Low frequency of cytomegalovirus (CMV) disease despite high prevalence of CMV viraemia in patients with advanced HIV infection: a clinical and immunological 48-week follow-up study.

OBJECTIVES: The aim of the study was to investigate the dynamics of cytomegalovirus (CMV) replication and CMV-specific immune response recovery after antiretroviral treatment (ART) initiation in patients with advanced HIV infection. METHODS: A prospective observational study of patients with HIV infection and CD4 counts of < 100 cells/µL was carried out (September 2015 to July 2018). HIV viral load (VL), CD4 count and CMV VL were determined by quantitative polymerase chain reaction (PCR) at baseline and at 4, 12, 24 and 48 weeks, and CMV-specific immune response was determined by QuantiFERON-CMV assay at baseline and 48 weeks. All patients were started on ART but only those with CMV end-organ disease (EOD) received anti-CMV treatment. RESULTS: Fifty-three patients with a median age of 43.6 [interquartile range (IQR) 36.7-52.4] years were included in the study. At baseline, the median CD4 count was 30 cells/µL (IQR 20-60 cells/µL) and the median HIV VL was 462 000 HIV-1 RNA copies/mL (IQR 186 000-1 300 000 copies/mL). At baseline, 32% patients had detectable CMV viraemia but none had detectable CMV viraemia at 48 weeks. Only one of 53 (1.9%) patients developed EOD during follow-up. Seven (13.2%) patients were lost to follow-up and six (11.3%) died; none of the deaths was related to CMV. Similar percentages of patients had a CMV-specific immune response at baseline (71.7%) and at 48 weeks (70.0%). The magnitude of this response tended to increase over time [median 1.63 (IQR 0.15-5.77) IU/mL at baseline vs. median 2.5 (IQR 0.1-8.325) IU/mL at 48 weeks; P = 0.11]. We did not find any risk factors associated with 48-week mortality. CONCLUSIONS: Although the prevalence of CMV viraemia in patients with advanced HIV infection remains high, achieving a good immunological recovery through ART is enough to suppress CMV viraemia, without an increased risk of CMV EOD. The prevalence of a CMV-specific immune response was high and endured over time.

Safety and Efficacy of Prolonged Use of Dalbavancin in Bone and Joint Infections.

Dalbavancin is a lipoglycopeptide with potent activity against Gram-positive microorganisms, a long half-life, a favorable safety profile, and a high concentration in bone, which makes it an interesting alternative for treatment of osteoarticular infections. We performed a multicentric retrospective study of all patients with an osteoarticular infection (septic arthritis, spondylodiscitis, osteomyelitis, or orthopedic implant-related infection) treated with at least one dose of dalbavancin between 2016 and 2017 in 30 institutions in Spain. In order to evaluate the response, patients with or without an orthopedic implant were separated. A total of 64 patients were included. Staphylococcus epidermidis and Staphylococcus aureus were the most frequent microorganisms. The reasons for switching to dalbavancin were simplification (53.1%), adverse events (25%), or failure (21.9%). There were 7 adverse events, and no patient had to discontinue dalbavancin. In 45 cases, infection was related to an orthopedic implant. The implant material was retained in 23 cases, including that in 15 (65.2%) patients that were classified as cured and 8 (34.8%) that presented improvement. In 21 cases, the implants were removed, including those in 16 (76.2%) cases that were considered successes, 4 (19%) cases were considered improved, and 1 (4.8%) case that was considered a failure. Among the 19 cases without implants, 14 (73.7%) were considered cured, 3 (15.8%) were considered improved, and 2 (10.5%) were considered failures. The results show that dalbavancin is a well-tolerated antibiotic, even when >2 doses are administered, and is associated with a high cure rate. These are preliminary data with a short follow-up; therefore, it is necessary to gain more experience and, in the future, to establish the most appropriate dose and frequency.

[Translated article] The effect of showing preoperative photographs on patient satisfaction following forefoot surgery.

BACKGROUND: Postoperative outcome measurement typically relies on postoperative radiological results and clinical-functional scales; however, there is a growing interest in considering patient satisfaction (including subjective aspects) as part of the success of forefoot surgery. OBJECTIVE: To determine whether showing a preoperative photograph improves satisfaction in postoperative forefoot surgery patients. MATERIAL AND METHODS: An observational, cross-sectional, analytical study was conducted in the foot and ankle unit of our centre. We included 120 participants between 18 and 90 years old who underwent forefoot surgery. The degree of satisfaction was compared using the PSQ-10 questionnaire between a group of patients who received a preoperative foot appearance image at their 3-month postoperative follow-up and those who did not receive it. RESULTS: The overall satisfaction rate was 78.33% at 3 months after the intervention. The 93.6% of patients who received the photograph were satisfied at the postoperative follow-up, while in the control group, it was 86.2% with a p value of 0.218. CONCLUSION: The degree of satisfaction in patients undergoing forefoot surgery is not associated with the presentation of preoperative photographs.

The effect of showing preoperative photographs on patient satisfaction following forefoot surgery. / Influencia de la fotografía preoperatoria en el grado de satisfacción en pacientes postoperados de cirugía de antepié.

BACKGROUND: Postoperative outcome measurement typically relies on postoperative radiological results and clinical-functional scales; however, there is a growing interest in considering patient satisfaction (including subjective aspects) as part of the success of forefoot surgery. OBJECTIVE: To determine whether showing a preoperative photograph improves satisfaction in postoperative forefoot surgery patients. MATERIAL AND METHODS: An observational, cross-sectional, analytical study was conducted in the foot and ankle unit of our center. We included 120 participants between 18 and 90 years old who underwent forefoot surgery. The degree of satisfaction was compared using the PSQ-10 questionnaire between a group of patients who received a preoperative foot appearance image at their 3-month postoperative follow-up and those who did not receive it. RESULTS: The overall satisfaction rate was 78.33% at 3 months after the intervention. The 93.6% of patients who received the photograph were satisfied at the postoperative follow-up, while in the control group, it was 86.2% with a p-value of 0.218. CONCLUSION: The degree of satisfaction in patients undergoing forefoot surgery is not associated with the presentation of preoperative photographs.

Neurofibromatosis and early onset of cancers in hMLH1-deficient children.

Hereditary nonpolyposis colon cancer is a common hereditary disorder caused by the germ-line mutations of DNA mismatch repair (MMR) genes, especially hMLH1 and hMSH2. We report here the first identification of human compounds with a homozygous inactivation of a MMR gene. In a typical hereditary nonpolyposis colon cancer family, MMR-deficient children conceived from matings between heterozygotes for a hMLH1 deleterious mutation exhibited clinical features of de novo neurofibromatosis type I and early onset of extracolonic cancers. This observation demonstrates that MMR deficiency is compatible with human development but may lead to mutations during embryogenesis. On the basis of clinical symptoms observed in MMR-deficient children, we speculate that the neurofibromatosis type 1 gene is a preferential target for such alterations.

Arylpiperazines with serotonin-3 antagonist activity: a comparative molecular field analysis.

Comparative molecular field analysis (CoMFA) is applied to antagonists of the 5-HT3 receptor. Analysis is done separately on three published sets of arylpiperazines and on a combination of the three sets. d-Tubocurarine, a conformationally restricted 5-HT3 ligand, is used as a template to assist in selecting the conformation of the antagonists for CoMFA alignment. Two forms of the arylpiperazines (neutral and protonated) and three different kinds of calculated charges (Gasteiger-Hückel, AM1, and AM1 with solvation effect included) are compared. Protonated structures give better statistical results than the neutral species. The way in which charges are calculated does not greatly affect the results. In terms of molecular fields, the behavior in each separate set of compounds cannot be extrapolated to the combined set of 47 compounds. The average value of r2cv from PLS cross-validation on the combined set is 0.70 and varies between 0.56 and 0.80 depending on the orientation of the molecules in the coordinate system. The CoMFA model is tested on four compounds not in the training set: quipazine, N-methylquipazine, 4-phenyl-N-methylquipazine, and KB-6933. Mean agreement of experimental and predicted pKi values of the antagonists is 0.7 log unit. Novel structural modifications are interpreted by the CoMFA model.

Superimposition-based protocol as a tool for determining bioactive conformations. I. Application to ligands of the glycinergic receptor (GlyR).

The natural templates (NT) approach, which is a superimposition-based protocol that has been successfully employed in several studies, is here applied to ligands of the glycine ligand-gated ion channel receptor. Bioactive conformations for glycine and its analogs were obtained using strychnine (a natural and specific competitive antagonist) as template. Experimental evidence was used to guide the superimposition protocol. Three essential regions have been defined in strychnine's structure that serve as a pharmacophore for agonist and antagonist activities. Reasonable alignments of known ligands were found in the majority of the cases. Molecular mechanics (i.e., conformational searches for the relatively flexible ligands) and molecular dynamics (for relatively rigid ligands such as strychnine and 5,6,7,8-tetrahydro-4H-isoxazolo[3,4-d]azepin-3-ol) were used to assess the energetic accessibility of the proposed bioactive conformations.

Superimposition-based protocol as a tool for determining bioactive conformations. II. Application to the GABA(A) receptor.

The natural templates (NT) superimposition method is used to determine the pharmacophoric requirements of the A subtype of the gamma-aminobutyric acid (GABA) receptor. Bioactive conformations for antagonists and agonists are found by superimposing them on a relatively rigid alkaloid bicuculline, which itself is a competitive antagonist at this ligand-gated ion channel receptor. As has been usual in the application of this modeling method, consideration of available experimental data is the cornerstone for obtaining realistic models. The identification of two substructural fragments of bicuculline permitted classification of the ligands. Analysis of the antagonists and agonists with respect to the two substructural fragments revealed two bioactive conformations of the highly flexible GABA molecule, one of which is extended with the nonhydrogenic atoms roughly coplanar torsional angles of -37 and -179 degrees at N-C-C-C and C-C-C-C (carboxyl), respectively. The second bioactive compound is clearly non planar (torsional angles of -81 and -109 degrees at N-C-C-C and C-C-C-C (carboxyl), respectively).

Conformational analysis of some alpha-phenylpropionic acids with anti-inflammatory activity.

CNDO/2 quantum mechanical conformational calculations, as well as 13C and 1H NMR measurements, have been carried out for the propionic acid residues of 2-(p-isobutylphenyl)propionic acid (ibuprofen) and 2-methyl-2-(p-isobutylphenyl)propionic acid. A relationship between the conformational angle of the propionic acid residue and the anti-inflammatory activity appears to exist. The more open the Ph--C alpha--COOH dihedral angle, the larger the anti-inflammatory activity.

Self-consistent field-molecular orbital (SCF-MO) calculations and nuclear magnetic resonance measurements for fosfomycin and related compounds.

In the present work, the mechanism of action of fosfomycin [(-)-(1R,2S)-(1,2-epoxypropyl)phosphonic acid] as an antibiotic agent is studied by "ab initio" quantum mechanical calculations and by 1H, 13C, and 31P NMR measurements. Attention is focused on the relative charge density and chemical shift of the C(2) atom of the epoxy ring, which seems to be closely related with the activity of this antibiotic. The theoretical results suggest that the sulfhydryl addition should be preceded by a necessary anchoring of the phosphonate moiety on a positive group of the receptor.

Quantum mechanical study and nuclear magnetic resonance measurements of some alpha-arylcarboxyalkyl acids as anti-inflammatory agents.

The CNDO/2 quantum mechanical conformation method of analysis, charge density and protonation energy calculations, as well as 13C and 1H NMR measurements were carried out for ibufenac, ibuprofen, methylibuprofen, and for a series of alpha-arylpropionic acids. It was found that the nature of the terminal lipophilic residue does not significantly influence the conformation of the alpha-arylcarboxyalkyl acid side chain. The preferred conformational angle, for the torsion of the phenyl-C alpha bond, was found to be 90, 120, and 180 degrees in ibufenac, ibuprofen, and methylibuprofen, respectively. This conformational angle is calculated to be the same in all the alpha-arylpropionic acids. The protonation energies of the alpha-arylpropionic acids are correlated with the anti-inflammatory activity. It was found that the smaller the protonation energy, the larger the anti-inflammatory activity.

[Somatization symptoms. An emerging pediatric entity]. / Trastornos somatomorfos: una entidad emergente en pediatría.

BACKGROUND: Somatization symptoms are a clinical reality in our environment. However, many pediatricians have little information about this condition or experience of its management. OBJECTIVE: To determine the clinical and differential characteristics of these patients. The early identification of these patients and initiation of therapy in the initial stages of the process would improve prognosis. MATERIAL AND METHOD: A retrospective review was performed of the children admitted to the short-stay unit of a tertiary hospital because of somatic complaints and whose final diagnosis was that of a somatization disorder. RESULTS: Sixty medical records were analyzed, of which 38 (63 %) corresponded to girls, with a mean age of 11 years at presentation. The most frequent reasons for consultation were related to the digestive and neurological systems. Thirty-four patients (57 %) had previously consulted for the same reason. In the sample analyzed, the most frequent personality trait was anxiety. The main triggers were familial and school factors. The most frequent diagnosis was pain disorder in 42 children (70 %). All patients received psychotherapy and 39 received complementary pharmacological treatment. CONCLUSIONS: The data analyzed in this study indicate that somatization symptoms most frequently occur in anxious, prepubescent girls, with migraine or non-specific abdominal pain of approximately one month's duration. Patients have usually made several previous visits and no organic causes are discovered on physical examination.

Comparison of binding mechanisms at cholinergic, serotonergic, glycinergic and GABAergic receptors.

Employing computational methods and published data from molecular biological studies involving amino acid sequences in the polypeptide receptors, the authors studied and compared how two excitatory neurotransmitters, ACh and 5-HT, and two inhibitory neurotransmitters, glycine and GABA, can bind to their respective recognition sites at CNS receptors. Models for each neurotransmitter interaction with specific amino acids are described and identified. Molecular mechanisms are identified that can explain how the binding process initiates ion flow through channels located within the postsynaptic membrane such that if the neurotransmitter is inhibitory, hyperpolarization occurs, and if excitatory, depolarization occurs. Although the theoretical work described indicates that there is a difference in molecular mechanisms operative at the anionic and cationic channels, and provides an explanation why the former is more specific, the molecular modeling data and the similarities of specific amino acids in the sequence in all four receptor polypeptides used to construct the four models support ACh, 5-HT, glycine and GABA as being members of the same ligand-gated ion channel superfamily.

On identifying a second molecular antagonistic mechanism operative at the glycine receptor.

We used molecular modeling techniques to examine six reported antagonists of glycine with varying Ki values against strychnine. We found the data suggest two groups operating with different mechanisms. In group 1 (strychnine, brucine, Pitrazepin, and bicuculline methobromide) the antagonist contains two or three sites that can electrostatically bind to the three comparable groups of opposite charge in the recognition site where the natural neurotransmitter binds, thus opening the chloride channel. In addition, when in this position, the antagonist is able to also block the now opened chloride channel with a different portion of its structure. In many cases, this involves an interaction between a carbonyl group on the antagonist and the guanidinium group of arginine which is part of the polypeptide segment of the outer mouth of the chloride channel (Grenningloh et al., Nature 330:25-26, 1987). In group 2 (R5135 and 1,5-diphenyl-3,7-diazaadamantan-9-ol) the antagonist contains charged sites but when one of these molecules attaches to the recognition site, the chloride channel is not opened. In addition, R5135 contains a carbonyl group which attaches to arginine as pointed out in the text, whereas 1,5-diphenyl-3,7-diazaadamantan-9-ol contains a phenyl group that can block the channel.

The nicotinic cholinergic receptor: a theoretical model.

Based on published affinity-labeling and mutagenesis experiments describing the effect of changes in specific amino acids in molecular biological studies on the nicotinic acetylcholinergic receptor (nAChR), we have identified 12 amino acids which are important in functioning at the nicotinic cholinergic receptor. The work presented here provides an atomistic model of this important receptor based on our molecular modeling studies. We found five of these amino acids (TRP86, ASP89, TYR93, ASP138, and THR191) to be associated with the cationic end of acetylcholine (ACh), which is electron-deficient. Three other amino acids (ARG209, TYR190, and TYR198) are associated with the ester end, where an enhanced electron density is present. After hydrogen bonding between the two oxygen atoms at the ester end, and two of the guanidinium hydrogen atoms in ARG209. ASP200 hydrogen bonds to the other two hydrogen atoms of the guanidinium group, thus forming a pseudo-ring. Two aromatic amino acids (TRP149 and TYR151) then enhance the binding at the pseudo-ring through additional hydrogen bonding and charge-transfer complexation, with THR150 functioning to further stabilize this evolving charge-transfer complex. We postulate that this latter process allows the ion channel to twist, thus opening it. From the published amino acid sequence in the polypeptides at the 5HT-3, GABA, and glycine receptors (Maricq et al.: Science 254:432-437, 1991), we also speculate on which amino acids are involved in these three receptors.

Identification of a second glycine-like fragment on the strychnine molecule.

Strychnine is a complex molecule that inhibits the physiological actions of glycine, an important inhibitory neurotransmitter in the spinal cord, brain stem, and other areas of many vertebrates. Since 1987, we have employed atomistic molecular modeling tools to find an explanation at the molecular level for how this antagonism works. We have located a second glycine-like fragment in the strychnine molecule that, when compared to glycine in a three pair atom analysis, provides an excellent topological and electronic charge congruence. The topological congruence in the second glycine-like fragment is much better than with the first fragment reported in 1987 when using a truncated strychnine molecule in the quantum mechanical analysis. A fourth negative atom, a characteristic of antagonists which we reported earlier (Aprison and Lipkowitz: J Neurosci Res 30:442-446, 1991; Aprison and Lipkowitz: J Neurosci Res 31:166-174, 1992) was found in strychnine. This result follows the pattern reported recently for the three weak glycine antagonists N,N-dimethylmuscimol, N-methyl-THIP, and iso-THAO, a bicyclic 5-isoxazolol zwitterion.

On a molecular comparison of strong and weak antagonists at the glycinergic receptor.

Using molecular modeling techniques, we studied nine glycine antagonists in order to try to identify the molecular descriptors that characterize strychnine as a strong antagonist and N,N-dimethyl-muscimol, iso-THIA, THIA, N-methyl-THIP, iso-THAZ, THAZ, iso-THPO, and iso-THAO (see Experimental for chemical names) as weak glycine antagonists. We confirm that all nine compounds have the three-atom regions (two negative and one positive) that we have postulated are necessary to permit such compounds to attach to the recognition site in the glycinergic synapse. Furthermore, in the case of antagonists we have postulated the presence of a fourth atom that can attach to the top of the chloride ion channel. Each of the nine antagonists has such a fourth negative atom and the latter property gives each of these compounds their antagonistic characteristic. Further, only in the case of strychnine is there evidence that at its positively charged end does the positive charge extend to cover a region that could bind through electrostatic domains to a tertiary carboxyl group in an amino acid like aspartate. Published molecular biological data show that such an amino acid is present in the portion of the polypeptides identified in the glycine receptor. The bidentate binding is superior to the single site attachment that is present in the other eight weak glycine antagonists. In addition, the two negative atom sites in each antagonist are also in a position to participate in electrostatic binding through bidentate involvement with the positively charged guanidinium group of arginine. The latter amino acid also has been identified in the portion of the polypeptide chain at the glycine receptor. Finally, our molecular data predict that after strychnine, the eight weak glycine antagonists listed above are in order of decreasing potency, i.e., N,N-dimethyl-muscimol is the best of the weak antagonists and iso-THAO should be the weakest.

Prevalence of germline mutations of hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 genes in 75 French kindreds with nonpolyposis colorectal cancer.

Hereditary nonpolyposis colorectal cancer (HNPCC) is a syndrome characterized by familial predisposition to colorectal carcinoma and extracolonic cancers of the gastrointestinal, urological, and female reproductive tracts. This dominant disorder is caused by germline defects in one of at least five DNA mismatch repair (MMR) genes: hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 (GTBP). Germline mutations of hMSH2 and hMLH1 are also frequently identified in families not fulfilling all the Amsterdam criteria, thereby demonstrating that the involvement of these genes is not confined to typical HNPCC. To evaluate the respective involvement of the various MMR genes in typical and incomplete HNPCC syndromes, we have performed an analysis of the hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6 genes in a large series of French kindreds (n=75) with colorectal tumors and/or aggregation of extracolonic cancers belonging to the HNPCC spectrum. Mutational analysis has been performed in all families, without preselection for the tumor phenotype. We have detected 26 pathogenic germline mutations of the hMLH1 and hMSH2 genes and several novel variants of the hPMS1, hPMS2, and hMSH6 genes. Our data confirm that, regardless of the type of families and the tumor phenotype, hPMS1, hPMS2, and hMSH6 germline mutations are rare in familial aggregation of colorectal cancers. Furthermore, they suggest that the presence of multiple primary malignancies in a single individual and the observation of extracolonic tumors in relatives of a colorectal cancer patient should be included among the guidelines for referring patients for genetic testing.

Glycine and GABA receptors: molecular mechanisms controlling chloride ion flux.

We have been able to show that the three clearly identified atoms common to the inhibitory neurotransmitters glycine and GABA, that we previously hypothesized to serve as attachment points at the glycinergic and gabanergic receptor, can indeed interact through both electrostatic and hydrogen bonding to several amino acids, which have been identified in molecular biological investigations as both present and critical in the physiological functioning of key polypeptides common to these inhibitory receptors. In addition, amino acids also involved in stabilizing the interaction between the antagonists strychnine and R5135 at the glycinergic and gabanergic receptors, respectively, have been shown to fit our complex model. We identify in detail molecular mechanisms to explain how glycine and GABA initiate chloride ion movement from extraneuronal fluid in the synaptic cleft to intraneuronal volume. In addition, we also identify the molecular mechanisms involved in the blocking of chloride ion movement by strychnine at the glycinergic receptor and by R5135 at the gabanergic receptor. We also present two computer-generated color prints, one for the glycine receptor and one for the GABA receptor, which show the quantum mechanically geometry optimized complex formed between receptor side chains, i.e., the part of the amino acids in the polypeptide that interacts with the zwitterionic inhibitory neurotransmitters. These computer-generated color figures also show a) the important electrostatic and hydrogen bonding in these interactions, b) a van der Waals model of this complex to illustrate that no steric repulsions exist, and c) the molecular electrostatic potential energy map showing the electrostatic potentials of neurotransmitter bound to the receptor model. Finally, we show with computer calculations that the pseudo-rings, formed between the positive quanidinium group in arginine and one of the oxygen atoms in the carboxyl group in both glycine or GABA, result in a positive planar region which appears to be involved in a charge-transfer complex with aromatic benzene groups in amino acids such as phenylalanine and tryosine.