Perilipin-2 limits remyelination by preventing lipid droplet degradation

Foamy macrophages and microglia containing lipid droplets (LDs) are a pathological hallmark of demyelinating disorders affecting the central nervous system (CNS). We and others showed that excessive accumulation of intracellular lipids drives these phagocytes towards a more inflammatory phenotype, thereby limiting CNS repair. To date, however, the mechanisms underlying LD biogenesis and breakdown in lipid-engorged phagocytes in the CNS, as well as their impact on foamy phagocyte biology and lesion progression, remain poorly understood. Here, we provide evidence that LD-associated protein perilipin-2 (PLIN2) controls LD metabolism in myelin-containing phagocytes. We show that PLIN2 protects LDs from lipolysis-mediated degradation, thereby impairing intracellular processing of myelin-derived lipids in phagocytes. Accordingly, loss of Plin2 stimulates LD turnover in foamy phagocytes, driving them towards a less inflammatory phenotype. Importantly, Plin2-deficiency markedly improves remyelination in the ex vivo brain slice model and in the in vivo cuprizone-induced demyelination model. In summary, we identify PLIN2 as a novel therapeutic target to prevent the pathogenic accumulation of LDs in foamy phagocytes and to stimulate remyelination.

Depressive symptoms in higher education students during the first wave of the COVID-19 pandemic. An examination of the association with various social risk factors across multiple high- and middle-income countries

Higher-education students face substantial risks for developing depressive symptoms during the COVID-19 pandemic or experiencing exacerbated pre-existing depressive symptoms. This study uses data from the COVID-19 International Student Well-Being Study, which collected data through a non-representative convenience sample in 125 higher-education institutions (HEI) across 26 high- and middle-income countries (N: 20,103) during the first wave of the COVID-19 pandemic. It describes the prevalence of depressive symptoms in higher-education students. We find substantial cross-national variation in depressive symptoms, with lowest mean levels established in the Nordic countries and France, while highest mean levels of depressive symptoms were found in Turkey, South Africa, Spain and the USA. Elevated risk for depressive symptoms was found in female students, students with fewer social support resources and in a more disadvantaged socioeconomic position, and students with a migrant background. COVID-19 related stressors, such as reduced social contact, increased financial insecurity, and academic stress explained a relatively larger proportion of the variance in depressive symptoms compared to non-COVID-19 related stressors. This finding shows that not the pandemic itself, but rather the secondary effects of the pandemic relate to students' mental health. Our results enable HEIs to be better equipped to target groups that are particularly at risk during a pandemic.

Process evaluation of care scale up for hypertension in diabetes in Belgium, Slovenia and Cambodia

Background

Effective integrated care interventions for hypertension (HT) and type 2 diabetes (T2D) exist and need to be scaled-up. The ‘SCale-Up diaBetes and hYpertension care' SCUBY project aims to facilitate scale-up of integrated care for HT and T2D through the implementation of contextualised scale-up roadmaps in Cambodia, Slovenia and Belgium and co-creation in policy dialogues. We herewith describe the plan for the process and scale-up evaluation of the SCUBY project, including the development, adoption and implementation of the roadmaps. The specific goals of the process evaluation are to (i) analyse how the reality of scale-up adheres to the developed roadmaps and (ii) assess how the different contexts can influence the implementation process of the scale-up strategies.

Methods

A comprehensive framework was developed to include context, process, scale-up and impact evaluation that is embedded in implementation and political theory. A diverse range of mostly qualitative tools - including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping - will be used to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. Key implementation outcomes include acceptability, feasibility relevance, adaptation, adoption and cost of roadmap activities. The role of context is relevant, and barriers and facilitators to scale-up will be continuously assessed.

Conclusions

The SCUBY project presents a comprehensive framework to guide the evaluation of scale-up of complex interventions. We describe three contextualised roadmaps, for Belgium, Slovenia and Cambodia, each adopting their own (horizontal/diversification/vertical) scale-up strategy(ies) as a basis to monitor adaptations through a co-creation process. This study protocol will be a guide for other scale-up interventions making use of knowledge translation and co-creation activities.

Key messages

Process evaluation is needed to keep track of complex interventions including scale up. The SCUBY project developed an evaluation plan to comprehensively monitor the scale-up of HT and T2D care.

The COVID-19 International Student Well-being Study

Background

We will present the COVID-19 International Student Well-being Study (C19 ISWS). The C19 ISWS is a cross-sectional multi-country study that collected data on higher education students during the first wave of the COVID-19 outbreak (spring 2020).

Methods

The dataset allows to describe (1) the living conditions, financial conditions and academic workload before and during the COVID-19 outbreak, (2) the current level of mental well-being and changes in healthy lifestyles, (3) perceived stressors, (4) resources (e.g., social support and economic capital), (5) COVID-19 related knowledge, and (6) attitudes towards COVID-19 measures implemented by the government and higher education institution (HEI). The dataset additionally includes information about COVID-19 measures taken by the government and HEI that were in place during the period of data collection.

Results

As a large international consortium of 26 countries and 110 higher education institutions (HEIs), we successfully developed and executed an online student survey during or directly after the initial peak of the Covid-19 pandemic.

Conclusions

The collected data provide a comprehensive and comparative dataset on student well-being. In this article, we present the rationale for this study, the development and content of the survey, the methodology of data collection and sampling, and the limitations of the study. In addition, we highlight the opportunities that the dataset provides for advancing social science research on student well-being during the COVID-19 pandemic in varying policy contexts. Thus far, this is the first cross-country student well-being survey during the COVID-19 pandemic, resulting in a unique dataset that enables high priority and socially relevant research.

Stearoyl-CoA desaturase-1 impairs the reparative properties of macrophages and microglia in the brain

Failure of remyelination underlies the progressive nature of demyelinating diseases such as multiple sclerosis. Macrophages and microglia are crucially involved in the formation and repair of demyelinated lesions. Here we show that myelin uptake temporarily skewed these phagocytes toward a disease-resolving phenotype, while sustained intracellular accumulation of myelin induced a lesion-promoting phenotype. This phenotypic shift was controlled by stearoyl-CoA desaturase-1 (SCD1), an enzyme responsible for the desaturation of saturated fatty acids. Monounsaturated fatty acids generated by SCD1 reduced the surface abundance of the cholesterol efflux transporter ABCA1, which in turn promoted lipid accumulation and induced an inflammatory phagocyte phenotype. Pharmacological inhibition or phagocyte-specific deficiency of Scd1 accelerated remyelination ex vivo and in vivo. These findings identify SCD1 as a novel therapeutic target to promote remyelination.

Altered PPARγ Expression Promotes Myelin-Induced Foam Cell Formation in Macrophages in Multiple Sclerosis

Macrophages play a crucial role during the pathogenesis of multiple sclerosis (MS), a neuroinflammatory autoimmune disorder of the central nervous system. Important regulators of the metabolic and inflammatory phenotype of macrophages are liver X receptors (LXRs) and peroxisome proliferator-activated receptors (PPARs). Previously, it has been reported that PPARγ expression is decreased in peripheral blood mononuclear cells of MS patients. The goal of the present study was to determine to what extent PPARγ, as well as the closely related nuclear receptors PPARα and β and LXRα and β, are differentially expressed in monocytes from MS patients and how this change in expression affects the function of monocyte-derived macrophages. We demonstrate that monocytes of relapsing-remitting MS patients display a marked decrease in PPARγ expression, while the expression of PPARα and LXRα/β is not altered. Interestingly, exposure of monocyte-derived macrophages from healthy donors to MS-associated proinflammatory cytokines mimicked this reduction in PPARγ expression. While a reduced PPARγ expression did not affect the inflammatory and phagocytic properties of myelin-loaded macrophages, it did impact myelin processing by increasing the intracellular cholesterol load of myelin-phagocytosing macrophages. Collectively, our findings indicate that an inflammation-induced reduction in PPARγ expression promotes myelin-induced foam cell formation in macrophages in MS.

CNS delivery of anti-CD52 antibodies modestly reduces disease severity in an animal model for multiple sclerosis

Background and aims

Alemtuzumab is a humanized monoclonal antibody that depletes CD52-bearing B and T lymphocytes. Clinical trials defined that systemic administration of alemtuzumab reduces disease severity in the relapsing-remitting phase of multiple sclerosis (MS). However, its efficacy in progressive MS patients is limited, which may reflect the inability of alemtuzumab to cross the reconstituted BBB in these patients. Objective: to study whether central nervous system (CNS) delivery of anti-CD52 antibodies reduces disease severity and the neuroinflammatory burden in the experimental autoimmune encephalomyelitis (EAE) model.

Methods

Anti-CD52 antibodies were administered intrathecally during the acute and chronic phases of EAE. Flow cytometry and immunohistochemistry were utilized to define immunological and pathological parameters.

Results

We show that subcutaneously administrated anti-CD52 antibodies completely abolish EAE disease severity. CNS delivery of anti-CD52 antibodies during both the acute and chronic phases of EAE moderately reduces disease severity and the neuroinflammatory burden. Our findings further suggest that CNS delivery of anti-CD52 antibodies impacts both the peripheral and CNS immune cell compartments in the EAE model but not in healthy mice.

Conclusion

Collectively, our findings highlight the therapeutic potential of CNS delivery of alemtuzumab for the treatment of progressive as well as early MS.

CD36-mediated uptake of myelin debris by macrophages and microglia reduces neuroinflammation

Background

The presence of foamy macrophages and microglia containing intracellular myelin remnants is a pathological hallmark of neurodegenerative disorders such as multiple sclerosis (MS). Despite the importance of myelin internalization in affecting both central nervous system repair and neuroinflammation, the receptors involved in myelin clearance and their impact on the phagocyte phenotype and lesion progression remain to be clarified.

Methods

Flow cytometry, quantitative PCR, and immunohistochemistry were used to define the mRNA and protein abundance of CD36 in myelin-containing phagocytes. The impact of CD36 and nuclear factor erythroid 2–related factor 2 (NRF2) on the phagocytic and inflammatory features of macrophages and microglia was assessed using a pharmacological CD36 inhibitor (sulfo-N-succinimidyl oleate) and Nrf2^−/− bone marrow-derived macrophages. Finally, the experimental autoimmune encephalomyelitis (EAE) model was used to establish the impact of CD36 inhibition on neuroinflammation and myelin phagocytosis in vivo.

Results

Here, we show that the fatty acid translocase CD36 is required for the uptake of myelin debris by macrophages and microglia, and that myelin internalization increased CD36 expression through NRF2. Pharmacological inhibition of CD36 promoted the inflammatory properties of myelin-containing macrophages and microglia in vitro, which was paralleled by a reduced activity of the anti-inflammatory lipid-sensing liver X receptors and peroxisome proliferator-activated receptors. By using the EAE model, we provide evidence that CD36 is essential for myelin debris clearance in vivo. Importantly, CD36 inhibition markedly increased the neuroinflammatory burden and disease severity in the EAE model.

Conclusion

Altogether, we show for the first time that CD36 is crucial for clearing myelin debris and suppressing neuroinflammation in demyelinating disorders such as MS.

Multiresidue Determination of Pesticides in Drinking and Related Waters by Solid-Phase Extraction and Liquid Chromatography with Ultraviolet Detection: Interlaboratory Study

As part of a project funded by the European Commission (EC) for the development and evaluation of multiresidue methods for analysis of drinking and related waters, 17 European laboratories evaluated a method using styrene–divinylbenzene copolymer solid-phase extraction followed by liquid chromatography with diode array detection. The main aim of the study was to evaluate whether the method meets the requirements of EC Drinking Water Directive 98/83 in terms of accuracy, precision, and detection limit for 21 pesticides according to the following requirements: limit of detection, ≤0.025 μg/L; accuracy expressed as recovery, between 75 and 125%; and precision expressed as repeatability relative standard deviation of the method, <12.5%, and as reproducibility relative standard deviation of the method, <25%. Analyses for unknown concentrations were performed with commercial bottled and tap waters. All laboratories were able to achieve detection limits of 0.01 μg/L for all pesticides except pirimicarb (0.02 μg/L). The criteria for repeatability were met for all compounds. Terbutryn in bottled water and carbendazim in tap water did not meet the criteria for reproducibility. In terms of accuracy, the method met the requirements for all pesticides in both matrixes, except for metamitron. However, several compounds (linuron, terbutryn, propazine, metobromuron, and isoproturon) showed recoveries slightly below 75%.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium

Key messages

Innovative strategies are needed to scale up integrated chronic care for non-communicable diseases. The SCUBY project develops, implements and assesses roadmaps for the scale-up of an integrated chronic care package for hypertension and diabetes.

Liver X Receptor Alpha Is Important in Maintaining Blood-Brain Barrier Function

Dysfunction of the blood-brain barrier (BBB) contributes significantly to the pathogenesis of several neuroinflammatory diseases, including multiple sclerosis (MS). Potential players that regulate BBB function are the liver X receptors (LXRs), which are ligand activated transcription factors comprising two isoforms, LXRα, and LXRβ. However, the role of LXRα and LXRβ in regulating BBB (dys)function during neuroinflammation remains unclear, as well as their individual involvement. Therefore, the goal of the present study is to unravel whether LXR isoforms have different roles in regulating BBB function under neuroinflammatory conditions. We demonstrate that LXRα, and not LXRβ, is essential to maintain barrier integrity in vitro. Specific knockout of LXRα in brain endothelial cells resulted in a more permeable barrier with reduced expression of tight junctions. Additionally, the observed dysfunction was accompanied by increased endothelial inflammation, as detected by enhanced expression of vascular cell adhesion molecule (VCAM-1) and increased transendothelial migration of monocytes toward inflammatory stimuli. To unravel the importance of LXRα in BBB function in vivo, we made use of the experimental autoimmune encephalomyelitis (EAE) MS mouse model. Induction of EAE in a constitutive LXRα knockout mouse and in an endothelial specific LXRα knockout mouse resulted in a more severe disease score in these animals. This was accompanied by higher numbers of infiltrating leukocytes, increased endothelial VCAM-1 expression, and decreased expression of the tight junction molecule claudin-5. Together, this study reveals that LXRα is indispensable for maintaining BBB integrity and its immune quiescence. Targeting the LXRα isoform may help in the development of novel therapeutic strategies to prevent BBB dysfunction, and thereby neuroinflammatory disorders.

Stigma as a barrier to the use of occupational health units for tuberculosis services in South Africa

SETTING

Tuberculosis (TB) is the leading cause of death in South Africa, and health care workers (HCWs) are disproportionally affected. The resulting absenteeism strains the already overburdened health system. Although hospital occupational health care units (OHUs) are cost-effective and of crucial importance in tackling the TB epidemic, the fear of being stigmatised by other colleagues might lead HCWs to avoid using OHUs.

OBJECTIVE

To investigate whether the perception of TB stigma among colleagues has a negative effect on the willingness to use OHUs for TB services.

DESIGN

In the Free State Province, South Africa, a representative sample of 804 HCWs from six hospitals were surveyed on workplace stigma as a predictor for the use of OHUs for TB services. Applying structural equation modelling, we also controlled for exogenous variables.

RESULTS

There was a significant negative relationship between the perception of stigmatising attitudes and behaviours among co-workers and the use of OHUs for TB screening (β -0.21, P = 0.000), treatment (β -0.16, P = 0.001) and isoniazid preventive therapy (β -0.17, P = 0.000).

CONCLUSION

The negative effect of TB stigma on OHU use among HCWs can impact upon their health and increase hospital costs. This needs to be addressed by interventions combating TB stigma among HCWs in the workplace.

Evidence-based interventions to reduce tuberculosis stigma: a systematic review

SETTING

While substantial progress is being made in tuberculosis (TB) control, the success of public health efforts is hampered by pervasive stigma.

OBJECTIVE

To perform a systematic literature review to assess the effectiveness of interventions aimed at reducing TB stigma in patients, health care workers, care givers and the general community.

DESIGN

Studies were eligible for inclusion if they evaluated interventions aimed at reducing TB stigma and were published between 1950 and 2015. We searched eight databases (PubMed, Cochrane Library, Ovid, Embase, PsycInfo, Sociological Abstracts, Cumulative Index to Nursing and Allied Health Literature, World Health Organization Latin American and Caribbean Health Sciences Literature), and complemented the searches by using the snowball strategy and by reviewing relevant grey literature.

RESULTS

Only seven studies were identified as providing quantitative (n = 4) or qualitative (n = 3) evidence of effectiveness in reducing TB stigma. Quality assessment of the studies was poor. Knowledge-shaping and attitude-changing interventions aimed at the public, patients and their families were effective in reducing anticipated stigma. Home visits and support groups were effective in reducing both anticipated and internalised stigma.

CONCLUSION

There is a dearth of reliable information on the effectiveness of TB stigma-reduction interventions. Knowledge-shaping, attitude-changing and patient-support interventions can be effective in reducing TB stigma, but more rigorous evaluations are needed.

Measuring HIV- and TB-related stigma among health care workers in South Africa: a validation and reliability study

SETTING

Recent evidence indicates that human immunodeficiency virus (HIV) and tuberculosis (TB) related stigma act as a key barrier to the utilisation of associated occupational health services by South African health care workers (HCWs). It also highlights a dearth of appropriate tools to measure HIV and TB stigma among HCWs.

OBJECTIVE

To test four scales measuring different aspects of stigma: respondent's external stigma (RES) and others' external stigma (OES) towards TB as well as HIV across different professional categories of HCWs.

DESIGN

The current study employs data from a study on HIV and TB stigma among HCWs, a cluster randomised controlled trial for the collection of data among 882 HCWs in the Free State Province of South Africa. Confirmatory factor analyses and structural equation modelling were used to assess the validity and reliability of the scales.

RESULTS

All four scales displayed adequate internal construct validity. Subsequent analysis demonstrated that all four scales were metric-invariant, and that the OES scales were even scalar-invariant across patient and support staff groups. The scales displayed good reliability and external construct validity.

CONCLUSION

Our results support the use of the scales developed to measure TB and HIV stigma among HCWs. Further research is, however, needed to fine tune the instruments and test them across different resource-limited countries.

Scavenger receptor collectin placenta 1 is a novel receptor involved in the uptake of myelin by phagocytes

Myelin-containing macrophages and microglia are the most abundant immune cells in active multiple sclerosis (MS) lesions. Our recent transcriptomic analysis demonstrated that collectin placenta 1 (CL-P1) is one of the most potently induced genes in macrophages after uptake of myelin. CL-P1 is a type II transmembrane protein with both a collagen-like and carbohydrate recognition domain, which plays a key role in host defense. In this study we sought to determine the dynamics of CL-P1 expression on myelin-containing phagocytes and define the role that it plays in MS lesion development. We show that myelin uptake increases the cell surface expression of CL-P1 by mouse and human macrophages, but not by primary mouse microglia in vitro. In active demyelinating MS lesions, CL-P1 immunoreactivity was localized to perivascular and parenchymal myelin-laden phagocytes. Finally, we demonstrate that CL-P1 is involved in myelin internalization as knockdown of CL-P1 markedly reduced myelin uptake. Collectively, our data indicate that CL-P1 is a novel receptor involved in myelin uptake by phagocytes and likely plays a role in MS lesion development.

Active liver X receptor signaling in phagocytes in multiple sclerosis lesions

OBJECTIVE

We sought to determine the liver X receptor (LXR) ligands present in human macrophages after myelin phagocytosis and whether LXRs are activated in multiple sclerosis (MS) lesions.

METHODS

We used real-time quantitative polymerase chain reaction (PCR) and immunohistochemistry to determine expression of LXRs and their response genes in human phagocytes after myelin phagocytosis and in active MS lesions. We used gas chromatographic/mass spectrometric analysis to determine LXR-activating oxysterols and cholesterol precursors present and formed in myelin and myelin-incubated cells, respectively.

RESULTS

Myelin induced LXR response genes ABCA1 and ABCG1 in human monocyte-derived macrophages. In active MS lesions, we found that both gene expression and protein levels of ABCA1 and apolipoprotein E ( APOE) are upregulated in foamy phagocytes. Moreover, we found that the LXR ligand 27-hydroxycholesterol (27OHC) is significantly increased in human monocyte-derived macrophages after myelin uptake.

CONCLUSION

LXR response genes are upregulated in phagocytes present in active MS lesions, indicating that LXRs are activated in actively demyelinating phagocytes. In addition, we have shown that myelin contains LXR ligands and that 27OHC is generated in human monocyte-derived macrophages after myelin processing. This suggests that LXRs in phagocytes in active MS lesions are activated at least partially by (oxy)sterols present in myelin and the generation thereof during myelin processing.

Operational Definition of Active and Healthy Ageing (AHA): A Conceptual Framework

Health is a multi-dimensional concept, capturing how people feel and function. The broad concept of Active and Healthy Ageing was proposed by the World Health Organisation (WHO) as the process of optimizing opportunities for health to enhance quality of life as people age. It applies to both individuals and population groups. A universal Active and Healthy Ageing definition is not available and it may differ depending on the purpose of the definition and/or the questions raised. While the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has had a major impact, a definition of Active and Healthy Ageing is urgently needed. A meeting was organised in Montpellier, France, October 20-21, 2014 as the annual conference of the EIP on AHA Reference Site MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif en Languedoc Roussillon) to propose an operational definition of Active and Healthy Ageing including tools that may be used for this. The current paper describes the rationale and the process by which the aims of the meeting will be reached.

Two cases of rickets presenting with poor growth, hypotonia, and respiratory problems

Rickets is a rare disease in developed countries. In children, it is a disease which affects growing bone. Depending on the severity, it can present with a wide variety of symptoms. Because it is such a rare disease in developed countries, symptoms suggesting rickets are often not easily recognized. This can cause a delay in diagnosing and treating rickets. Often unnecessary and sometimes invasive investigations are performed. First leading clues to rickets on physical examination are poor growth, especially length, thickening of wrists, bow legs, and craniotabes. At further examination, special attention should be paid to osteopenia and cupping and fraying at the metaphyses on X-rays. Laboratory results suggestive for rickets are elevated alkaline phosphatase and disturbances in calcium and phosphate homeostasis. In this report, we present two cases presenting with poor growth, severe pain, and respiratory problems secondary to calcipenic rickets.

Central role for protein kinase C in oxytocin and epidermal growth factor stimulated cyclooxygenase 2 expression in human myometrial cells

BACKGROUND

Prostaglandins are important mediators of uterine contractility and cervical ripening during labour. Cyclooxygenase-2 (COX-2), also known as prostaglandin-endoperoxide synthase 2, is a rate limiting enzyme involved in the conversion of arachidonic acid into prostaglandins at parturition. In this paper, the pathways underlying agonist-induced cyclooxygenase-2 expression in human myometrial cells were studied.

RESULTS

Myometrial cells were stimulated with different agonists: oxytocin (OXT), epidermal growth factor (EGF), interleukin-1β (IL1β), and phorbol-12-myristate-13-acetate (PMA) alone and in the presence of specific signalling pathway inhibitors. The nuclear factor kappa-light-chain-enhancer of activated B cells (NFKB) pathway was inhibited by means of the IKK-2 inhibitor TPCA-1. Signalling through extracellular signal-regulated kinases (ERK) was inhibited using the MEK1/2 inhibitor PD-184352. Bisindolylmaleimide-I was used to inhibit protein kinase C (PKC) signalling. COX-2 expression and ERK phosphorylation were measured using immunoblotting.OXT induced COX-2 expression by activating PKC and ERK. EGF increased COX-2 expression via stimulation of PKC, ERK and NFKB. As expected, the pro-inflammatory cytokine IL1β induced COX-2 expression by activating PKC- and NFKB-dependent pathways. Stimulation of PKC directly with PMA provoked strong COX-2 expression.

CONCLUSIONS

PKC plays a central role in OXT and EGF induced COX-2 expression in human myometrial cells. However, other pathways, notably ERK and NFKB are also involved to an extent which depends on the type of agonist used.

Predictors of uptake of human immunodeficiency virus testing by tuberculosis patients in Free State Province, South Africa

SETTING

Two districts of the Free State Province in South Africa.

OBJECTIVE

To determine the predictors of human immunodeficiency virus (HIV) test uptake by tuberculosis (TB) patients.

DESIGN

A cross-sectional survey was conducted among 600 TB patients in 61 primary health care facilities. Probability proportional-to-size sampling was used to determine the number of patients recruited at each facility. Structured exit interviews were conducted with convenience samples of patients at these facilities. Descriptive and logistic regression analyses were performed on the data.

RESULTS

The average age of the recruited TB patients was 38.4 years. The majority were female (n = 310, 51.7%), unmarried (n = 439, 73.3%), unemployed (n = 513, 85.5%) and had undertaken HIV testing (n = 405, 67.5%). In multivariate analysis, having received information on the relationship between TB and HIV (OR 5.4, 95%CI 3.1-9.5) was the strongest predictor of HIV test uptake among unmarried patients. Other associated factors included knowing/having lost someone ill with HIV/AIDS (acquired immune-deficiency syndrome; OR 3.6, 95%CI 2.2-5.8), female sex (OR 2.3, 95%CI 1.4-3.7), unemployment (OR 2.2, 95%CI 1.2-4.1) and undergoing retreatment for TB (OR 2.0, 95%CI 1.2-3.2).

CONCLUSION

HIV test scale-up efforts should aim to increase TB patients' awareness of the relationship between TB and HIV/AIDS and consider the impact of socio-demographic factors.

[COPD: from obstructive lung disease to chronic systemic inflammatory syndrome?]

COPD is a complex and heterogeneous disease, in which multiple genes and environmental factors are involved. The disease is associated with a high risk of comorbidity and systemic manifestations. The majority of the patients with COPD suffer from additional chronic diseases like hypertension, diabetes, heart disease, osteoporosis or cancer. Parameter, assessing selectively the lung function, are only conditionally suited for capturing the COPD as a whole. In future subtyping of COPD might give the opportunity to better understand the heterogeneity of the disease. A holistic approach, understanding COPD not as an isolated disease of the lung, but as a "chronic systemic inflammatory syndrome" (CSIS), promises further improvement. Systemic inflammations seems to be a common mechanism leading to chronic diseases by sharing risk factors like smoking, overweight, hypertension and elevated blood lipids. In response to this approach, the diagnosis and therapy of COPD must include the whole entity of comorbidities.

State of the ART: clinical efficacy and improved quality of life in the public antiretroviral therapy program, Free State province, South Africa

The South African public-sector antiretroviral treatment (ART) program has yielded promising early results. To extend and reinforce these preliminary findings, we undertook a detailed assessment of the clinical efficacy and outcomes over two years of ART. The primary objective was to assess the clinical outcomes and adverse effects of two years of ART, while identifying the possible effects of baseline health and patient characteristics. A secondary objective was to address the interplay between positive and negative outcomes (clinical benefits versus adverse effects) in terms of the patients' physical and emotional quality of life (QoL). Clinical outcome, baseline characteristics, health status, and physical and emotional QoL scores were determined from clinical files and interviews with 268 patients enrolled in the Free State ART program at three time points (6, 12, and 24 months of ART). Age, sex, education, and baseline health (CD4 cell count and viral load) were all independently associated with the ART outcome in the early stages of treatment, but their impact diminished as the treatment progressed. The number of patients classified as treatment successes increased over the first two years of ART, whereas the proportion of patients experiencing adverse effects diminished. Importantly, our findings show that ART had strong and stable positive effects on physical and emotional QoL. These favorable results demonstrate that a well-managed public-sector ART program can be very successful within a high-HIV-prevalence resource-limited setting. This finding emphasizes the need to adopt treatment scale-up as a key policy priority, while at the same time ensuring that the highest standards of healthcare provision are maintained. Healthcare services should also target vulnerable groups (males, less-educated patients, those with low baseline CD4 cell counts, and high baseline viral loads) who are most likely to experience treatment failure.

Slow to share: social capital and its role in public HIV disclosure among public sector ART patients in the Free State province of South Africa

HIV serostatus disclosure to community members has been shown to have potential public and personal health benefits. This study examined the impact of bonding and bridging social capital (i.e. close and distant ties) on public disclosure and described the complex relationship between bonding and bridging social capital in the context of serostatus disclosure among AIDS patients enrolled in South Africa's public sector antiretroviral treatment (ART) program. Data were collected from a cohort of patients enrolled in the public sector ART program in the Free State province of South Africa. Semi-structured, face-to-face interviews were conducted with a random sample of 268 patients at three points in time (<6 months of ART, 6-12 months of ART, and 18-24 of months ART). The relationship between bonding and bridging social capital and the impact of different forms of social capital on public disclosure were determined using a fully cross-lagged regression model. The impact of bonding social capital (treatment and emotional buddy) on public disclosure was positive and invariant across time. The results from the cross-lagged regression indicated that bridging social capital (community health worker and support group) only encouraged public disclosure in the second year of treatment. At the start of treatment, bivariate analysis showed a strong negative association between bonding and bridging social capital, which diminished at follow-up and eventually disappeared in the second year of treatment. This study identified bonding social capital as a leverage to maximize potential benefits and minimize potential risks in order to shift the balance toward consistent public disclosure. Furthermore, the importance of bridging social capital initiatives is demonstrated, especially for the most vulnerable patients, those who cannot capitalize their bonding social capital by disclosing their HIV serostatus to family and friends at the start of treatment.

Primary care spirometry

Primary care spirometry is a uniquely valuable tool in the evaluation of patients with respiratory symptoms, allowing the general practitioner to diagnose or exclude chronic obstructive pulmonary disease (COPD), sometimes to confirm asthma, to determine the efficacy of asthma treatment and to correctly stage patients with COPD. The use of spirometry for case finding in asymptomatic COPD patients might become an option, once early intervention studies have shown it to be beneficial in these patients. The diagnosis of airway obstruction requires accurate and reproducible spirometric measurements, which should comply with the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. Low acceptability of spirometric manoeuvres has been reported in primary care practices. This may hamper the validity of the results and affect clinical decision making. Training and refresher courses may produce and maintain good-quality testing, promote the use of spirometric results in clinical practice and enhance the quality of interpretation. Softening the stringent ATS/ERS criteria could enhance the acceptability rates of spirometry when used in a general practice. However, the implications of potential simplifications on the quality of the data and clinical decision making remain to be investigated. Hand-held office spirometers have been developed in recent years, with a global quality and user-friendliness that makes them acceptable for use in general practices. The precision of the forced vital capacity measurements could be improved in some of the available models.