Dynamics of cognitive change in impaired HIV-positive patients initiating antiretroviral therapy

OBJECTIVE

To rigorously evaluate the time course of cognitive change in a cohort of individuals with HIV-associated neurocognitive disorders (HAND) initiating combination antiretroviral therapy (CART), and to investigate which demographic, laboratory, and treatment factors are associated with neuropsychological (NP) outcome (or "any NP improvement").

METHODS

Study participants included 37 HIV+ individuals with mild to moderate NP impairment who initiated CART and underwent NP testing at 12, 24, 36, and 48 weeks thereafter. NP change was assessed using a regression-based change score that was normed on a separate NP-stable group thereby controlling for regression toward the mean and practice effect. Mixed-effect regression models adjusting for loss to follow-up were used to evaluate the time course of cognitive change and its association with baseline and time-varying predictors.

RESULTS

In persons with HAND initiating CART, cognitive improvement happens soon after initiation (13% at week 12), but more often 24, 36, and up to 48 weeks after initiation (up to 41%), with fewer than 5% demonstrating significant worsening. In multivariate analyses, unique predictors of NP improvement included more severe baseline NP impairment and higher CART CNS penetration index. Greater viral load decrease was associated with NP improvement only in univariate analyses.

CONCLUSION

Clinically meaningful neuropsychological improvement seemed to peak around 24-36 weeks after combination antiretroviral therapy initiation and was prolonged over the 1-year study period. This study also provides new evidence that benefit may be maximized by choosing antiretroviral medications that reach therapeutic concentrations in the CNS.

Survey of public perceptions of prion disease risks in Canada: what does the public care about?

A national public survey on public perceptions of prion disease risk in Canada was conducted from October to December 2007. The survey aimed at documenting the public's perceptions of prion diseases, within the broader context of food safety, in establishing parameters of risk acceptability. It also documented the public's perceptions of prion diseases in delineating social values and ethics that can guide Canada's future policies on prion disease risk management. In addition, the survey served to establish baseline data against which to monitor the evolution of the public's views on and understanding of this important risk issue. In total, 1517 Canadians were randomly selected to be representative of the adult population by region, age, and gender, as per the 2001 Census. This study presents descriptive findings from the survey regarding perceived risk, perceived control, uncertainty, sources of information, trust and knowledge, and beliefs pertaining to bovine spongiform encephalopathy (BSE). The survey data reveal that Canadians do not perceive mad cow disease as a salient risk but consider it more of an economic, political, social, and foreign trade issue than a public health one. Canadians are somewhat prepared to pay a premium to have a safer food supply, but not to the same extent that they desire extra measures pertaining to BSE risk management. In the context of increasing accountability in risk management decisions about food safety and population health issues, it is important to understand the way Canadians perceive such matters and identify their information needs and the factors that influence the acceptability of risks and of risk management policies.

Hepatitis C is associated with type 2 diabetes mellitus in HIV-infected persons without traditional risk factors

OBJECTIVES

Hepatitis C virus (HCV) monoinfection has been linked to type 2 diabetes mellitus (DM). We evaluated the effect of HCV on risk of DM in relation to traditional risk factors such as age, body mass index (BMI) and family history of DM in an HIV-infected population.

METHODS

This was a retrospective, cross-sectional study of 1529 HIV-infected out-patients. An adjusted multivariate logistic regression was performed to assess the effect of HCV seropositivity on DM stratified by low and high propensity for DM based on age, BMI and family history.

RESULTS

Race, age, BMI, family history and HCV were associated with DM. Use of protease inhibitors (PIs) was not associated with DM, but HIV/HCV-coinfected patients were less likely to be on PIs than those with HIV infection alone. In a multivariate analysis controlled for race, the association between HCV and DM was stronger in lean, young patients without a family history of DM; the low-risk group. No association between HCV and type 2 DM was seen in patients who were older or overweight or had a family history of DM; the high-risk group. PI use did not affect the association between HCV and DM.

CONCLUSIONS

Hepatitis C is an independent risk factor for type 2 diabetes in young, lean, HIV-infected patients. HIV-infected patients with HCV infection, regardless of whether they are on PIs, should be carefully screened for DM even if traditional risk factors for DM are not present.

Platelet-derived growth factor receptors and ligands are up-regulated in paediatric fibromatoses

AIMS

Platelet-derived growth factors (PDGF) and their receptors (PDGFR) play an essential role in pathways involved in the regulation of cell proliferation, growth and function. Overexpression of PDGF/R is reported in a wide range of solid tumours. The aim was to determine levels of PDGF/R expression in paediatric fibromatoses and myofibromatosis.

METHODS AND RESULTS

Quantitative real-time polymerase chain reaction was used to examine the expression level of alpha and beta isoforms of PDGF/R in 17 fibromatoses, four myofibromatoses and three dermatofibrosarcoma protuberans (DFSP) in children. Fifteen of 17 (88%) fibromatoses and all myofibromatoses and DFSPs demonstrated increased expression of PDGFalpha and beta compared with a panel of normal tissues. In terms of the cognate receptors, 13/17 (76%) fibromatoses demonstrated increased expression for PDGFRalpha and Rbeta, whereas 3/4 myofibromatoses demonstrated increased expression of PDGFRalpha and all four had increased PDGFRbeta expression. All DFSPs were associated with increased expression of both PDGFRalpha and PDGFRbeta compared with normal control tissues.

CONCLUSIONS

Increased expression of PDGF/Ralphabeta may play an important role in the mechanism of growth of these paediatric fibromatous lesions and warrants further investigation, since novel therapeutic interventions could potentially be developed in the light of the expression patterns.

Investigation of the effect of a countywide protected learning time scheme on prescribing rates of ramipril: interrupted time series study

BACKGROUND

Protected learning time (PLT) schemes have been set up in primary care across the UK. There is little published evidence of their effectiveness.

OBJECTIVE

To investigate the effect of a PLT intervention for general practice to increase prescribing of ramipril for prevention of cardiovascular outcomes.

DESIGN

Quasi-experimental, interrupted time series.

SETTING

Lincolnshire, UK.

METHODS

Prescribing data were analysed one year before and after the education for change in rate of increase of prescribing of ramipril, whether change in prescribing was related to postulated explanatory variables and to determine intervention costs.

MAIN OUTCOME

The primary outcome was the rate of change of ramipril (10 mg) prescription items 12 months after compared with before the educational intervention. Secondary outcomes included cost.

RESULTS

Ramipril prescribing at therapeutic dosage increased significantly (odds ratio 1.50, 95% CI 1.07-1.93) following education by 52,345 items (31,132 items at 10 mg) at a cost of pound 292k to pound 460k depending on formulation. This occurred despite a background of secular change. Most practices were represented by GPs, nurses or both during the education. Single-handed GPs were less likely to attend. Practices showed considerable variation in response to the educational intervention. The only predictor of whether practices increased in prescribing rate after the education was whether a practice nurse had undertaken specific diabetes training. Total list size, dispensing, training or single-handed status and GP attendance did not predict a change in prescribing.

CONCLUSION

PLT schemes can contribute to beneficial changes in prescribing across a large geographical area.

Prolonged function of macrophage, von Willebrand factor-deficient porcine pulmonary xenografts

Porcine von Willebrand factor (vWF) activates human and primate platelets. Having determined the importance of pulmonary intravascular macrophages (PIMs) in pulmonary xenotransplantation, we evaluated whether, in the absence of PIMs, vWF might play a role in pulmonary xenograft dysfunction. Utilizing a left single-lung transplant model, baboons depleted of anti-alphaGal antibodies received lungs from either vWF-deficient (n = 2); MCP-expressing (n = 5); MCP PIM-depleted (n = 5); or vWF-deficient PIM-depleted swine (n = 3). Two out of three of the PIM-depleted, pvWF deficient grafts survived longer than any previously reported pulmonary xenografts, including PIM-depleted xenografts expressing human complement regulatory proteins. Depletion of PIM's from vWF-deficient lungs, like depletion of PIM's from hMCP lungs, resulted in abrogation of the coagulopathy associated with pulmonary xenotransplantation. Thus, in terms of pulmonary graft survival, control of adverse reactions involving pvWF appears to be equally or even more important than is complement regulation using hMCP expression. However, based on the rapid failure of PIM-sufficient, pvWF-deficient pulmonary xenografts, pVWF-deficient pulmonary xenografts appear to be particularly sensitive to macrophage-mediated damage. These data provide initial evidence that vWF plays a role in the 'delayed' (24 h) dysfunction observed in pulmonary xenotransplantation using PIM depleted hMCP organs.

Risk of malignancy associated with chronic lymphocytic leukemia: A population based Canadian study

20020

Background: Patients with Chronic Lymphocytic Leukemia (CLL) may have an increased risk of other malignancies. Available literature reports on malignancies that develop after the diagnosis of CLL, but does not discuss malignancies that precede the diagnosis of CLL. Methods: All patients diagnosed with CLL between 01/1998 and 12/2003 were extracted from the provincial cancer registry and a centralized flow cytometry database. All other malignancies were obtained from the cancer registry. Dates of diagnoses were compared. A malignancy within 30 days before or after the diagnosis of CLL was considered synchronous with that diagnosis. Results were compared with the age-adjusted incidence of cancer in the province, excluding CLL. Results: Of the 713 cases of CLL, 333 invasive cancers and 38 in situ neoplasia were identified before, synchronous to, or after the diagnosis of CLL. Synchronous malignancies occurred in 4% of cases. The Standardized Incidence Ratio (SIR) for other malignancy subsequent to CLL was 1.40 (95% confidence interval [CI] 1.09–1.80) derived from 65 tumors for males, and 1.29 (95% CI 0.90–1.80) from 35 tumors for females. Mean time to diagnosis of subsequent cancer was 2.0 years (standard deviation[SD] 1.5). The SIR for other malignancy in the 5 years preceding the diagnosis of CLL was 1.36 (95% CI 0.93–1.94) from 31 tumors for males and 0.77 (95% CI 0.54–1.08) from 35 tumors for females. Mean time from diagnosis of preceding malignancy to CLL was 9.4 years (SD 8.7). Conclusions: In this population based study, patients with CLL are at increased risk of other invasive and in situ cancers. This risk is apparent after but not before the diagnosis of CLL, particularly in males. The mechanism of this increased risk may be acquired with the presence of CLL through an underlying but undetermined mechanism, as opposed to an inherent or more longstanding predisposition to malignancy.

No significant financial relationships to disclose.

Expression of ETV6-NTRK in classical, cellular and mixed subtypes of congenital mesoblastic nephroma

AIM

Congenital mesoblastic nephroma (CMN) is the commonest renal tumour of infancy, with classical, cellular and mixed histological subtypes described. A specific ETV6-NTRK3 fusion-gene product is reported in association with the cellular variant. The aim was to investigate the relationship between the presence of this product and morphological phenotype using paraffin-embedded archival material.

METHODS AND RESULTS

Cases of CMN from a single centre during a 15-year period (1989-1994) were identified, anonymized and blindly classified using morphological criteria. RNA was extracted from frozen and paraffin sections for both conventional reverse transcriptase-polymerase chain reaction (RT-PCR) and quantitative real-time RT-PCR. Fifteen samples were analysed; two were non-informative and three expressed ETV6-NTRK3 using both techniques, two showing similar expression, whilst one showed expression two orders of magnitude lower, from a cellular tumour. All fusion positive cases were previously classified as cellular subtype. Six patients had mixed-subtype tumours in which the cellular components, morphologically indistinguishable from cellular tumours, were fusion negative, as were all classical cases.

CONCLUSIONS

Real-time PCR Taqman assays, using both fixed and frozen tissue, provide highly reproducible detection and quantification of fusion transcript expression. Differences in expression levels may explain previous conflicting data on fusion gene detection in these tumours.

On judgment and judgmentalism: how counselling can make people better

Counsellors, like other members of the caring professions, are required to practise within an ethical framework, at least in so far as they seek professional accreditation. As such, the counsellor is called upon to exercise her moral agency. In most professional contexts this requirement is, in itself, unproblematic. It has been suggested, however, that counselling practice does present a problem in this respect, in so far as the counsellor is expected to take a non-judgemental stance and an attitude of "unconditional positive regard" toward the client. If, as might appear to be the case, this stance and attitude are at odds with the making of moral judgments, the possibility of an adequate ethics of counselling is called into question. This paper explores the nature and extent of the problem suggesting that, understood in a Kantian context, non-judgmentalism can be seen to be at odds with neither the moral agency of the counsellor nor that of the client. Instead, it is argued, the relationship between the non-judgmental counsellor and her client is a fundamentally moral relationship, based on respect for the client's unconditional worth as a moral agent.

The importance of metabolic rate and the folly of body surface area calculations

Mathematical formulae to calculate body surface area from measurements of height, weight and other parameters date from the late 19th century. Drug doses, fluid therapy, caloric requirements and physiological parameters such as cardiac output, glomerular filtration rate and a variety of respiratory function parameters are all frequently expressed in terms of a body surface area. Body surface area is often used in preference to body mass (weight). However, the original rationale for using body surface area as an estimate for metabolic rate has never been tested and the algorithms used to approximate body surface area have little evidence to support their use in this role. Recent developments in technology using indirect calorimetry allow easy measurement of metabolic rate in the clinical setting. Such measurements should be used for standardisation when weight alone is considered inadequate.

Dietary sugars and micronutrient dilution in normal adults aged 65 years and over

OBJECTIVE

To examine the relationship between non-milk extrinsic sugars (NMES) concentration and micronutrient intakes and status in free-living older people.

DESIGN

The National Diet and Nutrition Survey of people aged 65 years and over; a cross-sectional study in Britain in 1994/5.

SUBJECTS AND METHODS

Eight hundred and six men and women living in private households who were not on medication for nutritional disorders. Subjects were classified into four groups (Q1 to Q4), using cut-off points corresponding to quartiles of energy from NMES. Relationships were examined between dietary NMES concentration and intakes of calcium, iron, riboflavin, folate, vitamin C and vitamin D. Status indices were also assessed in each group.

RESULTS

Overall, a small proportion of men and women had intakes below the Lower Reference Nutrient Intake (LRNI) for calcium, iron, folate, riboflavin or vitamin C, while vitamin D intakes were universally low. Intakes of micronutrients tended to be highest at moderate levels of NMES in the diet (Q2 and Q3, equivalent to 8-15% of energy from NMES). Micronutrient status was low for riboflavin in 38% of the sample, while 15% had low vitamin C status and more than 10% were anaemic. There was little evidence that poorer nutrient status was associated with higher levels of dietary NMES. Although some indices of folate status were lower in Q4, this is most likely to reflect confounding by smoking. Energy intake accounted for 20-40% of the variance in micronutrient intakes, compared with less than 5% for NMES concentration.

CONCLUSIONS

A diet moderately high in NMES (up to around 15% of energy) is unlikely to have a detrimental impact on micronutrient intake or status in this age group. Energy intake is the major determinant of micronutrient adequacy.

Comparison of test characteristics of urine dipstick and urinalysis at various test cutoff points

STUDY OBJECTIVE

We compare the test characteristics of urine dipstick and urinalysis at various test cutoff points in women presenting to emergency departments and an intermediate care center with symptoms of urinary tract infection.

METHODS

This was a prospective, observational study of adult women presenting to 1 of 2 community hospital EDs or an intermediate care center with dysuria, urgency, or urinary frequency on history, or suprapubic or costovertebral angle tenderness on examination. Patients who had taken antibiotics in the past 72 hours, had indwelling Foley catheters, symptomatic vaginal discharge, diabetes mellitus, immunodeficiency disorders, or were unable to provide a reliable history were excluded. The patient's clean-catch or catheterized urine specimen was tested immediately by a nurse using a Multistix 9 SG reagent strip. A second aliquot was sent within 1 hour of collection to the hospital laboratory, where a semiautomated microscopic urinalysis and a urine culture were performed. A positive urine culture was defined as more than 100,000 colonies of 1 or 2 uropathogenic bacteria per mL of urine at 48 hours. Dipstick and urinalysis data were compared with urine culture results. Sensitivity, specificity, and predictive values were calculated at various definitions of a positive test, or "test cutoff points," for combinations of leukocyte esterase, nitrite, and blood on dipstick and for RBCs and WBCs on urinalyses. The probability of an erroneous decision to withhold treatment on the basis of a negative test result was defined as "undertreatment," or 1 minus the negative predictive value. "Overtreatment" was defined as 1 minus the positive predictive value.

RESULTS

Three hundred forty-three patients were enrolled in this study. Twelve patients were withdrawn because of missing laboratory results. Forty-six percent (152/331) of patients had positive urine cultures. If urine dipstick results are defined as positive when leukocyte esterase or nitrite is positive or blood is more than trace, the overtreatment rate is 47% (156/331) and the undertreatment rate is 13% (43/331). If urinalysis results are defined as positive when WBCs are more than 3 per high-power field or RBCs are more than 5 per high-power field, the overtreatment rate is 44% (146/331) and the undertreatment rate is 11% (36/331). Matched pairs of test characteristics were identified when the analysis was repeated using more than 10,000 colonies per mL as a positive culture.

CONCLUSION

In this patient population, similar overtreatment and undertreatment rates were identified for various test cutoff points for urine dipstick tests and urinalysis. Although a urine dipstick may be equivalent to a urinalysis for the diagnosis of urinary tract infection, the limitations in the diagnostic accuracy of both tests should be incorporated into medical decisionmaking.