Progress towards the UNAIDS 95-95-95 targets in the Fifth Botswana AIDS Impact Survey (BAIS V 2021): a nationally representative survey

BACKGROUND

In 2014, UNAIDS set a goal to end the AIDS epidemic by achieving targets for the percentage of people living with HIV who were aware of their status, on antiretroviral therapy (ART), and virally suppressed. In 2020, these targets were revised to 95% for each measure (known as 95-95-95), to be reached among people living with HIV by 2025. We used data from the Fifth Botswana AIDS Impact Survey (BAIS V) to measure progress towards these testing and treatment targets in Botswana.

METHODS

BAIS V used a two-stage cluster design to obtain a nationally representative sample of people aged 15-64 years in Botswana. During March-August, 2021, 14 763 consenting participants were interviewed and tested for HIV in their households by survey teams. HIV-positive specimens were tested for viral load, presence of antiretroviral drugs, and recency of infection using the HIV-1 limiting antigen avidity enzyme immunoassay. Estimates of HIV-positive status and use of ART were based on self-report and the analysis of blood specimens for antiretroviral drugs. Viral load suppression was defined as an HIV RNA concentration of less than 1000 copies per mL. HIV incidence was calculated using the recent infection testing algorithm. Data were weighted to account for the complex survey design.

FINDINGS

The national HIV prevalence in Botswana among people aged 15-64 years was 20·8% and the annual incidence of HIV infection was 0·2%. 95·1% (men 93·0%, women 96·4%) of people living with HIV aged 15-64 years were aware of their status, 98·0% (men 97·2%, women 98·4%) of those aware were on ART, and 97·9% (men 96·6%, women 98·6%) of those on ART had viral load suppression. Among young people (aged 15-24 years) living with HIV, 84·5% were aware of their status, 98·5% of those aware were on ART, and 91·6% of those on ART had viral load suppression. The prevalance of viral load suppression among all people living with HIV was 91·8%, and varied by district-ranging from 85·3% in Gaborone to 100·0% in Selibe Phikwe.

INTERPRETATION

BAIS V is the first population-based survey worldwide to report the achievement of the UNAIDS 95-95-95 goals, both overall and among women. Strategies to reach undiagnosed men and young people, including young women, are needed.

FUNDING

US President's Emergency Plan for AIDS Relief.

Protecting the gains: analysis of HIV treatment and service delivery programme data and interventions implemented in 19 African countries during COVID-19

INTRODUCTION

The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR).

METHODS

We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility- and community-based interventions implemented to mitigate COVID-19.

RESULTS

The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,959-7,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,178-324,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021.

CONCLUSIONS

With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies.

Hazardous alcohol use and HIV indicators in six African countries: results from the Population-based HIV Impact Assessments, 2015-2017

INTRODUCTION

Hazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue.

METHODS

We used weighted pooled data (2015-2017) from the nationally representative Population-based HIV Impact Assessments among adults who provided written consent aged 18-59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 indicators between PLHIV by HAU status using log-binomial regression, stratified by sex. HAU was determined using the Alcohol Use Identification Test-Consumption.

RESULTS

Among the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18-1.46) compared to those who did not report HAU. For the UNAIDS 90-90-90 targets, women who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.22, 95% CI: 1.01-1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26-2.37). Men who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.56, 95% CI 1.39-1.76) and not on ART (aPR = 1.72, 95% CI: 1.30-2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex.

CONCLUSIONS

PLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol-based venues, may help countries reach HIV epidemic control by 2030.

Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017

BACKGROUND

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region.

SETTING

Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia.

METHODS

We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables.

RESULTS

Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex.

CONCLUSION

Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

First Report of Pseudomonas cichorii Causing Bacterial vein necrosis on Perilla plants [Perilla frutescens (L.) Britton.] in South Korea

Perilla (Perilla frutescens L.) is the second most important upland crop and the third largest edible oil crop in Korea (Shin and Kim 1994). During a disease survey in Busan, Korea in September 2021, symptoms of vein necrosis were observed in perilla plants, with incidences of approximately 30% and 50% in two fields. Symptoms of spots on the perilla appeared as leaf dryness and spots with water-soaked blotches largely concentrated on the mid-veins of leaves. The lesions were initiated with water-soaked spots on the leaf or stem and gradually turned black or brown. Necrosis was also observed in the stems. A bacterium was isolated on Luria-Bertani (LB) agar from diseased leaf tissues that were surface-disinfected with 70% ethyl alcohol for 3-5 min and then washed with sterile water three times. Three pieces of sterilized leaf tissue (size: 0.5 × 0.5 cm) were mixed with 500 µL sterile water for 30 min, and then the suspension was serially diluted and spread on LB agar. Subsequently, isolates were cultivated on LB agar and King's Medium B agar (KMB) (Schaad et al. 2001), and they were predominantly cream-colored and circular bacterial colonies with undulated margins. The bacterial colonies on KMB displayed fluorescence under 365 nm UV light. The isolates were analyzed with the GEN III MicroPlate (Biolog, Hayward, CA, USA), and all isolates were identified as Pseudomonas cichorii, a devastating plant bacterium that damages a wide range of host plants worldwide, including in South Korea (Hikichi et al. 2013; Ramkumar et al. 2015). To identify the species of the bacterial pathogen, genomic DNA of four isolates (BS4922, BS4167, BS4345, and BS4560) was extracted, and the 16S rRNA gene and hrcRST gene were amplified with universal primers, 27F/1492R and Hcr1/Hcr2, and sequencing was then done (Patel et al. 2019). In the BLAST analysis, the 16S rRNA sequences (GenBank OM060656, OM275434, OM275435, OM275436) showed a 100% and 99% similarity to P. cichorii strains MAFF 302698 (AB724286) and P. cichorii strain Pc-Gd-4 (KU923373), respectively. Further, hrcRST gene sequences (GenBank OM143596, OM268864, OM268865, and OM268866) showed high similarity (>99%) with P. cichorii strain P16-51 (MG518230). A pathogenicity test of the four isolates was performed on 3 - 4 weeks old perilla plants by creating wounds with a needle on the lower leaves and stems, and then the plants were inoculated by spraying inoculum (108 CFU/ml). The plants that served as the negative control were wounded and sprayed with unsterilized water. The inoculated perilla plants were placed in a greenhouse at 28 ± 2oC , 80-85% relative humidity, and a natural photoperiod. The inoculation site began to show symptoms of water-soaked brown lesions. Disease symptoms such as leaf dryness, water-soaked blotches on the mid-vein of leaves, and necrosis on plant stems were observed in the inoculated plants 7-10 days after inoculation, whereas the plants of the negative control group did not show any symptoms. The bacteria were re-isolated from the diseased tissues of the plants, and DNA sequence analysis identified them as P. cichorii. Additionally, all isolates induced hypersensitivity reactions in tobacco and tomato leaves within 24 h after inoculation. To our knowledge, this is the first report of P. cichorii infecting perilla in South Korea. The findings in this study will provide the basic information for the development of diagnostic tools and management measures against P. cichorii in perilla.

Taking care to the patients: a qualitative evaluation of a community-based ART care program in northern Namibia

Background

Namibia is a large sparsely populated country with a high prevalence of HIV. People living with HIV who reside in remote areas often travel long distances through tough desert terrain to access HIV care and treatment. To address this barrier, community-based antiretroviral therapy (C-BART) sites were established in Okongo (2007–2008) and Eenhana districts (2016) of northern Namibia with the goal of bringing HIV and other health services closer patients’ homes. We conducted a qualitative evaluation of the acceptability and challenges of C-BART to guide program improvement.

Methods

For this qualitative descriptive study, research assistants collected data (August-December 2017) through in-depth interviews with 40 patients, seven health extension workers, and 11 policy/program managers, and through four focus group discussions with healthcare workers. Interviews were audio-recorded, translated, and coded using MAXQDA v.12. Data were analyzed using thematic analysis.

Results

The evaluation identified five themes: community ownership, acceptance of the C-BART sites, benefits of the C-BART program for the PLHIV community and their social networks, benefits of the C-BART program to the main health facility, and challenges with the C-BART program. The C-BART program was reported as life-changing by many patients who had previously struggled to afford four-wheel drive vehicles to access care. Patients and healthcare workers perceived that the community as a whole benefited from the C-BART sites not only due to the financial pressure lifted from friends and family members previously asked to help cover expensive transportation, but also due to the perception of diminished stigmatization of people living with HIV and improved health. The C-BART sites became a source of community and social support for those accessing the sites. Healthcare workers reported greater job satisfaction and decongestion of health facilities. The challenges that they reported included delays in authorization of vehicles for transportation to C-BART sites and lack of incentives to provide services in the community.

Conclusion

The C-BART program can serve as a model of care to expand access to HIV care and treatment and other health services to populations in remote settings, including rural and difficult-to-reach regions. The needs of healthcare workers should also be considered for the optimal delivery of such a model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07928-0.

Pretreatment HIV drug resistance among treatment naïve infants newly diagnosed with HIV in 2016 in Namibia: results of a nationally representative study

Background

The World Health Organization (WHO) recommends routine surveillance of pretreatment human immunodeficiency virus (HIV) drug resistance (HIVDR) in children <18 months of age diagnosed with HIV through early infant diagnosis (EID). In 2016, 262 children <18 months of age were diagnosed with HIV in Namibia through EID. Levels of HIVDR in this population are unknown.

Methods

In 2016, Namibia surveyed pretreatment HIVDR among children aged <18 months following WHO guidance. Reverse transcriptase, protease, and integrase regions of HIV-1 were genotyped from remnant dried blood spot specimens from all infants diagnosed with HIV in Namibia in 2016. HIVDR was predicted using the Stanford HIVdb algorithm.

Results

Of 262 specimens genotyped, 198 HIV-1 protease and reverse transcriptase sequences and 118 HIV-1 integrase sequences were successfully amplified and analyzed. The prevalence of efavirenz/nevirapine (EFV/NVP), abacavir (ABC), zidovudine, lamivudine/emtricitabine (3TC/FTC), and tenofovir (TDF) resistance was 62.6%, 17.7%, 5.6%, 15.7%, and 10.1%, respectively. No integrase inhibitor resistance was detected.

Conclusions

The high level of EFV/NVP resistance is unsurprising; however, levels of ABC and TDF resistance are among the highest observed to date in infants in sub-Saharan Africa. The absence of resistance to dolutegravir (DTG) is reassuring but underscores the need to further study the impact of ABC and 3TC/FTC resistance on pediatric protease inhibitor– and DTG-based regimens and accelerate access to other antiretroviral drugs. Results underscore the need for antiretroviral therapy optimization and prompt management of high viral loads in infants and pregnant and breastfeeding women.

Purely laparoscopic explant hepatectomy and hybrid laparoscopic/robotic graft implantation in living donor liver transplantation

This report describes a purely laparoscopic/robotic technique for successful living donor liver transplantation (LDLT). Purely laparoscopic explant hepatectomy followed by purely laparoscopic and robotic graft implantation can be performed in LDLT.

Improving the benefits of HIV testing and referrals in large household surveys through active linkages to care: lessons and recommendations from the Namibia population-based HIV impact assessment (NAMPHIA), 2017

In household-based surveys that include rapid HIV testing services (HTS), passive referral systems that give HIV-positive participants information about how and where to access ART but minimal follow-up support from survey staff may result in suboptimal linkage. In the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA), we piloted a system of active linkage to care and ART (ALCART) that utilized the infrastructure of existing community-based partner organizations (CBPOs). All HIV-positive participants age 15-64 years not on ART were given standard passive referrals to ART plus the option to participate in ALCART. Cases were assigned to CBPOs in participants' localities. Healthcare workers from the CBPO's contacted cases and facilitated their linkage to facility-based ART. A total of 510 participants were eligible and consented to ALCART. The majority were new diagnoses (80.8%), while the remainder were previously diagnosed but not on ART (19.2%). Of the 510, 473 (92.7%) were successfully linked into care. Of these, all but one initiated ART. Our ALCART system used existing CBPOs and contributed to >90% linkage-to-care and >99% ART-initiation among linked participants in a large, nationally-representative survey. This approach can be used to improve the potential benefits of HTS in other large population-based surveys.

High levels of HIV drug resistance among adults failing second-line antiretroviral therapy in Namibia

To support optimal third-line antiretroviral therapy (ART) selection in Namibia, we investigated the prevalence of HIV drug resistance (HIVDR) at time of failure of second-line ART. A cross-sectional study was conducted between August 2016 and February 2017. HIV-infected people ≥15 years of age with confirmed virological failure while receiving ritonavir-boosted protease inhibitor (PI/r)-based second-line ART were identified at 15 high-volume ART clinics representing over >70% of the total population receiving second-line ART. HIVDR genotyping of dried blood spots obtained from these individuals was performed using standard population sequencing methods. The Stanford HIVDR algorithm was used to identify sequences with predicted resistance; genotypic susceptibility scores for potential third-line regimens were calculated. Two hundred thirty-eight individuals were enrolled; 57.6% were female. The median age and duration on PI/r-based ART at time of enrolment were 37 years and 3.46 years, respectively. 97.5% received lopinavir/ritonavir-based regimens. The prevalence of nucleoside reverse transcriptase inhibitor (NRTI), non-nucleoside reverse transcriptase inhibitor (NNRTI), and PI/r resistance was 50.6%, 63.1%, and 13.1%, respectively. No significant association was observed between HIVDR prevalence and age or sex. This study demonstrates high levels of NRTI and NNRTI resistance and moderate levels of PI resistance in people receiving PI/r-based second-line ART in Namibia. Findings underscore the need for objective and inexpensive measures of adherence to identify those in need of intensive adherence counselling, routine viral load monitoring to promptly detect virological failure, and HIVDR genotyping to optimize selection of third-line drugs in Namibia.

Barriers to condom use among key populations in Namibia

Key populations (KPs), particularly female sex workers (FSWs) and men who have sex with men (MSM), are at increased risk for HIV. Namibia is a global priority for HIV prevention interventions. Marginalized communities must be provided effective and culturally appropriate means to prevent HIV, namely condom use. This cross-sectional analysis of data collected by The Society for Family Health was conducted from 2016 to 2017 in Namibia. Demographics and consistent condom use (CCU) barriers were analyzed among 621 FSWs, MSM, and Other KPs. From the data, 37% FSWs, 24% MSM, and 28% Other KPs were HIV-positive. One-quarter of FSWs and Other KPs reported CCU, while 46% MSM reported CCU. Consistent condom users were more likely to be HIV-negative, have achieved a higher education and use condom-compatible lubricant (CCL). In a multivariate model, higher education, being HIV-negative, and always using CCL remained independent correlates of CCU. Substance use and condom unavailability were the most commonly identified barriers to CCU. FSWs reported client-focused reasons for not using condoms. To the best of our knowledge, this is the first peer-reviewed study assessing condom use behavior and associated factors among FSWs and MSM in Namibia.

Introduction of an Alcohol-Related Electronic Screening and Brief Intervention (eSBI) Program to Reduce Hazardous Alcohol Consumption in Namibia's Antiretroviral Treatment (ART) Program

Alcohol is the most widely abused substance in Namibia and is associated with poor adherence and retention in care among people on antiretroviral therapy (ART). Electronic screening and brief interventions (eSBI) are effective in reducing alcohol consumption in various contexts. We used a mixed methods approach to develop, implement, and evaluate the introduction of an eSBI in two ART clinics in Namibia. Of the 787 participants, 45% reported some alcohol use in the past 12 months and 25% reported hazardous drinking levels. Hazardous drinkers were more likely to be male, separated/widowed/divorced, have a monthly household income > $1000 NAD, and report less than excellent ART adherence. Based on qualitative feedback from participants and providers, ART patients using the eSBI for the first time found it to be a positive and beneficial experience. However, we identified several programmatic considerations that could improve the experience and yield in future implementation studies.

Content guidance for mobile phones short message service (SMS)-based antiretroviral therapy adherence and appointment reminders: a review of the literature

Mobile phones are increasingly being used to support health activities, including the care and management of people living with HIV/AIDS. Short message service (SMS) has been explored as a means to optimize and support behaviour change. However, there is minimal guidance on messaging content development. The purpose of this review was to inform the content of SMS messages for mobile health (mHealth) initiatives designed to support anti-retroviral therapy adherence and clinic appointment keeping in resource-limited settings. PubMed, OvidMedline, Google Scholar, K4Health's mHealth Evidence database, the mHealth Working Group project resource, and Health COMpass were searched. A request to online communities for recommendations on message content was also made. 1010 unique sources were identified, of which 51 were included. The information was organized into three categories: pre-message development, message development, and security and privacy. Fifteen of the publications explicitly provided their message content. Important lessons when developing the content of SMS were: (1) conducting formative research; (2) grounding content in behaviour change theory; and (3) reviewing proposed content with experts. Best practices exist for developing message content for behaviour change. Efforts should be continued to apply lessons learned from the existing literature to inform mHealth initiatives supporting HIV/AIDS care and treatment.

Reuse of Living-Donor Liver Graft in Second Recipient with Long-Term Survival

Brain death is a rare situation after living-donor liver transplantation. However, the recipient who suffers from brain death and has functional liver graft is a potential liver donor. We report the 1st case of successful reuse of extended right living-donor liver graft after brain death of the first recipient. The first recipient, who had acute liver failure caused by hepatitis A virus, experienced brain death on the 2nd day after the transplantation. The allograft had a favorable regeneration and functional recovery. On the 7th day, the allograft was procured with a patent hepatic artery, bile duct, portal vein, and reconstructed outflow (right hepatic vein and middle hepatic vein) and successfully implanted into the second recipient. The second recipient has experienced a long-term survival without any complications.

Hanging Hepato-Atrial Anastomosis in Deceased-Donor Liver Transplantation for Budd-Chiari Syndrome With Extensive Vena Cava Obliteration: A Case Report

INTRODUCTION

Although outcomes of liver transplantation (LT) have improved as the result of progress in surgical procedures, a failure to restore sufficient graft outflow may yield fatal consequences including graft dysfunction and even graft loss to date. In particular, patients with pre-existing obliterated venous drainage, such as those with Budd-Chiari syndrome (BCS), are at high risk of having venous complications followed by conventional LT. In selected cases, the transplant surgeons are compelled to modify the surgical procedures of LT from the conventional procedure.

METHODS

We describe an LT performed in a BCS patient with complete inferior vena cava (IVC) obstruction. A procedure that we named "hanging hepato-atrial anastomosis" was performed, in which 2 major modifications were made. One modification was the dissection of the lower inlet of the right atrium by use of a trans-abdominal approach and hepato-atrial anastomosis. This was performed by exposing the thoracic IVC through a trans-abdominal approach. The other modification was the manufacture of a blind pouch from the graft's infra-hepatic IVC without anastomosis.

RESULTS

Modifications were made possible as the result of meticulous examination of the patient's vascular anatomy before the operation. Fortunately, the patient had a heavy network of pre-vertebral veins that drained blood from the lower extremity and both kidneys to the azygos-hemi-azygos veins.

CONCLUSIONS

We learned that a meticulous assessment of vascular anatomy and complete understanding of hemodynamics are the keys to the successful LT for BCS in patients with extensive IVC abnormality. Thoracotomy may not be necessary to explore thoracic IVC when performing hepato-atrial anastomosis in LT for BCS.

Seizures in patients with acute pesticide intoxication, with a focus on glufosinate ammonium

The incidence and clinical aspects of seizures remain to be elucidated in patients with acute pesticide intoxication. The present study included subjects who ingested pesticide with the intention of committing suicide and were treated at Soonchunhyang University Hospital (Cheonan, Korea) between January 2011 and December 2014. We analyzed the incidence and characterized the type and frequency of seizure, from the medical records of 464 patients with acute pesticide intoxication, according to the pesticide class. The effect of seizure on the clinical outcome was assessed. The incidence of seizure was 31.5% in patients who ingested glufosinate ammonium {2-amino-4-[hydroxyl (methyl) phosphinoyl] butyrate; ammonium DL-homoalanin-4-yl (methyl) phosphinate}, followed by those who ingested pyrethroid (5.9%) or glycine derivatives (5.4%). All of the seizures developed between 12 and 24 h of pesticide ingestion and had ceased by 72 h after seizure initiation, following treatment with antiseizure medication. Generalized tonic-clonic seizures were the most commonly observed (85.7% of the cases). Multivariable logistic regression analysis showed that the effect of seizure on mortality was not statistically significant. In conclusion, glufosinate ammonium herbicide is the most common seizurogenic pesticide class. Seizure itself was not a risk factor for mortality in patients with acute glufosinate ammonium intoxication.

Assessment of the World Health Organization's HIV Drug Resistance Early Warning Indicators in Main and Decentralized Outreach Antiretroviral Therapy Sites in Namibia

BACKGROUND

The World Health Organization (WHO) early warning indicators (EWIs) of HIV drug resistance (HIVDR) assess factors at individual ART sites that are known to create situations favourable to the emergence of HIVDR.

METHODS

In 2014, the Namibia HIV care and treatment program abstracted the following adult and pediatric EWIs from all public ART sites (50 main sites and 143 outreach sites): On-time pill pick-up, Retention in care, Pharmacy stock-outs, Dispensing practices, and Viral load suppression. Comparisons were made between main and outreach sites and between 2014 and 2012 using the Wilcoxon signed-rank test in a matched analysis.

RESULTS

The national estimates were: On-time pill pick-up 81.9% (95% CI 81.1-82.8) for adults and 82.4% (81.3-83.4) for pediatrics, Retention in care 79% retained on ART after 12 months for adults and 82% for pediatrics, Pharmacy stock-outs 94% of months without a stock-out for adults and 88% for pediatrics, and Dispensing practices 0.01% (0.001-0.056) dispensed mono- or dual-therapy for adults and 0.01% (0.001-0.069) for pediatrics. Viral load suppression was significantly affected by low rates of Viral load completion. Main sites had higher On-time pill pick-up than outreach sites for adults (p<0.001) and pediatrics (p<0.001), and no difference between main and outreach sites for Retention in care for adults (p = 0.761) or pediatrics (p = 0.214). From 2012 to 2014 in adult sites, On-time pill pick-up (p = 0.001), Retention in care (p<0.001), and Pharmacy stock-outs (p = 0.002) worsened. In pediatric sites, On-time pill pick-up (p<0.001) and Pharmacy stock-outs (p = 0.012) worsened.

CONCLUSIONS

Results of EWIs monitoring in Namibia provide evidence about ART programmatic functioning and contextualize results from national surveys of HIVDR. These results are worrisome as they show a decline in program performance over time. The national ART program is taking steps to minimize the emergence of HIVDR by strengthening adherence and retention of patients on ART, reducing stock-outs, and strengthening ART data quality.

HIV drug resistance early warning indicators in namibia with updated World Health Organization guidance

BACKGROUND

In response to concerns about the emergence of HIV drug resistance (HIVDR), the World Health Organization (WHO) has developed a comprehensive set of early warning indicators (EWIs) to monitor HIV drug resistance and good programme practice at antiretroviral therapy (ART) sites.

METHODS

In 2012, Namibia utilized the updated WHO EWI guidance and abstracted data from adult and pediatric patients from 50 ART sites for the following EWIs: 1. On-time Pill Pick-up, 2. Retention in Care, 3. Pharmacy Stock-outs, 4. Dispensing Practices, and 5. Virological Suppression.

RESULTS

Data for EWIs one through four were abstracted and validated. EWI 5--Virological Suppression was not included due to poor data entry at many sites. On-time Pill Pick-up national estimate was 87.9% (87.2-88.7) of patients picking up pills on time for adults and 90.0% (88.9-90.9) picking up pills on time for pediatrics. Retention in Care national estimate was 82% of patients retained on ART after 12 months for adults and 83% for pediatrics. Pharmacy Stock-outs national estimate was 99% of months without a stock-out for adults and 97% for pediatrics. Dispensing Practices national estimate was 0.01% (0.003-0.064) of patients dispensed mono- or dual-therapy for adults and 0.25% (0.092-0.653) for pediatrics.

CONCLUSIONS

The successful 2012 EWI exercise provides Namibia a solid evidence base, which can be used to make national statements about programmatic functioning and possible HIVDR. This evidence base will serve to contextualize results from Namibia's surveys of HIVDR, which involves genotype testing. EWI abstraction has prompted the national program and its counterparts to engage sites in dialogue regarding the need to strengthen adherence and retention of patients on ART. The EWI collection process and EWI results will serve to optimize patient care and support Namibia in making evidence-based recommendations and take action to minimize the emergence of preventable HIVDR.

Correlates of non-adherence to antiretroviral therapy in a cohort of HIV-positive drug users receiving antiretroviral therapy in Hanoi, Vietnam

The HIV epidemic in Vietnam is concentrated, with high prevalence estimates among injection drug users and commercial sex workers. Socio-demographics, substance use and clinical correlates of antiretroviral therapy non-adherence were studied in 100 HIV-1 infected drug users receiving antiretroviral therapy for at least 6 months in Hanoi, Vietnam. All study participants were men with a mean age of 29.9 ± 4.9 years. The median duration on antiretroviral therapy was 16.2 ± 12.7 months; 83% reported 'very good' or 'perfect' adherence in the past 30 days on a subjective one-item Likert scale at time of study enrollment; 48% of participants reported drug use within the previous 6 months, with 22% reporting current drug use. Injection drug use with or without non-injection drug use in the past 6 months (95% C.I. 2.19, 1.30-3.69) and years on antiretroviral therapy (95% C.I. 1.43, 1.14-1.78) were correlated with suboptimal adherence. These findings support Vietnam's ongoing scale-up of harm reduction programmes for injection drug users and their integration with antiretroviral therapy delivery. Moreover, results highlight the need to identify and implement new ways to support high levels of antiretroviral therapy adherence as duration on antiretroviral therapy increases.

Systematic review of HIV drug resistance in Southeast Asia

In 2010, 3.5 million people were living with HIV in the World Health Organization Southeast Asia Region (SEAR), giving this region the greatest burden of HIV after Africa. Scale-up of antiretroviral therapy has resulted in over 717,000 benefitting from it by the end of 2010. A systematic review of studies of HIV drug resistance in the SEAR published between 2000 and 2011 was performed. Of 10 studies of transmitted HIV drug resistance in recently infected patients, all but two reported low levels (< 5%) of transmitted resistance. Of 23 studies of HIV drug resistance in pretreatment populations initiating antiretroviral therapy, three reported moderate levels (5-15%) of HIV drug resistance and 20 reported low levels. Amongst 17 studies of acquired HIV drug resistance, levels of nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor resistance ranged from 52 to 92% and 43 to 100%, respectively, amongst those with virological failure. Overall, data included in this review suggest that currently recommended first- and second-line regimens are appropriate for the cohorts studied. However, data were only available from two of 11 Southeast Asia Region countries and studies largely examined urban populations. Results are unlikely to be representative of the region. Studies lacked standardized methods, which greatly limits comparability of data and their use for public health and antiretroviral therapy program planning. Routine, standardized, and nationally representative HIV drug resistance surveillance should be strongly encouraged in the Southeast Asia Region countries to best characterize population-level HIV drug resistance. National-level HIV drug resistance surveillance data may be used to optimize delivery of HIV care and treatment and minimize emergence of population-level HIV drug resistance, thus promoting the long-term efficacy and durability of available first- and second-line antiretroviral therapy regimens.

HIV drug resistance early warning indicators in Namibia for public health action

Background

HIV drug resistance (HIVDR) testing is not routinely available in many resource-limited settings, therefore antiretroviral therapy (ART) program and site factors known to be associated with emergence of HIVDR should be monitored to optimize the quality of patient care and minimize the emergence of preventable HIVDR.

Methods

In 2010, Namibia selected five World Health Organization Early Warning Indicators (EWIs) and scaled-up monitoring from 9 to 33 ART sites: ART prescribing practices, Patients lost to follow-up (LTFU) at 12 months, Patients switched to a second-line regimen at 12 months, On-time antiretroviral (ARV) drug pick-up, and ARV drug-supply continuity.

Results

Records allowed reporting on three of the five selected EWIs. 22 of 33 (67%) sites met the target of 100% initiated on appropriate first-line regimens. 17 of 33 (52%) sites met the target of ≤20% LTFU. 15 of 33 (45%) sites met the target of 0% switched to a second-line regimen.

Conclusions

EWI monitoring directly resulted in public health action which will optimize the quality of care, specifically the strengthening of ART record systems, engagement of ART sites, and operational research for improved adherence assessment and ART patient defaulter tracing.

Development of a nutrient-dense food supplement for HIV-infected women in rural Kenya using qualitative and quantitative research methods

OBJECTIVE

Formative research to facilitate the development, packaging and delivery of a culturally acceptable nutrition intervention for HIV-infected women in rural Kenya for an intervention trial.

DESIGN

Focus group discussion on three areas: (i) ingredients and form of the nutrition intervention, (ii) packaging and delivery and (iii) monitoring of adherence. Two single-blind taste tests with eleven different porridge formulations of various combinations of maize flour, soyabeans, peanuts, sorghum, mung beans, dried fish, raisins and dried whole milk. Follow-up acceptability focus group discussion was also conducted.

SETTING

Voi, Kenya, community based.

SUBJECTS

Focus group discussion and two taste tests (twenty-one women aged 16-55 years). Follow-up acceptability focus group discussion (four women enrolled in intervention trial).

RESULTS

The preferred porridge for taste consisted of maize, soyabeans and peanuts. For animal protein, dried whole milk and dried fish were used. Although the women disliked the taste of dried fish, it was acceptable if added in small undetectable quantities. Sugar over lime was favoured for taste. Women believed they could consume at least two cups of porridge per day without displacing their usual meals. The optimal delivery interval was believed to be every two weeks in individual serving packages. Women who had been consuming porridge for several weeks felt the taste was acceptable for long-term consumption.

CONCLUSIONS

This formative research resulted in the development, packaging and delivery of a nutrient-dense food supplement using local ingredients to meet the dietary needs of the population and acceptable for daily consumption by women in Kenya for evaluation in an intervention trial.

Evaluation of programmatic changes to an antimicrobial stewardship program with house officer feedback

RATIONALE, AIMS AND OBJECTIVES

A collegial relationship between prescribers and antimicrobial stewards, along with an appreciation of the importance of antimicrobial stewardship, is essential for optimal functioning of an antimicrobial stewardship program (ASP). Programmatic adjustments based on feedback may be beneficial to the success of ASPs. The objective of this study is to assess the experience of house officers with the ASP and the effect of programmatic improvements.

METHODS

A survey of house officers at an academic medical centre was conducted assessing their experience with the ASP before (2008) and after (2010) programmatic interventions were instituted.

RESULTS

Of 225 house officer surveys sent, we received 97 responses (88% from medical doctors). The majority indicated that ASP was either very or somewhat important in fighting antibiotic resistance (100%), improving patient care (97%), preventing medication errors (91%) and containing health care costs (89%). Ninety-one per cent indicated either a very good or good educational experience with the ASP. The ASP often reminded respondents of a patient's allergy (31%), to adjust for renal function (78%), and 38% were prevented from making a medication error. Comparing 2008 and 2010, a higher proportion of respondents in 2010 said they had a very good or good educational experience with ASP [84% versus 98%, odds ratio (OR) = 8.40, P = 0.022] and a lower proportion of respondents reported confusion about ASP procedures (59% versus 39%, OR = 0.43, P = 0.048).

CONCLUSIONS

House officer feedback resulted in ASP policy changes which improved the ASP experience.

Medication possession ratio associated with short-term virologic response in individuals initiating antiretroviral therapy in Namibia

The visual-analogue scale (VAS), Likert item (rating scale), pills identification test (PIT), and medication possession ratio (MPR) provide estimates of antiretroviral therapy (ART) adherence which correlate with HIV viral suppression. These simple adherence measures are inexpensive and easy to administer; however, require validation and adjustment prior to implementation. The objective of this study was to define the optimal adherence assessment measure in Namibia to identify patients at risk for sub-optimal adherence and poor virologic response 6 months after ART initiation. We conducted a cross-sectional survey in HIV-infected adults receiving ART for 6-12 months prior to the adherence assessment. Adherence measures included 30-day VAS, 30-day Likert item, self-reported treatment interruptions, PIT, and MPR. Association of adherence measures with 6-month HIV-1 RNA level was assessed using two thresholds (1000 copies/mL and 5000 copies/mL). Adherence was assessed in 236 patients, mean age 37.3 years, 54% female. Mean adherence was 98.1% by 30-day VAS, 84.7% by 30-day Likert item, 97.0% by self-reported treatment interruptions, 90.6% by PIT, and 98.8% by MPR. Agreement between adherence measures was poor using kappa statistic. 76% had HIV-1 RNA <1000 copies/ml, and 88% had HIV-1 RNA <5000 copies/ml. MPR (continuous) was associated with viral suppression <5000 copies/ml (p = 0.036). MPR <75% was associated with virologic failure at ≥5000 copies/ml with OR 3.89 (1.24, 12.21), p = 0.013. Adherence was high with all measures. Only MPR, was associated with short-term virologic response, suggesting its cross-culturally utility for early identification of patients at high risk for virologic failure.

Effects of physical tracing on estimates of loss to follow-up, mortality and retention in low and middle income country antiretroviral therapy programs: a systematic review

BACKGROUND

A large proportion of patients receiving antiretroviral therapy (ART) in low and middle income countries (LMICs) have unknown treatment outcomes and are classified as lost to follow-up (LTFU). Physical tracing of patients classified as LTFU is common; however, effects of tracing on outcomes remains unclear. The objective of this systematic review is to compare estimates of LTFU, mortality and retention in LMIC in cohorts of patients with and without physical tracing.

METHODS AND FINDINGS

We systematically identified studies in LMIC programmatic settings using MEDLINE (2003-2011) and HIV conference abstracts (2009-2011). Studies reporting the proportion LTFU 12-months after ART initiation were included. Tracing activities were determined from manuscripts or by contacting study authors. Studies were classified as "tracing studies" if physical tracing was available for the majority of patients. Summary estimates from the 2 groups of studies (tracing and non-tracing) for LTFU, mortality, stop of ART, transfers out, and retention on ART were determined. 261 papers and 616 abstracts were identified of which 39 studies comprising 54 separate cohorts (n = 187,666) met inclusion criteria. Of those, physical tracing was available for 46% of cohorts. Treatment programs with physical tracing activities had lower estimated LTFU (7.6% vs. 15.1%; p<.001), higher estimated mortality (10.5% vs. 6.6%; p = .006), higher retention on ART (80.0 vs. 75.8%; p = .04) and higher retention at the original site (80.0% vs. 72.9%; p = .02).

CONCLUSIONS

Knowledge of patient tracing is critical when interpreting program outcomes of LTFU, mortality and retention. The reduction of the proportion LTFU in tracing studies was only partially explained by re-classification of unknown outcomes. These data suggest that tracing may lead to increased re-engagement of patients in care, rather than just improved classification of unknown outcomes.

HIV drug resistance early warning indicators in cohorts of individuals starting antiretroviral therapy between 2004 and 2009: World Health Organization global report from 50 countries

The World Health Organization developed a set of human immunodeficiency virus drug resistance (HIVDR) early warning indicators (EWIs) to assess antiretroviral therapy clinic and program factors associated with HIVDR. EWIs are monitored by abstracting data routinely recorded in clinical records, and the results enable clinics and program managers to identify problems that should be addressed to minimize preventable emergence of HIVDR in clinic populations. As of June 2011, 50 countries monitored EWIs, covering 131 686 patients initiating antiretroviral treatment between 2004 and 2009 at 2107 clinics. HIVDR prevention is associated with patient care (appropriate prescribing and patient monitoring), patient behavior (adherence), and clinic/program management efforts to reduce treatment interruptions (follow up, retention on first-line ART, procurement and supply management of antiretroviral drugs). EWIs measure these factors and the results have been used to optimize patient and population treatment outcomes.

Update on World Health Organization HIV drug resistance prevention and assessment strategy: 2004-2011

The HIV drug resistance (HIVDR) prevention and assessment strategy, developed by the World Health Organization (WHO) in partnership with HIVResNet, includes monitoring of HIVDR early warning indicators, surveys to assess acquired and transmitted HIVDR, and development of an accredited HIVDR genotyping laboratory network to support survey implementation in resource-limited settings. As of June 2011, 52 countries had implemented at least 1 element of the strategy, and 27 laboratories had been accredited. As access to antiretrovirals expands under the WHO/Joint United Nations Programme on HIV/AIDS Treatment 2.0 initiative, it is essential to strengthen HIVDR surveillance efforts in the face of increasing concern about HIVDR emergence and transmission.

A case of methanol intoxication caused by methomyl pesticide ingestion

When clinicians treat patients with pesticide poisoning, they often pay attention only to the chief toxic agent and ignore the toxicity of the pesticide’s additives or solvents. Occasionally, however, a solvent (e.g. methanol) may itself be the cause of poisoning. We report a case of acute methanol intoxication that occurred after ingestion of a methomyl pesticide that contained methanol as an additive. A 49-year-old man was brought to the emergency department in an unconscious state after ingestion of 20 ml of a carbamate pesticide (chief ingredient: methomyl; active ingredient: methanol). Upon arrival, he was semicomatose and did not breathe spontaneously; however, his cholinesterase level was within normal limits and cholinergic symptoms were not observed. High anion gap metabolic acidosis was present. His blood ethanol level was 74.8 mg/dL. The urine methanol level was 55.60 mg/dL, and urine ethanol level was 22.0 mg/dL. He was treated with hemodialysis; subsequently, his metabolic acidosis resolved and he returned to normal mental status. We guessed that methanol, as the solvent of the methomyl, had produced the symptoms. When treating pesticide-poisoned patients, clinicians should identify the solvent used in the pesticide, because solvents such as methanol may exacerbate the symptoms of poisoned patients.

Knowledge of HIV Transmission and Associated Factors among HIV-Positive and HIV-Negative Patients in Rural Kenya

Knowledge of HIV transmission is a prerequisite to practicing safer behaviors to prevent HIV infections and may be expected to vary by region because of cultural and socioeconomic determinants. A cross-sectional study was conducted in rural Kenya using a standardized questionnaire assessing HIV transmission knowledge, socio-demographic and other characteristics. Participants were recruited from the voluntary counseling and testing clinic and the general hospital population of Moi District Hospital. "High" HIV transmission knowledge scorers (≥ 81%) (Mean score) were compared with "low" scorers (<81%). Bivariate and multivariate logistic regression analyses were performed to examine factors associated with HIV transmission knowledge. Of 214 participants, 70 (33%) were HIV-positive, 104 (49%) were HIV-negative, and 40 (19%) did not know. Factors associated with low knowledge in multivariate analyses were lower education (OR 2.36, CI 1.03-5.46), lower household money on healthcare (OR 2.03, CI 1.28-3.21), higher clinic transportation costs (OR 3.14, CI 1.20-9.82), sex without a condom (OR 2.18, CI 1.12-4.26), positive HIV status vs. negative (OR 2.50, CI 1.22-5.26) and positive HIV status vs. unknown (OR 3.57, CI 1.33-9.09). Mean HIV transmission knowledge score was relatively high; however, a large proportion of patients demonstrated low knowledge. Identifying individuals at risk for low knowledge will support targeted HIV education and prevention programs.

Antimicrobial prescribing in the USA for adult acute pharyngitis in relation to treatment guidelines

RATIONALE, AIMS AND OBJECTIVES

American College of Physicians (ACP) published guidelines for the diagnosis and treatment of acute pharyngitis in adults in 2001. The objective of this study is to characterize antibiotic prescribing patterns in the USA for acute pharyngitis and evaluate concordance with the 2001 ACP pharyngitis treatment guidelines.

METHODS

Patients aged ≥18 years identified with acute pharyngitis via diagnosis codes (ICD-9 CM) were identified from data collected annually (1996-2006) by the National Center for Health Statistics and Centers for Disease Control and Prevention from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Total US office visits for acute pharyngitis were estimated. Logistic regression was performed to determine whether antibiotic prescribing was associated with the publishing of the ACP guidelines.

RESULTS

A total of 3791 office visits met study criteria. We extrapolated 78.0 million visits for acute pharyngitis from 1996 to 2006. Antibiotics were prescribed in 62.6% of cases and 7.5% of cases received ACP-recommended antibiotics. There was a significant decrease in the rate of antibiotic prescriptions from 66.5% to 59.1% after publication of ACP guidelines. Univariate analysis showed that antibiotic prescribing decreased by 27% (OR = 0.73, 95% CI 0.55-0.95, P = 0.021). Multivariate analyses confirmed this finding (OR = 0.72, 95% CI 0.56-0.94, P = 0.014). The prescribing of ACP-recommended antibiotics did not significantly change (8.5% to 6.6%, P = 0.519).

CONCLUSIONS

Publishing of ACP guidelines for the diagnosis and treatment of pharyngitis was associated with a decrease in the overall prescribing of antibiotics but not the prescribing of ACP-recommended antibiotics.

HIV treatment adherence, drug resistance, virologic failure: evolving concepts

Poor adherence to combined antiretroviral therapy (cART) has been shown to be a major determinant of virologic failure, emergence of drug resistant virus, disease progression, hospitalizations, mortality, and health care costs. While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of cART, long-term adherence remains a challenge regardless of available resources. Barriers to optimal adherence may originate from individual (biological, socio-cultural, behavioral), pharmacological, and societal factors. Although patients and providers should continuously strive for maximum adherence to cART, there is accumulating evidence that each class of antiretroviral therapy has specific adherence-drug resistance relationship characteristics allowing certain regimens more flexibility than others. There is not a universally accepted measure for cART adherence, since each method has distinct advantages and disadvantages including cost, complexity, accuracy, precision, intrusiveness and bias. Development of a real-time cART adherence monitoring tool will enable the development of novel, pre-emptive adherence-improving strategies. The application of these strategies may ultimately prove to be the most cost-effective method to reduce morbidity and mortality for the individual and decrease the likelihood of HIV transmission and emergence of resistance in the community.

The global status of HIV drug resistance: clinical and public-health approaches for detection, treatment and prevention

Antiretroviral therapy (ART) scale-up in resource limited settings (RLS) has been successful, utilizing a standardized population-based approach to ART delivery. An unintended consequence of treatment scale-up is the inevitable emergence of HIV drug resistance (HIV DR) in populations even when patient adherence to ART is optimally supported. HIV DR has the potential to undermine the dramatic gains that ART has had in reducing the morbidity and mortality of HIV-infected patients in RLS. Sustaining and expanding ART coverage in RLS will depend upon the ability of ART programs to deliver ART in a way that minimizes the emergence of HIVDR. Fortunately, current evidence demonstrates that HIVDR in RLS has neither emerged nor been transmitted to the degree that had initially been feared. However, due to a lack of standardized methodologies, HIVDR data from RLS can be difficult to interpret and may not provide the programmatic evidence necessary for public health action. The World Health Organization has developed simple, standardized surveys that generate comparable results to assess acquired and transmitted HIVDR for routine public health implementation in RLS. These HIVDR surveys are designed to be implemented in conjunction with annual monitoring of program and site factors known to create situations favorable to the developments of HIV DR.

Pharmacy adherence measures to assess adherence to antiretroviral therapy: review of the literature and implications for treatment monitoring

Prescription or pill-based methods for estimating adherence to antiretroviral therapy (ART), pharmacy adherence measures (PAMs), are objective estimates calculated from routinely collected pharmacy data. We conducted a literature review to evaluate PAMs, including their association with virological and other clinical outcomes, their efficacy compared with other adherence measures, and factors to consider when selecting a PAM to monitor adherence. PAMs were classified into 3 categories: medication possession ratio (MPR), pill count (PC), and pill pick-up (PPU). Data exist to recommend PAMs over self-reported adherence. PAMs consistently predicted patient outcomes, but additional studies are needed to determine the most predictive PAM parameters. Current evidence suggests that shorter duration of adherence assessment (≤ 6 months) and use of PAMs to predict future outcomes may be less accurate. PAMs which incorporate the number of days for which ART was prescribed without the counting of remnant pills, are reasonable minimum-resource methods to assess adherence to ART.

Reduced expression of angiopoietin-1 in Hantaan virus-infected human umbilical vein endothelial cell increases their permeability

Hemorrhagic fever with renal syndrome (HFRS) caused by Hantaan virus (HTNV) is characterized by vascular hemorrhage and acute renal failure. Angiopoietin-1 (Ang-1) is a glycoprotein that maintains vessel integrity and reduces endothelial permeability. We found that in HTNV-infected human umbilical vein endothelial cells (HUVECs) the levels of Ang-1 mRNA and protein were reduced on days 2 and 3 post-infection (p.i.), when endothelial permeability was increased. The HTNV-stimulated permeability was reduced by treatment of HUVECs with Ang-1. The plasma Ang-1 level was lower in HFRS patients than in healthy persons. Paired plasma samples of HFRS patients revealed markedly lower Ang-1 levels during the acute phase of HFRS as compared to the convalescent phase. These findings suggested that HTNV reduced the Ang-1 expression in endothelial cells that might play an important role in the increase of vascular permeability in HFRS.

Structure and stability of molybdenum sulfide fullerenes

MoS2 nanooctahedra are believed to be the smallest stable closed-cage structures of MoS2, i.e., the genuine inorganic fullerenes. Here a combination of experiments and density functional tight binding calculations with molecular dynamics annealing are used to elucidate the structures and electronic properties of octahedral MoS2 fullerenes. Through the use of these calculations MoS2 octahedra were found to be stable beyond nMo > 100 but with the loss of 12 sulfur atoms in the six corners. In contrast to bulk and nanotubular MoS2, which are semiconductors, the Fermi level of the nanooctahedra is situated within the band, thus making them metallic-like. A model is used for extending the calculations to much larger sizes. These model calculations show that, in agreement with experiment, the multiwall nanooctahedra are stable over a limited size range of 104-105 atoms, whereupon they are converted into multiwall MoS2 nanoparticles with a quasi-spherical shape. On the experimental side, targets of MoS2 and MoSe2 were laser-ablated and analyzed mostly through transmission electron microscopy. This analysis shows that, in qualitative agreement with the theoretical analysis, multilayer nanooctahedra of MoS2 with 1000-25 000 atoms (Mo + S) are stable. Furthermore, this and previous work show that beyond approximately 105 atoms fullerene-like structures with quasi-spherical forms and 30-100 layers become stable. Laser-ablated WS2 samples yielded much less faceted and sometimes spherically symmetric nanocages.

Phylogenetic analysis of protozoa in the rumen contents of cow based on the 18S rDNA sequences

AIMS

To examine the diversity of protozoa in the rumen contents of cow.

METHODS AND RESULTS

Protozoa that inhabit the rumen were detected by PCR using protozoan-specific primers. Libraries of protozoan rDNA sequences were constructed from rumen fluid, solid tissues and epithelium. Twenty-three clones isolated from rumen fluid fell into two genera identified as Entodinium (69.6% of clones) and Epidinium (31.4% of clones). Of the clones isolated from rumen fluid, a moderate number were unidentifiable (30.4%).

CONCLUSIONS

The predominant protozoan genus identified in the whole rumen belonged to the Entodinium group (81.1%). Protozoa were not detected in the rumen epithelium.

SIGNIFICANCE AND IMPACT OF THE STUDY

These findings suggest that rumen fluid and solid tissues contain different protozoan populations that may play specific roles in rumen function. Quantitative PCR techniques and a more specific set of phylogenetic probes that distinguish between protozoan species are needed to determine the significance of newly identified groups and to determine the distribution of identified protozoan clusters in rumen microbial communities.

Cloning and characterization of ce/8A gene from Rhizobium leguminosarum bv. trifolii 1536

AIMS

To isolate the cellulase gene from Rhizobium leguminosarum bv. trifolii 1536.

METHODS AND RESULTS

By the shot-gun method a clone (cel8A) harbouring 3.1 kb genomic DNA fragment from R. leguminosarum bv. trifolii 1536 was obtained. The cel8A gene coded 348 amino acids and it belongs to the glycosyl hydrolase family 8. The molecular mass of Cel8A protein induced from Escherichia coli DH5alpha, appeared to be 35 kDa. The optimum pH and optimum temperature was 7.0, and about 30 degrees C for its enzymatic activity respectively.

CONCLUSIONS

R. leguminosarum bv. trifolii 1536 had cel8A gene having an open reading frame of 1047 bp coded for the activity of hydrolyzation of carboxymethyl cellulose.

SIGNIFICANCE AND IMPACT OF THE STUDY

The production of celluloytic enzyme by R. leguminosarum bv. trifolii was confirmed, which would play specific roles in rhizobia. Future study should focus on its role in the infection and nodulation phenomena.

Reuse of wastewater sludge with marine clay as a new resource of construction aggregates

The disposal of sludge from wastewater treatment presents highly complex problems to any municipality. Most of the sludge disposal methods have varying degrees of environmental impact. Hence, it is necessary to explore potential areas of reuse in order to alleviate sludge disposal problems and to conserve natural resources. Industrial sludge and marine clay are two forms of high-volume wastes. Using these wastes as a resource of raw materials to produce construction aggregates would enable large-scale sludge reuse. The aggregates were produced at various sludge-clay combinations containing 0, 20, 50, 80 and 100% clay contents, respectively. The pelletized aggregates displayed lower particle densities ranged between 1.48 and 2.25 g/cm3, compared to the density of granite at 2.56 g/cm3. Good 28-day concrete compressive strength of 38.5 N/mm2 achieved by the 100% sludge aggregate was comparable to the value of 38.0 N/mm2 achieved of the granite control specimens. The leachate contamination levels from the aggregates after 150 days were found acceptable when used in concrete, indicating insignificant environmental contamination. The heat flow study showed increases in heat flow at the temperatures of 480 degrees C and between 660 degrees C and 900 degrees C, indicating a need for the extension of heating time around these temperatures.

A comparison of ultrasound treatment on primary and secondary sludges

Ultrasound treatment of primary and secondary sludges was conducted to improve the qualities of sludges for the anaerobic digestion. The impacts of different sonication times, sonication densities and solids concentrations on ultrasonication efficiency were examined. The experimental results indicated that the significant reduction in particle size and increase in soluble organics could be achieved, implying that ultrasonication could offer a feasible treatment method to efficiently disintegrate sludge. The greater decrease in particle size and increase in soluble organics of sludge indicated that the secondary sludge has a more remarkable improvement after sonication over the primary sludge. With respects to the extent of disintegration and energy consumption, higher sonication density performed more effectively in terms of specific energy. There exists an optimal solids concentration range for both the sludges for optimum sonication. Within the optimal solids concentration range, efficient sonication can be effected and sludge would be disintegrated efficiently. The ultrasound would be attenuated by scattering and absorption if the solids concentration exceeds the optimal range. It appeared from the study that the mechanical shear forces caused by ultrasonic cavitation could be a key factor for sludge disintegration and collapse of cavitation bubbles could significantly alter the sludge characteristics.

Manufacturing artificial aggregates from industrial sludge and marine clay with addition of sodium salt

The potential of converting industrial sludge and dredged marine clay into building and construction materials as an alternative to disposal was investigated in this study. The industrial sludge was mixed with marine clay at various compositions and was shaped into round pellets to be used as concrete aggregates. The pellets were then dried and transferred into a high temperature kiln where they were heated at 1,135 degrees C. The artificial aggregates were more porous then the normal granite aggregate. The occurrence of this condition was suspected to be attributed to two factors, viz. the firing temperature and the amount of sodium in the aggregates. To validate this hypothesis, the aggregates with and without added sodium chloride were fired at temperatures of 1,100 and 1, 200 degrees C. Results showed a reduction in the densities of the aggregates with the addition of sodium chloride and the increase in firing temperature.

4G/5G polymorphism of the plasminogen activator inhibitor-1 gene and insertion/deletion polymorphism of the tissue-type plasminogen activator gene in atherothrombotic stroke

BACKGROUND AND PURPOSE

Decreased fibrinolytic capacity due to increased plasminogen activator inhibitor-1 (PAI-1) activity and decreased tissue-type plasminogen activator (t-PA) activity has been associated with hypertension or atherothrombotic disorders. The aims of this study were to observe associations of the genetic polymorphism for PAI-1 and t-PA with hypertension and atherothrombotic stroke, and to elucidate whether impaired fibrinolytic activity in atherothrombotic stroke was related to atherothrombosis per se or to other risk factors such as hypertension.

METHODS

Patients with atherothrombotic stroke (n = 60), hypertension (n = 100), and control subjects (n = 100) were enrolled. We genotyped all subjects for 4G/5G polymorphism in the promoter region of the PAI-1 gene and the Alu-repeat insertion/deletion (I/D) polymorphism in intron h of the t-PA gene by polymerase chain reaction and endonuclease digestion.

RESULTS

The frequency of the 4G/4G genotype of PAI-1 was significantly higher in the atherothrombotic stroke patients than the control subjects (41.7 versus 21%; p = 0.005), but not in the hypertensive subjects. There was a significant association between 4G/4G genotype of PAI-1 and atherothrombotic stroke (adjusted odds ratio = 3.11, 95% confidence interval 1.18-8.15), adjusting for age, sex, total cholesterol, low-density lipoprotein, triglyceride, and body mass index. However, the number of the I/I genotype of t-PA in the atherothrombotic stroke or hypertensive patients was virtually identical to the control subjects.

CONCLUSION

Our results suggest that the 4G/4G genotype of the PAI-1 gene is significantly associated with an increased risk of atherothrombotic stroke. This finding also supports that impaired fibrinolytic activity in atherothrombotic stroke is related to atherothrombosis per se, but not to hypertension, one of the most important risk factors of atherothrombotic stroke.

The effect of a disrupted yhjQ gene on cellular morphology and cell growth in Escherichia coli

The 5' upstream region of the cellulose synthase operon ( bcs operon) has been isolated by cloning from Escherichia coli. A gene encoding YhjQ is located 1.0 kb upstream of the bcs operon in E. coli. The function of YhjQ remains unknown. Insertional inactivation of the yhjQ gene causes abnormal cell division, resulting in incomplete partition of the chromosome and filamentous cells of various sizes. These results suggest that the product of yhjQ may affect normal doubling and cellular morphology.

Is tumor necrosis factor genotype (TNFA2/TNFA2)a genetic prognostic factor of an unfavorable outcome in IgA nephropathy?

The purpose of this study was to examine whether there are the associations between TNF alpha and TNF beta gene polymorphisms and the development and progression of Ig A nephropathy (IgAN). A cross-sectional study on TNF alpha and TNF betagene polymorphisms by polymerase chain reaction with restriction fragment length poly-morphisms was performed on 76 patients with primary IgAN confirmed by renal biopsy and 100 healthy controls. The allele with G-->A substitution was designated as TNFA2 for the TNF alpha gene and TNFB2 for the TNF betagene. A patient in whom dialysis treatment was started or whose serum creatinine became double or over during the follow-up duration was designated as a "progressor". The TNFA2/ TNFA2 genotype was more prevalent in the progressor than in the non-pregressor group (20.0 vs 3.3%, p<0.05). Clinical factors such as serum creatinine, systolic and diastolic blood pressure (p<0.001, respectively) were higher and pathologic factor such as Grade IV or V renal lesions was more prevalent (p<0.01) in the progressor than in the non-progressor group. Therefore, TNFA2/TNFA2 genotype may be a risk factor for the progression of IgAN.

New frontiers in the continuum of dental education

During the past 150 years, dental education and training have changed from an apprenticeship to a university-based dental school. The future of dental education will be shaped by changing demographics, advances in technology, and a greater integration of science and research into the dental profession. We are entering an age of interdisciplinary practice, where dentistry provides oral health care as an integral part of an individual's overall health care.