Sulforaphane has an additive anticancer effect to FOLFOX in highly metastatic human colon carcinoma cells

Colorectal cancer (CRC) is one of the most common malignancies worldwide. Patients with CRC may need chemotherapy (CTx) in a neoadjuvant, adjuvant or palliative setting through the course of the disease. Unfortunately, its effect is limited by chemoresistance and chemotoxicity. Novel more effective and non‑toxic CTx regimens are needed to further improve CRC treatment outcomes. Thus, the present study was designed to test the hypothesis that non‑toxic sulforaphane (SF) is effective against CRC and has additive effects in combination with conventional 5‑fluorouracil, oxaliplatin and folinic acid (FOLFOX) CTx in vitro. Highly metastatic human colon cancer cells, CX‑1, and fibroblasts were treated with FOLFOX ± SF. Cell viability was assessed using an MTT assay. The level of apoptosis and the expression of apoptotic proteins were measured by TUNEL assay and quantitative PCR analysis. Aldehyde dehydrogenase isoform 1 (ALDH1) and multidrug resistance protein 2 (MRP2) levels were evaluated. The ability of cells to form spheroids was measured in three‑dimensional cell culture. SF alone and in combination with FOLFOX effectively decreased the viability of the CX‑1 cells, promoted apoptosis within the CX‑1 cells, prevented cellular spheroid formation and decreased ALDH1 activity. However, SF promoted MRP2 expression and protein levels. In conclusion, SF together with conventional FOLFOX has additive anticancer effects against highly metastatic human CRC in vitro.

[Which patient needs controls of laboratory values after elective laparoscopic cholecystectomy?-Can a score help?]

BACKGROUND

Laparoscopic cholecystectomy is nearly exclusively carried out as an inpatient operation in Germany. The aim of the study was to evaluate for which patients postoperative laboratory control values are necessary.

METHODS

This retrospective analysis included 100 patients who underwent elective laparoscopic cholecystectomy. A scoring and data collection sheet was developed, which enables a risk stratification. Using the scoring system patients can achieve between 3 and 15 points.

RESULTS

In total 100 patients were included in the study. Of the patients 64 (group 1) had between 3 and 8 points, 29 patients (group 2) between 9 and 11 points and 7 patients (group 3) between 12 and 15 points. In comparison to group 1 the C‑reactive protein values as well as the duration of hospital stay were significantly increased in group 2 and group 3 (p > 0.05). In group1 a total of 60 patients (93.7%) were discharged regularly on postoperative days 1-3. In group 2 there were 17 patients (58.6%) who could be discharged with unremarkable blood values and in group 3 there were 3 patients (42.8%). In the total collective hospital discharge without a laboratory control of blood values would have been justified in 80% of the patients.

CONCLUSION

A postoperative control of laboratory blood values is not routinely necessary for patients after elective laparoscopic cholecystectomy with a score <9 points.

Glycine Protects the Liver from Reperfusion Injury following Pneumoperitoneum

<b><i>Background:</i></b> Experimental pneumoperitoneum induces ischemia/reperfusion injury (IRI) in the liver, most likely via Kupffer cell (KC)-dependent mechanisms. Glycine has been shown to ameliorate IRI in various animal models. Thus, this study was performed to assess the effects of glycine on the liver after pneumoperitoneum.<b><i> Materials and Methods:</i></b> Sprague-Dawley rats (220–250 g in weight) underwent CO₂ pneumoperitoneum (12 mm Hg) for 90 min. Some rats received i.v. glycine (1.5 mL, 300 mM) 10 min before pneumoperitoneum. Controls were given the same volume of Ringer’s solution. Transaminases, hepatic microcirculation, and phagocytosis of latex beads indexing both liver injury and KC activation were examined following pneumoperitoneum. Analysis of variance (ANOVA), plus a subsequent <i>t</i> test or χ² test (or Fisher’s exact test) were carried out as appropriate. Results are presented as mean ± SEM. <b><i>Results:</i></b> Glycine significantly decreased lactate dehydrogenase at 1 h and both aspartate aminotransferase and alanine aminotransferase at 2 h after pneumoperitoneum from 477 ± 43, 154 ± 17, and 60 ± 6 U/L in controls to 348 ± 25, 101 ± 11, and 34 ± 3 U/L, respectively (<i>p</i> &#x3c; 0.05). In parallel, glycine significantly decreased both the rate of permanent adherence of leukocytes to the endothelium by up to 35% and the rate of phagocytosis by &#x3e; 50% compared to the control group. <b><i>Conclusion:</i></b> Glycine decreased IRI after pneumoperitoneum, most likely via KC-dependent mechanisms.

Impact of Inter-Laboratory Variability on Model of End-Stage Liver Disease (MELD) Score Calculation

BACKGROUND The model for end-stage liver disease (MELD) is a laboratory-based scoring system for assessing the severity of liver disease. Since 16 December 2006, MELD-based organ allocation for liver transplantation (LT) has been established in Germany to prioritize the sickest patients. The present study was designed to evaluate the effect of using different laboratories on the calculated MELD score, despite the use of mandatory round-robin testing for comparable of inter-laboratory results. MATERIAL AND METHODS Blood samples were taken from 10 patients with liver disease. Bilirubin, creatinine, and INR were measured in 6 different laboratories. The patients' MELD scores were calculated and the inter-laboratory variability was compared. RESULTS The highest discrepancy between the laboratories was 5 MELD score points and the highest inter-laboratory difference for bilirubin, INR, and creatinine was 4.6, 1.2, and 0.99 mg/dl, respectively. Pairwise comparison of the laboratory values showed a significant inter-laboratory difference (p<0.05). CONCLUSIONS Results clearly demonstrate, for the first time, that liver allocation for LT in Germany is based on nationwide noncomparable laboratory readouts for the MELD score.

Strong Impact of Smoking on Multimorbidity and Cardiovascular Risk Among Human Immunodeficiency Virus-Infected Individuals in Comparison With the General Population

AIDS-associated morbidity has diminished due to excellent viral control. Multimorbidity are more prevalent and incident in Swiss HIV-positive persons compared to HIV-negative controls. However, smoking, but not HIV status, had a strong impact on cardiovascular risk and multimorbidity.

Background. Although acquired immune deficiency syndrome-associated morbidity has diminished due to excellent viral control, multimorbidity may be increasing among human immunodeficiency virus (HIV)-infected persons compared with the general population.

Methods. We assessed the prevalence of comorbidities and multimorbidity in participants of the Swiss HIV Cohort Study (SHCS) compared with the population-based CoLaus study and the primary care-based FIRE (Family Medicine ICPC-Research using Electronic Medical Records) records. The incidence of the respective endpoints were assessed among SHCS and CoLaus participants. Poisson regression models were adjusted for age, sex, body mass index, and smoking.

Results. Overall, 74 291 participants contributed data to prevalence analyses (3230 HIV-infected; 71 061 controls). In CoLaus, FIRE, and SHCS, multimorbidity was present among 26%, 13%, and 27% of participants. Compared with nonsmoking individuals from CoLaus, the incidence of cardiovascular disease was elevated among smoking individuals but independent of HIV status (HIV-negative smoking: incidence rate ratio [IRR] = 1.7, 95% confidence interval [CI] = 1.2–2.5; HIV-positive smoking: IRR = 1.7, 95% CI = 1.1–2.6; HIV-positive nonsmoking: IRR = 0.79, 95% CI = 0.44–1.4). Compared with nonsmoking HIV-negative persons, multivariable Poisson regression identified associations of HIV infection with hypertension (nonsmoking: IRR = 1.9, 95% CI = 1.5–2.4; smoking: IRR = 2.0, 95% CI = 1.6–2.4), kidney (nonsmoking: IRR = 2.7, 95% CI = 1.9–3.8; smoking: IRR = 2.6, 95% CI = 1.9–3.6), and liver disease (nonsmoking: IRR = 1.8, 95% CI = 1.4–2.4; smoking: IRR = 1.7, 95% CI = 1.4–2.2). No evidence was found for an association of HIV-infection or smoking with diabetes mellitus.

Conclusions. Multimorbidity is more prevalent and incident in HIV-positive compared with HIV-negative individuals. Smoking, but not HIV status, has a strong impact on cardiovascular risk and multimorbidity.

Early markers of reperfusion injury after liver transplantation: association with primary dysfunction

BACKGROUND

In patients with end-stage liver disease, liver transplantation is the only available curative treatment. Although the outcome and quality of life in the patients have improved over the past decades, primary dys- or nonfunction (PDF/PNF) can occur. Early detection of PDF and PNF is crucial and could lead to individual therapies. This study was designed to identify early markers of reperfusion injury and PDF in liver biopsies taken during the first hour after reperfusion.

METHODS

Biopsies from donor livers were prospectively taken as a routine during the first hour after reperfusion. Recipient data, transaminases and outcome were routinely monitored. In total, 10 biopsy specimens taken from patients with 90-day mortality and PDF, and patients with long-term survival but without PDF were used for DNA microarrays. Markers that were significantly up- or down-regulated in the microarray were verified using quantitative real-time PCR.

RESULTS

Age, indications and labMELD score were similar in both groups. Peak-transaminases during the first week after transplantation were significantly different in the two groups. In total, 20 differentially regulated markers that correlated to PDF were identified using microarray analysis and verified with quantitative real-time PCR.

CONCLUSIONS

The markers identified in this study could predict PDF at a very early time point and might point to interventions that ameliorate reperfusion injury and thus prevent PDF. Identification of patients and organs at risk might lead to individualized therapies and could ultimately improve outcome.

A systematic review of pharmacological treatment options used to reduce ischemia reperfusion injury in rat liver transplantation

BACKGROUND

Although animal studies models are frequently used for the purpose of attenuating ischemia reperfusion injury (IRI) in liver transplantation (LT), many of pharmacological agents have not become part of clinical routine.

METHODS

A search was performed using the PubMed database to identify agents, from which 58 articles containing 2700 rat LT procedures were selected. The identified pharmacological agents were categorized as follows: I - adenosine agonists, nitric oxide agonists, endothelin antagonists, and prostaglandins, II - Kupffer cell inactivator, III - complement inhibiter, IV - antioxidant, V - neutrophil inactivator, VI -anti-apoptosis agent, VII - heat shock protein and nuclear factor kappa B inducer, VIII - metabolic agent, IX - traditional Chinese medicine, and X - others. Meta-analysis using 7-day-survival rate was also performed with Mantel-Haenszel's Random effects model.

RESULTS

The categorization revealed that the rate of donor-treated experiments in each group was highest for agents from Group II (70%) and VII (71%), whereas it was higher for agents from Group V (83%) in the recipient-treated experiments. Furthermore, 90% of the experiments with agents in Group II provided 7-day-survival benefits. The Risk Ratio (RR) of the meta-analysis was 2.43 [95% CI: 1.88-3.14] with moderate heterogeneity. However, the RR of each of the studies was too model-dependent to be used in the search for the most promising pharmacological agent.

CONCLUSION

With regard to hepatic IRI pathology, the categorization of agents of interest would be a first step in designing suitable multifactorial and pleiotropic approaches to develop pharmacological strategies.

Obesity Trends and Body Mass Index Changes After Starting Antiretroviral Treatment: The Swiss HIV Cohort Study

BACKGROUND

The factors that contribute to increasing obesity rates in human immunodeficiency virus (HIV)-positive persons and to body mass index (BMI) increase that typically occurs after starting antiretroviral therapy (ART) are incompletely characterized.

METHODS

We describe BMI trends in the entire Swiss HIV Cohort Study (SHCS) population and investigate the effects of demographics, HIV-related factors, and ART on BMI change in participants with data available before and 4 years after first starting ART.

RESULTS

In the SHCS, overweight/obesity prevalence increased from 13% in 1990 (n = 1641) to 38% in 2012 (n = 8150). In the participants starting ART (n = 1601), mean BMI increase was 0.92 kg/m(2) per year (95% confidence interval, .83-1.0) during year 0-1 and 0.31 kg/m(2) per year (0.29-0.34) during years 1-4. In multivariable analyses, annualized BMI change during year 0-1 was associated with older age (0.15 [0.06-0.24] kg/m(2)) and CD4 nadir <199 cells/µL compared to nadir >350 (P < .001). Annualized BMI change during years 1-4 was associated with CD4 nadir <100 cells/µL compared to nadir >350 (P = .001) and black compared to white ethnicity (0.28 [0.16-0.37] kg/m(2)). Individual ART combinations differed little in their contribution to BMI change.

CONCLUSIONS

Increasing obesity rates in the SHCS over time occurred at the same time as aging of the SHCS population, demographic changes, earlier ART start, and increasingly widespread ART coverage. Body mass index increase after ART start was typically biphasic, the BMI increase in year 0-1 being as large as the increase in years 1-4 combined. The effect of ART regimen on BMI change was limited.

Prediction of postoperative mortality in liver transplantation in the era of MELD-based liver allocation: a multivariate analysis

BACKGROUND AND AIMS

Liver transplantation is the only curative treatment for end-stage liver disease. While waiting list mortality can be predicted by the MELD-score, reliable scoring systems for the postoperative period do not exist. This study's objective was to identify risk factors that contribute to postoperative mortality.

METHODS

Between December 2006 and March 2011, 429 patients underwent liver transplantation in our department. Risk factors for postoperative mortality in 266 consecutive liver transplantations were identified using univariate and multivariate analyses. Patients who were <18 years, HU-listings, and split-, living related, combined or re-transplantations were excluded from the analysis. The correlation between number of risk factors and mortality was analyzed.

RESULTS

A labMELD ≥20, female sex, coronary heart disease, donor risk index >1.5 and donor Na+>145 mmol/L were identified to be independent predictive factors for postoperative mortality. With increasing number of these risk-factors, postoperative 90-day and 1-year mortality increased (0-1: 0 and 0%; 2: 2.9 and 17.4%; 3: 5.6 and 16.8%; 4: 22.2 and 33.3%; 5-6: 60.9 and 66.2%).

CONCLUSIONS

In this analysis, a simple score was derived that adequately identified patients at risk after liver transplantation. Opening a discussion on the inclusion of these parameters in the process of organ allocation may be a worthwhile venture.

Alternatives to islet transplantation: future cell sources of beta-like cells

Cell transplantation is a treatment option for diabetes, metabolic liver disease in children, and leukemia. Except for the latter indication, solid organ transplantation is one of the available therapies but can be replaced by cell transplantation. However, due to the limited amount of cells that can be transplanted and due to rejection, results of cell transplants are still inferior to solid organ transplantation; there is a general shortage of donor organs, and cell isolation is limited to organs which cannot be transplanted as a whole for anatomic reasons. Therefore, alternatives to islets and beta cells are needed. There are some cells which can be generated from the recipient and would not be rejected; still, immunosuppression would be required to prevent reoccurrence of type I diabetes unless durable tolerance to beta cells could be induced. Generating beta cells for transplant from the recipient would help to overcome the lack of available organs. Moreover, understanding the underlying mechanisms of differentiation of these cells into beta-like cells would deepen our understanding of both pathophysiology and development of diabetes mellitus type I. This article examines embryonal stem cells, induced pluripotent cells, mesenchymal stromal cells, and hepatocytes as potential alternatives to beta-cell transplantation.

Therapeutic potential and adverse events of everolimus for treatment of hepatocellular carcinoma - systematic review and meta-analysis

Everolimus is an orally administrated mammalian target of rapamycin (mTOR) inhibitor. Several large-scale randomized controlled trials (RCTs) have demonstrated the survival benefits of everolimus at the dose of 10 mg/day for solid cancers. Furthermore, mTOR-inhibitor-based immunosuppression is associated with survival benefits for patients with hepatocellular carcinoma (HCC) who have received liver transplantation. However, a low rate of tumor reduction and some adverse events have been pointed out. This review summarizes the antitumor effects and adverse events of everolimus and evaluates its possible application in advanced HCC. For the meta-analysis of adverse events, we used the RCTs for solid cancers. The odds ratios of adverse events were calculated using the Peto method. Manypreclinical studies demonstrated that everolimus had antitumor effects such as antiproliferation and antiangiogenesis. However, some differences in the effects were observed among in vivo animal studies for HCC treatment. Meanwhile, clinical studies demonstrated that the response rate of single-agent everolimus was low, though survival benefits could be expected. The meta-analysis revealed the odds ratios (95% confidence interval [CI]) of stomatitis: 5.42 [4.31-6.73], hyperglycemia: 3.22 [2.37-4.39], anemia: 3.34 [2.37-4.67], pneumonitis: 6.02 [3.95-9.16], aspartate aminotransferase levels: 2.22 [1.37-3.62], and serum alanine aminotransferase levels: 2.94 [1.72-5.02], respectively. Everolimus at the dose of 10 mg/day significantly increased the risk of the adverse events. In order to enable its application to the standard conventional therapies of HCC, further studies are required to enhance the antitumor effects and manage the adverse events of everolimus.

First report of sandfly fever virus infection imported from Malta into Switzerland, October 2011

We report the first documented cases of sandfly fever virus infection in travellers returning from Malta to Switzerland in autumn 2011. These cases illustrate the importance of considering sandfly-borne viral infection in the differential diagnosis of febrile patients from the Mediterranean island Malta. Raising awareness among physicians is relevant especially now at the beginning of the summer tourist season.

Evaluation of porcine mesenchymal stem cells for therapeutic use in human liver cancer

Mesenchymal stem cell (MSC) transplantation is suggested for therapy of end-stage liver disease, due to e.g. liver cancer and metastasis. Liver transplantation is the only therapeutic option so far but donor organs are short. Also, the availability of allogeneic human MSCs for liver regeneration is limited. Therefore, we evaluated the suitability of porcine bone marrow MSCs from semi-adult pigs and found that morphology, surface expression pattern and multilineage differentiation are similar to those of human MSCs. Porcine MSCs differentiated to a hepatocyte-like phenotype and expressed porcine mRNA of typical liver proteins. However, hepatocyte-like MSCs failed to express the corresponding proteins and did not produce glycogen and urea as primary porcine hepatocytes do. Porcine MSCs were immunotolerated, since they did not activate resting human PBMCs, and were not attacked by human activated PBMCs. However, porcine MSCs led to enhanced proliferation of human pre-activated PBMCs suggesting that immunotoleration of porcine MSCs in the human system has limitations. Together, the potential of porcine MSCs for xenogenous use in human liver therapy is promising but needs further evaluation prior to clinical use.

High specificity of line-immunoassay based algorithms for recent HIV-1 infection independent of viral subtype and stage of disease

Background

Serologic testing algorithms for recent HIV seroconversion (STARHS) provide important information for HIV surveillance. We have shown that a patient's antibody reaction in a confirmatory line immunoassay (INNO-LIA^TM HIV I/II Score, Innogenetics) provides information on the duration of infection. Here, we sought to further investigate the diagnostic specificity of various Inno-Lia algorithms and to identify factors affecting it.

Methods

Plasma samples of 714 selected patients of the Swiss HIV Cohort Study infected for longer than 12 months and representing all viral clades and stages of chronic HIV-1 infection were tested blindly by Inno-Lia and classified as either incident (up to 12 m) or older infection by 24 different algorithms. Of the total, 524 patients received HAART, 308 had HIV-1 RNA below 50 copies/mL, and 620 were infected by a HIV-1 non-B clade. Using logistic regression analysis we evaluated factors that might affect the specificity of these algorithms.

Results

HIV-1 RNA <50 copies/mL was associated with significantly lower reactivity to all five HIV-1 antigens of the Inno-Lia and impaired specificity of most algorithms. Among 412 patients either untreated or with HIV-1 RNA ≥50 copies/mL despite HAART, the median specificity of the algorithms was 96.5% (range 92.0-100%). The only factor that significantly promoted false-incident results in this group was age, with false-incident results increasing by a few percent per additional year. HIV-1 clade, HIV-1 RNA, CD4 percentage, sex, disease stage, and testing modalities exhibited no significance. Results were similar among 190 untreated patients.

Conclusions

The specificity of most Inno-Lia algorithms was high and not affected by HIV-1 variability, advanced disease and other factors promoting false-recent results in other STARHS. Specificity should be good in any group of untreated HIV-1 patients.

Autoantibodies against inosine-5'-monophosphate dehydrogenase 2--characteristics and prevalence in patients with HCV-infection

BACKGROUND

Indirect immunofluorescence (IIFT) on in house HEp-2 cell preparations revealed a novel antibody giving a granular cytoplasmic pattern not described before, which on two commercial cell preparations revealed a "rings and rods" pattern. This pattern was also observed in four HCV-RNA carriers and prompted the identification of the reactive antigen and the evaluation of the antibody prevalence in HCV-RNA carriers and control groups.

METHODS

The antigen's molecular weight was determined by radioimmunoprecipitation of 35S-methionine labeled cell proteins. Expression library screening and sequencing was performed by standard techniques using an oligo(dT)-primed human HeLa cell cDNA expression library. Antibodies against the novel antigen Inositol-5'-monophosphatdehydrogenase 2 (IMPDH2) were analyzed by IIFT, western blot, line blot, and radioimmunoprecipitation assay (RIPA). IIFT was performed on commercial HEp-2 cells and cells cultivated in house for 24 - 60 hours, with or without the IMPDH2 inhibitors mycophenolic acid (MPA) or ribavirin, and subjected to various fixation conditions. Western and line blots were performed with IMPDH2 synthesized in E. coli, RIPA with 35S-methionine-IMPDH2 from in vitro transcription/translation products. Sera screened were positive for HCV-RNA (108), HBV-DNA (100), anti-mitochondrial (31), anti-actin (42), and anti-nuclear antibodies (51) and negative for HCV-RNA (100) and blood donors (100).

RESULTS

IMPDH2 is capable of considerable intracellular rearrangements (upon action of inhibitors like MPA and ribavirin), which explains the contrasting immunofluorescence patterns in cells from different sources. By RIPA, proven to be the sole assay suitable for screening of anti-IMPDH2 in human sera, autoantibodies were found in 35.2% of HCV-RNA carriers and in low concentrations in 31% of anti-actin positive patients suspicious of autoimmune hepatitis. Antibodies reacted preferentially with conformational epitopes. Compared to the low concentration of anti-IMPDH2 found in other disease groups, high antibody concentrations were observed in HCV-RNA carriers.

CONCLUSIONS

The common occurrence of anti-IMPDH2 in HCV-RNA carriers may be related to ribavirin therapy, causing intracellular aggregation of IMPDH2 thereby altering its immunogenicity. In this study the "rods and rings" immunofluorescence pattern observed could be ascribed to anti-IMPDH2. Anti-IMPDH2 may cause difficulties in interpretation of immunofluorescence patterns in routine autoantibody testing.

[Surgical treatment of liver trauma: resection--when and how?]

Liver resection as an emergency procedure in patients with liver injury due to abdominal trauma has become a rare procedure. In most cases liver trauma can be managed conservatively. Currently surgery is only indicated in hemodynamically instable patients and in cases of progredient haematoma where the main aim is control of bleeding. Anatomical liver resection should be avoided and may only be performed in cases of total vascular avulsion. Debridement of devascularized tissue can also be carried out in terms of an atypical liver resection. This article elucidates the current indications for liver resection after traumatic liver injury.

[First case of nephropathia epidemica acquired in Switzerland]

A 43 year healthy old man complains of fever with abdominal pain, vomiting, diarrhoea, followed by the development of thrombocytopenia and acute renal failure. The laboratory tests show the presence of Hantavirus specific IgM and IgG which is confirmed by a specific test revealing Puumala serotype as responsible. The patient received a symptomatic treatment with a favourable evolution allowing discharge about ten days after the beginning of symptoms. Hantavirus are transmitted by rodents, and this patient has certainly been infected in Switzerland in the absence of travel abroad during the incubation period. This means that when confronted in Switzerland with an acute nephritis of unknown origin, a diagnosis of nephropathia epidemica must be taken into account.

Tenofovir Use is associated with a Reduction in Calculated Glomerular Filtration Rates in the Swiss HIV Cohort Study

Background

A growing number of case reports have described tenofovir (TDF)-related proximal renal tubulopathy and impaired calculated glomerular filtration rates (cGFR). We assessed TDF-associated changes in cGFR in a large observational HIV cohort.

Methods

We compared treatment-naive patients or patients with treatment interruptions ≥12 months starting either a TDF-based combination antiretroviral therapy (cART) ( n=363) or a TDF-sparing regime ( n=715). The predefined primary endpoint was the time to a 10 ml/min reduction in cGFR, based on the Cockcroft-Gault equation, confirmed by a follow-up measurement at least 1 month later. In sensitivity analyses, secondary endpoints including calculations based on the modified diet in renal disease (MDRD) formula were considered. Endpoints were modelled using pre-specified covariates in a multiple Cox proportional hazards model.

Results

Two-year event-free probabilities were 0.65 (95% confidence interval [CI] 0.58–0.72) and 0.80 (95% CI 0.76–0.83) for patients starting TDF-containing or TDF-sparing cART, respectively. In the multiple Cox model, diabetes mellitus (hazard ratio [HR]=2.34 [95% CI 1.24–4.42]), higher baseline cGFR (HR=1.03 [95% CI 1.02–1.04] by 10 ml/min), TDF use (HR=1.84 [95% CI 1.35–2.51]) and boosted protease inhibitor use (HR=1.71 [95% CI 1.30–2.24]) significantly increased the risk for reaching the primary endpoint. Sensitivity analyses showed high consistency.

Conclusion

There is consistent evidence for a significant reduction in cGFR associated with TDF use in HIV-infected patients. Our findings call for a strict monitoring of renal function in long-term TDF users with tests that distinguish between glomerular dysfunction and proximal renal tubulopathy, a known adverse effect of TDF.

Adverse Events to Antiretrovirals in the Swiss HIV Cohort Study: Effect on Mortality and Treatment Modification

Background

Antiretroviral therapy (ART) decreases morbidity and mortality in HIV-infected patients but is associated with considerable adverse events (AEs).

Methods

We examined the effect of AEs to ART on mortality, treatment modifications and drop-out in the Swiss HIV Cohort Study. A cross-sectional evaluation of prevalence of 13 clinical and 11 laboratory parameters was performed in 1999 in 1,078 patients on ART. AEs were defined as abnormalities probably or certainly related to ART. A score including the number and severity of AEs was defined. The subsequent progression to death, drop-out and treatment modification due to intolerance were evaluated according to the baseline AE score and characteristics of individual AEs.

Results

Of the 1,078 patients, laboratory AEs were reported in 23% and clinical AEs in 45%. During a median follow up of 5.9 years, laboratory AEs were associated with higher mortality with an adjusted hazard ratio (HR) of 1.3 (95% confidence interval [CI] 1.2–1.5; P<0.001) per score point. For clinical AEs no significant association with increased mortality was found. In contrast, an increasing score for clinical AEs (HR 1.11, 95% CI 1.04–1.18; P=0.002), but not for laboratory AEs (HR 1.07, 95% CI 0.97–1.17; P=0.17), was associated with antiretroviral treatment modification. AEs were not associated with a higher drop-out rate.

Conclusions

The burden of laboratory AEs to antiretroviral drugs is associated with a higher mortality. Physicians seem to change treatments to relieve clinical symptoms, while accepting laboratory AEs. Minimizing laboratory drug toxicity seems warranted and its influence on survival should be further evaluated.

Treatment and Prognosis of AIDS-Related Lymphoma in the Era of Highly Active Antiretroviral Therapy: Findings from the Swiss HIV Cohort Study

Objective

To assess the characteristics of combination antiretroviral therapy (cART) administered concomitantly with chemotherapy and to establish prognostic determinants of patients with AIDS-related non-Hodgkin's lymphoma.

Methods

The study included 91 patients with AIDS-related non-Hodgkin's lymphoma from the Swiss HIV Cohort Study enrolled between January 1997 and October 2003, excluding lymphomas of the brain. We extracted AIDS-related non-Hodgkin's lymphoma- and HIV-specific variables at the time of lymphoma diagnosis as well as treatment changes over time from charts and from the Swiss HIV Cohort Study database. Cox regression analyses were performed to study predictors of overall and progression-free survival.

Results

During a median follow up of 1.6 years, 57 patients died or progressed. Thirty-five patients stopped chemotherapy prematurely (before the sixth cycle) usually due to disease progression; these patients had a shorter median survival than those who completed six or more cycles (14 versus 28 months). Interruptions of cART decreased from 35% before chemotherapy to 5% during chemotherapy. Factors associated with overall survival were CD4+ T-cell count (<100 cells/μl) (hazard ratio [HR] 2.95 [95% confidence interval (CI) 1.53–5.67], hepatitis C seropositivity (HR 2.39 [95% CI 1.01–5.67]), the international prognostic index score (HR 1.98–3.62 across categories) and Burkitt histological subtypes (HR 2.56 [95% CI 1.13–5.78]).

Conclusions

Interruptions of cART were usually not induced by chemotherapy. The effect of cART interruptions on AIDS-related non-Hodgkin's lymphoma prognosis remains unclear, however, hepatitis C seropositivity emerged as a predictor of death beyond the well-known international prognostic index score and CD4+ T-cell count.

CD4+ T-Cell Count Increase in HIV-1-Infected Patients with Suppressed Viral Load Within 1 year after start of antiretroviral therapy

Background

CD4+ T-cell recovery in patients with continuous suppression of plasma HIV-1 viral load (VL) is highly variable. This study aimed to identify predictive factors for long-term CD4+ T-cell increase in treatment-naive patients starting combination antiretroviral therapy (cART).

Methods

Treatment-naive patients in the Swiss HIV Cohort Study reaching two VL measurements <50 copies/ml >3 months apart during the 1st year of cART were included ( n=1,816 patients). We studied CD4+ T-cell dynamics until the end of suppression or up to 5 years, subdivided into three periods: 1st year, years 2–3 and years 4–5 of suppression. Multiple median regression adjusted for repeated CD4+T-cell measurements was used to study the dependence of CD4+ T-cell slopes on clinical covariates and drug classes.

Results

Median CD4+ T-cell increases following VL suppression were 87, 52 and 19 cells/μl per year in the three periods. In the multiple regression model, median CD4+ T-cell increases over all three periods were significantly higher for female gender, lower age, higher VL at cART start, CD4+ T-cell <650 cells/μ l at start of the period and low CD4+ T-cell increase in the previous period. Patients on tenofovir showed significantly lower CD4+T-cell increases compared with stavudine.

Conclusions

In our observational study, long-term CD4+ T-cell increase in drug-naive patients with suppressed VL was higher in regimens without tenofovir. The clinical relevance of these findings must be confirmed in, ideally, clinical trials or large, collaborative cohort projects but could influence treatment of older patients and those starting cART at low CD4+ T-cell levels.

A Smoking Cessation Programme in HIV-Infected Individuals: A Pilot Study

Background

Antiretroviral therapy (ART) is a risk factor for cardiovascular disease (CVD) and smoking the most important modifiable cardiovascular risk factor.

Methods

We prospectively evaluated a smoking cessation programme (SCP) in HIV-infected individuals (intervention: counselling and nicotine replacement therapy). Primary endpoint was the smoking cessation rate at 12 months; secondary endpoints were CVD morbidity and mortality. Controls were a not randomized control group of smokers not participating in the SCP.

Results

Four-hundred and seventeen of 680 (61%) patients were smokers, and 34 of these participated in the SCP. Of these 34 individuals, 82% were male, the median age was 43 years, prior AIDS was recorded in 29%, and depressive disorder was recorded in 18%. Twenty-five (74%) patients were receiving ART. Additional risk factors were dyslipidaemia (68%), a prior cardiovascular event (24%), hypertension (15%), and a family history of CVD in 2/34 (6%) individuals. According to the Framingham equation, the 10-year risk of CVD was higher in SCP participants than in controls (11.2% versus 8.5%, P=0.06). At termination of the SCP, 17/34 (50%) individuals had stopped smoking compared with 57/383 (15%) controls. Self-reported smoking abstinence for ≥12 months was 13/34 (38%) in the intervention group and 27/383 (7%) in the control group (odds ration 6.2, 95% confidence interval 2.8–14.3). During the follow-up, two SCP participants and 4 controls experienced a myocardial infarction. One patient in the control group died of CVD.

Conclusions

SCP in HIV-infected individuals is feasible and should be encouraged. The long-term impact of smoking cessation on CVD morbidity and mortality should be evaluated in comparative trials.

Isolation of dengue virus serotype 1 from the blood of a Swiss traveler prior to seroconversion

Dengue virus serotype 1 was isolated from the blood of a patient who had returned to Switzerland from Brazil with fever of unknown origin. After 2 days of culture on Aedes albopictus (C6/36) cell line, the dengue virus was identified as serotype 1 using a type-specific indirect immunofluorescence assay. The diagnosis was confirmed by seroconversion of anti-dengue virus-specific IgM and IgG antibodies and by amplification of a serotype 1-specific region of the dengue virus genome. This is the first description of dengue virus isolation from the blood of a traveler returning to Switzerland. We recommend detection of dengue viremia during the 1st week of illness, before serological tests usually yield conclusive results, as the most efficient means of early specific diagnosis.

Tula virus infection associated with fever and exanthema after a wild rodent bite

Reported here is the first case of human acute infection with Tula virus, which occurred in a 12-year-old boy in Switzerland. This hantavirus had been considered apathogenic to humans, and in Switzerland only TULV-genome sequences have been demonstrated in wild rodents to date. In this case, paronychia, fever and exanthema occurred after the patient was bitten by a wild rodent, indicating an unusual route of hantavirus transmission. Thus, Tula virus infection should be taken into account in patients with appropriate clinical symptoms and contact with rodents.

Evaluation of an optical immunoassay for the rapid detection of influenza A and B viral antigens

An optical immunoassay for the rapid detection of influenza types A and B viral antigens, FLU OIA (Biostar, USA), was prospectively compared with antigen detection methods and cell culture on 400 respiratory specimens during an influenza outbreak that occurred in Switzerland in 1998/1999. The FLU OIA had an overall sensitivity of 64.4% (95%CI, 56.3-71.7%) and a specificity of 94.9% (95%CI, 89.8-97.7%). Using specimens from pediatric and adolescent patients, the sensitivity obtained (71.8%; 95%CI, 61.7-80%) was different than that achieved with specimens from adult patients (51.4%; 95%CI, 36.5-65%) (P=0.004). The results show that rapid diagnostic tests with higher sensitivity and specificity for the detection of influenza virus are needed.

Matrix metalloproteinases and TACE play a role in the pathogenesis of endometriosis

Endometriosis, a benign gynecologic disorder, occurs in about 10% of women in reproductive age and in up to 50% of women with infertility. The basic etiologic factors causing this disease are unknown as yet. Matrix metalloproteinases (MMP) are involved in degradation of the extracellular matrix (ECM). Their proteolytic activity is regulated by tissue inhibitors of metalloproteinases (TIMPs). Tumor necrosis factor-alpha converting enzyme (TACE) is a membrane-bound disintegrin metalloproteinase that processes the membrane-associated cytokine proTNF-alpha to its mature soluble form. TNF-alpha induces the secretion of several MMPs. In order to study the expression of MMP-1, -2, -3 and -9, TIMP-1 and -2, TACE and TNF-alpha in endometrium and endometriotic tissue, we investigated formalin-fixed paraffin sections of endometriotic tissues and normal endometrium with immunohistochemical techniques and in situ hybridisation. Furthermore, quantitative PCR was used for quantification of TACE-mRNA in fresh tissue. We found in this study significant higher protein expression of MMP-1 and TACE and significant lower protein expression of TMP-1 and -2 in endometriotic tissue compared to endometrium. This data may suggest that high TACE expression causes the increased conversion of membrane-bound proTNF-alpha into its soluble form, which stimulates the increased secretion of MMP-1. The simultaneous deficiency of TIMP-1 and -2 in endometriotic tissue suppose an additional proteinase inhibitor imbalance in endometriosis.

Atypical herpes simplex encephalitis presenting as operculum syndrome

This case report demonstrates the course of herpes simplex virus cerebritis in a patient aged 7 years 2 months who presented with non-specific symptoms followed by an epileptic attack. Subcortical, bilateral opercular and bilateral thalamic lesions were detected, but the temporal and inferior frontal lobes were spared. The patient developed anarthria, impairment of mastication and swallowing consistent with operculum syndrome. Diagnosis was made by magnetic resonance imaging and elevation of oligoclonal antibodies specific to herpes simplex virus in cerebrospinal fluid after an unexpectedly negative polymerase chain reaction test.

[Diagnosis of Chlamydia trachomatis infections in routine ambulatory care of a gynecologic-obstetrical clinic: comparison of genome, antigen and cell culture detection methods for various indications]

OBJECTIVE

Comparison of four different assays for routine diagnosis of urogenital Chlamydia trachomatis infections.

METHODS

Samples from 285 female patients were tested using each of the following tests: PCR (Amplicor Chlamydia trachomatis), ELFA (VIDAS Chlamydia), cell culture and direct immunofluorescence assay (DFA).

RESULTS

C. trachomatis was detected by PCR in 13 endocervical swab specimens obtained from 189 female patients (6.9%). Among 13 PCR-positive samples, 10 tested positive by cell culture and DFA, and 8 were positive by ELFA. For 3 patients with pregnancy-related complications, a positive result was obtained by PCR only. Each of the 96 urethral swabs proved to be negative.

CONCLUSIONS

PCR is more sensitive than cell culture, DFA and ELFA, especially in the context of C. trachomatis infection during pregnancy. In addition and in order to avoid false-negative PCR results, a careful collection of epithelial cells infected with C. trachomatis is imperative.

[Imported dengue fever in Switzerland--serological evidence for a hitherto unexpectedly high prevalence]

Dengue fever is probably the most important arthropod-borne viral infection worldwide. The World Health Organization estimates an incidence of 100 million cases per year. Dengue fever is of clinical importance mainly in tropical and subtropical zones, but the increasing number of travellers visiting these endemic areas means that physicians in temperate zones will meet this tropical infectious disease more frequently. To estimate the frequency of dengue fever in Switzerland, we retrospectively analyzed a cohort of patients in whom clinicians wished to rule out a case of malaria on the assumption that some of these patients may have been exposed to dengue virus while travelling in tropical and subtropical areas. Dengue was diagnosed by serology on contemporary stored serum samples with a commercially available assay that has been evaluated before. During the study period (1.1.93 to 1.7.94) a malaria diagnosis was requested by the physicians in our center in 87 cases and malaria was diagnosed in 10 (11.5%). In 38 of these 87 cases a stored serum sample was available for dengue serology. All of these patients had visited an area where not only malaria but dengue virus was endemic. In 7 of these 38 cases (18%) malaria was diagnosed. In 3 patients (8%) the dengue serology (IgM and IgG) was indicative of acute dengue fever. All 3 cases had clinical findings compatible with the disease. In 4 more patients (10%) anti-dengue IgG antibodies were found. All of these 4 patients had previous exposure to dengue virus but no acute clinical illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular characterization of mumps virus strains circulating during an epidemic in eastern Switzerland 1992/93

Ten mumps virus isolates recovered during an epidemic in Switzerland between Autumn 1992 and Spring 1993 were compared by nucleotide sequence analysis of the SH gene. The isolates were found to belong to two distinct yet closely related wild type strains in a newly identified European mumps virus lineage.

Parvovirus B19 infection during pregnancy and development of hydrops fetalis despite the evidence for pre-existing anti-B19 antibody: how reliable are serological results?

BACKGROUND

Primary infection with human parvovirus B19 during pregnancy can lead to fetal hydrops, abortion, or stillbirth. However, reinfection in the presence of pre-existing anti-B19 antibody is generally assumed to have no significant effect on the developing fetus.

OBJECTIVES

To describe a case of fetal loss at 28 weeks' gestation associated with parvovirus B19 infection which took place in a 26-year-old woman despite the evidence for pre-existing anti-B19 IgG antibodies.

STUDY DESIGN

A nested-PCR assay for parvovirus B19 DNA was performed on maternal and fetal samples. Blood samples were tested by various enzyme immunoassays (EIA) for the presence of both anti-B19 IgM and IgG antibodies.

RESULTS

B19 DNA together with anti-B19 IgG antibody were detected in maternal blood at the time of intrauterine fetal demise. Amniotic fluid, chorionic villi and various fetal tissues also tested positive for viral DNA. In retrospect, presence of anti-B19 IgG antibody, but no viral DNA, was repeatedly demonstrated in maternal blood before infection took place. However, the serological results differed with the test system used.

CONCLUSIONS

Provided that the positive serological results are reliable, the presence of anti-B19 IgG in blood samples collected as early as four years before pregnancy neither protected the mother from reinfection not the fetus from transplacental infection with B19 virus. However, discrepant (negative) serological results were also obtained depending on the test system used. Therefore, and in the light of the possible severe consequences of B19-infection during pregnancy, the means for assessment of the significance of anti-B19 titers have to be urgently established by development of both qualitative and quantitative anti-B19 IgM and IgG standards.

Persistent human parvovirus B19 infection following an acute infection with meningitis in an immunocompetent patient

A case in which parvovirus B19 infection persisted over a prolonged period of time in the blood of an immunocompetent patient following an acute infection with meningitis is reported. Using a nested polymerase chain reaction assay the viral genome was detected in cerebrospinal fluid as well as in blood at the time of overt disease and in consecutive blood samples collected for up to nine months.

Renin and prorenin-like activities in bovine ovarian follicles

Recent reports emerging from several laboratories have strengthened the concept of a physiological intrinsic ovarian renin-angiotensin system. Encouraged by these studies carried out mostly so far in human subjects, we decided to investigate if prorenin- and renin-like activities could be demonstrated in the follicular fluid obtained from bovine ovaries. The results obtained in this study show that in a total of 58 follicles examined, significant quantities of both prorenin- and renin-like activities could be demonstrated. The prorenin-like activity measured was invariably 30-40 times greater than the renin-like activity in the follicular fluid samples. There was an inverse relationship between the ratio of estradiol to progesterone concentrations and prorenin-like activity in the follicular fluid. Similarly, a significant negative correlation was seen between the estradiol concentration and prorenin-like activity in follicular fluid. On the other hand, there was no discernible relationship between androstendione concentrations and prorenin-like activity. With respect to progesterone, in large follicles with high (greater than 50 ng/ml) progesterone content, the prorenin-like activity was 3 times as high as that in the low (less than 50 ng/ml) progesterone group. There was, however, no difference in the levels of prorenin-like activity between the high and low progesterone groups in the case of small follicles. Furthermore, analysis of the contents of prorenin- and renin-like activities in extract prepared from granulosa and thecal cells revealed thecal cells of bovine ovarian follicles to be a major source of the enzyme activities. The ratio of prorenin to renin activity in thecal cell extract was close to 1. By analyzing the relationship between various steroid concentrations and prorenin-like activity in follicular fluid, it appears that the atretic follicles are likely to have significantly higher levels of prorenin-like activity in their fluid.