Reshaping human antibodies for therapy

A human IgGI antibody has been reshaped for serotherapy in humans by introducing the six hypervariable regions from the heavy- and light-chain variable domains of a rat antibody directed against human lymphocytes. The reshaped human antibody is as effective as the rat antibody in complement and is more effective in cell-mediated lysis of human lymphocytes.

Affect, accessibility of material in memory, and behavior: A cognitive loop?

Two studies investigated the effect of good mood on cognitive processes. In the first study, conducted in a shopping mall, a positive feeling state was induced by giving subjects a free gift, and good mood, thus induced, was found to improve subjects' evaluations of the performance and service records of products they owned. In the second study, in which affect was induced by having subjects win or lose a computer game in a laboratory setting, subjects who had won the game were found to be better able to recall positive material in memory. The results of the two studies are discussed in terms of the effect that feelings have on accessibility of cognitions. In addition, the nature of affect and the relationship between good mood and behavior (such as helping) are discussed in terms of this proposed cognitive process.

Atrial natriuretic factor in normal subjects and heart failure patients. Plasma levels and renal, hormonal, and hemodynamic responses to peptide infusion

We investigated atrial natriuretic factor (ANF) in humans, measuring plasma immunoreactive (ir) ANF (in femtomoles per milliliter), and renal, hormonal, and hemodynamic responses to ANF infusion, in normal subjects (NL) and congestive heart failure patients (CHF). Plasma irANF was 11 +/- 0.9 fmol/ml in NL and 71 +/- 9.9 in CHF (P less than 0.01); the latter with twofold right ventricular increment (P less than 0.05). In NL, ANF infusion of 0.10 microgram/kg per min (40 pmol/kg per min) induced increases (P less than 0.05) of absolute (from 160 +/- 23 to 725 +/- 198 mueq/min) and fractional (1-4%) sodium excretion, urine flow rate (from 10 +/- 1.6 to 20 +/- 2.6 ml/min), osmolar (from 3.2 +/- 0.6 to 6.8 +/- 1.2 ml/min) and free water (from 6.8 +/- 1.6 to 13.6 +/- 1.6 ml/min) clearances, and filtration fraction (from 20 +/- 1 to 26 +/- 2%). Plasma renin and aldosterone decreased 33% and 40%, respectively (P less than 0.01). Systolic blood pressure fell (from 112 +/- 3 to 104 +/- 5 mmHg, P less than 0.05) in seated NL; but in supine NL, the only hemodynamic response was decreased pulmonary wedge pressure (from 11 +/- 1 to 7 +/- 1 mmHg, P less than 0.05). In CHF, ANF induced changes in aldosterone and pulmonary wedge pressure, cardiac index, and systemic vascular resistance (all P less than 0.05); however, responses of renin and renal excretion were attenuated. ANF infusion increased hematocrit and serum protein concentration by 5-7% in NL (P less than 0.05) but not in CHF.

A case-management system for coronary risk factor modification after acute myocardial infarction

OBJECTIVE

To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification.

DESIGN

Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction.

SETTING

5 Kaiser Permanente Medical Centers in the San Francisco Bay area.

PATIENTS

585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction.

INTERVENTION

In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy.

OUTCOME

Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction.

RESULTS

In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 +/- 0.69 mmol/L and 3.41 +/- 0.90 mmol/L (107 +/- 30 mg/dL and 132 +/- 30 mg/dL) (P = 0.001), and functional capacities were 9.3 +/- 2.4 METS and 8.4 +/- 2.5 METS (P = 0.001), respectively.

CONCLUSION

In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.

Association of muscle power with functional status in community-dwelling elderly women

BACKGROUND

Identification of the physiologic factors most relevant to functional independence in the elderly population is critical for the design of effective interventions. It has been suggested that muscle power may be more directly related to impaired physical performance than muscle strength in elderly persons. We tested the hypothesis that peak muscle power is closely associated with self-reported functional status in sedentary elderly community-dwelling women.

METHODS

We used baseline data that were collected as part of a 1-year randomized controlled clinical trial of a combined program of strength, power, and endurance training in 80 elderly women (mean age 74.8 +/- 5.0 years) with 3.2 +/- 1.9 chronic diseases, selected for baseline functional impairment and/or falls.

RESULTS

Functional status at baseline was related in univariate analyses to physiologic capacity, habitual physical activity level, neuropsychological status, and medical diagnoses. Leg power had the strongest univariate correlation to self-reported functional status (r = -.47, p < .0001) of any of the physiologic factors we tested. In a forward stepwise regression model, leg press power and habitual physical activity level were the only two factors that contributed independently to functional status (r = .64, p < .0001), accounting for 40% of the variance in functional status.

CONCLUSIONS

Leg power is a strong predictor of self-reported functional status in elderly women.

Incorporation of surface tension into molecular dynamics simulation of an interface: a fluid phase lipid bilayer membrane

In this paper we report on the molecular dynamics simulation of a fluid phase hydrated dimyristoylphosphatidylcholine bilayer. The initial configuration of the lipid was the x-ray crystal structure. A distinctive feature of this simulation is that, upon heating the system, the fluid phase emerged from parameters, initial conditions, and boundary conditions determined independently of the collective properties of the fluid phase. The initial conditions did not include chain disorder characteristic of the fluid phase. The partial charges on the lipids were determined by ab initio self-consistent field calculations and required no adjustment to produce a fluid phase. The boundary conditions were constant pressure and temperature. Thus the membrane was not explicitly required to assume an area/phospholipid molecule thought to be characteristic of the fluid phase, as is the case in constant volume simulations. Normal to the membrane plane, the pressure was 1 atmosphere, corresponding to the normal laboratory situation. Parallel to the membrane plane a negative pressure of -100 atmospheres was applied, derived from the measured surface tension of a monolayer at an air-water interface. The measured features of the computed membrane are generally in close agreement with experiment. Our results confirm the concept that, for appropriately matched temperature and surface pressure, a monolayer is a close approximation to one-half of a bilayer. Our results suggest that the surface area per phospholipid molecule for fluid phosphatidylcholine bilayer membranes is smaller than has generally been assumed in computational studies at constant volume. Our results confirm that the basis of the measured dipole potential is primarily water orientations and also suggest the presence of potential barriers for the movement of positive charges across the water-headgroup interfacial region of the phospholipid.

Bright Spots, Structure, and Magmatism in Southern Tibet from INDEPTH Seismic Reflection Profiling

INDEPTH seismic reflection profiling shows that the decollement beneath which Indian lithosphere underthrusts the Himalaya extends at least 225 kilometers north of the Himalayan deformation front to a depth of approximately 50 kilometers. Prominent reflections appear at depths of 15 to 18 kilometers near where the decollement reflector apparently terminates. These reflections extend north of the Zangbo suture to the Damxung graben of the Tibet Plateau. Some of these reflections have locally anomalous amplitudes (bright spots) and coincident negative polarities implying that they are produced by fluids in the crust. The presence of geothermal activity and high heat flow in the regions of these reflections and the tectonic setting suggest that the bright spots mark granitic magmas derived by partial melting of the tectonically thickened crust.

Health care system in Saudi Arabia: an overview

The government of Saudi Arabia has given high priority to the development of health care services at all levels: primary, secondary and tertiary. As a consequence, the health of the Saudi population has greatly improved in recent decades. However, a number of issues pose challenges to the health care system, such a shortage of Saudi health professionals, the health ministry's multiple roles, limited financial resources, changing patterns of disease, high demand resulting from free services, an absence of a national crisis management policy, poor accessibility to some health care facilities, lack of a national health information system, and the underutilization of the potential of electronic health strategies. This paper reviews the historical development and current structure of the health care system in Saudi Arabia with particular emphasis on the public health sector and the opportunities and challenges confronting the Saudi health care system.

A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization

The effectiveness of heart failure management in clinical practice is limited by physicians' suboptimal utilization of effective medications, patients' poor adherence to dietary sodium limitation and optimal drug therapy, and the lack of systematic monitoring of patients after hospitalization. The present study evaluated the feasibility and safety of MULTIFIT, a physician-supervised, nurse-mediated, home-based system for heart failure management that implements consensus guidelines for pharmacologic and dietary therapy using a nurse manager to enhance dietary and pharmacologic adherence and to monitor clinical status by frequent telephone contact. Fifty-one patients with the clinical diagnosis of heart failure were followed for 138 +/- 44 days. Daily dietary sodium intake fell by 38%, from 3,393 to 2,088 mg (p = 0.0001); average daily medication doses increased significantly (lisinopril: 17 to 23 mg, p <0.001; hydralazine: 140 to 252 mg, p = 0.01). Functional status and exercise capacity improved significantly (p = 0.01). Compared with the 6 months before enrollment and normalized for variable follow-up, the frequency of general medical and cardiology visits declined by 23% and 31%, respectively (both p <0.03); emergency room visits for heart failure and for all causes declined 67% and 53%, respectively (both p <0.001). Hospitalization rates for heart failure and for all causes declined 87% and 74%, respectively (p = 0.001), compared with the year before enrollment. The MULTIFIT system enhanced the effectiveness of pharmacologic and dietary therapy for heart failure in clinical practice, improving clinical outcomes and reducing medical resource utilization.

Identification of a form of acyl-CoA:cholesterol acyltransferase specific to liver and intestine in nonhuman primates

The present study demonstrates that two different forms of the intracellular cholesterol esterification enzyme acyl-CoA:cholesterol acyltransferase (ACAT) are present in the nonhuman primate hepatocyte; one is similar to that originally cloned from human genomic DNA, here termed ACAT1, while a second gene product, termed ACAT2, is reported here. The primate ACAT2 gene product was cloned from an African green monkey liver cDNA library. Sequence analysis of an isolated, full-length clone of ACAT2 cDNA identified an open reading frame encoding a 526-amino acid protein with essentially no sequence similarity to the ACAT1 cDNA over the N-terminal 101 amino acids but with 57% identity predicted over the remaining 425 amino acids. Transfection of the cloned ACAT2 cDNA into two different mammalian cell types resulted in the production of abundant ACAT activity which was sensitive to ACAT inhibitors. Northern blot analysis showed that the ACAT2 mRNA was expressed primarily in liver and intestine in monkeys. In contrast, ACAT1 mRNA was expressed in almost all tissues examined. Topologic predictions from the amino acid sequence of ACAT2 indicates that it has seven trans-membrane domains in a configuration that places the putative active site of the enzyme in the lumen of the endoplasmic reticulum. This orientation of ACAT2 in the endoplasmic reticulum membrane, in addition to its expression only in liver and intestine, suggests that this enzyme may have as a primary function, the secretion of cholesteryl esters into apoB-containing lipoproteins.

Peak Pruritus Numerical Rating Scale: psychometric validation and responder definition for assessing itch in moderate-to-severe atopic dermatitis

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) is a chronic disease characterized by intense, persistent and debilitating itch, resulting in sleep deprivation, signs of anxiety and depression, impaired quality of life and reduced productivity. The Peak Pruritus Numerical Rating Scale (NRS) was developed and validated as a single-item, patient-reported outcome (PRO) of itch severity.

OBJECTIVES

To describe the content validity and psychometric assessment (test-retest reliability, construct validity, known-groups validity, sensitivity to change) of the Peak Pruritus NRS, and to derive empirically a responder definition to identify adults with a meaningful change in itch.

METHODS

Content validity was assessed through in-depth patient interviews. Psychometric assessments used data from phase IIb and phase III dupilumab clinical trials and included test-retest reliability, construct validity, known-groups validity and sensitivity to change in patients with moderate-to-severe AD.

RESULTS

Interview participants indicated that the Peak Pruritus NRS was a relevant, clear and comprehensive assessment of itch severity. Peak Pruritus NRS scores showed large, positive correlations with existing PRO measures of itch, and weak or moderate correlations with clinician-reported measures assessing objective signs of AD. Peak Pruritus NRS score improvements were highly correlated with improvements in other itch PROs, and moderately correlated with improvements in clinician-reported measures assessing objective signs of AD. The most appropriate threshold for defining a clinically relevant, within-person response was ≥ 2-4-point change in the Peak Pruritus NRS.

CONCLUSIONS

The Peak Pruritus NRS is a well-defined, reliable, sensitive and valid scale for evaluating worst itch intensity in adults with moderate-to-severe AD.

Analgesic use in the emergency department

The relief of pain is one of the most common reasons for seeking care in an emergency department. We conducted a retrospective chart review to see whether children received analgesic treatment similar to that of adults with the same acute, painful conditions. Charts of 112 pediatric patients from the Children's Hospital of Philadelphia ED and 156 patients from the Medical College of Pennsylvania ED were reviewed. Patient ages ranged from a few months to 97 years. All patients had acute pain due to sickle cell crises (20%), lower-extremity fractures (31%), or second- or third-degree burns (49%). Hospitalization was required in 15% of cases. In the ED, 60% of patients with painful conditions received no pain medication at all. When medications were given, they were usually narcotics. Children (aged 19 years or younger) were much less likely to receive pain medications than adults (P = .001). Those less than 2 years old received analgesics less often than older children (P less than .01). Senior citizens (aged 65 years or older) received analgesics as often as other adults. On discharge from the ED, 55% of all patients had no pain medications prescribed; and children were less likely than adults to receive analgesics at discharge (P less than .001). Pediatricians and emergency physicians are reluctant to use analgesics for children in pain. The data suggest that these physicians need additional education about management of acute pain.

Macrophages in experimental and human brain tumors. Part 2: studies of the macrophage content of human brain tumors

The authors have analyzed 47 tumors of the central nervous system (11 glioblastomas, nine meningiomas, three medulloblastomas, 12 assorted primary neural tumors, and 12 brain metastases) for their content of macrophages. Cell suspensions were prepared by enzymatic digestion and macrophages were quantitated by IgGEAC rosette formation. Adsorption of sensitized indicator cells (EA) to sections of tumor was used as a measure to determine the distribution of IgGFc receptor-positive cells within the tumors and to serve as a control for selective release of IgGFc receptor-positive cells by enzyme digestion. The 11 glioblastomas had a mean macrophage content of 45% (range: 8% to 78%), the nine meningiomas had a mean of 44% (range: 5% to 81%), the three medulloblastomas a mean of 6% (range 2% to 15%), and the metastatic tumors a mean of 24% (range: 4% to 70%). Adsorption of EA demonstrated that IgGFc receptor-positive cells were distributed throughout the tumor mass, although different types of patterns were observed. There was an excellent correlation between the percent of IgGEAC positive cells in suspensions and the extent of EA adsorption to the tumor sections. Compared to systemic neoplasms, most nervous system tumors have a high macrophage content. It is possible that the high macrophage content of brain tumors is related to their immunogenicity, and may be a partial explanation for tha rarity of brain-tumor metastases.

Endomysial antibody: is it the best screening test for coeliac disease?

The sensitivities and specificities of the IgA and IgG antigliadin antibody and the IgA antireticulin antibody have been compared with the recently described endomysial antibody directed against the basement membrane of smooth muscle in monkey oesophagus. One hundred and seventeen patients with adult coeliac disease (21 untreated), 84 patients with inflammatory bowel disease, systemic lupus erythematosus and rheumatoid arthritis (comprising the disease control group), 47 normal controls and a miscellaneous group of 29 patients, who were selected because of a positive reticulin staining pattern, were investigated. These results were correlated with the degree of abnormality of the intestinal mucosa in patients with adult coeliac disease. Endomysial antibodies were found in all patients with untreated coeliac disease and subtotal villous atrophy and in 47% of patients on a non-strict gluten free diet. One patient on a strict gluten free diet was positive and had partial villous atrophy while all patients in disease control groups were negative. Results were variable with the antireticulin and antigliadin antibodies. Sensitivity and correlation with subtotal villous atrophy in the untreated patients was 100%. It is concluded that the endomysial antibody is superior to other current antibody tests and should be used in preference for the diagnosis of coeliac disease.

Antibody humanization: a case of the 'Emperor's new clothes'?

The antiglobulin response is perceived as a major problem in the clinical development of therapeutic antibodies. Successive technical developments such as chimeric, humanized and, now, fully human antibodies claim to offer improved solutions to this problem. Although there is clear evidence that chimeric antibodies are less immunogenic than murine monoclonal antibodies, little evidence exists to support claims for further improvements as a result of more elaborate humanization protocols.

Linkage between male infertility and trinucleotide repeat expansion in the androgen-receptor gene

BACKGROUND

Androgens acting via the androgen receptor bring about stimulation and maintenance of spermatogenesis. If mutations in the androgen-receptor gene interfere with the receptor's function, this effect may partly account for impaired spermatogenesis. We aimed to find out whether expansion of a trinucleotide repeat in the androgen-receptor gene is associated with male infertility.

METHODS

We analysed 67 coded semen and blood samples from a predominantly white group of male infertility patients and controls. Clinical analyses included cause of infertility, sperm count, and reproductive hormone concentrations. Analysis of trinucleotide (CAG) repeat length and point mutations in the androgen-receptor gene was done by PCR, single-stranded conformational polymorphism, and DNA sequencing.

FINDINGS

Screening and characterisation of the androgen-receptor gene in 35 patients and 32 controls showed no point mutations in the gene. 30 of the infertile patients had idiopathic azoospermia or oligozoospermia, and these men had significantly longer CAG repeat tracts than controls (mean 23.2 [SE 0.7] vs 20.5 [0.3], p=0.0001). The odds of having CAG repeat lengths of 20 were six-fold higher for fertile men than for men with a spermatogenic disorder.

INTERPRETATION

Our results indicate a relation between CAG repeat length in the androgen-receptor gene and the risk of defective spermatogenesis. With the use of intracytoplasmic sperm injection, this mutation could be inherited, possibly leading to an increase in male infertility in future generations. Should further elongation of the CAG repeat occur in these future generations, there is an added risk of increased severity of male infertility, and potentially an increased incidence of neurodegenerative disease.

A crucial component of the endoderm formation pathway, CASANOVA, is encoded by a novel sox-related gene

casanova (cas) mutant zebrafish embryos lack endoderm and develop cardia bifida. In a substractive screen for Nodal-responsive genes, we isolated an HMG box-containing gene, 10J3, which is expressed in the endoderm. The cas phenotype is rescued by overexpression of 10J3 and can be mimicked by 10J3-directed morpholinos. Furthermore, we identified a mutation within 10J3 coding sequence that cosegregates with the cas phenotype, clearly demonstrating that cas is encoded by 10J3. Epistasis experiments are consistent with an instructive role for cas in endoderm formation downstream of Nodal signals and upstream of sox17. In the absence of cas activity, endoderm progenitors differentiate into mesodermal derivatives. Thus, cas is an HMG box-containing gene involved in the fate decision between endoderm and mesoderm that acts downstream of Nodal signals.

The generation of a humanized, non-mitogenic CD3 monoclonal antibody which retains in vitro immunosuppressive properties

CD3 antibodies are proven immunosuppressants capable of reversing transplant rejection episodes. Their general application has been limited both by their immunogenicity and, in particular, by the "first-dose" cytokine-release syndrome experienced by patients after the initial administration of antibody. We have produced a set of variants of the humanized YTH 12.5 CD3 monoclonal antibody (mAb) (Routledge et al., Eur. J. Immunol. 1991. 21: 2717) bearing different human heavy (H) chain constant regions, with the intention of finding a form of the antibody that is not able to activate T cells. Comparison of the variants having gamma 1, gamma 2, gamma 3 and gamma 4 H chains in a competitive binding assay showed that antibody avidity was not affected by IgG subclass. Using a sensitive indicator of FcR binding activity (the capacity of the CD3 mAb to redirect cytotoxic T cells to kill the monocytic cell line U-937) we demonstrated a functional hierarchy of gamma 1 = gamma 4 > alpha 2 =/> gamma 3 mb >> gamma 2. An aglycosyl version of the gamma 1 CD3 mAb, produced by site-directed mutagenesis (Asn297 to Ala), still had considerable activity in this assay (intermediate to the gamma 1 and alpha 2 CD3 mAb), albeit at a level approximately 10-fold lower than that of the parental gamma 1 form. When we tested their ability to stimulate T cell proliferation in vitro in the presence of 5% human serum, all of the wild-type immunoglobulin isotypes were found to be active, although there were T cell donor-dependent variations in the extent of the responses. The aglycosyl gamma 1 mAb was, however, completely non-mitogenic in all of ten donors tested, unless the assay was performed in IgG-free medium. Despite being non-stimulatory, this mAb was also able to inhibit the mixed lymphocyte reaction responses of both naive and primed T cells. Comparison of the gamma 1 and aglycosyl gamma 1 mAb in an experimental mouse model for CD3 mAb-induced cytokine release indicated that removal of the carbohydrate moiety from the gamma 1 constant region reduced the in vivo tumor necrosis factor-alpha response by a factor of at least 16-fold. These data suggest that the aglycosyl gamma 1 CD3 mAb is a promising candidate for immunosuppressive therapy without "first dose" side effects.

Home or hospital for stroke rehabilitation? results of a randomized controlled trial : I: health outcomes at 6 months

BACKGROUND AND PURPOSE

We wished to examine the effectiveness of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.

METHODS

This was a randomized, controlled trial comparing early hospital discharge and home-based rehabilitation with usual inpatient rehabilitation and follow-up care. The trial was carried out in 2 affiliated teaching hospitals in Adelaide, South Australia. Participants were 86 patients with acute stroke (mean age, 75 years) who were admitted to hospital and required rehabilitation. Forty-two patients received early hospital discharge and home-based rehabilitation (median duration, 5 weeks), and 44 patients continued with conventional rehabilitation care after randomization. The primary end point was self-reported general health status (SF-36) at 6 months after randomization. A variety of secondary outcome measures were also assessed.

RESULTS

Overall, clinical outcomes for patients did not differ significantly between the groups at 6 months after randomization, but the total duration of hospital stay in the experimental group was significantly reduced (15 versus 30 days; P<0.001). Caregivers among the home-based rehabilitation group had significantly lower mental health SF-36 scores (mean difference, 7 points).

CONCLUSIONS

A policy of early hospital discharge and home-based rehabilitation for patients with stroke can reduce the use of hospital rehabilitation beds without compromising clinical patient outcomes. However, there is a potential risk of poorer mental health on the part of caregivers. The choice of this management strategy may therefore depend on convenience and costs but also on further evaluations of the impact of stroke on caregivers.

Affect, accessibility of material in memory, and behavior: a cognitive loop?

Two studies investigated the effect of good mood on cognitive processes. In the first study, conducted in a shopping mall, a positive feeling state was induced by giving subjects a free gift, and good mood, thus induced, was found to improve subjects' evaluations of the performance and service records of products they owned. In the second study, in which affect was induced by having subjects win or lose a computer game in a laboratory setting, subjects who had won the game were found to be better able to recall positive material in memory. The results of the two studies are discussed in terms of the effect that feelings have on accessibility of cognitions. In addition, the nature of affect and the relationship between good mood and behavior (such as helping) are discussed in terms of this proposed cognitive process.

Can melatonin improve shift workers' tolerance of the night shift? Some preliminary findings

The pineal hormone melatonin is potentially useful in the treatment of disorders, especially sleep disorders, associated with circadian rhythm disturbance. We have examined its effects on sleep, mood, and behaviour in a double-blind, placebo-controlled study of a small group of police officers working spans of seven successive night shifts. Compared to placebo, and to no treatment, melatonin (5 mg) taken at the desired bedtime improved problems related to sleep and increased alertness during working hours, especially during the early morning. In letter-target performance tests visual search speed and accuracy were either unchanged or slightly improved. Memory scanning speed and perception of mental load were adversely affected. This preliminary study suggests that melatonin has beneficial effects on sleep and alertness, but that its effects on performance need careful evaluation.

Effect of long-term treatment with salmeterol on asthma control: a double blind, randomised crossover study

OBJECTIVES

To determine the effect of adding salmeterol 50 micrograms twice daily for six months to current treatment in subjects with asthma who control their inhaled corticosteroid dose according to a management plan.

DESIGN

A double blind, randomised crossover study.

SETTING

Nottingham.

SUBJECTS

101 subjects with mild or moderate asthma taking at least 200 micrograms twice daily of beclomethasone dipropionate or budesonide.

INTERVENTIONS

Salmeterol 50 micrograms twice daily and placebo for six months each, with a one month washout. Subjects adjusted inhaled steroid dose according to guidelines.

MAIN OUTCOME MEASURE

Reduction in inhaled steroid use, exacerbations of asthma, and use of oral steroids.

RESULTS

Data were available for 87 subjects. When compared with placebo salmeterol treatment was associated with a 17% reduction in inhaled steroid use (95% confidence interval 12% to 22%) with no significant difference in the number of subjects who had an exacerbation (placebo 25%, salmeterol 16%) or use of oral steroids. For secondary end points salmeterol treatment was associated with higher morning and evening peak expiratory flow and forced expiratory volume in one second; a reduction in symptoms, bronchodilator use and airway responsiveness to methacholine; and no effect on serum potassium concentration, 24 hour heart rate, or the final forced expiratory volume in one second achieved during a salbutamol dose-response study.

CONCLUSIONS

In subjects who adjusted their inhaled steroid treatment according to guidelines the addition of salmeterol 50 micrograms twice daily was associated with a reduction in inhaled steroid use and improved lung function and symptom control.

Cervical cancer as an AIDS-defining illness

OBJECTIVE

To evaluate the importance of cervical cancer in the spectrum of human immunodeficiency virus (HIV)-related diseases at a single high-risk institution and to compare disease characteristics in HIV-infected women with cervical cancer and those with other AIDS-related malignancies.

METHODS

We retrospectively reviewed data on cervical cancer and AIDS in women registered through the New York City Department of Health and institutional tumor registries from 1987 through 1995.

RESULTS

During the study period, cervical cancer was diagnosed in 28 HIV-positive women. In 26, cervical cancer was the initial AIDS-defining illness, representing 4% (26 of 725) of the subjects, and it was the sixth most common initial AIDS-defining illness in women. Cervical cancer was the most common AIDS-related malignancy among women, representing 55% of the cases, followed by lymphoma (29%) and Kaposi sarcoma (16%). In 71% of the women with cervical cancer, HIV infection was diagnosed at the time of cancer presentation by routine testing, whereas in women with other malignancies, HIV diagnosis preceded cancer diagnosis (70%) by a mean of 2.7 years. Patients with other malignancies had greater immunosuppression (mean CD4 count 153/microL) than those with cervical cancer (mean CD4 count 312/microL). The recurrence rate for women with cervical cancer was 88%. Although the interval from cancer diagnosis to death was similar in all three groups (9.1-12.4 months), cancer was the cause of death in 95% of HIV-infected women with cervical cancer, compared with 60% of those with other AIDS-related malignancies.

CONCLUSION

In urban populations at increased risk for both diseases, cervical cancer is an important AIDS-defining illness and may be the most common AIDS-related malignancy in women.