The effects of policy changes and human mobility on the COVID-19 epidemic in the Dominican Republic, 2020-2021

Recent advances in technology can be leveraged to enhance public health research and practice. This study aimed to assess the effects of mobility and policy changes on COVID-19 case growth and the effects of policy changes on mobility using data from Google Mobility Reports, information on public health policy, and COVID-19 testing results. Multiple bivariate regression analyses were conducted to address the study objectives. Policies designed to limit mobility led to decreases in mobility in public areas. These policies also decreased COVID-19 case growth. Conversely, policies that did not restrict mobility led to increases in mobility in public areas and led to increases in COVID-19 case growth. Mobility increases in public areas corresponded to increases in COVID-19 case growth, while concentration of mobility in residential areas corresponded to decreases in COVID-19 case growth. Overall, restrictive policies were effective in decreasing COVID-19 incidence in the Dominican Republic, while permissive policies led to increases in COVID-19 incidence.

Experience in colorectal surgery at a quaternary care hospital in Bogotá, Colombia

INTRODUCTION AND AIMS

Colorectal cancer is among the three most common cancers worldwide. Knowledge and identification of suboptimal outcome-associated factors enable comprehensive patient management. The aim of the present study was to present the results of the surgical management of colorectal cancer at a quaternary care university hospital.

MATERIALS AND METHODS

An observational, analytic, cross-sectional study was conducted. Information was collected on a retrospective cohort of patients diagnosed with colorectal cancer from 2013 to 2017 at the Hospital Universitario Mayor Méderi, Bogotá, Colombia.

RESULTS

Data on 452 patients, within the study period, were collected. A total of 48.5% of the patients were men, the overall complication rate was 24%, the surgical site infection (SSI) rate was 15.38%, anastomotic dehiscence occurred in 4.18% of the patients, bleeding required reoperation in 1.32%, and the intrahospital mortality rate was 7.47%.

CONCLUSION

Colorectal cancer management at a university hospital was as beneficial as that provided by other types of hospitals, showing a direct association with complete R0 dissections; low complication rates, according to international reports; and reduced overall morbidity.

The role of defects in the persistent photoconductivity of BaSnO3thin films

Time-dependent photoconductivity (PC) and PC spectra have been studied in oxygen deficient BaSnO₃thin films grown on different substrates. X-ray spectroscopy measurements show that the films have epitaxially grown on MgO and SrTiO₃substrates. While on MgO the films are nearly unstrained, on SrTiO₃the resulting film is compressive strained in the plane. Electrical conductivity in dark is increased in one order of magnitude for the films on SrTiO₃in comparison to the one on MgO. This leads to an increase of PC in the latter film in at least one order of magnitude. PC spectra show a direct gap with a value ofEG=3.9eV for the film grown on MgO while on SrTiO₃EG=3.36eV. For both type of films, time-dependent PC curves show a persistent behavior after illumination is removed. These curves have been fitted employing an analytical procedure based on the frame of PC as a transmission phenomenon showing the relevant role of donor and acceptor defects as carrier traps and as a source of carriers. This model also suggests that in the BaSnO₃film on SrTiO₃more defects are created probably due to strain. This latter effect can also explain the different transition values obtained for both type of films.

O-077 The chromosomal constitution of embryos developing from 0PN zygotes

Study question

To compare the ploidy status of embryos originated from zygotes with absence of pronuclei (0PN) with those developing from normal two pronuclei (2PN) fertilization.

Summary answer

We did not find significant differences in euploidy rates between blastocysts from 0PN and 2PN zygotes.

What is known already

Information regarding the ploidy number of 0PN zygotes, even when the pronuclei number is assessed by time-lapse microscope coupled incubators, is still insufficient. Because of this, embryos originating from 0PN zygotes are usually discarded or individualized in order not to include them in first transfers. Even more, abnormal fertilization is considered as a proxy of poor embryo quality.

Study design, size, duration

A retrospective observational study from March 2016 and December 2021 including 80 PGT-A cycles in which at least one of the blastocysts studied developed from oocytes in which pronuclei were not seen at the time of fertilization check.

Participants/materials, setting, methods

307 blastocysts were studied, of which 115 originated from 0PN and 192 from 2PN zygotes. Pronuclear number was assessed 16-20 h after insemination. Zygotes with 0PN were cultured separately from 2PN ones of the same cohort. After extended culture, a biopsy was performed and the material obtained was genetically studied using Next Generation Sequencing. Statistical comparisons were made with Fisher's exact and Chi-square tests. Significance level was set at P<0.05.

Main results and the role of chance

No differences were observed in euploidy rates between the 2PN and 0PN groups [55.2% (106/193) VS 43.5% (50/115)]. In aneuploid embryos originating from 2PN zygotes, a similar amount of trisomies and monosomies was observed (56 and 56 respectively). In contrast, aneuploid embryos from 0PN oocytes showed a greater number of trisomies than monosomies (55 and 35 respectively, P < 0.05). None of the blastocysts resulting from 0PN was haploid, that is, we did not find parthenogenic embryos. Blastocysts derived from 0PN zygotes showed similar quality scoring than those from 2PN ones. To date, 20 euploid blastocysts from the 0PN group have been transferred, producing 12 pregnancies: 6 still ongoing and 4 healthy live births.

Limitations, reasons for caution

Non-visualization of pronuclei in oocytes that later generate normal diploid blastocysts may be due to a faster or slower cell cycle progression. Modifications in the daily fertilization check schedules of busy laboratories should also be considered.

Wider implications of the findings

Contrary to expectations, aneuploid embryos from 0PN oocytes showed a greater number of trisomies than monosomies. A significant fraction of the embryos generated from 0PN zygotes were actually diploid, with similar quality and outcome results than 2PN ones. This makes them perfectly usable in IVF routines.

Trial registration number

Not applicable

P-223 Women aged 40 or older and non-male factor have the same reproductive outcome using intracytoplasmic sperm injection (ICSI) or conventional in vitro fertilization (cIVF)

Study question

Do women aged 40 or older have the same reproductive outcome using ICSI or cIVF when male factor infertility is not present?

Summary answer

Women aged 40 or older with non-male factor partners achieved similar reproductive outcomes either with ICSI or cIVF.

What is known already

Although initially proposed to treat couples with severe male factor infertility, ICSI has become the preferred tool to treat patient populations others than initially intended. Many studies and international forums, however, have alerted that its overuse is not free due to its safety, cost and time-consuming concerns. Moreover, it was noted that it does not increase clinical outcomes even in cases of compromised oocyte factor such as poor responder patients or few oocytes retrieved. However, there is still no information regarding its use in the group of patients of advanced reproductive age.

Study design, size, duration

Retrospective cohort study including 412 women aged 40 or older with non-male factor infertility performing ICSI or cIVF between May 2015 and October 2017.

Participants/materials, setting, methods

Patients underwent ICSI (n = 109) or cIVF (n = 303) according to medical indication. The decision to use ICSI in non-male factor patients was merely operational, with the objective of evaluating oocyte maturity.Those cycles with own oocytes, non-male factor and fresh embryo transfers were included. Semen samples were considered normal following the World Health Organization fifth edition sperm parameters values, and prepared by density gradient selection.

Main results and the role of chance

The primary outcome was clinical pregnancy rate. Secondary outcomes included ongoing pregnancy, miscarriage and implantation rates. Statistical significance was denoted by P < 0.05. The mean age of the women were 41.4 in the ICSI group and 41.6 years in the cIVF group, while the mean age for male couple was 43.6 and 41.6 respectively.

No differences between ICSI and cIVF groups were observed regarding clinical pregnancy [16.5% (18/109) vs. 20.8% (63/303)], ongoing pregnancy [9.2% (10/109) vs. 7.9% (24/303)], miscarriage [41.2% (7/17) vs. 46,5% (20/43)], and implantation rates [11.3% (17/151) vs. 9.9% (50/506)].

Limitations, reasons for caution

These results need confirmation with a bigger population size. As with any retrospective study, the potential for residual confounding exists.

Wider implications of the findings

These data suggest that ICSI offers no clinical benefit for women aged 40 and older with non-male factor infertility, beyond oocyte maturation classification.

Trial registration number

not applicable

Morphine exposure alters Fos expression in a sex-, age-, and brain region-specific manner during adolescence

Data in both humans and preclinical animal models clearly indicate drug exposure during adolescence, when the "reward" circuitry of the brain develops, increases the risk of substance use and other mental health disorders later in life. Human data indicate that different neural and behavioral sequelae can be observed in early versus late adolescence. However, most studies with rodent models examine a single adolescent age compared to a mature adult age, and often only in males. Herein, we sought to determine whether the acute response to the opioid morphine would also differ across adolescence, and by sex. By quantifying Fos positive cells, a proxy for neural activity, at different stages during adolescence (pre-, early, mid-, and late adolescence) and in multiple reward regions (prefrontal cortex, nucleus accumbens, caudate/putamen), we determined that the neural response to acute morphine is highly dependent on adolescent age, sex, and brain region. These data suggest that heterogeneity in the consequences of adolescent opioid exposure may be due to age- and sex-specific developmental profiles in individual reward processing regions. In future studies, it will be important to add age within adolescence as an independent variable for a holistic view of healthy or abnormal reward-related neural development.

Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis

BACKGROUND

We updated a 2017 systematic review and compared the effects of HIV self-testing (HIVST) to standard HIV testing services to understand effective service delivery models among the general population.

METHODS

We included randomized controlled trials (RCTs) comparing testing outcomes with HIVST to standard testing in the general population and published between January 1, 2006 and June 4, 2019. Random effects meta-analysis was conducted and pooled risk ratios (RRs) were reported. The certainty of evidence was determined using the GRADE methodology.

FINDINGS

We identified 14 eligible RCTs, 13 of which were conducted in sub-Saharan Africa. Support provided to self-testers ranged from no/basic support to one-on-one in-person support. HIVST increased testing uptake overall (RR:2.09; 95% confidence interval: 1.69-2.58; p < 0.0001;13 RCTs; moderate certainty evidence) and by service delivery model including facility-based distribution, HIVST use at facilities, secondary distribution to partners, and community-based distribution. The number of persons diagnosed HIV-positive among those tested (RR:0.81, 0.45-1.47; p = 0.50; 8 RCTs; moderate certainty evidence) and number linked to HIV care/treatment among those diagnosed (RR:0.95, 0.79-1.13; p = 0.52; 6 RCTs; moderate certainty evidence) were similar between HIVST and standard testing. Reported harms/adverse events with HIVST were rare and appeared similar to standard testing (RR:2.52: 0.52-12.13; p = 0.25; 4 RCTs; very low certainty evidence).

INTERPRETATION

HIVST appears to be safe and effective among the general population in sub-Saharan Africa with a range of delivery models. It identified and linked additional people with HIV to care. These findings support the wider availability of HIVST to reach those who may not otherwise access testing.

Country adherence to WHO recommendations to improve the quality of HIV diagnosis: a global policy review

Introduction

Ensuring a correct and timely HIV diagnosis is critical. WHO publishes guidelines on HIV testing strategies that maximise the likelihood of correctly determining one’s HIV status. A review of national HIV testing policies in 2014 found low adherence to WHO guidelines. We updated this review to determine adherence to current recommendations.

Methods

We conducted a comprehensive policy review through April 2018. We extracted data on HIV testing strategies, recommendations on HIV retesting prior to antiretroviral therapy (ART) initiation and pre-exposure prophylaxis (PrEP)-related HIV testing information. Descriptive analyses disaggregated by region were conducted to ascertain adherence to recommendations and to describe testing strategy characteristics.

Results

Of 91 policies included, 26% (n=24/91) adhered to WHO recommendations. Having a two-assay testing strategy to rule-in HIV infection as opposed to the recommended three-assay testing strategy was a major reason for non-adherence. Of 72 country policies providing sufficient information, 31% (n=22) recommended retesting for HIV prior to initiating ART. Of 25 countries and two regions reporting PrEP-related HIV testing guidelines, almost all recommended testing prior to initiating PrEP and every 3 months during PrEP use.

Conclusions

Global adherence to WHO recommendations for HIV testing strategies have improved since 2014 but remain low. We found adherence existed on a continuum. Such a system provides insights into how countries can move towards adherence by making relatively minor changes to testing strategies. Guidance from WHO on the role of new HIV testing technologies within testing algorithms and identifying ways to simplify testing guidance is warranted.

Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis

BACKGROUND

We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations.

METHODS

We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology.

RESULTS

After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare.

CONCLUSIONS

HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

A semi-automated brain atlas-based analysis pipeline for c-Fos immunohistochemical data

BACKGROUND

The use of immunohistochemistry to quantify neural markers in various brain regions is a staple of neuroscience research. Numerous programs exist to automate quantification, but manual assignment of regions of interest (ROIs) within individual brain sections remains time consuming and can introduce interobserver variability.

NEW METHOD

We have developed a novel open source FIJI-based immunohistochemical data analysis pipeline, Atlas-Based Analysis (ABA). ABA uses landmark-based image warping to adjust the experimental image to closely align with a published rat brain atlas. c-Fos positive cells are then quantified within predetermined ROI coordinates derived from the brain atlas. Image warping adjusts for natural variation in brain sections to ensure reliable alignment of ROIs for data analysis. This pipeline can be adapted for new atlases, landmarks, ROIs, and quantification measurements.

RESULTS

ABA permits rapid quantification of immunoreactivity in multiple ROIs and produces results with high levels of interobserver consistency.

COMPARISON WITH EXISTING METHODS

Compared to manual ROI designation, ABA reduces total analysis time by ∼70%. With correct use of landmarks for image warping, ABA produces similar results to manually drawn ROIs, results in no interobserver variability, and maintains c-Fos+ pixel dimensions.

CONCLUSIONS

ABA reduces time to obtain reliable results when performing automated immunoreactivity quantification and allows multiple users to analyze data without compromising the reliability of data obtained.

The safety of isoniazid tuberculosis preventive treatment in pregnant and postpartum women: systematic review and meta-analysis

BACKGROUND

The World Health Organization (WHO) recommends tuberculosis (TB) preventive treatment for high-risk groups. Isoniazid preventive therapy (IPT) has been used globally for this purpose for many years, including in pregnancy. This review assessed current knowledge about the safety of IPT in pregnancy.

METHODS

We searched PubMed, Embase, CENTRAL, Global Health Library and HIV and TB-related conference abstracts, until May 15, 2019, for randomised controlled trials (RCTs) and non-randomised studies (NRS) where IPT was administered to pregnant women. Outcomes of interest were: 1) maternal outcomes, including permanent drug discontinuation due to adverse drug reactions, any grade 3 or 4 drug-related toxic effects, death from any cause and hepatotoxicity; and 2) pregnancy outcomes, including in utero fetal death, neonatal death or stillbirth, preterm delivery/prematurity, intrauterine growth restriction, low birth weight and congenital anomalies. Meta-analyses were conducted using a random-effects model.

RESULTS

After screening 1342 citations, nine studies (of 34 to 51 942 participants) met inclusion criteria. We found an increased likelihood of hepatotoxicity among pregnant women given IPT (risk ratio 1.64, 95% CI 0.78-3.44) compared with no IPT exposure in one RCT. Four studies reported on pregnancy outcomes comparing IPT exposure to no exposure among pregnant women with HIV. In one RCT, adverse pregnancy outcomes were associated with IPT exposure during pregnancy (odds ratio (OR) 1.51, 95% CI 1.09-2.10), but three NRS showed a protective effect.

CONCLUSIONS

We found inconsistent associations between IPT and adverse pregnancy outcomes. Considering the grave consequences of active TB in pregnancy, current evidence does not support systematic deferral of IPT until postpartum. Research on safety is needed.

Marijuana use and outcomes in adult and pediatric trauma patients after legalization in California

BACKGROUND

Marijuana has become legal in eight states since 2012. We hypothesized the incidence of marijuana-positive trauma patients and rate of mortality has increased post-legalization.

METHODS

A single level-I trauma center was used to identify patients screening positive for marijuana on urine-toxicology. Patients in the pre-legalization and post-legalization periods were compared.

RESULTS

In the pre-legalization cohort 9.4% were marijuana-positive versus 11.0% in the post-legalization cohort (p = 0.001). Marijuana-positive patients post-legalization had higher rates of critical trauma activation (20.0% vs. 15.0%, p = 0.01) and mortality (2.6% vs. 1.2%, p = 0.03). In the pediatric (age 12-17) subgroup, the incidence of marijuana-positive patients did not change after legalization (pre: 39.3%, post: 46.4%, p = 0.24).

CONCLUSION

The incidence of marijuana-positive trauma patients increased post-legalization. Adult marijuana-positive trauma patients post-legalization were more likely to meet criteria for critical trauma activation and have a higher mortality rate. A subgroup of pediatric patients had an alarmingly high rate of marijuana use.

SUMMARY

The rate of marijuana use among trauma patients increased post-legalization in California. The rate of critical trauma activation also increased as well as the mortality rate.

The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis

INTRODUCTION

The prevalence of undiagnosed HIV is declining in Africa, and various HIV testing approaches are finding lower positivity rates. In this context, the epidemiological impact and cost-effectiveness of community-based HIV self-testing (CB-HIVST) is unclear. We aimed to assess this in different sub-populations and across scenarios characterized by different adult HIV prevalence and antiretroviral treatment programmes in sub-Saharan Africa.

METHODS

The synthesis model was used to address this aim. Three sub-populations were considered for CB-HIVST: (i) women having transactional sex (WTS); (ii) young people (15 to 24 years); and (iii) adult men (25 to 49 years). We assumed uptake of CB-HIVST similar to that reported in epidemiological studies (base case), or assumed people use CB-HIVST only if exposed to risk (condomless sex) since last HIV test. We also considered a five-year time-limited CB-HIVST programme. Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER; cost-per-disability-adjusted life-year (DALY) averted) below US$500 over a time horizon of 50 years. The efficiency of targeted CB-HIVST was evaluated using the number of additional tests per infection or death averted.

RESULTS

In the base case, targeting adult men with CB-HIVST offered the greatest impact, averting 1500 HIV infections and 520 deaths per year in the context of a simulated country with nine million adults, and impact could be enhanced by linkage to voluntary medical male circumcision (VMMC). However, the approach was only cost-effective if the programme was limited to five years or the undiagnosed prevalence was above 3%. CB-HIVST to WTS was the most cost-effective. The main drivers of cost-effectiveness were the cost of CB-HIVST and the prevalence of undiagnosed HIV. All other CB-HIVST scenarios had an ICER above US$500 per DALY averted.

CONCLUSIONS

CB-HIVST showed an important epidemiological impact. To maximize population health within a fixed budget, CB-HIVST needs to be targeted on the basis of the prevalence of undiagnosed HIV, sub-population and the overall costs of delivering this testing modality. Linkage to VMMC enhances its cost-effectiveness.

Reliability of HIV rapid diagnostic tests for self-testing compared with testing by health-care workers: a systematic review and meta-analysis

Background

The ability of individuals to use HIV self-tests correctly is debated. To inform the 2016 WHO recommendation on HIV self-testing, we assessed the reliability and performance of HIV rapid diagnostic tests when used by self-testers.

Methods

In this systematic review and meta-analysis, we searched PubMed, PopLine, and Embase, conference abstracts, and additional grey literature between Jan 1, 1995, and April 30, 2016, for observational and experimental studies reporting on HIV self-testing performance. We excluded studies evaluating home specimen collection because patients did not interpret their own test results. We extracted data independently, using standardised extraction forms. Outcomes of interest were agreement between self-testers and health-care workers, sensitivity, and specificity. We calculated κ to establish the level of agreement and pooled κ estimates using a random-effects model, by approach (directly assisted or unassisted) and type of specimen (blood or oral fluid). We examined heterogeneity with the I² statistic.

Findings

25 studies met inclusion criteria (22 to 5662 participants). Quality assessment with QUADAS-2 showed studies had low risk of bias and incomplete reporting in accordance with the STARD checklist. Raw proportion of agreement ranged from 85·4% to 100%, and reported κ ranged from fair (κ 0·277, p<0·001) to almost perfect (κ 0·99, n=25). Pooled κ suggested almost perfect agreement for both types of approaches (directly assisted 0·98, 95% CI 0·96–0·99 and unassisted 0·97, 0·96–0·98; I²=34·5%, 0–97·8). Excluding two outliers, sensitivity and specificity was higher for blood-based rapid diagnostic tests (4/16) compared with oral fluid rapid diagnostic tests (13/16). The most common error that affected test performance was incorrect specimen collection (oral swab or finger prick). Study limitations included the use of different reference standards and no disaggregation of results by individuals taking antiretrovirals.

Interpretation

Self-testers can reliably and accurately do HIV rapid diagnostic tests, as compared with trained health-care workers. Errors in performance might be reduced through the improvement of rapid diagnostic tests for self-testing, particularly to make sample collection easier and to simplify instructions for use.

Funding

The Bill & Melinda Gates Foundation and Unitaid.

The HepTestContest: a global innovation contest to identify approaches to hepatitis B and C testing

BACKGROUND

Innovation contests are a novel approach to elicit good ideas and innovative practices in various areas of public health. There remains limited published literature on approaches to deliver hepatitis testing. The purpose of this innovation contest was to identify examples of different hepatitis B and C approaches to support countries in their scale-up of hepatitis testing and to supplement development of formal recommendations on service delivery in the 2017 World Health Organization hepatitis B and C testing guidelines.

METHODS

This contest involved four steps: 1) establishment of a multisectoral steering committee to coordinate a call for contest entries; 2) dissemination of the call for entries through diverse media (Facebook, Twitter, YouTube, email listservs, academic journals); 3) independent ranking of submissions by a panel of judges according to pre-specified criteria (clarity of testing model, innovation, effectiveness, next steps) using a 1-10 scale; 4) recognition of highly ranked entries through presentation at international conferences, commendation certificate, and inclusion as a case study in the WHO 2017 testing guidelines.

RESULTS

The innovation contest received 64 entries from 27 countries and took a total of 4 months to complete. Sixteen entries were directly included in the WHO testing guidelines. The entries covered testing in different populations, including primary care patients (n = 5), people who inject drugs (PWID) (n = 4), pregnant women (n = 4), general populations (n = 4), high-risk groups (n = 3), relatives of people living with hepatitis B and C (n = 2), migrants (n = 2), incarcerated individuals (n = 2), workers (n = 2), and emergency department patients (n = 2). A variety of different testing delivery approaches were employed, including integrated HIV-hepatitis testing (n = 12); integrated testing with harm reduction and addiction services (n = 9); use of electronic medical records to support targeted testing (n = 8); decentralization (n = 8); and task shifting (n = 7).

CONCLUSION

The global innovation contest identified a range of local hepatitis testing approaches that can be used to inform the development of testing strategies in different settings and populations. Further implementation and evaluation of different testing approaches is needed.

Improving HIV test uptake and case finding with assisted partner notification services

OBJECTIVE

Despite the enormous expansion of HIV testing services (HTS), an estimated 40% of people with HIV infection remain undiagnosed. To enhance the efficiency of HTS, new approaches are needed. The WHO conducted a systematic review on the effectiveness of assisted partner notification in improving HIV test uptake and diagnosis, and the occurrence of adverse events, to inform the development of normative guidelines.

METHODS

We systematically searched five electronic databases through June 2016. We also contacted experts in the field and study authors for additional information where needed. Eligible studies compared assisted HIV partner notification services to passive or no notification. Where multiple studies reported comparable outcomes, meta-analysis was conducted using a random-effects model to produce relative risks (RRs) or risk ratios and 95% confidence intervals (CIs).

RESULTS

Of 1742 citations identified, four randomized controlled trials and six observational studies totalling 5150 index patients from eight countries were included. Meta-analysis of three individually randomized trials showed that assisted partner notification services resulted in a 1.5-fold increase in HTS uptake among partners compared with passive referral (RR = 1.46; 95% CI: 1.22-1.75; I = 0%). The proportion of HIV-positive partners was 1.5 times higher with assisted partner notification than with passive referral (RR = 1.47; 95% CI: 1.12-1.92; I = 0%). Few instances of violence or harm occurred.

CONCLUSION

Assisted partner notification improved partner testing and diagnosis of HIV-positive partners, with few reports of harm. WHO strongly recommends voluntary assisted HIV partner notification services to be offered as part of a comprehensive package of testing and care.

Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis

INTRODUCTION

HIV self-testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV-positive persons, linkage to care, social harm, and risk behaviour.

METHODS

We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta-analyses of studies reporting comparable outcomes were conducted using a random-effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE.

RESULTS

After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral-fluid rapid tests for HIVST and were among men. Meta-analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta-analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12-15-month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta-analysis of two RCTs showed HIVST also doubled the likelihood of an HIV-positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk-taking behaviour appeared to be minimal.

CONCLUSIONS

HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV-positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.

Consolidating emerging evidence surrounding HIVST and HIVSS: a rapid systematic mapping protocol

BACKGROUND

HIV self-testing (HIVST) is becoming popular with policy makers and commissioners globally, with a key aim of expanding access through reducing barriers to testing for individuals at risk of HIV infection. HIV self-sampling (HIVSS) was available previously to self-testing but was confined mainly to the USA and the UK. It remains to be seen whether the momentum behind HIVST will also energise efforts to expand HIVSS. Recent years have seen a rapid growth in the type of evidence related to these interventions as well as several systematic reviews. The vast majority of this evidence relates to acceptability as well as values and preferences, although new types of evidence are emerging. This systematic map aims to consolidate all emerging evidence related to HIVST and HIVSS to respond to this rapidly changing area.

METHODS

We will systematically search databases and the abstracts of five conferences from 2006 to the present date, with monthly-automated database searches. Searches will combine key terms relating to HIV (e.g. HIV, AIDS, human immune-deficiency syndrome) with terms related to self-testing (e.g. home-test, self-test, mail-test, home dried blood spot test). Abstracts will be reviewed against inclusion criteria in duplicate. Data will be manually extracted through a standard form and then entered to an open access relational map (HIVST.org). When new and sufficient evidence emerges which addresses existing knowledge gaps, we will complete a review on a relevant topic.

DISCUSSION

This innovative approach will allow rapid cataloguing, documenting and dissemination of new evidence and key findings as they emerge into the public domain.

SYSTEMATIC REVIEW REGISTRATION

This protocol has not been registered with PROSPERO as they do not register systematic maps.

Can trained lay providers perform HIV testing services? A review of national HIV testing policies

BACKGROUND

Only an estimated 54% of people living with HIV are aware of their status. Despite progress scaling up HIV testing services (HTS), a testing gap remains. Delivery of HTS by lay providers may help close this testing gap, while also increasing uptake and acceptability of HIV testing among key populations and other priority groups.

METHODS

50 National HIV testing policies were collated from WHO country intelligence databases, contacts and testing program websites. Data regarding lay provider use for HTS was extracted and collated. Our search had no geographical or language restrictions. This data was then compared with reported data from the Global AIDS Response Progress Reporting (GARPR) from July 2015.

RESULTS

Forty-two percent of countries permit lay providers to perform HIV testing and 56% permit lay providers to administer pre-and post-test counseling. Comparative analysis with GARPR found that less than half (46%) of reported data from countries were consistent with their corresponding national HIV testing policy.

CONCLUSIONS

Given the low uptake of lay provider use globally and their proven use in increasing HIV testing, countries should consider revising policies to support lay provider testing using rapid diagnostic tests.

Beyond the 90-90-90: refocusing HIV prevention as part of the global HIV response

INTRODUCTION

The remarkable expansion in availability of antiretroviral therapy (ART) over the past two decades has transformed HIV infection into a manageable chronic condition. People with HIV infection now live long and healthy lives on treatment that is simpler, safer and cheaper. According to UNAIDS estimates, the global coverage of ART reached 46% in 2015, resulting in a 26% decrease in annual HIV-related deaths since 2010. Such success has positioned treatment access at the centre of the global HIV response as a way to prevent mortality, morbidity and HIV transmission through a "Treat All" approach. Continuing expansion of treatment is needed to further reduce HIV-related mortality. This progress with treatment, however, masks a stagnation in the estimated annual number of new HIV infections. Continuing levels of HIV incidence despite treatment scale-up stem from several factors, which should be addressed in order to prevent new infections and decrease the numbers of people requiring treatment in the future.

DISCUSSION

ART can only reach those already diagnosed, and although it is unclear what proportion of new infections occur during acute and early infection prior to treatment initiation, phylogenetic studies suggest that it might be substantial. Thus, better testing approaches to reach the 40% of people with undiagnosed HIV infection as early as possible are critical. New approaches to reach men, young people and key populations, where HIV risk is highest and HIV prevention, testing and treatment coverage is lowest, are also needed. Overall coverage of effective prevention interventions remains low, enabling HIV transmission to occur, or time is required to show population-level effects. For example, the full impact of the medical male circumcision intervention will be seen once a larger proportion of men in age cohorts with high incidence are circumcised. Finally, strategically focused pre-exposure prophylaxis interventions have the potential to prevent HIV acquisition among populations at substantial risk, averting treatment costs in coming years.

CONCLUSIONS

The United Nations (UN) targets to end AIDS include the "90-90-90" targets for HIV diagnosis, treatment and viral suppression. While 90-90-90 has been widely emphasized and adopted by countries and international funders, the focus thus far has largely been on increasing access to ART - the second "90." A similar emphasis on achieving UN HIV prevention targets and adequate funding for meeting these is essential, alongside treatment, in order to reduce population-level incidence and change the trajectory of the HIV epidemic over the long term.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]

Objetivos

Conocer el perfil sociosanitario de los pacientes mayores atendidos en consultas; conocer las acciones preventivas que se llevan a cabo, de forma rutinaria, en hospitales, residencias geriátricas y otros centros asistenciales en España.

Diseño

Estudio descriptivo transversal, basado en un cuestionario a médicos que atienden a población mayor de 65 años en España (2013).

Emplazamiento

Centros de diferentes comunidades autónomas en España.

Participantes: Un total de 420 médicos de hospitales, residencias y otros centros. Se obtuvieron datos de 840 consultas a pacientes geriátricos.

Mediciones principales

Variables principales de resultados: dependencia, comorbilidad, motivo de consulta, actuación en consulta y recomendación de estilos de vida saludable. Factor asociado, tipo de institución en la que se atendió al paciente. Análisis de prevalencias y diferencias con Chi-cuadrado.

Resultados

El 66,7% presentaban dependencia, siendo mayor entre las mujeres: 68,9% vs 62,4% (p = 0,055). El 88,6% de mujeres atendidas con 85 o más años presentaban comorbilidad, mientras que en hombres de ese mismo grupo de edad eran un 79,8%. Solo un 6,6% de pacientes con comorbilidad recibieron recomendaciones saludables durante la consulta. El 79,6% de pacientes atendidos en hospitales recibieron recomendaciones de estilo de vida saludable, mientras que en las residencias geriátricas las recibieron el 59,62% de los pacientes (p < 0,001).

Conclusiones

Se detecta una escasa acción preventiva y de promoción de la salud hacia las personas mayores, con diferencias entre hospitales y residencias geriátricas. Parece necesario incentivar la actitud promotora de salud y las intervenciones preventivas en la práctica clínica gerontológica.

HIV and Hepatitis Testing: Global Progress, Challenges, and Future Directions

HIV infection and viral hepatitis due to HBV and HCV infection are major causes of chronic disease worldwide, and share some common routes of transmission, epidemiology, initial barriers faced in treatment access, and in strategies for a global public health response. Testing and diagnosis of HIV, HBV, and HCV infection is the gateway for access to both care and treatment and prevention services, and crucial for an effective HIV and hepatitis epidemic response. In this review article, we first summarize the common goals and guiding principles in a public health approach to HIV and hepatitis testing. We summarize the impressive global progress in HIV testing scale-up and evolution of approaches, with expansion of provider-initiated testing and counseling in clinical settings (particularly antenatal and tuberculosis clinics), the introduction of more community based testing services, and use of rapid diagnostic tests enabling provision of same-day test results. However, 46% of all people living with HIV are still unaware of their serostatus, and many continue to be diagnosed and start antiretroviral therapy late. As testing and treatment scale-up accelerates for an "treat all" approach, other challenges to address include how to better focus testing and reach those yet undiagnosed and most at risk, especially key populations, men, adolescents, and children. We summarize future directions in HIV testing to speed scale-up and close gaps that are addressed in the WHO 2015 consolidated HIV testing guidelines. In contrast to HIV, action in hepatitis testing and treatment has been fragmented and limited to a few countries, and there remains a large burden of undiagnosed cases globally. We summarize key challenges in the hepatitis testing response, including lack of simple, reliable, and low-cost diagnostic tests, laboratory capacity, and testing facilities; inadequate data to guide country specific hepatitis testing approaches and who to screen; stigmatization and social marginalization of those with or at risk of viral hepatitis; and lack of international or national guidelines on hepatitis testing for resource-limited settings. We highlight some of the key lessons applicable to hepatitis from the experience of expansion and diversification of HIV testing approaches over the last 30 years of the HIV response; in addition to forthcoming WHO tools to support the hepatitis global response. This includes a new 2016-2020 global hepatitis health sector strategy with testing and diagnosis targets, and 2016 WHO guidelines on hepatitis testing.

Attitudes and Acceptability on HIV Self-testing Among Key Populations: A Literature Review

HIV self-testing (HIVST) is a potential strategy to overcome disparities in access to and uptake of HIV testing, particularly among key populations (KP). A literature review was conducted on the acceptability, values and preferences among KP. Data was analyzed by country income World Bank classification, type of specimen collection, level of support offered and other qualitative aspects. Most studies identified were from high-income countries and among men who have sex with men (MSM) who found HIVST to be acceptable. In general, MSM were interested in HIVST because of its convenient and private nature. However, they had concerns about the lack of counseling, possible user error and accuracy. Data on the values and preferences of other KP groups regarding HIVST is limited. This should be a research priority, as HIVST is likely to become more widely available, including in resource-limited settings.

Low knowledge and anecdotal use of unauthorized online HIV self-test kits among attendees at a street-based HIV rapid testing programme in Spain

OBJECTIVES

The objectives of this study were to estimate the percentage of potential users who know that unauthorized HIV self-tests can be purchased online and the percentage of those who have already used them, and to determine socio-demographic and behavioural correlates.

METHODS

A self-administered questionnaire was employed to collect data from attendees at a street-based HIV testing programme. Logistic regression for rare events was performed.

RESULTS

Of the 3340 participants, 5.3% (95% confidence interval (CI) 4.5-6.0%) had knowledge of self-tests being sold online and 7.5% (95% CI 6.6-8.5%) thought they existed but had never seen them; only 0.6% (95% CI 0.3-0.9%) had ever used one. Knowing that self-tests are sold online (odds ratio (OR) 3.6, 95% CI 2.4-5.4) and using them (OR 7.3, 95% CI 2.2-23.8) were associated with having undergone more than two previous HIV tests. Use was also associated with being neither Spanish nor Latin American (OR 3.8, 95% CI 1.2-12.0) and with having a university degree (OR 0.2, 95% CI 0.1-0.7).

CONCLUSIONS

At the time of the study, the impact on the population of issues related to the use of unauthorized tests was very low. However, media coverage following the approval of self-testing in the USA might have changed the situation.

Estimation of central aortic forces in the ballistocardiogram under rest and exercise conditions

The ballistocardiogram (BCG) signal represents the movements of the body in response to cardiac ejection of blood. The BCG signal can change considerably under various physiological states; however, little information exists in literature describing how these forces are generated. A physical analysis is presented using a finite element model of thoracic aortic vasculature to quantify forces generated by the blood flow during the cardiac cycle. The traction at the fluid-solid interface of this deformable wall model generates a Central Aortic Force (CAF) which appears of similar magnitude to recorded BCG forces. The increased pulse pressure in an exercise simulation caused a significant increase in CAF, which is consistent with recent BCG measurements in exercise recovery.

Evaluation and applications of optical cell density probes in mammalian cell bioreactors

On-line optical cell density probes were implemented to continuously monitor the cell densities in mammalian cell bioreactor and to achieve advanced bioreactor controls. We tested cell density probes from six manufacturers in high cell density bioreactors. When externally calibrated, Aquasant and Ingold backscattering probes produced the most linear probe responses (PR) versus cell density (CD), followed by the ASR and Cerex laser probes. Monitek and Wedgewood transmission probes had lower resolutions. All probes were tested in two murine hybridoma fermentations. Cell densities varied between 1 x 10(6) cells/mL to 20 x 10(6) cells/mL and the bioreactors were operated for 5 to 7 weeks. For our bioreactors, Aquasant, Ingold, ASR, Wedgewood, and Monitek probes gave satisfactory responses. Little fouling was observed with any probe at the end of 2 weeks. Fouling was a possibility after 3 weeks in one bioreactor but its effect can be easily corrected. Cell density control and specific perfusion control of bioreactors based on the Aquasant probe were achieved. Implementation of cell density probe based perfusion control, instead of "step perfusion adjustments" based on manual hemacytometer control, will result in smoother operation, healthier cultures, increased medium delivery efficiency, and reduced operational excursions.

Prenylated Rab acceptor protein is a receptor for prenylated small GTPases

Localization of Ras and Ras-like proteins to the correct subcellular compartment is essential for these proteins to mediate their biological effects. Many members of the Ras superfamily (Ha-Ras, N-Ras, TC21, and RhoA) are prenylated in the cytoplasm and then transit through the endomembrane system on their way to the plasma membrane. The proteins that aid in the trafficking of the small GTPases have not been well characterized. We report here that prenylated Rab acceptor protein (PRA1), which others previously identified as a prenylation-dependent receptor for Rab proteins, also interacts with Ha-Ras, RhoA, TC21, and Rap1a. The interaction of these small GTPases with PRA1 requires their post-translational modification by prenylation. The prenylation-dependent association of PRA1 with multiple GTPases is conserved in evolution; the yeast PRA1 protein associates with both Ha-Ras and RhoA. Earlier studies reported the presence of PRA1 in the Golgi, and we show here that PRA1 co-localizes with Ha-Ras and RhoA in the Golgi compartment. We suggest that PRA1 acts as an escort protein for small GTPases by binding to the hydrophobic isoprenoid moieties of the small GTPases and facilitates their trafficking through the endomembrane system.

Peroxisomal proteins in rat gametes

Peroxisomes are essential subcellular organelles, which appear to be derived from pre-existing organelles. This biogenetic mechanism assumes the presence of peroxisomes in either or both mammalian gametes (sperms and/or oocytes). In order to test the presence and subcellular localization of peroxisomal proteins in rat sperms and oocytes, the authors carried out fractionation and immunofluorescence experiments. The results showed that rat oocytes contain peroxisome-like structures, which were detected by indirect immunofluorescence, using an antisera against total peroxisomal proteins. In contrast, such structures were not detected in rat sperms, which appear to contain catalase localized in the cell cytosol. The results reported herein show evidence for the first time of the presence of peroxisome-like structures in mammalian oocytes, and provide evidence for the peroxisome biogenesis hypothesis, by division of pre-existing organelles.

[Clinical characterization of 450 patients with cerebrovascular disease admitted to a public hospital during 1997]

BACKGROUND

In Chile, cerebrovascular diseases are the fifth cause of death among men and the third cause among women.

AIM

To assess the clinical features and management of patients with cerebrovascular disease admitted to a public hospital during 1997.

PATIENTS AND METHODS

A retrospective analysis of clinical records of patients discharged with a diagnosis of cerebrovascular disease. Those records in which there was discordance between the discharge diagnosis and the clinical picture were not considered in the analysis.

RESULTS

Of the 563 discharges from the hospital with the diagnosis of cerebrovascular disease, 487 records were located and 450 were considered in the analysis. Fifty four percent of patients were male and ages ranged from 17 to 96 years old. Fifty-one percent of patients had an ischemic stroke, 34% a cerebral hemorrhage, 12% a subarachnoidal hemorrhage and 3% a transient ischemic attack. There was a history of hypertension in 64% patients and 20% had an adequate treatment. Eighteen percent were diabetics, 34% had a heart disease and 20% had a previous episode of stroke. Mean hospital stay was 6.3 days in the emergency room and 11 days in the neurology ward. Hospital infections appeared in 21% of patients (respiratory in 68% and urinary in 22%), lethality was 30.5% and a CAT scan was done in 94%. At the moment of admission, 10% of patients had an evolution of less than 2 hours, 27% had an evolution between 2 and 6 hours and nine cases were potential eligible for thrombolysis.

CONCLUSION

This is a picture of the local features of patients with cerebrovascular diseases that can be used as a reference for future studies.

Negative regulation of the serine/threonine kinase B-Raf by Akt

B-Raf contains multiple Akt consensus sites located within its amino-terminal regulatory domain. One site, Ser(364), is conserved with c-Raf but two additional sites, Ser(428) and Thr(439), are unique to B-Raf. We have investigated the role of both the conserved and unique phosphorylation sites in the regulation of B-Raf activity in vitro and in vivo. We show that phosphorylation of B-Raf by Akt occurs at multiple residues within its amino-terminal regulatory domain, at both the conserved and unique phosphorylation sites. The alteration of the serine residues within the Akt consensus sites to alanines results in a progressive increase in enzymatic activity in vitro and in vivo. Furthermore, expression of Akt inhibits epidermal growth factor-induced B-Raf activity and inhibition of Akt with LY294002 up-regulates B-Raf activity, suggesting that Akt negatively regulates B-Raf in vivo. Our results demonstrate that B-Raf activity can be negatively regulated by Akt through phosphorylation in the amino-terminal regulatory domain of B-Raf. This cross-talk between the B-Raf and Akt serine/threonine kinases is likely to play an important role in modulating the signaling specificity of the Ras/Raf pathway and in promoting biological outcome.

Allopurinol encapsulated in polycyanoacrylate nanoparticles as potential lysosomatropic carrier: preparation and trypanocidal activity

The activity of allopurinol-loaded polyethylcyanoacrylate nanoparticles against Trypanosoma cruzi was compared to that of free allopurinol using in vitro cultures of epimastigotes. Ethylcyanoacrylate nanoparticles were prepared by an emulsion polymerization process, and formulations containing different concentrations of allopurinol, polyethylcyanoacrylate and surfactants were investigated and analyzed in size and amount of drug entrapped. The nanoparticles obtained were less than 200 nm in size, as measured by electron microscopy and cytometry. The peak amount of allopurinol entrapped in the nanoparticles was 62.8+/-1.9 microg mg(-1) of nanoparticles using 400 microl of polyethylcyanoacrylate, 200 microl of surfactant (Tween 20) and 20 mg of allopurinol in 50 ml of polymerization medium and the association efficiency was 100.7%. After 6 h of incubation at pH 7.4 the release of allopurinol from the nanoparticles was 7.4%, while at pH 1.2 only 3.1% was released after 4-6 h (t=42.8, P<0.0001). The in vitro studies, using cultures of T. cruzi epimastigotes, demonstrated considerable increases in the trypanocidal activity of the allopurinol-loaded nanoparticles in comparison with a standard solution of allopurinol (91.5 vs. 45.9%) at an allopurinol concentration of 16.7 microg ml(-1). In addition, it was shown that the unloaded nanoparticles, by mechanisms not completely elucidated, had a trypanocidal activity similar to that of standard solutions of allopurinol. To study cytotoxicity, increasing concentrations of unloaded nanoparticles were incubated on vero-line cell cultures. The concentration that killed 50% cells was 200 microg ml(-1), four times higher than that necessary to kill 50% of T. cruzi. It is concluded that the polyethylcyanoacrylate nanoparticles constitute a good carrier of drugs against the T. cruzi. The allopurinol loaded-nanoparticles significantly increased the trypanocidal activity in comparison to the free drug.

The long-term reinfection rate and the course of duodenal ulcer disease after eradication of Helicobacter pylori in a developing country

OBJECTIVE

The aim of this study was to evaluate the effect of Helicobacter pylori (H. pylori) eradication on the natural history of duodenal ulcer disease and the reinfection rate after treatment in a developing country.

METHODS

A total of 111 H. pylori-infected patients with duodenal ulcer were treated with either omeprazole or famotidine plus two antibiotics for 2 wk. Those failed to respond to treatment were retreated with bismuth-based triple therapy.

RESULTS

The radication rate was 76% (95% CI: 67-83%). Eventually, H. pylori was eradicated in 96 of the 111 patients (86%), who were followed-up clinically and endoscopically for a mean of 37.2 months. The cumulative reinfection rate after eradication (Kaplan-Meier) was 8%+/-3% in yr 1, 11%+/-4% in yr 2, and 13%+/-4% in yr 3. Nine of the 12 reinfections occurred during yr 1. Recurrence of duodenal ulcer was detected in five patients (5.2%), all of them during yr 1 of follow-up. Histologically, gastritis scores (according to the Sydney system) improved significantly after eradication.

CONCLUSIONS

In a high prevalence setting, H. pylori eradication and early reinfection rates after treatment are similar to rates observed in a low prevalence environment, whereas the late reinfection rate seems to be higher. However, up to 3 yr after treatment, most treated patients are free of H. pylori infection and/or ulcer activity. Even longer follow-up studies are necessary to determine whether specific retreatment policies are necessary to maintain long term eradication in developing countries.

[Microbiological study of gallbladder bile in a high risk zone for gallbladder cancer]

BACKGROUND

Gallbladder cancer is frequent in Chile and there is sparse information about the association between this type of cancer and the presence of bacteria in the gallbladder bile.

AIM

To determine the presence of aerobic bacteria in gallbladder bile in patients with and without gallbladder cancer.

MATERIAL AND METHODS

A microbiological analysis of bile and pathological study was performed in 608 gallbladders, obtained during to cholecystectomies performed to 513 women and 95 men aged 44 years old as a mean.

RESULTS

Pathological study showed a chronic cholecystitis in 468 cases (77%), an acute cholecystitis in 140 (33%), cancer in 24 (3.9%) and dysplasia in 5 cases (0.8%). A positive culture was obtained in 22.5% of women and 28.5% of males. Twenty seven percent of women over 30 years old had positive cultures compared with 10% of younger women (p < 0.001). Thirty two percent of acute cholecystitis had positive cultures, compared with 24% of chronic cholecystitis (p = 0.03). E Coli was isolated in 51% of positive cases, Streptococci-Enterococci in 24%, Enterobacter sp in 9%, Klebsiella and Proteus in lower proportions. Salmonella sp was isolated in 4 cases, being all women with chronic cholecystitis. Thirteen of 29 cases with cancer or dysplasia had positive cultures (45%), compared with 25% of patients with inflammatory gallbladder diseases (p = 0.02). Streptococci-Enterococci were isolated in 7 cases and Enterobacter sp in three.

CONCLUSIONS

The presence of Salmonella sp in gallbladder bile was not frequent in the studied patients. Its role in the pathogenesis of gallbladder cancer must be reassessed.

Successful related umbilical cord blood transplantation for graft failure following T cell-depleted non-identical bone marrow transplantation in a child with major histocompatibility complex class II deficiency

Major histocompatibility complex (MHC) class II deficiency is a rare form of primary combined immunodeficiency that can only be corrected by stem cell transplantation. We report a 4(1/2)-year-old girl with MHC class II deficiency who underwent a related CBT due to graft failure following T cell-depleted non-identical BMT. The patient is alive and well 2 years after the second transplant. A sustained hematopoietic engraftment and a progressive immune recovery have been detected. We conclude that cord blood may be an effective source of hematopoietic stem cells for patients with immuno- deficiency disorders including diseases with a high rate of graft failure.

Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay

OBJECTIVE

The clinical usefulness of preoperative localization and intraoperative PTH assay (QPTH) in primary hyperparathyroidism have been established. However, without the use of QPTH, the parathyroidectomy failure rate remains 5% to 10% in large reported series and is probably much higher in the hands of less experienced parathyroid surgeons. Persistent hypercalcemia requires another surgical procedure. The authors compared the outcomes in 50 consecutive patients undergoing more difficult secondary parathyroidectomy with and without the adjunctive support of QPTH.

METHODS

Two groups of similar patients underwent reoperative parathyroidectomy for failed surgery or recurrent disease. The successful return to normocalcemia in group I, with QPTH used to localize and confirm complete excision of all hyperfunctioning glands, was compared with group II, who did not have this intraoperative adjunct.

RESULTS

In 31/33 patients in group I, calcium levels returned to normal. With good preoperative localization studies, 17 patients underwent successful straightforward parathyroidectomies as predicted by QPTH. In the other 14 patients, QPTH assay proved extremely beneficial by facilitating localization with differential venous sampling; measuring the increase in hormone secretion after massage of specific areas; recognizing suspicious nonparathyroid tissue excised without a decrease in hormone levels, avoiding frozen-section delay; and correctly identifying the excision of abnormal tissue despite false-positive/false-negative sestamibi scans. In group II, who underwent surgery before QPTH was available, 4 of 17 patients (24%) remained hypercalcemic after extensive reexploration.

CONCLUSION

With the intraoperative hormone assay used to facilitate localization and confirm excision of all hyperfunctioning tissue, the success rate of reoperative parathyroidectomy has improved from 76% to 94%.

[Bone marrow transplantation for severe aplastic anemia]

Severe aplastic anemia is a hematological disease with a high mortality rate, for which bone marrow transplantation is the treatment of choice, specially in children and young adults. The number of transfusions undergone before the transplant is the most important factor to predict the possibility of graft failure. Twenty patients with severe aplastic anemia, most of them already multiple transfused, were transplanted utilizing cyclophosphamide combined with antilymphocyte globulin as a conditioning regiment. All the evaluable patients engrafted and there were no episodes of graft failure. Three patients died, and 17 (85%) are alive with hematopoietic recovery at a median of 27.7 months post-transplant. Bone marrow transplantation was an excellent therapeutic option in this series of patients with severe aplastic anemia and the conditioning regiment appeared to be sufficiently myeloablative and immunosuppressive to avoid early or late graft failure.

Accuracy of invasive and noninvasive tests to diagnose Helicobacter pylori infection after antibiotic treatment

OBJECTIVES

To compare the diagnostic accuracy of the most widely available tests for diagnosis of Helicobacter pylori infection after antibiotic treatment.

METHODS

A total of 59 H. pylori-positive, duodenal ulcer patients (mean age, 40.7 +/- 11.7 yr; 40 male and 19 female) were treated for 2 wk with either amoxicillin-metronidazole (n = 36) or omeprazole-amoxicillin-tinidazole (n = 23), and after 4 wk, were tested for H. pylori infection by [14C]urea breath test (UBT), serum IgG antibody level, and multiple antral biopsies for rapid urease testing, histology, Warthin-Starry stain, and polymerase chain reaction to detect H. pylori DNA. Infection status was established by a concordance of test results.

RESULTS

H. pylori was eradicated in 47 patients (80%). UBT and rapid urease testing had the best sensitivity and specificity, although not statistically different to Warthin-Starry stain and polymerase chain reaction. Serology and histology had little diagnostic value in this setting due to high proportion of false-positive results.

CONCLUSIONS

Noninvasive UBT is as accurate in predicting H. pylori status after antibiotic treatment as rapid urease testing and Warthin-Starry stain. Especially for duodenal ulcer patients, UBT could be considered the gold standard to confirm eradication of H. pylori.

Estrogen and luminal stimulation of rat uterine kallikrein

To understand the regulation of rat uterine kallikrein, we evaluated its variations in animals that had been ovariectomized and supplemented with estradiol or progesterone, in pseudopregnant animals intraluminally oil-stimulated or unstimulated, and in unilaterally pregnant animals. The content of kallikrein, determined by an RIA highly specific for rK1 (true tissue kallikrein), rose in ovariectomized rats with estradiol supplementation (0.28 +/- 0.03 to 0.44 +/- 0.05 ng/mg) and decreased with progesterone (0.13 +/- 0.02 ng/mg; n = 15; p < 0.001). Kallikrein content rose from Day 1 of pseudopregnancy (PP1) to a maximum on PP7 (0.18 +/- 0.01 to 0.39 +/- 0.04 ng/mg protein; n = 36; p < 0.001). On PP7 with unilateral oil intraluminal stimulation, the decidualized horn had higher kallikrein content than did the contralateral (0.98 +/- 0.09 vs. 0.35 +/- 0.05 ng/mg protein; n = 7; p < 0.001). Immunocytochemistry revealed that mainly rK1 is localized in the luminal and glandular epithelium, and it increased in the stimulated horn. In the unilaterally pregnant rat on Day 7, the fertile horn had a higher kallikrein content than its contralateral control (0.71 +/- 0.07 vs. 0.37 +/- 0.03 ng/mg protein, p < 0.001; n = 8), as well as a higher kininogenase activity (239 +/- 34.3 vs. 83.5 +/- 7.9 ng bradykinin(BK)/h per horn, p < 0.003; and 945 +/- 90 vs. 585 +/- 40 ng BK/h per gram tissue, p < 0.002; n = 6). These results indicate that estrogen stimulates, whereas progesterone inhibits, kallikrein production, and that hormonal regulation is overridden by intraluminal stimulation, thus associating the enzyme with decidualization.