A genetically modulated Toll-like-receptor-tolerant phenotype in peripheral blood cells of children with multisystem inflammatory syndrome

Dysregulated innate immune responses contribute to multisystem inflammatory syndrome in children (MIS-C), characterized by gastrointestinal, mucocutaneous, and/or cardiovascular injury occurring weeks after SARS-CoV-2 exposure. To investigate innate immune functions in MIS-C, we stimulated ex vivo peripheral blood cells from MIS-C patients with agonists of Toll-like receptors (TLR), key innate immune response initiators. We found severely dampened cytokine responses and elevated gene expression of negative regulators of TLR signaling. Increased plasma levels of zonulin, a gut leakage marker, were also detected. These effects were also observed in children enrolled months after MIS-C recovery. Moreover, cells from MIS-C children carrying rare genetic variants of lysosomal trafficking regulator (LYST) were less refractory to TLR stimulation and exhibited lysosomal and mitochondrial abnormalities with altered energy metabolism. Our results strongly suggest that MIS-C hyperinflammation and/or excessive or prolonged stimulation with gut-originated TLR ligands drive immune cells to a lasting refractory state. TLR hyporesponsiveness is likely beneficial, as suggested by excess lymphopenia among rare LYST variant carriers. Our findings point to cellular mechanisms underlying TLR hyporesponsiveness; identify genetic determinants that may explain the MIS-C clinical spectrum; suggest potential associations between innate refractory states and long COVID; and highlight the need to monitor long-term consequences of MIS-C.

Clinical evaluation of a fully electronic microfluidic white blood cell analyzer

The White Blood Cell (WBC) count is one of the key parameters signaling the health of the immune system. Abnormal WBC counts often signal a systemic insult to the body such as an underlying infection or an adverse side effect to medication. Typically, the blood collected is sent to a central lab for testing, and results come back within hours, which is often inconvenient and may delay time-sensitive diagnosis or treatment. Here, we present the CytoTracker, a fully electronic, microfluidic based instant WBC analyzer with the potential to be used at point-of-care. The CytoTracker is a lightweight, portable, affordable platform capable of quantifying WBCs within minutes using only 50 μl of blood (approximately one drop of blood). In this study, we clinically evaluated the accuracy and performance of CytoTracker in measuring WBC and granulocyte counts. A total of 210 adult patients were recruited in the study. We validated the CytoTracker against a standard benchtop analyzer (Horiba Point of Care Hematology Analyzer, ABX Micros 60). Linear dynamic ranges of 2.5 k/μl- 35 k/μl and 0.6 k/μl- 26 k/μl were achieved for total WBC count and granulocyte count with correlation coefficients of 0.97 and 0.98. In addition, we verified CytoTracker's capability of identifying abnormal blood counts with above 90% sensitivity and specificity. The promising results of this clinical validation study demonstrate the potential for the use of the CytoTracker as a reliable and accurate point-of-care WBC analyzer.

Researching COVID to enhance recovery (RECOVER) pediatric study protocol: Rationale, objectives and design

Importance

The prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or "Long COVID") in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults.

Observations

We describe the protocol for the Pediatric Observational Cohort Study of the NIH's RE searching COV ID to E nhance R ecovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of five cohorts that comprise RECOVER-Pediatrics: 1) a de novo RECOVER prospective cohort of children and young adults with and without previous or current infection; and 2) an extant cohort derived from the Adolescent Brain Cognitive Development (ABCD) study ( n =10,000). The de novo cohort incorporates three tiers of data collection: 1) remote baseline assessments (Tier 1, n=6000); 2) longitudinal follow-up for up to 4 years (Tier 2, n=6000); and 3) a subset of participants, primarily the most severely affected by PASC, who will undergo deep phenotyping to explore PASC pathophysiology (Tier 3, n=600). Youth enrolled in the ABCD study participate in Tier 1. The pediatric protocol was developed as a collaborative partnership of investigators, patients, researchers, clinicians, community partners, and federal partners, intentionally promoting inclusivity and diversity. The protocol is adaptive to facilitate responses to emerging science.

Conclusions and Relevance

RECOVER-Pediatrics seeks to characterize the clinical course, underlying mechanisms, and long-term effects of PASC from birth through 25 years old. RECOVER-Pediatrics is designed to elucidate the epidemiology, four-year clinical course, and sociodemographic correlates of pediatric PASC. The data and biosamples will allow examination of mechanistic hypotheses and biomarkers, thus providing insights into potential therapeutic interventions.

Clinical Trialsgov Identifier

Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT05172011.

Challenges and Barriers to Providing Primary Care to Children of South Asian Origin: Pediatricians' Perspectives

South Asian (SA) Americans have a high risk of metabolic and cardiovascular disease. Prevention efforts should start in childhood and should be culturally appropriate. We sought to understand the challenges and barriers that pediatricians face in providing care for SA children to inform professional education on culturally effective care. Qualitative interviews were conducted with a diverse sample (N = 17) of pediatricians. Challenges reported included feeding problems, inadequate physical activity, and mental health concerns. Communication barriers included parents' anxiety around feeding, influence of grandparents, stigma around mental health, and cultural communication gaps. Effective strategies included clear communication, a gradual approach, ensuring buy-in from grandparents, greater attention to family history, and improved cultural knowledge in pediatrician. Addressing feeding problems was the most mentioned challenge, which is especially concerning given the high chronic disease risk in SAs. Education on culturally appropriate strategies can equip pediatricians to effectively counsel SA families to address these risks.

E-cigarette or vaping product use associated lung injury (EVALI) in the time of COVID-19: A clinical dilemma

AIM

To report on the clinical, laboratory, and radiological findings of adolescents who presented during the SARS-CoV-2 surge with symptoms of Coronavirus disease 2019 (COVID-19), did not test positive for the infection, and were diagnosed with E-cigarette and vaping product use associated lung injury (EVALI).

METHODS

A retrospective review of 12 cases of EVALI admitted to the Bristol Meyers Squibb Children's Hospital between February 2020 and June 2020 was conducted.

RESULTS

The ages of the patients ranged from 14 to 19 years. There were six males and six females. Three patients had a past history of anxiety, depression, or other psychiatric/mental health disorder, 9 had prolonged coagulation profile (prothrombin time, partial thromboplastin time, and/or International Normalized Ratio), and 11 had elevated inflammatory markers. Eight needed respiratory support. All 12 were negative for SARS-CoV-2 PCR. Four were tested for IgG antibodies and were negative. As these cases were admitted to rule out COVID infection, initial treatment included hydroxychloroquine. Steroids were started only after SARS-CoV-2 PCR was shown to be negative. Urine tetrahydrocannabinol was positive in all cases. Chest X-ray and computed tomography findings showed ground glass opacities.

CONCLUSIONS

Clinical and radiological features are similar in both EVALI and SARS-CoV-2 infection. Inflammatory markers are elevated in both conditions. A detailed social and substance use history in patients presenting with "typical" COVID pneumonia like illness is important. EVALI should be ruled in early to start the appropriate treatment. Given the ongoing pandemic, pediatricians and other health-care providers need to be aware of other conditions that can masquerade as SARS-CoV-2.

Dichotomy between the humoral and cellular responses elicited by mRNA and adenoviral vector vaccines against SARS-CoV-2

BACKGROUND

Protection from severe disease and hospitalization by SARS-CoV-2 vaccination has been amply demonstrated by real-world data. However, the rapidly evolving pandemic raises new concerns. One pertains efficacy of adenoviral vector-based vaccines, particularly the single-dose Ad26.COV2.S, relative to mRNA vaccines.

MAIN BODY

We investigated the immunogenicity of Ad26.COV2.S and mRNA vaccines in 33 subjects vaccinated with either vaccine class 5 months earlier on average. After controlling for the time since vaccination, Spike-binding antibody and neutralizing antibody levels were higher in the mRNA-vaccinated subjects, while no significant differences in antigen-specific B cell and T cell responses were observed between the two groups.

CONCLUSIONS

A dichotomy exists between the humoral and cellular responses elicited by the two vaccine classes. Testing only for humoral responses to compare the durability of SARS-CoV-2 vaccine-induced responses, as typically performed for public health and research purposes, is insufficient.

Dichotomy between the humoral and cellular responses elicited by mRNA and adenoviral vector vaccines against SARS-CoV-2

Protection from severe disease and hospitalization by SARS-CoV-2 vaccination has been amply demonstrated by real-world data. However, the rapidly evolving pandemic raises new concerns. One pertains efficacy of adenoviral vector-based vaccines, particularly the single-dose Ad26.COV2.S, relative to mRNA vaccines. We investigated the immunogenicity of Ad26.COV2.S and mRNA vaccines in 33 subjects vaccinated with either vaccine class five months earlier on average. After controlling for time since vaccination, Spike-binding antibody and neutralizing antibody levels were higher in the mRNA-vaccinated subjects, while no significant differences in antigen-specific B cell and T cell responses were observed between the two groups. Thus, a dichotomy exists between humoral and cellular responses elicited by the two vaccine classes. Our results have implications for the need of booster doses in vaccinated subjects and might explain the dichotomy reported between the waning protection from symptomatic infection by SARS-CoV-2 vaccination and its persisting efficacy in preventing hospitalization and death.

Determinants and dynamics of SARS-CoV-2 infection in a diverse population: 6-month evaluation of a prospective cohort study

Background

We studied risk factors, antibodies, and symptoms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a diverse, ambulatory population.

Methods

A prospective cohort (n = 831) previously undiagnosed with SARS-CoV-2 infection underwent serial testing (SARS-CoV-2 polymerase chain reaction, immunoglobulin G [IgG]) for 6 months.

Results

Ninety-three participants (11.2%) tested SARS-CoV-2-positive: 14 (15.1%) asymptomatic, 24 (25.8%) severely symptomatic. Healthcare workers (n = 548) were more likely to become infected (14.2% vs 5.3%; adjusted odds ratio, 2.1; 95% confidence interval, 1.4–3.3) and severely symptomatic (29.5% vs 6.7%). IgG antibodies were detected after 79% of asymptomatic infections, 89% with mild-moderate symptoms, and 96% with severe symptoms. IgG trajectories after asymptomatic infections (slow increases) differed from symptomatic infections (early peaks within 2 months). Most participants (92%) had persistent IgG responses (median 171 days). In multivariable models, IgG titers were positively associated with symptom severity, certain comorbidities, and hospital work. Dyspnea and neurologic changes (including altered smell/taste) lasted ≥ 120 days in ≥ 10% of affected participants. Prolonged symptoms (frequently more severe) corresponded to higher antibody levels.

Conclusions

In a prospective, ethnically diverse cohort, symptom severity correlated with the magnitude and trajectory of IgG production. Symptoms frequently persisted for many months after infection.

Clinical Trials Registration. NCT04336215.

Culturally-adapted behavioral intervention to improve colorectal cancer screening uptake among foreign-born South Asians in New Jersey: the Desi Sehat trial

Objectives: Colorectal cancer (CRC) is the third most common cancer among Americans of South Asian (SA) descent and is a significant public health concern in SA communities. Rates of screening compliance among foreign-born SAs are very low. The goal of this study was to report on the development, acceptability, and preliminary impact of a culturally-targeted 1:1 intervention delivered in English, Hindi, and Urdu, called Desi-Sehat.Design: Ninety-three foreign-born SAs between the ages of 50 and 75 were recruited using community-based organization methods. Participants completed a baseline survey, participated in a 1:1 session with a community health educator, and a follow-up survey was administered four months after the baseline.Results: The acceptance rate was moderate (52.8%). Attendance at the intervention session was high. More than half of the population did not complete the follow-up survey (58.7%). Participant evaluations of the intervention were high. Intent-to-treat analyses indicate a 30% four month follow-up CRC screening uptake. There were significant increases in knowledge and significant reductions in perceived barriers to screening, worry about CRC screening tests, and worry about CRC. Effect sizes for significant changes were in the medium to large range.Conclusions: Desi Sehat was a well-evaluated and participation in the session was high, participant knowledge significantly increased, and screening barriers, worry about CRC, and worry about CRC screening tests declined significantly. Future studies should focus on enhancing recruitment and retention and include a randomized control design.

Pediatric COVID-19 and Appendicitis: A Gut Reaction to SARS-CoV-2?

BACKGROUND

We describe the temporal pattern of COVID-19 admissions to a tertiary care children's hospital in central New Jersey during the SARS-CoV-2 surge, covering the time period from March 29 to July 26, 2020.

METHODS

Medical charts were reviewed for the date of admission, past medical history, and demographic variables, presenting signs and symptoms, admitting laboratory values, diagnostic imaging, diagnosis, treatment modalities, and outcomes including length of stay and disease severity.

RESULTS

Patients with symptomatic SARS-CoV-2 infection tended to present with pneumonia early during the study period, which coincided with the early surge in New Jersey cases. Approximately 2 weeks after the peak in reported SARS-CoV-2 cases in New Jersey, we began to see fewer pneumonia cases and an increase in admissions for Multi-Inflammatory Syndrome in Children and cases of acute appendicitis in association with a diagnosis of SARS-CoV-2 infection.

CONCLUSIONS

We present a novel association of acute appendicitis in children infected with SARS-CoV-2 and postulate that it may represent a postinfectious hyperinflammatory complication of SARS-CoV-2 infection occurring 2 weeks after the early manifestation of acute pneumonia disease in children.

Acute respiratory distress syndrome and COVID-19 in a child with systemic lupus erythematosus

We report a case of COVID-19 in a pediatric patient with systemic lupus erythematosus (SLE), who presented with respiratory distress marked by increased work of breathing and low oxygen saturation. Lab tests confirmed COVID-19, and showed lymphocytopenia and elevated markers of inflammation and coagulopathy. Chest X-ray showed bilateral mid-lung opacities, and the patient required intubation early in his disease course. Imaging and clinical findings were consistent with acute respiratory distress syndrome (ARDS) with inflammation. The patient was treated with different combinations of antivirals (hydroxychloroquine and remdesivir), cytokine inhibitors (anakinra and tocilizumab), glucocorticoids (hydrocortisone and methylprednisolone), and an anticoagulant (enoxaparin). Inflammatory markers decreased before clinical improvement in lung aeration. This case highlights the potential for pediatric patients with SLE to present with COVID-19 similar to the clinical presentation described in adults.

Bell's Palsy Associated with SARS-CoV-2 Infection in a 2-Year-Old Child

Bell's palsy (BP) is an acute, unilateral facial nerve palsy (FNP) that is a diagnosis of exclusion, sometimes associated with infectious causes. In this article, we described a previously healthy 2-year-old child patient who presented with left-sided facial droop, positive severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) real-time reverse transcription polymerase chain reaction (RT-PCR), positive SARS-CoV-2 immunoglobulin (Ig)-G antibody, and negative cerebrospinal fluid (CSF) SARS-CoV-2 (PCR and serology). This is the second reported pediatric case of BP in the setting of SARS-CoV-2, and the first in a child without comorbidities. Due to the positive antibody test, we presented the idea that SARS-CoV-2 could be a triggering factor of the FNP, possibly occurring in the later stages of disease.

A Rare Case of Chronic Myeloid Leukemia with t(3;9;22) 3-way Translocation

Introduction/Objective

Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm originating from malignant clonal proliferation of a pluripotent hematopoietic stem cell. CML is characterized by a reciprocal translocation between chromosomes 9 and 22, t(9;22)(q34;q11), that gives rise to an abnormal chromosome 22 called the Philadelphia (Ph) chromosome. The translocation results in the formation of a chimeric BCR-ABL1 fusion gene, which is the molecular hallmark of the disease. However, 5-10% of CML patients present with additional chromosomal abnormalities which is often considered a sign of clonal evolution, genetic instability, and is generally thought to portend a poor prognosis.

Methods

We present a case of CML with a rare 3- way translocation, t(3;9;22)(q21;q34;q11.2), who achieved a major molecular response on imatinib for 18 months. A review of the literature and Mitelman database search is presented focusing on the prognostic implications of this 3 way translocation in the era of tyrosine kinase inhibitors starting in 2001 till now.

Results

Twenty seven cases were reported, but the patient therapeutic response to imatinib and clinical outcome were only reported in 11 cases. Nine cases achieved a cytogenetic remission while the remaining two cases had an adverse outcome.

Conclusion

Taken in conjunction with the favorable outcome in our patient, we suggest that t(3;9;22) is not an adverse prognostic factor in the era of tyrosine kinase inhibitors.

Effectiveness of a Cultural Stroke Prevention Program in the United States-South Asian Health Awareness About Stroke (SAHAS)

There are few stroke education programs focused on the South Asian population in the United States. The South Asian Health Awareness about Stroke (SAHAS) program was developed to provide culturally appropriate stroke education to South Asians from 2014 to 2017. Participants recruited for the SAHAS program were educated through a uniquely developed, culturally-specific, educational presentation. Each participant was asked to complete identical educational questionnaires both before (pre-) and after (post-) the intervention, which were then scored and evaluated. Overall, the 357 participants who completed the SAHAS program had a significant, modest 9% improvement in questionnaire score (p < 0.0001). After adjusting for confounders, those ≤ 60 years had a 2.9-point greater increase in score than those > 60 (p < 0.0001). Having programs targeted and developed for specific minority groups with an emphasis on familial commitment and active participation may aid in raising awareness and reducing the elevated adverse stroke outcomes in South Asians.

P2238Prognostic value and incremental benefit of ischaemic myocardial burden subtended by non-invasive CT-derived fractional flow reserve (FFRCT) significant stenoses

Background

Fractional flow reserve derived from CT-coronary angiography (FFRCT) accurately identifies ischaemic vessels which may be associated with clinical outcomes. Its predictive value in grey zone FFRCT values between 0.7–0.8 is not defined. The technique permits estimation of burden of ischaemic myocardium subtended by FFRCT significant vessels.

Purpose

To evaluate the prognostic value and incremental benefit of FFRCT defined ischaemic myocardial burden when compared to FFRCT alone.

Methods

This is a subanalysis of NXT (Analysis of Coronary Blood-Flow Using CTA:Next-Steps), a prospective study of stable coronary artery disease (CAD) patients referred for invasive angiography (ICA) undergoing invasive FFR, CTA and FFRCT in whom treating physicians had been blinded to FFRCT results. Primary endpoint, defined as a composite of non-fatal myocardial infarction and any revascularisation, was determined in 206 patients (age 64±9.5 years, 64% male) and 618 vessels. Burden of ischaemic myocardium was defined as percentage of myocardium subtended beyond the point at which a vessel's FFRCT becomes ≤0.8 as estimated by APPROACH score (FFRCT-APPROACH). In significant FFRCT vessels, the predictive value and incremental benefit of FFRCT-APPROACH was compared with significant FFRCT (≤0.8) for primary endpoint as measured by area under the receiver operator characteristic curve (AUC). Significant ischaemic myocardial burden was defined as >10%. The incidence and relationship between the primary endpoint with each 10% increase in FFRCT-APPROACH and 0.05-unit decrease in FFRCT values ≤0.8 was determined.

Results

Significant FFRCT was identified in 52.9% of patients (109/206) and 29.3% of vessels (181/618). At 4.7 years median follow-up the incidence of the primary endpoint in vessels with significant FFRCT-APPROACH was 58.9% (96/163) which was comparable with vessels with significant FFRCT (55.2%,100/181; P=0.50). The predictive value of FFRCT-APPROACH for the primary endpoint was comparable with FFRCT (AUC 0.72 [95% CI 0.65–0.79] vs 0.71 [0.63–0.78], P=0.79). When combined, there was significant predictive improvement compared with FFRCT alone (AUC 0.77 [0.70–0.84]; P=0.01). The largest incremental benefit upon FFRCT was observed in vessels with FFRCT values in the grey zone between 0.70–0.80 (AUC 0.76 [0.65–0.86] vs 0.62 [0.48–0.74]; P<0.01). Each 10% increase in FFRCT-APPROACH (Adjusted-HR 1.36; 95% CI 1.16–1.60; P<0.001) and each 0.05-unit FFRCT decrease (Adjusted-HR 1.42; 1.19–1.70; P<0.001) were independently associated with significant increase in the incidence of the primary-endpoint.

Conclusion

In patients with stable CAD referred for ICA, the burden of ischaemic myocardium subtended by FFRCT significant vessels predicted non-fatal myocardial infarction and future revascularisation. This provided significant incremental benefit when used in combination with FFRCT particularly at FFRCT values in the grey zone between 0.7 to 0.8.

South Asian Health: Inflammation, Infection, Exposure, and the Human Microbiome

This paper presents the results of the literature review conducted for the working group topic on inflammation, infection, exposure, and the human microbiome. Infection and chronic inflammation can elevate risk for cardiovascular disease and cancer. Environmental exposures common among South Asian (SA) subgroups, such as arsenic exposure among Bangladeshis and particulate matter air pollution among taxi drivers, also pose risks. This review explores the effects of exposure to arsenic and particulate matter, as well as other infections common among SAs, including human papillomavirus (HPV) and hepatitis B/C infection. Emerging research on the human microbiome, and the effect of microbiome changes on obesity and diabetes risk among SAs are also explored.

Abstract P5-13-07: Tolerance of HER-2 directed therapy for early stage breast cancer in a predominantly Hispanic population with high prevalence of cardiovascular risk factors

Introduction:

Trastuzumab based therapy is recommended for patients with early stage HER-2 overexpressing breast cancer, because it improves survival. Significant racial disparities exist in the receipt of trastuzumab with minorities being 25% less likely than whites in being treated with it. (Reeder-Hayes K et al, JCO 2016; 34:2003-2009).

Trastuzumab can affect cardiac function. Cardiac complications associated with trastuzumab are influenced by age and pre-existing risk factors including obesity, hypertension and diabetes mellitus. These co-morbidities occur more frequently in medically underserved minority populations and might influence the practitioner's decision regarding withholding the drug.

We previously identified a high prevalence of metabolic syndrome and obesity in our predominantly Hispanic, medically underserved patient population (SABCC 2015 abstract P1-09-07)). For this study, we analyzed the echocardiographic data and cardiac complications associated with trastuzumab use in this patient population.

Methods:

All patients diagnosed with early stage (stage 1, 2 or 3) HER 2 positive breast cancer between Jan 1st, 2010 and Jan 1st, 2015 at our institution were identified. Age, race, body mass index, pre-existing cardiovascular risk factors, and antihypertensive medication use was collected. Tumor size, nodal status, ER, PR and HER 2 status was recorded. All echocardiograms obtained were reviewed for ejection fraction changes. Repeated measures one sided ANOVA was used to analyze changes in EF. Hospitalization for cardiac complications was recorded. Early interruption of planned therapy and its reasons were recorded. Study was approved by the institutional IRB.

Results:

Sixty patient were treated with trastuzumab based chemo immunotherapy over the study period. 93% were Hispanic, median age was 61 years (Range 31-83), 40% had hypertension, 35% had dyslipidemia, 35% had glucose intolerance or type II diabetes mellitus and 70% were overweight or obese. 33% were dependent on charity care. 26% had stage 1, 37% had stage 2 and 37% had stage 3 cancer. Docetaxel, carboplatin, trastuzumab (TCH) was the most commonly used regimen (63%) followed by doxorubicin, cyclophosphamide, paclitaxel and transtuzumab (28%).

Ten patients (16.6%) required early discontinuation of cytotoxic chemotherapy. Only 1 patient was unable to complete planned 1 year of trastuzumab due to declining ejection fraction. There were no hospitalizations related to cardiac events during therapy.

Trastuzumab based treatment elicited statistically significant changes in LVEF over time, F (2,98) =13.974, p&lt;.0005, with LVEF decreasing from 65.4±.844 prior to therapy to 64.7±.724 during 3-6months of therapy and 62.2±.81 at the end of therapy. Two patients had a decline in LVEF ≥ 10%. Of these, 1 resolved at follow up ECHO in 6 weeks.

Conclusion

In a predominantly Hispanic, HER 2+ breast cancer cohort, with a high prevalence of cardiovascular risk factors and limited health care access, we found that the vast majority were able to complete 1 year of trastuzumab without significant cardiac complications. As trastuzumab improves survival, practitioners should adhere to national guidelines regarding its use as much as possible.

Citation Format: Gaur S, McAlice M, Alshaban A, Mahfoud A, Corral J, Philipovskiy A. Tolerance of HER-2 directed therapy for early stage breast cancer in a predominantly Hispanic population with high prevalence of cardiovascular risk factors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-07.

Latent Tuberculosis Infection Beliefs and Testing and Treatment Health Behaviors Amongst Non-US-Born South Asians in New Jersey: A Cross-Sectional Community Survey

Latent tuberculosis infection (LTBI) remains a problem in the United States as reactivation leads to active TB disease particularly in persons with risk factors. The objective of this study is to assess the knowledge, attitudes and health behaviors related to testing and treatment of LTBI among non-US-born South Asians (SA) in New Jersey (NJ). A cross-sectional, community-based survey was the primary tool for gathering data. Eligibility criteria included being at least 18 years of age, self-identifying as SA, verbal consent for participation, and birth in a high TB endemic country. A hardcopy survey was distributed at local South Asian health fairs. The survey included questions about demographics, knowledge, beliefs on TB, and health behaviors (testing and treatment). Descriptive statistics were performed for all survey responses. Logistic regression models were constructed to assess the association of characteristics/beliefs and study outcomes. The survey sample size included 387 respondents. A total of 197 (54%) of respondents reported ever been tested for TB. Those who were tested for TB were generally younger, had higher educational levels, higher household incomes, and were more likely to have health insurance than those not ever tested for TB. Significantly more respondents who self-reported ever been tested for TB believed that TB was very or extremely serious (71.1% vs. 56.2%, p = 0.004). Also, significantly more respondents who self-reported ever been tested for TB believed that it was important to get tested (91.2% vs. 63.3%, p < 0.001). The survey analysis concluded that high-risk SA residents in NJ demonstrated a low rate of testing for TB.

Cutaneous Leishmaniasis in an American Adolescent Returning From Israel

We present here the case of a healthy 16-year-old American girl who returned from an organized trip to Israel with cutaneous leishmaniasis caused by Leishmania major; the infection was treated successfully with paromomycin-gentamicin ointment. She was initially misdiagnosed with staphylococcal and pseudomonal cellulitis. Although cutaneous leishmaniasis is seen only rarely in the United States, it should be considered when diagnosing new skin lesions after travel to affected countries.

Changes in prostate cancer detection rate of MRI-TRUS fusion vs systematic biopsy over time: evidence of a learning curve

BACKGROUND

To determine the effect of urologist and radiologist learning curves and changes in MRI-TRUS fusion platform during 9 years of NCI's experience with multiparametric magnetic resonance imaging (mpMRI)/TRUS fusion biopsy.

METHODS

A prospectively maintained database of patients undergoing mpMRI followed by fusion biopsy (Fbx) and systematic biopsy (Sbx) from 2007 to 2016 was reviewed. The patients were stratified based on the timing of first biopsy. Cohort 1 (7/2007-12/2010) accounted for learning curve. Cohort 2 (1/2011-5/2013) and cohort 3 (5/2013-4/2016) included patients biopsied prior to and after debut of a new software platform, respectively. Clinically significant (CS) disease was defined as Gleason 7 (3+4) or higher. McNemar's test compared cancer detection rates (CDRs) of Sbx and Fbx between time periods.

RESULTS

1528 patients were included in the study with 230, 537 and 761 patients included in three respective cohorts. Median age (interquartile range) was 61.0 (±9.0), 62.0 (±7.3), and 64.0 (±11.0) years in three cohorts, respectively (P<0.001). Fbx and Sbx had comparable CS CDR in cohort 1 (24.8 vs 22.2%, P=0.377). Fbx detected significantly more CS disease compared to Sbx in the following two periods (cohort 2: 31.5 vs 25.0%, P=0.001; cohort 3: 36.4 vs 30.3%, P<0.001) and detected significantly less low risk disease in the same period (cohort 2: 14.5 vs 19.6%, P<0.001; cohort 3: 12.6 vs 16.7%, P<0.001). Even after multivariate adjustment with age, PSA, race, clinical stage and MRI suspicion score, Fbx CS cancer detection increased in successive cohorts (cohort 2: OR 2.23, P=0.043; cohort 3: OR 2.92, P=0.007).

CONCLUSIONS

In the past 9 years, there has been significant improvement in the accuracy of Fbx. Our results show that after an early learning period, Fbx detected higher rates of CS cancer and lower rates of clinically insignificant cancer than Sbx. Software advances allowed for even greater detection of CS disease.

Adverse Outcomes Among Asian Indian Singleton Births in New Jersey, 2008-2011

The study determined the incidence of low birth weight (LBW), small for gestational age (SGA), preterm birth, and perinatal morbidity among Asian Indians (AI) in New Jersey (NJ), as well as identified predictors of SGA. We analyzed birth records for singletons born to mothers identified as AI and non-Hispanic white from 2008 to 2011, obtained from the NJ Department of Health. For AI, rates of LBW and SGA were elevated, rates of preterm birth were similar, and neonatal intensive care unit admission was lower, compared to whites. Factors associated with SGA in AI included nulliparity, anemia, hypertension, placental abruption, and lack of prenatal care. Maternal education, marital status, substance abuse, and timing of prenatal care were associated with SGA in whites, but not in AI. SGA incidence was higher among AI despite preterm rates similar to whites. Anemia was associated with SGA uniquely among AI.

Note: Effect of Barley Flour, Wet Gluten and Ascorbic Acid on Bread Crumb Texture

Barley flour (0, 10 and 20% w/w), wet gluten (0, 7.5 and 15% w/w) and ascorbic acid (0, 10 and 20 ppm) were incorporated into wheat flour to prepare bread. The addition of barley flour alone tended to reduce bread volume whereas wet gluten and ascorbic acid improved loaf volume. Effect of staling on bread crumb texture was studied over a period of 72 h using an Instron universal testing machine. It was found that barley flour, ascorbic acid and wet gluten have antistaling effects and a synergistic effect was also observed since in combination the three ingredients had a greater antistaling effect. A regression model ( R2 > 0.8) is presented to predict the bread volume, cohesiveness and firmness of bread crumb.

Abstract P1-09-07: Effects of breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic patient population

Background: Adjuvant chemotherapy improves survival in early breast cancer, however has been reported to contribute to weight gain and insulin resistance. Hispanics are reported to have higher levels of insulin resistance and features of metabolic syndrome as compared to caucasians and as such may be at higher risk of metabolic decompensation during treatment of their cancer. We sought to evaluate the effects of adjuvant/ neo-adjuvant breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic population. Study was funded by the institutions department of medicine seed grant funds.

Methods: We enrolled 35 consecutive patients who were about to commence adjuvant or neo-adjuvant chemotherapy for breast cancer. Patients with diabetes mellitus or hyperlipidemia were excluded. Fasting glucose, HBA1C, insulin levels, HDL cholesterol, triglyceride levels, waist circumference and blood pressure were measured before starting chemotherapy and then every 3 months for 1 year. Results were analyzed using repeated measures ANOVA for normally distributed data. For data that was not normally distributed, Friedmans non parametric test was utilized.

A survey of dietary habits, exercise frequency and life style factors was administered before initiating treatment and at completion of the study.

Results:

Baseline characteristics: Of the 35 patients enrolled 31 were hispanics (89%). Median age was 47 years (33-68). 31 (82.8%) were over weight or obese. 13 (37%) had insulin resistance as assessed by HOMA (homeostatic model assessment)-IR, and 12 (34%) met the international diabetic federation (IDF) criteria for metabolic syndrome. 17% had stage 1, 52% had stage 2 and 31% had stage 3 disease. Most common chemotherapy regimen used was dose dense doxorubicin, cyclophosphamide and weekly paclitaxel.

No significant change was noted in the fasting glucose, HBA1C levels, insulin levels, HOMA-IR, weight or waist circumference at any point during the 1 year follow up. Triglyceride levels increased from a mean of 162.2mg/dl prior to therapy to 202.8mg/dl by 3 months, p=0.014. HDL-cholesterol fell from a mean of 50.6 mg/dl to 44mg/dl by 3 months, p=0.04.

Both triglyceride levels and HDL levels returned to baseline by 9 months and there was no change noted by 12 months. Overall 12 patients (34%) met the IDF criteria for metabolic syndrome before initiating adjuvant therapy as compared to 14 (40%) at 1 year.

Subgroup analysis of patients with preexisting metabolic syndrome, obesity or insulin resistance (HOMA-IR &gt;3.8) showed similar results.

Analysis of the survey data showed 22 of the 35 patients (62%) had improved their dietary and exercise habits over the course of the study.

Conclusions: Contrary to other studies, we did not find a significant difference in most of the parameters of metabolic syndrome in a predominantly hispanic patient population. A transient increase in triglyceride levels and a decline in HDL cholesterol level was noted at 3 months, however resolved by the 9th month of treatment. Our data suggests that life style modification may mitigate most of the metabolic adverse effects of therapy and women, at the time of diagnosis, may be particularly motivated to make such changes.

Citation Format: Gaur S, Ochoa C, Sanchez L, Nahleh Z. Effects of breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic patient population. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-07.

Clinical and cost burden of rotavirus infection before and after introduction of rotavirus vaccines among commercially and Medicaid insured children in the United States

This study aims to quantify clinical and economic burden of rotavirus (RV) infection pre- and post-vaccine introduction in commercially insured and Medicaid populations. Beneficiaries with continuous enrollment for ≥6 months while <5 years of age were identified separately in commercial (2000–2010) and Medicaid (2002–2009) claims databases. Commercial and Medicaid databases included 3 998 708 and 1 034 440 eligible children, respectively, observed from enrollment start date(s) to end of eligibility or 5-years-old. Rates of RV-coded and diarrhea-coded encounters and first RV episodes, and incremental cost of first RV episodes were calculated. In the post-vaccine period, rates per 10 000 person-years for RV-coded hospitalizations, outpatient visits and ER visits were 5.58 (95% CI, 5.37–5.80), 6.96 (95% CI, 6.75–7.20), and 4.85 (95% CI, 4.66–5.06), respectively (pre-vaccine, 16.67 [95% CI, 16.19–17.15], 13.20 [95% CI, 12.78–13.63], 11.26 [95% CI, 10.87–11.66], respectively), for commercially insured. In Medicaid the corresponding rates were 10.53 (95% CI, 9.60–11.56), 11.72 (95% CI, 10.73–12.80), and 9.11 (95% CI, 8.24–10.07) (pre-vaccine, 19.78 [95% CI, 19.14–20.45], 19.39 [95% CI, 18.75–20.05], 27.61 [95% CI, 26.84–28.40]). Incidence rate per 10 000 person-years for first RV episode pre- vs. post-vaccine were 27.03 (95% CI, 26.42–27.65) vs. 10.14 (95% CI, 9.86–10.44) in the commercially insured population and 37.71 (95% CI, 36.81–38.63) vs. 18.64 (95% CI, 17.37–19.99) in Medicaid. Incremental per-patient per-month cost of first RV episode was $3363 (95% CI, $3308-$3418) among commercially insured and $1831 (95% CI, $1768-$1887) in Medicaid. Since vaccine introduction clinical burden of RV disease decreased among children; costs associated with RV episodes remained significant across insured populations.

Acute leukemia of ambiguous lineage with trisomy 4 as the sole cytogenetic abnormality: A case report and literature review

We describe a patient with acute leukemia of ambiguous lineage who had trisomy 4 as the sole cytogenetic abnormality. Clinical, pathological, immunophenotypic and molecular features are presented and compared with the previous 4 published cases. Over expression of c-kit, which is localized to chromosome 4, was documented on the leukemic blasts. Prognosis seems to be poor. Treatment with acute lymphoblastic leukemia like regimens seems to be superior compared to acute myeloid leukemia like regimens and allogeneic stem cell transplant is recommended after achieving remission.

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Acute leukemia of ambiguous lineage with trisomy 4 as the sole abnormality is a rare disease.

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Clinical and pathological details of a case are presented and compared with prior 4 published cases.

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Over expression of c-kit, localized to chromosome 4, may play a pathogenic role in this disease.

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Prognosis seems to be poor.

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Treatment with ALL like regimens seems to be superior compared to AML like regimens.

Treatment Response in Association with Adherence Patterns to Highly Active Antiretroviral Therapy in Pediatric Patients with Perinatally Acquired HIV Infection

Background:

Assessment of longitudinal adherence patterns on virologic and immunologic responses to HAART in perinatally acquired HIV patients has not been studied.

Methods:

Perinatally infected pediatric HIV patients with adherence documented at least twice and corresponding viral load and T-cell (%) data measured during 2008-2009 were studied. Multiple adherence measures were utilized to identify patients with persistent adherence, nonadherence, or alteration of adherence. Virologic and immunologic outcomes were assessed.

Results:

Persistent adherence, nonadherence, and alteration of adherence to HAART were recorded in 41.9%, 8.1%, and 50.0% of 62 studied patients. Persistent adherence was associated with higher likelihood for persistent virologic suppression and lower risk for persistent virologic failure.

Conclusion:

Alteration of adherence to HAART is a significant predictor of persistent virologic failure and high viremia in perinatally infected HIV patients. Implementation of longitudinal adherence assessments may target patients with nonsustained adherence patterns and help decrease the risk for virologic failure and disease progression.

A rare presentation of orbital complication of invasive fungal sinusitis in an immunocompetent young boy-a rare case

We present a case of allergic fungal sinusitis (AFS) in a 24 -year old man with history of left sided nasal obstruction and discharge since few years. Since few months he developed epiphora in the left eye associated with discomfort on eye movements. Patient was examined and CT with contrast was done. CT contrast showed an enhancing lesion in Left maxillary and ethmoid sinuses and erosion of the inferior bony wall of the orbit and medial wall of maxillary sinus. Though most patients of fungal sinusitis are immunocompromised but this patient was young male immunocompetent and made an unusual presentation with visual epiphora and painful eye movements. CT showed bony erosion of the Left inferior Bony wall of the Orbit and medial wall of Maxillary Sinus. After through examination and specific investigations, the patient was posted for surgery. We planed for Cald well –Luc’s Surgery and Endoscopic excision of the mass .Histological examination was reported as non malignant and microscopy showed Fungal Hyphae. After the surgery patient was discharged satisfactorily within couple of days and followed up regularly. Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-1, 48-51 DOI: http://dx.doi.org/10.3126/jcmsn.v8i1.6826

Health care practices of the foreign born Asian Indians in the United States. A community based survey

Although successful utilization of medical and preventive care by members of the non-US born communities is an important public health concern, our knowledge regarding health practices of different ethnic subgroups is limited. In the present study, participants of the health fairs organized during South Asian cultural and religions events were asked anonymously to complete the South Asian Total Health Initiative (SATHI) health survey questionnaire to evaluate their health-related practices, self-health perception, and satisfaction with medical care. Among 1,250 surveyed, 1,016 foreign born Asian Indians adults that represented the fastest growing subgroups of the South Asian born nationals in the US were included in the analysis. We found that the majority reported healthy behavior (exercise activities and abstinence from alcohol or tobacco), high self-health perception, satisfaction with medical care, and compliance with annual routine medical examinations that was directly associated with the annual house income. Approximately 40% of women complied with breast and cervical cancer screenings and less than 20% of men complied with prostate cancer screening guidelines. Presence of chronic conditions (mostly cardiovascular pathology and/or diabetes) that were reported by approximately half of the participants negatively impacted their self-health perception. In conclusion, positive self-reported health perception and compliance with routine health examinations of the surveyed foreign born Asian Indians was reported along with an increased rate of chronic morbidity and underutilization of specific preventive services. Observed discrepancy between self-health perception and health status highlights the need to enhance utilization of preventive services among the non-US born Asian Indian community.

Pharmacotherapy for multidrug resistant tuberculosis

The current global concern in the treatment of tuberculosis (TB) is the emergence of resistance to the two most potent drugs namely, isoniazid and rifampicin. Emergence of multidrug resistance tuberculosis (MDR-TB) is now a health problem faced by most of the developing countries as well as developed countries across the globe. MDR-TB is a man-made disease that is caused by improper treatment, inadequate drug supplies, and poor patient supervision. HIV infection and AIDS have been implicated as important cause for this. The review of a published literature suggests that the most powerful predictor of treatment of MDR-TB is a history of treatment of TB. Although the treatment is efficacious, there are also a number of adverse effects caused by drugs used in the treatment of MDR-TB.

Multi-Criteria Decision Analysis for Identifying a Suitable Location for Groundwater Pumping Wells

The paper presents the methodology for the combined use of GIS-based multi-criteria analysis and simulation-optimisation modelling for management of the groundwater resources of the Dore river basin in France. The study identifies the suitable location and maximum discharge for the new groundwater pumping wells. The multi-criteria analysis (MCA), with the help of GIS-based geospatial analysis, was performed to identify those areas suitable for pumping wells by considering different criteria, such as hydraulic conductivity, land use, river aquifer exchange, depth to water, and geomorphology. Different criteria were selected with the help of regional experts and stakeholders. For the study area, the groundwater flow model was developed. Further, new pumping wells in the suitable zones, those identified by MCA, were considered and a simulation-optimisation technique was used to identify the maximum discharge from those wells. Finally, the results obtained from both the methods were to finalise the potential zone. The developed methodology proves to be a more realistic approach to identifying new locations for pumping wells.

Children with partial IgA deficiency: clinical characteristics observed in the pediatric rheumatology clinic

Literature is lacking on partial IgA deficiency. In this study, the authors propose to describe the clinical manifestations of patients with partial IgA deficiency. Methods. The authors conducted a retrospective chart review of 13 patients with partial IgA deficiency followed at the pediatric rheumatology clinic at Robert Wood Johnson Medical School. They looked for the presence of rashes, joint pain, joint swelling, and morning stiffness. The authors also examined charts for a history of frequent infections, allergies, and the presence of elevated antinuclear antibody. Results. Eleven out of the 13 patients complained of joint pain, joint swelling, or morning stiffness. Six patients carried a diagnosis of a definitive rheumatic disease. Four patients suffered from frequent infections and 2 patients reported allergies. Conclusion. Partial IgA deficiency appears to be associated with rheumatic diseases and complaints of joint pain, joint swelling, and morning stiffness. A larger study is needed to confirm these results.

Underweight in low socioeconomic status preschool children with severe early childhood caries

BACKGROUND

The prevalence of severe early childhood caries (sECC) is high in developing nations like India. It has local as well as systemic manifestations.

AIMS

This study evaluated the influence of sECC and its management on growth parameters and quality of life (QoL) of preschool children from low socioeconomic status families.

MATERIALS AND METHODS

100 preschool children (50 with sECC and 50 with no dental caries; mean age 5.42 ± 0.74 years) from low socioeconomic status were studied. QoL; Decayed, extracted and filled teeth (def) index; Height (Ht); Weight (Wt); Head circumference (HC); Mid arm circumference (MAC); and, Body Mass Index (BMI) were recorded at baseline and compared after six months of dental rehabilitation. The test group included children with sECC having def > 6 and at least one pulpally involved tooth.The control group children did not have DC (def =0). Both the groups were age, gender and socioeconomic status matched.

STATISTICAL ANALYSIS

Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) v.11.0 computer software. Chi-square test, Analysis of Variance (ANOVA), Fisher's exact and paired t tests were performed for comparing the groups at baseline and six month recall visit.

RESULTS

Baseline measurements showed that 46% of children with sECC had Wt below 3rd percentile (underweight; mean 15.49 ± 1.87Kg) which was less than the controls (mean Wt 16.34 ± 1.46 kg). They also complained of pain (40%), avoidance of hard food (24%), noticed Wt loss (18%) and sleep disturbances (12%). After 6 months of dental rehabilitation, there was a significant improvement in their Wt (P= 0.002) and QoL.

CONCLUSIONS

sECC negatively influenced the Wt and QoL of children. Awareness, education of parents and facilitation of oral health services may help in improving their Wt and QoL.

Oral findings in a child with lipoid proteinosis: a case report and review

Lipoid proteinosis, a very rare autosomal recessive genodermatosis, results in hyaline material deposition in the skin and mucous membrane of various organs leading to multisystem involvement. A case report of a 12-year-old female child is presented here who showed classic features of the disease with generalized thickening, hardening, and scarring of the skin and vocal cord infiltration causing voice changes. The patient also had numerous oral mucosal and dental findings. The knowledge of the clinical features of the disease may help the oral health professional in rendering the appropriate treatment in order to improve the quality of life deteriorated by the disease.

Adherence to antiretroviral therapy in pediatric patients with human immunodeficiency virus (HIV-1)

The evaluation of HIV treatment adherence is essential to manage the development of resistant mutations, treatment failure, and disease progression in patients with HIV-1 infection; however, none of the commonly used measures of treatment adherence have been found to be accurate. The objective of this study was to evaluate three treatment adherence measures (caregiver reports, pharmacy refill, and appointment maintenance data) in association with viral load suppression in pediatric patients with HIV-1 infection. Although viral suppression was not found to be significantly associated with adherence defined by any single measure, treatment adherence could be predicted if all three measures were in agreement.

Disparity in hospital utilization of rapid HIV-1 testing for women in labor with undocumented HIV status

OBJECTIVES

The implementation of rapid HIV-1 testing for women in labor with undocumented HIV status is an essential tool for the prevention of perinatal HIV transmission. Unfortunately, practices of rapid HIV testing for women with unknown HIV status in labor have not been studied. We evaluated the utilization of rapid HIV testing prior to and after implementation of CDC recommendations as well as factors that may affect the utilization rate.

DESIGN STUDY

participants were randomly selected from all deliveries (n = 2,359) six months prior to (n = 422) and after (n = 403) hospital implementation of the rapid HIV testing protocol. We reviewed prenatal and labor/delivery records to identify HIV testing history during pregnancy and HIV status at admission; we studied Rapid HIV testing utilization in respect to the implementation of the CDC recommendation; and we analyzed maternal sociodemographic and perinatal factors in association with rapid HIV testing utilization.

RESULTS

Unknown HIV status at admission was recorded for 22.0% of women who gave birth prior to, and 18.1% after, implementation of the hospital policy due to either no offering or no acceptance of HIV testing during the pregnancy. Among those eligible for rapid HIV testing, 7.6% were tested prior to, and 9.6% were tested after, implementation of the new policy. As compared with tested women, women not tested were more likely to be white, married, and to have received prenatal primary care from a private physician.

CONCLUSIONS

We found that low utilization of rapid HIV-1 testing for women in labor with undocumented HIV status is mostly associated with the sociodemographic inequality of the population of women served. Continuous education of health care providers and a systematic review of rapid HIV testing utilization in the hospital setting are needed in order to achieve successful implementation of the current CDC recommendations.

Poststreptococcal reactive arthritis in children: a retrospective study

The duration of treatment and appropriate guidelines for antibiotic prophylaxis for children with poststreptococcal reactive arthritis (PSRA) have not been determined. The authors performed a retrospective chart review of 40 children with PSRA and examined their clinical features at initial evaluation and at 6, 12, and 24 months. At baseline, 18% (n = 7) had a finding noted on the echocardiogram. Although most patients developed cardiac findings early on in the course of their disease, 2 patients with a normal baseline echocardiogram may have developed findings after 12 months of follow-up. The mean duration of prophylaxis was 22 months. During the follow-up period, there was improvement in Physician's Global Assessment, number of patients with arthralgia, tender and swollen joints, erythrocyte sedimentation rate, anti-streptolysin O, and anti-DNAse B antibody titers. The authors conclude that marked improvement in clinical features and laboratory values was seen over time. Patients may benefit with long-term cardiac follow-up.

The impact of environmental risk factors on HIV-associated cognitive decline in children

Both the human immunodeficiency virus (HIV) and environmental stress have been independently associated with decreased cognitive functioning in children. Given that they are also known to have a strong relationship with each other, the present study sought to test the hypothesis that children in conditions of high environmental risk would be at greater risk for the cognitive complications related to immunosuppression. A retrospective review was conducted to examine the records of 141 children treated at a large pediatric AIDS clinic from 1993 to 2000. CD4+ lymphocyte levels were recorded from laboratory results and IQ scores were recorded from routine psychological evaluations. Key indicators of environmental risk were collected and combined into one measure of overall environmental risk. Pearson product moment correlations were conducted to examine the relationship between environmental risk, age-adjusted CD4 and IQ. Results indicated a significant correlation between CD4 and IQ, with higher levels of immunocompetence predicting higher IQ scores. When subjects were dichotomized based on their environmental risk score, there was no relationship between CD4 count and IQ in the low environmental risk group. In contrast, CD4 was positively associated with IQ in the high environmental risk group. It is proposed that this may be due to gp120 levels in immunocompromised children being particularly toxic to the hippocampus and cortex under conditions of high stress but not so under conditions of low stress.