1
|
Deme P, Moniruzzaman M, Moore D, Heaton R, Ellis R, Letendre S, Haughey N. Association of Plasma Eicosanoid Levels With Immune, Viral, and Cognitive Outcomes in People With HIV. Neurology 2022; 99:e1251-e1264. [PMID: 35851253 PMCID: PMC9576290 DOI: 10.1212/wnl.0000000000200945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/20/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To determine whether plasma eicosanoid levels are associated with immune, viral, and cognitive outcomes in people with HIV (PWH). METHODS We measured 42 eicosanoids in a longitudinal study of 95 PWH and 25 demographically comparable uninfected participants. Routine clinical chemistry, virologic, immune markers, and a neuropsychological test battery assessing 7 cognitive domains were administered to all participants at 2 study visits over an average of 6.5 months. RESULTS Plasma eicosanoid concentrations were elevated in PWH (n = 95) compared with seronegative controls (n = 25) (100% prediction power at 5% false discovery rate [FDR], α = 0.0531) and were negatively associated with lower current and nadir CD4 lymphocyte counts. Higher levels of eicosanoids were associated with impairments in working memory, verbal fluency, and executive function. Higher plasma viral load was associated with elevated proinflammatory eicosanoids (24% prediction power at 5% FDR and 42.4% prediction power at 10% FDR, α = 0.10). Longitudinal analyses showed that eicosanoid levels were correlated with viral load and with plasma creatinine. Despite associations of eicosanoids with viral loads, elevated plasma eicosanoids were similar in virally suppressed and not fully suppressed PWH. DISCUSSION These data show that HIV infection is associated with a robust production of eicosanoids that are not substantially reduced by antiretroviral therapy (ART). The sustained elevation of these oxylipins in PWH despite ART may contribute to an accelerated aging phenotype that includes earlier than expected brain and peripheral organ damage.
Collapse
Affiliation(s)
- Pragney Deme
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohammed Moniruzzaman
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Moore
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert Heaton
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald Ellis
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Scott Letendre
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Norman Haughey
- From the Department of Neurology (P.D., M.M., N.H.), Johns Hopkins University School of Medicine, Baltimore, MD; HIV Neurobehavioral Research Program and Departments of Neurosciences and Psychiatry (D.M., R.H., R.E., S.L.), School of Medicine, University of California, San Diego, La Jolla; and the Department of Psychiatry (N.H.), Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
2
|
Wetherill MS, Bakhsh C, Caywood L, Williams MB, Hartwell ML, Wheeler DL, Hubach RD, Teague TK, Köhler G, Hebert JR, Weiser SD. Unpacking determinants and consequences of food insecurity for insulin resistance among people living with HIV: Conceptual framework and protocol for the NOURISH-OK study. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3. [PMID: 36225538 PMCID: PMC9552993 DOI: 10.3389/fcdhc.2022.947552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Over the past four decades, advances in HIV treatment have contributed to a longer life expectancy for people living with HIV (PLWH). With these gains, the prevention and management of chronic co-morbidities, such as diabetes, are now central medical care goals for this population. In the United States, food insecurity disproportionately impacts PLWH and may play a role in the development of insulin resistance through direct and indirect pathways. The Nutrition to Optimize, Understand, and Restore Insulin Sensitivity in HIV for Oklahoma (NOURISH-OK) will use a novel, multi-level, integrated framework to explore how food insecurity contributes to insulin resistance among PLWH. Specifically, it will explore how food insecurity may operate as an intermediary risk factor for insulin resistance, including potential linkages between upstream determinants of health and downstream consequences of poor diet, other behavioral risk factors, and chronic inflammation. Methods/design: This paper summarizes the protocol for the first aim of the NOURISH-OK study, which involves purposeful cross-sectional sampling of PLWH (n=500) across four levels of food insecurity to test our conceptual framework. Developed in collaboration with community stakeholders, this initial phase involves the collection of anthropometrics, fasting blood samples, non-blood biomarkers, 24-hour food recall to estimate the Dietary Inflammatory Index (DII®) score, and survey data. A 1-month, prospective observational sub-study (total n=100; n=25 for each food security group) involves weekly 24-hour food recalls and stool samples to identify temporal associations between food insecurity, diet, and gut microbiome composition. Using structural equation modeling, we will explore how upstream risk factors, including early life events, current discrimination, and community food access, may influence food insecurity and its potential downstream impacts, including diet, other lifestyle risk behaviors, and chronic inflammation, with insulin resistance as the ultimate outcome variable. Findings from these analyses of observational data will inform the subsequent study aims, which involve qualitative exploration of significant pathways, followed by development and testing of a low-DII® food as medicine intervention to reverse insulin resistance among PLWH (ClinicalTrials.gov Identifier: NCT05208671). Discussion: The NOURISH-OK study will address important research gaps to inform the development of food as medicine interventions to support healthy aging for PLWH.
Collapse
Affiliation(s)
- Marianna S. Wetherill
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Tulsa Schusterman Center, Tulsa, OK, United States
- Department of Family and Community Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK, United States
- *Correspondence: Marianna S. Wetherill,
| | | | - Lacey Caywood
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Tulsa Schusterman Center, Tulsa, OK, United States
| | - Mary B. Williams
- Department of Family and Community Medicine, University of Oklahoma School of Community Medicine, Tulsa, OK, United States
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Tulsa Schusterman Center, Tulsa, OK, United States
| | - Micah L. Hartwell
- Department of Psychiatry, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Denna L. Wheeler
- Center for Rural Health, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Randolph D. Hubach
- Department of Public Health, Purdue University, West Lafayette, IN, United States
| | - T. Kent Teague
- Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, United States
- Department of Psychiatry, University of Oklahoma School of Community Medicine, Tulsa, OK, United States
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Gerwald Köhler
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - James R. Hebert
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, United States
| | - Sheri D. Weiser
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, United States
| |
Collapse
|
4
|
Goldschmied JR, Sengupta A, Sharma A, Taylor L, Morales KH, Thase ME, Thase ME, Weljie A, Kayser MS. Treatment of Insomnia with Zaleplon in HIV+ Significantly Improves Sleep and Depression. PSYCHOPHARMACOLOGY BULLETIN 2021; 51:50-64. [PMID: 34421144 PMCID: PMC8374930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
More than 50% of individuals who are HIV positive report insomnia, which can reduce HIV treatment adherence, impair quality of life, and contribute to metabolic dysfunction. Major depressive disorder is also highly comorbid in this population, leading to further impairment. There is evidence that treating insomnia may improve not only sleep, but depression and metabolic function, as well. The present study aimed to examine the effects of pharmacotherapeutic treatment of insomnia on sleep, depression, and metabolic functioning in individuals with HIV. 20 individuals with asymptomatic seropositive HIV and comorbid insomnia and depression were administered zaleplon for 6 weeks. Insomnia severity was assessed using the Insomnia Severity Index and Epworth Sleepiness Scale, and depression severity was assessed using the Quick Inventory of Depression, both prior to treatment and 6 weeks post treatment. Metabolomic changes were assessed using a comprehensive platform measuring ~2000 lipid features and polar metabolites. Linear mixed effects models demonstrated that 6 weeks of treatment with zaleplon significantly improved symptoms of both insomnia and depression. Metabolomic analyses also demonstrated that changes in insomnia severity were associated with significant changes in key branched chain amino acid metabolites. Our results show that improvement in insomnia is associated with reduced depressive symptoms and beneficial metabolomic changes. Additionally, changes in key branched chain amino acid metabolites following treatment may serve as useful biomarkers of treatment response.
Collapse
Affiliation(s)
- Jennifer R Goldschmied
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Arjun Sengupta
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Anup Sharma
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Lynne Taylor
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Knashawn H Morales
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Michael E Thase
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Michael E Thase
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Aalim Weljie
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| | - Matthew S Kayser
- Goldschmied, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA. Sengupta, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Sharma, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Taylor, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA. Morales, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA. Thase, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA. Weljie, Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA. Kayser, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Chronobiology and Sleep Institute, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
6
|
Masters MC, Perez J, Wu K, Ellis RJ, Goodkin K, Koletar SL, Andrade A, Yang J, Brown TT, Palella FJ, Sacktor N, Tassiopoulos K, Erlandson KM. Baseline Neurocognitive Impairment (NCI) Is Associated With Incident Frailty but Baseline Frailty Does Not Predict Incident NCI in Older Persons With Human Immunodeficiency Virus (HIV). Clin Infect Dis 2021; 73:680-688. [PMID: 34398957 DOI: 10.1093/cid/ciab122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 02/08/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neurocognitive impairment (NCI) and frailty are more prevalent among persons with human immunodeficiency virus (HIV, PWH) compared to those without HIV. Frailty and NCI often overlap with one another. Whether frailty precedes declines in neurocognitive function among PWH or vice versa has not been well established. METHODS AIDS Clinical Trials Group (ACTG) A5322 is an observational cohort study of older PWH. Participants undergo annual assessments for NCI and frailty. ACTG A5322 participants who developed NCI as indexed by tests of impaired executive functioning and processing speed during the first 3 years were compared to persons who maintained normal cognitive function; those who demonstrated resolution of NCI were compared to those who had persistent NCI. Participants were similarly compared by frailty trajectory. We fit multinomial logistic regression models to assess associations between baseline covariates (including NCI) and frailty, and associations between baseline covariates (including frailty) and NCI. RESULTS In total, 929 participants were included with a median age of 51 years (interquartile range [IQR] 46-56). At study entry, 16% had NCI, and 6% were frail. Over 3 years, 6% of participants developed NCI; 5% developed frailty. NCI was associated with development of frailty (odds ratio [OR] = 2.06; 95% confidence interval [CI] = .94, 4.48; P = .07). Further adjustment for confounding strengthened this association (OR = 2.79; 95% CI = 1.21, 6.43; P = .02). Baseline frailty however was not associated with NCI development. CONCLUSIONS NCI was associated with increased risk of frailty, but frailty was not associated with development of NCI. These findings suggest that the presence of NCI in PWH should prompt monitoring for the development of frailty and interventions to prevent frailty in this population.
Collapse
Affiliation(s)
- Mary Clare Masters
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeremiah Perez
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kunling Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ronald J Ellis
- University of California, San Diego, San Diego, California, USA
| | - Karl Goodkin
- University of Nebraska Medical Center, Omaha, Omaha, Nebraska, USA
| | | | | | | | - Todd T Brown
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Frank J Palella
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ned Sacktor
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | |
Collapse
|