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PURPOSE: To determine the etiologies of esophageal symptoms in human immunodeficiency virus (HIV)-infected patients failing antifungal treatment. METHODS: Between August 1, 1990 and December 31, 1994, all HIV-infected patients seen at a large inner-city hospital who had esophageal complaints despite being on antifungal therapy were prospectively evaluated for the cause of symptoms. Thus, the population studied included patients given empiric antifungal therapy for esophageal symptoms and patients who developed symptoms while on long-term antifungal therapy. Endoscopy was performed in all patients. The cause of symptoms was determined by the clinical, endoscopic, and pathologic findings, and follow-up after treatment. RESULTS: Over the 53-month study period, patients failing empiric antifungal therapy were identified. The majority (77%) of these patients had esophageal ulcers; 25 patients had idiopathic ulcers and 24 had cytomegalovirus. In 2 patients, Candida was present with other causes of ulcerative esophagitis. Candida esophagitis alone was diagnosed in only 3 patients. No endoscopic abnormalities were observed in 14 patients (19%). An additional patients developed esophageal symptoms while receiving antifungal therapy; endoscopic findings in these patients included ulceration in 16 (67%), Candida esophagitis alone in 2, and normal in 6. Empirically treated patients in whom odynophagia was not the only symptom, those with dysphagia alone, and those with a CD4 count >100/mm3 were less likely to have an endoscopic diagnosis. CONCLUSIONS: Esophageal ulceration is the most common cause of esophageal symptoms in HIV-infected patients failing empiric antifungal therapy and those developing symptoms while receiving antifungal agents. Given these findings, endoscopy should be the test of choice for these nonresponders, rather than escalating the dose of antifungal agent, adding other empiric treatments, or performing barium esophagography. [C] 1996 by Excerpta Medica, Inc. Am J Med. 1996;101:599-604

PURPOSE: Although cytomegalovirus (CMV) esophagitis is an important complication of acquired immunodeficiency syndrome, there has been little study specifically addressing the response to currently available antiviral therapy, relapse rate without; maintenance therapy, and long-term outcome. PATIENTS AND METHODS: Over a 45-month period, 44 patients with CMV esophagitis established endoscopically and histopathologically were prospectively identified from among all human immunodeficiency virus (HIV)-infected patients undergoing endoscopy. Induction therapy consisted of intravenous ganciclovir at 10 mg/kg per day for approximately 14 days. Foscarnet was given at 60 mg/kg every 8 hours for nonresponders to ganciclovir. RESULTS: Of these patients, 35 completed induction ganciclovir therapy, resulting in a complete response in 17 (49%) and a partial response in 10 (29%), yielding a 77% overall response rate. Seven of 8 nonresponders were subsequently treated with foscarnet, with a clinical response seen in 5 patients. In the 18 eventual complete responders to ganciclovir or foscarnet followed up without maintenance therapy, 7 (39%) relapsed at a median of 4 months (range 2 to 18 months). In all cases, relapse was manifested by recurrent odynophagia. Reinduction ganciclovir therapy yielded a complete response in 1 patient and a partial response in 2, and induction foscarnet treatment resulted in a complete response in the other treated patients. During long-term follow-up, 1 complete responder developed CMV colitis with concurrent retinitis, and 4 other patients developed retinitis. The median survival after diagnosis was 8.2 months, although survival for greater than 1 year was seen in 4 patients. No patient died as a direct result of esophageal disease, although ulcer-related bleeding may have contributed to death in 2 patients with end-stage liver diseases and hepatic encephalopathy. CONCLUSIONS: CMV esophagitis has a favorable response to induction ganciclovir therapy, and a long-term remission may occur after induction therapy alone. Despite the favorable response to ganciclovir therapy, the long-term survival is poor, reflecting the severe immunodeficiency of these patients.

ABSTRACTGSK1322322 is a novel inhibitor of peptide deformylase (PDF) with good in vitroactivity against bacteria associated with community-acquired pneumonia and skin infections. We have characterized the in vivopharmacodynamics (PD) of GSK1322322 in immunocompetent animal models of infection with Streptococcus pneumoniaeand Haemophilus influenzae(mouse lung model) and with Staphylococcus aureus(rat abscess model) and determined the pharmacokinetic (PK)/PD index that best correlates with efficacy and its magnitude. Oral PK studies with both models showed slightly higher-than-dose-proportional exposure, with 3-fold increases in area under the concentration-time curve (AUC) with doubling doses. GSK1322322 exhibited dose-dependent in vivoefficacy against multiple isolates of S. pneumoniae, H. influenzae, and S. aureus. Dose fractionation studies with two S. pneumoniaeand S. aureusisolates showed that therapeutic outcome correlated best with the free AUC/MIC (fAUC/MIC) index in S. pneumoniae(R2, 0.83), whereas fAUC/MIC and free maximum drug concentration (fCmax)/MIC were the best efficacy predictors for S. aureus(R2, 0.9 and 0.91, respectively). Median daily fAUC/MIC values required for stasis and for a 1-log10reduction in bacterial burden were 8.1 and 14.4 for 11 S. pneumoniaeisolates (R2, 0.62) and 7.2 and 13.0 for five H. influenzaeisolates (R2, 0.93). The data showed that for eight S. aureusisolates, fAUC correlated better with efficacy than fAUC/MIC (R2, 0.91 and 0.76, respectively), as efficacious AUCs were similar for all isolates, independent of their GSK1322322 MIC (range, 0.5 to 4 μg/ml). Median fAUCs of 2.1 and 6.3 μg · h/ml were associated with stasis and 1-log10reductions, respectively, for S. aureus.

Triple-negative breast cancer (TNBC) and ovarian carcinomas (OvCas) with BRCA1promoter methylation (BRCA1meth) respond more poorly to alkylating agents compared to those bearing mutations in BRCA1and BRCA2(BRCAmut). This is a conundrum given the biologically equivalent homologous recombination deficiency (HRD) induced by these genetic and epigenetic BRCAperturbations. We dissected this problem through detailed genomic analyses of TNBC and OvCa cohorts and experimentation with patient-derived xenografts and genetically engineered cell lines. We found that despite identical downstream genomic mutational signatures associated with BRCA1meth and BRCAmut states, BRCA1meth uniformly associates with poor outcomes. Exposure of BRCA1meth TNBCs to platinum chemotherapy, either as clinical treatment of a patient or as experimental in vivo exposure of preclinical patient derived xenografts, resulted in allelic loss of BRCA1methylation and increased BRCA1expression and platinum resistance. These data suggest that, unlike BRCAmut cancers, where BRCAloss is a genetically “fixed” deficiency state, BRCA1meth cancers are highly adaptive to genotoxin exposure and, through reversal of promoter methylation, recover BRCA1expression and become resistant to therapy. We further found a specific augmented immune transcriptional signal associated with enhanced response to platinum chemotherapy but only in patients with BRCA-proficient cancers. We showed how integrating both this cancer immune signature and the presence of BRCAmutations results in more accurate predictions of patient response when compared to either HRD status or BRCAstatus alone. This underscores the importance of defining BRCAheterogeneity in optimizing the predictive precision of assigning response probabilities in TNBC and OvCa.

The biochemical performance of brewer's yeast (Saccharomyces cerevisiae) during the fermentation process will significantly influence beer quality. Yeast produces a number of biochemical compounds, including platelet-activating factor (PAF; 1-o-alkyl-2-o-acetyl-sn-glycero-3-phosphocholine). PAF is a potent signaling phospholipid with pleiotropic physiologic-biochemical properties in addition to activating platelets. PAF appears to be of critical importance for many cellular events, including division and metabolism. Yeast cells produce PAF, and this unique biochemical controls the cell-cycle phase in budding yeast. The study objective was to determine temporal PAF production by ale and lager yeast strains at two different culture temperatures (14 and 20°C). At different culture times (1–100 hr), aliquots (100 μL) of media were removed for PAF analysis by a specific radioimmunoassay (125I). There was a significant difference (P< 0.001) between ale (16.35 ± 1.28 pM/106cells) and lager yeast (26.68 ± 2.15 pM/106cells) in PAF levels. Both culture temperature and time had significant (P< 0.001) effects on PAF production. There was a cyclic pattern to PAF production in both strains of yeast; however, this was most evident in the lager strain. The data confirms that brewer's yeast produces PAF and production levels are cyclic in nature and strain and temperature dependent. Additional studies are warranted to determine the impact of PAF in yeast fermentation and attendant beer quality.

The clinical findings in cirrhosis and systemic amyloidosis may be similar, leading to difficulties in diagnosis. We studied three patients with systemic amyloidosis with a 99mTc sulfur colloid liver-spleen scan. In all three patients, uptake by the spleen was less than the liver, in contrast with the increased splenic uptake seen in patients with cirrhosis. The liver-spleen scan may be a useful tool in differentiating patients with cirrhosis from those with systemic amyloidosis when clinical findings fail to give the proper diagnosis.

The variable appearance of gut-associated lymphoid tissue at videocolonoscopy has not been well documented. Over a 3-year period all patients undergoing high resolution videocolonoscopy underwent biopsy of any identified abnormalities for correlating histopathologic findings with endoscopic appearance. We identified several distinct patterns for lymphoid tissue: small well-circumscribed nodules, red rings, large coalescing vesicles with or without central pits, or white plaques. A mass-like appearance of the ileocecal valve was present in one patient. Although individually each of these patterns appeared characteristic, overall, variability appeared dependent on the colonic location and underlying disease. Prominent lymphoid tissue was most frequently seen in patients with underlying disorders resulting in stimulation of the immune system. We take this to mean that there is a broader spectrum of colonic lymphoid tissue as assessed by videocolonoscopy than previously appreciated. The variability of these normal structures has potential diagnostic implications.