Circulating clonal CLA(+) and CD4(+) T cells in Sezary syndrome express the skin-homing chemokine receptors CCR4 and CCR10 as well as the lymph node-homing chemokine receptor CCR7

BACKGROUND

Adhesion molecules and chemokine receptors are involved in tissue-specific homing of T cells to the skin and play an important role in the pathophysiology of cutaneous lymphoma. It has recently been reported that the chemokine CCL27 expressed by keratinocytes attracts lymphocytes bearing the chemokine receptor CCR10.

OBJECTIVES

To investigate the expression of CCR4, CCR7 and CCR10 on skin-homing CLA(+) and CD4(+) T cells in the peripheral blood of patients with Sezary syndrome (SS), a rare leukaemic variant of cutaneous T-cell lymphoma.

METHODS

Lymphocytes from five patients with SS, six patients with mycosis fungoides and four healthy volunteers were isolated and analysed using flow cytometry. Additionally, the T-cell receptor (TCR)-Vbeta CDR3 regions were cloned and sequenced in two patients.

RESULTS

We found that CCR4 is expressed on almost all CLA(+) and CD4(+) memory T cells. Using monoclonal antibodies specific for single TCR-Vbeta chains we identified malignant T cells in four patients with SS. Importantly, we found that most but not all malignant Sezary cells expressed the skin-homing chemokine receptor CCR10. Additionally, we found that a significant proportion of these cells also expressed the lymph node-homing chemokine receptor CCR7.

CONCLUSIONS

Our results support the concept that chemokine receptors play an important role in the pathophysiology of SS and suggest that the malignant clone may represent an expansion of skin-homing cutaneous 'central' memory T cells in the peripheral blood of these patients.

Increased mortality of preterm infants transferred between tertiary perinatal centres

Over 18 months almost one quarter of infants born before 30 weeks' gestation in a tertiary perinatal centre who required intensive care had to be transferred to other tertiary centres because intensive care facilities were fully occupied. When infants with lethal congenital malformations were excluded half of the 34 infants who were transferred died; this was twice the mortality (24%) in the 111 infants remaining. The difference between the groups was significant (relative odds = 3.1) and remained so after adjustment for any discrepancies in gestational age (relative odds = 4.0). After adjustment for potential confounding variables by logistic function regression the risk of dying for those transferred remained significantly higher than that for infants who remained (relative odds = 4.6, 95% confidence interval 1.8 to 12.1). As the requirement for neonatal intensive care is episodic and unpredictable more flexibility has to be built into the perinatal health care system to enable preterm infants delivered in tertiary perinatal centres to be cared for where they are born.

Size and shape of the corpus callosum in adult Niemann-Pick type C reflects state and trait illness variables

BACKGROUND AND PURPOSE

Variable alterations to the structure of the corpus callosum have been described in adults with NPC, a neurometabolic disorder known to result in both white and gray matter pathology. This study sought to examine the structure of the callosum in a group of adult patients with NPC and compared callosal structure with a group of matched controls, and to relate callosal structure with state and trait illness variables.

MATERIALS AND METHODS

Nine adult patients with NPC were matched to control subjects (n = 26) on age and sex. The corpus callosum was segmented from the midsagittal section of T1-weighted images on all subjects, and total area, length, bending angle, and mean thickness were calculated. In addition, 39 regional thickness measures were derived by using a previously published method. All measures were compared between groups, and analyzed alongside symptom measures, biochemical parameters, and ocular-motor measures.

RESULTS

The callosal area and mean thickness were significantly reduced in the patient group, and regional thickness differences were greatest in the genu, posterior body, isthmus, and anterior splenium. Global callosal measures correlated significantly with duration of illness and symptom score, and at trend level with degree of filipin staining. Measures of reflexive saccadic peak velocity and gain, and self-paced saccades, correlated strongly with total callosal area.

CONCLUSIONS

Callosal structure and size reflect both state and trait markers in adult NPC, and they may be useful biomarkers to index both white and gray matter changes that reflect illness severity and progression.

Altered Monocyte and Endothelial Cell Adhesion Molecule Expression Is Linked to Vascular Inflammation in Human Immunodeficiency Virus Infection

BACKGROUND

Human immunodeficiency virus (HIV)-infected individuals have increased risk for vascular thrombosis, potentially driven by interactions between activated leukocytes and the endothelium.

METHODS

Monocyte subsets (CD14⁺CD16^-, CD14⁺CD16⁺, CD14^DimCD16⁺) from HIV negative (HIV^-) and antiretroviral therapy-treated HIV positive (HIV⁺) participants (N = 19 and 49) were analyzed by flow cytometry for adhesion molecule expression (lymphocyte function-associated antigen 1 [LFA-1], macrophage-1 antigen [Mac-1], CD11c/CD18, very late antigen [VLA]-4) and the fractalkine receptor (CX3CR1); these receptors recognize ligands (intercellular adhesion molecules [ICAMs], vascular cell adhesion molecule [VCAM]-1, fractalkine) on activated endothelial cells (ECs) and promote vascular migration. Plasma markers of monocyte (soluble [s]CD14, sCD163) and EC (VCAM-1, ICAM-1,2, fractalkine) activation and systemic (tumor necrosis factor receptor [TNFR-I], TNFR-II) and vascular (lipoprotein-associated phospholipase A₂ [Lp-PLA₂]) inflammation were measured by enzyme-linked immunosorbent assay.

RESULTS

Proportions of CD16⁺ monocyte subsets were increased in HIV⁺ participants. Among all monocyte subsets, levels of LFA-1 were increased and CX3CR1 levels were decreased in HIV⁺ participants (P < .01). Levels of sCD163, sCD14, fractalkine, ICAM-1, VCAM-1, TNFR-II, and Lp-PLA₂ were also increased in HIV⁺ participants (P < .05), and levels of sCD14, TNFR-I, and TNFR-II were directly related to ICAM-1 and VCAM-1 levels in HIV⁺ participants. Expression of CX3CR1 on monocyte subsets was inversely related to plasma Lp-PLA₂ (P < .05 for all).

CONCLUSIONS

Increased proportions of CD16⁺ monocytes, cells with altered adhesion molecule expression, combined with elevated levels of their ligands, may promote vascular inflammation in HIV infection.

Changing mortality and causes of death in infants 23-27 weeks' gestational age

OBJECTIVE

To contrast the mortality rates and changes in the causes of death of very preterm infants (23-27 weeks), before and after the introduction of exogenous surfactant in 1991, and to identify any preventable causes of death remaining in the 1990s.

METHODOLOGY

This was a cohort study on consecutive preterm infants of 23-27 weeks' gestational age born in the Royal Women's Hospital, Melbourne, a level III perinatal centre. The infants were livebirths free of lethal anomalies from two distinct eras, 1983-90, and 1992-96, inclusive. The main outcome measures were mortality during the primary hospitalization and the causes of death before and after the introduction of exogenous surfactant in 1991.

RESULTS

In 1983-90, 261 of 508 livebirths (51.4%) of 23-27 weeks' gestational age died, a significantly higher proportion than the 109 of 384 (28.4%) livebirths who died in the period 1992-96. The mortality rate fell significantly with increasing gestational age and was lower at each week of gestational age in 1992-96. More infants who died in 1992-96 were treated intensively in the neonatal intensive care unit (NICU). Of the group of infants who died or who were treated intensively in NICU, respiratory causes of death predominated. However, the causes of death changed over time. In 1992-96 proportionally fewer infants died from respiratory causes (1983-90, 82.5%; 1992-96, 60.0%; odds ratio (OR) 0.31, 95%; confidence interval (CI) 0.16-0.57), but more from septic causes (1983-90, 14.3%; 1992-96, 43.8%; OR 4.9, 95%; CI 2.6-9.2).

CONCLUSIONS

As the mortality rate has fallen over time, respiratory causes of death have diminished, but septic causes of death have increased. Further advances in the use of exogenous surfactant and respiratory support may reduce respiratory deaths. Effective strategies to reduce nosocomial infections are urgently required.

Pontine-to-midbrain ratio indexes ocular-motor function and illness stage in adult Niemann-Pick disease type C

BACKGROUND AND PURPOSE

Niemann-Pick disease type C (NPC) is a progressive neurovisceral disorder associated with dystonia, ataxia and a characteristic gaze palsy. Neuropathological studies have demonstrated brainstem atrophy associated with neuronal inclusions and loss, and neurofibrillary tangles, although it is not known whether this pathology can be detected in vivo or how these changes relate to illness variables, particularly ocular-motor changes. Our aim was to utilize a method for brainstem atrophy, validated in progressive supranuclear palsy (PSP), in a group of adult patients with NPC, and explore its relationship to illness variables and ocular-motor functioning.

METHODS

We calculated the midbrain and pontine area, and pontine-to-midbrain ratio (PMR) from midsagittal images of 10 adult patients with NPC and 27 age- and gender-matched controls. Measures were correlated with illness variables, and measures of horizontal saccadic functioning.

RESULTS

Pontine-to-midbrain ratio was 14% higher in the NPC group, but this difference was not significant. However, PMR showed a significant positive correlation with duration of illness and a measure of illness severity. Furthermore, PMR was significantly negatively correlated with saccadic peak velocity and gain, and self-paced saccadic performance.

CONCLUSIONS

Pontine-to-midbrain ratio was increased in adult patients with NPC compared to controls, although not to the same degree as previously described in PSP, which also presents with significant gaze palsy. These changes were driven predominantly by progressive midbrain atrophy. The strong correlation with illness and ocular-motor variables suggests that it may be a useful marker for illness progression in NPC.

Continuing morbidity in extremely low birthweight infants

The pattern of lesser but continuing morbidity in the first 2 years was reported in 36 survivors who weighed 500-799 g at birth and in 83 survivors who weighed 800-999 g at birth. Over this period, there was one post-discharge death. Sixty-one percent of children were rehospitalized, most commonly for respiratory tract disorders and surgical procedures such as aural ventilation tube insertion and inguinal herniorrhaphy. Their three most common medical disorders were otitis media (55%), wheezing episode (48%) and lower respiratory tract infection (29%). At 2 years of age, 44% remained below the tenth percentile for weight, 45% for height and 12% for head circumference. Other lesser morbidity included iatrogenic scarring, abnormal head shape and behavioural problems. Except for otitis media, survivors of 500-799 g birthweight did not have a significantly higher rate of neurodevelopmental impairment, health problems, rehospitalization, suboptimal growth or behavioural disorders, compared to those of 800-999 g birthweight. This study confirms the need for providing extremely low birthweight children and their families with a continuity of comprehensive medical care and social support after hospital discharge.

Prospective Analysis of Lipid Composition Changes with Antiretroviral Therapy and Immune Activation in Persons Living with HIV

Background

Lipid profiles are altered by HIV infection and antiretroviral therapy (ART). Among HIV-uninfected (HIV-) populations the concentrations of various lipid classes (ie, lyso-phosphatidylcholine, LPC) and their saturated (SaFA), mono-unsaturated (MUFA), and polyunsaturated fatty acid (PUFA) composition are related to cardiometabolic disease risk. Associations between changes in the lipidome and immune activation in HIV-infected (HIV+) individuals beginning ART have not been described.

Methods

Plasma lipid concentrations and their fatty acid composition were measured by differential mobility spectroscopy in samples from 35 treatment-naive HIV+ participants beginning raltegravir (RAL)-based ART and from HIV- individuals (n = 13) matched for age and sex.

Results

The levels of SaFA, including palmitic (16:0) and stearic (18:0) acid were enriched in HIV+ participants (pre- and post-ART), and SaFA levels were often positively correlated with levels of immune activation (ie, IL-6, sCD14, and TNFR1) at baseline and week 48. Levels of PUFAs (including 18:3, 20:4, and 20:5) were lower in HIV+ participants at baseline compared to levels in HIV- participants (P < 0.01), and levels of these PUFAs were increased following 48 weeks of ART. Levels of PUFAs were often inversely related to immune activation. Levels of LPC were increased in HIV+ participants, both pre- and post-ART vs HIV- participants, and the composition of LPC was enriched for SaFAs among HIV+ individuals. At week 48, several LPC molecules containing SaFAs were positively correlated with levels of sCD14, D-dimer, and TNFR1 (P < 0.01), and levels of PUFA-containing LPC (18:3, 20:5, 22:5, 22:6) were positively correlated with CD4+ T cell counts and inversely correlated with sCD14 and IL-6 (P < 0.01).

Conclusions

The composition of the lipidome is altered in HIV infection and changes when ART is administered. Alterations in SaFAs were generally associated with inflammatory markers and may contribute to comorbid disease pathogenesis.

The cost of improving the outcome for infants of birthweight 500-999 g in Victoria. The Victorian Infant Collaborative Study Group

The aim of this study was to conduct an economic evaluation of neonatal intensive care for extremely low birthweight (ELBW) infants born in the state of Victoria. Two distinct eras (1979-80 and 1985-87) were compared. Follow-up data at 2 years of age were available for all 89 survivors from the 351 live births in 1979-80, and for 211 of 212 survivors from the 560 live births in 1985-87. The overall cost-effectiveness for ELBW infants during 1985-87 compared with 1979-80 was $104,990 ($A 1987) per additional survivor, or $5390 ($A 1987) per additional life year gained. Cost-effectiveness improved with increasing birthweight. If the quality of life of the survivors was considered, the economic outlook was more favourable. The cost per quality-adjusted life year gained was $5090 ($A 1987), approximately one-tenth of that obtained from the only previous full economic evaluation of neonatal intensive care. Although neonatal intensive care is expensive, it compares favourably with some other health care programmes, particularly as the outcome for ELBW infants continues to improve.

Gender dimorphism in siblings with schizophrenia-like psychosis due to Niemann-Pick disease type C

We describe the differential presentation of schizophrenia-like psychosis in two siblings with the 'variant' biochemical presentation of adult Niemann-Pick disease type C. The male sibling presented with psychosis at age 16 years and cognitive and motor disturbance at age 25 years, whereas his elder sister, sharing the same mutation but showing less severe biochemical, neuroimaging and ocular motor parameters, presented with a similar schizophrenia-like illness with associated cognitive and motor disturbance at age 31 years. Their illness onset, course and response to treatment mirrors the sex dimorphism seen in schizophrenia, and is suggestive of an interaction between the neurobiology of their metabolic disorder and sex differences in neurodevelopment.

Changes over time in attitudes to treatment and survival rates for extremely preterm infants (23-27 weeks' gestational age)

We determined the changes over time in attitude to treatment of very preterm infants (23-27 weeks of gestational age) born at the Royal Women's Hospital, Melbourne, and their survival rate. The subjects were consecutive livebirths at 23-27 weeks' gestational age born from 1983-1994, inclusive. The main outcomes measured were the proportions of livebirths treated intensively and survival rates to hospital discharge, both excluding lethal abnormalities. Over the 12 years of the study there were 788 livebirths free of lethal abnormalities born at 23-27 week's gestational age. Overall 669 (85%) were treated intensively; the proportions treated intensively rose significantly over time from 74% in 1983-1985 to 91% in 1992-1994, and with increasing gestational age, from 19% at 23 weeks to 100% at 27 weeks. Overall 439 (56%) survived their primary hospitalization; the survival rate rose significantly over time, from 43% in 1983-1985 to 70% in 1992-1994, and with increasing gestational age, from 3% at 23 weeks to 78% at 27 weeks. In 1992-1994, the survival rates were 11% at 23 weeks, 53% at 24 weeks, 70% at 25 weeks, 81% at 26 weeks, and 87% at 27 weeks. For infants treated intensively, the survival rate rose significantly from 53% in 1983-1985 to 76% in 1992-1994. The largest increases in survival have occurred in the 1990s, and at 24 and 25 weeks' gestational age. The proportions of very preterm infants treated intensively and their survival rates have increased over time, and have always been higher with increasing gestational age.

Lipidome Abnormalities and Cardiovascular Disease Risk in HIV Infection

PURPOSE OF REVIEW

Human immunodeficiency virus (HIV) infection and its treatment with antiretroviral therapy (ART) are associated with lipid abnormalities that may enhance cardiovascular disease risk (CVD).

RECENT FINDINGS

Chronic inflammation persists in HIV+ individuals, and complex relationships exist among lipids and inflammation, as immune activation may be both a cause and a consequence of lipid abnormalities in HIV infection. Advances in mass spectrometry-based techniques now allow for detailed measurements of individual lipid species; improved lipid measurement might better evaluate CVD risk compared with the prognostic value of traditional assessments. Lipidomic analyses have begun to characterize dynamic changes in lipid composition during HIV infection and following treatment with ART, and further investigation may identify novel lipid biomarkers predictive of adverse outcomes. Developing strategies to improve management of comorbidities in the HIV+ population is important, and statin therapy and lifestyle modifications, including diet and exercise, may help to improve lipid levels and mitigate CVD risk.

Elucidation of the 2-aminoethylphosphonate biosynthetic pathway in Tetrahymena pyriformis

The biosynthetic reaction pathway leading to the natural product, 2-aminoethylphosphonate in Tetrahymena pyriformis has been elucidated. Incubation of [32P]PEP and [14C]PEP with T.pyriformis cellular homogenate fortified with Mg2+ and alanine/pyridoxal phosphate, yielded 2-aminoethylphosphonate as the minor reaction product (2-5% yield) and phosphoglycerate and pyruvate plus orthophosphate as the major products. Inclusion of thiamine pyrophosphate in the reaction mixture increased the yield of 2-aminoethylphosphonate by a factor of 10. Incubation of phosphonoacetaldehyde or phosphonopyruvate in the cellular homogenate also provided 2-aminoethylphosphonate. The cellular homogenate catalyzed the transformation of phosphonoacetaldehyde to 2-aminoethylphosphonate in an ca. 80% yield. However, the maximum yield of 2-aminoethylphosphonic acid obtained by use of phosphonopyruvate was only 15%. The major reaction pathways induced by treatment of phosphonopyruvate with the cellular extract involved its competitive conversion to PEP and pyruvate plus orthophosphate.

Changes in the Fungal Marker β-D-Glucan After Antiretroviral Therapy and Association With Adiposity

BACKGROUND

Bacterial translocation in HIV is associated with inflammation and metabolic complications; few data exist on the role of fungal translocation.

METHODS

A5260s was a substudy of A5257, a prospective open label randomized trial in which treatment-naïve people with HIV (PWH) were randomized to tenofovir-emtricitabine (TDF/FTC) plus atazanavir-ritonavir (ATV/r), darunavir-ritonavir (DRV/r), or raltegravir (RAL) over 96 weeks. Baseline was assessed, and changes in β-D-glucan (BDG) were assessed at weeks 4, 24, and 96. Wilcoxon rank-sum tests were used to compare distribution shifts in the changes from baseline between treatment arms and linear regression models to assess associations between BDG and measures of inflammation, body composition, and insulin resistance.

RESULTS

Two hundred thirty-one participants were randomized; 90% were male, the median age was 36 years, HIV-1 RNA was 4.56 log10c/mL, and CD4 cell count was 338 cells/mm3. There was an overall increase in BDG over 96 weeks (1.57 mean fold-change; 95% confidence interval, 1.39 to 1.77) with no differences between arms. Twofold higher BDG levels at week 96 were associated with increases in trunk fat (8%) and total fat (7%) over 96 weeks (P ≤ .035). At week 4, BDG correlated with I-FABP, a marker of enterocyte damage, and zonulin, a marker of intestinal permeability (r = .19-.20; P < .01).

CONCLUSIONS

In treatment-naïve participants initiating antiretroviral therapy (ART) with TDF/FTC and either RAL or ATV/r, DRV/r, BDG, a marker of fungal translocation, increased similarly in all arms over 96 weeks. This may represent continued intestinal damage during ART and resulting fungal translocation. Higher BDG was associated with larger fat gains on ART.

Insulin resistance and intestinal integrity in children with and without HIV infection in Uganda

OBJECTIVES

The risk of cardiometabolic complications in children with perinatally acquired HIV infection (PHIVs) and in perinatally HIV-exposed but uninfected children (HEUs) and its relationship to systemic inflammation and markers of gut integrity are not well established. In this current study, we assed insulin resitance in PHIV compared to HEUs and HIV unexposed uninfected children and explored potential association with intestinal damage biomarkers.

METHODS

This was a cross-sectional study in PHIVs, HEUs and HIV-unexposed, uninfected children (HUUs) aged 2-10 years enrolled in Uganda. PHIVs were on stable antiretroviral therapy (ART) with HIV viral load  < 400 HIV-1 RNA copies/mL. Insulin resistance was estimated using the homeostasis model assessment of insulin resistance (HOMA-IR). We measured markers of systemic inflammation, monocyte activation and gut integrity. Kruskal-Wallis tests were used to compare markers by HIV status; Pearson correlation and multiple linear regressions were used to assess associations of the HOMA-IR index with biomarkers of intestinal damage and translocation.

RESULTS

Overall, 172 participants were enrolled in the study (57 PHIVs, 59 HEUs and 56 HUUs). The median age was 7.8 [interquartile range (IQR) 6.39, 8.84] years, 55% were female and the median body mass index (BMI) was 15 (IQR 14.3, 15.8) kg/m² . Among PHIVs, the median CD4% was 37%, and 93% had viral load ≤ 20 copies/mL. PHIVs had higher waist:hip ratio, high-density lipoprotein (HDL) cholesterol, triglycerides and HOMA-IR index than the other groups (P ≤ 0.02). Factors correlated with insulin resistance included higher BMI and HDL cholesterol and lower soluble tumour necrosis factor receptor I (sTNFRI) (P ≤ 0.02). There was no correlation between any of the other inflammatory or gut biomarkers and HOMA-IR index (P ≥ 0.05). After adjusting for age and sTNFRI, BMI remained independently associated with the HOMA-IR index (β = 0.16; P < 0.01).

CONCLUSIONS

Despite viral suppression, Ugandan PHIVs have disturbances in glucose metabolism. Higher BMI, and not immune activation or alteration of gut integrity, was associated with insulin resistance in this population.

Serum Albumin Is Associated With Higher Inflammation and Carotid Atherosclerosis in Treated Human Immunodeficiency Virus Infection

Background

This study was conducted to explore the associations between serum albumin and markers of inflammation and cardiovascular disease in treated human immunodeficiency virus (HIV)-infected adults.

Methods

We conducted a nested study within in the SATURN-HIV trial in which 147 HIV⁺ adults on stable antiretroviral therapy were (1) virally suppressed, (2) had a low-density lipoprotein (LDL)-cholesterol level <130 mg/dL, and (3) were randomized to 10 mg daily rosuvastatin or placebo. Measures of serum albumin, carotid intima media thickness ([cIMT] surrogate marker of atherosclerosis), inflammation, T cells, monocyte activation, and gut integrity were assessed at baseline, 48 and 96 weeks later. Spearman correlations and linear mixed-effect models were used to assess associations with serum albumin.

Results

Mean age was 45 years, 80% of participants were male, and 69% were African American. Mean serum albumin was similar between the groups at all time points (4.01-4.09 g/dL in statin arm vs 4.02-4.11 g/dL in placebo arm; P = .08-0.35). Lower baseline serum albumin significantly predicted larger changes in cIMT, interleukin 6, D-dimer, tumor necrosis factor α receptor 1, fibrinogen, and high-sensitivity C-reactive protein (P ≤ .03) over 96 weeks independently of statin therapy. After adjusting for age, gender, smoking, body mass index, creatinine clearance, and LDL cholesterol, every 1 g/dL decrease in serum albumin at baseline remained associated with a 0.05-mm increase in cIMT over 96 weeks (P = .05).

Conclusions

Lower serum albumin in controlled HIV is associated with higher markers of chronic inflammation and hypercoagulation, which could explain the prior observation that serum albumin predicts nonacquired immune deficiency syndrome events in HIV. Serum albumin may predict progression of carotid atherosclerosis independent of traditional risk factors.

Subclinical Vascular Disease in Children With Human Immunodeficiency Virus in Uganda Is Associated With Intestinal Barrier Dysfunction

BACKGROUND

The risk of cardiovascular disease (CVD) and its mechanisms in children living with perinatally acquired HIV (PHIV) in sub-Saharan Africa has been understudied.

METHODS

Mean common carotid artery intima-media thickness (IMT) and pulse-wave velocity (PWV) were evaluated in 101 PHIV and 96 HIV-negative (HIV-) children. PHIV were on ART, with HIV-1 RNA levels ≤400 copies/mL. We measured plasma and cellular markers of monocyte activation, T-cell activation, oxidized lipids, and gut integrity.

RESULTS

Overall median (interquartile range, Q1-Q3) age was 13 (11-15) years and 52% were females. Groups were similar by age, sex, and BMI. Median ART duration was 10 (8-11) years. PHIV had higher waist-hip ratio, triglycerides, and insulin resistance (P ≤ .03). Median IMT was slightly thicker in PHIVs than HIV- children (1.05 vs 1.02 mm for mean IMT and 1.25 vs 1.21 mm for max IMT; P < .05), while PWV did not differ between groups (P = .06). In univariate analyses, lower BMI and oxidized LDL, and higher waist-hip ratio, hsCRP, and zonulin correlated with thicker IMT in PHIV (P ≤ .05). After adjustment for age, BMI, sex, CD4 cell count, triglycerides, and separately adding sCD163, sCD14, and hsCRP, higher levels of intestinal permeability as measured by zonulin remained associated with IMT (β = 0.03 and 0.02, respectively; P ≤ .03).

CONCLUSIONS

Our study shows that African PHIV have evidence of CVD risk and structural vascular changes despite viral suppression. Intestinal intestinal barrier dysfunction may be involved in the pathogenesis of subclinical vascular disease in this population.

Assisted ventilation and survival of extremely low birthweight infants

OBJECTIVE

To determine the incremental consumption of ventilator resources associated with the improving survival rate of extremely low birthweight (ELBW birthweight 500-999g) infants, from the time assisted ventilation was introduced.

METHODOLOGY

Cohort study of ELBW infants born in one tertiary perinatal centre (The Royal Women's Hospital, Melbourne). All ELBW infants born from 1971 to 1993 were included in the study. In hospital survival rates and patient-days of assisted ventilation were the main outcome measures. Discrete eras of relatively stable survival rate and consumption of ventilator resources were identified. These comprised the years 1971-74, 1977-83, 1985-90, and 1992-93. Cost-effectiveness ratios (the incremental consumption of ventilator resources per additional survivor) were calculated between adjacent eras by dividing the increment in the consumption of ventilator resources by the increment in the survival rate.

RESULTS

The survival rates rose progressively between eras (6.2, 33.9, 49.1, 68.8%, respectively, as did the consumption of ventilator resources (0.1, 6.6, 16.2, 24.7 patient-days of assisted ventilation per livebirth, respectively). The cost-effectiveness ratio deteriorated initially, increasing from 23.2 to 63.5 additional patient-days of assisted ventilation per additional survivor, but then improved, falling to 43.1 additional patient-days of assisted ventilation per additional survivor in the last era. These changes were even more marked for those of birthweight 750-999g (20.0, 63.2 to 35.9 additional patient-days of assisted ventilation per additional survivor, respectively). In contrast, the cost-effectiveness ratio was initially worse for those of birthweight 500-749 g, being three-fold higher than for the larger infants, and only improved substantially in the last era (59.8, 58.3 to 44.1 additional patient-days of assisted ventilation per additional survivor, respectively).

CONCLUSIONS

The initial deterioration in cost-effectiveness ratios between successive eras probably reflected the increased availability of resources for assisted ventilation, without any other major advances in perinatal care. The improvement in cost-effectiveness in the last era reflected, in part, the increased use of antenatal steroid therapy and the introduction of exogenous surfactant to neonatal intensive care.

The appearance of endogenous opiates in cerebrospinal fluid following opiate injection in various animal species

Phenylquinone writhing, tail-flick, stimulated guinea pig ileum and mouse vas deferens were used to quantitate opiate-like activity in CSF taken prior to and at various times after the injection of morphine. The injection of various doses of morphine caused a dose responsive increase in opiate-like material in rabbit CSF taken at the peak of activity (60 min later). Morphine also caused an increase in opiate activity in dog CSF. Quantitation of radioactivity in CSF after the injection of radiolabelled morphine, stability studies and other assays were used to rule out the possibility that the increased activity in CSF was due to morphine itself. CSF taken after morphine injection produced a peak on HPLC with a 15 minute retention time which was not present in CSF taken prior to the injection. This peak was not caused by morphine, met-enkephalin, leu-enkephalin, dynorphin 1-13 or beta-endorphin which have retention times of 5, 7, 9, 22 and 30 minutes, respectively. Preinjection of the rabbit with naloxone blocked the increased opiate-like effects of CSF taken after morphine and the opiate effects of the CSF were antagonized by naloxone injected into mice or the isolated organ bath.

Immunomodulatory and Anti-Inflammatory Strategies to Reduce Comorbidity Risk in People with HIV

PURPOSE OF REVIEW

In this review, we will discuss treatment interventions targeting drivers of immune activation and chronic inflammation in PWH.

RECENT FINDINGS

Potential treatment strategies to prevent the progression of comorbidities in PWH have been identified. These studies include, among others, the use of statins to modulate lipid alterations and subsequent innate immune receptor activation, probiotics to restore healthy gut microbiota and reduce microbial translocation, hydroxychloroquine to reduce immune activation by altering Toll-like receptors function and expression, and canakinumab to block the action of a major pro-inflammatory cytokine IL-1β. Although many of the treatment strategies discussed here show promise, due to the complex nature of chronic inflammation and comorbidities in PWH, larger clinical studies are needed to understand and target the prominent drivers and inflammatory cascades underlying these end-organ diseases.

Preterm infants 30-36 weeks' gestation in Victoria--where should they be delivered?

There is little doubt that very preterm infants <30 weeks' gestation should be born in level-3 perinatal centres. For preterm infants 30-36 weeks' gestation, however, the optimum place of birth is not so clear-cut. The aims of this study of livebirths 30-36 weeks' gestational age born in Victoria were to determine: 1) the proportions delivered outside level-3 centres, and 2) for infants born outside level-3 centres, the proportions transferred after birth to a level-3 nursery in the first days after birth. Data on the number of livebirths 30-36 weeks' gestational age in Victoria in the 3 years 1994-1996, inclusive, were supplied by the Victorian Perinatal Data Collection Unit. Data were obtained from the Newborn Emergency Transport Service (NETS) on all transfers within the first 3 days after birth to a level-3 centre for infants born outside level-3 centres. For the 3 years 1994-1996 there were 11,375 livebirths 30-36 weeks' gestational age in Victoria. The proportion born outside a level-3 perinatal unit was 57.9% overall, and rose with increasing gestational age, from 10.9% at 30 weeks to 69.0% at 36 weeks. Of the 6,587 livebirths outside a level-3 centre, 808 (12.3%) were transferred within the first 3 days after birth by NETS to a level-3 centre, the proportions falling with increasing maturity, being 73.7%, 48.5%, 28.4%, 26.9%, 18.8%, 11.8%, and 7.0% at 30, 31, 32, 33, 34, 35, and 36 weeks, respectively. These data may help medical practitioners when determining the place of delivery for infants 30-36 weeks' gestation.

Micronutrients, Metabolic Complications, and Inflammation in Ugandan Children With HIV

BACKGROUND

Selenium, zinc, and chromium are essential micronutrients. Their alterations have been associated with HIV disease progression, metabolic complications, and mortality.

METHODS

This is a cross-sectional study in children with perinatally acquired HIV (PHIV, n = 57), HIV-exposed uninfected (HEU, n = 59), and HIV-unexposed uninfected (HIV-, n = 56) children aged 2 to 10 years old, age- and sex-matched, enrolled in Uganda. PHIV were on stable antiretroviral therapy (ART) with undetectable viral load. We measured plasma concentrations of selenium, zinc, and chromium as well as markers of systemic inflammation, monocyte activation, and gut integrity.

RESULTS

Among PHIV children, 93% had viral load ≤20 copies/mL, median CD4 was 37%, and 77% were receiving a nonnucleotide reserve transcriptase regimen. Median age of all participants was 8 years and 55% were girls. Median selenium concentrations were higher in PHIV compared with the HEU and HIV groups (P < 0.001), 46% of children overall had low zinc status (P = 0.18 between groups). Higher selenium, but not chromium or zinc, was associated with lower IL6, sTNFRI and II, and higher beta d glucan, a marker of fungal translocation, zonulin, a marker of gut permeability, oxidized LDL and insulin resistance (P ≤ 0.01).

CONCLUSION

In this cohort of PHIV on ART in Uganda, there is a high prevalence of low zinc status overall. Higher plasma selenium concentrations were associated with lower systemic inflammation and higher gut integrity markers. Although our findings do not support the use of micronutrient supplementation broadly for PHIV in Uganda, further studies are warranted to assess the role of selenium supplements in attenuating heightened inflammation.