Risk factors for mortality in Malawian children with human immunodeficiency virus and tuberculosis co-infection

SETTING

A large urban pediatric human immunodeficiency virus (HIV) clinic in Lilongwe, Malawi.

OBJECTIVE

To identify demographic and clinical risk factors for mortality in children co-infected with HIV and tuberculosis (TB).

DESIGN

A retrospective cohort study of HIV-infected children (aged <18 years) enrolled between October 2004 and October 2010 with at least one current or historical TB diagnosis. Descriptive statistics and logistic regression analyses were performed to determine factors associated with mortality.

RESULTS

A total of 1561 patients met the inclusion criteria, representing 32% of patients ever enrolled. Median age at TB diagnosis was 3.8 years (interquartile range 1.5-7.4); 60.9% had severe immune suppression and 47.6% of those with available data had some degree of acute malnutrition at TB diagnosis. Of the 1113 patients with known outcomes, 225 (20.2%) died. Children with TB-HIV co-infection not initiated on antiretroviral therapy (ART) at any time were 8.8 times more likely to die compared to those initiated on ART 0-2 months after initiation of anti-tuberculosis treatment (adjusted OR 8.83, 95%CI 4.42-17.63). Severe immunosuppression and World Health Organization Stage IV were also associated with mortality.

CONCLUSIONS

Pediatric TB-HIV co-infection is common and mortality is high in this cohort of Malawian children. Prompt initiation of ART should be emphasized in this high-risk patient population.

Measurement of J/ψ azimuthal anisotropy in Au+Au collisions at sqrt[s(NN)]=200 GeV

The measurement of J/ψ azimuthal anisotropy is presented as a function of transverse momentum for different centralities in Au+Au collisions at sqrt[s(NN)]=200 GeV. The measured J/ψ elliptic flow is consistent with zero within errors for transverse momentum between 2 and 10 GeV/c. Our measurement suggests that J/ψ particles with relatively large transverse momenta are not dominantly produced by coalescence from thermalized charm quarks, when comparing to model calculations.

Task shifting an inpatient triage, assessment and treatment programme improves the quality of care for hospitalised Malawian children

OBJECTIVE

We aimed to improve paediatric inpatient surveillance at a busy referral hospital in Malawi with two new programmes: (i) the provision of vital sign equipment and implementation of an inpatient triage programme (ITAT) that includes a simplified paediatric severity-of-illness score, and (ii) task shifting ITAT to a new cadre of healthcare workers called 'vital sign assistants' (VSAs).

METHODS

This study, conducted on the paediatric inpatient ward of a large referral hospital in Malawi, was divided into three phases, each lasting 4 weeks. In Phase A, we collected baseline data. In Phase B, we provided three new automated vital sign poles and implemented ITAT with current hospital staff. In Phase C, VSAs were introduced and performed ITAT. Our primary outcome measures were the number of vital sign assessments performed and clinician notifications to reassess patients with high ITAT scores.

RESULTS

We enrolled 3994 patients who received 5155 vital sign assessments. Assessment frequency was equal between Phases A (0.67 assessments/patient) and B (0.61 assessments/patient), but increased 3.6-fold in Phase C (2.44 assessments/patient, P < 0.001). Clinician notifications increased from Phases A (84) and B (113) to Phase C (161, P = 0.002). Inpatient mortality fell from Phase A (9.3%) to Phases B (5.7) and C (6.9%).

CONCLUSION

ITAT with VSAs improved vital sign assessments and nearly doubled clinician notifications of patients needing further assessment due to high ITAT scores, while equipment alone made no difference. Task shifting ITAT to VSAs may improve outcomes in paediatric hospitals in the developing world.

Observation of an energy-dependent difference in elliptic flow between particles and antiparticles in relativistic heavy ion collisions

Elliptic flow (v(2)) values for identified particles at midrapidity in Au + Au collisions, measured by the STAR experiment in the beam energy scan at RHIC at sqrt[s(NN)] = 7.7-62.4 GeV, are presented. A beam-energy-dependent difference of the values of v(2) between particles and corresponding antiparticles was observed. The difference increases with decreasing beam energy and is larger for baryons compared to mesons. This implies that, at lower energies, particles and antiparticles are not consistent with the universal number-of-constituent-quark scaling of v(2) that was observed at sqrt[s(NN)] = 200 GeV.

Phase I clinical trial of valacyclovir and standard of care cyclophosphamide in children with endemic Burkitt lymphoma in Malawi

Treatment options for Epstein-Barr virus (EBV)-associated Burkitt lymphoma in Africa are limited because of chemotherapy-associated toxicity. Since other EBV-associated diseases respond to antiviral agents, we investigated adding an antiviral agent, valacyclovir, to the current chemotherapy regimen in Malawi. In this phase I safety study, we showed that cyclophosphamide combined with valacyclovir was safe. Phase II efficacy trials should now be undertaken.

BACKGROUND

Nucleoside analogues, including acyclovir, ganciclovir, and their precursors, have shown some efficacy against several Epstein-Barr virus (EBV)-associated diseases, including active EBV infection and posttransplantation lymphoproliferative disorder (PTLD). They have also been proposed as a possible treatment for EBV-associated malignancies, including endemic Burkitt lymphoma. The safety of nucleoside analogues in combination with chemotherapy in the developing world has not been studied and is necessary before any large scale efficacy trials are conducted.

PATIENTS AND METHODS

Children 3-15 years old meeting inclusion criteria were assigned to a 3+3 dose escalation trial of combination valacyclovir (15 and 30 mg/kg, 3 times daily for 40 days) and cyclophosphamide (CPM) (40 mg/kg day 1, 60 mg/kg on days 8, 18, and 28) or CPM monotherapy. Subjects were monitored for clinical and laboratory toxicity and had EBV levels measured regularly. Dose-limiting toxicity (DLT) was our primary outcome.

RESULTS

We found that the combination of valacyclovir and CPM was safe and did not lead to any DLT compared with CPM monotherapy. The most common side effects were vomiting, abdominal pain, and tumor site pain, which were similar in both arms. Patients with measurable serum EBV showed decreased loads over their treatment course.

CONCLUSIONS

We recommend a phase II valacyclovir dose of 30 mg/kg 3 times daily for 40 days. We also observed that 6 of our 12 patients with presumed Burkitt lymphoma had measurable EBV viral loads that decreased over the course of their treatment, suggesting that phase II studies should investigate this correlation further. This study paves the way for a phase II efficacy trial of combined valacyclovir and CPM in the treatment of endemic Burkitt lymphoma.

Recruitment, asthma characteristics, and medication behaviors in Midwestern Puerto Rican youth: data from Project CURA

BACKGROUND

Puerto Rican children have the highest prevalence of asthma, but detailed descriptions of this population have been limited to the island of Puerto Rico and the northeastern United States.

OBJECTIVE

To describe the asthma characteristics of this urban Midwest cohort of Puerto Rican youth, focusing on medication behaviors, and to test whether their asthma outcomes are associated with their demographic and psychosocial variables.

METHODS

Data are from the baseline cohorts of a randomized controlled trial designed to improve medication adherence in Puerto Rican youth. Recruitment used a community-based participatory research approach. Data were collected in the home. Medications and medication technique were visually assessed, and adherence was determined using electronic medication monitors or counters. Data on asthma symptoms and morbidity, demographics, and psychosocial factors were collected.

RESULTS

The recruitment of 101 participants (51 in elementary school and 50 in high school) was completed in 14 months. Despite overall high asthma severity and poor asthma control, 20% of participants had no reliever medicine in their home. Self-report of controller use was higher than actual controller medications visualized in the home. For those who had an inhaled corticosteroid medicine (only 45% of elementary school participants and 12% of high school participants), median adherence was 1.0 doses per day. Rates of depression and stress were very high among both caregivers and children.

CONCLUSION

Puerto Rican youth in the Midwest bear a significant asthma burden in addition to other stressors, including depression. Visual inspection of medications and monitoring of adherence are critical for understanding asthma morbidity in this high-risk population.

Directed flow of identified particles in Au+Au collisions at √[SNN]=200 GeV at RHIC

STAR's measurements of directed flow (v1) around midrapidity for π±, K±, KS0, p, and p[over ¯] in Au+Au collisions at √[sNN]=200  GeV are presented. A negative v1(y) slope is observed for most of produced particles (π±, K±, KS0, and p[over ¯]). In 5%-30% central collisions, a sizable difference is present between the v1(y) slope of protons and antiprotons, with the former being consistent with zero within errors. The v1 excitation function is presented. Comparisons to model calculations (RQMD, UrQMD, AMPT, QGSM with parton recombination, and a hydrodynamics model with a tilted source) are made. For those models which have calculations of v1 for both pions and protons, none of them can describe v1(y) for pions and protons simultaneously. The hydrodynamics model with a tilted source as currently implemented cannot explain the centrality dependence of the difference between the v1(y) slopes of protons and antiprotons.

Indurated vascular plaques on the legs of an 85-year-old woman

This is a case of classic type Kaposi sarcoma occurring in an 85-year-old woman who presented with indurated vascular plaques on both legs below the knee that has been present for two years. A brief review of the literature on Kaposi sarcoma is included.

Identified hadron compositions in p+p and Au+Au collisions at high transverse momenta at √S(NN)=200 GeV

We report transverse momentum (p(T)≤15  GeV/c) spectra of π(±), K(±), p, p[over ¯], K(S)(0), and ρ(0) at midrapidity in p+p and Au+Au collisions at √S(NN)=200  GeV. Perturbative QCD calculations are consistent with π(±) spectra in p+p collisions but do not reproduce K and p(p[over ¯]) spectra. The observed decreasing antiparticle-to-particle ratios with increasing p(T) provide experimental evidence for varying quark and gluon jet contributions to high-p(T) hadron yields. The relative hadron abundances in Au+Au at p(T)≳8  GeV/c are measured to be similar to the p+p results, despite the expected Casimir effect for parton energy loss.

Strangeness enhancement in Cu-Cu and Au-Au collisions at √S(NN)=200 GeV

We report new STAR measurements of midrapidity yields for the Λ, Λ[over ¯], K(S)(0), Ξ(-), Ξ[over ¯](+), Ω(-), Ω[over ¯](+) particles in Cu+Cu collisions at √S(NN)==200  GeV, and midrapidity yields for the Λ, Λ[over ¯], K(S)(0) particles in Au+Au at √S(NN)==200  GeV. We show that, at a given number of participating nucleons, the production of strange hadrons is higher in Cu+Cu collisions than in Au+Au collisions at the same center-of-mass energy. We find that aspects of the enhancement factors for all particles can be described by a parametrization based on the fraction of participants that undergo multiple collisions.

Clear cell Basal cell carcinoma

Introduction. Clear cell basal cell carcinoma (BCC) is an uncommon and unusual variant of BCC, which is characterized by a variable component of clear cells. The pathogenesis of this histological variant and its clinical significance has not been clarified. Differentiation of this uncommon variant of BCC from other clear cell tumors is important for the treatment. Case Presentation. A 65-year-old male presented with a 0.9 cm dome-shaped lesion on his upper chest. A shave biopsy revealed a dermal basaloid tumor that comprised nests with a peripheral palisading pattern, retraction artifacts, and striking clear cell changes. Histopathologic examination, along with findings from immunohistochemical studies and special staining of the clear cells, supports the diagnosis of clear cell basal cell carcinoma. Conclusion. Clear cell BCC is a rare and unusual variant of BCC. The underlying pathogenesis of this subtype is unclear; however, accurate identification may affect treatment and prognosis.

Measurement of the parity-violating longitudinal single-spin asymmetry for W± boson production in polarized proton-proton collisions at sqrt[s] = 500 GeV

We report the first measurement of the parity-violating single-spin asymmetries for midrapidity decay positrons and electrons from W+ and W- boson production in longitudinally polarized proton-proton collisions at sqrt[s] = 500 GeV by the STAR experiment at RHIC. The measured asymmetries, A(L)(W+) = -0.27 ± 0.10(stat.) ± 0.02(syst.) ± 0.03(norm.) and A(L)(W-) = 0.14 ± 0.19(stat.) ± 0.02(syst.) ± 0.01(norm.), are consistent with theory predictions, which are large and of opposite sign. These predictions are based on polarized quark and antiquark distribution functions constrained by polarized deep-inelastic scattering measurements.

Gene expression and mutation assessment provide clues of genetic and epigenetic mechanisms in liver tumors of oxazepam-exposed mice

Liver tumors from a previous National Toxicology Program study were examined using global gene expression and mutation analysis to define the mechanisms of carcinogenesis in mice exposed to oxazepam. Five hepatocellular adenomas and 5 hepatocellular carcinomas from male B6C3F1 mice exposed to 5000 ppm oxazepam and 6 histologically normal liver samples from control animals were examined. One of the major findings in the study was upregulation of the Wnt/β-catenin signaling pathway. Genes that activate β-catenin, such as Sox4, were upregulated, whereas genes that inhibit Wnt signaling, such as APC and Crebbp, were downregulated. In addition, liver tumors from oxazepam-exposed mice displayed β-catenin mutations and increased protein expression of glutamine synthetase, a downstream target in the Wnt signaling pathway. Another important finding in this study was the altered expression of oxidative stress-related genes, specifically increased expression of cytochrome p450 genes, including Cyp1a2 and Cyp2b10, and decreased expression of genes that protect against oxidative stress, such as Sod2 and Cat. Increased oxidative stress was confirmed by measuring isoprostane expression using mass spectrometry. Furthermore, global gene expression identified altered expression of genes that are associated with epigenetic mechanisms of cancer. There was decreased expression of genes that are hypermethylated in human liver cancer, including tumor suppressors APC and Pten. Oxazepam-induced tumors also exhibited decreased expression of genes involved in DNA methylation (Crebbp, Dnmt3b) and histone modification (Sirt1). These data suggest that formation of hepatocellular adenomas and carcinomas in oxazepam-exposed mice involves alteration of the Wnt signaling pathway, oxidative stress, and potential epigenetic alterations.

Measurement of the bottom quark contribution to nonphotonic electron production in p + p collisions at √s=200 GeV

The contribution of B meson decays to nonphotonic electrons, which are mainly produced by the semileptonic decays of heavy-flavor mesons, in p + p collisions at √s=200  GeV has been measured using azimuthal correlations between nonphotonic electrons and hadrons. The extracted B decay contribution is approximately 50% at a transverse momentum of pT≥5  GeV/c. These measurements constrain the nuclear modification factor for electrons from B and D meson decays. The result indicates that B meson production in heavy ion collisions is also suppressed at high pT.

Higher moments of net proton multiplicity distributions at RHIC

We report the first measurements of the kurtosis (κ), skewness (S), and variance (σ2) of net-proton multiplicity (Np-Np) distributions at midrapidity for Au+Au collisions at square root of s(NN)=19.6, 62.4, and 200 GeV corresponding to baryon chemical potentials (μB) between 200 and 20 MeV. Our measurements of the products κσ2 and Sσ, which can be related to theoretical calculations sensitive to baryon number susceptibilities and long-range correlations, are constant as functions of collision centrality. We compare these products with results from lattice QCD and various models without a critical point and study the square root of s(NN) dependence of κσ2. From the measurements at the three beam energies, we find no evidence for a critical point in the QCD phase diagram for μB below 200 MeV.

Three-particle coincidence of the long range pseudorapidity correlation in high energy nucleus-nucleus collisions

We report the first three-particle coincidence measurement in pseudorapidity (Δη) between a high transverse momentum (p⊥) trigger particle and two lower p⊥ associated particles within azimuth |Δϕ|<0.7 in square root of s(NN)=200 GeV d+Au and Au+Au collisions. Charge ordering properties are exploited to separate the jetlike component and the ridge (long range Δη correlation). The results indicate that the correlation of ridge particles are uniform not only with respect to the trigger particle but also between themselves event by event in our measured Δη. In addition, the production of the ridge appears to be uncorrelated to the presence of the narrow jetlike component.