Jeannette Y. Lee

Potent suppression of HIV-1 replication in humans by T-20, a peptide inhibitor of gp41-mediated virus entry.

T-20, a synthetic peptide corresponding to a region of the transmembrane subunit of the HIV-1 envelope protein, blocks cell fusion and viral entry at concentrations of less than 2 ng/ml in vitro. We administered intravenous T-20 (monotherapy) for 14 days to sixteen HIV-infected adults in four dose groups (3, 10, 30 and 100 mg twice daily). There were significant, dose-related declines in plasma HIV RNA in all subjects who received higher dose levels. All four subjects receiving 100 mg twice daily had a decline in plasma HIV RNA to less than 500 copies/ml, by bDNA assay. A sensitive RT–PCR assay (detection threshold 40 copies/ml) demonstrated that, although undetectable levels were not achieved in the 14-day dosing period, there was a 1.96 log10 median decline in plasma HIV RNA in these subjects. This study provides proof-of-concept that viral entry can be successfully blocked in vivo. Short-term administration of T-20 seems safe and provides potent inhibition of HIV replication comparable to anti-retroviral regimens approved at present.

A Prospective Observational Study of Candidemia: Epidemiology, Therapy, and Influences on Mortality in Hospitalized Adult and Pediatric Patients

We conducted a prospective, multicenter observational study of adults (n=1447) and children (n=144) with candidemia at tertiary care centers in the United States in parallel with a candidemia treatment trial that included nonneutropenic adults. Candida albicans was the most common bloodstream isolate recovered from adults and children (45% vs. 49%) and was associated with high mortality (47% among adults vs. 29% among children). Three-month survival was better among children than among adults (76% vs. 54%; P<.001). Most children received amphotericin B as initial therapy, whereas most adults received fluconazole. In adults, Candida parapsilosis fungemia was associated with lower mortality than was non-parapsilosis candidemia (24% vs. 46%; P<.001). Mortality was similar among subjects with Candida glabrata or non-glabrata candidemia; mortality was also similar among subjects with C. glabrata candidemia who received fluconazole rather than other antifungal therapy. Subjects in the observational cohort had higher Acute Physiology and Chronic Health Evaluation II scores than did participants in the clinical trial (18.6 vs. 16.1), which suggests that the former subjects are more often excluded from therapeutic trials.

Antifungal Susceptibility Survey of 2,000 Bloodstream Candida Isolates in the United States

ABSTRACT Candida bloodstream isolates (n = 2,000) from two multicenter clinical trials carried out by the National Institute of Allergy and Infectious Diseases Mycoses Study Group between 1995 and 1999 were tested against amphotericin B (AMB), flucytosine (5FC), fluconazole (FLU), itraconazole (ITR), voriconazole (VOR), posaconazole (POS), caspofungin (CFG), micafungin (MFG), and anidulafungin (AFG) using the NCCLS M27-A2 microdilution method. All drugs were tested in the NCCLS-specified RPMI 1640 medium except for AMB, which was tested in antibiotic medium 3. A sample of isolates was also tested in RPMI 1640 supplemented to 2% glucose and by using the diluent polyethylene glycol (PEG) in lieu of dimethyl sulfoxide for those drugs insoluble in water. Glucose supplementation tended to elevate the MIC, whereas using PEG tended to decrease the MIC. Trailing growth occurred frequently with azoles. Isolates were generally susceptible to AMB, 5FC, and FLU. Rates of resistance to ITR approached 20%. Although no established interpretative breakpoints are available for the candins (CFG, MFG, and AFG) and the new azoles (VOR and POS), they all exhibited excellent antifungal activity, even for those strains resistant to the other aforementioned agents.

A Randomized and Blinded Multicenter Trial of High-Dose Fluconazole plus Placebo versus Fluconazole plus Amphotericin B as Therapy for Candidemia and Its Consequences in Nonneutropenic Subjects

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

A randomized trial of itraconazole in allergic bronchopulmonary aspergillosis.

BACKGROUND Allergic bronchopulmonary aspergillosis is a hypersensitivity disorder that can progress from an acute phase to chronic disease. The main treatment is systemic corticosteroids, but data from uncontrolled studies suggest that itraconazole, an orally administered antifungal agent, may be an effective adjunctive therapy. METHODS We conducted a randomized, double-blind trial of treatment with either 200 mg of itraconazole twice daily or placebo for 16 weeks in patients who met immunologic and pulmonary-function criteria for corticosteroid-dependent allergic bronchopulmonary aspergillosis. A response was defined as a reduction of at least 50 percent in the corticosteroid dose, a decrease of at least 25 percent in the serum IgE concentration, and one of the following: an improvement of at least 25 percent in exercise tolerance or pulmonary-function tests or resolution or absence of pulmonary infiltrates. In a second, open-label part of the trial, all the patients received 200 mg of itraconazole per day for 16 weeks. RESULTS There were responses in 13 of 28 patients in the itraconazole group (46 percent), as compared with 5 of 27 patients in the placebo group (19 percent, P=0.04). The rate of adverse events was similar in the two groups. In the subsequent open-label phase, 12 of the 33 patients who had not had a response during the double-blind phase (36 percent) had responses, and none of the patients who had a response in the double-blind phase of the trial had a relapse. CONCLUSIONS For patients with corticosteroid-dependent allergic bronchopulmonary aspergillosis, the addition of itraconazole can lead to improvement in the condition without added toxicity.

Prospective Multicenter Surveillance Study of Funguria in Hospitalized Patients

Although fungal urinary tract infections are an increasing nosocomial problem, the significance of funguria is still not clear. This multicenter prospective surveillance study of 861 patients was undertaken to define the epidemiology, management, and outcomes of funguria. Diabetes mellitus was present in 39% of patients, urinary tract abnormalities in 37.7%, and malignancy in 22.2%; only 10.9% had no underlying illnesses. Concomitant nonfungal infections were present in 85%, 90% had received antimicrobial agents, and 83.2% had urinary tract drainage devices. Candida albicans was found in 51.8% of patients and Candida glabrata in 15.6%. Microbiological and clinical outcomes were documented for 530 (61.6%) of the 861 patients. No specific therapy for funguria was given to 155 patients, and the yeast cleared from the urine of 117 (75.5%) of them. Of the 116 patients who had a catheter removed as the only treatment, the funguria cleared in 41 (35.3%). Antifungal therapy was given to 259 patients, eradicating funguria in 130 (50.2%). The rate of eradication with fluconazole was 45.5%, and with amphotericin B bladder irrigation it was 54.4%. Only 7 patients (1.3%) had documented candidemia. The mortality rate was 19.8%, reflecting the multiple serious underlying illnesses found in these patients with funguria.

Supplementation with folic acid during methotrexate therapy for rheumatoid arthritis. A double-blind, placebo-controlled trial.

The folic acid antagonist methotrexate (n-10-methyl-aminopterin) is useful in low doses (2.5 to 20 mg/wk) for treating chronic inflammatory diseases [1-7]. Many trials have established the efficacy of methotrexate in rheumatoid arthritis [7-13]. Compared with other disease-modifying drugs, methotrexate has the highest probability of drug continuation at 10 years. Dose response-related toxic effects have been reported in 30% to 90% of patients given methotrexate [13]. Toxic effects include gastrointestinal intolerance, hematologic abnormalities, alopecia, hepatotoxicity, and pulmonary toxicity [14-22]. Some side effects of methotrexate administration, such as gastrointestinal intolerance, mimic complicated folate deficiency [23]. Folate deficiency occurs frequently in patients with rheumatoid arthritis; further, folate stores are decreased in patients with rheumatoid arthritis who take methotrexate, suggesting that impaired folate status is related to toxicity [24-26]. Folic acid supplementation has been reported anecdotally to lessen toxicity in patients receiving methotrexate treatment [27, 28]. In a 6-month, double-blind, placebo-controlled trial, 7 mg of folic acid weekly (1 mg/d or 2265 nmol/d) decreased methotrexate toxicity without affecting efficacy [29]. This was confirmed by Stewart and colleagues [30] in a retrospective chart review. Folinic acid (leucovorin, citrovorum factor) is a one-carbon-substituted, fully reduced folate that has also been administered during methotrexate therapy [31-36]. Low doses of the vitamin (1 to 7 mg/wk) have decreased methotrexate toxicity [35, 36]. Higher doses negate efficacy and lessen toxicity [31, 32]. Thus, the folinic acid dose may critically affect the efficacy of methotrexate therapy. The influence of the folic acid dose on methotrexate toxicity and efficacy remains controversial, and the effects of different doses of folic acid are not known [37, 38]. Some investigators argue that if toxic effects occur, the most rational approach is to reduce the dose of methotrexate rather than to provide folic acid supplements [37]. We designed a larger and longer study to evaluate different doses of folic acid, assuming that toxicity could be reduced without changing the efficacy of methotrexate. Methods Participants Patients aged 19 to 78 years who fulfilled the American College of Rheumatologys revised criteria for rheumatoid arthritis consented to participate in the trial [39]. Enrollment criteria included rheumatoid arthritis diagnosed more than 6 months previously, onset after the age of 16 years, and at least three of the following signs or symptoms: 3 or more swollen joints, 6 or more tender joints, at least 45 minutes of morning stiffness, and a Westergren erythrocyte sedimentation rate 28 mm/h. Referring rheumatologists and the principal investigator did the screening. Exclusion criteria included serious concomitant medical illnesses, liver enzyme levels twice the upper limit of normal, leukocyte counts less than 3.5 109/L or platelet counts less than 150 109/L, and use of methotrexate within the past 6 months. Gold salts were stopped for at least 10 days before the trial. This short washout period mirrors actual rheumatology practice. Patients remained under the care of their rheumatologists, abstained from alcohol use, did not become pregnant, and received stable doses of aspirin and nonsteroidal anti-inflammatory drugs. If prednisone was taken at entry, the dose could not exceed 10 mg/d. Hydroxychloroquine therapy was allowed during the study. Study Design Figure 1 shows the trial design. To maintain the double-blind status of the trial, the statistician carried out the randomization using a computer program in which the algorithm was transparent and a coded vial number represented the treatment assignment. Patients were assigned to treatment groups by a sequential treatment assignment process designed to balance the sample with respect to baseline features, including age, sex, folate-containing vitamin use, rheumatoid factor status, and prednisone use [40]. Patients agreed to discontinue therapy with folate-containing vitamins during the trial. Rheumatoid factor was considered positive if the level was more than 30 IU/mL or if the titer was more than 1:160. Patients received either visually identical placebo or 5 mg (low-dose folic acid group) or 27.5 mg folic acid (high-dose folic acid group) each week, prepared by the Hospital Investigational Drug Service. Spectrophotometric analysis indicated that the mean SD folic acid content was 1 0.15 mg (2.3 0.3 mol) and 5.5 0.3 mg (12.5 0.7 mol) per capsule in the low-dose and high-dose folic acid groups, respectively. Lederle Laboratories provided the methotrexate (Rheumatrex; Pearl River, New York), which was started in a median oral dose of 16.5 mol (7.5 mg) per week and increased in 5.5-mol (2.5 mg) increments at the rheumatologists discretion. Methotrexate was taken either in an undivided or a divided dose (that is, every 12 hours for three doses). The methotrexate dosing regimens were identical among the study groups. Folic acid supplements were given 5 days per week when methotrexate was not ingested. Compliance with the regimen was reinforced using a digital reminder cap (Counter Cap; Senetics, Boulder, Colorado). All participants and investigators were blinded to vitamin capsule content until the study was complete. Figure 1. Study design for the double-blind, placebo-controlled trial. Clinical Assessment Patients were evaluated immediately before methotrexate initiation at a mean of 13, 26, 39, and 53 weeks (Figure 1). Each patient was assessed by the same physician-nutritionist (SLM). Two research assistants (JSA or WHV) did the joint evaluations. In most cases, patients were examined by the same observer throughout the study. The joint counts for tenderness and swelling were not significantly different between the two observers (P = 0.6 for tenderness; P = 0.9 for swelling). The following variables were evaluated at each visit: 1) number of the 58 diarthrodial joints with swelling; 2) number of the 60 joints with tenderness on pressure or with pain on passive motion (or both); 3) joint swelling and tenderness indices, expressed as a sum, with each joint graded for swelling as 0 (none), 1 (mild), 2 (moderate), or 3 [severe]; 4) mean grip strength (three measurements) for both hands expressed in mm Hg; 5) duration of morning stiffness expressed in hours; 6) patients and physicians global assessments of disease activity graded as 0 (asymptomatic), 1 (mild), 2 (moderate), 3 (severe), or 4 (very severe); 7) current medications and doses; 8) a 1-day dietary recall using the Minnesota Nutrition Data System software, Food Database version 6A, Nutrient Database version F21 [41]; 9) eight activities of daily living assessed and averaged at baseline and at 12 months using the modified Health Assessment Questionnaire and scored on a scale of 1 (no difficulty) to 4 (unable to perform) [42]; and 10) presence, duration, intensity, and severity of toxic effects at every follow-up visit and every 3 weeks by telephone interview (done by SLM). Laboratory Assessments At the initial visit, complete blood cell count, Westergren erythrocyte sedimentation rate, liver enzyme (aspartate amino transferase and alkaline phosphatase), rheumatoid factor by nephelometry, and serum creatinine values were obtained. The complete blood cell count, creatinine, and liver function tests were repeated at all visits. If laboratory values were obtained more frequently than stipulated in the protocol, they were recorded and became part of the toxicity score. Blood for plasma and erythrocyte folate levels, using a methotrexate-resistant Lactobacillus casei microbiological assay, was drawn at all visits [43]. At baseline, blood was drawn for a vitamin panel (plasma and erythrocyte folate, vitamins B12, A, C, and E, carotene, riboflavin, thiamin, pyridoxine) [44-51]. If patients had abnormal values for any of the vitamins, other than folate, the abnormality was treated with single vitamin supplements. Radiographic Assessment Hand and wrist radiographs taken within 6 months of entering the trial were assessed by one of the rheumatologists (GSA) without knowledge of study status. Joint erosions and space narrowing were determined by the modified method of Sharp [52]. Results were expressed as the mean raw scores for joint erosion and joint space narrowing. Toxicity: Frequency and Severity Toxic effects and discontinuation of therapy with study medications due to toxicity were considered primary outcomes. We determined a toxicity score, modified from the one previously used, for each patient at each visit or until methotrexate therapy was discontinued [29] (Appendix). Efficacy We determined patient response to treatment using a modification of the criteria used in our previous folic acid supplementation trial and by others [8, 29, 53]. We defined marked improvement in the joint swelling index and the joint tenderness and pain index as a net decrease of 50% or more in value at any follow-up visit compared with visit 1. We defined moderate improvement as a 30% to 49% net decrease in the index, and no change as the index value remaining within 30% of the original value. We defined worsening as an increase in the index value of 30% or more. We examined the effects of folic acid supplementation on changes in physician and patient global assessments, grip strength, morning stiffness, erythrocyte sedimentation rate, findings of the modified Health Assessment Questionnaire, complete blood cell counts, blood folate levels, and dietary folate and vitamin B12 intake. Table 1. Demographic and Selected Clinical Characteristics of 79 Patients with Rheumatoid Arthritis* Statistical Analysis Sample Size and Analysis In our previous study, the mean toxicity scores for patients receiving low-dose folic acid and placebo recipients were 0.21 and 1.06, respectively, for

Aberrantly glycosylated IgA1 in IgA nephropathy patients is recognized by IgG antibodies with restricted heterogeneity

IgA nephropathy (IgAN) is characterized by circulating immune complexes composed of galactose-deficient IgA1 and a glycan-specific IgG antibody. These immune complexes deposit in the glomerular mesangium and induce the mesangioproliferative glomerulonephritis characteristic of IgAN. To define the precise specificities and molecular properties of the IgG antibodies, we generated EBV-immortalized IgG-secreting lymphocytes from patients with IgAN and found that the secreted IgG formed complexes with galactose-deficient IgA1 in a glycan-dependent manner. We cloned and sequenced the heavy- and light-chain antigen-binding domains of IgG specific for galactose-deficient IgA1 and identified an A to S substitution in the complementarity-determining region 3 of the variable region of the gene encoding the IgG heavy chain in IgAN patients. Furthermore, site-directed mutagenesis that reverted the residue to alanine reduced the binding of recombinant IgG to galactose-deficient IgA1. Finally, we developed a dot-blot assay for the glycan-specific IgG antibody that differentiated patients with IgAN from healthy and disease controls with 88% specificity and 95% sensitivity and found that elevated levels of this antibody in the sera of patients with IgAN correlated with proteinuria. Collectively, these findings indicate that glycan-specific antibodies are associated with the development of IgAN and may represent a disease-specific marker and potential therapeutic target.

Candiduria: A Randomized, Double-Blind Study of Treatment with Fluconazole and Placebo

Management of candiduria is limited by the lack of information about its natural history and lack of data from controlled studies on the efficacy of treating it with antimycotic agents. We compared fungal eradication rates among 316 consecutive candiduric (asymptomatic or minimally symptomatic) hospitalized patients treated with fluconazole (200 mg) or placebo daily for 14 days. In an intent-to-treat analysis, candiduria cleared by day 14 in 79 (50%) of 159 receiving fluconazole and 46 (29%) of 157 receiving placebo (P<.001), with higher eradication rates among patients completing 14 days of therapy (P<.0001), including 33 (52%) of 64 catheterized and 42 (78%) of 54 noncatheterized patients. Pretreatment serum creatinine levels were inversely related to candiduria eradication. Fluconazole initially produced high eradication rates, but cultures at 2 weeks revealed similar candiduria rates among treated and untreated patients. Oral fluconazole was safe and effective for short-term eradication of candiduria, especially following catheter removal. Long-term eradication rates were disappointing and not associated with clinical benefit.

Chemotherapy for Human Immunodeficiency Virus–Associated Non-Hodgkin’s Lymphoma in Combination With Highly Active Antiretroviral Therapy

PURPOSE This study investigated the efficacy, toxicity, and pharmacokinetic interactions resulting from simultaneous combination chemotherapy and highly active antiretroviral therapy (HAART) for patients with human immunodeficiency virus (HIV)-associated non-Hodgkins lymphoma (NHL). In addition, the effects on viral load, CD4 counts, and opportunistic infections were examined with the use of combination chemotherapy combined with HAART. PATIENTS AND METHODS Sixty-five patients with previously untreated and measurable disease at any stage of HIV-associated NHL of intermediate or high grade were entered onto this study at 17 different centers. The first 40 patients entered onto the study received reduced doses of cyclophosphamide and doxorubicin, combined with vincristine and prednisone (modified CHOP [mCHOP]), whereas the subsequent 25 patients entered onto the study received full doses of CHOP combined with granulocyte colony-stimulating factor (G-CSF). All patients also received stavudine, lamivudine, and indinavir. RESULTS The complete response rates were 30% and 48% among patients who received mCHOP and full-dose CHOP combined with HAART, respectively. Grade 3 or 4 neutropenia occurred in 25% of patients receiving mCHOP and 12% of those receiving full-dose CHOP combined with G-CSF (25% v 12%). There were similar numbers of patients with grade 3 or 4 hyperbilirubinemia (12% and 17%), constipation and abdominal pain (18% and 17%), and transaminase elevation (48% and 52%) on the modified and full-dose arms of the study, respectively. Doxorubicin clearance and indinavir concentration curves were similar among patients on this study and historical controls, whereas cyclophosphamide clearance was 1.5-fold reduced as compared with control values. Human immunodeficiency virus (HIV) load declined from a median baseline value of 29,000 copies/mL to a median minimum value on therapy of 500 copies/mL. CONCLUSION Either modified-dose or full-dose CHOP chemotherapy for HIV-NHL, delivered with HAART, is effective and tolerable.