The hepatitis B virus-encoded transcriptional trans-activator hbx appears to be a novel protein serine/threonine kinase

To study the functional mechanism of the hepatitis B virus (HBV) X (hbx) gene product, we have expressed the hbx protein in E. coli and purified it by HPLC. The purified hbx protein was shown to be active in transactivating transcription directed by the LTR sequence of HIV-1. The hbx protein was found to have an intrinsic serine/threonine protein kinase activity. The hbx protein was detected in hepatitis B virions, and tryptic phosphopeptide maps of the hbx protein phosphorylated in the virion and of the in vitro phosphorylated bacterially expressed hbx protein were similar. Inactivation of the hbx protein by heat, protein-denaturing agents, or an ATP affinity analog, p-fluorosulfonylbenzoyl 5'-adenosine, resulted in loss of both protein kinase activity and trans-activation activity. These results suggest that the HBV-encoded trans-activator hbx is a novel protein kinase.

Mortality in perinatally HIV-infected young people in England following transition to adult care: an HIV Young Persons Network (HYPNet) audit

OBJECTIVES

Mortality in young people with perinatally acquired HIV infection (PHIV) following transfer to adult care has not been characterized in the UK. We conducted a multicentre audit to establish the number of deaths and associated factors.

METHODS

Fourteen adult clinics caring for infected young people reported deaths to 30 September 2011 on a proforma. Deaths were matched to the Collaborative HIV Paediatric Study, a clinical database of HIV-infected children in the UK/Ireland, to describe clinical characteristics in paediatric care of those who died post-transition.

RESULTS

Eleven deaths were reported from 14 clinics which cared for 248 adults with PHIV. For the 11 deaths, the median age at transfer to adult care was 17 years (range 15-21 years), and at death was 21 years (range 17-24 years). Causes of death were suicide (two patients), advanced HIV disease (seven patients) and bronchiectasis (one patient), with one cause missing. At death, the median CD4 count was 27 cells/μL (range 0-630 cells/μL); five patients were on antiretroviral therapy (ART) but only two had a viral load < 50 HIV-1 RNA copies/mL. Nine had poor adherence when in paediatric care, continuing into adult care despite multidisciplinary support. Eight had ART resistance, although all had potentially suppressive regimens available. Nine had mental health diagnoses.

CONCLUSIONS

Our findings highlight the complex medical and psychosocial issues faced by some adults with PHIV, with nine of the 11 deaths in our study being associated with poor adherence and advanced HIV disease. Novel adherence interventions and mental health support are required for this vulnerable cohort.

Modelling the impact on Hepatitis C transmission of reducing syringe sharing: London case study

BACKGROUND

Hepatitis C virus (HCV) prevalence and incidence among injecting drug users (IDUs) has increased in London and rest of UK. To inform public health action, mathematical modelling is used to explore the possible impact of strategies to decrease syringe sharing.

METHODS

A mathematical model was developed to simulate HCV transmission amongst IDUs in London. Because of parameter uncertainty, numerical search algorithms were used to obtain different model fits to HCV seroprevalence data from London for 2002-03. These simulations were used to explore the likely impact of HCV prevention activities that reduce syringe sharing amongst all IDUs, IDUs that have injected for greater than one year, or IDUs with lower or higher frequencies of syringe sharing.

RESULTS

Key differences between model fits centred on how they simulated the high HCV incidence amongst new injectors, either through assuming increased HCV infectivity during acute infection, a large sub-group of high frequency syringe sharers, or increased sharing among new IDUs. Despite parameter uncertainty, the model projections suggest that modest reductions in syringe sharing frequency (<25%) will reduce the HCV seroprevalence in newly initiated IDUs (injecting less than four years) but much larger and sustained reductions (>50%) are required to reduce the HCV seroprevalence in long-term IDUs (injecting more than 8 years). Critically the model also suggested that large reductions in HCV seroprevalence will be achieved only if interventions target all IDUs and reach IDUs within 12 months of injecting.

DISCUSSION

Public health interventions must reduce syringe sharing amongst all IDUs, including newly initiated IDUs, and be sustained for many years to reduce HCV infection. More accurate data on key behavioural (sharing frequency) and biological (percentage of infected IDUs that clear infection) parameters is required to improve model projections.

Prevalence of hepatitis C among injection drug users in England and Wales: is harm reduction working?

OBJECTIVES

This study sought to establish the prevalence of hepatitis C antibodies (anti-HCV) and hepatitis B antibodies (anti-HBc) among injection drug users in England and Wales.

METHODS

A voluntary cross-sectional survey collected oral fluid samples and behavioral information; 2203 injectors were recruited through drug agencies, and 758 were recruited in the community.

RESULTS

Prevalence was 30% for anti-HCV, 21% for anti-HBc, and 0.9% for HIV antibodies. Anti-HCV prevalence rates were significantly greater among those with longer injecting careers, those in older age groups, those residing in London, those recruited in drug agencies, those positive for anti-HBc, and those with a previous voluntary HIV test.

CONCLUSIONS

Anti-HCV prevalence rates among injectors in England and Wales, where comprehensive harm reduction programs exist, are lower than rates in other industrialized countries.

Expression of immunogenic epitopes of hepatitis B surface antigen with hybrid flagellin proteins by a vaccine strain of Salmonella

A nonvirulent Salmonella dublin flagellin-negative, aromatic-dependent live vaccine strain has been used to express hepatitis B virus surface antigen epitopes in an immunogenic form. The envelope proteins of the virion are encoded by the S gene, which contains the pre-S1, pre-S2, and S coding regions. Synthetic oligonucleotides corresponding to amino acid residues S-(122-137) and pre-S2-(120-145) were inserted in-frame into the hypervariable region of a cloned Salmonella flagellin gene, and the recombinant plasmids were introduced into a flagellin-negative aroA mutant live vaccine strain of S. dublin, SL5928. The flagellin gene was expressed in bacteria carrying the plasmids as detected by immunoblotting with anti-flagellin (H1-d) serum. Both the S and pre-S2 epitopes were detected in bacteria carrying the relevant plasmid by immunoblotting with anti-HBs (antibody to hepatitis B virus surface antigen) and anti-peptide antisera. Animals immunized intramuscularly or orally with the live recombinant bacteria developed antibodies specific to these hepatitis B virus epitopes as detected by ELISA.

Prevalence of, and risk factors for, hepatitis C virus infection among recent initiates to injecting in London and Glasgow: cross sectional analysis

Our aim was to compare the prevalence of antibody to hepatitis C virus (anti-HCV) among recently initiated injecting drug users (IDUs) in London and Glasgow, and to identify risk factors which could explain differences in prevalence between the cities. Complementary studies of community recruited IDUs who had initiated injection drug use since 1996 were conducted during 2001-2002. Data on HCV risk behaviours were gathered using structured questionnaires with identical core questions and respondents were asked to provide an oral fluid specimen which was tested anonymously for anti-HCV but was linked to the questionnaire. Sensitivities of the anti-HCV assays for oral fluid were 92-96%. Prevalence of anti-HCV was 35% (122/354) in London and 57% (207/366) in Glasgow (P < 0.001). Multifactorially, factors significantly associated with raised odds of anti-HCV positivity were increasing length of injecting career, daily injection, polydrug use, having had a needlestick injury, and having served a prison sentence. In addition lower odds of anti-HCV positivity were associated with non-injection use of crack cocaine and recruitment from drug agencies. After adjustment for these factors, the increased odds of anti-HCV associated with being a Glasgow IDU were diminished but remained significant. HCV continues to be transmitted among the IDU population of both cities at high rates despite the availability of syringe exchange and methadone maintenance. Effectiveness of harm reduction interventions may be compromised by inadequate coverage and failure to reduce sufficiently the frequency of sharing different types of injecting equipment, as well as the high background prevalence of HCV, and its high infectivity. Comprehensive action is urgently required to reduce the incidence of HCV among injectors.

Higher rates of triple-class virological failure in perinatally HIV-infected teenagers compared with heterosexually infected young adults in Europe

OBJECTIVES

The aim of the study was to determine the time to, and risk factors for, triple-class virological failure (TCVF) across age groups for children and adolescents with perinatally acquired HIV infection and older adolescents and adults with heterosexually acquired HIV infection.

METHODS

We analysed individual patient data from cohorts in the Collaboration of Observational HIV Epidemiological Research Europe (COHERE). A total of 5972 participants starting antiretroviral therapy (ART) from 1998, aged < 20 years at the start of ART for those with perinatal infection and 15-29 years for those with heterosexual infection, with ART containing at least two nucleoside reverse transcriptase inhibitors (NRTIs) and a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (bPI), were followed from ART initiation until the most recent viral load (VL) measurement. Virological failure of a drug was defined as VL > 500 HIV-1 RNA copies/mL despite ≥ 4 months of use. TCVF was defined as cumulative failure of two NRTIs, an NNRTI and a bPI.

RESULTS

The median number of weeks between diagnosis and the start of ART was higher in participants with perinatal HIV infection compared with participants with heterosexually acquired HIV infection overall [17 (interquartile range (IQR) 4-111) vs. 8 (IQR 2-38) weeks, respectively], and highest in perinatally infected participants aged 10-14 years [49 (IQR 9-267) weeks]. The cumulative proportion with TCVF 5 years after starting ART was 9.6% [95% confidence interval (CI) 7.0-12.3%] in participants with perinatally acquired infection and 4.7% (95% CI 3.9-5.5%) in participants with heterosexually acquired infection, and highest in perinatally infected participants aged 10-14 years when starting ART (27.7%; 95% CI 13.2-42.1%). Across all participants, significant predictors of TCVF were those with perinatal HIV aged 10-14 years, African origin, pre-ART AIDS, NNRTI-based initial regimens, higher pre-ART viral load and lower pre-ART CD4.

CONCLUSIONS

The results suggest a beneficial effect of starting ART before adolescence, and starting young people on boosted PIs, to maximize treatment response during this transitional stage of development.

M protein (M1) of influenza virus: antigenic analysis and intracellular localization with monoclonal antibodies

A panel of 16 monoclonal antibodies recognizing M protein (M1) of influenza virus was generated. Competition analyses resulted in localization of 14 monoclonal antibodies to three antigenic sites. Three monoclonal antibodies localized to site 1B recognized a peptide synthesized to M1 (residues 220 to 236) with enzyme-linked immunosorbent assay titers equivalent to or greater than that seen with purified M1; therefore, site 1B is located near the C terminus of M1. Sites 2 and 3 localize to the N-terminal half of M1. Antigenic variation of M proteins was seen when the monoclonal antibodies were tested against 14 strains of type A influenza viruses. Several monoclonal antibodies showed specific recognition of A/PR/8/34 and A/USSR/90/77 M proteins and little or no reactivity for all other strains tested. Immunofluorescence analysis with the monoclonal antibodies showed migration of M protein to the nucleus during the replicative cycle and demonstrated association of M protein with actin filaments in the cytoplasm. Use of a vaccinia virus recombinant containing the M-protein gene demonstrated migration of M protein to the nucleus in the absence of synthesis of gene products from other influenza virus RNA segments.

Measuring injecting risk behaviour in the second decade of harm reduction: a survey of injecting drug users in England

AIMS

To measure risk behaviour among injecting drug users (IDUs) using the Injecting Risk Questionnaire (IRQ).

METHODS

Data were analysed from the first multi-site survey of injecting risk behaviour among IDUs not in contact with drug services in England. A total of 1214 IDUs were recruited from community settings in seven sites.

FINDINGS

Fifty-two per cent reported sharing injecting equipment in the previous 4 weeks in response to a single question on sharing. This rose to 78% when asked more detailed and multiple questions on injecting risk practices. Levels of injecting risk behaviour did not differ substantially by gender, age, length of injecting career, main drug of injection, previous treatment contact or geographical location. However, sharing partners were restricted to a median of two others.

CONCLUSION

These data raise questions concerning the extent to which levels of injecting risk behaviour have increased over recent years, or the extent to which previous monitoring systems underestimated levels of risk. None the less, the data confirm that the promotion of safer injecting continues to be an important public health issue with regard to reducing blood-borne infections.

The distribution of lithium, sodium and magnesium in rat brain and plasma after various periods of administration of lithium in the diet

1 The tissue solubilizer Soluene-100 provides an efficient and easy means of preparing small amounts of rat tissue for cation analysis. 2 Administration of lithium ions to rats for two days to 42 days by the addition of lithium chloride to the diet at a concentration of 30 mmol/kg dry weight results in (a) the uniform distribution of lithium throughout the brain at a concentration comparable to that found in plasma; (b) decrease in the brain sodium concentration: (c) a decrease in brain magnesium concentration and an increase in plasma magnesium concentration; (d)no change in brain water content. 3 The inclusion of LiCl in the diet at a concentration of 30 mmol/kg dry food gives consistent and predictable plasma and brain levels of lithium in the rat without the occurrence of serious side effects over periods of up to 42 days.

Premedication with lorazepam before bone marrow biopsy

Fifty patients were randomised in a double blind placebo controlled study to examine the influence of lorazepam (4 mg orally) before bone marrow aspiration and trephine biopsy. Assessment was made by a visual analogue linear pain scale compiled after the procedure and again 24 hours later. There was no difference in the pain recalled immediately after the procedure between the two groups, but the next day the patients who had received lorazepam showed amnesia with a 60% (p less than 0.01) reduction in the pain scale; 36% of the patients in this group had no recall of the procedure at all. There was no amnesic effect in the group taking placebo. Side effects were few, and it is concluded that lorazepam is a useful premedication agent before bone marrow biopsy.

T-cell proliferative response to human papillomavirus type 16 peptides: relationship to cervical intraepithelial neoplasia

The incidence of human papillomavirus (HPV)-related cervical intraepithelial neoplasia (CIN) and cervical cancer is increased with immunodeficiency, but the role of immune response, including cell-mediated immunity, in disease prevention is not well understood. In this study, T-cell proliferative responses to six synthetic peptides with predicted immunogenic determinants from the HPV-16 E4, E6, E7, and L1 open reading frames were analyzed in 22 sexually active women with new-onset CIN and 65 sexually active women without cervical disease, characterized by cytology, colposcopy, and HPV testing. T-cell proliferative responses were demonstrated to all six HPV-16 peptides. Although not statistically significant, rates of reactivity to E6 (24-45) were higher among sexually active women without disease (26%) than among women with current CIN (7%), as was the overall number of peptides stimulating a response. Women with CIN may not respond to selected HPV antigens as well as women without disease do.

Identifying alcohol-related harm in young drinkers: the role of accident and emergency departments

Data are presented from a screening study of ambulant attendees at two London Accident and Emergency (A&E) departments. Among young people (aged 16-24 years), 37.2% were drinking harmfully [an Alcohol-Use Disorders Identification Test (AUDIT) score of 8 or more]; 17.3% admitted to drinking alcohol in the 6 h prior to attendance; and 14.6% considered that their attendance was alcohol related. Young women were as likely as men to score 8 or over. This age group had nearly twice the odds of scoring highly on the AUDIT, compared to those over 25 years old, and were more likely to report that their attendance was alcohol related. Screening in A&E departments would identify considerable numbers of young people who might benefit from brief intervention, but the problems of doing so are acknowledged.

Prevalence of sexual dysfunction in new heterosexual attenders at a central London genitourinary medicine clinic in 1998

OBJECTIVE

To determine the prevalence of sexual dysfunction and dissatisfaction (SD) among new heterosexual attendees at a central London genitourinary medicine (GUM) clinic.

METHODS

Consecutive new attendees seen by a single clinician were asked a probe question about SD in the previous year. A clinical interview followed a positive response to the probe question. Demographic information was obtained using standard clinic forms.

RESULTS

37% of 103 men and 20% of 100 women participants gave positive responses, and 24% of the men and 12% of the women wanted treatment for their problems.

CONCLUSIONS

Our results indicate a relatively high rate of SD in new GUM clinic attendees that is not currently being detected or managed. SD may lead to psychological problems, which can be reversed with appropriate treatment. The financial implications of such treatment are discussed.

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance

OBJECTIVE

The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged > or =13 years.

METHODS

A retrospective review of HIV diagnoses reported to well-established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted.

RESULTS

Forty-two young people with vertically acquired HIV diagnosed aged > or =13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub-Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13-20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/microL (range, 0-689 cells/microL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis.

CONCLUSION

A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age > or =13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV-infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.

Twenty years of selective hepatitis B vaccination: is hepatitis B declining among injecting drug users in England and Wales?

Injection drug use is a common route of infection for the hepatitis B virus (HBV) in the UK. The aim of this study was to establish the prevalence and force of infection for HBV among injecting drug users (IDUs) recruited from multiple community and drug agency settings in England and Wales between 1990 and 2004. Cross-sectional studies of IDUs in and out of contact with drug agencies were conducted throughout the 15-year period. Oral fluid samples were tested for antibodies to the hepatitis B core antigen (anti-HBc). Logistic regression was used to investigate associations between risk factors and anti-HBc positivity and force of infection models were explored. In total, 2527 injectors were recruited from community settings, and 29 386 from drug agencies. Anti-HBc prevalence was 31% (95% CI 30.7-31.8%). It declined in the early 1990s from around 50% in 1992 to 25% in 1999, after which it increased slightly. It was also higher in those who had injected for longer, older IDUs, those recruited in London and North West England, and those reporting having a previous voluntary confidential HIV test. The force of infection models suggested that the incidence of infection increased in 1999-2004 compared with 1993-1998, and was higher in new injectors compared with those injecting for > or =1 year. In conclusion, findings suggest ongoing HBV transmission in recent years despite an overall decline in prevalence in the early and mid-1990s, and highlight the importance of targeting vaccination programmes at new IDUs who have high incidence rates of infection.

Prevalence of Chlamydia trachomatis in young men in north west London

BACKGROUND

Chlamydia trachomatis is the most common, treatable, bacterial sexually transmitted infection in England and Wales. Among men, chlamydial infection is an important cause of non-gonococcal urethritis, epididymitis, and proctitis. The case for wider screening among women has been accepted by an expert advisory group. In the absence of estimates of the prevalence of infection in men, its potential impact at the population level is difficult to assess.

OBJECTIVE

To estimate the prevalence of Chlamydia trachomatis in young men in clinic and community based samples in north west London.

METHOD

Cross sectional survey in healthcare centres and general practices in north west London. 1002 males aged 18-35 years, living in north west London, were recruited by staff in occupational health departments, general practices, student health services, and a "well man" clinic and by postal recruitment in four GP practices. The men were tested for C trachomatis using the ligase chain reaction assay on urine samples. The main outcome measure was prevalence of C trachomatis infection in men aged 18-35 years.

RESULTS

The overall response rate was 51%. Prevalence of confirmed infection was 1.9% (95% CI: 1.14% to 2.96%) in all men. Best estimated minimum prevalence of infection was 1% (95% CI: 0.58% to 1.50%). Estimated prevalence was highest among men aged over 30 years.

CONCLUSIONS

The estimated prevalence among men is commensurate with that described for female populations in London. The results suggest that recruitment of men to screening programmes would be difficult. However, a higher proportion of chlamydial infection may be detected in men than in women by existing approaches to control through genitourinary medicine clinic based case finding and contact tracing. Screening of young women and the contact tracing of the male partners of positive females may be an efficient approach to improving chlamydia control.

Hepatitis B vaccine uptake among injecting drug users in England 1998 to 2004: is the prison vaccination programme driving recent improvements?

In 1999, the Department of Health allocated additional funding to Health Authorities in England to expand hepatitis B immunization among injecting drug users (IDUs), with the aim of increasing coverage by 20%. In 2001, a vaccination programme for prison inmates in England was also instigated. Between 1998 and 2004 current IDUs participated in a series of annual unlinked anonymous surveys that recorded vaccine uptake (n = 11 383). The proportion self-reporting vaccine uptake rose significantly from 27% in 1998 to 59% in 2004 [adjusted odds ratio: 3.7 (95% CI 3.2-4.3); increase in uptake of 25% per annum (95% CI 22-27%)]. A second survey, which recruited 852 current IDUs from community settings in 2003/04, found that prisons were the most common source (38%) of vaccine doses, followed by drug services (28%) and general practitioners (17%), with only 14% receiving doses through needle exchanges. These data suggest that the 20% target of improving vaccination coverage has been met, with the prison vaccination programme likely to have made a substantive contribution in recent years. However, prevalence of antibodies to the hepatitis B core antigen was stable (21%) and is currently similar among the vaccinated and unvaccinated. Consideration needs to be given to improving community vaccination provision for IDUs, targeting recent initiates, and determining when surveillance data should indicate reductions in infection so that the effectiveness of the targeted strategy can be assessed.

The role of noradrenaline, dopamine and 5-hydroxytryptamine in the hyperactivity response resulting from the administration of tranylcypramine to rats pretreated with lithium or rubidium

1. The administration of 15 mg/kg tranylcypromine sulphate (Tc) to rats which have been given lithium chloride (LiCl) in the diet (30 mmol/kg dry food) for 14 days produces hyperactivity within 4 hrs, and this lasts for at least 4 further hours. 2. If LiCl is replaced by rubidium chloride (RbCl) at the same dose, the hyperactivity following Tc is increased and it appears within 2 hrs. 3. 5-Hydroxytryptamine (5HT) accumulation after a monoamine oxidase inhibitor (Tc) is increased 46% and 85% respectively above control values by LiCl and RbCl administration. 4. The hyperactivity produced by the above combinations is inhibited by alpha-methyl-p-tyrosine (alphampt). The inhibition is more effective following LiCl than RbCl treatment. 5. After sodium chloride (NaCl) and LiCl treatment, but not after RbCl treatment, the combination of alphampt and Tc produced rat brain concentrations of dopamine (DA) significantly below control values. 6. The smaller increase of brain noradrenaline (NA) after Tc and RbCl suggests that a lower percentage of NA is being metabolised by MAO. The greater decrease of NA after giving alphampt to RbCl and LiCl treated rats suggests an increased "turnover" rate of Na. 7. The hyperactivity syndrome seen in rats after the administration of LiCl or RbCl and Tc is dependent upon both 5HT and dopamine mechanisms.

Patients' knowledge concerning their medications on discharge from hospital

Fifty patients were interviewed, on discharge from hospital, about their medications. Nine (18%) patients did not know, and a further four (8%) had inappropriate beliefs about why they were taking at least one of their discharge medications. Very few patients knew of significant side-effects which they might expect, or precautions which they should take, and over half did not know how long they were to continue taking their medicines. A small proportion was unable to read the bottle or open the container. Thus, even patients who, by virtue of an in-patient stay, have had a prolonged opportunity for education regarding their medicines have very little knowledge of their medicines upon discharge from hospital.

Women injecting drug users in London: the extent and nature of their contact with drug and health services

Improved access to drug treatment and other health services remains central to HIV prevention and other harm reduction strategies among injecting drug users (IDUs) in the UK. Efforts have therefore been focused upon making such services more accessible and 'user friendly'. Women who use drugs are considered a 'hard to reach' population. This is largely based on data from a variety of official sources which have suggested that women are under-represented as clients of drug services. While current literature provides numerous explanations for this, there have been few empirical studies exploring the nature and extent of women's contact with such services. This paper presents findings from an European Community funded survey of women IDUs in London. Data from this survey suggest that women IDUs have surprisingly high levels of contact with a range of specialist and generic health services in relation to their drug use.