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Using the short-high module of the Infrared Spectrograph on the Spitzer Space Telescope, we have measured the [S IV] 10.51, [Ne II] 12.81, [Ne III] 15.56, and [S III] 18.71-micron emission lines in nine H II regions in the dwarf irregular galaxy NGC 6822. These lines arise from the dominant ionization states of the elements neon (Ne$^{++}$, Ne$^+$) and sulphur (S$^{3+}$, S$^{++}$), thereby allowing an analysis of the neon to sulphur abundance ratio as well as the ionic abundance ratios Ne$^+$/Ne$^{++}$ and S$^{3+}$/S$^{++}$. By extending our studies of H II regions in M83 and M33 to the lower metallicity NGC 6822, we increase the reliability of the estimated Ne/S ratio. We find that the Ne/S ratio appears to be fairly universal, with not much variation about the ratio found for NGC 6822: the median (average) Ne/S ratio equals 11.6 (12.2$\pm$0.8). This value is in contrast to Asplund et al.'s currently best estimated value for the Sun: Ne/S = 6.5. In addition, we continue to test the predicted ionizing spectral energy distributions (SEDs) from various stellar atmosphere models by comparing model nebulae computed with these SEDs as inputs to our observational data, changing just the stellar atmosphere model abundances. Here we employ a new grid of SEDs computed with different metallicities: Solar, 0.4 Solar, and 0.1 Solar. As expected, these changes to the SED show similar trends to those seen upon changing just the nebular gas metallicities in our plasma simulations: lower metallicity results in higher ionization. This trend agrees with the observations., 22 pages, 13 figures. To be published in MNRAS. reference added and typos fixed. arXiv admin note: text overlap with arXiv:0804.0828, which is paper II by Rubin et al. (2008)

We report spectrophotometric observations made with SOFIA/FORCAST on 2011 June 2 UT. Optical measurements have previously shown that the abundance discrepancy factor (adf) varies with position in several high-adf PNe, and is highest close to the central star. The very low electron temperature inclusions postulated to explain the abundance discrepancy, must be cooled predominantly by fine structure IR lines. These SOFIA data will map mid-IR FS lines (and our related Herschel program will add several far-IR FS lines) in the bright, well-characterized, high-adf PN NGC 7009. We will compare these IR results with FS optical line measurements in order to correlate ratios of IR to optical fluxes with position, and thus correlate with where the adf peaks.

We present Spitzer Space Telescope observations of 11 regions SE of the Bright Bar in the Orion Nebula, along a radial from the exciting star theta1OriC, extending from 2.6 to 12.1'. Our Cycle 5 programme obtained deep spectra with matching IRS short-high (SH) and long-high (LH) aperture grid patterns. Most previous IR missions observed only the inner few arcmin. Orion is the benchmark for studies of the ISM particularly for elemental abundances. Spitzer observations provide a unique perspective on the Ne and S abundances by virtue of observing the dominant ionization states of Ne (Ne+, Ne++) and S (S++, S3+) in Orion and H II regions in general. The Ne/H abundance ratio is especially well determined, with a value of (1.01+/-0.08)E-4. We obtained corresponding new ground-based spectra at CTIO. These optical data are used to estimate the electron temperature, electron density, optical extinction, and the S+/S++ ratio at each of our Spitzer positions. That permits an adjustment for the total gas-phase S abundance because no S+ line is observed by Spitzer. The gas-phase S/H abundance ratio is (7.68+/-0.30)E-6. The Ne/S abundance ratio may be determined even when the weaker hydrogen line, H(7-6) here, is not measured. The mean value, adjusted for the optical S+/S++ ratio, is Ne/S = 13.0+/-0.6. We derive the electron density versus distance from theta1OriC for [S III] and [S II]. Both distributions are for the most part decreasing with increasing distance. A dramatic find is the presence of high-ionization Ne++ all the way to the outer optical boundary ~12' from theta1OriC. This IR result is robust, whereas the optical evidence from observations of high-ionization species (e.g. O++) at the outer optical boundary suffers uncertainty because of scattering of emission from the much brighter inner Huygens Region.

Rationale and Objectives The role of transthoracic needle biopsy (TTNB) in patients with hematologic malignancies, particularly in discriminating between malignant and benign etiologies, has not been well studied. Hence, the diagnostic efficacy and safety of computed tomography–guided TTNB were retrospectively evaluated in this population. Materials and Methods The records of 53 patients with hematologic malignancies who underwent TTNB from August 1, 1999, to July 31, 2007, were reviewed. Potential factors for increased diagnostic yield and risk for complications were collected and analyzed, including the status of neutropenia, thrombocytopenia, chemotherapy, and transplant as well as lesion size and location. Both cytopathologic and microbiologic results were assessed. Results The most common underlying hematologic malignancy was non-Hodgkin lymphoma, in 20 patients (37.7%). Lesions were most frequently located in the left upper lobe (16 [30.2%]); 33 lesions were pleural based (63.5%), and nine had cavitation (17.0%). TTNB established specific diagnoses in 22 patients (41.5%): malignancies was found in 12 (22.6%) and infections in 10 (18.9%). Sensitivity for detecting malignancy was 50.0%, and sensitivity for the detection of a specific infection was 40.0%. There were no false-positive results. Complications occurred in nine patients (17.0%): self-limited small-volume hemoptysis in one patient (1.9%) and pneumothorax in eight patients (15.1%), one requiring chest tube placement. The results of TTNB led to changes in antimicrobial therapy for eight of the 22 patients with specific diagnoses (36.4%). Conclusions TTNB is a safe diagnostic procedure in patients with hematologic malignancies and has the potential of making specific diagnoses with minimal morbidity.

We have observed emission lines of [S iv] 10.51, H(7–6) 12.37, [Ne ii] 12.81, [Ne iii] 15.56 and [S iii] 18.71 μm in a number of extragalactic H ii regions with the Spitzer Space Telescope. A previous paper presented our data and analysis for the substantially face-on spiral galaxy M83. Here we report our results for the Local Group spiral galaxy M33. The nebulae selected cover a wide range of galactocentric radii (RG). The observations were made with the Infrared Spectrograph with the short wavelength, high-resolution module. The above set of five lines is observed cospatially, thus permitting a reliable comparison of the fluxes. From the measured fluxes, we determine the ionic abundance ratios including Ne++/Ne+, S3+/S++, and S++/Ne+ and find that there is a correlation of increasingly higher ionization with larger RG. By sampling the dominant ionization states of Ne (Ne+, Ne++) and S (S++, S3+) for H ii regions, we can estimate the Ne/H, S/H and Ne/S ratios. We find from linear least-squares fits that there is a decrease in metallicity with increasing RG: d log (Ne/H)/dRG=−0.058 ± 0.014 and d log (S/H)/dRG=−0.052 ± 0.021 dex kpc−1. There is no apparent variation in the Ne/S ratio with RG. Unlike our previous similar study of M83, where we conjectured that this ratio was an upper limit, for M33 the derived ratios are likely a robust indication of Ne/S. This occurs because the H ii regions have lower metallicity and higher ionization than those in M83. Both Ne and S are primary elements produced in α-chain reactions, following C and O burning in stars, making their yields depend very little on the stellar metallicity. Thus, it is expected that the Ne/S ratio remains relatively constant throughout a galaxy. The median (average) Ne/S ratio derived for H ii regions in M33 is 16.3 (16.9), just slightly higher than the Orion Nebula value of 14.3. The same methodology is applied to Spitzer observations recently published for three massive H ii regions: NGC 3603 (Milky Way), 30 Dor (LMC) and N 66 (SMC) as well as for a group of blue compact dwarf galaxies. We find median Ne/S values of 14.6, 11.4, 10.1, and 14.0, respectively. All of these values are in sharp contrast with the much lower ‘canonical’, but controversial, solar value of ∼5. A recent nucleosynthesis, galactic chemical evolution model predicts an Ne/S abundance of ∼9. Our observations may also be used to test the predicted ionizing spectral energy distribution of various stellar atmosphere models. We compare the ratio of fractional ionizations 〈Ne++〉/〈S++〉, 〈Ne++〉/〈S3+〉, and 〈Ne++〉/〈Ne+〉 versus 〈S3+〉/〈S++〉 with predictions made from our photoionization models using several of the state-of-the-art stellar atmosphere model grids. The trends of the ionic ratios established from the prior M83 study are remarkably similar, but continued to higher ionization with the present M33 objects.

We present Spitzer IRS spectra (R ~600, 10 - 38 micron) of 38 positions in the Galactic Center (GC), all at the same Galactic longitude and spanning plus/minus 0.3 degrees in latitude. Our positions include the Arches Cluster, the Arched Filaments, regions near the Quintuplet Cluster, the ``Bubble'' lying along the same line-of-sight as the molecular cloud G0.11-0.11, and the diffuse interstellar gas along the line-of-sight at higher Galactic latitudes. From measurements of the [O IV], [Ne II], [Ne III], [Si II], [S III], [S IV], [Fe II], [Fe III], and H_2 S(0), S(1), and S(2) lines we determine the gas excitation and ionic abundance ratios. The Ne/H and S/H abundance ratios are ~ 1.6 times that of the Orion Nebula. The main source of excitation is photoionization, with the Arches Cluster ionizing the Arched Filaments and the Quintuplet Cluster ionizing the gas nearby and at lower Galactic latitudes including the far side of the Bubble. In addition, strong shocks ionize gas to O^{+3} and destroy dust grains, releasing iron into the gas phase (Fe/H ~ 1.3 times 10^{-6} in the Arched Filaments and Fe/H ~ 8.8 times 10^{-6} in the Bubble). The shock effects are particularly noticeable in the center of the Bubble, but O$^{+3}$ is present in all positions. We suggest that the shocks are due to the winds from the Quintuplet Cluster Wolf-Rayet stars. On the other hand, the H_2 line ratios can be explained with multi-component models of warm molecular gas in photodissociation regions without the need for H_2 production in shocks., 51 pages, 17 figures To be published in the Astrophysical Journal

Item does not contain fulltext BACKGROUND: Computed tomography (CT) of the chest may be used to identify the halo sign, a macronodule surrounded by a perimeter of ground-glass opacity, which is an early sign of invasive pulmonary aspergillosis (IPA). This study analyzed chest CT findings at presentation from a large series of patients with IPA, to assess the prevalence of these imaging findings and to evaluate the clinical utility of the halo sign for early identification of this potentially life-threatening infection. METHODS: Baseline chest CT imaging findings from 235 patients with IPA who participated in a previously published study were systematically analyzed. To evaluate the clinical utility of the halo sign for the early identification and treatment of IPA, we compared response to treatment and survival after 12 weeks of treatment in 143 patients who presented with a halo sign and in 79 patients with other imaging findings. RESULTS: At presentation, most patients (94%) had > or =1 macronodules, and many (61%) also had halo signs. Other imaging findings at presentation, including consolidations (30%), infarct-shaped nodules (27%), cavitary lesions (20%), and air-crescent signs (10%), were less common. Patients presenting with a halo sign had significantly better responses to treatment (52% vs. 29%; P

Recent Hubble Space Telescope images have allowed the determination with unprecedented accuracy of motions and changes of shocks within the inner Orion Nebula. These originate from collimated outflows from very young stars, some within the ionized portion of the nebula and others within the host molecular cloud. We have doubled the number of Herbig-Haro objects known within the inner Orion Nebula. We find that the best-known Herbig-Haro shocks originate from a relatively few stars, with the optically visible X-ray source COUP 666 driving many of them. While some isolated shocks are driven by single collimated outflows, many groups of shocks are the result of a single stellar source having jets oriented in multiple directions at similar times. This explains the feature that shocks aligned in opposite directions in the plane of the sky are usually blue shifted because the redshifted outflows pass into the optically thick Photon Dominated Region behind the nebula. There are two regions from which optical outflows originate for which there are no candidate sources in the SIMBAD data base., 152 pages, 46 figures, 7 tables. Accepted by AJ

We present Spitzer IRS R ~ 600 spectra (10 - 38 μm) of 38 positions in the Galactic Center (GC), all at the same Galactic longitude of and including the Arches Cluster. Our positions include the Arched Filaments, regions near the Quintuplet Cluster, the ''Bubble'' lying along the same line-of-sight as the molecular cloud MO.13-0.13, and the diffuse interstellar gas along the line of sight at higher Galactic latitudes. From measurements of the [O IV], [Ne II], [Ne III], [Si II], [S III], [Fe II], [Fe III], and H2 S(0), S(1), and S(2) lines we determine the gas excitation and ionic abundance ratios. The main source of excitation is photoionization, with the Arches Cluster ionizing the Arched Filaments and the Quintuplet Cluster ionizing the gas nearby and at lower Galactic latitudes including the far side of the Bubble. In addition, strong shocks ionize gas to O+3 and destroy dust grains, releasing iron into the interstellar medium (ISM); the shock effects are particularly noticeable in the center of the Bubble but the highly ionized gas is present in all positions. The H2 lines are formed both in photodissociation regions in the GC and along the line of sight to the GC.

Received 6 September 2006; accepted 6 September 2006;electronically published 13 September 2006.Author affiliations are listed at the end of the text.Reprints or correspondence: Dr. Elias J. Anaissie, MyelomaInstitute for Research and Therapy, University of Arkansasfor Medical Sciences, 4301 W. Markham, Slot 816, LittleRock, AR 72205 (anaissieeliasj@uams.edu).

Latin America in the past two decades has increasingly become a significant contributor of clinical research. The future capacity of clinical and specifically cardiovascular research has the potential to positively affect human health in the region and foster economic growth. However, the challenges of conducting clinical research in Latin America include a need for logistical support from local governments, continued commitment to education of physicians and ethics committees, and creation of oversight bodies to guarantee the highest quality of research. Bibliometric analyses were conducted to assess trends in clinical research. Latin American investigators demonstrated a tendency to publish clinical results in local and regional journals. The region offers many opportunities for clinical research including large treatment-naive patient populations and most importantly motivated investigators capable of producing high-quality results. Strategies to foster clinical research in Latin America must be based on development of a positive regulatory environment, leveraged protection of intellectual property, creation of alliances between private and public sectors with incentives for investment in science and technology, and finally focus on areas of clinical expertise such as cardiovascular disease, epidemiology, gastroenterology, and infectious diseases. Fostering the creation of research alliances across and between continents will help in establishing the supportive environment for dissemination of important ethical clinical research in the region.

We have analyzed HST ACS and WFPC2 new and archival images of eight HII regions to look for new proto-planetary disks (proplyds) similar to those found in the Orion Nebula. We find a wealth of features similar in size (though many are larger) to the bright cusps around the Orion Nebula proplyds. None of them, however, contains a definitive central star. From this, we deduce that the new cusps may not be proplyds, but instead are fragments of molecular cloud material. Out of all the features found in the eight HII regions examined, only one, an apparent edge-on silhouette in M17, may have a central star. This feature might join the small number of bona fide proplyds found outside the Orion Nebula, in M8, M20 and possibly in M16. In line with the results found recently by Smith et al. (2005), the paucity of proplyds outside the Orion Nebula, may be explained by their transient nature as well as by the specific environmental conditions under whichthey can be observed.

The close linkage of infection with the nature and intensity of the transplant immunosuppressive program has led to the concept of the therapeutic prescription. This has two components: an immunosuppressive one to prevent or treat rejection and graft-versus-host disease and an antimicrobial one to make it safe. This review provides a conceptual framework to approach the risk and risk periods for infection in solid organ and hematopoietic stem cell transplant recipients as well as an approach to antimicrobial use in this population.

Background. In a previous randomized trial of voriconazole versus amphotericin B deoxycholate for primary therapy of invasive aspergillosis, voriconazole demonstrated superior efficacy and better survival. In that trial, treatment with voriconazole or amphotericin B deoxycholate could be followed with other licensed antifungal therapies (OLAT). Here, we report the impact of OLAT on the outcome of patients with invasive aspergillosis. Methods. Data on dose, duration, and the reason for switching to the first OLAT were analyzed, and outcome at week 12 was assessed. Results. Fewer patients in the voriconazole group (52 [36%] of 144) switched to OLAT, compared with patients in the amphotericin B deoxycholate group (107 [80%] of 133). Lipid formulations of amphotericin B were the most common OLAT (38% of patients). Switches were made because of intolerance or insufficient response in 70% for patients in the amphotericin B deoxycholate group, compared with 24% of patients in the voriconazole group. Favorable responses to OLAT in the amphotericin B deoxycholate group occurred in only 19% of patients with initial insufficient response and 38% of patients with intolerance. Salvage therapy with a lipid formulation of amphotericin B after initial treatment with amphotericin B deoxycholate was successful for only 30% of patients (14 of 47). Treatment success among patients randomized to receive amphotericin B, including those whose treatment was switched to OLAT, was 32%, compared with 55% among patients who received voriconazole alone (P

We present Infrared Space Observatory (ISO) measurements of the far-infrared (FIR) fine-structure lines [S IV] (10.5 μm), [S III] (33.5 μm), [O III] (51.8 and 88.4 μm), [N III] (57.3 μm), [N II] (121.9 μm), [O I] (63.2 and 145.5 μm), and [C II] (157.7 μm) at five positions on the thermal ``Arched'' Filaments in the Galactic center region in order to investigate the influence of the massive, young Arches cluster on the interstellar medium. Serendipitous measurements of OH (119.3 μm) are also presented. Radio recombination line and ISO spectroscopic measurements provide strong evidence that the Arches cluster is responsible for the excitation of the Arched Filaments. The observations reported here were selected to provide measurements close to the Arches cluster and at uniformly increasing projected distances over the range 0-9 pc. Within the measurement uncertainties, the diagnostic line ratios most sensitive to excitation and least sensitive to density fluctuations, [O III]/[S III] and [S IV]/[S III], appear to decrease with projected distance from the Arches cluster. In agreement with other studies, this provides additional evidence that the cluster is the primary ionization source for the Arched Filaments. The total FIR luminosity also generally falls with projected distance from the Arches cluster. The best predictions from photoionization models for the rapid decrease in the measured line flux ratios with projected distance from the Arches cluster, however, are only accurate to a factor of 1.5, including allowance for additional offset along the line of sight. The measurements of lines formed predominantly in photodissociation regions are not well matched by current models. High-resolution spectra indicate gas moving at -70 km s-1 only at the location of the Arches cluster, significantly different from the predominant -30 km s-1 gas seen in the underlying molecular cloud.

Energy levels, lifetimes and transition probabilities for transitions between computed levels of 3d 5 of Fe iv are reported. The E2 and M1 transition probabilities are compared with earlier theoretical results, often only the values published by Garstang in 1958. From the available astronomical observations of optical emission lines arising from the same level, a few direct tests are now possible and they show consistency with the theoretical calculations.

Stavudine, a potent antiviral agent for treating human immunodeficiency virus (HIV) infections, was radiolabeled with (11)C by methylation of a specifically designed precursor, 5'-O-(2-tetrahydropyranyl)-5-bromo-2',3'-didehydro-3'-deoxythymidine, with (11)C H(3)I. The radiolabeled drug was isolated by reverse phase HPLC. A total time of approximately 45 minutes was required for synthesis, purification and isolation of (11)C stavudine with chemical and radiochemical purities of greater than 98%. (11)C stavudine was combined with unlabeled drug (2.0 mg/kg) and used to study its pharmacokinetics in rats by measurement of radioactivity in excised tissues. In this species, there was rapid accumulation of drug in all tissue. In all tissues, with the exceptions of testis and brain, highest concentrations of drug were detected at 5 minutes after injection and decreased monotonically thereafter. The peak concentration (microg/g) of stavudine in blood was 1.78 +/- 0.16 and similar levels were achieved in most other tissues; heart 1.66 +/- 0.11, lung 1.60 +/- 0.15, liver 2.13 +/- 0.17, spleen 1.61 +/- 0.15, adrenal 1.47 +/- 0.20, stomach 1.40 +/- 0.11, GI tract 1.44 +/- 0.14, skeletal muscle 1.38 +/- 0.15 and bone 1.30 +/- 0.16. Much higher peak concentrations were achieved in kidney; 7.23 +/- 0.57 microg/g. Concentrations in testis were lower and remained relatively constant over 1 hour; peak 0.62 +/- 0.14 microg/g at 15 min Brain concentrations were low but increased monotonically over time; peak 0.26 +/- 0.02 microg/g at 60 min. Future PET studies with this radiopharmaceutical will allow in vivo measurements of the pharmacokinetics of stavudine in both animal models and human subjects.

We investigated the abundance ratio of $^{12}$C/$^{13}$C in planetary nebulae by examining emission lines arising from \ion{C}{3} $2s2p ^3P_{2,1,0} \to 2s^2 ^1S_0$. Spectra were retrieved from the International Ultraviolet Explorer archives, and multiple spectra of the same object were coadded to achieve improved signal-to-noise. The $^{13}$C hyperfine structure line at 1909.6 \AA was detected in NGC 2440. The $^{12}$C/$^{13}$C ratio was found to be $\sim4.4\pm$1.2. In all other objects, we provide an upper limit for the flux of the 1910 \AA line. For 23 of these sources, a lower limit for the $^{12}$C/$^{13}$C ratio was established. The impact on our current understanding of stellar evolution is discussed. The resulting high signal-to-noise \ion{C}{3} spectrum helps constrain the atomic physics of the line formation process. Some objects have the measured 1907/1909 flux ratio outside the low-electron density theoretical limit for $^{12}$C. A mixture of $^{13}$C with $^{12}$C helps to close the gap somewhat. Nevertheless, some observed 1907/1909 flux ratios still appear too high to conform to the presently predicted limits. It is shown that this limit, as well as the 1910/1909 flux ratio, are predominantly influenced by using the standard partitioning among the collision strengths for the multiplet $^1S_0$--$^3P_J$ according to the statistical weights. A detailed calculation for the fine structure collision strengths between these individual levels would be valuable., Comment: ApJ accepted: 19 pages, 3 Figures, 2 Tables

Background & Aims: Adefovir dipivoxil possesses potent in vitro and in vivo antiviral activity in wild-type hepatitis B. This study assessed the safety and efficacy of adefovir dipivoxil alone and in combination with lamivudine compared with ongoing lamivudine therapy in patients with chronic hepatitis B with compensated liver disease and lamivudine-resistant hepatitis B virus (HBV). Methods: Fifty-nine hepatitis B e antigen (HBeAg)-positive patients with genotypic evidence of lamivudine-resistant HBV, serum alanine aminotransferase (ALT) level ≥1.2 times the upper limit of normal, and serum HBV DNA level ≥6 log 10 copies/mL despite ongoing treatment with lamivudine were randomized to adefovir dipivoxil 10 mg, lamivudine 100 mg, or addition of adefovir dipivoxil to ongoing lamivudine daily. The primary end point was the time-weighted average change from baseline in serum HBV DNA level (DAVG) up to week 16. Results: Rapid reductions in serum HBV DNA level were seen by 4 weeks in all recipients of adefovir dipivoxil; DAVG 16 was −0.07 in the lamivudine group compared with −2.45 and −2.46 log 10 copies/mL in the adefovir dipivoxil/lamivudine and adefovir dipivoxil monotherapy groups, respectively ( P 10 copies/mL in the lamivudine, adefovir dipivoxil/lamivudine, and adefovir dipivoxil groups, respectively. ALT level normalized in 10 of 19 (53%) and 9 of 18 (47%) recipients of adefovir dipivoxil/lamivudine and adefovir dipivoxil, respectively, compared with 1 of 19 (5%) recipients of lamivudine. Three patients receiving adefovir dipivoxil or adefovir dipivoxil/lamivudine and none receiving lamivudine monotherapy were HBeAg negative at week 48 and one became hepatitis B surface antigen negative. Conclusions: These data, limited to patients with compensated liver disease, indicate that adefovir dipivoxil alone or in combination with ongoing lamivudine therapy provides effective antiviral therapy in patients with lamivudine-resistant HBV.

Background. Invasive fungal infections (IFI), particularly those caused by Aspergillus and other angioinvasive molds, are associated with an excessive mortality despite therapy. Methods. Voriconazole was prescribed on a compassionate basis to patients with IFI who were intolerant to or who had progressed despite standard therapy. Outcome was determined by protocol-based criteria as established by the consensus definitions (complete response [CR], partial response [PR], stable disease, failure, and intolerance). Results. Forty-five patients were enrolled in a compassionate release program (29 [64%] because of failure of response to standard therapy), between 1998 and 2002. Of the 45 patients enrolled, 35 (78%) had invasive Aspergillus, 3 (7%) had Fusarium, and 2 (4%) had Scedosporium infections. Underlying illnesses were as follows: 13 (29%) solid-organ transplant (SOT), 11 (24%) BMT, and 7 (13%) hematologic malignancy. Site of infection was as follows: 26 (58%) pulmonary, 9 (20%) disseminated, 5 (11%) central nervous system (CNS), and 3 (7%) sinus. Overall response rates were as follows: 9 (20%) CR, 17 (38%) PR, 15 (33%) failure, and 4 (9%) intolerant. Seven of the eight (88%) patients with sinus or CNS disease demonstrated stabilization of the IFI. The median duration of voriconazole therapy was 79 days with 9 (20%) patients receiving over 1 year of therapy. Nine thousand one hundred twenty-eight days of therapy were given with only four serious adverse events in two cases considered possibly or probably drug related. Conclusions. In this population of severely immuno-compromised patients with life-threatening IFI who have failed or were intolerant to standard antifungal therapy, voriconazole demonstrated substantial efficacy and an acceptable level of toxicity.

A randomized, blinded, multicenter trial was conducted to compare fluconazole (800 mg per day) plus placebo with fluconazole plus amphotericin B (AmB) deoxycholate (0.7 mg/kg per day, with the placebo/AmB component given only for the first 5-6 days) as therapy for candidemia due to species other than Candida krusei in adults without neutropenia. A total of 219 patients met criteria for a modified intent-to-treat analysis. The groups were similar except that those who were treated with fluconazole plus placebo had a higher mean (+/- standard error) Acute Physiology and Chronic Health Evaluation II score (16.8+/-0.6 vs. 15.0+/-0.7; P=.039). Success rates on study day 30 by Kaplan-Meier time-to-failure analysis were 57% for fluconazole plus placebo and 69% for fluconazole plus AmB (P=.08). Overall success rates were 56% (60 of 107 patients) and 69% (77 of 112 patients; P=.043), respectively; the bloodstream infection failed to clear in 17% and 6% of subjects, respectively (P=.02). In nonneutropenic subjects, the combination of fluconazole plus AmB was not antagonistic compared with fluconazole alone, and the combination trended toward improved success and more-rapid clearance from the bloodstream.

Presentation of Case A 43-year-old man was admitted to the hospital because of fever and rapid deterioration of vision in the left eye. The patient had been well until six weeks earlier, when fevers, sweats, myalgias, and right-sided pleuritic chest pain developed. Three days later, a chest radiograph reportedly showed pneumonia in the right lower and middle lobes. A five-day course of azithromycin was prescribed. He felt better with treatment, but one day after the course of medication ended, he felt worse. Twenty-six days before admission, a repeated chest radiograph revealed a right-sided pleural effusion. He refused to undergo thoracentesis . . .

Background. The efficacy of trimethoprim-sulfamethoxazole (TMP/SMX) in the prevention of toxoplasmosis after orthotopic cardiac transplantation has been the subject of some controversy, with many transplant groups preferring to use the combination of pyrimethamine and sulfadiazine. Although effective, this latter regimen does not offer equal protection against other pathogens, such as Nocardia or Listeria. To assess the value of TMP/SMX, we reviewed the experience in our heart transplant patients, all of whom received TMP/SMX (160/800 mg) three times weekly for approximately 8 months after transplantation. Methods. We report on 417 orthotopic cardiac transplants during a 17-year period. We have 100% one-year patient follow-up after transplantation. Data was collected on pretransplantation donor and recipient anti-Toxoplasma serology, immunosuppression, allograft rejection, survival, yearly posttransplantation anti-Toxoplasma serology, development of acute toxoplasmosis, and the occurrence of other infections. Results. In this cohort, acute toxoplasmosis developed after transplantation in one case (0.2%). Among the highest risk patients (D+R-) who were treated for at least one episode of rejection, the risk of acute toxoplasmosis was 5% (1 of 22 patients). No change in survival was found between the different anti-Toxoplasma IgG serogroups (D-R-, D-R+, D+R-, or D+R+). Anti-Toxoplasma IgG seroconversion occurred in eight Toxoplasma-seronegative recipients after transplantation; all patients, except the case already noted, were asymptomatic and required no specific anti-Toxoplasma therapy. No cases of Listeria, Nocardia, or Salmonella infections were identified. Five proven and two suspected cases of Pneumocystis carinii pneumonia were found (only 2 of these 7 patients were receiving TMP/SMX at the time of Pneumocystis carinii pneumonia diagnosis). Conclusions. These data demonstrate that TMP/SMX prophylaxis (160/800 mg) three times per week is effective Toxoplasma prophylaxis after orthotopic cardiac transplantation and has prophylactic benefits against other posttransplantation opportunistic pathogens.

We present new HST/WFPC2 imagery and STIS long-slit spectroscopy of the planetary nebula NGC 7009. The primary goal was to obtain high spatial resolution of the intrinsic line ratio [O III] 4364/5008 and thereby evaluate the electron temperature (T_e) and the fractional mean-square T_e variation (t_A^2) across the nebula. The WFPC2 T_e map is rather uniform; almost all values are between 9000 - 11,000 K, with the higher T_e's closely coinciding with the inner He^++-zone. The results indicate very small values

(Abridged) We present the analysis of the main FIR fine structure lines emission in NGC1313 and NGC6946. We calculate that a component probably associated with the diffuse disks contributes

Background. Pseudomonas aeruginosa is an uncommon cause of infection in the female genital tract. We report a case of postmenopausal tubo-ovarian abscess (TOA) due to P. aeruginosa in a renal transplant recipient. The presentation included mild abdominal symptoms with rapid progression of peritonitis and surgical abscess drainage. This is the first such case in an organ transplant recipient described in the English literature. Methods and Results. Published reports of 1040 cases of TOA were reviewed. The most common features were a history of sexually transmitted disease or pelvic inflammatory disease, and symptoms including abdominal pain and fever. Escherichia coli, Bacteroides spp., and Klebsiella pneumoniae were the most frequently encountered pathogens. Neisseria gonorrhoeae and Chlamydia trachomatis, which are frequently isolated from cervical cultures, are uncommonly isolated from tubo-ovarian abscesses. Forty percent of patients were treated with antibiotics alone, 18.8% with abdominal surgery, and 32% with surgery and antimicrobial therapy. Conclusion. This report illustrates the muted presentation and atypical microbiology of gynecologic infection in an organ transplant recipient.

It is often very difficult to distinguish between infection-related and immunosuppression-related gastrointestinal (GI) complications after transplantation. The risk of infection itself is determined by the patient's net state of immunosuppression as well as the presence of anatomic or technical abnormalities and the patient's epidemiological exposures. Of the anatomic abnormalities, diverticulitis is a particular problem in transplant patients, with a high rate of perforation and abscess formation. The causes of infectious disease syndromes are very different immediately after, early after, and late after transplantation. Infection during the first month may result from a pre-existing infection in the donor or recipient, or from the surgical wound, endotracheal tube, vascular access or drainage. During 1-6 months after transplantation, viruses attack and, with sustained immunosuppression, make opportunistic infections possible. Beyond 6 months after transplantation, the 80% of patients with good result from the transplant are at risk primarily for community-acquired microbes, including such enteric pathogens as Salmonella. Of the remaining patients, 10% have chronic viral infections and the 10% who have poor allograft function are at greatest risk for opportunistic infection. This time line is helpful in determining whether a GI complication is likely to be related to infection rather than a specific effect of an immunosuppressant drug. Fever, inflammatory cells in the stool, abnormalities on endoscopy or computed tomography and leukocytosis can be useful in the diagnosis but are inconsistent markers for an infectious cause.

Infectious complications are still a significant cause of morbidity and death in solid-organ transplant patients, with significant infection being found in up to two-thirds of these individuals. The risk of infection in the organ transplant patient, particularly of opportunistic infection, is largely determined by 3 factors: the net state of immunosuppression, the epidemiologic exposures the patient encounters, and the consequences of the invasive procedures to which the patient is subjected. The most important principles of patient treatment are prevention, early diagnosis, and specific therapy. This issue is designed as a position paper by a group of experts on epidemiology, prevention, diagnosis, and management of infections in solid-organ transplant patients. We feel that our efforts may serve as an important first step in the development of guidelines in this area.

This review presents evidence-based guidelines for the prevention of infection after blood and marrow transplantation. Recommendations apply to all myeloablative transplants regardless of recipient (adult or child), type (allogeneic or autologous) or source (peripheral blood, marrow or cord blood) of transplant.In Section I, Dr. Dykewicz describes the methods used to rate the strength and quality of published evidence supporting these recommendations and details the two dozen scholarly societies and federal agencies involved in the genesis and review of the guidelines.In Section II, Dr. Longworth presents recommendations for hospital infection control. Hand hygiene, room ventilation, health care worker and visitor policies are detailed along with guidelines for control of specific nosocomial and community-acquired pathogens.In Section III, Dr. Boeckh details effective practices to prevent viral diseases. Leukocyte-depleted blood is recommended for cytomegalovirus (CMV) seronegative allografts, while ganciclovir given as prophylaxis or preemptive therapy based on pp65 antigenemia or DNA assays is advised for individuals at risk for CMV. Guidelines for preventing varicella-zoster virus (VZV), herpes simplex virus (HSV) and community respiratory virus infections are also presented.In Section IV, Drs. Baden and Rubin review means to prevent invasive fungal infections. Hospital design and policy can reduce exposure to air contaminated with fungal spores and fluconazole prophylaxis at 400 mg/day reduces invasive yeast infection.In Section V, Dr. Sepkowitz details effective clinical practices to reduce or prevent bacterial or protozoal disease after transplantation. In Section VI, Dr. Sullivan reviews vaccine-preventable infections and guidelines for active and passive immunizations for stem cell transplant recipients, family members and health care workers.

Four IRAS-detected early type galaxies were observed with ISO. With the exception of the 15 micron image of NGC1052, the mid-IR emission from NGC1052, NGC1155, NGC5866 and NGC6958 at 4.5, 7 and 15 microns show extended emission. Mid-IR emission from NGC1052, NGC1155, and NGC6958 follows a de Vaucouleurs profile. The ratio of 15/7 micron flux decreases with radius in these galaxies, approaching the values empirically observed for purely stellar systems. In NGC5866, the 7 and 15 micron emission is concentrated in the edge-on dust lane. All the galaxies are detected in the [CII] line, and the S0s NGC1155 and NGC5866 are detected in the [OI] line as well. The ISO-LWS observations of the [CII] line are more sensitive measures of cool, neutral ISM than HI and CO by about a factor of 10-100. Three of four early type galaxies, namely NGC1052, NGC6958 and NGC5866, have low ratio FIR/Blue and show a lower [CII]/FIR, which is due to a softer radiation field from old stellar populations. The low [CII]/CO ratio in NGC5866 ([CII]/CO(1-0) < 570) confirms this scenario. We estimate the UV radiation expected from the old stellar populations in these galaxies and compare it to that needed to heat the gas to account for the cooling observed [CII] and [OI] lines. In three out of four galaxies, NGC1052, NGC5866 and NGC6958, the predicted UV radiation falls short by a factor of 2-3. In view of the observed intrinsic scatter in the "UV-upturn" in elliptical galaxies and its great sensitivity to age and metallicity effects, this is not significant. However, the much larger difference (about a factor of 20) between the UV radiation from old stars and that needed to produce the FIR lines for NGC 1155 is strong evidence for the presence of young stars, in NGC1155.

Background: Optimal prophylaxis against cytomegalovirus (CMV) disease for organ transplant patients at risk for primary infection (donor seropositive, recipient seronegative, D+R−) remains to be determined. We hypothesized that prolonged oral ganciclovir therapy following intravenous therapy would provide increased protection. Methods: A total of 155 evaluable D+R− organ transplant recipients from 13 transplant centers were entered into the study: all received intravenous ganciclovir (5 mg/kg/day) for 5–10 days and then either oral acyclovir (400 mg tid) or oral ganciclovir (1 g tid) for an additional 12 weeks. Patients were assigned to their treatment groups at a central randomization site, with a separate randomization scheme for each of the organs transplanted (kidney, heart, or liver). In the case of kidney transplants, the patients were stratified according to source of the kidney (living related vs. cadaveric donor). The primary endpoint was the incidence of CMV disease in the first six months post-transplant. Results: Treatment with oral ganciclovir was associated with a significant decrease in the incidence of symptomatic disease or viremia when compared with the oral acyclovir group (32% vs. 50%, P

Cytomegalovirus (CMV) remains the most important infection affecting heart-transplant recipients. Treatment of clinical disease is with a two to three-week course of intravenous ganciclovir, which is effective in more than 90% of individuals. However, relapsing disease, particularly in those with primary infection, is an increasing problem, occasionally with the development of ganciclovir-resistant infection. In those instances, foscarnet is needed, despite its nephro- and neurotoxicities. Increasingly, in order to prevent relapse, more prolonged oral courses of anti-viral therapy are being added to the standard two to three-week course of intravenous treatment. In the prevention of CMV disease, those at risk of primary disease (donor seropositive, recipient seronegative) should receive prophylaxis; for seropositive transplant patients, preemptive strategies linked to immunosuppression or viremia monitoring are becoming increasingly prevalent. In the future, as new drugs become available, the essential question will be whether chronic allograft injury (i.e., accelerated coronary artery atherosclerosis) can be prevented with an anti-viral strategy.

We present mid-infrared maps and preliminary analysis for 61 galaxies observed with the ISOCAM instrument aboard the Infrared Space Observatory. Many of the general features of galaxies observed at optical wavelengths---spiral arms, disks, rings, and bright knots of emission---are also seen in the mid-infrared, except the prominent optical bulges are absent at 6.75 and 15 microns. In addition, the maps are quite similar at 6.75 and 15 microns, except for a few cases where a central starburst leads to lower 6.75/15 ratios in the inner region. We also present infrared flux densities and mid-infrared sizes for these galaxies. The mid-infrared color 6.75/15 shows a distinct trend with the far-infrared color 60/100. The quiescent galaxies in our sample (60/100 < 0.6) show 6.75/15 near unity, whereas this ratio drops significantly for galaxies with higher global heating intensity levels. Azimuthally-averaged surface brightness profiles indicate the extent to which the mid-infrared flux is centrally concentrated, and provide information on the radial dependence of mid-infrared colors. The galaxies are mostly well resolved in these maps: almost half of them have < 10% of their flux in the central resolution element. A comparison of optical and mid-infrared isophotal profiles indicates that the optical flux at 4400 Angstroms near the optical outskirts of the galaxies is approximately eight (seven) times that at 6.75 microns (15 microns), comparable with observations of the diffuse quiescent regions of the Milky Way.

We present high-resolution spectrophotometric observations of the Orion Nebula, made with the Cassegrain echelle spectrograph on the Blanco 4 m telescope at Cerro Tololo Inter-American Observatory (CTIO). The resolution and signal-to-noise ratio make it possible to identify 444 emission lines in the 3498-7468 ? range, down to 104 times fainter than H?. We present a detailed atlas of these emission lines along with an analysis of the associated errors. This data set is used to study the velocity field in the Orion Nebula. The forbidden lines split into two distinct groups. The low-ionization group has ions with an ionization potential less than 20 eV. Lines of these ions, [O I], [N I], [Ni II], and [Fe II], have recession velocities, relative to the hydrogen lines, of +10 to +15 km s-1. There is a sharp change to the second, high-ionization group, which includes lines of ions with ionization potentials larger than 20 eV, namely, [S II], [O II], [N II], and [Fe III]. These lines have velocities around +3 km s-1, with a slight trend of decreasing velocity with the increasing ionization potential. This is consistent with previously proposed dynamical models in which lines of ions with different ionization potentials originate at different distances from the ionizing stars. Significant acceleration appears to take place across the narrow region where Fe2+ exists. Across this region the gas receives an acceleration of ~ 2.5 ? 10-5 cm s-2. This provides a constraint on hydrodynamical models. We set a limit He II 4686/H? < 7 ? 10-5, which in turn sets a limit to the intensity of the ionizing continuum at energies higher than 54 eV. Modern stellar atmospheres predict a continuum that is far stronger than is present in the region near ?1 Ori C.

Background: Although the primary treatment of symptomatic cytomegalovirus (CMV) disease in organ transplant recipients is successful in >90% of individuals, relapsing disease, particularly in those with primary infection, remains an important problem. Previously, we had observed that the rate of symptomatic recurrence was >60% in those with primary disease (seronegative for CMV prior to transplant), and approximately 20% in those who were seropositive prior to transplant. The present study was undertaken to determine whether a maintenance regimen of oral ganciclovir for 2–3 months added to the routine 14–21 days of intravenous ganciclovir would further prevent symptomatic CMV recurrence. Methods: From May 1995 until June 1998, all kidney and liver transplant recipients with confirmed tissue-invasive CMV disease or CMV syndrome were treated with 14–21 days of intravenous ganciclovir (5 mg/kg b.i.d. with dose adjusted for renal dysfunction) followed by 2–3 months of oral ganciclovir (2 g daily). The incidence of recurrence of CMV disease and/or viremia during and after oral therapy was then determined over a mean follow-up of 530.6 days. Results: Thirty-seven patients, 19 kidney and 18 liver transplant recipients, were studied; 5 had biopsy-proven tissue-invasive disease (13.5) and 32 suffered a CMV syndrome (86.5). Twenty-one of these patients (58.6) were seronegative for CMV prior to transplant and received an allograft from a seropositive donor (D+/R−). Overall, 10 patients (27.0) developed CMV recurrence. Eight of 21 patients who were D+/R− for CMV (38.1) developed recurrence as opposed to 2 of 16 patients with other serologic status (12.5) (P=0.14). Patients with recurrent CMV disease and/or viremia had a peak antigenemia assay titer during their initial CMV event of 319.2 positive cells/2 slides compared with 109.8 positive cells/2 slides for patients without recurrent CMV infection (P=0.14); the trend of having a higher peak antigenemia assay titer among patients who recurred occurred both in patients who were at risk of primary CMV infection (D+/R− for CMV) and in those who were not. Two patients developed recurrent infection with strains of CMV that were resistant to ganciclovir. Conclusions: This new therapeutic regimen of oral ganciclovir following intravenous ganciclovir slightly reduced the overall rate of recurrent CMV disease and/or viremia, but it still did not adequately prevent CMV recurrence in patients who are at risk of primary infection prior to transplant. Of particular concern, 2 patients with primary infection treated with this regimen developed ganciclovir-resistant recurrent disease ( Note).

BACKGROUND Leukopenia is not infrequently encountered following solid organ transplantation, most often in the setting of cytomegalovirus (CMV) disease and/or its treatment with ganciclovir. The present study was undertaken to determine the safety and efficacy of granulocyte colony-stimulating factor (G-CSF) in renal and liver transplant recipients with leukopenia. METHODS Between 1 June 1991 and 1 June 1998, patients received G-CSF for 2 indications: 1) white blood cell count (WBC) < 3000/mm3, with a decline from baseline; 2) to shorten the duration of leukopenia associated with chemotherapy. A retrospective review of the outcome of such therapy was undertaken. RESULTS 50 patients were given 100 courses of treatment with G-CSF; 35 of 168 liver transplant recipients (20.8%), 14 of 391 kidney transplant recipients (3.6%), and 1 of 4 recipients of combined liver-kidney transplants (25.0%) received from 1 to 9 courses of G-CSF. Presumed causes of leukopenia were identified as ganciclovir in 28 cases (28.0%), CMV in 21 (21.0%), chemotherapy in 12 (12.0%), sepsis in 11 (11.0%), azathioprine in 5 (5.0%), interferon in 3 (3.0%) and other causes in 20 cases (20.0%). The median length of therapy was 10.0 days (range 1-154 days) and the average dose of daily G-CSF received was 3.9+/-1.5 microg/kg/day. The average WBC was (2.4+/-1.3 )x 10(3)/microl at the beginning of therapy, and (13.8+/-9.1) x 10(3)/microl at the end of therapy. In 7 of 100 treatments (7.0%) a WBC of 5.0 x 10(3)/microl was not reached during G-CSF therapy; in 6 of these 7 cases, G-CSF therapy lasted fewer than 4 days. The mean time needed to reach a WBC count of 5 x 10(3)/microl was 3.7+/-3.3 days among 71 patients who had daily WBC counts sent. Eight G-CSF treatments (8.0%) were followed by episodes of rejection appearing during or within 2 months of treatment; 5 of them were biopsy-documented. No relation was found between the highest WBC obtained during G-CSF therapy and the risk of rejection. Eight patients (16.0%) died while receiving G-CSF, all from infection. Six of these 8 patients were receiving G-CSF for leukopenia secondary to sepsis. Overall, 25 patients (50.0%) received 49 courses of G-CSF secondary to CMV and/or ganciclovir therapy. In 40 of 49 courses (81.6%), ganciclovir could be continued at recommended doses. Twenty-one of 22 patients (95.5%) with symptomatic CMV infection had a clinical response to ganciclovir. Sixteen of 18 patients (88.9%) treated for a CMV infection and followed with serial antigenemia assays attained microbiological cure; both patients who did not were infected with ganciclovir resistant CMV. CONCLUSION G-CSF was well tolerated in solid organ transplant recipients. It was particularly useful in patients with CMV disease, allowing optimal ganciclovir therapy.

Background. The optimal regimen for the prevention and treatment of cytomegalovirus (CMV) disease in solid organ transplant recipients remains to be defined, particularly for patients with abnormal or changing renal function. Methods. A prospective trial was conducted in patients receiving i.v. ganciclovir using a standardized dosing nomogram that corrects for renal function. Steady state peak (P) and trough (T) serum levels were determined by high-performance liquid chromatography and correlated with therapeutic outcomes and toxicities attributable to ganciclovir. Results. Over the study period, 44 individuals received ganciclovir prophylaxis (5 mg/kg/day) and 25 patients were treated (5 mg/kd q12 hr) for symptomatic CMV disease. Ganciclovir levels (mg/ml6SD) achieved in prophylaxis were P: 7.9863.34, T: 3.0362.63; and in treatment were P: 9.0063.72, T: 2.6561.82. Despite corrections for renal dysfunction, undialyzed patients with serum creatinine >3.0 mg/dl had trough levels in excess of the population mean (T: range 3‐ 8 mg/ml). Failure of prophylaxis (disease) or therapy (relapse) occurred in 14 patients; 8 of these were at risk for primary infection (donor CMV seropositive, recipient seronegative, P 3.0, 1.25 mg/kg QOD for Cr >5.0). Some groups of transplant recipients may require more intensive anti-CMV regimens. Cytomegalovirus (CMV*) is a major cause of morbidity in solid organ transplant recipients (1‐9). In various series, between 20 and 70% of organ transplant recipients are affected by CMV infection (2, 10 ‐12). Ganciclovir, in both i.v. and oral formulations, is commonly used to prevent and to treat CMV infection, although the optimal dose and duration of therapy have not yet been completely defined (13‐21). In clinical practice, patients requiring prophylaxis or treatment for CMV infection often have abnormal or fluctuating renal function. This is particularly relevant in the setting of recent organ transplantation or during acute renal allograft rejection. However, few data are available on which to base decisions about the dosing of ganciclovir in such patients (22‐23). In the attempt to optimize antiviral therapy in solid organ transplant recipients with variable renal function, a prospective study was performed to study blood levels and clinical outcomes associated with the routine administration of i.v. ganciclovir based on a standardized nomogram. Peak and trough serum ganciclovir levels were measured by highpressure liquid chromatography. An attempt was made to assess the dosing of ganciclovir and to assess the impact of dosage and serum levels on the efficacy and toxicities of antiviral therapy and any impact that might be detected with the use of prophylactic or therapeutic ganciclovir on the development of or recurrence of symptomatic CMV infection.

Infection and rejection, the two major barriers to successful organ transplantation, are closely linked, with immunosuppressive therapy being central to the pathogenesis of both. After almost two decades when azathioprine and prednisone, supplemented by antilymphocyte antibody therapy, were the cornerstones of post-transplant immunosuppressive programs, there has been a major increase in the therapeutic armamentarium available to treat rejection: cyclosporine, tacrolimus, mycophenolate mofetil, rapamycin, and antibodies directed against the interleukin-2 receptor. These agents are potent inhibitors of microbial specific T cell function, thus potentiating opportunistic infection with herpes group viruses, fungal and mycobacterial species, Strongyloides stercoralis, and a variety of intracellular pathogens. The mechanisms by which each of these drugs exerts its effects are an important determinant of the antimicrobial strategies that will be necessary to combat infection. Indeed, strategies to limit these infections are being linked to the nature of the immunosuppressive therapy required in a particular patient. Thus, the therapeutic prescription for the transplant patient is said to have two components: an immunosuppressive component to prevent and treat rejection, and an antimicrobial one to make it safe. In addition to using antimicrobial agents therapeutically, in the transplant patient prevention is stressed in which antibiotics are deployed prophylactically or preemptively ( Note).

Background. Due to the limited supply and increased demand for donor livers, waiting times are progressively lengthening, which may lead to transplantation at more advanced and less cost-effective stages of disease. The purpose of this study was to evaluate the outcomes and hospital charges of liver transplantation during two recent eras to identify areas for providing more cost-effective care. Methods. A total of 144 primary liver allografts were performed from 1991 to 1996. Patient characteristics, outcome measures, and hospital charges were compared for patients receiving allografts between 1991 and 1993 (group A) versus those receiving grafts between 1994 and 1996 (group B) using unpaired Student t tests for continuous data and chi-squared tests for categorical data. Results. In comparing groups A and B, no significant differences in patient demographics, relative contraindications, or indication for transplantation existed; median waiting time from date of listing until transplant increased from 88 days to 159 days; and a shift in UNOS priority status at time of transplantation occurred, as the percentage of patients requiring inpatient care increased from 58% to 75% (P=0.034). Despite this, patient hospital and 1-year survival significantly improved from 75.0% to 90.3% (P=0.016), and from 68.1% to 88.9% (P=0.002), respectively. Total hospital charges, without correction for inflation, were $174,908

Background, Organ transplant recipients who are seropositive for cytomegalovirus (CMV) and who are treated with antilymphocyte antibody (ALA) therapy have a high rate of symptomatic CMV disease. The intravenous administration of ganciclovir therapy once daily during ALA therapy decreased the incidence from 24% to 10% in patients receiving ALA as an induction therapy and from 64% to 22% in those treated for rejection. The present study was undertaken to determine whether a more intensive and sustained antiviral regimen could be more effective. Methods. From April 1995 to December 1997, all CMV seropositive renal and liver transplant recipients who received ALA therapy were treated with intravenously administered ganciclovir (5 mg/kg/day with dose adjusted for renal dysfunction) for the length of ALA therapy and then with orally administered acyclovir (400 mg three times/day) or ganciclovir (1 gm twice/day) for 3 to 4 months. The incidence of CMV viremia and of CMV disease was determined during the 6 months after completion of ALA therapy. Results. Forty-one patients (35 renal and 6 liver transplant recipients) were studied. CMV disease occurred in 2 patients (4.9%), both of whom were treated for rejection; it occurred in 1 of 21 patients (4.8%) treated with orally administered acyclovir, and in 1 of 20 patients (5%) treated with orally administered ganciclovir. The only patient who developed CMV disease in the ganciclovir group had received only 26 days of oral antiviral therapy. No CMV disease was documented in the group of patients receiving ALA therapy as induction therapy. CMV viremia occurred in three patients in the acyclovir group (14.3%) and in one patient in the ganciclovir group (5%). Among renal transplant recipients only, 1 of 35 patients developed CMV disease (2.9%) and no case of CMV disease was documented in patients treated with orally administered ganciclovir. All six patients receiving two courses of ALA therapy each were free of CMV disease. Toxicity of the regimen was minimal, and antiviral resistance did not develop. Conclusions. Preemptive antiviral therapy with intravenously administered ganciclovir during ALA therapy and then orally administered ganciclovir for 3 to 4 months provides virtually complete protection against the excessive rate of CMV disease that occurs in CMV seropositive allograft recipients receiving ALA therapy.

Using the Short Wavelength Spectrometer on the Infrared Space Observatory, we measured in the Orion Nebula several components of the He I Brα transition, the first detections to the best of our knowledge in an H II region, and the H I Brα line. A value of He+/H+=0.085±0.003 is inferred from these data and is typical of previous values found for Orion. The IR method to obtain He+/H+ is very insensitive to extinction. The measurement of the weak He I 2.855 μm (5p 3Po→4s 3S) flux permits an assessment of Te in the He+ region. Its flux relative to the flux of He I 4.0490 μm (5g 3G→4f 3Fo, 5g 1G→4f 1Fo blend) is roughly ∝Te (for Te range applicable to most H II regions and planetary nebulae) and depends little on Ne. From our measured ratio, using Ne = 104 cm-3, Te is slightly less than 104 K. We stress that many IR measurements of a hydrogen line are likely to also include one or more significant helium line contributions. Attributing all of the flux to the stronger H I line will result in underestimates for abundance ratios relative to H+. This has usually not been taken into account in the past when deriving abundances of other ions/elements relative to H. Errors in the velocity and line width inferred may also occur by failure to consider the blended He component. Because the strongest He I lines will generally be on the blue side of their counterpart H I line, interpreting a blended feature as only H I will cause a spurious bias to lower velocities.

A primary goal in organ transplantation is the prevention or effective treatment of infection, the most common life-threatening complication of long-term immunosuppressive therapy. The challenges involved in achieving this goal are several: a broad range of potential sources of infection ranging from latent viruses to pathogens of both community and hospital origin; immunosuppression-induced impairment of the inflammatory response, which attenuates the signs and symptoms of invasive infection; and the adverse effects of the antimicrobial drugs used for prophylaxis and therapy, which result both from the duration of therapy required and from interactions with the immunosuppressive drugs cyclosporine and tacrolimus. Our . . .