Very low level viraemia and risk of virological failure in treated HIV-1-infected patients

OBJECTIVES

The aim of the study was to investigate whether very low level viraemia (VLLV) (20-50 HIV-1 RNA copies/mL) was associated with increased risk of virological failure (VF) as compared with persistent full suppression (< 20 copies/mL).

METHODS

From the VACH Cohort database, we selected those patients who started antiretroviral therapy (ART) after January 1997 and who achieved effective viral suppression [two consecutive viral loads (VLs) < 50 copies/mL] followed by full suppression (at least one VL <20 copies/mL). We carried out survival analyses to investigate whether the occurrence of VLLV rather than maintaining full suppression at < 20 copies/mL was associated with virological failure (two consecutive VLs > 200 copies/mL or one VL > 200 copies/mL followed by a change of ART regimen, administrative censoring or loss to follow-up), adjusted for nadir CD4 cell count, sex, age, ethnicity, transmission group, type of ART and time on effective suppression at < 50 copies/mL.

RESULTS

Of 21 480 patients who started ART, 13 674 (63.7%) achieved effective suppression at < 50 copies/mL, of whom 4289 (31.4%) further achieved full suppression at < 20 copies/mL after May 2009. A total of 2623 patients (61.1%) remained fully suppressed thereafter, while 1666 had one or more episodes of VL detection > 20 copies/mL (excluding virological failure). A total of 824 patients had VLLV after suppression at < 20 copies/mL. VLLV was not associated with virological failure as compared with persistent full suppression [hazard ratio (HR) 0.67; 95% confidence interval (CI) 0.44-1.00], independently of the number of blips recorded (from one to 18).

CONCLUSIONS

In our population of HIV-infected patients on ART who achieved viral suppression at < 20 copies/mL, the risk of virological failure was no different for patients who remained fully suppressed compared with those who experienced subsequent episodes of VLLV.

Reproductive desire in women with HIV infection in Spain, associated factors and motivations: a mixed-method study

Background

Antiretroviral therapy has created new expectations in the possibilities of procreation for persons living with HIV. Our objectives were to evaluate reproductive desire and to analyze the associated sociodemographic and clinical factors in HIV-infected women in the Spanish AIDS Research Network Cohort (CoRIS).

Methods

A mixed qualitative-quantitative approach was designed. Women of reproductive age (18–45) included in CoRIS were interviewed by phone, and data were collected between November 2010 and June 2012 using a specifically designed questionnaire. Reproductive desire was defined as having a desire to be pregnant at present or having unprotected sex with the purpose of having children or wanting to have children in the near future.

Results

Overall, 134 women were interviewed. Median age was 36 years (IQR 31–41), 55% were Spanish, and 35% were unemployed. 84% had been infected with HIV through unprotected sex, with a median time since diagnosis of 4.5 years (IQR 2.9-6.9). Reproductive desire was found in 49% of women and was associated with: 1) Age (women under 30 had higher reproductive desire than those aged 30–39; OR = 4.5, 95% CI 1.4-14.3); 2) having no children vs. already having children (OR = 3.2; 1.3-7.7 3); Being an immigrant (OR = 2.2; 1.0-5.0); and 4) Not receiving antiretroviral treatment (OR = 3.6; 1.1-12.1). The main reasons for wanting children were related to liking children and wanting to form a family. Reasons for not having children were HIV infection, older age and having children already. Half of the women had sought or received information about how to have a safe pregnancy, 87% had disclosed their serostatus to their family circle, and 39% reported having experienced discrimination due to HIV infection.

Conclusions

The HIV-infected women interviewed in CoRIS have a high desire for children, and the factors associated with this desire are not fundamentally different from those of women in the general population. Maternity may even help them face a situation they still consider stigmatized and prefer not to disclose. Health-care protocols for handling HIV-positive women should incorporate specific interventions on sexual and reproductive health to help them fulfill their procreation desire and experience safe pregnancies.

Prevalencia de factores de riesgo cardiovascular en pacientes con infección por el VIH

INTRODUCTION

To determine the prevalence of cardiovascular risk factors in human immunodeficiency virus (HIV)-infected patients.

PATIENTS AND METHOD

A cross-sectional study was performed with HIV-infected patients aged 20 or over managed at the outpatient Infectious Disease Unit during 2003. Clinical and epidemiological characteristics of HIV infection and cardiovascular risk factors were evaluated.

RESULTS

The final 760 patients included in the study had a mean of 1.5 cardiovascular risk factors, with smoking being the most prevalent (66.8%; CI 95%: 63.4-70.2). The cardiovascular risk factor of age and gender was present in 26.4% (CI 95%: 23.3-29.7) of patients and family history of premature coronary heart disease in 14.3% (CI 95%: 11.8-16.9). The prevalence of hypertension and diabetes mellitus was 13.2% (CI 95%: 10.8-15.8) and 4.3% (CI 95%: 3.0-6.0), respectively. High density lipoprotein (HDL) cholesterol concentration under 40 mg/dl was found in 29.3% (CI 95%: 26.1-32.7) and above 60 mg/dl in 16.3% (CI 95%: 13.8-19.1). Twenty-five patients (3.3%; CI 95%: 2.1-4.8) had suffered overt cardiovascular disease.

CONCLUSION

Smoking and HDL cholesterol were the main cardiovascular risk factors in this HIV-infected cohort.

Sotalol exhibits reverse use-dependent action on monophasic action potentials in normal but not in infarcted canine ventricular myocardium

In 12 anesthetized mongrel dogs (30 mg/kg pentobarbital), a thoracotomy was performed, and the left anterior descending coronary artery was ligated proximally. Eight to 12 days later, monophasic action potentials were recorded endocardially from the apex of the noninfarcted right ventricle and infarcted areas of the left ventricle, and the effects of 1.5 mg/kg intravenous sotalol were evaluated. Monophasic action potentials from the infarcted zone of the left ventricle were obtained from areas where fractionated bipolar electrograms could be recorded; this was histologically confirmed. After sotalol, in sinus rhythm, the monophasic action potential duration at 90% repolarization of the infarcted zone increased from 186 +/- 31 to 226 +/- 45 ms (+ 22%, p less than 0.05), and monophasic action potential duration of the noninfarcted zone increased from 184 +/- 31 to 225 +/- 47 ms (+ 22%, p less than 0.05). Programmed ventricular stimulation was performed with single extrastimuli at a basic drive cycle length of 300 ms. With long coupling intervals (290 ms), monophasic action potential duration of the infarcted zone increased from 165 +/- 23 to 183 +/- 25 ms (+ 11%, p less than 0.05) after sotalol; and monophasic action potential duration of the noninfarcted zone increased from 159 +/- 20 to 180 +/- 25 ms (+ 13%, p less than 0.05). With short coupling intervals (200 ms), the monophasic action potential duration of the noninfarcted zone increased from 157 +/- 19 to 173 +/- 18 ms (+ 10%, p less than 0.05), and monophasic action potential duration of the noninfarcted zone increased from 150 +/- 18 to 157 +/- 18 ms (+ 5%, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

A Lower Baseline CD4/CD8 T-Cell Ratio Is Independently Associated with Immunodiscordant Response to Antiretroviral Therapy in HIV-Infected Subjects

We explored if baseline CD4/CD8 T-cell ratio is associated with immunodiscordant response to antiretroviral therapy in HIV-infected subjects. Comparing immunodiscordant and immunoconcordant subjects matched by pretreatment CD4 counts, we observed a lower pretreatment CD4/CD8 T-cell ratio in immunodiscordant subjects. Furthermore, pretreatment CD4/CD8 T-cell ratio, but not CD4 counts, correlated with the main immunological alterations observed in immunodiscordants, including increased regulatory T-cell (Treg) frequency and T-cell turnover-related markers. Then, in a larger cohort, only baseline CD4/CD8 T-cell ratio was independently associated with immunodiscordance, after adjusting by the viral CXCR4-tropic HIV variants. Our results suggest that the CD4/CD8 T-cell ratio could be an accurate biomarker of the subjacent immunological damage triggering immunodiscordance.

Acute and chronic antiarrhythmic efficacy of d-sotalol in patients with sustained ventricular tachyarrhythmias

To evaluate the clinical efficacy of d-sotalol, 84 patients with a history of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF), who had inducible sustained VT/VT at baseline electrophysiologic study (EPS), were investigated after intravenous (IV) d-sotalol (1.5-2.5 mg.kg-1). A total of 29 additional patients received only oral d-sotalol, (400-600 mg.day-1). Acute success of antiarrhythmic therapy was defined as suppression of inducible sustained VT/VF. The overall success rate of IV d-sotalol was 38% (32/84) after a mean of 4.3 drugs failed to suppress inducibility. A 78% success rate (31/40) was demonstrated in patients who were also assessed after oral d-sotalol. Torsade de pointes type VT was seen in one patient. After 1 year, only 16% of patients with a positive EPS had a recurrence compared to 43% of patients with a negative EPS (P < 0.05). Estimated survival rates were 95 and 88% after 1 and 2 years of follow-up, respectively. Only five of 56 patients discontinued d-sotalol therapy because of adverse effects. IV d-sotalol appears to be an effective antiarrhythmic agent. Its long-term efficacy is predictable on the basis of therapy guided by electrophysiologic testing in patients with refractory ventricular tachyarrhythmias. The efficacy of d-sotalol seems comparable to that reported for d,l-sotalol.

Recording of transmembrane action potentials in chronic ischemic heart disease and dilated cardiomyopathy and the effects of the new class III antiarrhythmic agents D-sotalol and dofetilide

We recorded intracellular endocardial action potentials (AP) in left ventricular specimens obtained from 10 patients with dilated cardiomyopathy (dil CMP) and 7 patients with chronic ischemic heart disease (CAD) in whom orthotopic heart transplantation had been performed. The concentration-dependent electrophysiological effects of the new class III antiarrhythmic agents dofetilide (Dof) (3 x 10(-8)-10(-6) M) and D-sotalol (D-Sot) 10(-5)-5 x 10(-4) M) were determined. The following parameters were recorded: action potential amplitude (APA), resting membrane potential (RMP), AP duration at 95 and 50% of repolarization (APD95, APD50), maximal upstroke velocity (V(max)), and effective refractory period (ERP) at a cycle length of 1 Hz. The measured AP parameters did not differ in dil CMP and CAD. APD50, APD95, and ERP were significantly prolonged at Dof concentration > or = 10(-7) M and at D-Sot concentrations > or = 10(-4) M. No effects were observed on RMP, APA, or V(max). The AP characteristics of dil CMP and CAD did not differ. The data demonstrate class III effects of Dof and D-Sot on endocardial AP of diseased human ventricular myocardium. As compared with those of D-Sot, the effects of Dof on APD and ERP were similar but were obtained with lower concentrations.

Tenofovir disoproxil fumarate/emtricitabine and severity of coronavirus disease 2019 in people with HIV infection

BACKGROUND

Effective, safe, and affordable antivirals are needed for coronavirus disease 2019 (COVID-19). Several lines of research suggest that tenofovir may be effective against COVID-19, but no large-scale human studies with appropriate adjustment for comorbidities have been conducted.

METHODS

We studied HIV-positive individuals on antiretroviral therapy (ART) in 2020 at 69 HIV clinics in Spain. We collected data on sociodemographics, ART, CD4+ cell count, HIV-RNA viral-load, comorbidities and the following outcomes: laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, COVID-19 hospitalization, intensive care unit (ICU) admission and death. We compared the 48-week risks for individuals receiving tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), tenofovir alafenamide (TAF)/FTC, abacavir (ABC)/lamivudine (3TC), and other regimes. All estimates were adjusted for clinical and sociodemographic characteristics via inverse probability weighting.

RESULTS

Of 51 558 eligible individuals, 39.6% were on TAF/FTC, 11.9% on TDF/FTC, 26.6% on ABC/3TC, 21.8% on other regimes. There were 2402 documented SARS-CoV-2 infections (425 hospitalizations, 45 ICU admissions, 37 deaths). Compared with TAF/FTC, the estimated risk ratios (RR) (95% confidence interval) of hospitalization were 0.66 (0.43, 0.91) for TDF/FTC and 1.29 (1.02, 1.58) for ABC/3TC, the RRs of ICU admission were 0.28 (0.11, 0.90) for TDF/FTC and 1.39 (0.70, 2.80) for ABC/3TC, and the RRs of death were 0.37 (0.23, 1.90) for TDF/FTC and 2.02 (0.88-6.12) for ABC/3TC. The corresponding RRs of hospitalization for TDF/FTC were 0.49 (0.24, 0.81) in individuals ≥50 years and 1.15 (0.59, 1.93) in younger individuals.

DISCUSSION

Compared with other antiretrovirals, TDF/FTC lowers COVID-19 severity among HIV-positive individuals with virological control. This protective effect may be restricted to individuals aged 50 years and older.

Agenesis of the scrotum

Congenital agenesis of the scrotum skin is an extremely rare disorder with only two cases previously reported. We report a newborn with scrotal agenesis and congenital hypothyroidism.

Is Visceral Leishmaniasis Different in Immunocompromised Patients Without Human Immunodeficiency Virus? A Comparative, Multicenter Retrospective Cohort Analysis

Although visceral leishmaniasis (VL) can affect immunocompromised patients, data from the human immunodeficiency virus (HIV) infection context are limited, and the characteristics of VL in other immunosuppression scenarios are not well defined. A retrospective review of all cases of VL in immunocompromised patients from January 1997 to December 2014 in two Spanish hospitals on the Mediterranean coast was performed. We included 18 transplant recipients (kidney: 7, liver: 4, lung: 3, heart: 2, and blood marrow: 2), 12 patients with other causes of immunosuppression (myasthenia gravis: 3 and rheumatoid arthritis: 2), and 73 VL HIV-positive patients. Fever was more common in transplant patients (94.4%) and patients with other types of immunosuppression (100%) than in HIV-positive individuals (73.3%). Hepatomegaly was less common in transplant recipients (27.8%) and patients with other types of immunosuppression (41.7%) compared with HIV-positive patients (69.9%) (P = 0.01; P = 0.001, respectively). Patients with other types of immunosuppression had a median leukocyte count of 1.5 × 10⁹/L, significantly lower than HIV-positive patients (2.5 × 10⁹/L) (P = 0.04). Serology was more commonly positive in nontransplant immunosuppressed individuals (75%) and transplant recipients (78.6%) than in HIV-patients (13.8%) (P < 0.001). Antimonial therapy was rarely used in transplant recipients (1.9%) and never in patients with other immunosuppressive conditions, whereas 34.2% of HIV-positive patients received it (P = 0.05 and P = 0.01, respectively). Mortality was 16.7% in both transplant recipients and patients with other immunosuppressive conditions and 15.1% in HIV-positive patients. The features of VL may be different in immunosuppressed patients, with more fever and less hepatomegaly and leukopenia than in HIV-infected patients.

Measurement of 'in situ' mitochondrial membrane potential in Ehrlich ascites tumor cells during aerobic glycolysis

(1) A method is presented for continuous and simultaneous monitoring of the 'in situ' mitochondrial membrane potential (delta psi m) and respiration rate of Ehrlich ascites tumor cells. The method involves permeabilization of the plasma membrane, achieved by treatment with low digitonin concentration, and the use of a TPP+ selective electrode attached to an oxygraph vessel. Binding of the probe inside the cells was analyzed assuming a proportional relationship between the amount of bound TPP+ and the free concentration of the lipophilic cation. (2) Evidence is reported that the addition of glucose to digitonin-permeabilized Ehrlich ascites tumor cells causes a decrease of mitochondrial membrane potential that coincided with a transient enhancement of the respiration rate and remained unchanged during the subsequent Crabtree effect. We have characterized the effect of glucose on delta psi m by determining its dependent on the glycolytic pathway and its sensitivity towards oligomycin. The mutual relationships between glucose and ADP effects on the mitochondrial membrane potential were also studied. A plausible mechanism underlying the depolarization of mitochondrial membrane induced by glucose is presented.

Evolving understanding of cardiovascular, cerebrovascular and peripheral arterial disease in people living with HIV and role of novel biomarkers. A study of the Spanish CoRIS cohort, 2004-2015

OBJECTIVES

To analyze the incidence rates (IR) and spectrum of vascular events in people living with HIV (PLWH) in Spain from 2004 to 2015. Serial measurements of different plasma cardiovascular biomarkers were assessed in relation to disease development.

METHODS

Longitudinal study in a nationwide contemporary multicenter cohort of PLWH. A nested case-control study was performed to evaluate the predictive value of cardiovascular biomarkers. Additive generalized and Cox mixed models were used for the analyses.

RESULTS

9,712 PLWH and 48,341 person-years of follow-up were analysed. During 2004-2015, 147 persons developed 154 vascular events; 80 (54.42%) coronary-related; 65 (44.22%) cerebrovascular-related, and 9 (6.12%) peripheral arterial disease. The 2004-2015 IR (95% confidence interval) of vascular events was 3.17 (2.69-3.71) x1,000 person-years; 1.64 (1.30-2.05) for coronary events; 1.34 (1.03-1.70) for cerebrovascular events; and 0.19 (0.09-0.35) for peripheral arterial disease (p<0.001). IR of vascular events gradually increased from 0.37 (0.12-0.85) x1,000 patient-years in the stratum 25-34-years to 19.65 (6.38-45.85) x1,000 patient-years in the stratum 75-84-years. Compared to the general population, there was a higher incidence of acute myocardial infarction (AMI) in men (sIR ratio 1.29 [95% CI 1.16-1.42]), of cerebrovascular events in women (sIR ratio 2.44 [95% CI 1.68-3.19]), and of both types of events specifically among the younger age-strata. CD4 count (hazard ratio 0.80, [95% CI, 0.79-0.81]), age (1.86 [1.47-2.34] for 45-65 years and 3.44 [2.37-4.97] for >65 years) and vascular event (1.81 [1.12-2.94]) were associated with total mortality. Adjusted levels of intercellular-adhesion-molecule (sICAM), pro-b-type-natriuretic-peptide (pro-BNP) and marginally sCD14, were higher among patients who subsequently developed vascular events.

CONCLUSION

Vascular events in PLWH do preferentially occur in the older age-strata, they are associated with increased mortality and, compared to the general population, the excess risk occurs at younger ages. Peripheral arterial disease is unusual. Vascular events are preceded by increased levels of sICAM, pro-BNP and, marginally, sCD14.

Differential effects of quinidine on transmembrane action potentials of normal and infarcted canine Purkinje fibers

Fourteen days after proximal ligation of the left anterior descending coronary artery (LAD) of mongrel dogs, the effects of quinidine on action potentials of normal and infarcted Purkinje fibers were evaluated. The concentration-dependent (10(-7)-3 x 10(-5) M) and frequency-dependent (1 and 3 Hz) actions of quinidine were evaluated by the following parameters: maximum upstroke velocity (Vmax), action potential duration at 50 and 95% repolarization (APD50, APD95), effective refractory period (ERP), resting membrane potential (RMP), and action potential amplitude (APA). Quinidine reduced Vmax in normal and abnormal Purkinje fibers in a concentration- and frequency-dependent manner; these effects were more pronounced in infarcted tissue. The APD50 was shortened significantly at 1 Hz in noninfarcted Purkinje fibers, whereas in infarcted Purkinje fibers quinidine had no effect on APD50. The APD95 was not significantly altered by quinidine in normal Purkinje fibers; in infarcted areas APD95 was significantly prolonged at 1 and 3 Hz. The effective refractory period (ERP) was prolonged in normal and infarcted Purkinje fibers, these effects were more marked in ischemically damaged fibers. No effects were observed on resting membrane potential (RMP). APA was reduced significantly after quinidine at 1 and 3 Hz; there was no difference between normal and infarcted tissue. These data indicate a differential effect of quinidine in normal and infarcted Purkinje fibers which may be an important mechanism of action of quinidine in infarcted tissue.

The algorithm used for the interpretation of doravirine transmitted drug resistance strongly influences clinical practice and guideline recommendations

OBJECTIVES

We report the results of the reverse transcriptase (RT)/protease (PR) transmitted drug resistance (TDR) prevalence study in 2018, focusing on doravirine resistance-associated mutations and the differences observed when Stanford or French National Agency for AIDS Research (ANRS)/Spanish Network of AIDS Research (RIS)/IAS-USA resistance interpretation algorithms are used to describe clinically relevant resistance.

METHODS

We used the WHO 2009 list to investigate the prevalence of NNRTI, NRTI and PI TDR, in treatment-naive HIV-1-infected patients, adding mutations E138A/G/K/Q/R, V106I, V108I, V179L, G190Q, H221Y, F227C/L/V, M230IDR, L234I, P236L and Y318F in RT. The prevalence of doravirine resistance-associated mutations, as described by Soulie et al. in 2019, was evaluated. Clinically relevant TDR was investigated using the latest versions of ANRS, RIS, IAS-USA and Stanford algorithms.

RESULTS

NNRTI mutations were detected in 82 of 606 (13.5%) patients. We found 18 patients (3.0%) with NRTI mutations and 5 patients (0.8%) with PI mutations. We detected 11 patients harbouring doravirine resistance-associated mutations (prevalence of 1.8%). Furthermore, we observed important differences in clinically relevant resistance to doravirine when ANRS/RIS (0.7%), IAS-USA (0.5%) or Stanford algorithms (5.0%) were used. V106I, which was detected in 3.8% of the patients, was the main mutation driving these differences. V106I detection was not associated with any of the clinical, demographic or virological characteristics of the patients.

CONCLUSIONS

The prevalence of NRTI and PI TDR remains constant in Spain. Doravirine TDR is very infrequent by RIS/ANRS/IAS-USA algorithms, in contrast with results using the Stanford algorithm. Further genotype-phenotype studies are necessary to elucidate the role of V106I in doravirine resistance.

Yarrowia lipolytica cell wall architecture: interaction of Ywp1, a mycelial protein, with other wall components and the effect of its depletion

Linkages of Ywp1 to other components of the Yarrowia lipolytica mycelial cell wall were studied by extraction with beta-mercaptoethanol and zymolyase (a beta-glucanase complex) and by the use of rabbit polyclonal antibody preparation raised against Ywp1. Ywp1 complexed with an N-glycosylated cell wall protein(s) to form supramolecular complexes through disulphide bridges (extractable with beta-mercaptoethanol) or bonded to beta-1,3-glucan (extractable with zymolyase). The lack of a specific morphological phenotype when YWP1 was knocked out by gene disruption might indicate that other proteins present in the cell wall of Y. lipolytica compensated for its loss. In this mutant, the electrophoretic pattern of proteins, detected with polyclonal antibodies against the entire cell wall, was different from that obtained with the parental strain, but sensitivity to calcofluor white, zymolyase and chitinase did not change. Quantitative analysis of fluorescence emitted by cells in the presence of fluorescent wheat germ agglutinin (FITC-WGA) indicated that chitin was organized in the cell wall of the mutant cells in a form different from that in the parental strain.

A new microplate red blood cell monolayer technique for screening and identifying red blood cell antibodies

A new method has been developed to immobilize red blood cells in wells of microplates using a cell fixation buffer. This method has been employed for detecting and identifying red blood cell antibodies with greater sensitivity than haemagglutination antiglobulin tests, without loss of specificity. This method decreases the amount of test erythrocytes and anti-human globulin reagents employed per test, consequently lowering the cost.

Production and characterization of human gamma interferon from Escherichia coli

The production of human gamma interferon as intracellular inclusion bodies in Escherichia coli, which simplified the purification process, is described. An expression plasmid carrying lipoprotein and the tryptophane promoters in tandem was used. Preparation of highly pure interferon was achieved using high resolution chromatography after denaturation and renaturation steps. Structural characteristics of this protein were verified by mass spectrometric analysis. Additional control tests have shown the suitability of the final product for clinical purposes.

The pathway for refilling intracellular Ca2+ stores passes through the cytosol in human leukaemia cells

The pathway for refilling the intracellular Ca2+ stores of HL60 and U937 human leukaemia cells loaded with fura-2 has been investigated. On addition of external Ca2+ to cells with empty stores there was an increase in the cytosolic Ca2+ concentration ([Ca2+]i) which preceded the refilling of the stores. The increase in [Ca2+]i was faster than the refilling, by 3- to 15-fold, depending on the cell type. In measurements in single HL60 cells we found that the refilling of the stores correlated with the extent of the [Ca2+]i increase on addition of external Ca2+. The cells showing no [Ca2+]i increase were unable to refill their stores. The addition of Ni2+ to the extracellular medium prevented both the [Ca2+]i increase and the refilling of the stores. These results indicate that the limiting step for store refilling is the entry of Ca2+ from the extracellular medium to the cytosol. Hence, we conclude that extracellular Ca2+ cannot gain access directly to the intracellular Ca2+ stores in these cells, but must first enter the cytosol and be taken up from there into the stores.

Tuberculosis in a cohort of HIV-positive patients: epidemiology, clinical practice and treatment outcomes

OBJECTIVE

To describe tuberculosis (TB) incidence, risk factors, clinical presentation, disease management and outcomes in human immunodeficiency virus (HIV) infected patients from the CoRIS cohort, Spain, 2004-2010.

DESIGN

Open multicentre cohort of antiretroviral treatment (ART) naïve patients at entry. Incidence and risk factors were evaluated using multivariate Poisson regression.

RESULTS

Among 6811 patients, 271 were eligible for the study and 198 for the estimation of the incidence rate; TB incidence ranged from 12.1 to 14.1/1000 person-years. TB was associated with low education level (rate ratio [RR] 2.65, 95%CI 1.73-4.07), being sub-Saharan African (RR 3.14, 95%CI 1.81-5.45), heterosexual (RR 2.01, 95%CI 1.22-3.29) or an injecting drug user (RR 2.11, 95%CI 1.20-3.69), not undergoing ART (RR 3.33, 95%CI 2.22-4.76), CD4 <200 cells/mm(3) (RR 5.20, 95%CI 3.25-8.33) and log-viral load of 4-5 (RR 5.44, 95%CI 3.28-9.02) or >5 (RR 13.10, 95%CI 8.27-20.76). Overall, 87% were new cases and 13% were previously treated cases; 175 (65%) were bacteriologically confirmed. Drug susceptibility testing was performed in 146 (83%) patients: resistance to first-line drugs was 11.1% in new and 36.4% in previously treated cases. Standard anti-tuberculosis treatment with four or three drugs was prescribed in respectively 55% and 36% of cases. Treatment default was 11%, and was higher among previously treated cases; 80% received ART during anti-tuberculosis treatment, 80% of new and 50% of previously treated cases were cured or completed treatment, and 18 (6.6%) died.

CONCLUSION

TB incidence in HIV-infected patients remains high. Interventions should include early HIV diagnosis and access to ART, enhanced bacteriological confirmation, wider use of four-drug regimens and reduction in treatment default.

Reproductive history before and after HIV diagnosis: A cross-sectional study in HIV-positive women in Spain

The aim of this study is to examine the reproductive history of human immunodeficiency virus (HIV)-positive women, before and after HIV diagnosis, to describe the characteristics of women with pregnancies after HIV diagnosis, and to assess the prevalence of mother-to-child transmission.A cross-sectional study was performed among women within reproductive ages (18-49) selected from the cohort in the Spanish AIDS Research Network (CoRIS). A descriptive analysis of the pregnancy outcomes was made according to women's serostatus at the moment of pregnancy and association of women's characteristics with having pregnancy after HIV diagnosis was evaluated using logistic regression models.Overall, 161 women were interviewed; of them, 86% had been pregnant at least once and 39% after HIV diagnosis. There were 347 pregnancies, 29% of them occurred after HIV diagnosis and in these, 20% were miscarriages and 29% were voluntary termination of pregnancy. There were 3 cases of mother-to-child transmission among the 56 children born from HIV-positive mothers; in these cases, women were diagnosed during delivery. Having a pregnancy after HIV diagnosis was more likely when the younger women were at the time of diagnosis: odds ratio (OR) = 1.29 (95% confidence interval 0.40-4.17) for 25 to 29 years old, OR = 0.59 (0.15-2.29) for 30 to 34 years old, OR = 0.14 (0.03-0.74) for ≥35 years old, compared with those <25 years at diagnosis, who were diagnosed for ≥5 years (OR = 5.27 [1.71-16.18]), who received antiretroviral treatment at some point (OR = 9.38 [1.09-80.45]), and who received information on reproductive health (OR = 4.32 [1.52-12.26]).An important number of pregnancies occurred after HIV diagnosis, reflecting a desire for motherhood in these women. Reproductive and sexual health should be tackled in medical follow-ups.

[Identification of doctors with high pharmaceutical expenditure]

OBJECTIVE

[corrected] To identify doctors with high pharmaceutical expenditure through multiple regression of variables not exclusively dependent on the doctor's decision. To compare the agreement with the method of the Spanish national health servicem which only considered the percentage of pensioners of the doctor's list.

METHODS

Cross-sectional, retrospective, descriptive study of the pharmaceutical expenditure of 220 general practitioners in the health district of Toledo (Spain) in 1999. The following variables were collected: pharmaceutical expenditure for policy-holder/month (PEP-H); age; sex; habitat; size of the list; percentage of pensioners; frequency of attendance (consults/policy-holder-year) and workload (consultations per day). A multiple regression model with backwards elimination was constructed, taking like PEP-H as the dependent variable and the remaining as the independent variables. The resultant equation enabled calculation of the expected PEP-H for each doctor and the deviation of their real expenditure ofrom the expected. Doctors were considered to have high pharmaceutical expenditure when the deviation was more than the mean plus 1 standard deviation of this distribution.

RESULTS

The mean PEP-H was 2,584.4 pesetas. Differences were found (F = 11.665; p < 0.005) in PEP-H per habitat (2,723.2 in rural, 2,521.4 in semi urban and 2,168.2 in urban). A significant correlation was found (p < 0.005) between PEP-H and percentage of pensioners (r = 0.728) and frequency of attendance (r = 0.607). Our final model included percentage of pensioners, frequency of attendance, and age (F = 102.33; p < 0.005; r = 0.767; r² = 0.588; β = 206.05; β₁ = 48.27; β₂ = 61.26; β₃ = 9.55). This model were identified 25 DHPC. With the INSALUD model the identification were of 31. The Kappa index showed that agreement between both methods was 0.706 (SE 0.056) and simple disagreement was found in the classification of 24 doctors (10.9%).

CONCLUSIONS

Frequency of attendance and the percentage of pensioners on doctors' lists are iclosely related to PEP-H. The indicator currently used by the Spanish national health system to identify doctors with high pharmaceutical expenditure could be improved if other variables, such as frenquency of attendance and the doctors' age, were taken into account. The adoption of this method would make budget allocation more impartial and fair.

Effects of Cyclosporine, Tacrolimus, and Rapamycin on Osteoblasts

PURPOSE

One factor that can contribute to severe bone loss after transplantation is the direct action of immunosuppressants on bone cells. The aim of this work was to study the effects of cyclosporine (CsA), tacrolimus (FK-506), and rapamycin (RAPA) on the release of three local factors directly implicated in bone-remodeling regulation and apoptosis of human osteoblasts: interleukin (IL)-6, osteoprotegerin, and receptor activator of nuclear factor κβ (RANKL).

BASIC PROCEDURES

Human osteoblasts were obtained from five different patients who underwent orthopedic surgery. These cells were treated with what are considered to be a clinically high dose and an acceptable dose of each immunosuppressant-RAPA 50 ng/mL and 12 ng/mL, FK-506 20 ng/mL and 5 ng/mL, CsA 1000 ng/mL and 250 ng/mL-or vehicle. Apoptotic cell death was quantified using flow cytometry of DNA content in permeabilized, propidium iodide-stained cells. IL-6 was measured using enzyme-linked immunosorbent assay (ELISA; Quantikine Human IL6, R&D Systems, Minneapolis, Minn, United States). Messenger RNA (mRNA) expression of osteoprotegerin, RANKL, and IL-6 was measured using quantitative RT-PCR.

MAIN FINDINGS

A significant increase in IL-6 (mRNA and released protein) was observed in the presence of FK-506 and RAPA. Addition of RAPA to the cultures of osteoblasts produced a significant increase in the OPG/RANKL ratio. A significant increase in osteoblast apoptosis was observed in the cells treated with FK-506 and RAPA 24 hours after the addition of immunosuppressants. CsA did not produce any significant changes in osteoblasts.

PRINCIPAL CONCLUSIONS

These results suggest that an increase in osteoblast apoptosis by osteoblasts may be one of the mechanisms by which bone loss occurs after RAPA and FK-506 treatments.