Alcohol and gastric motility: pathophysiological and therapeutic implications

Alcohol has been associated with alterations in gastric motility. The literature identifies that various factors play a role in alcohol's effect on gastric emptying including differences in alcohol concentration, osmolarity, caloric content, amino acids as well as different processing techniques (fermentation vs distillation). Additionally, chronic alcohol consumption has been shown to alter the myenteric nitrergic system resulting in impaired gastrointestinal motor function, and it also has an inhibitory effect on the release of several neurotransmitters that play a key role in gastrointestinal motility, including acetylcholine. Whether social or limited intake of alcohol could have a therapeutic role has not been apparent. Serendipitously, we have identified a therapeutic role for alcohol with a meal in the entity of dumping syndrome (DS) where there is postprandial rapid emptying of voluminous and hyperosmolar gastric contents into the small bowel. In the clinical setting of DS attributed to impaired vagal nerve function, there was normalization of gastric emptying and resolution of accompanying symptoms when drinking a glass of wine before and during meals. We propose that alcohol's anticholinergic effect was augmented in the setting of vagal nerve denervation resulting in slowing of gastric emptying and in alleviation of symptoms of early DS. This review article provides an in-depth analysis of the published literature on alcohol and gastric motility focusing on the accumulated knowledge that may have clinical application and relevance.

Time to first positive HIV-1 DNA PCR may differ with antiretroviral regimen in infants infected with non-B subtype HIV-1

OBJECTIVE

To evaluate the association of type and timing of prophylactic maternal and infant antiretroviral regimen with time to first positive HIV-1 DNA PCR test, in nonbreastfed HIV-infected infants, from populations infected predominantly with HIV-1 non-B subtype virus.

DESIGN

Analysis of combined data on nonbreastfed HIV-infected infants from prospective cohorts in Botswana, Thailand, and the United Kingdom (N = 405).

METHODS

Parametric models appropriate for interval-censored outcomes estimated the time to first positive PCR according to maternal or infant antiretroviral regimen category and timing of maternal antiretroviral initiation, with adjustment for covariates.

RESULTS

Maternal antiretroviral regimens included: no antiretrovirals (n = 138), single-nucleoside analog reverse transcriptase inhibitor (n = 165), single-dose nevirapine with zidovudine (n = 66), and combination prophylaxis with 3 or more antiretrovirals [combination antiretroviral therapy (cART), n = 36]. Type of maternal/infant antiretroviral regimen and timing of maternal antiretroviral initiation were each significantly associated with time to first positive PCR (multivariate P < 0.0001). The probability of a positive test with no antiretrovirals compared with the other regimen/timing groups was significantly lower at 1 day after birth, but did not differ significantly after age 14 days. In a subgroup of 143 infants testing negative at birth, infant cART was significantly associated with longer time to first positive test (multivariate P = 0.04).

CONCLUSION

Time to first positive HIV-1 DNA PCR in HIV-1-infected nonbreastfed infants (non-B HIV subtype) may differ according to maternal/infant antiretroviral regimen and may be longer with infant cART, which may have implications for scheduling infant HIV PCR-diagnostic testing and confirming final infant HIV status.

Vital signs: leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States - 2009-2013

BACKGROUND

Hispanics and Latinos (Hispanics) are estimated to represent 17.7% of the U.S. population. Published national health estimates stratified by Hispanic origin and nativity are lacking.

METHODS

Four national data sets were analyzed to compare Hispanics overall, non-Hispanic whites (whites), and Hispanic country/region of origin subgroups (Hispanic origin subgroups) for leading causes of death, prevalence of diseases and associated risk factors, and use of health services. Analyses were generally restricted to ages 18-64 years and were further stratified when possible by sex and nativity.

RESULTS

Hispanics were on average nearly 15 years younger than whites; they were more likely to live below the poverty line and not to have completed high school. Hispanics showed a 24% lower all-cause death rate and lower death rates for nine of the 15 leading causes of death, but higher death rates from diabetes (51% higher), chronic liver disease and cirrhosis (48%), essential hypertension and hypertensive renal disease (8%), and homicide (96%) and higher prevalence of diabetes (133%) and obesity (23%) compared with whites. In all, 41.5% of Hispanics lacked health insurance (15.1% of whites), and 15.5% of Hispanics reported delay or nonreceipt of needed medical care because of cost concerns (13.6% of whites). Among Hispanics, self-reported smoking prevalences varied by Hispanic origin and by sex. U.S.-born Hispanics had higher prevalences of obesity, hypertension, smoking, heart disease, and cancer than foreign-born Hispanics: 30% higher, 40%, 72%, 89%, and 93%, respectively.

CONCLUSION

Hispanics had better health outcomes than whites for most analyzed health factors, despite facing worse socioeconomic barriers, but they had much higher death rates from diabetes, chronic liver disease/cirrhosis, and homicide, and a higher prevalence of obesity. There were substantial differences among Hispanics by origin, nativity, and sex.

IMPLICATIONS FOR PUBLIC HEALTH

Differences by origin, nativity, and sex are important considerations when targeting health programs to specific audiences. Increasing the proportions of Hispanics with health insurance and a medical home (patientcentered, team-based, comprehensive, coordinated health care with enhanced access) is critical. A feasible and systematic data collection strategy is needed to reflect health diversity among Hispanic origin subgroups, including by nativity.

Hispanic Medical Organizations' Support for LGBT Health Issues

Hispanics represent the fastest growing ethnic segment of the lesbian, gay, bisexual, and transgender (LGBT) community in the United States and are disproportionately burdened by LGBT-related health issues and limited political support from Hispanic medical organizations. Recently, the Latino Medical Student Association, the National Hispanic Medical Association, and the Hispanic Serving Health Professions Schools, representing over 60,000 Hispanic students and providers and 35 institutions, collaborated to support a resolution opposing discrimination based on sexual orientation or gender identity and recognizing the obstacles encountered by LGBTQ Hispanics. The resolution provides an important framework for organizational members and leaders to address LGBT health issues and serve to support a more positive sociopolitical climate for the Hispanic LGBT community nationally and internationally.

Cervical pap screening cytological abnormalities among HIV-infected adolescents in the LEGACY cohort

OBJECTIVES

To determine the prevalence of cervical Pap screening (CPAP-S), identify factors associated with CPAP-S, and explore risk factors for abnormal cervical cytology in female adolescents with perinatally and behaviorally acquired HIV infection.

DESIGN

Cross-sectional.

SETTING

LEGACY is a national observational cohort chart review study of 1478 HIV-infected persons (<age 24 years) managed in 22 HIV specialty clinics in the United States.

PARTICIPANTS

Sexually active females aged 13-24 years in the LEGACY cohort.

MAIN OUTCOME MEASURES

CPAP-S and abnormal cervical cytology.

RESULTS

Of 231 sexually active female LEGACY participants 13-24 years of age 49% had documentation of CPAP-S between 2001 and 2006. Fifty-eight percent of 113 cervical tests were abnormal (2% high-grade). In multivariable analysis, perinatal HIV infection and black race were associated with decreased likelihood of CPAP-S (adjusted prevalence ratio [APR] 0.66, 95% CI 0.45-0.96 and APR 0.74, 95% CI 0.56-0.96, respectively). Presence of any sexually transmitted infection (STI) was independently associated with increased likelihood of CPAP-S (APR 1.56, 95% CI 1.21, 2.02). CD4+ T-lymphocyte count <200 cells/mL and previous STI diagnosis were independently associated with increased likelihood of abnormal cervical cytology (APR 2.19, 95% CI 1.26-3.78 and APR 1.94, 95% CI 1.29-2.92, respectively).

CONCLUSIONS

Among sexually active HIV-infected adolescent females, prevalence of CPAP-S was low and cytology was abnormal in more than half of Pap smears. Perinatally HIV-infected, sexually active females were less likely to undergo CPAP-S than their behaviorally HIV-infected counterparts. Interventions targeted at HIV-infected adolescents and care providers are needed to improve CPAP-S in HIV-infected young women, especially those with perinatally acquired HIV infection.

Knowledge and practice of prechewing/prewarming food by HIV-infected women

OBJECTIVE

HIV transmission has been associated with offering a child food prechewed by an HIV-infected caregiver. We assessed awareness of prechewing and oral prewarming of food by an adult before offering it to a child among HIV-infected pregnant women and clinical investigators in 3 Latin American countries.

METHODS

HIV-infected pregnant women at 12 sites (Eunice Kennedy Shriver National Institute of Child Health and Human Development International Site Development Initiative Perinatal Longitudinal Study in Latin American Countries, a prospective cohort trial) in Argentina, Brazil, and Peru were administered a screening survey about prechewing/prewarming of infant foods and cautioned against these feeding practices. Survey responses were analyzed, overall, and stratified according to country.

RESULTS

Of the 401 HIV-infected pregnant women interviewed, 34% had heard about prechewing (50% from Argentina, 32% from Brazil, and 36% from Peru), 23% knew someone who prechewed food for infants, and 4% had prechewed food in the past. Seventeen percent had heard about oral prewarming of food, 13% knew someone who prewarmed food for infants, and 3% had prewarmed food for an infant in the past. Women who reported knowing someone who prechewed were more likely to also know someone who prewarmed food (P < .0001). Few site investigators anticipated that their patients would be aware of these practices.

CONCLUSIONS

Prechewing food, a potential risk factor for HIV transmission, and orally prewarming food, which has not been associated with HIV transmission but might expose a child to blood from an HIV-infected adult, are not uncommon practices in Latin America. Both practices should be further investigated. Site investigator responses underscore that health care providers could be missing information about cultural practices that patients may not report unless specifically asked.

A novel nuclease activity that is activated by Ca(2+) chelated to EGTA

Most nucleases require a divalent cation as a cofactor, usually Mg(2+) or Ca(2+), and are inhibited by the chelators EDTA and EGTA. We report the existence of a novel nuclease activity, initially identified in the luminal fluids of the mouse male reproductive tract but subsequently found in other tissues,that requires EGTA chelated to calcium to digest DNA. We refer to this unique enzyme as CEAN (Chelated EGTA Activated Nuclease). Using a fraction of vas deferens luminal fluid, plasmid DNA was degraded in the presence of excess Ca(2+) (Ca(2+) :EGTA = 16) or excess EGTA (Ca(2+) :EGTA = 0.25), but required the presence of both. Higher levels of EGTA (Ca(2+) :EGTA = 0.10) prevented activity, suggesting that unchelated EGTA may be a competitive inhibitor. The EGTA-Ca(2+) activation of CEAN is reversible as removing EGTA-Ca(2+) stops ongoing DNA degradation, but adding EGTA-Ca(2+) again reactivates the enzyme. This suggests the possibility that CEAN binds directly to EGTA-Ca(2+). CEAN has a greater specificity for the chelator than for the divalent cation. Two other chelators, BAPTA and sodium citrate, do not activate CEAN in the presence of cation, but chelated EDTA does. EGTA chelated to other divalent cations such as Mn(2+), Zn(2+) , and Cu(2+) activate CEAN, but not Mg(2+) . The activity is lost upon boiling suggesting that it is a protein. These data suggest that EGTA and EDTA may not always protect DNA from nuclease damage.

Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years--United States, 2008

For adults and adolescents (i.e., persons aged >/=13 years), the human immunodeficiency virus (HIV) infection classification system and the surveillance case definitions for HIV infection and acquired immunodeficiency syndrome (AIDS) have been revised and combined into a single case definition for HIV infection. In addition, the HIV infection case definition for children aged <13 years and the AIDS case definition for children aged 18 months to <13 years have been revised. No changes have been made to the HIV infection classification system, the 24 AIDS-defining conditions for children aged <13 years, or the AIDS case definition for children aged <18 months. These case definitions are intended for public health surveillance only and not as a guide for clinical diagnosis. Public health surveillance data are used primarily for monitoring the HIV epidemic and for planning on a population level, not for making clinical decisions for individual patients. CDC and the Council of State and Territorial Epidemiologists recommend that all states and territories conduct case surveillance of HIV infection and AIDS using the 2008 surveillance case definitions, effective immediately.

Mouse spermatozoa contain a nuclease that is activated by pretreatment with EGTA and subsequent calcium incubation

We demonstrated that mouse spermatozoa cleave their DNA into approximately 50 kb loop-sized fragments with topoisomerase IIB when treated with MnCl(2) and CaCl(2) in a process we term sperm chromatin fragmentation (SCF). SCF can be reversed by EDTA. A nuclease then further degrades the DNA in a process we term sperm DNA degradation (SDD). MnCl(2) alone could elicit this activity, but CaCl(2) had no effect. Here, we demonstrate the existence of a nuclease in the vas deferens that can be activated by ethylene glycol tetraacetic acid (EGTA) to digest the sperm DNA by SDD. Spermatozoa were extracted with salt and dithiothreitol to remove protamines and then incubated with EGTA. Next, the EGTA was removed and divalent cations were added. We found that Mn(2+), Ca(2+), or Zn(2+) could each activate SDD in spermatozoa but Mg(2+) could not. When the reaction was slowed by incubation on ice, EGTA pretreatment followed by incubation in Ca(2+) elicited the reversible fragmentation of sperm DNA evident in SCF. When the reactions were then incubated at 37 degrees C they progressed to the more complete degradation of DNA by SDD. EDTA could also be used to activate the nuclease, but required a higher concentration than EGTA. This EGTA-activatable nuclease activity was found in each fraction of the vas deferens plasma: in the spermatozoa, in the surrounding fluid, and in the insoluble components in the fluid. These results suggest that this sperm nuclease is regulated by a mechanism that is sensitive to EGTA, possibly by removing inhibition of a calcium binding protein.

Hospitalization trends among children and youths with perinatal human immunodeficiency virus infection, 1990-2002

BACKGROUND

Major improvements in disease progression among HIV-infected children have followed the adoption of combination antiretroviral therapy.

METHODS

We examined trends in hospitalization rates between 1990-2002 among 3,927 children/youths with perinatal HIV infection, ranging in age from newborn to 21 years. We used Poisson regression to test for trends in hospitalization rates by age and year; binomial regression to test for trends in intensive care unit (ICU) admissions and hospitalization at least once and more than once, by age and year; and multivariate logistic regression to examine factors associated with hospitalization, ICU admission, and hospitalization longer than 10 days.

RESULTS

Statistically significant downward trends in hospitalization rates and multiple hospitalizations were observed in all age groups from 1990-2002. The proportion of HIV-infected children/youths who were hospitalized at least once declined from 30.4% in 1990 to 12.9% in 2002, with a steady decline occurring after 1996, when the U.S. Public Health Service issued guidelines recommending triple-drug antiretroviral therapy (triple therapy) for HIV-infected children. ICU admissions declined significantly in all age groups except among children younger than 2 years. Logistic regression results indicated that black and Hispanic children/youths were significantly more likely to be hospitalized than white children/youths and that children/youths receiving triple therapy were significantly more likely to be hospitalized than therapy-naive children; the latter association was not observed among children monitored from 1997-2002.

CONCLUSIONS

Substantial reductions in rates of hospitalization, multiple hospitalizations, and ICU admission have occurred among HIV-infected children/youths from 1990-2002, particularly after 1996, with increased use of triple therapy.

Updated estimates of healthcare utilization and costs among perinatally HIV-infected children

OBJECTIVES

This study examined changes in healthcare use among perinatally HIV-infected children and developed new estimates of expected lifetime treatment costs.

METHODS

The study analyzed longitudinal medical record data from the Pediatric Spectrum of Disease study on perinatally HIV-infected children enrolled in 6 US sites during 1995 and 2001 for enrollee characteristics including healthcare utilization. For the year 2001, costs were assigned to hospitalization, HIV-related drug usage, and laboratory testing. To estimate lifetime treatment costs based on those categories, median survival times of 9, 15, and 25 years were assumed and average annual healthcare utilization costs were applied to each year of survival.

RESULTS

From 1995 to 2001, hospitalization rates fell from 0.67 per child-year to 0.23 per child-year (P < 0.05). In 2001, the average cost of healthcare utilization per child was $12,663, including $2164 for hospitalization, $9505 for HIV-related drugs, and $994 for laboratory tests. The discounted lifetime treatment cost, based on those 3 cost categories, was $113,476 for 9 years of survival, $151,849 for 15 years, and $228,155 for 25 years.

CONCLUSIONS

Hospitalizations among perinatally HIV-infected children decreased significantly from 1995 to 2001. Compared with previously published estimates, lifetime treatment costs for children perinatally infected with HIV have remained relatively stable. However, as years of survival increase for this population, lifetime costs also are likely to increase.

Assessing the risk of birth defects associated with antiretroviral exposure during pregnancy

OBJECTIVE

The purpose of this study was to examine teratogenic risk of antiretroviral (ARV) drugs.

STUDY DESIGN

The Antiretroviral Pregnancy Registry (APR) monitors prenatal exposures to ARV drugs and pregnancy outcome through a prospective exposure-registration cohort. Statistical inference uses exact methods for binomial proportions.

RESULTS

Through July 2003, APR has monitored 3583 live births exposed to ARV. Among 1391 first trimester exposures, there were 38 birth defects, prevalence of 2.7% (95% CI 1.9-3.7), not significantly higher than the CDC's population surveillance rate, 3.1 per 100 live births (95% CI 3.1-3.2). For lamivudine, nelfinavir, nevirapine, stavudine, and zidovudine, sufficient numbers of live births (>200) following first-trimester exposures have been monitored to allow detection of a 2-fold increase in risk of birth defects overall; no increases have been detected.

CONCLUSION

APR data demonstrate no increase in prevalence of birth defects overall or among women exposed to lamivudine, nelfinavir, nevirapine, stavudine, and zidovudine.

Missed opportunities for perinatal HIV prevention among HIV-exposed infants born 1996-2000, pediatric spectrum of HIV disease cohort

OBJECTIVE

Despite dramatic reductions in perinatal human immunodeficiency virus (HIV) transmission in the United States, obstacles to perinatal HIV prevention that include lack of prenatal care; failure to test pregnant women for HIV before delivery; and lack of prenatal, intrapartum, or neonatal antiretroviral (ARV) use remain. The objective of this study was to describe trends in perinatal HIV prevention methods, perinatal transmission rates, and the contribution of missed opportunities for perinatal HIV prevention to perinatal HIV infection.

METHODS

We analyzed data obtained from infant medical records on 4755 HIV-exposed singleton deliveries in 1996-2000, from 6 US sites that participate in the Centers for Disease Control and Prevention's Pediatric Spectrum of HIV Disease Project. HIV-exposed deliveries refer to deliveries in which the mother was known to have HIV infection during the pregnancy.

RESULTS

Of the 4287 women with data on prenatal care, 92% had prenatal care. From 1996 to 2000, among the 3925 women with prenatal care, 92% had an HIV test before delivery; the use of prenatal zidovudine (ZDV) alone decreased from 71% to 9%, and the use of prenatal ZDV with other ARVs increased from 6% to 70%. Complete data on maternal and neonatal ARVs were available for 3284 deliveries. Perinatal HIV transmission was 3% in 1651 deliveries with prenatal ZDV in combination with other ARVs, intrapartum ZDV, and neonatal ZDV; 6% in 1111 deliveries with prenatal, intrapartum, and neonatal ZDV alone; 8% in 152 deliveries with intrapartum and neonatal ZDV alone; 14% of 73 deliveries with neonatal ZDV only started within 24 hours of birth; and 20% in 297 deliveries with no prenatal, intrapartum, and neonatal ARVs. Complete data on prenatal events were available in 328 HIV-infected and 3258 HIV-uninfected infants. A total of 56% of mothers of HIV-infected infants had missed opportunities for perinatal HIV prevention versus 16% of mothers of HIV-uninfected infants. Forty-four percent of the infected infants were born to mothers who had prenatal care, a prenatal HIV diagnosis, and documented prenatal ARV therapy. Seventeen percent of women with reported illicit drug use had no prenatal care versus 3% of women with no reported drug use. In a multivariate analysis, maternal illicit drug use was significantly associated with lack of prenatal care. In a multivariate analysis, year of infant birth and the combination of lack of maternal HIV testing before delivery and lack of prenatal antiretroviral therapies were significantly associated with perinatal HIV transmission.

CONCLUSIONS

Missed opportunities for perinatal HIV prevention contributed to more than half of the cases of HIV-infected infants. Prenatal care and HIV testing before delivery are major opportunities for perinatal HIV prevention. Illicit drug use was highly associated with lack of prenatal care, and lack of HIV testing before delivery was highly associated with perinatal HIV transmission.

Mother-to-child transmission of the human immunodeficiency virus in Texas

BACKGROUND

The Pediatric Spectrum of HIV Diseases (PSD) project has been collecting data on HIV-exposed children in Texas since 1989. These data have now been analyzed to describe mother-to-child transmission in Texas and to provide much needed information on the magnitude of the pediatric HIV epidemic in the state.

METHODS

We examined trends in the numbers of perinatally exposed children and perinatally acquired cases of HIV in the Texas PSD cohort. We calculated transmission rates and relative risks for 656 children born from January, 1995, to July, 1998, that received all or part of the ACTG 076 regimen.

RESULTS

Only a small proportion (38%) of pairs of an HIV-infected mother and her HIV-exposed child received the full AIDS Clinical Trial Group 076 (ACTG 076) regimen; only 73% of the mothers received at least some prenatal care. In recent years, however, the numbers of perinatally exposed children and perinatally acquired cases of HIV have decreased in Texas. Univariate analyses showed that a reduction in the vertical transmission of HIV was associated with receipt of a full ACTG 076 regimen, receipt of a partial ACTG 076 regimen and residence in Dallas County.

CONCLUSIONS

Findings identify a gap in meeting the health care needs of pregnant HIV-infected women and suggest missed opportunities to prevent mother-to-child transmission of HIV. At the same time this study confirms progress in prevention efforts to reduce mother-to-child transmission of HIV in Texas.

Lack of definitive severe mitochondrial signs and symptoms among deceased HIV-uninfected and HIV-indeterminate children < or = 5 years of age, Pediatric Spectrum of HIV Disease project (PSD), USA

BACKGROUND

In response to recent reports of mitochondrial dysfunction in HIV-uninfected infants exposed to antiretroviral (ARV) prophylaxis, the Perinatal Safety Review Working Group reviewed deaths in five large HIV-exposed perinatal cohorts in the United States to determine if similar cases of severe mitochondrial toxicity could be detected. We describe the results of this review for the PSD cohort.

METHODS

Hospitalization, clinic and death records for deceased HIV-uninfected and HIV-indeterminate children who were less than 5 years of age were reviewed. Standard definitions were used to classify HIV infection status and the likelihood that signs and symptoms were related to mitochondrial dysfunction. Children were classified as having signs and symptoms that were considered (1) unrelated, (2) unlikely, (3) consistent with, or (4) likely related to mitochondrial disease. SIDS deaths were put into a separate category.

RESULTS

8,465 of 13,125 HIV-exposed children were either HIV-uninfected or HIV-indeterminate. Among the 84 deaths in the subgroup of 8,465 children, 9 were considered in Class 2 (unlikely), 4 were considered in Class 3 (consistent with), and none were considered in Class 4 (likely). 97% of those children who received ARV prophylaxis received zidovudine alone. None of the HIV-uninfected deaths were classified in 2, 3, or 4; and only one of these was exposed to ARV prophylaxis. Among the 3 HIV-indeterminate children who were classified in 3 (consistent with), 2 had no or unknown ARV exposure before 1994 when use of ZDV prophylaxis became the standard of care. Both HIV-uninfected and HIV-indeterminate children with ARV exposure or unknown exposure had lower mortality rates than children without ARV exposure.

CONCLUSION

Monoprophylaxis with ZDV was not associated with higher death rates in the cohort of 8,465 children or with any findings likely consistent with mitochondrial dysfunction among the 85 deaths. Ongoing monitoring of drug safety in large multi-site prospective cohort studies of HIV-exposed children is essential in the era of highly active antiretroviral therapy.

[The use of ion-selective field transistors (ISFT) with photopolymerizable polyurethane membranes in nephrology for determination of potassium concentration (activity)]

The applicability is examined of ion selective field transistors with photocurable polyurethane membranes to control of the electrolytic composition of dialyzing solutions used in artificial kidney apparatus, and also of plasma in patient treated by chronic hemodialysis. The short- and long-time characteristics of the efficiency of K(+)-selective field transistors in continuous contact with solutions. Comparative testing of such transistors and other sensing systems is made. It is demonstrated that a sufficient reliability of measurements in the range of physiological concentrations in combination with low cost provide the possibility of using K(+)-selective field transistors for monitoring of the potassium concentration both in dialyzing solutions and plasma in patients on chronic hemodialysis treatment.