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Mangan JM, Hedges KNC, Salerno MM, Tatum K, Bouwkamp B, Frick MW, McKenna L, Muzanyi G, Engle M, Coetzee J, Yvetot J, Elskamp M, Lamunu D, Tizora MET, Namutamba D, Chaisson RE, Swindells S, Nahid P, Dorman SE, Kurbatova E. Facilitators and barriers to adolescent participation in a TB clinical trial. Int J Tuberc Lung Dis 2024; 28:243-248. [PMID: 38659142 DOI: 10.5588/ijtld.23.0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The inclusion of adolescents in TB drug trials is essential for the development of safe, child-friendly regimens for the prevention and treatment of TB. TB Trials Consortium Study 31/AIDS Clinical Trials Group A5349 (S31/A5349) enrolled adolescents as young as 12 years old. We assessed investigator and coordinator described facilitators and barriers to adolescent recruitment, enrollment, and retention.METHODS Interviews were conducted with six investigators from sites that enrolled adolescent participants and six investigators from non-enrolling sites. Additionally, two focus groups were conducted with study coordinators from enrolling sites and two focus groups with non-enrolling sites. Discussions were transcribed, analyzed, summarized, and summaries were reviewed by Community Research Advisors Group members and research group representatives for content validity.RESULTS Investigators and coordinators attributed the successful enrollment of adolescents to the establishment and cultivation of external partnerships, flexibility to accommodate adolescents' schedules, staff engagement, recruitment from multiple locations, dedicated recruitment staff working onsite to access potential participants, creation of youth-friendly environments, and effective communications. Non-enrolling sites were mainly hindered by regulations. Suggestions for improvement in future trials focused on study planning and site preparations.CONCLUSION Proactive partnerships and collaboration with institutions serving adolescents helped identify and reduce barriers to their inclusion in this trial..
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Affiliation(s)
- J M Mangan
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA
| | - K N C Hedges
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA
| | - M M Salerno
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, New York, NY
| | - K Tatum
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA
| | - B Bouwkamp
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, Oak Ridge Institute for Science and Education
| | - M W Frick
- Treatment Action Group, New York, NY, USA
| | - L McKenna
- Treatment Action Group, New York, NY, USA
| | - G Muzanyi
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - M Engle
- UTHSCSA & San Antonio Veterans Administration Medical Center, TX, USA
| | - J Coetzee
- Family Centre for Research with Ubuntu, University of Stellenbosch, Capetown, South Africa
| | - J Yvetot
- Les Centres GHESKIO, Port Au Prince, Haïti
| | - M Elskamp
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, New York, NY
| | - D Lamunu
- Uganda National Council for Science and Technology, Kampala, Uganda
| | - M E Theunissen Tizora
- Family Centre for Research with Ubuntu, University of Stellenbosch, Capetown, South Africa
| | - D Namutamba
- International Community of Women Living with HIV Eastern Africa, Bujumbura, Burundi
| | | | - S Swindells
- University of Nebraska Medical Center, Omaha, NE
| | - P Nahid
- UCSF Center for Tuberculosis, University of California, San Francisco, CA
| | - S E Dorman
- Medical University of South Carolina, Charleston, SC, USA
| | - E Kurbatova
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA
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Gomes I, Garg T, Churchyard G, Gupta A, Hesseling AC, Swindells S, Gurupira W, Martel B, Mbata L, Patil S, Riviere C, Tonquin M, Dowdy D, Sohn H. The cascade of care for household contacts of people with drug-resistant TB. Int J Tuberc Lung Dis 2023; 27:154-156. [PMID: 36853100 PMCID: PMC10115168 DOI: 10.5588/ijtld.22.0473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- I Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - T Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G Churchyard
- Aurum Institute, Johannesburg, South Africa, School of Public Health, University of Witwatersrand, Johannesburg, South Africa, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - A Gupta
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - A C Hesseling
- Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - S Swindells
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NB, USA
| | - W Gurupira
- Clinical Trials Research Centre (UZ-CTRC), University of Zimbabwe, Harare, Zimbabwe
| | - B Martel
- Socios En Salud Sucursal Peru, Lima, Peru
| | - L Mbata
- Aurum Institute, Rustenburg, South Africa
| | - S Patil
- Byramjee Jeejeebhoy Government Medical College CRS, Johns Hopkins University Baltimore-Washington-India Clinical Trials Unit, Pune, India
| | - C Riviere
- Les Centres GHESKIO, Port-au-Prince, Haiti
| | - M Tonquin
- Research Division, De La Salle Medical and Health Sciences Institute, Dasmarinas City, Cavite, The Philippines
| | - D Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - H Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
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Rouzier V, Murrill M, Kim S, Naini L, Shenje J, Mitchell E, Raesi M, Lourens M, Mendoza A, Conradie F, Suryavanshi N, Hughes M, Shah S, Churchyard G, Swindells S, Hesseling A, Gupta A. Caregiver willingness to give TPT to children living with drug-resistant TB patients. Int J Tuberc Lung Dis 2022; 26:949-955. [PMID: 36163664 PMCID: PMC9524515 DOI: 10.5588/ijtld.21.0760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pediatric household contacts (HHCs) of patients with multidrug-resistant TB (MDR-TB) are at high risk of infection and active disease. Evidence of caregiver willingness to give MDR-TB preventive therapy (TPT) to children is limited.METHODS This was a cross-sectional study of HHCs of patients with MDR-TB to assess caregiver willingness to give TPT to children aged <13 years.RESULTS Of 743 adult and adolescent HHCs, 299 reported caring for children aged <13 years of age. The median caregiver age was 35 years (IQR 27-48); 75% were women. Among caregivers, 89% were willing to give children MDR TPT. In unadjusted analyses, increased willingness was associated with TB-related knowledge (OR 5.1, 95% CI 2.3-11.3), belief that one can die of MDR-TB (OR 5.2, 95% CI 1.2-23.4), concern for MDR-TB transmission to child (OR 4.5, 95% CI 1.6-12.4), confidence in properly taking TPT (OR 4.5, 95% CI 1.6-12.6), comfort telling family about TPT (OR 5.5, 95% CI 2.1-14.3), and willingness to take TPT oneself (OR 35.1, 95% CI 11.0-112.8).CONCLUSIONS A high percentage of caregivers living with MDR- or rifampicin-resistant TB patients were willing to give children a hypothetical MDR TPT. These results provide important evidence for the potential uptake of effective MDR TPT when implemented.
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Affiliation(s)
- V Rouzier
- GHESKIO Centers, Port-au-Prince, Haiti and Weill Cornell Medicine, Center for Global Health, Department of Medicine, New York, NY
| | - M Murrill
- Johns Hopkins Medical Institutions, Baltimore, MD
| | - S Kim
- Frontier Science Foundation, Brookline, MA
| | - L Naini
- Social and Scientific Systems, Inc., Silver Springs, MD, USA
| | - J Shenje
- South African Tuberculosis Vaccine Initiative (SATVI), Cape Town, South Africa
| | - E Mitchell
- University of Cape Town Lung Institute, Mowbray, South Africa
| | - M Raesi
- Gaborone Clinical Research Site, Gaborone, Botswana
| | - M Lourens
- TASK Applied Science Clinical Research Site, Bellville, South Africa
| | - A Mendoza
- Asociación Civil Impacta Salud y Educación - Barranco Clinical Research Site, Lima, Peru
| | - F Conradie
- Sizwe Tropical Disease Hospital, Johannesburg, South Africa
| | - N Suryavanshi
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
| | - M Hughes
- Harvard T H Chan School of Public Health, Boston, MA
| | - S Shah
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - G Churchyard
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Aurum Institute, Johannesburg, South Africa
| | - S Swindells
- University of Nebraska Medical Center, Omaha, NE, USA
| | - A Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - A Gupta
- GHESKIO Centers, Port-au-Prince, Haiti and Weill Cornell Medicine, Center for Global Health, Department of Medicine, New York, NY
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Podany AT, Leon-Cruz J, Hakim J, Supparatpinyo K, Omoz-Oarhe A, Langat D, Mwelase N, Kanyama C, Gupta A, Benson CA, Chaisson RE, Swindells S, Fletcher CV. Nevirapine pharmacokinetics in HIV-infected persons receiving rifapentine and isoniazid for TB prevention. J Antimicrob Chemother 2021; 76:718-721. [PMID: 33241266 DOI: 10.1093/jac/dkaa470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of rifamycin antibiotics for TB prevention carries a risk of detrimental drug-drug interactions with concomitantly used ART. OBJECTIVES To evaluate the interaction of the antiretroviral drug nevirapine in combination with 4 weeks of daily rifapentine and isoniazid for TB prevention in people living with HIV. METHODS Participants were individuals enrolled in the BRIEF-TB study receiving nevirapine and randomized to the rifapentine/isoniazid arm of the study. Participants provided sparse pharmacokinetic (PK) sampling at baseline and weeks 2 and 4 for trough nevirapine determination. Nevirapine apparent oral clearance (CL/F) was estimated and the geometric mean ratio (GMR) of CL/F prior to and during rifapentine/isoniazid was calculated. RESULTS Seventy-eight participants had evaluable PK data: 61 (78%) female, 51 (65%) black non-Hispanic and median (range) age of 40 (13-66) years. Median (IQR) nevirapine trough concentrations were: week 0, 7322 (5266-9302) ng/mL; week 2, 5537 (3552-8462) ng/mL; and week 4, 5388 (3516-8243) ng/mL. Sixty out of 78 participants (77%) had nevirapine concentrations ≥3000 ng/mL at both week 2 and 4. Median (IQR) nevirapine CL/F values were: week 0 pre-rifapentine/isoniazid, 2.03 (1.58-2.58) L/h; and during rifapentine/isoniazid, 2.62 (1.81-3.42) L/h. The GMR (90% CI) for nevirapine CL/F was 1.30 (1.26-1.33). CONCLUSIONS The CL/F of nevirapine significantly increased with concomitant rifapentine/isoniazid. The decrease in nevirapine trough concentrations during rifapentine/isoniazid therapy suggests induction of nevirapine metabolism, consistent with known rifapentine effects. The magnitude of this drug-drug interaction suggests daily rifapentine/isoniazid for TB prevention should not be co-administered with nevirapine-containing ART.
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Affiliation(s)
- A T Podany
- University of Nebraska Medical Center, Omaha, NE, USA
| | - J Leon-Cruz
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - J Hakim
- Parirenyatwa CRS, Harare, Zimbabwe
| | - K Supparatpinyo
- Chiang Mai University HIV Treatment CRS, Chiang Mai, Thailand
| | - A Omoz-Oarhe
- Molepolole Clinical Research Site, Molepolole, Botswana
| | - D Langat
- Kenya Medical Research Institute/Walter Reed Project Clinical Research Center CRS, Kericho, Kenya
| | - N Mwelase
- University of the Witwatersrand Helen Joseph CRS, Johannesburg, South Africa
| | | | - A Gupta
- Johns Hopkins Hospital, Baltimore, MD, USA
| | - C A Benson
- University of California San Diego, San Diego, CA, USA
| | | | - S Swindells
- University of Nebraska Medical Center, Omaha, NE, USA
| | - C V Fletcher
- University of Nebraska Medical Center, Omaha, NE, USA
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5
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Tweed CD, Wills GH, Crook AM, Amukoye E, Balanag V, Ban AYL, Bateson ALC, Betteridge MC, Brumskine W, Caoili J, Chaisson RE, Cevik M, Conradie F, Dawson R, Del Parigi A, Diacon A, Everitt DE, Fabiane SM, Hunt R, Ismail AI, Lalloo U, Lombard L, Louw C, Malahleha M, McHugh TD, Mendel CM, Mhimbira F, Moodliar RN, Nduba V, Nunn AJ, Sabi I, Sebe MA, Selepe RAP, Staples S, Swindells S, van Niekerk CH, Variava E, Spigelman M, Gillespie SH. A partially randomised trial of pretomanid, moxifloxacin and pyrazinamide for pulmonary TB. Int J Tuberc Lung Dis 2021; 25:305-314. [PMID: 33762075 PMCID: PMC8009598 DOI: 10.5588/ijtld.20.0513] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND: Treatment for TB is lengthy and toxic, and new regimens are needed.METHODS: Participants with pulmonary drug-susceptible TB (DS-TB) were randomised to receive: 200 mg pretomanid (Pa, PMD) daily, 400 mg moxifloxacin (M) and 1500 mg pyrazinamide (Z) for 6 months (6Pa200MZ) or 4 months (4Pa200MZ); 100 mg pretomanid daily for 4 months in the same combination (4Pa100MZ); or standard DS-TB treatment for 6 months. The primary outcome was treatment failure or relapse at 12 months post-randomisation. The non-inferiority margin for between-group differences was 12.0%. Recruitment was paused following three deaths and not resumed.RESULTS: Respectively 4/47 (8.5%), 11/57 (19.3%), 14/52 (26.9%) and 1/53 (1.9%) DS-TB outcomes were unfavourable in patients on 6Pa200MZ, 4Pa200MZ, 4Pa100MZ and controls. There was a 6.6% (95% CI -2.2% to 15.4%) difference per protocol and 9.9% (95%CI -4.1% to 23.9%) modified intention-to-treat difference in unfavourable responses between the control and 6Pa200MZ arms. Grade 3+ adverse events affected 68/203 (33.5%) receiving experimental regimens, and 19/68 (27.9%) on control. Ten of 203 (4.9%) participants on experimental arms and 2/68 (2.9%) controls died.CONCLUSION: PaMZ regimens did not achieve non-inferiority in this under-powered trial. An ongoing evaluation of PMD remains a priority.
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Affiliation(s)
- C D Tweed
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - G H Wills
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - A M Crook
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - E Amukoye
- Centre for Respiratory Disease Research, Kenya Medical Research Institute (KEMRI), Kenyatta National Hospital, Nairobi, Kenya
| | - V Balanag
- Lung Center of the Philippines, National Centre for Pulmonary Research, Quezon City, The Philippines
| | - A Y L Ban
- Pusat Perubatan Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | | | - M C Betteridge
- Global Alliance for TB Drug Development, New York, NY, USA
| | | | - J Caoili
- Tropical Disease Foundation, Makati Medical Centre, Makati City, Phillippines
| | - R E Chaisson
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - M Cevik
- Medical School, University of St Andrews, St Andrews, UK
| | - F Conradie
- University of the Witwatersrand, Clinical HIV Research Unit, Johannesburg
| | - R Dawson
- University of Cape Town Lung Institute, Cape Town
| | - A Del Parigi
- Global Alliance for TB Drug Development, New York, NY, USA
| | - A Diacon
- TASK Applied Science, Bellville, South Africa & Division of Physiology, Department of Medical Biochemistry, University of Stellenbosch, Tygerberg, South Africa
| | - D E Everitt
- Global Alliance for TB Drug Development, New York, NY, USA
| | - S M Fabiane
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - R Hunt
- Centre for Clinical Microbiology, UCL, London, UK
| | - A I Ismail
- Universiti Teknologi MARA, Selangor, Malaysia
| | - U Lalloo
- Enhancing Care Foundation, Durban International Clinical Research Site, Wentworth Hospital, Durban
| | - L Lombard
- Global Alliance for TB Drug Development, New York, NY, USA
| | - C Louw
- Madibeng Centre for Research, Brits, & Department of Family Medicine, University of Pretoria, Pretoria
| | - M Malahleha
- Setshaba Research Centre, Soshanguve, South Africa
| | - T D McHugh
- Centre for Clinical Microbiology, UCL, London, UK
| | - C M Mendel
- Global Alliance for TB Drug Development, New York, NY, USA
| | - F Mhimbira
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - R N Moodliar
- THINK (Tuberculosis and HIV Investigative Network), Durban, South Africa
| | | | - A J Nunn
- Medical Research Council Clinical Trials Unit, University College London (UCL), London, UK
| | - I Sabi
- Mbeya Medical Research Center, National Institute for Medical Research, Mbeya, Tanzania
| | - M A Sebe
- The Aurum Institute, Tembisa Clinical Research Centre, Tembisa
| | | | - S Staples
- THINK (Tuberculosis and HIV Investigative Network), Durban, South Africa
| | - S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - E Variava
- Klerksdorp Tshepong Hospital, Klerksdorp, South Africa
| | - M Spigelman
- Global Alliance for TB Drug Development, New York, NY, USA
| | - S H Gillespie
- Medical School, University of St Andrews, St Andrews, UK
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6
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Opollo VS, Wu X, Hughes MD, Swindells S, Gupta A, Hesseling A, Churchyard G, Kim S, Lando R, Dawson R, Mave V, Mendoza A, Gonzales P, Kumarasamy N, von Groote-Bidlingmaier F, Conradie F, Shenje J, Fontain SN, Garcia-Prats A, Asmelash A, Nedsuwan S, Mohapi L, Mngqibisa R, Garcia Ferreira AC, Okeyo E, Naini L, Jones L, Smith B, Shah NS. HIV testing uptake among the household contacts of multidrug-resistant tuberculosis index cases in eight countries. Int J Tuberc Lung Dis 2019; 22:1443-1449. [PMID: 30606316 DOI: 10.5588/ijtld.18.0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING The household contacts (HHCs) of multidrug-resistant tuberculosis (MDR-TB) index cases are at high risk of tuberculous infection and disease progression, particularly if infected with the human immunodeficiency virus (HIV). HIV testing is important for risk assessment and clinical management. METHODS This was a cross-sectional, multi-country study of adult MDR-TB index cases and HHCs. All adult and child HHCs were offered HIV testing if never tested or if HIV-negative >1 year previously when last tested. We measured HIV testing uptake and used logistic regression to evaluate predictors. RESULTS A total of 1007 HHCs of 284 index cases were enrolled in eight countries. HIV status was known at enrolment for 226 (22%) HHCs; 39 (4%) were HIV-positive. HIV testing was offered to 769 (98%) of the 781 remaining HHCs; 544 (71%) agreed to testing. Of 535 who were actually tested, 26 (5%) were HIV-infected. HIV testing uptake varied by site (median 86%, range 0-100%; P < 0.0001), and was lower in children aged <18 years than in adults (59% vs. 78%; adjusted for site P < 0.0001). CONCLUSIONS HIV testing of HHCs of MDR-TB index cases is feasible and high-yield, with 5% testing positive. Reasons for low test uptake among children and at specific sites-including sites with high HIV prevalence-require further study to ensure all persons at risk for HIV are aware of their status.
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Affiliation(s)
- V S Opollo
- Kenya Medical Research Institute, Kisumu, Kenya
| | - X Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - M D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - S Swindells
- University of Nebraska Medical Center, Omaha, Nebraska
| | - A Gupta
- Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - A Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | | | - S Kim
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - R Lando
- Kenya Medical Research Institute, Kisumu, Kenya
| | - R Dawson
- University of Cape Town Lung Institute, Mowbray, South Africa
| | - V Mave
- Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune, India
| | - A Mendoza
- Asociacion Civil Impacta Salud y Educacion, Barranco Clinical Research Site, Lima
| | - P Gonzales
- Asociación Civil Impacta Salud y Educación, San Miguel Clinical Research Site (CRS), Lima, Peru
| | - N Kumarasamy
- Chennai Antiviral Research and Treatment CRS, Chennai, India
| | | | - F Conradie
- University of the Witwatersrand, Helen Joseph Hospital, Johannesburg
| | - J Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - S N Fontain
- GHESKIO (Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes) Centers Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | | | - S Nedsuwan
- Prevention and Treatment of HIV infection, Chiangrai Prachanukroh Hospital, Chiangrai, Thailand
| | | | - R Mngqibisa
- Durban International CRS, Durban, South Africa
| | | | - E Okeyo
- Kenya Medical Research Institute, Kisumu, Kenya
| | - L Naini
- Social & Scientific Systems, Inc, Silver Springs, Maryland
| | - L Jones
- Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - B Smith
- National Institutes of Health, Bethesda, Maryland
| | - N S Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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7
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Rajoli RKR, Podany AT, Moss DM, Swindells S, Flexner C, Owen A, Siccardi M. Modelling the long-acting administration of anti-tuberculosis agents using PBPK: a proof of concept study. Int J Tuberc Lung Dis 2019; 22:937-944. [PMID: 29991405 DOI: 10.5588/ijtld.17.0515] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Anti-tuberculosis formulations necessitate uninterrupted treatment to cure tuberculosis (TB), but are characterised by suboptimal adherence, which jeopardises therapeutic efficacy. Long-acting injectable (LAI) formulations or implants could address these associated issues. OBJECTIVE niazid, rifapentine, bedaquiline and delamanid-in adults for treatment for latent tuberculous infection (LTBI). DESIGN PBPK models were developed and qualified against available clinical data by integrating drug physicochemical properties and in vitro and population pharmacokinetic data into a mechanistic description of drug distribution. Combinations of optimal dose and release rates were simulated such that plasma concentrations were maintained over the epidemiological cut-off or minimum inhibitory concentration for the dosing interval. RESULTS The PBPK model identified 1500 mg of delamanid and 250 mg of rifapentine as sufficient doses for monthly intramuscular administration, if a formulation or device can deliver the required release kinetics of 0.001-0.0025 h-1 and 0.0015-0.0025 h-1, respectively. Bedaquiline and isoniazid would require weekly to biweekly intramuscular dosing. CONCLUSION We identified the theoretical doses and release rates of LAI anti-tuberculosis formulations. Such a strategy could ease the problem of suboptimal adherence provided the associated technological complexities for LTBI treatment are addressed.
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Affiliation(s)
- R K R Rajoli
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - A T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - D M Moss
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK, School of Pharmacy, Keele University, Newcastle, UK
| | - S Swindells
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - C Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A Owen
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - M Siccardi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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8
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Swindells S, Siccardi M, Barrett SE, Olsen DB, Grobler JA, Podany AT, Nuermberger E, Kim P, Barry CE, Owen A, Hazuda D, Flexner C. Long-acting formulations for the treatment of latent tuberculous infection: opportunities and challenges. Int J Tuberc Lung Dis 2019; 22:125-132. [PMID: 29506608 DOI: 10.5588/ijtld.17.0486] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Long-acting/extended-release drug formulations have proved very successful in diverse areas of medicine, including contraception, psychiatry and, most recently, human immunodeficiency virus (HIV) disease. Though challenging, application of this technology to anti-tuberculosis treatment could have substantial impact. The duration of treatment required for all forms of tuberculosis (TB) put existing regimens at risk of failure because of early discontinuations and treatment loss to follow-up. Long-acting injections, for example, administered every month, could improve patient adherence and treatment outcomes. We review the state of the science for potential long-acting formulations of existing tuberculosis drugs, and propose a target product profile for new formulations to treat latent tuberculous infection (LTBI). The physicochemical properties of some anti-tuberculosis drugs make them unsuitable for long-acting formulation, but there are promising candidates that have been identified through modeling and simulation, as well as other novel agents and formulations in preclinical testing. An efficacious long-acting treatment for LTBI, particularly for those co-infected with HIV, and if coupled with a biomarker to target those at highest risk for disease progression, would be an important tool to accelerate progress towards TB elimination.
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Affiliation(s)
- S Swindells
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - S E Barrett
- Sterile Formulation Sciences, West Point, Pennsylvania, USA
| | - D B Olsen
- Infectious Disease, Merck Sharp & Dohme, West Point, Pennsylvania, USA
| | - J A Grobler
- Infectious Disease, Merck Sharp & Dohme, West Point, Pennsylvania, USA
| | - A T Podany
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - P Kim
- Office of AIDS Research, National Institutes of Health, Bethesda, Maryland, USA
| | - C E Barry
- National Institute of Allergy & Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - A Owen
- University of Liverpool, Liverpool, UK
| | - D Hazuda
- Infectious Disease, Merck Sharp & Dohme, West Point, Pennsylvania, USA
| | - C Flexner
- Johns Hopkins University, Baltimore, Maryland, USA
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9
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Swindells S, Gupta A, Kim S, Hughes MD, Sanchez J, Mave V, Dawson R, Kumarasamy N, Comins K, Smith B, Rustomjee R, Naini L, Shah NS, Hesseling A, Churchyard G. Resource utilization for multidrug-resistant tuberculosis household contact investigations (A5300/I2003). Int J Tuberc Lung Dis 2018; 22:1016-1022. [PMID: 30092866 DOI: 10.5588/ijtld.18.0163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current guidelines recommend evaluation of the household contacts (HHCs) of individuals with multidrug-resistant tuberculosis (MDR-TB); however, implementation of this policy is challenging. OBJECTIVE To describe the resource utilization and operational challenges encountered when identifying and characterizing adult MDR-TB index cases and their HHCs. DESIGN Cross-sectional study of adult MDR-TB index cases and HHCs at 16 clinical research sites in eight countries. Site-level resource utilization was assessed with surveys. RESULTS Between October 2015 and April 2016, 308 index cases and 1018 HHCs were enrolled. Of 280 index cases with sputum collected, 94 were smear-positive (34%, 95%CI 28-39), and of 201 with chest X-rays, 87 had cavitary disease (43%, 95%CI 37-50) after a mean duration of treatment of 8 weeks. Staff required 512 attempts to evaluate the 308 households, with a median time per attempt of 4 h; 77% (95%CI 73-80) of HHCs were at increased risk for TB: 13% were aged <5 years, 8% were infected with the human immunodeficiency virus, and 79% were positive on the tuberculin skin test/interferon-gamma release assay. One hundred and twenty-one previously undiagnosed TB cases were identified. Issues identified by site staff included the complexity of personnel and participant transportation, infection control, personnel safety and management of stigma. CONCLUSION HHC investigations can be high yield, but are labor-intensive.
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Affiliation(s)
- S Swindells
- University of Nebraska Medical Center, Omaha, Nebraska
| | - A Gupta
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - S Kim
- Frontier Science Foundation, Brookline, Massachusetts
| | - M D Hughes
- Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - J Sanchez
- Asociación Civil Impacta Salud y Educación, Lima, Peru
| | - V Mave
- Byramjee Jeejeebhoy Government Medical College Clinical Research Site, Pune, India
| | - R Dawson
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - N Kumarasamy
- Chennai Antiviral Research and Treatment CRS, Chennai, India
| | - K Comins
- Task Applied Science CRS, Bellville, South Africa
| | - B Smith
- National Institutes of Health, Bethesda, MD, USA
| | - R Rustomjee
- National Institutes of Health, Bethesda, MD, USA
| | - L Naini
- Social & Scientific Systems, Inc, Silver Springs, Maryland
| | - N S Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - A Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg
| | - G Churchyard
- The Aurum Institute, Johannesburg, School of Public Health, University of Witwatersrand, Johannesburg, Advancing Care and Treatment for TB and HIV, South African Medical Research Council, Johannesburg, South Africa
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10
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Shiboski CH, Chen H, Ghannoum MA, Komarow L, Evans S, Mukherjee PK, Isham N, Katzenstein D, Asmelash A, Omozoarhe AE, Gengiah S, Allen R, Tripathy S, Swindells S. Role of oral candidiasis in TB and HIV co-infection: AIDS Clinical Trial Group Protocol A5253. Int J Tuberc Lung Dis 2015; 18:682-8. [PMID: 24903939 DOI: 10.5588/ijtld.13.0729] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To evaluate the association between oral candidiasis and tuberculosis (TB) in human immunodeficiency virus (HIV) infected individuals in sub-Saharan Africa, and to investigate oral candidiasis as a potential tool for TB case finding. METHODS Protocol A5253 was a cross-sectional study designed to improve the diagnosis of pulmonary TB in HIV-infected adults in high TB prevalence countries. Participants received an oral examination to detect oral candidiasis. We estimated the association between TB disease and oral candidiasis using logistic regression, and sensitivity, specificity and predictive values. RESULTS Of 454 participants with TB culture results enrolled in African sites, the median age was 33 years, 71% were female and the median CD4 count was 257 cells/mm(3). Fifty-four (12%) had TB disease; the prevalence of oral candidiasis was significantly higher among TB cases (35%) than among non-TB cases (16%, P < 0.001). The odds of having TB was 2.4 times higher among those with oral candidiasis when controlling for CD4 count and antifungals (95%CI 1.2-4.7, P = 0.01). The sensitivity of oral candidiasis as a predictor of TB was 35% (95%CI 22-48) and the specificity 85% (95%CI 81-88). CONCLUSION We found a strong association between oral candidiasis and TB disease, independent of CD4 count, suggesting that in resource-limited settings, oral candidiasis may provide clinical evidence for increased risk of TB and contribute to TB case finding.
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Affiliation(s)
- C H Shiboski
- Department of Orofacial Sciences, School of Dentistry, University of California San Francisco, San Francisco, California, USA
| | - H Chen
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | - M A Ghannoum
- Center for Medical Mycology, Department of Dermatology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio, USA
| | - L Komarow
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | - S Evans
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | - P K Mukherjee
- Center for Medical Mycology, Department of Dermatology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio, USA
| | - N Isham
- Center for Medical Mycology, Department of Dermatology, University Hospitals Case Medical Center and Case Western Reserve University, Cleveland, Ohio, USA
| | - D Katzenstein
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts, USA
| | - A Asmelash
- Stanford University Medical Center, Stanford, California, USA
| | | | - S Gengiah
- Princess Marina Hospital, Gaborone, Botswana
| | - R Allen
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - S Tripathy
- AIDS Clinical Trial Group Operations Center, Silver Spring, Maryland, USA
| | - S Swindells
- Molecular Virology Clinic National AIDS Research Institute, Maharashtra Industrial Development Corporation, Bhosari, India
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11
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Swindells S, Komarow L, Tripathy S, Cain KP, MacGregor RR, Achkar JM, Gupta A, Veloso VG, Asmelash A, Omoz-Oarhe AE, Gengiah S, Lalloo U, Allen R, Shiboski C, Andersen J, Qasba SS, Katzenstein DK. Screening for pulmonary tuberculosis in HIV-infected individuals: AIDS Clinical Trials Group Protocol A5253. Int J Tuberc Lung Dis 2013; 17:532-9. [PMID: 23485388 DOI: 10.5588/ijtld.12.0737] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improved tuberculosis (TB) screening is urgently needed for human immunodeficiency virus (HIV) infected patients. METHODS An observational, multi-country, cross-sectional study of HIV-infected patients to compare a standardized diagnostic evaluation (SDE) for TB with standard of care (SOC). SOC evaluations included TB symptom review (current cough, fever, night sweats and/or weight loss), sputum Ziehl-Neelsen staining and chest radiography. SDE screening added extended clinical signs and symptoms and fluorescent microscopy (FM). All participants underwent all evaluations. Mycobacterium tuberculosis on sputum culture was the primary outcome. RESULTS A total of 801 participants were enrolled from Botswana, Malawi, South Africa, Zimbabwe, India, Peru and Brazil. The median age was 33 years; 37% were male, and median CD4 count was 275 cells/mm(3). Thirty-one participants (4%) had a positive culture on Löwenstein-Jensen media and 54 (8%) on MGIT. All but one positive culture came from sub-Saharan Africa, where the prevalence of TB was 54/445 (12%). SOC screening had 54% sensitivity (95%CI 40-67) and 76% specificity (95%CI 72-80). Positive and negative predictive values were respectively 24% and 92%. No elements of the SDE improved the predictive values of SOC. CONCLUSIONS Symptom-based screening with smear microscopy was insufficiently sensitive. More sensitive diagnostic testing is required for HIV-infected patients.
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Affiliation(s)
- S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198-8106, USA.
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12
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Stapleton JT, Bennett K, Bosch RJ, Polgreen PM, Swindells S. Effect of antiretroviral therapy and hepatitis c co-infection on changes in lipid levels in HIV-Infected patients 48 weeks after initiation of therapy. HIV Clin Trials 2008; 8:429-36. [PMID: 18042508 DOI: 10.1310/hct0806-429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis C virus (HCV) commonly co-infects HIV-infected individuals. Antiretroviral therapy (ART) is associated with elevated serum lipid levels, and HCV infection is associated with low serum lipid levels. Fasting lipid levels were investigated in 1,434 ART-naïve HIV-infected people participating in the AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) protocol who prospectively initiated ART with 3 agents. Subjects with elevated liver-associated enzymes (>5 x ULN) were excluded. Demographics, body mass index, HCV status, CD4 cell count, HIV RNA, liver enzymes, lipid levels, and glucose were assessed before and following 48 weeks of ART. HCV-positive subjects (n = 160; 11%) were older, more likely to be Black, have a history of intravenous drug use (IDU), have higher baseline liver-associated enzyme levels than the HCV-negative group (p < .001 for each), and to have diabetes at baseline (5% vs. 2%, p = .07). Lipid levels rose in both groups following ART, and the differences were not significant except that HDL levels increased significantly more in the HCV-positive group (p = .006). In summary, HCV infection did not appear to provide significant protection against ART-induced hyperlipidemia in this cohort of HIV-infected subjects prospectively enrolled in ART trials, although HDL levels rose to a greater degree.
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Affiliation(s)
- J T Stapleton
- Iowa City VA Medical Center and the University of Iowa, Iowa City, Iowa, USA.
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13
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Hogeland GW, Swindells S, McNabb JC, Kashuba ADM, Yee GC, Lindley CM. Lopinavir/ritonavir reduces bupropion plasma concentrations in healthy subjects. Clin Pharmacol Ther 2007; 81:69-75. [PMID: 17186001 DOI: 10.1038/sj.clpt.6100027] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Limited data are available about the effect of steady-state lopinavir and ritonavir (LPV/r) on bupropion pharmacokinetics. As patients may benefit by using these two agents in combination, this study determined the extent and direction of this drug-drug interaction. Twelve healthy volunteers received a single 100 mg dose of sustained-release bupropion before and after 2 weeks of treatment with LPV/r 400 mg/100 mg twice daily. Pharmacokinetics profiles were determined on days 1 and 30 for bupropion and hydroxybupropion and days 29 and 30 for LPV/r. LPV/r administration significantly decreased bupropion maximum plasma concentration (C(max)) by 57% (90% confidence interval (CI), 38-76%; P<0.01) and area under the curve (AUC) infinity by 57% (90% CI, 32-83%; P<0.01). Hydroxybupropion C(max) and AUC infinity decreased by 31% (90% CI, 7-55%; P<0.01) and by 50% (90% CI, 34-65%; P<0.01), respectively. No significant changes in the pharmacokinetics of LPV/r were found following administration of a single dose of bupropion. Concurrent use of LPV/r and bupropion resulted in decreased exposure to bupropion and its active metabolite hydroxybupropion that may necessitate as much as a 100% dose increase of bupropion. A probable mechanism for this interaction is the concurrent induction of cytochrome P450 2B6 and UDP-glucuronosyltransferase enzymes. LPV/r exposure is unaffected by a single dose of bupropion.
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Affiliation(s)
- G W Hogeland
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA
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14
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Wohl DA, McComsey G, Tebas P, Brown TT, Glesby MJ, Reeds D, Shikuma C, Mulligan K, Dube M, Wininger D, Huang J, Revuelta M, Currier J, Swindells S, Fichtenbaum C, Basar M, Tungsiripat M, Meyer W, Weihe J, Wanke C. Current concepts in the diagnosis and management of metabolic complications of HIV infection and its therapy. Clin Infect Dis 2006; 43:645-53. [PMID: 16886161 DOI: 10.1086/507333] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 06/08/2006] [Indexed: 12/12/2022] Open
Abstract
Changes in fat distribution, dyslipidemia, disordered glucose metabolism, and lactic acidosis have emerged as significant challenges to the treatment of human immunodeficiency virus (HIV) infection. Over the past decade, numerous investigations have been conducted to better define these conditions, identify risk factors associated with their development, and test potential therapeutic interventions. The lack of standardized diagnostic criteria, as well as disparate study populations and research methods, have led to conflicting data regarding the diagnosis and treatment of metabolic and body shape disorders associated with HIV infection. On the basis of a review of the medical literature published and/or data presented before April 2006, we have prepared a guide to assist the clinician in the detection and management of these complications.
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Affiliation(s)
- D A Wohl
- Div. of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599, USA.
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15
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16
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Klingler ET, Bernal K, Paustian F, Schafer D, Hoagbin J, Gentry J, Swindells S. A 48-Year-Old HIV-Positive Man with Chronic Intermittent Diarrhea. Clin Infect Dis 2004. [DOI: 10.1086/424461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Klingler ET, Bernal K, Paustian F, Schafer D, Hoagbin J, Gentry J, Swindells S. A 48-year-old HIV-positive man with chronic intermittent diarrhea. Clin Infect Dis 2004; 39:1174, 1239-40. [PMID: 15495344 DOI: 10.1086/424448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- E Toubes Klingler
- Sections of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-5400, USA.
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18
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Poluektova L, Moran T, Zelivyanskaya M, Swindells S, Gendelman HE, Persidsky Y. The regulation of alpha chemokines during HIV-1 infection and leukocyte activation: relevance for HIV-1-associated dementia. J Neuroimmunol 2001; 120:112-28. [PMID: 11694326 DOI: 10.1016/s0165-5728(01)00413-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cellular immunity against human immunodeficiency virus type 1 (HIV-1)-infected brain macrophages serves to prevent productive viral replication in the nervous system. Inevitably, during advanced disease, this antiretroviral response breaks down. This could occur through virus-induced dysregulation of lymphocyte trafficking. Thus, we studied the production of non-ELR-containing alpha-chemokines and their receptor (CXCR3) expression in relevant virus target cells. Macrophages, lymphocytes, and astrocytes secreted alpha-chemokines after HIV-1 infection and/or immune activation. Lymphocyte CXCR3-mediated chemotactic responses were operative. In all, alpha-chemokine-mediated T cell migration continued after HIV-1 infection and the neuroinflammatory events operative during productive viral replication in brain.
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MESH Headings
- AIDS Dementia Complex/blood
- AIDS Dementia Complex/immunology
- AIDS Dementia Complex/physiopathology
- Adult
- Aged
- Astrocytes/immunology
- Astrocytes/metabolism
- Astrocytes/virology
- Brain/immunology
- Brain/metabolism
- Brain/virology
- Cells, Cultured/immunology
- Cells, Cultured/metabolism
- Cells, Cultured/virology
- Chemokine CXCL10
- Chemokine CXCL11
- Chemokine CXCL9
- Chemokines, CXC/blood
- Chemokines, CXC/immunology
- Chemokines, CXC/metabolism
- Chemokines, CXC/pharmacology
- Chemotaxis, Leukocyte/drug effects
- Chemotaxis, Leukocyte/physiology
- Child
- Child, Preschool
- Fetus
- HIV-1/immunology
- HIV-1/pathogenicity
- Humans
- Immunity, Cellular/immunology
- Intercellular Signaling Peptides and Proteins
- Interferon-gamma/pharmacology
- Leukocytes/immunology
- Leukocytes/metabolism
- Leukocytes/virology
- Lymphocyte Activation/immunology
- Lymphocytes/immunology
- Lymphocytes/metabolism
- Lymphocytes/virology
- Macrophages/immunology
- Macrophages/metabolism
- Macrophages/virology
- Middle Aged
- RNA, Messenger/immunology
- RNA, Messenger/metabolism
- Receptors, CXCR3
- Receptors, Chemokine/genetics
- Receptors, Chemokine/immunology
- Receptors, Chemokine/metabolism
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Affiliation(s)
- L Poluektova
- Center for Neurovirology and Neurodegenerative Disorders, 985215 Nebraska Medical Center, Omaha, NE 68198-5215, USA
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19
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Ryan LA, Zheng J, Brester M, Bohac D, Hahn F, Anderson J, Ratanasuwan W, Gendelman HE, Swindells S. Plasma levels of soluble CD14 and tumor necrosis factor-alpha type II receptor correlate with cognitive dysfunction during human immunodeficiency virus type 1 infection. J Infect Dis 2001; 184:699-706. [PMID: 11517430 DOI: 10.1086/323036] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2001] [Revised: 05/31/2001] [Indexed: 11/03/2022] Open
Abstract
The relationship between monocyte immune responses and cognitive impairment during progressive human immunodeficiency virus type 1 (HIV-1) infection was investigated in 28 subjects receiving highly active antiretroviral therapy. The mean+/-SEM CD4(+) T lymphocyte count and virus load for all patients were 237+/-41 cells/mm(3) and 77,091+/-195,372 HIV-1 RNA copies/mL, respectively. Levels of soluble tumor necrosis factor-alpha type II receptor (sTNF-RII) and soluble CD14 (sCD14) were measured in plasma by ELISA and were correlated with results from neuropsychological, magnetic resonance imaging, and magnetic resonance spectroscopy tests. Plasma sCD14 and sTNF-RII levels were elevated in subjects with cognitive impairment and in those with brain atrophy. Furthermore, both factors were correlated with spectroscopic choline:creatine ratios. These findings support the idea that peripheral immune responses are linked to cognitive dysfunction during advanced HIV-1 disease.
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Affiliation(s)
- L A Ryan
- Center for Neurovirology and Neurodegenerative Disorders and Department of Pathology, University of Nebraska Medical Center, Omaha, NE, USA.
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20
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Vergis EN, Paterson DL, Wagener MM, Swindells S, Singh N. Dyslipidaemia in HIV-infected patients: association with adherence to potent antiretroviral therapy. Int J STD AIDS 2001; 12:463-8. [PMID: 11394983 DOI: 10.1258/0956462011923507] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Metabolic complications are being increasingly recognized among HIV-infected patients treated with potent combination antiretroviral therapies. We sought to assess the association of dyslipidaemia with adherence to protease inhibitor (PI) therapy and with the markers of clinical response to antiretroviral therapy (CD4 count, HIV RNA viral level) through a prospective, cross-sectional cohort study. Fifty-six HIV-infected patients who were already on, or who were started on PI-containing antiretroviral therapy were monitored for the development of dyslipidaemias. Therapy with PI-containing antiretroviral therapy was significantly associated with elevated serum triglyceride level (>250 mg/dl) (52% vs 8%, P=0.001). Patients with an adherence rate of at least 80% to a PI-containing regimen were significantly more likely to have elevated low density lipoprotein (LDL) cholesterol level as compared to patients with an adherence rate of <80% (79% vs 26%, P=0.03). Patients with an adherence rate of at least 80% to a PI-containing regimen were also significantly more likely to have severe hypertriglyceridaemia (>800 mg/dl) as compared to patients with an adherence rate of <80% (21% vs 4%, P=0.04). Viral load at the last study visit did not correlate with total cholesterol (r=-0.39, P=0.30), LDL cholesterol (r=0.57, P=0.30), or triglyceride level (r=0.55, P=0.20). However, there was a significant correlation between the last viral load and high density lipoprotein (HDL) cholesterol (r=0.79, P=0.035), i.e. lower viral load was associated with higher HDL cholesterol level. In conclusion, dyslipidaemia in patients with HIV infection was significantly associated with adherence to PI-containing antiretroviral therapy. Patients who are adherent to PI-containing regimens at least 80% of the time warrant close monitoring for the development of dyslipidaemia.
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Affiliation(s)
- E N Vergis
- Veterans Affairs Medical Center, Pittsburgh, Pennsylvania 15240, USA
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21
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Eron JJ, Murphy RL, Peterson D, Pottage J, Parenti DM, Jemsek J, Swindells S, Sepulveda G, Bellos N, Rashbaum BC, Esinhart J, Schoellkopf N, Grosso R, Stevens M. A comparison of stavudine, didanosine and indinavir with zidovudine, lamivudine and indinavir for the initial treatment of HIV-1 infected individuals: selection of thymidine analog regimen therapy (START II). AIDS 2000; 14:1601-10. [PMID: 10983647 DOI: 10.1097/00002030-200007280-00016] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Comparison of stavudine (d4T), didanosine (ddI) and indinavir (IDV) with zidovudine (ZDV), lamivudine (3TC) and IDV in HIV-1 infected patients. DESIGN Randomized, open-label. SETTING Fourteen HIV Clinical Research Centers. PATIENTS Two-hundred and five patients with less than 4 weeks antiretroviral treatment, naive to 3TC and protease inhibitors and with CD4 cell counts > or = 200 x 10(6)/l and plasma HIV-1 RNA levels > or = 10,000 copies/ml. INTERVENTIONS Stavudine 40 mg and ddI 200 mg twice daily plus IDV 800 mg every 8 h compared with ZDV 200 mg every 8 h or 300 mg twice daily, 3TC 150 mg twice daily plus IDV. MAIN OUTCOME MEASURES The proportion of patients with plasma HIV-1 RNA levels < 500 copies/ml and < or = 50 copies/ml and changes in CD4 cell counts were compared. RESULTS In an analysis of the primary endpoint, 61% of patients on d4T + ddI + IDV and 45% of patients on ZDV + 3TC + IDV had all HIV-1 RNA values obtained between weeks 40 and 48 < 500 copies/ml [95% confidence interval (CI) for the difference between proportions, 1.7-30.3%; P = 0.038]. In an intent-to-treat analysis, the percentage of all patients randomized with all HIV-1 RNA levels < 500 copies/ml between 40 and 48 weeks were 53% for the d4T + ddI + IDV arm and 41% for the ZDV + 3TC + IDV arm (95% CI, -1.4% to 25.7%; P = 0.068). At 48 weeks 41% and 35% were < or = 50 copies/ml for the stavudine- and ZDV-containing arms respectively (P > 0.2). The median time-weighted average increases in CD4 cells count over 48 weeks were 150 x 10(6)/l cells for the d4T arm and 106 x 10(6)/l cells for the ZDV arm (P= 0.001). The occurrence of serious adverse events was not significantly different between arms. CONCLUSION The combination of stavudine, ddl and IDV resulted in potent antiretroviral effects over a 48-week period, comparable or superior to zidovudine, 3TC and IDV supporting the use of stavudine, ddI and a protease inhibitor as an initial antiretroviral treatment.
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Affiliation(s)
- J J Eron
- University of North Carolina School of Medicine, Chapel Hill 27599-7030, USA
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22
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Abstract
BACKGROUND Combination antiretroviral therapy with protease inhibitors has transformed HIV infection from a terminal condition into one that is manageable. However, the complexity of regimens makes adherence to therapy difficult. OBJECTIVE To assess the effects of different levels of adherence to therapy on virologic, immunologic, and clinical outcome; to determine modifiable conditions associated with suboptimal adherence; and to determine how well clinicians predict patient adherence. DESIGN Prospective, observational study. SETTING HIV clinics in a Veterans Affairs medical center and a university medical center. PATIENTS 99 HIV-infected patients who were prescribed a protease inhibitor and who neither used a medication organizer nor received their medications in an observed setting (such as a jail or nursing home). MEASUREMENTS Adherence was measured by using a microelectronic monitoring system. The adherence rate was calculated as the number of doses taken divided by the number prescribed. Patients were followed for a median of 6 months (range, 3 to 15 months). RESULTS During the study period, 45,397 doses of protease inhibitor were monitored in 81 evaluable patients. Adherence was significantly associated with successful virologic outcome (P < 0.001) and increase in CD4 lymphocyte count (P = 0.006). Virologic failure was documented in 22% of patients with adherence of 95% or greater, 61% of those with 80% to 94.9% adherence, and 80% of those with less than 80% adherence. Patients with adherence of 95% or greater had fewer days in the hospital (2.6 days per 1000 days of follow-up) than those with less than 95% adherence (12.9 days per 1000 days of follow-up; P = 0.001). No opportunistic infections or deaths occurred in patients with 95% or greater adherence. Active psychiatric illness was an independent risk factor for adherence less than 95% (P = 0.04). Physicians predicted adherence incorrectly for 41% of patients, and clinic nurses predicted it incorrectly for 30% of patients. CONCLUSIONS Adherence to protease inhibitor therapy of 95% or greater optimized virologic outcome for patients with HIV infection. Diagnosis and treatment of psychiatric illness should be further investigated as a means to improve adherence to therapy.
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Affiliation(s)
- D L Paterson
- Veterans Affairs Medical Center, Pittsburgh, Pennsylvania 15240, USA
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23
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Affiliation(s)
- S L George
- Department of Internal Medicine, Iowa City Veterans Administration Medical Center, and the University of Iowa College of Medicine, USA
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Singh N, Berman SM, Swindells S, Justis JC, Mohr JA, Squier C, Wagener MM. Adherence of human immunodeficiency virus-infected patients to antiretroviral therapy. Clin Infect Dis 1999; 29:824-30. [PMID: 10589897 DOI: 10.1086/520443] [Citation(s) in RCA: 184] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The impact of demographic, psychosocial, and medical regimen-related variables on adherence of 123 human immunodeficiency virus (HIV)-infected patients to antiretroviral therapy was assessed by means of refill methodology. Satisfaction with social support (P = .029), problem-focused coping (P = .027), and active-behavioral coping (P = .011) correlated significantly with adherence, whereas loss of motivation (P = .006), hopelessness (P = .16), and avoidant coping (p = .015) correlated with nonadherence. At the 6-month follow-up, the mean CD4 cell count differed significantly among adherent versus nonadherent patients (a mean increase of 78/mm3 vs. a mean decrease of 5/mm3; P = .018). Adherence did not correlate with the number of antiretroviral medications consumed per day (mean, 3.0 vs. 2.5). Non-Caucasian patients were more likely to be nonadherent than Caucasian patients (relative risk, 2.5; 95% confidence interval, 1.2-5.3; P = .013); this difference was not explained by age, education, employment, income, history of intravenous drug use, or medical regimen. Non-Caucasian patients, however, were less satisfied with their social support (P = .04) and informational support (P = .016) and were more likely to utilize emotion-focused coping (P = .01). Thus, satisfaction with social support and coping style significantly impacted adherence and likely accounted for the observed racial difference in adherence among HIV-infected patients.
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Affiliation(s)
- N Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, Pennsylvania 15240, USA
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25
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Abstract
OBJECTIVES To evaluate the predictive value of baseline plasma HIV-1 RNA levels and CD4 lymphocyte counts and early changes in these markers after initiating antiretroviral therapy on the risk of development of specific opportunistic infections (OIs). DESIGN Patient data from four antiretroviral therapy studies were combined for a retrospective analysis. The analysis included 842 participants from the virology substudies of these trials who had baseline measurements for both HIV-1 RNA levels and CD4 cell counts. METHODS Cox proportional hazards models were used to assess the joint effects of baseline CD4 cell count and HIV-1 RNA level and early treatment-associated changes in these values on the risk of development of Pneumocystis carinii pneumonia (PCP), cytomegalovirus (CMV), or Mycobacterium avium complex (MAC). The effects of potential confounders such as prior prophylaxis and previous OIs were also addressed. RESULTS Baseline CD4 cell counts and HIV-1 RNA measurements showed significant associations with the risk of PCP, CMV, and MAC. Patients with higher levels of HIV-1 RNA were estimated to have three to six times the risk of these OIs than those with lower levels. Reductions in viral load were linked to significantly reduced risks of PCP, CMV, and MAC. Early decreases in RNA were generally more predictive of risk than were early increases in CD4 cell counts. CONCLUSIONS Baseline viral load and reductions in viral load during therapy appeared to influence the risk of these OIs independently of the CD4 cell count. Future guidelines for the initiation of prophylaxis for these OIs may be improved by incorporating information on viral load.
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Affiliation(s)
- P L Williams
- Department of Biostatistics, Harvard School of Public Health, Boston, MA 02115, USA.
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Swindells S, Mohr J, Justis JC, Berman S, Squier C, Wagener MM, Singh N. Quality of life in patients with human immunodeficiency virus infection: impact of social support, coping style and hopelessness. Int J STD AIDS 1999; 10:383-91. [PMID: 10414881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
We aimed to determine whether the quality of life (QOL) in the patients infected with human immunodeficiency virus (HIV) infection was influenced by satisfaction with social support, coping style and hopelessness. One hundred and thirty-eight HIV-infected patients were prospectively studied in this multicentre, longitudinal study. The QOL was assessed by Medical Outcome Study Health Survey SF-36, social support by Sarason Social Support Questionnaire, hopelessness by Beck Hopelessness Scale, and coping by Billing and Moos Inventory of coping with illness. The QOL did not correlate with age, sex, race, HIV risk factor, education or marital status. Employment (P = 0.0001), higher income (P = 0.03), satisfaction with social support (P = 0.04), regardless of the source of that support, and problem-focused coping (P = 0.03) were associated with a significantly better QOL, while, emotion-focused coping (r = -0.19, P = 0.04), avoidant coping (r = 0.40, P = 0.0001), hopelessness (r = -0.64, P = 0.0001) and AIDS (P = 0.09) were predictors of poorer QOL. Physical functioning correlated positively with employment (P = 0.0001), and inversely with AIDS (P = 0.0002), hopelessness (P = 0.03), avoidant coping (P = 0.03), and age (P = 0.10). At 6 months follow up, QOL score had changed in 20% of the patients; older age (P = 0.01), and lesser satisfaction with social support (P = 0.15) were associated with a decline in QOL, while adherence with antiretroviral therapy (P = 0.006) was associated with an increase in QOL score. Seven of 138 patients died during follow up; these patients had significantly lower QOL at baseline than all other patients (P = 0.003). Interventions to alleviate hopelessness, maladaptive coping, and enhancement of satisfaction with social support may improve overall QOL in HIV-infected patients. Older patients with HIV were less satisfied with their social support, were more likely to utilize unhealthy coping styles, and experienced a greater decline in QOL over time.
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Affiliation(s)
- S Swindells
- University of Nebraska Medical Center, Omaha, USA
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Abstract
Remarkable progress was made in recent years in the therapeutics of HIV-1-associated dementia (HAD) and in unraveling the complex pathophysiology that follows viral invasion of the central nervous system (CNS). Viral replication in and outside of the CNS was significantly reduced in HIV-1 infected subjects by new potent antiretroviral therapies. This has resulted in partial repair of cellular immune function with improvement in, and the prevention of, neurologic deficits associated with progressive HIV-1 disease. In regard to HAD pathophysiology, it is now known that CNS damage induced by HIV-1 infection occurs indirectly. Neuronal loss is mediated through immune activation and viral infection of mononuclear phagocytes (MPs) (brain macrophages and microglia). Cellular and viral factors secreted by brain MPs produce, over time, neuronal damage and drop out. Viral growth in the brain appears necessary, but not sufficient, to produce cognitive and motor impairments in affected individuals. Indeed, the best predictor for neurologic impairment following HIV-1 infection is the absolute number of immune-competent macrophages; not the level of viral production in affected brain tissue. As yet, an understanding of macrophage-related neurodegeneration has not translated into significant improvements in the treatment of this devastating complication of HIV disease. Nonetheless, adjunctive antiinflammatory and neuroprotective therapies are being developed. New ideas regarding HAD neuropathogenesis, and implications for the diagnosis and treatment of HAD are summarized in this article.
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Affiliation(s)
- S Swindells
- Center for Neurovirology and Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, USA.
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28
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Swindells S. Metabolic complications of HIV disease. Nurse Pract 1999; 24:125-6, 129. [PMID: 10048085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, USA
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29
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Gendelman HE, Zheng J, Coulter CL, Ghorpade A, Che M, Thylin M, Rubocki R, Persidsky Y, Hahn F, Reinhard J, Swindells S. Suppression of inflammatory neurotoxins by highly active antiretroviral therapy in human immunodeficiency virus-associated dementia. J Infect Dis 1998; 178:1000-7. [PMID: 9806027 DOI: 10.1086/515693] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A human immunodeficiency virus type 1 (HIV)-seropositive, antiretroviral-naive patient presented with significant cognitive dysfunction. Neuropsychologic, neuroradiologic, immunologic, and virologic studies confirmed HIV-associated dementia (HAD). After 12 weeks of highly active antiretroviral therapy (HAART) with ibuprofen, dramatic improvements were demonstrated in neurologic function and were sustained for > 1 year. HIV-1 RNA in cerebrospinal fluid (CSF) decreased from 10(5) to 10(4) copies/mL after 4 weeks. After 20 weeks of therapy, plasma viremia decreased from 10(6) copies/mL to undetectable (< 96 copies/mL). Assays of neurotoxins (tumor necrosis factor-alpha, quinolinic acid, and nitric oxide) in plasma and CSF were considerably elevated at presentation and significantly decreased after therapy. Baseline plasma and CSF demonstrated neurotoxic activities in vitro, which also reduced markedly. These data, taken together, support the notion that HAD is a reversible metabolic encephalopathy fueled by viral replication. HAART used with nonsteroidal antiinflammatory agents leads to the suppression of inflammatory neurotoxins and can markedly improve neurologic function in HAD.
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Affiliation(s)
- H E Gendelman
- Center for Neurovirology and Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha 68198-5400, USA
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30
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Paul S, Li L, Kalaga R, O'Dell J, Dannenbring RE, Swindells S, Hinrichs S, Caturegli P, Rose NR. Characterization of thyroglobulin-directed and polyreactive catalytic antibodies in autoimmune disease. J Immunol 1997; 159:1530-6. [PMID: 9233652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Polyreactive and thyroglobulin (Tg)-directed proteolytic activities present in the serum IgG of healthy controls and patients with autoimmune disease were studied by electrophoretic separation of 125I-labeled Tg reaction products and spectrofluorometric measurement of Pro-Phe-Arg-methylcoumarinamide cleavage at the Arg-methylcoumarinamide bond. A decrease of the polyreactive proteolytic activity accompanying an increase of the Tg-cleaving activity in IgG from autoimmune thyroiditis (ATh) and systemic lupus erythematosus (SLE) patients was evident. The Tg, a known target of autoimmune reactions in ATh, was cleaved at lower levels by Abs from patients with this disease than from SLE patients. The Tg-cleaving and Tg-binding activities of the autoantibody preparations were not correlated. Enhanced rates of cleavage at saturating substrate concentrations (Vmax), not increased Tg-binding affinities, were evident in IgG preparations with the greatest Tg-cleaving activity. Similarly, diminution of the polyreactive proteolytic activity in IgG from the autoimmune disease patients was due to decreased Vmax values, not decreased substrate-binding affinities. No cleavage of Tg by IgG from subjects with HIV-1 infection, or from mice hyperimmunized with an albumin-hapten conjugate was evident, suggesting that generation of Tg-cleaving Abs does not accompany V region affinity maturation in response to unrelated Ags. These observations establish Tg as a target of catalytic autoantibodies in SLE and ATh, suggest a transition from polyreactive proteolytic activity to autoantigen-directed activity in autoimmune disease, and open the possibility that combining site chemical reactivity is a factor driving the expression of catalytic activity by autoantibodies.
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Affiliation(s)
- S Paul
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
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31
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Paul S, Li L, Kalaga R, O'Dell J, Dannenbring RE, Swindells S, Hinrichs S, Caturegli P, Rose NR. Characterization of thyroglobulin-directed and polyreactive catalytic antibodies in autoimmune disease. The Journal of Immunology 1997. [DOI: 10.4049/jimmunol.159.3.1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Polyreactive and thyroglobulin (Tg)-directed proteolytic activities present in the serum IgG of healthy controls and patients with autoimmune disease were studied by electrophoretic separation of 125I-labeled Tg reaction products and spectrofluorometric measurement of Pro-Phe-Arg-methylcoumarinamide cleavage at the Arg-methylcoumarinamide bond. A decrease of the polyreactive proteolytic activity accompanying an increase of the Tg-cleaving activity in IgG from autoimmune thyroiditis (ATh) and systemic lupus erythematosus (SLE) patients was evident. The Tg, a known target of autoimmune reactions in ATh, was cleaved at lower levels by Abs from patients with this disease than from SLE patients. The Tg-cleaving and Tg-binding activities of the autoantibody preparations were not correlated. Enhanced rates of cleavage at saturating substrate concentrations (Vmax), not increased Tg-binding affinities, were evident in IgG preparations with the greatest Tg-cleaving activity. Similarly, diminution of the polyreactive proteolytic activity in IgG from the autoimmune disease patients was due to decreased Vmax values, not decreased substrate-binding affinities. No cleavage of Tg by IgG from subjects with HIV-1 infection, or from mice hyperimmunized with an albumin-hapten conjugate was evident, suggesting that generation of Tg-cleaving Abs does not accompany V region affinity maturation in response to unrelated Ags. These observations establish Tg as a target of catalytic autoantibodies in SLE and ATh, suggest a transition from polyreactive proteolytic activity to autoantigen-directed activity in autoimmune disease, and open the possibility that combining site chemical reactivity is a factor driving the expression of catalytic activity by autoantibodies.
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Affiliation(s)
- S Paul
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - L Li
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - R Kalaga
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - J O'Dell
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - R E Dannenbring
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - S Swindells
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - S Hinrichs
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - P Caturegli
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
| | - N R Rose
- Department of Anesthesiology, Eppley Cancer Research Institute, University of Nebraska Medical Center, Omaha 68198, USA.
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32
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Brichacek B, Swindells S, Janoff EN, Pirruccello S, Stevenson M. Increased plasma human immunodeficiency virus type 1 burden following antigenic challenge with pneumococcal vaccine. J Infect Dis 1996; 174:1191-9. [PMID: 8940208 DOI: 10.1093/infdis/174.6.1191] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Primary factors that influence virus burden during human immunodeficiency virus type 1 (HIV-1) disease progression remain a fundamental issue in pathogenesis. Because pneumococcal vaccine is routinely given to HIV-1-infected patients and replication of HIV-1 within CD4 T cells is dependent on the activation state of the cell, it was investigated whether the T cell activation that enhances the immune response to vaccines may also enhance HIV-1 replication. Vaccination of asymptomatic HIV-1-infected patients led to rapid and significant increases in virus burden in some patients. The magnitude of these increases correlated significantly with the extent of the antibody response to the vaccination. Thus, antigenic stimulation by vaccines designed to prevent secondary infections may promote HIV-1 replication in certain patients. These findings provide a window for examining HIV-1 pathogenesis and for determining the appropriate preventive measures against other diseases in HIV-1-infected persons.
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Affiliation(s)
- B Brichacek
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, USA
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33
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Anderson J, Clark RA, Watts DH, Till M, Arrastia C, Schuman P, Cohn SE, Young M, Bessen L, Greenblatt R, Vogler M, Swindells S, Boyer P. Idiopathic genital ulcers in women infected with human immunodeficiency virus. J Acquir Immune Defic Syndr Hum Retrovirol 1996; 13:343-7. [PMID: 8948372 DOI: 10.1097/00042560-199612010-00007] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A national survey of investigators caring for human immunodeficiency virus (HIV)-infected women was undertaken to describe the clinical presentation of idiopathic genital ulcer disease. Patients with negative syphilis and herpes simplex testing and/or negative genital ulcer biopsy were included in this study. Study participants (n = 29) were generally severely immunocompromised (median CD4 cell count was 50/mm3, and 68% had an acquired immunodeficiency syndrome [AIDS]-defining opportunistic process). Thirty-seven percent had coexistent oral ulcers and 19% had their genital ulcer progress to fistula formation (four rectovaginal and one vaginal-perineal). There was generally a favorable response to topical, systemic, and intralesional steroid treatment. This study suggests that idiopathic or probable aphthous genital ulcers in women have similar clinical characteristics to aphthous oroesophageal ulcers. Although infrequent, these genital ulcers can cause severe morbidity. Further research is warranted to better define the pathophysiology and optimal management.
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Affiliation(s)
- J Anderson
- Johns Hopkins University, Baltimore Maryland, USA
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34
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Ragni MV, Belle SH, Jaffe R, Locker J, Duerstein SL, Bass DC, Addiego JE, Aledort LM, Barron LE, Brettler DB, Buchanan GR, Gill JC, Ewenstein BM, Green D, Hilgartner MW, Hoots WK, Kisker CT, Lovrien EW, Rutherford CJ, Sanders NL, Smith KJ, Stabler SP, Swindells S, White GC, Kingsley LA. AIDS-associated non-Hodgkin's lymphomas as primary and secondary AIDS diagnoses in hemophiliacs. Hemophilia Malignancy Study Group. J Acquir Immune Defic Syndr Hum Retrovirol 1996; 13:78-86. [PMID: 8797689 DOI: 10.1097/00042560-199609000-00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We studied the characteristics and temporal trends of AIDS- associated non-Hodgkin's lymphoma (AIDS-NHL) in individuals with hemophilia. Prospective data were collected on 33 HIV-positive hemophiliacs with AIDS-NHL enrolled in the Hemophilia Malignancy Study (HMS), of whom 21 had primary and 12 had secondary or subsequent AIDS-defining illnesses, and analyzed for frequency and temporal trends. As compared with primary AIDS- NHL, secondary AIDS-NHL occurred at an older mean age, 37 versus 29 years (p = 0.12); at a lower mean CD4 count, 46 versus 154 (p = 0.07); after a longer period of immunosuppression (CD4 < 200/microl), 41 versus 16 months (p = 0.03); and with shorter median survival, 2 versus 7 months (p = 0.09). The presence of EBV in tumor tissue was associated with shorter survival, 1 versus 7 months (p = 0.17). Between 1981 and 1988 and 1989 and 1994, the proportion of primary AIDS diagnoses that were AIDS-NHL changed minimally, 4.6 versus 6.1%, whereas there were significant decreases in Pneumocystis carinii pneumonia (PCP, p = 0.02) and wasting (p = 0.07), and an increase in Candida (p = 0.004). These findings confirm that an increasing proportion of AIDS-NHL in hemophiliacs are occurring as secondary or later AIDS diagnoses, and they are associated with prolonged duration of immunosuppression.
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Affiliation(s)
- M V Ragni
- University of Pittsburgh School of Medicine, Hemophilia Center of Western Pennsylvania 15213, USA
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35
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Nottet HS, Persidsky Y, Sasseville VG, Nukuna AN, Bock P, Zhai QH, Sharer LR, McComb RD, Swindells S, Soderland C, Gendelman HE. Mechanisms for the transendothelial migration of HIV-1-infected monocytes into brain. J Immunol 1996; 156:1284-95. [PMID: 8558009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
HIV-1 penetration of the brain is a pivotal event in the neuropathogenesis of AIDS-associated dementia. The establishment of productive viral replication or up-regulation of adhesion molecule expression on brain microvascular endothelial cells (BMVEC) could permit entry of HIV into the central nervous system. To investigate the contribution of both, we inoculated primary human BMVEC with high titer macrophage-tropic HIV-1 or cocultured them with virus-infected monocytes. In both instances, BMVEC failed to demonstrate productive viral replication. Cell to cell contact between monocytes and microvascular endothelium resulted in E-selectin expression on BMVEC. BMVEC. cocultured with LPS-activated HIV-infected monocytes expressed even higher levels of E-selectin and vascular cell adhesion molecule-1 (VCAM-1). Transwell assays supported a role of soluble factors, from virus-infected monocytes, for the induction of adhesion molecules on BMVEC. To verify the in vivo relevance of these findings, levels of adhesion molecules were compared with those of proinflammatory cytokines and HIV-1 gene products in brain tissue of AIDS patients with or without encephalitis and HIV-seronegative controls. E-Selectin, and to a lesser degree VCAM-1, paralleled the levels of HIV-1 gene products and proinflammatory cytokines in brain tissue of subjects with encephalitis. Most importantly, an association between macrophage infiltration and increased endothelial cell adhesion molecules was observed in encephalitic brains. Monocyte binding to encephalitic brain tissue was blocked with Abs to VCAM-1 and E-selectin. These data, taken together, suggest that HIV entry into brain is, in part, a consequence of the ability of virus-infected and immune-activated monocytes to induce adhesion molecules on brain endothelium.
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Affiliation(s)
- H S Nottet
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
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36
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Swindells S, Baldwin T, Kelly C, Baca-Regen L, Loomis L, Post D, Brichacek B, Stevenson M, Dominguez EA, Reddy R, Klein R, Liao MJ, Testa D, McDonald T, Bellanti J, Skurkovich S, Gendelman HE. Regulation and characterization of the interferon-alpha present in patients with advanced human immunodeficiency virus type 1 disease. J Interferon Cytokine Res 1996; 16:127-37. [PMID: 8742365 DOI: 10.1089/jir.1996.16.127] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
To examine a possible association between plasma viremia and interferon-alpha (IFN-alpha) in patients with the acquired immunodeficiency syndrome (AIDS), we performed IFN plasma immunoadsorption by apheresis (IFN-alpha apheresis) in four volunteers with AIDS who had sustained levels of endogenous plasma IFN-alpha. IFN-alpha apheresis with two plasma volume exchanges was performed daily for 5 days. Clinical signs and symptoms and hematologic, virologic, and immunologic parameters were monitored. Two subjects developed anemia from phlebotomy, and one had a catheter++-associated bacteremia. The IFN-alpha apheresis was effective only in transiently removing IFN-alpha: depletion of IFN-alpha led only to its rapid reconstitution. Cell-associated HIV-1 was unchanged, but three of four subjects had a modest decrease in culturable plasma virus burden following the procedures. The recovery of in vivo HIV-1-related IFN-alpha by apheresis allowed its biologic and biochemical characterization. The HIV-1 IFN-alpha showed characteristics on ELISA, western blot, and biologic assays similar to two subspecies of the natural protein. The natural, recombinant, and HIV-1-induced IFN-alpha s demonstrated nearly identical antiviral activities. The HIV-1 IFN-alpha eluted from the column was not acid labile. The inability of large amounts of plasma IFN-alpha found in some patients with AIDS to affect viral burden likely reflects properties of the virus or of host factors independent of IFN-alpha.
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Affiliation(s)
- S Swindells
- Department of Medicine, University of Nebraska Medical Center, Omaha, USA
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37
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Nottet HS, Persidsky Y, Sasseville VG, Nukuna AN, Bock P, Zhai QH, Sharer LR, McComb RD, Swindells S, Soderland C, Gendelman HE. Mechanisms for the transendothelial migration of HIV-1-infected monocytes into brain. The Journal of Immunology 1996. [DOI: 10.4049/jimmunol.156.3.1284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
HIV-1 penetration of the brain is a pivotal event in the neuropathogenesis of AIDS-associated dementia. The establishment of productive viral replication or up-regulation of adhesion molecule expression on brain microvascular endothelial cells (BMVEC) could permit entry of HIV into the central nervous system. To investigate the contribution of both, we inoculated primary human BMVEC with high titer macrophage-tropic HIV-1 or cocultured them with virus-infected monocytes. In both instances, BMVEC failed to demonstrate productive viral replication. Cell to cell contact between monocytes and microvascular endothelium resulted in E-selectin expression on BMVEC. BMVEC. cocultured with LPS-activated HIV-infected monocytes expressed even higher levels of E-selectin and vascular cell adhesion molecule-1 (VCAM-1). Transwell assays supported a role of soluble factors, from virus-infected monocytes, for the induction of adhesion molecules on BMVEC. To verify the in vivo relevance of these findings, levels of adhesion molecules were compared with those of proinflammatory cytokines and HIV-1 gene products in brain tissue of AIDS patients with or without encephalitis and HIV-seronegative controls. E-Selectin, and to a lesser degree VCAM-1, paralleled the levels of HIV-1 gene products and proinflammatory cytokines in brain tissue of subjects with encephalitis. Most importantly, an association between macrophage infiltration and increased endothelial cell adhesion molecules was observed in encephalitic brains. Monocyte binding to encephalitic brain tissue was blocked with Abs to VCAM-1 and E-selectin. These data, taken together, suggest that HIV entry into brain is, in part, a consequence of the ability of virus-infected and immune-activated monocytes to induce adhesion molecules on brain endothelium.
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Affiliation(s)
- H S Nottet
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - Y Persidsky
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - V G Sasseville
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - A N Nukuna
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - P Bock
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - Q H Zhai
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - L R Sharer
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - R D McComb
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - S Swindells
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - C Soderland
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
| | - H E Gendelman
- Department of Pathology, Eppley Institute for Cancer and Allied Disease, University of Nebraska Medical Center, Omaha 68198, USA
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38
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Swindells S. Nebraska physicians and AIDS. Nebr Med J 1996; 81:10-13. [PMID: 8584063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- S Swindells
- University of Nebraska Medical Center, Omaha 68198-5400, USA
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Swindells S, McConnell JR, McComb RD, Gendelman HE. Utility of cerebral proton magnetic resonance spectroscopy in differential diagnosis of HIV-related dementia. J Neurovirol 1995; 1:268-74. [PMID: 9222365 DOI: 10.3109/13550289509114023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Opportunistic infections often coexist with human immunodeficiency virus (HIV) infection in brain. Making the correct diagnosis is often difficult despite recent advances in neuroimaging techniques. 1H magnetic resonance spectroscopy (1H MRS) is an emerging non-invasive examination for diagnosis and monitoring of brain disorders. 1H MRS measures a variety of organic compounds using magnetism and radio waves. Biochemical aberrations in brain, not shown by conventional tests, may be demonstrated by 1H MRS testing. A patient coinfected with HIV and hepatitis B (HBV) presented with progressive dementia. Clinical, neuroradiological and cerebrospinal fluid (CSF) examinations failed to provide a diagnosis in support of either HIV-1-associated cognitive/motor complex or HBV-induced hepatic encephalopathy (HE), 1H MRS was used in an attempt to discriminate between these diagnoses. Spectroscopy demonstrated increased glutamine and normal N-acetyl aspartate (NAA) levels, metabolic changes consistent with HE. These findings were later confirmed pathologically. Proton magnetic resonance spectroscopy is a non-invasive test with utility for the differential diagnosis of HIV-associated dementia.
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Affiliation(s)
- S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Stevenson M, Brichacek B, Heinzinger N, Swindells S, Pirruccello S, Janoff E, Emerman M. Molecular basis of cell cycle dependent HIV-1 replication. Implications for control of virus burden. Adv Exp Med Biol 1995; 374:33-45. [PMID: 7572399 DOI: 10.1007/978-1-4615-1995-9_4] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Research is beginning to yield insight into determinants which govern cell cycle dependence of provirus establishment by the onco-retroviruses. In the case of HIV-1, nucleophilic components associated with the viral preintegration complex facilitate mitosis independent nuclear localization of viral DNA and provirus establishment. Differences in the metabolic activity between G0 T cells and macrophages, the two primary targets for HIV-1 infection, lead to significantly different outcomes with regards to provirus establishment following infection of these cells. Thus, macrophages appear fully permissive to productive HIV-1 replication while non-dividing (G0 T cells) restrict virus replication at a step which proceeds nuclear import of viral DNA. The requirement for T cell activation in productive HIV-1 replication has important implications for the relationship between immune activation and virus burden. It remains to be determined whether modulating the immune activation status of the infected individual may provide an opportunity for modulating virus burden and influencing disease course.
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Affiliation(s)
- M Stevenson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha 68198-5120, USA
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Walzak D, Swindells S, Bhardwaj A. Primary care physicians and the cost of drugs: a study of prescribing practices based on recognition and information sources. J Clin Pharmacol 1994; 34:1159-63. [PMID: 7738210 DOI: 10.1002/j.1552-4604.1994.tb04726.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Rapidly inflating health care costs limit patient care, and prescription drug costs constitute a major component of this expenditure. This study examines attitudes toward and knowledge of prescription drug costs of primary care physicians. Access to information about drug costs and implications for medical education are also explored. A questionnaire survey was sent to 137 internists, family, and general practitioners, randomly selected from a list provided by the Ohio State Medical Board. The questionnaire elicited information on demographic characteristics of respondents, influence of drug costs on prescribing habits, actual knowledge of prices of the 20 most commonly used drugs, attitudes toward generic drug use, sources of information on costs, and desire for emphasis on drug costs in medical education. Responding physicians indicated consideration of drug costs in therapeutic decisions, but lacked information and often made inaccurate assumptions about costs of drugs prescribed. Most felt they could provide better service and reduce costs if information about drug prices was readily available. Most agreed medical education should address drug costs. Drug cost estimates varied widely; correct responses ranged from 9% to 53%. No statistically significant pattern emerged regarding demographics of respondents or information sources used. Primary care physicians consider drug costs important and realize that cost-effective prescribing may lower health care costs. However, because physician knowledge of drug costs is inadequate and costs are not readily accessible, implications for better physician education and improved abscess are substantial.
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Affiliation(s)
- D Walzak
- Department of General Medicine, Ohio State University, Columbus
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Gendelman HE, Baldwin T, Baca-Regen L, Swindells S, Loomis L, Skurkovich S. Regulation of HIV1 replication by interferon alpha: from laboratory bench to bedside. Res Immunol 1994; 145:679-84; discussion 684-5. [PMID: 7754219 DOI: 10.1016/s0923-2494(05)80054-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- H E Gendelman
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha 68198, USA
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McConnell JR, Swindells S, Ong CS, Gmeiner WH, Chu WK, Brown DK, Gendelman HE. Prospective utility of cerebral proton magnetic resonance spectroscopy in monitoring HIV infection and its associated neurological impairment. AIDS Res Hum Retroviruses 1994; 10:977-82. [PMID: 7811549 DOI: 10.1089/aid.1994.10.977] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Neurological manifestations of HIV disease occur in most adults and children with AIDS. Many of those affected will inevitably suffer clinical neurological deficits involving mental function, movement, and sensation. Surprisingly, there are not as yet adequate monitoring systems to predict the onset and/or progression of HIV infection of the CNS. Neurological, neuropsychological, CSF, and magnetic resonance imaging (MRI) analyses cannot accurately detect mental deterioration during advancing HIV disease. Reports suggest that in vivo proton MR spectroscopy (1H MRS) of the brain could be a predictor of virus-induced neurological deterioration. H MRS can measure N-acetylaspartate (NAA), a metabolite present only in neurons. Decreased NAA reflects neuronal loss seen during HIV infection of brain. To uncover possible associations between NAA levels and HIV-induced neurological disease we performed serial 1H MRS brain tests in HIV-infected patients with or at risk for encephalopathy. Serial testing, for 1 year, of 10 patients showed that brain NAA levels decreased in all HIV-infected subjects. The most severe NAA reductions were associated with progressive neurological impairment. These findings suggest that NAA can be used as a noninvasive measure of neuronal loss in patients with HIV disease. Most important, the results suggest that 1H MRS could be used to monitor therapeutics directed against HIV infection within the CNS.
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Affiliation(s)
- J R McConnell
- Department of Radiology, University of Nebraska Medical Center, Omaha 68198
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Gelbard HA, Nottet HS, Swindells S, Jett M, Dzenko KA, Genis P, White R, Wang L, Choi YB, Zhang D. Platelet-activating factor: a candidate human immunodeficiency virus type 1-induced neurotoxin. J Virol 1994; 68:4628-35. [PMID: 8207837 PMCID: PMC236390 DOI: 10.1128/jvi.68.7.4628-4635.1994] [Citation(s) in RCA: 246] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The pathogenesis of central nervous system disease during human immunodeficiency virus type 1 (HIV-1) infection revolves around productive viral infection of brain macrophages and microglia. Neuronal losses in the cortex and subcortical gray matter accompany macrophage infection. The question of how viral infection of brain macrophages ultimately leads to central nervous system (CNS) pathology remains unanswered. Our previous work demonstrated high-level production of tumor necrosis factor alpha, interleukin 1 beta, arachidonic acid metabolites, and platelet-activating factor (PAF) from HIV-infected monocytes and astroglia (H. E. Gendelman, P. Genis, M. Jett, and H. S. L. M. Nottet, in E. Major, ed., Technical Advances in AIDS Research in the Nervous System, in press; P. Genis, M. Jett, E. W. Bernton, H. A. Gelbard, K. Dzenko, R. Keane, L. Resnick, D. J. Volsky, L. G. Epstein, and H. E. Gendelman, J. Exp. Med. 176:1703-1718, 1992). These factors, together, were neurotoxic. The relative role(s) of each of these candidate neurotoxins in HIV-1-related CNS dysfunction was not unraveled by these initial experiments. We now report that PAF is produced during HIV-1-infected monocyte-astroglia interactions. PAF was detected at high levels in CSF of HIV-1-infected patients with immunosuppression and signs of CNS dysfunction. The biologic significance of the results for neurological disease was determined by addition of PAF to cultures of primary human fetal cortical or rat postnatal retinal ganglion neurons. Here, PAF at concentrations of > or = 300 pg/ml produced neuronal death. The N-methyl-D-aspartate receptor antagonist MK-801 or memantine partially blocked the neurotoxic effects of PAF. The identification of PAF as an HIV-1-induced neurotoxin provides new insights into how HIV-1 causes neurological impairment and how it may ultimately be ameliorated.
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Affiliation(s)
- H A Gelbard
- Department of Neurology, University of Rochester Medical Center, Rochester, New York 14642
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Abstract
Histoplasmosis is a frequent complication of HIV infection and is usually the result of reactivation. In the immunocompromised host, histoplasmosis may cause a chronic pulmonary infection or disseminated disease. In the setting of disseminated disease, oral lesions are present in 30% to 50% of patients and may occur in almost every part of the oral mucosa. The most common sites are the tongue, palate, and buccal mucosa. In some cases, oral lesions appear to be the primary or only manifestation of disease. We have been able to find only five case reports in the literature of histoplasmosis in HIV infection with oral lesions. In two of the cases, histoplasmosis was apparently localized to the oral cavity, whereas two cases also had evidence of disseminated disease, the fifth was undetermined. We report one such case of apparently localized oral histoplasmosis in a patient with HIV infection.
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Affiliation(s)
- S Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha
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Abstract
Mucocutaneous candidiasis caused by Candida albicans is a common complication of human immunodeficiency virus (HIV) infection. Recent reports of isolation of resistant strains of C. albicans raise the specter of more widespread resistance, but limited series are available to analyze situations in which the likelihood of resistance is greatest. We present our experience with fluconazole-resistant candidiasis in patients with HIV infection obtained from retrospective chart review and by testing strains of C. albicans isolated during relapse for susceptibility to antifungal agents. The possible reasons for failure of antifungal therapy are discussed, as well the correlation between in vivo and in vitro data. Resistant candidiasis in patients with HIV disease is an emerging problem of considerable concern that merits further study.
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Affiliation(s)
- D J Boken
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-5400
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Davenport A, Will EJ, Davison AM, Swindells S, Cohen AT, Miloszewski KJ, Losowsky MS. Changes in intracranial pressure during machine and continuous haemofiltration. Int J Artif Organs 1989; 12:439-44. [PMID: 2767789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nine consecutive patients with both fulminant hepatic failure and acute oliguric renal failure were treated either by daily machine haemofiltration (MHF), or by continuous arterio-venous haemofiltration (CAVHF). Six patients received a total of twenty treatments by MHF and four CAVHF, mean duration of treatment 56 hours, range 24-160. Intracranial pressure (ICP) was measured using a subdural catheter. During treatment with MHF, the mean ICP increased from 8.9 +/- 1.4 mmHg at the start of filtration to 14.8 +/- 2.1 mmHg at the end of treatment (p less than 0.05), whereas there was no corresponding increase during the same period of time with CAVHF treatment, the mean ICP fell, but not significantly from 19.4 +/- 4.8 mmHg to 11.2 +/- 2.3 mmHg. The mean ICP increased to greater than 25 mmHg on eleven occasions during treatment with MHF, requiring treatment with bolus mannitol or propofol, during the same period of treatment with CAVHF no such surges in ICP were recorded. This suggests that continuous haemofiltration is to be preferred to intermittent machine haemofiltration in the management of patients with acute hepatorenal failure.
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Affiliation(s)
- A Davenport
- Department of Renal Medicine, St. James's University Hospital, Leeds, U.K
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Davenport A, Will EJ, Davison AM, Swindells S, Cohen AT, Miloszewski KJ, Losowsky MS. Changes in intracranial pressure during haemofiltration in oliguric patients with grade IV hepatic encephalopathy. Nephron Clin Pract 1989; 53:142-6. [PMID: 2812168 DOI: 10.1159/000185727] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Seven consecutive patients with grade IV hepatic encephalopathy, due to fulminant hepatic failure complicated by oliguric renal failure were allocated at random to treatment with daily machine haemofiltration (MHF) or continuous arteriovenous haemofiltration (CAVHF). Intracranial pressure (ICP) was continuously monitored using a subdural catheter. Four patients received 17 treatments by MHF, and ICP increased from 8.4 +/- 1.5 mm Hg (mean + SEM) prior to treatment to 12.6 +/- 1.8 mm Hg on completion (p less than 0.05). Active intervention was required on twenty occasions to treat sustained increases in ICP (greater than 25 mm Hg maintained for 5 min or longer). A total of 12 haemofilters were used in the treatment of 3 patients by CAVHF. The ICP showed greater stability during CAVHF therapy, the mean pressure prior to treatment was 15.6 +/- 5.2 mm Hg and fell to 11.7 +/- 2.3 mm Hg at 4 h. Sustained increases in ICP occurred in only 1 patient as a preterminal event. These findings suggest that CAVHF is the preferred method of treatment in patients with fulminant hepatic failure complicated by oliguric renal failure who are at risk of developing cerebral oedema.
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Affiliation(s)
- A Davenport
- Department of Renal Medicine, St. James's University Hospital, Leeds, UK
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Davenport A, Will EJ, Losowsky MS, Swindells S. Continuous arteriovenous haemofiltration in patients with hepatic encephalopathy and renal failure. Br Med J (Clin Res Ed) 1987; 295:1028. [PMID: 3120861 PMCID: PMC1248075 DOI: 10.1136/bmj.295.6605.1028] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- A Davenport
- Department of Renal Medicine, St James's University Hospital, Leeds
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