Predictors of trend in CD4-positive T-cell count and mortality among HIV-1-infected individuals with virological failure to all three antiretroviral-drug classes

BACKGROUND

Treatment strategies for patients in whom HIV replication is not suppressed after exposure to several drug classes remain unclear. We aimed to assess the inter-relations between viral load, CD4-cell count, and clinical outcome in patients who had experienced three-class virological failure.

METHODS

We undertook collaborative joint analysis of 13 HIV cohorts from Europe, North America, and Australia, involving patients who had had three-class virological failure (viral load >1000 copies per mL for >4 months). Regression analyses were used to quantify the associations between CD4-cell-count slope, HIV-1 RNA concentration, treatment information, and demographic characteristics. Predictors of death were analysed by Cox's proportional-hazards models.

FINDINGS

2488 patients were included. 2118 (85%) had started antiretroviral therapy with single or dual therapy. During 5015 person-years of follow-up, 276 patients died (mortality rate 5.5 per 100 person-years; 3-year mortality risk 15.3% (95% CI 13.5-17.3). Risk of death was strongly influenced by the latest CD4-cell count with a relative hazard of 15.8 (95% CI 9.28-27.0) for counts below 50 cells per microL versus above 200 cells per microL. The latest viral load did not independently predict death. For any given viral load, patients on treatment had more favourable CD4-cell-count slopes than those off treatment. For patients on treatment and with stable viral load, CD4-cell counts tended to be increasing at times when the current viral load was below 10000 copies per mL or 1.5 log10 copies per mL below off-treatment values.

INTERPRETATION

In patients for whom viral-load suppression to below the level of detection is not possible, achievement and maintenance of a CD4-cell count above 200 per microL becomes the primary aim. Treatment regimens that maintain the viral load below 10000 copies per mL or at least provide 1.5 log10 copies per mL suppression below the off-treatment value do not seem to be associated with appreciable CD4-cell-count decline.

Screening for hepatocellular carcinoma in patients with Child's A cirrhosis: an 8-year prospective study by ultrasound and alphafetoprotein

One hundred and forty-seven patients with Child's A cirrhosis and no evidence of hepatocellular carcinoma were followed up in an 8-year prospective surveillance program with testing by ultrasound and alphafetoprotein every 6 months. Eighteen of 147 patients were HBsAg positive. Anti-hepatitis C virus antibodies were found in 103 out of 133 cases tested. Sixteen patients had a history of heavy drinking. Thirty hepatocellular carcinomas were detected during follow up. At the time of diagnosis, ultrasound detected focal lesions in all the patients whereas alphafetoprotein was below diagnostic levels. The hepatocellular carcinoma was single in 26 patients and multiple in four. The overall 8-year cumulative tumor-free rate was 69% (95% confidence interval = 58-73). The yearly hepatocellular carcinoma incidence from 1985 to 1992 was respectively 2%, 1.5%, 2%, 3%, 5%, 4.8%, 7% and 10%. The initial value of AFP > 50 ng/ml and < 400 ng/ml was significantly related to the development of hepatocellular carcinoma. This series shows that the cumulative incidence of hepatocellular carcinoma in cirrhosis in Italy is higher than previously reported, but lower than that observed in Asiatic areas. A 6-month interval for ultrasound is reasonable to detect treatable tumors. Alphafetoprotein has no value for early diagnosis, although its intermediate values (> 50 and < 400 ng/ml) may indicate the presence of undetectable cancer which will appear during the follow up, and suggests that ultrasound should be employed more frequently in patients with these values.

Asymptomatic hepatocellular carcinoma in Child's A cirrhosis. A comparison of natural history and surgical treatment

The present study deals with the natural history of 37 asymptomatic patients with cirrhosis and hepatocellular carcinoma, 25 with 2-9-cm tumors who were not surgically treated (first group) and 12 with tumors smaller than 4 cm who underwent resection (second group). All patients were in Child's A class. Two-year survival (according to life-table analysis by the Kaplan-Meier method) was 50% in the first group and 39% in the second group. This difference was not significant. In the first group no relation was found between survival and initial tumor size or alpha-fetoprotein levels. Ultrasound examinations at 3-mo intervals revealed the following patterns of tumor growth: (a) no significant growth during the follow-up (9 patients); (b) significant growth (tumor size at least doubling) only in the final stage of the disease (11 patients); (c) initial significant growth followed by a period of no increase in size (5 patients). These findings show that in our geographical area (a) 2-yr survival of untreated asymptomatic patients with hepatocellular carcinoma associated with cirrhosis does not differ from that of similar patients undergoing resection and (b) the tumor can exhibit long periods of no growth alternating with periods of exponential growth.

HIV-associated thrombotic microangiopathy in the era of highly active antiretroviral therapy: an observational study

The prevalence and predisposing factors of thrombotic microangiopathy (TMA) in the era of highly active antiretroviral therapy (HAART) were evaluated among patients in the Collaborations in Human Immunodeficiency Virus (HIV) Outcomes Research/US cohort. Of 6022 patients, 17 (0.3%) had TMA, with unadjusted incidences per 100 person-years of 0.079 for TMA, 0.009 for thrombotic thrombocytopenic purpura, and 0.069 for hemolytic-uremic syndrome. Compared with patients without TMA, patients with TMA had lower mean CD4(+) cell counts (197 vs. 439 cells/mm(3); P=.0009) and higher mean log(10) HIV-1 RNA levels (4.6 vs. 3.3 copies/mL; P=.0001) at last follow-up and a significantly greater incidence of acquired immune deficiency syndrome (82.4% vs. 55.3%; P=.025), Mycobacterium avium complex infection (17.6% vs. 3.3%; P=.018), hepatitis C (29.4% vs. 11.3%; P=.001), and death (41.2% vs. 7.4%; P<.0001). The prevalence of herpes and use of antiherpetics were slightly higher for patients with TMA, but unadjusted distributions were not statistically significant. TMA in a cohort surveyed after the introduction of HAART was rare and was associated with advanced HIV disease.

How many processes are responsible for phenotypic evolution?

In addressing phenotypic evolution, this article reconsiders natural selection, random drift, developmental constraints, and internal selection in the new extended context of evolutionary developmental biology. The change of perspective from the "evolution of phenotypes" toward an "evolution of ontogenies" (evo-devo perspective) affects the reciprocal relationships among these different processes. Random drift and natural selection are sibling processes: two forms of post-productional sorting among alternative developmental trajectories, the former random, the latter nonrandom. Developmental constraint is a compound concept; it contains even some forms of natural ("external" and "internal") selection. A narrower definition ("reproductive constraints") is proposed. Internal selection is not a selection caused by an internal agent. It is a form of environment-independent selection depending on the level of the organism's internal developmental or functional coordination. Selection and constraints are the main deterministic processes in phenotypic evolution but they are not opposing forces. Indeed, they are continuously interacting processes of evolutionary change, but with different roles that should not be confused.

Ultrasonography and alpha-fetoprotein in diagnosis of hepatocellular carcinoma in cirrhosis

The accuracy of ultrasound (US) and alpha-fetoprotein (AFP) in the diagnosis of hepatocellular carcinoma (HCC) in 363 patients with cirrhosis (C) and a clinical suspicion of HCC was assessed. The ultrasonographic patterns of HCC and their relationship with AFP values were analyzed. Echographic patterns were distributed as follows: 47 patients had sonodense lesions; 30 patients had hypoechoic lesions; 47 had mixed-pattern lesions, and in four patients focal dilated intrahepatic bile ducts were demonstrated. The sensitivity of US was 90%; specificity was 93.3%. Serum AFP level greater than or equal to 500 ng/ml (RIA) was the first clue to the diagnosis in 71 patients (48.6%); specificity was 100%. In 28 patients AFP levels became significantly elevated during follow-up after US detection of HCC. No relationship between echo pattern and serum AFP levels was demonstrated. An algorithm for diagnosis of HCC is proposed.

Serum selenium and coronary heart disease risk factors in southern Italian men

The association between serum selenium concentration and a number of coronary heart disease risk factors is studied in 364 males from southern Italy participating in the Olivetti Heart Study. Selenium correlates positively and significantly with serum cholesterol (r = 0.120; P = 0.022), and this positive association persists after adjustment for age and body mass index. Selenium levels in heavy smokers are lower than both light smokers and current non-smokers, but these differences do not reach statistical significance. Selenium is not significantly associated with any of the other CHD risk factors (e.g., triglycerides, HDL cholesterol, blood pressure, age, and body mass index). It is hypothesized that the association between selenium and serum cholesterol reported in this and previous studies could be due to dietary interrelationships between selenium intake and foods that affect serum cholesterol concentrations.

Sludge and stones in gallbladder after pregnancy. Prevalence and risk factors

The prevalence of sludge and stones in the gallbladder of 298 women in the immediate post-partum period was ultrasonographically assessed. We have investigated some risk factors for the development of sludge or stones in these patients and followed up most of these patients by ultrasonography to detect the presence of sludge and/or stones in the year following their discovery. We found sludge in 80 (26.2%) and gallstones in 16 (5.2%) of these patients. Age, obesity and months of oral contraceptive use were risk factors only for the presence of gallstones. After 1 year of follow-up only 2 out of 45 patients with sludge but 13 out of 15 patients with gallstones still had abnormal ultrasonographic findings.

Comparing pioglitazone to insulin with respect to cancer, cardiovascular and bone fracture endpoints, using propensity score weights

Background

Diabetes is an important global disease, associated with significant morbidity and an increased risk of death due to chronic end-organ complications. The thiazolidinediones, used mainly as third-line agents in type 2 diabetes mellitus (T2DM), have been associated with some safety concerns, such as an increased risk of bladder cancer, an increased risk of bone fracture and heterogeneous effects on cardiovascular events.

Objective

This study aimed to evaluate safety data on pioglitazone for several outcomes and examine them in context with each other as well as with insulin, another third-line treatment for T2DM.

Methods

This retrospective cohort study extracted data from May 1, 2000 until June 30, 2010, from the i3 InVision Data Mart™ database. To adjust for the testing of multiple hypotheses, the Holm method was applied to endpoints representing potential harm from pioglitazone treatment, separately from those representing potential benefit from pioglitazone. The study population included patients with T2DM ≥ 45 years old who were new users of either pioglitazone or insulin. Key outcomes were incident cases of a composite of myocardial infarction (MI) or stroke requiring hospitalization; bone fracture requiring hospitalization; bladder cancer; and a composite of nine other selected cancers. Kaplan–Meier curves were generated and hazard ratios (HRs) for pioglitazone versus insulin were estimated from Cox proportional hazards models adjusted with inverse probability of treatment weights derived from propensity scores.

Results

A total of 56,536 patients (pioglitazone group 38,588; insulin group 17,948) qualified for the study. The mean follow-up was 2.2 years for pioglitazone and 1.9 years for insulin patients. Weighted survival analysis of the composite of MI and stroke, as well as the composite of nine cancers, yielded significant differences in favour of pioglitazone. For the composite of MI and stroke, the HR for pioglitazone versus insulin was 0.44 (95 % confidence interval [CI] 0.39–0.50, p < 0.0001). Modelling of the composite of nine selected cancers produced an HR of 0.78 (95 % CI 0.71–0.85, p < 0.0001). A non-statistically significant difference in favour of pioglitazone was observed in the incidence rate of bone fracture requiring hospitalization (HR 0.86, 95 % CI 0.74–1.01, p = 0.058). For bladder cancer, the overall incidence rates were relatively low and showed no significant difference between the two groups; the HR for pioglitazone versus insulin was 0.92 (95 % CI 0.63–1.33, p = 0.64).

Conclusion

Compared with insulin, pioglitazone was associated with a significant reduction in the risk of MI and stroke requiring hospitalization, and a significant reduction in the risk of other selected cancers. While pioglitazone treatment may be linked with a lower risk of bladder cancer and bone fracture relative to insulin, these differences were not statistically significant.

Neospora caninum in pastured cattle: determination of climatic, environmental, farm management and individual animal risk factors using remote sensing and geographical information systems

A cross-sectional serological survey was conducted on cattle pasturing in an area of the southern Italian Apennines to evaluate the seroprevalence to Neospora caninum, and to investigate the climatic, environmental, farm management, and individual animal factors that influence the distribution of this protozoan. Blood samples were collected from 864 pastured cattle raised on 81 farms. Serum samples were tested for antibodies to N. caninum using an ELISA assay (HerdCheck), IDEXX). A geographical information system (GIS) for the study area was constructed using the following remote sensing (RS) and landscape feature data: autumn-winter, spring and summer normalized difference vegetation index (NDVI), land cover, elevation, slope, aspect, mean rainfall and minimum, mean, and maximum temperature in spring, summer, autumn and winter. Data on each of these features were then extracted for "buffer zones" consisting of the area included in a circle of 3 km diameter centered on the 81 geo-referenced centroids of the main cattle pastures. Climatic and environmental data obtained from RS and GIS and individual animal characteristics and farm management data obtained from a questionnaire were analyzed in relation to N. caninum seropositivity and antibody titres both by linear and logistic regression models. Out of the 81 farms sampled, 63 (77.8%) had at least one tested animal positive for N. caninum. Out of the 864 bovine sera samples, 266 (30.8%) were found to have antibodies to N. caninum. The results of the logistic regression model show that significantly high seroprevalence to N. caninum was found in heifers/steers and adults, in cattle raised on farms having a large number of dogs, and in cattle raised in buffer zones having high minimum temperatures in the spring, and a narrow extension of summer NDVI. In addition, positive linear correlations were found between N. caninum antibody titres and the number of dogs on farm, and the minimum temperature in spring. All the above determined risk factors for N. caninum seroprevalence indicate that horizontal infection resulting from the ingestion of oocysts shed by dogs is the most probable route of N. caninum infection in pastured cattle of the southern Italian Apennines.

Neosporosis in water buffalo (Bubalus bubalis) in Southern Italy

A study was carried on 1377 water buffalo serum samples from 50 farms in southern Italy to test the presence of Neospora caninum antibodies by indirect fluorescence antibody test (IFAT). Rabbit anti-buffalo immunoglobulins conjugated to fluorescein were used in the test. Fluorescence in sera dilutions above 1:200 was considered as indicative of the presence of N. caninum antibodies. The overall prevalence of infection in the animals was 34.6%. The prevalence increased in relation to the age of subjects and most of the herds examined (82%) were found infected. In two farms abortions and neurological signs were reported. No suppurative inflammatory lesions were seen, but few protozoan-like cysts were observed on foetal tissues by histology.

Baldness and coronary heart disease risk factors

The present report focuses on the association between baldness pattern and coronary heart disease risk factors in 872 male factory workers from southern Italy participating in an epidemiological study. Participants were divided according to presence or absence of baldness and baldness pattern. Participants with fronto-occipital baldness (male-type baldness) (n = 280) characterized by hair loss centered over the vertex with an m-shaped frontal-temporal recession had, on the average, higher serum cholesterol and blood pressure compared to participants with no baldness (n = 321) and/or participants with just frontal baldness (n = 273). For serum cholesterol, a significant interaction was detected between age and fronto-occipital baldness (i.e. the association between fronto-occipital baldness and elevated levels of serum cholesterol became weaker with age). No interaction was detectable between age and fronto-occipital baldness for blood pressure. The results of this cross-sectional study indicate that male-type pattern of baldness is associated with elevated CHD risk profile, and that this relation between age and serum cholesterol differs in younger compared to older men.

Permanent genetic resources added to Molecular Ecology Resources Database 1 December 2010-31 January 2011

This article documents the addition of 238 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Alytes dickhilleni, Arapaima gigas, Austropotamobius italicus, Blumeria graminis f. sp. tritici, Cobitis lutheri, Dendroctonus ponderosae, Glossina morsitans morsitans, Haplophilus subterraneus, Kirengeshoma palmata, Lysimachia japonica, Macrolophus pygmaeus, Microtus cabrerae, Mytilus galloprovincialis, Pallisentis (Neosentis) celatus, Pulmonaria officinalis, Salminus franciscanus, Thais chocolata and Zootoca vivipara. These loci were cross-tested on the following species: Acanthina monodon, Alytes cisternasii, Alytes maurus, Alytes muletensis, Alytes obstetricans almogavarii, Alytes obstetricans boscai, Alytes obstetricans obstetricans, Alytes obstetricans pertinax, Cambarellus montezumae, Cambarellus zempoalensis, Chorus giganteus, Cobitis tetralineata, Glossina fuscipes fuscipes, Glossina pallidipes, Lysimachia japonica var. japonica, Lysimachia japonica var. minutissima, Orconectes virilis, Pacifastacus leniusculus, Procambarus clarkii, Salminus brasiliensis and Salminus hilarii.

Genotypic and phenotypic cross-resistance patterns to lopinavir and amprenavir in protease inhibitor-experienced patients with HIV viremia

Genotypic correlates of reduced phenotypic susceptibility to amprenavir (APV) and lopinavir (LPV) were examined in 271 HIV isolates from 207 protease inhibitor (PI)-experienced subjects. All samples were from LPV-naive subjects; two were from APV-experienced subjects. Using a fold resistance (FR) of <2.5, 179 (66%) were APV susceptible. Using FRs of <2.5 and <10, 107 (39%) and 194 (72%), respectively, were LPV susceptible. The I84V mutation was the strongest APV resistance marker in PI-experienced subjects in both univariate and multivariate analyses, with an increased relative incidence (RI) of 6.9 with >2.5 FR. Mutations L10I (RI, 1.7), M46I (RI, 2.3), and L90M (RI, 1.9, but 65% linked with the I84V) were associated with decreased APV susceptibility in the univariate analysis (p < 0.001). Mutations L10I, G48V, I54T, I54V, and V82A were significantly associated with decreased LPV susceptibility (p < 0.001 for each) and had increased RIs of 2.2, 4.4, 13, 4.6, and 3.2, respectively. Decreased susceptibility to LPV (FR, >or=10) was significantly associated with prior exposure to the following PIs: ritonavir (RTV) (p < 0.001), saquinavir (SQV) (p < 0.001), nelfinavir (NFV) (p = 0.008), and indinavir (IDV) (p = 0.028). Decreased APV susceptibility (FR, >or=2.5) was significantly associated with prior exposure to RTV (p = 0.009), NFV (p = 0.003), and IDV (p = 0.021) but not with prior SQV (p = 0.103). These results suggest that APV and LPV have different cross-resistance mutation patterns that may help determine choice of PI therapy after therapy failure.

Self-similarity in biological classifications

Size distributions of supraspecific taxa, e.g. genera, measured as the number of included subtaxa, e.g. species, are found to follow a power law. This behaviour has been verified for a number of taxa of different size and taxonomic rank, thus suggesting a fractal structure of biological classifications. This is regarded as probably dependent on evolutionary processes shaping the phylogenetic tree, especially speciation and extinction, as well as on the topological properties of developmental constraints and/or of the ecospace(s) with which the group has been confronted during its history. The role of taxonomic bias is deemphasized.

Food contamination by PCBs and waste disposal crisis: Evidence from goat milk in Campania (Italy)

AIM

The study aims at investigating whether, and if so, to what extent the strong presence of urban and industrial waste in a territory may cause PCB contamination in goat milk produced therein.

METHODS

We compared PCB concentrations in goat milk from three different locations in the Campania region (Italy). One of the three locations, together with its surrounding area, has long suffered from illegal waste disposal and burning mainly by the so-called Ecomafia. The other locations, not involved in these illegal activities, allowed us to create a control group of goats with characteristics very similar to those of main interest.

RESULTS

In milk from the waste contaminated area we identified high PCB concentrations (six indicator PCBs amounted to 170 ng g^-1 on lipid weight, on average), whereas there was an almost total absence of such pollutants in milk from the control group. Concentrations of the six indicator PCBs were above the current European maximum residue limit fixed by the EU. At the same time, we found a lower average value of lipid content and a negative relationship between lipid content and PCB concentrations.

CONCLUSION

Evidence indicates the potential health risk for consumers living in areas involved in illegal dumping of waste.

Allozyme divergence and phylogenetic relationships among Capra, Ovis and Rupicapra (Artyodactyla, Bovidae)

Genetic divergence and phylogenetic relationships between the chamois (Rupicaprini, Rupicapra rupicapra rupicapra) and three species of the Caprini (Capra aegagrus hircus, Capra ibex ibex and Ovis ammon musimon) have been studied by multilocus protein electrophoresis. Dendrograms have been constructed both with distance and parsimony methods. Goat, sheep and chamois pair-wise genetic distances had very similar values. All the topologies showed that Capra, Ovis and Rupicapra originate from the same internode, suggesting the hypothesis of a common, and almost contemporaneous, ancestor. The estimated divergence times among the three genera ranged from 5.28 to 7.08 Myr. These findings suggest the need to reconsider the evolutionary relationships in the Capriae.

Survey of Neospora caninum and bovine herpes virus 1 coinfection in cattle

A seroprevalence survey of Neospora caninum and bovine herpesvirus 1 (BHV-1) was conducted in cattle pasturing in an area of the southern Italian Apennines to investigate the coinfection of these two pathogens. Blood samples were collected from 948 pastured cattle raised on 81 farms. Sera were tested for antibodies to N. caninum and to BHV-1 using an ELISA assay and a neutralization test, respectively. Out of the 81 farms sampled, 63 (77.8%) were positive for N. caninum and 80 (98.8%) for BHV-1. Coinfection was found in 62 (76.5%) farms. Out of the 948 bovine sera samples, 303 (32.0%) had antibodies to N. caninum and 735 (77.5%) to BHV-1. The copresence of antibodies to N. caninum and BHV-1 was found in 256 (27.0%) cattle. The logistic regression results indicated that seropositivity for BHV-1 was a risk factor for N. caninum seropositivity and seropositivity for N. caninum was a risk factor for BHV-1 seropositivity.