The Alopecia Areata Severity and Morbidity Index (ASAMI) Study: Results From a Global Expert Consensus Exercise on Determinants of Alopecia Areata Severity

Importance

Current measures of alopecia areata (AA) severity, such as the Severity of Alopecia Tool score, do not adequately capture overall disease impact.

Objective

To explore factors associated with AA severity beyond scalp hair loss, and to support the development of the Alopecia Areata Severity and Morbidity Index (ASAMI).

Evidence Review

A total of 74 hair and scalp disorder specialists from multiple continents were invited to participate in an eDelphi project consisting of 3 survey rounds. The first 2 sessions took place via a text-based web application following the Delphi study design. The final round took place virtually among participants via video conferencing software on April 30, 2022.

Findings

Of all invited experts, 64 completed the first survey round (global representation: Africa [4.7%], Asia [9.4%], Australia [14.1%], Europe [43.8%], North America [23.4%], and South America [4.7%]; health care setting: public [20.3%], private [28.1%], and both [51.6%]). A total of 58 specialists completed the second round, and 42 participated in the final video conference meeting. Overall, consensus was achieved in 96 of 107 questions. Several factors, independent of the Severity of Alopecia Tool score, were identified as potentially worsening AA severity outcomes. These factors included a disease duration of 12 months or more, 3 or more relapses, inadequate response to topical or systemic treatments, rapid disease progression, difficulty in cosmetically concealing hair loss, facial hair involvement (eyebrows, eyelashes, and/or beard), nail involvement, impaired quality of life, and a history of anxiety, depression, or suicidal ideation due to or exacerbated by AA. Consensus was reached that the Alopecia Areata Investigator Global Assessment scale adequately classified the severity of scalp hair loss.

Conclusions and Relevance

This eDelphi survey study, with consensus among global experts, identified various determinants of AA severity, encompassing not only scalp hair loss but also other outcomes. These findings are expected to facilitate the development of a multicomponent severity tool that endeavors to competently measure disease impact. The findings are also anticipated to aid in identifying candidates for current and emerging systemic treatments. Future research must incorporate the perspectives of patients and the public to assign weight to the domains recognized in this project as associated with AA severity.

Comment on 'Treatment of moderate-to-severe alopecia areata with baricitinib in preadolescent children with baricitinib': authors' reply

In this response to a recent article on the off-label use of baricitinib for paediatric alopecia areata (AA), we raise additional points regarding the relationship between viral infections and AA relapse on Janus kinase inhibitor (JAKi) therapy, and the potential benefits of concomitant oral minoxidil therapy in mitigating the risk of relapse during JAKi dose reduction or discontinuation.

Contact injuries in field hockey and the potential role for personal protective equipment

Field hockey is played with sticks and a hard ball. It is fast-paced, with athletes playing together in close proximity. Athletes may be at increased risk of sustaining injuries through contact. The aim of this study was to investigate the epidemiological characteristics of contact injuries in field hockey. Data were collected during the 2017/2018 and 2018/2019 Irish Hockey League seasons. This study included two methods of data collection among male athletes: self-reported injuries and via those reported by the teams' physiotherapists. Injuries were defined as any physical complaint sustained during field hockey, supplemented by medical attention and time-loss injuries. Only contact injuries were included for analysis. Overall, 107 contact injuries were incurred, giving rise to an injury incidence rate of 3.1/1000 h, and accounting for 33.1% of all injuries. Athletes had an absolute risk of 0.372 of sustaining a contact injury. Contusions (48.6%) were the most common type of contact injury, while injuries to the head/face (20.6%) were the most frequently reported location. Contact injuries represent an important proportion of all injuries. Rule changes to mandate the use of personal protective equipment in field hockey may assist in reducing the absolute risk and severity of contact injuries in field hockey.

A National Referral Service for Paediatric Brachytherapy: An Evolving Practice and Outcomes Over 13 Years

AIMS

Most children requiring radiotherapy receive external beam treatment and few have tumours suitable for brachytherapy. No paediatric radiotherapy centre will treat enough patients from its own normal catchment population for expertise in brachytherapy to be developed and sustained. Following discussion and agreement in the national paediatric radiotherapy group, a service for paediatric brachytherapy in the UK has been developed. We report the process that has evolved over more than 10 years, with survival and functional outcome results.

MATERIALS AND METHODS

Since 2009, potential patients have been referred to the central paediatric oncology multidisciplinary team meeting, where imaging, pathology and treatment options are discussed. Since 2013, the National Soft Tissue Sarcoma Advisory Panel has also reviewed most patients, with the principal aim of advising on the most suitable primary tumour management for complex patients. Clinical assessment and examination under anaesthetic with biopsies may be undertaken to confirm the appropriateness of brachytherapy, either alone or following conservative surgery. Fractionated high dose rate brachytherapy was delivered to a computed tomography planned volume after implantation of catheters under ultrasound imaging guidance. Since 2019, follow-up has been in a dedicated multidisciplinary clinic.

RESULTS

From 2009 to 2021 inclusive, 35 patients (16 female, 19 male, aged 8 months to 17 years 6 months) have been treated. Histology was soft-tissue sarcoma in 33 patients and carcinoma in two. The treated site was pelvic in 31 patients and head and neck in four. With a median follow-up of 5 years, the local control and overall survival rates are 100%. Complications have been few, and functional outcome is good.

CONCLUSION

Brachytherapy is effective for selected paediatric patients, resulting in excellent tumour control and good functional results. It is feasible to deliver paediatric brachytherapy at a single centre within a national referral service.

The reliability and validity of a measure to assess the health-related quality of life of female alopecia areata patients

Alopecia areata (AA) impacts on health-related quality of life (HRQoL). The Women's Androgenetic Alopecia Quality of Life (WAA-QoL) is a reliable, validated HRQoL measure in female patients with androgenetic alopecia (AGA). There is no equivalent measure for females with AA. Data were collected as part of GRASS Australia. The WAA-QoL, DLQI, and Skindex-16 for AA, as well as SALT score, were extracted from GRASS for adult female patients. Cronbach's alpha and factor analysis was employed to determine the internal consistency of the measure, while non-parametric correlation testing assessed the validity of the questionnaire. Overall, 137 individuals completed the questionnaires. There was excellent internal consistency of the WAA-QoL among female AA patients (Cronbach's α = 0.98). A moderate and high positive correlation was found between the WAA-QoL and the DLQI and the Skindex-16 for AA, respectively. The WAA-QoL is a reliable and valid assessment of HRQoL among female patients with AA.

The knowledge and attitudes of field hockey athletes to injury, injury reporting and injury prevention: A qualitative study

OBJECTIVES

Researchers have often struggled to successfully implement injury prevention strategies in real-world practice. This is despite such strategies proving successful in reducing overall injury incidence and burden. It has been hypothesised that this may be because the behavioural and contextual factors related to sports injury are not fully understood. Such factors stem from multiple key stakeholders, including the athlete. The primary aim of this study was to investigate athletes' knowledge and attitudes towards injury, injury reporting and prevention, as well as some of the barriers that may impact the future implementation of prevention strategies.

DESIGN

Qualitative; with semi-structured interviews following an interpretivist approach.

METHODS

Twenty-two field hockey athletes, playing in the top-tier Irish Hockey League were interviewed. Data were analysed using reflexive thematic analysis, with three general dimensions containing six higher-order themes.

RESULTS

The findings highlighted that athletes have a varied understanding of injury, which tends to improve with experience. The reporting of injuries by athletes to members of the coaching staff was relatively poor. This may be due to limited resources and supports available to athletes which also cause challenges to injury prevention.

CONCLUSIONS

Future injury prevention strategies in field hockey need to account for athletes' varied understanding of what constitutes an injury. Furthermore, policy changes to influence potential barriers to injury may assist in preventing or reducing the number of injuries being sustained by athletes.

Expression of type I interferon-associated genes at antiretroviral therapy interruption predicts HIV virological rebound

Although certain individuals with HIV infection can stop antiretroviral therapy (ART) without viral load rebound, the mechanisms under-pinning 'post-treatment control' remain unclear. Using RNA-Seq we explored CD4 T cell gene expression to identify evidence of a mechanism that might underpin virological rebound and lead to discovery of associated biomarkers. Fourteen female participants who received 12 months of ART starting from primary HIV infection were sampled at the time of stopping therapy. Two analysis methods (Differential Gene Expression with Gene Set Enrichment Analysis, and Weighted Gene Co-expression Network Analysis) were employed to interrogate CD4+ T cell gene expression data and study pathways enriched in post-treatment controllers versus early rebounders. Using independent analysis tools, expression of genes associated with type I interferon responses were associated with a delayed time to viral rebound following treatment interruption (TI). Expression of four genes identified by Cox-Lasso (ISG15, XAF1, TRIM25 and USP18) was converted to a Risk Score, which associated with rebound (p < 0.01). These data link transcriptomic signatures associated with innate immunity with control following stopping ART. The results from this small sample need to be confirmed in larger trials, but could help define strategies for new therapies and identify new biomarkers for remission.

The incidence of injury in male field hockey players: A systematic review and meta-analysis

OBJECTIVE

Few studies have investigated injury incidence in field hockey. The aim of this systematic review was to determine the incidence and characteristics of injury in male field hockey athletes.

DESIGN

Prognosis systematic review with meta-analysis.

LITERATURE SEARCH

MEDLINE via PubMed; EMBASE via Ovid; CINAHL via EBSCO; SPORTDiscus; and Web of Science were searched.

STUDY SELECTION CRITERIA

Prospective studies and retrospective studies employing video analysis, written in English and published in peer-reviewed journals, expressing the incidence of injury in male field hockey athletes were included. Studies must have been of a duration of a minimum one season or one tournament. Studies were screened by two authors, assessing the eligibility of each record. Following selection of the studies, data were extracted by the two authors.

DATA SYNTHESIS

Levels of heterogeneity were assessed in aggregate data using the I² statistic.

RESULTS

In total, 1722 records were identified. Twelve studies were included in the review. Injury incidence ranged from 4.5 to 57.9/1000h (I² = 98.5%). Nine studies were undertaken in tournament settings, with the remaining three conducted in club-based athletes in season-long settings. When a medical attention definition was used, there was a pooled incidence rate of 48.1/1000h, all in tournament studies. Contusions and muscle strains were the most frequently reported injury types, while the lower limb was the most common site of injury. Contact injuries were most common in tournament-based studies, while non-contact was more common in season-long studies.

CONCLUSION

Prospective, season-long epidemiological studies investigating injury incidence in field hockey are lacking.

Coaches' attitudes to injury and injury prevention: a qualitative study of Irish field hockey coaches

Translating injury prevention research into practice has been challenging, which may be due to a poor understanding of the contextual factors influencing the occurrence of injury. Coaches are key figure in sporting environments and hold pivotal roles in preventing injury. Therefore, the aim of this study was to investigate the attitudes of field hockey coaches to injury and injury prevention. Thirteen field hockey coaches from the amateur Irish Hockey League were interviewed. Reflexive thematic analysis led to three general dimensions comprised five higher-order themes, categorised from 16 lower-order themes. Coaches had positive beliefs regarding the benefits of injury prevention over injury management. However, they lacked the necessary knowledge and skills to successfully implement injury prevention strategies with players. Coaches recognised the importance of empowering players to self-manage training loads to promote injury prevention but acknowledged the need to protect younger players from increased loads. Many barriers to injury prevention were not controllable by coaches including fixture congestion and poor structuring of the sport's domestic calendar. While coaches can play a key role in the implementation of injury prevention strategies, there is also a requirement to examine how system level barriers to injury prevention can be reduced.

The burden of injury in field hockey: A secondary analysis of prospective cohort data

Most studies report injuries based upon their incidence rate, or the number of injuries which occur in a sport per unit of time. While this is recommended across numerous consensus statements on reporting injury data in sport, it may be of benefit to consider injury burden also. Reporting injuries as the duration of injury per 1000 exposure hours highlights those injuries which will likely cause greater disruption within a team. Therefore, the primary aim of this study was to report the burden of injury in field hockey. This secondary analysis of epidemiological data employed two methods of data collection: self-reported through an online reporting software, and through contact with the team physiotherapist. Athletes reported injury-related symptoms for 4170 days in total, giving rise to an injury burden of 121.0/1000 h, of which 61.4/1000 h were days lost through injury. Injuries to the hamstring, as well as muscle strain injuries, caused the most significant injury burden in athletes (22.6 and 35.8/1000 h respectively). Reporting injuries as the duration of injuries per 1000 hours highlights those injuries which cause the most significant disruption within a squad. Future injury prevention strategies in field hockey should prioritize the injuries which are most burdensome.

Essential medicine selection during the COVID-19 pandemic: Enabling access in uncharted territory

The COVID-19 pandemic requires urgent decisions regarding treatment policy in the face of rapidly evolving evidence. In response, the South African Essential Medicines List Committee established a subcommittee to systematically review and appraise emerging evidence, within very short timelines, in order to inform the National Department of Health COVID-19 treatment guidelines. To date, the subcommittee has reviewed 14 potential treatments, and made recommendations based on local context, feasibility, resource requirements and equity. Here we describe the rapid review and evidence-to-decision process, using remdesivir and dexamethasone as examples. Our experience is that conducting rapid reviews is a practical and efficient way to address medicine policy questions under pandemic conditions.

Endometrial uNK cell counts do not predict successful implantation in an IVF population

STUDY QUESTION

Are uterine natural killer (uNK) cell numbers and their distribution relative to endometrial arterioles altered in women with recurrent implantation failure (RIF) compared to women with embryo implantation success (IS)?

SUMMARY ANSWER

uNK cell numbers and their distribution relative to endometrial arterioles are not significantly different in women with RIF compared to women in whom embryo implantation occurs successfully following IVF.

WHAT IS ALREADY KNOWN

uNK cells are regulators of decidual angiogenesis and spiral arteriole remodelling during early pregnancy. Although some studies have shown that uNK cell numbers may be altered in women with RIF, the methods used to measure uNK cell numbers have proven inconsistent, making reproduction of these results difficult. It is unclear, therefore, whether the results reported so far are reproducible. Moreover, it is not known how uNK cell numbers may impact IVF outcomes. Despite the lack of conclusive evidence, uNK cell numbers are often evaluated as a prognostic criterion in women undergoing assisted reproductive procedures.

STUDY DESIGN, SIZE, DURATION

Endometrial pipelle biopsies were collected 6-8 days post-LH surge in natural cycles from women with RIF (n = 14), women with IS (n = 11) and women with potential RIF at the time of the study (PRIF; n = 9) from 2013 to 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

uNK cells (i.e. CD56+ and/or CD16+ phenotypes) and their distribution relative to endometrial arterioles were investigated by standard immunohistochemistry protocols and quantified using Aperio ScanScopeXT images digitized by ImageJ and deconvoluted into binary images for single cell quantification using a Gaussian Blur and Yen algorithm.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no significant difference in the cell density of CD56+ or CD16+ uNK cells in women with RIF compared to women with IS or PRIF. There was a higher proportion of uNK cells in the distal regions compared to the regions closest to the arterioles in all patient groups. Further, we identified a significant reduction in uNK cell density in women who had a previous pregnancy compared to those who had not, regardless of their current implantation status.

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

Spiral arterioles could not always be accurately identified by digital image analysis; therefore, all endometrial arterioles were selected and analysed. Patient numbers for the study were low. However, as the clinical phenotypes of each patient were well defined, and endometrial dating was accurately determined by three independent pathologists, differences between patient groups with respect to the uNK numbers and distribution should have been measurable if uNK cell counts were to be useful as a prognostic marker of RIF.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings demonstrate that CD56+ and CD16+ uNK cell numbers are not significantly different in women with RIF in a typical cohort of women undergoing IVF. Further, prior pregnancy was associated with a significantly reduced number of uNK cells in both the RIF and IS patient groups, suggestive of a long-term pregnancy induced suppression of uNK cells. Combined, these findings do not support the clinical value of using uNK cell numbers as a prognostic indicator of implantation success with IVF treatment.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this work was provided by Royal Women's Hospital Foundation. P.P. was supported by an NHMRC Early Career Fellowship [TF 11/14] and W.T.T. was supported by an NHMRC Postgraduate Scholarship [1055814]. The authors do not have any competing interests with this study.

Epidemiology of injuries in senior men's field hockey: A two-season prospective observational injury surveillance study

Determining the rate and severity of injuries incurred through sport is accepted as the primary step towards designing, implementing and evaluating injury prevention programmes. The aim of this study was to determine the injury incidence rate and characteristics of male field hockey athletes participating in the Irish Hockey League. Athletes from eight field hockey teams were assigned to an online reporting system, where they logged injuries as they were incurred. Injuries were defined as any physical complaint. Coaches and physiotherapists were contacted weekly to corroborateinjuries. Overall 323 injuries were reported across 34,449 exposure hours, giving rise to an incidence rate of 9.4/1000 h. On average, athletes sustained one injury over the course of two seasons. Muscle strains, pain and contusions were the most common types of injury, while the hamstring, knee and hip/groin were the most frequently reported locations. While 66.9% of injuries occurred through non-contact mechanisms, contact injuries were also common. Injury recurrences accounted for 16.1% of injuries. In conclusion, the incidence of injury in field hockey is high, occurring from a variety of mechanisms. Future injury prevention strategies should prioritise injuries to the hamstring, knee and ankle, and be specific to particular playing positions.

The role of serological testing in the SARS-CoV-2 outbreak

Antibody tests for the novel coronavirus, SARS-CoV2, have been developed both as rapid diagnostic assays and for high-throughput formal serology platforms. Although these tests may be a useful adjunct to a diagnostic strategy, they have a number of limitations. Because of the antibody and viral dynamics of the coronavirus, their sensitivity can be variable, especially at early time points after symptom onset. Additional data are required on the performance of the tests in the South African population, especially with regard to development and persistence of antibody responses and whether antibodies are protective against reinfection. These tests may, however, be useful in guiding the public health response, providing data for research (including seroprevalence surveys and vaccine initiatives) and development of therapeutic strategies.

Managing dangerous people with severe personality disorder: a survey of forensic psychiatrists' opinions

Aims and Method

To canvass the opinions of psychiatrists working in forensic settings on the recent proposals relating to dangerous people with severe personality disorder (DSPD). Psychiatrists from secure settings were invited to a series of meetings. A questionnaire was circulated and the discussions recorded.

Results

Opinion remains divided over diagnosis, treatability and assessment of risk in personality disorders. The medicalisation of DSPD to allow indeterminate detention in unconvicted cases is unacceptable to the majority (75%). There is no consensus on the Government proposals relating to DSPD. Only a minority (20%) of psychiatrists would work in a new specialist service, which has significant implications for service development.

Clinical Implications

The involvement of psychiatrists in preventative detention solely for public protection requires greater discussion.

Nothophytophthora gen. nov., a new sister genus of Phytophthora from natural and semi-natural ecosystems

During various surveys of Phytophthora diversity in Europe, Chile and Vietnam slow growing oomycete isolates were obtained from rhizosphere soil samples and small streams in natural and planted forest stands. Phylogenetic analyses of sequences from the nuclear ITS, LSU, β-tubulin and HSP90 loci and the mitochondrial cox1 and NADH1 genes revealed they belong to six new species of a new genus, officially described here as Nothophytophthora gen. nov., which clustered as sister group to Phytophthora. Nothophytophthora species share numerous morphological characters with Phytophthora: persistent (all Nothophytophthora spp.) and caducous (N. caduca, N. chlamydospora, N. valdiviana, N. vietnamensis) sporangia with variable shapes, internal differentiation of zoospores and internal, nested and extended (N. caduca, N. chlamydospora) and external (all Nothophytophthora spp.) sporangial proliferation; smooth-walled oogonia with amphigynous (N. amphigynosa) and paragynous (N. amphigynosa, N. intricata, N. vietnamensis) attachment of the antheridia; chlamydospores (N. chlamydospora) and hyphal swellings. Main differing features of the new genus are the presence of a conspicuous, opaque plug inside the sporangiophore close to the base of most mature sporangia in all known Nothophytophthora species and intraspecific co-occurrence of caducity and non-papillate sporangia with internal nested and extended proliferation in several Nothophytophthora species. Comparisons of morphological structures of both genera allow hypotheses about the morphology and ecology of their common ancestor which are discussed. Production of caducous sporangia by N. caduca, N. chlamydospora and N. valdiviana from Valdivian rainforests and N. vietnamensis from a mountain forest in Vietnam suggests a partially aerial lifestyle as adaptation to these humid habitats. Presence of tree dieback in all forests from which Nothophytophthora spp. were recovered and partial sporangial caducity of several Nothophytophthora species indicate a pathogenic rather than a saprophytic lifestyle. Isolation tests from symptomatic plant tissues in these forests and pathogenicity tests are urgently required to clarify the lifestyle of the six Nothophytophthora species.

Testing for her2 in breast cancer: current pathology challenges faced in Canada

This review is designed to highlight several key challenges in the diagnosis of human epidermal growth factor receptor 2 (her2)-positive breast cancer currently faced by pathologists in Canada: Pre-analysis issues affecting the accuracy of her2 testing in non-excision sample types: core-needle biopsies, effusion samples, fine-needle aspirates, and bone metastasesher2 testing of core-needle biopsies compared with surgical specimensCriteria for retesting her2 status upon disease recurrenceLiterature searches for each topic were carried out using the medline, Embase, International Pharmaceutical Abstracts, and biosis databases. In addition, the congress databases of the American Society of Clinical Oncology (2005-2011) and the San Antonio Breast Cancer Symposium (2007-2011) were searched for relevant abstracts.All authors are expert breast pathologists with extensive experience of her2 testing, and several participated in the development of Canadian her2 testing guidelines. For each topic, the authors present an evaluation of the current data available for the guidance of pathology practice, with recommendations for the optimization or improvement of her2 testing practice.

Abstract P2-10-09: The incidence of false negative of HER2/Neu status in primary breast cancer in the era of standardized testing: a Canadian prospective study

The efficacy of trastuzumab in the treatment of primary breast cancer has mandated accurate and timely testing of all patients with a new diagnosis of breast cancer. Testing is centralized in designated laboratories across Canada with adherence to guidelines and mandatory participation in quality assurance programs. The Canadian testing algorithm recommends starting with immunohistochemistry (IHC) followed by in situ hybridization (ISH) for equivocal cases. Early HER2 testing showed that approximately 25–30% of invasive breast cancer is HER2 positive. Recent data shows that the HER2/neu positive rate in breast cancer in Canada is 17.6%.

Design: The study was designed to assess the rate of false-negative HER2 tests based on the IHC-first algorithm used in 8 pathology centres across Canada. Surgical excisions with invasive carcinoma were tested using the standardized local methodology for both IHC and ISH. The cases were scored by the local breast pathologist and in 2 of 8 centers image analysis was used in the evaluation of ISH. We compared consecutive HER2-negative IHC results (score 0/1+) to the corresponding ISH (either silver or fluorescence) result. False negative cases were defined as a negative IHC with an ISH ratio of≥ 2, since these patients are eligible for trastuzumab therapy.

Results: 715 cases were analyzed by IHC using Ventana 4B5 (287), HercepTest (253), or SP3 (175), and by ISH kits: Vysis FISH (303), Ventana SISH (412). The HER2 and CEP17 counts were available in all cases.

There were 4 cases with an ISH score ≥2 (4B5: 2/4, HercepTest 1/4, SP3 1/4). In 3 additional cases the absolute HER2 copy number was ≥6 but the HER2/CEP17 amplification ratio was &lt;2 due to an increased number of CEP 17 signal (“polysomy 17”) or amplification of the pericentromeric region. The overall rate of false negative cases was 0.98% (7/715). These cases had a low level of amplification (ratio 2 to 2.45) or an absolute HER2 count of 6–8.

Conclusion: Our observation confirms that IHC is an adequate test to predict negative HER2 status in primary breast cancer in surgical excision specimens, even when different antibodies and IHC platforms are used. The study supports and justifies the Canadian algorithm of IHC followed by ISH in equivocal cases in view of the extremely low percentage of false negative cases observed. This reflects the strict adherence to internal protocols and mandatory participation in quality assurance programs. These results provide further confirmation that the vast majority of patients eligible for trastuzumab are not deprived from an effective treatment by using this algorithm.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-09.

Memantine attenuates responses of spinothalamic tract cells to cutaneous stimulation in neuropathic monkeys

Several lines of evidence indicate that N-methyl-D-aspartate (NMDA) receptors play an important role in nociception in general and in pathological pain in particular. It has been previously demonstrated in behavioral studies that NMDA receptor antagonists attenuate pathological pain in humans and nociceptive behaviors in animals. In the present study, we investigated the effect of the NMDA receptor antagonist memantine (MEM) on the responses of spinothalamic tract (STT) cells in normal and neuropathic monkeys. Memantine was delivered into the spinal cord through a microdialysis fiber acutely implanted into the dorsal horn. Responses of STT cells to peripheral stimulation within their receptive fields were recorded before and after MEM infusion. In normal animals (n = 7), 10 mm MEM did not affect STT cell (n = 7) baseline activity or responses to mechanical stimuli (brush, press or pinch). In neuropathic animals (n = 6), 1.0, 3.0, 10.0 and 100 mm MEM did not affect baseline activity of STT cells (n = 7); however, in a dose-dependent fashion, it significantly reduced responses of these cells to all cutaneous stimuli. The data suggest that MEM can have a direct effect on STT cells, blocking NMDA receptors known to be present on this cell population and, furthermore, may be a therapeutic agent for chronic pain.

Guideline on safer conception in fertile HIV-infected individuals and couples

Ninety years ago the isolation of insulin transformed the lives of people with type 1 diabetes. Now, models based on empirical data estimate that a 25-year-old person with HIV, when appropriately treated with antiretroviral therapy, can expect to enjoy a median survival of 35 years, remarkably similar to that for someone of the same age with type 1 diabetes. It is high time we normalised the lives of people living positively with HIV. This includes the basic human right to conceive and raise children. HIV-positive individuals may be in serodiscordant relationships or in seroconcordant relationships. As health care providers, it is our responsibility to ensure we understand the opportunities and risks of natural conception in these scenarios, so that we can help our patients to make informed decisions about their own lives. Most of all, it is our duty to make family planning in the setting of positive prevention as safe as we can. This includes informed decisions on contraception, adoption, fostering, conception and prevention of mother-to-child transmission. Some months ago a dedicated group of individuals, invited and sponsored by the Southern African HIV Clinicians Society, came together in Cape Town to devise guidance in this area, recognising that there are ideal strategies that may be outside the realm of the resource constraints of the public sector or health programmes in southern Africa. This guideline therefore attempts to provide a range of strategies for various resource settings. It is up to us, the providers, to familiarise ourselves with the merits/benefits and risks of each, and to then engage patients in meaningful discussions. All the above, however, is based on the premise and prerequisite that the subject of family planning is actively raised and frequently discussed in our patient encounters.Please find a link to the update of this guideline: http://sajhivmed.org.za/index.php/hivmed/article/view/399

Replicating viral vectors as HIV vaccines: summary report from the IAVI-sponsored satellite symposium at the AIDS vaccine 2009 conference

In October 2009, The International AIDS Vaccine Initiative (IAVI) convened a satellite symposium entitled 'Replicating Viral Vectors for use in AIDS Vaccines' at the AIDS Vaccine 2009 Conference in Paris. The purpose of the symposium was to gather together researchers, representatives from regulatory agencies, and vaccine developers to discuss issues related to advancement of replication-competent viral vector- based HIV vaccines into clinical trials. The meeting introduced the rationale for accelerating the development of replicating viral vectors for use as AIDS vaccines. It noted that the EMEA recently published draft guidelines that are an important first step in providing guidance for advancing live viral vectors into clinical development. Presentations included case studies and development challenges for viral vector-based vaccine candidates. These product development challenges included cell substrates used for vaccine manufacturing, the testing needed to assess vaccine safety, conducting clinical trials with live vectors, and assessment of vaccination risk versus benefit. More in depth discussion of risk and benefit highlighted the fact that AIDS vaccine efficacy trials must be conducted in the developing world where HIV incidence is greatest and how inequities in global health dramatically influence the political and social environment in developing countries.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2

BACKGROUND

Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1.

METHODS

We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses.

RESULTS

A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed.

CONCLUSIONS

Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

A potential model for the first all Wales mental health service user and carer-led research group

This paper will inform mental health service users and carers on how a University in Wales established a service user and carer-led research group. * The group's primary aim will be to undertake its own service user and carer-led research projects. * Mental health service users have undergone empowerment and research training at a University in Wales. This is an important initiative because it is the first service user and carer-led research group in Wales. * This paper is co-authored by a mental health service user and includes transcripts of service users' stories written in their words. Abstract Service user and carer involvement in research has been gaining momentum in recent years. However, this involvement to date has primarily been as research respondents or 'subjects' in research studies. A group of mental health service users at a University in Wales underwent empowerment and research training to enable them to become active participants in the research process; this training was a necessary step to equip mental health service users with the skills to become independent researchers and to carry out service user-led research. We included transcripts from mental health service users on their views of the empowerment and research training received. We are not reporting, in this paper, on the findings from a research study rather it aims to inform readers how a service user and carer-led research group has been established in Wales. The group has two purposes: (1) to train service users in research methodologies, and thus for them to gain essential research skills; and (2) to undertake their own service user and carer-led research projects thereby implementing the research skills they have acquired from the training. The latter is a primary aim of the group; a future paper will report on its development.

Factors associated with HIV testing among sexually active South African youth aged 15-24 years

HIV infection is high among South African youth but most report being unaware of their HIV status. We explored the correlates of HIV testing using data from youth aged 15-24 years old who reported being sexually experienced during a national survey conducted in South Africa in 2003 (N=7665). Among sexually experienced youth, 32.7% of females and 17.7% of males reported having been tested for HIV. In multivariable analysis, ever being pregnant (OR = 2.97; 95% CI 2.36-3.73), ever starting a conversation about HIV/AIDS (OR = 1.29; 95% CI 1.0-1.65) and urban residence (OR = 2.0; 95% CI 1.58-2.52) were independent correlates of HIV testing among sexually experienced females. Among sexually experienced males, HIV-positive status (OR = 1.76; 95% CI 1.14-2.73), personally knowing someone that died of AIDS (OR = 1.68; 95% CI 1.14-2.47), being aged 20-24 years (OR = 1.56; 95% CI 1.10-2.22) and having completed high school (OR = 1.58; 95% CI 1.17-2.12) were independent correlates of HIV testing. The following factors were significantly associated with HIV testing among both men and women; ever talking to parents about HIV/AIDS, ever participating in a loveLife programme, a higher frequency of visits to a clinic in the past 12 months and non-black race (p<0.05). There is a need to better understand the correlates of HIV testing to ensure that adolescent HIV prevention programmes actively promote HIV testing among this group. Specific attention needs to be paid to young women who do not access antenatal care and young men who are less regular users of routine clinical care. Communication is a significant predictor of having tested for HIV and should be encouraged with parents and through intervention programmes for adolescents. Finally, specific attention must be paid to increasing access to HIV testing for at-risk adolescents in rural communities.

Attentional bias to incentive stimuli in frequent ketamine users

BACKGROUND

The attention-grabbing properties of drugs to drug-using individuals have been well documented and recent research has begun to suggest that such attentional bias may be related to the severity of drug dependency. Dependence on ketamine has been reported anecdotally but no systematic study has investigated this phenomenon. We aimed to explore attentional biases to incentive stimuli in different populations of ketamine users.

METHOD

Using a dot-probe paradigm, attentional bias to both drug-related and money-related stimuli was investigated in 150 participants: 30 frequent ketamine users, 30 infrequent ketamine users, 30 ex-ketamine users, 30 poly-drug users and 30 non-drug-using controls. Two stimulus presentation times were used (200 and 2000 ms) to investigate whether attentional bias was as a result of an automatic or a more conscious attentional shift. Participants also rated the degree to which stimuli used in the dot-probe paradigm were pleasurable.

RESULTS

Frequent ketamine users demonstrated an attentional bias to both types of incentive stimuli only at the short stimulus presentation interval and this was significantly correlated with degree of ketamine use. No attentional biases were observed in any of the other groups. All groups rated money stimuli as more pleasurable than neutral stimuli.

CONCLUSIONS

These data support incentive models of drug use and demonstrate the ability of the attentional bias paradigm to discriminate recreational drug users from those with more dependent patterns of use. Ketamine is a potentially dependence-forming drug.

Journey through the K-hole: phenomenological aspects of ketamine use

Although recreational use of the dissociative anaesthetic drug ketamine is currently increasing, little is known about the phenomenological aspects of its use. We therefore designed a structured interview to examine initiation experiences, positive and negative effects of ketamine use, and concerns about the drug and its long-term effects. Ninety participants (30 frequent users, 30 infrequent 'recreational' users and 30 ex-users who had abstained from use for at least 3 months) were interviewed and reported drug use was verified by hair sample analysis. The most appealing aspects of ketamine for two-thirds of users were "melting into the surrounding", "visual hallucinations", "out-of-body experiences" and "giggliness". Unappealing effects for half of users were "memory loss" and "decreased sociability". Frequent ketamine users expressed more concerns than other groups about long-term effects on physical health problems, especially K-cramps and cystitis, whereas ex-users were more concerned about mental health problems. Addictive/dependent patterns of behaviour were also a concern: the majority of frequent users reported using the drug without stopping until supplies ran out and the mean increase in dosage in this group was six-fold from initiation to current use. We have identified specific health issues which seem uniquely related to ketamine use. Additionally, the dependence on ketamine frequently reported by users may be a cause for concern as its popularity grows and substance misuse services should be made aware of this when clients present in the future.