Healthcare utilisation and cost expenditures for pneumonia in individuals with diabetes mellitus in the USA.

Pneumonia is one of the leading causes of hospitalisations among adults in the USA. Individuals with diabetes mellitus (DM) have been associated with increased risk for pneumonia and complications including death. The objectives of this study were to (1) compare the prevalence and healthcare utilisation patterns for pneumonia in individuals with and without DM, and (2) identify risk factors for pneumonia in those with DM. We performed a retrospective, cross-sectional analysis of the US adult population using Medical Expenditure Panel Surveys (MEPS) data from 2014. Overall, the data represented 24 million individuals with DM and 218 million without DM in the USA. The population-based rate for a pneumonia event was 34 per 1000 persons for individuals with DM and 19 per 1000 persons without DM. Compared to the non-DM group, individuals with DM were treated 1.8x, 2.6x and 1.4x more in the ED, hospital and outpatient, respectively. Furthermore, the average cost per pneumonia event was significantly higher among individuals with DM compared to non-DM in the inpatient setting ($11 931 vs. $7751; P < 0.001). Among individuals with DM, female sex, DM complications, smokers and administration of pneumococcal vaccines were significant factors associated with a pneumonia event.

Not all hip arthroplasties are created equal: increased complications and re-admissions after total hip arthroplasty for femoral neck fractures compared with osteoarthritis.

AIMS: Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNFs), especially in physiologically younger patients. While THA for osteoarthritis (OA) has demonstrated low complication rates and increased quality of life, results of THA for acute FNF are not as clear. Currently, a THA performed for FNF is included in an institutional arthroplasty bundle without adequate risk adjustment, potentially placing centres participating in fracture care at financial disadvantage. The purpose of this study is to report on perioperative complication rates after THA for FNF compared with elective THA performed for OA of the hip. PATIENTS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2008 and 2016 was queried. Patients were identified using the THA Current Procedural Terminology (CPT) code and divided into groups by diagnosis: OA in one and FNF in another. Univariate statistics were performed. Continuous variables were compared between groups using Student's t-test, and the chi-squared test was used to compare categorical variables. Multivariate and propensity-matched logistic regression analyses were performed to control for risk factors of interest. RESULTS: Analyses included 139 635 patients undergoing THA. OA was the indication in 135 013 cases and FNF in 4622 cases. After propensity matching, mortality within 30 days (1.8% vs 0.3%; p < 0.001) and major morbidity (24.2% vs 19%; p < 0.001) were significantly higher among FNF patients. Re-operation (3.7% vs 2.7%; p = 0.014) and re-admission (7.3% vs 5.5%; p = 0.002) were significantly higher among FNF patients. Hip fracture patients had significantly longer operative time and length of stay (LOS), and were significantly less likely to be discharged to their home. Multivariate analyses gave similar results. CONCLUSION: This large database study showed a higher risk of postoperative complications including mortality, major morbidity, re-operation, re-admission, prolonged operative time, increased LOS, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. While THA is a good option for FNF patients, there are increased costs and financial risks to centres with a joint arthroplasty bundle programme participating in fracture care. Cite this article: Bone Joint J 2019;101-B(6 Supple B):84-90.

When are anti-fat attitudes understood as prejudice versus truth? An experimental study of social influence effects.

BACKGROUND/OBJECTIVES: If people who hold anti-fat attitudes believe these attitudes to be true, then anti-prejudice appeals are likely to be unsuccessful, if only because the targets will not see their attitudes as in need of change. The current study examined processes that may lead people to see their anti-fat attitudes as 'truth' or as 'prejudice'. SUBJECTS/METHODS: Participants (N = 482) read anti-fat statements and were then presented with an interpretation of these statements as 'truth' or 'prejudice'. The source of this interpretation was either an (i) in-group or out-group member and (ii) expert or non-expert. Participants' judgements of the statements were expected to vary such that in-group others and experts would exert more influence than would out-group others and non-experts. RESULTS: Participants aligned their own interpretations of an anti-fat statement with those of an expert, but not with those of a non-expert, F(1,466) = 8.97, p < 0.05, ηp 2 = 0.02. The group membership variable had no effect on judgements of 'truth' or 'prejudice' of the anti-fat statement. CONCLUSION: The expressions that people believe constitute anti-fat prejudice versus truth about people described as overweight are influenced by exposure to expert opinion (in this case, by medical doctors). Implications for the success of weight-based anti-prejudice appeals and for healthcare provision are discussed.

'Hot Joints' infection protocol reduces unnecessary post-operative re-admissions following total hip and knee arthroplasty.

AIMS: To evaluate the effectiveness of an institutionally developed algorithm for evaluation and diagnosis of prosthetic joint injection and to determine the impact of this protocol on overall hospital re-admissions.p PATIENTS AND METHODS: We retrospectively evaluated 2685 total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients prior to (1263) and following (1422) the introduction of an infection detection protocol. The protocol used conservative thresholds for C-reactive protein to direct the medical attendant to aspirate the joint. The protocol incorporated a clear set of laboratory and clinical criteria that allowed a patient to be discharged home if all were met. Patients were included if they presented to our emergency department within 120 days post-operatively with concerns for swelling, pain or infection and were excluded if they had an unambiguous infection or if their chief complaint was non-orthopaedic in nature. RESULTS: Concern for infection was the single most common (32%) reason for presentation. A total of 296 patients made an emergency visit and were included following THA or TKA. In the pre-protocol cohort, 11 of 27 patients were formally re-admitted to the hospital with concern for infection but only five (45%) patients had actual infections and received additional treatment. In comparison, in the post-protocol cohort, 11 patients were admitted for suspected infection, nine (82%) of whom were truly infected (p = 0.04). Sensitivity increased from 83% to 100% and specificity increased from 71% to 96%. Implementation of this protocol did not miss any infections. CONCLUSION: A standardised protocol for evaluation of THA and TKA infections significantly reduced unnecessary hospital re-admissions. The protocol was both sensitive and specific and did not compromise quality of care. Cite this article: Bone Joint J 2017;99-B:1603-10.

Predictors of community-associated Staphylococcus aureus, methicillin-resistant and methicillin-susceptible Staphylococcus aureus skin and soft tissue infections in primary-care settings.

Skin and soft tissue infections (SSTIs) due to Staphylococcus aureus have become increasingly common in the outpatient setting; however, risk factors for differentiating methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) SSTIs are needed to better inform antibiotic treatment decisions. We performed a case-case-control study within 14 primary-care clinics in South Texas from 2007 to 2015. Overall, 325 patients [S. aureus SSTI cases (case group 1, n = 175); MRSA SSTI cases (case group 2, n = 115); MSSA SSTI cases (case group 3, n = 60); uninfected control group (control, n = 150)] were evaluated. Each case group was compared to the control group, and then qualitatively contrasted to identify unique risk factors associated with S. aureus, MRSA, and MSSA SSTIs. Overall, prior SSTIs [adjusted odds ratio (aOR) 7·60, 95% confidence interval (CI) 3·31-17·45], male gender (aOR 1·74, 95% CI 1·06-2·85), and absence of healthcare occupation status (aOR 0·14, 95% CI 0·03-0·68) were independently associated with S. aureus SSTIs. The only unique risk factor for community-associated (CA)-MRSA SSTIs was a high body weight (⩾110 kg) (aOR 2·03, 95% CI 1·01-4·09).

Patient-specific cutting blocks: Of Unproven Value.

Patient specific instrumentation (PSI) uses advanced imaging of the knee (CT or MRI) to generate individualised cutting blocks aimed to make the procedure of total knee arthroplasty (TKA) more accurate and efficient. However, in this era of healthcare cost consciousness, the value of new technologies needs to be critically evaluated. There have been several comparative studies looking at PSI versus standard instrumentation. Most compare PSI with conventional instrumentation in terms of alignment in the coronal plane, operative time and surgical efficiency, cost effectiveness and short-term outcomes. Several systematic reviews and meta-analyses have also been published. PSI has not been shown to be superior compared with conventional instrumentation in its ability to restore traditional mechanical alignment in primary TKA. Most studies show comparative efficacy and no decrease in the number of outliers in either group. In terms of operative time and efficiency, PSI tended towards decreasing operative time, saving a mean of five minutes per patient (0 to 20). Furthermore, while some cost savings could be realised with less operative time and reduced instrumentation per patient, these savings were overcome by the cost of the CT/MRI and the cutting blocks. Finally, there was no evidence that PSI positively affected clinical outcomes at two days, two months, or two years. Consequently, current evidence does not support routine use of PSI in routine primary TKA.

Which patients need critical care intervention after total joint arthroplasty? : a prospective study of factors associated with the need for intensive care following surgery.

Older patients with multiple medical co-morbidities are increasingly being offered and undergoing total joint arthroplasty (TJA). These patients are more likely to require intensive care support, following surgery. We prospectively evaluated the need for intensive care admission and intervention in a consecutive series of 738 patients undergoing elective hip and knee arthroplasty procedures. The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk factors, correlating with the need for critical care intervention, according to published guidelines, were analysed to identify high-risk patients who would benefit from post-operative critical care monitoring. A total of 50 patients (6.7%) in our series required critical care level interventions during their hospital stay. Six independent multivariate clinical predictors were identified (p < 0.001) including a history of congestive heart failure (odds ratio (OR) 24.26, 95% confidence interval (CI) 9.51 to 61.91), estimated blood loss > 1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index > 35 kg/m(2) (OR 2.70, 95% CI 123 to 5.94). The model was then validated against an independent, previously published data set of 1594 consecutive patients. The use of this risk stratification model can be helpful in predicting which high-risk patients would benefit from a higher level of monitoring and care after elective TJA and aid hospitals in allocating precious critical care resources.

How do radiologists evaluate osteonecrosis?

OBJECTIVES: Management of patients with osteonecrosis of the hip remains controversial and challenging. Because the prognosis and treatment are determined in large part by the stage and extent of the disease, it is important to use a reliable and efficient method for evaluation and staging. The objective of this study was to determine how musculoskeletal (MSK) radiologists evaluate osteonecrosis and whether this evaluation is adequate. MATERIALS AND METHODS: A 12-part questionnaire was designed to determine how MSK radiologists evaluate patients with osteonecrosis of the femoral head (ONFH). This was sent to 888 members of the Society of Skeletal Radiology. RESULTS: One hundred and twenty-one members responded to essentially all questions. Patients were evaluated using plain radiographs and MRI. All agreed that it is clinically important to determine the extent of necrosis and joint involvement, and 115 (95 %) stated that this should be part of the radiologists' evaluation. However, only 55 (46 %) said that in practice they used a specific system of classification, and most of these used the Ficat and Arlet classification, which does not indicate the extent of involvement. One hundred and seven (88 %) respondents included a simple visual estimate of the extent of involvement, and a small number added a specific measurement of lesion size. The majority indicated that they were infrequently consulted about which imaging studies should be obtained. CONCLUSIONS: Although radiologists recognize the clinical importance of determining the extent of necrosis and joint involvement in patients with ONFH, in practice the methods used to evaluate these patients often do not accomplish this satisfactorily. The use of an effective classification, which includes both stage and extent of involvement, should be stressed, as it will lead to improved treatment of patients with ON. Physicians who order imaging studies for patients with ON should be encouraged to consult routinely with their radiology colleagues regarding which studies to request, as well as on the interpretation of these studies.

Cell-culture-based immunochromatography for rapid detection of group A human rotaviruses in aquatic environments.

In an effort to detect rapidly and conveniently the infectious waterborne group A human rotaviruses that cause diarrhea in infants and children, the authors developed the first-ever cell-culture-based immunochromatography method. An immunochromatography kit interacted only with the human rotaviruses VP6 antigen, and the cell-culture-based immunochromatography detected group A human rotaviruses with a sensitivity as low as 1.99 TCID50 ml(-1). This detection sensitivity was similar to that of the cytopathic effect-based method. There were no actual differences between the sensitivity of this method and that of the real-time reverse transcription polymerase chain reaction method, which is known as a method with a relatively high sensitivity. Furthermore, while cell culture detection methods, that is total culturable virus assay, can determine only the presence of infectious waterborne viruses, the cell-culture-based immunochromatography is advantageous for the accurate detection of group A human rotaviruses. Compared with the real-time reverse transcription polymerase chain reaction method, the cell-culture-based immunochromatography is advantageous because it requires a relatively simple process that enables easy quality controls and low test costs. Thus, this study proposed a new method for the identification of group A human rotaviruses, and it is suggested that this cell-culture-based immunochromatography may be applied to detect group A human rotaviruses in aquatic environments.

Linezolid versus vancomycin for prosthetic joint infections: a cost analysis.

BACKGROUND: Prosthetic joint infections (PJIs) caused by methicillin-resistant gram-positive bacteria are primarily treated by intravenous vancomycin. Linezolid, active against methicillin-resistant strains and available in oral and intravenous dosage forms, is a potential alternative to vancomycin for the treatment of PJIs. OBJECTIVE: To analyze the cost of linezolid therapy (outpatient setting) and vancomycin therapy (inpatient and outpatient settings) for PJIs caused by methicillin-resistant gram-positive bacteria. METHODS: A decision tree was designed to simulate the clinical outcome and healthcare resource utilization of linezolid, vancomycin by outpatient and home parenteral antimicrobial therapies (OHPAT) and vancomycin administered in inpatient setting (rehabilitation facility) for patients with PJIs caused by methicillin-resistant strains. Clinical inputs were estimated from literature and the cost analysis was conducted from the perspective of the public healthcare provider in Hong Kong. RESULTS: The base-case analysis showed that the vancomycin (OHPAT) group (USD14,470 per patient) was the least costly alternative, followed by the linezolid group (USD17,877 per patient) and the vancomycin (rehabilitation) group (USD19,980 per patient) (1USD = 7.8HKD). The clinical treatment success rates of vancomycin and linezolid were influential factors. Monte Carlo 10,000 simulations showed that the vancomycin (OHPAT) group was less costly than the arms of linezolid and vancomycin (rehabilitation) 64% and 100% of the time, respectively. The linezolid group was less costly than the vancomycin (rehabilitation) group in 65%of the times. CONCLUSION: Home-infusion of vancomycin therapy appears to be the least costly treatment approach for PJIs caused by methicillin-resistant gram-positive bacteria from the perspective of a Hong Kong public health organization.

Multiple mutagenesis of the Candida rugosa LIP1 gene and optimum production of recombinant LIP1 expressed in Pichia pastoris.

Candida rugosa lipase, a significant catalyst, had been widely employed to catalyze various chemical reactions such as non-specific, stereo-specific hydrolysis and esterification for industrial biocatalytic applications. Several isozymes encoded by the lip gene family, namely lip1 to lip7, possess distinct thermal stability and substrate specificity, among which the recombinant LIP1 showed a distinguished catalytic characterization. In this study, we utilized PCR to remove an unnecessary linker of pGAPZalphaC vector and used overlap extension PCR-based multiple site-directed mutagenesis to convert the 19 non-universal CTG-serine codons into universal TCT-serine codons and successfully express a highly active recombinant C. rugosa LIP1 in the Pichia expression system. Response surface methodology and 4-factor-5-level central composite rotatable design were adopted to evaluate the effects of growth parameters, such as temperature (21.6-38.4 degrees C), glucose concentration (0.3-3.7%), yeast extract (0.16-1.84%), and pH (5.3-8.7) on the lipolytic activity of LIP1 and biomass of P. pastoris. Based on ridge max analysis, the optimum LIP1 production conditions were temperature, 24.1 degrees C; glucose concentration, 2.6%; yeast extract, 1.4%; and pH 7.6. The predicted value of lipolytic activity was 246.9+/-39.7 U/ml, and the actual value was 253.3+/-18.8 U/ml. The lipolytic activity of the recombinant LIP1 resulting from the present work is twofold higher than that achieved by a methanol induction system.

Arteriovenous fistula using transposed basilic vein in chronic hypotensive hemodialysis patients.

AIM: Chronic hypotension is not uncommon in uremic patients on regular hemodialysis. This subset of patients often requires multiple operations to maintain their vascular access due to frequent thrombosis and occlusion of the arteriovenous fistula. Our aims was to assess whether surgical intervention with the brachial artery-transposed basilic vein fistula is effective in chronic hypotensive hemodialysis patients. MATERIALS AND METHODS: Fifty-four hemodialysis patients with chronic hypotension were enrolled in this study. Most ofthem were referred from local hospitals. They were 23 men and 31 women. The brachial artery-transposed basilic vein arteriovenous fistula was performed in a period of 46 months at the teaching hospital. Primary patency was defined as the length of time from the fistula creation until the development of thrombosis or a complication that required operative revision ofthe fistula. Secondary patency was defined by whether the fistula could be salvaged by revision such that blood flow was maintained. RESULTS: There was no technical failure and none of these patients died due to the surgical operation. The primary patency rate was 89.80% at 1 year, 73.08% at 2 years, and 64.710% at 3 years. The secondary patency rate was 95.92% at 1 year, 84.62% at 2 years, and 76.47% at 3 years. CONCLUSIONS: Brachial artery-transposed basilic vein arteriovenous fistula may present good primary alternative vascular access in chronic hypotensive hemodialysis patients.

Increase in the expression of human leukocyte antigen class I in human fibroblasts by soluble factors secreted from human cytomegalovirus-infected cells.

The human cytomegalovirus (HCMV) is known to downregulate the expression of the human leukocyte antigen (HLA) class I for escape from immune surveillance. In order to understand the HCMV immune evasion mechanism, expression of HLA class I on the surface of HCMV-infected cells was investigated. A decrease in the HLA class I expression was observed at higher MOI; whereas at a lower MOI a slight increase in the HLA class I expression was observed. When HCMV-infected and uninfected cells were separately prepared on coverslips and co-cultured, the increased HLA class I expression was observed in uninfected cells. Treatment of the uninfected cells with the culture supernatant from HCMV-infected cells resulted in an increase in the HLA class I expression. A biochemical analysis of the HCMV-infected cell culture supernatant revealed the presence of interferon (IFN) beta interleukin (IL)-1beta, and IL-6. The HLA class I-enhancing activity of the culture supernatant was mimicked by IFN beta, but not by IL1-beta or IL-6, and was partially reversed by pretreatment with an antibody to IFN beta. Therefore, it appears that the HCMV infection of human foreskin fibroblast cells induces interferon beta and other soluble factor(s) that are responsible for the up-regulation of the HLA class I expression.

Recombinant expression and characterization of the Candida rugosa lip4 lipase in Pichia pastoris: comparison of glycosylation, activity, and stability.

Although Candida rugosa utilizes a nonuniversal serine codon (CUG) for leucine, it is possible to express lipase genes (LIP) in heterologous systems. After replacing the 19 CUG codons in LIP4 with serine codons by site-directed mutagenesis, a recombinant LIP4 was functionally overexpressed in Pichia pastoris in this study. This recombinant glycosylated lipase was secreted into the culture medium with a high purity of 100 mg/liter in a culture broth. Purified recombinant LIP4 had a molecular mass of 60 kDa, showing a range similar to that of lipase in a commercial preparation. Since LIP4 has only a glycosylation site at position Asn-351, this position may also be the major glycosylation site in C. rugosa lipases. Although the thermal stability of recombinant LIP4 significantly increased from 52 to 58 degrees C after glycosylation, there were no significant differences in the catalytic properties of recombinant glycosylated lipase from P. pastoris and the unglycosylated one from Escherichia coil. These two recombinant LIP4s showed higher esterase activities toward long-chain ester (C16 and C18) and exhibited higher lipase activities toward unsaturated and long-chain lipids. In addition, LIP4 does not show interfacial activation as compared with LIP1 toward lipid substrates of tributyrin and triolein. These observations demonstrated that LIP4 shows distinguished catalytic activities with LIP1 in spite of their high sequence homology.

Recombinant expression of the Candida rugosa lip4 lipase in Escherichia coli.

It is difficult to express recombinant Candida rugosa lipases (CRLs) in heterologous systems, since C. rugosa utilizes a nonuniversal serine codon CUG for leucine. In this study, recombinant LIP4 in which all 19 CUG codons had been converted to a universal serine codon was overexpressed in Escherichia coli BL21(DE3). The recombinant LIP4 was found mainly in the inclusion bodies and showed a low catalytic activity. To increase the amount of soluble form and activity of recombinant LIP4, the DNA was fused to the gene for thioredoxin (TrxFus-LIP4) and then expressed in E. coli strain AD494(DE3). This strategy promotes the formation of disulfide bonds in the cytosol and yields enzymatically active forms of LIP4. The purified recombinant TrxFus-LIP4 and LIP4 expressed in AD494(DE3) had the same catalytic profiles. In addition, recombinant LIP4 had higher esterase activities toward long-chain ester and lower lipase activities toward tributyrin, triolein, and olive oil. This system for the expression of fungal lipase in E. coli strain AD494(DE3) is reliable and may produce enzymatically active forms of recombinant lipase without an in vitro refolding procedure.

Expression of transforming growth factor-alpha mRNA in livers of patients with chronic viral hepatitis and hepatocellular carcinoma.

BACKGROUND: Transforming growth factor-alpha (TGFalpha) is an important autocrine growth factor of hepatocytes. The authors evaluated the roles of TGFalpha in chronic viral hepatitis (CVH) and hepatocellular carcinoma (HCC). METHODS: The authors measured the amounts of TGFalpha mRNA in liver tissues from 18 patients with HCC, 31 patients with CVH, and 7 normal controls. " Hot-start" reverse transcription-polymerase chain reaction (RT-PCR) using oligo-dT and specific primers detected TGFalpha mRNA in total cellular RNA extracted from liver tissues. The levels of TGFalpha mRNA were determined by the end point titers of serial, two-fold dilutions of cDNA. The amounts of hepatitis B virus RNA (HBV-RNA) in livers of patients with chronic hepatitis B also were measured by Northern blot hybridization. RESULTS: TGFalpha mRNA levels were extremely higher in patients with HCC compared with patients with CVH and normal controls, and the levels in patients with CVH also were elevated compared with normal controls. The levels of TGFalpha mRNA were overexpressed in the underlying livers of patients with HCC compared with patients with CVH, although they were lower than those found in HCC tissues. The levels of TGFalpha mRNA were higher in samples from patients with chronic hepatitis B than in samples from patients with chronic hepatitis C. The levels of TGFalpha mRNA were not correlated with serum alanine aminotransferase or HBV-RNA levels in liver tissues in patients with chronic hepatitis B. However, the expression of TGFalpha mRNA tended to be higher in the livers of patients with raised serum alpha-fetoprotein levels. CONCLUSIONS: The overexpression of TGFalpha mRNA in the liver seems to be associated with the regeneration of hepatocytes rather than hepatic necrosis or viral replication. Also, it may be related closely to the development or progression of HCC, especially in the livers of patients with chronic hepatitis B.

Persistent endemicity of Gymnophalloides seoi infection in a southwestern coastal village of Korea with special reference to its egg laying capacity in the human host.

Follow-up studies have been conducted every three years on the endemicity of Gymnophalloides seoi infection in a small coastal village of Chollanam-do (Province), Korea, since it was first known as an endemic area in 1994. Special attention was given to its egg laying capacity in the human host. In fecal examinations, the overall helminth egg and/or cyst positive rate was 78.7% (74/94) in 1997 and 76.6% (82/107) in 2000. Among them G. seoi eggs showed the highest rate; 71.3% (67/94) in 1997 and 72.0% (77/107) in 2000. The average number of eggs per gram of feces (EPG) was 1,015 in 1997, while a reduced rate of 353 was observed in 2000. In 1997, total of 320,677 adult flukes of G. seoi (av. 10,344/person, 94-69,125 in range) were collected from the diarrheic stools of 31 treated patients. The EPG/worm obtained from 21 cases ranged from 0.04 to 0.77 (av. 0.23), suggesting density-dependent constraints on the worm fecundity. The relationship between the worm burden (X) and EPG/worm (Y) can be expressed as Y = 0.42.e-1.2 chi (r = 0.49). The results showed that G. seoi infection is persistently endemic in this village.

Combined therapy consisting of intraarterial cisplatin infusion and systemic interferon-alpha for hepatocellular carcinoma patients with major portal vein thrombosis or distant metastasis.

BACKGROUND: Hepatocellular carcinoma (HCC) patients with major vascular involvement or extrahepatic metastasis are not good candidates for surgery or transarterial chemoembolization (TACE). In this study, the authors evaluated the efficacy of combined therapy with intraarterial cisplatin infusion and systemic administration of interferon-alpha (IFN-alpha) as a palliative treatment for these patients. METHODS: Sixty-eight HCC patients with major portal vein thrombosis (n = 47) or distant metastasis (n = 27) were randomly allocated to 1 of 3 groups. Group I (n = 19) received combined therapy consisting of intraarterial cisplatin infusion and systemic IFN-alpha, Group II (n = 23) received intraarterial cisplatin infusion, and Group III (n = 26) was managed with only supportive care. Cisplatin 2 mg/kg was infused through the proper hepatic artery every 8 weeks, and IFN-alpha 3 million IU/m2 was administered subcutaneously 3 times a week. RESULTS: The partial response (defined as a 50% or greater reduction in the product of the 2 longest perpendicular tumor measurements) rate of Group I was significantly higher than that of Group II (33% vs. 14%; P < 0.05). Also, the 1-year survival rate of Group I (27%) was higher than that of Group II (9%) or Group III (0%) (P < 0.05 and P < 0.01, respectively). The median survival period of Group I was 19 weeks, which was significantly longer than that of Group II (11 weeks) or Group III (5 weeks) (P < 0.05 and P < 0.01, respectively). CONCLUSIONS: These results suggest that combined therapy consisting of intraarterial cisplatin infusion and systemic IFN-alpha may be useful as a palliative treatment for HCC patients with major vascular involvement or extrahepatic metastasis.

Analysis of the gene family encoding lipases in Candida rugosa by competitive reverse transcription-PCR.

Synthesis of multiple extracellular lipases in Candida rugosa has been demonstrated. However, it is difficult to characterize the expression spectrum of lip genes, since the sequences of the lip multigene family are very closely related. A competitive reverse transcription-PCR assay was developed to quantify the expression of lip genes. In agreement with the protein profile, the abundance of lip mRNAs was found to be (in decreasing order) lip1, lip3, lip2, lip5, and lip4. To analyze the effects of different culture conditions, the transcript concentrations for these mRNA species were normalized relative to the values for gpd, encoding glyceraldehyde-3-phosphate dehydrogenase. In relative terms, lip1 and lip3 were highly and constitutively expressed (about 10(5) molecules per microg of total RNA) whereas the other inducible lip genes, especially lip4, showed significant changes in mRNA expression under different culture conditions. These results indicate that differential transcriptional control of lip genes results in multiple forms of lipase proteins.

Factors affecting human cytomegalovirus gene expression in human monocyte cell lines.

To understand the mechanisms for establishing and reactivating monocytes and macrophages from latency by human cytomegalovirus (HCMV), human monocyte cell lines were infected and HCMV gene expression was investigated. Indirect immunofluorescence assay (IFA) with monoclonal antibody to HCMV major immediate early (MIE) IE1 or IE2 proteins revealed that HCMV MIE genes were expressed at low levels in relatively more differentiated THP-1 cells with TPA treatment after virus infection (posttreatment). Less differentiated cells such as U937 or HL60 did not support MIE gene expression even after TPA treatment. If THP-1 cells were pretreated before virus infection with TPA and became differentiated at the time of HCMV infection, MIE gene expression increased by 5-6 fold. Therefore, the relative degree of monocyte cell differentiation appears to be an important factor for regulating HCMV gene expression. Further IFA studies using monoclonal antibodies specific for IE1 or IE2 proteins indicate that the sequence and general pattern of IE1 and IE2 gene expression in THP-1 cells treated with TPA were similar to those in permissive human fibroblast cells with some delay in time. Formation of the replication compartment detected with monoclonal antibody to HCMV polymerase accessory protein UL44 in THP-1 cells suggests a fully productive replication process of HCMV in these cells. Monocytes are known to be induced to differentiate by hydrocortisone (HC), tumor necrosis factor (TNF)-alpha or interferon (IFN)-gamma. HC, which is known to stimulate HCMV replication in permissive human fibroblast (HF) cells, enhanced HCMV gene expression by 2-3 fold in TPA-pre or posttreated THP-1 cells, but TNF-alpha or IFN-gamma had little effect. Nitric oxide (NO) is released by immune cells in the defense against foreign stimuli and was shown to inhibit HCMV gene expression in HF cells. Increasing NO by nitroprusside significantly reduced HCMV gene expression in THP-1 cells. Therefore, it appears that the expression of HCMV immediate early genes in THP-1 cells treated with TPA closely resembles those in permissive HF cells.