Association between severe anaemia and inflammation, risk of IRIS and death in persons with HIV: A multinational cohort study

BACKGROUND

After initiating antiretroviral therapy (ART), approximately 25% of people with HIV (PWH) may develop Immune Reconstitution Inflammatory Syndrome (IRIS), which is associated with increased morbidity and mortality. Several reports have demonstrated that low haemoglobin (Hb) levels are a risk factor for IRIS. To what extent the severity of anaemia contributes to the risk of IRIS and/or death is still insufficiently explored.

METHODS

We investigated both the presence and severity of anaemia in PWH in a multinational cohort of ART-naïve patients. A large panel of plasma biomarkers was measured pre-ART and patients were followed up for 6 months. IRIS or deaths during this period were considered as outcomes. We performed multidimensional analyses, logistic regression, and survival curves to delineate associations.

FINDINGS

Patients with severe anaemia (SA) presented a distinct systemic inflammatory profile, characterized by higher TNF, IL-6, and IL-27 levels. SA was independently associated with IRIS, with a higher risk of both early IRIS onset and death. Among IRIS patients, those with SA had a higher risk of mycobacterial IRIS.

INTERPRETATION

PWH with SA display a more pronounced inflammatory profile, with an elevated risk of developing IRIS earlier and a statistically significant higher risk of death.

FUNDING

Intramural Research Program of National Institute of Allergy and Infectious Diseases/National Institutes of Health (NIAID/NIH). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Finance code: 001) and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.

Brief Report: No Differences Between Lopinavir/Ritonavir and Nonnucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy on Clearance of Plasmodium falciparum Subclinical Parasitemia in Adults Living With HIV Starting Treatment (A5297)

BACKGROUND

HIV protease inhibitors anti-Plasmodium falciparum activity in adults remains uncertain.

METHODS

Adults with HIV CD4+ counts >200 cells/mm3 starting antiretroviral therapy (ART) with P. falciparum subclinical parasitemia (Pf SCP) were randomized 1:1 to (step 1) protease inhibitor lopinavir/ritonavir (LPV/r)-based (arm A) or nonnucleoside reverse transcriptase inhibitor (nNRTI)-based ART (arm B) for 15 days. In step 2, participants received nNRTI-based ART and trimethoprim/sulfamethoxazole prophylaxis for 15 days. P. falciparum SCP clearance was measured by polymerase chain reaction. The Fisher exact test [95% exact confidence interval (CI)] was used to compare proportions of P. falciparum SCP clearance (<10 parasites/μL on 3 occasions within 24 hours) between LPV/r and nNRTI arms at day 15. The Kaplan-Meier method and log-rank test were used to compare time-to-clearance.

RESULTS

Fifty-two adults from Kenya, Malawi, and Uganda with a median age = 31 (Q1, Q3: 24-39) years, 33% women, with baseline median CD4+ counts of 324 (259-404) cells/mm3, median HIV-1 RNA viremia of 5.18 log10 copies/mL (4.60-5.71), and median estimated P. falciparum density of 454 parasites/μL (83-2219) enrolled in the study. Forty-nine (94%) participants completed the study. At day 15, there was no statistically significant difference in the proportions of P. falciparum SCP clearance between the LPV/r (23.1% clearance; 6 of the 26) and nNRTI (26.9% clearance; 7 of the 26) arms [between-arm difference 3.9% (95% CI, -21.1% to 28.4%; P = 1.00)]. No significant difference in time-to-clearance was observed between the arms (P = 0.80).

CONCLUSIONS

In a small randomized study of adults starting ART with P. falciparum SCP, no statistically significant differences were seen between LPV/r- and nNRTI-based ART in P. falciparum SCP clearance after 15 days of treatment.

Development and validation of technologies suitable for the decontamination and re-use of contaminated N95 filtering facepiece respirators in response to the COVID-19 pandemic

Background

Coronavirus disease 2019 (COVID-19) has brought significant challenges to society globally, particularly in the area of healthcare provision. A pressing need existed in protecting those tasked with delivering healthcare solutions during the COVID-19 crisis by providing solutions for preserving adequate supplies of effective personal protective equipment (PPE).

Aim

To evaluate and validate available methods for the decontamination of N95 filtering facepiece respirators (FFRs) while maintaining functionality during re-use.

Methods

Multiple low-temperature steam and vaporized hydrogen peroxide (VHP) technologies were assessed for inactivation of Mycobacterium spp. and feline calicivirus (employed as representatives of the contamination challenge).

Findings

Virus (≥3log₁₀) and Mycobacterium spp. (≥6log₁₀) inactivation was achieved on various types of N95 FFRs using an array of heat (65–71^oC), humidity (>50% relative humidity) and VHP without affecting the performance of the PPE.

Conclusion

The methods have been validated and were authorized by the US Food and Drug Administration under a temporary emergency use authorization. Based on the findings, opportunities exist for development and deployment of decontamination methods made from simple, general purpose materials and equipment should a future need arise.

Attaining 95-95-95 through Implementation Science: 15 Years of Insights and Best Practices from the Walter Reed Army Institute of Research's Implementation of the U.S. President's Emergency Plan for AIDS Relief

The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR’s implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR’s contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.

Prospective International Study of Incidence and Predictors of Immune Reconstitution Inflammatory Syndrome and Death in People Living With Human Immunodeficiency Virus and Severe Lymphopenia

BACKGROUND

Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation.

METHODS

We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/μL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models.

RESULTS

We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/μL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 μg/mL and BMI <15.6 kg/m2 as predictive of death.

CONCLUSIONS

For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.

A randomized phase II trial of CRLX101 in combination with bevacizumab versus standard of care in patients with advanced renal cell carcinoma

BACKGROUND

Nanoparticle-drug conjugates enhance drug delivery to tumors. Gradual payload release inside cancer cells augments antitumor activity while reducing toxicity. CRLX101 is a novel nanoparticle-drug conjugate containing camptothecin, a potent inhibitor of topoisomerase I and the hypoxia-inducible factors 1α and 2α. In a phase Ib/2 trial, CRLX101 + bevacizumab was well tolerated with encouraging activity in metastatic renal cell carcinoma (mRCC). We conducted a randomized phase II trial comparing CRLX101 + bevacizumab versus standard of care (SOC) in refractory mRCC.

PATIENTS AND METHODS

Patients with mRCC and 2-3 prior lines of therapy were randomized 1 : 1 to CRLX101 + bevacizumab versus SOC, defined as investigator's choice of any approved regimen not previously received. The primary end point was progression-free survival (PFS) by blinded independent radiological review in patients with clear cell mRCC. Secondary end points included overall survival, objective response rate and safety.

RESULTS

In total, 111 patients were randomized and received ≥1 dose of drug (CRLX101 + bevacizumab, 55; SOC, 56). Within the SOC arm, patients received single-agent bevacizumab (19), axitinib (18), everolimus (7), pazopanib (4), sorafenib (4), sunitinib (2), or temsirolimus (2). In the clear cell population, the median PFS on the CRLX101 + bevacizumab and SOC arms was 3.7 months (95% confidence interval, 2.0-4.3) and 3.9 months (95% confidence interval 2.2-5.4), respectively (stratified log-rank P = 0.831). The objective response rate by IRR was 5% with CRLX101 + bevacizumab versus 14% with SOC (Mantel-Haenszel test, P = 0.836). Consistent with previous studies, the CRLX101 + bevacizumab combination was generally well tolerated, and no new safety signal was identified.

CONCLUSIONS

Despite promising efficacy data on the earlier phase Ib/2 trial of mRCC, this randomized trial did not demonstrate improvement in PFS for the CRLX101 + bevacizumab combination when compared with approved agents in patients with heavily pretreated clear cell mRCC. Further development in this disease is not planned.

CLINICAL TRIAL IDENTIFICATION

NCT02187302 (NIH).

Association of Clinical Events With Everolimus Exposure in Kidney Transplant Patients Receiving Low Doses of Tacrolimus

A key objective in the use of immunosuppression after kidney transplantation is to attain the optimal balance between efficacy and safety. In a phase 3b, multicenter, randomized, open-label, noninferiority study, the incidences of clinical events, renal dysfunction, and adverse events (AEs) were analyzed at 12 months in 309 de novo renal transplant recipients receiving everolimus (EVR), low-dose tacrolimus (LTac), and prednisone. Cox proportional hazard regression modeling was used to estimate the probability of clinical events at specified combinations of time-normalized EVR and Tac trough concentrations. At 12 months, the highest incidence of treated biopsy-proven acute rejection (tBPAR) and graft loss occurred most often in patients with EVR trough concentration <3 ng/mL (64.7% and 10.5%, respectively). At 1 month and 12 months, increasing EVR levels were associated with fewer tBPAR events (both p < 0.0001). Low estimated glomerular filtration rate (eGFR) and decreased eGFR occurred more often in patients with lower EVR and higher Tac levels. AEs were most often observed in patients with EVR levels <3 ng/mL. This study supports maintaining an EVR trough concentration of 3-8 ng/mL, when combined with LTac, to achieve balanced efficacy and safety in renal transplant recipients.

TRIAL REGISTRATION

NCT01025817.

Efficacy and Safety of Everolimus Plus Low-Dose Tacrolimus Versus Mycophenolate Mofetil Plus Standard-Dose Tacrolimus in De Novo Renal Transplant Recipients: 12-Month Data

In this 12-month, multicenter, randomized, open-label, noninferiority study, de novo renal transplant recipients (RTxRs) were randomized (1:1) to receive everolimus plus low-dose tacrolimus (EVR+LTac) or mycophenolate mofetil plus standard-dose Tac (MMF+STac) with induction therapy (basiliximab or rabbit anti-thymocyte globulin). Noninferiority of composite efficacy failure rate (treated biopsy-proven acute rejection [tBPAR]/graft loss/death/loss to follow-up) in EVR+LTac versus MMF+STac was missed by 1.4%, considering the noninferiority margin of 10% (24.6% vs. 20.4%; 4.2% [-3.0, 11.4]). Incidence of tBPAR (19.1% vs. 11.2%; p < 0.05) was significantly higher, while graft loss (1.3% vs. 3.9%; p < 0.05) and composite of graft loss/death/lost to follow-up (6.1% vs. 10.5%, p = 0.05) were significantly lower in EVR+LTac versus MMF+STac groups, respectively. Mean estimated glomerular filtration rate was similar between EVR+LTac and MMF+STac groups (63.1 [22.0] vs. 63.1 [19.5] mL/min/1.73 m² ) and safety was comparable. In conclusion, EVR+LTac missed noninferiority versus MMF+STac based on the 10% noninferiority margin. Further studies evaluating optimal immunosuppression for improved efficacy will guide appropriate dosing and target levels of EVR and LTac in RTxRs.

A2 to B Blood Type Incompatible Deceased Donor Kidney Transplantation in a Recipient Infected with the Human Immunodeficiency Virus: A Case Report

BACKGROUND

With the introduction of the Kidney Allocation System in the United States in December 2014, transplant centers can list eligible B blood type recipients for A2 organ offers. There have been no prior reports of ABO incompatible A2 to B deceased donor kidney transplantation in human immunodeficiency virus-positive (HIV+) recipients to guide clinicians on enrolling or performing A2 to B transplantations in HIV+ candidates. We are the first to report a case of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results.

METHODS AND RESULTS

We describe an HIV+ 39-year-old African American man with end-stage renal disease who underwent A2 to B blood type incompatible deceased donor kidney transplantation. Prior to transplantation, he had an undetectable HIV viral load. The patient was unsensitized, with his most recent anti-A titer data being 1:2 IgG and 1:32 IgG/IgM. Induction therapy of basiliximab and methylprednisolone was followed by a postoperative regimen of plasma exchange, intravenous immunoglobulin, and rituximab with maintenance on tacrolimus, mycophenolate mofetil, and prednisone. He had delayed graft function without rejection on allograft biopsy. Nadir serum creatinine was 2.0 mg/dL. He continued to have an undetectable viral load on the same antiretroviral therapy adjusted for renal function.

CONCLUSIONS

To our knowledge, this is the first report of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results, suggesting that A2 donor kidneys may be considered for transplantation into HIV+ B-blood type wait list candidates.

Excellent retention, virologic and clinical outcomes after transitioning from an antiretroviral treatment clinical trial to locally-provided care and treatment in Africa

<p class="abstract"><strong>Background:</strong> Little is known about outcomes among clinical trial participants following completion of study-provided care and treatment in resource limited settings. We sought to describe outcomes among HIV clinical trial participants after transitioning to local routine care in Africa<span lang="EN-IN">. </span></p><p class="abstract"><strong>Methods:</strong> In the OCTANE study, 741 women with CD4 &lt;200 cells/mm³ in 7 African countries were randomized to initiate antiretroviral treatment (ART) with tenofovir/emtricitabine (TDF/FTC) plus either lopinavir/ritonavir (LPV/r) or nevirapine (NVP). When study-specified ART ended (48-191 weeks after study entry), participants transitioned to locally-provided HIV care and non-study ART. Consenting participants were interviewed and had toxicity labs, CD4 and HIV-1 RNA testing, and clinical outcomes assessed at 12 and 72 weeks after transition to local care<span lang="EN-IN">.</span></p><p class="abstract"><strong>Results:</strong> Five hundred thirteen (77%) of the 669 women in follow-up at completion of the interventional trial participate in the extended follow-up. 513 women, 476 (93%) had HIV-1 RNA &lt;400 cp/mL at time of transition, and 489 (95%) completed follow-up.  Seventy-seven women (19%) had a total of 99 antiretroviral regimen changes during post-trial follow-up. 30% of the 99 regimen changes-were due to lack of local drug availability. Thirteen (3%) women had Grade ≥3 laboratory abnormalities and 3 experienced worsening of the WHO HIV stage. Two women died. Eighty-nine percent of 484 with results had HIV-1 RNA ≤400 cp/mL at 72 weeks after transition to local non-study HIV care and treatment<span lang="EN-IN">.  </span></p><p class="abstract"><strong>Conclusions:</strong> The vast majority of women were able to continue key components of their ART and to maintain virologic suppression through 72 weeks of locally-provided post-study care.</p><p><strong>Trial registration:</strong> ClinicalTrials.gov NCT00089505</p>

A web-based application for initial screening of living kidney donors: development, implementation and evaluation

Most centers utilize phone or written surveys to screen candidates who self-refer to be living kidney donors. To increase efficiency and reduce resource utilization, we developed a web-based application to screen kidney donor candidates. The aim of this study was to evaluate the use of this web-based application. Method and time of referral were tabulated and descriptive statistics summarized demographic characteristics. Time series analyses evaluated use over time. Between January 1, 2011 and March 31, 2012, 1200 candidates self-referred to be living kidney donors at our center. Eight hundred one candidates (67%) completed the web-based survey and 399 (33%) completed a phone survey. Thirty-nine percent of donors accessed the application on nights and weekends. Postimplementation of the web-based application, there was a statistically significant increase (p < 0.001) in the number of self-referrals via the web-based application as opposed to telephone contact. Also, there was a significant increase (p = 0.025) in the total number of self-referrals post-implementation from 61 to 116 per month. An interactive web-based application is an effective strategy for the initial screening of donor candidates. The web-based application increased the ability to interface with donors, process them efficiently and ultimately increased donor self-referral at our center.

ART treatment costs and retention in care in Kenya: a cohort study in three rural outpatient clinics

INTRODUCTION

After almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV-positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability.

METHODS

Using patient-level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non-ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation.

RESULTS

The cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non-ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%).

CONCLUSIONS

At all three sites, 12-month retention in care compared favourably to retention rates reported in the literature from other low-income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.

Antiretroviral therapies in women after single-dose nevirapine exposure

BACKGROUND

Peripartum administration of single-dose nevirapine reduces mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) but selects for nevirapine-resistant virus.

METHODS

In seven African countries, women infected with HIV-1 whose CD4+ T-cell counts were below 200 per cubic millimeter and who either had or had not taken single-dose nevirapine at least 6 months before enrollment were randomly assigned to receive antiretroviral therapy with tenofovir–emtricitabine plus nevirapine or tenofovir-emtricitabine plus lopinavir boosted by a low dose of ritonavir. The primary end point was the time to confirmed virologic failure or death.

RESULTS

A total of 241 women who had been exposed to single-dose nevirapine began the study treatments (121 received nevirapine and 120 received ritonavir-boosted lopinavir). Significantly more women in the nevirapine group reached the primary end point than in the ritonavir-boosted lopinavir group (26% vs. 8%) (adjusted P=0.001). Virologic failure occurred in 37 (28 in the nevirapine group and 9 in the ritonavir-boosted lopinavir group), and 5 died without prior virologic failure (4 in the nevirapine group and 1 in the ritonavir-boosted lopinavir group). The group differences appeared to decrease as the interval between single-dose nevirapine exposure and the start of antiretroviral therapy increased. Retrospective bulk sequencing of baseline plasma samples showed nevirapine resistance in 33 of 239 women tested (14%). Among 500 women without prior exposure to single-dose nevirapine, 34 of 249 in the nevirapine group (14%) and 36 of 251 in the ritonavir-boosted lopinavir group (14%) had virologic failure or died.

CONCLUSIONS

In women with prior exposure to peripartum single-dose nevirapine (but not in those without prior exposure), ritonavir-boosted lopinavir plus tenofovir–emtricitabine was superior to nevirapine plus tenofovir–emtricitabine for initial antiretroviral therapy. (Funded by the National Institute of Allergy and Infectious Diseases and the National Research Center; ClinicalTrials.gov number, NCT00089505.).

Improvements in physical wellbeing over the first two years on antiretroviral therapy in western Kenya

Improvements in physical wellbeing during the first six months on antiretroviral therapy (ART) are well known, but little is known regarding long-term follow-up. We conducted a prospective cohort study among 222 HIV-positive adult tea plantation workers in western Kenya to assess wellbeing over their first two years on ART. Study subjects completed a standardized questionnaire during repeat ART clinic visits. A 30-day recall period was used to elicit the number of days when subjects experienced poor health and the number of days that pain made it difficult to complete usual activities at home and work. A seven-day recall period was used to assess the severity of bodily pain, nausea, fatigue, and rash. Prevalence of most symptoms declined over time. A median of seven days poor health during the first month on ART declined to three days in the 24th month (p=0.043). For pain making usual activities difficult, a median of seven days during the first month on ART fell to zero by 12 months (p< or =0.0001) but increased to three days by two years. Any bodily pain (range 59-83%) and fatigue (range 51-84%) over the past seven days were common through two years. However, pain and fatigue often over the past seven days declined over two years (from 24-10% (p=0.067) and 41-15% (p=0.002)). Skin rash was rare at all times, though higher at two years (8.6%) than any other time. Initial improvements in physical wellbeing were sustained over two years, however, increased pain and skin rash at year two may indicate problems as treatment programs mature. These improvements in physical wellbeing will be important in sustaining the long-term success of HIV treatment programs.

A phase 1/2 study of a multiclade HIV-1 DNA plasmid prime and recombinant adenovirus serotype 5 boost vaccine in HIV-Uninfected East Africans (RV 172)

BACKGROUND

Human immunodeficiency virus (HIV) vaccine development remains a global priority. We describe the safety and immunogenicity of a multiclade DNA vaccine prime with a replication-defective recombinant adenovirus serotype 5 (rAd5) boost.

METHODS

The vaccine is a 6-plasmid mixture encoding HIV envelope (env) subtypes A, B, and C and subtype B gag, pol, and nef, and an rAd5 expressing identical genes, with the exception of nef. Three hundred and twenty-four participants were randomized to receive placebo (n=138), a single dose of rAd5 at 10(10) (n = 24) or 10(11) particle units (n = 24), or DNA at 0, 1, and 2 months, followed by rAd5 at either 10(10) (n= 114) or 10(11) particle units (n = 24) boosting at 6 months. Participants were followed up for 24 weeks after the final vaccination.

RESULTS

The vaccine was safe and well tolerated. HIV-specific T cell responses were detected in 63% of vaccinees. Titers of preexisting Ad5 neutralizing antibody did not affect the frequency and magnitude of T cell responses in prime-boost recipients but did affect the response rates in participants that received rAd5 alone (P = .037).

CONCLUSION

The DNA/rAd5 vaccination regimen was safe and induced HIV type 1 multi-clade T cell responses, which were not significantly affected by titers of preexisting rAd5 neutralizing antibody. Trial Registration. ClinicalTrials.gov identifier: NCT00123968 .

Do the socioeconomic impacts of antiretroviral therapy vary by gender? A longitudinal study of Kenyan agricultural worker employment outcomes

BACKGROUND

As access to antiretroviral therapy (ART) has grown in Africa, attention has turned to evaluating the socio-economic impacts of ART. One key issue is the extent to which improvements in health resulting from ART allows individuals to return to work and earn income. Improvements in health from ART may also be associated with reduced impaired presenteeism, which is the loss of productivity when an ill or disabled individual attends work but accomplishes less at his or her usual tasks or shifts to other, possibly less valuable, tasks.

METHODS

Longitudinal data for this analysis come from company payroll records for 97 HIV-infected tea estate workers (the index group, 56 women, 41 men) and a comparison group of all workers assigned to the same work teams (n = 2485, 1691 men, 794 women) for a 37-month period covering two years before and one year after initiating ART. We used nearest neighbour matching methods to estimate the impacts of HIV/AIDS and ART on three monthly employment outcomes for tea estate workers in Kenya--days plucking tea, days assigned to non-plucking assignments, and kilograms harvested when plucking.

RESULTS

The female index group worked 30% fewer days plucking tea monthly than the matched female comparison group during the final 9 months pre-ART. They also worked 87% more days on non-plucking assignments. While the monthly gap between the two groups narrowed after beginning ART, the female index group worked 30% fewer days plucking tea and about 100% more days on non-plucking tasks than the comparison group after one year on ART. The male index group was able to maintain a similar pattern of work as their comparison group except during the initial five months on therapy.

CONCLUSION

Significant impaired presenteeism continued to exist among the female index group after one year on ART. Future research needs to explore further the socio-economic implications of HIV-infected female workers on ART being less productive than the general female workforce over sustained periods of time.

Psychiatric outcome of localized head injury in children

Previous studies have shown a high prevalence of psychiatric disturbance in children with brain injury. Studies on localized lesions have suggested that injury to the young organism carries a better prognosis for recovery of function than injury at a later age. The present study was designed to investigate these phenomena systematically. A representative sample of children (n = 98) who had been hospitalized for treatment of a compound depressed fracture, associated with a dural tear and visible damage to the underlying cortex, was identified from the records of neurosurgical units throughout the United Kingdom. The children were aged between 3 months and 12 years at the time of injury and between 5 and 15 years at the time of examination. The interval between injury and examination varied but the sample was designed to include only children who had been injured at least two years before examination. The children were examined neurologically and psychometrically, a detailed account of their current psychiatric state was obtained from one or both parents, and their mental state was assessed in a standard psychiatric examination. Preliminary data are presented which relate psychiatric, educational and intellectual status at the time of examination to site and severity of injury, age at injury, and to a number of psychosocial variables.

Multi-center study evaluating circulating tumor cells (CTCs) as a surrogate for survival in men treated for castration refractory prostate cancer (CRPC)

5016

Background: Monitoring CTCs in patients undergoing therapy for metastatic breast cancer is an effective means to predict outcome and monitor treatment. The primary endpoint of this prospective multi-center study was to demonstrate a significant relation between the presence of CTCs and survival in men treated for CRPC. Methods: 276 patients with diagnosed CRPC, PSA progression, and an ECOG score of 0–2 about to begin initial or salvage chemo and/or combination therapy were enrolled. CTCs were enumerated with the CellSearch System in blood drawn pre-treatment and monthly thereafter for up to 18 months. Patient data were collected and maintained by an independent CRO. Median overall survival (OS) was determined for patients with =5 CTC /7.5mL at baseline and specified intervals. Results: Of 240 evaluable patients, 142 (59%) are alive - mean follow-up 11.4 ± 4.4 months. Median OS (in months) and significance between the two groups (logrank p-value) at different time points after the initiation of therapy are indicated in the table . Median OS for 40 (19%) patients with a reduction of CTCs below 5 CTCs 2–5 weeks after initiation of therapy was significantly longer as compared to those 78 (38%) patients that remained above 5 CTCs (>20 vs. 9.3mth, p=0.0000) and was not significantly different from the 83 (40%) patients with 20 vs. >20mth, p=0.2725). In multivariate analyses, which included stage at diagnosis, age, ECOG, Gleason score, LDH, Alkaline Phosphotase, and PSA, CTCs remained the most significant independent predictor of outcome. Conclusions: CTC levels in CRPC patients are a strong predictor of OS. The persistence of CTCs after initiation of therapy suggests that the patients are deriving less than optimal benefit from their current therapy. CTC levels may be a valid surrogate end-point in monitoring response to chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

The nonhomologous end joining factor Artemis suppresses multi-tissue tumor formation and prevents loss of heterozygosity

Nonhomologous end joining (NHEJ) is a critical DNA repair pathway, with proposed tumor suppression functions in many tissues. Mutations in the NHEJ factor ARTEMIS cause radiation-sensitive severe combined immunodeficiency in humans and may increase susceptibility to lymphoma in some settings. We now report that deficiency for Artemis (encoded by Dclre1c/Art in mouse) accelerates tumorigenesis in several tissues in a Trp53 heterozygous setting, revealing tumor suppression roles for NHEJ in lymphoid and non-lymphoid cells. We also show that B-lineage lymphomas in these mice undergo loss of Trp53 heterozygosity by allele replacement, but arise by mechanisms distinct from those in Art Trp53 double null mice. These findings demonstrate a general tumor suppression function for NHEJ, and reveal that interplay between NHEJ and Trp53 loss of heterozygosity influences the sequence of multi-hit oncogenesis. We present a model where p53 status at the time of tumor initiation is a key determinant of subsequent oncogenic mechanisms. Because Art deficient mice represent a model for radiation-sensitive severe combined immunodeficiency, our findings suggest that these patients may be at risk for both lymphoid and non-lymphoid cancers.

Antidepressants in child and adolescent depression: where are the bugs?

OBJECTIVE

To examine the data on the effect of antidepressant medication in depressed children and adolescents and the causes of the results obtained.

METHOD

A systematic literature search was conducted, supplemented by a manual search, and a search of public online information on paediatric antidepressant trials reviewed by regulatory agencies.

RESULTS

Data gathered from published and unpublished randomized controlled trials vary in their findings, with most of the studies showing a lack of efficacy characterized by a high placebo response rate.

CONCLUSION

Differences from efficacy results with the same drugs in adult depression may be because of neurobiological developmental correlates, developmental differences in pharmacokinetics and pharmacodynamics, high rates of placebo response in children, and a number of methodological influences. There are several areas needing more attention in paediatric antidepressant clinical trials. Judicious use of published and unpublished studies to assess who may benefit from treatment with antidepressants seems warranted.

Characteristics of HIV infected patients cared for at "academic model for the prevention and treatment of HIV/AIDS" clinics in western Kenya

BACKGROUND

With the new initiatives to treat large numbers of HIV infected individuals in sub-Saharan Africa, policy makers require accurate estimates of the numbers and characteristics of patients likely to seek treatment in these countries.

OBJECTIVE

To describe characteristics of adults receiving care in two Kenyan public HIV clinics.

DESIGN

Cross-sectional cohort analysis of data extracted from an electronic medical records system.

SETTING

Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) HIV clinics in Kenya's second national referral (urban) hospital and a nearby rural health center.

SUBJECTS

Adult patients presenting for care at HIV clinics.

MAIN OUTCOME MEASURES

Gender and inter-clinic stratified comparisons of demographic, clinical, and treatment data.

RESULTS

In the first nineteen months, 790 adults visited the urban clinic and 294 the rural clinic. Mean age was 36 +/- 9 (SD) years. Two-thirds were women; a quarter had spouses who had died of acquired immune deficiency syndrome (AIDS). HIV/AIDS behavioural risk factors (multiple sexual partners, rare condom use) and constitutional symptoms (fatigue, weight loss, cough, fever, chills) were common. Rural patients had more symptoms and less prior and current tuberculosis. Men more commonly presented with symptoms than women. The cohort CD4 count was low (223 +/- 197 mm3), with men having significantly lower CD4 count than women (185 +/- 175 vs. 242 +/- 205 p = 0.0007). Eighteen percent had an infiltrate on chest radiograph. Five percent (most often men) had received prior antiretroviral drug therapy, (7% in urban and 1% in rural patients, p = 0.0006). Overall, 393 (36%) received antiretroviral drugs, 89% the combination of lamivudine, stavudine, and nevirapine. Half received prophylaxis for tuberculosis and Pneumocystis jirovecii. Men were sicker and more often received antiretroviral drugs.

CONCLUSIONS

Patients presenting to two Kenyan HIV clinics were predominantly female, ill and naive to retroviral therapy with substantial differences by clinic site and gender. Behavioural risk factors for HIV/AIDS were common. A thorough understanding of clinical and behavioural characteristics can help target prevention and treatment strategies.

Calcineurin Inhibitor Avoidance Versus Steroid Avoidance Following Kidney Transplantation: Postoperative Complications

This study compared early postoperative complications in kidney transplant recipients treated with either a sirolimus-based calcineurin inhibitor (CNI)-free regimen or a tacrolimus-based steroid-free regimen. We used a single-center, prospective, sequential but nonrandomized study design. Consecutive recipients of primary cadaveric or non-HLA identical kidney transplant recipients received either a CNI-free regimen, consisting of sirolimus 5 mg daily beginning postoperative day 3, mycophenolate mofetil 1 gm twice a day, and methylprednisolone 500 mg intraoperatively, then prednisone 30 mg daily tapered to 10 mg daily at 3 months, or a prednisone-free regimen, consisting of methylprednisolone 500 mg, 250 mg, and 125 mg from days 0 to 2, then no further steroids, tacrolimus 0.075 mg/kg twice a day, and mycophenolate mofetil 1 g twice a day. All patients received thymoglobulin induction 6 mg/kg total dose. Outcome measures were patient and graft survival, BPAR, surgical and wound complications, viral infections and posttransplant diabetes mellitus (PTDM). Both groups had excellent early outcomes with no significant difference in patient or graft survival, early renal function, BPAR, surgical or wound complications, or viral infections between the two groups. Patients in the sirolimus-based CNI-free group had a significantly higher incidence of PTDM and a trend toward more discontinuation due to drug toxicity. Whether either regimen improves long-term outcomes awaits longer follow-up.

Short-term Results Under Three Different Immunosuppressive Regimens at One Center

We examined short-term outcomes and posttransplant medical complications under three different immunosuppressive regimens at a single center. The study design was a randomized, prospective, open-label trial comparing a calcineurin inhibitor-free (CNI) protocol to standard triple therapy with tacrolimus, prednisone, and mycophenolate mofetil. They were also compared to a concurrent but nonrandomized third cohort treated with a prednisone-free protocol. All three groups had excellent early outcomes with no significant difference in patient or graft survival or biopsy-proven acute rejection. Serum creatinine was significantly lower in the CNI-free recipients. Lipid panels and posttransplant diabetes mellitus were significantly lower in the prednisone-free patients. Prednisone-free kidney transplant recipients have improved early glucose metabolism and hyperlipidemia compared to CNI-free or standard triple therapy recipients with comparable rejection and graft survival rates.

Kidney transplantation in a veterans administration medical center: 40 years' experience

OBJECTIVES

Advances in immunosuppressive therapy have led to substantial improvements in kidney transplant outcomes in the past 20 years. Kidney transplantation activity started in 1963 at the Veterans Administration Medical Center in Nashville, Tennessee, and continues to grow with increasing numbers of transplants from living-related and unrelated donors. In this study, patient and graft survival rates during 2 different periods were evaluated and compared with non-veterans-administration centers.

MATERIALS AND METHODS

Six hundred fourteen kidney transplants were performed between March 1963 and December 2002. For analytic purposes, the 40-year experience was divided into 2 eras based on the immunosuppressive agents used. Azathioprine and prednisone were the immunosuppressive agents used in era 1. A calcineurin-inhibitor-based triple immunosuppressive regimen initially including azathioprine and prednisone and later, mycophenolate mofetil and prednisone, was the preferred immunosuppressive regimen in era 2.

RESULTS

In era 1, 1-year patient and graft survival rates were 72.5% and 50%, and 89% and 75% for deceased-donor and living-donor transplants respectively. In era 2, patient survival rates increased to 95.1% and 87.8% for 1 and 3 years respectively, while graft survival increased to 87.6% and 74.9%. Forty-three percent of deceased-donor and 21% of living-donor kidneys were lost owing to rejection in era 1. In era 2, the incidence of acute rejection was 14.5% overall.

CONCLUSIONS

Overall, our results are comparable with non-veterans-administration centers and the national average and show that kidney transplantation offers veteran patients with end-stage renal disease a safe and effective treatment with increased quality of life.

Tardive Dyskinesia Risks and Metoclopramide Use Before and After U.S. Market Withdrawal of Cisapride

OBJECTIVE

To assess risk factors for tardive dyskinesia (TD) in spontaneous reports of metoclopramide and TD and evaluate metoclopramide prescribing patterns before and after withdrawal of cisapride from the market in the United States.

DESIGN

Retrospective and observational analyses.

SETTING

International metoclopramide adverse event reports and domestic drug-use data for the continental United States.

PATIENTS

Users of metoclopramide for 30 days or more who experienced adverse events reported as TD.

INTERVENTIONS

Analyses of the Food and Drug Administration Adverse Event Reporting System (AERS) and IMS HEALTH data.

MAIN OUTCOME MEASURES

Pharmacoepidemiological patterns in AERS reports and utilization data from IMS HEALTH.

RESULTS

The case series comprised 87 reports of primarily older (mean+/-SD, 60+/-22 years ) women (67% of all cases). While average metoclopramide daily dose (33+/-14 mg) was within recommended product labeling limits, duration of use was considerably longer (753+/-951 days). Overall, 37% of the reports included concomitant drugs believed to be TD risk factors. Similarly, 18% of the reports noted comorbid diseases that are considered risk factors for development of TD. Metoclopramide utilization decreased following cisapride marketing in 1993 and increased following cisapride withdrawal in 2000. The majority (62%) of metoclopramide prescriptions were intended for women. Intended use overall increased with age and was highest in the seventh and eighth decades, with nearly one quarter of all utilization being in persons older than 70 years.

CONCLUSION

Well-described TD risk factors were common in metoclopramide-associated TD reports. Given the cisapride market withdrawal and associated increased metoclopramide utilization, the incidence of TD may increase accordingly. TD risk factors relative to the intended benefit and duration of use should be considered in metoclopramide prescribing.

Guidelines and algorithms for the use of methylphenidate in children with Attention-Deficit/ Hyperactivity Disorder

OBJECTIVE

To review published algorithms for guiding the use of methylphenidate (MPH) in the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children and adolescents.

METHODS

A consensus roundtable of 12 experts was convened to review the evidence for the safety and efficacy of MPH in the treatment of ADHD, as well as the published algorithms and practice guidelines for using MPH. The experts reviewed the algorithms for practicality and acceptability by clinicians.

RESULTS

Algorithms that included MPH commonly selected it as the initial medication to be employed in the treatment of children with ADHD. Factors involved included its high efficacy, good safety record, and the ubiquitous nature of its appearance in the ADHD treatment literature.

CONCLUSIONS

MPH should be considered as the first medication to be used in a treatment algorithm for children and adolescents with ADHD.

Increased US prescription trends associated with the CDC Bacillus anthracis antimicrobial postexposure prophylaxis campaign

PURPOSE

We evaluated national outpatient antimicrobial prescription trends in relation to the first United States case of inhalational anthrax due to the intentional delivery of Bacillus anthracis (B. anthracis) spores.

METHODS

We queried IMS HEALTH's National Prescription Audit Plus7 database for two 6-month periods (July-December) in 2001 and 2000 to describe outpatient prescription trends of antimicrobials recommended during the Centers for Disease Control and Prevention's (CDC) postexposure prophylaxis campaign.

RESULTS

Overall, antimicrobial utilization for the referent 6-month time frame was greater in 2000 compared to 2001. In contrast, ciprofloxacin utilization was greater in 2001 during October, the month following the index case, increasing by more than 40% over utilization in October 2000. Similarly, doxycycline utilization increased by 30% during October/November. This corresponded to relative increases in US utilization for ciprofloxacin of approximately 160,000 prescriptions for the month of October and for doxycycline of approximately 96,000 prescriptions during October and 120,000 prescriptions for November.

CONCLUSIONS

We conclude more widespread prescribing of ciprofloxacin and doxycycline occurred in response to the first US bioterrorist-associated anthrax attacks than was warranted based upon confirmed or suspected B. anthracis exposure alone.

Concomitant risk factors in reports of torsades de pointes associated with macrolide use: review of the United States Food and Drug Administration Adverse Event Reporting System

In this case series, we examined concomitant risk factors mentioned in reports of torsades de pointes, a rare ventricular arrhythmia, that occurred in association with administration of macrolide antimicrobials (e.g., azithromycin, clarithromycin, dirithromycin, and erythromycin). Increasing age, female sex, and concomitant diseases and drug administration believed to increase risks for torsades de pointes were commonly reported.

Fasting and 2-hour postchallenge serum glucose measures and risk of incident cardiovascular events in the elderly: the Cardiovascular Health Study

BACKGROUND

The contributions of fasting and 2-hour postchallenge glucose level to cardiovascular events remain ill-defined, especially for nondiabetic adults. This study examined the relative predictive power of fasting and 2-hour glucose level on cardiovascular event risk.

METHODS

A total of 4014 community-dwelling adults 65 years or older who participated in the baseline visit of the Cardiovascular Health Study and who were without treated diabetes or previous myocardial infarction or stroke were eligible for analyses. Participants with treated diabetes at baseline were excluded. Incident myocardial infarction or stroke, or coronary death, was the outcome of interest. Age-, sex-, and race-adjusted proportional hazards regression models described individual and joint associations between baseline measures of fasting and 2-hour postchallenge glucose level and event risk.

RESULTS

There were 764 incident cardiovascular events during 8.5 years of follow-up. Fasting glucose level of 115 mg/dL (6.4 mmol/L) or more was associated with an increased cardiovascular risk (hazard ratio [HR], 1.66 [95% confidence interval (CI), 1.39-1.98]) in adjusted analyses compared with fasting glucose level less than 115 mg/dL. Two-hour glucose level was associated with a linear risk (HR, 1.02 [95% CI, 1.00-1.04] per 10 mg/dL [0.6 mmol/L]) that included an additional increase in risk for 2-hour glucose level of 154 mg/dL (8.5 mmol/L) or more (HR, 1.29 [95% CI, 1.04-1.59]) in adjusted analyses. In joint fasting and 2-hour glucose models, only 2-hour glucose level remained predictive of event risk.

CONCLUSIONS

Two-hour glucose level was better than fasting glucose level alone at identifying older adults at increased risk of major incident cardiovascular events.

Psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation

OBJECTIVE

To identify the independent psychosocial and risk behavior correlates of suicidal ideation and attempts.

METHOD

The relationships between suicidal ideation or attempts and family environment, subject characteristics, and various risk behaviors were examined among 1,285 randomly selected children and adolescents, aged 9 through 17 years, of whom 42 (3.3%) had attempted suicide and 67 (5.2%) had expressed suicidal ideation only. The youths and their parents were enumerated and interviewed between December 1991 and July 1992 as part of the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

RESULTS

Compared with subjects with suicidal ideation only, attempters were significantly more likely to have experienced stressful life events, to have become sexually active, to have smoked more than one cigarette daily, and to have a history of ever having smoked marijuana. After adjusting for sociodemographic characteristics, a statistically significant association was found between suicidal ideation or attempt and stressful life events, poor family environment, parental psychiatric history, low parental monitoring, low instrumental and social competence, sexual activity, marijuana use, recent drunkenness, current smoking, and physical fighting. Even after further adjusting for the presence of a mood, anxiety, or disruptive disorder, a significant association persisted between suicidal ideation or attempts and poor family environment, low parental monitoring, low youth instrumental competence, sexual activity, recent drunkenness, current smoking, and physical fighting.

CONCLUSION

Low parental monitoring and risk behaviors (such as smoking, physical fighting, alcohol intoxication, and sexual activity) are independently associated with increased risk of suicidal ideation and attempts, even after adjusting for the presence of psychiatric disorder and sociodemographic variables.

The DISC Predictive Scales (DPS): efficiently screening for diagnoses

OBJECTIVE

To derive and test a series of brief diagnosis-specific scales to identify subjects who are at high probability of meeting diagnostic criteria and those who may safely be spared more extensive diagnostic inquiry.

METHOD

Secondary data analysis of a large epidemiological data set (n = 1,286) produced a series of gate and contingent items for each diagnosis. Findings were replicated in a second retrospective analysis from a residential care sample (n = 884). The DISC Predictive Scales (DPS) were then used prospectively as a self-report questionnaire in two studies, in which parents (n = 128) and/or adolescents (n = 208) had subsequent diagnostic interviewing with the Diagnostic Interview Schedule for Children or the Schedule for Affective Disorders and Schizophrenia for School-Age Children.

RESULTS

All analyses showed that gate item selection was valid and that any missed cases were due solely to inconsistent reports on the same questions. Screening performance of the full scales was shown to be good, and substantial reductions in scale length were not associated with significant changes in discriminatory power.

CONCLUSIONS

The DPS can accurately determine subjects who can safely be spared further diagnostic inquiry in any diagnostic area. This has the potential to speed up structured diagnostic interviewing considerably. The full DPS can be used to screen accurately for cases of specific DSM-III-R disorders.

Risk behavior in a community sample of children and adolescents

OBJECTIVES

First, to investigate whether there is covariation between risk behaviors, including suicidality, in a community probability sample of children and adolescents; and second, to investigate whether risk behavior is associated with selected potential correlates.

METHOD

A sample of 9- to 17-year-old youths (N = 1,285) and their caretakers were interviewed in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The risk behaviors were marijuana smoking, alcohol use, intercourse, fighting, cigarette smoking, and suicidal ideation/attempts. Relationships between the risk behaviors were described using odds ratios. Linear regression analyses of an index of risk behavior on the selected potential correlates of risk behavior were conducted.

RESULTS

There were significant relationships between all pairs of risk behaviors. The score on the index of risk behavior was associated with stressors, lack of resources, family psychiatric disorder, psychopathology, and functional impairment.

CONCLUSIONS

Clinicians should be alerted to the possibility of risk behaviors, especially in children and adolescents engaging in other risk behaviors and those with inadequate resources, stressors, functional impairment, or psychopathology.

Major depression and dysthymia in children and adolescents: discriminant validity and differential consequences in a community sample

OBJECTIVES

To evaluate evidence, in a community sample, for discriminant validity between major depression (MDD) and dysthymia (Dy) in children and adolescents and to examine differential consequences of the 2 disorders for functioning.

METHOD

The National Institute of Mental Health (NIMH) Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study consists of probability samples of youths. Data for this study are derived from interviews with 1,285 complete parent-youth pairs aged 9 to 17 years from 4 geographic areas in the United States. Youths with MDD were contrasted with those with Dy and those with both (MDD-Dy) on the NIMH Diagnostic Interview Schedule for Children, Non-Clinician Children's Global Assessment Scale, Columbia Impairment Scale, and the Service Utilization and Risk Factors Module.

RESULTS

Groups with MDD, Dy, or MDD-Dy did not differ on sociodemographic, clinical, or family and life event variables. Youths with combined MDD-Dy were significantly less competent and more impaired than youths with either disorder alone.

CONCLUSIONS

The findings do not provide support for the differentiation of MDD and Dy but strongly suggest the importance of addressing the needs of youths who meet criteria for both MDD and Dy because this combination is likely to be both serious and disruptive of normal developmental processes.

NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses

OBJECTIVE

To describe the National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV) and how it differs from earlier versions of the interview. The NIMH DISC-IV is a highly structured diagnostic interview, designed to assess more than 30 psychiatric disorders occurring in children and adolescents, and can be administered by "lay" interviewers after a minimal training period. The interview is available in both English and Spanish versions.

METHOD

An editorial board was established in 1992 to guide DISC development and ensure that a standard version of the instrument is maintained. Preliminary reliability and acceptability results of the NIMH DISC-IV in a clinical sample of 84 parents and 82 children (aged 9-17 years) drawn from outpatient child and adolescent psychiatric clinics at 3 sites are presented. Results of the previous version in a community sample are reviewed.

RESULTS

Despite its greater length and complexity, the NIMH DISC-IV compares favorably with earlier versions. Alternative versions of the interview are in development (the Present State DISC, the Teacher DISC, the Quick DISC, the Voice DISC).

CONCLUSIONS

The NIMH DISC is an acceptable, inexpensive, and convenient instrument for ascertaining a comprehensive range of child and adolescent diagnoses.

Features of interviews questions associated with attenuation of symptom reports

Previous studies have suggested that discrepant reporting in a test-retest reliability paradigm is not purely random measurement error, but partly a function of a systematic tendency to say "no" during retest to questions answered positively at initial testing ("attenuation"). To examine features of interview questions that may be associated with attenuation, three raters independently assessed the structural and content features of questions from the Diagnostic Interview Schedule for Children (version 2.3) and linked these to data from a test-retest reliability study of 223 community respondents (parent and child reports). Results indicated that for both parent and youth reports, item features most strongly associated with attenuation were (a) being a "stem" question (asked of all respondents, regardless of any skip structure); (b) question placement in the first half of the interview; (c) question length; (d) question complexity; or (e) requiring assessment of the timing, duration, or frequency of a symptom. Findings may be explained by participants' conscious efforts to avoid further questions or by their learning more about the nature and purpose of the interview as they gain more experience; alternatively, findings may represent a methodological artifact of structured interview design.

Evidence for glial-mediated inflammation in aged APP(SW) transgenic mice

Chronic expression of inflammatory cytokines, including interleukin-1beta, tumor necrosis factor alpha, and interleukin-6, by glia may underlie the neurodegenerative events that occur within the brains of patients with Alzheimer's disease (AD). The present study determined whether these markers of inflammation could be observed within the brains of Tg(HuAPP695.K670N/M671L)2576 transgenic mice (Tg2576) that have recently been shown to mimic many features of AD. Interleukin-1beta- and tumor necrosis factor alpha-immunopositive microglia were localized with thioflavine-positive (fibrillar) Abeta deposits. Moreover, interleukin-6 immunoreactive astrocytes surrounded fibrillar Abeta deposits. These findings provide evidence that Tg2576 mice exhibit features of the inflammatory pathology seen in AD and suggest that these mice are a useful animal model for studying the role inflammation may play in this disease.