Symptoms of anxiety and depression in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studies

OBJECTIVES

Anxiety and depression are relevant comorbidities in asthma, but, in Portugal and Spain, data on this topic are scarce. We assessed, in patients with asthma, the frequency of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and the European Quality of Life Five Dimension Questionnaire (EQ-5D); the level of agreement between these questionnaires, and the factors associated with these symptoms.

METHODS

This is a secondary analysis of the INSPIRERS studies. A total of 614 adolescents and adults with persistent asthma (32.6±16.9 years, 64.7% female) were recruited from 30 primary care centres and 32 allergy, pulmonology and paediatric clinics. Demographic and clinical characteristics, HADS and EQ-5D were collected. A score ≥8 on Hospital Anxiety and Depression Scale-Anxiety/Hospital Anxiety and Depression Scale-Depression or a positive answer to EQ-5D item 5 indicated the presence of these symptoms. Agreement was determined by Cohen's kappa. Two multivariable logistic regressions were built.

RESULTS

According to HADS, 36% of the participants had symptoms of anxiety and 12% of depression. According to EQ-5D, 36% of the participants had anxiety/depression. The agreement between questionnaires in identifying anxiety/depression was moderate (k=0.55, 95% CI 0.48 to 0.62). Late asthma diagnosis, comorbidities and female gender were predictors of anxiety/depression, while better asthma control, health-related quality of life and perception of health were associated with lower odds for anxiety/depression.

CONCLUSION

At least 1/3 of the patients with persistent asthma experience symptoms of anxiety/depression, showing the relevance of screening these disorders in patients with asthma. EQ-5D and HADS questionnaires showed a moderate agreement in the identification of anxiety/depression symptoms. The identified associated factors need to be further investigated in long-term studies.

Measuring adherence to inhaled control medication in patients with asthma: Comparison among an asthma app, patient self-report and physician assessment

BACKGROUND

Previous studies have demonstrated the feasibility of using an asthma app to support medication management and adherence but failed to compare with other measures currently used in clinical practice. However, in a clinical setting, any additional adherence measurement must be evaluated in the context of both the patient and physician perspectives so that it can also help improve the process of shared decision making. Thus, we aimed to compare different measures of adherence to asthma control inhalers in clinical practice, namely through an app, patient self-report and physician assessment.

METHODS

This study is a secondary analysis of three prospective multicentre observational studies with patients (≥13 years old) with persistent asthma recruited from 61 primary and secondary care centres in Portugal. Patients were invited to use the InspirerMundi app and register their inhaled medication. Adherence was measured by the app as the number of doses taken divided by the number of doses scheduled each day and two time points were considered for analysis: 1-week and 1-month. At baseline, patients and physicians independently assessed adherence to asthma control inhalers during the previous week using a Visual Analogue Scale (VAS 0-100).

RESULTS

A total of 193 patients (72% female; median [P25-P75] age 28 [19-41] years old) were included in the analysis. Adherence measured by the app was lower (1 week: 31 [0-71]%; 1 month: 18 [0-48]%) than patient self-report (80 [60-95]) and physician assessment (82 [51-94]) (p < 0.001). A negligible non-significant correlation was found between the app and subjective measurements (ρ 0.118-0.156, p > 0.05). There was a moderate correlation between patient self-report and physician assessment (ρ = 0.596, p < 0.001).

CONCLUSIONS

Adherence measured by the app was lower than that reported by the patient or the physician. This was expected as objective measurements are commonly lower than subjective evaluations, which tend to overestimate adherence. Nevertheless, the low adherence measured by the app may also be influenced by the use of the app itself and this needs to be considered in future studies.

Elimination of Hepatic Rodent Plasmodium Parasites by Amino Acid Supplementation

Plasmodium parasites, causative agents of malaria, scavenge host nutrients to sustain their intracellular replication. Modulation of the host's nutritional status can potentially help control infection by limiting the parasite's access to nutrients, or by boosting the immune system. Here, we show that dietary supplementation of mice employing a combination of arginine (R) with two additional amino acids, lysine (K) and valine (V), termed RKV, significantly decreases Plasmodium liver infection. RKV supplementation results in the elimination of parasites at a late stage of their development in the liver. Our data employing genetic knockout mouse models and in vivo depletion of specific cell populations suggest that RKV supplementation boosts the host's overall innate immune response, and that parasite elimination is dependent on MyD88 signaling in immune cells. The immunostimulatory effect of RKV supplementation opens a potential role for dietary supplementation as an adjuvant for prophylaxis or immunization strategies against Plasmodium infection.

Learnings from a decade experience of a community-based HIV and STI testing and counseling center in Lisbon – Portugal

Background

In the context of an increased number of men who have sex with men (MSM) being diagnosed with HIV infection in many European countries, it became a matter of maximum priority to consider new strategies to monitor and tackle the epidemic. In this scenario, CheckpointLX and a cohort study were projected as a sexual health and research center oriented towards MSM in Portugal.

Methods

In 2011 CheckpointLX was launched in Lisbon as a community-based center for anonymous and free rapid HIV and other sexually transmitted diseases (STI) testing with a strong component of counseling for sexual health, specially targeted at MSM. In the case of a reactive test, a medical appointment is proposed and scheduled. The Lisbon Cohort of MSM is an ongoing observational prospective study conducted at CheckpointLX. Collected data include sexual behaviors, preventive strategies, and history of STI.

Results

Until July 2019, 7,351 HIV-negative MSM chose to participate in the Lisbon Cohort of MSM. 3,523 had at least one follow-up visit. The median age was 29 (IQR 25 - 37), and 27% were born in a foreign country, including 15% born in Africa and South America. HIV incidence increased up until 2015, reaching 5 reactive tests per 100 tested annually. There has been a sustained decrease in HIV observed since 2015. The use of HIV prevention tools was provided: 31% used condoms consistently, 3% reported PrEP, and 4% PEP.

Conclusions

A decade since the beginning of this experience shows positive results, such as increased access and testing. We promoted a stigma-free service that facilitated MSM's and other key population's access to sexual health care. We contribute unique data for assisting in the monitoring of the Dublin Declaration in Portugal.

HIV test and knowledge of U=U: insights from MSM living in Portugal and participating in EMIS 2017

Recently, it became clear that undetectable equals untransmittable (U=U), stressing the importance of engaging in medical care and adhering to antiretroviral therapy. HIV testing and counselling (HTC) are offered in different settings and can be an opportunity to inform people. We aimed to understand if HIV testing history, including recency, place and, result, was associated with U=U knowledge.

We used data from 2242 MSM living in Portugal participating in EMIS 2017 that answered if they already knew that “A person with HIV who is on effective treatment (called 'undetectable viral load') cannot pass their virus to someone else during sex”, opting of 5 possible answers, dichotomized in “I already knew” vs. any other option. Regarding HIV testing history, participants were categorized as follows:1. HIV positive; 2. HIV negative and last test ≤12 months in a community setting; 3. HIV negative and last test ≤12 months in a medical setting, and 4. never tested for HIV or last test &gt;12 months or tested in other settings (reference). Logistic regression models were fitted to estimate crude and city size and education-adjusted associations.

The median (P25; P75) age of participants was 34 (25; 43) years. No significant statistical association was found with age or current occupation. Those with more years of education and living in a big or very big city were more likely to know that U=U (aOR:1.55; 95%CI:1.20-1.99 and aOR:1.26; 95%CI:1.04-1.53, respectively). Considering HIV testing history and diagnosis, men with diagnosed HIV (aOR:6.33; 95%CI:4.50-8.90), those who had the last test in community setting (aOR:2.44; 95%CI:1.87-3.17) and those who had the last test in a medical setting (aOR: 1.57; 95%CI:1.26-1.95) were more aware of U=U than those not tested in the last 12 months.

Our results suggest that there is a gradient of U=U knowledge associated with HIV testing history among MSM. Efforts should focus on improving counselling about U=U at all HIV testing settings.

Key messages

The knowledge of U=U seems to be associated with the place, recency and result of the last HIV test. Counselling should focus on the best evidence available at all HIV testing settings, to inform and empower the individuals.

Host AMPK Is a Modulator of Plasmodium Liver Infection

Manipulation of the master regulator of energy homeostasis AMP-activated protein kinase (AMPK) activity is a strategy used by many intracellular pathogens for successful replication. Infection by most pathogens leads to an activation of host AMPK activity due to the energetic demands placed on the infected cell. Here, we demonstrate that the opposite is observed in cells infected with rodent malaria parasites. Indeed, AMPK activity upon the infection of hepatic cells is suppressed and dispensable for successful infection. By contrast, an overactive AMPK is deleterious to intracellular growth and replication of different Plasmodium spp., including the human malaria parasite, P. falciparum. The negative impact of host AMPK activity on infection was further confirmed in mice under conditions that activate its function. Overall, this work establishes the role of host AMPK signaling as a suppressive pathway of Plasmodium hepatic infection and as a potential target for host-based antimalarial interventions.

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Plasmodium-infected hepatic cells exhibit decreased AMPK activity

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AMPK suppression favors hepatic infection; its activation reduces parasite development

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AMPK activating compounds efficiently reduce liver infection in vitro and in vivo

GLUT1-mediated glucose uptake plays a crucial role during Plasmodium hepatic infection

Intracellular pathogens have evolved mechanisms to ensure their survival and development inside their host cells. Here, we show that glucose is a pivotal modulator of hepatic infection by the rodent malaria parasite Plasmodium berghei and that glucose uptake via the GLUT1 transporter is specifically enhanced in P. berghei‐infected cells. We further show that ATP levels of cells containing developing parasites are decreased, which is known to enhance membrane GLUT1 activity. In addition, GLUT1 molecules are translocated to the membrane of the hepatic cell, increasing glucose uptake at later stages of infection. Chemical inhibition of GLUT1 activity leads to a decrease in glucose uptake and the consequent impairment of hepatic infection, both in vitro and in vivo. Our results reveal that changes in GLUT1 conformation and cellular localization seem to be part of an adaptive host response to maintain adequate cellular nutrition and energy levels, ensuring host cell survival and supporting P. berghei hepatic development.

Incident risk factors as predictors of HIV seroconversion in the Lisbon cohort of men who have sex with men: first results, 2011-2014

HIV incidence in men who have sex with men (MSM) is increasing in western countries, including Portugal. We aimed to estimate HIV incidence and to assess how individual short-term changes in exposures over time predict seroconversion. We evaluated participants of an open cohort of HIV-negative MSM enrolled after testing at a community-based voluntary HIV counselling and testing centre in Lisbon. At each evaluation a structured questionnaire was completed and HIV status was ascertained using rapid followed by confirmatory testing. Between April 2011 and February 2014, 804 MSM were followed for a total of 893 person-years. Predictors of HIV seroconversion were identified using Poisson generalised linear regression. The overall seroincidence was 2.80/100 person-years (95% confidence interval: 1.89-4.14). Men who seroconverted had a higher mean number of tests per year. Seroconversions were significantly associated with partner disclosure of HIV status during follow-up, newly-adopted unprotected anal intercourse (UAI) with a steady partner and being newly-diagnosed with syphilis during follow-up. Likewise, sexual intercourse with HIV-positive men, having an HIV-positive steady partner at least once during follow-up and persistent UAI with occasional partners were predictors of seroconversion. High HIV incidence in this cohort is likely driven by short-term contextual and behavioural changes during follow-up.

Novel endoperoxide-based transmission-blocking antimalarials with liver- and blood-schizontocidal activities

In a search for effective compounds against both the blood- and liver-stages of infection by malaria parasites with the ability to block the transmission of the disease to mosquito vectors, a series of hybrid compounds combining either a 1,2,4-trioxane or 1,2,4,5-tetraoxane and 8-aminoquinoline moieties were synthesized and screened for their antimalarial activity. These hybrid compounds showed high potency against both exoerythrocytic and erythrocytic forms of malaria parasites, comparable to representative trioxane-based counterparts. Furthermore, they efficiently blocked the development of the sporogonic cycle in the mosquito vector. The tetraoxane-based hybrid 5, containing an amide linker between the two moieties, effectively cleared a patent blood-stage P. berghei infection in mice after i.p. administration. Overall, these results indicate that peroxide-8-aminoquinoline hybrids are excellent starting points to develop an agent that conveys all the desired antimalarial multistage activities in a single chemical entity and, as such, with the potential to be used in malaria elimination campaigns.

Loss-of-function analyses defines vital and redundant functions of the Plasmodium rhomboid protease family

Rhomboid-like proteases cleave membrane-anchored proteins within their transmembrane domains. In apicomplexan parasites substrates include molecules that function in parasite motility and host cell invasion. While two Plasmodium rhomboids, ROM1 and ROM4, have been examined, the roles of the remaining six rhomboids during the malaria parasite's life cycle are unknown. We present systematic gene deletion analyses of all eight Plasmodium rhomboid-like proteins as a means to discover stage-specific phenotypes and potential functions in the rodent malaria model, P. berghei. Four rhomboids (ROM4, 6, 7 and 8) are refractory to gene deletion, suggesting an essential role during asexual blood stage development. In contrast ROM1, 3, 9 and 10 were dispensable for blood stage development and exhibited no, subtle or severe defects in mosquito or liver development. Parasites lacking ROM9 and ROM10 showed no major phenotypic defects. Parasites lacking ROM1 presented a delay in blood stage patency following liver infection, but in contrast to a previous study blood stage parasites had similar growth and virulence characteristics as wild type parasites. Parasites lacking ROM3 in mosquitoes readily established oocysts but failed to produce sporozoites. ROM3 is the first apicomplexan rhomboid identified to play a vital role in sporogony.