HIV viraemia during hepatitis B vaccination shortens the duration of protective antibody levels

OBJECTIVES

Individuals with HIV infection often have early waning of protective antibody following hepatitis B virus (HBV) vaccination. HIV viraemia at the time of vaccination may limit the durability of serum anti-HBV surface antibody (HBsAb) levels. We investigated the relationship of HIV plasma viral load (VL) and duration of HBsAb among vaccinees enrolled in the US Military HIV Natural History Study.

METHODS

We included in the study participants who had no history of prior HBV infection, who had received all HBV vaccine doses after HIV diagnosis, and who had demonstrated an initial vaccine response, defined as HBsAb ≥ 10 IU/L. Responders were retrospectively followed with serial HBV serology from the time of the last vaccine dose until the development of waning (HBsAb < 10 IU/L) or the last HBsAb measurement. Time to and risk for waning were evaluated with Kaplan-Meier survival methods and Cox proportional hazards models, respectively.

RESULTS

A total of 186 initial vaccine responders were identified. During 570 person-years of observation, HBsAb waned in 52 of 186 participants (28%). The cumulative proportion maintaining HBsAb ≥ 10 IU/L was 83% at 2 years and 56% at 5 years. Participants with an undetectable VL [hazard ratio (HR) 0.37; 95% confidence interval (CI) 0.18-0.76] or with detectable VL of ≤ 10 000 copies/mL (HR 0.46; 95% CI 0.21-1.00) had reduced risk of waning. Other factors including age, number of vaccine doses, CD4 count, and receipt of highly active antiretroviral therapy (HAART) were not significantly associated with risk of waning HBsAb.

CONCLUSIONS

Undetectable or low HIV VL at the time of HBV vaccination is associated with greater durability of vaccine response in patients with HIV infection.

Determinants of incident chronic kidney disease and progression in a cohort of HIV-infected persons with unrestricted access to health care

OBJECTIVES

As socioeconomic factors may impact the risk of chronic kidney disease (CKD), we evaluated the incidence and risk factors of incident CKD among an HIV-infected cohort with universal access to health care and minimal injecting drug use (IDU).

METHODS

Incident CKD was defined as an estimated glomerular filteration rate (eGFR) <60 ml/min/1.73 m(2) for ≥ 90 days. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Rates were calculated per 1000 person-years (PY). Associations with outcomes were assessed using two separate Cox proportional hazard models, adjusting for baseline and time-updated covariates.

RESULTS

Among 3360 participants [median age 29 years; 92% male; 44% African American (AA)] contributing 23,091 PY of follow-up, 116 developed incident CKD [5.0/1000 PY; 95% confidence interval (CI) 4.2-6.0/1000 PY]. The median first eGFR value was 97.0 mL/min/1.73 m(2) [interquartile range (IQR) 85.3-110.1 mL/min/1.73 m(2)]. Baseline factors associated with CKD included older age, lower CD4 count at HIV diagnosis [compared with CD4 count ≥ 500 cells/μL, hazard ratio (HR) 2.1 (95% CI 1.2-3.8) for CD4 count 350-499 cells/μL; HR 3.6 (95% CI 2.0-6.3) for CD4 count 201-349 cells/μL; HR 4.3 (95% CI 2.0-9.4) for CD4 count ≤ 200 cells/μL], and HIV diagnosis in the pre-highly active antiretroviral therapy (HAART) era. In the time-updated model, low nadir CD4 counts, diabetes, hepatitis B, hypertension and less HAART use were also associated with CKD. AA ethnicity was not associated with incident CKD in either model.

CONCLUSIONS

The low incidence of CKD and the lack of association with ethnicity observed in this study may in part be attributable to unique features of our cohort such as younger age, early HIV diagnosis, minimal IDU, and unrestricted access to care. Lower baseline CD4 counts were significantly associated with incident CKD, suggesting early HIV diagnosis and timely introduction of HAART may reduce the burden of CKD.

Immunoglobulin G subclass levels and antibody responses to the 2009 influenza A (H1N1) monovalent vaccine among human immunodeficiency virus (HIV)-infected and HIV-uninfected adults

Immunoglobulin (Ig)G levels are important for antibody vaccine responses and IgG subclass deficiencies have been associated with severe 2009 influenza A (H1N1) infections. Studies have demonstrated variations in immune responses to the H1N1 vaccine, but the aetiology of this is unknown. We determined the associations between pre-vaccination overall and influenza-specific IgG subclass levels and 2009 H1N1-specific antibody responses post-vaccination (robust versus poor at day 28) stratified by human immunodeficiency virus (HIV) status. Logistic regression models were utilized to evaluate whether pre-vaccination IgG subclass levels were associated with the antibody response generated post-vaccination. We evaluated 48 participants as part of a clinical study who were stratified by robust versus poor post-vaccination immune responses. Participants had a median age of 35 years; 92% were male and 44% were Caucasian. HIV-infected adults had a median CD4 count of 669 cells/mm(3) , and 79% were receiving highly active anti-retroviral therapy. HIV-infected participants were more likely to have IgG2 deficiency (<240 mg/dl) than HIV-uninfected individuals (62% versus 4%, P < 0·001). No association of pre-vaccination IgG subclass levels (total or influenza-specific) and the antibody response generated by HIN1 vaccination in either group was found. In summary, pre-vaccination IgG subclass levels did not correlate with the ability to develop robust antibody responses to the 2009 influenza A (H1N1) monovalent vaccine. IgG2 deficiencies were common among HIV-infected individuals but did not correlate with poor influenza vaccine responses. Further investigations into the aetiology of disparate vaccine responses are needed.

Outcomes with daptomycin versus standard therapy for osteoarticular infections associated with Staphylococcus aureus bacteraemia

OBJECTIVES

To evaluate the clinical characteristics, treatment and outcomes of patients with osteoarticular infections (OAIs) associated with Staphylococcus aureus bacteraemia (SAB).

METHODS

The clinical characteristics and outcomes for patients with OAI were described using a post hoc analysis of an open label, randomized trial comparing daptomycin with standard therapy (vancomycin or anti-staphylococcal penicillin with initial gentamicin) for the treatment of SAB.

RESULTS

OAI occurred in 32 of 121 patients (21 daptomycin and 11 standard therapy) with complicated SAB (18 septic arthritis, 9 vertebral osteomyelitis and 7 others). Two patients had osteomyelitis in more than one site. Success rates seen in two groups were as follows: vertebral osteomyelitis [3/5 (60%) daptomycin versus 0/2 (0%) comparator], septic arthritis [7/11 (64%) versus 3/5 (60%)], sternal osteomyelitis [3/3 (100%) versus 1/2 (50%)] and long bone osteomyelitis [0/1 (0%) versus 1/1 (100%)]. Success rates in both treatment groups improved with surgical therapy. Creatine phosphokinase elevations to >500 IU/L occurred in one patient on daptomycin who discontinued therapy, whereas renal impairment developed in three patients on standard therapy, two of whom discontinued therapy. Two patients treated with daptomycin and one patient on vancomycin had increases in S. aureus MICs to daptomycin and vancomycin, respectively. Three patients treated with daptomycin died following completion of therapy, with mortality attributed to multiple co-morbid conditions and inadequate debridement of OAIs in these patients. No deaths were reported in the standard therapy group.

CONCLUSIONS

Daptomycin may be considered an alternative to standard therapy in the treatment of patients with complicated SAB and OAI.

Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database

Infective endocarditis due to coagulase-negative staphylococci is increasingly recognized as a difficult-to-treat disease associated with poor outcome. The aim of this report is to describe the characteristics and outcome of patients with prosthetic valve endocarditis (PVE) due to coagulase-negative staphylococci versus those of patients with PVE due to Staphylococcus aureus and viridans streptococci. Patients were identified through the International Collaboration on Endocarditis Merged Database. A total of 54 cases of coagulase-negative staphylococci PVE, 58 cases of S. aureus PVE, and 63 cases of viridans-streptococci-related PVE were available for analysis. There was no difference between the three groups with respect to the type of valve involved or the rate of embolization. However, heart failure was encountered more frequently with coagulase-negative staphylococci (54%) than with either S. aureus (33%; p=0.03) or viridans streptococci (32%; p=0.02). In addition, valvular abscesses complicated 39% of infections due to coagulase-negative staphylococci compared with 22% of those due to S. aureus (p=0.06) and 6% of those due to viridans streptococci (p<0.001). Mortality was highest in patients with S. aureus and coagulase-negative staphylococcal endocarditis (47 and 36%, respectively; p=0.22) and was considerably lower in patients with viridans streptococcal endocarditis (p=0.002 compared to patients with coagulase-negative staphylococcal endocarditis). The results of this analysis demonstrate the aggressive nature of coagulase-negative staphylococcal PVE and the substantially greater morbidity and mortality associated with this infection compared to PVE caused by other pathogens.

Biology of IL-5 in health and disease

LEARNING OBJECTIVES

Reading this article will increase the readers' knowledge of the biology of interleukin-5 (IL-5), an important cytokine. The immune and inflammatory responses of any organism are the basis of the defense mechanism ensuring its survival. The role of IL-5 in these processes, as well as in the pathogenesis of various diseases has been discussed along with the effects of various pharmacologic agents on the production and function of IL-5.

DATA SOURCES

A detailed literature search was performed. Studies considered relevant and important, in all languages, which involved humans and animals were used.

STUDY SELECTION

Information was obtained only from peer reviewed journals.

RESULTS

Interleukin-5 is normally produced by T-cells, mast cells, and eosinophils while Reed Sternberg and Epstein Barr virus (EBV) transformed cells also produce IL-5. Monoclonal antibodies (mAb) to IL-5 are potent inhibitors of IL-5 mediated tissue damage, secondary to eosinophil infiltration. The majority of the studies on IL-5 are preliminary, often the information is obtained from animal studies or in vitro systems and occasionally from pathologic tissue analysis. This along with the absence of confirmatory studies is a limiting factor. Nonetheless, the role of IL-5 in allergic and immunologic disease and asthma may be central to their pathogenesis.

CONCLUSIONS

Interleukin-5 is an important molecule that is participant to many processes that maintain health and are involved directly or indirectly in the pathogenesis of disease. Some pharmacologic agents can modify IL-5 production in vivo. Development of selective inhibitors of IL-5 may have a potential use for specific therapy of certain autoimmune, inflammatory, and neoplastic diseases.

The scarring processes in mucosal tissues after immune injury

OBJECTIVES

An important feature of the healing processes is scar formation which may be necessary for organism survival. If it proceeds to the pathological state, it may impair normal function. The purpose of this review is to focus on some of the factors that may influence this process after immune injury, comparing it in the skin and mucosa.

METHODS

A detailed literature search of peer-reviewed journals was conducted. Studies reported in all languages considered relevant and important were used, including humans, animals, and tissue culture.

RESULTS

Analysis of the data indicate that the scarring process is mainly dependent on (1) the type of the lesion, (2) the cause and duration of injury, and (3) the tissue involved and its microenvironment. Equally important is the large spectrum and heterogenicity in the biological activity of fibroblasts and their role in scar formation.

CONCLUSIONS

The process of scar formation is complex and multistep process and is affected and influenced by local and systemic factors. Although it appears irreversible, there are pharmacological agents available, and under investigation, that may minimize its detrimental effects.

Massive edema of the ovary: high resolution MR findings using a phased-array pelvic coil

We report a rare premenarchal case of massive ovarian edema in which high resolution MRI findings more accurately reflected characteristic pathologic changes of this condition compared with CT and ultrasound. A potential role of MR in preoperative diagnosis of massive ovarian edema is suggested.

Correlations of placental vascular anatomy and clinical outcomes in 69 monochorionic twin pregnancies

Monochorionic monozygotic twins frequently suffer complications from the presence of vascular anastomoses in their monochorionic placentas. Also, sharing of perfusion zones may be unequal, leading to marked growth discordance. This paper analyzes four measures of perinatal outcome (gestational age at delivery, perinatal mortality, birth weight discordance, and presence/absence of hydramnios) according to the vascular patterns of the monochorionic placentas. The worst clinical outcomes were associated with arteriovenous anastomoses in the absence of arterio-arterial and veno-venous anastomoses. The vascular patterns of monochorionic placentas cause significant fetal environmental differences within pairs of monochorionic monozygotic twins. These differences may cause life-long discordance for several phenotypic traits that are not genetically based, and which cause monochorionic monozygotic twins to be "non-identical."