CDK4/6i-treated HR+/HER2- breast cancer tumors show higher ESR1 mutation prevalence and more altered genomic landscape

As CDK4/6 inhibitor (CDK4/6i) approval changed treatment strategies for patients with hormone receptor-positive HER2-negative (HR+/HER2-) breast cancer (BC), understanding how exposure to CDK4/6i affects the tumor genomic landscape is critical for precision oncology. Using real-world data (RWD) with tumor genomic profiling from 5910 patients with metastatic HR+/HER2- BC, we investigated the evolution of alteration prevalence in commonly mutated genes across patient journeys. We found that ESR1 is more often altered in tumors exposed to at least 1 year of adjuvant endocrine therapy, contrasting with TP53 alterations. We observed a similar trend after first-line treatments in the advanced setting, but strikingly exposure to aromatase inhibitors (AI) combined with CDK4/6i led to significantly higher ESR1 alteration prevalence compared to AI alone, independent of treatment duration. Further, CDK4/6i exposure was associated with higher occurrence of concomitant alterations in multiple oncogenic pathways. Differences based on CDK4/6i exposure were confirmed in samples collected after 2L and validated in samples from the acelERA BC clinical trial. In conclusion, our work uncovers opportunities for further treatment personalization and stresses the need for effective combination treatments to address the altered tumor genomic landscape following AI+CDK4/6i exposure. Further, we demonstrated the potential of RWD for refining patient treatment strategy and guiding clinical trial design.

Efficacy of a Clinical Decision Rule to Enable Direct Oral Challenge in Patients With Low-Risk Penicillin Allergy: The PALACE Randomized Clinical Trial

Importance

Fewer than 5% of patients labeled with a penicillin allergy are truly allergic. The standard of care to remove the penicillin allergy label in adults is specialized testing involving prick and intradermal skin testing followed by an oral challenge with penicillin. Skin testing is resource intensive, limits practice to specialist-trained physicians, and restricts the global population who could undergo penicillin allergy delabeling.

Objective

To determine whether a direct oral penicillin challenge is noninferior to the standard of care of penicillin skin testing followed by an oral challenge in patients with a low-risk penicillin allergy.

Design, Setting, and Participants

This parallel, 2-arm, noninferiority, open-label, multicenter, international randomized clinical trial occurred in 6 specialized centers, 3 in North America (US and Canada) and 3 in Australia, from June 18, 2021, to December 2, 2022. Eligible adults had a PEN-FAST score lower than 3. PEN-FAST is a prospectively derived and internationally validated clinical decision rule that enables point-of-care risk assessment for adults reporting penicillin allergies.

Interventions

Patients were randomly assigned to either direct oral challenge with penicillin (intervention arm) or a standard-of-care arm of penicillin skin testing followed by oral challenge with penicillin (control arm).

Main Outcome and Measure

The primary outcome was a physician-verified positive immune-mediated oral penicillin challenge within 1 hour postintervention in the intention-to-treat population. Noninferiority was achieved if a 1-sided 95% CI of the risk difference (RD) did not exceed 5 percentage points (pp).

Results

A total of 382 adults were randomized, with 377 patients (median [IQR] age, 51 [35-65] years; 247 [65.5%] female) included in the analysis: 187 in the intervention group and 190 in the control group. Most patients had a PEN-FAST score of 0 or 1. The primary outcome occurred in 1 patient (0.5%) in the intervention group and 1 patient (0.5%) in the control group, with an RD of 0.0084 pp (90% CI, -1.22 to 1.24 pp). The 1-sided 95% CI was below the noninferiority margin of 5 pp. In the 5 days following the oral penicillin challenge, 9 immune-mediated adverse events were recorded in the intervention group and 10 in the control group (RD, -0.45 pp; 95% CI, -4.87 to 3.96 pp). No serious adverse events occurred.

Conclusions and Relevance

In this randomized clinical trial, direct oral penicillin challenge in patients with a low-risk penicillin allergy was noninferior compared with standard-of-care skin testing followed by oral challenge. In patients with a low-risk history, direct oral penicillin challenge is a safe procedure to facilitate the removal of a penicillin allergy label.

Trial Registration

ClinicalTrials.gov Identifier: NCT04454229.

An Open-label Phase I Study of GDC-0927 in Postmenopausal Women with Locally Advanced or Metastatic Estrogen Receptor-Positive Breast Cancer

PURPOSE

GDC-0927 is a novel, potent, nonsteroidal, orally bioavailable, selective estrogen receptor (ER) degrader that induces tumor regression in ER+ breast cancer xenograft models.

PATIENTS AND METHODS

This phase I dose-escalation multicenter study enrolled postmenopausal women with ER+/HER2- metastatic breast cancer to determine the safety, pharmacokinetics, and recommended phase II dose of GDC-0927. Pharmacodynamics was assessed with [18F]-fluoroestradiol (FES) PET scans.

RESULTS

Forty-two patients received GDC-0927 once daily. The MTD was not reached. The most common adverse events (AE) regardless of causality were nausea, constipation, diarrhea, arthralgia, fatigue, hot flush, back pain, and vomiting. There were no deaths, grade 4/5 AEs, or treatment-related serious AEs. Two patients experienced grade 2 AEs of special interest of deep vein thrombosis and jugular vein thrombosis, both considered unrelated to GDC-0927. Following dosing, approximately 1.6-fold accumulation was observed, consistent with the observed half-life and dosing frequency. There were no complete or partial responses. Pharmacodynamics was supported by >90% reduction in FES uptake and an approximately 40% reduction in ER expression, suggesting ER degradation is not the mechanistic driver of ER antagonism. Twelve patients (29%) achieved clinical benefit; 17 patients (41%) showed a confirmed best overall response of stable disease. Baseline levels of ER and progesterone receptor protein and mutant ESR1 circulating tumor DNA did not correlate with clinical benefit.

CONCLUSIONS

GDC-0927 appeared to be well tolerated with pharmacokinetics supporting once-daily dosing. There was evidence of target engagement and preliminary evidence of antitumor activity in heavily pretreated patients with advanced/metastatic ER+/HER2- breast cancer with and without ESR1 mutations.

Identification of Youthful Neurocognitive Trajectories in Adults Aging with HIV: A Latent Growth Mixture Model

Despite the neurocognitive risks of aging with HIV, initial cross-sectional data suggest a subpopulation of older people with HIV (PWH) possess youthful neurocognition (NC) characteristic of SuperAgers (SA). Here we characterize longitudinal NC trajectories of older PWH and their convergent validity with baseline SA status, per established SuperAging criteria in PWH, and baseline biopsychosocial factors. Growth mixture modeling (GMM) identified longitudinal NC classes in 184 older (age ≥ 50-years) PWH with 1–5 years of follow-up. Classes were defined using ‘peak-age’ global T-scores, which compare performance to a normative sample of 25-year-olds. 3-classes were identified: Class 1_{Stable Elite} (n = 31 [16.8%], high baseline peak-age T-scores with flat trajectory); Class 2_{Quadratic Average} (n = 100 [54.3%], intermediate baseline peak-age T-scores with u-shaped trajectory); Class 3_{Quadratic Low} (n = 53 [28.8%], low baseline peak-age T-scores with u-shaped trajectory). Baseline predictors of Class 1_{Stable Elite} included SA status, younger age, higher cognitive and physiologic reserve, and fewer subjective cognitive difficulties. This GMM analysis supports the construct validity of SuperAging in older PWH through identification of a subgroup with longitudinally-stable, youthful neurocognition and robust biopsychosocial health.

Gibbin mesodermal regulation patterns epithelial development

Proper ectodermal patterning during human development requires previously identified transcription factors such as GATA3 and p63, as well as positional signalling from regional mesoderm1-6. However, the mechanism by which ectoderm and mesoderm factors act to stably pattern gene expression and lineage commitment remains unclear. Here we identify the protein Gibbin, encoded by the Xia-Gibbs AT-hook DNA-binding-motif-containing 1 (AHDC1) disease gene7-9, as a key regulator of early epithelial morphogenesis. We find that enhancer- or promoter-bound Gibbin interacts with dozens of sequence-specific zinc-finger transcription factors and methyl-CpG-binding proteins to regulate the expression of mesoderm genes. The loss of Gibbin causes an increase in DNA methylation at GATA3-dependent mesodermal genes, resulting in a loss of signalling between developing dermal and epidermal cell types. Notably, Gibbin-mutant human embryonic stem-cell-derived skin organoids lack dermal maturation, resulting in p63-expressing basal cells that possess defective keratinocyte stratification. In vivo chimeric CRISPR mouse mutants reveal a spectrum of Gibbin-dependent developmental patterning defects affecting craniofacial structure, abdominal wall closure and epidermal stratification that mirror patient phenotypes. Our results indicate that the patterning phenotypes seen in Xia-Gibbs and related syndromes derive from abnormal mesoderm maturation as a result of gene-specific DNA methylation decisions.

Participants Switching to Second-Line Antiretroviral Therapy with Susceptible Virus Display Inferior Adherence and Worse Outcomes: An Observational Analysis

Evidence on the impact of human immunodeficiency virus (HIV) drug resistance on regimens following treatment failure is varied and inconclusive. Differential medication adherence may explain this variation. We aimed to test the association between drug resistance at first-line antiretroviral therapy (ART) switch and adherence to and virologic failure on subsequent ART. We conducted a secondary analysis of data from an open-labeled randomized trial of second-line ART (ACTG A5234). ART susceptibility was determined from study entry plasma using the Stanford Drug Resistance database version 8.7. Adherence was measured with microelectronic monitors. Three adherence variables and rates of virologic failure (HIV-1 RNA ≥1000 copies/mL) on second-line ART were compared between participants with and without resistance at first-line ART failure. Of 214 participants switching to second-line ART with baseline resistance results, 113 (53%) were men, mean age was 39 years (standard deviation 10.3), and 37 (17%) had susceptible virus at study entry. Cumulative genotypic susceptibility score (cGSS) was inversely associated with adherence, adjusted odds ratio (aOR) 0.15, 95% confidence interval (CI) (0.05-0.40), p < 0.001. The aOR of virologic failure for a one-unit increase in cGSS was 1.72, 95% CI (1.22-2.41), p < 0.001. Participants switched to second-line ART without resistance displayed inferior adherence and had higher rates of virologic failure. Therefore, these individuals warrant additional adherence interventions to help them achieve virologic success. Clinical Trial Registration number: NCT00608569.

108. Selective Decay of Intact HIV-1 Proviral DNA on Antiretroviral Therapy

Background

HIV-1 proviruses persist in people on antiretroviral therapy (ART) but most are defective and do not constitute a replication-competent reservoir. The decay of infected cells carrying intact compared with defective HIV-1 proviruses has not been well-defined in people on ART.

Methods

We separately quantified intact and defective proviruses (using an intact proviral DNA assay), residual plasma viremia, and markers of inflammation and activation in people on long-term ART. Longitudinal measurements were done at three timepoints: timepoint 1 was a median of 7.1 years on ART; timepoint 2 was a median of 3.7 years later; timepoint 3 was a median of 5.5 years after timepoint 1 and a median 12 years after starting ART (Figure 1).

Figure 1: Study timepoints

Results

Among 40 participants tested longitudinally from a median of 7.1 years to 12 years after ART initiation, intact provirus levels declined significantly over time (median half-life 7.1 years; 95% confidence interval [CI], 3.9, 18), whereas defective provirus levels did not decrease. The median half-life of total HIV-1 DNA was 41.6 years (95% CI, 13.6, 75). When we evaluated the change in proviral DNA per year, intact proviral DNA declined significantly more (p< 0.001) than defective proviral DNA (the latter did not change) (Figure 2). The proportion of all proviruses that were intact diminished over time on ART, from about 10% at the first on-ART timepoint to about 5% at the last timepoint (Figure 3). At timepoint 1, intact provirus levels on ART correlated with total HIV-1 DNA and residual plasma viremia, but there was no evidence for associations between intact provirus levels and inflammation or immune activation.

Figure 2: Percent change in HIV-1 proviral DNA per year

Figure 3: Total HIV-1 proviruses (grey bars) and the percentage of intact proviruses (red lines, displaying median, Q1, Q3) by timepoint.

Conclusion

Cells containing intact, replication-competent proviruses are selectively lost during suppressive ART. Defining the mechanisms involved should inform strategies to accelerate HIV-1 reservoir depletion.

Disclosures

Rajesh Gandhi, MD, Merck (Advisor or Review Panel member) Gregory Laird, PhD, Accelevir Diagnostics (Shareholder, Other Financial or Material Support, Employee) Albine Martin, PhD, Accelevir Diagnostics (Shareholder, Other Financial or Material Support, Employee) Bernard Macatangay, MD, Gilead (Grant/Research Support) Joseph J. Eron, MD, Gilead Sciences (Consultant, Research Grant or Support)Janssen (Consultant, Research Grant or Support)Merck (Consultant)ViiV Healthcare (Consultant, Research Grant or Support) Janet Siliciano, PhD, Gilead (Advisor or Review Panel member)US Military HIV Research Program (Advisor or Review Panel member) John Mellors, MD, Abound Bio (Shareholder)Accelevir Diagnostics (Consultant)Co-Crystal Pharmaceuticals (Shareholder)Gilead (Consultant, Grant/Research Support)Merck (Consultant)

A Place to Live and to Die: A Qualitative Exploration of the Social Practices and Rituals of Death in Residential Aged Care

In many countries, an increasing proportion of deaths occur in residential aged care (RAC) (nursing homes) meaning that these have become both a place to live - a home- and a place to die. This paper reports on death practices and rituals in 49 RAC facilities in Aotearoa/New Zealand narrated in semi-structured interviews with staff. Themes coalesced around 'good death'. Dying alone was not seen as a good death and the demands of trying to prevent this caused tension for staff. Meeting family wishes, post death decision-making, after death practices and rituals, including communicating and remembrance of the death, were explored as part of good death. Overall, death rituals in RAC were limited. Balancing the needs of the living, the dying and the dead created tension. The rituals and practices facilities are currently enacting in death/post-death require attention, since more people will die in RAC with increasingly diverse needs.

A-03 Ethnic/Racial Differences in Longitudinal Neurocognitive Change among People Living with HIV

HIV disproportionately affects Black and Latino people in the United States, but data on longitudinal neurocognitive patterns for these groups are scarce. This study evaluated the incidence and predictors of neurocognitive decline by ethnicity/race in a cohort of Black, Latino, and White people living with HIV (PLWH). Participants included 499 PLWH (43.5% White, 42.7% Black, 13.8% Latino; mean age at baseline = 43.5) from the six-site CNS HIV Anti-Retroviral Therapy Effects Research (CHARTER) study. Participants completed comprehensive neurocognitive and neuromedical evaluations over 3-7 study visits for an average of 2.8 years (SD = 1.1). Interpertation of neurocognitive change was based on published methods using regression-based norms that correct for baseline performance and practice effects. Survival analyses investigated the relationship between ethnicity/race and neurocognitive change, and predictors of neurocognitive decline. In follow-up, 108 participants (21.6%) declined, 311 (62.3%) remained stable, and 80 (16.0%) improved. In Cox proportional hazard models, hazard ratios for neurocognitive decline were increased for Latinos compared to Whites (HR = 2.19, 95%CI = 1.32-3.63, p = .002) and Blacks (HR = 1.87, 95%CI = 1.14-3.04, p = .01). Including significant covariates (baseline nadir CD4, hepatitis C Virus, and VACS Index: a composite marker of physical health among PLWH)did not significantly decrease the elevated risk for decline among Latinos. We found that Latino PLWH appear to have higher risk of neurocognitive decline compared to White and Black PLWH. Traditional markers of HIV disease and physical health at baseline did not explain this elevated risk of neurocognitive decline. Future research examining economic, socio-environmental, and culturally-relevant biomedical factors may help to explain this observed ethnic/racial disparity in longitudinal neurocognitive function in HIV.

Dose-response between frequency of interruption of sedentary time and fasting glucose, the dawn phenomenon and night-time glucose in Type 2 diabetes

AIM

To explore the dose-response between frequency of interruption of sedentary time and basal glucose (fasting glucose, the dawn phenomenon and night-time glucose) in Type 2 diabetes.

METHODS

In a randomized three-treatment, two-period balanced incomplete block trial, 12 people with Type 2 diabetes (age, 60.0 ± 3.2 years; BMI, 30.2 ± 1.4 kg/m² ) completed two of three conditions: sitting for 7 h interrupted every 60 min (Condition 1), 30 min (Condition 2), and 15 min (Condition 3) by 3-min light-intensity walking breaks. The activPAL3 and FreeStyle Libre were used to assess physical activity/sedentary behaviour and continuous glucose profile. Standardized meals were provided, and changes in basal glucose of the nights and early mornings before and after treatment conditions were calculated (mean ± SE).

RESULTS

After treatment conditions, fasting glucose and duration of the dawn phenomenon were lower for Condition 3 (-1.0 ± 0.2 mmol/l, P < 0.02; -3.1 ± 1.3 h, P = 0.004) compared with Condition 1 (-0.1 ± 0.2 mmol/l; 1.9 ± 1.2 h). The magnitude of the dawn phenomenon was reduced in Condition 3 (-0.6 ± 0.4 mmol/l, P = 0.041) compared with Condition 2 (0.6 ± 0.3 mmol/l). Night-time glycaemic variability (coefficient of variation) was reduced in Condition 3 (-9.7 ± 3.9%) relative to Condition 2 (6.1 ± 4.8%, P < 0.03) and Condition 1 (2.5 ± 1.8%, P = 0.02). There was no change in night-time mean glucose.

CONCLUSIONS

Frequent interruptions of prolonged sitting with 3 min of light-intensity walking breaks every 15 min improves fasting glucose, the dawn phenomenon and night-time glycaemic variability, and this might be a simple therapeutic intervention to improve glucose control. Clinicaltrials.gov Identifier: NCT02738996.

Diagnosis of gestational diabetes: a 'teachable moment'

AIMS

Research regarding the determinants of concordance with gestational diabetes mellitus (GDM) treatment is limited. Here, we test whether the psychosocial changes outlined in the teachable moments model, as proposed by McBride et al. (McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003; 18: 156-170) are associated with following GDM treatment recommendations.

METHODS

Fifty-nine women completed a baseline questionnaire (1 week after GDM diagnosis) in which they reported risk perception, social support, emotional response, the importance of their maternal identity and self-efficacy. One month later, participants reported their concordance with instructions regarding glucose monitoring, diet and, if applicable, medication. We used regression analysis to test for associations between the psychosocial factors measured at baseline and concordance at 1-month follow-up.

RESULTS

Those who perceived their risk as higher or felt supported by family or friends were more likely to report a high level of concordance with GDM treatment. Emotional response, identity salience and self-efficacy were not related to concordance.

CONCLUSIONS

Future interventions designed to increase concordance could benefit from a focus on risk perception and social support, as these factors appear to be most strongly associated with following GDM treatment recommendations.

White matter damage, neuroinflammation, and neuronal integrity in HAND

HIV-associated neurocognitive disorders (HANDs) persist even with virologic suppression on combination antiretroviral therapy (cART), and the underlying pathophysiological mechanisms are not well understood. We performed structural magnetic resonance imaging and MR spectroscopy (MRS) in HIV+ individuals without major neurocognitive comorbidities. Study participants were classified as neurocognitively unimpaired (NU), asymptomatic (ANI), mild neurocognitive disorder (MND), or HIV-associated dementia (HAD). Using structural MRI, we measured volumes of cortical and subcortical gray matter and total and abnormal white matter (aWM). Using single-voxel MRS, we estimated metabolites in frontal gray matter (FGM) and frontal white matter (FWM) and basal ganglia (BG) regions. Adjusted odds ratios were used to compare HAND to NU. Among 253 participants, 40% met HAND criteria (21% ANI, 15% MND, and 4% HAD). Higher risk of HAND was associated with more aWM. Both HAD and MND also had smaller gray and white matter volumes than NU. Among individuals with undetectable plasma HIV RNA, structural volumetric findings were similar to the overall sample. MND had lower FWM creatine and higher FGM choline relative to NU, whereas HAD and ANI had lower BG N-acetyl aspartate relative to NU. In the virologically suppressed subgroup, however, ANI and MND had higher FGM choline compared to NU. Overall, HAND showed specific alterations (more aWM and inflammation; less gray matter volume and lower NAA). Some MR measures differentiated less severe subtypes of HAND from HAD. These MR alterations may represent legacy effects or accumulating changes, possibly related to medical comorbidities, antiretroviral therapy, or chronic effects of HIV brain infection.

Diabetes, malignancy and age as predictors of Candida glabrata bloodstream infection: A re-evaluation of the risk factors

OBJECTIVE

Echinocandins and azoles are widely used in the treatment of candidaemia. Guidelines of the Infectious Diseases Society of America recommend commencing treatment with an echinocandin in candidaemic patients with risk factors for Candida glabrata i.e. patients who are elderly, or who have diabetes or malignancy, or those with recent prescription of azoles. We attempted to validate whether age, diabetes and malignancy are associated with C. glabrata candidaemia.

PATIENTS, MATERIALS AND METHODS

Information in relation to demographics, patient associated risk factors, and laboratory parameters were collected from the casenotes and the laboratory information system. We then analysed the distribution of the risk factors (age, diabetes, and malignancy) in candidaemic patients with C. glabrata and patients with species other than C. glabrata (excluding Candida krusei).

RESULTS

Over a 42-month period (April 2011-September 2017), 124 patients had candidaemia. We analysed data for 119 patients of whom 33 (27.7%) had C. glabrata and the remaining 86 (72.2%) were infected with other species. Sixty-five patients were elderly (age≥65), 40 had some form of malignancy, 34 had diabetes, and 4 patients were prescribed azoles in the 30 days prior to candidaemia (many patients had multiple risk factors). Comparing patients with C. glabrata to patients infected with other species, we found no association with diabetes (39.3% vs. 24.4%, P=0.1), malignancy (36.3 vs. 32.5%, P=0.69), and age (54.5% vs. 54.6%, P=0.99).

CONCLUSIONS

Diabetes, malignancy and age are not reliable predictors of candidaemia due to C. glabrata.

Abstract B12: Expression of Integrated Stress Response proteins during the progression of UVB-induced squamous cell carcinoma

The major environmental risk factor for developing non-melanoma skin cancers (NMSCs) is exposure to the ultraviolet-B (UVB) wavelengths found in sunlight. Unlike other types of cancer where the occurrence each year is precisely known, so many NMSCs occur each year in the United States that the incidence of NMSC is not accurately reported. Treatment of NMSC costs the U.S. healthcare system over 1 billion dollars annually. Therefore while NMSC is rarely lethal, the expense of NMSC treatment is the fifth highest among all cancer treatments. In response to a myriad of environmental stresses, including UVB irradiation, eukaryotic cells rapidly modulate protein synthesis. An important mechanism for translation regulation involves phosphorylation of the α subunit of eukaryotic initiation factor 2 (eIF2α), which results in a prompt decrease in global protein synthesis, concurrent with preferential translation of cytoprotective gene transcripts. Because a range of different stresses can activate one of four eIF2 kinases, this pathway is referred to as the Integrated Stress Response (ISR). Although the ISR pathway has been implicated in carcinogenesis in a variety of tissues, little is known about whether the ISR can modulate the development of NMSC in human skin. We previously defined the cytoprotective role of the ISR in response to UVB-irradiation of human keratinocytes in vitro. Following UVB exposure, keratinocytes lacking an ISR response have a shortened G1 arrest, a decreased ability to repair UVB-damaged DNA, a diminished senescence response, and an increased susceptibility to apoptosis. Collectively, these functions attributed to the ISR response in keratinocytes following UVB-irradiation are tumor suppressive. To address how the ISR is involved during photocarcinogenesis, we analyzed the expression of ISR proteins (eIF2α-phosphorylation, ATF4, CHOP, GADD34) in the progression of a subtype of NMSC, squamous cell carcinoma (SCC). The progression ranges from normal skin, to a precursor lesion of SCC (actinic keratosis, AK), and finally to SCC tumors. ISR marker proteins were detected using immunofluorescence on formalin-fixed, paraffin-embedded tissue from at least four distinct specimens in each category. In normal skin, expression of ISR proteins were found in differentiating layers of the epidermis. eIF2α phosphorylation was predominantly observed in both the nucleus and cytoplasm of keratinocytes in the squamous and granular layers of the skin. Similarly, GADD34, ATF4, and CHOP were expressed in normal differentiating keratinocytes. In contrast, using a human skin model of AK, ATF4 expression was greatly increased in all but the basal cell layer of the epidermis. CHOP and GADD34 expression, as well as eIF2α phosphorylation, in human AKs followed a similar pattern. Progression to SCC resulted in a striking decrease in ISR protein expression. ATF4 and CHOP expression were absent, no eIF2α phosphorylation was detected, and GADD34 expression was greatly diminished. Therefore, the standard ISR response in differentiating keratinocytes is enhanced in AK lesions but silenced as the tumor progresses to SCC. These data suggest that sustaining the ISR response in UVB-damaged epidermis could be a valuable therapeutic target for the prevention of SCC development.

Citation Format: Dan F. Spandau, Ann Collier, Ron Wek. Expression of Integrated Stress Response proteins during the progression of UVB-induced squamous cell carcinoma. [abstract]. In: Proceedings of the AACR Special Conference on Translational Control of Cancer: A New Frontier in Cancer Biology and Therapy; 2016 Oct 27-30; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2017;77(6 Suppl):Abstract nr B12.

Gender differences and patterns of cardiovascular risk factors in Type 1 and Type 2 diabetes: a population-based analysis from a Scottish region

AIM

To explore the gender differences, along with the relationships between BMI, glycaemic control, cardiovascular risk factors and the prevalence of diabetes complications, in a representative population-based group of people with Type 1 and Type 2 diabetes.

METHODS

Data were obtained from general practices in Ayrshire and Arran, Scotland for 15 351 patients.

RESULTS

In the cohort with Type 1 diabetes, after adjustment for age, men had a significantly lower BMI (P = 0.007) and significantly lower total cholesterol (P = 0.005), HDL-cholesterol (P = 2.5*10(-17)) and HbA1c levels (P = 0.003) than women. By contrast, men had higher blood pressure, both systolic (P = 0.034) and diastolic (P = 0.0003), and higher non-fasting triglyceride levels (P = 0.001). Men with Type 1 diabetes had a higher prevalence of neuropathy (P = 0.021). Among people with Type 2 diabetes, men had a significantly lower BMI (P = 4.26*10(-37)), and significantly lower total cholesterol (P = 2.96*10(-62)) and HDL-cholesterol levels (P = 8.25*10(-141)) but higher non-fasting triglyceride levels (P = 0.0002). In Type 2 diabetes, men had a higher prevalence of ischaemic heart disease (P = 1.66*10(-25)), stroke (P = 0.002) and peripheral vascular disease (P = 1.68*10(-12)), while women were older (P = 4.83*10(-23)), heavier and had a higher prevalence of hypertension (P = 5.32*10(-12)). More people with Type 2 diabetes were on lipid-lowering treatment (84.7 vs 52.4%; P = 5.51*10(-8)) than were those with Type 1 diabetes. The prevalence of retinopathy was higher among non-smokers thank smokers in people with both Type 1 and Type 2 diabetes (Type 1, P = 0.016; Type 2, P = 0.001).

CONCLUSIONS

The study shows gender differences between Type 1 and 2 diabetes that are of clinical significance and require further investigation. Follow-up of the patients included in the present study should give us much greater understanding of the importance of gender in the development of metabolic abnormalities and diabetes complications.

Impact of socioeconomic status and gender on glycaemic control, cardiovascular risk factors and diabetes complications in type 1 and 2 diabetes: a population based analysis from a Scottish region

AIMS

In this cross-sectional study, the aims were to investigate the association of the socioeconomic status and gender on the prevalence of type 1 and 2 diabetes, glycaemic control, cardiovascular risk factors plus the complications of diabetes in a population-based analysis in the county of Ayrshire and Arran, Scotland.

METHODS

Quality Outcome Framework data was obtained from General Practices in Ayrshire and Arran, Scotland (n=15,351 patients).

RESULTS

In type 1 diabetes, there was an increasing linear trend in HbA1c across deprivation levels (P<0.01). In type 1 diabetes, obesity in women (P<0.01) and increased non-fasting triglyceride levels in both men and women were associated with deprivation (P<0.05). In type 2 diabetes, there was a significant prevalence trend with deprivation for women (P<0.01) but not with glycaemic control (P=0.12). Smoking, ischaemic heart disease and neuropathy (P<0.01) were all associated with increasing deprivation with gender differences. In type 2 diabetes, reduced HDL cholesterol (P<0.01 both genders), and percentage of people on lipid lowering therapy (men P<0.05; women P<0.01) were associated with deprivation. Smoking, ischaemic heart disease, peripheral vascular disease and neuropathy plus foot ulcers (P<0.05) were all associated with increasing deprivation with gender differences.

CONCLUSIONS

Socioeconomic status and gender are associated with changes in glycaemic control and cardiovascular risk factors plus complication development in both type 1 and 2 diabetes. The mechanisms are unclear but follow-up of these patients should allow greater understanding.

Is Clostridium difficile associated with the '4C' antibiotics? A retrospective observational study in diabetic foot ulcer patients

AIMS

Clostridium difficile is an anaerobic cytotoxin-producing bacterium that can cause infectious diarrhoea, pseudomembranous colitis and toxic megacolon. The major risk factors for developing C. difficile infection include recent or current antimicrobial use, diabetes, age over 65, proton pump inhibitor use, immunosuppression and previous infection with C. difficile. Most diabetic foot ulcers are polymicrobial.

METHODS

As a result guidelines advise treatment with broad spectrum antibiotics which include the '4C's' (clindamycin, cephalosporins, co-amoxiclav and ciprofloxacin) which are associated with a higher risk of C. difficile infection. Retrospective observational data (June 2008 to January 2012) for the diabetes foot ulcers were gathered from the Diabetes/Podiatry Clinic database in NHS Ayrshire and Arran and cross-matched with the NHS Ayrshire and Arran Microbiology database. There were 111 patients with mean age 59 years (range 24-94 years), 33 type 1 patients, 78 type 2 patients, mean duration of diabetes 16 years (6 months-37 years) and mean HbA1c 67 mmol/mol (54-108 mmol/mol) [8.3% (7.1-12%)].

RESULTS

The total number of days antimicrobials prescribed for all patients was 7938 (mean number of antimicrobial days per patient = 71.5 days). There was one case of C. difficile infection of 111 patients giving an incidence of 1.25 cases per 10,000 patient-days of antibiotics/1 case per 209 foot ulcers.

CONCLUSIONS

Large doses, numbers and greater duration of antibiotic therapy all result in a greater degree of normal gut flora depletion. It is possible that the alterations in gut flora in diabetic foot ulcer patients protect them from antibiotic-induced C. difficile overgrowth.

Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries

OBJECTIVE

To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

METHODS

Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

RESULTS

In total, 379,865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/μL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/μL (76% increase), 88 to 135 cells/μL (53%), and 209 to 274 cells/μL (31%). In 2009, compared with LIC, median counts were 13 cells/μL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/μL (-62 to +18) lower in UMIC, and 112 cells/μL (+75 to +149) higher in HIC. They were 23 cells/μL (95% CI: +18 to +28 cells/μL) higher in women than men. Median counts were 88 cells/μL (95% CI: +35 to +141 cells/μL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

CONCLUSIONS

Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/μL in LIC and MIC and below 300 cells/μL in HIC. Earlier start of cART will require substantial efforts and resources globally.

Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology

BACKGROUND

Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delirium when caring for people with cancer, the elderly or older people requiring psychiatric care in the inpatient setting.

METHODS

Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses' views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective.

RESULTS

A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others.

DISCUSSION

Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.

Missing data on the estimation of the prevalence of accumulated human immunodeficiency virus drug resistance in patients treated with antiretroviral drugs in north america

Determination of the prevalence of accumulated antiretroviral drug resistance among persons infected with human immunodeficiency virus (HIV) is complicated by the lack of routine measurement in clinical care. By using data from 8 clinic-based cohorts from the North American AIDS Cohort Collaboration on Research and Design, drug-resistance mutations from those with genotype tests were determined and scored using the Genotypic Resistance Interpretation Algorithm developed at Stanford University. For each year from 2000 through 2005, the prevalence was calculated using data from the tested subset, assumptions that incorporated clinical knowledge, and multiple imputation methods to yield a complete data set. A total of 9,289 patients contributed data to the analysis; 3,959 had at least 1 viral load above 1,000 copies/mL, of whom 2,962 (75%) had undergone at least 1 genotype test. Using these methods, the authors estimated that the prevalence of accumulated resistance to 2 or more antiretroviral drug classes had increased from 14% in 2000 to 17% in 2005 (P < 0.001). In contrast, the prevalence of resistance in the tested subset declined from 57% to 36% for 2 or more classes. The authors' use of clinical knowledge and multiple imputation methods revealed trends in HIV drug resistance among patients in care that were markedly different from those observed using only data from patients who had undergone genotype tests.

Normative data and validation of a regression based summary score for assessing meaningful neuropsychological change

Reliable detection and quantification of longitudinal cognitive change are of considerable importance in many neurological disorders, particularly to monitor central nervous system effects of disease progression and treatment. In the current study, we developed normative data for repeated neuropsychological (NP) assessments (6 testings) using a modified standard regression-based (SRB) approach in a sample that includes both HIV-uninfected (HIV-, N = 172) and neuromedically stable HIV-infected (HIV+, N = 124) individuals. Prior analyses indicated no differences in NP change between the infected and uninfected participants. The norms for change included correction for factors found to significantly affect follow-up performance, using hierarchical regression. The most robust and consistent predictors of follow-up performance were the prior performance on the same test (which contributed in all models) and a measure of prior overall NP competence (predictor in 97% of all models). Demographic variables were predictors in 10-46% of all models and in small amounts; while test-retest interval contributed in only 6% of all models. Based on the regression equations, standardized change scores (z scores) were computed for each test measure at each interval; these z scores were then averaged to create a total battery change score. An independent sample of HIV- participants who had completed 8 of the 15 tests was used to validate an abridged summary change score. The normative data are available in an electronic format by e-mail request to the first author. Correction for practice effects based on normative data improved the consistency of NP impairment classification in a clinically stable longitudinal cohort after baseline.

Continued high prevalence and adverse clinical impact of human immunodeficiency virus-associated sensory neuropathy in the era of combination antiretroviral therapy: the CHARTER Study

OBJECTIVE

To provide updated estimates of the prevalence and clinical impact of human immunodeficiency virus-associated sensory neuropathy (HIV-SN) and neuropathic pain due to HIV-SN in the combination antiretroviral therapy (CART) era.

DESIGN

Prospective, cross-sectional analysis. Clinical correlates for HIV-SN and neuropathic pain, including age, exposure to CART, CD4 levels, plasma viral load, hepatitis C virus infection, and alcohol use disorders, were evaluated in univariate and multivariate models.

SETTING

Six US academic medical centers.

PATIENTS

One thousand five hundred thirty-nine HIV-infected individuals enrolled in the CNS (Central Nervous System) HIV Anti-Retroviral Therapy Effects Research study.

MAIN OUTCOME MEASURES

The presence of HIV-SN, defined by 1 or more clinical signs (diminished vibration or sharp sensation in the legs and feet; reduced ankle reflexes) in a distal, symmetrical pattern. Neuropathic pain was defined as aching, stabbing, or burning in a similar distribution. The effect on quality of life was assessed with the Medical Outcomes Study HIV Health Survey.

RESULTS

We found HIV-SN in 881 participants. Of these, 38.0% reported neuropathic pain. Neuropathic pain was significantly associated with disability in daily activities, unemployment, and reduced quality of life. Risk factors for HIV-SN after adjustment were advancing age (odds ratio, 2.1 [95% confidence interval, 1.8-2.5] per 10 years), lower CD4 nadir (1.2 [1.1-1.2] per 100-cell decrease), current CART use (1.6 [1.3-2.8]), and past "D-drug" use (specific dideoxynucleoside analogue antiretrovirals) (2.0 [1.3-2.6]). Risk factors for neuropathic pain were past D-drug use and higher CD4 nadir.

CONCLUSIONS

Neuropathic pain and HIV-SN remain prevalent, causing substantial disability and reduced quality of life even with successful CART. The clinical correlates of HIV-SN have changed with the evolution of treatment. These findings argue for redoubled efforts to determine HIV-SN pathogenesis and the development of symptomatic and neuroregenerative therapies.

HIV testing in dementia: clinical, ethical and patient safety implications

This article presents patient safety issues along with the professional and ethical challenges in relation to UK guidelines on HIV testing in patients who are incapacitated as a result of dementia. Current protocols are designed to protect the patient, but may have undesirable consequences for patients, carers and doctors.

Cochrane Skin Group systematic reviews are more methodologically rigorous than other systematic reviews in dermatology

BACKGROUND

The Cochrane collaboration aims to produce high-quality systematic reviews. It is not known whether the methods used in producing Cochrane Skin Group (CSG) reviews result in higher quality reviews than other systematic reviews in dermatology.

OBJECTIVES

To determine how the methodological quality of dermatological CSG reviews published in The Cochrane Library and in peer-reviewed journals compare with non-Cochrane systematic reviews.

METHODS

Two blinded investigators independently assessed review quality using the 10-item Oxman and Guyatt scale.

RESULTS

Thirty-eight systematic reviews (17 Cochrane reviews published in The Cochrane Library, 11 Cochrane reviews published in peer-reviewed journals and 10 non-Cochrane reviews published in peer-reviewed journals) were examined. The Cochrane Library reviews included quality of life (11/17 vs. 1/10, P = 0.014) and adverse outcomes (14/17 vs. 2/10, P = 0.003) more often than non-Cochrane reviews published in peer-reviewed journals. Cochrane reviews published in both peer-reviewed journals and The Cochrane Library were more likely to include comprehensive search strategies (11/11 and 17/17 vs. 6/10, P-values = 0.04 and 0.01), take steps to minimize selection bias (11/11 and 16/17 vs. 3/10, P-values = 0.003 and 0.001) and appropriately assess the validity of all included trials (10/11 and 16/17 vs. 4/10, P-values = 0.04 and 0.007) than non-Cochrane reviews. Overall, Cochrane reviews published both in peer-reviewed journals and in The Cochrane Library were assigned higher quality scores by reviewers than non-Cochrane reviews (median = 6.0 and 6.5 vs. 4.5, P-values = 0.01 and 0.002).

CONCLUSIONS

The Cochrane Library systematic review methodology leads to higher quality reviews on dermatological topics.

A Multicenter Observational Study of the Potential Benefits of Initiating Combination Antiretroviral Therapy during Acute HIV Infection

OBJECTIVE

Uncontrolled studies have suggested a benefit, after treatment discontinuation, of initiating highly active antiretroviral therapy (HAART) during primary human immunodeficiency virus (HIV) infection. We assessed whether initiation of HAART within 2 weeks of (acute treatment) or between 2 weeks and 6 months after (early treatment) HIV seroconversion was associated with improvements in the viral load and the CD4+ T cell count after discontinuation of treatment in an observational cohort.

METHODS

Subjects from the multicenter Acute Infection and Early Disease Research Program cohort were enrolled in the present study within 6 months of HIV seroconversion and self-selected whether to initiate HAART. Subjects who received acute (n=13) or early (n=45) treatment received HAART for at least 12 weeks and then subsequently stopped treatment, whereas untreated subjects (n=337) declined treatment. HIV RNA levels and CD4+ T cell counts at 24, 48, and 72 weeks after treatment cessation in the 2 treatment groups were compared with those noted in the untreated group during the same periods of observation after enrollment.

RESULTS

The acute treatment group had lower mean HIV RNA levels at 24 weeks without therapy (-0.48 log(10) copies/mL [95% confidence interval {CI}, -0.82 to -0.13 log(10) copies/mL]) and higher mean CD4+ T cell counts (112 cells/ mu L [95% CI, 20-205 cells/ microL]), compared with the untreated group at 24 weeks. The differences in the laboratory values for the acute treatment group versus the untreated group at 72 weeks without therapy were as follows: for the HIV RNA level, -0.35 log(10) copies/mL (95% CI, -0.91 to 0.21 log(10) copies/mL) and, for the CD4 T+ cell count, 112 cells/ microL (95% CI, -15 to 213 cells/ microL). The early treatment group had lower HIV RNA levels at 24 weeks than did the untreated group, but differences were no longer apparent by week 48; CD4+ T cell counts were higher in the early treatment group at week 24 (116 cells/ microL [95% CI, 75-157 cells/ microL]) and week 72 (70 cells/ microL [95% CI, 2-138 cells/ microL]).

CONCLUSIONS

Initiation of HAART within 2 weeks of antibody seroconversion was associated with viral load and CD4+ T cell count benefits for 24 weeks after termination of HAART, with there being trends toward a longer-term benefit. Later initiation of HAART was associated with a persistent but decreasing CD4+ T cell count benefit and a loss of the viral load benefit by week 72 after discontinuation of treatment.

Psychological functioning in African American women at an increased risk of hereditary breast and ovarian cancer

Despite attention to psychological issues during genetic counselling and testing for hereditary breast and ovarian cancer risk, limited information is available on cancer-specific distress among African American women being targeted for participation in counselling and testing. Therefore, the purpose of this study is to examine cancer-specific distress in African American women at an increased risk of hereditary breast and ovarian cancer and to identify factors having significant associations with distress in this population. Respondents were 141 African American women identified for participation in genetic counselling and testing for BRCA1/2 mutations. Overall, respondents reported moderate levels of cancer-specific distress. Younger age (coefficient=6.0, p=0.001), being unemployed (coefficient=-5.0, p=0.01), and having a personal history of cancer (coefficient=5.0, p=0.02) had significant associations with intrusion. Younger age was also associated significantly with greater avoidance (r=6.0, p=0.02). These results suggest that African American women aged 50 and younger, those who are unemployed and women with a personal history of breast or ovarian cancer may be the most vulnerable to experiencing elevated levels of distress during genetic counselling and testing. Greater attention to psychological issues, including concerns about cancer and cancer risks, may be needed during genetic counselling and testing for BRCA1/2 mutations with these women.

Accuracy, precision, and consistency of expert HIV type 1 genotype interpretation: an international comparison (The GUESS Study)

BACKGROUND

Resistance testing is considered standard of care in HIV medicine, but there is no standard interpretation system for genotype tests. We sought to determine how much agreement exists within a group of experts in the interpretation of complex genotypes.

METHODS

Genotypes from clinical specimens were sent to an international panel of 12 resistance experts. Phenotypic susceptibility testing of these clinical isolates was performed with antivirogram. Experts predicted phenotype fold change category (<2.5-fold change, 2.5-4.0-fold change, >4.0- to 7.0-fold change, >7.0- to 10-fold change, >10- to 20-fold change, or >20-fold change) and predicted expected drug activity for each of 16 antiretroviral drugs. Experts were also asked to make treatment recommendations on the basis of the genotype.

RESULTS

The experts predicted the exact phenotype fold change category correctly 44% of the time, but they varied widely by antiretroviral drug (range, 25%-74%). The highest accuracy was observed for lamivudine (74%) and the nonnucleoside reverse transcriptase inhibitors (66%-69%). Experts generally predicted higher levels of resistance to the remaining nucleoside reverse transcriptase inhibitors than what was found by phenotypic testing. Agreement among experts in predicting phenotype fold change category ranged widely depending on the drug (median agreement, 42% [range, 28%-74%]); the same pattern was observed in predicting expected drug activity (median agreement, 45% [range, 32%-87%]). Experts agreed on treatment recommendations in a median of 79% of instances, and recommendations were consistent over time, with blinded retesting.

CONCLUSIONS

Although their ability to predict phenotype from a genotype varied for individual antiretroviral drugs, this expert panel had a high degree of agreement in deriving treatment recommendations from the genotype.

Effect of adjunct hydroxyurea on helper T cell immunity in HIV type 1-infected patients with virological suppression

Hydroxyurea (HU) has preferential activity in virus reservoirs not effectively targeted by current antiretroviral drug regimens, but concern for potential toxicity has precluded its routine use. The effect of adjunct HU on T cell proliferative responses and phenotypic markers was examined in a randomized study of 39 chronically HIV-1-infected patients with virological suppression on potent antiretroviral therapy. While patients in the HU arm showed modest declines in the median CD4(+) T cell counts (total, -151 cells/mm(3); naive, -91 cells/mm(3)), no significant differences were noted in the Candida, HIV-1 p24, and HIV-1 gp160 responses between the treatment arms following 24 weeks of therapy. In conclusion, although adjunct HU was associated with modest declines in the CD4(+) T cell counts, there was no significant adverse effect on helper T cell function. Further trials to address the role of HU in HIV-1 treatment may be appropriate after careful selection of HU dose and the adjunct drugs to avoid nonhematological toxicity.

Pharmacokinetics of indinavir and nelfinavir in treatment-naive, human immunodeficiency virus-infected subjects

AIDS Clinical Trials Group protocol 388 was designed to compare a three-drug regimen (indinavir with dual nucleosides) to a four-drug regimen (indinavir plus nelfinavir or indinavir plus efavirenz with dual nucleosides). Blood samples from patients taking indinavir and nelfinavir were collected over 8 to 12 h following a specified dose and were analyzed with high-performance liquid chromatography. Pharmacokinetic data were derived by using noncompartmental analysis. Following administration of indinavir every 8 h in the absence of nelfinavir (n = 8), the median predose indinavir concentration (C(0)) was 369 ng/ml (range, <10 to 949 ng/ml; one subject had a concentration of <10 ng/ml), and the concentration 8 h after administration of the study dose was 159 ng/ml (range, 85 to 506 ng/ml). In the group receiving 1000 mg of indinavir every 12 h with nelfinavir (n = 10), the median indinavir C(0) was <10 ng/ml (range, <10 to 3740 ng/ml; six subjects had a value of <10 ng/ml), and the C(12 h) was 44 ng/ml (range, <10 to 4236 ng/ml; five subjects had a value of <10 ng/ml), while the subjects who received 1200 mg of indinavir every 12 h with nelfinavir (n = 7) had a C(0) of 146 ng/ml (range, 58 to 5215 ng/ml) and a C(12 h) of 95 ng/ml (range, 12 to 954 ng/ml). Indinavir clearance was significantly lower in the presence of nelfinavir (median [interquartile range], 34.1 liters/h [range, 22.6 to 45.8 liters/h] versus 47.9 liters/h [range, 42.7 to 70.3 liters/h]; P < 0.017). For subjects receiving 1,000 mg of indinavir every 12 h, the median C(0) value for nelfinavir (n = 9) was 1,779 ng/ml (range, <187.5 to 4579 ng/ml), and the C(12 h) was 1554 ng/ml (range, <187.5 to 5,540 ng/ml). Due to the unacceptable number of undetectable indinavir trough concentrations, 1200 mg of indinavir appears to be the preferred dose in a twice-daily regimen that includes nelfinavir.

Treatment of Primary HIV

Primary HIV-1 infection refers to the events surrounding the acquisition of HIV-1 infection. It is commonly associated with a nonspecific clinical syndrome that occurs within 2 to 4 weeks after exposure in 40% to 90% of persons acquiring HIV-1. Patients identified prior to seroconversion often have plasma titers in excess of 500,000 copies/mL. Over time, plasma HIV-1 RNA titers decrease and eventually reach a "set point." Treatment of primary HIV-1 infection with highly active antiretroviral therapy does not prevent establishment of chronic infection. However, it potentially may decrease the viral set point, prevent evolution of resistant mutants, preserve immune function, improve clinical outcome, and possibly allow for viral control after withdrawal of antiretroviral therapy. Transmission of viral strains with decreased susceptibility to antiviral drugs increases the difficulty of choosing an antiretroviral regimen. Other medications, including immunomodulators, are under study as adjuvant therapy for treatment of primary HIV-1 infection.

Hydroxyurea does not enhance the anti-HIV activity of low-dose tenofovir disoproxil fumarate

Tenofovir disoproxil fumarate (DF) is an adenosine analogue with significant activity against HIV-1. Hydroxyurea decreases the intracellular concentrations of deoxyadenosine triphosphate, the active metabolite of adenosine. We therefore tested the hypothesis that hydroxyurea could enhance the anti-HIV activity of low-dose tenofovir in vivo. Eight patients received tenofovir DF, 75 mg, plus hydroxyurea, 500 mg bid, for 28 days. Changes in plasma HIV RNA levels were compared with a previously studied cohort of patients treated with tenofovir DF, 75 mg once daily ( n = 8), or tenofovir placebo ( n = 12). The median change in HIV RNA levels after 28 days of continuous treatment was -0.01 log(10) copies/ml for tenofovir placebo, -0.33 log(10) copies/ml for tenofovir 75 mg once daily, and -0.22 log(10) copies RNA/ml for tenofovir plus hydroxyurea. The difference between placebo and tenofovir-treated groups was significant ( p <.05); however, the difference between the tenofovir and tenofovir plus hydroxyurea groups was not significant ( p =.90). We conclude that hydroxyurea does not significantly enhance the antiviral activity of low-dose tenofovir.