Antiretroviral treatment outcomes among late HIV presenters initiating treatment with integrase inhibitors or protease inhibitors

OBJECTIVES

The aim of the study was to investigate the efficacy and safety of first-line antiretroviral therapy (ART) with integrase inhibitor (INI) or protease inhibitor (PI)-based regimens in patients with low CD4 cell counts and/or an AIDS-defining disease.

METHODS

We conducted a retrospective, multicentre analysis to investigate discontinuation proportions and virological response in patients with CD4 cell counts < 200 cells/µL and/or AIDS-defining disease when starting first-line ART. Proportions of those discontinuing ART were compared using univariate analysis. Virological response was analysed using the Food & Drug Administration (FDA) snapshot analysis (HIV-1 RNA < 50 HIV-1 RNA copies/mL at week 48).

RESULTS

Two hundred and eighteen late presenters were included in the study: 13.8% were women and 23.8% were of non-European ethnicity, and the mean baseline CD4 count was 91 cells/µL (standard deviation 112 cells/µL). A total of 131 late presenters started on INI- and 87 on PI-based treatment. It was found that 86.1% of patients treated with INIs and 81.1% of patients treated with PIs had a viral load < 50 copies/mL at week 48; proportions of discontinuation because of adverse events were 6.1% in the INI group and 11.5% in the PI group. No significant differences in discontinuation proportions were observed at week 12 or 48 between INI- and PI-based regimens (P = 0.76 and 0.52, respectively). Virological response was equally good in those receiving INIs and those receiving PIs (86.1% vs. 81.1%, respectively; P = 0.36).

CONCLUSIONS

In a European cohort of late presenters starting first-line INI or PI-based ART regimens, there were no significant differences in discontinuation proportions or virological response at week 48.

Measuring Sarcopenia Severity in Older Adults and the Value of Effective Interventions

OBJECTIVES

Little is known about the severity and long-term health and economic consequences of sarcopenia. We developed a sarcopenia index to measure severity in older Americans and estimated the long-term societal benefits generated by effective interventions to mitigate severity.

DESIGN

Using a micro-simulation model, we quantified the potential societal value generated in the US in 2010-2040 by reductions in sarcopenia severity in older adults. All analyses were performed in Stata and SAS.

SETTING AND PARTICIPANTS

Secondary data from the National Health and Nutrition Examination Survey (NHANES) (N = 1634) and Health and Retirement Study (HRS) (N = 952) were used to develop a sarcopenia severity index in older adults.

MEASUREMENTS

Multi-trait multi-method and factor analyses were used to validate and calibrate the sarcopenia severity index, which was modeled as a function of gait speed, walking without an assistive device, and moderate physical activity.

RESULTS

In representative elderly populations, reducing sarcopenia severity by improving gait speed by 0.1 m/s in those with gait speed under 0.8 m/s generated a cumulative benefit of $65B by 2040 (2015 dollars). Improving walking ability in those with walking difficulty generated cumulative social benefit of $787B by 2040.

CONCLUSIONS

Reducing sarcopenia severity would generate significant health and economic benefits to society-almost $800B in the most optimistic scenarios.

Use of Phosphite Salts in Laboratory and Semicommercial Tests to Control Citrus Postharvest Decay

Potassium phosphite (KP) concentrations that inhibited the germination of 50% of Penicillium digitatum conidia were 229, 334, 360, 469, 498, or 580 mg/liter at pH 3, 4, 5, 6, 7, or 8, respectively. Increasing phosphate content in media reduced phosphite toxicity. To control green or blue mold, fruit were inoculated with P. digitatum or P. italicum, then immersed 24 h later in KP, calcium phosphite (CaP), sodium carbonate, sodium bicarbonate, or potassium sorbate for 1 min at 20 g/liter for each at 25 or 50°C. Mold incidence was lowest after potassium sorbate, CaP, or KP treatments at 50°C. CaP was often more effective than KP but left a white residue on fruit. KP was significantly more effective when fruit were stored at 10 or 15°C after treatment compared with 20°C. Acceptable levels of control were achieved only when KP was used in heated solutions or with fungicides. KP was compatible with imazalil (IMZ) and other fungicides and improved their effectiveness. KP increased thiabendazole or IMZ residues slightly. Phosphite residues did not change during storage for 3 weeks, except they declined when KP was applied with IMZ. KP caused no visible injuries or alteration in the rate of color change of citrus fruit in air or ethylene at 5 μl/liter.

Self-Assembled β-Sheet Architectures for Bone-Tissue Engineering

Advances in the understanding of biomineralization processes in a variety of organisms have revealed the critical role of three-dimensional scaffolding architectures to create a highly functionalized surface. These complex matrices function on a variety of length scales ranging from the macromolecular (10–100 nm) to the cellular (1–10mm) and larger. One dominant structural motif found in many of these architectures is macromolecules containing antiparallel β-pleated sheets. These “hints” from Nature have lead to the iterative design and development of a novel multipurpose platform technology based on a self-assembled periodic peptide architecture for use in bone-tissue engineering. Combining molecular modeling, structural biochemistry and synthetic techniques, we have produced a β-sheet hollow tube peptide nanoassembly. Such a synthetic approach allows for the template's designed parameters of electrostatic, geometric and stereochemical complimentarily to match those of the desired biomineral. Consequently, these templates readily nucleate calcite. Future studies will investigate the in vitro osteoconductive and osteogenic properties of these templates.

Quantification of the Toxicity of Aqueous Chlorine to Spores of Penicillium digitatum and Geotrichum citri-aurantii

Chlorine toxicity to Penicillium digitatum and Geotrichum citri-aurantii, causes of green mold and sour rot of citrus, respectively, was quantified. In 3% wt/vol NaHCO₃ containing 200 µg free chlorine per ml at pH 8.3, 95% of P. digitatum spores died (LT₉₅) by 180 s at 5°C, while only 32 s were required at 24°C. The LT₉₅ of G. citri-aurantii arthrospores was 108 and 31 s at 5 and 24°C, respectively. Mortality slowed 2- to 4-fold for each unit of increase from pH 7 to 10. The LT₉₅ of P. digitatum spores in 200 µg free chlorine per ml at 24°C at pH 7, 8, 9, and 10 was 13.2, 19.1, 29.4, and 88.4 s, respectively. The LT₉₅ of G. citri-aurantii at pH 7, 8, 9, and 10 was 3.0, 12.6, 56.6, and 114 s, respectively. Models were prepared describing mortality. Brief immersion in 200 µg free chlorine per ml reduced viable spores of P. digitatum and G. citri-aurantii from 10⁶ to 10³ spores per lemon, and naturally occurring yeast and molds from 10⁶ to 10⁴ CFU. In fruit wound-inoculated and immersed 24 h later in water, 4,000 µg free chlorine per ml, or 3% wt/vol NaHCO₃, green mold occurrence after storage was 98.5, 68.3 and 7.5%, respectively.

Discharge disposition from acute care after traumatic brain injury: the effect of insurance type

OBJECTIVE

To determine if persons with traumatic brain injury (TBI) who are insured by Medicaid or health maintenance organizations (HMOs) are more likely to receive postacute care in skilled nursing facilities (SNFs) than in rehabilitation facilities, compared with persons insured by commercial fee-for-service (FFS) plans.

DESIGN

Retrospective cohort study.

SETTING

County hospital admitting 30% of all Washington State TBI patients.

PATIENTS

Patients with moderate to severe TBI discharged to rehabilitation facilities or SNFs between 1992 and 1997 (n = 1271); 56.3% were insured by Medicaid, 26.1% by FFS plans, and 17.6% by HMOs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disposition on discharge from acute care (rehabilitation facilities vs SNF); adjusted relative risk (RR) and confidence interval (CI) for different insurance types.

RESULTS

After accounting for confounding factors, Medicaid patients were 68% more likely (RR = 1.68, 95% CI = 1.34-2.11) and HMO patients were 23% more likely (RR = 1.23, 95% CI =.90-1.68) to go to a SNF than FFS patients. However, the latter difference was not statistically significant.

CONCLUSIONS

An association exists between insurance type and postacute care site. Efforts should be made to determine the effect this relationship has on the cost and outcomes for TBI patients.

Functional status examination: a new instrument for assessing outcome in traumatic brain injury

The Functional Status Examination (FSE) is a new measure designed to evaluate change in activities of everyday life as a function of an event or illness, including traumatic brain injury. The measure covers physical, social, and psychological domains. The FSE is based on a structured interview and includes levels of functioning that accommodate the full spectrum of possible outcomes, from death through recovery to preinjury functioning. Based on 133 prospectively studied patients with moderate to severe traumatic brain injury, the FSE has favorable psychometric properties including good test-retest reliability (r = 0.80) and close correspondence of assessments provided by the patient and their significant other (SO; r = 0.80). The FSE correlated significantly with each of three severity indices with closest relationships occurring between the FSE assessed by the SO and posttraumatic amnesia (r = 0.76). The FSE assessed by the SO was significantly (p < 0.05) more closely related to each severity index than the Glasgow Outcome Scale (GOS) or Sickness Impact Profile and, for two of the three indices, than the SF-36. All measures showed significant change from 1 to 6 months after injury with the FSE showing the largest effect sizes. The FSE is significantly related to important constructs such as family burden, SO depression, and sacrifices the family makes, as well as overall indices of recovery and satisfaction with level of functioning. The latter relationships are significantly stronger than for the GOS. The FSE has demonstrated good reliability, validity, and sensitivity, and appears to be a promising instrument for monitoring recovery and assessing functional status in clinical trials.

Describing and predicting the nature of procedural pain after thermal injuries: implications for research

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

Genomic imprinting in plants: observations and evolutionary implications

The epigenetic phenomenon of genomic imprinting occurs among both plants and animals. In species where imprinting is observed, there are parent-of-origin effects on the expression of imprinted genes in offspring. This review focuses on imprinting in plants with examples from maize, where gene imprinting was first described, and Arabidopsis. Our current understanding of imprinting in plants is presented in the context of cytosine methylation and imprinting in mammals, where developmentally essential genes are imprinted. Important considerations include the structure and organization of imprinted genes and the role of regional, differential methylation. Imprinting in plants may be related to other epigenetic phenomena including paramutation and transgene silencing. Finally, we discuss the role of gene structure and evolutionary implications of imprinting in plants.

Managed oncology care: the disease management model

BACKGROUND

As oncology becomes an increasing financial burden on the U.S. health care system, effort is being focused on finding methods to more effectively deliver, manage, and monitor the highly complex panoply of cancer care services required by patients. This issue has growing significance and importance in light of an aging U.S. population and the rapid penetration of managed care.

METHODS

SalickNet, Salick Health Care's disease management and managed care company, has been a pioneer in the development and implementation of cancer disease management programs. The cornerstone is a proprietary computer-based disease management system called OMARS (Oncology Management Assessment Reporting System). The flexible yet sophisticated architecture allows for the management of integrated care, data processing, and the generation of compelling custom reporting, fulfilling the goal of maximizing coordinated and effective patient care.

CONCLUSIONS

Based on data collected and analyzed across critical clinical, quality of life, and patient satisfaction outcome measures, strong evidence exists that the SalickNet Disease Management Model is a highly effective vehicle for bringing about cost, quality, and outcomes advantages in cancer care.

Effects of inhaled budesonide on allergen-induced airway responses and airway inflammation

Allergen inhalation by sensitized subjects results in acute bronchoconstriction, which can be followed by a later bronchoconstrictor response, allergen-induced airway hyperresponsiveness, and increases in airway inflammatory cells. Treatment with inhaled glucocorticosteroids attenuates allergen-induced asthmatic airway responses. The purpose of this study was to determine whether a 1-wk pretreatment with inhaled budesonide influences allergen-induced changes in inflammatory cells in blood and induced sputum. Seven subjects with mild atopic asthma were treated in a double-blind, placebo-controlled, randomized, crossover fashion with either inhaled budesonide 400 microg/d, or placebo for 7 d. Allergen challenges were carried out the morning after treatment was discontinued and sputum samples were obtained 7 h after allergen inhalation. Methacholine airway responsiveness was measured, and blood and sputum samples were obtained 24 h post-allergen. Budesonide treatment attenuated the magnitude of both the early and the late asthmatic response, reduced allergen-induced methacholine airway hyperresponsiveness, and attenuated allergen-induced increases in total eosinophils and activated eosinophils. These results suggest that the effects of inhaled glucocorticosteroids on allergen-induced airway responses may be mediated through their inhibition of allergen-induced eosinophil migration and activation.

Differential responses of the dopa decarboxylase gene to 20-OH-ecdysone in Drosophila melanogaster

The dopa decarboxylase gene (Ddc) of Drosophila melanogaster responds to 20-OH-ecdysone in the mature larval epidermis and in imaginal discs (presumptive adult epidermis) in a tissue-specific manner. Exposure of the mature larval epidermis to 20-OH-ecdysone caused a rapid accumulation of DDC transcripts. In the absence of protein synthesis, transcript accumulation was substantially reduced suggesting an indirect hormonal effect on DDC transcription (and/or RNA turnover). By contrast, neither DDC activity induction nor transcript accumulation was detected in imaginal discs cultured in the continuous presence of the hormone. However, when discs were exposed to 20-OH-ecdysone and then cultured in its absence, DDC activity and DDC transcript levels started to increase 6 hr after hormone withdrawal. A Northern analysis failed to reveal any novel transcripts in discs making the utilization of an alternative promotor an unlikely explanation for the very different responses of the Ddc gene in the two epidermal tissues. The results demonstrate that the Ddc gene in the larval epidermis responds rapidly to an increase in hormone titer. In imaginal discs a fall in hormone titer is required before DDC transcripts accumulate.

Procuticle proteins and chitin-like material in the inner epicuticle of the Drosophila pupal cuticle

The inner (protein) epicuticle of the pupal cuticle of Drosophila is shown to contain at least two hydrophobic proteins (19 and 21 kD) that are also present in the outer procuticle lamellae. An N-acetylglucosamine-containing carbohydrate is also present in the inner epicuticle. This represents the first attempt to characterize the non-lipid components of an insect epicuticle.

The pupal cuticle of Drosophila: biphasic synthesis of pupal cuticle proteins in vivo and in vitro in response to 20-hydroxyecdysone

We investigated the synthesis and localization of Drosophila pupal cuticle proteins by immunochemical techniques using both a complex antiserum and monoclonal antibodies. A set of low molecular weight (15,000-25,000) pupal cuticle proteins are synthesized by the imaginal disk epithelium before pupation. After pupation, synthesis of the low molecular weight proteins ceases and a set of unrelated high molecular weight proteins (40,000-82,000) are synthesized and incorporated into the pupal cuticle. Ultrastructural changes in the cuticle deposited before and after pupation correlate with the switch in cuticle protein synthesis. A similar biphasic accumulation of low and high molecular weight pupal cuticle proteins is also seen in imaginal discs cultured in vitro. The low molecular weight pupal cuticle proteins accumulate in response to a pulse of the insect steroid hormone 20-hydroxyecdysone and begin to appear 6 h after the withdrawal of the hormone from the culture medium. The high molecular weight pupal cuticle proteins accumulate later in culture; a second pulse of hormone appears to be necessary for the accumulation of two of these proteins.

Pupal and larval cuticle proteins of Drosophila melanogaster

Proteins, soluble in 7 M urea, were extracted from third-instar larval and pupal cuticles of Drosophila melanogaster. Both extracts contain a limited number of polypeptides resolved by one- or two-dimensional electrophoresis. The five major larval proteins have low molecular weights (less than 20000) and are not glycosylated. The major pupal cuticle proteins fall into two size classes: two with apparent molecular weights of 56K and 82K and four with molecular weights between 15K and 25K. The proteins with high apparent molecular weights are glycosylated. In nondenaturing gels, no components of the larval and pupal cuticle extracts comigrate. One-dimensional "fingerprints" indicate that cuticle proteins from these two stages have unique primary structures. Immunological results indicate that the major low molecular weight larval and pupal cuticle proteins are comprised of two families of proteins that share antigenic determinants. The high molecular weight pupal cuticle proteins are immunologically unrelated to the low molecular weight components. We conclude that the pupal and larval proteins are encoded in part by multigene families that have arisen by gene duplication and evolutionary divergence.