Brief Report: Relationship Between Adiposity and Biomarkers of Aging and Frailty Among Adults Aging With HIV

BACKGROUND

This study examined the relationships among adiposity, handgrip, physical function, inflammation (ie, senescence-associated secretory phenotype chemokines as biomarkers of aging and frailty), and sex hormones in aging people with HIV.

METHODS

This cross-sectional exploratory study included 150 people with HIV aged ≥40 years (67.3% of participants were male). Our measures included (1) body mass index and waist circumference as measures of adiposity; (2) handgrip as a measure of muscle strength; (3) short physical performance battery as a measure of physical function; (4) interleukin-6, tumor necrosis factor alpha receptor II, high sensitivity C-reactive protein, C-X-C motif chemokine 10, and C-X3-C motif chemokine ligand 1 also known as fractalkine as senescence-associated secretory phenotype chemokines; and (5) free testosterone, estradiol, sex hormone-binding globulin, and dehydroepiandrosterone as sex hormones. Quantile regression analyses were used to identify relationships among inflammatory markers and hormones with age, adiposity, handgrip, and physical function.

RESULTS

Overall, 74% (n = 111) of participants were classified as overweight or obese and 53.3% (n = 80) presented with abdominal obesity. After controlling for age and sex, body mass index was positively associated with estradiol (β = 0.043, P < 0.01), and waist circumference was positively associated with high sensitivity C-reactive protein (β = 2.151, P < 0.01). After controlling for sex, age was positively associated with C-X-C motif chemokine 10 (β = 0.024, P = 0.03) and tumor necrosis factor alpha receptor II (β = 2.205, P = 0.01). After controlling for age and sex, short physical performance battery was negatively associated with dehydroepiandrosterone (β = -0.004, P = 0.01); no statistically significant associations were observed for handgrip.

CONCLUSION

Adiposity levels and aging were associated with inflammation (ie, C-X-C motif chemokine 10, tumor necrosis factor alpha receptor II, and high sensitivity C-reactive protein) among people with HIV aged 40 years and older.

An Internship Approach to Strengthen the Pathway for Historically Underrepresented Groups in Health Sciences Research: The North Carolina Diversity and Inclusion Pathway Program

BACKGROUND

To increase engagement of historically underrepresented groups in health sciences research, we created the North Carolina Diversity and Inclusion Pathway Program (NC-DIPP). This year-long, paid internship provides undergraduate and graduate students from 2 historically Black colleges and universities an opportunity to gain real-world experience under the mentorship of expert faculty.

METHODS

To evaluate the early experiences with the NC-DIPP program, we conducted semi-structured interviews with interns and program leaders. Faculty mentors completed an online questionnaire to describe their experiences to date. A thematic approach was used to analyze the findings.

RESULTS

In March-April 2023, 7 of 8 interns (88%), 6 of 11 mentors (54%), and 4 of 4 program leaders (100%) participated in various evaluation components. Overall, respondents agreed about the importance of programs like NC-DIPP, which further engage historically underrepresented groups in the health sciences. Interns had positive feedback about the internship, including real-world work experience, connections to experienced mentors, and early career planning. On a scale of 1 (poor) to 10 (excellent), interns rated their experience as a median of 8.3 (range: 4.5-10.0). Mentors had favorable but slightly lower scores (median: 7.0, range: 5.0-8.0). Areas for improvement were noted, including clearer expectations, improved logistical support, and central engagement of interns across projects.

CONCLUSIONS

This early evaluation of NC-DIPP was generally favorable across all stakeholder groups. By providing a long-term experience in health science research, such programs can contribute to work experience, career planning, and professional networking.

Immune regulatory gene polymorphisms, frequent cannabis use, and psychosis: implications to Treg hypofunction

Introduction

We have previously shown that the association between frequent cannabis use and psychosis is more likely in subgroups with low-grade inflammation than subgroups without (PMID: 33736715). The role of immune-related polymorphisms remains unknown.

Objectives

To explore whether polymorphisms affecting the function of key immune regulatory proteins moderate the association between cannabis and psychosis, namely: ENTPD1 and NT5E, involved in the synthesis of CD39, CD73, respectively, and anti-inflammatory adenosine; CTLA4 and FOXP1, essential for Treg functional capacity.

Methods

We genotyped blood samples from 283 community-based controls and 140 recent-onset psychosis patients in Brazil (EU-GEI consortium, Ribeirão Preto/SP) for twelve polymorphisms (ENTPD1: rs3814159, rs3176891, rs10748643; NT5E: rs9444348, rs2295890; CTLA4: rs3087243, rs231775, rs5742909, rs4553808; FOXP1: rs6803008, rs6786408, rs830599; Illumina Human Core Exome-24). Cannabis frequency (daily, less than daily, never) was assessed by self-report (Cannabis Experience Questionnaire). Binary logistic regression models (OR,95%CI) included case status as the outcome, genotype (dominant model), cannabis frequency, and an interaction term between the two as exposure, adjusting for confounders (age, sex, ethnicity, tobacco smoking).

Results

We found significant interactions between cannabis use and polymorphisms for ENTPD1 (rs3814159), NT5E (rs9444348), and FOXP1 (rs6786408). Less than daily or daily use were, in a dose-response fashion, only associated with psychosis in those with the variant and heterozygous genotypes; less than daily: ENTPD1 AG/GG (3.34,1.71-6.50); NT5E AG/AA (3.71,1.87-7.33); FOXP1 AC/CC (2.98,1.54-5.77); daily: ENTPD1 AG/GG (16.81;5.89-47.96); NT5E AG/AA (21.20,6.81-66.01); FOXP1 AC/CC (13.75,5.22-36.21).

Conclusions

Variation in genes that affect Treg function appears to modify the effect of cannabis consumption on psychosis in keeping with Treg hypofunction hypothesis (PMID:33713699).

Disclosure

No significant relationships.

Human Immunodeficiency Virus Type 1 RNA Detected in the Central Nervous System (CNS) After Years of Suppressive Antiretroviral Therapy Can Originate from a Replicating CNS Reservoir or Clonally Expanded Cells

BACKGROUND

Human immunodeficiency virus type 1 (HIV-1) populations are detected in cerebrospinal fluid (CSF) of some people on suppressive antiretroviral therapy (ART). Detailed analysis of these populations may reveal whether they are produced by central nervous system (CNS) reservoirs.

METHODS

We performed a study of 101 asymptomatic participants on stable ART. HIV-1 RNA concentrations were cross-sectionally measured in CSF and plasma. In participants with CSF HIV-1 RNA concentrations sufficient for analysis, viral populations were genetically and phenotypically characterized over multiple time points.

RESULTS

For 6% of participants (6 of 101), the concentration of HIV-1 RNA in their CSF was ≥0.5 log copies/mL above that of plasma (ie, CSF escape). We generated viral envelope sequences from CSF of 3 participants. One had a persistent CSF escape population that was macrophage-tropic, partially drug resistant, genetically diverse, and closely related to a minor macrophage-tropic lineage present in the blood prior to viral suppression and enriched for after ART. Two participants (1 suppressed and 1 not) had transient CSF escape populations that were R5 T cell-tropic with little genetic diversity.

CONCLUSIONS

Extensive analysis of viral populations in 1 participant revealed that CSF escape was from a persistently replicating population, likely in macrophages/microglia, present in the CNS over 3 years of ART. CSF escape in 2 other participants was likely produced by trafficking and transient expansion of infected T cells in the CNS. Our results show that CNS reservoirs can persist during ART and that CSF escape is not exclusively produced by replicating CNS reservoirs.

Predicting Efavirenz Concentrations in the Brain Tissue of HIV-Infected Individuals and Exploring their Relationship to Neurocognitive Impairment

Sparse data exist on the penetration of antiretrovirals into brain tissue. In this work, we present a framework to use efavirenz (EFV) pharmacokinetic (PK) data in plasma, cerebrospinal fluid (CSF), and brain tissue of eight rhesus macaques to predict brain tissue concentrations in HIV-infected individuals. We then perform exposure-response analysis with the model-predicted EFV area under the concentration-time curve (AUC) and neurocognitive scores collected from a group of 24 HIV-infected participants. Adult rhesus macaques were dosed daily with 200 mg EFV (as part of a four-drug regimen) for 10 days. Plasma was collected at 8 time points over 10 days and at necropsy, whereas CSF and brain tissue were collected at necropsy. In the clinical study, data were obtained from one paired plasma and CSF sample of participants prescribed EFV, and neuropsychological test evaluations were administered across 15 domains. PK modeling was performed using ADAPT version 5.0 Biomedical Simulation Resource, Los Angeles, CA) with the iterative two-stage estimation method. An eight-compartment model best described EFV distribution across the plasma, CSF, and brain tissue of rhesus macaques and humans. Model-predicted median brain tissue concentrations in humans were 31 and 8,000 ng/mL, respectively. Model-predicted brain tissue AUC was highly correlated with plasma AUC (γ = 0.99, P < 0.001) but not CSF AUC (γ = 0.34, P = 0.1) and did not show any relationship with neurocognitive scores (γ < 0.05, P > 0.05). This analysis provides an approach to estimate PK the brain tissue in order to perform PK/pharmacodynamic analyses at the target site.

Stable Caloric Intake and Continued Virologic Suppression for HIV-Positive Antiretroviral Treatment-Experienced Women After Switching to a Single-Tablet Regimen of Emtricitabine, Rilpivirine, and Tenofovir Disoproxil Fumarate

Benefits of switching to a single-tablet regimen (STR) of emtricitabine/rilpivirine/tenofovir (FTC/RPV/TDF) in virologically suppressed antiretroviral treatment (ART) experienced HIV-positive women include pregnancy category B rating and lack of clinically significant drug interactions between RPV and oral contraceptives. Unfortunately, studies involving switching to FTC/RPV/TDF enrolled fewer than 25% women. We undertook this 48-week study to assess the ability of virologically suppressed HIV-positive women switching to RPV STR to remain virologically suppressed and comply with the caloric intake requirement. HIV-positive women on ART with viral load <50 c/mL for 6 months before study entry and no known resistance to FTC, TDF, or RPV were enrolled and switched to STR RPV/FTC/TDF. Caloric intake (≥400 kcal) compliance and concurrency with oral STR RPV/FTC/TDF were evaluated with a 3-day food diary, which was validated by obtaining participant's caloric consumption through phone calls on randomly chosen dates. For each 3-day food diary, the daily median caloric intake and median value for each macronutrient consumed concurrent with FTC/RPV/TDF were computed. Medication adherence was measured using a visual analog scale. We enrolled 33 women, 73% of whom were African American. At week 48, virologic suppression (HIV RNA <40 c/mL) was maintained in 96% of women, including those (n = 4) who reported imperfect ART adherence. The daily median caloric intake concurrent with FTC/RPV/TDF was 820 kcal by food diary and 677 kcal by random phone call. Median kcal intake (food diary) did not change significantly from baseline (684 kcal) to week 48 (820 kcal); median change 102 kcal, p = .15. Women who reported noncompliance with a ≥400 kcal meal did not experience virologic failure. Significant concordance between caloric adherence and virologic suppression was not detected. Our study demonstrated that HIV-positive women who switched to STR FTC/RPV/TDF continued to experience virologic suppression and were readily able to comply with the recommended caloric intake requirement.

Physician assistant students' attitudes towards a clinical doctoral degree

PURPOSE

The introduction of clinical doctorate degrees in several health professions has fueled the debate about an entry-level clinical doctorate in the physician assistant profession. However, there is limited knowledge of the attitudes of physician assistant students toward obtaining a clinical doctorate.

METHODS

All 147 accredited physician assistant programs in the United States were invited to participate in a Web-based survey conducted in January 2010; physician assistant students in any program year were eligible to participate. The survey examined physician assistant students' attitudes towards (a) enrolling in a clinical doctorate program, (b) additional schooling time, (c) monetary costs, and (d) perceived benefits of a clinical doctorate. Chi-square tests were conducted to examine differences in survey item responses and composite variables.

RESULTS

From 37 states and 53 physician assistant programs, 1815 physician assistant students completed the survey and 1658 were included in this analysis. Nearly half (49.8%) of the responding physician assistant students overall had a positive attitude toward a clinical doctorate degree. More respondents favored than opposed enrolling in a clinical doctorate program if schooling time were an additional 12 months or less (55.5% vs 29.9%, P < .0001) and additional costs were between 20% and 29% of current expenditure (44.8% vs 36.4%, P < .0001). More than half (56.2%) of the physician assistant students considered perceived benefits (composite variable) as a reason to obtain a clinical doctorate.

CONCLUSIONS

This large study comprising more than one-third of physician assistant programs and representing 80% of the US states with physician assistant programs finds that physician assistant students' interest in enrolling in a clinical doctorate program may be dependent on additional school time and monetary costs.

Abstract W P399: Magnetic Resonance Imaging Based Cerebral Blood Flow Changes in Asymptomatic Human Immunodeficiency Virus Infected Subjects

Background: Human Immunodeficiency Virus (HIV) infected individuals are at high risk for ischemic stroke. Magnetic resonance imaging (MRI) method of measurement of cerebral blood flow (CBF) and oxygen extraction fraction (OEF) may help assess the stroke risk in asymptomatic HIV subjects.

Objectives: To evaluate MR measured CBF and OEF in treatment naïve asymptomatic HIV+ subjects and HIV- controls.

Methods: Treatment naïve asymptomatic HIV+ subjects and age-gender-race matched HIV- controls were assessed for CBF using a pulsed arterial spin labeling (PASL) approach and Oxygen Extraction Fraction (OEF) using MRI T2*-weighted echo-planar imaging (EPI) sequences. All images were acquired using a Siemens 3T MR scanner (Treo, Siemens Medical Systems Inc). Quantitative CBF and OEF measurements were made in the whole-brain, gray matter and white matter and compared between the groups using unpaired t-test.

Results: A total of 65 subjects of who, 35 treatment naïve HIV+ subjects (Mean age ± SD=30±7,89% male, 31% white, 49% black and 20% others) and 30 age-gender-race matched HIV- controls (Mean age± SD= 31±8,93% male, 37% white, 53% black and 10% others) consented to the protocol. HIV+ subjects compared to HIV- controls had significantly higher whole brain CBF (58.0 ± 13.8 ml/100g/min vs. 51.3 ± 9.0 ml/100g/min; p=0.03) and gray matter CBF (72.9 ± 16.2 ml/100g/min vs. 63.9 ± 9.9 ml/100g/min; p=0.01). However, values for whole brain OEF (0.4 ± 0.04) and gray matter OEF (0.4 ± 0.05) were similar for both groups. White matter CBF in HIV+ subjects (41.5 ± 13.1 ml/100g/min) compared to HIV- controls (37.2 ± 9.2 ml/100g/min) was not significantly higher (p=0.16) while white matter OEF (0.4 ± 0.04 HIV+ subjects vs. 0.4 ± 0.03 HIV-controls) showed no changes.

Conclusions: The observed increase of whole brain CBF in treatment naïve HIV + subjects compared to HIV- matched controls, without corresponding changes in the OEF appears to be driven by a pronounced significant change in the gray matter compared with the white matter. These changes in CBF without corresponding changes in OEF suggest increase in metabolic activity, and may explain the higher stroke risk in asymptomatic HIV subjects.

Prevention and control of sexually transmissible infections among hotel-based female sex workers in Dhaka, Bangladesh

BACKGROUND

Hotel-based sex workers in Bangladesh have high rates of sexually transmissible infections (STIs), high client turnover and low condom use. Two monthly clinic-based strategies were compared: periodic presumptive treatment (PPT) and enhanced syndromic management (ESM) - one round of presumptive treatment followed by treatment based on assessment and laboratory tests.

METHODS

A randomised controlled trial compared PPT and ESM by prevalence and incidence, behaviour, retention, cost and STI incidence and prevalence. Demographic, behavioural and clinical data were collected from women at two clinics in Dhaka. All women received presumptive treatment and were randomised to receive PPT or ESM at nine monthly visits.

RESULTS

In total, 549 women (median age: <20 years) were enrolled. At baseline, the prevalence of chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) was 41% (ESM: 41%; PPT: 42%). After 9 months, chlamydia and gonorrhoea decreased to 7% overall, (ESM: 7.4%; PPT: 6.8%). At each visit, 98% of women receiving ESM met the therapy criteria and were treated. Retention was low (50%). Total costs were 50% lower per visit for each woman for PPT (ESM: $11.62 v. PPT: $5.80). The number of sex work sessions was reduced from 3.3 to 2.5 (P<0.001), but income did not change. Coercion was reduced but condom use at last sex did not change significantly.

CONCLUSIONS

Monthly PPT and ESM were effective approaches for STI control. PPT offered a feasible, low-cost alternative to ESM. Educational aspects led to a reduction in coercion and fewer sessions. Implementation studies are needed to improve condom use and retention.

Systemically circulating viral and tumor-derived microRNAs in KSHV-associated malignancies

MicroRNAs (miRNAs) are stable, small non-coding RNAs that modulate many downstream target genes. Recently, circulating miRNAs have been detected in various body fluids and within exosomes, prompting their evaluation as candidate biomarkers of diseases, especially cancer. Kaposi's sarcoma (KS) is the most common AIDS-associated cancer and remains prevalent despite Highly Active Anti-Retroviral Therapy (HAART). KS is caused by KS-associated herpesvirus (KSHV), a gamma herpesvirus also associated with Primary Effusion Lymphoma (PEL). We sought to determine the host and viral circulating miRNAs in plasma, pleural fluid or serum from patients with the KSHV-associated malignancies KS and PEL and from two mouse models of KS. Both KSHV-encoded miRNAs and host miRNAs, including members of the miR-17–92 cluster, were detectable within patient exosomes and circulating miRNA profiles from KSHV mouse models. Further characterization revealed a subset of miRNAs that seemed to be preferentially incorporated into exosomes. Gene ontology analysis of signature exosomal miRNA targets revealed several signaling pathways that are known to be important in KSHV pathogenesis. Functional analysis of endothelial cells exposed to patient-derived exosomes demonstrated enhanced cell migration and IL-6 secretion. This suggests that exosomes derived from KSHV-associated malignancies are functional and contain a distinct subset of miRNAs. These could represent candidate biomarkers of disease and may contribute to the paracrine phenotypes that are a characteristic of KS.

Circulating microRNAs (miRNAs), such as those found in exosomes, have emerged as diagnostic tools and hold promise as minimally invasive, stable biomarkers. Transfer of tumor-derived exosomal miRNAs to surrounding cells may be an important form of cellular communication. Kaposi's sarcoma-associated herpesvirus (KSHV) is the etiological agent of Kaposi's sarcoma (KS), the most common AIDS-defining cancer worldwide. Here, we survey systemically circulating miRNAs and reveal potential biomarkers for KS and Primary Effusion Lymphoma (PEL). This expands previous tissue culture studies by profiling clinical samples and by using two new mouse models of KSHV tumorigenesis. Profiling of circulating miRNAs revealed that oncogenic and viral miRNAs were present in exosomes from KS patient plasma, pleural effusions and mouse models of KS. Analysis of human oncogenic miRNAs, including the well-known miR-17-92 cluster, revealed that several miRNAs were preferentially incorporated into exosomes in our KS mouse model. Gene ontology analysis of upregulated miRNAs showed that the majority of pathways affected were known targets of KSHV signaling pathways. Transfer of these oncogenic exosomes to immortalized hTERT-HUVEC cells enhanced cell migration and IL-6 secretion. These circulating miRNAs and KS derived exosomes may therefore be part of the paracrine signaling mechanism that mediates KSHV pathogenesis.

Abstract WP227: Magnetic Resonance Measurement Of Static Global And Regional Cerebral Autoregulation

Background: Reliable methods used to test static cerebral autoregulation are time-consuming and/or invasive.

Objectives: To evaluate if noninvasive magnetic resonance measured oxygen extraction fraction (OEF), cerebral blood flow (CBF), and oxygen metabolic index (OMI=CBF×OEF) can consistently detect expected physiological changes in humans under normal and 10-15% lowered mean arterial pressure (MAP).

Methods: Static cerebral autoregulation was determined by measuring changes in CBF using a pseudo continuous arterial spin labeling (pCASL) approach and Oxygen Extraction Fraction (OEF) using MRI T2‘-weighted asymmetric spin echo echo-planar imaging (EPI) sequences, in response to 10-15% reductions in MAP in stroke-free controls induced by using IV Nicardipine. Images were acquired in 3T MR scanner (Trio, Siemens Medical Systems Inc). Autoregulation was measured globally and regionally in the anterior (ACA), the middle (MCA) and the posterior cerebral artery (PCA) territories of the brain manually defined using autopsy based model. Autoregulatory Index (AI) was computed (AI = %CBF change/% MAP change) supplemented by CBF associated OEF changes. Baseline regional CBF and OEF, AI, CBF and OEF changes to 10-15% lowering of MAP

Results: Nineteen normal volunteers (mean age 30, 95% male, 50% white, 40% black, 10% others) were consented to the protocol approved by the institutional review board. MAP lowering was successfully achieved in all subjects (Mean ± standard deviation of MAP lowering of 12.5 ± 5.6 mm Hg). At a global level this resulted in no significant change between pre-MAP lowering CBF (56.0 ± 8.5 ml/100g/min) and post-MAP lowering CBF (55.9± 8.8 ml/100g/min). This translated to a AI of 0 ± 1.2. The CBF results corroborated with no significant change in OEF and OMI. Baseline regional CBF was higher in the MCA territory (66.1 ± 7.6 ml/100g/min) compared with the ACA territory (52.8 ± 8.6ml/100g/min, p<0.001). The AIs were consistent (ANOVA p=0.15) at regional levels across ACA (-1.5 ± 3.1), MCA(-0.3± 2.1) and PCA (-0.1 ± 1.4) territories.

Conclusions: Global and regional static cerebral autoregulation can be measured using MR measurement of CBF, OEF and OMI, before and after 10-15% reductions in MAP in healthy volunteers.

Low prevalence of antiretroviral resistance among HIV type 1-positive prisoners in the Southeast United States

Drug-resistant HIV complicates management of HIV infection. Although an estimated 14% of all HIV-positive persons pass through a prison or jail in the United States each year, little is known about the overall prevalence of antiretroviral (ARV) resistance in incarcerated persons. All genotypic sequence data on HIV-positive prisoners in the North Carolina (NC) Department of Corrections (DOC) were obtained from LabCorp. Screening for major resistance mutations in protease (PI) and reverse transcriptase (NRTI and NNRTI) was done using Genosure and the Stanford HIV Database. For subjects with multiple genotype reports, each mutation was counted only once and considered present on all subsequent genotypes. Between October 2006 and February 2010, the NC DOC incarcerated 1,911 HIV(+) individuals of whom 19.2% (n=367) had at least one genotype performed. The overall prevalence of a major resistance mutation was 28.3% (95% CI 23.7, 33.0). Among prisoners ever exposed to an ARV during incarceration (n=329) prevalence of a major resistance mutation was 29.8% (95% CI 24.9, 34.7); resistance by class was 20.4% (95% CI 16.0, 24.7) for NRTIs, 19.8% (95% CI 15.5, 24.1) for NNRTIs, and 8.8% (95% CI 5.8,11.9) for PIs. Single class drug resistance was most prevalent at 14.2% (10.2,17.7) followed by dual 12.5% (I8.9,16.0) and triple class 3.3% (1.4,5.3) resistance. The three most prevalent mutations were K103N 15.8% (12.0, 20.2), M184V 14.3% (10.7,18.5), and M41L 4.9% (2.8,7.8). In the NC DOC ARV resistance prevalence, dual and triple class drug resistance was moderate over the study period. Resistance to PIs was lower than NNRTIs and NRTIs, likely reflecting higher usage of these two classes or a lower barrier to resistance.

Expression of p16(INK4a) as a biomarker of T-cell aging in HIV-infected patients prior to and during antiretroviral therapy

The p16(INK4a) tumor suppressor gene is a mediator of cellular senescence and has been suggested to be a biomarker of 'molecular' age in several tissues including T cells. To determine the association of both active and suppressed HIV infection with T-cell aging, T-cell p16(INK4a) expression was compared between 60 HIV+ suppressed subjects, 23 HIV+ untreated subjects, and 18 contemporaneously collected HIV-negative controls, as well as 148 HIV-negative historical samples. Expression did not correlate with chronologic age in untreated HIV+ patients, consistent with an effect of active HIV replication on p16(INK4a) expression. In patients on cART with suppressed viral loads, however, p16(INK4a) levels were similar to uninfected controls and correlated with chronologic age, with a trend toward an inverse correlation with CD4 count. These data show that p16(INK4a) is a reliable biomarker of T-cell aging in HIV+ patients with suppressed viral loads and suggest that poor CD4 cell recovery on cART may be associated with increased T-cell expression of p16(INK4a), a marker of cellular senescence.

Cardiac autonomic dysfunction in anabolic steroid users

This study aimed to evaluate if androgenic-anabolic steroids (AAS) abuse may induce cardiac autonomic dysfunction in recreational trained subjects. Twenty-two men were volunteered for the study. The AAS group (n = 11) utilized AAS at mean dosage of 410 ± 78.6 mg/week. All of them were submitted to submaximal exercise testing using an Astrand-Rhyming protocol. Electrocardiogram (ECG) and respired gas analysis were monitored at rest, during, and post-effort. Mean values of VO2 , VCO2 , and VE were higher in AAS group only at rest. The heart rate variability variables were calculated from ECG using MATLAB-based algorithms. At rest, AAS group showed lower values of the standard deviation of R-R intervals, the proportion of adjacent R-R intervals differing by more than 50 ms (pNN50), the root mean square of successive differences (RMSSD), and the total, the low-frequency (LF) and the high-frequency (HF) spectral power, as compared to Control group. After submaximal exercise testing, pNN50, RMSSD, and HF were lower, and the LF/HF ratio was higher in AAS group when compared to control group. Thus, the use of supraphysiological doses of AAS seems to induce dysfunction in tonic cardiac autonomic regulation in recreational trained subjects.

Does HAART efficacy translate to effectiveness? Evidence for a trial effect

BACKGROUND

Patients who participate in clinical trials may experience better clinical outcomes than patients who initiate similar therapy within clinical care (trial effect), but no published studies have evaluated a trial effect in HIV clinical trials.

METHODS

To examine a trial effect we compared virologic suppression (VS) among patients who initiated HAART in a clinical trial versus in routine clinical care. VS was defined as a plasma HIV RNA ≤ 400 copies/ml at six months after HAART initiation and was assessed within strata of early (1996-99) or current (2000-06) HAART periods. Risk ratios (RR) were estimated using binomial models.

RESULTS

Of 738 persons initiating HAART, 30.6% were women, 61.7% were black, 30% initiated therapy in a clinical trial and 67% (n =  496) had an evaluable six month HIV RNA result. HAART regimens differed between the early and current periods (p < 0.001); unboosted PI regimens (55.6%) were more common in the early and NNRTI regimens (46.4%) were more common in the current period. Overall, 78% (95%CI 74, 82%) of patients achieved VS and trial participants were 16% more likely to achieve VS (unadjusted RR 1.16, 95%CI 1.06, 1.27). Comparing trial to non-trial participants, VS differed by study period. In the early period, trial participants initiating HAART were significantly more likely to achieve VS than non-trial participants (adjusted RR 1.33; 95%CI 1.15, 1.54), but not in the current period (adjusted RR 0.98; 95%CI 0.87, 1.11).

CONCLUSIONS

A clear clinical trial effect on suppression of HIV replication was observed in the early HAART period but not in the current period.

The major genetic determinants of HIV-1 control affect HLA class I peptide presentation

Infectious and inflammatory diseases have repeatedly shown strong genetic associations within the major histocompatibility complex (MHC); however, the basis for these associations remains elusive. To define host genetic effects on the outcome of a chronic viral infection, we performed genome-wide association analysis in a multiethnic cohort of HIV-1 controllers and progressors, and we analyzed the effects of individual amino acids within the classical human leukocyte antigen (HLA) proteins. We identified >300 genome-wide significant single-nucleotide polymorphisms (SNPs) within the MHC and none elsewhere. Specific amino acids in the HLA-B peptide binding groove, as well as an independent HLA-C effect, explain the SNP associations and reconcile both protective and risk HLA alleles. These results implicate the nature of the HLA-viral peptide interaction as the major factor modulating durable control of HIV infection.

Recruitment of HIV/AIDS treatment-naïve patients to clinical trials in the highly active antiretroviral therapy era: influence of gender, sexual orientation and race

BACKGROUND

In the USA, women, racial/ethnic minorities and persons who acquire HIV infection through heterosexual intercourse represent an increasing proportion of HIV-infected persons, and yet are frequently underrepresented in clinical trials. We assessed the demographic predictors of trial participation in antiretroviral-naïve patients.

METHODS

Patients were characterized as trial participants if highly active antiretroviral therapy (HAART) was initiated within a clinical trial. Prevalence ratios (PRs) were obtained using binomial regression.

RESULTS

Between 1996 and 2006, 30% of 738 treatment-naïve patients initiated HAART in a clinical trial. Trial participation rates for men who have sex with men (MSM), heterosexual men, and women were respectively 36.5, 29.6 and 24.3%. After adjustment for other factors, heterosexual men appeared less likely to participate in trials compared with MSM [PR 0.79, 95% confidence interval (CI) 0.57, 1.11], while women were as likely to participate as MSM (PR 0.97, 95% CI 0.68, 1.39). The participation rate in Black patients (25.9%) was lower compared with non-Black patients (37.5%) (adjusted PR 0.80, 95% CI 0.60, 1.06).

CONCLUSIONS

In our clinical setting, gender did not appear to impact participation in HIV treatment trials, but Black patients were slightly less likely to participate in these trials. Considering the substantial proportion of HIV-infected patients who are Black, future trials need to consider strategies to incorporate such underrepresented populations.

Microalbuminuria predicts overt proteinuria among patients with HIV infection

BACKGROUND

This study examines the association between microalbuminuria and the development of proteinuria among HIV-infected persons.

METHODS

A total of 948 subjects provided urine samples for albumin, protein and creatinine measurements semiannually. Microalbuminuria was defined as an albumin-to-creatinine ratio of >30 mg/g. Proteinuria was defined as a protein-to-creatinine ratio of > or =0.350 mg/mg. The progression from microalbuminuria to proteinuria was described.

RESULTS

At baseline, 69.4% of the subjects had no detectable proteinuria, 20.2% had microalbuminuria, and 10.4% had proteinuria. Subjects with microalbuminuria and proteinuria were more likely to be black (P=0.02), have lower CD4 cell counts (P=0.02 comparing subjects without abnormal urine protein excretion to subjects with microalbuminuria; P=0.0001 comparing subjects with microalbuminuria to subjects with proteinuria), and have a higher HIV RNA level (P=0.08 and 0.04, respectively). Among 658 subjects with normal urine protein, 82.7% continued to have no abnormality, 14.3% developed microalbuminuria, and 3.0% developed proteinuria. Subjects without baseline proteinuria (i.e. either normal protein excretion or microalbuminuria) who developed proteinuria were more likely to have microalbuminuria (P=0.001), a lower CD4 cell count (P=0.06), and a higher plasma HIV RNA (P=0.03) than those who did not progress to proteinuria. In multivariate analysis, only microalbuminuria remained associated with the development of proteinuria (odds ratio 2.9; 95% confidence interval 1.5, 5.5; P=0.001).

CONCLUSION

Microalbuminuria predicts the development of proteinuria among HIV-infected persons. Because proteinuria has been linked to poorer outcomes, strategies to affect microalbuminuria should be tested.

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND

Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence.

METHOD

A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy.

RESULTS

The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia.

CONCLUSIONS

Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

Factors associated with fewer visits for HIV primary care at a tertiary care center in the Southeastern U.S

In this study we sought to evaluate sociodemographic and clinical characteristics associated with decreased access to HIV outpatient care in a University-based clinic in the Southeastern U.S. The number of HIV outpatient clinic visits per person-year was estimated among 1,404 HIV-infected individuals participating in a large observational clinical cohort study. On average, participants attended 3.38 visits per person-year (95% CI = 3.32, 3.44), with 71% attending fewer than 4 visits per year. Younger persons, of Black race/ethnicity, with less advanced HIV disease, and a shorter time from entry to HIV care, had poorer access to care, as did participants without health insurance and residing a greater distance from care. Vulnerable subgroups of HIV-infected patients in the South have decreased access to ongoing HIV health care. Interventions including more intensive counseling and active outreach for newly HIV diagnosed individuals and support with obtaining health insurance and transportation may lead to improved outcomes.

Infrequent diagnosis of primary human immunodeficiency virus infection: missed opportunities in acute care settings

Although primary human immunodeficiency virus infection (PHI) is usually symptomatic and early management is likely important, the diagnosis is infrequently made. We examined a prospectively enrolled cohort of individuals diagnosed as having PHI in the southeastern United States to determine problems associated with the diagnosis of PHI. The following information was collected on each individual: site of initial presentation, number of visits to health care settings before diagnosis, diagnosing physician, alternative diagnoses, presumptive therapies, and time to diagnosis of PHI. Data were available for 29 of 30 patients (17 white, 12 nonwhite). Most patients were seen at least 3 times before the diagnosis of PHI was made. White persons were seen more frequently by primary care providers (P =.09). Nonwhite persons were diagnosed more quickly (P =.045). Only 5 patients (17%) were correctly diagnosed during their first encounter with the health care system, while 5 (17%) remained undiagnosed for more than 1 month after first presentation. Infectious diseases specialists diagnosed 83% of the cases. Human immunodeficiency virus is infrequently diagnosed during primary infection. More expeditious diagnosis of human immunodeficiency virus infection is a clinical and public health imperative.

Envelope diversity, coreceptor usage and syncytium-inducing phenotype of HIV-1 variants in saliva and blood during primary infection

OBJECTIVE

To determine whether oral fluids can serve as a model for studying HIV-1 shedding, we compared the genetic diversity, coreceptor use, and syncytium-inducing (SI) phenotype of viral variants in saliva and blood during primary HIV-1 infection.

DESIGN

Observational cross-sectional cohort study.

METHODS

Blood plasma and saliva were sampled from 17 men early in primary HIV-1 infection. Viral diversity, predicted X4/R5 genotype and SI phenotype in samples were determined by heteroduplex tracking assays (HTAs) targeting the V1/V2 and V3 gp120 regions, sequence analyses and MT-2 cell assay.

RESULTS

Identical or very similar HTA banding and deduced amino acid sequence patterns in the V1/V2 and V3-encoding regions were observed between paired fluids of each subject. As assessed by V1/V2 HTA, 10 subjects had a single major viral variant and seven subjects exhibited multiple yet highly related variants. Two subjects had V1/V2 variants in blood that were identical to saliva but present in different relative abundances. A sexual transmission pair exhibited genetically dissimilar variants, suggesting transmission of a minor variant or rapid evolution during initial viremia. All subjects harbored R5 non-SI variants.

CONCLUSIONS

Relatively homogenous viral populations detected in plasma and saliva prior to seroconversion suggests that HIV-1 is disseminated to oral fluids early in infection and reflects the quasispecies in blood. These findings suggest that the oral cavity may serve as an easily accessible surrogate model for studying the dynamics of HIV-1 shedding at mucosal sites.

Impact of adherence to antiretroviral therapy in HIV-1-infected patients at a university public service in Brazil

The objective of this study was to assess if a simple evaluation, adherence to antiretroviral therapy, would correlate to clinical and laboratory outcomes. We followed an open cohort of patients from a public teaching hospital AIDS outpatient clinic. Patients were categorized according to adherence as: regular (Reg), optimal, all doses all days, tolerating only irregular timing (+/- 2 hours) of intake; quasi-regular (qReg), those missing up to four doses or 1 full day during a month; irregular (Irreg), all other irregular regimens, and ignored (Ign), those without information. The results from a simple questionnaire were compared to CD4+ cell counts and human immunodeficiency virus type 1 (HIV-1) RNA plasma viremia. One hundred eighty-two HIV-1-infected patients (126 males, 69%; 56 females, 31%) were analyzed. Information on adherence was available for 168 (90%). Reg adherence was reported by 75 (41%) patients, qReg adherence by 35 (19%), and Irreg by 53 (29%) of patients. The main reasons for nonadherence were forgetfulness, intolerance, use of alcohol, and misunderstanding of prescription. A significant increase of CD4+ T-cell counts and absolute gain were only observed among Reg and qReg users (p < 0.001). The median viral RNA load log10 decreases were -1.68, -1.45, -0.9 log, respectively, for Reg, qReg, and Irreg patients (p = 0.043, Kruskal-Wallis). Development of and death from AIDS occurred almost exclusively among those with Ign or Irreg adherence. Previous use of antiretroviral therapy may have had an impact in treatment response. Individuals who were treatment-naive were more likely to be Reg users (41%). Although more refined methods to assess adherence should be implemented when available, the inability to do so should not prevent simple, albeit subjective measurements that also correlate with favorable outcome. Mechanisms to improve adherence should be considered an integral part of antiretroviral therapy.

HIV in body fluids during primary HIV infection: implications for pathogenesis, treatment and public health

OBJECTIVE

To describe initial viral dissemination to peripheral tissues and infectious body fluids during human primary HIV infection.

DESIGN

Observational cohort study.

METHODS

Blood plasma, cerebrospinal fluid (CSF), seminal plasma, cervicovaginal lavage fluid and/or saliva were sampled from 17 individuals with primary HIV infection (range of time from symptoms onset to sampling, 8--70 days) and one individual with early infection (168 days). Subjects' HIV-1 RNA levels in each fluid were compared with levels from antiretroviral-naive controls with established HIV infection. For study subjects, correlations were assessed between HIV-1 RNA levels and time from symptoms onset. Responses to antiretroviral therapy with didanosine + stavudine + nevirapine +/- hydroxyurea were assessed in each compartment.

RESULTS

HIV-1 RNA levels were highest closest to symptoms onset in blood plasma (18 patients) and saliva (11 patients). CSF HIV-1 RNA levels (five patients) appeared lower closer to symptoms onset, although they were higher overall in primary versus established infection. Shedding into seminal plasma (eight patients) and cervicovaginal fluid (two patients) was established at levels observed in chronic infection within 3--5 weeks of symptoms onset. High-level seminal plasma shedding was associated with coinfection with other sexually transmitted pathogens. Virus replication was suppressed in all compartments by antiretroviral therapy.

CONCLUSIONS

Peak level HIV replication is established in blood, oropharyngeal tissues and genital tract, but potentially not in CSF, by the time patients are commonly diagnosed with primary HIV infection. Antiretroviral therapy is unlikely to limit initial virus spread to most tissue compartments, but may control genital tract shedding and central nervous system expansion in primary infection.

Preliminary results of a randomized controlled trial of prophylactic shock wave lithotripsy for small asymptomatic renal calyceal stones

OBJECTIVE

To report a prospective, randomized study to determine whether prophylactic extracorporeal shockwave lithotripsy (ESWL) is justified as a treatment for small, asymptomatic calyceal stones.

PATIENTS AND METHODS

The study included 228 patients with small (< 15 mm total diameter) asymptomatic calyceal stones; 113 patients were randomized to undergo ESWL and 115 to the control group who were kept under observation. Outcome measurements included the stone-free rate, requirement for additional treatment, symptoms, quality of life and renal function.

RESULTS

In all, 200 patients had at least one annual follow-up; all outcome measurements reported were those at the most recent follow-up (mean 2.2 years, range 1-5). In the ESWL group 28 patients (28%) were stone-free, compared with 16 (17%) in the observation group (odds ratio 1.95, 95% confidence interval, CI, 0.97-3.89, P = 0.06). Additional treatment in the form of analgesics, antibiotics, ESWL, stent insertion and ureteroscopy, was required in 21 (21%) patients in the observation group and 15 (15%) in the ESWL group (odds ratio 0.66, 95% CI 0.32-1.37, P = 0.27). Ten patients in the observation group required invasive procedures, vs none in the ESWL group. There was no evidence of differences in the symptoms, quality of life or renal function tests between the arms of the trial at the final follow-up.

CONCLUSIONS

Prophylactic ESWL for small asymptomatic renal calyceal stones does not appear to offer any advantage to patients in terms of stone-free rate, quality of life, renal function, symptoms or hospital admissions. However, a policy of observation is associated with a greater risk of requiring more invasive procedures. A longer follow-up is required to assess the validity of these preliminary findings.

Early observations of the effect of extracorporeal shockwave lithotripsy on blood pressure: a prospective randomized control clinical trial

OBJECTIVE

To determine, in a randomized controlled clinical trial, the effect of extracorporeal shock wave lithotripsy (ESWL) on blood pressure.

PATIENTS AND METHODS

The trial included 228 patients with small (< 15 mm) asymptomatic calyceal stones who were randomised to undergo ESWL (113 patients) or to an untreated (observed) control group (115 patients). Blood pressure was recorded at randomization using a standardized protocol. Patients undergoing ESWL received a mean (SD) of 5281 (3462) shocks over a mean of 1.75 sessions on one of two lithotripters. Patients were then followed annually, assessing blood pressure and changes in medication. Data were analysed on an intention-to-treat basis.

RESULTS

At randomization, 43% of patients in the control group and 53% in the ESWL group were hypertensive. Of the 228 randomized, 200 patients completed at least one annual follow-up, of whom 192 (93 in the control and 99 in the ESWL group) had their blood pressure recorded. The mean follow-up was 2.2 years; 35 (37%) patients in the control and 46 (46%) in the ESWL group were hypertensive (P = 0.19). Seven (7%) patients in the control group and 11 (11%) in the ESWL group were newly diagnosed to be hypertensive (P = 0.35).

CONCLUSIONS

In this randomized controlled clinical trial there was no evidence that ESWL causes changes in blood pressure.

A randomized trial comparing lithoclast with an electrokinetic lithotripter in the management of ureteric stones

OBJECTIVE

To compare two in situ ballistic lithotripters, the lithoclast and the electrokinetic lithotripter (EKL), both of which can be used through the newer small-bore ureteroscopes, for their ease of use, robustness, fragmentation time, adequacy of fragmentation and stone-free rate.

PATIENTS AND METHODS

Forty-six consecutive patients with ureteric stones refractory to treatment by extracorporeal shock wave lithotripsy were randomized to undergo fragmentation using the lithoclast (23 patients) or the EKL (23 patients). One patient was excluded from analysis in the EKL group. The adequacy of fragmentation was recorded, with the degree and significance of proximal migration for each device. After treatment patients were assessed by plain X-ray and the stone-free rate was determined.

RESULTS

The mean (median) initial stone burdens in the lithoclast and EKL groups were 69 (50) mm2 and 72 (52) mm2, respectively. The respective mean (median) procedure duration and fragmentation time were 54 (50) min and 90 (49) s in the lithoclast group, and 50 (42.5) min and 87 (52.5) s in the EKL group; the differences were not statistically significant. In four (14%) patients of each group there was significant proximal migration of the stones. The stones were completely fragmented in 17 of 23 (74%) patients in the lithoclast group and 19 of 22 (86%) in the EKL group. There was no fragmentation in one patient in each group. In the lithoclast and EKL groups, 20 of 23 (87%) and 17 of 22 (77%) were rendered stone-free, respectively (P > 0.5). The equipment failed on two occasions in each group.

CONCLUSION

In this randomized trial there was no significant difference in the stone-free rate, procedure duration, fragmentation time, proximal stone migration rate and equipment failure between these in situ ballistic lithotripters.

Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones

OBJECTIVE

To report our experience of using flexible ureterorenoscopy for upper urinary tract stones.

PATIENTS AND METHODS

Thirty-seven patients (13 females, 24 males, mean age 48 years, range 10-76) with upper urinary tract stones not responding to other treatments had their residual symptomatic stones treated through a 9.3 F flexible ureterorenoscope. Electrohydraulic lithotripsy (EHL) was used to fragment the stones and a basket or a grasper used to retrieve the fragments.

RESULTS

Twenty-three patients were completely freed of stone and a further five had asymptomatic residual fragments of < 5 mm. Of 15 patients with ureteric stones, 14 were rendered stone-free at the end of the procedure and 14 of the 22 patients with kidney stones were treated successfully; 80% of the lower calyceal stones were treated successfully and a firm decision was possible on the further management of the remaining stones. There were no major complications.

CONCLUSION

Flexible ureterorenoscopy should be considered in patients with symptomatic upper ureteric or renal stones refractory to other treatments, but the instrumentation is expensive and delicate, and its use should be reserved for such cases.

Substance misuse and risk of aggression and offending among the severely mentally ill

BACKGROUND

The aim of this study was to investigate whether 'dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending.

METHOD

Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and keyworkers asked to rate substance misuse and aggression.

RESULTS

The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P = 0.001), or recent hostile behaviour (P = 0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P = 0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables.

CONCLUSIONS

Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.

The recognition and treatment of depression in older people in primary care

OBJECTIVES

To examine general practitioners' (GP) awareness of depression in their elderly patients (aged over 65) and to identify characteristics of those patients least likely to be recognized and treated.

DESIGN

A cross-sectional study comparing the clinical opinion of the GP with assessment of mental state using a validated interview schedule (the Short Comprehensive Assessment and Referral Evaluation).

SETTING AND SUBJECTS

510 elderly residents in the Gospel Oak area of Camden in North London registered with 28 GPs at 13 practices.

MAIN OUTCOME MEASURES

Agreement between GP view and patients interview. Evidence of active management measured by examining GP records for appointments, referrals and prescription of psychotropic mediation.

RESULTS

GPs were aware of depression in 36 (51%) of 70 depressed patients. Those least likely to be recognized were men, the married, those with high levels of physical handicap, those suffering from visual impairment and those who were least well educated. Of the 32 patients believed to be depressed, 12 (38%) were prescribed antidepressant medication and/or referred to mental health/social services.

CONCLUSIONS

Levels of recognition of depression were lower than other recent reports. These findings may reflect the continued debate about the most suitable management of the elderly depressed in primary care and stress the need for further evaluation of appropriate treatment strategies for this group.

Multicenter evaluation of proposed standardized procedure for antifungal susceptibility testing of filamentous fungi

A multicenter study was conducted to expand the generation and analysis of data that supports the proposal of a reference method for the antifungal susceptibility testing of filamentous fungi. Broth microdilution MICs of amphotericin B and itraconazole were determined in 11 centers against 30 coded duplicate pairs of Aspergillus spp., Fusarium spp., Pseudallescheria boydii, and Rhizopus arrhizus. The effect of inoculum density (approximately 10(3) and 10(4) CFU/ml), incubation time (24, 48, and 72 h), and procedure of MIC determination (conventional and colorimetric [Alamar Blue] evaluation of growth inhibition) on intra- and interlaboratory agreement was analyzed. Based on intra- (97 to 100%) and interlaboratory (94 to 95%) agreement for both drugs, the overall optimal testing conditions identified were determination of colorimetric MICs after 48 to 72 h of incubation with an inoculum density of approximately 10(4) CFU/ml. These testing conditions are proposed as guidelines for a reference broth microdilution method.