Ultrastructural characterization of host-parasite interactions of Plasmodium coatneyi in rhesus macaques

Plasmodium coatneyi has been proposed as an animal model for human Plasmodium falciparum malaria as it appears to replicate many aspects of pathogenesis and clinical symptomology. As part of the ongoing evaluation of the rhesus macaque model of severe malaria, a detailed ultrastructural analysis of the interaction between the parasite and both the host erythrocytes and the microvasculature was undertaken. Tissue (brain, heart and kidney) from splenectomized rhesus macaques and blood from spleen-intact animals infected with P. coatneyi were examined by electron microscopy. In all three tissues, similar interactions (sequestration) between infected red blood cells (iRBC) and blood vessels were observed with evidence of rosette and auto-agglutinate formation. The iRBCs possessed caveolae similar to P. vivax and knob-like structures similar to P. falciparum. However, the knobs often appeared incompletely formed in the splenectomized animals in contrast to the intact knobs exhibited by spleen intact animals. Plasmodium coatneyi infection in the monkey replicates many of the ultrastructural features particularly associated with P. falciparum in humans and as such supports its use as a suitable animal model. However, the possible effect on host–parasite interactions and the pathogenesis of disease due to the use of splenectomized animals needs to be taken into consideration.

Restoring Carboxylates on Highly Modified Alginates Improves Gelation, Tissue Retention and Systemic Capture

Alginate hydrogels are gaining traction for use in drug delivery, regenerative medicine, and as tissue engineered scaffolds due to their physiological gelation conditions, high tissue biocompatibility, and wide chemical versatility. Traditionally, alginate is decorated at the carboxyl group to carry drug payloads, peptides, or proteins. While low degrees of substitution do not cause noticeable mechanical changes, high degrees of substitution can cause significant losses to alginate properties including complete loss of calcium cross-linking. While most modifications used to decorate alginate deplete the carboxyl groups, we propose that alginate modifications that replenish the carboxyl groups could overcome the loss in gel integrity and mechanics. In this report, we demonstrate that restoring carboxyl groups during functionalization maintains calcium cross-links as well as hydrogel shear-thinning and self-healing properties. In addition, we demonstrate that alginate hydrogels modified to a high degree with azide modifications that restore the carboxyl groups have improved tissue retention at intramuscular injection sites and capture blood-circulating cyclooctynes better than alginate hydrogels modified with azide modifications that deplete the carboxyl groups. Taken together, alginate modifications that restore carboxyl groups could significantly improve alginate hydrogel mechanics for clinical applications. STATEMENT OF SIGNIFICANCE: Chemical modification of hydrogels provides a powerful tool to regulate cellular adhesion, immune response, and biocompatibility with local tissues. Alginate, due to its biocompatibility and easy chemical modification, is being explored for tissue engineering and drug delivery. Unfortunately, modifying alginate to a high degree of substitution consumes carboxyl group, which are necessary for ionic gelation, leading to poor hydrogel crosslinking. We introduce alginate modifications that restore the alginate's carboxyl groups. We demonstrate that modifications that reintroduce carboxyl groups restore gelation and improve gel mechanics and tissue retention. In addition to contributing to a basic science understanding of hydrogel properties, we anticipate our approach will be useful to create tissue engineered scaffolds and drug delivery platforms.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

OBJECTIVES

Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response.

METHODS

HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated.

RESULTS

New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007).

CONCLUSIONS

The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.

Monitoring the HIV continuum of care in key populations across Europe and Central Asia

OBJECTIVES

The aim of the study was to measure and compare national continuum of HIV care estimates in Europe and Central Asia in three key subpopulations: men who have sex with men (MSM), people who inject drugs (PWID) and migrants.

METHODS

Responses to a 2016 European Centre for Disease Prevention and Control (ECDC) survey of 55 European and Central Asian countries were used to describe continuums of HIV care for the subpopulations. Data were analysed using three frameworks: Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; breakpoint analysis identifying reductions between adjacent continuum stages; quadrant analysis categorizing countries using 90% cut-offs for continuum stages.

RESULTS

Overall, 29 of 48 countries reported national data for all HIV continuum stages (numbers living with HIV, diagnosed, receiving treatment and virally suppressed). Six countries reported all stages for MSM, seven for PWID and two for migrants. Thirty-one countries did not report data for MSM (34 for PWID and 41 for migrants). In countries that provided key-population data, overall, 63%, 40% and 41% of MSM, PWID and migrants living with HIV were virally suppressed, respectively (compared with 68%, 65% and 68% nationally, for countries reporting key-population data). Variation was observed between countries, with higher outcomes in subpopulations in Western Europe compared with Eastern Europe and Central Asia.

CONCLUSIONS

Few reporting countries can produce the continuum of HIV care for the three key populations. Where data are available, differences exist in outcomes between the general and key populations. While MSM broadly mirror national outcomes (in the West), PWID and migrants experience poorer treatment and viral suppression. Countries must develop continuum measures for key populations to identify and address inequalities.

Significant differences in maternal child-feeding style between ethnic groups in the UK: the role of deprivation and parenting styles

BACKGROUND

Nonresponsive maternal child-feeding interactions, such as restricting, pressurising and emotional feeding, can affect the ability of a child to self-regulate intake and increase the risk of becoming overweight. However, despite findings that South Asian and Black children living in the UK are more likely to be overweight, UK research has not considered how maternal child-feeding style might differ between ethnic groups. The present study aimed to explore variations in maternal child-feeding style between ethnic groups in the UK, taking into account associated factors such as deprivation and parenting style.

METHODS

Six hundred and fifty-nine UK mothers with a child who was aged 5-11 years old completed a questionnaire. Items included ethnicity and demographic data, as well as copies of the Child Feeding Questionnaire, Parental Feeding Styles Questionnaire and Parenting Styles and Dimensions Questionnaire.

RESULTS

Significant differences in perceived responsibility (P = 0.002), restriction (P = 0.026), pressure to eat (P = 0.045), instrumental feeding (P = 0.000) and emotional feeding (P = 0.000) were found between the groups. Mothers from South Asian backgrounds reported higher levels of pressure to eat, emotional feeding and indulgent feeding styles, whereas mothers from Chinese backgrounds reported greater perceived responsibility and restriction. Mothers from Black and White British backgrounds were not significantly higher with respect to any behaviour. Maternal child-feeding style was also associated with deprivation and parenting style, although these did not fully explain the data.

CONCLUSIONS

Understanding cultural factors behind maternal child-feeding style, particularly around pressurising and indulgent feeding behaviours, may play an important part in reducing levels of children who are overweight and obese in the UK.

People with diagnosed HIV infection not attending for specialist clinical care: UK national review

Background

Regular clinical care is important for the well-being of people with HIV. We sought to  audit and describe the characteristics of adults with diagnosed HIV infection not reported to be attending for clinical care in the UK.

Methods

Public Health England (PHE) provided clinics with lists of patients diagnosed or seen for specialist HIV care in 2010 but not linked to a clinic report or known to have died in 2011. Clinics reviewed case-notes of these individuals and completed questionnaires. A nested case–control analysis was conducted to compare those who had remained in the UK in 2011 while not attending care with individuals who received specialist HIV care in both 2010 and 2011.

Results

Among 74,418 adults living with diagnosed HIV infection in the UK in 2010, 3510 (4.7 %) were not reported as seen for clinical care or died in 2011. Case note reviews and outcomes were available for 2255 (64 %) of these: 456 (20.2 %) remained in the UK and did not attend care; 590 (26.2 %) left UK; 508 (22.6 %) received care in the UK: 73 (3.2 %) died and 628 (27.8 %) had no documented outcome. Individuals remaining in the UK and not attending care were more likely to be treatment naïve than those in care, but duration since HIV diagnosis was not significant. HIV/AIDS related hospitalisations were observed among non-attenders.

Conclusion

Retention in UK specialist HIV care is excellent. Our audit indicates that the ‘true’ loss to follow up rate in 2011 was <2.5 % with no evidence of health tourism. Novel interventions to ensure high levels of clinic engagement should be explored to minimise disease progression among non-attenders.

A Review of Plasmodium coatneyi-Macaque Models of Severe Malaria

Malaria remains one of the most significant public health concerns in the world today. Approximately half the human population is at risk for infection, with children and pregnant women being most vulnerable. More than 90% of the total human malaria burden, which numbers in excess of 200 million annually, is due to Plasmodium falciparum. Lack of an effective vaccine and a dwindling stockpile of antimalarial drugs due to increased plasmodial resistance underscore the critical need for valid animal models. Plasmodium coatneyi was described in Southeast Asia 50 years ago. This plasmodium of nonhuman primates has been used sporadically as a model for severe malaria, as it mimics many of the pathophysiologic features of human disease. This review covers the reported macroscopic, microscopic, ultrastructural, and molecular pathology of P. coatneyi infection in macaques, specifically focusing on the rhesus macaque, as well as describing the critical needs still outstanding in the validation of this crucial model of human disease.

An overview of the HIV epidemic among men who have sex with men in the United Kingdom, 1999-2013

We describe epidemiological trends in HIV among men who have sex with men (MSM) in the United Kingdom (UK) to inform prevention strategies. National HIV surveillance data were analysed for trends. Multivariable analyses identified predictors of late diagnosis (<350 copies/µL) and mortality. Between 1999 and 2013, 37,560 MSM (≥15 years) were diagnosed with HIV in the UK. New diagnoses rose annually from 1,440 in 1999 to 3,250 in 2013. The majority of MSM were of white ethnicity (85%) and UK-born (68%). Median CD4 count increased steadily from 350 cells/µL to 463 cells/µL. HIV testing in England increased from 10,900 tests in 1999 to 102,600 in 2013. One-year death rates after diagnosis declined among late presenters (4.7% to 1.9%). Despite declining late diagnosis (50% to 31%), the number of men diagnosed late annually has remained high since 2004. Older age (≥50 years), and living outside London were predictors of late presentation; older age and late presentation were predictors of one-year mortality. Increases in new diagnoses reflect increased testing and ongoing transmission. Over 900 men present late each year and mortality in this group remains high and preventable. Appropriate prevention and testing strategies require strengthening to reduce HIV transmission and late diagnosis.

Quality of HIV care in the United Kingdom: key indicators for the first 12 months from HIV diagnosis

OBJECTIVES

Prompt HIV diagnosis and treatment are associated with increased longevity and reduced transmission. The aim of the study was to examine late diagnoses and to assess the quality of care following diagnosis.

METHODS

National surveillance and cohort data were used to examine late HIV diagnoses and to assess the quality of care received in the 12 months following HIV diagnosis.

RESULTS

In 2011, 79% (4910/6219) of persons (15 years and over) diagnosed with HIV infection had CD4 counts reported within 3 months; of these, 49% were diagnosed late (CD4 count < 350 cells/μL). Adults aged 50 years and over were more likely to be diagnosed late (67%) compared with those aged 15-24 years (31%). Sixty-four per cent of heterosexual men were diagnosed late compared with 46% of women and 36% of men who have sex with men (MSM) (P < 0.01). The percentage of late diagnoses was highest among black African adults (66%) compared with other ethnicities; 96% of black African adults diagnosed late were born abroad. Overall, 88% and 97% of patients were linked to care within 1 and 3 months of diagnosis, respectively, with little variation by demographics and exposure category. The crude 1-year mortality rate was 31.6 per 1000 persons diagnosed in 2010. It was highest among adults diagnosed late (40.3/1000 versus 5.2/1000 for prompt diagnoses) and particularly among those aged 50 years and over. Excluding deaths, 85% of the 5833 diagnosed in 2010 were retained in care in 2011; 92% of the 2264 adults diagnosed late in 2010 received antiretroviral therapy by the end of 2011.

CONCLUSIONS

The National Health Service provides high-quality care to persons newly diagnosed with HIV infection in the UK, with no evidence of health inequalities. Despite excellent care, half of adults are diagnosed late according to the threshold at which national guidelines recommend treatment should begin. Such patients have an 8-fold increased risk of 1-year mortality compared with those diagnosed promptly. Reducing late diagnosis of HIV infection remains a public health priority in the UK.

Maternal trait personality and childbirth: the role of extraversion and neuroticism

BACKGROUND

anxiety during pregnancy and childbirth can increase risk of complications and interventions for both mother and infant. Although considerable work has explored fear of childbirth and anxiety during labour and subsequent birth outcomes there has been less consideration of the role of more stable maternal personality upon childbirth. Traits of neuroticism and extraversion are however predictive of health outcomes in other fields potentially through biological, psychological and social mechanisms. The aim of the current research was thus to examine the relationship between trait personality and childbirth experience.

METHODS

seven hundred and fifty-five mothers with an infant aged 0-6 months completed a self-report questionnaire including the Ten Item Personality Measure and descriptions of birth experience including mode of birth [vaginal vs. caesarean section] and complications [failure to progress, fetal distress, post-partum haemorrhage, assisted birth and severe tear].

FINDINGS

personality traits were significantly associated with birth experience. Specifically mothers scoring low in extraversion and emotional stability were significantly more likely to have a caesarean section and experience a number of complications during labour and birth including an assisted birth, fetal distress, failure to progress and a severe tear. Findings were independent of maternal age, education and parity.

CONCLUSIONS

the personality traits of extraversion and emotional stability appear to facilitate likelihood of normal birth. Potential explanations for this include biological (physiological reactivity, pain thresholds, oxytocin and dopamine release) and psychological (coping mechanisms, social support, self-efficacy) factors. The findings have important implications for antenatal education and support during labour.

Novel diabetes mellitus treatment: mature canine insulin production by canine striated muscle through gene therapy

Muscle-targeted gene therapy using insulin genes has the potential to provide an inexpensive, low maintenance alternative or adjunctive treatment method for canine diabetes mellitus. A canine skeletal muscle cell line was established through primary culture, as well as through transdifferentiation of canine fibroblasts after infection with a myo-differentiation gene containing adenovirus vector. A novel mutant furin-cleavable canine preproinsulin gene insert (cppI4) was designed and created through de novo gene synthesis. Various cell lines, including the generated canine muscle cell line, were transfected with nonviral plasmids containing cppI4. Insulin and desmin immunostaining were used to prove insulin production by muscle cells and specific canine insulin ELISA to prove mature insulin secretion into the medium. The canine myoblast cultures proved positive on desmin immunostaining. All cells tolerated transfection with cppI4-containing plasmid, and double immunostaining for insulin and desmin proved present in the canine cells. Canine insulin ELISA assessment of medium of cppI4-transfected murine myoblasts and canine myoblast and fibroblast mixture proved presence of mature fully processed canine insulin, 24 and 48 h after transfection. The present study provides proof of principle that canine muscle cells can be induced to produce and secrete canine insulin on transfection with nonviral plasmid DNA containing a novel mutant canine preproinsulin gene that produces furin-cleavable canine preproinsulin. This technology could be developed to provide an alternative canine diabetes mellitus treatment option or to provide a constant source for background insulin, as well as C-peptide, alongside current treatment options.

A maize line resistant to herbivory constitutively releases (E) -beta-caryophyllene

Various pests, such as those in the order Lepidoptera, frequently feed on young maize (Zea mays) plants and pose a significant threat to plant development and survival. To manage this problem, maize generates a wide variety of responses to attack by pests, from activation of wound-response pathways to the release of volatile compounds. Mp708, an inbred line resistant to feeding by the larvae of the fall armyworm (Spodoptera frugiperda J.E. Smith Lepidoptera: Noctuidae), has been developed through traditional breeding methods, but its underlying mechanisms of resistance are still not completely understood. Mp708 has been shown to have a moderately high constitutive expression of jasmonic acid (JA) before infestation by fall armyworm. However, Tx601, a genotype susceptible to feeding by fall armyworm, activates JA pathway only in response to feeding, suggesting that Mp708 is "primed" to respond swiftly to an attack. Current research indicates that fall armyworm show a lack of preference to feeding on Mp708, leading to the hypothesis that volatiles constitutively released by the plant may also play an important role in its resistance. Analysis of volatiles released by Mp708 and Tx601 in the presence and absence of fall armyworm larvae identified (E)-beta-caryophyllene, a terpenoid associated with resistance, released constitutively in Mp708. Fall armyworm fed samples of both Mp708 and Tx601 showed high transcript number of tps23, the gene responsible for the synthesis of (E)-beta-caryophyllene. In addition, fall armyworm larvae show a preference for Tx601 whorl tissue over Mp708 tissue, and the dosage of Tx601 whorl with (E)-beta-caryophyllene repels the fall armyworm.

Men who have sex with men: estimating the size of at-risk populations in London primary care trusts

The objective of this study was to estimate local at-risk populations of men who have sex with men (MSM) in London primary care trusts (PCTs) to inform the commissioning of targeted health interventions. Estimated population size and prevalence of diagnosed HIV in MSM in all of London were calculated using data from the British National Survey of Sexual Attitudes and Lifestyles (NATSAL), Greater London Authority population estimates and the annual survey of diagnosed MSM (Survey of Prevalent HIV Infections Diagnosed [SOPHID]). Estimated MSM population sizes at the PCT level were calculated using un-weighted and SOPHID-weighted methods and methods discussed. Four-fifths of MSM with diagnosed HIV infection in Greater London lived in inner London. Estimated population size of MSM 16-44 years in inner London was 66,000; estimated overall prevalence of diagnosed HIV infection among MSM was 9.5%. Our models show substantial variation at the PCT level between the two methods. Using the SOPHID-weighted method MSM account for up to 16% of the male population in some London PCTs, compared with as low as 3% in others. We provide a novel method of estimating at-risk MSM populations living in inner London PCTs indicating that proportions of MSM vary widely between PCTs. Significant proportions of MSM among the resident populations in several PCTs warrant inclusion of MSM health needs in core PCT prevention and service programming. In light of data source limitations further validation studies are needed.

Production and immunological responses associated with controlled-release-capsule vs 5-drench preventive anthelmintic programmes for parasite control in lambs

AIMS

To determine whether: a) using a controlled-release anthelmintic capsule (CRC) instead of a programme of 5 oral drenches administered at 3-4 week intervals, would delay the development of anti-parasite immunity in lambs; b) the use of ivermectin instead of albendazole, administered either as a CRC or as a programme of 5 oral drenches, would delay the development of anti-parasite immunity in lambs; c) lambs treated with CRCs would have higher liveweight gains than lambs drenched orally 5 times at 3-4 week intervals, and; d) delayed onset of anti-parasite immunity is associated with reduced liveweight gains in the period following anthelmintic treatment.

METHODS

Three field trials were conducted, 1 on a research farm and 2 on commercial sheep farms, in which groups of 30 lambs were treated with either a CRC containing albendazole, a CRC containing ivermectin, 5 oral drenches with albendazole, or 5 oral drenches with ivermectin, administered at 3-4 week intervals. Liveweights and faecal nematode egg counts (FECs) were recorded in all trials. Immunoglobulin-G (IgG) antibody levels to Ostertagia circumcincta and Trichostrongylus colubriformis adult and larval antigens were measured in Trials 1 and 3, and fleece weights and resistance of animals to nematode challenge infection were measured in Trial 1.

RESULTS

CRC-treated lambs had higher levels of antibodies to O. circumcincta infective-stage larvae (L3) than orally drenched lambs in Trial 3, but no other immunological differences due to mechanism of delivery were detected. Antibody levels were lower in lambs treated with ivermectin than albendazole, as a CRC or oral drench in Trial 1, but this was not associated with any measurable effects on FEC or productivity. No significant differences (p>0.05) were detected between drench types (albendazole vs ivermectin) or delivery mechanisms (CRC vs oral drenching) in any of the production parameters measured, in any of the trials. Albendazole-CRCs failed to control FECs in all 3 trials.

CONCLUSIONS

Although some differences between treatments in antibody levels were detected these were not associated with measurable differences in level of parasitism or productivity of lambs. CRC use did not appear to offer substantial gains in productivity over a structured programme of 5 oral drenches administered at 3-4 week intervals.

Travel for HIV care in England: a choice or a necessity?

OBJECTIVES

The aims of the study were (1) to measure the distance required to travel, and the distance actually travelled, to HIV services by HIV-infected adults, and (2) to calculate the proportion of patients who travelled beyond local services and identify socio-demographic and clinical predictors of use of non-local services.

METHODS

The straight-line distance between a patient's residence and HIV services was determined for HIV-infected patients in England in 2007. 'Local services' were defined as the closest HIV service to a patient's residence and other services within an additional 5 km radius. Multivariable logistic regression was used to identify socio-demographic and clinical predictors of accessing non-local services.

RESULTS

In 2007, nearly 57 000 adults with diagnosed HIV infection accessed HIV services in England; 42% lived in the most deprived areas. Overall, 81% of patients lived within 5 km of a service, and 8.7% used their closest HIV service. The median distance to the closest HIV service was 2.5 km [interquartile range (IQR) 1.5-4.2 km] and the median actual distance travelled was 4.8 km (IQR 2.5-9.7 km). A quarter of patients used a 'non-local' service. Patients living in the least deprived areas were twice as likely to use non-local services as those living in the most deprived areas [adjusted odds ratio (AOR) 2.16; 95% confidence interval (CI) 1.98-2.37]. Other predictors for accessing non-local services included living in an urban area (AOR 0.77; 95% CI 0.69-0.85) and being diagnosed more than 12 months (AOR 1.48; 95% CI 1.38-1.59).

CONCLUSION

In England, 81% of HIV-infected patients live within 5 km of HIV services and a quarter of HIV-infected adults travel to non-local HIV services. Those living in deprived areas are less likely to travel to non-local services.

Triazine herbicide resistance in the photosynthetic bacterium Rhodopseudomonas sphaeroides

The photoaffinity herbicide azidoatrazine (2-azido-4-ethylamino-6-isopropylamino-s-triazine) selectively labels the L subunit of the reaction center of the photosynthetic bacterium Rhodopseudomonas sphaeroides. Herbicide-resistant mutants retain the L subunit and have altered binding properties for methylthio- and chloro-substituted triazines as well as altered equilibrium constants for electron transfer between primary and secondary electron acceptors. We suggest that a subtle alteration in the L subunit is responsible for herbicide resistance and that the L subunit is the functional analog of the 32-kDa Q(B) protein of chloroplast membranes.

Implications for HIV testing policy derived from combining data on voluntary confidential testing with viral sequences and serological analyses

OBJECTIVES

Laboratory, clinical and sequence-based data were combined to assess the differential uptake of voluntary confidential HIV testing (VCT) according to risk and explore the occurrence of HIV transmission from individuals with recently acquired HIV infection, before the diagnostic opportunity.

METHODS

Between 1999 and 2002, nearly 30,000 anonymous tests for previously undiagnosed HIV infection were conducted among men who have sex with men (MSM) attending 15 sentinel sexually transmitted infection (STI) clinics in England, Wales and Northern Ireland. Using a serological testing algorithm, undiagnosed HIV-infected men were categorised into those with recent and non-recent infection. VCT uptake was compared between HIV-negative, recently HIV-infected and non-recently HIV-infected men. A phylogenetic analysis of HIV pol sequences from 127 recently HIV-infected MSM was conducted to identify instances in which transmission may have occurred before the diagnostic opportunity.

RESULTS

HIV-negative MSM were more likely to receive VCT at clinic visits compared with undiagnosed HIV-infected MSM (56% (14,020/24,938) vs 31% (335/1072); p<0.001). Recently HIV-infected MSM were more likely to receive VCT compared with those with non-recent infections (42% (97/229) vs 28% (238/844); p<0.001). 22% (95/425) of undiagnosed HIV-infected MSM with STI received VCT. Phylogenetic analysis revealed at least seven transmissions may have been generated by recently HIV-infected MSM: a group that attended STI clinics soon after seroconversion.

CONCLUSIONS

The integration of clinical, laboratory and sequence-based data reveals the need for specific targeting of the recently HIV exposed, and those with STI, for VCT. VCT promotion alone may be limited in its ability to prevent HIV transmission.

Routine urine culture at the time of percutaneous urinary drainage: does every patient need one?

PURPOSE

To determine the clinical variables associated with bacteriuria in patients undergoing primary percutaneous antegrade urinary drainage procedures in order to predict the utility of routinely obtaining urine cultures at the time of the procedure.

METHODS

Between October 1995 and March 1998 urine cultures were prospectively obtained in all patients undergoing a primary percutaneous antegrade urinary drainage procedure. One hundred and eighty-seven patients underwent 264 procedures. Results were available in 252 cases. Culture results were correlated with clinical, laboratory, and demographic variables. Anaerobic cultures were not uniformly performed.

RESULTS

Urine cultures were positive in 24 of 252 (9.5%) cases. An indwelling or recently removed ipsilateral device (catheter or stent) and a history of previous cystectomy with urinary diversion were significant predictors of a positive culture. Patients without either of these predictors, and without clinical or laboratory evidence of infection, were rarely found to have positive cultures.

CONCLUSION

The likelihood of a positive urine culture can be predicted on the basis of the aforementioned clinical variables. In the absence of these clinical indicators routine urine cultures are neither useful nor cost-effective.

Monitoring the effectiveness of HIV and STI prevention initiatives in England, Wales, and Northern Ireland: where are we now?

Primary and secondary prevention are essential components of the response to HIV and sexually transmitted infections (STIs). We present findings from nationally implemented HIV/STI prevention interventions. In 2003, of those attending STI clinics at least 64% of men who have sex with men (MSM) and 55% of heterosexuals accepted a confidential HIV test; 88% of all HIV infections in women giving birth in England were diagnosed before delivery; 85% of MSM eligible for hepatitis B vaccination received a first dose of vaccine at their first STI clinic attendance; 74% of STI clinic attendees for emergency appointments, and 20% of those for routine appointments were seen within 48 hours of initiating an appointment; the National Chlamydia Screening Programme in England found a positivity of 10% and 13% among young asymptomatic women and men, respectively. Prevention initiatives have seen recent successes in limiting further HIV/STI transmission. However, more work is required if current levels of transmission are to be reduced.

Epidemiology of HIV among black and minority ethnic men who have sex with men in England and Wales

OBJECTIVES

To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (E&W).

METHODS

Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth.

RESULTS

Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in E&W were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p<0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%.

CONCLUSIONS

Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in E & W; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in E&W was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in E&W.

Calpain inhibition and insulin action in cultured human muscle cells

Variation in the calpain 10 gene has been reported to increase susceptibility to type 2 diabetes. Part of this susceptibility appears to be mediated by a decrease in whole body insulin sensitivity. As skeletal muscle is the primary tissue site of the peripheral insulin resistance in type 2 diabetes, the aim of this study was to use a human skeletal muscle cell culture system to explore the effects of calpain inhibition on insulin action. Calpain 10 mRNA and protein expression was examined in cultured myoblasts, myotubes, and whole skeletal muscle from non-diabetic subjects using RT-PCR and Western blotting. Changes in insulin-stimulated glucose uptake and glycogen synthesis in response to the calpain inhibitors ALLN and ALLM were measured. Calpain 10 expression was confirmed in cultured human myoblasts, myotubes, and native skeletal muscle. Insulin-stimulated glucose uptake was significantly decreased following preincubation with ALLN [404+/-40 vs 505+/-55 (mean+/-SEM)pmol/mg/min; with vs without ALLN: p = 0.04] and ALLM [455+/-38 vs 550+/-50 pmol/mg/min; with vs without ALLM: p = 0.025] in day 7 fused myotubes, but not in myoblasts. Neither ALLN nor ALLM affected insulin-stimulated glycogen synthesis in myoblasts or myotubes. These studies confirm calpain 10 expression in cultured human muscle cells and support a role for calpains in insulin-stimulated glucose uptake in human skeletal muscle cells that may be relevant to the pathogenesis of the peripheral insulin resistance in type 2 diabetes.

Burkitt's lymphoma: an unusual cause of lip numbness

A 38-year-old man was referred by his dental surgeon with a painful swelling in the right mandibular sulcus and an ipsilateral numb lip. Dental infection secondary to caries was initially diagnosed but biopsy revealed this to be a Burkitt's lymphoma. After intense chemotherapy, the patient is still in remission three years later. This case is a reminder that malignancy should always be high on a clinician's list of differential diagnoses of jaw swelling associated with neurological abnormalities and prompt referral is essential.

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.

HLA class I serotypes and cytotoxic T-lymphocyte responses among human immunodeficiency virus-1-uninfected Thai volunteers immunized with ALVAC-HIV in combination with monomeric gp120 or oligomeric gp160 protein boosting

Antigen-induced cellular immunogenicity may vary between populations due to differences in human leukocyte antigen (HLA) diversity and, hence, may play a critical role in the protection afforded by vaccines. In the setting of two, phase I/II human immunodeficiency virus-1 vaccine trials of a recombinant canarypox prime, and boosting with either recombinant monomeric gp120 or oligomeric gp160, we assessed the association between specific human leukocyte antigen (HLA) class I serotypes and the presence of cytotoxic T-lymphocyte response measured by 51Cr-release assay. HLA class I serotypes A11, A24, A33, B46, and B75 were the most common, present in 10% or more of 245 individuals studied. Forty of 187 (21.4%) Thai adults who received either ALVAC-HIV with gp120 or oligomeric gp160 or ALVAC alone had a precursor cytolytic CD8 T-cell response (pCTL). HLA-B44 was positively and significantly associated with a pCTL response (odds ratio 7.6, 95% CI: 2.7-21.2), whereas B46 was negatively associated but not robust when adjusted for multiple comparisons. Responses to Env proteins accounted for the majority (nine of 11) of pCTL activity among those persons with B44. This HLA class I serotype occurred in 9.4% of participants overall (including the placebo group), less commonly than what is reported from populations of European ancestry. These results strengthen the importance of assessing HLA class I distributions in conjunction with studies of vaccines designed to elicit cellular immunity in different populations.

Recent trends in HIV and other STIs in the United Kingdom: data to the end of 2002

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

Black Caribbean adults with HIV in England, Wales, and Northern Ireland: an emerging epidemic?

BACKGROUND

HIV is now well established in the Caribbean, with prevalence in several countries being surpassed only by those of sub-Saharan Africa. Continuing inward migration from the Caribbean and a high incidence of some bacterial STIs among Britain's black Caribbean communities, suggests a considerable potential for HIV spread.

METHODS

Data from three national HIV/AIDS surveillance systems were reviewed, providing information on new HIV diagnoses, numbers accessing treatment and care services, and HIV prevalence.

RESULTS

Between 1997 and 2001, 528 black Caribbean adults were newly diagnosed with HIV; 62 new diagnoses in 1997, rising to 176 in 2001. Probable heterosexual acquisition accounted for 335 (63%) infections (161 (48%) males, 174 females), and sex between men 171 (32%). Infection was acquired both in the Caribbean and in the United Kingdom. Numbers of black Caribbeans accessing treatment and care services more than doubled between 1997 (294) and 2001 (691). In 2001, 528 (76%) black Caribbeans accessing services were London residents. Among the Caribbean born previously undiagnosed heterosexuals, HIV prevalence was 0.7%; among men who have sex with men (MSM) it was 10.4%. Of those born in the Caribbean, 73% of male heterosexuals, 50% of female heterosexuals, and 65% of MSM who were previously undiagnosed left the clinic unaware of their HIV infection.

CONCLUSIONS

Numbers of black Caribbean adults newly diagnosed and accessing treatment and care services in England, Wales, and Northern Ireland increased between 1997 and 2001. Despite a high prevalence of diagnosed bacterial STIs, prevalence among Caribbean born heterosexuals remains low, but it is high among MSM. Surveillance data highlight the need for targeted HIV prevention among black Caribbeans.

Is HIV incidence increasing in homo/bisexual men attending GUM clinics in England, Wales and Northern Ireland?

Laboratory recognition of recent infection allows HIV incidence to be monitored. We have determined HIV incidence in homo/bisexual men attending 15 genitourinary medicine clinics (GUM) across England, Wales and Northern Ireland (EW&NI). The estimated HIV incidence for 2002 was 3.5%, an increase from the 2.5% incidence seen in 2000 and 2001. Incidence was higher in London than outside, though outside London the overall incidence has recently increased over two-fold from 1% in 2001 to 2.5% in 2002. Throughout the UK HIV incidence may have risen in homo/bisexual men attending GUM clinics.

Epidemiology of HIV in young people in England, Wales and Northern Ireland

We describe the epidemiology of HIV among young people (15-24 years) in England, Wales and Northern Ireland (E, W&NI) between 1997 and 2001 inclusive. Rising rates of sexually transmitted infections (STIs) and 'risk' behaviours suggest that they are at increased risk of acquiring HIV. Data from three national surveillance systems are reviewed. Over the period, 1,624 young people were diagnosed with HIV (10% of all new diagnoses). In 1997 there were 254 new diagnoses, rising to 493 in 2001, a 1.9-fold increase. Of the total, 890 (55%) were heterosexually infected (81% female), 631 through sex between men, and the remainder via other routes. Where probable country of infection was reported (1,139), 618 (54%) were infected in Africa and 362 (32%) in the UK. In 1997, 675 young people accessed HIV-related services, rising to 975 in 2001: an increase of 1.4 fold. In 2001, for 34 of those accessing services the likely route of infection was perinatal. Between 1997 and 2001 inclusive, HIV prevalence among young heterosexual genitourinary medicine (GUM) clinic attendees was 0.17% (193/116,443), and for young homo/bisexual males, 3.4% (174/5,086). Sixty-five percent (104/159) of previously undiagnosed HIV-infected heterosexuals and 47% (51/108) of previously undiagnosed HIV-infected homo/bisexual males left the clinic unaware of their infection. In 2000 and 2001, overall prevalence was 0.11% (77/70,455) among young women giving birth. HIV diagnoses in young people have increased in recent years, while HIV prevalence among young people attending GUM clinics and giving birth has remained low. However, with dramatic increases in chlamydia rates among young women over the past decade, and the highest rates of gonorrhoea and concurrent partnerships among young people, concern about the potential for HIV transmission remains.

Resistance to prophylactic treatment with macrocyclic lactone anthelmintics in Teladorsagia circumcincta

Sixty-four Romney ewe lambs were allocated to 12 groups on the basis of liveweight. Four groups (n=5) were administered oral ivermectin (IVM), 4 (n=6) oral moxidectin (MOX) and the remaining 4 (n=5) controlled-release capsules containing IVM (IVM-CRCs). Nine and 10 days later, the groups within each treatment type were challenged with infective-stage larvae (L3) of 1 of 4 different isolates of Teladorsagia circumcincta (two doses each of 5000 L3). The first of these (S) was known to be anthelmintic-susceptible; the second (OR) was a multiple anthelmintic-resistant strain recovered from the field following therapeutic failure of both ivermectin and moxidectin and subsequently maintained in the laboratory without further anthelmintic selection; the third (R) was derived from OR but had been passaged for five generations indoors with each generation being screened with all three broad-spectrum anthelmintic classes; and the fourth (RxS) was an F1 cross between the R and S isolates. As anticipated, because of its limited residual activity, IVM had no significant effect on the establishment, 9 and 10 days post-treatment, of any of the parasite isolates. In contrast MOX, which has greater residual activity, was highly effective at preventing the establishment of the S isolate but showed no significant effect against the OR, R or RxS isolates. The IVM-CRC was also highly effective at preventing the establishment of the S isolate and furthermore it significantly reduced establishment of both the OR and RxS isolates, although it had no significant effect against the R isolate. The results suggest that with respect to the establishment of T. circumcincta L3s following anthelmintic treatment, macrocyclic lactone (ML) resistance is effectively a dominant trait in the presence of MOX, while it behaves as a partially dominant/recessive trait under treatment with IVM-CRCs. The potential implications of this finding in relation to selection for ML resistance in T. circumcincta are discussed.

The effect of anthelmintic capsules on the egg output and larval viability of drug-resistant parasites

Challenge with an equal mix of drug-resistant and drug-susceptible larvae of Teladorsagia circumcincta resulted in infections in groups of lambs (n = 6) either untreated or given controlled-release capsules, containing either albendazole or ivermectin. Lambs treated with albendazole capsules contained similar numbers of adult worms at necropsy to the other groups but had no detectable faecal egg count. Animals treated with ivermectin capsules had similar worm burdens and faecal egg counts to the control group but the worms had significantly higher numbers of eggs in utero. These results provide evidence for suppression of egg production by both anthelmintic treatments. The observation that albendazole caused a significant reduction in the developmental success of parasite eggs also has implications for the use of faecal egg count as an indicator for pasture contamination with resistant parasites. In two further groups of lambs, either untreated or given albendazole capsules, treatment caused a significant reduction in egg count and adult worm burden of Trichostrongylus colubriformis. No significant effects were observed on in utero egg counts or egg viability and the apparent effect on the number of eggs produced in faeces per adult female was not significant (p = 0.077). There was, therefore, no evidence that albendazole controlled-release capsules caused suppression of egg output in this species.

Safe and cost effective use of alteplase for the clearance of occluded central venous access devices

PURPOSE

To determine whether cryopreserved solutions of the thrombolytic agent alteplase could be used as a safe, effective, and economically reasonable alternative to urokinase in patients presenting with occluded central venous access devices (CVADs).

MATERIALS AND METHODS

Alteplase has been reported as an efficacious alternative to urokinase for treatment of occluded CVADs. However, the practicality of using alteplase as the thrombolytic of choice for this indication remained conjectural. To make this approach economically feasible, alteplase was diluted to 1 mg/mL and 2.5-mL aliquots were stored at -20 degrees C until use. A need to confirm that the cryopreserving and thawing of the reconstituted solution did not compromise the safety and efficacy reported from prior trials was recognized. A quality assessment initiative was undertaken to concurrently monitor the safety and efficacy of this approach. Patients presenting with occluded CVADs received a sufficient volume of the thawed alteplase solution to fill the occluded catheter(s). Data, including efficacy, adverse reactions, dwell time, and catheter type, were collected over a 5-month period.

RESULTS

One hundred twenty-one patients accounting for 168 attempted clearances were assessable for safety and efficacy. One hundred thirty-six (81%) of the 168 catheter clearance attempts resulted in successful catheter clearance (95% confidence interval, 74% to 86%). No adverse events were reported.

CONCLUSION

Cryopreserved 1-mg/mL aliquots of alteplase are safe and effective in the clearance of occluded CVADs when stored at -20 degrees C for 30 days. The ability to cryopreserve alteplase aliquots makes it an economically reasonable alternative to urokinase in the setting of CVAD occlusion.

Comparison of VIDAS enzyme-linked fluorescent immunoassay using Moore swab sampling and conventional culture method for Salmonella detection in bulk tank milk and in-line milk filters in California dairies

A comparison of the VIDAS Salmonella (SLM) assay using the manufacturer's recommended sampling method or a Moore swab sampling method demonstrated that the Moore swab method detected a greater number of positive samples (83.0% vs. 67.92%). When results using a conventional culture technique were compared to the VIDAS SLM assay using Moore swab sampling, there was good agreement (97.5%). When the VIDAS SLM assay was used to test in-line milk filters and compared to results from the conventional culture method, there was also good correlation between test results (95.57%). Overall, the VIDAS SLM assay using a modified sampling method compared favorably to the conventional culture method and had the advantages of taking less time to obtain a negative or presumptive positive result, being less technically complicated and requiring less screening of non-lactose fermenting colonies from negative samples.

Clinical prognosis of patients with early-stage human immunodeficiency virus (HIV) disease: contribution of HIV-1 RNA and T lymphocyte subset quantitation

Systems for the staging of individuals with human immunodeficiency virus type 1 (HIV-1) infection were developed 15 years ago. Subsequently, assays for quantitating HIV-1 RNA and immunophenotyping of lymphocyte subsets have been developed and validated. The utility of these assays for improved staging in early disease was evaluated in 256 HIV-infected adults (52% minority) with CD4 counts > or = 400 cells/microL followed in U.S. military medical centers before the highly active anti-retroviral therapy era. HIV viral load (RNA) was quantitated; the frequencies of select CD4+ immunophenotypes were determined in 112 subjects. The results were analyzed in relation to three outcome measures: death, first acquired immunodeficiency syndrome-defining opportunistic infection, and CD4 count < or = 200 cells/microL. Serum RNA level and CD4 count were each found to be predictive of all three outcomes. In addition, increases in the T-cell subsets CD28-CD4+ and CD29+CD26-CD4+ were found to be independently predictive of more rapid progression. The classification of early-stage HIV patients is improved by the quantitation of both viral RNA and T-lymphocyte subsets.

HIV viral load in Thai men and women with subtype E infections

The assessment of potential "breakthrough infections" in HIV vaccine trials requires knowledge of viral load in unvaccinated persons. Therefore, HIV-1 RNA was quantitated in plasma from Thai adults with subtype E infections. RNA was detectable (> or =500 copies/ml) in 93% of 255 specimens, with a mean (standard deviation) value of 4.09 (0.88) log copies/ml. The concentration of RNA was directly related to the presence of AIDS-defining illnesses, inversely related to CD4 count, and independent of gender after adjustment for CD4 count.

Evaluation of a new fourth-generation microwell enzyme-linked immunosorbent assay for detection of HIV-1 subtype B and E antibodies

The recent fourth-generation enzyme-immunoassays have been used to increase the sensitivity for detecting HIV-1 antibodies and reduce the window period of HIV infection. The HIV antigens utilized in those assays were prepared from HIV-1 clade B which is different from HIV-1 subtypes circulating in Thailand. We evaluated 323 HIV-1 seropositives either B or E subtype to determine whether they were detected with the new combined anti-HIV and the p24 Ag assay. Under evaluation we found that this enzyme immunoassay manufactured by Organon Teknika showed the high sensitivity and specificity with a greater delta (delta) value with B than E subtypes samples (+15.29 vs +5.73).

Detection and quantification of HIV type 1 RNA in nasopharyngeal washes from HIV-infected subjects

Human immunodeficiency virus type 1 (HIV) RNA load was measured in paired samples of peripheral blood plasma and nasopharyngeal (NP) washes from 97 Thai subjects infected with subtype E or B. HIV RNA was quantifiable in 93% of peripheral blood plasma samples tested and was inversely correlated (rho =-0.524; p < 0.001) with CD4 absolute count. HIV RNA was quantifiable in 29% of NP samples tested, and the median value was less than that of plasma viral load. HIV RNA load in NP samples was correlated (rho = 0.388; p < 0.001) with viral load in peripheral blood. HIV RNA was not detected in NP washes from subjects with undetectable plasma viral load. Virus isolation attempts on two NP samples were negative. The results do not support local HIV production in the nasopharynx, but extend current knowledge of HIV shedding to include the NP compartment.

Suprafascial dissection of the radial forearm flap and donor site morbidity

A cutaneous free radial forearm flap was harvested from 25 patients using a suprafascial dissection technique. The donor site was managed with either a full or split thickness skin graft and a negative pressure wound dressing. The incidence of initial complete graft take was 96% at day 5 and 100% by 1 month. There was 100% early and complete graft take in the full thickness group but one area of partial loss in the split thickness group. This area of graft loss represented less than 0.5% of the total grafted area in this series. The mean time to wound healing was 14 days. There were no cases of tendon exposure or delayed healing. The suprafascial dissection creates a superior graft recipient bed. When combined with the negative pressure wound dressing technique it ensured early and complete graft take.