Differential and defective transcription of koala retrovirus indicates the complexity of host and virus evolution

Koala retrovirus (KoRV) is unique amongst endogenous (inherited) retroviruses in that its incorporation to the host genome is still active, providing an opportunity to study what drives this fundamental process in vertebrate genome evolution. Animals in the southern part of the natural range of koalas were previously thought to be either virus-free or to have only exogenous variants of KoRV with low rates of KoRV-induced disease. In contrast, animals in the northern part of their range universally have both endogenous and exogenous KoRV with very high rates of KoRV-induced disease such as lymphoma. In this study we use a combination of sequencing technologies, Illumina RNA sequencing of 'southern' (south Australian) and 'northern' (SE QLD) koalas and CRISPR enrichment and nanopore sequencing of DNA of 'southern' (South Australian and Victorian animals) to retrieve full-length loci and intregration sites of KoRV variants. We demonstrate that koalas that tested negative to the KoRV pol gene qPCR, used to detect replication-competent KoRV, are not in fact KoRV-free but harbour defective, presumably endogenous, 'RecKoRV' variants that are not fixed between animals. This indicates that these populations have historically been exposed to KoRV and raises questions as to whether these variants have arisen by chance or whether they provide a protective effect from the infectious forms of KoRV. This latter explanation would offer the intriguing prospect of being able to monitor and selectively breed for disease resistance to protect the wild koala population from KoRV-induced disease.

Transcriptomic and genomic variants between koala populations reveals underlying genetic components to disorders in a bottlenecked population

Historical hunting pressures on koalas in the southern part of their range in Australia have led to a marked genetic bottleneck when compared with their northern counterparts. There are a range of suspected genetic disorders such as testicular abnormalities, oxalate nephrosis and microcephaly reported at higher prevalence in these genetically restricted southern animals. This paper reports analysis of differential expression of genes from RNAseq of lymph nodes, SNPs present in genes and the fixation index (population differentiation due to genetic structure) of these SNPs from two populations, one in south east Queensland, representative of the northern genotype and one in the Mount Lofty Ranges South Australia, representative of the southern genotype. SNPs that differ between these two populations were significantly enriched in genes associated with brain diseases. Genes which were differentially expressed between the two populations included many associated with brain development or disease, and in addition a number associated with testicular development, including the androgen receptor. Finally, one of the 8 genes both differentially expressed and with a statistical difference in SNP frequency between populations was SLC26A6 (solute carrier family 26 member 6), an anion transporter that was upregulated in SA koalas and is associated with oxalate transport and calcium oxalate uroliths in humans. Together the differences in SNPs and gene expression described in this paper suggest an underlying genetic basis for several disorders commonly seen in southern Australian koalas, supporting the need for further research into the genetic basis of these conditions, and highlighting that genetic selection in managed populations may need to be considered in the future.

Pathological Findings in Koala Retrovirus-positive Koalas (Phascolarctos cinereus) from Northern and Southern Australia

Koala retrovirus (KoRV) infection shows differences in prevalence and load between northern and southern Australian koala populations; however, the effect of this on diseases such as lymphoma and chlamydial disease is unclear. This study compared clinicopathological findings, haematology and splenic lymphoid area of KoRV-positive koalas from northern (Queensland [Qld], n = 67) and southern (South Australia [SA], n = 92) populations in order to provide further insight into KoRV pathogenesis. Blood was collected for routine haematology and for measurement of KoRV proviral load by quantitative polymerase chain reaction (qPCR). Plasma samples were assessed for KoRV viral load by reverse transcriptase qPCR and conjunctival and cloacal swabs were collected for measurement of the load of Chlamydia pecorum (qPCR). During necropsy examination, spleen was collected for lymphoid area analysis. Lymphoma was morphologically similar between the populations and occurred in koalas with the highest KoRV proviral and viral loads. Severe ocular chlamydial disease was observed in both populations, but urinary tract disease was more severe in Qld, despite similar C. pecorum loads. No associations between KoRV and chlamydial disease severity or load were observed, except in SA where viral load correlated positively with chlamydial disease severity. In both populations, proviral and viral loads correlated positively with lymphocyte and metarubricyte counts and correlated negatively with erythrocyte and neutrophil counts. Splenic lymphoid area was correlated positively with viral load. This study has shown further evidence for KoRV-induced oncogenesis and highlighted that lymphocytes and splenic lymphoid tissue may be key sites for KoRV replication. However, KoRV infection appears to be highly complex and continued investigation is required to fully understand its pathogenesis.

Identification of stable reference genes for quantitative PCR in koalas

To better understand host and immune response to diseases, gene expression studies require identification of reference genes with stable expression for accurate normalisation. This study describes the identification and testing of reference genes with stable expression profiles in koala lymph node tissues across two genetically distinct koala populations. From the 25 most stable genes identified in transcriptome analysis, 11 genes were selected for verification using reverse transcription quantitative PCR, in addition to the commonly used ACTB and GAPDH genes. The expression data were analysed using stable genes statistical software - geNorm, BestKeeper, NormFinder, the comparative ΔCt method and RefFinder. All 13 genes showed relative stability in expression in koala lymph node tissues, however Tmem97 and Hmg20a were identified as the most stable genes across the two koala populations.

A randomized, double-blind, placebo-controlled study of the effects of pomegranate extract on rising PSA levels in men following primary therapy for prostate cancer

BACKGROUND

The primary objective of this study was to compare the effects of pomegranate juice on PSA doubling times (PSADT) in subjects with rising PSA levels after primary therapy for prostate cancer.

METHODS

Double-blind, placebo-controlled multi-institutional study, evaluated the effects of pomegranate liquid extract on serum PSA levels. The primary end point of this study was change in serum PSADT. Additional secondary and exploratory objectives were to evaluate the safety of pomegranate juice and to determine the interaction of manganese superoxide dismutase (MnSOD) AA genotype and pomegranate treatment on PSADT.

RESULTS

One-hundred eighty-three eligible subjects were randomly assigned to the active and placebo groups with a ratio of 2:1 (extract N=102; placebo N=64; juice N=17). The majority of adverse events were of moderate or mild grade. Median PSADT increased from 11.1 months at baseline to 15.6 months in the placebo group (P<0.001) compared with an increase from 12.9 months at baseline to 14.5 months in the extract group (P=0.13) and an increase from 12.7 at baseline to 20.3 in the juice group (P=0.004). However, none of these changes were statistically significant between the three groups (P>0.05). Placebo AA patients experienced a 1.8 month change in median PSADT from 10.9 months at baseline to 12.7 months (P=0.22), while extract patients experienced a 12 month change in median PSADT from 13.6 at baseline to 25.6 months (P=0.03).

CONCLUSIONS

Compared with placebo, pomegranate extract did not significantly prolong PSADT in prostate cancer patients with rising PSA after primary therapy. A significant prolongation in PSADT was observed in both the treatment and placebo arms. Men with the MnSOD AA genotype may represent a group that is more sensitive to the antiproliferative effects of pomegranate on PSADT; however, this finding requires prospective hypothesis testing and validation.

Extended-spectrum beta-lactamase (ESBL)-producing enterobacteria: factors associated with infection in the community setting, Auckland, New Zealand

We aimed to document the epidemiology of extended-spectrum beta-lactamase (ESBL)-producing enterobacteria in the Auckland community and identify factors associated with infection using a case-control study design. ESBL-producing enterobacteria were isolated from 107 infected patients, for which demographic and clinical data were available for 98 cases (92%). Escherichia coli was the predominant organism (82%), with urine as the commonest source (97%). Compared with a control group infected with ESBL-negative enterobacteria, factors significantly associated with infection on univariate analysis were: living in a residential care home (RCH); recent admission to hospital 'M'; recent antibiotic use; older age (>75 years); presence of a urinary catheter; and a history of comorbid chronic obstructive pulmonary disease (COPD), cardiovascular disease, neurological disease or recurrent urinary tract infection. On multivariate analysis, residence in RCH and COPD remained significant associations. Pulsed-field gel electrophoresis typing of the ESBL-producing E. coli identified a common strain. We concluded that residence in RCH and a history of COPD are significant associations with ESBL-producing enterobacterial infection in the Auckland community. Several spatial clusters in RCHs and a common strain suggest point-source outbreaks. A substantial number of community cases did not live in an RCH nor had been recently hospitalised, suggesting the independent generation of ESBL-producing enterobacteria in the broader community.

Characterization of a Brucella sp. strain as a marine-mammal type despite isolation from a patient with spinal osteomyelitis in New Zealand

Naturally acquired infection of humans with a marine mammal-associated Brucella sp. has only been reported once previously in a study describing infections of two patients from Peru. We report the isolation and characterization of a strain of Brucella from a New Zealand patient that appears most closely related to strains previously identified from marine mammals. The isolate was preliminarily identified as Brucella suis using conventional bacteriological tests in our laboratory. However, the results profile was not an exact match, and the isolate was forwarded to four international reference laboratories for further identification. The reference laboratories identified the isolate as either B. suis or B. melitensis by traditional bacteriological methods in three laboratories and by a molecular test in the fourth laboratory. Molecular characterization by PCR, PCR-restriction fragment length polymorphism, and DNA sequencing of the bp26 gene; IS711; the omp genes omp25, omp31, omp2a, and omp2b; IRS-PCR fragments I, III, and IV; and five housekeeping gene fragments was conducted to resolve the discrepant identification of the isolate. The isolate was identified to be closely related to a Brucella sp. originating from a United States bottlenose dolphin (Tursiops truncatus) and common seals (Phoca vitulina).

Sesame seed products contaminated with Salmonella: three outbreaks associated with tahini

In November 2002, the first of three outbreaks of Salmonella Montevideo infection in Australia and New Zealand was identified in New South Wales, Australia. Affected persons were interviewed, and epidemiologically linked retail outlets inspected. Imported tahini was rapidly identified as the source of infection. The contaminated tahini was recalled and international alerts posted. A second outbreak was identified in Australia in June-July 2003 and another in New Zealand in August 2003. In a total of 68 S. Montevideo infections, 66 cases were contacted. Fifty-four (82%) reported consumption of sesame seed-based foods. Laboratory analyses demonstrated closely related PFGE patterns in the S. Montevideo isolates from human cases and sesame-based foods imported from two countries. On the basis of our investigations sesame-based products were sampled in other jurisdictions and three products in Canada and one in the United Kingdom were positive for Salmonella spp., demonstrating the value of international alerts when food products have a wide distribution and a long shelf life. A review of the controls for Salmonella spp. during the production of sesame-based products is recommended.

An outbreak of hepatitis A associated with consumption of raw blueberries

This report describes the epidemiology, investigation and control of a hepatitis A (HAV) outbreak in New Zealand. Descriptive and analytical epidemiology, virology, product traceback and an orchard investigation were carried out. A case-control study revealed that 56% of 39 cases had consumed raw blueberries, compared with 14% of 71 controls (odds ratio 7.6; 95% confidence intervals 2.6-22.4). Traceback of product through retailers and wholesalers implicated a single commercial orchard. Hepatitis A virus was detected by reverse transcriptase polymerase chain reaction in faecal specimens from cases as well as a blueberry product from the orchard. Presence of hepatitis A virus was confirmed by DNA hybridization and sequencing of PCR products. Sanitary audit of the orchard revealed multiple opportunities for contamination of blueberries by pickers. This outbreak highlights the need for food safety programmes in the berry fruit industry.

Evidence for a post-entry barrier to R5 HIV-1 infection of CD4 memory T cells

BACKGROUND

HIV-1 strains R5 and X4 can infect CD4 memory T cells in vivo. Anti-CD3/28 stimulation induces beta-chemokines and CCR5 down-regulation and renders these cells resistant to R5 HIV-1 infection. Here we describe an additional cellular mechanism that blocks productive R5 HIV-1 infection of CD4 memory T cells.

METHODS

Blood-derived CD4 memory T cells and CD4 T-cell clones were infected with primary R5 and X4 HIV-1 strains. Virus replication was correlated with CCR5 expression and beta-chemokine production. Virus entry and infectivity were measured by PCR for early and late products of HIV reverse transcription respectively.

RESULTS

R5 strains were up to 1000-fold less infectious than X4 viruses for CD4 memory T cells. This resistance was independent of CCR5 levels and of the Delta-32 mutation and the CCR2-V64I/CCR5-59653T linked mutations. Blocking endogenous beta-chemokines relieved minimally this restriction. At the single cell level, CD4 memory cells were either permissive or non-permissive for R5 HIV-1 infection. R5 HIV titre was up to 10-fold lower than X4 virus titre even in a permissive clone. However, R5 viruses replicated as efficiently as X4 viruses in the permissive clone when neutralizing anti-beta chemokine antibodies were added. Non-permissive cells blocked a post-entry step of the virus life-cycle and expressed early but not late HIV transcripts. Neutralizing anti-beta chemokine antibodies promoted R5 virus replication marginally in the non-permissive clone.

CONCLUSION

Some blood memory CD4 T cells retard R5 HIV-1 replication via endogenous beta-chemokines whereas others block productive R5 HIV-1 infection by an additional mechanism that interferes with a post-entry step of the virus life cycle. These natural barriers might contribute to lower pathogenicity of R5 HIV-1 strains for CD4 memory T cells than X4 viruses that emerge late in disease.

Antecedents to hospital deaths

BACKGROUND

Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals.

AIM

This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors.

METHODS

The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6-month period as well as antecedent factors present within 0-8 and 8-48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on 'not for resuscitation' deaths.

RESULTS

There were a total of 778 deaths, of which 549 (71%) were 'not for resuscitation'. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non-do not resuscitate (DNR) subgroup. Concern about the patient's condition was expressed in the patient's notes by attending nursing staff and junior medical staff in approximately one-third of non-DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non-DNR deaths.

CONCLUSION

There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention.

Raw oyster consumption and outbreaks of viral gastroenteritis in New Zealand: evidence for risk to the public's health

OBJECTIVE

To investigate the relationship between consumption of raw Pacific half shell oysters and outbreaks of Norwalk-like virus (NLV) gastroenteritis in Auckland in the last third of 1999.

METHOD

Ten outbreaks were investigated as retrospective cohorts using standardised questionnaires relating to food and drink exposures. Trace back of oysters and site inspections of implicated commercial growing areas were performed. Virological analyses compared oysters linked to outbreaks and faecal samples from cases.

RESULTS

Eighty-six cases were identified, of whom 32 (37.2%) were confirmed NLV positive on faecal analysis. The summary risk estimate for illness among oyster consumers for all outbreaks was RR 8.23 (95% CI 4.55-14.90; p< 0.001) and in five of seven outbreaks permitting statistical analysis, the risk for those consuming raw oysters was greater than five-fold that of non-consumers. NLVs were identified in two batches of oysters from different growing areas, implicated in four outbreaks. In both the strain (Genogroup II/3 'Mexico-like virus') from cases matched that in the oysters from the same harvest batch.

CONCLUSION

The epidemiological and virological evidence implicates oysters as the source of a number of outbreaks of NLV gastroenteritis. This is the first time NLVs have been identified in commercially farmed Pacific oysters in New Zealand. Sewage effluent from recreational boats was the likely source of faecal contamination of growing waters in one site.

IMPLICATIONS

Combined use of virological and epidemiological methods have proved invaluable in investigating NLV outbreaks. Further research is needed into enteric viral contamination of commercial oyster farms.

A chimeric MIP-1alpha/RANTES protein demonstrates the use of different regions of the RANTES protein to bind and activate its receptors

Human RANTES (CCL5) and MIP-1alpha (CCL3) bind and activate several CC chemokine receptors. RANTES is a high-affinity ligand for CCR1 and CCR5, and it binds CCR3 with moderate affinity and CCR4 with low affinity. MIP-1alpha has similar binding characteristics to RANTES except that it does not bind to CCR3. Here we have generated a chimera of human MIP-1alpha and RANTES, called MIP/RANTES, consisting of the eight amino terminal residues of MIP-1alpha preceding the CC motif, and the remainder of the sequence is RANTES. The chimera is able to induce chemotaxis of human monocytes. MIP/RANTES has >100-fold reduction in binding to CCR1 and does not bind to CCR3 but retains full, functional binding to CCR5. It has equivalent affinity for CCR5 to MIP-1alpha and RANTES, binding with an IC(50) of 1.12 nM, and is able to mobilize calcium and induce endocytosis of CCR5 in PBMC in a manner equi-potent to RANTES. It also retains the ability to inhibit R5 using HIV-1 strains. Therefore, we conclude that the amino terminus of RANTES is not involved in CCR5 binding, but it is essential for CCR1 and CCR3.

Phylogenetic analysis of multiple heterosexual transmission events involving subtype b of HIV type 1

Between 1996 and 1999 thirteen cases of HIV infection were detected in Doncaster, a small town in the north of England (population approximately 250,000). A complex network of shared sexual histories involving local nightclubs linked these cases, with the only known risk factor being heterosexual intercourse. A series of frozen blood samples was collected in 1998-1999 and amplified by PCR to generate full-length gp120 clones. Sequencing demonstrated that all the transmission events in this heterosexual group involved the B subtype of HIV-1. When relationships between the samples were assessed it became clear that these 13 cases represented at least three separate strains of HIV-1, indicating that HIV is well established in this community. Eleven of the 13 cases were related, forming two distinct groups. Further investigation revealed that one group contained five patients whose general health was good and who were not receiving HAART. In contrast, the second group of six patients, including the putative index case, were symptomatic, receiving HAART, and may have been infected with a CXCR-4-utilizing virus. Several of the cases that were linked by genetic criteria were not linked by contact tracing, implying that further undiagnosed cases may exist in this community. To our knowledge, this is the largest outbreak of HIV studied within the heterosexual community in the United Kingdom to date, suggesting that this route of infection is becoming more common within the United Kingdom.

Changing risk behaviours for non-communicable disease in New Zealand working men--is workplace intervention effective?

AIMS

To evaluate the effectiveness of a health promotion programme targeting dietary behaviours and physical activity among male hourly-paid workers and to explore demographic and attitudinal influences on dietary patterns at baseline.

METHODS

A controlled field trial compared workers at one intervention and one control worksite. The intervention comprised nutrition displays in the cafeteria and monthly 30-minute workshops for six months. Key outcome measures at six and twelve-months were self-reported dietary and lifestyle behaviours, nutrition knowledge, body mass index (BMI), waist circumference and blood pressure.

RESULTS

132 men at the intervention site and 121 men at the control site participated in the study and a high retention rate (94% at 6-months and 89% at 12-months) was achieved. At baseline, 40% of the total sample (253) were obese, 30% had elevated blood pressure, 59% indicated an excessive fat intake and 92% did not meet the recommended vegetable and fruit intake. The intervention reduced fat intake, increased vegetable intake and physical activity, improved nutrition knowledge and reduced systolic blood pressure when compared to the control site. There was no difference in change in mean BMI or waist circumference. Reduction in BMI was associated with reduction in fat intake.

DISCUSSION

Low intensity workplace intervention can significantly improve reported health behaviours and nutrition knowledge although the impact on more objective measures of risk was variable. A longer duration or more intensive intervention may be required to achieve further reduction in risk factors.

Carriage of Neisseria meningitidis among household contacts of patients with meningococcal disease in New Zealand

The aims of this study were to estimate carriage prevalence, identify factors predictive of carriage, and compare strains of Neisseria meningitidis isolated from patients with meningococcal disease and their household contacts. A total of 954 contacts of 160 patients had a nasopharyngeal swab and an interview relating to factors associated with carriage. The carriage prevalence was 20.4% for Neisseria meningitidis, 11.3% for serogroup B, and 2.6% for serogroup C. Age-standardised carriage was higher in Maori (36.8%) than in Pacific Island (21.5%) or European/other (11.1%) ethnic groups. Factors associated with carriage were smoking, with personal smokers (odds ratio [OR] 2.5) and passive smokers (OR 1.6) having a higher carriage risk than those in smoke-free houses; ethnicity, with Maoris having a higher carriage risk than those of non-Maori or non-Pacific Island ethnicity (OR 2.2); gender, with males at higher risk than females (OR 1.7); and age, with 0-4-year-olds less likely and 15-24-year-olds more likely to be carriers than those over 25 years. Strong patient-contact clustering by meningococcal strain (chi-square1 = 16.7, P=0.00004) suggested an important role for the household setting in transmission. The low carriage prevalence of serogroup B Neisseria meningitidis among household contacts may reflect its low transmissibility but high virulence. No direct relationship was found between prevalence of ethnic-specific carriage and the incidence of meningococcal disease.

Contamination of potable roof-collected rainwater in Auckland, New Zealand

One-hundred and twenty-five domestic roof-collected rainwater supplies in four rural Auckland districts were investigated in a cross-sectional survey to determine water quality. Samples of cold faucet water were analysed for physico-chemical and microbiological determinands, including metals (zinc, copper and lead), bacterial indicator organisms--heterotrophic plate count (HPC), total coilforms (TC), faecal coliforms (FC), enterococci (ENT), bacterial pathogens including Salmonella spp., Legionella spp., Campylobacter spp., Aeromonas spp. and the protozoa, Cryptosporidium and Giardia. Twenty-two supplies (17.6%) exceeded one or more of the maximum acceptable values (MAV) or maximum guideline values for chemical determinands of the New Zealand Drinking Water Standards (NZDWS) and 70 (56.0%) supplies exceeded the microbiological criteria of < 1 FC/100 mL. Eighteen supplies (14.4%) exceeded the NZDWS MAV for lead of 0.01 mg/L and three (2.4%) exceeded that for copper, of 2 mg/L. Those supplies with lead or galvanised iron comprising part of the roof or collecting system were more likely to show lead contamination (p = 0.019) as were those supplies with a pH less than 7 (p = 0.013). The presence of the indicator organisms HPC, TC, FC and ENT were all significantly correlated with one another. Aeromonas spp. were identified in 20 (16.0%) supplies. There was a positive association between the presence of Aeromonas and the bacterial indicator organisms. Households reporting at least one member with gastrointestinal symptoms in the month prior to sampling, were more likely to have Aeromonas spp. identified in their water supply than those households without symptoms (odds ratio 3.22, 95% CI 1.15-9.01, p = 0.021). Salmonella typhimurium was detected in one of 115 (0.9%) supplies. Legionella spp. and Campylobacter spp. were not detected. There were 50 supplies sampled for protozoa (sampling criteria: > or = 30 FC or > or = 60 ENT). Cryptosporidium oocysts were detected in 2 (4%) of these. Giardia was not detected. This study demonstrates that roof-collected rainwater systems provide potable supplies of relatively poor physiochemical and microbiological quality in the Auckland area. Further research is required on Aeromonas spp. as potential indicators of both microbiological quality and health risk along with design and maintenance strategies to minimise contamination of potable roof-collected rainwater supplies.

Development of multianalyte sensor arrays composed of chemically derivatized polymeric microspheres localized in micromachined cavities

The development of a chip-based sensor array composed of individually addressable polystyrene-poly(ethylene glycol) and agarose microspheres has been demonstrated. The microspheres are selectively arranged in micromachined cavities localized on silicon wafers. These cavities are created with an anisotropic etch and serve as miniaturized reaction vessels and analysis chambers. A single drop of fluid provides sufficient analysis media to complete approximately 100 assays in these microetch pits. The cavities possess pyramidal pit shapes with trans-wafer openings that allows for both fluid flow through the microreactors/analysis chambers and optical access to the chemically sensitive microspheres. Identification and quantitation of analytes occurs via colorimetric and fluorescence changes to receptor and indicator molecules that are covalently attached to termination sites on the polymeric microspheres. Spectral data are extracted from the array efficiently using a charge-coupled device allowing for the near-real-time digital analysis of complex fluids. The power and utility of this new microbead array detection methodology is demonstrated here for the analysis of complex fluids containing a variety of important classes of analytes including acids, bases, metal cations, metabolic cofactors, and antibody reagents.

Laparoscopic transverse hemicystectomy with ileocystoplasty in a porcine model

BACKGROUND AND PURPOSE

The ideal replacement for bladder tissue is yet to be described, although multiple alternatives have been studied. Currently, enterocystoplasty, despite its limitations, is considered the gold standard for bladder augmentation. This study evaluated the feasibility, safety, and morbidity of laparoscopic ileocystoplasty in a large-animal model.

MATERIALS AND METHODS

In eight minipigs, laparoscopy was performed using four ports. A segment of ileum was delivered through a 3-cm umbilical incision and detubularized and refashioned using standard open surgical technique. Laparoscopic hemicystectomy was then performed, followed by laparoscopic suturing of the ileal patch to the bladder. The bladder was drained with a Foley catheter, but no pelvic drain was placed. All animals were followed for for a minimum of 3 months. Preoperative and postoperative evaluation included measurement of bladder capacity, ultrasound imaging of the kidneys, blood counts, and serum electrolyte and creatinine measurements. Two of the animals were sacrificed at 3 months and one at 6 months, and the bladders were harvested.

RESULTS

Eight animals underwent ileocystoplasty without intraoperative or postoperative complications. The average operating and anastomosis time was 250 minutes and 96 minutes, respectively. All animals had normal preoperative blood values that remained normal during follow-up. Bladder capacity decreased initially to 71% of the baseline volume and then increased to 83% and 117% at 3 and 6 months. One of three animals sacrificed was noted to have a right midureteral stricture.

CONCLUSIONS

We developed a reliable laparoscopic technique for ileocystoplasty that may extend the advantages of laparoscopy, including better cosmesis and reduced risk of postoperative adhesions, to bladder augmentation.

Tuberculosis: reasons for diagnostic delay in Auckland

AIMS

First, to quantify the interval between the onset of symptoms and the start of anti-tuberculous treatment in a series of Auckland tuberculosis patients. Second, to examine the help-seeking behaviour of the patients and the responses of the health-care providers whom they consulted about their symptoms. Third, to identify potentially modifiable reasons for delayed presentation or diagnosis.

METHODS

100 patients with tuberculosis (TB) were interviewed using a questionnaire which sought symptom duration and help-seeking behaviour. The doctors whom they consulted were surveyed about their diagnostic, therapeutic and referral responses.

RESULTS

Delayed presentation by patients ('patient delay') was found in smokers, patients who reported cough, patients who hoped their symptoms would go away on their own, and patients reporting fear of what would be found on diagnosis. 'Doctor delay' (the interval from first consultation with a doctor to start of treatment) was longer than that found in most published series and was a more important component of total delay than delayed presentation by patients. Longer doctor delay was found if patients had pre-existing lung disease or consulted multiple doctors, and if doctors did not inquire into past exposure to TB or request a chest X-ray.

CONCLUSIONS

Awareness programmes for high-risk communities are needed to encourage early reporting of symptoms. Continuing medical education for general practitioners is needed to encourage vigilance for TB and earlier use of diagnostic tests in patients who have symptoms of TB and are in high-risk groups.

Co-receptor use by HIV and inhibition of HIV infection by chemokine receptor ligands

Human and simian immunodeficiency viruses (HIV and SIV) require a seven transmembrane chemokine (7TM) receptor in addition to CD4 for efficient entry into cells. CCR5 and CXCR4 act as major co-receptors for non-syncytium-inducing and syncytium-inducing strains respectively. We have examined the co-receptor requirement for HIV-1 infection of cells of macrophage lineage. Both CCR5 and CXCR4 can operate as functional co-receptors for infection in these cell types. Other co-receptors utilised by multi-co-receptor-using strains of HIV-1, including CCR3 and STRL33, were not used for macrophage infection. HIV-2 and SIV strains, however, can replicate in both peripheral blood mononuclear cells (PBMCs) and other primary cell types such as fibroblasts independently of CCR5 or CXCR4. HIV co-receptors, particularly CCR5, will be major targets for new therapeutics in this decade. We have therefore investigated different chemokines and derivatives that bind co-receptors for their capacity to inhibit HIV infection. These included derivatives of a CCR5 ligand, RANTES, with modified N-termini as well as Kaposi's sarcoma-associated herpesvirus-encoded chemokines that bind a wide range of co-receptors, including CCR5, CXCR4, CCR3 and CCR8, as well as the orphan 7TM receptors GPR1 and STRL33. One compound, aminooxypentane or AOP-RANTES, was a particularly potent inhibitor of HIV infection on PBMCs, macrophages and CCR5+ cell lines and demonstrated the great promise of therapeutic strategies aimed at CCR5.

A small molecule antagonist of chemokine receptors CCR1 and CCR3. Potent inhibition of eosinophil function and CCR3-mediated HIV-1 entry

We describe a small molecule chemokine receptor antagonist, UCB35625 (the trans-isomer J113863 published by Banyu Pharmaceutical Co., patent WO98/04554), which is a potent, selective inhibitor of CCR1 and CCR3. Nanomolar concentrations of UCB35625 were sufficient to inhibit eosinophil shape change responses to MIP-1alpha, MCP-4, and eotaxin, while greater concentrations could inhibit the chemokine-induced internalization of both CCR1 and CCR3. UCB35625 also inhibited the CCR3-mediated entry of the human immunodeficiency virus-1 primary isolate 89.6 into the glial cell line, NP-2 (IC(50) = 57 nm). Chemotaxis of transfected cells expressing either CCR1 or CCR3 was inhibited by nanomolar concentrations of the compound (IC(50) values of CCR1-MIP-1alpha = 9.6 nm, CCR3-eotaxin = 93.7 nm). However, competitive ligand binding assays on the same transfectants revealed that considerably larger concentrations of UCB35625 were needed for effective ligand displacement than were needed for the inhibition of receptor function. Thus, it appears that the compound may interact with a region present in both receptors that inhibits the conformational change necessary to initiate intracellular signaling. By virtue of its potency at the two major eosinophil chemokine receptors, UCB35625 is a prototypic therapy for the treatment of eosinophil-mediated inflammatory disorders, such as asthma and as an inhibitor of CCR3-mediated human immunodeficiency virus-1 entry.

Carriage of N. lactamica in a population at high risk of meningococcal disease

Carriage of Neisseria lactamica among household contacts of meningococcal disease (MCD) cases was investigated during an epidemic in Auckland, New Zealand. The overall carriage rate for N. lactamica was 10.5% (95% CI 7.4-13.5%) with a peak carriage rate in 2-year-olds of 61.5% (95% CI 26.6-88.1%). Factors associated with a significant (P < 0.05) increase in the likelihood of carriage included runny nose, the number of people per bedroom and youth. Genetic analysis of isolates revealed a striking correlation of strains within the same household but a high level of diversity between households, suggesting that household contact is an important factor in acquisition. For household contacts aged less than 5 years, there was a higher rate of carriage amongst those in contact with MCD cases under 8 years old than for contacts of cases aged 8 years and over. It is likely that development of MCD is a reflection of the nature and intensity of the exposure to a virulent strain of N. meningitidis, coupled with an absence of host resistance among those individuals not carrying N. lactamica.

Equivalence of ceftriaxone and rifampicin in eliminating nasopharyngeal carriage of serogroup B Neisseria meningitidis

The efficacy of ceftriaxone in eliminating nasopharyngeal carriage of Neisseria meningitidis was compared with that of rifampicin during an epidemic of serogroup B meningococcal disease in Auckland, New Zealand. Household contacts of cases had a throat swab taken and were randomized to treatment. Carriers had a repeat swab taken 6 days later to determine efficacy of treatment. Ceftriaxone (98.2%) was equivalent to rifampicin (97.6%) in eliminating serogroup B N. meningitidis. It is cheaper than rifampicin and has the advantage of full compliance and fewer contraindications, but its acceptability by patients may limit its use as a first-line prophylactic agent.

Differential activation of CC chemokine receptors by AOP-RANTES

RANTES (regulated on activation normal T cell expressed) has been found at elevated levels in biological fluids from patients with a wide range of allergic and autoimmune diseases and is able to attract several subtypes of leukocytes including eosinophils and monocytes into inflamed tissue. Amino-terminal modifications of RANTES produce receptor antagonists which are candidates for blocking this cellular recruitment. Met-RANTES has been shown to modulate inflammation in vivo, while AOP-RANTES is a potent inhibitor of R5 human immunodeficiency virus type 1 (HIV-1) strains and has been shown to down-modulate CCR5 and prevent recycling of the receptor. We have studied the effect of AOP-RANTES in eosinophil activation and have found that it is able to efficiently elicit eosinophil effector functions through CCR3, as measured by the release of reactive oxygen species and calcium mobilization, whereas Met-RANTES is inactive in these assays. AOP-RANTES is found to inhibit CCR3-mediated HIV-1 infection with moderate potency, in contrast to its potent inhibition of CCR5-mediated HIV-1 infection. Furthermore, we have investigated the abilities of these modified proteins to down-modulate CCR1 and CCR3 from the surface of monocytes and eosinophils. We show here that AOP-RANTES is much less effective than RANTES in down-modulation of CCR1. Surprisingly, recycling of CCR1 was minimal after incubation with RANTES while there was complete recycling with AOP-RANTES. In the case of CCR3, no significant difference was found between RANTES and AOP-RANTES in down-modulation and recycling. It therefore appears that trafficking of RANTES receptors follows different patterns, which opens up potential new targets for therapeutic intervention.

KSHV-encoded CC chemokine vMIP-III is a CCR4 agonist, stimulates angiogenesis, and selectively chemoattracts TH2 cells

Kaposi's sarcoma-associated herpesvirus (KSHV) encodes 3 genes that are homologous to cellular chemokines. vMIP-III, the product of open reading frame K4.1, is the most distantly related to human chemokines and has yet to be characterized. We have examined the interaction of vMIP-III with chemokine receptors, its expression in KS lesions, and its in ovo angiogenic properties. We show expression of vMIP-III in KS lesions and demonstrate the stimulation of angiogenesis by this chemokine, like vMIP-I and vMIP-II, in the chick chorioallantoic membrane assay. vMIP-III does not block human immunodeficiency virus entry through the coreceptors CCR3, CCR5, or CXCR4. However, vMIP-III is an agonist for the cellular chemokine receptor CCR4. CCR4 is expressed by TH2-type T cells. Consistent with this, vMIP-III preferentially chemoattracts this cell type. Because of these biologic properties and because it is expressed in KS lesions, vMIP-III may play an important role in the pathobiology of KS. (Blood. 2000;95:1151-1157)

Expanded tropism of primary human immunodeficiency virus type 1 R5 strains to CD4(+) T-cell lines determined by the capacity to exploit low concentrations of CCR5

Human immunodeficiency virus type 1 (HIV-1) non-syncytium-inducing (NSI) strains predominantly use the chemokine receptor CCR5, while syncytium-inducing (SI) strains use CXCR4. In vitro, SI isolates infect and replicate in a range of CD4(+) CXCR4(+) T-cell lines, whereas NSI isolates usually do not. Here we describe three NSI strains that are able to infect two CD4(+) T-cell lines, Molt4 and SupT1. For one strain, a variant of JRCSF selected in vitro, replication on Molt4 was previously shown to be conferred by a single amino-acid change in the V1 loop (M.T. Boyd et al., J. Virol. 67:3649-3652, 1993). On CD4(+) cell lines expressing different coreceptors, these strains use CCR5 predominantly and do not replicate in CCR5-negative peripheral blood mononuclear cells derived from individuals homozygous for Delta32 CCR5. Furthermore, infection of Molt4 and SupT1 by each of these three strains is potently inhibited by ligands for CCR5, including 2D7, a monoclonal antibody specific for CCR5. CCR5 mRNA was present in both Molt4 and SupT1 by reverse transcription-PCR, although CCR5 protein could not be detected either on the cell surface or in intracellular vesicles. The expanded tropism of the three strains shown here is therefore not due to adaptation to a new coreceptor but due to the capacity to exploit extremely low levels of CCR5 on Molt4 and SupT1 cells. This novel tropism observed for a subset of primary HIV-1 isolates may represent an extended tropism to new CD4(+) cell types in vivo.

Primary human immunodeficiency virus type 2 (HIV-2) isolates infect CD4-negative cells via CCR5 and CXCR4: comparison with HIV-1 and simian immunodeficiency virus and relevance to cell tropism in vivo

Cell surface receptors exploited by human immunodeficiency virus (HIV) and simian immunodeficiency virus (SIV) for infection are major determinants of tropism. HIV-1 usually requires two receptors to infect cells. Gp120 on HIV-1 virions binds CD4 on the cell surface, triggering conformational rearrangements that create or expose a binding site for a seven-transmembrane (7TM) coreceptor. Although HIV-2 and SIV strains also use CD4, several laboratory-adapted HIV-2 strains infect cells without CD4, via an interaction with the coreceptor CXCR4. Moreover, the envelope glycoproteins of SIV of macaques (SIV(MAC)) can bind to and initiate infection of CD4(-) cells via CCR5. Here, we show that most primary HIV-2 isolates can infect either CCR5(+) or CXCR4(+) cells without CD4. The efficiency of CD4-independent infection by HIV-2 was comparable to that of SIV, but markedly higher than that of HIV-1. CD4-independent HIV-2 strains that could use both CCR5 and CXCR4 to infect CD4(+) cells were only able to use one of these receptors in the absence of CD4. Our observations therefore indicate (i) that HIV-2 and SIV envelope glycoproteins form a distinct conformation that enables contact with a 7TM receptor without CD4, and (ii) the use of CD4 enables a wider range of 7TM receptors to be exploited for infection and may assist adaptation or switching to new coreceptors in vivo. Primary CD4(-) fetal astrocyte cultures expressed CXCR4 and supported replication by the T-cell-line-adapted ROD/B strain. Productive infection by primary X4 strains was only triggered upon treatment of virus with soluble CD4. Thus, many primary HIV-2 strains infect CCR5(+) or CXCR4(+) cell lines without CD4 in vitro. CD4(-) cells that express these coreceptors in vivo, however, may still resist HIV-2 entry due to insufficient coreceptor concentration on the cell surface to trigger fusion or their expression in a conformation nonfunctional as a coreceptor. Our study, however, emphasizes that primary HIV-2 strains carry the potential to infect CD4(-) cells expressing CCR5 or CXCR4 in vivo.

Coreceptor ligand inhibition of fetal brain cell infection by HIV type 1

The capacity of a panel of HIV-1 isolates to infect primary mixed fetal brain cell cultures was estimated and their sensitivity to inhibition by a range of coreceptor ligands assessed. Our results show that (1) HIV-1 strains that predominantly use CCR5 or only CXCR4 are able to infect microglia in primary brain cell cultures, and (2) ligands to these two coreceptors can inhibit brain cell infection. CCR5 ligands (including AOP-RANTES, a potent inhibitor of CCR5-dependent infection), however, blocked infection only weakly, raising the possibility that alternative unidentified coreceptors are also used. Interestingly, vMIP-II, a chemokine encoded by the Kaposi sarcoma-associated herpes virus (KSHV), reduced brain cell infection by all HIV-1 strains tested, including both R5 and X4 viruses. Our results therefore indicate that novel drugs targeted to the major HIV-1 coreceptors will influence HIV replication in the brain, if they cross the blood-brain barrier.

HIV coreceptors, cell tropism and inhibition by chemokine receptor ligands

HIV is a persistent virus that survives and replicates despite an onslaught by the host's immune system. A strategy for cell entry, requiring the use of two receptors, has evolved that may help evade neutralizing antibodies. HIV and SIV usually require both CD4 and a seven transmembrane (7TM) coreceptor for infection. At least eleven different 7TM coreceptors have been identified that confer HIV and/or SIV entry. For HIV-1, the major coreceptors are CCR5 and CXCR4, while the role of other coreceptors for replication and cell tropism in vivo is currently unclear. Polymorphisms in the CCR5 gene that reduce CCR5 expression levels, protect against disease progression, suggesting that drugs targeted to CCR5 could be effective. Such therapies however will not work if HIV simply adapts to use alternative coreceptors. In the light of these themes, this review will discuss the following topics: (i) the coreceptors used by primary HIV-1 and HIV-2 viruses, (ii) the properties and coreceptors of HIV-2 strains that infect cells without CD4, (iii) the role of coreceptors in HIV cell tropism and particularly macrophage infection and (iv) the properties of chemokine receptor ligands that block HIV infection.

CXCR4 as a functional coreceptor for human immunodeficiency virus type 1 infection of primary macrophages

The coreceptors used by primary syncytium-inducing (SI) human immunodeficiency virus type 1 isolates for infection of primary macrophages were investigated. SI strains using only CXCR4 replicated equally well in macrophages with or without CCR5 and were inhibited by several different ligands for CXCR4 including SDF-1 and bicyclam derivative AMD3100. SI strains that used a broad range of coreceptors including CCR3, CCR5, CCR8, CXCR4, and BONZO infected CCR5-deficient macrophages about 10-fold less efficiently than CCR5(+) macrophages. Moreover, AMD3100 blocked infection of CCR5-negative macrophages by these strains. Our results therefore demonstrate that CXCR4, as well as CCR5, is used for infection of primary macrophages but provide no evidence for the use of alternative coreceptors.

Artificial urinary sphincter in the treatment of urinary incontinence: preoperative urodynamics do not predict the need for future bladder augmentation

PURPOSE

The artificial urinary sphincter has been used to treat urinary incontinence in pediatric patients with neurogenic bladders secondary to myelodysplasia. Frequently bladder augmentation is performed in conjunction with the artificial urinary sphincter implantation. Identifying patients with adequate urinary reservoirs who are candidates for implantation without bladder augmentation is a clinical challenge. We reviewed our experience with the artificial urinary sphincter in children with myelodysplasia to determine whether preoperative urodynamic findings predict the need for future augmentation cystoplasty.

MATERIALS AND METHODS

We identified 38 patients younger than 18 years at artificial urinary sphincter implantation who did not undergo augmentation enterocystoplasty before or at implantation. We evaluated preoperative bladder capacity and compliance to determine whether these standard preoperative urodynamic measurements predict the eventual need for bladder augmentation in these patients.

RESULTS

In the 15 patients who required eventual bladder augmentation after artificial urinary sphincter implantation mean bladder capacity plus or minus standard deviation was 62.9+/-29.9% of age expected capacity and mean bladder compliance was 8.0+/-4.8 ml./cm. water. In the 23 patients who did not require eventual bladder augmentation mean bladder capacity was 59.2+/-25.4% of age expected capacity and compliance was 7.0+/-3.3 ml./cm. water. There was no statistically significant difference between the 2 groups.

CONCLUSIONS

Standard preoperative urodynamics do not predict the patients who undergo isolated artificial urinary sphincter implantation and eventually require bladder augmentation.

Aminooxypentane-RANTES induces CCR5 internalization but inhibits recycling: a novel inhibitory mechanism of HIV infectivity

CCR5, a chemokine receptor expressed on T cells and macrophages, is the principal coreceptor for M-tropic HIV-1 strains. Recently, we described an NH2-terminal modification of the CCR5 ligand regulated on activation, normal T cell expressed and secreted (RANTES), aminooxypentane-RANTES (AOP-RANTES), that showed potent inhibition of macrophage infection by HIV-1 under conditions where RANTES was barely effective. To investigate the mechanism of AOP-RANTES inhibition of HIV infectivity we examined the surface expression of CCR5 using a monoclonal anti-CCR5 antibody, MC-1. We demonstrate that AOP-RANTES rapidly caused >90% decrease in cell surface expression of CCR5 on lymphocytes, monocytes/ macrophages, and CCR5 transfected Chinese hamster ovary (CHO) cells. RANTES also caused a loss of cell surface CCR5, although its effect was less than with AOP-RANTES. Significantly, AOP-RANTES inhibited recycling of internalized CCR5 to the cell surface, whereas RANTES did not. When peripheral blood mononuclear cells are cultured for prolonged periods of time in the presence of RANTES, CCR5 expression is comparable to that seen on cells treated with control medium, whereas there is no CCR5 surface expression on cells cultured in the presence of AOP-RANTES. Immunofluorescence indicated that both AOP-RANTES and RANTES induced downmodulation of cell surface CCR5, and that the receptor was redistributed into endocytic organelles containing the transferrin receptor. When RANTES was removed, the internalized receptor was recycled to the cell surface; however, the receptor internalized in the presence of AOP-RANTES was retained in endosomes. Using human osteosarcoma (GHOST) 34/CCR5 cells, the potency of AOP-RANTES and RANTES to inhibit infection by the M-tropic HIV-1 strain, SF 162, correlated with the degree of downregulation of CCR5 induced by the two chemokines. These differences between AOP-RANTES and RANTES in their effect on receptor downregulation and recycling suggest a mechanism for the potent inhibition of HIV infection by AOP-RANTES. Moreover, these results support the notion that receptor internalization and inhibition of receptor recycling present new targets for therapeutic agents to prevent HIV infection.

Cardiovascular disease risk factors in 65-84 year old men and women: results from the Auckland University Heart and Health Study 1993-4

AIM

To describe the distribution of the major cardiovascular risk factors among older men and women in the Auckland region, New Zealand.

METHODS

Means and prevalences of the major cardiovascular risk factors were estimated for non-Maori, non-Pacific Islands men and women in the age groups 65-74 and 75-84 years using data from the 1993-4 survey of the University of Auckland Heart and Health Study, a cross-sectional, population-based study of cardiovascular risk factors.

RESULTS

996 people aged 65-84 years participated, with men and women and the two ten-year age groups almost equally represented. Fewer than half engaged in regular leisure time physical activity; around 35% were overweight (BMI 25-30) and 10% were obese (BMI > 30). Total mean cholesterol levels were higher in women and 46% of women had a cholesterol level > or = 6.5 mmol/L compared with only 17% of men. However, total cholesterol:HDL ratios were higher among men. Age and sex differences in blood pressure were small. Around 50% had raised blood pressure (BP > 150/90) or were currently on antihypertensive medication; only 8% smoked; around 6% were diabetic. Almost 8% had three or all of four major modifiable cardiovascular risk factors (elevated blood pressure, total cholesterol:HDL ratio > or = 6.5, current smoking and physical inactivity).

CONCLUSIONS

These results are broadly comparable to those from other Western populations. Differences between 65-74 and 75-84 year age groups are few but important differences in cholesterol, smoking and physical activity between older men and women are noted. These findings indicate that there is considerable potential for prevention of cardiovascular disease among older people.

The effect of lossy discrete cosine transform compression on subtle bone fractures

Extensive research efforts have been devoted to the feasibility of picture archiving and communication systems (PACS) in recent years. The advantages of PACS are numerous but mainly include reduced cost and improvement in the operational efficiency of a PACS-based radiology department. In digital radiography, images are viewed either in hard-copy or soft-copy format. Usually, these images are subsequently compressed and archived for future evaluation. There are various methods used in image compression. In this study, computed radiography images showing subtle pediatric bone fractures were compressed with the lossy method of image compression after they had been initially evaluated on workstation monitors. These studies were subsequently evaluated by observers, who were unaware of the interpretations of these images before compression, to determine if they could detect similar abnormalities. Our conclusion is that there is no difference in the interpretation of soft-copy computed radiographic images before or after lossy 10:1 compression in studies of subtle pediatric bone fractures. This is a US government work. There are no restrictions on its use.

Langerhans cell tropism of human immunodeficiency virus type 1 subtype A through F isolates derived from different transmission groups

To test the hypothesis that some subtypes of human immunodeficiency virus type 1 (HIV-1), especially subtype E, are more likely to infect mature Langerhans cells (mLC), we titrated a panel of 26 primary HIV-1 isolates of subtypes A through F on peripheral blood mononuclear cells (PBMC) and mLC. The majority of HIV-1 isolates from heterosexually infected patients did not show a preferred tropism for mLC compared to homosexually transmitted HIV-1 isolates. Only 6 of 26 isolates, 2 from patients infected by homosexual contact and 4 from patients infected by heterosexual contact, showed a higher infectivity for mLC than for PBMC. Both syncytium-inducing and non-syncytium-inducing isolates were able to infect mLC which express mRNA for the chemokine receptors CCR3, CCR5, and CXCR4.

A broad-spectrum chemokine antagonist encoded by Kaposi's sarcoma-associated herpesvirus

Kaposi's sarcoma-associated herpesvirus encodes a chemokine called vMIP-II. This protein displayed a broader spectrum of receptor activities than any mammalian chemokine as it bound with high affinity to a number of both CC and CXC chemokine receptors. Binding of vMIP-II, however, was not associated with the normal, rapid mobilization of calcium from intracellular stores; instead, it blocked calcium mobilization induced by endogenous chemokines. In freshly isolated human monocytes the virally encoded vMIP-II acted as a potent and efficient antagonist of chemotaxis induced by chemokines. Because vMIP-II could inhibit cell entry of human immunodeficiency virus (HIV) mediated through CCR3 and CCR5 as well as CXCR4, this protein may serve as a lead for development of broad-spectrum anti-HIV agents.

The effect of intravenous ketorolac given intraoperatively versus postoperatively on outcome from gynecologic abdominal surgery

STUDY OBJECTIVES

To examine the effect of timing of an intravenous (i.v.) dose (intraoperative vs. postoperative) of ketorolac tromethamine on pain scores and overall outcome after total abdominal hysterectomy (TAH) and myomectomy.

DESIGN

Prospective, randomized, placebo-controlled study.

PATIENTS

248 ASA physical status I and II adult female patients scheduled for elective hysterectomy or myomectomy.

INTERVENTIONS

General anesthesia was administered that consisted of thiopental sodium for induction, enflurane or isoflurane in nitrous oxide-oxygen for maintenance, and small doses of fentanyl and midazolam. Patients were randomized into three groups to receive toradol/placebo on a dosing schedule of dose 1 given one-half hour prior to expected end of surgery, dose 2 given on awakening in the postanesthesia care unit, and doses 3, 4, and 5 given at 6, 12, and 18 hours, respectively, after dose 2; Group 1 patients received placebo (saline) for dose 1, ketorolac 60 mg i.v. for dose 2, and ketorolac 30 mg i.v. for doses 3, 4, and 5. Group 2 patients received ketorolac 60 mg i.v. for dose 1, placebo for dose 2, and ketorolac 30 mg i.v. for doses 3, 4, and 5. Group 3 patients received placebo for all doses. All patients were given i.v. morphine PCA postoperatively, and morphine usages, visual analog pain intensity (VAS) scores, as well as adverse events and median times to recovery milestones were recorded.

MEASUREMENTS AND MAIN RESULTS

VAS scores (mean) before dose 2 were significantly lower in Group 2 than Group 1, as were at-rest evaluations at 15 minutes and one hour. Group 2 patients also had decreased morphine requirements as compared to placebo. Both ketorolac groups (Groups 1 and 2) had significantly higher values for patient and observer overall ratings, case of nursing care, and tolerability as compared to placebo (Group 3). There were no significant differences among groups in adverse events or median times to recovery milestones.

CONCLUSIONS

Although it is possible to demonstrate an improvement in early postoperative pain scores with intraoperative ketorolac and better overall ratings of ketorolac both intraoperatively and postoperatively as compared with placebo, the lack of clinically significant differences in analgesic efficacy in the two active study groups indicates the need for a careful consideration by the clinician of the risks versus benefits involved in the administration of antiplatelet medication in the perioperative period.

Biological characterization of human immunodeficiency virus type 1 clones derived from different organs of an AIDS patient by long-range PCR

In order to characterize the biological properties of human immunodeficiency virus type 1 (HIV-1) variants from different tissues (peripheral blood mononuclear cells [PBMC], lymph node, spleen, brain, and lung) of one patient, we have chosen long-range PCR to amplify virtually full-length HIV proviruses and to construct replication-competent viruses by adding a patient-specific 5' long terminal repeat. To avoid selection during propagation in CD4+ target cells, we transfected 293 cells and used the supernatants from these cells as challenge viruses for tropism studies after titration on human PBMC. Despite differences in the V3 loop of the major variants found in brain and lung compared to lymphoid tissues all recombinant HIV clones obtained showed identical cell tropism and replicative kinetics. After infection of human PBMC these viruses replicated with similar kinetics, with a slow/low-titer, non-syncytium-inducing phenotype. In contrast to the prediction of macrophage tropism, drawn from the V3 loop sequence, none of these viruses infected monocyte-derived macrophages. The challenge of blood dendritic cells by these recombinant viruses in the presence of tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, and interleukin-4 resulted in a productive infection only after adding stimulated CD4+ T lymphocytes. Therefore, the biological properties of the HIV-1 variants derived from nonlymphoid tissue of this patient did not differ from those of HIV-1 variants from lymphoid tissue with respect to tropism for primary cells such as PBMC, macrophages, and blood dendritic cells.

Multiple extracellular domains of CCR-5 contribute to human immunodeficiency virus type 1 entry and fusion

Human immunodeficiency virus type 1 (HIV-1) entry is governed by the interaction of the viral envelope glycoprotein (Env) with its receptor. The HIV-1 receptor is composed of two molecules, the CD4 binding receptor and a coreceptor. The seven-membrane-spanning chemokine receptor CCR-5 is one of the coreceptors used by primary isolates of HIV-1. We demonstrate that the mouse homolog of CCR-5 (mCCR-5) does not function as an HIV-1 coreceptor. A set of chimeras of human CCR-5 and mCCR-5 was studied for Env-induced cell fusion and HIV-1 infection. Using the HIV-1ADA envelope glycoprotein in a syncytium formation assay, we show that replacement of any fragment containing extracellular domains of mCCR-5 by its human counterparts is sufficient to allow Env-induced fusion. Conversely, replacement of any fragment containing human extracellular domains by its murine counterpart did not lead to coreceptor function loss. These results show that several domains of CCR-5 participate in coreceptor function. In addition, using a panel of primary nonsyncytium-inducing and syncytium-inducing isolates that use CCR-5 or both CXCR-4 and CCR-5 as coreceptors, we show that the latter dual-tropic isolates are less tolerant to changes in CCR-5 than strains with a more restricted coreceptor use. Thus, different strains are likely to have different ways of interacting with the CCR-5 coreceptor.

CD4-independent infection by HIV-2 (ROD/B): use of the 7-transmembrane receptors CXCR-4, CCR-3, and V28 for entry

We have assayed a variety of 7tm chemokine receptors (CCR-2b, CCR-3, CCR-4, CCR-5, CXCR-1, CXCR-4) and two orphan 7tm receptors (V28 and EBI.1) for their ability to allow infection of CD4-negative feline kidney CCC cells by the HIV-2 strains ROD/A and ROD/B. We found that ROD/B was able to use CXCR-4 transiently expressed in CCC cells, and infection by ROD/A was enhanced 15-fold in the presence of sCD4. Feline CCC cells also became permissive to ROD/B and ROD/A entry when transiently transfected with the chemokine receptor CCR-3 or the orphan 7tm receptor V2B, when cultured in the presence of sCD4. Entry of ROD/A into CCC cells expressing CCR-3 could be blocked by 800 ng/ml eotaxin, the natural ligand for CCR-3.