Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society-USA

OBJECTIVE: To provide recommendations for the treatment of acquired immunodeficiency syndrome-related cytomegalovirus (CMV) end-organ diseases, including retinitis, colitis, pneumonitis, and neurologic diseases. PARTICIPANTS: A 17-member panel of physicians with expertise in clinical and virological research and inpatient care in the field of CMV diseases. EVIDENCE: Available clinical and virological study results. Recommendations are rated according to the quality and strength of available evidence. Recommendations were limited to the treatment of CMV diseases; prophylaxis recommendations are not included. PROCESS: The panel was convened in February 1997 and met regularly through November 1997. Subgroups of the panel summarized and presented available information on specific topics to the full panel; recommendations and ratings were determined by group consensus. CONCLUSIONS: Although the epidemiological features of CMV diseases are changing in the setting of potent, combination antiretroviral therapy, continued attention must be paid to CMV diseases in patients infected with the human immunodeficiency virus to prevent irreversible endorgan dysfunction. The initial and maintenance treatment of CMV retinitis must be individualized based on the characteristics of the lesions, including location and extent, specific patient factors, and characteristics of available therapies among others. Management of relapse or refractory retinitis must be likewise individualized. Ophthalmologic screening for patients at high risk for retinitis or who have a prior diagnosis of extraretinal disease is recommended. Recommendations for gastrointestinal, pulmonary, and neurologic manifestations are included.     

Systemic venous collateral development after the bidirectional cavopulmonary anastomosis. Prevalence and predictors

OBJECTIVES: To determine the prevalence of systemic venous collaterals after the bidirectional cavopulmonary anastomosis and the factors associated with their development. BACKGROUND: Systemic venous collaterals have been found after cavopulmonary anastomosis. Methods. Cardiac catheterization was performed in 103 patients before and after a bidirectional cavopulmonary anastomosis. RESULTS: After surgery, 51 venous collaterals were identified in 32 patients (31%). Collateral development was associated with an abnormal superior vena caval connection (56% incidence vs. 26% with a single right superior vena cava, p = 0.01) and postoperative factors including pulmonary artery distortion (53% incidence vs. 22% without distortion, p = 0.002); increased superior vena caval mean pressure (14 +/- 5 mm Hg versus 11 +/- 4 mm Hg with no collaterals, p = 0.0002); increased pulmonary artery mean pressure (13 +/- 4 mm Hg vs. 11 +/- 4 mm Hg with no collaterals, p = 0.02); lower right atrial mean pressure (5 +/- 2 mm Hg vs. 6 +/- 3 mm Hg with no collaterals, p = 0.04); and increased mean gradient between superior vena cava and right atrium (8 +/- 3 mm Hg vs. 5 +/- 4 mm Hg with no collaterals, p = 0.0002). Using multiple logistic regression, only this last factor was independently associated with collateral development with an odds ratio per 1 mm Hg of 1.33 (95% CI 1.12-1.58, p = 0.001) for their presence. CONCLUSIONS: Systemic venous collaterals occur frequently after a bidirectional cavopulmonary anastomosis and are found postoperatively when a significant pressure gradient occurs between cava and right atrium.     

Radiosensitization and apoptosis

The toxicity of radiation to living tissues was discovered soon after the discovery of radioactivity itself and this toxicity is the basis for cancer therapy with radiation. Although this mode of therapy is often effective, its success is far from assured. One major difficulty in the implementation of radiotherapy is that normal tissues are also sensitive to killing by radiation so that treatment is often limited by the tolerance of normal tissues for radiation. Thus methods that sensitize tumor cells while sparing normal tissues could potentially lead to greater success with radiation as a therapy. Oncogenes are frequently altered in tumors, but are not in normal tissue making them potential targets for altering radiosensitivity and apoptosis in tumors.     

Persistent thrombin generation in humans during specific thrombin inhibition with hirudin

BACKGROUND: The degree to which antithrombotic drugs suppress thrombin generation is unknown. Because hirudin, unlike antithrombin III, binds intravascular thrombin rapidly and selectively to yield a circulating inactive complex of 3- to 4-hour half-life, we used intravenous hirudin in humans to investigate the course of thrombin generation during and early after anticoagulation with this potent, direct antithrombin. METHODS AND RESULTS: Intravascular thrombin was measured with an ELISA for the thrombin-hirudin complex formed during and for 18 hours after stopping a 6-hour infusion of hirudin at 0.1, 0.2, and 0.3 mg.kg-1.h-1 in three groups of six patients each. With free hirudin in 20- to 10,000-fold molar excess of thrombin and peak activated partial thromboplastin times of 2.3 to 3.0 times baseline, mean plasma thrombin-hirudin complex increased from 794 +/- 85 pg/mL (mean +/- SEM) 15 minutes after the start of the infusion to 1617 +/- 151 pg/mL at 6 hours of infusion to 2667 +/- 654 pg/mL at 24 hours. During the 24-hour observation period, plasma concentration of fragment 1.2 (the peptide released during conversion of prothrombin to thrombin) never fell below baseline but rather increased transiently during the hirudin infusion. Plasma concentrations of thrombin-antithrombin III complex (in ng/mL) decreased from 4.34 +/- 0.40 at baseline to 1.64 +/- 0.13 at 6 hours (P < .001) and gradually increased after stopping the infusion to 5.7 +/- 0.87 at 24 hours (nonsignificant compared with baseline). CONCLUSIONS: Measurement of thrombin-hirudin complex may be used as a marker of thrombin generation in humans. Persistent accumulation of thrombin-hirudin complex and generation of fragment 1.2 during and after completion of potent anticoagulation with hirudin suggest thrombin generation is not blocked by high-affinity thrombin inhibition. The persistent formation of thrombin during declining plasma levels of hirudin may contribute to the pathogenesis of rethrombosis early after antithrombin therapy or during inadequate anticoagulation.     

Hereditary febrile seizures: phenotype and evidence for a chromosome 19p locus

Three flagellates of the family Trypanosomatidae were isolated from mango fruits (Mangifera indica) and from the stems of clover (Trifolium glomeratum) and Amaranth (Amaranthus retroflexus) in southeastern Spain and were adapted to in vitro culture in monophase media. The parasites showed an ultrastructural pattern similar to that of other species of the genus Phytomonas. Mango and clover isolates differed from amaranth isolates in ultrastructural terms. The isolates were characterized by isoenzymatic analysis and by kDNA analysis using five different restriction endonucleases. With eight of the nine enzymatic systems, mango and clover isolates were distinguished from those of amaranth. Nevertheless, with the enzymes malate dehydrogenase and superoxide dismutase, flagellates isolated from clover were differentiated from those isolated from mango. Electrophoretic and restriction-endonuclease analysis of kDNA minicircles showed similar restriction cleavage patterns for the isolates from mango and clover, whereas the patterns of the amaranth isolates differed. The results of the present study confirm that the strains isolated from mango and clover constitute a phylogenetically closely related group of plant trypanosomatids, which is more distantly related to the strain isolated from amaranth. The similarities in the results obtained for isolates from mango and clover foliage, on the one hand, and those obtained from tomato and cherimoya fruits (studied previously), on the other, as well as the geographic proximity of the different plants support the contention that only one strain is involved, albeit one strain that can parasitize different plants. Furthermore, some of the plants appear to act as reservoirs for the parasites. On the other hand, the metabolism studies using [1H]-nuclear magnetic resonance spectroscopy did not reveal that the catabolism of Phytomonas in general follows a pattern common to all the species or isolates. Phytomonas are incapable of completely degrading glucose, excreting a large part of their carbon skeleton into the medium as fermentative metabolites (acetate, ethanol, glycine, glycerol, and succinate).     

Value of electron-beam computed tomography for the noninvasive detection of high-grade coronary-artery stenoses and occlusions

BACKGROUND: Reliable noninvasive assessment of coronary-artery stenoses and occlusions would constitute an advantage in the care of patients with known or suspected coronary artery disease. We investigated the accuracy of contrast-enhanced electron-beam computed tomography (CT) for the detection of high-grade coronary-artery stenoses and occlusions. METHODS: Electron-beam CT was performed in 125 patients. After intravenous injection of a contrast agent, 40 cross-sectional images of the heart were acquired during inspiration, triggered by the electrocardiogram in diastole. Three-dimensional reconstructions of the heart and coronary arteries were rendered to facilitate evaluation of the images. The proximal and middle segments of the major coronary arteries were evaluated for the presence or absence of high-grade stenoses and occlusions. The results were compared with those of invasive coronary angiography in a blinded fashion. RESULTS: Because of technical problems that impaired the quality of the images, 124 (25 percent) of the 500 coronary arteries studied (left main, left anterior descending, left circumflex, and right coronary) in a total of 125 patients were excluded from evaluation. No vessels could be evaluated in 19 patients (15 percent), and another 28 patients (22 percent) had one, two, or three vessels that could not be evaluated. In the remaining coronary arteries with adequate image quality, electron-beam CT permitted visualization of 69 of 75 high-grade stenoses and occlusions (sensitivity, 92 percent), whereas in 282 of 301 arteries, the absence of high-grade stenoses and occlusions was correctly detected (specificity, 94 percent). CONCLUSIONS: When image quality is adequate, electron-beam CT may be useful to detect or rule out high-grade coronary-artery stenoses and occlusions.     

The measurement of bioreductive capacity of tumor cells using methylene blue

PURPOSE: Methylene blue (MB) can be used as an intracellular electron acceptor. The purpose of this study was to demonstrate the usefulness of MB for the determination of total bioreductive capacity of cell suspensions. METHODS AND MATERIALS: We measured oxygen consumption by Clark electrode and pentose cycle activity by release of 14CO2 from 1-14C-glucose. RESULTS: Methylene blue catalyzes the reaction of intracellular reductants NADPH, NADH, and reduced glutathione (GSH) with oxygen, causing the production of hydrogen peroxide. The reaction rate correlates with the negative charge of molecule (NADPH(-4) > NADH(-2) > GSH(-1)), suggesting that reaction with positively charged oxidized MB is the limiting step of the reaction. In a cellular system MB causes the electron flow from cellular endogenous substrates to oxygen. It is activated by the disruption of the NADP+/NADPH ratio due to several processes. These are direct oxidation of NADPH and GSH, the GSH peroxidase catalyzed reaction of GSH with H2O2, followed by NADPH oxidation by oxidized glutathione (GSSG). This results in increased cellular oxygen consumption and stimulation of the oxidative limb of pentose cycle (PC) in the presence of MB. The cellular effect of MB differs from other electron accepting drugs. Diamide and tert-butylhydroperoxide act as direct oxidants, while MB is an electron carrier to oxygen. Accordingly, MB shows the highest effect on PC activation and oxygen consumption. CONCLUSIONS: Our results indicate that MB may be used for the determination of the total bioreductive capacity of the cells, measured by oxygen consumption and PC activation.