-degree relatives 5. 1-fold (95% CI, 1.7-15.1). Relatives of cases with adenocarcinoma of the lung were at highest risk (RR = 6.3, 95% CI 2.0-20). Mean age of breast cancer diagnosis among relatives of cases was 52.2 years and not statistically different from relatives of controls. Three case families also reported early ovarian cancers (mean age of diagnosis of 35 years). These findings suggest that shared susceptibility genes may act to increase risk of early onset lung and breast cancer in families.

The antiangiogenic agent linomide inhibits the growth rate of von Hippel-Lindau paraganglioma xenografts to mice

The aim of this study was to ascertain the potential usefulness of the antiangiogenic compound linomide for treatment of von Hippel-Lindau (VHL)-related tumors. Paraganglioma tissue fragments obtained at surgery from a VHL type 2a patient were transplanted s.c. to male BALB/c nu/nu (nude) mice: (a) 2-3-mm fragments for "prevention" experiments; and (b) 2-3-mm fragments allowed to grow to 1 cm for "intervention" studies. Both groups received either 0.5 mg/ml linomide in drinking water or acidified water and were followed until tumor diameter reached 3 cm or for 4 weeks. In both the prevention and intervention experiments, a significant diminution of tumor size and weight was observed in the drug-treated animals. In vivo nuclear magnetic resonance analysis of tumor blood flow in linomide-treated animals showed localization of blood vessels almost exclusively to the periphery of the poorly vascularized tumors with a significant reduction of both vascular functionality and vasodilation. Histological examination of tumors from linomide-treated animals revealed marked avascularity. Treated animals also displayed a 2.4-fold reduction of tumor vascular endothelial growth factor mRNA levels. Taken together, our data indicate that in VHL disease, therapy directed at inhibition of constitutively expressed VEGF induction of angiogenesis by VHL tumors may constitute an effective medical treatment.

Restoration of normal interleukin-2 production by CD4+ T cells of human immunodeficiency virus-infected patients after 9 months of highly active antiretroviral therapy

The present study investigated immune restoration in patients at intermediate stages of human immunodeficiency virus (HIV) disease after initiation of highly active antiretroviral therapy (HAART). A progressive increase in both memory and naive CD4+ T cells was observed from the first weeks of therapy, concomitant with a decrease in the expression of activation markers on CD8+ T cells. The early-activation marker CD69 remained, however, overexpressed on T cells after suboptimal stimulation in vitro, indicative of persistent immune activation. The percentage of interleukin (IL)-2-producing CD4+ T cells significantly increased from 9 months of HAART. In most patients, CD4+ T cells recovered an ability to produce IL-2 on stimulation, similar to that of HIV-seronegative controls. Reversal of T-cell anergy may be a key event in immune restoration for achieving long-term clinical benefit with HAART.

Allogeneic cell therapy in murine B-cell leukemia (BCL1): 2. The role of non-activated and rIL-2-activated CD4+ and CD8+ T cells in immunotherapy for leukemia

Graft-versus-leukemia (GVL) effects play a key role in the elimination of residual leukemia cells in the course of allogeneic bone marrow transplantation (alloBMT). GVL effects can also be induced by donor lymphocyte infusion following alloBMT. We have investigated the role of CD4+ and CD8+ T cells in the development of GVL in mice with B-cell leukemia/lymphoma (BCL1) following allogeneic cell therapy. Sublethally irradiated (C57BL/6 x BALB/c)F1 mice were intravenously inoculated with 10(5) BCL1 cells and given untreated or recombinant human Interleukin-2 (rIL-2)-activated C57BL/6 spleen cells. Effective elimination of clonogenic BCL1 cells was confirmed by adoptive transfer of spleen cells obtained from treated mice into secondary BALB/c recipients. GVL effects were maintained after inactivation of CD4+ cells with monoclonal anti-CD4 antibodies in the inoculum, while inactivation of CD8+ cells with monoclonal anti-CD8 antibodies resulted in complete loss of GVL effects induced both by resting and rIL-2-activated allogeneic spleen lymphocytes. These results indicate that Thy-1 cells play the major role in the induction of GVL effects, mediated by C57BL/6 effector T cells in this model. Since the number of natural killer (NK) cells also increased during in vitro culture with rIL-2, their contribution, especially that of CD8+ NK cells, in GVL effects mediated by rIL-2-activated CD8+ cells cannot be ruled out.

Allogeneic cell therapy in murine B-cell leukemia (BCL1): 1. Alloimmune-mediated graft-versus-leukemia (GVL) effects induced by unmodified and in vitro rIL-2-activated bone marrow and lymphocytes from different lymphoid compartments

We have investigated the efficacy of graft-versus-leukemia (GVL) effects induced by cells obtained from different syngeneic and allogeneic lymphoid compartments, by comparing the response to cell therapy with syngeneic (BALB/c x C57BL/6)F1 (H-2d/b) (F1) or allogeneic C57BL/6 (H-2b) (B6) lymphocytes in F1 recipients inoculated with B-cell leukemia (BCL1) of BALB/c (H-2d) origin. Eradication of BCL1 was confirmed in vivo by adoptive transfer of 10(5) spleen cells obtained from treated mice into syngeneic BALB/c recipients. Immunotherapy induced by allogeneic but not syngeneic spleen and lymph node lymphocytes was therapeutically more effective than thymocytes and bone marrow cells (BMC). Alloreactive cells could be further activated in vivo with recombinant human interleukin-2 (rIL-2). The GVL effect of allogeneic lymphocytes was cell-dose-dependent; a heavy leukemia load was more efficiently eradicated after three doses than after a single dose of allogeneic spleen cells (100% versus 23% disease-free survival rate of secondary adoptive recipients respectively). The GVL effect induced by allogeneic spleen cells was preserved after ex vivo exposure of cells to 250 cGy, but not 500 cGy or more. Interestingly, GVL was preserved following administration of ex vivo irradiated (500 cGy) spleen cells when rIL-2 was administered in vivo (p < 0.05). Syngeneic effector cells did not induce GVL, regardless of in vitro and in vivo activation with rIL-2. Our data suggest that allogeneic but not syngeneic (in analogy to autologous) cell therapy may be an effective tool to control residual leukemia following high-dose chemo-radiotherapy. The feasibility of augmenting GVL by successive doses of activated allogeneic donor lymphocytes, partly inactivated in vitro by low-dose ionizing irradiation to prevent severe graft-versus-host disease (GVHD), may lead to safer therapeutic approaches that can be used to reduce the incidence of relapse while avoiding the risk of uncontrolled GVHD.

The plasma levels of homocysteine are elevated in moderate renal insufficiency but do not predict the rate of progression

BACKGROUND

Chronic renal failure is characterized by specific alterations of the lipoprotein metabolism. It is also characterized by elevated plasma levels of total homocysteine (tHcy). Hyperhomocysteinemia has been shown to be a risk factor for atherosclerosis in both the general population and in patients with end-stage renal disease.

AIM

To analyze whether elevated tHcy levels also may contribute to a higher rate of progression of renal insufficiency in patients with moderately advanced renal failure.

METHODS

To investigate whether tHcy concentrations are associated with an accelerated rate of progression of renal insufficiency, we have correlated baseline plasma concentrations of tHcy with the progressive decline of renal function in an observational study of human chronic renal disease.

RESULTS

Sixty-three nondiabetic patients (49 men, 14 women) were studied as part of an observational study of patients with moderately advanced renal insufficiency. The average follow-up time of the patient population was 3.0 years, and the mean rate of decline in glomerular filtration rate ((51)Cr- EDTA clearance) was -3.2 +/- (SD) 3.9 ml/min x 1.73 m(2) body surface area. The mean plasma concentration of tHcy at the beginning of the study was 28.3 +/- 12.0 micromol/l. Plasma tHcy concentrations correlated significantly with the glomerular filtration rate (r = -0. 32, p < 0.01). However, there was no association between the initial plasma level of tHcy and the rate of progression as assessed by linear regression analysis (r = 0.02; NS). In contrast, increased levels of apolipoprotein B, low-density lipoprotein cholesterol, and proteinuria were all significantly associated with a more rapid decline in renal function.

CONCLUSIONS

Patients with moderately advanced chronic renal insufficiency have elevated plasma levels of homocysteine. The tHcy plasma levels increase in parallel with the degree of reduction in renal function. However, the hyperhomocysteinemia is not prospectively associated with a higher rate of progression of the renal functional impairment. Hence, there is no indication that elevated homocysteine levels play a contributing role for an accelerated glomerulosclerotic process.

A pilot study of exercise training to reduce trunk fat in adults with HIV-associated fat redistribution

OBJECTIVE

Body fat redistribution ('lipodystrophy'), with gain in abdominal and trunk fat, and decline in facial and limb fat, is a newly recognized problem in patients with HIV infection that has been linked to use of HIV-1 protease inhibitors. Increased abdominal fat may predispose these patients to hypertension, diabetes, and coronary artery disease. At this time no effective treatment is available. We examined whether exercise training could reduce trunk fat in men with fat redistribution.

DESIGN

Open-label pilot study.

METHODS

Ten men with increasing abdominal girth participated in a 16 week pilot study of progressive resistance training with an aerobic component. They trained in a community health club three times per week. Total body lean and fat mass, and trunk fat mass, were assessed by dual-energy x-ray absorptiometry (DXA).

RESULTS

After 16 weeks of exercise, strength increased for three of the four exercises tested (leg press + 13% [p < 0.02], leg extension + 19% [p < 0.03], seated row + 7% [p < 0.13], chest press + 18% [p < 0.0051). There was a significant decline in total body fat by 1.5 kg (= 2.1 percentage points, p < 0.01); most of the decline in body fat occurred in trunk fat, which decreased by 1.1 kg (p < 0.03). Weight, lean mass (+ 1.1 + 2.6 kg, p = 0.23), and bone mineral density measured by DXA did not change. No adverse effects were seen from the training.

CONCLUSIONS

Exercise training may reduce trunk fat mass in HIV-positive men with fat redistribution. Controls trials of this approach are warranted.

Efficacy of a five-drug combination including ritonavir, saquinavir and efavirenz in patients who failed on a conventional triple-drug regimen: phenotypic resistance to protease inhibitors predicts outcome of therapy

OBJECTIVE

to assess the safety and efficacy of a combination of ritonavir, efavirenz and two recycled nucleosides in patients who failed on a conventional triple-drug regimen including indinavir or ritonavir.

METHODS

An open label study of ritonavir (100 mg twice daily), saquinavir (1000 mg twice daily), efavirenz (600 mg per day) and nucleoside analogues in 32 saquinavir- and efavirenz-naive protease inhibitor-experienced patients. Patients were included on the basis of plasma levels of HIV RNA above 5000 copies/ml while on conventional antiretroviral therapy. Phenotypic resistance and genotypic resistance mutations to saquinavir were assessed at baseline. Peak and trough plasma levels of saquinavir were monitored throughout the study.

RESULTS

Median CD4 cell counts and median plasma HIV RNA at baseline were 258 x 10(6)/l and 4.31 log10 copies/ml, respectively. The plasma viral load decreased by a median of 1.20 log10 copies/ml and the CD4 cell count increased by a median 60 x 10(6) cells/l at week 24 of therapy. Seventy-one per cent of the patients achieved a plasma viral load < 500 copies/ml and 45% achieved a viral load < 50 copies/ml. Patients exhibiting phenotypic resistance to saquinavir at baseline experienced a median decrease in HIV RNA of 0.91 log10 copies/ml at week 24 of therapy, as compared with a decrease of 1.52 log10 copies/ml in those exhibiting sensitive viral strains (P = 0.03). Genotypic resistance to saquinavir was not predictive of virologic failure.

CONCLUSION

Our results indicate that the combination of ritonavir, saquinavir and efavirenz is safe and effective at 24 weeks in over two-thirds of patients who previously failed on highly active antiretroviral therapy, and that the determination of phenotypic resistance may be of greater value than the detection of resistance mutations to predict the outcome of salvage therapy in this setting.

Care provided by VA mobile clinic staff during Northridge earthquake relief

INTRODUCTION

From 25 January 1994 to 02 February 1994, staff aboard four Veterans Affairs Mobile Clinics treated Northridge earthquake victims. This study examined the types of conditions treated by Clinic staff during the disaster.

METHODS

A descriptive case series using 1,123 ambulatory encounter forms was undertaken. Case-mix was assessed by classifying diagnoses into 120 possible diagnostic clusters.

RESULTS

Forty-five percent of patients were infants or children and 60% were female. The primary diagnoses were characterized by acute conditions: 1) upper respiratory infection (34.6%); 2) stress reactions (11.9%); 3) otitis media (10.1%); and injuries (8%). Two-thirds of the infants and children either had an upper respiratory infection (46.4%) or otitis media (20.1%). Increasing age indicated an increased likelihood of stress and anxiety reactions.

CONCLUSIONS

The results provide additional information for agencies involved in planning for and responding to disasters. Based on the types of conditions diagnosed at the VA mobile clinics (i.e., a high prevalence of acute conditions, including stress and anxiety reactions, and the large numbers of children), staff trained in primary care, mental health, and pediatrics should be considered for relief missions that begin several days after an event resulting in a disaster.

Comparison of subcutaneous and intravenous interleukin-2 in asymptomatic HIV-1 infection: a randomised controlled trial. ANRS 048 study group

BACKGROUND

Intermittent interleukin-2 therapy for HIV-1 by continuous intravenous infusion leads to sustained increase of CD4 T cells. This method of administration is, however, inconvenient and has limiting toxic effects. We did a randomised study to compare safety and efficacy of antiviral treatment alone or combined with various interleukin-2 regimens in HIV-1-infected patients.

METHODS

94 symptom-free patients, naïve to antiretroviral treatment, with CD4-T-cell counts of 250-550 cells/microL at baseline were randomly assigned zidovudine and didanosine alone (n=26) or combined with interleukin-2 administered intravenously (12 million IU/day, n=22) or subcutaneously (3 million IU/m2 twice daily, n=24) for 5 days, or were given polyethylene-glycol-modified (PEG) interleukin-2 (2 million IU/m2 intravenous bolus, n=22) administered every 2 months from week 2 to week 50 (seven cycles). Safety and immunological and virological results were monitored until week 56.

FINDINGS

CD4-T-cell count increased to higher than baseline by a mean of 564 cells/microL (subcutaneous group), 676 cells/microL (intravenous group), 105 cells/microL (PEG group), and 55 cells/microL (antiretroviral-therapy group, p=0.0001). 68% and 77% of patients in the subcutaneous and intravenous groups, respectively, achieved an 80% increase of CD4 T cells (p<0.001). In these two groups, 50% of patients restored a CD4/CD8-T-cell ratio of more than 1. The groups did not differ significantly for changes in plasma HIV-1 RNA loads throughout the study. The duration of common side-effects of interleukin-2 was shorter in the subcutaneous group, which enabled outpatient treatment. Naïve and memory CD4 T cells, CD28 expression on CD4 and CD8 T cells, and restoration of in-vitro proliferative response to mitogens and recall antigens increased in the intravenous and subcutaneous groups.

INTERPRETATION

Subcutaneous interleukin-2 is a convenient regimen that, as well as intravenous therapy, improves immunological function in HIV-1-infected patients receiving two nucleosides. Larger studies are needed to show whether immunological improvements translate into clinical benefit.

Prevention and treatment of graft-versus-host disease by down-regulation of anti-host reactivity with veto cells of host origin

Control of graft-versus-host disease (GVHD) post allogeneic spleen cell transplantation was partly achieved by administration of host-type lymphocytes. (C57BL/6 x BALB/c) F1 mice were conditioned by total body irradiation and transplanted with parental C57BL/6 spleen cells to induce severe GVHD. Infusion of mature host-type lymphocytes did not change the degree of chimerism but protected most of the recipients from lethal GVHD. Treatment of host-type blood cells with anti-CD8 antibodies resulted in loss of the GVHD protective effects mediated by host cells, whereas after treatment of the host with anti-CD4 antibodies protective host cells given 4 days after induction of GVHD resulted in successful rescue of all transplanted recipients from lethal GVHD. Administration of host blood cells could effectively protect against GVHD induced by donor spleen cells and low-dose rIL-2. GVHD protection resulted from down-regulation of alloreactive donor T cells and not by rejection of GVHD effector cells. Taken together, administration of host hematopoietic cells particularly host CD8+ T cells, may be considered for prevention or control of GVHD following allogeneic bone marrow transplantation, thus also explaining the increased resistance of mixed chimeras to GVHD.

Short-term progressive resistance training increases strength and lean body mass in adults infected with human immunodeficiency virus

BACKGROUND

To assess the efficacy of progressive resistance training (PRT) in increasing strength and lean body mass (LBM) in HIV-infected adults.

METHODS

Twenty-five adults with HIV infection were trained using a highly intensive PRT regimen for 8 weeks, followed by an additional 8 weeks of observation under ad libitum physical activity conditions.

RESULTS

Twenty-four of the 25 patients completed the first phase of the study. They had significant increases in strength on all four exercises tested (P < 0.0001), and an increase in LBM of 1.75 +/- 1.94 kg (mean +/- SD, P < 0.0002), with a concomitant decline in fat of 0.92 +/- 2.22 kg (P < 0.05), and no significant change in weight or bone mineral content. Twenty-one of the patients returned for follow-up 8 weeks after completing the PRT. Compared with their baseline values, their mean lean mass remained 1.40 +/- 1.8 kg higher (P < 0.003). Among those who continued to train to some extent, lean mass increased by a mean of 1.1 +/- 1.6 kg (n = 9, P < 0.05 versus end of PRT), whereas those who did no further training showed an increase in lean mass of 0.28 +/- 1.4 kg (n = 12, P = NS versus end of PRT). The difference between the two groups was not, however, significant (P = 0.25). Among six patients with AIDS wasting, the increase in LBM was larger than among non-wasted patients (2.8 versus 1.4 kg, P < 0.06), and there was an increase in both weight (+3.9 versus -0.2 kg, P < 0.002) and fat mass (+ 0.95 versus -1.5 kg, P < 0.002) at 8 weeks, which persisted at 16 weeks (weight: +4.0 versus -1.6 kg, P < 0.0002; fat: +1.6 versus -1.9 kg, P < 0.01).

CONCLUSION

This preliminary study suggests that short-term, high intensity PRT can significantly increase LBM and strength in HIV infection, and may be used as an alternative or adjunct to pharmacological anabolic treatments in this disease.