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An assay method for the determination of acyclovir from pharmaceutical preparations has been developed for assessment of product quality utilising high-performance liquid chromatography. The chromatographic conditions comprised a reversed-phase C18 column (250 x 4.6 mm i.d.) with a mobile phase of acetonitrile-20 mmol l(-1) aqueous ammonium acetate buffer of pH 4.5 (40:60). The flow rate was 0.8 ml min(-1) and UV detection was used at 250 nm. Calibration graph was linear in the range 1.98-59.4 microg ml(-1). The method has been validated according to current guidelines including assay of pharmacopoeial standard tablets. Recoveries ranged from 96.64 to 99.53%. The exipients present in the tablets did not interfere with the method.
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We report two CMV naïve children who received deceased donor renal transplants from a CMV IgG-negative single donor. CMV IgG in both recipients and the donor were negative immediately prior to transplant. Both recipients had early recurrences of their original disease in their transplants, requiring multiple sessions of plasmapheresis. All blood products used were leukoreduced or CMV seronegative. A few days post-transplant, both recipients developed significant positive CMV viremia. Both required initiation of oral valganciclovir. Case 1 responded to oral valganciclovir only while the case 2 had a delayed response to it and hence required intravenous ganciclovir with good response. When checked retrospectively, CMV IgM in the donor was positive along with positive CMV DNA PCR from the white cells. Here we describe a very unusual scenario of CMV transmission in two pediatric renal transplant recipients from a single donor during the CMV window period.
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A Markov model was developed using a randomized, placebo-controlled trial of valaciclovir prophylaxis, together with a published epidemiological study and national renal transplant registry data. The model's population was stratified into two risk groups by donor/recipient cytomegalovirus (CMV) serostatus at transplantation: donor-positive/recipient-negative (D+R-) and recipient-positive (R+) patients. The model estimated costs and health outcomes over a 30-yr period from the perspective of Australian health care providers.
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We found a significant difference among all 3 groups in numbers of cytomegaloviral disease episodes in the 1st year after transplantation. The number of rejection episodes in the 3 groups during the 1st post-transplant year gradually decreased from Group 1 to Group 3. We identified no statistically significant benefit in the time to BOS occurrence or in actuarial survival.
We developed a surgical procedure that allows efficient, non-invasive delivery (during 2 months) of recombinant Ad via the intra-hepatic artery (IHA) route.
Human herpesvirus virus type 7 (HHV-7) is a T-lymphotropic herpesvirus which uses the CD4 receptor as main receptor to infect its target cells. Measuring the decrease of CD4 expression during HHV-7 infection is a convenient and accurate method to monitor the efficacy of antiviral agents against HHV-7 infection. Different classes of compounds, such as heparin, pentosan polysulfate (PS), dextran sulfate (DS), aurintricarboxylic acid (ATA), phosphonoformic acid (PFA), 9-(2-phosphonylmethoxyethyl)adenine (PMEA), 2-amino-7-[(1,3-dihydroxy-2-propoxy) methyl] purine (S2242), polyvinylalcohol sulfate (PVAS) and the co-polymer of vinylalcohol sulfate with acrylic acid (PAVAS), acyclovir (ACV), ganciclovir (GCV), penciclovir (PCV), brivudin (BVDU), cidofovir (HPMPC), lobucavir, (R)-9-[4-hydroxy-2-(hydroxymethyl)butyl]guanine] (H2G), (R)-9-(2-phosphonylmethoxypropyl)adenine (PMPA) and sorivudine (BVaraU), were evaluated for their anti-HHV-7 activity in the SupT1 T cell line and in purified CD4+ T lymphocytes. Antiviral activity was monitored by inhibition of: (i) CD4 expression down-regulation; (ii) giant cell formation and (iii) apoptosis induction. In general, PS, DS, PVAS, PAVAS, ATA, PFA, PMEA, S2242, lobucavir and HPMPC had comparable anti-HHV-7 activity in the two cell lines, irrespective of the parameters followed to monitor antiviral activity. One of the exceptions was heparin which had an IC50 of 9.6 microg/ml in SupT1 cells and >250 microg/ml in CD4+ T lymphocytes. The compounds PCV, GCV, H2G and PMPA showed some activity in CD4+ T lymphocytes, but not in SupT1 cells. ACV, BVDU and BVaraU did not show activity in either cell system. None of the chemokines tested, such as platelet factor-4 (PF-4), eotaxin, stromal cell-derived factor 1alpha(SDF-1alpha) and RANTES, had detectable activity against HHV-7. In contrast, the HIV-1 envelope glycoprotein, gp120, and the two anti-CD4 mAbs, 13B8-2 and OKT4, were clearly active against HHV-7 infection.
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Moderate-quality evidence from randomised controlled trials showed no additional benefit from the combination of antivirals with corticosteroids compared to corticosteroids alone for the treatment of Bell's palsy of various degrees of severity. Moderate-quality evidence showed a small but just significant benefit of combination therapy compared with corticosteroids alone in severe Bell's palsy. Corticosteroids alone were more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no benefit from antivirals alone over placebo.Moderate-quality evidence indicated that the combination of antivirals and corticosteroids reduced sequelae of Bell's palsy compared with corticosteroids alone.We found no significant increase in adverse events from the use of antivirals compared with either placebo or corticosteroids, based on moderate-quality evidence.
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N-methanocarbathymidine ((N)-MCT), a thymidine analog incorporating a pseudosugar with a fixed Northern conformation, exhibits potent antiherpetic activity against herpes simplex virus types 1 (HSV-1) and 2 (HSV-2). This study contrasts the metabolic pathway of (N)-MCT and the well-known antiherpetic agent ganciclovir (GCV) in HSV-1-infected and uninfected Vero cells. Treatment of HSV-1 infected Vero cells immediately after viral infection with (N)-MCT profoundly inhibited the development of HSV-1 infection. Using standard plaque reduction assay to measure viral infection, (N)-MCT showed a potency greater than that of ganciclovir (GCV), the IC50s were 0.02 and 0.25 microM for (N)-MCT and GCV, respectively. (N)-MCT showed no cytotoxic effect on uninfected Vero cells (CC50>100 microM). Dose and time dependence studies showed high levels of (N)-MCT-triphosphate ((N)-MCT-TP), and GCV-triphosphate (GCV-TP) in HSV-1-infected cells incubated with (N)-MCT or GCV, respectively. In contrast, uninfected cells incubated with (N)-MCT showed elevated levels of (N)-MCT-monophosphate only, while low levels of mono, di- and triphosphates of GCV were found following incubation with GCV. Although the accumulation rate of (N)-MCT and GCV phosphates in HSV-1-infected cells were similar, the decay rate of (N)-MCT-TP was slower than that of GCV-TP. These results suggest that: (1) the antiviral activity of (N)-MCT against herpes viruses is mediated through its triphosphate metabolite; (2) in contrast to GCV, the diphosphorylation of (N)-MCT in HSV-1- infected cells is the rate limiting step; (3) (N)-MCT-TP accumulates rapidly and has a long half-life in HSV-1-infected cells; and (4) HSV-tk catalyzed the mono, and diphosphorylation of (N)-MCT while monophosphorylating GCV only. These results provide a biochemical rational for the highly selective and effective inhibition of HSV-1 by (N)-MCT.
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A previously healthy boy aged 9 years and 11 months was admitted due to herpetic gingivostomatitis with poor intake. He also had fever, neutropenia, and elevated serum aminotransferase level (> 1000 IU/mL). Prolonged prothrombin time, mild gastrointestinal hemorrhage and transient decreased conscious level were noted during hospital days 2 and 3. Intravenous acyclovir therapy commenced on hospital day 2 and his serum aminotransferase level peaked (> 4000 IU/mL) on hospital day 3 and then improved gradually. A throat swab was positive for human herpes simplex virus (HSV)-1, serological test was positive for acute primary HSV-1 infection, and a blood specimen was also strongly positive for HSV-1 by polymerase chain reaction. He received a 14-day course of intravenous acyclovir and recovered uneventfully. Herpetic gingivostomatitis, although mostly benign and self-limited, may be complicated with severe hepatitis, even in immunocompetent hosts.
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We report a 47-year-old bone marrow transplant recipient with haemorrhagic cystitis caused by adenovirus successfully treated with ganciclovir. This is the first report on the use of ganciclovir for the successful treatment of adenoviral infection. Shell vial culture may be more sensitive than conventional culture in the detection of adenovirus in such patients.
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We conducted a randomized, placebo-controlled trial of valganciclovir therapy in neonates with symptomatic congenital CMV disease, comparing 6 months of therapy with 6 weeks of therapy. The primary end point was the change in hearing in the better ear ("best-ear" hearing) from baseline to 6 months. Secondary end points included the change in hearing from baseline to follow-up at 12 and 24 months and neurodevelopmental outcomes, with each end point adjusted for central nervous system involvement at baseline.
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Using a replication-defective adenoviral vector (cytomegalovirus, CMV) containing the beta-galactosidase gene (Ad-CMV-beta-gal) as a control and Ad-CMV-TK as the therapeutic vector under the transcriptional control of the CMV promoter, transduction efficiency was assessed in vitro by infecting LNCaP and PC-3 androgen-dependent and independent human prostate cancer cells with Ad-CMV-beta-gal, and using X-gal staining. The TK activity in prostate cancer cells infected with Ad-CMV-TK was determined by measuring TK-mediated [3H]-gancyclovir phosphorylation. The sensitivity of LNCaP and PC-3 cells to Ad-CMV-TK in vitro was determined after infection with the therapeutic vector with or without acyclovir. The inhibition of PC-3 tumour growth in vivo induced by the Ad-CMV-TK/acyclovir suicide-gene system was assessed in separate and controlled experiments using human prostate cancer mouse models. Ki-67 proliferative antigen and proliferating cell nuclear antigen (PCNA), both useful proliferative indices, were evaluated using immunohistochemical staining (MIB-1 monoclonal antibody and monoclonal anti-PCNA antibody) in formalin-fixed, paraffin-embedded tissues from gene therapy-treated and control animals.
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A case report of recurrent unilateral granulomatous iridocyclitis with ocular hypertension without retinitis caused by cytomegalovirus (CMV) in an immunocompetent patient.
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A 12-year-old boy presented to a community hospital with fever, malaise and fatigue. A polymerase chain reaction test of the cerebrospinal fluid was positive for Epstein-Barr virus. Despite intensive care treatment and antiviral drugs, the patient died 1 month after his initial presentation.
In the HAART era, systemic anti-CMV therapy, while there is immune compromise, seems to provide benefits in terms of longer survival and decreased CMV dissemination.
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The Focal Acne Scar Treatment technique is an effective method of improving the appearance of atrophic acne scars. Higher energy and density levels can be used when utilizing this technique, resulting in improved outcomes when compared with whole face fractional CO2 laser resurfacing. Healing is improved and faster with this technique and no increased incidence of permanent adverse events were found. More studies are needed to further evaluate this new technique.
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Two apparently immunocompetent adult patients developed acute fulminant hepatitis during presumptive primary herpes simplex virus type 1 (HSV-1) infection without any visible mucocutaneous lesions. HSV hepatitis was not suspected in the case of patient 1, who died without treatment. Patient 2 was empirically treated with acyclovir because of the triad of high fever, leukopenia, and markedly elevated levels of aminotransferases, and this patient survived. Most immunocompetent patients with fulminant HSV hepatitis do not have visible mucocutaneous ulcers, and HSV is frequently not considered as a cause of acute hepatitis. In summary, fulminant hepatitis can occur during HSV infections, the diagnosis is frequently missed or delayed because of the absence of mucocutaneous ulcerations, and patients who receive early empirical treatment with acyclovir can survive this illness.
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Our data demonstrate that HSV-TK/GCV suicide gene therapy system is effective for treating experimental human pancreatic cancer, which is largely resistant to the common therapies, so the suicide gene therapy system may be a potential treatment approach for pancreatic cancer.
A 14-year-old girl presented with a 3-week history of mucosal erosions, injected conjunctiva, dehydration, and respiratory distress. She had been treated with intravenous acyclovir for herpes simplex infection with positive herpes simplex virus immunoglobulin M and immunoglobulin G. Physical examination and imaging revealed a large abdominal mass. Incisional biopsy was obtained, and pathology demonstrated angiofollicular hyperplasia with hyalinized germinal centers and Castleman's syndrome-like features. Based on the mucosal erosions, herpes simplex virus serology and positive herpes simplex virus-1 direct fluorescent antibody, Castleman's disease secondary to overwhelming herpes simplex virus infection was the initial impression. The poor response to antivirals and subsequent development of a bullous eruption on the hands resulted in dermatology consultation. Skin biopsy was obtained from a bullae and revealed suprabasilar acantholysis with necrosis as well as upper dermal, perivascular, and interface infiltrate of lymphocytes and eosinophils. No viropathic changes were present. Direct immunofluorescence was significant for immunoglobulin G deposition intercellularly and along the dermoepidermal junction and focal trace C3 deposition along the dermoepidermal junction consistent with paraneoplastic pemphigus, later confirmed by indirect immunofluorescence. We report this case of paraneoplastic pemphigus secondary to Castleman's syndrome confounded by herpes simplex virus-1 positive mucosal erosions.
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To examine clinical associations, evolution of the condition, and response to treatment of erythema multiforme (EM) in prepubertal children.
Therapeutic cells producing amphotropic retrovirus, which are able to transduce in vivo thymidine kinase gene of Herpes simplex virus were prepared. Single-cell clone cells with high virus productivity (PA-3 17JH5c113) were obtained by cell cloning. The cells were found free of replication competent retrovirus, they were non-tumorigenic in xenogeneic host and highly sensitive to ganciclovir treatment in vitro and in vivo. The therapeutic efficacy of PA-317JH5c113 cells was tested in rat brain tumor model. Increase in survival in the group of treated versus untreated rats was observed. Therefore, these cells are suitable for application in human clinical trial.
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ARN carries poor visual prognosis in Tunisia.
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Late-onset cytomegalovirus (CMV) disease is a significant problem with a standard 3-month prophylaxis regimen. This multicentre, double-blind, randomized controlled trial compared the efficacy and safety of 200 days' versus 100 days' valganciclovir prophylaxis (900 mg once daily) in 326 high-risk (D+/R-) kidney allograft recipients. Significantly fewer patients in the 200-day group versus the 100-day group developed confirmed CMV disease up to month 12 posttransplant (16.1% vs. 36.8%; p < 0.0001). Confirmed CMV viremia was also significantly lower in the 200-day group (37.4% vs. 50.9%; p = 0.015 at month 12). There was no significant difference in the rate of biopsy-proven acute rejection between the groups (11% vs. 17%, respectively, p = 0.114). Adverse events occurred at similar rates between the groups and the majority were rated mild-to-moderate in intensity and not related to study medication. In conclusion, this study demonstrates that extending valganciclovir prophylaxis (900 mg once daily) to 200 days significantly reduces the incidence of CMV disease and viremia through to 12 months compared with 100 days' prophylaxis, without significant additional safety concerns associated with longer treatment. The number needed to treat to avoid one additional patient with CMV disease up to 12 months posttransplant is approximately 5.
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Herpetic gingivostomatitis is the most common specific, clinical manifestation of primary herpes simplex type I infection. It is prevalent in the 1-3-year age group. The disease involves the buccal and gingival mucosa, and tongue and lasts approximately 2 weeks. Two recent open studies reported a more rapid regression of symptoms after treatment with acyclovir suspension. Three randomized double-blind placebo-control trials have clearly demonstrated that early acyclovir treatment significantly shortens the duration of all clinical manifestations and infectivity of affected children compared to placebo.
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Varicella zoster virus (VZV) infection is one of the frequent opportunistic infections after allogeneic bone marrow transplantation, with a high incidence of 30-50%. However, no data have been reported on VZV infection after allogeneic peripheral blood stem cell transplantation (PBSCT).
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In cases of HSE, the initial EEG severity and seizure presentation may be useful predictive factors for the outcome at 6 months after acyclovir treatment.
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From 2004 to 2006, we conducted a cross-sectional analysis of baseline data from patients presenting with GUD at a reference STI clinic in Lilongwe, Malawi. Participants were enrolled in a randomized clinical trial of acyclovir added to syndromic management and followed up for up to 28 days. Serologies for HIV (using parallel rapid tests), herpes simplex virus type 2 (HSV-2; using Focus HerpeSelect IgG2 ELISA [Focus Technologies, Cypress Hill, CA]), and syphilis (rapid plasma reagin confirmed by Treponema pallidum hemagglutination) were determined, with plasma HIV-1 RNA and CD4 count in HIV-positive patients. Genital ulcer disease etiology was determined by real-time multiplex polymerase chain reaction from lesional swabs.
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Kaposis varicelliform eruption (KVE) represents widespread cutaneous herpes simplex virus (HSV) infection in patients with preexisting dermatoses. Occasionally, this infection can present as a nosocomial infection in skin wards, if adequate bed-spacing and barrier nursing methods are not followed. We are reporting five cases of KVE; four cases acquired the infection in a makeshift ward after admission of the first case in May 2005, due to the renovation work of the regular skin ward.
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Studies were carried out, for the first time, to investigate the charge-transfer reactions of ganciclovir as n-electron donor with the sigma-acceptor iodine and various pi-acceptors: 7,7,8,8-tetracyanoquinodimethane; tetracyanoethylene; 2,3-dichloro-5,6-dicyano-1,4-benzoquinone; p-chloranilic acid; 2,3,5,6-tetrabromo-1,4-benzoquinone; 2,3,5,6-tetrachloro-1,4-benzoquinone and 2,4,7-trinitro-9-fluorenone. The formation of the colored charge-transfer complexes was utilized in the development of simple, rapid and accurate spectrophotometric methods for the analysis of ganciclovir in pure form as well as in its pharmaceutical formulation (capsules). Different variables affecting the reactions were studied and optimized. Under the optimum reaction conditions, linear relationships with good correlation coefficients (0.9993-0.9998) were found between the absorbance and the concentration of ganciclovir in the range of 2.0-240 microg mL(-1). For more accurate analysis, Ringbom optimum concentration range was found to be between 5.0 and 225 microg mL(-1). The limits of detection ranged from 0.36 to 2.45 microg mL(-1) and the limits of quantification ranged from 1.20 to 8.17 microg mL(-1). A Job's plot of the absorbance versus the molar ratio of ganciclovir to each of acceptors under consideration indicated (1:1) ratio. The proposed methods were applied successfully for simultaneous determination of ganciclovir in capsules with good accuracy and precision and without interferences from common additives. The recovery percentages ranged from 99.45+/-0.73% to 100.35+/-1.40%. The results were compared favourably with the reported method.
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To present an unusual cause of bilateral sensorineural hearing loss mimicking chemotherapy-induced ototoxicity.
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Interactions between pharmaceutical ingredients play an important role in the development of drug formulations. It was the aim of our present studies to investigate drug-polymer interactions. Interaction of the antiviral drug acyclovir with polyethylenimines, polyvinylamines and the non-ionic PVP was investigated using a modified equilibrium dialysis. The membrane was only permeable to free acyclovir, while polymers and acyclovir-polymer-associates did not pass through. Significant amounts of acyclovir were bound with the polyethylenimines. The formation of associates consisting of acyclovir and either PVP or polyvinylamine could not be demonstrated. In solutions of acyclovir and polyethylenimine (Mr=25,000) the amount of bound drug is increased with increasing concentration of acyclovir. Between 7.9 µg and 31.7 µg take part in the formation of associates. Differences in the osmotic pressure of the solutions do not play an important role in the permeation of acyclovir. In solutions containing acyclovir and high molecular weight polyethylenimine (Mr=750,000) the bound amount of drug increases with increasing acyclovir concentration up to c(0)=400 µg/100 ml. Further addition of free drug to the solution does not change the amount of bound drug significantly, due to possible limitations in the binding capacity. Molecular modeling investigations were performed. According to the calculations, about 85% of the interactions can be attributed to electrostatic interactions.
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Podophyllotoxin and its derivatives were examined for inhibitory effects on the replication of herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), including acyclovir-resistant virus and clinical isolates. Deoxypodophyllotoxin (RD4-6266) proved to be a highly potent and selective inhibitor of all HSV strains in MRC-5 cells. EC50 values of RD4-6283 (in which the methylenedioxy ring A is modified) for HSV-1 and -2 were inferior to those of deoxypodophyllotoxin. However, podorhizol (RD4-6277) and 5'-methoxy-podorhizol (RD4-6276), in which ring C is absent, did not inhibit HSV replication. Moreover, RD4-6266 also inhibited the production of infectious virus particles of HSV-1 KOS strain and HSV-2 G strain. In contrast, none of the podophyllotoxin derivatives were found to have an antiviral effect against influenza A virus, respiratory syncytial virus or human cytomegalovirus in doses not toxic to the cells.
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Chronic herpes simplex virus type-1 encephalitis (HSE-1) is uncommon. Past reports focused on its association with prior documented acute infection. Here, we describe a patient with increasingly intractable epilepsy from chronic HSE-1 reactivation without history of acute central nervous system infection.
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The aim of this study was to investigate the selective killing effect of the herpes simplex virus-thymidine kinase/ganciclovir (TK/GCV) suicide gene system controlled by the survivin promoter on hepatocellular carcinoma (HCC) cells in vitro. Recombinant plasmid vectors driven by the survivin promoter were constructed. HepG2 HCC and LO2 normal human liver cells were transfected with the recombinant plasmids, green fluorescent protein (GFP)/pSURV, TK/pSURV and TAT-TK/pSURV. GFP expression was detected by fluoroscopy and flow cytometry (FCM). TK gene expression was detected using RT-PCR and western blot analysis. The selective killing effects after GCV application were evaluated by tetrazolium assay, FCM and western blot analysis. Statistical analysis was performed by ANOVA. After transfection with GFP/pSURV, TK/pSURV and TAT-TK/pSURV for 48 h, GFP expression was observed in the HepG2 cells, but not in the L02 cells and TK gene expression was evidently detected by RT-PCR and western blot analysis in the HepG2 cells. Three stably transfected cell lines (HepG2/pSURV, HepG2/TK/pSURV and HepG2/TAT-TK/pSURV) were successfully established. Compared with the HepG2/TK/pSURV group, a significant 'bystander effect' was observed in the HepG2/TAT-TK/pSURV group with the incorporation of unmodifed HepG2 cells at different ratios. Following transfection with TK/pSURV and TAT-TK/pSURV, the growth of HepG2 cells in the presence of GCV was markedly inhibited. This finding was further corroborated by FCM and immunoblot analysis revealed the repressed expression of proliferating cell nuclear antigen (PCNA). Our results showed that the plasmid vectors carrying the TK and TAT-TK fusion protein gene driven by the survivin promoter were successfully constructed and their specific expression in HepG2 cells provided the basis for the targeted gene therapy of HCC.
Varicella-zoster virus (VZV) replicates in quiescent T cells, neurons, and skin cells. In cultured fibroblasts (HFFs), VZV induces host cyclin expression and cyclin-dependent kinase (CDK) activity without causing cell cycle progression. CDK1/cyclin B1 phosphorylates the major viral transactivator, and the CDK inhibitor roscovitine prevents VZV mRNA transcription. We investigated the antiviral effects of additional compounds that target CDKs or other cell cycle enzymes in culture, ex vivo, and in vivo. Cytotoxicity and cell growth arrest doses were determined by Neutral Red assay. Antiviral effects were evaluated in HFFs by plaque assay, genome copy number, and bioluminescence. Positive controls were acyclovir (400 microM) and phosphonoacetic acid (PAA, 1 mM). Test compounds were roscovitine, aloisine A, and purvalanol A (CDK inhibitors), aphidicolin (inhibits human and herpesvirus DNA polymerase), l-mimosine (indirectly inhibits human DNA polymerase), and DRB (inhibits casein kinase 2). All had antiviral effects below the concentrations required for cell growth arrest. Compounds were tested in skin organ culture at EC(99) doses; all prevented VZV replication in skin, except for aloisine A and purvalanol A. In SCID mice with skin xenografts, roscovitine (0.7 mg/kg/day) was as effective as PAA (36 mg/kg/day). The screening systems described here are useful models for evaluating novel antiviral drugs for VZV.
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In solid organ transplant recipients and patients with AIDS, HCMV symptomatic infections mostly appear when antigenemia values are > 300 pp65-positive PBL/2 x 10(5) examined. To avoid the appearance of overt HCMV disease antiviral treatment could be administered when antigenemia levels are > 100 pp65-positive PBL/2 x 10(5) examined. Bone marrow transplant recipients show symptomatic HCMV infections when antigenemia values are > 100 pp65-positive PBL/2 x 10(5) examined. This group of patients should be treated when antigenemia levels are < 10 pp65-positive PBL/2 x 10(5) examined due to the higher mortality rate associated with HCMV complications. A decrease in antigenemia levels during therapy indicates a good response to antiviral drug, while stable or increasing values document a treatment failure and the emergence of drug-resistant HCMV strains.