Retinal hypoplasia and degeneration result in vision loss in Friedreich ataxia

OBJECTIVE

Friedreich ataxia (FRDA) is an inherited condition caused by a GAA triplet repeat (GAA-TR) expansion in the FXN gene. Clinical features of FRDA include ataxia, cardiomyopathy, and in some, vision loss. In this study, we characterize features of vision loss in a large cohort of adults and children with FRDA.

METHODS

Using optical coherence tomography (OCT), we measured peripapillary retinal nerve fiber layer (RNFL) thickness in 198 people with FRDA, and 77 controls. Sloan letter charts were used to determine visual acuity. RNFL thickness and visual acuity were compared to measures of disease severity obtained from the Friedreich Ataxia Clinical Outcomes Measures Study (FACOMS).

RESULTS

The majority of patients, including children, had pathologically thin RNFLs (mean = 73 ± 13 μm in FRDA; 98 ± 9 μm in controls) and low-contrast vision deficits early in the disease course. Variability in RNFL thickness in FRDA (range: 36 to 107 μm) was best predicted by disease burden (GAA-TR length X disease duration). Significant deficits in high-contrast visual acuity were apparent in patients with an RNFL thickness of ≤68 μm. RNFL thickness decreased at a rate of -1.2 ± 1.4 μm/year and reached 68 μm at a disease burden of approximately 12,000 GAA years, equivalent to disease duration of 17 years for participants with 700 GAAs.

INTERPRETATION

These data suggest that both hypoplasia and subsequent degeneration of the RNFL may be responsible for the optic nerve dysfunction in FRDA and support the development of a vision-directed treatment for selected patients early in the disease to prevent RNFL loss from reaching the critical threshold.

Omaveloxolone: an activator of Nrf2 for the treatment of Friedreich ataxia

INTRODUCTION

Friedreich ataxia (FRDA) is a rare autosomal recessive degenerative disorder characterized by ataxia, dysarthria, diabetes, cardiomyopathy, scoliosis, and occasionally vision loss in late-stage disease. The discovery of the abnormal gene in FRDA and its product frataxin has provided insight into the pathophysiology and mechanisms of treatment.

AREAS COVERED

Although the neurologic phenotype of FRDA is well defined, there are currently no established pharmacological treatments. Omaveloxolone, a nuclear factor erythroid 2-related factor 2 (Nrf2) activator, is currently under review by the Food and Drug Administration (FDA) and has the potential to be the first approved treatment for FRDA. In the present report, we have reviewed the basic and clinical literature on Nrf2 deficiency in FRDA, and evidence for the benefit of omaveloxolone.

EXPERT OPINION

The present perspective suggests that omaveloxolone is a rational and efficacious therapy that is possibly disease modifying in treatment of FRDA.

Friedreich ataxia: clinical features and new developments

Friedreich's ataxia (FRDA), a neurodegenerative disease characterized by ataxia and other neurological features, affects 1 in 50,000-100,000 individuals in the USA. However, FRDA also includes cardiac, orthopedic and endocrine dysfunction, giving rise to many secondary disease characteristics. The multifaceted approach for clinical care has necessitated the development of disease-specific clinical care guidelines. New developments in FRDA include the advancement of clinical drug trials targeting the NRF2 pathway and frataxin restoration. Additionally, a novel understanding of gene silencing in FRDA, reflecting a variegated silencing pattern, will have applications to current and future therapeutic interventions. Finally, new perspectives on the neuroanatomy of FRDA and its developmental features will refine the time course and anatomical targeting of novel approaches.

Long-term efficacy and safety of addition of carboplatin with or without veliparib to standard neoadjuvant chemotherapy in triple-negative breast cancer: 4-year follow-up data from BrighTNess, a randomized phase 3 trial

BACKGROUND

Primary analyses of the phase 3 BrighTNess trial showed addition of carboplatin with/without veliparib to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) rates with manageable acute toxicity in patients with triple-negative breast cancer (TNBC). Here, we report 4.5-year follow-up data from the trial.

DESIGN

Women with untreated stage II-III TNBC were randomized (2:1:1) to paclitaxel (weekly for 12 doses) plus either: (a) carboplatin (every 3 weeks for four cycles) plus veliparib (twice daily); (b) carboplatin plus veliparib placebo; or (c) carboplatin placebo plus veliparib placebo. All patients then received doxorubicin and cyclophosphamide (AC) every 2‒3 weeks for four cycles. The primary endpoint was pCR. Secondary endpoints included event-free survival (EFS), overall survival (OS), and safety. Since the co-primary endpoint of increased pCR with carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel was not met, secondary analyses are descriptive.

RESULTS

Of 634 patients, 316 were randomized to carboplatin plus veliparib with paclitaxel, 160 to carboplatin with paclitaxel, and 158 to paclitaxel. With median follow-up of 4.5 years, the hazard ratio [HR] for EFS for carboplatin plus veliparib with paclitaxel versus paclitaxel was 0.63 (95% confidence interval [CI] 0.43‒0.92, P=0.02), but 1.12 (95% CI 0.72‒1.72, P=0.62) for carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel. In post hoc analysis, HR for EFS was 0.57 (95% CI 0.36‒0.91, P=0.02) for carboplatin with paclitaxel versus paclitaxel. OS did not differ significantly between treatment arms, nor did rates of myelodysplastic syndromes, acute myeloid leukemia, or other secondary malignancies.

CONCLUSION

Improvement in pCR with addition of carboplatin was associated with long-term EFS benefit with a manageable safety profile, and without increasing the risk of second malignancies, while adding veliparib did not impact EFS. These findings support the addition of carboplatin to weekly paclitaxel followed by AC neoadjuvant chemotherapy for early stage TNBC.

C-68 Expanding Pediatric Performance Validity Tests

Objective

Effort testing with children has started to gain traction in the literature. The following case presents data from several number recall tasks similar to the Wechsler Digit Span and may expand the opportunities for embedded performance validity tests (PVTs).

Method

For the purpose of psychoeducational testing, a comprehensive battery of standardized neuropsychological tests was administered, including visual and auditory attention, language, visual-motor and fine motor skills, visual and auditory processing, executive functioning, and academics.

Results

The child showed impaired performance on Number Recall from the Kaufman Assessment Battery for Children, 2nd Edition (KABC-II) and Memory for Digits on the Comprehensive Test of Phonological Processing, 2nd Edition (CTOPP-2) that met the Weschler Digit Span cutoff indicative of poor effort. Evidence of Ganser symptoms (e.g., nearly correct or approximate answers) was present on math calculation performance on the Woodcock Johnson Tests of Achievement, 4th Edition (WJTA-IV). Further, apparently deliberate markings of “X” solely on his incorrect responses on a dichotomous (yes/no) reading task also suggested deliberate feigning of low reading skills.

Conclusions

This case highlights the importance of effort testing in children, especially as poor effort was not apparent to the examiner, nor did there appear to be any obvious gain. Comparing data on tasks similar to already established PVTs may help expand opportunities to test effort systematically and frequently throughout a neuropsychological evaluation, and has implications for other professionals (e.g., School Psychologists, Speech Language Pathologists, etc.) who evaluate children.

Evaluation of How Integrative Oncology Services Are Valued between Hematology/Oncology Patients and Hematologists/Oncologists at a Tertiary Care Center

Evidence regarding opinions on integrative modalities by patients and physicians is lacking. Methods. A survey study was conducted assessing how integrative modalities were valued among hematology/oncology patients and hematologists and oncologists at a major tertiary medical center. Results. 1008 patients and 55 physicians were surveyed. With the exception of support groups, patients valued nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services significantly more than physicians (P ≤ 0.05). Conclusion. With the exception of support groups, patients value integrative modalities more than physicians. Perhaps with increasing education, awareness, and acceptance by providers and traditional institutions, integrative modalities could be equally valued between patients and providers. It is possible that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction, quality of life, and other clinical endpoints.

Abstract P3-13-05: Eribulin mesylate as first-line therapy for locally recurrent or metastatic HER2-negative breast cancer: Results of a phase 2, multicenter, single-arm study

Background: Eribulin mesylate is a novel nontaxane microtubule dynamics inhibitor that is approved for treatment of metastatic breast cancer (MBC) in patients who have previously received at least two chemotherapeutic regimens for MBC. We present final data from a phase 2 study that evaluated the efficacy and safety of eribulin as first-line therapy for HER2-negative (HER2-) MBC.

Methods: Patients with measureable HER2- locally recurrent or MBC with ≥12 months since prior neoadjuvant or adjuvant chemotherapy received eribulin mesylate 1.4 mg/m2 IV on days 1 and 8 of each 3-week cycle. Endpoints included objective response rate (ORR) (primary), safety, progression-free survival (PFS), time to response (TTR), and duration of response (DOR). Tumor assessments were conducted every 6 weeks for the first 6 cycles and every 6-12 weeks thereafter per RECIST 1.1.

Results: Fifty-six patients enrolled and received eribulin. Patients had a median age of 56 years (range 31-85); 32 (57%) had an ECOG status of 0; 17 (30%) had de novo stage IV; 33 (59%) had prior (neo)adjuvant therapy, including anthracycline and/or taxane (A/T) chemotherapy. Thirty-nine patients (70%) had visceral disease (45% liver, 32% lung); 41(73%) had estrogen receptor-positive (ER+) disease and 12 (21%) had triple negative (TN) disease. Thirty-two patients (57%) completed at least 6 cycles of treatment; among the 24 patients who completed fewer than 6 cycles, reasons for not completing were progressive disease (PD; n = 18), adverse events (AEs; n = 3) and patient choice (n = 3). The median number of cycles delivered was 7 (range 1-39); 6 patients (11%) received treatment for ≥12 months. Overall ORR was 27%, with median TTR of 1.4 months and median DOR of 7.4 months; stable disease (SD) rate was 48% (Table 1). Median PFS was 6.8 months. Thirty-five patients (63%) had grade 3/4 treatment-related AEs (Table 2). Treatment-related serious AEs occurred in 5 (9%) patients: neutropenia (5%), febrile neutropenia (5%), and leukopenia (2%).

Conclusions: The results of this study suggest that first-line eribulin has antitumor activity in ER+/HER2- and TN MBC with safety consistent with the known profile. Further exploration of this treatment as part of earlier lines of breast cancer therapy, including neo/adjuvant, is warranted.

Table 1. Summary of EfficacyEfficacyEribulin-treated patients N = 56ORR, n (%)15 (27)CR0PR15 (27)SD27 (48)PD12 (21)Clinical benefit rate (ORR + ≥6 mo SD)27 (48)Median months (95% CI) TTR1.4 (1.2, 2.7)DOR7.4 (4.7, NE)PFS6.8 (4.4, 7.4)NE, not estimable

Table 2. Treatment-Related AEsAE (N = 56)All events (%)Grade 3/4 (%)Leading to study drug withdrawal1111Leading to dose reduction3427Common AEs (≥25%)  Alopecia820Neutropenia7050Fatigue572Peripheral neuropathy5420Nausea460Anemia364Leukopenia3018Constipation270

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-13-05.

Internet cognitive behavioural therapy for mixed anxiety and depression: a randomized controlled trial and evidence of effectiveness in primary care

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) have the highest co-morbidity rates within the internalizing disorders cluster, yet no Internet-based cognitive behavioural therapy (iCBT) programme exists for their combined treatment.

METHOD

We designed a six-lesson therapist-assisted iCBT programme for mixed anxiety and depression. Study 1 was a randomized controlled trial (RCT) comparing the iCBT programme (n = 46) versus wait-list control (WLC; n = 53) for patients diagnosed by structured clinical interview with MDD, GAD or co-morbid GAD/MDD. Primary outcome measures were the Patient Health Questionnaire nine-item scale (depression), Generalized Anxiety Disorder seven-item scale (generalized anxiety), Kessler 10-item Psychological Distress scale (distress) and 12-item World Health Organization Disability Assessment Schedule II (disability). The iCBT group was followed up at 3 months post-treatment. In study 2, we investigated the adherence to, and efficacy of the same programme in a primary care setting, where patients (n = 136) completed the programme under the supervision of primary care clinicians.

RESULTS

The RCT showed that the iCBT programme was more effective than WLC, with large within- and between-groups effect sizes found (>0.8). Adherence was also high (89%), and gains were maintained at 3-month follow-up. In study 2 in primary care, adherence to the iCBT programme was low (41%), yet effect sizes were large (>0.8). Of the non-completers, 30% experienced benefit.

CONCLUSIONS

Together, the results show that iCBT is effective and adherence is high in research settings, but there is a problem of adherence when translated into the 'real world'. Future efforts need to be placed on developing improved adherence to iCBT in primary care settings.

P5-18-09: The Incidence of Febrile Neutropenia in the First Course of Adjuvant Chemotherapy with Docetaxel/Cyclophosphamide with or without Pegfilgrastim

Background

In our original doxorubicin-cyclophosphamide/docetaxel-cyclophosphamide (AC/TC) adjuvant study (JCO 27: 1177–1183, 2009), we reported an incidence of febrile neutropenia (FN) of 5% (8% in women ≥65 years) with the TC regimen without prophylactic WBC growth factors but with a recommendation for prophylactic antibiotics. There is a paucity of data on the incidence of FN with the TC regimen aside from this clinical trial. Because we have been conducting a randomized adjuvant study of TC compared to other regimens, we used this opportunity to analyze the incidence of FN during the first course of chemotherapy with TC in the first cohort of randomized patients (US Oncology Network study 06090). The prophylactic use of WBC growth factors was at the investigator's discretion.

Patients and Methods

The study included 1298 patients entered between May 2007 and May 2009. Of these, 649 were included in the TC arm. Median age was 54 years (range 27–71), 75.5% were Caucasian, 561 (86.4%) were in PS 0 at baseline, and about half were node negative. Eight patients did not receive study treatment for various reasons. Among the 641 patients who received TC; 213 (33.3%) received pegfilgrastim, 48 (7.5%) received filgrastim and were not included in this analysis, and 380 (59.2%) patients did not receive either during the first cycle. Thus, this analysis focused on 593 women who did or did not receive prophylactic pegfilgrastim in cycle 1.

Results: All patients with a reported adverse event of FN or with a reported AE of fever with some degree of neutropenia (in order to capture all possible cases of FN) during the first cycle of TC were identified [Table 1]. FN and fever + neutropenia occurred in a total of 6 (2.8%) patients who received pegfilgrastim and 36 (9.5%) patients who did not. A comparison of age, race, performance status and stage of disease between these 2 groups revealed that they were similar. The 213 patients who received pegfilgrastim were slightly older (median 56 years, range 27–71) compared to those who did not (median 53 years, range 30–71).

Three-Year Follow-Up of Survival and Progression in a Phase II Trial of Gemcitabine Plus Carboplatin (Plus Trastuzumab in HER2+ Patients) in Metastatic Breast Cancer Patients

Background: We have previously reported (Loesch, et al. Clin Breast Cancer, 2008) the efficacy and safety of gemcitabine and carboplatin with or without trastuzumab in patients with metastatic breast cancer. We now report time-to-progression (TTP) and overall survival (OS) after up to 3.5 years of extended follow-up.Patients and Methods: Patients were stratified into 3 groups at registration; Group 1: HER2 positive (+) regardless of prior taxane; Group 2: HER2 negative (–) and taxane naïve or remote (no taxanes within the past 2 years); and Group 3: HER2– and taxane pretreated. Women ≥18 years of age, with ECOG performance status 0-2, with RECIST-defined measurable disease, and either HER2– or HER2+ (3+ score) by immunohistochemistry or fluorescence in situ hybridization were enrolled. Treatment: Day 1 gemcitabine 1500 mg/m2 over 30 minutes followed by carboplatin AUC=2.5 repeated every 14 days up to Cycle 9. Group 1 also received trastuzumab 8 mg/kg in Cycle 1 followed by 4 mg/kg in Cycles 2-9, followed thereafter by 6 mg/kg every 21 days until progression or intolerable toxicity.Results: A total of 150 patients were registered (50, 51, and 49 in Groups 1, 2, and 3, respectively). Median follow-up for surviving patients, calculated from registration, was 31.3, 27.1, and 25.4 months, respectively. Median TTP (calculated as progression-free survival), was 7.2, 5.6, and 4.6 months, respectively. Median OS (range) has not been reached for Group 1 (range, 1.2-46.9); for Group 2 was 21.7 months (<1-44.3); and, for Group 3 was 11.9 months (<1-33.6). At 24-months, survival rates were 73.3%, 41.4%, and 20.5%, respectively; at 36-months, survival rates were 60.6%, 25.7%, and ≤8.3%, respectively. For Group 1 only, the remaining 3 responding patients were followed for 3.5 years, at which time they were relapse-free.Conclusions: Gemcitabine plus carboplatin with or without trastuzumab has been shown to be highly active in metastatic breast cancer. HER2+ patients receiving trastuzumab had the highest TTP and survival rates of all treatment groups. As expected, taxane-pretreated patients had shortened TTP and decreased OS rates compared to taxane-naïve patients.Research support was provided, in part, by Lilly USA, LLC; Indianapolis, IN.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2105.

Motivating Persons with Schizophrenia Spectrum Disorders to Exercise: Rationale and Design

Persons with schizophrenia spectrum disorders (SSDs) are not only at risk because of disabling disease symptoms but because necessary medications create health risks associated with high rates of obesity. Despite the well-known benefits of exercise, persons with SSDs rarely adhere to such regimens; few interventions to motivate exercise behavior have been tested in this group.The purpose of this study is to examine effects of the Walk, Address sensations, Learn about exercise, Cue exercise behavior for persons with SSDs (WALC-S) motivational intervention upon exercise behavior. We will recruit a total of eighty outpatients 18-68 years, meeting these criteria: 1) chart diagnosis of schizophrenia, any subtype, schizoaffective disorder or schizophreniform disorder, according to the criteria described in the Diagnostic and Statistical Manual for Mental Disorders, 2) English speaking, 3) Stable medication regimen (defined as no medication changes within the last month), and 4) medical clearance for moderate exercise in writing from primary care provider. Participants will be randomly assigned to the experimental (4-week WALC-S motivational intervention), or the control group (4-week time and attention control). After the first 4 weeks, all participants will attend a 16-week walking group.The primary measures of the effectiveness of the WALC-S are attendance, persistence and compliance to the 16-week walking group. The study will be completed in approximately January 2010. In addition to hypothesis testing, this study will provide information to estimate effect sizes to calculate power and determine appropriate sample sizes for future inquiries. This paper describes the rationale and design of the study.

The Head to Head trial: Letrozole vs anastrozole as adjuvant treatment of postmenopausal patients with node positive breast cancer

10672

Introduction: Aromatase Inhibitors (AIs) have demonstrated both efficacy and safety advantages over tamoxifen (T) in all treatment settings in breast cancer (BC) and are becoming the new standard of care as endocrine therapy for postmenopausal patients (PM) with BC. Rationale: Cumulative evidence suggests that all AIs may not be the same, raising the question of whether there is a superior AI, and whether any specific patient populations derive differing degrees of benefit from a particular AI. In the ATAC trial, evaluating anastrozole (A) in PM patients with early breast cancer (EBC), at 33 months median follow up the risk of recurrence in the hormone receptor positive (HR+) population was reduced by 22%.The BIG 1–98 Trial, evaluating letrozole (L) in PM women with EBC, showed a significant benefit in favor of L over T at a median follow up of 26 months, with a 19% reduction in the risk of recurrence; in subgroup analyses, L significantly decreased the risk of recurrence in LN+ patients and in patients who received adjuvant chemotherapy. This study is a head to head comparison of L and A in HR+, LN+ PM patients with EBC and aims to compare L vs A in the adjuvant treatment of these patients. Design and Methods: This is a Phase IIIb open-label, randomized, multicentre study including 4000 PM patients from up to 250 international sites. PM patients with HR+, LN+ BC who have recently undergone surgery for primary BC will be randomized to either receive L 2.5 mg or A 1 mg daily. Treatment will commence following completion of standard chemotherapy (if given) and concurrently with radiotherapy (if given)Patients will receive treatment until disease recurrence/relapse for up to 5 years. Patients will be stratified by number of LN and HER2 status. The primary objective is disease free survival at 5 years for L and A. Secondary objectives include safety, overall survival, time to distant metastases and time to contralateral breast cancer. Data analysis will be conducted by an independent group of investigators. Summary: Updated patient accrual figures, including any available early safety data, will be presented at the meeting.

No significant financial relationships to disclose.

Substantial between-hospital variation in outcome following first emergency admission for heart failure

BACKGROUND

Following hospitalization with a range of cardiovascular disorders, substantial variation has been noted in clinical outcome, both between and within countries.

OBJECTIVES

To examine the variation, between hospitals, in the clinical outcomes of death and readmission following hospitalization with heart failure in Scotland. Setting All 29 acute hospitals in Scotland with more than 200 beds.

PATIENTS

All 31 452 patients discharged from these hospitals between January 1990 and December 1995 with a first-ever, primary, diagnosis at discharge/death of heart failure.

ANALYSIS

An analysis of the Scottish database of discharge summaries linking index admissions with subsequent admissions and deaths. Death rates and readmission rates were adjusted for baseline age, co-morbidity and socio-economic status and were calculated at different time periods (inpatient, 30 days, 1 year). Rates were calculated separately for large teaching hospitals (n=6, category A), large general hospitals with specialist units (n=8, category B) and medium sized general hospitals with limited specialist units (n=15 category C).

RESULTS

A total of 31 452 patients were discharged between 1990-1995 - 10 219 (33%), 9735 (31%) and 11 498 (37%) to category A, B and C hospitals, respectively. The national, average, inpatient case fatality rate was 15.3%, ranging, in individual hospitals, from the lowest rate of 8.5% to the highest rate of 23.4%. The average 1 year case fatality rate was 42.4%, ranging between 35.3% and 50.8%. A similar two- to threefold variation was found in hospital readmission rates - thus the average 30 day readmission rate was 5.3% (lowest 3.3%, highest 7.3%). This variation, in both case-fatality and readmission rates, was apparent within all three groups of hospitals and persisted after adjustment for the baseline factors outlined above.

CONCLUSIONS

A patient admitted to one Scottish hospital with heart failure may be two to three times more likely to die or be readmitted, both in the short and longer term, compared to a patient admitted to another hospital. Although we may not have accounted for some sources of variation, it is both surprising and disturbing that large, statistically significant, differences in adjusted death and readmission rates can apparently exist for such an important condition in a relatively small country with generally homogenous health care provision. Further, detailed investigation of this apparent variation is required.

The Saccharomyces cerevisiae MUM2 gene interacts with the DNA replication machinery and is required for meiotic levels of double strand breaks

The Saccharomyces cerevisiae MUM2 gene is essential for meiotic, but not mitotic, DNA replication and thus sporulation. Genetic interactions between MUM2 and a component of the origin recognition complex and polymerase alpha-primase suggest that MUM2 influences the function of the DNA replication machinery. Early meiotic gene expression is induced to a much greater extent in mum2 cells than in meiotic cells treated with the DNA synthesis inhibitor hydroxyurea. This result indicates that the mum2 meiotic arrest is downstream of the arrest induced by hydroxyurea and suggests that DNA synthesis is initiated in the mutant. Genetic analyses indicate that the recombination that occurs in mum2 mutants is dependent on the normal recombination machinery and on synaptonemal complex components and therefore is not a consequence of lesions created by incompletely replicated DNA. Both meiotic ectopic and allelic recombination are similarly reduced in the mum2 mutant, and the levels are consistent with the levels of meiosis-specific DSBs that are generated. Cytological analyses of mum2 mutants show that chromosome pairing and synapsis occur, although at reduced levels compared to wild type. Given the near-wild-type levels of meiotic gene expression, pairing, and synapsis, we suggest that the reduction in DNA replication is directly responsible for the reduced level of DSBs and meiotic recombination.

Autologous graft-versus-host disease induction in advanced breast cancer: role of peripheral blood progenitor cells

The purpose of the present study was to investigate the impact of the use of peripheral blood progenitor cells (PBPCs) on the induction of autologous graft-versus-host disease (GVHD) in patients with advanced breast cancer. 14 women with stage IIIB and 36 women with stage IV breast cancer received cyclosporine (CsA) 2.5 mg kg-1 i.v. daily, d 0-28, and interferon-gamma (IFNg) 0.025 mg/m2 s.c. qod, d7-28, following PBPC-T +/- bone marrow transplantation (BMT). Preceding high-dose chemotherapy consisted of cyclophosphamide 6 g/m2 and thiotepa 800 mg/m2. Histologically proven > or = grade II cutaneous GVHD was induced in18/50 (36%) of patients and was independent of the source of haematopoietic support. In vitro studies showed that post-transplant, 76% of patients had developed auto-cytotoxicity against their own pre-transplant PHA-lymphoblasts. A significant correlation between the occurrence of GVHD > or = grade II and cytolysis was observed in the NK cell-line K562 and the T47D breast cancer cell-line. With a median follow-up of 2(1/2) years, the overall survival (OS) is 58%, the disease-free survival (DFS) 26%, both independent of the development of GVHD and similar to what has been observed in other studies on high-dose chemotherapy in advanced breast cancer. It therefore remains unclear whether the induction of autologous GVHD with the occurrence of auto-cytotoxic lymphocytes can result in an anti-tumour effect in this group of patients.

Dimensions of decreased psychological well-being in advanced dementia

Evaluation of psychological well-being among persons with an advanced dementia is primarily dependent on verbal and non-verbal cues and behaviors that are observed and interpreted by others. The purpose of the present study was to determine how many components of psychological well-being can be measured. Fifty-seven individuals who were institutionalized for advanced dementia and exhibited agitation or withdrawal were evaluated by direct observations and by interviews with nursing home staff. Engagement was measured by the Lawton Positive Affect scale, visual analog scale, and reported degree of patient's interest in the environment. Mood was measured by a global indicator of mood interpreted from facial expression and two mood items from the Multidimensional Observation Scale for Elderly Subjects. Agitation was measured by a visual analog scale and by the Short Form of the Cohen-Mansfield Agitation Inventory. Correlation analyses and multidimensional scaling provided evidence for three dimensions of psychological well-being: engagement-apathy, happy sad mood, and calm-agitation. Evaluation of these three dimensions is important for measuring quality of care in long-term care settings and for determining effectiveness of therapeutic interventions.

Randomized, double-blind, placebo-controlled trial to evaluate the hematopoietic growth factor PIXY321 after moderate-dose fluorouracil, doxorubicin, and cyclophosphamide in stage II and III breast cancer

PURPOSE

To measure the effect of PIXY321 (granulocyte-macrophage colony-stimulating factor/interleukin-3 S. cerevisiae fusion protein) on the incidence, duration, and complications of neutropenia and thrombocytopenia after moderate-dose fluorouracil 600 mg/m(2), doxorubicin 60 mg/m(2), and cyclophosphamide 750 mg/m(2) (FAC) chemotherapy in patients with stage II and III breast cancer.

PATIENTS AND METHODS

In this multicenter, randomized, double-blind placebo-controlled trial, 71 women were to receive four 21-day cycles of treatment with moderate-dose FAC chemotherapy by short intravenous infusion on day 1, followed by either placebo or PIXY321 (375 microg/m(2) subcutaneously twice a day) on days 3 to 15. All patients were to receive prophylactic oral ciprofloxacin when the absolute neutrophil count was less than 1,000/microL.

RESULTS

PIXY321 significantly reduced the incidence and duration of grade 3 and grade 4 neutropenia in cycles 1 and 2 and the duration of grade 3 neutropenia in cycles 1 through 4. In cycles 3 and 4, grade 3 thrombocytopenia was significantly more common with PIXY321 (P <.05). Two patients, both in the PIXY321 group, required platelet transfusions. Fever and hospitalization for intravenous antibiotics were significantly more common in the PIXY321 group during cycle 1 only. More patients in the PIXY321 group achieved hematologic recovery by day 22 in cycles 1 through 3, and time to recovery was significantly shorter with PIXY321 in all cycles. FAC dose intensity was roughly 2% higher in the PIXY321 group (P = NS). Nonhematologic events of any intensity occurring with significantly greater overall frequency in the PIXY321 group included injection-site reactions, fever, chills, abdominal pain, and arthralgia. No patient died on study or within 30 days of her last dose of study drug.

CONCLUSION

PIXY321 decreased the incidence and duration of FAC-induced grade 3 and 4 neutropenia in cycles 1 and 2 and significantly shortened the time to hematologic recovery in all cycles. However, it produced more systemic toxicity as well as thrombocytopenia in cycles 3 and 4.

Serum lysozyme activity can differentiate infection from rejection in organ transplant recipients

BACKGROUND

The presentation of infection in immunocompromised patients can be subtle. Patients often undergo extensive testing and empiric treatment for rejection and infection while awaiting the results of the biopsy and culture results. Delay in diagnosis of either entity can result in a worse clinical outcome. Lysozyme activity has been found to be both a sensitive and a specific marker for infection in laboratory animals and trauma patients. Our goal was to determine whether lysozyme activity could serve as a reliable marker for infection in immunocompromised organ transplant recipients.

METHODS

Transplant recipients from three clinical categories were enrolled in this study. Group 1 (n = 16) were patients hospitalized for sepsis (culture-positive), and Group 2 (n = 13) for biopsy-proven rejection. Group 3 (n = 51) were recipients who had routine blood sampling in the clinic. In Groups 1 and 2, blood was collected within 24 h of hospital admission and centrifuged, and serum samples were stored at 80 degrees C until processing. Lysozyme activity was assayed by turbidimetric measurement on a sample of a standard suspension (0.15 mg/ml) of Micrococcus lysodeikticus in buffer using a spectrophotometer to read the optical density at 450 nm. The lysozyme activity level was then determined by the measuring activity at 1 min subtracted from activity at 4 min. White blood cell count was determined by using a flow cytometer. Statistical comparisons between groups were made using paired Student's t test.

RESULTS

Serum lysozyme was found to be significantly elevated in Group 1; the mean level of activity was 60.1 +/- 13 (P < 0.05) compared to the level of activity in Group 2, mean 41.1 +/- 11, and Group 3, mean 40.8 +/- 13. A level of 45 units of activity/ml of serum or above indicated infection and not rejection in the patients admitted to the hospital.

CONCLUSIONS

These findings indicate that the lysozyme activity assay appears to be useful in differentiating infection from rejection in transplant recipients.

Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease

OBJECTIVE

To evaluate the efficacy of Simulated Presence, a personalized approach to enhance well-being among nursing home residents with Alzheimer's disease and related dementia's (ADRD).

DESIGN

Latin-Square, double blinded, 3-factor design with restrictive randomization of three treatments (the study intervention, a placebo audio tape of a person reading the newspaper, and usual care). The three factors were treatment, time, and facility type.

SETTING

Nine nursing homes in Eastern Massachusetts and Southern New Hampshire.

PARTICIPANTS

Fifty-four subjects with documented ADRD who were aged 50 years or older, medically stable, had resided in their current nursing home for at least 3 months, and who had no planned discharge. All subjects had a history of agitated or withdrawn behaviors.

INTERVENTION

The purpose of Simulated Presence is to provide a personalized intervention for persons with moderate to severe cognitive impairment. Through a unique testing process, some of the best loved memories of the ADRD person's lifetime are identified and then those memories are introduced to the patient in the format of a telephone conversation using a continuous play audio tape system. The intervention may be used for extended periods of time because each repetition is viewed as a fresh, live telephone call as a result of the short-term memory deficit of the person with ADRD.

MEASUREMENTS

Direct observations of outcomes included using a newly developed scale, the Scale for the Observation of Agitation in Persons with Dementia, an agitation visual analog scale, the Positive Affect Rating Scale (mood and "interest"), a withdrawal visual analog scale, and facial diagrams of mood. Reported measures included daily staff observation logs of responses to interventions offered, and weekly staff surveys using the short-form Cohen-Mansfield Agitation Inventory and the Multidimensional Observation Scale for Elderly Subjects (mood and "interest"). Severity of dementia was assessed by the Mini-Mental State Exam, the Test for Severe Impairment, the Bedford Alzheimer's Nursing Scale, and the ADL Self-Performance Scale.

RESULTS

Chi-square analysis of direct observations, using facial diagrams, revealed that Simulated Presence was equivalent to usual care (P = .141) and superior to placebo for producing a happy facial expression (P = .001). A positive effect was also documented in nursing staff observation logs using Analysis of Variance techniques (ANOVA) for subjects during Simulated Presence phases compared with the placebo phases (P < .001) and usual care phases (P < .001). According to ANOVA analyses of "interest" from weekly surveys, Simulated Presence was superior to both usual care (P = .001) and placebo (P = .008). We were unable to find evidence of significant differences (P < .05) among interventions for other direct observations and weekly reports of overall agitation or mood aspects of withdrawal. Subjects accepted the intervention most of the time, except for five subjects who refused it more than 50% of the time.

CONCLUSION

This study provided evidence that Simulated Presence can be effective in enhancing well-being and decreasing problem behaviors in the nursing home setting as a substitute for or complement to usual care.

Novel, cross-restricted, conserved, and immunodominant cytotoxic T lymphocyte epitopes in slow progressors in HIV type 1 infection

HIV-specific cytotoxic T lymphocytes (CTLs) play an important role in the immune response to HIV infection. Long-term nonprogressors (LTNPs) or slow progressors (SPs) in HIV infection may make qualitatively different CTL responses compared to those generated by seropositive individuals who progress to disease at a faster rate. The class I molecule HLA-B*57 has been identified as one restriction element overrepresented in SP groups studied, and, together with the closely related molecule HLA-B*58, occurs commonly in ethnic groups where HIV is most prevalent. In this study, we have identified five new HLA-B*57-restricted CTL epitopes recognized by SP donors, one of which is also HLA-B*5801 restricted. These HLA-B*57-restricted responses represent the dominant HIV-specific CTL response in each of the SP donors tested. These and other such epitopes may be an important component in future vaccine design.

Reproduction in mice lacking a functional type 1 IL-1 receptor

Growth factors and cytokines have been identified in having critical roles at mediating maternal-fetal interactions during pregnancy, with interleukin-1 being a recently implicated factor. Previous experiments indicated that repeated intraperitoneal injections of the Il-1 receptor antagonist (Il-1Ra), which inhibits binding of interleukin-1 (Il-1) to the type 1 Il-1 receptor (Il-1Rt1) blocks blastocyst implantation in superovulated mice. To gain a greater insight into the role of Il-1 receptor in implantation, we analyzed the reproduction of mice deficient for the Il-1Rt1. Our results show that mice lacking this receptor do not exhibit any profound alterations in their reproduction, apart from a slight reduction in mean litter size. Furthermore, repeated intraperitoneal injections of either IL-1Ra or the monoclonal antibody 35F5, which also blocks ligand binding to the Il-1Rt1, did not affect embryo implantation in either wild type and Il-1 receptor deficient mice.

Endoscopic management of benign and malignant biliary strictures

BACKGROUND

It is now possible to manage most extrahepatic bile duct strictures, benign or malignant, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic dilatation and stenting.

METHODS

Over a 5-year period we treated 218 patients with strictures of extrahepatic bile ducts. Eighty-six patients had benign biliary stricture. Endoscopic treatment was performed in 67 (78%) of these patients. Open surgical biliary drainage was preferred in 12 patients (14%), and 7 patients (8%) were managed conservatively without stenting or surgery. One hundred and thirty-two patients had malignant biliary stricture. One hundred and one patients (77%) underwent endoscopic stent placement. Thirty-one patients (23%) underwent surgery for potential curative resection after diagnostic ERCP. The average life span in the malignant stricture group was 5 months (range 0.1 to 25 months) after the initial endoscopic procedure.

RESULTS

Altogether 313 endoscopic procedures in 218 patients were performed for benign and malignant bile duct strictures. Complications included hemorrhage in 8 (3%), pancreatitis in 10 (3%), and suspected retroperitoneal perforation in 2 (0.6%). There were no ERCP related deaths; one patient died of uncontrolled bleeding from transhepatic stenting. In benign strictures, there has been no recurrence of strictures after the last stent removal with a mean followup of 21 months (range 0.1 to 31 months). All complications were successfully treated conservatively.

CONCLUSIONS

Endoscopic management of benign and malignant biliary stricture is possible with minimal morbidity and mortality and should be considered an acceptable option to surgical management.

Role of CD14 in hemorrhagic shock-induced alterations of the monocyte tumor necrosis factor response to endotoxin

OBJECTIVE

To determine if the shock-induced alterations in whole blood monocyte tumor necrosis factor (TNF) response are mediated by the CD14 receptor.

DESIGN

Prospective controlled animals experiments.

MATERIALS AND METHODS

New Zealand White rabbits (n = 15) were subjected to hemorrhage and resuscitation. Blood samples obtained before shock and 24, 72, and 120 hours after shock were stimulated with lipopolysaccharide in the presence or absence of the anti-CD14 monoclonal antibody, 63D3. Tumor necrosis factor was assayed using L929 cells.

MEASUREMENTS AND MAIN RESULTS

There are no detectable TNF activity in unstimulated blood. The CD14 inhibition resulted in a 55% reduction in baseline TNF activity. After shock, there was a marked increase in TNF activity with lipopolysaccharide stimulation. Addition of 63D3 resulted in a dose-dependent 95% reduction in TNF activity at 24 and 72 hours after shock, (p < 0.05).

CONCLUSION

The enhanced whole blood monocyte TNF response after hemorrhage is CD14 dependent.

Liposomes modulate Kupffer cell endotoxin response

OBJECTIVES

To test the hypothesis that pretreatment with liposomes enriched with the omega 3 fatty acid docosahexaenoic acid (22:6 omega 3) will alter the Kupffer's cell and systemic cytokine (tumor necrosis factor and interleukin-6) response to endotoxin challenge, and to demonstrate alterations in Kupffer's cell phospholipid fatty acid composition after in vivo liposome treatment.

DESIGN

Nonrandomized controlled laboratory investigation in Wistar rats.

INTERVENTIONS

Animals were assigned to three pretreatment groups: no liposomes; liposomes, 100 mg/kg; or liposomes, 400 mg/kg given by bolus intravenous injection with the animals under inhalation anesthesia. Eighteen hours after liposome treatment, each group was challenged with Escherichia coli lipopolysaccharide (3 mg/kg intraperitoneally in 10 mL of lactated Ringer's solution) or lactated Ringer's solution only. In a separate set of experiments, Kupffer's cells were obtained from animals pretreated with liposome, 400 mg/kg, or controls and challenged with lipopolysaccharide (1, 100, or 10(4) ng/mL) in vitro.

OUTCOME MEASURES

Serum and Kupffer's cell supernatant tumor necrosis factor and interleukin-6 bioactivity, Kupffer's cell phospholipid fatty acid composition, survival, and liver histologic findings.

RESULTS

In vivo liposome pretreatment (400 mg/kg) resulted in significant increases in serum tumor necrosis factor and interleukin-6 levels 90 minutes after intraperitoneal lipopolysaccharide challenge (P < .05 vs no liposomes). Kupffer's cells isolated from liposome-treated animals (400 mg/kg) compared with untreated controls release significantly more tumor necrosis factor and interleukin-6 after lipopolysaccharide stimulation in vitro in a dose-dependent response (P < .05). Liposome treatment increased total polyunsaturated fatty acid, total omega 3, and docosahexaenoic acid 22:6 omega 3 content in Kupffer's cell phospholipids compared with untreated controls. Survival 24 hours after lipopolysaccharide challenge was reduced by liposome (400 mg/kg) pretreatment (P < .05 by chi 2 test). Livers from each treatment group demonstrated focal areas of hepatocyte necrosis and inflammatory cells.

CONCLUSION

Liposome pretreatment increases the circulating and Kupffer's cell cytokine response to endotoxemia, increases Kupffer's cell polyunsaturated fatty acid content, and is associated with reduced survival.

Differential TNF secretion by wound fibroblasts compared to normal fibroblasts in response to LPS

Fibroblasts cultured from wound sites have been shown to have an altered phenotype compared to normal dermal fibroblasts and are generally regarded as target cells of the cytokine response at sites of injury. This study was undertaken to determine whether wound fibroblasts can contribute to proinflammatory cytokine production in wounds and, in particular, whether they are capable of secreting TNF. Wound fibroblasts were cultured from polyvinyl alcohol sponges implanted subcutaneously for 2 weeks in Balb/c mice. Fibroblasts harvested from the skin and subcutaneous tissue of untreated mice served as a control population of cells. All cells were passaged at least twice and then stimulated with a dose range of LPS. Supernatants were harvested 8 hr following stimulation and TNF was assayed using a standard L929 cell-killing assay. There was a significant TNF response to LPS by wound fibroblasts, evident as early as 4 hr following exposure to LPS and associated with an upregulation of TNF mRNA. Normal dermal fibroblasts did not secrete any measurable amounts of TNF in response to LPS. The results indicate that wound fibroblasts generate a brisk TNF response to stimulation with LPS, in contrast to normal subcutaneous fibroblasts. These data reveal an additional unique property of wound-harvested fibroblasts and suggest a possible contributing mechanism to disordered wound healing in the face of infection or conditions characterized by excessive fibrosis.

X-ray structure analysis of the iron-dependent superoxide dismutase from Mycobacterium tuberculosis at 2.0 Angstroms resolution reveals novel dimer-dimer interactions

The X-ray structure of the tetrameric iron-dependent superoxide dismutase from Mycobacterium tuberculosis has been refined to an R-factor of 0.167 and a correlation coefficient of 0.954 at 2.0 A resolution. The crystals are monoclinic P2(1) and have four subunits related by strong non-crystallographic 222 (or D2) symmetry in the asymmetric unit. 198 of the 207 amino acids of each subunit are defined by the electron density which shows that they adopt the conserved fold of other iron- or manganese-dependent SODs. The structure can be divided into two domains, the N-terminal domain involving an extended region followed by two projecting antiparallel alpha-helices, and the C-terminal domain containing four more helical segments with a three-stranded antiparallel beta-sheet inserted sequentially between the fourth and fifth helices. The catalytic iron is co-ordinated by five ligands: three histidines (residues 28, 76 and 164), one aspartate (160) and a solvent molecule. The inferred positions of protons at the active site are consistent with the solvent ligand being a hydroxide ion. This ligand interacts with His145 in the Mycobacterium tuberculosis SOD. In the highly homologous Mycobacterium leprae Mn-SOD, the histidine is replaced by glutamine, this being the only significant residue difference within 10 A of the Fe3+. The nature of the amino acid at this position may influence the metal ion specificity of these enzymes. The subunits of the Mycobacterium tuberculosis SOD associate by polar contacts to form dimers, which closely resemble those of other dimeric or tetrameric Fe- or Mn-SODs. However, the dimer-dimer interactions within the tetramer are novel, being dominated by dimerisation of the 144 to 152 loop regions which connect the outer two beta-strands of the three-membered beta-sheet. This contrasts strongly with the other tetrameric Fe- or Mn-SODs where the dimer-dimer association is dominated by the projecting alpha alpha-turn in the N-terminal domain.

Neuroinvasion and persistence of human herpesvirus 6 in children

Human herpesvirus 6 (HHV-6) causes a febrile illness in children and has been implicated as a cause of encephalitis and recurrent seizures. Paired samples of cerebrospinal fluid (CSF) and peripheral blood mononuclear cells (PBMC) from 487 children were evaluated by nested polymerase chain reaction (PCR) for evidence of current or past infection with HHV-6. PBMC were also cultured for isolation of HHV-6. These data were correlated with the patients' clinical information. HHV-6 DNA was detected in 72 (14.8%) of 487 CSF samples. HHV-6 persistence was documented in 142 children by PCR detection of HHV-6 DNA in PBMC or CSF (or both) in the absence of primary HHV-6 infection; the central nervous system was the only site of HHV-6 DNA persistence in 28.9%. HHV-6 DNA can be detected in the CSF of children during and after primary infection, and the central nervous system may be the sole site of persistence.

Acute-phase hepatocytes regulate liver sinusoidal cell mediator production

BACKGROUND

Overproduction of liver sinusoidal cell (LCS) mediators in response to endotoxemia or gram-negative infection that follows tissue injury may contribute to hepatic dysfunction.

OBJECTIVE

To better define the role of hepatocyte-derived acute-phase reactants in the regulation of sinusoidal cell mediator production following sequential insults, we tested the hypothesis that interleukin-6 (IL-6) prestimulation alters hepatocyte regulation of lipopolysaccharide (LPS)-stimulated sinusoidal cell tumor necrosis factor (TNF), IL-6, and nitric oxide production.

METHODS

Hepatocytes and LSCs were isolated from Wistar rats, and in vitro responses were compared between LSCs alone and hepatocyte-LSC cocultures. Cocultures and LSCs alone were sequentially stimulated with IL-6 (5000 U/mL) then LPS (dose-response), and culture supernatants were analyzed for TNF (L929 cytolysis), IL-6 (7TD1 proliferation), and nitric oxide (Griess reaction). Induction of acute-phase protein synthesis by the stimulation of hepatocytes with IL-6 and dexamethasone (0.1 mumol/L) was assayed by methionine radiolabeling and SDS-PAGE (sodium dodecyl sulfate-polyacrylamide gel electrophoresis). Coculture levels of messenger RNA for TNF-alpha and IL-6 were examined by RNA extraction and reverse transcriptase polymerase chain reaction with specific primers.

RESULTS

Interleukin-6 and dexamethasone signal hepatocyte acute-phase protein synthesis. Prestimulation of cocultures, but not of LSCs alone, with IL-6 inhibits LPS-stimulated IL-6 and nitric oxide production significantly. Bioactivity of TNF is reduced to a lesser extent. Polymerase chain reaction analysis demonstrated similar levels of TNF and IL-6 message following sequential stimulation.

CONCLUSIONS

Interleukin-6-stimulated acute-phase hepatocytes limit LPS-stimulated coculture cytokine bioactivity and nitric oxide production. This hepatocyte response may provide a local counterregulatory mechanism to limit LSC-mediated injury.

Augmented tumor necrosis factor response to lipopolysaccharide after thermal injury is regulated posttranscriptionally

BACKGROUND AND OBJECTIVE

Thermal injury has been shown to enhance macrophage sensitivity to lipopolysaccharide (LPS), resulting in augmented tumor necrosis factor alpha (TNF-alpha) production. This study was designed to examine whether enhanced TNF-alpha response after thermal injury and LPS stimulation is regulated at the level of transcription.

DESIGN

Tumor necrosis factor alpha release in alveolar macrophages harvested from sham- or thermal-injured Wistar rats was determined using an L929 cytotoxicity bioassay on days 1, 3, and 5 following 40% scald burn and incubation for 24 hours with LPS (0 or 10 micrograms/mL). Separate groups of rats underwent intraperitoneal injection of LPS (5 mg/kg) 3 days following sham or thermal injury. Lung tissue RNA was isolated and probed for TNF-alpha messenger RNA (mRNA), using nuclease protection analysis. Finally, pooled alveolar macrophages were harvested 3 days following sham or thermal injury and cultured in the presence or absence of LPS (10 micrograms/mL) for 4 hours. The RNA from the pooled alveolar macrophages was extracted and probed for TNF-alpha mRNA levels.

RESULTS

Thermal injury alone did not significantly increase alveolar macrophage TNF-alpha bioactivity, whole-lung TNF-alpha mRNA levels, or pooled alveolar macrophages TNF-alpha mRNA levels when compared with levels in sham-injured rats. However, alveolar macrophages from postburn day 3 (PBD 3) demonstrated increased sensitivity to LPS (10 micrograms/mL) compared with alveolar macrophages from sham-injured animals undergoing similar LPS treatment (2365 +/- 1011 vs 169 +/- 79 ng/mL; P < .05). Whole-lung mRNA levels in both sham-injured and PBD-3 rats receiving intraperitoneal LPS, while elevated approximately 2.5-fold from those of non-LPS treated rats, were not different from each other. Finally, pooled alveolar macrophages from sham-injured and PBD-3 rats cultured in the presence of LPS had approximately 1.7-fold and threefold increased TNF-alpha mRNA levels, respectively, compared with alveolar macrophages not cultured with LPS.

CONCLUSIONS

Thermal injury induces priming of alveolar macrophages, resulting in significant increases in macrophage TNF-alpha production after exposure to LPS. The majority of this effect appears to be regulated at a posttranscriptional level, since there were only moderate increases in TNF-alpha mRNA levels after LPS stimulation, which did not coincide with large differences in bioactivity.

Burn injury enhances alveolar macrophage endotoxin sensitivity

Systemic activation of inflammatory cascades has been implicated in the pathogenesis of the multiple organ dysfunction syndrome. To begin to determine whether dysregulation of macrophage cytokine expression after burn plays a role in organ failure, we examined tumor necrosis factor alpha bioactivity of liver and lung macrophages under two conditions: (1) at 1, 3, 5, and 7 days after 40% scald burn, and (2) after sequential insult consisting of 40% scald burn followed by in vitro incubation with endotoxin. Burn alone did not significantly alter alveolar macrophage or Kupffer cell tumor necrosis factor alpha bioactivity at any of the timepoints examined. Sequential insult did not result in significant changes in Kupffer cell tumor necrosis factor alpha, but tumor necrosis factor alpha was increased 11.1 times in alveolar macrophages harvested on postburn day 3. Therefore macrophage cytokine responses to thermal injury are apparently both tissue-specific and time-dependent.

Human herpesvirus 6 (HHV-6) variant B accounts for the majority of symptomatic primary HHV-6 infections in a population of U.S. infants

Two variants of human herpesvirus 6 were identified. To assess their epidemiology and disease association, we analyzed viral isolates and/or uncultured peripheral blood mononuclear cells from 76 infants with symptomatic primary infection. In 97% of cases, human herpesvirus 6 variant B was detected, but variant A was not.

Phenotypic and genetic polymorphisms among human herpesvirus-6 isolates from North American infants

Fifteen human herpesvirus-6 (HHV-6) isolates from North American infants with primary infection manifest as febrile or roseola (exanthem subitum) like illnesses were characterized phenotypically on the basis of their in vitro growth in continuous T-cell lines and primary human mononuclear cells and by their reactivity with monoclonal antibodies. All isolates replicated efficiently in primary human cord blood mononuclear cells, but five distinct patterns of viral replication in human cells lines were observed. Two of the HHV-6 isolates from infants were found to replicate in HSB-2 cells, a property associated with so-called group A viruses, which had previously been isolated only from adults. These same isolates also reacted with a panel of A-specific monoclonal antibodies. Genomic characterization of viral isolates using well-characterized restriction site polymorphisms indicated that these two isolates contained a mixture of both A- and B-type genomes, in different proportions. These data suggest that not all HHV-6 isolates can be categorized into one of two broad groups and that such segregation of HHV-6 isolates may in fact be misleading.

Overexpression, purification, and characterization of yeast cyclophilins A and B

Two isoforms of yeast cyclophilins, yCyPA and yCyPB, have been subcloned, expressed in Escherichia coli, and purified to homogeneity. The full-length (163-amino acid) yeast CyPA was easily expressed and purified; however, only a genetically truncated, 186-residue form of yCyPB lacking a putative 20-amino acid signal sequence could be purified. Each yeast cyclophilin isoform is a peptidyl-prolyl isomerase, inhibitable by the immunosuppressive drug CsA (IC50's of 40 +/- 8 nM and 101 +/- 14 nM at 18 nM concentrations of yCyPA and yCyPB, respectively). Polyclonal antibodies raised against recombinant yCyPA detected native yCyPA in yeast cell extracts by both immunoprecipitation and Western blot analysis. However, polyclonal antibodies raised against recombinant yCyPB detected no native yCyPB in yeast cell extracts by Western blot analysis; small amounts of yCyPB were found in the culture broth, suggesting secretion extracellularly of this isoform. Northern analysis indicated that both yCyPA mRNA and yCYPB mRNA (at a much lower level) were detectable in cell-free extracts. Characterization of the yeast cyclophilin proteins demonstrated that their catalytic properties and sensitivity to CsA parallel those of the human cyclophilins.

A new method of diagnosing diaphragmatic injury using intraperitoneal technetium: case report

The diagnosis of diaphragmatic laceration following blunt or penetrating trauma is often difficult to establish. Delay in recognition of this injury can be life threatening, resulting in herniation of abdominal viscera with possible strangulation or respiratory embarrassment. Previous animal studies from our institution have documented that intra-abdominal instillation of technetium sulfur colloid is a sensitive method to diagnose diaphragmatic disruption. We now present a case of diaphragmatic injury where the preoperative diagnosis was accurately made using this method when other imaging studies were inconclusive.