Children's estimates of food portion size: the development and evaluation of three portion size assessment tools for use with children

A number of methods have been developed to assist subjects in providing an estimate of portion size but their application in improving portion size estimation by children has not been investigated systematically. The aim was to develop portion size assessment tools for use with children and to assess the accuracy of children's estimates of portion size using the tools. The tools were food photographs, food models and an interactive portion size assessment system (IPSAS). Children (n 201), aged 4–16 years, were supplied with known quantities of food to eat, in school. Food leftovers were weighed. Children estimated the amount of each food using each tool, 24 h after consuming the food. The age-specific portion sizes represented were based on portion sizes consumed by children in a national survey. Significant differences were found between the accuracy of estimates using the three tools. Children of all ages performed well using the IPSAS and food photographs. The accuracy and precision of estimates made using the food models were poor. For all tools, estimates of the amount of food served were more accurate than estimates of the amount consumed. Issues relating to reporting of foods left over which impact on estimates of the amounts of foods actually consumed require further study. The IPSAS has shown potential for assessment of dietary intake with children. Before practical application in assessment of dietary intake of children the tool would need to be expanded to cover a wider range of foods and to be validated in a ‘real-life’ situation.

Tuberculosis antigen-specific immune responses can be detected using enzyme-linked immunospot technology in human immunodeficiency virus (HIV)-1 patients with advanced disease

There are limited data on the efficacy of T cell-based assays to detect tuberculosis (TB) antigen-specific responses in immune-deficient human immunodeficiency virus (HIV) patients. The aim of this study is to determine whether TB antigen-specific immune responses can be detected in patients with HIV-1 infection, especially in those with advanced disease (CD4 T cell count < 300 cells/microl). An enzyme-linked immunospot (ELISPOT) assay, which detects interferon (IFN)-gamma secreted by T cells exposed to TB antigens, was used to assess specific immune responses in a prospective study of 201 HIV-1-infected patients with risk factors for TB infection, attending a single HIV unit. The performance of the ELISPOT assay to detect TB antigen-specific immune responses is independent of CD4 T cell counts in HIV-1 patients. The sensitivity and specificity of this assay for the diagnosis of active tuberculosis does not differ significantly from values obtained in immunocompetent subjects. The negative predictive value of the TB ELISPOT test is 98.2%. A positive predictive value of 86% for the diagnosis of active tuberculosis was found when the combined number of early secretory antigen target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) IFN-gamma spots to CD4 T cell count ratio was > 1.5. TB antigen-specific immune responses can be detected in HIV patients with low CD4 T cell counts using ELISPOT technology in a routine diagnostic laboratory and is a useful test to exclude TB infection in immune-deficient HIV-1 patients. A combination of TB antigen-specific IFN-gamma responses and CD4 T cell counts has the potential to distinguish active tuberculosis from latent infection.

8. Modelling and teaching collaboration: The interprofessional education in geriatric care project

The Interprofessional Education in Geriatric Care (IEGC) project is an Interprofessional Education for Collaborative Patient-centred Practice Initiative (Health Canada) funded project that was launched in June 2005 and ends March 2008. The goal of the IEGC project is to develop a sustainable clinical experience that models and teaches the core concepts of patient centred collaboration (goal directedness, leadership, flexibility, team dynamics, conflict resolution, communication, and disciplinary articulation) which directly reflect the enabling competencies of the “Collaborator Role” outlined in the 2005 CanMEDS Framework. The primary learners are Internal Medicine/Family Medicine residents and senior students in nursing, occupational therapy, physiotherapy, and pharmacy. The interprofessional education occurs at three geriatric day hospitals where collaborative patient-centred care of community dwelling older clients is the standard of practice, and clinicians traditionally accept students for clinical placements. The IEGC project identified instances that learners from two or more disciplines were at Day Hospital simultaneously for approximately three weeks. During this time, experiential learning activities emphasizing the skills needed for effective collaboration were added to typical preceptor based teaching. Feedback early in the project from students and preceptors indicated that the original design, (practice simulations and didactic small group sessions), were not meeting clinical learning objectives. In response, the clinical teams initiated team led discussions regarding core concepts and students were given the opportunity to assess and develop care plans for “student team” designated patients. In addition structured team observations, directed readings, self-reflective exercises and “ice-breakers” are utilized. Informal feedback from participants has suggested that this is more effective, and relevant way to teach patient centred collaborative practice. The IEGC project has extensive research and evaluation methods based on the JET’s modification of Kirkpatrick’s Model of Educational Outcomes which will assess the effectiveness and viability of the IEGC educational approach. The Interprofessional Joint Evaluation Team. (2002). A Critical Review of Evaluations of Interprofessional Education. http://www.health.heacademy.ac.uk/publications/ occasionalpaper/occasionalpaper02.pdf/view. Accessed September 9, 2005. Frank JR, Jabbour M, et al. Eds. Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada. March, 2005.

Children's estimates of food portion size: the effect of timing of dietary interview on the accuracy of children's portion size estimates

For food intakes to be converted into nutrient intakes a measure or estimate of the amount of food consumed is required. A number of methods have been developed to assist subjects in providing an estimate of portion size. Children's ability to use perception, conceptualisation and memory skills to estimate food portion size has not been investigated systematically. The aim of the present study was to test the effect of the timing of a dietary interview on the accuracy of estimates of food portion sizes made by children, using food photographs, food models and an interactive portion size assessment system, developed for use with children and based on portion sizes of foods consumed by children. Children (n 108) aged 4–14 years were supplied with known quantities of foods and asked to estimate the portion size of each food using each of the three portion size assessment tools. Interviews took place (a) with the food in view, (b) just after the child had eaten the food or (c) 24 h after the child had eaten the food. There were no significant differences in children's ability to estimate food portion size (either as served or as eaten) with timing of interview. That is, children were as accurate in their estimates of portion size 24 h after consuming the food as when the food was in view. Under these conditions many children were able to estimate food portion size utilising perception, conceptualisation and memory skills.

The contribution of school meals to food consumption and nutrient intakes of young people aged 4–18 years in England

Objectives

To undertake secondary analyses of the 1997 National Diet and Nutrition Survey of Young People aged 4–18 years in order to describe the contribution of school meals to daily food and nutrient intakes; and to compare the findings from 1997 with data collected in English primary and secondary schools in 2004–2005.

Design

Cross-sectional analysis of 7-day weighed inventory food consumption data according to age, sex, household income, free school meals and breakfast consumption. Comparison of food consumption with the Balance of Good Health and of nutrient intake data with the Caroline Walker Trust (CWT) guidelines.

Setting

United Kingdom.

Subjects

One thousand four hundred and fifty-six UK schoolchildren aged 4–18 years, 7058 English primary-school pupils and 5695 English secondary-school pupils.

Results

Pupils' school meal choices in 1997 did not accord with the Balance of Good Health. Food choices in school were less healthy than choices outside school. School meals failed to make good the shortfalls in daily intakes of non-starch polysaccharides and zinc in primary-school pupils, and of calcium, iron, zinc, vitamin A and non-starch polysaccharides in secondary-school pupils, nor excess daily intakes of saturated fatty acids, non-milk extrinsic sugars and sodium at all ages. School meals typically failed to meet CWT guidelines. They were more likely to meet CWT guidelines when choice of foods was restricted.

Conclusions

School meals need substantial improvement to meet CWT guidelines for healthy eating. The introduction of food-based guidelines for school meals in England in 2001 did not improve the food choices in school meals.

Rituximab induces long-term remissions in patients with HIV-associated multicentric Castleman's disease

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Background: HIV associated multicentric Castlemans (MCD) is rare lympohproliferative disorder and most treatment options to date, have proved largely unsuccessful. This study investigated the efficacy of the anti CD20 monoclonal antibody rituximab in patients with this disease. Methods: Between 2003 and 2006, patients with histological proven HIV related MCD received a course of 4 infusions of rituximab 375mg/m2 at weekly intervals. Results: Twenty one consecutive patients (18 male) were recruited into this study and the median follow-up is 12 months (range 1–49). The median age was 37 years and all patients were either on highly active antiretroviral therapy (HAART) (62%) or started HAART at the time of MCD diagnosis (38%). The median CD4 cell count at MCD diagnosis was 275/mm3 (range 77–725). One died within 2 weeks of starting rituximab (not evaluable); 20 evaluable patients all achieved clinical remission of symptoms and 71% achieved a radiological response according to RECIST criteria. Rituximab lead to a significant fall in anaemia, thrombocytopenia, CRP, ESR, serum HHV8 viral load and IL-10. Rituximab caused transitory fall in the CD19 count, but had no effect on the CD4, CD8 and NK cell counts or plasma HIV viral load. The disease free survival at 2 years is 79% (95%CI: 49–100%) and overall survival is 95% (95%CI: 86–100%). Two patients have relapsed after 1.6 & 2.8 years and were successfully retreated with rituximab therapy. Conclusions: Rituximab therapy results in a sustained clinical, radiological and biochemical remission in patients with HIV related MCD.

No significant financial relationships to disclose.

CD8 count measurement has independent prognostic significance in individuals with AIDS-Kaposi sarcoma

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Background: We recently published a prognostic index for Acquired Immunodeficiency Syndrome (AIDS)-associated Kaposi sarcoma (KS) diagnosed in the era of highly active antiretroviral therapy (HAART) based on clinical and routine laboratory characteristics. Because immune subset measurement is often performed in human immunodeficiency virus (HIV) positive individuals, we examined whether these were predictive of mortality independently of the prognostic index, or could predict time to progression of KS. Methods: We performed univariate and multivariate Cox regression analyses on a dataset of 326 individuals with AIDS-KS to identify immune subset covariates predictive of overall survival and time to progression. Adaptive (CD8 T cell and CD19 B cell) and innate (CD16/56 natural killer cell) immune parameters were studied by flow cytometry. Results: In univariate analyses all 3 immune subsets had significant effects on overall survival (p < 0.025). In multivariate analyses including the prognostic index, only CD8 counts remained significant (p = 0.026) although its effect on the overall prognostic index is small. An increase of 100 cells/mm3 in the CD8 count confers a 5% improvement in overall survival. Individuals with a higher CD8 count did not have an increased time to progression. Patients who were already on HAART at the time of KS diagnosis did not have a shorter time to progression than those who were antiretroviral naïve at KS diagnosis. Conclusions: The CD8 count appears to provide independent prognostic information in individuals with AIDS-KS. Measurement of the CD8 count is clinically useful in patients with KS.

No significant financial relationships to disclose.

Why do patients fail HIV therapy?

Despite huge advances in terms of the impact of antiretroviral therapy on HIV-related morbidity and mortality patients continue to fail therapy. We discuss the reasons why failure occurs including primary or transmitted resistance, poor adherence, toxicity and drug potency. We performed a review of PubMed, Medline and recent conference abstracts for information on antiretroviral toxicity, adherence, failure and transmitted resistance. Most first-line regimens are now similar in potency and, assuming susceptibility to the selected regimen determined by genotypic resistance testing, tolerability and toxicity are the key issues differentiating currently available agents. New developments such as pharmacogenomics have already proven useful in predicting toxicity and may play an increasingly important role. With all regimens good adherence remains the key to successful therapy; minimising toxicity and other barriers to adherence wherever possible is crucial.

Long-term complications of antiretroviral therapy: lipoatrophy

The effective use of potent antiretroviral therapy has dramatically improved the life expectancy for HIV-infected individuals. Long-term complications of both HIV-infection and antiretroviral agents are therefore of increasing concern. Lipoatrophy (LA) or fat wasting is a complication most frequently associated with nucleoside reverse transcriptase inhibitors, thymidine analogues particularly. LA can be stigmatising and is associated with psychosocial complication. It can occur in isolation or as part of the 'metabolic' or 'lipodystrophy' syndrome, a triad of LA, fat accumulation and metabolic disturbance (insulin resistance and dyslipidaemia) with a subsequently increased risk of cardiovascular events. We aimed to review the definition, prevalence, pathogenesis, implications and treatment of HIV/highly active antiretroviral therapy-associated fat loss. We performed a review of PubMed, Medline and recent conference abstracts for information on LA. The current treatments available for treating LA are limited. Switching away from thymidine analogues can provide a small benefit but improvement is, at best, slow and partial. Specific medical therapies such as glitazones, metformin and stating have been disappointing to date. Surgical fillers can yield marked results but are costly, time consuming and only of value for facial LA, not other sites. Ultimately, prevention of this condition is the best approach by avoiding thymidine analogues wherever possible or careful monitoring with early switching away from these agents. New therapies to treat pre-existing fat loss are required.

Renal complications in HIV

Highly Active Antiretroviral Therapy has revolutionised the care of individuals living with HIV-1. As the prognosis for this population has improved, there is an increased risk of other major causes of morbidity and mortality, including renal disease. This review discusses the frequency and causes of renal pathology, how to make the diagnosis and monitor for renal disease in HIV-infected individuals. The review was conducted having examined the key evidence focussing upon HIV and renal complications obtained from peer-reviewed journals (level of evidence I-IV). As the population of individuals living with HIV increases, so too does the prevalence of renal disease. Physicians should be vigilant and recognise individuals at risk of renal complications, and be aware of how to monitor, investigate and treat those affected.

High-resolution microscopy coil MR-Eye

The eye is involved in several pathologies where precise identification of the underlying condition is essential for the optimal patient care. This preliminary report presents the potential of high-resolution microscopy coil magnetic resonance imaging (HR-MRI) to undertake this task being actively used in the clinical setting. We used a commercially available MRI scanner and a microscopy surface coil. Exquisite anatomic detail of the eye and orbit with depiction of previously unobserved structures and clear demonstration of the underlying pathology was achieved. This report supports the idea that orbital imaging can be revolutionized with the introduction of HR-MRI with broad clinical implications.

Non-nucleoside reverse transcriptase inhibitors: a review

Non-nucleoside reverse transcriptase inhibitors form the backbone of antiretroviral treatment for many HIV-infected individuals. The tolerability, pill burden and efficacy associated with this class of agents make them a frequent choice for first-line therapy. Here we review nevirapine and efavirenz in terms of efficacy, resistance and toxicity, focusing particularly on the use of nevirapine to prevent mother-to-child transmission in developing countries.

A single centre cohort experience with a new once daily antiretroviral drug

BACKGROUND

Atazanavir, an azadipeptide protease inhibitor (PI) with once daily dosing, a lack of insulin resistance, lipid increase, and gastrointestinal toxicities, is approved in combination with other antiretrovirals for the treatment of patients infected with HIV. Unboosted atazanavir is also used in highly active antiretroviral therapy (HAART) naive patients.

METHODS

The study prospectively followed up an established cohort of patients who received atazanavir, and for whom one year of follow up data were available.

RESULTS

It was found that use of atazanavir in intent to treat and on treatment analyses, maintained and led to virological suppression and increases in CD4 count in both PI naive and experienced patients. Virological failure occurred in 7% of patients and the main toxicity was hyperbilirubinaemia, which led to treatment withdrawal in 2%. Its efficacy and safety profile was similar to that seen in previous randomised studies investigating its use.

CONCLUSIONS

These data should provide reassurance for clinicians wishing to introduce a new antiretroviral into an established cohort.

Novel anti-hepatitis B agents: A focus on telbivudine

Although preventable by vaccination, hepatitis B infection is common, affecting more than 350 million individuals worldwide. Chronic hepatitis B infection is associated with the complications of chronic liver disease including cirrhosis and hepatocellular carcinoma. Current agents designed to target hepatitis B are hindered by the development of resistance, poor tolerability or limited efficacy and a demand for new agents and strategies continues. This review focuses on telbivudine, a novel agent in the fight against hepatitis B.

Highly active anti-retroviral therapy (HAART)-induced maintenance of adaptive but not innate immune parameters is associated with protection from HIV-induced mortality

Immunosuppression induced by the human immunodeficiency virus (HIV-1) increases the risk of death. We measured the influence of immunological and virological factors and the type of highly active anti-retroviral therapy (HAART) on this risk. Adaptive (lymphocyte) and innate (natural killer) immune correlates and maximum HIV viral loads were assessed for association with mortality using univariate and multivariate analyses. The protective effect of HAART regimens, containing protease inhibitors (PI) and/or non-nucleoside reverse transcriptase inhibitors (NNRTI) on mortality were also examined in a prospectively recorded cohort of 9621 HIV-infected individuals. From this entire cohort, 5873 HIV infected individuals (61%) have been followed-up in the HAART era and of these 499 (8.5%) have died. In multivariate analyses, CD4 counts below the 50th centile and CD8 and CD19 counts below the 25th centile were significantly associated with mortality, as was increased age (P < 0.001). Innate immune subset levels had no effect on mortality. A maximum HIV viral load greater than the 75th centile was also associated independently with mortality (P < 0.035). Exposure to either a PI or an NNRTI-containing HAART regimen, or both together, was protective against death compared with no anti-retrovirals (P < 0.001). Effective HAART-induced maintenance of the adaptive immune system (CD4, CD8 and CD19 counts) protects from HIV-related mortality.

Management of advanced HIV disease in patients with tuberculosis or hepatitis co-infection

Advanced human immunodeficiency virus (HIV) disease can be defined as a cluster of differentiation 4 (CD4) count <50 cells/mm(3) or the presence of an acquired immunodeficiency syndrome (AIDS)-defining illness. In the UK and Ireland, the number of patients who present with advanced HIV disease is increasing, with 301/977 (31%) of patients presenting late (<200 CD4 cells/mm(3)). Many patients who present with advanced HIV disease will have comorbid conditions, such as hepatitis B or C or tuberculosis (TB), which complicates the choice of therapy. This article reviews the evidence and some clinical scenarios for specific patient groups who may present with advanced HIV disease: those with comorbid TB, hepatitis B or hepatitis C. The aim is to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease on the basis of available clinical evidence.

Pulmonary Kaposi sarcoma in the era of highly active antiretroviral therapy

OBJECTIVE

Since the introduction of highly active antiretroviral therapy (HAART) there has been a dramatic reduction in the incidence of Kaposi sarcoma (KS) and an improvement in survival. We wished to examine whether the outcome in pulmonary KS (pKS) has also altered.

METHODS

In a single-institution cohort of 1140 HIV-positive patients with KS, 305 patients were diagnosed in the HAART era (1996-2004). We examined the clinicopathological features and outcomes of these patients, of whom 25 had pKS and 280 did not.

RESULTS

Patients with pKS had lower CD4 cell counts at the time of KS diagnosis (Mann-Whitney U-test P=0.005). The incidence of pKS was higher in African patients than in non-African patients in this sample (Fisher's test, P=0.001). There were no significant differences in age, gender, plasma HIV-1 viral load or prior HAART treatment at the time of KS diagnosis. Five-year overall survival in the pKS group was 49% [95% confidence interval (CI) 26-73%] as compared with 82% (95% CI 76-87%) for the non-pKS group (log rank, P<0.0001).

CONCLUSION

PKS remains an ominous diagnosis in the era of HAART, with a median survival of just 1.6 years.

Impact of antiretroviral choice on hypercholesterolaemia events: the role of the nucleoside reverse transcriptase inhibitor backbone

BACKGROUND

The use of highly active antiretroviral therapy (HAART) has profoundly altered the life expectancy of individuals infected with HIV. Metabolic abnormalities associated with antiretrovirals and cumulative exposure to combination antiretroviral therapy, including dyslipidaemia and insulin resistance, have been linked to an increased risk of myocardial infarction.

METHODS

Longitudinal data from a large prospectively collected clinical database were analysed. All patients who commenced first antiretroviral therapy (ART) [two nucleoside reverse transcriptase inhibitors (NRTIs)+one nonnucleoside reverse transcriptase inhibitor (NNRTI) or one active protease inhibitor (PI)] since 1996 were identified. Patients with elevated cholesterol levels [>5.5 mmol/L (215 mg/dL)] prior to therapy initiation were excluded. Quantitative data were categorized into quartiles and presented stratified by individuals developing abnormal levels of cholesterol during first-line HAART. Event time was defined as time from commencing first-line ART to either development of cholesterol level >6.5 mmol/L (254 mg/dL) or switch of first-line therapy. The Kaplan-Meier product limit survival method was used to estimate time to abnormal cholesterol level, and the chi2 test was used for comparisons between drug classes. Cox's proportional hazards regression analysis was used to identify factors predicting a likelihood of raised cholesterol level.

RESULTS

A total of 1664 patients were included in the study: 57.1% on two NRTIs+one NNRTI, 38.4% on two NRTIs+one PI, and 4.4% on two NRTIs+a boosted PI regimen. Regimens containing stavudine or PIs were associated with a significantly higher event risk and earlier time to event. No differences between efavirenz and nevirapine or between didanosine and lamivudine were observed. In 28 patients exposed to the combination of tenofovir+lamivudine+efavirenz, there were no episodes of elevated cholesterol level.

CONCLUSION

Dyslipidaemia has emerged as an important issue in HIV-infected individuals receiving antiretroviral therapy. This study demonstrates that age at start of therapy, baseline cholesterol level, stavudine use and PI use are all associated with increased risk of hypercholesterolemia on initial therapy. Both NRTI and NNRTI/PI choice influence risk of hypercholesterolaemia.

Non cutaneous AIDS-associated Kaposi’s sarcoma

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Background: Acquired immune deficiency syndrome related Kaposi’s sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe for the first time a proportion of patients with AIDS-KS who presented with no evidence of cutaneous disease. Methods: From our cohort of 5,932 individuals infected with the human immunodeficiency virus (HIV-1) treated in the HAART era, 319 were identified with KS. Of these, 11 patients (5.4%) were diagnosed with KS without the presence of any cutaneous disease. We compared their survival, clinical, immunologic and virologic characteristics to other individuals with KS. Results: There were no statistically significant differences in survival, CD4 count or HIV viral load at KS presentation. We observed that tumour-associated edema (p=0.046) and non-oral gastro-intestinal KS (p=0.042) were significantly more common in patients with non-cutaneous KS. Only 1 case of non-cutaneous KS was observed prior to the era of highly active anti-retroviral therapy (HAART). Conclusions: Non-cutaneous KS is a recognisable condition; patients should be treated with the standard of care as their prognosis is not inferior. This is likely to reflect a strong immune response, in the era of HAART.

No significant financial relationships to disclose.

Influence of tea drinking on manganese intake, manganese status and leucocyte expression of MnSOD and cytosolic aminopeptidase P

OBJECTIVE

Since black tea contains high levels of manganese (Mn), we investigated the relationship between dietary Mn intake, circulating Mn levels and leucocyte expression of two Mn-dependent enzymes in tea drinkers and non-tea drinkers.

DESIGN

We assessed Mn intakes (food frequency questionnaire), fasting whole blood and plasma Mn levels, and quantitative expression of peripheral blood mononuclear cell Mn-dependent superoxide dismutase (MnSOD) and cytosolic aminopeptidase-P (cAP-P).

SETTING AND SUBJECTS

In total, 24 tea drinkers (> or = 1 l black tea/day) and 28 non-tea drinkers were recruited from the staff and students of King's College London by circular email.

RESULTS

Dietary Mn intakes (mean (range)) were significantly lower (P < 0.0001) in non tea drinkers (3.2 mg/day (0.5-6.5)) than tea drinkers (5.5 mg/day (2-12) or 10 mg/day (5-20) depending upon the value used for Mn levels of black tea). Whole blood, plasma Mn levels and expression of MnSOD and cAP-P did not differ between the groups. In a continuous analysis, whole blood Mn levels and expression of MnSOD correlated inversely but no other parameters associated with each other.

CONCLUSIONS

Tea drinking is a major source of dietary Mn and intakes commonly exceed proposed adequate intake values of 1.8-2.3 mg Mn/day and, on occasion, exceed upper limits of 10-11 mg/day. Dietary Mn intake has little influence on markers of Mn status or expression of Mn-dependent enzymes. Fasting whole blood Mn levels and leucocyte expression of MnSOD could, together, be further investigated as markers of Mn status.

The presentation and survival of patients with non-cutaneous AIDS-associated Kaposi's sarcoma

BACKGROUND

Acquired immune deficiency syndrome related Kaposi's sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe for the first time a proportion of patients with AIDS-KS who presented with no evidence of cutaneous disease.

PATIENTS AND METHODS

From our cohort of 5932 individuals infected with the human immunodeficiency virus (HIV-1) treated in the HAART era, 319 were identified with KS. Of these, 11 patients (5.4%) were diagnosed with KS without the presence of any cutaneous disease. We compared their survival, clinical, immunological and virological characteristics to other individuals with KS.

RESULTS

There were no statistically significant differences in survival, CD4 count or HIV viral load at KS presentation. We observed that tumour-associated oedema (P = 0.046) and non-oral gastrointestinal KS (P = 0.042) were significantly more common in patients with non-cutaneous KS. Only one case of non-cutaneous KS was observed prior to the era of highly active anti-retroviral therapy (HAART).

CONCLUSIONS

Non-cutaneous KS is a recognisable condition; patients should be treated with the standard of care as their prognosis is not inferior. This is likely to reflect a strong immune response, in the era of HAART.

Assessment of the efficacy of total lymphocyte counts as predictors of AIDS defining infections in HIV-1 infected people

BACKGROUND

The CD4 count is a dominant prognostic and predictive factor in HIV infection. This study assessed the utility of the total lymphocyte count (TLC) in place of the CD4 count to predict the development of AIDS defining opportunistic infections (ADOI).

METHODS

The Chelsea and Westminster cohort was used to identify those people with a first episode of an ADOI. Corresponding CD4 and TLCs were recorded before diagnosis or at the time of first prescribing prophylaxis; patients without an AIDS defining opportunistic infection were defined as being at "risk" and receiver operating characteristic (ROC) curves were used to display the results of sensitivity and the false positive error rate of total lymphocyte and CD4 count groups.

RESULTS

A significant linear correlation was seen between the log(10) CD4 count and log(10) TLC (Pearson's correlation coefficient = 0.70, p<0.001). The finer cut off value for TLC where false positive error rate is minimum and sensitivity maximum was 1500-2000 cells/mm(3). Patients with TLC 1000-1500 cells/mm(3) were estimated to be at 40% increased risk of developing an ADOI. The cut off value for CD4 counts measured 200 cells/mm(3) above which the risk developing an ADOI decreased. Patients with a CD4 count of 150-200 cells/mm(3) were at a 34% increased risk of developing an ADOI. The area under the ROC curve for TLC was 10% lower than that for CD4 count.

CONCLUSIONS

The TLC is minimally less reliable than the CD4 count as a predictor of ADOIs. In the absence of expensive equipment for CD4 measurement, the TLC is a useful test.

Microbial isolates from patients in an intensive care unit, and associated risk factors

A retrospective one-year analysis of blood, sputum and urine samples taken from all patients admitted for more than 48 hours to the Intensive Care Unit at the University Hospital of the West Indies (UHWI) was undertaken. Positive trapped sputum cultures were found in 50% of patients, positive blood cultures in 32.7% and positive urine cultures in 23.1%. Gram-negative organisms predominated especially Pseudomonas aeruginosa (41.3%) and Acinetobacter spp (33.5%). Coagulase-negative staphylococcus (20%) and streptococcus group D (18.7%) were the most common gram-positive organisms. The Acinetobacter spp showed marked resistance to most antibiotics except for meropenem (82.7% susceptibility) while P. aeruginosa was most susceptible to ceftazidime (84.4%) and amikacin (89.1%). Both the coagulase-negative staphylococcus and streptococcus group D were relatively sensitive to amoxycillin/clavulanate (80.6% and 79.3% respectively). There was a high incidence of yeast found in sputum (27.1%) and urine (16.8%). Mechanical ventilation was a significant risk factor for developing a positive sputum culture (p = 0.01), this effect being particularly prominent in those ventilated for > 5 days. Central venous pressure lines significantly increased the risk of a positive blood culture (p = 0.005). This increase was seen particularly in those with CVP lines for > 7 days. Other risk factors for developing positive cultures included preadmission infection, antibiotic use just prior to ICU admission, increasing APACHE II score and increasing age.

A quantitative model of error accumulation during PCR amplification

The amplification of target DNA by the polymerase chain reaction (PCR) produces copies which may contain errors. Two sources of errors are associated with the PCR process: (1) editing errors that occur during DNA polymerase-catalyzed enzymatic copying and (2) errors due to DNA thermal damage. In this study a quantitative model of error frequencies is proposed and the role of reaction conditions is investigated. The errors which are ascribed to the polymerase depend on the efficiency of its editing function as well as the reaction conditions; specifically the temperature and the dNTP pool composition. Thermally induced errors stem mostly from three sources: A+G depurination, oxidative damage of guanine to 8-oxoG and cytosine deamination to uracil. The post-PCR modifications of sequences are primarily due to exposure of nucleic acids to elevated temperatures, especially if the DNA is in a single-stranded form. The proposed quantitative model predicts the accumulation of errors over the course of a PCR cycle. Thermal damage contributes significantly to the total errors; therefore consideration must be given to thermal management of the PCR process.

Comparison between household budget survey and 24-hour recall data in a nationally representative sample of Polish households

OBJECTIVE

Household budget survey (HBS) data are used regularly for nutritional epidemiological purposes. The validity of HBS data, however, is not well established. The aim of this project was to compare HBS and individual nutrition survey (INS) data in a nationally representative sample of Polish households.

DESIGN

Estimates of food consumption and nutrient intake were compared between household food acquisition data collected over 1 month and a single 24-hour recall collected from every household member in a nationally representative sample of Polish households surveyed between September and November 2000. To facilitate the comparison, INS food consumption data excluded food eaten away from home and were modified using a computer program to estimate food 'as purchased' (including disaggregation of recipe data) and to allow for wastage.

SETTING

Poland.

SUBJECTS

Participants were 3716 individuals in 1215 households (representing co-operation rates of 86.2% and 89.2%, respectively).

RESULTS

Good agreement was shown between median estimates of foods such as potatoes, vegetables (including processed), meat, meat products and poultry, and animal fats (excluding butter), but agreement was poor for bread and rolls, fruit, vegetable fats and oils, eggs and six other food groups. Estimates of energy and nutrient intake were within +/-10% with the exceptions of polyunsaturated fats, potassium and vitamin C.

CONCLUSIONS

Possible reasons for differences in findings between the two surveys include survey bias (e.g. social approval bias leading to overreporting of fruit), seasonal variations (e.g. high potato purchases between September and November) and aspects of the methodology (e.g. HBS data were based on records collected over 1 month, whereas 24-hour recall data were based on recalls collected from all household respondents on only 1 day and averaged for each household type). HBSs provide useful data for epidemiological research, but findings need to be interpreted in the light of other data regarding consumption, and numerous factors that may affect consumption need to be taken into account.

Anaesthesia for operative deliveries at the University Hospital of the West Indies: a change of practice

There has been an increasing trend worldwide to use regional anaesthesia for operative deliveries. The Confidential Enquiry into Maternal Deaths in the United Kingdom has demonstrated a steady decline in the anaesthesia-related deaths since the introduction of regional anaesthesia. There are lower morbidity profiles in mothers delivering under regional anaesthesia as well as better infant Apgar scores. In 1997, a decision was taken to have at least 60% of all elective Caesarean sections done at the University Hospital of the West Indies (UHWI) performed under spinal anaesthesia. This is a review of the anaesthetic technique for Caesarean sections at the UHWI since 1996. The Deliveries and Anaesthetic Books on the labour ward were reviewed and the type of anaesthesia for elective and emergency Caesarean sections recorded for the period January 1996 to December 2001. At the beginning of the period under study, more than 90% of the Caesarean sections were being done under general anaesthesia. By the middle of 1998, spinal anaesthesia was more commonly employed than general anaesthesia for Caesarean sections and by December 2001, more than eight out of every ten Caesarean sections were being done under spinal anaesthesia. The main reasons for the successful change of practice were that it was consultant-led, there was good communication between relevant departments, the junior staff were properly trained, there was a consistent supply of appropriate drugs and there was a high level of patient satisfaction.

Dietary patterns and their socio-demographic determinants in 10 European countries: data from the DAFNE databank

OBJECTIVE

To describe the dietary patterns of 10 European countries and their socio-demographic determinants, using the comparable between-countries DAFNE data.

DESIGN

Analysis of standardized and postharmonized data collected through the national household budget surveys.

SETTING

Nationally representative surveys undertaken in 10 European countries, generally in the second half of the 1990s.

RESULTS

The differences in the fruit and vegetable consumption previously identified between Mediterranean and Northern European countries seem to be leveling out, particularly in relation to fruit consumption. Pulses, however, still characterize the diet of the Mediterraneans. Straying from their traditional food choices, Mediterraneans recorded high availability of unprocessed red meat, while Central and Northern Europeans preferably consumed meat products. The household availability of beverages (alcoholic and non-alcoholic) is generally higher among Central and Northern European populations. Principal component (PC) analysis led to the identification of two dietary patterns in each of the 10 countries. The first was similar in all countries and indicated 'wide-range' food buyers. The second was slightly more varied and described 'beverage and convenience' food buyers. PC1 was common among households of retired and elderly members, while PC2 was common among households located in urban or semi-urban areas and among adult Scandinavians living alone.

CONCLUSIONS

The dietary patterns identified point towards a progressive narrowing of dietary differences between North and South European countries. The comparable between-countries DAFNE data could prove useful in ecological studies, in the formulation of dietary guidelines and public health initiatives addressing specific population groups.

SPONSORSHIP

European Commission.

Mycobacterial immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy is associated with deregulated specific T-cell responses: beneficial effect of IL-2 and GM-CSF immunotherapy

BACKGROUND

With the advent of antiretroviral therapy (ART) cases of immune reconstitution inflammatory syndrome (IRIS) have increasingly been reported. IRIS usually occurs in individuals with a rapidly rising CD4 T-cell count or percentage upon initiation of ART, who develop a deregulated immune response to infection with or without reactivation of opportunistic organisms. Here, we evaluated rises in absolute CD4 T-cells, and specific CD4 T-cell responses in 4 HIV-1+ individuals presenting with mycobacterial associated IRIS who received in conjunction with ART, IL-2 plus GM-CSF immunotherapy.

METHODS

We assessed CD4 T-cell counts, HIV-1 RNA loads, phenotype for naïve and activation markers, and in vitro proliferative responses. Results were compared with those observed in 11 matched, successfully treated asymptomatic clinical progressors (CP) with no evidence of opportunistic infections, and uninfected controls.

RESULTS

Median CD4 T-cell counts in IRIS patients rose from 22 cells/microl before initiation of ART, to 70 cells/microl after 8 months of therapy (median 6.5 fold increase). This coincided with IRIS diagnosis, lower levels of naïve CD4 T-cells, increased expression of immune activation markers, and weak CD4 T-cell responses. In contrast, CP had a median CD4 T-cell counts of 76 cells/microl at baseline, which rose to 249 cells/microl 6 months post ART, when strong T-cell responses were seen in > 80% of patients. Higher levels of expression of immune activation markers were seen in IRIS patients compared to CP and UC (IRIS > CP > UC). Immunotherapy with IL-2 and GM-CSF paralleled clinical recovery.

CONCLUSION

These data suggest that mycobacterial IRIS is associated with inadequate immune reconstitution rather than vigorous specific T-cell responses, and concomitant administration of IL-2 and GM-CSF immunotherapy with effective ART may correct/augment T-cell immunity in such setting resulting in clinical benefit.

The durability of virological success of tenofovir and didanosine dosed at either 400 or 250 mg once daily

Tenofovir (TDF) co-administered with didanosine (ddI) 400 mg increases ddI plasma concentrations by up to 60%, raising concerns over toxicity. To limit this interaction, the dosage of ddI may be reduced to 250 mg once daily when co-prescribed with TDF. In this clinical cohort, highly active antiretroviral therapy regimens containing TDF and ddI 250 mg were significantly better tolerated than combinations with TDF and ddI at a dose of 400 mg. Low-dose ddI 250 mg once daily plus TDF as part of antiretroviral therapy was effective.

HIV and hepatitis C co-infection

HIV/HCV co-infection is emerging as a major cause of morbidity and mortality in the 21st century. This editorial reviews the prevalence of co-infection, the factors involved in acquisition of HCV, and the influence of co-infection on disease progression. We examine the results of the major co-infection trials including APRICOT, ACTG 5071 and RIBAVIC. These trials, in association with emerging evidence for future therapies currently undergoing investigation, have led to increased hope of treatment success in co-infected individuals.

A Randomized Trial to Evaluate Lopinavir/Ritonavir versus Saquinavir/Ritonavir in HIV-1-Infected Patients: The Maxcmin2 Trial

Objective

To assess the rate of protocol-defined treatment failure and safety of lopinavir/ritonavir (LPV/r) and saquinavir/ritonavir (SAQ/r).

Design

Open-label, prospective, randomized (1:1), international multi-centre trial.

Methods

Adult HIV-1-infected patients were assigned LPV/r 400/100 mg twice daily or SAQ/r 1000/100 mg twice daily with two or more nucleoside reverse transcriptase inhibitors (NRTIs)/non-NRTIs. All patients, whether on or off the assigned treatment, were followed for 48 weeks.

Results

Of 339 randomized patients, 324 initiated assigned treatment (intention-to-treat/exposed [ITT/e] population). At 48 weeks, treatment failure occurred in 29/163 (18%) and 53/161 (33%) of patients in the LPV/r and SAQ/r arms, respectively (ITT/e, P=0.002, log rank test). In an analysis that also considered those patients who discontinued treatment as having failed treatment (ITT/e/discontinuation=failure), 40/161 (25%) LPV/r-treated individuals versus 63/161 (39%) SAQ/R-treated individuals failed treatment ( P=0.005, log rank test). Discontinuation of the assigned treatment occurred in 23/163 (14%) patients in the LPV/r-treated group, compared with 48/161 (30%) in the SAQ/r-treated group (ITT/e; P=0.001). The primary reasons for premature discontinuation were non-fatal adverse events (LPV/r: 12/163; SAQ/r: 21/161) and patients’ choice (LPV/r: 7/163; SAQ/r: 8/161). In the on-treatment analysis of time to treatment failure, no difference was observed between the two arms ( P=0.27, log rank test).

Conclusion

LPV/r had better antiretroviral effects compared with SAQ/r at the doses and in the formulations studied. This may have been a result of patients’ preferences and ability to adhere to assigned therapy, rather than a result of differences in the intrinsic potency of the study protease inhibitors.

Immune Reconstitution Inflammatory Syndrome Associated With Kaposi's Sarcoma

Purpose

A proportion of patients with HIV infection who subsequently receive highly active antiretroviral therapy (HAART) exhibit a deterioration in their clinical status, despite control of virologic and immunologic parameters. This clinical response, known as the immune reconstitution inflammatory syndrome (IRIS), occurs secondary to an immune response against previously diagnosed pathogens.

Patients and Methods

From our cohort of 5,832 patients treated in the HAART era, we identified 150 therapy-naive patients with a first presentation of Kaposi's sarcoma (KS). Their clinicopathologic features and progress were recorded prospectively.

Results

After commencing HAART, ten patients (6.6%) developed progressive KS, which we identify as IRIS-associated KS. In a comparison of these individuals with those whose KS did not progress, we found that IRIS-KS occurred in patients with higher CD4 counts (P = .03), KS-associated edema (P = .01), and therapy with both protease inhibitors and non-nucleosides together (P = .03). Time to treatment failure was similar for both groups, although the CD4 count declined more rapidly at first, in those patients with IRIS-associated KS. Despite this initial decline, in our clinical experience HAART could be successfully continued in those with IRIS-associated KS.

Conclusion

We have identified IRIS-KS in a cohort of HIV patients with KS who start HAART.

Vomiting post tonsillectomy at the University Hospital of the West Indies

A three-year observational study of patients undergoing tonsillectomy at the University Hospital of the West Indies was conducted to determine the incidence of postoperative vomiting. Data were collected to assess possible risk factors for vomiting as well as possible alleviating agents. Two hundred and fifty-two patients were included in the study and a thirteen per cent incidence of postoperative vomiting was found. This is significantly less than that quoted in other studies (40-73%). Results also showed that steroids significantly reduced the incidence of postoperative vomiting in the study population. Muscle relaxants reversal agents and antibiotics particularly co-trimoxazole and ceftriaxone significantly increased its incidence. Usual antiemetic agents including dimenhydrinate (gravol) and promethazine (phenergan), as well as drugs known to possess antiemetic properties such as midazolam and propofol, lacked any significant protective effect against emesis. Opioid analgesia, inhalational induction and blood loss of greater than 10% of estimated blood volume appeared to increase emesis but failed to achieve statistical significance.

Colouterine fistula mimicking pyometrium--diagnosis established with multi-detector computed tomography

Images

Comparison of gatifloxacin, moxifloxacin and ciprofloxacin for treatment of experimental Burkholderia pseudomallei infection

OBJECTIVES

To compare the efficacy of moxifloxacin, gatifloxacin and ciprofloxacin for the post-exposure prophylaxis and treatment of experimental Burkholderia pseudomallei infection. The presence of persistent infection in treated animals and the rate of relapse following dexamethasone treatment were also investigated.

METHODS

BALB/c mice were inoculated subcutaneously with 1.75 x 10(6) cfu of B. pseudomallei strain 576. Gatifloxacin, moxifloxacin and ciprofloxacin (100 mg/kg) were given orally at 12 hourly intervals for 14 days starting at 6 h, 7 days or 12 days post-challenge. Control mice did not receive antibiotic therapy.

RESULTS

No regimen gave 100% protection. Prophylaxis was most effective when started 6 h post-challenge, with survival rates at 42 days for ciprofloxacin, gatifloxacin and moxifloxacin being 58%, 75% and 75%, respectively. For treatment started at day 7 post-challenge, survival rates were 17%, 11% and 44%, respectively. When antibiotic treatment was delayed until day 12 post-challenge, survival rates fell to 21%, 17% and 28%, respectively. Following dexamethasone treatment of survivors at 42 days post-challenge, relapses occurred in all treatment groups.

CONCLUSIONS

Fluoroquinolones do not provide good post-exposure protection against infection with B. pseudomallei. The newer agents moxifloxacin and gatifloxacin are not significantly better than ciprofloxacin for this purpose.

Anticoagulation therapy in patients with chronic atrial fibrillation: a retrospective claims data analysis

OBJECTIVES

This study assessed the risk of thrombo embolic events and bleeding complications among atrial fibrillation patients.

METHODS

A cohort of patients with chronic non-valvular atrial fibrillation were identified from medical claims (diagnosis codes 427.31 and 427.32). Subjects were identified from 1 January 1998-31 December 2000 and were continuously enrolled for 6 months prior to the first occurring atrial fibrillation medical claim. Cox proportional hazards analysis with time varying covariates was used for the event analysis.

RESULTS

Of 6764 subjects retained for analysis, 3541 (52.4%) were exposed to warfarin. Adjusting for baseline characteristics, warfarin exposure was associated with lower likelihood of an arterial thromboembolic event compared to no exposure (HR: 0.710, CI: 0.540-0.934). No benefit was found in the use of warfarin in the prevention of intracranial events (HR: 1.119, CI: 0.929-1.349). Use of warfarin increased the risk of minor bleeding events (HR: 3.600, CI: 2.537-5.109), and all bleeding events (HR: 1.502, CI: 1.289-1.749).

CONCLUSIONS

The risk of arterial thromboembolic events was associated with warfarin exposure as expected. An increase in the risk of minor and total bleeding events among patients treated with warfarin was observed. The results of this study suggest that there may be a gap between the clinical trial and coagulation clinic performance of warfarin in reducing the risk of thromboembolic events versus what is achievable in general practice.