A qualitative study of the role of Australian general practitioners in the surgical management of obesity

General practitioners (GPs) are increasingly managing patients with class 2 and 3 obesity (body mass index [BMI] > 35 and 40 kg/m² , respectively). Bariatric surgery is considered for patients with class 2 obesity and comorbidities or class 3 obesity where sustained weight loss using non-surgical interventions has not been achieved. In Australia, GPs facilitate access to surgery through referral processes, but the nature of GP involvement in bariatric pre- and post-surgery care is currently unclear. This qualitative study involved 10 in-depth interviews with GPs and 20 interviews with adults who had all undergone laparoscopic adjustable gastric banding (LAGB) for weight management in Tasmania, Australia. Interviews were transcribed and analysed thematically. Referrals for bariatric surgery commonly occurred at the patient's request or to manage comorbidity. Consistent with previous studies, for GPs, referral patterns were influenced by previous case experience and patients' financial considerations. Accessibility of surgery was also a consideration. Post-surgery, there was a lack of clarity about the role of GPs, with patients generally preferring the surgical team to manage the LAGB. In bariatric surgery, patient preference for surgery, access and comorbidity are key drivers for referral and post-surgical monitoring and support. Greater role clarity and enhanced collaboration between surgeons, GPs and patients following surgery is likely to enhance the experience and outcomes for patients.

A cross-sectional study to evaluate the association of hyperbilirubinaemia on markers of cardiovascular disease, neurocognitive function, bone mineral density and renal markers in HIV-1 infected subjects on protease inhibitors

BACKGROUND

Ongoing inflammation in controlled HIV infection contributes to non-AIDS comorbidities. High bilirubin appears to exhibit an anti-inflammatory effect in vivo. We therefore examined whether increased bilirubin in persons with HIV was associated with differences in markers of inflammation and cardiovascular, bone, renal disease, and neurocognitive (NC) impairment.

METHODS

This cross-sectional study examined inflammatory markers in individuals with stable HIV infection treated with two nucleoside reverse transcriptase inhibitors and a boosted protease inhibitor. Individuals recruited were those with a normal bilirubin (NBR; 0-17 μmol/L) or high bilirubin (>2.5 × upper limit of normal). Demographic and anthropological data were recorded. Blood and urine samples were taken for analyses. Pulse wave velocity (PWV) measurement, carotid intimal thickness (CIT), and calcaneal stiffness (CSI) were measured. Males were asked to answer a questionnaire about sexual function; NC testing was performed using CogState.

RESULTS

101 patients were screened, 78 enrolled (43 NBR and 35 HBR). Atazanavir use was significantly higher in HBR. Whilst a trend for lower CIT was seen in those with HBR, no significant differences were seen in PWV, bone markers, calculated cardiovascular risk (Framingham), or erectile dysfunction score. VCAM-1 levels were significantly lower in the HBR group. HBR was associated with lower LDL and triglyceride levels. NBR was associated with a calculated FRAX significantly lower than HBR although no associations were found after adjusting for tenofovir use. No difference in renal markers was observed. Component tests of NC testing revealed differences favouring HBR but overall composite scores were similar.

DISCUSSION

High bilirubin in the context of boosted PI therapy was found not to be associated with differences in with the markers examined in this study. Some trends were noted and, on the basis of these, a larger, clinical end point study is warranted.

Regulation of Trophic Factor Expression by Innervating Target Regions in Intraocular Double Transplants

Trophic factors have been found to play a significant role both in long-term survival processes and in more rapid and dynamic processes in the brain and spinal cord. However, little is known regarding the regulation of expression of growth factors, and how these proteins interact on a cell-to-cell basis. We have studied protein levels of one growth factor known to affect the noradrenergic innervation of the hippocampal formation, namely brain-derived neurotrophic factor (BDNF). The purpose of the present study was to determine if appropriate innervation or contact between the LC noradrenergic neurons and their target, the hippocampus, affects expression of this growth factor in either brain region. Fetal brain stem tissue, containing the LC, and hippocampal formation were dissected from embryonic day 17 rat fetuses and transplanted together or alone into the anterior chamber of the eye of adult Fisher 344 rats. The tissue was grown together for 6 weeks, after which the animals were sacrificed and ELISAs for BDNF were undertaken. Transplantation to the anterior chamber of the eye increased the expression of BDNF in the hippocampal but not the brain stem tissue, compared with levels observed in fetal and adult rats in vivo. In addition, double grafting with hippocampal tissue more than tripled BDNF levels in brain stem grafts and doubled BDNF levels in the hippocampal portion of double grafts compared with hippocampal single grafts. Triple grafts containing basal forebrain, hippocampus, and brain stem LC tissue increased brain stem and hippocampal BDNF levels even further. Colchicine treatment of LC-hippocampal double grafts gave rise to a significant decrease in hippocampal BDNF levels to levels seen in single hippocampal grafts, while only a partial reduction of BDNF levels was seen in the brain stem portion of the same double grafts treated with colchicine. The findings suggest that an appropriate hippocampal innervation or contact with its target tissues is essential for regulation of BDNF expression in the brain stem, and that retrograde transport of BDNF can occur between double grafted fetal tissues in oculo.

A tale of two countries: all-cause mortality among people living with HIV and receiving combination antiretroviral therapy in the UK and Canada

Objectives

We sought to compare all‐cause mortality of people living with HIV and accessing care in Canada and the UK.

Methods

Individuals from the Canadian Observational Cohort (CANOC) collaboration and UK Collaborative HIV Cohort (UK CHIC) study who were aged ≥ 18 years, had initiated antiretroviral therapy (ART) for the first time between 2000 and 2012 and who had acquired HIV through sexual transmission were included in the analysis. Cox regression was used to investigate the difference in mortality risk between the two cohort collaborations, accounting for loss to follow‐up as a competing risk.

Results

A total of 19 960 participants were included in the analysis (CANOC, 4137; UK CHIC, 15 823). CANOC participants were more likely to be older [median age 39 years (interquartile range (IQR): 33, 46 years) vs. 36 years (IQR: 31, 43 years) for UK CHIC participants], to be male (86 vs. 73%, respectively), and to report men who have sex with men (MSM) sexual transmission risk (72 vs. 56%, respectively) (all P < 0.001). Overall, 762 deaths occurred during 98 798 person‐years (PY) of follow‐up, giving a crude mortality rate of 7.7 per 1000 PY [95% confidence interval (CI): 7.1, 8.3 per 1000 PY]. The crude mortality rates were 8.6 (95% CI: 7.4, 10.0) and 7.5 (95% CI: 6.9, 8.1) per 1000 PY among CANOC and UK CHIC study participants, respectively. No statistically significant difference in mortality risk was observed between the cohort collaborations in Cox regression accounting for loss to follow‐up as a competing risk (adjusted hazard ratio 0.86; 95% CI: 0.72–1.03).

Conclusions

Despite differences in national HIV care provision and treatment guidelines, mortality risk did not differ between CANOC and UK CHIC study participants who acquired HIV through sexual transmission.

Recreational drug use and chemsex among HIV-infected in-patients: a unique screening opportunity

OBJECTIVES

While a high rate of recreational drug use (RDU) has been documented among HIV-infected out-patients, particularly in men who have sex with men (MSM), there is a distinct lack of data for HIV-infected in-patients. Hospital admission offers a unique opportunity to engage drug users. We aimed to establish and characterize RDU among new admissions to a large dedicated London HIV in-patient unit and compare it to RDU among general medical admissions to inform clinical pathways.

METHODS

A prospective opt-out survey was administered to all new HIV-positive admissions over a 10-week period (cases) and all medical Acute Assessment Unit admissions over two 24-h periods (controls). All provided consent for urine toxicology upon admission.

RESULTS

Data were collected in 59 of 65 (91%) newly admitted HIV-positive individuals and in 48 of 54 (89%) non-HIV-positive medical admissions. HIV-infected in-patients were more likely than non-HIV-positive medical admissions to be male (P < 0.0001) (71% MSM), to be younger (P < 0.0001), to report current RDU (41 vs. 10%, respectively; P = 0.0001), to have a positive urine toxicology screen (19 vs. 2%, respectively; P = 0.0091) and to be a drug-related admission (15% vs. none; P = 0.004). Thirteen of 26 HIV-infected current recreational drug users admitted to sexualized drug taking and nine to injecting drugs. Twenty-seven per cent (seven of 26) were known to drug services. Crystal methamphetamine, mephedrone, gamma butyrolactone/gamma hydroxybutyrate and ketamine were exclusively taken by MSM. In total, 13 of 59 HIV-infected in-patients had current or past infection with hepatitis C virus, of whom 92% reported lifetime drug use.

CONCLUSIONS

These data strongly support the use of formal screening and drug service referral pathways at the time of admission to hospital to engage HIV-positive drug users.

Low levels of neurocognitive impairment detected in screening HIV-infected men who have sex with men: The MSM Neurocog Study

This study aimed to determine the prevalence of HIV neurocognitive impairment in HIV-infected men who have sex with men aged 18-50 years, using a simple battery of screening tests in routine clinical appointments. Those with suspected abnormalities were referred on for further assessment. The cohort was also followed up over time to look at evolving changes. HIV-infected participants were recruited at three clinical sites in London during from routine clinical visits. They could be clinician or self-referred and did not need to be symptomatic. They completed questionnaires on anxiety, depression, and memory. They were then screened using the Brief Neurocognitive Screen (BNCS) and International HIV Dementia Scale (IHDS). Two hundred and five HIV-infected subjects were recruited. Of these, 59 patients were excluded as having a mood disorder and two patients were excluded due to insufficient data, leaving 144 patients for analysis. One hundred and twenty-four (86.1%) had a normal composite z score (within 1 SD of mean) calculated for their scores on the three component tests of the BNCS. Twenty (13.9%) had an abnormal z score, of which seven (35%) were symptomatic and 13 (65%) asymptomatic. Current employment and previous educational level were significantly associated with BNCS scores. Of those referred onwards for diagnostic testing, only one participant was found to have impairment likely related to HIV infection. We were able to easily screen for mood disorders and cognitive impairment in routine clinical practice. We identified a high level of depression and anxiety in our cohort. Using simple screening tests in clinic and an onward referral process for further testing, we were not able to identify neurocognitive impairment in this cohort at levels consistent with published data.

Giant cell aortitis in treatment-naive human immunodeficiency virus and hepatitis C coinfection

Giant cell arteritis is a common form of vasculitis, although involvement of the aorta is unusual. There is no established association between giant cell aortitis and human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We present the case of a 46-year-old female coinfected with HIV and HCV who had never received antiretroviral therapy and developed symptoms of deteriorating shortness of breath on exertion. Investigations demonstrated aortic root and ascending aorta dilatation, along with severe aortic valve regurgitation, for which the patient underwent valve-sparing aortic root replacement (a David procedure). Histopathology confirmed giant cell aortitis.

Dynamics of microvesicle generation in B-cell chronic lymphocytic leukemia: implication in disease progression

Previously, we reported that B-cell chronic lymphocytic leukemia (CLL) patients contained elevated levels of microvesicles (MVs). However, given the quiescent nature of CLL B-cells and the relative indolence of the disease, the dynamics of MV generation and their unique phenotypes are not clearly defined. In this study, we find that CLL B-cells generate MVs spontaneously and can be further induced by B-cell receptor-ligation. Most interestingly, CLL B-cells predominantly generate CD52⁺ MVs, but not CD19⁺ MVs in vitro, suggesting preferential usage of CD52 into leukemic-MVs and that the CLL plasma MV phenotypes corroborate well with the in vitro findings. Importantly, we detected increased accumulation of CD52⁺ MVs in previously untreated CLL patients with progressive disease. Finally, sequential studies on MVs in pre- and post-therapy CLL patients demonstrate that while the plasma CD52⁺ MV levels drop significantly after therapy in most and remain at low levels in some patients, a trend of increased accumulation of CD52⁺ MVs was detected in majority of post-therapy CLL patients (25 of 33). In total this study emphasizes that dynamic accumulation of CD52⁺ MVs in plasma can be used to study CLL progression and may be a useful biomarker for patients as they progress and require therapy.

A global survey of HIV-positive people's attitudes towards cure research

OBJECTIVES

Involvement of people living with HIV (PLHIV) in the design of HIV cure studies is important, given the potential risks to participants. We present results of an international survey of PLHIV to define these issues and inform cure research.

METHODS

PLHIV were recruited in June-November 2014 through HIV websites, advocacy forums, social media and 12 UK HIV clinics. The survey included questions concerning demographics, HIV disease history, the desirability of types of cure and the patient's willingness to accept potential toxicity and treatment interruption (TI). We examined factors associated with TI and willingness to accept substantial risks.

RESULTS

A total of 982 PLHIV completed the survey; 87% were male, 79% white and 81% men who have sex with men (MSM). Fifty-one per cent were aged 25-44 years and 69% were UK residents. The median time since diagnosis was 7 years [interquartile range (IQR) 2-17 years]. Eighty-eight per cent were receiving antiretrovirals (91% reported undetectable viral load). Health/wellbeing improvements (96%) and an inability to transmit HIV (90%) were more desirable cure characteristics than testing HIV-negative (69%). Ninety-five per cent were interested in participating in cure studies, and 59% were willing to accept substantial risks. PLHIV with a low CD4 count [201-350 cells/μL vs. ≥ 350 cells/μL; odds ratio (OR) 2.11; 95% confidence interval (CI) 1.11-4.00] were more likely to accept risks, whereas those with limited knowledge of HIV treatments vs. excellent/good knowledge and those aged ≥ 65 years vs. 45-64 years were less likely to accept risks [OR 0.58 (95% CI 0.37-0.90) and OR 0.18 (95% CI 0.07-0.45), respectively]. TI was acceptable for 62% of participants, with the main concerns being becoming unwell (82%), becoming infectious (76%) and HIV spreading through the body (76%).

CONCLUSIONS

Cure research was highly acceptable to the PLHIV surveyed. Most individuals would accept risks, including TI, even in the absence of personal benefit. An optimal cure would improve health and minimize onward transmission risk.

The Benefits of Peer Review and a Multisemester Capstone Writing Series on Inquiry and Analysis Skills in an Undergraduate Thesis

This study examines the relationship between the introduction of a four-course writing-intensive capstone series and improvement in inquiry and analysis skills of biology senior undergraduates. To measure the impact of the multicourse write-to-learn and peer-review pedagogy on student performance, we used a modified Valid Assessment of Learning in Undergraduate Education rubric for Inquiry and Analysis and Written Communication to score senior research theses from 2006 to 2008 (pretreatment) and 2009 to 2013 (intervention). A Fisher-Freeman-Halton test and a two-sample Student's t test were used to evaluate individual rubric dimensions and composite rubric scores, respectively, and a randomized complete block design analysis of variance was carried out on composite scores to examine the impact of the intervention across ethnicity, legacy (e.g., first-generation status), and research laboratory. The results show an increase in student performance in rubric scoring categories most closely associated with science literacy and critical-thinking skills, in addition to gains in students' writing abilities.

The clinical application of plasma Kaposi sarcoma herpesvirus viral load as a tumour biomarker: results from 704 patients

OBJECTIVES

The aim of the study was to evaluate the role of plasma Kaposi sarcoma herpesvirus (KSHV) as a diagnostic and prognostic biomarker in people living with HIV (PLWH) and diagnosed with KSHV-associated diseases.

METHODS

Using quantitative nested polymerase chain reaction (PCR) targeting the open reading frame-26 gene of KSHV, plasma levels of KSHV were measured in consecutive PLWH with KSHV-associated diseases or as part of the investigation of lymphadenopathy.

RESULTS

Plasma KSHV assays were performed on samples from 684 PLWH and 20 HIV-seronegative people with KSHV-associated malignancies. In PLWH, plasma KSHV was detected in 39% of those with KS, 99% of those with multicentric Castleman disease (MCD), 9% of those with non-Hodgkin lymphoma (NHL), 2% of those with non-AIDS-defining malignancies and 0% of those with nonmalignant lymphadenopathy. There was no significant difference in plasma KSHV viral load among those with KS, MCD and KSHV-associated NHL. The 5-year overall survival rate from KS diagnosis of 335 PLWH was 95.2% (95% confidence interval 92.6-97.8%). Plasma KSHV viraemia did not predict overall survival in those with KS (P = 0.73), nor when those with T0 stage KS (P = 0.52) or T1 stage KS (P = 0.62) were analysed separately.

CONCLUSIONS

Measuring the plasma levels of KSHV as a biomarker in KSHV-associated disease has a very limited value in either diagnosis or prognostication. The only potential role of clinical value is the suggestion that an undetectable plasma KSHV excludes a diagnosis of MCD in PLWH.

Acute hepatitis C infection in HIV-negative men who have sex with men

Acute hepatitis C infection is recognized in HIV-infected men who have sex with men (MSM), but the risk in HIV-negative MSM remains unclear. We evaluated a population of MSM with acute hepatitis C. From January 2010 to May 2014, all cases of HCV antibody positive HIV-negative MSM were identified. European AIDS Network criteria were applied to determine acute infection, and 44 individuals fulfilled the criteria for acute hepatitis C. Ten were RNA negative at baseline and classed as prior spontaneous clearance. 15 (34.1%) had a previously negative HCV antibody within 1 year. 11 (25.0%) had significant elevation in ALT levels, and 18 (40.9%) were clinically diagnosed from risk exposure and history. Median age was 37 years (range 24-75). 41 (93.2%) individuals reported unprotected anal sex, 36 with (87.8%) both insertive and receptive intercourse, 4 (9.8%) with receptive intercourse, 1 (2.4%) with insertive intercourse, and no data were recorded for 3 (7.3%) patients. Individuals had an average of 7.3 reported (median 2, range 1-100) partners. 12 (27.3%) engaged in group sex, 11 (25.0%) practised fisting, 11 (25.0%) admitted using drugs during sexual activity, 16 (36.4%) reported nasal, and 9 (20.5%) reported injection drug use. 14 (31.8)% had unprotected sex whilst under the influence of recreational drugs. 29 individuals were aware of a partner's status. 2 (4.5%) individuals had sexual contact with a known HCV monoinfected partner, 13 (29.5%) with a HIV monoinfected partner and 6 (13.6%) with a HCV/HIV coinfected partner. 9 (20.5%) reported a partner/partners with no known infection. No data were available in 14 (31.8%) individuals. 13 (29.5%) individuals had a coexisting STI at the time of acute HCV diagnosis. 8 (18.2%) received HIV postexposure prophylaxis (PEP) within the 6 months prior to the HCV diagnosis (2 were participants in a HIV pre-exposure prophylaxis trial). 15 (34.1%) individuals achieved spontaneous clearance of HCV, and 11 patients received HCV treatment. Similar to the ongoing epidemic of acute HCV infection in HIV+ MSM, HIV-negative MSM remain at risk.

Efficacy of etravirine combined with darunavir or other ritonavir-boosted protease inhibitors in HIV-1-infected patients: an observational study using pooled European cohort data

OBJECTIVES

This observational study in antiretroviral treatment-experienced, HIV-1-infected adults explored the efficacy of etravirine plus darunavir/ritonavir (DRV group; n = 999) vs. etravirine plus an alternative boosted protease inhibitor (other PI group; n = 116) using pooled European cohort data.

METHODS

Two international (EuroSIDA; EUResist Network) and five national (France, Italy, Spain, Switzerland and UK) cohorts provided data (collected in 2007-2012). Stratum-adjusted (for confounding factors) Mantel-Haenszel differences in virological responses (viral load < 50 HIV-1 RNA copies/mL) and odds ratios (ORs) with 95% confidence intervals (CIs) were derived.

RESULTS

Baseline characteristics were balanced between groups except for previous use of antiretrovirals (≥ 10: 63% in the DRV group vs. 49% in the other PI group), including previous use of at least three PIs (64% vs. 53%, respectively) and mean number of PI resistance mutations (2.3 vs. 1.9, respectively). Week 24 responses were 73% vs. 75% (observed) and 49% vs. 43% (missing = failure), respectively. Week 48 responses were 75% vs. 73% and 32% vs. 30%, respectively. All 95% CIs around unadjusted and adjusted differences encompassed 0 (difference in responses) or 1 (ORs). While ORs by cohort indicated heterogeneity in response, for pooled data the difference between unadjusted and adjusted for cohort ORs was small.

CONCLUSIONS

These data do not indicate a difference in response between the DRV and other PI groups, although caution should be applied given the small size of the other PI group and the lack of randomization. This suggests that the efficacy and virology results from DUET can be extrapolated to a regimen of etravirine with a boosted PI other than darunavir/ritonavir.

Exploring the innate immunological response of an alternative nonhuman primate model of infectious disease; the common marmoset

The common marmoset (Callithrix jacchus) is increasingly being utilised as a nonhuman primate model for human disease, ranging from autoimmune to infectious disease. In order to fully exploit these models, meaningful comparison to the human host response is necessary. Commercially available reagents, primarily targeted to human cells, were utilised to assess the phenotype and activation status of key immune cell types and cytokines in naive and infected animals. Single cell suspensions of blood, spleen, and lung were examined. Generally, the phenotype of cells was comparable between humans and marmosets, with approximately 63% of all lymphocytes in the blood of marmosets being T cells, 25% B-cells, and 12% NK cells. The percentage of neutrophils in marmoset blood were more similar to human values than mouse values. Comparison of the activation status of cells following experimental systemic or inhalational infection exhibited different trends in different tissues, most obvious in cell types active in the innate immune response. This work significantly enhances the ability to understand the immune response in these animals and fortifies their use as models of infectious disease.

Statistical analysis of relative pose of the thalamus in preterm neonates

Preterm neonates are at higher risk of neurocognitive and neurosensory abnormalities. While numerous studies have looked at the effect of prematurity on brain anatomy, none to date have attempted to understand the relative pose of subcortical structures and to assess its potential as a biomarker of abnormal growth. Here, we perform the first relative pose analysis on a point distribution model (PDM) of the thalamus between 17 preterm and 19 term-born healthy neonates. Initially, linear registration and constrained harmonic registration were computed to remove the irrelevant global pose information and obtain correspondence in vertices. All the parameters for the relative pose were then obtained through similarity transformation. Subsequently, all the pose parameters (scale, rotation and translation) were projected into a log-Euclidean space, where univariate and multivariate statistics were performed. Our method detected relative pose differences in the preterm birth for the left thalamus. Our results suggest that relative pose in subcortical structures is a useful indicator of brain injury, particularly along the anterior surface and the posterior surface. Our study supports the concept that there are regional thalamic asymmetries in the preterm that may be related to subtle white matter injury, have prognostic significance, or be related to preterm birth itself.

Abstract P2-16-24: Folate targeted SMDC’s: A possible new treatment alternative for folate receptor expressing TNBC patients

Triple negative breast cancer (TNBC) is a subtype characterized by lack of gene expression for the estrogen receptor, progesterone receptor and the Her2/neu protein. Hence, the lack of hormonal or Her2 targeted therapy options makes TNBC difficult to treat, resulting in a death rate which is disproportionately higher than for other breast cancer subtypes. Recently, the folate receptor (FR) was shown to be highly expressed in TNBC, and expression significantly correlated with the higher grades of malignancy as well as poor outcomes. These observations suggest that TNBC patients may benefit from treatment with an FR-targeted therapy. To address this question, an established FR-positive subcutaneous TNBC pre-clinical model (MDA-MB-231) was chosen to evaluate a panel of FR-targeted small molecule drug conjugates (SMDC) with high potencies and varying mechanisms of action. Thus, EC1456 (folate-tubulysin B; IC50 ∼ 1 nM) and EC1744 (a folate-DNA cross-linking agent; IC50 ∼0.1 nM) were dosed intravenously at 2 μmol/kg following a three times per week, two week schedule in tumor-bearing mice. Both FR-targeted agents were found to be highly active against the MDA-MB-231 tumors, with 80-100% cure rates. In all cases, the observed anti-tumor activity was not accompanied by any significant weight loss in the test animals. These findings suggest that folate-targeted SMDCs may be active against TNBC and that further preclinical studies are warranted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-24.

The effects of age on associations between markers of HIV progression and markers of metabolic function including albumin, haemoglobin and lipid concentrations

OBJECTIVES

We investigated whether age modified associations between markers of HIV progression, CD4 T lymphocyte count and HIV RNA viral load (VL), and the following markers of metabolic function: albumin, haemoglobin, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC).

METHODS

A retrospective analysis of data from the United Kingdom Collaborative HIV Cohort was carried out. Analyses were limited to antiretroviral-naïve subjects to focus on the impact of HIV disease itself. A total of 16670 subjects were included in the analysis. Multilevel linear regression models assessed associations between CD4 count/VL and each of the outcomes. Statistical tests for interactions assessed whether associations differed among age groups.

RESULTS

After adjustment for gender and ethnicity, there was evidence that lower CD4 count and higher VL were associated with lower TC, LDL-C, haemoglobin and albumin concentrations but higher triglyceride concentrations. Age modified associations between CD4 count and albumin (P < 0.001) and haemoglobin (P = 0.001), but not between CD4 count and HDL-C, LDL-C and TC, or VL and any outcome. Among participants aged < 30, 30-50 and > 50 years, a 50 cells/μL lower CD4 count correlated with a 2.4 [95% confidence interval (CI) 1.7-3.0], 3.6 (95% CI 3.2-4.0) and 5.1 (95% CI 4.0-6.1) g/L lower haemoglobin concentration and a 0.09 (95% CI 0.07-0.11), 0.12 (95% CI 0.11-0.13) and 0.16 (95% CI 0.13-0.19) g/L lower albumin concentration, respectively.

CONCLUSIONS

We present evidence that age modifies associations between CD4 count and plasma albumin and haemoglobin levels. A given reduction in CD4 count was associated with a greater reduction in haemoglobin and albumin concentrations among older people living with HIV. These findings increase our understanding of how the metabolic impact of HIV is influenced by age.

Hyponatraemia in cancer patients on an inpatient rehabilitation unit

This study identifies the incidence of hyponatraemia in cancer patients on an inpatient rehabilitation unit and examines the association between admission hyponatraemia and rehabilitation length of stay (LOS), functional outcome, and survival. After institutional review committee's approval, we retrospectively reviewed medical records of 295 consecutive patients who were admitted to this inpatient cancer rehabilitation unit between 27 January 2009 through 31 July 2010 in a tertiary cancer centre. The incidence of hyponatraemia in cancer patients admitted to our inpatient rehabilitation unit was 41.4%. Median rehabilitation LOS for patients with mild (Na 130-134 mEq/L) and moderate-severe (Na < 130 mEq/L) hyponatraemia was 11 and 15 days, respectively, which was significantly longer than patients with eunatraemia (10 days; P = 0.03). Functional Independence Measure gain for ambulation and transfers during inpatient rehabilitation stay was not significantly different between three different patient groups. We concluded that large portion of patients who require acute inpatient rehabilitation presented with hyponatraemia, which is associated with prolonged rehabilitation LOS. Whether aggressive management of hyponatraemia will shorten rehabilitation stay needs further study.

Cutaneous aspergillosis associated with HIV infection

Primary cutaneous aspergillosis is rare but has been described in immunosuppressed individuals. Cutaneous aspergillosis associated with HIV infection, to date, has primarily been described in hospitalized individuals with advanced HIV following skin trauma. We describe a case of primary cutaneous aspergillosis in a HIV-infected, antiretroviral therapy naïve patient with moderate immunosuppression.

Health ownership in American indigenous communities

INTRODUCTION

Although the Indian Health Service (IHS) has adequately stifled acute infectious diseases that once devastated American Indian and Alaska Native (AIAN) communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. Presently, AIAN communities suffer disproportionally from chronic diseases that demand adequate, long-term health maintenance such as hepatitis, renal failure, and diabetes to name a few. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. The objective of this study was to examine the efficacy of both the Indian Health Service (IHS) and the relative few tribal healthcare systems (PL 93-638) respectively in their sociopolitical contexts, to determine their utility among a financially lame IHS.

METHODS

Domestic and international indigenous health systems were compared through analysis of the current literature on community and indigenous health. Informal interviews were carried out with indigenous practitioners, community members, and political figures to determine how AIAN communities were receiving PL 93-638 programs.

RESULTS

Although the IHS has adequately stifled the acute infectious diseases that once devastated AIAN communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. International indigenous health systems are noted to have a greater component of community involvement in the successful administration of health services.

CONCLUSION

Reinstating notions of ownership in multiple paradigms, along with novel approaches to empowerment is requisite to creating viable solutions to the unique health circumstances in Native America. This article demonstrates the importance and need of more qualitative data to better characterize how PL 93-638 healthcare delivery is actually experienced by AIAN patients.