Clinical Application of Variation in Replication Kinetics During Episodes of Post-transplant Cytomegalovirus Infections.

BACKGROUND: Cytomegalovirus (CMV) infection in transplant recipients is reported to replicate with a doubling time of 1.2-2 days, and weekly screening is recommended for early diagnosis. We re-evaluated these features in our cohort of transplant recipients. METHODS: The CMV doubling time of the first CMV infection in the first year post-transplant could be calculated for 193 recipients of haematopoietic stem cell or solid organ transplantation. Factors determining the proportion of recipients with a high diagnostic CMV viral load (≥ 18,200 IU/mL) were explored using mathematical simulation. FINDINGS: The overall median doubling time was 4.3 days (IQR 2.5-7.8) and was not influenced by prior CMV immunity, or type of transplantation (p > 0.4). Assuming a fixed doubling time of 1.3 days and screening intervals of 7 or 10 days, 11.1% and 33.3% were projected to have a high CMV viral load at diagnosis, compared to 1.4% and 4.3% if the doubling time varies as observed in our cohort. Consistently, 1.9% of recipients screened weekly had a high diagnostic virus load. INTERPRETATION: Screening intervals can be extended to 10 days in cohorts with comparable CMV doubling time, whereas shorter than 7 days is required in cohorts with shorter doubling times to maintain pre-emptive screening quality.

Effects of levosimendan in patients with left ventricular hypertrophy undergoing aortic valve replacement.

BACKGROUND: Left ventricular hypertrophy is associated with adverse outcomes, including death, during cardiac surgery. This may be facilitated by an increased oxygen demand and diastolic dysfunction. Levosimendan augments haemodynamics without further oxygen consumption and improves echocardiographic indices of diastolic dysfunction. This study aimed to describe the haemodynamic effects of short-term pre- and intra-operative levosimendan infusion including advanced echocardiographic measures of diastolic and systolic heart function. METHODS: The study was randomised, double-blinded and placebo-controlled performed at a single-centre university hospital. Patients with left ventricular hypertrophy and ejection fraction > 45% scheduled for single procedure aortic valve replacement were included and randomised to infusion of either levosimendan 0.1 µg/kg/min or placebo from 4 h before anaesthesia to the end of surgery. Outcome measures were echocardiographic indices of left ventricular diastolic function: E/e' (primary endpoint), e', e'/a' and indices of systolic function: longitudinal strain, ejection fraction and s'. Patients were followed until 6 months after surgery. In addition, invasive haemodynamic measures were obtained perioperatively. RESULTS: The trial was prematurely terminated due to an overall high incidence of post-operative atrial fibrillation (15/20, P = 0.002) after inclusion of 20 patients. The relative decrease in perioperative cardiac index was lower (P = 0.016) in the levosimendan group. There was no difference in E/e', and similar results were found for all measures of systolic function. CONCLUSION: Short-term levosimendan caused a transient relative increase in cardiac index, but no effect was seen on the first post-operative day and up to 6 months post-operatively with indices of systolic and diastolic heart function.

Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures.

BACKGROUND: Unexpected cardiopulmonary complications are well described during surgery and anesthesia. Pre-operative evaluation by focused cardiopulmonary ultrasonography may prevent such mishaps. The aim of this study was to determine the frequency of unexpected cardiopulmonary pathology with focused ultrasonography in patients undergoing urgent surgical procedures. METHODS: We performed pre-operative focused cardiopulmonary ultrasonography in patients aged 18 years or above undergoing urgent surgical procedures at pre-defined study days. Known and unexpected cardiopulmonary pathology was recorded, and subsequent changes in the anesthesia technique or supportive actions were registered. RESULTS: A total of 112 patients scheduled for urgent surgical procedures were included. Their mean age (standard deviation) was 62 (21) years. Of these patients, 24% were American Society of Anesthesiologists (ASA) class 1, 39% were ASA class 2, 32% were ASA class 3, and 4% were ASA class 4. Unexpected cardiopulmonary pathology was disclosed in 27% [95% confidence interval (CI) 19-36] of the patients and led to a change in anesthesia technique or supportive actions in 43% (95% CI 25-63) of these. Unexpected pathology leading to changes in anesthesia technique or supportive actions was only disclosed in a group of patients above the age of 60 years and/or in ASA class ≥ 3. CONCLUSION: Focused cardiopulmonary ultrasonography disclosed unexpected pathology in patients undergoing urgent surgical procedures and induced changes in the anesthesia technique or supportive actions. Pre-operative focused ultrasonography seems feasible in patients above 60 year and/or with physical limitations but not in young, healthy individuals.

The time course of development and impact from viral resistance against ganciclovir in cytomegalovirus infection.

(Val)ganciclovir is used to treat cytomegalovirus (CMV) infection following solid organ (SOT) or hematopoietic stem cell (HSCT) transplantation. Treatment failures occur, but the contribution from 39 known ganciclovir-related mutations (GRMs) in the CMV-UL97 gene remains controversial. We propose a categorization of these GRMs potentially useful when interpreting sequence analyses in clinical settings. The UL97 gene was sequenced from first/recurrent CMV infections among consecutive SOT or HSCT recipients during 2004-2009. GRMs were categorized as: Signature GRM (sGRM) if in vitro ganciclovir IC(50) ratio for mutated versus wild-type virus >2 (n = 24); polymorphic GRM (pGRM) if ratio <2 (n = 15). (Val)ganciclovir treatment failure was defined as persistent viremia for 30 days or switch to foscarnet within this period. Of 99 (49 HSCT and 50 SOT) recipients with one CMV infection episode, 15 (13 HSCT and 2 SOT) experienced a total of 19 recurrent infection episodes. The prevalence of sGRM was 0% at start of first episode, whereas at start of recurrent episodes, prevalence was 37%. Only one sGRM was present at a time in individual patients. Patients with CMV containing an sGRM (vs. wild type)-but not with a pGRM-were at excess risk of treatment failure (odds ratio = 70.6 [95% CI:8.2-609.6]; p < 0.001). sGRMs emerged only following longer termed use of antiherpetic drugs and usually in recurrent CMV infection episodes. Risk of ganciclovir treatment failure was raised if an sGRM was detected.

Plasma TIMP-1 levels and treatment outcome in patients treated with XELOX for metastatic colorectal cancer.

BACKGROUND: The aim was to evaluate the association between plasma tissue inhibitor of metalloproteinase-1 (TIMP-1) and serum carcinoembryonic antigen (CEA) levels and outcome in patients with metastatic colorectal cancer (mCRC) receiving XELOX (combination chemotherapy with capecitabine and oxaliplatin) as first-line treatment. PATIENTS AND METHODS: One hundred and twenty patients were included. Blood samples were collected before treatment and 3 weeks later before the next treatment cycle. Plasma TIMP-1 and serum CEA levels were correlated to treatment outcome. RESULTS: No significant associations between baseline TIMP-1 or CEA levels and best response to treatment or progression-free survival (PFS) could be demonstrated. In contrast, high baseline plasma TIMP-1 levels were associated with poor overall survival (OS), P = 0.008, hazard ratio (HR) = 1.80 [95% confidence interval (CI): 1.17-2.78]. Furthermore, increase in TIMP-1 levels from baseline to immediately before the second cycle of chemotherapy had a significant negative effect on survival (P = 0.03, HR = 1.30, 95% CI: 1.02-1.65) while a decrease in TIMP-1 was significantly associated with a higher objective response rate (P = 0.03). CONCLUSIONS: Both high baseline and subsequent increase in TIMP-1 levels were associated with shorter OS in patients with mCRC receiving XELOX as first-line treatment, whereas baseline TIMP-1 levels were not associated with response or PFS following XELOX treatment.

New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners.

BACKGROUND: Cardiovascular status is a crucial determinant in the pre-operative assessment of patients for surgery as well as for the handling of patients with acute illness. We hypothesized that focus-assessed transthoracic echocardiography (FATE) could be performed with the subject in the semi-recumbent position. The aim was also to test whether the image quality of Vscan is interchangeable with a conventional high-quality portable echocardiography system. Furthermore, we evaluated the time needed to achieve an interpretable four-chamber view and to complete a full FATE examination. METHODS: Sixty-one subjects were included. All subjects were examined in accordance with the FATE protocol in the semi-recumbent position on two different systems: the novel Vscan pocket device and the high-quality portable Vivid i system. Two evaluations were performed. In group A (n=30), the focus was on image quality. In group B (n=31), the focus was on the time consumed. RESULTS: Group A: All patients (100%) had at least one image suitable for interpretation and no significant difference in image quality (P=0.32) was found between the two different systems. Group B: The mean value for the total time consumed for a full FATE was 69.3 s (59.8-78.8) on the Vscan and 63.7s (56.7-70.8) on the Vivid i, with no significant difference among the scanners (P=0.08). CONCLUSION: The Vscan displays image quality interchangeable with larger and more expensive systems. The apparatus is well suited for performing a FATE examination in a 1-day surgery setting and could very well also be applicable in almost any situation involving patients with acute illness.

Changes in plasma TIMP-1 levels after resection for primary colorectal cancer.

BACKGROUND: Increased plasma levels of tissue inhibitor of metalloproteinases (TIMP-1) are associated with poor outcome in colorectal cancer (CRC), however postoperative changes in plasma TIMP-1 levels after resections for CRC have not been thoroughly evaluated. MATERIALS AND METHODS: Plasma samples were collected from 45 patients with primary CRC, preoperatively, 2 hours after surgery, and at days 1, 2, 7, 28, 45, 60, 75 and 90 after surgery. TIMP-1 and CEA levels were determined using the ARCHITECT Immunoanalyzer. RESULTS: Postoperatively, the mean (geometric) TIMP-1 level increased and had a maximum level at day 1 (p < 0.0001). The mean TIMP-1 level then declined to a level at day 90 similar to the mean preoperative level. CONCLUSION: A mean decline in plasma TIMP-1 levels was not observed within 90 days. However, individual significant reductions of plasma TIMP-1 levels did occur within 28-60 days postoperatively.

Assessment of the biological variation of plasma tissue inhibitor of metalloproteinases-1.

BACKGROUND: Tissue inhibitor of metalloproteinases-1 (TIMP-1) measurements in plasma may be useful for the early detection and prognosis of colorectal cancer (CRC). Data on analytical performance and normal intra- and interindividual biological variation are required in order to interpret the utility of TIMP-1 in CRC. The aim of this study was to establish the biological and analytical variation of plasma TIMP-1 in volunteers. MATERIAL AND METHODS: Three separate studies were undertaken. 1: Plasma was collected from 23 volunteers 6 times within a 3-week period, first in September 2004 (round [R] 1), then repeated in May 2005 (R2) and May 2006 (R3) in the same group of individuals. TIMP-1 levels were determined by the MAC15 ELISA assay and with the Abbott ARCHITECT i2000 Immunoanalyzer. 2: Circadian variation was evaluated in plasma collected 7 times within a 24-hour period (n=16). 3: Effects of physical exercise were evaluated in plasma collected before and after bicycling (n=14). In studies 2 and 3 TIMP-1 levels were determined with the MAC15 ELISA assay only. RESULTS: A significant correlation between TIMP-1 MAC15 and ARCHITECT i2000 was shown (rs=0.78, p<0.002), with consistently higher levels being detected by the ARCHITECT i2000. Median levels of TIMP-1 (ARCHITECT) at 8 a.m. in each round were 74.9 ng/mL (range 65.7-89.9) (R1), 87.3 ng/mL (range 72.7-127.9) (R2), and 81.9 ng/mL (range 66.8-113.6) (R3). The within-subject variation was 10.7%, the variation between rounds was 7.4%, and the intraclass correlation was 46.2%. Comparison between the 3 rounds and time of collection showed that TIMP-1 values decreased by 11% after storage for more than 16 months (p=0.0002). A systematic circadian variation in plasma TIMP-1 levels was not observed (p=0.17). No significant variation of plasma TIMP-1 was found in relation to physical exercise (p=0.92 [global test]). CONCLUSION: Levels of plasma TIMP-1 in volunteers show limited circadian, day-to-day, week-to-week and season-to-season variation. In addition, physical exercise has no impact on plasma TIMP-1 levels. Possible storage-dependent decreases in plasma TIMP-1 levels warrant further investigation.

Tissue inhibitor of metalloproteinase-1 levels in plasma from tumour arteries and veins of patients with rectal cancer.

OBJECTIVE: Tissue inhibitor of metalloproteinase-1 (TIMP-1) plays a major role in the regulation of tissue growth, including cancer growth. The TIMP-1 protein can be determined in plasma, and increased plasma levels of TIMP-1 are associated with a poor prognosis of colorectal cancer patients. The aim of the present study was to evaluate whether tumour tissue release of the TIMP-1 protein contributes to the increased plasma levels of TIMP-1 observed in patients with colorectal cancer. MATERIAL AND METHODS: Preoperative blood samples from a peripheral vein and intraoperative blood samples from a tumour artery, a tumour vein and from a peripheral vein were drawn from 24 patients undergoing elective, intended curative surgery for primary rectal cancer. TIMP-1 levels were determined concurrently in plasma from all samples using a validated ELISA method. Counts of white blood cells and platelets were also carried out. RESULTS: No significant differences between plasma TIMP-1 levels could be demonstrated in any compartment. In particular, there was no significant difference in TIMP-1 levels in plasma from tumour arteries and tumour veins. However, there was a significant decrease in neutrophil cell counts from tumour arteries to tumour veins (p<0.001). CONCLUSIONS: The present results do not support the current hypothesis that tumour cells contribute substantially to increased plasma TIMP-1 levels observed in patients with colorectal cancer.

Identification of gene expression patterns in superficial and invasive human bladder cancer.

Multiple transcriptional events take place when normal urothelium is transformed into tumor tissue. These can now be monitored simultaneously by the use of oligonucleotide arrays, and expression patterns of superficial and invasive tumors can be established. Single-cell suspensions were prepared from bladder biopsies (36 normal, 29 tumor). Pools of cells were made from normal urothelium and from pTa grade I and II and pT2 grade III and IV bladder tumors. From these suspensions, and from 10 single-tumor biopsies, labeled cRNA was hybridized to oligonucleotide arrays carrying probes for 6500 genes. The obtained expression data were sorted according to a weighting scheme and were subjected to hierarchical cluster analysis of tissues and genes. Northern blotting was used to verify the array data, and immunohistology was used to correlate between RNA and protein levels. Hierarchical clustering of samples correctly identified the stage using both 4076 genes and a subset of 400 genes covarying with the stages and grades of tumors. Hierarchical clustering of gene expression levels identified several stage-characteristic, functionally related clusters, encoding proteins that were related to cell proliferation, oncogenes and growth factors, cell adhesion, immunology, transcription, proteinases, and ribosomes. Northern blotting correlated well with array data. Immunohistology showed a good concordance between transcript level and protein staining. The study indicates that gene expression patterns may be identified in bladder cancer by combining oligonucleotide arrays and cluster analysis. These patterns give new biological insight and may form a basis for the construction of molecular classifiers and for developing new therapy for bladder cancer.

Gene expression profiling: monitoring transcription and translation products using DNA microarrays and proteomics.

Novel and powerful technologies such as DNA microarrays and proteomics have made possible the analysis of the expression levels of multiple genes simultaneously both in health and disease. In combination, these technologies promise to revolutionize biology, in particular in the area of molecular medicine as they are expected to reveal gene regulation events involved in disease progression as well as to pinpoint potential targets for drug discovery and diagnostics. Here, we review the current status of these technologies and highlight some studies in which they have been applied in concert to the analysis of biopsy specimens.

Adrenaline influences the release of interleukin-6 from murine pituicytes: role of beta2-adrenoceptors.

In this study, we examined the effect of adrenaline and interleukin-1beta on interleukin-6 secretion from cultured murine neurohypophyseal cells. Cells were cultured from neurohypophyses of 3- to 5-week-old mice and experiments were performed after 13 days in culture. Interleukin-6 was measured in 24-h samples using a sandwich fluoroimmunoassay. Unstimulated cells released 19+/-3 fmol interleukin-6/neurohypophysis/24 h (mean +/- S.E.M., n = 42). Adrenaline and interleukin-1beta increased the release of interleukin-6 from the cells in a concentration-dependent manner. Incubation with adrenaline (10(-6) M) or interleukin-1beta (11 pM) induced maximal secretion of interleukin-6, resulting in a 2.2-fold and 19.8-fold increase, respectively (P<0.01). The action of adrenaline (10(-6) M) and interleukin-1beta (1.1 pM) was examined separately and together. The sum of the effect of the two compounds given alone was significantly less (P<0.05) than the effect when adrenaline and interleukin-1beta were given together. We examined the effect of the beta-adrenoceptor antagonist propranolol (3.4x10(-6) M), the beta2-adrenoceptor antagonist (+/-)-1-[2,3-(Dihydro-7-methyl-1H-inden-4-yl)oxy]-3-[(1-methyl-eth yl)amino]-2-butanol (ICI 118551) (10(-7) M) and the beta1-adrenoceptor antagonist atenolol (10(-7) M and 10(-6) M) on the adrenaline-stimulated release of interleukin-6. Propranolol and ICI 118551 completely blocked the action of adrenaline, whereas atenolol was inactive. It is concluded that the stimulatory effect of adrenaline is mediated via beta2-adrenoceptors.