Polyfunctional Antigen Specific CD4+ T cell Responses in Patients With Human Immunodeficiency Virus/AIDS and Histoplasmosis Immune Reconstitution Inflammatory Syndrome

In the combination antiretroviral era, there are limited data regarding the pathogenesis of histoplasmosis immune reconstitution inflammatory syndrome (IRIS) in people with human immunodeficiency virus (HIV). We immunologically characterized 10 cases of histoplasmosis, 4 of whom developed histoplasmosis IRIS. CD4+ T cells in histoplasmosis IRIS demonstrated a significant polyfunctional cytokine response to histoplasma antigen.

First-Principles Density Limit Scaling in Tokamaks Based on Edge Turbulent Transport and Implications for ITER

A first-principles scaling law, based on turbulent transport considerations, and a multimachine database of density limit discharges from the ASDEX Upgrade, JET, and TCV tokamaks, show that the increase of the boundary turbulent transport with the plasma collisionality sets the maximum density achievable in tokamaks. This scaling law shows a strong dependence on the heating power, therefore predicting for ITER a significantly larger safety margin than the Greenwald empirical scaling [Greenwald et al., Nucl. Fusion, 28, 2199 (1988)NUFUAU0029-551510.1088/0029-5515/28/12/009] in case of unintentional high-to-low confinement transition.

The impact of the 2014 Ebola epidemic on HIV disease burden and outcomes in Liberia West Africa

BACKGROUND

Detailed longitudinal studies of HIV-positive individuals in West Africa are lacking. Here the HIV prevalence, incidence, all-cause mortality, and the proportion of individuals receiving treatment with cART in two cohorts of participants in Ebola-related studies are described.

SETTING

Individuals of all ages were enrolled and followed at four sites in the area of Monrovia, Liberia.

METHODS

Two cohorts identified in response to the Ebola epidemic are described to provide insights into the current state of the HIV epidemic. HIV testing was performed at baseline for participants in both cohorts and during follow-up in one cohort.

RESULTS

Prevalence and incidence of HIV (prevalence of 3.1% for women and 1.4% for men and incidence of 3.3 per 1,000) were higher in these cohorts compared to 2018 national estimates (prevalence of 1.3% and incidence of 0.39 per 1,000). Most participants testing positive did not know their status prior to testing. Of those who knew they were HIV positive, 7.9% reported being on antiretroviral treatment. The death rate among those with HIV was 12.3% compared to 1.9% in HIV-negative individuals (adjusted odds ratio of 6.87). While higher levels of d-dimer were associated with increased mortality, this was not specific to those with HIV, however lower hemoglobin levels were associated with increased mortality among those with HIV.

CONCLUSION

These findings point to a need to perform further research studies aimed at fulfilling these knowledge gaps and address current shortcomings in the provision of care for those living with HIV in Liberia.

Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia

BACKGROUND

Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation.

METHODS

We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models.

RESULTS

We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death.

CONCLUSIONS

For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

373. Immune Reconstitution Inflammatory Syndrome in Patients with HIV/AIDS and Histoplasmosis: A Case Series

Background

Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV infection is the unexpected clinical deterioration due to worsening (paradoxical) or uncovering (unmasking) of an infection or malignancy upon initiation of antiretroviral therapy (ART). Histoplasma capsulatum (H. capsulatum) is the most common endemic mycosis in patients with AIDS, usually manifesting as disseminated disease at CD4 counts < 150 cells/μl. In the ART era, histoplasmosis IRIS has been described in case reports, but there has been a limited description regarding clinical presentations and pathogenesis in the United States.

Methods

ART-naive HIV+ patients with a CD4⁺ T-cell count < 100 cells/µL enrolled in prospective studies at the National Institutes of Health (NIH) (NCT00286767, NCT02147405) were evaluated to identify those with histoplasmosis and followed after ART initiation to identify those who would eventually develop IRIS.

Results

From a total of 271 patients, we identified 9 patients with histoplasmosis. The median age, CD4+ count and HIV VL of these 9 patients was 36 years, 40 cells/mm³ and 193,184 copies/mL, respectively. Two patients developed IRIS only to histoplasmosis (1 unmasking and 1 paradoxical), 2 patients developed IRIS to both histoplasmosis and nontuberculous mycobacteria (NTM) and 3 patients developed IRIS to other infections (1 VZV, and 2 NTM). The manifestations of histoplasmosis IRIS in our cohort ranged from worsening lymphadenopathy to small bowel obstruction and worsening pulmonary symptoms.

Conclusion

Histoplasma-related IRIS can present with worsening lymphadenopathy, small bowel obstruction, and worsening pulmonary symptoms. The emergence of IRIS appears to be very common in people with HIV and disseminated histoplasmosis but the underlying trigger may be histoplasma, other co-infections or both.

Disclosures

All authors: No reported disclosures.

A Phase I, Randomized, Controlled Clinical Study of CC-11050 in People Living With HIV With Suppressed Plasma Viremia on Antiretroviral Therapy (APHRODITE)

Objective

Phosphodiesterase 4 inhibitors (PDE4i) are novel anti-inflammatory medications that have been approved for rheumatologic diseases and have been tested as host-directed therapy in tuberculosis. We examined the safety of CC-11050, a potent PDE4i in people living with HIV (PLWH) with suppressed HIV plasma viremia. We hypothesized that CC-11050 could be used to modulate HIV-related inflammation.

Method

Thirty PLWH on antiretroviral therapy (ART) ≥ 1 year with suppressed HIV viremia were enrolled and randomized 2:1 to 12 weeks of CC-11050 200mg twice daily or placebo with follow-up at weeks 2, 4, 8, 12, and 16. Primary endpoint was safety. Secondary endpoints were the effect of CC-11050 on cytokines, monocyte, and T-cell activation and potential pharmacokinetic interaction between CC-11050 and Efavirenz (EFV).

Results

At baseline, median age was 49.5 years and CD4 count 459 cells/µL. Most frequent adverse events (grade 1 and 2 only) in CC-11050 group were headache, diarrhea, nausea, cough, nasal congestion, and restlessness. Over a 12-week period, the CC-11050 group had lower level of IL-8, adjusted for baseline level, group, and week (0.72-fold, P = .02), lower percentage of NK cells (0.87-fold, P = .02) and higher IL-6 level (1.48-fold, P = .03) compared to placebo (0.87-fold, P = .02). CC-11050 and EFV co-administration did not reveal any pharmacokinetic interaction.

Conclusions

CC-11050 was well tolerated in PLWH, without affecting CD4 counts or plasma viremia, and led to a decrease in NK cells and plasma IL-8 level after 12-weeks of administration. Further study will be needed to elucidate the efficacy of CC-11050 as potential anti-inflammatory adjuvant strategy in HIV.

A phase 1, randomized, controlled clinical study of CC-11050 in people living with HIV with suppressed plasma viremia on antiretroviral therapy (APHRODITE)

Background

Phosphodiesterase 4 inhibitors (PDE4i) block the degradation of cyclic adenosine monophosphate and modulate both innate and adaptive immune responses. PDE4i have been approved for rheumatologic diseases and tested as host-directed therapy in TB. We examined the safety of CC-11050, a new potent PDE4i, in HIV+ people with suppressed viral load (VL). We hypothesized that CC-11050 could be used to modulate HIV-related inflammatory responses.

Methods

Thirty HIV+ participants, on antiretroviral therapy (ART) ≥ 1 year with HIV VL &lt;50 copies/mL were randomized 2:1 to 12 weeks of CC-11050 200mg BID or placebo with follow-up at weeks 2, 4, 8, 12 and 16. Primary endpoint was safety. We also assessed the effect of CC-11050 on CD4+, CD8+, NK, VL, plasma cytokines, monocyte and T-cell activation.

Results

At baseline, median age was 49.5 years and CD4+ 459 cells/μL. Most frequent adverse events (only grades 1–2) in CC-11050 group were headache, diarrhea, nausea, cough and nasal congestion. The CC-11050 group had lower IL-8 level after adjustment for baseline level, group and week (0.72 fold, p=0.02) and lower %NK cells compared to placebo (0.87 fold, p=0.02). At week 12, the CC-11050 group had higher %CD14++CD16+ monocytes than placebo (median 58.5% vs 50.7%, p=0.03). There was no significant effect on plasma HIV viremia, assessed by single copy assay and on cell-associated DNA and RNA in PBMC.

Conclusions

CC-11050 was well tolerated in HIV+ participants without affecting controlled viremia. CC-11050 had an effect on innate immune mechanisms, by decreasing NK cells and IL-8 level and increasing intermediate monocytes. Further study is needed to elucidate the efficacy of CC-11050 as potential anti-inflammatory adjuvant strategy in HIV.

Increased Metabolic Activity on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Human Immunodeficiency Virus-Associated Immune Reconstitution Inflammatory Syndrome

Background

Immune reconstitution inflammatory syndrome (IRIS) represents an unexpected inflammatory response shortly after initiation of antiretroviral therapy (ART) in some human immunodeficiency virus (HIV)-infected patients with underlying neoplasia or opportunistic infections, including tuberculosis. We hypothesized that IRIS is associated with increased glycolysis and that 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) could help identify high-risk subjects.

Methods

In this prospective cohort study, 30 HIV-infected patients (CD4+ count <100 cells/µL) underwent FDG-PET/CT scans at baseline and 4-8 weeks after ART initiation. Ten patients developed IRIS (6 mycobacterial).

Results

At baseline, total glycolytic activity, total lesion volume, and maximum standardized uptake values (SUVs) of pathologic FDG uptake (reflective of opportunistic disease burden) were significantly higher in IRIS vs non-IRIS (P = .010, .017, and .029, respectively) and significantly correlated with soluble inflammatory biomarkers (interferon-γ, myeloperoxidase, tumor necrosis factor, interleukin 6, soluble CD14). Baseline bone marrow (BM) and spleen FDG uptake was higher in mycobacterial IRIS specifically. After ART initiation, BM and spleen mean SUV decreased in non-IRIS (P = .004, .013) but not IRIS subjects. Our results were supported by significantly higher glucose transporter 1 (Glut-1) expression of CD4+ cells and monocytes after ART initiation in IRIS/mycobacterial IRIS compared with non-IRIS patients.

Conclusions

We conclude that increased pathologic metabolic activity on FDG-PET/CT prior to ART initiation is associated with IRIS development and correlates with inflammatory biomarkers. Abnormally elevated BM and spleen metabolism is associated with mycobacterial IRIS, HIV viremia, and Glut-1 expression on CD4+ cells and monocytes.

Clinical Trials Registration

NCT02147405.

Emergence of Kaposi's Sarcoma Herpesvirus-Associated Complications Following Corticosteroid Use in TB-IRIS

Corticosteroid use was associated with development of Kaposi's sarcoma or multicentric Castleman disease in 3 patients with mycobacterial immune reconstitution inflammatory syndrome (IRIS) treated with corticosteroids. Monitoring for development of Kaposi's sarcoma and alternative treatment may be beneficial for patients with IRIS, especially in the presence of preexisting co-infection with Kaposi's sarcoma-associated herpesvirus.

Clinical audit training improves undergraduates' performance in root canal therapy

AIM

To evaluate the effectiveness of clinical audit-feedback cycle as an educational tool in improving the technical quality of root canal therapy (RCT) and compliance with record keeping performed by dental undergraduates.

METHODS

Clinical audit learning was introduced in Year 3 of a 5-year curriculum for dental undergraduates. During classroom activities, students were briefed on clinical audit, selected their audit topics in groups of 5 or 6 students, and prepared and presented their audit protocols. One chosen topic was RCT, in which 3 different cohorts of Year 3 students conducted retrospective audits of patients' records in 2012, 2014 and 2015 for their compliance with recommended record keeping criteria and their performance in RCT. Students were trained by and calibrated against an endodontist (κ ≥ 0.8). After each audit, the findings were reported in class, and recommendations were made for improvement in performance of RCT and record keeping. Students' compliance with published guidelines was presented and their RCT performances in each year were compared using the chi-square test.

RESULTS

Overall compliance with of record keeping guidelines was 44.1% in 2012, 79.6% in 2014 and 94.6% in 2015 (P = .001). In the 2012 audit, acceptable extension, condensation and the absence of mishap were observed in 72.4, 75.7% and 91.5%; in the 2014 audit, 95.1%, 64.8% and 51.4%; and in 2015 audit, 96.4%, 82.1% and 92.8% of cases, respectively. In 2015, 76.8% of root canal fillings met all 3 technical quality criteria when compared to 48.6% in 2014 and 44.7% in 2012 (P = .001).

CONCLUSION

Clinical audit-feedback cycle is an effective educational tool for improving dental undergraduates' compliance with record keeping and performance in the technical quality of RCT.

Towards Better Precision Medicine: PacBio Single-Molecule Long Reads Resolve the Interpretation of HIV Drug Resistant Mutation Profiles at Explicit Quasispecies (Haplotype) Level

Development of HIV-1 drug resistance mutations (HDRMs) is one of the major reasons for the clinical failure of antiretroviral therapy. Treatment success rates can be improved by applying personalized anti-HIV regimens based on a patient's HDRM profile. However, the sensitivity and specificity of the HDRM profile is limited by the methods used for detection. Sanger-based sequencing technology has traditionally been used for determining HDRM profiles at the single nucleotide variant (SNV) level, but with a sensitivity of only ≥ 20% in the HIV population of a patient. Next Generation Sequencing (NGS) technologies offer greater detection sensitivity (~ 1%) and larger scope (hundreds of samples per run). However, NGS technologies produce reads that are too short to enable the detection of the physical linkages of individual SNVs across the haplotype of each HIV strain present. In this article, we demonstrate that the single-molecule long reads generated using the Third Generation Sequencer (TGS), PacBio RS II, along with the appropriate bioinformatics analysis method, can resolve the HDRM profile at a more advanced quasispecies level. The case studies on patients' HIV samples showed that the quasispecies view produced using the PacBio method offered greater detection sensitivity and was more comprehensive for understanding HDRM situations, which is complement to both Sanger and NGS technologies. In conclusion, the PacBio method, providing a promising new quasispecies level of HDRM profiling, may effect an important change in the field of HIV drug resistance research.

Clinically Indicated Corticosteroids Do Not Affect Bone Turnover During Immune Restoration of Severely Lymphopenic HIV-Infected Patients

Lymphopenia, corticosteroids, antiretroviral therapy (ART), and inflammation negatively impact bone turnover and decrease bone mineral density, but their combined effect has not been evaluated. We examined the association between corticosteroids on bone turnover markers in severely lymphopenic HIV-infected patients initiating ART. Levels of osteocalcin (bone formation marker) and C-terminal telopeptide (CTX; bone resorption marker) were measured at baseline, weeks 4, 12, and 48 of ART in individuals with severe lymphopenia and opportunistic infection (OI) who received (n=28) or did not receive corticosteroids (n=30) during the first year of ART, and in a control group with CD4 >200 (n=15). Wilcoxon tests were used to compare median values of variables between groups. Correlations between plasma interleukin (IL)-6 and tumor necrosis factor (TNF) levels with bone turnover marker levels were performed using Spearman's coefficient. Individuals given corticosteroids received a median of 21 days at a 35 mg prednisone-equivalent daily dose. Individuals with severe lymphopenia had lower osteocalcin levels at baseline and week 4 and higher CTX levels at ART initiation vs.

CONTROLS

Bone turnover markers did not differ in severely lymphopenic persons according to corticosteroid receipt. In those with severe lymphopenia, higher IL-6 was associated with higher CTX levels at ART initiation only. HIV-infected patients with severe lymphopenia and OI had lower levels of bone formation and higher levels of bone resorption than those initiating ART at higher CD4. Corticosteroid use, as prescribed during OI, was not associated with bone turnover. In contrast, higher markers of systemic inflammation prior to ART were associated with greater bone resorption.

Synthesis of biologically active bridged diazabicycloheptanes

The chemistry underlying how diazabicycloheptanes are assembled is described, subdivided according to chemical structure of two types, the 3,6 diazabicyclo[3.1.1]heptane and the 2,5-diazabicyclo[2.2.1]heptane ring system. Detailed information on myriad of activities of compounds derived from the two scaffolds are reported.

d-Dimer and CRP levels are elevated prior to antiretroviral treatment in patients who develop IRIS

Biomarkers could be useful in evaluating immune reconstitution inflammatory syndrome (IRIS). A cohort of 45 HIV-1-infected, antiretroviral treatment (ART)-naive patients with baseline CD4 T cell counts <or=100 cells/microL who were started on ART, suppressed HIV-RNA to <50 copies/mL, and seen every 1-3 months for 1 year were retrospectively evaluated for suspected or confirmed IRIS. d-Dimer, C-reactive protein (CRP), and selected autoantibodies were analyzed at baseline, 1 and 3 months post-ART in cryopreserved plasma. Median differences between cases and controls were compared with Mann-Whitney and Fisher's exact tests. Sixteen patients (35.6%) developed IRIS (median of 35 days post-ART initiation): unmasking=8, paradoxical=7, autoimmune=1. Pre-ART d-dimer and CRP were higher in IRIS cases versus controls (d-dimer: 0.89 mg/L versus 0.66 mg /L, p=0.037; CRP: 0.74 mg/L versus 0.39 mg/L, p=0.022), while d-dimer was higher in unmasking cases at IRIS onset (2.04 mg/L versus 0.36 mg /L, p=0.05). These biomarkers may be useful in identifying patients at risk for IRIS.

Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America

This report updates and combines earlier versions of guidelines for the prevention and treatment of opportunistic infections (OIs) in HIV-infected adults (i.e., persons aged >/=18 years) and adolescents (i.e., persons aged 13--17 years), last published in 2002 and 2004, respectively. It has been prepared by the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by clinicians and other health-care providers, HIV-infected patients, and policy makers in the United States. These guidelines address several OIs that occur in the United States and five OIs that might be acquired during international travel. Topic areas covered for each OI include epidemiology, clinical manifestations, diagnosis, prevention of exposure; prevention of disease by chemoprophylaxis and vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; discontinuation of secondary prophylaxis after immune reconstitution; and special considerations during pregnancy. These guidelines were developed by a panel of specialists from the United States government and academic institutions. For each OI, a small group of specialists with content-matter expertise reviewed the literature for new information since the guidelines were last published; they then proposed revised recommendations at a meeting held at NIH in June 2007. After these presentations and discussion, the revised guidelines were further reviewed by the co-editors; by the Office of AIDS Research, NIH; by specialists at CDC; and by HIVMA of IDSA before final approval and publication. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments. Major changes in the guidelines include 1) greater emphasis on the importance of antiretroviral therapy for the prevention and treatment of OIs, especially those OIs for which no specific therapy exists; 2) information regarding the diagnosis and management of immune reconstitution inflammatory syndromes; 3) information regarding the use of interferon-gamma release assays for the diagnosis of latent Mycobacterium tuberculosis (TB) infection; 4) updated information concerning drug interactions that affect the use of rifamycin drugs for prevention and treatment of TB; 5) the addition of a section on hepatitis B virus infection; and 6) the addition of malaria to the list of OIs that might be acquired during international travel. This report includes eleven tables pertinent to the prevention and treatment of OIs, a figure that pertains to the diagnois of tuberculosis, a figure that describes immunization recommendations, and an appendix that summarizes recommendations for prevention of exposure to opportunistic pathogens.

Demographic and socio-economic correlates of dental pain among adults in the United Kingdom, 1998

OBJECTIVE

To report the demographic and socio-economic correlates for dental pain in UK adults, and characterise those with dental pain who did not access dental services and perceived treatment need.

DESIGN

Secondary analysis of the 1998 UK Adult Dental Health Survey data.

SETTING

Survey of random sample of UK households between September and December 1998.

SUBJECTS AND METHODS

Face-to-face interviews with community-dwelling adults, aged 16 years and over. MAIN: outcome measures Self-reported dental pain in the past 12 months. Dental attendance and perceived treatment need of those reporting dental pain.

RESULTS

Of the 4,942 valid responses, 46.1% were men, the proportion of subjects in each 10-year band age group up to 65 years ranged from 10 to 23%, and 42.6% were manual workers. Dental pain was reported by 28%. After controlling for gender and age, manual workers were more likely to report dental pain (OR = 1.21, 95% CI = 1.06-1.37), non-utilisation of dental services (OR = 1.43, 95% CI = 1.12-1.82), and perceived treatment need (OR = 1.28, 95% CI = 1.03-1.60).

CONCLUSIONS

Inequality by social class, age and gender exists in the experience of dental pain, access to dental services and perceived treatment need in the UK adult population. Dental health services need to address the needs of this particular section of the population if the Government is to live up to its commitment to reducing oral health inequality and improving access.

Thienocinnolinone alkanoic acid derivatives as aldose reductase inhibitors

A new series of 8-halogen-4,4a,5,6-tetrahydrothieno[2,3-h]cinnolinone-N2-alkanoic acids was prepared and tested for aldose reductase (ALR2) inhibitory activities. These compounds showed significant inhibitory activity against bovine lens ALR2, with the best compound 2e showing an IC(50) value of 31.4 microM. The presence of the C8-substituents here studied (Cl, Br) on the thienocinnolinone scaffold caused a decrease of the inhibitory potency by a factor of about 4 with respect to the unsubstituted parent compound, while the presence of a C8-methyl group, considered in a previous paper decreased the activity by a factor of about 2. Moreover, the length of the N2 alkanoic chain influences strongly the enzyme inhibitory activity. While most of the carboxylic acids ALR2 inhibitors are acetic acid derivatives, in the case of thienocinnolinone compounds, homologues higher than acetic acids showed to be more active.

Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America

The National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, and CDC have developed guidelines for treatment of opportunistic infections (OIs) among adults and adolescents infected with human immunodeficiency virus (HIV). These guidelines are intended for clinicians and other health-care providers who care for HIV-infected adults and adolescents, including pregnant women; they complement companion guidelines for treatment of OIs among HIV-infected children and previously published guidelines for prevention of OIs in these populations. They include evidence-based guidelines for treatment of 28 OIs caused by protozoa, bacteria, fungi, and viruses, including certain OIs endemic in other parts of the world but that might be observed in patients in the United States. Each OI section includes information on epidemiology, clinical manifestations, diagnosis, treatment recommendations, monitoring and adverse events, management of treatment failure, prevention of recurrence, and special considerations in pregnancy. Tables address drugs and doses, drug toxicities, drug interactions, adjustment of drug doses in persons with reduced renal function, and data about use of drugs in pregnant women.

Synthesis and cytotoxicity of substituted 2-benzylnaphth[2,3-d]imidazoles

Designed as a new series of so called "bivalent ligand" containing the proposed 2-benzylnaphthimidazole-type structure, a number of 2-benzylnaphth[2,3-d]imidazoles, bearing various substituents, have been prepared by a synthetic approach involving an heterocyclization of 2,3-diaminonaphthalene 4 with appropriate imidates 3 (for 1b-i) followed by alkylation (for 1j-l) with the desired alkylating agent. Compounds 1b-f, h-l were subjected to primary biological evaluation for cancer cell growth inhibition (one-dose, three-cell assay), and the four most active terms, 1c, h, i and j, were then evaluated for their cytotoxic profiles in the National Cancer Institute's (NCI) human disease-oriented, 60 cell line, in vitro antitumor screening protocol. Among them, two compounds (1h and 1i) are the most representatives demonstrating not only high growth-inhibitory activities against some leukemia cancer cells, but also fairly good activities against the growth of certain cell lines of some solid tumors.

Synthesis and aldose reductase inhibitory activities of novel thienocinnolinone derivatives

A novel series of tetrahydrothieno[2,3-h]cinnolinone derivatives were synthesized and evaluated in vitro for their ability to inhibit aldose reductase (ALR2), an enzyme involved in the appearance of diabetic complications. Compounds 2e and 2j exert a remarkable inhibitory effect, with IC(50) of 7.6 and 18 microM, respectively. These compounds incorporate a valid pharmacophore for aldose reductase inhibitory activity represented by a thienocinnolinone template linked through a pentamethylene spacer to a carboxylic function.

Determination of phenol and o-cresol by GC/MS in a fatal poisoning case

A fatality due to the ingestion of solution containing phenol and o-cresol is described. The pathological findings were typical of acute substantial poisoning. Blood, urine and stomach content were obtained during post mortem examinations. Phenol and o-cresol were identified using GC/MS. The extractions from autopsy materials were obtained as follows: by gel permeation with cyclohexane/dichloromethane from stomach content, by solid phase extraction (SPE) from urine and by deproteinization with acetonitrile from blood. The phenol and o-cresol concentrations in the samples were found, respectively, as follows: 115.0 and 5.0 microg/g in the stomach contents, 58.3 and 1.9 microg/ml in the blood, 3.3 and 20.5 microg/ml in the urine. Distributions of phenol in fatal poisonings have been reported, but, usually, colorimetry was used as the analytical method and it cannot exclude the interference of other phenolic compounds.

The subchoroidal approach to the third ventricle: surgical anatomy according to Galen

THE SUBCHOROIDAL APPROACH has taken its place among the surgical access routes to the third ventricle. Eighteen centuries ago, in his major anatomic work, Galen detailed with astonishing accuracy the anatomy of the structures around the third ventricle and the procedure for exposing this cavity by entering the lateral ventricles and elevating its roof. Even more surprising is Galen's pioneering description of surgical maneuvers of the third ventricle in living animals in a way that anticipated the modern subchoroidal approach.

HIV-associated non-Hodgkin lymphoma: incidence, presentation, and prognosis

Patients with acquired immunodeficiency syndrome (AIDS)-associated non-Hodgkin lymphoma often present with multiple poor prognostic features, including significant tumor burden, advanced immunosuppression, and other concurrent morbidities. Strategies to manage such complex multiple-disease cases have often incorporated the assumption that prospects for long-term survival are poor and that intensive therapy cannot be tolerated and so is not justified. Since the advent of highly active antiretroviral therapy for human immunodeficiency virus infection, life expectancy has improved substantially for patients in whom the virus can be successfully suppressed. Thus, for complicated cases involving AIDS-associated malignancy, a reassessment of treatment strategies and the potential for long-term survival is warranted. Here, we present the case of a patient with poor prognosis due to AIDS-associated lymphoma with leptomeningeal involvement, advanced immunosuppression, and deep venous thrombosis. The management of this case illustrates that a multidisciplinary approach to complex AIDS cases involving malignancy and concurrent morbidity can result in a return to functional health in affected patients. Successful strategies for achieving favorable outcomes currently exist with available therapies.

Increased cell proliferation and associated expression of PDGFRbeta causing hypercellularity in patellar tendinosis

OBJECTIVE

This study assessed cellularity in patellar tendinosis with respect to cell proliferation and the expression of platelet-derived growth factor receptor beta (PDGFRbeta).

METHODS

Surgical samples were taken from 11 patients fulfilling criteria of patellar tendinosis and from 12 matched controls. Standard immunohistochemistry methods were used to detect expression of PDGFRbeta and proliferation cell nuclear antigen (PCNA). Results were analysed by computer-assisted microscopy. Tendon cells were isolated from nine tendinosis and eight control tissues for cell culture.

RESULTS

Increased cellularity (P<0.001) was observed in tendinosis tissues compared with controls, and also a higher proliferative index (P:<0.001). Increased expression of PDGFRbeta was demonstrated (P<0.001). Cultured tendinosis cells showed a higher proliferation rate than controls (P<0.001). This was maintained when the cells were cultured under various conditions of serum supplementation (P<0.01). Tendinosis cells also showed a higher proliferation rate (P<0.01) in medium containing 10 ng/ml PDGF.

CONCLUSION

Hypercellularity in patellar tendinosis is caused by increased cell proliferation and is associated with increased expression of PDGFRbeta.

Synthesis of substituted N-(4-piperidyl)-N-(3-pyridyl)amides with antiarrhythmic activity. Note 1

The synthesis of analogues of N,2-diphenyl-N-(4-piperidyl)acetamide endowed with antiarrhythmic activity is reported. Benzoyl, cinnamoyl, acetyl and propionyl groups replace the phenacyl group as N-acyl substituent, while pyridine replaces benzene as aromatic ring bound to the amide nitrogen. The title compounds were evaluated for antiarrhythmic activity on experimental arrhythmias induced by aconitine in rats. The presence of a n-propyl chain and an unsubstituted cinnamoyl moiety (1j) gives the highest protection against aconitine induced extrasystoles while the best efficacy against lethal effects is due to the presence of a n-propyl chain and an acetyl moiety (1m).

Antidermatophytic action of new 1-naphthylmethyl and benzo[b]thiophen-7-ylmethyl hydrazones related to inhibitors of squalene epoxidase

Two series of hydrazonic compounds related to main classes of inhibitors of fungal squalene epoxidase (SE) were designed and prepared on the hypothesis of a pharmacophoric model. The antifungal activity of the new compounds was evaluated in vitro against dermatophytes, moulds and yeasts. Antidermatophytic activity resulted for several hydrazones, particularly for those containing a tett-butylacetylenic group, supporting the hypothesis that the introduction of a hydrazonic function in the model could retain the antimycotic activity.

Embolisation of Orbital Varix via the Superficial Temporal Vein

SUMMARY

A case of orbital varix is presented, in which the lesion was successfully treated by means of embolisation with Guglielmi detachable coils, via the superficial temporal vein. Reports of endovascular treatment via transvenous route of orbital varix are lacking, only one case having previously been presented in the literature.We stress endovascular management for such an entity.

Synthesis of N-[4-(propyl)cyclohexyl]-amides with anti-inflammatory and analgesic activities

Seventeen (un)substituted N-[4-(propyl)cyclohexyl]-amides (6a-h, 7a-h and 8) were synthesized and tested as anti-inflammatory and analgesic agents. The substituents on the aromatic ring were chosen in order to study the influence of electron-withdrawing or electron-donating residues, that change the electronic density on the aromatic moiety. The pharmacological results allow drawing some preliminary considerations on structure-activity relationships.

The angiogenesis marker ED-B+ fibronectin isoform in intracranial meningiomas

Fibronectins (FNs), adhesive glycoproteins mainly expressed in the extracellular matrix, are polymorphic molecules whose various isoforms are dependent on alternative splicing patterns. The isoform containing the ED-B sequence and occurring in foetal and neoplastic tissues (oncofoetal or B+FN) has been previously recognized as a marker for angiogenesis. The distribution of this isoform was analyzed in a consecutive series of 134 surgically obtained intracranial meningiomas, using specific monoclonal antibodies. Oncofoetal FN was found to be widely distributed in the vessels of anaplastic meningiomas, with its expression being restricted in the vasculature of the typical subtypes. and absent in the neighbouring cerebral tissue. The ubiquitous vascular expression of B+FN in meningiomatous malignancies might provide a potential target for the in vivo delivery of angiosuppressive agents.

The effect of ritonavir on the pharmacokinetics of meperidine and normeperidine

STUDY OBJECTIVE

To determine the effects of ritonavir on the pharmacokinetics of meperidine and normeperidine.

DESIGN

Open-label, crossover, pharmacokinetic study.

SETTING

United States government research hospital.

SUBJECTS

Eight healthy volunteers who tested negative for the human immunodeficiency virus.

INTERVENTION

Subjects received oral meperidine 50 mg and had serial blood samples collected for 48 hours. They then received ritonavir 500 mg twice/day for 10 days, followed by administration of a second 50-mg meperidine dose and collection of serial samples.

MEASUREMENTS AND MAIN RESULTS

Plasma samples were assayed for meperidine, normeperidine, and ritonavir. Meperidine's area under the curve (AUC) decreased in all subjects by a mean of 67+/-4% in the presence of ritonavir (p<0.005). Mean +/- SD maximum concentration was decreased from 126+/-47 to 51+/-21 ng/ml. Normeperidine's mean AUC was increased 47%, suggesting induction of hepatic metabolism.

CONCLUSION

Meperidine's AUC is significantly reduced, not increased, by concomitant ritonavir. Based on these findings, the risk of narcotic-related adverse effects from this combination appears to be minimal. However, increased concentrations of normeperidine suggest a potential for toxicity with increased dosages or long-term therapy.

Anti-inflammatory and analgesic amides: new developments

A series of substituted N-cycloalkyl benzamides, cinnamamides, and indole-3-carboxamides were synthesized and evaluated for their analgesic, antiinflammatory activities as well as for their gastrointestinal irritation liability. Indomethacin was used as reference drug in both tests. Compounds 1k, 1b, 1h, 1j, and 1g were the most active in the antiinflammatory paw edema inhibition test, with a sharply dose-dependent effect. In terms of the analgesic activity (acetic acid writhing test), the most active compound was 5a followed by 3a, but many other compounds were found to have a non-negligible potency. Even in this case, the effect was dose dependent.

A risk-benefit assessment of interleukin-2 as an adjunct to antiviral therapy in HIV infection

Immunomodulation has become a major focus of HIV research in an effort to augment, boost or restore the patient's damaged immune system. Recombinant interleukin-2 is currently being studied in phase II/III trials in HIV-infected patients. Several clinical studies have demonstrated that intermittent regimens are associated with marked rises in CD4+ cell counts without an increase in viral load. Most of these studies employ 5 consecutive days of interleukin-2 therapy by continuous intravenous infusion or subcutaneous injection, repeated every 8 weeks. An alternative strategy is the daily administration of low doses of interleukin-2, but clinical experience with this regimen is limited. Interleukin-2 administration can adversely affect virtually every organ system, requiring aggressive supportive care. A variety of administration strategies and interventions are being evaluated to minimise toxicity. Currently, no clinical end-point data are available for interleukin-2 in HIV-infected patients. Until phase III studies are completed, interleukin-2 can be used in the research setting as an immunomodulator and adjunct to antiretroviral therapy. Its potential to activate latently infected cells and promote HIV eradication from reservoir sites is also an important area for further study. If clinical benefit can be demonstrated, interleukin-2 could be useful as an adjunct to antiretroviral therapy if adverse effects can be minimised and therapy can be given infrequently on an outpatient basis.

Synthesis of N-[4-(alkyl)cyclohexyl]-substituted benzamides with anti-inflammatory and analgesic activities

Two series of N-[4-(alkyl)cyclohexyl]-substituted benzamides, i.e. a series of N-[4-(tert-butyl)cyclohexyl]-substituted benzamides and a series of N-[4-(ethyl)cyclohexyl]-substituted benzamides, were synthesised and evaluated for their anti-inflammatory and analgesic potencies, and gastrointestinal irritation liability.

Monitoring of oxytetracycline in ovine milk by high-performance liquid chromatography

A method for 'in vivo' determination of the oxytetracyclin residues in ovine milk at low levels is described. Two groups of Sardinian breed sheep were treated with a dose of oxytetracycline by intramammary infusion and intramuscular administration, respectively. Oxytetracycline residues in extracts obtained from a preliminary cleanup procedure, were detected by an isocratic high-performance liquid chromatography (HPLC) method. Linear calibration plots were obtained over a large concentration range of 1 mg ml(-1)-10 ng ml(-1), with correlation coefficients higher than 0.996. Recoveries between 85.8 and 98.9% were obtained. Limit of detection (LOD) and limit of determination (LOQ) were 5.2 and 17.5 ng ml(-1), respectively. This method would be useful for routine monitoring of oxytetracycline residues in ovine dairy milk.

Long-term survival of a patient with a giant-cell tumor of the sphenoid body: a case report

Giant-cell tumors (osteoclastomas) of the sphenoid body are rare, histologically benign lesions that can grow in different directions within the bony structures of the skull base. To date, the precise role of the different surgical strategies (radical versus partial resection; biopsy) and of supplementary postoperative radiotherapy remains undefined due to the short follow-up of the majority of the reported cases. We present a patient who is alive without symptoms or signs of recurrence 44 years after a macroscopically radical excision of the neoplasm followed by radiotherapy.

Monitoring of benzylpenicillin in ovine milk by HPLC

A method for determination in vivo of the benzylpenicillin residues in ovine milk at low levels was described. Two groups of Sardinian breed sheep were treated with a dose of penicillin G sodium salt by intramammary infusion and intramuscular administration respectively. The residues were detected by isocratic HPLC method of the extract obtained from a previous cleanup procedure. Linear calibration plots were obtained over a large concentration range of 1 mg ml-1 -10 ng ml-1, with correlation coefficients greater than 0.998. Recoveries between 78.6 and 87.3% were obtained. Limit of detection (LOD) and limit of determination (LOQ) were 2.6 and 8.8 ng ml-1 respectively. This method would be useful for routine monitoring of penicillin G residues in ovine dairy milk.