Does Valganciclovir Hydrochloride (Valcyte) Provide Effective Prophylaxis Against Cytomegalovirus Infection in Liver Transplant Recipients?

INTRODUCTION

Cytomegalovirus (CMV) infection after solid organ transplantation is one of the most common viral infections, causing significant morbidity and mortality if not treated promptly. Ganciclovir has proven to be effective for the prophylaxis and treatment of CMV. However, oral absorption of ganciclovir is poor. Recently, oral administration of valganciclovir hydrochloride (Valcyte) has been observed to display 10-fold better absorption than oral ganciclovir. Valganciclovir has increasingly been used as prophylaxis against CMV after solid organ transplantation. The purpose of this study was to examine the efficacy of valganciclovir prophylaxis therapy after primary liver transplantation.

PATIENTS AND METHODS

Between July 2001 and May 2003, 203 consecutive liver transplant recipients, including 129 men and 74 women of overall mean age 53 +/- 11 years, received valganciclovir (900 mg/d or 450 mg every other day depending on renal function) for 3 to 6 months after primary liver transplantation. All patients were followed up for a minimum of 6 months. Mean follow-up was 19 +/- 5.8 months. CMV DNA in peripheral blood was tested using polymerase chain reaction (PCR) amplification. Symptomatic CMV was stratified according to the CMV immunoglobulin (Ig)G status of the donor and recipient at the time of liver transplantation. Donors and recipients were classified preoperatively into groups according to the presence or absence of CMV as follows: group 1 (n = 73; donor CMV+, recipient CMV+); group 2 (n = 41; donor CMV-, recipient CMV+); group 3 (n = 54; donor CMV+, recipient CMV-; high-risk group); and group 4 (n = 35; donor CMV-, recipient CMV-).

RESULTS

Twenty-nine patients (14.3%) developed symptomatic CMV disease at 169 +/- 117 days after liver transplantation: group 1, 16.4% versus group 2, 7.3% versus group 3, 25.9% versus group 4, 0%. Of these patients, 5 also had invasive CMV on liver biopsy, which was performed owing to abnormal liver functions. All 29 patients were treated with intravenous ganciclovir. One patient died owing to disseminated CMV, whereas the remaining 28 patients responded to treatment. Interestingly, 8 patients, including 1 who had invasive CMV hepatitis, developed symptomatic CMV within 90 days of liver transplantation even while on prophylactic valganciclovir.

CONCLUSION

Valganciclovir failed to provide adequate prophylaxis following liver transplantation in our patients. The overall rate of CMV in seropositive donors and/or recipients was 17%, and in the high-risk group was 26%. Further prospective studies with measurement of ganciclovir concentrations are needed to elucidate the reasons for this unexpected failure.

Evaluation of a 5-year school-based county-wide smoking education programme

Reports on an evaluation of Smoke Free Leitrim (SFL): a five-year (1996-2001) school-based county-wide smoking education programme that was offered to all fourth class students in all county Leitrim primary schools (n = 450). By programme end 208 (59%) SFL students and 147 (55%) of the control group had tried smoking. Sixty-six (19%) of the SFL group and 63 (24%) of the control group currently smoke. No significant differences were found between the groups for current smoking. Daily smoking of SFL and control males was identical: SFL 19 (10%); control 12 (10%). There was a significant difference between daily smoking of females: 14 (8%) SFL girls and 24 (16%) control group girls smoke everyday. The SFL intervention did not delay or prevent the uptake of smoking, but may have had some gendered effect. It reflected the limited effectiveness of long-term wide-scale smoking education interventions. A more sophisticated approach to young people and tobacco usage is required, that extends beyond the school to focus on tobacco usage in adults, families and the wider community.

Population based study of the cost of inpatient care for HIV-lnfected individuals in an Irish teaching hospital

A microcosting evaluation of the cost of inpatient care of 69 HIV-infected patients in an Irish teaching hospital was conducted from the hospital perspective. The median cost per admission was 6220 Euros and median cost per inpatient day was 557 Euros. HIV related admissions were associated with a greater cost per admission than non-HIV related admissions. There was an inverse relationship between inpatient costs and CD4 count. Ward costs accounted for the majority of inpatient expenditure. This is the first detailed study of the cost of inpatient care for HIV-infected individuals in Ireland. This study provides the data necessary to estimate the burden of HIV disease in Ireland and to evaluate the cost-effectiveness of antiretroviral and other strategies to manage HIV infection in the Irish context.

The diagnosis and management of common inherited bleeding disorders

Inherited bleeding disorders can be associated with significant morbidity and mortality. Bleeding episodes can be safely and effectively managed in the majority of patients provided the coagulation defect is identified and corrected with the appropriate replacement therapy. It is imperative that these patients are treated in centres that can provide full coagulation support, and a comprehensive care plan is formulated for each individual.

Gene expression analysis of human prostate carcinoma during hormonal therapy identifies androgen-responsive genes and mechanisms of therapy resistance

The androgen-signaling pathway is critical to the development and progression of prostate cancer and androgen ablation is a mainstay of therapy for this disease. We performed a genome-wide expression analysis of human prostate cancer during androgen ablation therapy to identify genes regulated by androgen and genes differentially expressed after the development of resistance. Six hundred and fifty-four of 63,175 probe sets detected significant expression changes after 3 months of treatment with goserelin and flutamide. This included 149 genes that were also differentially expressed 36 hours after androgen withdrawal in LNCaP cells. These genes reflect the physiological changes that occur in treated tumors and include potential direct targets of the androgen receptor. Expression profiles of androgen ablation-resistant tumors demonstrated that many of the gene expression changes detected during therapy were no longer present suggesting a reactivation of the androgen response pathway in the absence of exogenous hormone. Therapy resistance was associated with differential expression of a unique set of genes that reflect potential mechanisms of reactivation. Specifically an up-regulation of the androgen receptor and key enzymes for steroid biosynthesis suggest that resistant tumors have increased sensitivity to and endogenous synthesis of androgenic hormones. The specific pathways of reactivation provide opportunities for classification of resistant tumors and targeted therapies.

Congenital syphilis in the Russian Federation: magnitude, determinants, and consequences

OBJECTIVES

Reported cases of congenital syphilis in the Russian Federation increased 26-fold from 1991-9. Our objectives were to describe the frequency, risk factors, and consequences of delivering an infant with congenital syphilis among pregnant women with active syphilis.

METHODS

In a retrospective record review using consecutive sampling of logs at maternity hospitals in five geographic areas, data were abstracted for 850 women with active syphilis during pregnancy who had completed >/=20 weeks' gestation. Further information was abstracted from records in antenatal clinics, dermatovenereology clinics, and paediatric hospitals. We assessed the frequency of confirmed or probable congenital syphilis, used logistic modelling to identify independent predictors for delivering a baby with congenital syphilis, and calculated the proportion of infants with congenital syphilis who experienced late fetal death (20-27 weeks), stillbirth (>/=28 weeks), or infant death.

RESULTS

A total of 64% (n=544) of 850 pregnant syphilis infected women delivered an infant with confirmed or probable congenital syphilis; 40% of the sample had no prenatal care. Among women with no prenatal care, 77% received either no treatment or inadequate treatment and 86% delivered an infant with congenital syphilis. Important independent and modifiable risk factors for delivery of an infant with congenital syphilis included receiving no prenatal care (adjusted OR 2.8, 95% CI 1.7 to 4.7) and having the first test for syphilis at >/=28 weeks' gestation (adjusted OR 4.0, 95% CI 2.6 to 6.0). Fatal outcomes were observed in 26% of infants with congenital syphilis, including late fetal death (7%), stillbirth (16%), or neonatal death (3%).

CONCLUSIONS

In the Russian Federation, the frequency of congenital syphilis is high, risk factors for congenital syphilis are modifiable, and the consequences of congenital syphilis are severe.

Behavioral pharmacology of AR-A000002, a novel, selective 5-hydroxytryptamine(1B) antagonist

The present review summarizes the behavioral pharmacology conducted to profile the anxiolytic and antidepressant potential of the selective 5-hydroxytryptamine (HT)(1B) antagonist (R)-N-[5-methyl-8-(4-methylpiperazin-1-yl)-1,2,3,4-tetrahydro-2-naphthyl]-4-morpholinobenzamide (AR-A000002). AR-A000002 functions as a 5-HT(1B) antagonist in vivo, which was shown by the antagonism of the discriminative stimulus effects in the guinea pig of the 5-HT(1B) agonist 3-(N-methylpyrrolidin-2R-ylmethyl)-5-(3-nitropyrid-2-ylamino)-lH-indole (CP135,807). Anxiolytic activity of AR-A000002 was demonstrated in the separation-induced vocalization paradigm in guinea pig pups, and in a suppressed responding procedure in pigeons and guinea pigs, but only a weak trend was noted in a suppressed responding procedure in squirrel monkeys. Antidepressant efficacy was shown in a number of paradigms. In pigeons and guinea pigs responding under a differential reinforcement of low rates schedule of reinforcement (DRL), AR-A000002 increased the number of reinforcers earned without altering the number of responses made. In guinea pigs trained under a response duration differentiation paradigm, AR-A000002 increased mean lever-press duration. Finally, AR-A000002 was shown to block escape failures in guinea pigs submitted to a learned helplessness paradigm. Taken together, these data suggest utility for 5-HT(1B) antagonists in the treatment of both anxiety and affective disorders.

Nontuberculous mycobacteria: incidence in Southwest Ireland from 1987 to 2000

SETTING

The Southwest of Ireland (Counties Cork and Kerry) 1987-2000, average population 549,500.

OBJECTIVE

Nontuberculous mycobacteria (NTM) cause significant morbidity worldwide and the study of epidemiology and characteristics helps in their prevention and treatment. This study was performed to determine the incidence of NTM disease in comparison to Mycobacterium tuberculosis (M. tuberculosis) and Mycobacterium bovis (M. bovis) in Southwest Ireland, over the above time period.

DESIGN

A retrospective study was carried out in all human isolates of NTM, M. tuberculosis and M. bovis between 1987 and 2000, in the Southwest Region of Ireland.

RESULTS

The mean incidence of NTM (0.4/100,000 population) has risen since 1995, principally of pulmonary Mycobacterium avium intracellulare complex (MAC). The annual incidence of M. tuberculosis in humans over 14 years in the same region was 971/100,000 population with a significant reduction since 1994 and M. bovis remained constant at 0.5/100,000 population.

CONCLUSION

The increasing incidence of disease causing NTM noted in Southwest Ireland reflects global data and is surmised to be due to an ageing population, increased incidence related to chronic fibrotic lung disease, and environmental mycobacterial factors.

Paediatric day-stay myringoplasty: a review of 74 consecutive cases

Day-case surgery is particularly attractive for children, allowing post-operative recovery in the safe environment of the family home. Myringoplasty using the traditional method of underlay temporalis fasia is usually performed as an in-patient. From 1995 to 2000, 74 myringoplasties were performed in a dedicated paediatric day surgery unit at the Mayday University Hospital. We have retrospectively reviewed the outcome results of these procedures and reported them here. Only three patients required admission overnight (four per cent) and six grafts failed (8.5 per cent) complying with accepted standards. This series suggests that day-case surgery is a safe and desirable practice for children undergoing myringoplasty. However, there should be the facility for admission if required.

Safety and security policies on psychiatric acute admission wards: results from a London-wide survey

Very little research evidence is available regarding current safety and security procedures on acute psychiatric wards. This includes controversial areas such as the temporary removal of personal property, the searching of patients and visitors, the use of alarms and modern technology, and locking of entrances to regulate those entering and leaving. This is also despite widening dismay over increasing violence within a variety of hospital settings, the comparatively high risk of physical assault faced by mental health professionals and an abundance of literature and training in regards to violence management and prevention. To gain an understanding of current safety and security measures, a London-wide survey of acute admission wards was undertaken revealing a wide variety of measures and policies in operation. Over 100 NHS and private wards were sent questionnaires; there was a response rate of 70%. Results show that a significant proportion of acute admission wards are now locked at all times and a small proportion of units have 24-hour security/reception staff on-site and a low level of modern technology usage such as CCTV and electronic access systems. There is wide variation in items banned, restrictions placed on inpatients, and the searching of patients and visitors. Two independently varying emphases of ward security policies were identifiable, the first aimed at preventing harm to patients using door security, banning of item and restrictions on inpatients. The other is aimed at reducing risks to staff via searching of patients, use of security guards and sophisticated alarm systems. There is some preliminary evidence that these security policies are differentially associated with levels of absconding and violent incidents. Further research to guide practice is urgently required.

Physiological and metabolic characteristics of elite tug of war athletes

OBJECTIVE

To determine the aerobic power (VO(2)MAX), body composition, strength, muscular power, flexibility, and biochemical profile of an elite international squad of tug of war athletes.

METHODS

Sixteen male competitors (mean (SEM) age 34 (2) years) were evaluated in a laboratory. For comparative purposes, data were analysed relative to normative data for our centre and to a group of 20 rugby forwards from the Irish international squad.

RESULTS

The tug of war participants were lighter (83.6 (3.0) v 104.4 (1.8) kg, p<0.0001) and had less lean body mass (69.4 (2.1) v 86.2 (1.2) kg) than the rugby players and had lower than normal body fat (16.7 (0.9)%); all values are mean (SEM). Aerobic power measured during a treadmill test was 55.8 (1.6) ml/kg/min for the tug of war participants compared with 51.1 (1.4) ml/kg/min for the rugby forwards (p<0.03). A composite measure of strength derived from (sum of dominant and non-dominant grip strength and back strength)/lean body mass yielded a strength/mass ratio that was 32% greater (p<0.0001) for the tug of war group than the rugby group. Dynamic leg power was lower for the tug of war group than the rugby forwards (4659.8 (151.6) v 6198.2 (105) W respectively; p<0.0001). Leg flexibility was 25.4 (2.0) cm for the tug of war group. Back flexibility was 28.6 (1.4) cm which was lower (p<0.02) than the rugby forwards 34.2 (1.5) cm. Whereas blood chemistry and haematology were normal, packed cell volume, haemoglobin concentration, and erythrocyte volume were lower in the tug of war group than in the rugby players (p<0.05). All three haematological measures correlated with muscle mass (packed cell volume, r(2) = 0.37, p<0.0001; haemoglobin concentration, r(2) = 0.13, p<0.05; erythrocyte volume, r(2) = 0.21, p<0.01).

CONCLUSIONS

The data indicate that international level tug of war participants have excellent strength and above average endurance relative to body size, but have relatively low explosive leg power and back flexibility. The data provide reference standards for the sport and may be useful for monitoring and evaluating current and future participants.

Infliximab for refractory ulcerative colitis

Eight patients with active ulcerative colitis (UC), refractory to usual combination medical therapy, were treated with a single i.v. dose of chimeric monoclonal antibody to recombinant human tumor necrosis factor alpha; many of these patients were scheduled for surgical colectomy because of their active disease. All patients responded extremely well to a single 5 mg/kg infusion of infliximab, with marked improvement after the infusion clinically, colonoscopically, and histologically on colonic biopsy. There were no significant complications or side effects; mean duration of remission has not been determined because none of the patients have relapsed. Infliximab appears to be a potent agent for inducing remission in refractory patients with ulcerative colitis.

Expanding the research infrastructure for lesbian health

Interest in research about lesbian health has increased dramatically since the late 1980s and gained national attention in 1999 when the Institute of Medicine published the groundbreaking report Lesbian Health: Current Assessment and Directions for the Future. In March 2000, the Department of Health and Human Services and partner organizations presented the Scientific Workshop on Lesbian Health, during which invited experts on lesbian health worked with federal representatives to develop action steps to implement recommendations in the Institute of Medicine report. National priorities were thus established for the emerging field of lesbian health research. Although researchers of various sexual orientation and gender identities will contribute to this field, lesbian researchers have a unique perspective and an important role to play. This commentary focuses on the preparedness of these individuals to respond to challenges set forth by the Institute of Medicine and Scientific Workshop reports. Despite differences in their academic backgrounds, lesbian researchers have reported common experiences and needs. Substantial proportions have encountered barriers because they were lesbians or conducted lesbian research, and many expressed willingness to mentor others, to help others to conduct research about lesbians, or both.