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ObjectivePrimary sclerosing cholangitis (PSC) is characterised by bile duct strictures and progressive liver disease, eventually requiring liver transplantation. Although the pathogenesis of PSC remains incompletely understood, strong associations with HLA-class II haplotypes have been described. As specific HLA-DP molecules can bind the activating NK-cell receptor NKp44, we investigated the role of HLA-DP/NKp44-interactions in PSC.DesignLiver tissue, intrahepatic and peripheral blood lymphocytes of individuals with PSC and control individuals were characterised using flow cytometry, immunohistochemical and immunofluorescence analyses. HLA-DPA1 and HLA-DPB1 imputation and association analyses were performed in 3408 individuals with PSC and 34 213 controls. NK cell activation on NKp44/HLA-DP interactions was assessed in vitro using plate-bound HLA-DP molecules and HLA-DPB wildtype versus knock-out human cholangiocyte organoids.ResultsNKp44+NK cells were enriched in livers, and intrahepatic bile ducts of individuals with PSC showed higher expression of HLA-DP. HLA-DP haplotype analysis revealed a highly elevated PSC risk for HLA-DPA1*02:01~B1*01:01(OR 1.99, p=6.7×10−50). Primary NKp44+NK cells exhibited significantly higher degranulation in response to plate-bound HLA-DPA1*02:01-DPB1*01:01 compared with control HLA-DP molecules, which were inhibited by anti-NKp44-blocking. Human cholangiocyte organoids expressing HLA-DPA1*02:01-DPB1*01:01 after IFN-γ-exposure demonstrated significantly increased binding to NKp44-Fc constructs compared with unstimulated controls. Importantly, HLA-DPA1*02:01-DPB1*01:01-expressing organoids increased degranulation of NKp44+NK cells compared with HLA-DPB1-KO organoids.ConclusionOur studies identify a novel PSC risk haplotype HLA-DP A1*02:01~DPB1*01:01and provide clinical and functional data implicating NKp44+NK cells that recognise HLA-DPA1*02:01-DPB1*01:01 expressed on cholangiocytes in PSC pathogenesis.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S1055-3290(97)80030-1 Byline: Maureen A. Martin (a), Carol Kane (b) Abstract: Cytomegalovirus (CMV) retinitis, a late complication of infection with HIV, generally leads to blindness if untreated. Although the retinal damage from CMV cannot be reversed, disease progression can be arrested with any one of three antiviral agents, which must be continued indefinitely. Intravenous ganciclovir and foscarnet, the earliest therapies, must be administered every day and require placement of an indwelling catheter. Cidofovir, a newly introduced intravenous antiviral, requires the least frequent administration; after two once-a-week induction doses maintenance therapy is given only once every other week. However, cidofovir is potentially nephrotoxic and must be coadministered with nephroprotective probenecid and saline hydration. Careful adherence to treatment administration guidelines for cidofovir and probenecid is essential for safe administration of both drugs. Averting and managing adverse reactions to cidofovir and probenecid may present a true nursing challenge; however, with proper patient selection and appropriate use, cidofovir has the potential to greatly enhance the quality of life of a patient with CMV retinitis. Author Affiliation: (a) Department of Medicine, UCLA Medical Center, Center for Clinical AIDS Research and Education USA (b) Santa Clara Valley Medical Center USA

* Background. -- Pneumocystis carinii pneumonia (PCP) is a major cause of morbidity and the leading cause of death in patients with the acquired immunodeficiency syndrome. The prevention of the occurrence and recurrence of PCP is a cornerstone in the treatment of patients infected with the human immunodeficiency virus. There are few studies comparing PCP prophylactic regimens. Methods. -- The efficacy of three regimens for prophylaxis against PCP was assessed in a retrospective chart review of 211 human immunodeficiency virus-infected patients at risk for the disease. Over the course of the 2-year study period, 133 patients were prescribed trimetoprim-sulfamethoxazole (one double-strength tablet twice a day, thrice weekly) for a mean of 7.4 months (range, 1 to 25 months.) Seventy-seven patients received dapsone (50 mg daily) for a mean of 5.7 months (range, 1 to 23 months), and 125 patients received aerosolized pentamidine (300 mg via nebulizer once monthly) for a mean of 9.3 months (range, 1 to 21 months). The majority of patients (62%) received primary prophylaxis; 38% had one or more previous episodes of PCP; and 73% were receiving concomitant antiretroviral therapy. Results. -- Pneumocystis carinii pneumonia did not develop in any patient receiving trimethoprim-sulfamethoxazole in 1981 patient-months. Five patients receiving dapsone for 437 patient-months and 17 patients receiving aerosolized pentamidine for 1166 patient-months developed PCP. Fifty-six percent of the trimethopri-sulfamethoxazole group and 55% of the dapsone group changed drug due to adverse reactions, while only 2% in the aerosolized pentamidine group required drug change. Conclusion. -- Despite its adverse reaction profile, trimethoprim-sulfamethoxazole is the most effective agent to prevent the occurrence and recurrence of PCP. (Arch Intern Med. 1992;152:523-528)

Although natural killer (NK) cells are recognized for their modulation of immune responses, the mechanisms by which human NK cells mediate immune regulation are unclear. Here, we report that expression of human leukocyte antigen (HLA)-DP, a ligand for the activating NK cell receptor NKp44, is significantly upregulated on CD8+effector T cells, in particular in human cytomegalovirus (HCMV)+individuals. HLA-DP+CD8+T cells expressing NKp44-binding HLA-DP antigens activate NKp44+NK cells, while HLA-DP+CD8+T cells not expressing NKp44-binding HLA-DP antigens do not. In line with this, frequencies of HLA-DP+CD8+T cells are increased in individuals not encoding for NKp44-binding HLA-DP haplotypes, and contain hyper-expanded CD8+T cell clones, compared to individuals expressing NKp44-binding HLA-DP molecules. These findings identify a molecular interaction facilitating the HLA-DP haplotype-specific editing of HLA-DP+CD8+T cell effector populations by NKp44+NK cells and preventing the generation of hyper-expanded T cell clones, which have been suggested to have increased potential for autoimmunity.

Multiple genome-wide studies have identified associations between outcome of human immunodeficiency virus (HIV) infection and polymorphisms in and around the gene encoding the HIV co-receptor CCR5, but the functional basis for the strongest of these associations, rs1015164A/G, is unknown. We found that rs1015164 marks variation in an activating transcription factor 1 binding site that controls expression of the antisense long noncoding RNA (lncRNA) CCR5AS. Knockdown or enhancement of CCR5AS expression resulted in a corresponding change in CCR5 expression on CD4+T cells. CCR5AS interfered with interactions between the RNA-binding protein Raly and the CCR5 3' untranslated region, protecting CCR5 messenger RNA from Raly-mediated degradation. Reduction in CCR5 expression through inhibition of CCR5AS diminished infection of CD4+T cells with CCR5-tropic HIV in vitro. These data represent a rare determination of the functional importance of a genome-wide disease association where expression of a lncRNA affects HIV infection and disease progression.

Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. AVAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009–2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 1 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age =65) admitted to our trauma center with injury severity scores (ISS) =15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality [(>80 years, 21%) vs (65–79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.

WEBSITE: www.mshausa.org ESTABLISHED: Chartered in 1976; early meetings of speech and hearing professionals reported as early as the late 1950s. MEMBERS: Approximately 300-400 CONTACT: Maureen K. Martin, president, maureen.martin@usm.edu Q [...]

In her piece about New York City ["You Got a Problem With That?"], Joan Acocella presumes that eagerness to dispense unsolicited opinions is a manifestation of smartness. To the contrary, […]

Operative cases where there is a potential for massive blood loss necessitates a system to rapidly warm and transfuse large volumes of blood over short periods of time. An in-house system in which both crystalloid solutions and blood products can be quickly added, warmed and available for infusion was developed to meet this need. The purpose of this study was to evaluate how blood products are affected when warmed and recirculated for an extended period of time. A recirculating rapid infusion system was assembled utilizing two filtered cardiotomy reservoirs, a centrifugal pump, a stainless steel blood heat exchanger, and 1/4 inch tubing, and applied in six adult orthotopic liver transplantations. The system was primed with 2 to 4 units each of fresh frozen plasma and packed red blood cells. The prime was recirculated and warmed to 37°C. Samples for blood gases, oxygen saturation, hematocrit, plasma free hemoglobin, sodium and potassium levels were drawn after initial priming and then every 30 minutes until additional blood products were added. Results show no significant change in pH (6.57 ± 0.21), pO2(56 mmHg ± 23 mmHg), pCO2(173 mmHg ± 138 mmHg), hematocrit (27% ± 8.7%) and plasma free hemoglobin values (125 mg/dl ± 9.4 mg/dl), following 3 hours of recirculation. However, potassium levels significantly decreased from 11.6 meq/L ± 2.6 meq/L to 10.0 meq/L ± 2.3 meq/L (p<0.05), sodium levels significantly increased from 144 meq/L ± 5.9 meq/L to 147 meq/L ± 5.3 meq/L (p<0.05) and oxygen saturations significantly increased from 59%± 9.1% to 70% ± 16% (p<0.05). The results demonstrate that this system can maintain banked blood warm and available for immediate infusion without significant deterioration for up to 3 hours.

Initiation of antiretroviral therapy (ART) in infected neonates within hours after birth limits viral reservoir seeding but does not prevent long-term HIV-1 persistence. Here, we report parallel assessments of HIV-1 reservoir cells and innate antiviral immune responses in a unique cohort of 37 infected neonates from Botswana who started ART extremely early, frequently within hours after birth. Decline of genome-intact HIV-1 proviruses occurs rapidly after initiation of ART and is associated with an increase in natural killer (NK) cell populations expressing the cytotoxicity marker CD57 and with a decrease in NK cell subsets expressing the inhibitory marker NKG2A. Immune perturbations in innate lymphoid cells, myeloid dendritic cells, and monocytes detected at birth normalize after rapid institution of antiretroviral therapy but do not notably influence HIV-1 reservoir cell dynamics. These results suggest that HIV-1 reservoir cell seeding and evolution in early-treated neonates is markedly influenced by antiviral NK cell immune responses.

Laparoscopic appendectomy (LA) has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy (OA). LA in patients with a gangrenous or perforated appendicitis carries increased rate of pelvic abscess formation when compared with OA. We hypothesized routine placement of pelvic drains in gangrenous or perforated appendicitis decreases pelvic abscess formation after LA. Three hundred thirty-one patients undergoing LA between January 2007 and June 2011 were reviewed. Patients with perforated or gangrenous appendicitis were included. Group I had a Jackson-Pratt (JP) drain(s) placed and Group II had no JP drain. Data included patient demographics, emergency department laboratory values and vital signs, and computed axial tomography scan findings, intra-abdominal or pelvic abscess postoperatively, interventional radiology drainage, and length of stay. Clinic follow-up notes were reviewed. One hundred forty-eight patients were identified. Forty-three patients had placement of JP drains (Group I) and 105 patients had no JP drain (Group II). Three patients (three of 43 [6%]) in Group I developed pelvic abscess and 21 of 105 (20%) patients in Group II developed pelvic abscesses requiring subsequent drainage. This was statistically significant. Patient demographics, temperature, and mean white blood count before surgery were similar. Presurgery computed tomography (CT) with appendicolith and CT with abscess were more prevalent in Group I. The use of JP drainage in patients with perforated or gangrenous appendicitis during LA has decreased rates of pelvic abscess. This was demonstrated despite the drain group having appendicolith or abscess on preoperative CT.

Emergency department thoracotomy (EDT) is a dramatic lifesaving procedure demanding timely surgical intervention, technical expertise, and coordinated resuscitation efforts. Inappropriate use is costly and futile. All patients admitted to a Level II trauma center who underwent EDT from January 2003 to July 2012 were studied. The primary end point was appropriateness of EDT. Secondary end points were staff exposure, survival, and return to normal function. Eighty-seven patients including 59 patients with penetrating wounds had a mean loss of vital signs (LOV) 11.6 610.6 minutes and Injury Severity Score (ISS) of 45.8 ± 16.1, whereas 28 blunt injury patients had a mean LOVof 10.4 ± 11.5 minutes and ISS of 50.4 ± 19.4. Mortality was 81 per cent (48 of 59) in penetrating injury and 93 per cent (26 of 28) in blunt injury patients, respectively (odds ratio [OR] 2.99; P 0.21). Fifty-five EDTs were indicated with 10 survivors (18.2%) and 32 not indicated with three survivors (9.4%). Surgeons adhered to guidelines more compared with ED physicians (OR, 4.9; P= 0.03) whose patients were more likely to die (OR, 3.52; P= 0.124). Survivors (11 of 13 [84.6%]) were discharged home without significant long-term neurologic disability. EDT is lifesaving when performed for penetrating injury by experienced surgeons following established guidelines but futile in blunt injury or when performed by nonsurgeons regardless of mechanism.

Methicillin-resistant Staphylococcus aureus(MRSA) is an increasingly common cause of postoperative surgical site infections (SSIs). It is unclear, however, whether asymptomatic colonization or nosocomial acquisition of MRSA results in postoperative SSI. We conducted a retrospective review of patients screened for MRSA between May 2008 and October 2010 at our institution. End points included rates of MRSA infection, SSI, and the cost of routine MRSA screening of patients undergoing elective surgery. Of the 1039 patients screened preoperatively, 48 (4.6%) tested positive for MRSA by nasal or oral swab, whereas 991 (95.4%) tested negative. Forty-five (93.8%) MRSA-positive patients received vancomycin or linezolid and three (6.25%) received cefazolin peri-operatively. Three (6.25%) MRSA-positive patients developed postoperative SSIs. Two required rehospitalization for intravenous antimicrobials, whereas a third patient required removal of infected abdominal mesh. Twenty (2.02%) MRSA-negative patients and four (5.26%) unscreened patients developed non-MRSA SSIs. Regardless of MRSA status, none of 609 patients who had a laparoscopic procedure or inguinal hernia repair developed SSI. Twenty-two patients needed to be screened to obtain one positive test. The role of MRSA screening and longer perioperative coverage for MRSA-positive patients undergoing complex elective procedures remains to be determined.

The consistency of peripheral gene expression data and the overlap with brain expression has not been evaluated in biomarker discovery, nor has it been reported in multiple tissues from the same subjects on a genome wide transcript level. The effects of processing whole blood, transformation, and passaged cell lines on gene expression profiling was studied in healthy subjects using Affymetrix arrays. Ficoll extracted peripheral blood mononuclear cells PBMCs, Epstein–Barr virus EBV transformed lymphocytes, passaged lymphoblastic cell lines LCLs, and whole blood from Tempus tubes were compared. There were 6,813 transcripts differentially expressed between different methods of blood preparation. Principal component analysis resolved two partitions involving pre and posttransformation EBV effects. Combining results from Affymetrix arrays, postmortem subjects brain and PBMC profiles showed coexpression levels of summarized transcripts for 4,103 of 17,859 22.9 RefSeq transcripts. In a control experiment, rat hemibrain and blood showed similar expression levels for 19 of RefSeq transcripts. After filtering transcripts that were not significantly different in abundance between human cerebellum and PBMCs from the Affymetrix exon array the correlation in mean transcript abundance was high as expected r  0.98. Differences in the alternative splicing index in brain and blood were found for about 90 of all transcripts examined. This study demonstrates over 4,100 brain transcripts coexpressed in blood samples can be further examined by in vitro and in vivo experimental studies of blood and cell lines from patients with psychiatric disorders. © 2010 WileyLiss, Inc.

Blood transfusions cause altered immunity and the duration of storage is contributory. In the era of massive transfusion protocols (MTPs) this impact is unclear, particularly as it relates to balanced transfusions. Trauma patients requiring our MTP after admission to our Level II trauma center were studied. The average age of blood transfused was calculated; old blood was a storage time of =14 days versusnew blood <14 days. Blood to plasma ratios of 1:1 were compared with ratios >1:1. Infections, organ dysfunction multiorgan injury (MOD, and death were compared based on ratios and blood storage times. Of 2200 trauma admissions, 89 patients required MTP. Penetrating injuries were the majority, n = 53; and Injury Severity Score was 33 ± 14. Overall mortality was 31 per cent and sepsis was 28 per cent. Outcomes (storage time): Patients receiving old versusnew blood had comparable age and Injury Severity Score. Sepsis rates, multiorgan injury and mortality were similar. Outcomes (packed red blood cells:fresh frozen plasma): Balanced transfusions (ratios of 1:1) demonstrated significant survival benefit and less infections compared with ratios >1:1. These data underscore the complexity of transfusion-related morbidity. In the modern era of MTP and balanced transfusions, the age of stored blood may not impact outcomes as demonstrated historically.

The understanding of complex heritable psychiatric disorders such as schizophrenia could be clarified by examining endophenotypes within genetically isolated populations, such as the one found in the Central Valley of Costa Rica. The reduction of familial variability within a sample could allow the relationship between the cognitive and symptomatic manifestations of the illness and the genetic underpinnings to become more observable. This study investigates the neuropsychological test performances of 41 family members from four extended multiplex families within the Spanish origin population of the Central Valley of Costa Rica as potential endophenotypes for genetic studies.

Description

Killer immunoglobulin-like receptors (KIR) bind self–major histocompatibility complex class I molecules, allowing natural killer (NK) cells to recognize aberrant cells that have down-regulated class I. NK cells express variable numbers and combinations of highly homologous clonally restricted KIR genes, but uniformly express KIR2DL4. We show that NK clones express both 2DL4 alleles and either one or both alleles of the clonally restricted KIR 3DL1 and 3DL2 genes. Despite allele-independent expression, 3DL1 alleles differed in the core promoter by only one or two nucleotides. Allele-specific 3DL1 gene expression correlated with promoter and 5′ gene DNA hypomethylation in NK cells in vitro and in vivo. The DNA methylase inhibitor, 5-aza-2′-deoxycytidine, induced KIR DNA hypomethylation and heterogeneous expression of multiple KIR genes. Thus, NK cells use DNA methylation to maintain clonally restricted expression of highly homologous KIR genes and alleles.

IN AN 1835 ARTICLE PUBLISHED in the Rugby Magazine under the title “School a Little World,” A. P. Stanley wrote:

This study was conducted to evaluate follow-up results in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent either percutaneous transluminal septal myocardial ablation (PTSMA) or septal myectomy.

The discovery of dendritic cell (DC)-specific intercellular adhesion molecule (ICAM)-3–grabbing nonintegrin (DC-SIGN) as a DC-specific ICAM-3 binding receptor that enhances HIV-1 infection of T cells in trans has indicated a potentially important role for adhesion molecules in AIDS pathogenesis. A related molecule called DC-SIGNR exhibits 77% amino acid sequence identity with DC-SIGN. The DC-SIGN and DC-SIGNR genes map within a 30-kb region on chromosome 19p13.2-3. Their strong homology and close physical location indicate a recent duplication of the original gene. Messenger RNA and protein expression patterns demonstrate that the DC-SIGN–related molecule is highly expressed on liver sinusoidal cells and in the lymph node but not on DCs, in contrast to DC-SIGN. Therefore, we suggest that a more appropriate name for the DC-SIGN–related molecule is L-SIGN, liver/lymph node–specific ICAM-3–grabbing nonintegrin. We show that in the liver, L-SIGN is expressed by sinusoidal endothelial cells. Functional studies indicate that L-SIGN behaves similarly to DC-SIGN in that it has a high affinity for ICAM-3, captures HIV-1 through gp120 binding, and enhances HIV-1 infection of T cells in trans. We propose that L-SIGN may play an important role in the interaction between liver sinusoidal endothelium and trafficking lymphocytes, as well as function in the pathogenesis of HIV-1.

ABSTRACTThis randomized, double-blind, multicenter trial compared the efficacy and safety of linezolid, an oxazolidinone, with those of oxacillin-dicloxacillin in patients with complicated skin and soft tissue infections. A total of 826 hospitalized adult patients were randomized to receive linezolid (600 mg intravenously [i.v.]) every 12 h or oxacillin (2 g i.v.) every 6 h; following sufficient clinical improvement, patients were switched to the respective oral agents (linezolid [600 mg orally] every 12 h or dicloxacillin [500 mg orally] every 6 hours). Primary efficacy variables were clinical cure rates in both the intent-to-treat (ITT) population and clinically evaluable (CE) patients and microbiological success rate in microbiologically evaluable (ME) patients. Safety and tolerability were evaluated in the ITT population. Demographics and baseline characteristics were similar across treatment groups in the 819 ITT patients. In the ITT population, the clinical cure rates were 69.8 and 64.9% in the linezolid and oxacillin-dicloxacillin groups, respectively (P= 0.141; 95% confidence interval −1.58 to 11.25). In 298 CE linezolid-treated patients, the clinical cure rate was 88.6%, compared with a cure rate of 85.8% in 302 CE patients who received oxacillin-dicloxacillin. In 143 ME linezolid-treated patients, the microbiological success rate was 88.1%, compared with a success rate of 86.1% in 151 ME patients who received oxacillin-dicloxacillin. Both agents were well tolerated; most adverse events were of mild-to-moderate intensity. No serious drug-related adverse events were reported in the linezolid group. These data support the use of linezolid for the treatment of adults with complicated skin and soft tissue infections.

To compare the efficacy and safety of clindamycin vaginal ovules with oral metronidazole for treatment of bacterial vaginosis.

The creation of a specialized hepatobiliary surgery unit at our medical center has resulted in referral of 16 patients with bile duct complications following laparoscopic cholecystectomy over the last 18 months. No patient required conversion to open cholecystectomy. Although no injury was recognized at the time of surgery, 15 of 16 patients became symptomatic within the first 30 days. Two patients died from sepsis and multisystem organ failure after protracted hospital courses. Endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic cholangiography determined diagnosis and level of injury. Six of seven patients with cystic duct leak underwent successful endoscopic stent placement and one patient sealed spontaneously after percutaneous drainage of a large biloma. Nine patients required surgery that included hepaticojejunostomy (five), T-tube insertion and drainage of abscess (two), or segmental hepatic resection (two). Timely recognition of bile duct complications following laparoscopic cholecystectomy is critical to a successful long-term outcome. Although the majority of cystic duct leaks can be managed with endoscopic stenting, patients with ductal injuries require hepaticojejunostomy. Segmental liver resection may serve an important role in the management of carefully selected patients with high intrahepatic injuries to avoid long-term transhepatic stenting and complications such as episodic cholangitis and late stricture formation.

Abstract:  The human genome contains a large number of interspersed microsatellite repeats which exhibit a high degree of polymorphism and are inherited in a Mendelian fashion, making them extremely useful genetic markers. Several microsatellites have been described in the HLA region, but allele nomenclature, a set of broadly distributed controls, and typing methods have not been standardized, which has resulted in discrepant microsatellite data between laboratories. In this report we present a detailed protocol for genotyping microsatellites using a semi-automated fluorescence-based method. Twelve microsatellites within or near the major histocompatibility complex (MHC) were typed in the 10th International Histocompatibility Workshop homozygous typing cell lines (HTCs) and alleles were designated based on size. All loci were sequenced in two HTCs providing some information on the level of complexity of the repeat sequence. A comparison of allele size obtained by genotyping versus that obtained by direct sequencing showed minor discrepancies in some cases, but these were not unexpected given the technical differences in the methodologies. Fluorescence-based typing of microsatellites in the MHC described herein is highly efficient, accurate, and reproducible, and will allow comparison of results between laboratories.

The objective of this randomized, double-blind, controlled multicentre study was to evaluate the efficacy of saquinavir alone or in combination with zalcitabine compared to zalcitabine monotherapy in reducing progression of human immunodeficiency virus (HIV) disease. Nine hundred and forty HIV-infected patients with more than 16 weeks of prior zidovudine therapy and pre-study entry CD4 cell counts between 50 and 300 cells/mm3were randomized to saquinavir 600 mg every 8 h, zalcitabine 0.75 mg every 8 h or the combination of both drugs. In an intent-to-treat analysis, the treatment arms were balanced with respect to demographics, baseline HIV RNA (mean 5.0 log10copies/ml) and CD4 lymphocyte count (mean 170 cells/mm3). More patients in the zalcitabine arm stopped therapy because of toxicity than in the other two arms (25% versus 16%; P=0.005). Peripheral neuropathy was the most common treatment-limiting toxicity. Fifty-one patients in the saquinavir plus zalcitabine group developed an AIDS-defining event or died compared to 84 and 88 in the saquinavir and zalcitabine monotherapy groups respectively. Combination treatment with saquinavir plus zalcitabine reduced the risk of progression to AIDS by 49% (95% confidence interval 0.36 to 0.72, P=0.0001) and reduced death by 68% (95% confidence interval 0.16 to 0.64, P=0.001) compared to zalcitabine monotherapy. The addition of saquinavir to zalcitabine resulted in a significant reduction in progression to AIDS or death compared with zalcitabine alone.

Between May 1, 1993 and April 5, 1995, 154 pancreas allograft recipients at 9 institutions were given FK506 posttransplant. Three groups were studied: (1) recipients given FK506 initially for induction and maintenance therapy (n=82), (2) recipients switched to FK506 for antirejection or rescue therapy (n=61), and (3) recipients converted to FK506 for other reasons (n=11). Of 82 patients in the induction group, 7 (9%) had simultaneous bone marrow (BM) and pancreas-kidney(SPK-BM) transplants, 54 (66%) had SPK transplants without BM, 14 (17%) had pancreas transplants alone (PTA), and 7 (9%) had pancreas after previous kidney transplants (PAK). All but 1 recipient was given quadruple immunosuppression (anti-T cell agents plus azathioprine and prednisone) for induction. The median FK506 starting dose was 4 mg/day p.o.; the median average FK506 blood level, 12 ng/ml. The most common side effects were neurotoxicity (16%), nephrotoxicity (13%), and gastrointestinal toxicity (9%). New-onset diabetes mellitus requiring permanent insulin therapy did not occur. Of 61 transplants in the rescue group, 44 (72%) were SPK, 11 (18%) PTA, and 6(10%) PAK. All but 3 (95%) of the recipients had been on cyclosporine-azathioprine-prednisone triple immunosuppression before substitution of FK506 for cyclosporine; 46% of the recipients had one, and 54%≥2, rejection episodes preconversion. The most common side effects were nephrotoxicity (25%), neurotoxicity (23%), and gastrointestinal toxicity(21%). Two recipients were reconverted to cyclosporine because of transient hyperglycemia, and one recipient is on insulin. In the induction group, patient survival at 6 months was 90% for SPK, 100% for PTA, and 100% for PAK. According to a matched-pair analysis, pancreas graft survival for SPK recipients at 6 months was 87% for FK506 versus 70% for cyclosporine recipients (P=0.04); for PTA recipients, 84% versus 66%(P=n.s.); and for PAK recipients, 80% versus 14%(P=0.11). When technical failures and death with functioning grafts were censored, pancreas graft survival remained significantly better in the FK506 group. The incidence of first reversible rejection episodes by 6 months in FK506 recipients was 35% for SPK, 40% for PTA, and 20% for PAK. Of 75 pancreas grafts, 64 are currently functioning; in 5 recipients the pancreas failed (1 from rejection); 6 recipients died with a functioning pancreas graft. There were 3 posttransplant lymphomas (all EBV-positive); 2 recipients died and 1 is alive after subtotal colectomy and transplant pancreatectomy. In the antirejection rescue group, patient survival rates at 6 months were 91% for SPK, 100% for PTA, and 80% for PAK(P=n.s.). Pancreas graft survival rates at 6 months were 90% for SPK, 72% for PTA, and 40% for PAK. The incidence of first reversible rejection episodes after conversion to FK506 at 6 months was 44% in SPK, 54% in PTA, and 50% in PAK. Of 61 pancreas grafts, 51 are currently functioning; in 7 recipients the pancreas failed (5 from rejection); 3 recipients died with a functioning graft. There were no posttransplant lymphomas in the rescue group. This multicenter survey shows that FK506 in pancreas transplantation is associated with (1) a low rate of graft loss from rejection when used for induction therapy, (2) a high rate of graft salvage when used for rescue or rejection therapy, and(3) a very low rate of new-onset insulin-dependent diabetes mellitus. These encouraging results are tarnished by 3 posttransplant lymphomas in the induction group; a possible explanation is overimmunosuppression, but further (randomized) studies are necessary to analyze the long-term risk-benefit ratio of FK506 after pancreas transplantation.

We present our experience with 10 liver transplant recipients in whom cryptococcal meningitis developed after liver transplantation. Disease developed a median period of 3.5 months (range, 2-36 months) after transplantation and patients were diagnosed a median period of 9 days (range, 2-90 days) after initial symptoms. Headache, fever, and mental status changes were the most frequent clinical presentations, while meningismus was found in only 30% of patients. Cerebrospinal fluid analysis was diagnostic in all cases. All patients were treated with amphotericin B and flucytosine. Immunosuppression was either decreased or discontinued during therapy. Five patients died, four as a direct result of cryptococcal infection and one as a result of chronic rejection. Three patients had long-term survival without any sequelae. One long-term survivor suffered blindness consequent to the disease. We conclude that cryptococcal meningitis is a rare complication in liver transplant recipients (0.25%), and has a high mortality rate (50%). Early recognition, combination antifungal therapy, and decrease or discontinuation of immunosuppression are important for cure. No relapse has been seen in surviving patients.

Six months of abstinence from alcohol is a commonly used criterion for liver transplantation eligibility for patients with alcoholic cirrhosis. There is limited evidence to document the validity of this criterion with regard to risk of alcoholism relapse. Ninety‐one patients with alcoholic cirrhosis were interviewed for relapse risk using the High Risk Alcoholism Relapse (HRAR) Scale. The HRAR model can be used to predict relapse risk independent of duration of sobriety and therefore can be used to examine the validity of the 6 months of abstinence criteria in this clinical population. The two methods demonstrated poor to fair agreement. Agreement was highest with a cutoff allowing a 5% 6‐month relapse risk when 79% agreement (k= 0.56) was demonstrated between the two methods. Using the 6‐month abstinence criterion alone disallows a significant number of candidates who have a low relapse risk based on their HRAR score. The validity of the 6‐month abstinence criterion is supported somewhat by comparison with the HRAR model. However, use of the 6‐month abstinence criterion alone forces a significant number of patients with a low relapse risk by HRAR to wait for transplant listing. A relapse risk model based on an estimate of alcoholism severity in addition to duration of sobriety may more accurately select patients who are most likely to benefit from liver transplantation.

With the tremendous growth of solid organ transplantation over the past 30 years, a great deal has been learned about the significance of cytomegalovirus. Much knowledge regarding the epidemiology, pathogenesis, and diagnosis of cytomegalovirus infection has come from experience with renal transplants, which account for the largest number of solid organ transplantation procedures performed. Cytomegalovirus disease is clearly one of the most important infectious causes of morbidity and mortality in this population. The devastating effects of established cytomegalovirus disease have been ameliorated by effective antiviral treatment with ganciclovir therapy. The continued high incidence of cytomegalovirus infection, combined with the cost of treating cytomegalovirus disease, both in terms of patient well-being and financial issues, has stimulated great interest in the development of effective prophylactic and preemptive regimens. Philosophy regarding the best means of prevention varies. Prophylactic strategies provide therapy for all patients who are designated to be at risk for cytomegalovirus disease. These patients are usually stratified according to cytomegalovirus serologic status. Preemptive strategies provide preventative therapy selectively. Preemptive therapy is administered only when there is evidence for asymptomatic infection by established surveillance criteria (ie, positive cytomegalovirus cultures, positive antigenemia assays, or recent seroconversion). Unfortunately, the terms prophylaxis and preemptive are used loosely, which can lead to confusion when reviewing the literature. This overview focuses on pertinent issues regarding cytomegalovirus in renal transplantation and the various strategies for prophylaxis and preemptive therapy. The approach to cytomegalovirus prophylaxis among renal transplant centers varies widely. Often a specific approach within a given center is inconsistent, poorly documented, and based on anecdotal experience. Although the literature is replete with studies using single-agent or combination therapy, they are usually single-center studies of a relatively small number of patients. Large randomized prospective studies are unfortunately few in number. Hopefully, after reviewing the available data, it will be possible to propose an ideal strategy that is both cost-effective and maximally therapeutic.

Study Objective. To characterize a time‐dependent disposition of oral tacrolimus and its relationship with plasma endothelin‐1 concentrations.

Previous findings in liver transplantation patients have raised the concept that HLA plays a dualistic role. HLA matching will reduce rejection but may augment MHC restricted cellular immune mechanisms of liver allograft injury. To evaluate this concept, we studied CMV hepatitis in 399 FK506-treated liver transplant patients, including 355 cases for which complete HLA-A,B,DR,DQ typing information was available. CMV hepatitis developed in 25 patients, and 17 of them (or 68) showed a one or two HLA-DR antigen match with the donor. In contrast, HLA-DR matches were found in only 35 of 330 patients without CMV hepatitis (P=0.005). No significant associations were seen for HLA-A, HLA-B, and HLA-DQ antigens. In pretransplant CMV-seronegative patients with seropositive grafts (n=39), the frequency of CMV hepatitis was 44 for HLA-DR-matched livers but 14 for HLA-DR-un-matched livers. In seropositive recipients (n=187), these frequencies were 12 and 2 for HLA-DR-matched and unmatched liver grafts. Chronic rejection developed in 29 patients (or 8) during a follow-up between 10 and 24 months after transplantation. Its incidence was higher in the CMV hepatitis group (24 vs. 6) (P=0.007). Although no associations were found between HLA matching and the incidence of chronic rejection, there was an earlier onset of chronic rejection of HLA-DR-matched livers irrespective of CMV hepatitis.

Background: Spontaneous hepatic rupture associated with preeclampsia is a rare but life-threatening situation. Several different surgical treatments have been described, depending on the severity of the rupture. Liver transplantation has become the mainstay for patients with end-stage liver disease. Transplantation in the setting of liver trauma or massive parenchymal disruption is not well defined. To our knowledge, this treatment has not been reported for spontaneous hepatic rupture in pregnancy.

At this transplant center 1340 patients were entered on the liver transplant waiting list during the first 25 months (October 1987 to November 1989) after the initiation of the UNOS allocation system for liver grafts. Of these 972 (72.5) of the patients received a graft, 120 (9.0) died waiting for a graft, 109 (8.1) remained on the active list as of the study endpoint of December 15, 1989, 123 (9.2) were withdrawn from candidacy, and 16 (1.2) received a transplant at another center. A total of 1201 patients were candidates for a first graft. Of the 812 primary candidates who received a graft, 64.8 received their graft within one month of entry on the waiting list. Of the 109 primary candidates who died before a graft could be found, 79.0 died within a month of entry onto the waiting list. At time of transplantation, 135 (16.6) primary recipients of a graft were UNOS class 1, 326 (40.1) were UNOS class 2, 190 (23.4) were UNOS class 3, and 161 (19.8) were UNOS class 4. Actuarial survival rates (percentage) at 6 months for recipients in UNOS class 1, class 2, class 3, and class 4 were 88.7±2.9, 82.6±2.1, 78.4±3.2, and 68.4±3.9, respectively (P<0.001). At the time of death of recipients who failed to get a graft, 6 (5.5) were UNOS class 1, 14 (12.8) were UNOS class 2, 23 (21.1) were UNOS class 3, and 66 (60.6) were UNOS class 4.

The adult respiratory distress syndrome (ARDS) complicating liver failure carries a 100 mortality. Two cases of ARDS that resolved following liver transplantation have been reported, one associated with acute allograft rejection, and the second due to sepsis. There is, however, a great reluctance to transplant these very-high-risk patients. We report the first series of patients with ARDS secondary to liver failure who successfully underwent OLTX. No patient had sepsis or pneumonia. Posttransplant mechanical ventilation was required for a median of 14 days (range 6–37 days). All patients in this series are alive and well, with a follow-up of 6–15 months. This demonstrates that ARDS associated with liver failure, an otherwise uniformly lethal complication, can respond dramatically to OLTX.

Cytomegalovirus disease is an important cause of morbidity following liver transplantation. To date there has not been an effective prophylaxis for CMV disease after liver transplantation. One hundred forty-three patients were randomized to receive either high dose oral acyclovir (800 mg 4 times a day) alone for 3 months after transplantation (acyclovir group) or intravenous ganciclovir (5 mg/kg twice a day) for 14 days followed by high dose oral acyclovir to complete a 3-month regimen (ganciclovir group). Of 139 patients available for evaluation, 43 of 71 (61) patients from the acyclovir group developed CMV infection compared with 16 of 68 (24) from the ganciclovir group (relative risk, 3.69; 95 confidence interval, 2.07–6.56; P<0.00001). Of those randomized, CMV disease was seen in 20 (28) of the acyclovir group compared with 6 (9) of the ganciclovir group (relative risk, 5.11; 95 confidence interval, 2.05–12.75; P=0.0001). The median time to onset of CMV infection was 45 days in the acyclovir group compared with 78 days in the ganciclovir group (P=0.004). The median time to onset of CMV disease was 40 days in the acyclovir group compared with 78 days in the ganciclovir patients (P=0.02). With respect to primary CMV infection, there was no difference in the rates in the 2 groups, but tissue invasive disease and recurrent CMV disease were less frequent in the ganciclovir group. It is concluded that a course of 2 weeks of ganciclovir immediately after transplantation followed by high dose oral acyclovir for 10 weeks is superior to a 12-week course of high dose oral acyclovir alone for prevention of both CMV infection and CMV disease after liver transplantation. However, the lack of significant effect in sero-negative recipients who received grafts from sero-positive donors suggests that other strategies are needed to prevent CMV infection in this high risk population.

High-risk behaviors leading to traffic fatalities are often a result of severe traumatic brain and spine injuries. The objective of the study was to analyze patterns of behavior in drivers and motorcyclists that are associated with central nervous system (CNS)-related prehospital deaths that may serve as a basis for future prevention initiatives. Our study group comprised 514 fatalities with severe CNS injuries documented at autopsy. The majority (n = 491) was the result of motor vehicle collisions (MVCs). In this group, male drivers predominated and the majority, 80 per cent, wore seatbelts. Toxicology analysis revealed 53 per cent of drivers with a mean concentration of ethanol above the legal limit. Texting while driving comprised 45 per cent of the study group. Less than 5 per cent of the fatalities were the result of road or weather conditions. In the motorcycle group (n = 23), 100 per cent of the victims were unhelmeted. We report a large autopsy series of CNS-related deaths with analysis of behavioral factors associated with the fatalities. Substance abuse and distracted driving are dominant patterns of high-risk behavior in MVCs and not wearing a motorcycle helmet is deadly for victims of motorcycle crashes.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

This article presents several letters to the editor in response to articles from the 2008 April and May issues, including "You Got a Problem With That?" by Joan Acocella and "The Unmaking of the President," by Clay Risen.

Presents a letter to the editor about the earnings of general practitioners.