Hepatic steatosis and nonalcoholic fatty liver disease are common and associated with cardiometabolic risk in a primary prevention cohort of people with HIV

BACKGROUND

Hepatic steatosis, including nonalcoholic fatty liver disease (NAFLD), is common among people with HIV (PWH). We present baseline steatosis prevalence and cardiometabolic characteristics among REPRIEVE substudy participants.

METHODS

REPRIEVE is an international, primary cardiovascular disease prevention, randomized, controlled trial of pitavastatin calcium vs. placebo among 7769 PWH ages 40-75 years on antiretroviral therapy (ART) and with low-to-moderate cardiovascular risk. A subset of participants underwent noncontrast computed tomography, with hepatic steatosis defined as mean hepatic attenuation less than 40 HU or liver/spleen ratio less than 1.0, and NAFLD defined as steatosis in the absence of frequent alcohol use or viral hepatitis.

RESULTS

Of 687 evaluable persons, median age was 51 years, BMI 27 kg/m 2 , CD4 + T-cell count 607 cells/μl; 17% natal female sex, 36% Black, 24% Hispanic, and 98% HIV-1 RNA less than 400 copies/ml. Hepatic steatosis prevalence was 22% (149/687), and NAFLD 21% (96/466). Steatosis/NAFLD prevalence was higher in men and with older age, non-Black race, and higher BMI and waist circumference. Both were associated with BMI greater than 30 kg/m 2 , metabolic syndrome components, higher atherosclerotic cardiovascular disease (ASCVD) risk score, HOMA-IR, LpPLA-2 and hs-CRP, and lower high-density lipoprotein cholesterol. Of HIV-specific/ART-specific characteristics, only history of an AIDS-defining illness was more common among persons with steatosis/NAFLD. After adjusting for age, sex and race/ethnicity, BMI greater than 30 kg/m 2 , HOMA-IR greater than 2.0, Metabolic syndrome and each of its components were associated with NAFLD prevalence.

CONCLUSION

In this cohort with controlled HIV and low-to-moderate cardiovascular risk, hepatic steatosis and NAFLD were common and associated with clinically relevant metabolic and inflammatory disturbances but not current HIV-related or ART-related factors.

Plasma extracellular vesicles and cell-free mitochondrial DNA are associated with cognitive dysfunction in treated older adults with HIV

Extracellular vesicles (EVs) are nanoparticles with a role in intercellular communication. Cell-free mitochondrial DNA (cf-mtDNA) has been associated with cognitive dysfunction in people with HIV (PWH). We conducted a nested case-control study to test the hypothesis that plasma EVs are associated with cf-mtDNA and cognitive dysfunction in older PWH. A machine learning-based model identified total EVs, including select EV subpopulations, as well as urine cf-mtDNA and 4-meter walk time carry power to predict the neurocognitive impairment. These features resulted in an AUC-ROC of 0.845 + / - 0.109 (0.615, 1.00).

Longitudinal antibody response kinetics following SARS-CoV-2 messenger RNA vaccination in pregnant and nonpregnant persons

BACKGROUND

For some vaccine-preventable diseases, the immunologic response to vaccination is altered by a pregnant state. The effect of pregnancy on SARS-CoV-2 vaccine response remains unclear.

OBJECTIVE

We sought to characterize the peak and longitudinal anti-S immunoglobulin G, immunoglobulin M, and immunoglobulin A responses to messenger RNA-based SARS-CoV-2 vaccination in pregnant persons and compare them with those in nonpregnant, reproductive-aged persons.

STUDY DESIGN

We conducted 2 parallel prospective cohort studies among pregnant and nonpregnant persons who received SARS-CoV-2 messenger RNA vaccinations. Blood was collected at the time of first and second vaccine doses, 2 weeks post second dosage, and with serial longitudinal follow-up up to 41.7 weeks post vaccination initiation. Anti-S immunoglobulin M, immunoglobulin G, and immunoglobulin A were analyzed by enzyme-linked immunosorbent assay. We excluded those with previous evidence of SARS-CoV-2 infection by history or presence of antinucleocapsid antibodies. In addition, for this study, we did not include individuals who received a third or booster vaccine dosage during the study period. We also excluded pregnant persons who were not fully vaccinated (14 days post receipt of the second vaccine dosage) by time of delivery and nonpregnant persons who became pregnant through the course of the study. We studied the effect of gestational age at vaccination on the anti-S response using Spearman correlation. We compared the peak anti-S antibody responses between pregnant and nonpregnant persons using a Mann-Whitney U test. We visualized and studied the longitudinal anti-S antibody response using locally weighted scatterplot smoothing, Mann-Whitney U test, and mixed analysis of variance test.

RESULTS

Data from 53 pregnant and 21 nonpregnant persons were included in this analysis. The median (interquartile range) age of the pregnant and nonpregnant participants was 35.0 (33.3-37.8) years and 36.0 (33.0-41.0) years, respectively. Six (11.3%) participants initiated vaccination in the first trimester, 23 (43.3%) in the second trimester, and 24 (45.3%) in the third trimester, with a median gestational age at delivery of 39.6 (39.0-40.0) weeks. The median (interquartile range) follow-up time from vaccine initiation to the last blood sample collected was 25.9 (11.9) weeks and 28.9 (12.9) weeks in the pregnant and nonpregnant cohort, respectively. Among pregnant persons, anti-S immunoglobulin G, immunoglobulin A, and immunoglobulin M responses were not associated with gestational age at vaccine initiation (all P>.05). The anti-S immunoglobulin G response at 2 weeks post second dosage was not statistically different between pregnant and nonpregnant persons (P>.05). However, the anti-S immunoglobulin M and immunoglobulin A responses at 2 weeks post second dosage were significantly higher in nonpregnant persons (P<.001 for both). The anti-S immunoglobulin G and immunoglobulin M levels 6 to 8 months after vaccine initiation fell to comparable proportions of the peak 2 weeks post second dosage antibody levels between pregnant and nonpregnant persons (immunoglobulin G P=.77; immunoglobulin M P=.51). In contrast, immunoglobulin A levels 6 to 8 months after vaccine initiation fell to statistically significantly higher proportions of peak 2 weeks post second dosage antibody levels in pregnant compared with nonpregnant persons (P=.002). Maternal anti-S immunoglobulin G levels were strongly correlated with umbilical cord anti-S immunoglobulin G levels (R=0.8, P<.001).

CONCLUSION

The anti-S immunoglobulin A, immunoglobulin M, and immunoglobulin G response to SARS-CoV-2 vaccination in pregnancy is independent of gestational age of vaccine initiation. Maintenance of the immunoglobulin G response is comparable between pregnant and nonpregnant persons. The differential peak response of immunoglobulin M and immunoglobulin A and the differential decline of anti-S immunoglobulin A between pregnant and nonpregnant persons requires further investigation.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV

OBJECTIVE

People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH.

METHODS

We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models.

RESULTS

PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes.

CONCLUSIONS

Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

SARS CoV-2 mRNA vaccination exposes latent HIV to Nef-specific CD8+ T-cells

Efforts to cure HIV have focused on reactivating latent proviruses to enable elimination by CD8+ cytotoxic T-cells. Clinical studies of latency reversing agents (LRA) in antiretroviral therapy (ART)-treated individuals have shown increases in HIV transcription, but without reductions in virologic measures, or evidence that HIV-specific CD8+ T-cells were productively engaged. Here, we show that the SARS-CoV-2 mRNA vaccine BNT162b2 activates the RIG-I/TLR - TNF - NFκb axis, resulting in transcription of HIV proviruses with minimal perturbations of T-cell activation and host transcription. T-cells specific for the early gene-product HIV-Nef uniquely increased in frequency and acquired effector function (granzyme-B) in ART-treated individuals following SARS-CoV-2 mRNA vaccination. These parameters of CD8+ T-cell induction correlated with significant decreases in cell-associated HIV mRNA, suggesting killing or suppression of cells transcribing HIV. Thus, we report the observation of an intervention-induced reduction in a measure of HIV persistence, accompanied by precise immune correlates, in ART-suppressed individuals. However, we did not observe significant depletions of intact proviruses, underscoring challenges to achieving (or measuring) HIV reservoir reductions. Overall, our results support prioritizing the measurement of granzyme-B-producing Nef-specific responses in latency reversal studies and add impetus to developing HIV-targeted mRNA therapeutic vaccines that leverage built-in LRA activity.

Plasma Cell-Free Mitochondrial DNA as a Marker of Geriatric Syndromes in Older Adults With HIV

BACKGROUND

Older people with HIV experience more comorbidities and geriatric syndromes than their HIV-negative peers, perhaps due to residual inflammation despite suppressive antiretroviral therapy. Cell-free mitochondrial DNA (cfmtDNA) released during necrosis-mediated cell death potentially acts as both mediator and marker of inflammatory dysregulation. Thus, we evaluated plasma cfmtDNA as a potential biomarker of geriatric syndromes.

METHODS

Participants underwent the Montreal Cognitive Assessment (MoCA), frailty testing, and measurement of plasma cfmtDNA by qPCR and inflammatory markers including C-reactive protein, interleukin-6 (IL-6), interferon gamma, and tumor necrosis factor alpha in this cross-sectional study.

RESULTS

Across 155 participants, the median age was 60 years (Q1, Q3: 56, 64), one-third were female, and 92% had HIV-1 viral load <200 copies/mL. The median MoCA score was 24 (21, 27). The plasma cfmtDNA level was higher in those with cognitive impairment (MoCA <23) ( P = 0.02 by the t test) and remained significantly associated with cognitive impairment in a multivariable logistic regression model controlling for age, sex, race, CD4 T-cell nadir, HIV-1 viremia, and depression. Two-thirds of participants met the criteria for a prefrail or frail state; higher plasma cfmtDNA was associated with slow walk and exhaustion but not overall frailty state. Cognitive dysfunction was not associated with C-reactive protein, IL-6, interferon gamma, or tumor necrosis factor alpha, and frailty state was only associated with IL-6.

CONCLUSIONS

Plasma cfmtDNA may have a role as a novel biomarker of cognitive dysfunction and key components of frailty. Longitudinal investigation of cfmtDNA is warranted to assess its utility as a biomarker of geriatric syndromes in older people with HIV.

Tracking NSZD mass removal rates over decades: Site-wide and local scale assessment of mass removal at a legacy petroleum site

Long-term estimates of natural source zone depletion (NSZD) rates for petroleum LNAPL (light non-aqueous phase liquid) sites are not available. One-off measurements are often thought valid over the lifetime of LNAPL sites. In the context of site-wide LNAPL mass estimates, we report site-specific gasoline and diesel NSZD rates spanning 21-26 years. Using depth profiles of soil gases (oxygen, carbon dioxide, methane, volatiles) above LNAPL, NSZD rates were estimated in 1994, 2006 and 2020 for diesel and 1999, 2009 and 2020 for gasoline. Each date also had soil-core mass estimates, which together with NSZD rates allow estimation of the longevity for LNAPL presence. Site-wide coring (in 1992, 2002, 2007) estimated LNAPL mass reductions of 12,000 t. For diesel NSZD, the ratio of NSZD rates for 2006 (16,000-49,000 L/ha/y) to those in 2020 (2600-14,000 L/ha/y) was ~3-6. By 2020, the 1994 diesel NSZD rates would have predicted the entire removal of measured mass (16-42 kg/m²). For gasoline, NSZD rates in 1999 were extremely high (50,000-270,000 L/ha/y) but 9-27 times lower (5800-10,000 L/ha/y) a decade later. The gasoline NSZD rates in 1999 predicted near complete mass removal in 2-12 years, but 10-11 kg/m² was measured 10 and 21 years later which is 26% of the initial mass in 1999. The outcomes substantiate the need to understand NSZD rate changes over the lifetime of LNAPL-impacted sites.

Links Between Inflammation, Mood, and Physical Function Among Older Adults With HIV

OBJECTIVES

People living with human immunodeficiency virus (PLWH) treated with antiretrovirals have life spans similar to their HIV-negative peers. Yet, they experience elevated inflammation-related multimorbidity. Drawing on biopsychosocial determinants of health may inform interventions, but these links are understudied in older PLWH. We investigated cross-sectional relationships between psychosocial factors (mood, loneliness, and stigma), inflammatory markers, and age-related health outcomes among 143 PLWH aged 54-78 years.

METHOD

Participants provided blood samples for serum cytokine and C-reactive protein (CRP) analyses, completed surveys assessing psychosocial factors and health, and completed frailty assessments. Regression models tested relationships between key psychosocial-, inflammation, and age-related health variables, adjusting for relevant sociodemographic and clinical factors.

RESULTS

Participants with more depressive symptoms had higher composite cytokine levels than those with fewer depressive symptoms (β = 0.22, t(126) = 2.71, p = .008). Those with higher cytokine levels were more likely to be prefrail or frail (adjusted odds ratio = 1.72, 95% confidence interval = 1.01-2.93) and reported worse physical function (β = -0.23, t(129) = -2.64, p = .009) and more cognitive complaints (β = -0.20, t(129) = -2.16, p = .03) than those with lower cytokine levels. CRP was not significantly related to these outcomes; 6-month fall history was not significantly related to inflammatory markers.

DISCUSSION

Novel approaches are needed to manage comorbidities and maximize quality of life among older PLWH. Illustrating key expected biopsychosocial links, our findings highlight several factors (e.g., depressive symptoms, poorer physical function) that may share bidirectional relationships with chronic inflammation, a key factor driving morbidity. These links may be leveraged to modify factors that drive excessive health risk among older PLWH.

Urine Cell-Free Mitochondrial DNA as a Marker of Weight Loss and Body Composition in Older Adults With HIV

BACKGROUND

Older adults with HIV (OAH) experience more comorbidities and geriatric syndromes than their HIV-negative peers, perhaps because of chronic inflammation. Cell-free mitochondrial DNA (cfmtDNA) released from cells undergoing necrosis-mediated cell death potentially acts as both a mediator and marker of inflammatory dysregulation. We hypothesized that urinary cfmtDNA would be associated with frailty, body composition, and fall history in OAH.

METHODS

OAH completed frailty testing, a psychosocial survey, body composition assessment, and measurement of urine cfmtDNA and urine albumin:creatinine in this cross-sectional study. Urine cfmtDNA was measured by quantative polymerase chain reaction and normalized to urinary creatinine.

RESULTS

Across 150 participants, the mean age was 61 years (SD 6 years), half identified as Black, one-third were women, and 93% had HIV-1 viral load <200 copies/mL. Two-thirds met criteria for a prefrail or frail state. Those with unintentional weight loss had higher urine cfmtDNA concentrations (P = 0.03). Higher urine cfmtDNA was inversely associated with the skeletal muscle index (β = -0.19, P < 0.01) and fat mass index (β = -0.08, P = 0.02) in separate multiple linear regression models adjusted for age, sex, and presence of moderate-severe albuminuria.

CONCLUSIONS

In this cross-sectional study of OAH, higher levels of urine cfmtDNA were more common in subjects with less robust physical condition, including unintentional weight loss and less height-scaled body mass of fat and muscle. These findings suggest urine cfmtDNA may reflect pathophysiologic aging processes in OAH, predisposing them to geriatric syndromes. Longitudinal investigation of urine cfmtDNA as a biomarker of geriatric syndromes is warranted.

Childhood sexual abuse history amplifies the link between disease burden and inflammation among older adults with HIV

As they age, people living with HIV (PLWH) experience greater rates of inflammation-related health conditions compared to their HIV-negative peers. Because early life adversity can exaggerate proinflammatory effects of later physiological challenges, inflammation may be higher among PLWH with these combined risks, which could inform intervention approaches to mitigate multimorbidity. In this cross-sectional analysis, we investigated individual and combined effects of childhood sexual abuse (CSA) history and physiological burden (Veterans Aging Cohort Study Index scores) on serum cytokine and C-reactive protein (CRP) levels among PLWH. Participants (n ​= ​131; age 54 and older) were patients at an outpatient HIV clinic who completed a psychosocial survey and biomedical research visit as part of a larger study. 93% were virally suppressed, and 40% reported experiencing sexual abuse in childhood. Composite cytokine levels (summarizing IL-6, TNF-α, IFN-γ), CRP, and disease burden did not differ significantly between those who had a history of CSA and those who did not. Participants with greater disease burden had higher composite cytokine levels (r ​= ​0.29, p ​= ​0.001). The disease burden by CSA interaction effect was a significant predictor of composite cytokine levels (but not CRP), and remained significant after controlling for age, sex, race, BMI, anti-inflammatory medication use, selective serotonin reuptake inhibitor use, depressive symptoms, and smoking status (F(1, 114) ​= ​5.68, p ​= ​0.02). In follow-up simple slopes analysis, greater disease burden was associated with higher cytokine levels among those with CSA history (b ​= ​0.03, SE ​= ​0.008, p<0.001), but not among those without CSA history. Further, in the context of greater disease burden, individuals with a CSA history tended to have higher cytokine levels than those without a CSA history (b ​= ​0.38, SE ​= ​0.21, p ​= ​0.07). These data suggest that the physiological sequelae of childhood trauma may persist into older age among those with HIV. Specifically, links between physiological burden and inflammation were stronger among survivors of CSA in this study. The combined presence of CSA history and higher disease burden may signal a greater need for and potential benefit from interventions to reduce inflammation, an area for future work.

Factors associated with attitudes towards HIV cure research among transgender women and travestis: a cross-sectional survey in São Paulo, Brazil

OBJECTIVE

Characterising the perceptions of groups most affected by HIV is fundamental in establishing guidelines for biomedical advancement. Although Brazil has successfully fought HIV/AIDS through several measures, transgender women still have a likelihood of HIV infection 55 times higher than the general population. This study aimed to better understand the perception and awareness of HIV cure research among the trans-identifying population in São Paulo, Brazil, and to determine factors that motivate or discourage participation in HIV cure studies.

SETTING

This cross-sectional study analysed data collected from a questionnaire administered to 118 transgender women and travestis at 5 sites within the city of São Paulo. It uses quantitative methodology to describe the perspectives of transgender and travesti people in relation to HIV cure research and the context in which such perspectives are produced.

RESULTS

Of 118 participants, most participants (73%) had some knowledge of HIV cure research and were most willing to participate in online surveys (52%), interviews (52%), focus groups (52%) and studies involving blood draws (57%). Those with a higher education or employment status were more likely to agree that someone had been cured of HIV, people living with HIV are discriminated against, and more information about HIV cure research is needed before the community embraces it. Only 55% of participants completely trusted their physician. The biggest motivational factors included gaining additional knowledge about HIV infection (77%) and the potential for a longer, healthier life for all (73%).

CONCLUSIONS

As a primary analysis of HIV cure attitudes among the transgender and travesti population as well as the social context in which they are formed, this study identifies opportunities to strengthen the dialogue and develop more educational collaborations between scientific investigators, community educators and the trans-identifying population to ensure that HIV cure research is inclusive of diverse perspectives.

COVID-19 in Hospitalized Adults With HIV

BACKGROUND

The spread of SARS-CoV-2 and the COVID-19 pandemic have caused significant morbidity and mortality worldwide. The clinical characteristics and outcomes of hospitalized patients with SARS-CoV-2 and HIV co-infection remain uncertain.

METHODS

We conducted a matched retrospective cohort study of adults hospitalized with a COVID-19 illness in New York City between March 3, 2020, and May 15, 2020. We matched 30 people with HIV (PWH) with 90 control group patients without HIV based on age, sex, and race/ethnicity. Using electronic health record data, we compared demographic characteristics, clinical characteristics, and clinical outcomes between PWH and control patients.

RESULTS

In our study, the median age (interquartile range) was 60.5 (56.6-70.0) years, 20% were female, 30% were black, 27% were white, and 24% were of Hispanic/Latino/ethnicity. There were no significant differences between PWH and control patients in presenting symptoms, duration of symptoms before hospitalization, laboratory markers, or radiographic findings on chest x-ray. More patients without HIV required a higher level of supplemental oxygen on presentation than PWH. There were no differences in the need for invasive mechanical ventilation during hospitalization, length of stay, or in-hospital mortality.

CONCLUSIONS

The clinical manifestations and outcomes of COVID-19 among patients with SARS-CoV-2 and HIV co-infection were not significantly different than patients without HIV co-infection. However, PWH were hospitalized with less severe hypoxemia, a finding that warrants further investigation.

Gait Speed Is Associated with Cognitive Function among Older Adults with HIV

Objectives: To determine links between objectively and subjectively measured physical function and cognitive function among HIV-positive older adults, a growing yet understudied group with elevated risk for multimorbidity. Methods: At a biomedical research visit, 162 participants completed objective tests of gait speed (4-m walk), grip strength (dynamometer), and cognitive function (Montreal Cognitive Assessment, MoCA) and reported their well-being (Medical Outcomes Study-HIV survey). Results: Those with faster gait speed had better overall cognitive function than those with slower gait speed (b = 3.98, SE = 1.30, p = .003) in an adjusted regression model controlling for age, sex, race, height, preferred language, and assistive device use. Grip strength was not significantly associated with overall cognitive function. Self-rated cognitive function was weakly related to MoCA scores (r = .26) and gait speed (r = .14) but was strongly associated with emotional well-being (r = .53). Discussion: These observed, expected connections between physical and cognitive function could inform intervention strategies to mitigate age-related declines for older adults with HIV.

Elevated cardiac risk score by Atherosclerotic Cardiovascular Disease calculation is associated with albuminuria in older people living with HIV

: Globally, the proportion of older people living with HIV (PLWH) is growing and the burden of noncommunicable diseases, including cardiac and renal disease, is increasing. There are few studies of renal disease and cardiac risk in older PLWH. This study investigates the relationship between albuminuria and cardiac risk as estimated by the Atherosclerotic Cardiovascular Disease 10-year risk calculator. We report that albuminuria is associated with a higher Atherosclerotic Cardiovascular Disease risk score in both diabetic and nondiabetic older PLWH.

White Blood Cell Counts, Lymphocyte Subsets, and Incident Diabetes Mellitus in Women Living With and Without HIV

Diabetes mellitus (DM) is associated with expansion of proinflammatory lymphocyte subsets. We investigated the relationship of total white blood cell (WBC) count and lymphocyte subsets with incident DM in the Women's Interagency HIV Study (WIHS). Higher CD4 and CD8 T cell counts, lymphocyte count, and total WBC count were associated with incident DM among both women with and without HIV, although the association of CD8 was not statistically significant among women without HIV.

Internal Medicine Resident Attitudes, Prior Education, Comfort, and Knowledge Regarding Delivering Comprehensive Primary Care to Transgender Patients

Transgender patients face a multitude of health disparities and often a lack of understanding by healthcare professionals. A survey was undertaken of internal medicine residents in a large urban academic training program to determine prior education, attitudes, comfort, and knowledge in providing care for transgender individuals in a primary care setting. Total N=67 respondents (52% of those eligible). A full 97% of residents believe transgender medical issues are relevant to their practice, but only 45% had prior education about the care of transgender patients. Less than one-third of respondents felt comfortable describing hormonal/surgical therapy options or referring to another physician to meet these patient needs. HIV, gonorrhea, and chlamydia risk was underestimated for the trans woman population. Most medical residents did not feel up to date with screening guidelines. In contrast, most residents correctly identified higher rates of depression/suicidality in transgender individuals, as well as lower adherence to human papillomavirus screening recommendations for trans men.

Effect of compositional heterogeneity on dissolution of non-ideal LNAPL mixtures

The extent of dissolution of petroleum hydrocarbon fuels into groundwater depends greatly on fuel composition. Petroleum fuels can consist of thousands of compounds creating different interactions within the non-aqueous phase liquid (NAPL), thereby affecting the relative dissolution of the components and hence a groundwater plume's composition over long periods. Laboratory experiments were conducted to study the variability in the effective solubilities and activity coefficients for common constituents of gasoline fuels (benzene, toluene, p-xylene and 1,2,4-trimethylbenzene) (BTX) in matrices with an extreme range of molar volumes and chemical affinities. Four synthetic mixtures were investigated comprising BTX with the bulk of the NAPL mixtures made up of either, ethylbenzene (an aromatic like BTX with similar molar volume); 1,3,5-trimethylbenzene (an aromatic with a greater molar volume); n-hexane (an aliphatic with a low molar volume); and n-decane (an aliphatic with a high molar volume). Equilibrium solubility values for the constituents were under-predicted by Raoult's law by up to 30% (higher experimental concentrations) for the mixture with n-hexane as a filler and over-predicted by up to 12% (lower experimental concentrations) for the aromatic mixtures with ethylbenzene and 1,3,5-trimethylbenzene as fillers. Application of PP-LFER (poly-parameter linear free energy relationship) model for non-ideal mixtures also resulted in poor correlation between experimentally measured and predicted concentrations, indicating that differences in chemical affinities can be the major cause of deviation from ideal behavior. Synthetic mixtures were compared with the dissolution behavior of fresh and naturally weathered unleaded gasoline. The presence of lighter aliphatic components in the gasoline had a profound effect on estimating effective solubility due to chemical affinity differences (estimated at 0.0055 per percentage increase in the molar proportion of aliphatic) as well as reduced molar volumes (estimated at -0.0091 in the activity coefficient per unit increase in molar volume, mL/mol). Previously measured changes in activity coefficients due to natural weathering of 0.25 compares well to 0.27 calculated here based on changes in the chemical affinity and molar volumes. The study suggests that the initial estimation of the composition of a fuel is crucial in evaluating dissolution processes due to ideal and non-ideal dissolution, and in predicting long term dissolution trends and the longevity of NAPL petroleum plume risks.

Mass discharge assessment at a brominated DNAPL site: Effects of known DNAPL source mass removal

Management and closure of contaminated sites is increasingly being proposed on the basis of mass flux of dissolved contaminants in groundwater. Better understanding of the links between source mass removal and contaminant mass fluxes in groundwater would allow greater acceptance of this metric in dealing with contaminated sites. Our objectives here were to show how measurements of the distribution of contaminant mass flux and the overall mass discharge emanating from the source under undisturbed groundwater conditions could be related to the processes and extent of source mass depletion. In addition, these estimates of mass discharge were sought in the application of agreed remediation targets set in terms of pumped groundwater quality from offsite wells. Results are reported from field studies conducted over a 5-year period at a brominated DNAPL (tetrabromoethane, TBA; and tribromoethene, TriBE) site located in suburban Perth, Western Australia. Groundwater fluxes (qw; L(3)/L(2)/T) and mass fluxes (Jc; M/L(2)/T) of dissolved brominated compounds were simultaneously estimated by deploying Passive Flux Meters (PFMs) in wells in a heterogeneous layered aquifer. PFMs were deployed in control plane (CP) wells immediately down-gradient of the source zone, before (2006) and after (2011) 69-85% of the source mass was removed, mainly by groundwater pumping from the source zone. The high-resolution (26-cm depth interval) measures of qw and Jc along the source CP allowed investigation of the DNAPL source-zone architecture and impacts of source mass removal. Comparable estimates of total mass discharge (MD; M/T) across the source zone CP reduced from 104gday(-1) to 24-31gday(-1) (70-77% reductions). Importantly, this mass discharge reduction was consistent with the estimated proportion of source mass remaining at the site (15-31%). That is, a linear relationship between mass discharge and source mass is suggested. The spatial detail of groundwater and mass flux distributions also provided further evidence of the source zone architecture and DNAPL mass depletion processes. This was especially apparent in different mass-depletion rates from distinct parts of the CP. High mass fluxes and groundwater fluxes located near the base of the aquifer dominated in terms of the dissolved mass flux in the profile, although not in terms of concentrations. Reductions observed in Jc and MD were used to better target future remedial efforts. Integration of the observations from the PFM deployments and the source mass depletion provided a basis for establishing flux-based management criteria for the site.

The use of mass depletion-mass flux reduction relationships during pumping to determine source zone mass of a reactive brominated-solvent DNAPL

Mass depletion-mass flux relationships usually applied to a groundwater plume were established at field scale for groundwater pumped from within the source zone of a dense non-aqueous phase liquid (DNAPL). These were used as part of multiple lines of evidence in establishing the DNAPL source mass and architecture. Simplified source mass-dissolved concentration models including those described by exponential, power, and error functions as well as a rational mass equation based on the equilibrium stream tube approach were fitted to data from 285 days of source zone pumping (SZP) from a single well which removed 152 kg of dissolved organics from a multi-component, reactive brominated solvent DNAPL. The total molar concentration of the source compound, tetrabromoethane and its daughter products was used as a single measure of contaminant concentration to relate to source mass. A partitioning inter-well tracer test (PITT) conducted prior to the SZP provided estimates of groundwater travel times, enabling parameterisation of the models. After accounting for capture of the down-gradient dissolved plume, all models provided a good fit to the observed data. It was shown that differentiation between models would only emerge after appreciably more pumping from the source zone. The model fits were not particularly sensitive to the exponent parameters and variance of groundwater travel time. In addition, the multi-component nature of the DNAPL did not seem to affect the utility of the models for the period examined. Estimates of the DNAPL mass prior to the start of SZP from the models were greatest where the log of the variance of travel time was used explicitly in the source depletion models (mean 295kg) compared to where the associated power exponent and variance was fitted freely (mean 258 kg). The estimates of source mass were close to that of 220kg determined from the PITT. In addition to the PITT, multi-level groundwater sampling from within the source zone provided important supporting information for developing the conceptual model of the source zone. It is concluded that SZP may be an effective and relatively simple means for characterising DNAPL source zones.

The influence of lower face vertical proportion on facial attractiveness

This study investigated the influence of changing lower face vertical proportion on the attractiveness ratings scored by lay people.Ninety-two social science students rated the attractiveness of a series of silhouettes with normal, reduced or increased lower face proportions. The random sequences of 10 images included an image with the Eastman normal lower face height relative to total face height [lower anterior face height/total anterior face height (LAFH/TAFH) of 55 per cent], and images with LAFH/TAFH increased or decreased by up to four standard deviations (SD) from the Eastman norm. All the images had a skeletal Class I antero-posterior (AP) relationship. A duplicate image in each sequence assessed repeatability. The participants scored each image using a 10 point numerical scale and also indicated whether they would seek treatment if the image was their own profile. The profile image with normal vertical facial proportions was rated by the lay people as the most attractive. Attractiveness scores reduced as the vertical facial proportions diverged from the normal value. Images with a reduced lower face proportion were rated as significantly more attractive than the corresponding images with an increased lower face proportion. Images with a reduced lower face proportion were also significantly less likely to be judged as needing treatment than the corresponding images with an increased lower face proportion.

Effectiveness of in situ air sparging for removing NAPL gasoline from a sandy aquifer near Perth, Western Australia

In situ air sparging has the potential to augment the removal of nonaqueous phase liquid (NAPL) contaminants in soil vapour extraction (SVE) systems when the NAPL is present in the capillary fringe or below the water table. NAPL removal can also be enhanced from above the water table by improving air access. Results are presented from a pilot-scale field trial aimed at evaluating the performance of such a remediation strategy where in situ air sparging was used in conjunction with a soil vapour extraction system to remove weathered gasoline NAPL from an unconfined sandy aquifer. A simple analysis that partitions extracted soil vapour between air injected through the sparge well and air drawn from the atmosphere across the soil surface, together with petroleum hydrocarbon concentrations in the extracted soil vapour, was used to interpret the effectiveness of air sparging. The composition and mass of the NAPL in the aquifer were also monitored along with observations on the distribution of air in the aquifer. Results showed that sparged air constituted 42% of the extracted soil vapour but contributed the majority of the petroleum hydrocarbons removed. For the first 5 days of sparging, hydrocarbon concentrations in the sparged air were in equilibrium with the NAPL in the aquifer leading to total petroleum hydrocarbon concentrations in the combined system being three to four times greater than for soil vapour extraction alone. Petroleum hydrocarbon concentrations in the extracted soil vapour decreased over time as a result of the depletion of the more volatile constituents from the NAPL, possible development of mass transfer limitations and increased fraction of clean air from depleted zones. Overall, 65% of the 673 kg of petroleum hydrocarbons extracted in soil vapour over a period of 30 days was carried in sparged air from the single sparge well. Percentages of the mass carried in the sparged air were even higher (median 70%) for individual aromatic hydrocarbons. Inclusion of air sparging increased the mass extracted by a factor of 1.9 (more for individual petroleum hydrocarbons) over and above that for soil vapour extraction alone for the 30 days of sparging. Air sparging was also effective in removing residual NAPL from below the water table. The mass of petroleum hydrocarbons removed from the site was not reflected in changes to the mass of NAPL in the aquifer. This result is apparently due to lateral inflow of NAPL to the site although evidence of a depleted source of volatilised hydrocarbons suggests the possible development of mass transfer limitations.

The psychosocial impact of orthognathic surgery: a systematic review

The aim of this study was to review the reported psychosocial benefits of orthognathic surgery. A systematic review of the literature was conducted using MEDLINE (1966 to December 2000), Web of Science (1981 to December 2000), and reference sections of identified articles. We also hand searched key orthodontic, oral surgery, and psychology journals. No language limitations were imposed. Randomized controlled trials, other controlled clinical trials, prospective studies (with or without controls), and retrospective studies (with or without controls) were considered for inclusion. Two reviewers extracted the data and independently assessed the quality of the studies. In all, 29 studies, including a number of prospective and retrospective studies, were identified as relevant. The results of the review indicated that orthognathic patients experience psychosocial benefits as a result of orthognathic surgery, including improved self-confidence, body and facial image, and social adjustment. However, there were wide variations in the study designs and a lack of uniformity in measuring the psychosocial constructs. This made it difficult to quantify the extent and the duration of the psychosocial benefits.

Oral appliances for the management of severe snoring: a randomized controlled trial

The aim of this randomized controlled trial was to assess the effectiveness of a mandibular advancement appliance (MAA) in managing severe snoring. Twenty-eight adults with severe snoring and normal overnight oximetry were recruited from sleep disorder clinics. A maxillary placebo appliance and a MAA were worn by each subject for a period of 4-6 weeks each. Questionnaires at baseline and after each appliance period assessed bed partners' reports of snoring severity (loudness and number of nights per week), and patients' records of daytime sleepiness. Twenty-five subjects completed the entire trial. The MAA was significantly more effective than the placebo in reducing the frequency and loudness of snoring, the reported daytime sleepiness and the frequency of morning tiredness. Excessive salivation was the most commonly reported complication. It was concluded that the custom-made MAA was significantly more effective than the placebo in managing the main symptoms of severe snoring. However, not all subjects' partners reported an improvement with the MAA, with 84 per cent reporting a reduction in snoring loudness and 76 per cent reporting snoring on fewer nights per week.

The influence of dental to facial midline discrepancies on dental attractiveness ratings

This study investigated the perception of discrepancies between the dental and facial midlines by orthodontists and young laypeople. A smiling photograph of a young adult female was modified by moving the dental midline relative to the facial midline. Twenty orthodontists (10 males and 10 females) and 20 young adult laypeople (10 males and 10 females) scored the attractiveness of the smile on the original image and each of the modified images using a 10-point scale. The results showed that the images were scored as less attractive both by the orthodontists and laypeople as the size of the dental to facial midline discrepancy increased. The scores were unrelated to the direction of the midline discrepancy (left or right) or to the gender of the judge. Further analysis revealed that the orthodontists were more sensitive than laypeople to small discrepancies between the dental and facial midline. It was estimated that the probability of a layperson recording a less favourable attractiveness score when there was a 2-mm discrepancy between the dental and facial midlines was 56 per cent.

Cephalometric changes in adult pharyngeal morphology

This cephalometric study investigated morphological changes occurring in the pharynx between early and middle adult life. A sample of 16 young adults (mean age 20.2 years) had cephalometric films taken and repeated after an interval of 32 years. Changes in pharyngeal skeletal size, pharyngeal soft tissue thickness, pharyngeal airway depth, and soft palate dimensions were examined, in addition to standard craniofacial measurements. The results showed increases in maxillary prominence, and upper and lower anterior face height. The nasopharyngeal skeletal dimensions were unchanged over the 32-year interval, while the anteroposterior depth of the nasopharyngeal lumen increased as a result of a reduction in thickness of the posterior nasopharyngeal wall. In the oropharynx, the depth of the airway decreased with age, and the soft palate became longer and thicker. The findings indicate that pharyngeal morphology is not immutably established during childhood and adolescence, but changes throughout adult life. The tendency towards a longer and thicker soft palate, and narrower oropharynx during adulthood is discussed in relation to their possible role in explaining the increased prevalence of obstructive sleep apnoea and related disorders in later life.

The effects of sandblasting on the bond strength of molar attachments--an in vitro study

This study evaluated the effect of sandblasting foil mesh molar tube bases on the shear bond strength obtained when bonding to first molar teeth. Fifty-two recently extracted first molar teeth were etched with 35 per cent phosphoric acid gel for 30 seconds. Twenty-six sandblasted 'A' Company molar tube attachments and 26 non-sandblasted attachments were then bonded to the teeth using Phase II orthodontic bonding resin. After storage in water for 24 hours at 37 degrees C, the specimens were debonded in a direction parallel to the buccal surface. Survival analysis using the Weibull function revealed that for a 90 per cent probability of survival, the predicted bond strengths for sandblasted and non-sandblasted bases were 1.76 and 1.66 MPa, respectively. For larger shear stresses, the probabilities of bond survival with sandblasted molar tubes were greater than with non-sandblasted molar tubes although the differences were small, which may be explained by the large proportion of bond failures which occurred at the resin to enamel interface in both groups. It was concluded that sandblasting foil mesh bases is likely to provide only a minimal improvement in clinical performance when bonding to molar teeth.

A retrospective comparison of craniofacial form in Northern Irish children with unilateral cleft lip and palate

OBJECTIVE

This study evaluated the craniofacial form of a sample of Northern Irish children with unilateral cleft lip and palate (UCLP). The quality of the outcomes achieved was compared with the outcomes reported for the six centers involved in the European multicenter study (Mars et al., 1992; Mølsted et al, 1992).

DESIGN

Retrospective analysis.

PATIENTS

All children born with complete skeletal UCLP in Northern Ireland during the years 1983 to 1987.

MAIN OUTCOME MEASURES

Cephalometric analysis was used to determine the craniofacial form and soft tissue profile. The quality of the dental arch relationships was independently assessed using the Goslon ranking system.

RESULTS

The sample comprised 25 children with complete skeletal UCLP who had cephalometric radiographs and study casts recorded at a mean age of 9.4 years (range, 8 to 11 years). Cephalometric analysis revealed no important skeletal differences between the Northern Irish UCLP children and the published results from the six Eurocleft centers. The soft tissue profile of the Northern Irish UCLP children was significantly more convex than the soft tissue profile recorded for center D in the Eurocleft study. The Goslon ranking system revealed that 18 (72%) of the Northern Irish UCLP children had good or satisfactory dental arch relationships.

CONCLUSIONS

No clinically important differences were detected between the mean cephalometric skeletal parameters of the Northern Irish UCLP children and those published for the six cleft centers involved in the Eurocleft study. On average, the Northern Irish UCLP children were found to differ significantly from Eurocleft's center D in their soft tissue facial contour and sagittal lip profile. The quality of the dental arch relationships of the Northern Irish sample was between the best and the less good Eurocleft centers.

Bonding to molars--the effect of etch time (an in vitro study)

This study evaluated the effect of etch time on the shear bond strength obtained when bonding to the buccal enamel of first molar teeth. Recently extracted first molar teeth were etched with 37 per cent phosphoric acid gel for 15, 30 and 60 seconds. Preformed cylinders of Concise composite resin were then bonded to the buccal surfaces of the molar teeth. After storage in water for 24 hours at 37 degrees C, the specimens were debonded in a direction parallel to the buccal surface. Examination of the shear bond strengths showed significant differences in shear bond strength between 15 and 30 seconds (P < 0.01) and between 15 and 60 seconds (P < 0.001). Weibull analysis revealed that the probability of bond survival increased as etch time increased, however, the difference between 30 and 60 seconds was not statistically significant. The results indicate that, despite current recommendations of a 15-second etch for premolars, canines and anterior teeth, an etching time of at least 30 seconds should be used when bonding to the buccal surfaces of first molars. A further increase in etching time to 60 seconds produces no significant increase in bond strength.

The effect of etch duration on the microstructure of molar enamel: an in vitro study

This in vitro study evaluated the influence of varying etch time on the microstructure of molar buccal enamel. The buccal surfaces of four groups of extracted first molar teeth were etched for 15, 30, 45, and 60 seconds. The etch patterns obtained were photographed with a scanning electron microscope and rated with a 3-grade scale. The 15-second etch time failed to produce any optimal etch patterns. The best etch patterns were found in molars etched for 60 seconds.

Reinnervation of developing rat molars

The ability of regenerating inferior alveolar nerve (IAN) fibres to reinnervate dentine of developing rat first molar teeth was investigated. At intervals of 5, 15, 30 and 50 days after intramandibular transection of the IAN at the age of 20 days, the percentage of innervated dentinal tubules was estimated and compared with results from a series of control specimens. In addition, the myelinated axon populations of the root canal pulps were examined by light microscopy. Degeneration of almost all pulpal myelinated axons and dentinal unmyelinated axons occurred within 5 days of surgery. By 15 days after transection there was evidence of some pulpal reinnervation by myelinated axons but less than 2% of dentinal tubules showed reinnervation (control, 31.8%). At 30 days after surgery the figure for dentinal reinnervation was approximately 17.7% (control, 44.9%), and by 50 days after transection (70 days of age) mean innervation was about 70% of the level observed in control 70 days teeth, though the difference between control and experimental specimens was not significant at the 5% level of probability. The results indicate that reinnervation of dentine does occur in developing teeth after nerve transection. It is argued that the results suggest a faster and probably more complete reinnervation in young animals; and that reinnervation may be attributable more to an active than to a passive mechanism, and this may also apply to dentinal innervation during development.

Toxicologic and carcinogenic evaluation of Fenvalerate in the B6C3F1 mouse

Groups of 50 male and 50 female B6C3F1 mice were fed dietary concentrations of 10, 50, 250 or 1250 ppm Fenvalerate for 2 years. Two groups of control mice, 50 per sex per group, received basal diet only. Mortality was increased and body weight was significantly decreased in male and female mice in the 1250 ppm treatment group. Mean body weight of female mice in the 250 ppm group was also generally lower than controls after the 60th week of feeding. Decreased albumin and increased glutamic oxaloacetic transaminase levels in mice fed 1250 ppm Fenvalerate were the only effects observed in the hematology and serum chemistry parameters examined. The only treatment related non-neoplastic pathologic effect observed in the study was multifocal microgranulomata in lymph nodes, liver and spleen of 1250 ppm male mice and 250 and 1250 ppm female mice. Less severe microgranulomatous changes were present in mesenteric lymph nodes of 50 and 250 ppm male mice. No statistically significant differences were observed in either the number or type of neoplasms in mice fed Fenvalerate diets when compared to concurrent controls. Thus, Fenvalerate was found not to be carcinogenic in B6C3F1 mice under the conditions of the test.