Pregnancy in HIV-infected teenagers in London

OBJECTIVE

The aim of the study was to describe pregnancies in HIV-infected teenagers.

METHODS

A review of the case notes of HIV-infected pregnant teenagers aged 13-19 years from 12 London hospitals was carried out for the period 2000-2007.

RESULTS

There were 67 pregnancies in 58 young women, of whom one was known to have acquired HIV vertically. The overall mother-to-child transmission (MTCT) rate of HIV was 1.5% (one of 66). There were 66 live births. Median ages at HIV diagnosis and conception were 17 and 18 years, respectively. Sixty-three per cent of women were diagnosed with HIV infection through routine antenatal screening. Eighty-two per cent of pregnancies (41 of 50) were unplanned, with 65% of women (26 of 40) using no contraception. Forty-three per cent of the women (20 of 46) had a past history of a sexually transmitted infection (STI). In 63 pregnancies, antiretroviral therapy was started post-conception, with prevention of HIV MTCT the only indication in 81% of cases. Fifty-eight per cent of those on highly active antiretroviral therapy (HAART) had an undetectable HIV viral load by delivery. Eighty-seven per cent were uncomplicated pregnancies. Seventy-one per cent delivered by Caesarean section and 21% (14 of 64) had a preterm delivery (<37 weeks). In the 12 months after delivery, 45% of women received contraceptive advice and 25% of women became pregnant again.

CONCLUSION

Obstetric and virological outcomes were favourable in this group of HIV-infected young women. However, the majority of pregnancies were unplanned with poor documentation of contraception use and advice and low rates of STI screening. A quarter of women conceived again within 12 months of delivery. Effective measures to reduce STIs, unplanned pregnancies and onward HIV transmission in HIV-infected teenagers are needed.

Prevalence of human herpesvirus 8 and hepatitis C virus in a rural community with a high risk for blood-borne infections in central China

Illegal blood donation in the past decade has caused human immunodeficiency virus (HIV) outbreaks in some rural areas in China. Other HIV-associated virus infections, such as those caused by human herpesvirus 8 (HHV8), in such areas are still not well defined. In order to explore HHV8 and hepatitis C virus (HCV) seroprevalence and potential risk factors in such areas, a cross-sectional study with 305 HIV-positive and 315 HIV-negative subjects recruited from a rural county in Shanxi province was conducted, in which illegal blood collection was reported. Interview questionnaires and serum testing were carried out with these participants. HCV and HHV8 seroprevalence were found to be higher in the HIV-positive than in the HIV-negative group (76.4% vs. 2.5% and 15.4% vs. 4.8%, respectively), whereas the difference in HBV seroprevalence was not significant. Co-infection with HCV and HHV8 was also more prevalent in the HIV-positive group. HIV status (OR 2.71; 95% CI 1.16-6.30) and HBV status (OR 2.56; 95% CI 1.14-5.75) were independently associated with HHV8 infection. HIV status (OR 23.03; 95% CI 9.95-53.27) and blood/plasma selling history (OR 14.57; 95% CI 7.49-28.23) were strongly associated with HCV infection. These findings demonstrate that both HHV8 and HCV infections are prevalent in this community. HIV infection is an important risk factor for both HHV8 and HCV infection. HBV infection is associated with HHV8 infection but not with HCV infection. It is possible that HHV8 and hepatitis B virus, but not HCV, have similar modes of transmission in this population.

Anomalous Seebeck Coefficient in Boron Carbides

Boron carbides exhibit an anomalously large Seebeck coefficient with a temperature coefficient that is characteristic of polaronic hopping between inequivalent sites. The inequivalence in the sites is associated with disorder in the solid. The temperature dependence of the Seebeck coefficient for materials prepared by different techniques provides insight into the nature of the disorder.

Multi-National, Multi-Institutional Analysis of Clinical Decision Support Data Needs to Inform Development of the HL7 Virtual Medical Record Standard

An important barrier to the widespread dissemination of clinical decision support (CDS) is the heterogeneity of information models and terminologies used across healthcare institutions, health information systems, and CDS resources such as knowledge bases. To address this problem, the Health Level 7 (HL7) Virtual Medical Record project (an open, international standards development effort) is developing community consensus on the clinical information exchanged between CDS engines and clinical information systems. As a part of this effort, the HL7 CDS Work Group embarked on a multinational, collaborative effort to identify a representative set of clinical data elements required for CDS. Based on an analysis of CDS systems from 20 institutions representing 4 nations, 131 data elements were identified as being currently utilized for CDS. These findings will inform the development of the emerging HL7 Virtual Medical Record standard and will facilitate the achievement of scalable, standards-based CDS.

Responses to highly active antiretroviral therapy and clinical events in patients with a low CD4 cell count: late presenters vs. late starters

OBJECTIVE

We investigated whether adverse responses to highly active antiretroviral therapy (HAART) associated with late HIV presentation are secondary to low CD4 cell count per se or other confounding factors.

METHODS

A longitudinal analysis of the UK Collaborative HIV Cohort (CHIC) Study of individuals starting HAART in 1998-2007 was carried out, comparing late presenters (presenting/starting HAART at a CD4 count <200 cells/μL) with late starters (presenting at a CD4 count>350 cells/μL; starting HAART at a CD4 count<200 cells/μL), using 'ideal starters' (presenting at a CD4 count>350 cells/μL; starting HAART at a CD4 count of 200-350 cells/μL) as a comparator. Virological, immunological and clinical (new AIDS event/death) outcomes at 48 and 96 weeks were analysed, with the analysis being limited to those remaining on HAART for>3 months.

RESULTS

A total of 4978 of 9095 individuals starting first-line HAART with HIV RNA>500 HIV-1 RNA copies/mL were included in the analysis: 2741 late presenters, 947 late starters and 1290 ideal starters. Late presenters were more commonly female, heterosexual and Black African. Most started nonnucleoside reverse transcriptase inhibitors (NNRTIs); 48-week virological suppression was similar in late presenters and starters (and marginally lower than in ideal starters); by week 96 differences were reduced and nonsignificant. The median CD4 cell count increase in late presenters was significantly lower than that in late starters (weeks 48 and 96). During year 1, new clinical events were more frequent for late presenters [odds ratio (OR) 2.04; 95% confidence interval (CI) 1.19-3.51; P=0.01]; by year 2, event rates were similar in all groups.

CONCLUSION

Amongst patients who initiate, and remain on, HAART, late presentation is associated with lower rates of virological suppression, blunted CD4 cell count increases and more clinical events compared with late starters in year 1, but similar clinical and immunological outcomes by year 2 to those of both late and ideal starters. Differences between late presenters and late starters suggest that factors other than CD4 cell count alone may be driving adverse treatment outcomes in late-presenting individuals.

A pilot study to compare HIV status and cervical and penile pathology among couples attending the urology unit at the University Teaching Hospital Lusaka, Zambia

BACKGROUND

Cancer of the cervix is the most common malignancy in women of childbearing age in Zambia. It is known to be associated with HIV infection and oncogenic strains of HPV. However, there are few studies of penile lesions as a predictor of malignant and premalignant cervical lesions in female partners.

OBJECTIVES

The aim of the study was to determine the association between men with penile lesions and premalignant cervical lesions in their female partners.

DESIGN

Thirty-seven couples were screened for penile and cervical lesions to determine the association between the two. The male partners had a biopsy and the female partners had a Pap smear.

RESULTS

Among 37 female partners, 29 (78.3%) had some type of cervical lesion. Two (5.4%) were undetermined and 6 (16.3%) of the females had normal Pap smears. Among the spouses with diseased cervices 22 (59.4%) were premalignant and 5 (13.5%) were malignant. The combined prevalence of malignant or premalignant cervical lesions among female partners was 73.0%. The HIV prevalence in the cohort was 88.9% (among those who agreed to be tested). The prevalence of premalignant or malignant cervical lesions was 75% in HIV positive and HIV negative females, and 66.7% in those who refused HIV testing.

CONCLUSION

This small pilot study suggests a high prevalence of premalignant or malignant lesions in females whose partners have penile lesions. In this cohort, HIV infection was not associated with a higher risk of neoplastic cervical lesions.

Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies

BACKGROUND

Emergence agitation (EA) in children is increased after sevoflurane anaesthesia. The efficacy of prophylactic treatment is controversial. The aim of this study was to provide a meta-analysis of the studies of the pharmacological prevention of EA in children.

METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the prevention of EA in children anaesthetized with sevoflurane, desflurane, or both. The data from each trial were combined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% confidence interval. I(2) statistics were used to assess statistics heterogeneity and the funnel plot and the Begg-Mazumdar test to assess bias.

RESULTS

Thirty-seven articles were found which included a total of 1695 patients in the intervention groups and 1477 in the control ones. Midazolam and 5HT(3) inhibitors were not found to have a protective effect against EA [OR=0.88 (0.44, 1.76); OR=0.39 (0.12, 1.31), respectively], whereas propofol [OR=0.21 (0.16, 0.28)], ketamine [OR=0.28 (0.13, 0.60)], alpha(2)-adrenoceptors [OR=0.23 (0.17, 0.33)], fentanyl [OR=0.31 (0.18, 0.56)], and peroperative analgesia [OR=0.15 (0.07, 0.34)] were all found to have a preventive effect. Subgroup analysis according to the peroperative analgesia given does not affect the results.

CONCLUSIONS

This meta-analysis found that propofol, ketamine, fentanyl, and preoperative analgesia had a prophylactic effect in preventing EA. The analgesic properties of these drugs do not seem to have a role in this effect.

A review of the epidemiology of cancers at the University Teaching Hospital, Lusaka, Zambia

This is a retrospective study based on pathology reports of specimens reviewed at the University Teaching Hospital (UTH) pathology laboratory in Lusaka, Zambia, from January 1997 to December 2005. UTH is the main reference hospital in Zambia and has a catchment area covering 1.3 million people. The most common cancer among men was Kaposi's sarcoma followed by cancer of the eye, soft tissue sarcomas and cancer of the prostate. The most common cancer among women was cancer of the cervix, followed by cancer of the eye, cancer of the breast and Kaposi's sarcoma. Non-Hodgkin's lymphoma is the fifth most common cancer in both men and women. There has been a significant change in the pattern of malignancies at the UTH over the last 20 years, with an increase in Kaposi's sarcoma, cancer of the cervix and cancer of the eye.

Fine- and regional-scale genetic structure of the exotic ascidian Styela clava (Tunicata) in southwest England, 50 years after its introduction

Styela clava, an ascidian native to the northwest Pacific, was first recorded in the Atlantic at Plymouth, southwest England, in 1953. It now ranges in the northeast Atlantic from Portugal to northern Denmark, and has colonized the east coast of North America. Within the region of first introduction, we aimed to characterize current genetic diversity in the species, elucidate the respective roles of human-aided vs. natural dispersal, and assess the extent of larval dispersal by looking for genetic differentiation at very small scales. Eight sites, mostly marinas, were studied along c. 200 km of coast in southwest England encompassing Plymouth. Five microsatellite loci were genotyped in 303 individuals to analyse gene flow at regional (among sites) and fine (within sites) scales. F-statistics and assignment tests were used to investigate regional genetic structure. At the fine scale, deviation from mutation-drift equilibrium was tested, and isolation by distance and genetic clustering analyses were undertaken. Significant genetic differentiation existed between sites, unrelated to geographical separation; migration between geographically distant marinas was inferred, highlighting the likely importance of human-mediated dispersal in range expansion and occupancy by S. clava. Fine-scale population structure was present within at least four sites, which may be explained by the limited dispersal ability of this ascidian and recruitment from differentiated pools of larvae. Populations in enclosed marinas had higher self-recruitment rates than those in open sites. Some marinas might therefore function as reservoirs of propagules for subsequent spread, whereas others might be sinks for migrants.

[IMPaCCT: standards of paediatric palliative care]

The needs of children and families living with life-limiting and life-threatening illness are similar across all European countries. Meeting these needs requires a comprehensive and integrative approach, with the input of a skilled multidisciplinary paediatric team. It is essential that the core standards for paediatric palliative care recommended in this document of the European Association for Palliative Care (EAPC) now be implemented across Europe.

Cumulative Lifetime Migraine Incidence in Women and Men

The aim was to estimate lifetime sex and age-specific incidence of migraine. Data are from the American Migraine Prevalence and Prevention study, a mailed survey sent to 120 000 US households. Age-specific incidence was estimated using self-reported data relevant to identification of migraine cases, age of onset of migraine and age at interview. Migraine incidence peaked between the ages of 20 and 24 years in women (18.2/1000 person-years) and the ages of 15 and 19 years in men (6.2/1000 person-years). Cumulative incidence was 43± in women and 18± in men. Median age of onset was 25 years among women and 24 years among men. Onset in 50± of cases occurred before age 25 and in 75± before age 35 years. Four of every 10 women and two of every 10 men will contract migraine in their lifetime, most before age 35 years. The incidence estimates from this analysis are consistent with those reported in previous longitudinal studies.

Gully hotspot contribution to landscape methane (CH4) and carbon dioxide (CO2) fluxes in a northern peatland

Peatlands are long term carbon catchments that sink atmospheric carbon dioxide (CO(2)) and source methane (CH(4)). In the uplands of the United Kingdom ombrotrophic blanket peatlands commonly exist within Calluna vulgaris (L.) dominated moorland ecosystems. These landscapes contain a range of topographical features that influence local hydrology, climate and plant community composition. In this study we examined the variation in ecosystem CO(2) respiration and net CH(4) fluxes from typical plant-soil systems in dendritic drainage gullies and adjacent blanket peat during the growing season. Typically, Eriophorum spp., Sphagnum spp. and mixed grasses occupied gullies while C. vulgaris dominated in adjacent blanket peat. Gross CO(2) respiration was highest in the areas of Eriophorum spp. (650+/-140 mg CO(2) m(-2) h(-1)) compared to those with Sphagnum spp. (338+/-49 mg CO(2) m(-2) h(-1)), mixed grasses (342+/-91 mg CO(2) m(-2) h(-1)) and C. vulgaris (174+/-63 mg CO(2) m(-2) h(-1)). Measurements of the net CH(4) flux showed higher fluxes from the Eriophorum spp (2.2+/-0.6 mg CH(4) m(-2) h(-1)) locations compared to the Sphagnum spp. (0.6+/-0.4 mg CH(4) m(-2) h(-1)), mixed grasses (0.1+/-0.1 mg CH(4) m(-2) h(-1)) and a negligible flux detected from C. vulgaris (0.0+/-0.0 mg CH(4) m(-2) h(-1)) locations. A GIS approach was applied to calculate the contribution of gullies to landscape scale greenhouse gas fluxes. Findings from the Moor House National Nature Reserve in the UK showed that although gullies occupied only 9.3% of the total land surface, gullies accounted for 95.8% and 21.6% of the peatland net CH(4) and CO(2) respiratory fluxes, respectively. The implication of these findings is that the relative contribution of characteristic gully systems need to be considered in estimates of landscape scale peatland greenhouse gas fluxes.

Does larval aggregation pheromone of codling moth, Cydia pomonella, induce attraction or arrestment of receivers?

Cocoon-spinning larvae of the codling moth, Cydia pomonella, emit a pheromone that mediates aggregation by pupation site-seeking fifth-instar larvae. It was unknown and, thus, we tested whether the aggregation pheromone induces arrestment or attraction responses. In paired straight-tube experiment 1, fifth-instars moved faster and farther upwind toward cospecific cocoons compared to blank controls. In still-air cage experiment 2, fifth-instars selected more often as first and final choices of pupation sites those with cocooning conspecifics than those without. Finally, in Y-tube olfactometer experiment 3, fifth-instars anemotactically responded to, and preferred, side arms with cocooning conspecifics to those without. Our data provide evidence that codling moth larvae are attracted to, rather than merely arrested by, larval aggregation pheromone. These results help explain reported aggregations or clumped distributions of larvae on tree trunks, which would likely not occur if they were based merely on chance encounter of cocoon-spinning larvae by foraging larvae.

Early childhood infection by human herpesvirus 8 in Zambia and the role of human immunodeficiency virus type 1 coinfection in a highly endemic area

Kaposi's sarcoma occurs at high incidence among Zambian adults and children, but there is a paucity of data on human herpesvirus 8 (HHV-8) incidence and routes of infection, especially in children. Between 1998 and 2004, the authors conducted a prospective study of viral transmission in a cohort of 684 children in Lusaka, Zambia, to estimate the annual incidence of HHV-8 from birth through 48 months of age. Maternal and pediatric human immunodeficiency virus type 1 (HIV-1) infection status was also determined. The results, based on 1,532 child-years of follow-up, showed that HHV-8 seroconversion occurs early in life. The incidence rate of HHV-8 seroconversion was 13.8 infections per 100 child-years by 48 months of age. HIV-1-infected children were at substantially higher risk for HHV-8 seroconversion (adjusted hazard ratio = 4.60, 95% confidence interval: 2.93, 7.22). Maternal HIV-1 and HHV-8 infection status were not independently associated with risk of HHV-8 seroconversion in the child. HHV-8 antibody titers in children followed at all consecutive time points revealed sero-reversion of HHV-8 antibodies, with undetectable titers in some children at one or more time points after seroconversion. These results demonstrate that cross-sectional serologic screening probably underestimates true HHV-8 seroprevalence in young Zambian children because of fluctuations in detectable antibody titers.

Meaningful differences in maternal smoking behaviour during pregnancy: implications for infant behavioural vulnerability

BACKGROUND

Smoking during pregnancy has been consistently associated with risk of problem behaviour in offspring. There is debate about whether this association reflects a teratological effect or is a marker for problematic maternal characteristics. We test these "competing" hypotheses by examining whether (1) exposure is associated with an early risk pathway by testing its association with infant temperamental difficultness, and (2) whether pregnancy quitting is associated with an early protective pathway, testing its association with easy infant temperament.

METHODS

We used the 9-month-old sweep of the Millennium Cohort Study, a cohort of over 18,000 infants born in 2000-2. Mothers were classified as pregnancy non-smokers, quitters and light or heavy smokers. Temperamental positive mood, receptivity to novelty and regularity were assessed with the Carey Infant Temperament Scale.

RESULTS

Pregnancy quitters had infants with the highest scores of easy temperament and heavy smokers had infants with the lowest scores (F = 28.51, p<0.001). Pregnancy smoking also predicted difficult temperament: heavy smoking was associated with increased risk of low positive mood (OR = 1.17, p = 0.09). In contrast, pregnancy quitting exerted a protective effect with decreased risk of distress to novelty (OR = 0.79, p<0.01) and irregularity (OR = 0.89, p = 0.02) in these infants.

CONCLUSIONS

Pathways from pregnancy smoking to offspring behaviour are complex and multi-determined. These findings suggest that both exposure and maternal characteristics associated with pregnancy smoking status contribute to offspring behavioural patterns. Research that characterises differences between quitters and persistent smokers and examines the role of these differences in prediction of early vulnerabilities and problems in adaptation over time will be important for elucidating these pathways.

The effect of intra-neural local anaesthetic infusion on pain following major lower limb amputation

BACKGROUND

Critical lower limb ischaemia has an annual incidence of 500-1000 per million and around a quarter will undergo a major lower limb amputation. Post operative pain and phantom pain are recognised complications.

AIM

The aim of this study was to assess the role of postoperative intraneural infusion of local anaesthetic in patients under-going major lower limb amputation.

METHODS

Between May 1998 and July 2001, following amputation patients either had standard post-operative analgesia or had an intra-neural infusion of 0.5% bupivicaine via an infant feeding catheter connected to a standard syringe pump (Alaris). This was a retrospective review and clinical notes of these patients were analysed to assess their post operative course, analgesic requirements and to ascertain phantom limb pain/sensation rates. All the data collected was from standard drug charts, case note entries and out-patient letters.

RESULTS

During this time period 64 patients had a major lower limb amputation (31 patients treated routinely and 33 patients had an intra-neural anaesthetic (INA) catheter placed). In the INA group median post-operative opioid analgesia requirement was 10mg versus 74 mg (p=0.0002, Mann-Whitney U) and post-operative prescription of amitriptyline for phantom pain was less common (4 patients versus 11 patients; p=0.0281, Mann-Whitney U). There was no obvious increase in complications or significant adverse events.

CONCLUSIONS

Postoperative intra-neural local anaesthetic infusion is a safe and effective technique. It reduces post-operative opioid analgesia requirement and seems to reduce phantom pain development.

Consumption of soy protein isolate modulates the phosphorylation status of hepatic ATPase/ATP synthase beta protein and increases ATPase activity in rats

ATPase/ATP synthase plays important roles in the regulation of carbohydrate, protein, and lipid metabolism through modulating energy homeostasis. The purpose of this study was to examine the effects of feeding soy proteins and isoflavones (ISF) on the enzymatic activity and protein modification of hepatic mitochondrial ATPase/ATP synthase. In Expt. 1, Sprague-Dawley rats aged 50 d were fed diets containing either 20% casein or 20% alcohol-washed soy protein isolate (SPI) with or without supplemental ISF (770.7 micromol/kg diet) for 70 d. In Expt. 2, weanling Sprague-Dawley rats were fed diets containing 20% casein with or without added ISF (154.1 micromol/kg diet) or 20% SPI for 90 d. Hepatic mitochondrial ATPase activity was significantly higher in the rats fed SPI than in those fed casein. Addition of ISF to SPI eliminated the action of SPI. ATPase/ATP synthase beta protein contents in the liver were unchanged; however, its patterns measured by 2-dimensional Western blot were different among dietary groups. The rats fed SPI or SPI plus ISF had 3 more major protein spots with the same molecular weights (80 kDa and 55 kDa) as those presented in the rats fed casein but with different isoelectric points. Pretreatment of hepatic mitochondrial proteins from the rats fed casein with alkaline phosphatase produced the same ATPase/ATP synthase beta patterns as observed in the SPI-fed rats and significantly elevated the ATPase activity. These results suggest that consumption of soy proteins increases hepatic ATPase activity, which might be a consequence of increased dephosphorylation or decreased phosphorylation of the mitochondrial ATPase/ATP synthase beta protein.