High-Dose Isoniazid Lacks EARLY Bactericidal Activity Against Isoniazid-resistant Tuberculosis Mediated by katG Mutations: A Randomized, Phase 2 Clinical Trial

RATIONALE

Observational studies suggest that high-dose isoniazid may be efficacious in treating multidrug-resistant tuberculosis (MDR-TB). However, its activity against Mycobacterium tuberculosis (M.tb) with katG mutations (which typically confer high-level resistance) is not established.

OBJECTIVE

To characterize early bactericidal activity (EBA) of high-dose isoniazid in patients with tuberculosis caused by katG-mutated M.tb.

METHODS

A5312 was a Phase 2A randomized, open-label trial. Participants with tuberculosis caused by katG-mutated M.tb were randomized to receive 15 or 20 mg/kg isoniazid daily for 7 days. Daily sputum samples were collected for quantitative culture. Intensive PK sampling was performed on day 6. Data were pooled across all A5312 participants for analysis (drug-sensitive, inhA-mutated, and katG-mutated M.tb). EBA was determined using nonlinear mixed-effects modelling.

RESULTS

Of 80 treated participants, 21 had katG-mutated M.tb. Isoniazid PK was best described by a two-compartment model with an effect of NAT2 acetylator phenotype on clearance. Model-derived Cmax and AUC in the 15 and 20 mg/kg groups were 15.0 and 22.1 mg/L and 57.6 and 76.8 mg∙h/L, respectively. Isoniazid bacterial kill was described using an effect compartment and a sigmoidal Emax relationship. Isoniazid potency against katG-mutated M.tb was approximately 10-fold lower than against inhA-mutated M.tb. The highest dose (20 mg/kg) did not demonstrate measurable EBA, except in a subset of slow NAT2 acetylators (who experienced the highest concentrations). There were no grade 3 or higher drug-related adverse events.

CONCLUSIONS

This study found negligible bactericidal activity of high-dose isoniazid (15-20 mg/kg) in the majority of participants with tuberculosis caused by katG-mutated M.tb. Clinical trial registration available at www.

CLINICALTRIALS

gov, ID: NCT01936831.

Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification among Patients with Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-Income Countries

Article Summary

We assessed the association between C-reactive protein (CRP) and Mycobacterium tuberculosis (TB) diagnosis in symptomatic patients at HIV diagnosis. We found that CRP concentrations can improve tuberculosis risk stratification, facilitating decision making about whether (specific) tuberculosis testing is indicated before antiretroviral therapy initiation.

Background

The World Health Organization recommends initiating same-day ART while tuberculosis testing is underway for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve tuberculosis risk stratification in this population.

Methods

In this baseline analysis of 498 adults (>18 years) with tuberculosis symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP (≥3 mg/dL) using generalized linear models.

Results

Eighty-seven (17.5%) patients were diagnosed with baseline TB. The median CRP was 33.0 mg/L (IQR: 5.1, 85.5) in those with TB, and 2.6 mg/L (IQR: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4%, and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART, and 0.8% to 5.0% would have untreated TB at ART initiation.

Conclusions

CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3-fold to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.

Same-day testing with initiation of antiretroviral therapy or tuberculosis treatment versus standard care for persons presenting with tuberculosis symptoms at HIV diagnosis: A randomized open-label trial from Haiti

BACKGROUND

Same-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population.

METHODS AND FINDINGS

We conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA <200 copies/mL, with intention to treat (ITT) analysis. From November 6, 2017 to January 16, 2020, 500 participants were randomized (250/group); the final study visit occurred on March 1, 2021. Baseline TB was diagnosed in 40 (16.0%) in the standard and 48 (19.2%) in the same-day group; all initiated TB treatment. In the standard group, 245 (98.0%) initiated ART at median of 9 days; 6 (2.4%) died, 15 (6.0%) missed the 48-week visit, and 229 (91.6%) attended the 48-week visit. Among all who were randomized, 220 (88.0%) received 48-week HIV-1 RNA testing; 168 had <200 copies/mL (among randomized: 67.2%; among tested: 76.4%). In the same-day group, 249 (99.6%) initiated ART at median of 0 days; 9 (3.6%) died, 23 (9.2%) missed the 48-week visit, and 218 (87.2%) attended the 48-week visit. Among all who were randomized, 211 (84.4%) received 48-week HIV-1 RNA; 152 had <200 copies/mL (among randomized: 60.8%; among tested: 72.0%). There was no difference between groups in the primary outcome (60.8% versus 67.2%; risk difference: -0.06; 95% CI [-0.15, 0.02]; p = 0.14). Two new grade 3 or 4 events were reported per group; none were judged to be related to the intervention. The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain.

CONCLUSIONS

In patients with TB symptoms at HIV diagnosis, we found that same-day treatment was not associated with superior retention and viral suppression. In this study, a short delay in ART initiation did not appear to compromise outcomes.

TRIAL REGISTRATION

This study is registered with ClinicalTrials.gov NCT03154320.

A Standardized Approach for Collection of Objective Data to Support Outcome Determination for Late-Phase Tuberculosis Clinical Trials

Rationale: We developed a standardized method, possible poor treatment response (PPTR), to help ascertain efficacy endpoints in Study S31/A5349 (NCT02410772), an open-label trial comparing two 4-month rifapentine-based regimens with a standard 6-month regimen for the treatment of pulmonary tuberculosis (TB). Objectives: We describe the use of the PPTR process and evaluate whether the goals of minimizing bias in efficacy endpoint assessment and attainment of relevant data to determine outcomes for all participants were achieved. Methods: A PPTR event was defined as the occurrence of one or more prespecified triggers. Each PPTR required initiation of a standardized evaluation process that included obtaining multiple sputum samples for microbiology. Measurements and Main Results: Among 2,343 participants with culture-confirmed drug-susceptible TB, 454 individuals (19.4%) had a total of 534 individual PPTR events, of which 76.6% were microbiological (positive smear or culture at or after 17 wk). At least one PPTR event was experienced by 92.4% (133 of 144) of participants with TB-related unfavorable outcome and between 13.8% and 14.7% of participants with favorable and not-assessable outcomes. A total of 75% of participants with TB-related unfavorable outcomes had microbiological confirmation of failure to achieve a disease-free cure. Conclusions: Standardized methodologies, such as our PPTR approach, could facilitate unbiased efficacy outcome determinations, improve discrimination between outcomes that are related and unrelated to regimen efficacy, and enhance the ability to conduct pooled analyses of contemporary trials.

Isoniazid adherence reduces mortality and incident tuberculosis at 96 weeks among adults initiating antiretroviral therapy with advanced HIV in multiple high burden settings

Background

People with human immunodeficiency virus (HIV) and advanced immunosuppression initiating antiretroviral therapy (ART) remain vulnerable to tuberculosis (TB) and early mortality. To improve early survival, isoniazid preventive therapy (IPT) or empiric TB treatment have been evaluated; however, their benefit on longer-term outcomes warrants investigation.

Methods

We present a 96-week preplanned secondary analysis among 850 ART-naive outpatients (≥13 years) enrolled in a multicountry, randomized trial of efavirenz-containing ART plus either 6-month IPT (n = 426) or empiric 4-drug TB treatment (n = 424). Inclusion criteria were CD4 count <50 cells/mm³ and no confirmed or probable TB. Death and incident TB were compared by strategy arm using the Kaplan-Meier method. The impact of self-reported adherence (calculated as the proportion of 100% adherence) was assessed using Cox-proportional hazards models.

Results

By 96 weeks, 85 deaths and 63 TB events occurred. Kaplan-Meier estimated mortality (10.1% vs 10.5%; P = .86) and time-to-death (P = .77) did not differ by arm. Empiric had higher TB risk (6.1% vs 2.7%; risk difference, −3.4% [95% confidence interval, −6.2% to −0.6%]; P = .02) and shorter time to TB (P = .02) than IPT. Tuberculosis medication adherence lowered the hazards of death by ≥23% (P < .0001) in empiric and ≥20% (P < .035) in IPT and incident TB by ≥17% (P ≤ .0324) only in IPT.

Conclusions

Empiric TB treatment offered no longer-term advantage over IPT in our population with advanced immunosuppression initiating ART. High IPT adherence significantly lowered death and TB incidence through 96 weeks, emphasizing the benefit of ART plus IPT initiation and completion, in persons with advanced HIV living in high TB-burden, resource-limited settings.

Establishment of Ph. Eur. Somatropin/desamidosomatropin resolution mixture Chemical Reference Substance batch 2

The control of somatropin products according to the monographs of the European Pharmacopoeia (Ph. Eur.) requires a system suitability preparation for the test for related proteins by liquid chromatography. A preparation consisting in a mixture of somatropin and desamidosomatropin, such as the Ph. Eur. Somatropin/desamidosomatropin resolution mixture Chemical Reference Substance (CRS), is to be used to ascertain adequate resolution of the chromatographic setup. Due to low stocks, the Biological Standardisation Programme (BSP) of the Council of Europe and the European Union ran a study to establish a new batch of this system suitability CRS. A freeze-dried candidate batch (cCRS2) was produced and tested at the European Directorate for the Quality of Medicines and HealthCare (EDQM, Council of Europe). The resolution between the peaks due to somatropin and desamidosomatropin was 1.7 and the symmetry factor for the somatropin peak was 1.2. The mean percentage area of the desamidosomatropin peak was 14.6 %. These results showed that cCRS2 is suitable for its intended purpose. Based on these data, in May 2020 the Ph. Eur. Commission established the candidate batch as Ph. Eur. Soma-tropin/desamidosomatropin resolution mixture CRS batch 2.

How Fast Can Nurses Learn Therapeutic Communication Skills? A Pilot Study on Brief Hypnotic Communication Training Conducted with Oncology Nurses

Objective: This project aimed to train nurses on an oncology unit in hypnotic communication to reduce treatment-related pain and anxiety in their patients. A pilot study was conducted to assess changes in hypnotic communication behaviors associated with the training.

Methods: Nurses were recruited and their interactions during a simulated patient admission for treatment (before and after training) were recorded. Hypnotic communication skills were assessed by independent reviewers using a training checklist listing different hypnotic communication techniques and a validated assessment scale (Sainte-Justine Hypnotic Communication Assessment Scale, SJ-HCAS).

Results: Seven nurses were evaluated. Wilcoxon paired-sample tests (pre–post) reported significant improvement with large effect sizes in the total score of the training grid (P = 0.034, r = 0.832) and significant improvement with large effect sizes in the relational (P = 0.018, r = 0.930) and total (P = 0.021, r = 0.903) scores of the SJ-HCAS.

Conclusion: This pilot study shows promising results regarding the effectiveness of hypnotic communication training for nurses. These acquired skills could translate into improved treatment experience with patients and could be transferred to other professionals and settings in the health care system.

Superior Outcomes With Continuing Tenofovir Versus Switching to Zidovudine in Second-Line Antiretroviral Therapy in Haiti

We compared viral suppression rates between patients who continued tenofovir disoproxil fumarate (TDF)/lamivudine (3TC) vs switched to zidovudine (ZDV)/3TC in combination with a boosted protease inhibitor after failure of first-line efavirenz/TDF/3TC. We found higher rates of viral suppression with continued TDF/3TC compared with switching to ZDV/3TC.

P–756 Predictive factors influencing multiple live births in cumulative IVF cycles: retrospective analysis of over 265000 embryo transfer procedures from the national French registry

Study question

What are the factors that could predict the number of embryos to be transferred in order to diminish risk of multiple pregnancies?

Summary answer

Single embryo transfer (SET) is advisable for &lt;38 year-old women in fresh cycles and for &lt;35 year-old women in FET whatever the IVF number attempts.

What is known already

Multiple pregnancies are associated to increased maternal and perinatal complications. Risks associated to multiple implantations are significantly reduced with SET policy. However, while SET is more assertive with a lesser negative impact in younger patients (&lt;35 years), its feasibility is less evident for the older population, whom oocyte quality is likely compromised. A double embryo transfer (DET) could improve chances of implantation and shorten their time to pregnancy. Identification of risk factors for multiple pregnancies could help in decision making for a double or SET and reduce chances for multiple gestations without reducing the chances to achieve pregnancy.

Study design, size, duration

A retrospective study from the national French data registry provided and approved by the Agence de la Biomédecine was performed. A total of 196530 fresh and 68913 frozen cycles from women aged 18–43 year-old were included (2014–2017). Risk factors assessed included women’s age, number of attempts, number of oocytes, fertilization rate, embryo stage, number of embryos transferred, number of supernumerary embryos frozen. Secondary infertility, oocyte donor, oocyte freezing, PGT, freeze-all and IVM cycles were excluded.

Participants/materials, setting, methods

Cumulative cycles derived from 65% of ICSI, 32% of IVF and 3,2% IVF/ICSI. The distribution of patients age at oocyte retrieval was 60% &lt; 35, 21% &lt; 38, 11% &lt; 40, and 8% ≥ 40 years old. Multivariable logistic regression was conducted to calculate adjusted odds ratios with 95% confidence intervals for live birth chance and multiple live birth risk associated with each risk factor.

Main results and the role of chance

The chances of obtaining a cumulative live birth decreases with increased patients age (OR 0.71 for 35–38 years and 0.47 for 38–40 years, p &lt; 0.00001), with increased number of attempts (from OR 0.87 for attempt = 2 to OR 0.74 for attempt ≥ 4, p &lt; 0.00001), and for frozen embryos transferred (OR 0.14, p &lt; 0.00001). The chances of live birth increases with the increased number of oocytes (from OR 1.33 for 4–12 to OR 1.52 for &gt; 18, p &lt; 0.00001 in all cases), with a fertilisation rate &gt;40% (OR 1.29, p &lt; 0.00001), with blastocyst transfer (OR 1.29, p &lt; 0.00001), with the increase on the number of frozen embryos (OR 7.37 for &gt;1, OR 13.08 for &gt;2, and OR 16.92 for &gt;6, p &lt; 0.00001 in all cases) and number of embryos transferred (OR 1.42 for 2 embryos and OR 1.39 for &gt;2 embryos, p &lt; 0.00001 in all cases).

In case of live birth, the risks of multiple births when two embryos were transferred decreases in patients aged &gt;38 years (OR 0.50, p &lt; 0.00001) and for frozen embryos transferred (OR 0.65, p &lt; 0.00001). The risk increases with a fertilisation rate &gt;60% (OR 1.30, p &lt; 0.00001), with blastocysts transfer (OR 1.34, p &lt; 0.00001) and when at least one supernumerary embryo is frozen (OR &gt; 1.30, p &lt; 0.00001).

Limitations, reasons for caution

This study is limited in only providing a risk-benefit balance for multiples on the choice of transferring one or two embryos. Clinical data such as stimulation protocols and doses of gonadotropins were not considered in this evaluation.

Wider implications of the findings: This study provides help to develop a strategy for the medical staff in the decision making for the number of embryos to be transferred. It may also serve as a patient’s information aid and help to improve their chances of achieving a health singleton if pregnant.

Trial registration number

Not applicable

Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis

BACKGROUND

Rifapentine-based regimens have potent antimycobacterial activity that may allow for a shorter course in patients with drug-susceptible pulmonary tuberculosis.

METHODS

In an open-label, phase 3, randomized, controlled trial involving persons with newly diagnosed pulmonary tuberculosis from 13 countries, we compared two 4-month rifapentine-based regimens with a standard 6-month regimen consisting of rifampin, isoniazid, pyrazinamide, and ethambutol (control) using a noninferiority margin of 6.6 percentage points. In one 4-month regimen, rifampin was replaced with rifapentine; in the other, rifampin was replaced with rifapentine and ethambutol with moxifloxacin. The primary efficacy outcome was survival free of tuberculosis at 12 months.

RESULTS

Among 2516 participants who had undergone randomization, 2343 had a culture positive for Mycobacterium tuberculosis that was not resistant to isoniazid, rifampin, or fluoroquinolones (microbiologically eligible population; 768 in the control group, 791 in the rifapentine-moxifloxacin group, and 784 in the rifapentine group), of whom 194 were coinfected with human immunodeficiency virus and 1703 had cavitation on chest radiography. A total of 2234 participants could be assessed for the primary outcome (assessable population; 726 in the control group, 756 in the rifapentine-moxifloxacin group, and 752 in the rifapentine group). Rifapentine with moxifloxacin was noninferior to the control in the microbiologically eligible population (15.5% vs. 14.6% had an unfavorable outcome; difference, 1.0 percentage point; 95% confidence interval [CI], -2.6 to 4.5) and in the assessable population (11.6% vs. 9.6%; difference, 2.0 percentage points; 95% CI, -1.1 to 5.1). Noninferiority was shown in the secondary and sensitivity analyses. Rifapentine without moxifloxacin was not shown to be noninferior to the control in either population (17.7% vs. 14.6% with an unfavorable outcome in the microbiologically eligible population; difference, 3.0 percentage points [95% CI, -0.6 to 6.6]; and 14.2% vs. 9.6% in the assessable population; difference, 4.4 percentage points [95% CI, 1.2 to 7.7]). Adverse events of grade 3 or higher occurred during the on-treatment period in 19.3% of participants in the control group, 18.8% in the rifapentine-moxifloxacin group, and 14.3% in the rifapentine group.

CONCLUSIONS

The efficacy of a 4-month rifapentine-based regimen containing moxifloxacin was noninferior to the standard 6-month regimen in the treatment of tuberculosis. (Funded by the Centers for Disease Control and Prevention and others; Study 31/A5349 ClinicalTrials.gov number, NCT02410772.).

Prevalence of hypertension and cardiovascular risk factors among long-term AIDS survivors: A report from the field

HIV infection is associated with increased risk and progression of cardiovascular disease (CVD), yet little is known about the prevalence of CVD risk factors among long-term AIDS survivors in resource-limited settings. Using routinely collected data, we conducted a retrospective study to describe the prevalence of CVD risk factors among a cohort of HIV-infected patients followed for over 10 years in Port-au Prince, Haiti. This cohort includes 910 adults who initiated antiretroviral therapy (ART) between 2003 and 2004 and remained in care between 2014 and 2016 when routine screening for CVD risk factors was implemented at a large clinic in Haiti. A total of 397 remained in care ≥10 years and received screening. At ART initiation, 59% were female, median age was 38 years (IQR 33-44), and median CD4 count was 117 cells/mm3 (IQR 34-201). Median follow-up time from ART initiation was 12.1 years (IQR 11.7-12.7). At screening, median CD4 count was 574 cells/mm3 (IQR 378-771), and 84% (282 of 336 screened) had HIV-1 RNA < 1000 copies/mL. Seventy-four percent of patients had at least 1 risk factor including 58% (224/385) with hypertension, 8% (24/297) diabetes, 43% (119/275) hypercholesterolemia, 8% (20/248) active smoking, and 10% (25/245) obesity. Factors associated with hypertension were age (adjusted OR 1.06, P < .001) and weight at screening (adjusted OR 1.02, P = .019). Long-term AIDS survivors have a high prevalence of CVD risk factors, primarily hypertension. Integration of cardiovascular screening and management into routine HIV care is needed to maximize health outcomes among aging HIV patients in resource-limited settings.

Treating loss-to-follow-up as a missing data problem: a case study using a longitudinal cohort of HIV-infected patients in Haiti

Background

HIV programs are often assessed by the proportion of patients who are alive and retained in care; however some patients are categorized as lost to follow-up (LTF) and have unknown vital status. LTF is not an outcome but a mixed category of patients who have undocumented death, transfer and disengagement from care. Estimating vital status (dead versus alive) among this category is critical for survival analyses and program evaluation.

Methods

We used three methods to estimate survival in the cohort and to ascertain factors associated with death among the first cohort of HIV positive patients to receive antiretroviral therapy in Haiti: complete case (CC) (drops missing), Inverse Probability Weights (IPW) (uses tracking data) and Multiple Imputation with Chained Equations (MICE) (imputes missing data). Logistic regression was used to calculate odds ratios and 95% confidence intervals for adjusted models for death at 10 years. The logistic regression models controlled for sex, age, severe poverty (living on <$1 USD per day), Port-au-Prince residence and baseline clinical characteristics of weight, CD4, WHO stage and tuberculosis diagnosis.

Results

Age, severe poverty, baseline weight and WHO stage were statistically significant predictors of AIDS related mortality across all models. Gender was only statistically significant in the MICE model but had at least a 10% difference in odds ratios across all models.

Conclusion

Each of these methods had different assumptions and differed in the number of observations included due to how missing values were addressed. We found MICE to be most robust in predicting survival status as it allowed us to impute missing data so that we had the maximum number of observations to perform regression analyses. MICE also provides a complementary alternative for estimating survival among patients with unassigned vital status. Additionally, the results were easier to interpret, less likely to be biased and provided an alternative to a problem that is often commented upon in the extant literature.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6115-0) contains supplementary material, which is available to authorized users.

Consistency of photon emission intensities for efficiency calibration of gamma-ray spectrometers in the energy range from 20keV to 80keV

The efficiency calibration for different high-purity germanium detectors in the low-energy range was established by the conventional method, using standard radioactive sources. The peak shapes were carefully analysed taking account of natural linewidth, full-energy width at half maximum and scattering. Complementary information was obtained by Monte Carlo simulation using the PENELOPE code, after optimization of the geometrical parameters. This was used to measure photon emission intensities of some low-energy emitting radionuclides, including ¹³³Ba, and compared to the tabulated values.

Direct measurement of alpha emission probabilities in the decay of 226Ra

High-resolution alpha-particle spectrometry was performed to determine the main alpha-particle emission probabilities in the decay of ²²⁶Ra. Thin, homogeneous sources were prepared by electrodeposition on stainless steel disks. Alpha spectra with an energy resolution of 20keV were obtained in three laboratories and analysed with different deconvolution algorithms. In two set-ups, a magnet system was used to deflect conversion electrons to avoid their coincidental detection with the alpha particles. Spectra taken at close range without a magnet system yielded biased results which cannot be fully compensated by statistical corrections for coincidence summing. The derived emission probabilities of the three main alpha decays are 94.07 (1)%, 5.93 (1)%, and 0.0059 (15)%, respectively. They are in excellent agreement with calculated values derived from the P(γ+ce) decay scheme balance, which solves the existing discrepancy problem with two previous direct measurements published in literature.

Live with the Disease Like You Used to Before You Knew You Were Infected: A Qualitative Study Among 10-Year Survivors Living with HIV in Haiti

In 2003, the Haitian Study Group on Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), a nonprofit organization, began administering antiretroviral therapy (ART) to its patients. This practice transformed HIV from a fatal disease to a more manageable chronic condition. However, relatively few studies focus on the experiences of survivors. This study provided a unique opportunity to interview patients who survived at least 10 years after being treated with ART at GHESKIO. The goal of the study was to elicit from patients their perspectives on what enabled them to survive with AIDS. Grounded Theory, a qualitative research method was used to guide data collection, coding, and analysis. Individual interviews were conducted, audio-taped, transcribed and analyzed in Creole, and translated into English. Data saturation was reached at 25 participants. Of which, 64% were women, the mean age was 49, range of 43-55 years, 24% were married, 44% had not completed elementary school, and 72% had no income, the remaining participants had incomes ranging from $1000 to $5000 annually. Qualitative analysis resulted in 681 codes, which were grouped into six categories: being spiritually grounded, having supportive interactions with providers, caring for children, setting personal goals, persevering and living life as usual, and maintaining strict medication adherence practices. The overarching theory was that having a reason to live despite one's circumstances and living life as usual enabled one to survive. Having a strong spiritual foundation coupled with supportive family and providers motivated participants to live and adhere to their ART. As the number of patients who are living longer with HIV in Haiti increases, results from this study will be important in helping tailor interventions that enhance their overall quality of life.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Binge drinking is associated with differences in weekday and weekend adherence in HIV-infected individuals

BACKGROUND

Understanding patterns of antiretroviral adherence and its predictors is important for designing tailored interventions. Alcohol use is associated with non-adherence. This study aimed to evaluate: (1) if there was a difference in weekday compared with weekend adherence in HIV-infected individuals from low and middle income countries (LMIC), and (2) whether binge drinking was associated with this difference.

METHODS

Data from a randomized trial conducted at 9 sites in 8 LMIC were analyzed. Microelectronic monitors were used to measure adherence. Differences between weekday and weekend adherence in each quarter (successive 12-week periods) were compared using Wilcoxon signed rank tests and predictors of adherence, including baseline binge drinking, were evaluated using Generalized Estimating Equations.

RESULTS

Data from 255 participants were analyzed: 49.8% were male, median age was 37 years and 28.6% enrolled in Haiti. At study entry, only 2.7% reported illicit substance use, but 22.3% reported binge drinking at least once in the 30 days prior to enrollment. Adherence was higher on weekdays than weekends (median percent doses taken: 96.0% vs 94.4%; 93.7% vs 91.7%; 92.6% vs 89.7% and 93.7% vs 89.7% in quarters 1-4 respectively, all p<0.001). Binge drinking at baseline and time on study were both associated with greater differences between weekday and weekend adherence.

CONCLUSIONS

Adherence was worse on weekends compared to weekdays: difference was small at treatment initiation, increased over time and was associated with binge drinking. Screening and new interventions to address binge drinking, a potentially modifiable behavior, may improve adherence in HIV-infected individuals in LMIC.

Development of a primary thoron activity standard for the calibration of thoron measurement instruments

The LNHB and IRSN are working on a reference atmosphere for thoron ((220)Rn) instrument calibration. The LNHB, as the national metrology institute for activity measurement in France, has to create a new thoron reference standard in order to estimate with accuracy the thoron concentration of a reference atmosphere. The measurement system presented in this paper is based on a reference volume using an alpha detector, which is able to measure thoron and its decay products to define the thoron concentration of a thoron reference atmosphere. This paper presents the first results with this new system using a well-known radon ((222)Rn) atmosphere and a thoron ((220)Rn) atmosphere.

Overexpression of RoDELLA impacts the height, branching, and flowering behaviour of Pelargonium × domesticum transgenic plants

KEY MESSAGE : We reported the cloning of a rose DELLA gene. We obtained transgenic Pelargonium lines overexpressing this gene which presented several phenotypes in plant growth, root growth, flowering time and number of inflorescences. Control of development is an important issue for production of ornamental plant. The plant growth regulator, gibberellins (GAs), plays a pivotal role in regulating plant growth and development. DELLA proteins are nuclear negative regulator of GA signalling. Our objective was to study the role of GA in the plant architecture and in the blooming of ornamentals. We cloned a rose DELLA homologous gene, RoDELLA, and studied its function by genetic transformation of pelargonium. Several transgenic pelargonium (Pelargonium × domesticum 'Autum Haze') lines were produced that ectopically expressed RoDELLA under the control of the 35S promoter. These transgenic plants exhibited a range of phenotypes which could be related to the reduction in GA response. Most of transgenic plants showed reduced growth associated to an increase of the node and branch number. Moreover, overexpression of RoDELLA blocked or delayed flowering in transgenic pelargonium and exhibited defects in the root formation. We demonstrated that pelargonium could be used to validate ornamental gene as the rose DELLA gene. RoDELLA overexpression modified many aspects of plant developmental pathways, as the plant growth, the transition of vegetative to floral stage and the ability of rooting.

Effect of water temperature increase on HO-1 expression in European sea bass (Dicentrarchus labrax L.) tissues

One of the most pertinent environmental factors influencing the marine organism life is temperature. It has been demonstrated that an increase of temperature is able to induce the synthesis of heat shock proteins (HSP). In this study we investigated the expression of HO-1 mRNA, also referred to as HSP32, in different tissues of European sea bass (Dicentrarchus labrax, L.) at several time points after increased temperature exposure (from 12degC to 30degC). Our results showed that HO-1 was not expressed in gills, heart, muscle and brain while it was expressed at a basal level in intestine. In liver, spleen and kidneys, HO-1 expression was influenced by temperature increases. In the spleen, we found a significant decrease of the HO-1 expression at the end of 4 weeks. In kidneys a very fast collapse of HO-1 expression level was recorded reaching null value as soon as one hour after exposure to 30degC. In liver, HO-1 expression increased from one hour of exposure to 30degC confirming HO-1 involvement to heat shock response in this organ. This increasing trend reached a 4.5-fold higher value than the initial level after 4 weeks.

Intercomparison of methods for coincidence summing corrections in gamma-ray spectrometry--part II (volume sources)

The second part of an intercomparison of the coincidence summing correction methods is presented. This exercise concerned three volume sources, filled with liquid radioactive solution. The same experimental spectra, decay scheme and photon emission intensities were used by all the participants. The results were expressed as coincidence summing corrective factors for several energies of (152)Eu and (134)Cs, and different source-to-detector distances. They are presented and discussed.

Effects of water temperature increase and heavy metals contamination on WAP65 gene expression in sea bass (Dicentrarchus labrax) liver

It has been previously demonstrated that "Warm temperature Acclimation-related 65 kD Protein" (WAP65) is involved in temperature acclimation, response to intoxication and infection, as well as in development. The expression of wap65-1 was investigated in the liver of European sea bass (Dicentrarchus labrax) during exposure to the increased temperature (from 12 deg C to 30 deg C) and during intoxication with four heavy metals: lead, cadmium, copper and zinc. Post temperature increase wap65 expression was highest after one hour at 30 deg C. After 1 to 4 weeks at 30 deg C wap65 transcript levels did not differ from the 12 deg C control group, similar to observations regarding the heat shock protein, hsp70. Upregulation of wap65 was detected after treatment (intoxication) with cadmium (0.5 μg/l). In contrast, a slight, but significant down regulation of wap65 was seen after copper (5 μg/l) intoxication. These data indicate that functional analyses of WAP65 are needed to understand the differential regulation of this gene by metals. The role of WAP65 may be similar to that of HSP70, which has generalized functions in responding to certain stressors and maintaining normal cell physiology.

cDNA sequencing and expression analysis of Dicentrarchus labrax heme oxygenase-1

The liver cDNA encoding heme oxygenase--1 (HO-1) was sequenced from European sea bass (Dicentrarchus labrax) (accession number no. EF139130). The HO-1 cDNA was 1250 bp in nucleotide length and the open reading frame encoded 277 amino acid residues. The deduced amino acid sequence of the European sea bass had 75% and 50% identity with the amino acid sequences of tetraodontiformes (Tetraodon nigroviridis and Takifugu rubripes) and human HO-1 proteins, respectively. A short hydrophobic transmembrane domain at the C--terminal region was found, and four histidine residues were highly conserved, including human his25 that is essential for HO catalytic activity. RT-PCR of mRNA from eight different European sea bass tissues revealed that, in a homeostatis state, the heme oxygenase--1 was abundant in the spleen and liver but not in the brain.

A genetic algorithm for designing distributed computer network topologies

The topological design of distributed packet switched networks consists of finding a topology that minimizes the communication costs by taking into account a certain number of constraints such as the delay and the reliability. This paper proposes a genetic algorithm (GA) for generating low-cost feasible computer network topologies subject to these constraints. The implementation of this algorithm has been subjected to extensive tests in order to measure the quality of solutions. Computational results confirm the efficiency of the GA to provide good solutions for medium-sized computer networks, in comparison with well-tried conventional methods.

Clustering concept and QoS constraints in dense mobile ad hoc networks

In mobile ad hoc networks, many routing protocols use broadcast mechanism to find route whereas one of the wireless network challenges is the bandwidth optimisation. This mechanism increases the control overhead and consumes bandwidth and energy. The overhead penalty increases with the density and the network size. Thus is important to reduce the number of participants in that mechanism. One of the used solutions consists of determining clusterheads nodes. In this paper, we propose an algorithm for choosing clusterheads (SRCAC). Each node in the network broadcasts its ID, status and election index. The election index is a combination of potentiality index and stability index. The potentiality index is a linear combination of the mobile resources like processor speed, RAM and ROM memories. The stability index shows the cluster life time. Then, we use SRCAC to build clusters. We suggest a backup clusterhead which could become the principal clusterhead when the first breaks down. To improve the reliability of interclusters communications, we build a mesh between gateway and distributed gateway. Moreover, we introduce Quality of Service (QoS) constraints in the ODMRP (On Demand Multicast Routing Protocol) mobility prediction version.We compare our algorithm with the WCA (Weighted Clustering Algorithm for Mobile Ad hoc Networks) algorithm in terms of clusterheads. The results show that our algorithm performs better than the WCA and, finally, the deterioration of the performances imposed by the constraints on this ODMRP version is unimportant.

Retroperitoneal fibrosis: a case report of spontaneous resolution

AIM

The purpose of this case report is to document an occurrence of spontaneous resolution of idiopathic retroperitoneal fibrosis and to review the investigation and management of this unusual condition.

MATERIALS AND METHODS

A detailed case summary of a patient with retroperitoneal fibrosis is presented. Current citations in Index medicus from the English-speaking literature of relevance to the topic were reviewed.

CONCLUSIONS

In this patient who refused open surgical intervention, bilateral stent placement allowed stabilization of renal function. CT-guided biopsy did not reveal malignancy. Serial CT imaging demonstrated gradual disappearance of the retroperitoneal mass. From the literature review, spontaneous resolution of this condition appears to be a rare phenomenon. Although often utilized, CT-guided biopsy may fail to exclude the presence of malignancy. Open surgical biopsy of the retroperitoneal mass and ureterolysis remain the standard of care for operative candidates. Establishing renal drainage and considering a trial of steroids or surveillance may be an option in carefully selected individuals.

Protein associated with Myc (PAM) is a potent inhibitor of adenylyl cyclases

Using the yeast two-hybrid assay and the second of the two large cytosolic domains of type V adenylyl cyclase (ACV) as bait, we identified a small region (amino acids 1028-1231) in the protein associated with Myc (PAM) as an interaction site for ACV. This small region of PAM as well as purified full-length PAM inhibited the activity of ACV. Additionally, full-length PAM was a very potent inhibitor of ACI and AC activities in S49 cyc(-) cells and HeLa cells with IC(50) values in the pm and low nm range. Moreover, the regulator of chromatin condensation 1-like domain of PAM (amino acids 446-1062) was sufficient and as potent as full-length PAM at inhibiting the activity of ACV. Interestingly, full-length PAM did not inhibit ACII activity that was stimulated by either forskolin of Galpha(s). When endogenous levels of PAM in HeLa cells were decreased using antisense oligodeoxynucleotides, the basal cAMP content was elevated, and the dose-response curve for vasoactive intestinal peptide-elicited cAMP accumulation in HeLa cells was shifted to the left. Therefore, we conclude that PAM is a very potent, novel inhibitor of specific isoforms of AC. Furthermore, the regulator of chromatin condensation 1-like domain of PAM is sufficient to exert the effects of the full-length protein on AC and decreases in endogenous PAM levels in HeLa cells can modulate both basal and agonist stimulated cAMP accumulation.