Influence of neutralizing antibodies to adalimumab and infliximab on the treatment of psoriasis.

BACKGROUND: Current treatment with biologics has produced dramatic therapeutic effects in patients with psoriasis, although these agents occasionally decrease in efficacy. One of the main factors responsible for this attenuation is attributed to the development of antidrug antibodies (ADAs). OBJECTIVES: To analyse the relationship between serum drug concentrations, the presence of ADAs and treatment efficacy of adalimumab and infliximab, and to determine the optimal use of these biologics. METHODS: This was a 1-year prospective study in the dermatology departments of Kobe University Hospital and collaborating hospitals. All patients starting a regimen of adalimumab and infliximab for psoriasis were included. We measured the serum concentration of the drugs and titres of antibodies to adalimumab and infliximab, as well as the Psoriasis Area and Severity Index scores at weeks 0, 4, 12, 24 and 48 during the first year of treatment. RESULTS: We observed a 50% positive rate of ADAs to adalimumab, and a 41% positive rate of ADAs to infliximab. The titres of ADAs showed a wide range from low to high titres. In the high-titre groups, the patients exhibited a decreased clinical response, and demonstrated a negative correlation between titre and clinical response. However, an equivalent therapeutic effect was observed between the low-titre group and the group with no antibodies detected for adalimumab. For infliximab, the patients with ADAs showed decreased clinical response. An apparent negative correlation between antibody production and reduced clinical response was observed. CONCLUSIONS: Two biologics, adalimumab and infliximab, showed different therapeutic behaviour. The measurement of ADAs and drug concentrations has important implications for treatment with biologics.

The human immunodeficiency virus type 1 accessory protein Vpu induces apoptosis by suppressing the nuclear factor kappaB-dependent expression of antiapoptotic factors.

Human immunodeficiency virus (HIV) type 1 Vpu is an integral membrane protein with a unique affinity for betaTrCP (TrCP), a key member of the SkpI-Cullin-F-box E3 ubiquitin ligase complex that is involved in the regulated degradation of cellular proteins, including IkappaB. Remarkably, Vpu is resistant to TrCP-mediated degradation and competitively inhibits TrCP-dependent degradation of IkappaB, resulting in the suppression of nuclear factor (NF)-kappaB activity in Vpu-expressing cells. We now report that Vpu, through its interaction with TrCP, potently contributes to the induction of apoptosis in HIV-infected T cells. Vpu-induced apoptosis is specific and independent of other viral proteins. Mutation of a TrCP-binding motif in Vpu abolishes its apoptogenic property, demonstrating a close correlation between this property of Vpu and its ability to inhibit NF-kappaB activity. The involvement of NF-kappaB in Vpu-induced apoptosis is further supported by the finding that the levels of antiapoptotic factors Bcl-xL, A1/Bfl-1, and TNF receptor-associated factor (TRAF)1, all of which are expressed in an NF-kappaB-dependent manner, are reduced and, at the same time, levels of active caspase-3 are elevated. Thus, Vpu induces apoptosis through activation of the caspase pathway by way of inhibiting the NF-kappaB-dependent expression of antiapoptotic genes.

Soybean beta-conglycinin as the main allergen in a patient with food-dependent exercise-induced anaphylaxis by tofu: food processing alters pepsin resistance.

BACKGROUND: Food-dependent exercise-induced anaphylaxis (FDEIA) due to soybeans is a rare disorder. The allergen responsible for FDEIA due to soybeans has not yet been determined. OBJECTIVE: We characterized the clinical features of a patient with FDEIA due to tofu, who was well tolerant to drinking soy milk. We then sought to identify the responsible soybean allergen(s) in that patient. We further studied whether different stabilities of the allergen(s) to pepsin digestion between two soybean products are related to their clinical allergenicity. METHODS: Skin prick tests and provocation tests using soybean products were performed to detect the responsible food and other factors that induced the allergic symptoms. Specific IgE to various soybean allergens were examined by ImmunoCAP, ELISA and protein microarray assays. Immunoblotting for soybeans and soybean products using the patient's serum was also performed. Soybean products were serially digested by pepsin to disclose the stability of the allergens. RESULTS: Provocation with ingestion of tofu and exercise induced the allergic symptoms, while ingestion of soy milk and exercise did not. Immunoblot analysis, ELISA and protein microarray assay revealed that beta-conglycinin mainly reacts with IgE antibodies in the patient's serum. By immunoblot analysis, beta-conglycinin in soy milk completely disappeared after pepsin digestion within 20 min, whereas beta-conglycinin in tofu was almost intact after more than 120 min of pepsin digestion. CONCLUSION: We identified beta-conglycinin as the causative allergen in a patient with FDEIA induced by tofu. The difference in resistance to pepsin digestion between tofu and soy milk suggests that the presence of undigested allergens in the digestive tract is a prerequisite for the development of FDEIA.

Correlation of autophagy type in podocytes with histopathological diagnosis of IgA nephropathy.

OBJECTIVE: IgA nephropathy (IgA-N) frequently leads to progressive renal failure, thus estimation of the degree of progression is important for patient management. Autophagy is a mechanism that facilitates clearance of waste products to preserve renal function. The aim of this study was to assess autophagy in podocytes in children with progressive IgA-N at initial diagnosis by electron microscopy and investigate the relationship between the types of autophagy and severity of the disease. METHODS: Renal biopsies from 16 children with established progressive IgA-N were examined by light and transmission electron microscopy with reference to autophagy types in the podocytes and histopathological diagnosis of IgA-N. RESULTS: Two autophagy types were found. Type I rarely transformed to autophagic vacuoles and did not dissolve, thus possibly impairing cell function. However, type II frequently transformed to autophagosomes and autophagic vacuoles thus facilitating protein and lipid clearance. Of the 16 children studied, 8 (50%) with type I autophagy at initial diagnosis showed focal proliferative glomerulosclerosis (GN) of mild type (3 cases, 37.5%), mild/moderate type (2 cases, 25%) and moderate type (3 cases, 37.5%). In contrast, the remaining 8 children with type II autophagy at initial diagnosis showed focal proliferative GN of mild type in 7 (87.5%) and mild/moderate type in 1 (12.5%) case. CONCLUSION: In IgA-N children, the occurrence of type I autophagy is correlated with histopathologically more progressive disease, possibly reflecting a tendency to a poorer prognosis.

Development of a single-tube PCR-pyrosequencing method for the simultaneous and rapid detection of four variant alleles of CYP2C9 gene polymorphism.

BACKGROUND AND OBJECTIVE: CYP2C9 is a polymorphic enzyme that has been reported to metabolize several clinically useful drugs such as warfarin, phenytoin and non-steroidal anti-inflammatory drugs. We designed a rapid single-tube multiplex assay to detect four variant alleles of the CYP2C9 in a single polymerase chain reaction (PCR) and a single pyrosequencing reaction. METHODS: A multiplex PCR was designed to amplify two fragments simultaneously, one containing 430C>T (CYP2C9*2) polymorphism and other containing 1075A>C (CYP2C9*3), 1076T>C (CYP2C9*4) and 1080C>G (CYP2C9*5) polymorphisms. RESULTS: Four variants of the CYP2C9 gene could be simultaneously detected using only two varieties of pyrosequencing primers in a single-tube. The success rate for the four SNPs (*2, *3,*4 and *5) was high. Genotypes obtained by the multiplex reaction were 100% concordant with genotypes obtained using direct DNA sequencing (n = 96). The analysis time was halved, compared with existing simplex pyrosequencing. The system allowed high-throughput analysis of over 384 samples per hour. DISCUSSION: Our method reduces running cost and halves analysis time, compared to simplex pyrosequencing. Another advantage of this method is that it analyses and determines multiple bases around the polymorphic site thereby reducing the possibility of scoring a truncated PCR product.

Exaggerated triglyceride accretion in human preadipocyte-murine renal line hybrids composed of cells from massively obese subjects.

To learn about adipose differentiation of precursors from postnatal adipose tissue of lean and massively obese subjects, human omental adipocyte precursor-murine renal adenocarcinoma cell (RAG) hybrids were formed by fusion with polyethylene glycol, and cultured selectively with 50 microM ouabain in hypoxanthine aminopterin thymidine (HAT) medium. Under conditions in which the parent cells did not differentiate, a number of hybrids, which were cloned, revealed morphologic and biochemical evidence of differentiation. In addition to activation of human genes within the common nucleus of the hybrids, murine cytoplasmic activators are probably also involved because heterocaryons (fused cells with two interspecific nuclei) revealed the same phenomenon. Hybrids composed of precursors from massively obese subjects disclosed more frequent and prominent differentiation. Since these hybrids, in contrast to those from the lean, recapitulate this phenomenon in subcultures, they provide the potential system for mapping the human gene(s) responsible for adipose differentiation and its exaggeration in massive obesity.

Diurnal change of thyroid-stimulating hormone mRNA expression in the rat pars tuberalis.

Thyroid-stimulating hormone (TSH)-producing cells (TSH cells), which account for a large fraction of the cells in the rat pars tuberalis (PT), have been found to express MT1 melatonin receptor and mammalian clock genes at high densities. Although these findings suggest that TSH production in the rat PT is regulated by melatonin and/or the biological clock, there have been no studies focusing on the diurnal change and regulation mechanism of TSH production in the rat PT. Therefore, in the present study, we examined diurnal changes of in TSH beta and alpha-glycoprotein subunit (alpha GSU) mRNA expression and TSH immunoreactivity (-ir) in the rat PT, and also examined the relationship between melatonin and TSH production in vivo. Both TSH beta mRNA expression and alpha GSU mRNA expression in the PT showed diurnal variations: the expression levels were lowest at the light phase [Zeitgeber time (ZT)4] and high at the dark phase (ZT12 and ZT20). TSH-ir in the PT showed the lowest level at ZT4, as was found for mRNA expression. Interestingly, TSH-ir, which was confined to the Golgi apparatus at ZT4, spread to the cytoplasm, and most of the TSH cells in the PT were uniformly immunostained in the cytoplasm at ZT20. Despite the fact that chronic administration of melatonin suppressed TSH beta and alpha GSU mRNA expression, TSH-ir in the PT was significantly enhanced. These findings results clearly show that there are diurnal changes in TSH expression and accumulation in rat PT-TSH cells and suggest that these fluctuations are regulated by melatonin.

Electron microscopic specimen preparation from low concentration of cell suspension using cytospin technique.

Electron microscopic examinations are sometimes limited due to the small number of cells available for analysis. The purpose of this study was to determine the limit of cell concentration for a successful transmission electron microscopic preparation. Various concentrations of monocyte cell suspension were fixed in glutaraldehyde and osmium tetroxide according to the standard methods. Cell preparations were made on silane-coated glass slides in a cytospin centrifuge. The attached cells to the glass slides were dehydrated, and embedded in epoxy resin by routine electron microscopic technique. By this method, cell suspensions containing as low as 2x10(3) cells could show approximately 5 to 10 cells in each hole of the 150-mesh grids which was designated as the lowest limit for the successful preparation with detectable cells for evaluation. The fine structure of cells was clearly evident and the preparations were uniformly free from artifacts, similar or superior to those of cell pellet preparations. This method is useful whenever dealing with the samples containing a low number of cells, particularly those of clinical samples.

Two types of autophagy in the podocytes in renal biopsy specimens: ultrastructural study.

Two types of autophagy in the podocytes were found in renal biopsy specimens by electron microscopy. Type I autophagy (about 1 microm in diameter) was found in 10 out of the 100 cases with renal diseases, and showed a condensed ribosome area with a limiting membrane. The origin of limiting membrane appeared to be from degenerated mitochondria. During type I autophagy formation, the thickness of limiting membrane changed from 5-6 nm to about 8-10 nm thickness. Type I autophagy did not transform to autophagosomes and autophagic vacuoles. On the other hand, many cases (90 out of the 100 cases) showed type II autophagy. Type II autophagy (3-8 microm in diameter) showed that many ribosomes were aggregated, formed condensed ribosome area, which always included many aggregated lipid droplets at first. Next, during the formation of autophagosome, rough ER connected to condensed ribosome area, and partly formed limiting membranes from dilated ER membrane. Finally, the limiting membrane of autophagic vacuoles was completely formed, and this membrane changed from about 5-6 nm to 8-10 nm thickness. Ribosomes and lipid droplets were resolved in autophagic vacuoles. Thus, type II autophagy might play a significant role in clearance of proteins and lipids in comparison with type I autophagy. The occurrence of type I autophagy in the renal biopsy specimens was not clearly associated with age, sex or pathological diagnosis. However, cases with type I autophagy may show a tendency to poor prognosis.

The efficiency of X-ray microanalysis in low-vacuum scanning electron microscope: deposition of calcium on the surface of implanted hydrogel intraocular lens (IOL).

To examine the calcification of implanted hydrogel IOL by X-ray microanalysis, we compared conventional transmission electron microscopy (TEM) with low-vacuum scanning electron microscopy (SEM). We also compared metal coating with non metal coating in low-vacuum SEM. Calcification of IOL showed deposits which were located in the superficial substance of lens. In conventional TEM and X-ray microanalysis, calcium, phosphate and silicon were detected in the deposits. In low-vacuum SEM, the deposits detected in metal coating were calcium, phosphorus, sodium and magnesium, but not silicon. However, in non metal coating, the deposits contained not only calcium, phosphorus, silicon, sodium and magnesium, but also fluoride, aluminum and argentums. It was concluded that in conventional TEM where a specimen is fixed and dehydrated in ethanol, various elements leak out. On the other hand, when a specimen is coated with carbon and gold palladium for SEM, light elements might not be detected in X-ray microanalysis. Low-vacuum SEM preparation does not need metal coating and low-vacuum SEM appears to provide a highly efficient method for X-ray microanalysis.

Expression of nestin in rat and human glomerular podocytes.

Nestin is a neuroepithelial precursor cell marker expressed in a variety of human cell types during development. However, no information exists on the expression of nestin in mature glomeruli as well as during the glomerular development. Here, we examined nestin expression in rat and human glomerular tissues in quiescent states using RT-PCR and immunohistochemical methods. Nestin mRNA was detected in the rat glomeruli in parallel with its expression in developing rat brains. In the normal mature rat glomeruli, WT-1 positive cells expressed nestin. Co-expression of nestin and vimentin was observed in mature rat podocytes. Immunoelectron microscopy revealed nestin localization in the cell bodies and primary processes of podocytes. A similar expression pattern was observed for vimentin. In matured glomeruli, nestin was not expressed by mesangial and endothelial cells. In the newborn rat, early developing glomeruli (metanephric cap, metanephric vesicle, comma-shaped vesicle and S-shaped body phases) expressed nestin. In the capillary loop stage, Bowman's capsules also expressed nestin. Immunoelectron microscopy demonstrated that developing podocytes and endothelial cells in S-shaped phase glomeruli expressed nestin. Additionally, in immature glomeruli, the mesangial cells in capillary stage of glomerulus also expressed nexin. As in the rat, WT-1 positive cells in human glomeruli also expressed nestin and immunoelectron microscopy confirmed nestin expression in human glomerular podocytes. These results reveal that in normal condition nestin is expressed in several glomerular cell types at early stage of development and becomes confined to podocytes in mature glomeruli, thus implicating nestin in podocyte functions.

Possible origin of murine AIDS-inducing sequence.

The murine AIDS (MAIDS) virus has a unique sequence in its gag p12 region. A transcript which hybridizes with this sequence is expressed in normal C57BL/6 mice. This transcript has been proposed to be the origin of the MAIDS virus, since the virus was originally isolated from radiation-induced leukemic C57BL/6 mice. The transcript, designated Edv, was molecularly cloned and sequenced. Compared with the nucleotide sequence of the helper LP-BM5 ecotropic virus, the pathogenic defective MAIDS virus has 16-bp deletions and a 1-bp insertion in the 5' and 3' regions of the gag p12 sequence, respectively, and the Edv transcript contains only a 3-bp deletion. Therefore, the amino acid sequence of the gag p12 region of the MAIDS virus is less homologous to that of the helper virus and Edv transcript due to the frameshift mutations. This suggested that the MAIDS virus was generated by such frameshift mutations in the gag p12 region during recombination between the helper virus and the Edv or a related sequence.

Relationship between chromosomal instability and intratumoral regional DNA ploidy heterogeneity in primary gastric cancers.

The purpose of this study was to elucidate the relationship between intratumoral regional heterogeneity in DNA ploidy and chromosomal instability (CIN) in primary gastric adenocarcinomas. In 45 sporadic gastric adenocarcinomas, we measured DNA ploidy and numerical aberrations for chromosomes 7, 11, 17, and 18 by laser scanning cytometry and fluorescence in situ hybridization, respectively, in small tissue specimens taken from 2 to 6 (on the average 4) different portions of the same tumor. A total of 231 specimens including 45 normal control specimens were examined. All 98 tumor specimens with DNA aneuploidy (DNA index > or = 1.2) showed large intercellular variations in chromosome copy number, indicating CIN. In contrast, 85 tumor specimens with (near) diploidy (1.0 < or = DNA index < 1.2) exhibited much small intercellular variations in chromosome copy number as compared with aneuploid specimens (P < 0.0001). The relationship between DNA ploidy and intercellular variation in chromosome copy number was true for tumors consisting of a mixture of (near) diploid and aneuploid subpopulations. These data indicate that DNA aneuploidy is associated with CIN but that (near) diploidy is not. Intratumoral regional DNA ploidy heterogeneity was conspicuous in 33 (92%) of 36 tumors with regions of DNA aneuploidy, and all aneuploid specimens showed great intercellular variation in chromosome copy number. Diploid regions were predominant in early stage cancers (intramucosal and submucosal cancers), and five of eight early cancers contained only diploid population. In contrast, all tumors without (near) diploid regions were advanced cancers. These observations suggest that CIN is a necessary prerequisite for developing intratumoral DNA ploidy heterogeneity with DNA aneuploidy.

Reversible panhypopituitarism due to Cushing's syndrome.

A patient developed reversible panhypopituitarism due to an adrenal adenoma causing Cushing's syndrome. After removal of the adrenal adenoma, thyroid-stimulating hormone, corticotropin, growth hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin responses to various stimuli recovered completely. The reversible panhypopituitarism of this patient may have occurred at the level of the pituitary gland as a result of hypercortisolemia.

The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge.

One of the postoperative complications of retroperitoneal incision is a flank bulge that is suggested to be caused by 11th intercostal nerve injury leading to denervation of the ipsilateral muscles. To avoid this complication, we have tried to minimize retroperitoneal incision for abdominal aortic aneurysm (AAA) repair. The feasibility of the less incisional retroperitoneal approach for the repair of AAA to prevent postoperative flank bulge was investigated. Twenty-seven patients undergoing elective repair for infrarenal AAA through the left retroperitoneal approach were divided into group-L (less incision: 11.9+/-1.8 cm, n = 7) and group-C (conventional incision: 17.8+/-1.9 cm, n = 20). All operations were performed by a traditional hand-sewn anastomosis without laparoscopic support. Five bifurcated grafts were used in group-L and 15 in group-C. The postoperative course of all patients was uneventful except that one patient in group-C required reoperation for bleeding. Intraoperative parameters of both groups were almost comparable. All patients in group-L were extubated in the operating theater, whereas it was possible only for 11 patients in group-C. Resumption of alimentation was significantly earlier in group-L (P = 0.0117). There was no significant difference in postoperative hospital stay between groups. No late flank bulge was experienced. Significant late atrophy of the left rectus muscle (left/right thickness-ratio = 0.59+/-0.24) was seen in group-C (P = 0.0042 vs preoperative value), which was not observed in group-L (P = 0.0008 between groups). The less incisional retroperitoneal AAA repair seems feasible and safety technique that might prevent postoperative flank bulge and reduce surgical stress.

Electron microscopic studies on the occurrence of activated neutrophils in peripheral blood of children with acute leukemias.

Peripheral blood (PB) cells are examined to assess cellular maturity and the degree of bone marrow abnormality in children with acute leukemias. During the ultrastructural assessments of PB cells in these children, we noted a frequent occurrence of activated neutrophils. This phenomenon had not been reported previously. We here report for the first time the identification of activated neutrophils in PB of children with acute leukemias. To examine the impact of activated neutrophils, we compared two groups of children including 18 with acute lymphoblastic leukemia (ALL) and 7 with acute myelogenous leukemia (AML) by an ultrastructural leukocyte count method. Many cases (50%) showed more than 30% activated neutrophils per total neutrophil count in PB. Activated neutrophils were elongated or amoeboid-shaped cells ranging from 13-18 microns in greater diameter with a decreased number of granules in the cytoplasm. A significantly higher rate of activated neutrophils was observed in ALL as compared with AML (median: 42.97% vs. 10.64%). Non-leukemic hospitalized (n =3) and healthy (n = 3) control cases showed a median rate of 3.32% activated neutrophils in PB. These findings reveal that a significantly high rate of activated neutrophils occurs in PB of children with ALL which may be exploited in the diagnostic assessment of children with acute leukemias.

Reduplicated basal lamina of the peritubular capillaries in renal biopsy specimens.

Reduplicated basal lamina of the peritubular capillaries (PTC) is usually found in kidney allografts in association with chronic transplant nephropathy and sometimes in native renal biopsies. In order to assess the incidence of this phenomenon in native renal biopsy specimens, we have carried out a retrospective review of the diagnostic ultrastructural pathology records of 80 consecutive renal biopsies excluding renal allografts and children with clinical signs of heavy proteinuria. Reduplicated basal lamina of the PTC was found in 19 out of the 80 cases (23.8%) with renal diseases. It was frequently seen in lupus nephritis, IgA nephropathy, and membranoproliferative glomerulonephropathy, being the subtypes of mesangial proliferative lesions. In a few cases it was also found in anti-neutrophil cytoplasmic autoantibody (ANCA) associated glomerulonephritis and benign nephrosclerosis renal biopsies. Reduplicated basal lamina of the PTC was strongly associated with glomerular and peritubular inflammation, and tubular necrosis. Peritubular interstitial edema, slight to moderately increased collagen fibrils, many spiraled collagen fibrils (indicative of degeneration), and collagen fibrils drawing from basal lamina were found around the reduplicated basal lamina of the PTC but not in normal basal lamina. These results indicate that in native renal biopsy specimens, reduplication of the basal lamina of the PTC is associated with endothelial cell injury and capillary permeability abnormality.

Cloning and characterization of human MCM7 promoter.

MCM7 is a member of the MCM protein family which has been implicated in the regulatory machinery allowing DNA to replicate only once during S phase. In quiescent cells, human MCM7 (hMCM7) mRNA is almost undetectable. Stimulation of cells to enter the cell cycle results in induction of hMCM7 expression. Here, we report cloning and characterization of the hMCM7 promoter. We isolated and sequenced a 0.5 kb genomic fragment that contains putative transcription factor binding sites including three E2F sites, three GC boxes and an E box. Several transcription start sites, which were used upon growth stimulation, were identified. The minimal promoter region required for transcription of a luciferase reporter gene was delineated, and it contained an E box and one E2F site, which were important for promoter activity. Interestingly, the cloned sequence appears to act as a promoter for mu-adaptin-related protein 2 (mu-ARP2) gene in the opposite orientation.

Soluble Nef antigen of HIV-1 is cytotoxic for human CD4+ T cells.

We have previously shown that Nef-gene 10 fusion protein induces marked growth arrest of human primary CD4+ T cells. Here, in vitro cytostatic and cytotoxic activities of human immunodeficiency virus type 1 (HIV-1) Nef against CD4+ T cells were extensively investigated. Growth of human CD4+ cells was inhibited significantly just by the addition of purified full-length Nef to cultures. When Nef was cross-linked by anti-Nef antibodies, it became very cytocidal for CD4+ T cells. A high percentage of sera from HIV-1-infected individuals contained soluble Nef. Thus, soluble Nef in vivo may play an important role in immunodysfunction of CD4+ T lymphocytes in HIV-1 infection.

Human immunodeficiency virus type 1 Nef protein on the cell surface is cytocidal for human CD4+ T cells.

We have previously shown that the carboxyl-terminal region of human immunodeficiency virus type 1 (HIV-1) Nef antigen present on the outer surface of virus-infected cells has affinity for uninfected T cells. Here, the in vitro cytotoxic potential of HIV-1 Nef on the T cell surface against CD4+ T cells was investigated in detail. Human T cells expressing Nef on the cell surface by transfection with non-infectious mutant HIV-1 proviruses were demonstrated to kill CD4+ T cells efficiently. Furthermore, it was shown that the carboxyl-terminal portion of Nef was cytotoxic for CD4+ T cells and that monoclonal antibody against the carboxyl-terminal region of Nef inhibited Nef induced-cytolysis. Thus, we concluded that Nef protein on CD4+ T cells may play an important role in the specific loss of CD4+ T lymphocytes during HIV-1 infection.