Ecological study of the predictors of successful management of dyslipidemia in HIV-infected patients on ART: the Swiss HIV Cohort Study

PURPOSE: Antiretroviral therapy (ART) may induce metabolic changes and increase the risk of coronary heart disease (CHD). Based on a health care system approach, we investigated predictors for normalization of dyslipidemia in HIV-infected individuals receiving ART. METHOD: Individuals included in the study were registered in the Swiss HIV Cohort Study (SHCS), had dyslipidemia but were not on lipid-lowering medication, were on potent ART for >or= 3 months, and had >or= 2 follow-up visits. Dyslipidemia was defined as two consecutive total cholesterol (TC) values above recommended levels. Predictors of achieving treatment goals for TC were assessed using Cox models. RESULTS: Analysis included 958 individuals with median followup of 2.3 years (IQR 1.2-4.0). 454 patients (47.4%) achieved TC treatment goals. In adjusted analyses, variables significantly associated with a lower hazard of reaching TC treatment goals were as follows: older age (compared to 18-37 year olds: hazard ratio [HR] 0.62 for 45-52 year olds, 95% CI 0.47-0.82; HR 0.40 for 53-85, 95% CI 0.29-0.54), diabetes (HR 0.39, 95% CI 0.26-0.59), history of coronary heart disease (HR 0.27, 95% CI 0.10-0.71), higher baseline TC (HR 0.78, 95% CI 0.71-0.85), baseline triple nucleoside regimen (HR 0.12 compared to PI-only regimen, 95% CI 0.07-0.21), longer time on PI-only regimen (HR 0.39, 95% CI 0.33-0.46), longer time on NNRTI only regimen (HR 0.35, 95% CI 0.29-0.43), and longer time on PI/NNRTI regimen (HR 0.34, 95% CI 0.26-0.43). Switching ART regimen when viral load was undetectable was associated with a higher hazard of reaching TC treatment goals (HR 1.48, 95% CI 1.14-1.91). CONCLUSION: In SHCS participants on ART, several ART-related and not ART-related epidemiological factors were associated with insufficient control of dyslipidemia. Control of dyslipidemia in ART recipients must be further improved.

Optimal time for initiating antiretroviral therapy (ART) in HIV-infected, treatment-naive children aged 2 to 5 years old

BACKGROUND The use of combination antiretroviral therapy (cART) comprising three antiretroviral medications from at least two classes of drugs is the current standard treatment for HIV infection in adults and children. Current World Health Organization (WHO) guidelines for antiretroviral therapy recommend early treatment regardless of immunologic thresholds or the clinical condition for all infants (less than one years of age) and children under the age of two years. For children aged two to five years current WHO guidelines recommend (based on low quality evidence) that clinical and immunological thresholds be used to identify those who need to start cART (advanced clinical stage or CD4 counts ≤ 750 cells/mm(3) or per cent CD4 ≤ 25%). This Cochrane review will inform the current available evidence regarding the optimal time for treatment initiation in children aged two to five years with the goal of informing the revision of WHO 2013 recommendations on when to initiate cART in children. OBJECTIVES To assess the evidence for the optimal time to initiate cART in treatment-naive, HIV-infected children aged 2 to 5 years. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the AEGIS conference database, specific relevant conferences, www.clinicaltrials.gov, the World Health Organization International Clinical Trials Registry platform and reference lists of articles. The date of the most recent search was 30 September 2012. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared immediate with deferred initiation of cART, and prospective cohort studies which followed children from enrolment to start of cART and on cART. DATA COLLECTION AND ANALYSIS Two review authors considered studies for inclusion in the review, assessed the risk of bias, and extracted data on the primary outcome of death from all causes and several secondary outcomes, including incidence of CDC category C and B clinical events and per cent CD4 cells (CD4%) at study end. For RCTs we calculated relative risks (RR) or mean differences with 95% confidence intervals (95% CI). For cohort data, we extracted relative risks with 95% CI from adjusted analyses. We combined results from RCTs using a random effects model and examined statistical heterogeneity. MAIN RESULTS Two RCTs in HIV-positive children aged 1 to 12 years were identified. One trial was the pilot study for the larger second trial and both compared initiation of cART regardless of clinical-immunological conditions with deferred initiation until per cent CD4 dropped to <15%. The two trials were conducted in Thailand, and Thailand and Cambodia, respectively. Unpublished analyses of the 122 children enrolled at ages 2 to 5 years were included in this review. There was one death in the immediate cART group and no deaths in the deferred group (RR 2.9; 95% CI 0.12 to 68.9). In the subgroup analysis of children aged 24 to 59 months, there was one CDC C event in each group (RR 0.96; 95% CI 0.06 to 14.87) and 8 and 11 CDC B events in the immediate and deferred groups respectively (RR 0.95; 95% CI 0.24 to 3.73). In this subgroup, the mean difference in CD4 per cent at study end was 5.9% (95% CI 2.7 to 9.1). One cohort study from South Africa, which compared the effect of delaying cART for up to 60 days in 573 HIV-positive children starting tuberculosis treatment (median age 3.5 years), was also included. The adjusted hazard ratios for the effect on mortality of delaying ART for more than 60 days was 1.32 (95% CI 0.55 to 3.16). AUTHORS' CONCLUSIONS This systematic review shows that there is insufficient evidence from clinical trials in support of either early or CD4-guided initiation of ART in HIV-infected children aged 2 to 5 years. Programmatic issues such as the retention in care of children in ART programmes in resource-limited settings will need to be considered when formulating WHO 2013 recommendations.

High-resolution multi-proxy record of the last glacial period from Lake Van, eastern Anatolian high plateau, Turkey

Detailed analyses of the Lake Van pollen, Ca/K ratio and stable oxygen isotope record allow the identification of millennial-scale vegetation and environmental changes in eastern Anatolia throughout the last glacial (~75-15 ka BP). The climate within the last glacial was cold and dry, with low arboreal pollen (AP) levels. The driest and coldest period corresponds to Marine Isotope Stage (MIS) 2 (~28-14.5 ka BP) dominated by the highest values of xerophytic steppe vegetation. Our high-resolution multi proxy record shows rapid expansions and contractions of tree populations that reflects variability in temperature and moisture availability. This rapid vegetation and environmental changes can be linked to the stadial-interstadial pattern of the Dansgaard-Oeschger (DO) events as recorded in the Greenland ice cores. Periods of reduced moisture availability were characterized by enhanced xerophytic species and high terrigenous input from the Lake Van catchment area. Furthermore, comparison with the marine realm reveals that the complex atmosphere-ocean interaction can be explained by the strength and position of the westerlies, which is responsible for the supply of humidity in eastern Anatolia. Influenced by diverse topography of the Lake Van catchment, larger DO interstadials (e.g. DO 19, 17-16, 14, 12 and 8) show the highest expansion of temperate species within the last glacial. However, Heinrich events (HE), characterized by highest concentrations of ice-rafted debris (IRD) in marine sediments, are identified in eastern Anatolia by AP values not lower and high steppe components not more abundant than during DO stadials. In addition, this work is a first attempt to establish a continuous microscopic charcoal record over the last glacial in the Near East, which documents an initial immediate response to millennial-scale climate and environmental variability and enables us to shed light on the history of fire activity during the last glacial.

High-resolution multi-proxy record of the last interglacial period from Lake Van, eastern Anatolian high plateau, Turkey

A high-resolution multi-proxy record from Lake Van, eastern Anatolia, derived from a lacustrine sequence cored at the 357 m deep Ahlat Ridge (AR), allows a comprehensive view of paleoclimate and environmental history in the continental Near East during the last interglacial (LI). We combined paleovegetation (pollen), stable oxygen isotope (d18Obulk) and XRF data from the same sedimentary sequence, showing distinct variations during the period from 135 to 110 ka ago leading into and out of full interglacial conditions. The last interglacial plateau, as defined by the presence of thermophilous steppe-forest communities, lasted ca. 13.5 ka, from ~129.1-115.6 ka BP. The detailed palynological sequence at Lake Van documents a vegetation succession with several climatic phases: (I) the Pistacia zone (ca. 131.2-129.1 ka BP) indicates summer dryness and mild winter conditions during the initial warming, (II) the Quercus-Ulmus zone (ca. 129.1-127.2 ka BP) occurred during warm and humid climate conditions with enhanced evaporation, (III) the Carpinus zone (ca. 127.2-124.1 ka BP) suggest increasingly cooler and wetter conditions, and (IV) the expansion of Pinus at ~124.1 ka BP marks the onset of a colder/drier environment that extended into the interval of global ice growth. Pollen data suggest migration of thermophilous trees from refugial areas at the beginning of the last interglacial. Analogous to the current interglacial, the migration documents a time lag between the onset of climatic amelioration and the establishment of an oak steppe-forest, spanning 2.1 ka. Hence, the major difference between the last interglacial compared to the current interglacial (Holocene) is the abundance of Pinus as well as the decrease of deciduous broad-leaved trees, indicating higher continentality during the last interglacial. Finally, our results demonstrate intra-interglacial variability in the low mid-latitudes and suggest a close connection with the high-frequency climate variability recorded in Greenland ice cores.

Contradictio in terminis: dialéctica de la ambigüedad en la arquitectura contemporánea

The twentieth century brought a new sensibility characterized by the discredit of cartesian rationality and the weakening of universal truths, related with aesthetic values as order, proportion and harmony. In the middle of the century, theorists such as Theodor Adorno, Rudolf Arnheim and Anton Ehrenzweig warned about the transformation developed by the artistic field. Contemporary aesthetics seemed to have a new goal: to deny the idea of art as an organized, finished and coherent structure. The order had lost its privileged position. Disorder, probability, arbitrariness, accidentality, randomness, chaos, fragmentation, indeterminacy... Gradually new terms were coined by aesthetic criticism to explain what had been happening since the beginning of the century. The first essays on the matter sought to provide new interpretative models based on, among other arguments, the phenomenology of perception, the recent discoveries of quantum mechanics, the deeper layers of the psyche or the information theories. Overall, were worthy attempts to give theoretical content to a situation as obvious as devoid of founding charter. Finally, in 1962, Umberto Eco brought together all this efforts by proposing a single theoretical frame in his book Opera Aperta. According to his point of view, all of the aesthetic production of twentieth century had a characteristic in common: its capacity to express multiplicity. For this reason, he considered that the nature of contemporary art was, above all, ambiguous. The aim of this research is to clarify the consequences of the incorporation of ambiguity in architectural theoretical discourse. We should start making an accurate analysis of this concept. However, this task is quite difficult because ambiguity does not allow itself to be clearly defined. This concept has the disadvantage that its signifier is as imprecise as its signified. In addition, the negative connotations that ambiguity still has outside the aesthetic field, stigmatizes this term and makes its use problematic. Another problem of ambiguity is that the contemporary subject is able to locate it in all situations. This means that in addition to distinguish ambiguity in contemporary productions, so does in works belonging to remote ages and styles. For that reason, it could be said that everything is ambiguous. And that’s correct, because somehow ambiguity is present in any creation of the imperfect human being. However, as Eco, Arnheim and Ehrenzweig pointed out, there are two major differences between current and past contexts. One affects the subject and the other the object. First, it’s the contemporary subject, and no other, who has acquired the ability to value and assimilate ambiguity. Secondly, ambiguity was an unexpected aesthetic result in former periods, while in contemporary object it has been codified and is deliberately present. In any case, as Eco did, we consider appropriate the use of the term ambiguity to refer to the contemporary aesthetic field. Any other term with more specific meaning would only show partial and limited aspects of a situation quite complex and difficult to diagnose. Opposed to what normally might be expected, in this case ambiguity is the term that fits better due to its particular lack of specificity. In fact, this lack of specificity is what allows to assign a dynamic condition to the idea of ambiguity that in other terms would hardly be operative. Thus, instead of trying to define the idea of ambiguity, we will analyze how it has evolved and its consequences in architectural discipline. Instead of trying to define what it is, we will examine what its presence has supposed in each moment. We will deal with ambiguity as a constant presence that has always been latent in architectural production but whose nature has been modified over time. Eco, in the mid-twentieth century, discerned between classical ambiguity and contemporary ambiguity. Currently, half a century later, the challenge is to discern whether the idea of ambiguity has remained unchanged or have suffered a new transformation. What this research will demonstrate is that it’s possible to detect a new transformation that has much to do with the cultural and aesthetic context of last decades: the transition from modernism to postmodernism. This assumption leads us to establish two different levels of contemporary ambiguity: each one related to one these periods. The first level of ambiguity is widely well-known since many years. Its main characteristics are a codified multiplicity, an interpretative freedom and an active subject who gives conclusion to an object that is incomplete or indefinite. This level of ambiguity is related to the idea of indeterminacy, concept successfully introduced into contemporary aesthetic language. The second level of ambiguity has been almost unnoticed for architectural criticism, although it has been identified and studied in other theoretical disciplines. Much of the work of Fredric Jameson and François Lyotard shows reasonable evidences that the aesthetic production of postmodernism has transcended modern ambiguity to reach a new level in which, despite of the existence of multiplicity, the interpretative freedom and the active subject have been questioned, and at last denied. In this period ambiguity seems to have reached a new level in which it’s no longer possible to obtain a conclusive and complete interpretation of the object because it has became an unreadable device. The postmodern production offers a kind of inaccessible multiplicity and its nature is deeply contradictory. This hypothetical transformation of the idea of ambiguity has an outstanding analogy with that shown in the poetic analysis made by William Empson, published in 1936 in his Seven Types of Ambiguity. Empson established different levels of ambiguity and classified them according to their poetic effect. This layout had an ascendant logic towards incoherence. In seventh level, where ambiguity is higher, he located the contradiction between irreconcilable opposites. It could be said that contradiction, once it undermines the coherence of the object, was the better way that contemporary aesthetics found to confirm the Hegelian judgment, according to which art would ultimately reject its capacity to express truth. Much of the transformation of architecture throughout last century is related to the active involvement of ambiguity in its theoretical discourse. In modern architecture ambiguity is present afterwards, in its critical review made by theoreticians like Colin Rowe, Manfredo Tafuri and Bruno Zevi. The publication of several studies about Mannerism in the forties and fifties rescued certain virtues of an historical style that had been undervalued due to its deviation from Renacentist canon. Rowe, Tafuri and Zevi, among others, pointed out the similarities between Mannerism and certain qualities of modern architecture, both devoted to break previous dogmas. The recovery of Mannerism allowed joining ambiguity and modernity for first time in the same sentence. In postmodernism, on the other hand, ambiguity is present ex-professo, developing a prominent role in the theoretical discourse of this period. The distance between its analytical identification and its operational use quickly disappeared because of structuralism, an analytical methodology with the aspiration of becoming a modus operandi. Under its influence, architecture began to be identified and studied as a language. Thus, postmodern theoretical project discerned between the components of architectural language and developed them separately. Consequently, there is not only one, but three projects related to postmodern contradiction: semantic project, syntactic project and pragmatic project. Leading these projects are those prominent architects whose work manifested an especial interest in exploring and developing the potential of the use of contradiction in architecture. Thus, Robert Venturi, Peter Eisenman and Rem Koolhaas were who established the main features through which architecture developed the dialectics of ambiguity, in its last and extreme level, as a theoretical project in each component of architectural language. Robert Venturi developed a new interpretation of architecture based on its semantic component, Peter Eisenman did the same with its syntactic component, and also did Rem Koolhaas with its pragmatic component. With this approach this research aims to establish a new reflection on the architectural transformation from modernity to postmodernity. Also, it can serve to light certain aspects still unaware that have shaped the architectural heritage of past decades, consequence of a fruitful relationship between architecture and ambiguity and its provocative consummation in a contradictio in terminis. Esta investigación centra su atención fundamentalmente sobre las repercusiones de la incorporación de la ambigüedad en forma de contradicción en el discurso arquitectónico postmoderno, a través de cada uno de sus tres proyectos teóricos. Está estructurada, por tanto, en torno a un capítulo principal titulado Dialéctica de la ambigüedad como proyecto teórico postmoderno, que se desglosa en tres, de títulos: Proyecto semántico. Robert Venturi; Proyecto sintáctico. Peter Eisenman; y Proyecto pragmático. Rem Koolhaas. El capítulo central se complementa con otros dos situados al inicio. El primero, titulado Dialéctica de la ambigüedad contemporánea. Una aproximación realiza un análisis cronológico de la evolución que ha experimentado la idea de la ambigüedad en la teoría estética del siglo XX, sin entrar aún en cuestiones arquitectónicas. El segundo, titulado Dialéctica de la ambigüedad como crítica del proyecto moderno se ocupa de examinar la paulatina incorporación de la ambigüedad en la revisión crítica de la modernidad, que sería de vital importancia para posibilitar su posterior introducción operativa en la postmodernidad. Un último capítulo, situado al final del texto, propone una serie de Proyecciones que, a tenor de lo analizado en los capítulos anteriores, tratan de establecer una relectura del contexto arquitectónico actual y su evolución posible, considerando, en todo momento, que la reflexión en torno a la ambigüedad todavía hoy permite vislumbrar nuevos horizontes discursivos. Cada doble página de la Tesis sintetiza la estructura tripartita del capítulo central y, a grandes rasgos, la principal herramienta metodológica utilizada en la investigación. De este modo, la triple vertiente semántica, sintáctica y pragmática con que se ha identificado al proyecto teórico postmoderno se reproduce aquí en una distribución específica de imágenes, notas a pie de página y cuerpo principal del texto. En la columna de la izquierda están colocadas las imágenes que acompañan al texto principal. Su distribución atiende a criterios estéticos y compositivos, cualificando, en la medida de lo posible, su condición semántica. A continuación, a su derecha, están colocadas las notas a pie de página. Su disposición es en columna y cada nota está colocada a la misma altura que su correspondiente llamada en el texto principal. Su distribución reglada, su valor como notación y su posible equiparación con una estructura profunda aluden a su condición sintáctica. Finalmente, el cuerpo principal del texto ocupa por completo la mitad derecha de cada doble página. Concebido como un relato continuo, sin apenas interrupciones, su papel como responsable de satisfacer las demandas discursivas que plantea una investigación doctoral está en correspondencia con su condición pragmática.

Caracterización de la cerámica para su empleo como material de enfriamiento evaporativo en la envolvente de los edificios = Ceramic characterization towards its application as evaporative cooling material in building envelopes

El presente trabajo de investigación determina las características de la cerámica que más eficientemente se comporta a evaporación y a enfriamiento. Con el objeto de ser empleado como material integrado en la envolvente de los edificios para reducir su carga de refrigeración. La cerámica es un buen material para ser empleado para la refrigeración por evaporación. Es un sólido poroso inerte que, tras ser sometido a cocción a temperaturas por encima de los 900ºC, resulta uno de los materiales que mejor se comportan como contenedor de agua en su red capilar para, posteriormente, ir liberándola por evaporación al mismo tiempo que se enfría su superficie. La metodología general de investigación, se divide en tres etapas: Búsqueda y análisis del estado de la técnica y de la investigación. Estudio teórico de la eficacia del enfriamiento evaporativo como estrategia de enfriamiento pasivo en la arquitectura. Etapa experimental, desarrollada en tres fases: una primera de definición de los parámetros determinantes del Enfriamiento Evaporativo en piezas cerámicas, una segunda de selección cerámica y diseño de ensayos experimentales y una tercera de caracterización de la cerámica bajo criterios de evaporación y de enfriamiento. El recorrido por el estado de la cuestión ha identificado las aplicaciones tecnológicas y las investigaciones científicas que emplean el Enfriamiento Evaporativo con piezas cerámicas como técnica de enfriamiento. Como resultado se ha obtenido una tabla de clasificación de sistemas de enfriamiento evaporativo y se ha constatado que el conjunto de las aplicaciones están centradas en el diseño de piezas o sistemas pero que, sin embargo, no existe una definición de las características de la cerámica para su empleo como material de enfriamiento por evaporación. El estudio teórico de la eficacia del empleo del enfriamiento evaporativo como estrategia de enfriamiento pasivo en la arquitectura se ha realizado mediante cálculos de porcentaje de ampliación de horas en confort con empleo de técnicas de enfriamiento evaporativo directo e indirecto (EED y EEI). Como resultado se obtienen unos mapas para el ámbito español de potencial de aplicación del EED y EEI. Los resultados permiten afirmar que mediante EE se puede llegar a confort en prácticamente la totalidad de las horas de los días más cálidos del año en muchas localidades. La metodología experimental se ha desarrollado en tres fases. En la fase inicial, se han definido los parámetros determinantes del enfriamiento evaporativo en un medio cerámico mediante ensayos experimentales de capacidad de evaporación y de caracterización. Se realizaron un total de 12 ensayos. Se determinó que el material cerámico tiene una gran influencia en la capacidad de evaporación y enfriamiento en las piezas cerámicas, apoyando la hipótesis inicial y la necesidad de caracterizar el material. La primera fase empírica se centró en la selección cerámica y el diseño de los ensayos experimentales de comportamiento hídrico. Se seleccionaron muestras de 5 tipos de cerámica. Se realizaron 4 tipos de ensayos de caracterización y 6 tipos de ensayos experimentales de comportamiento hídrico (total 123 muestras ensayadas). Los resultados obtenidos son de dos tipos, por un lado, se determinó cuál es el tipo de cerámica que más eficientemente se comporta a EE y, por otro, se rediseñaron los ensayos de la última fase experimental. Para la segunda fase experimental se seleccionaron cerámicas de fabricación manual abarcando el mayor número de localidades del ámbito español. Se realizaron ensayos de caracterización de 7 tipos y ensayos de comportamiento hídrico de 5 tipos (total 197 muestras ensayadas). Los resultados de caracterización han permitido aportar unos rangos de las características de la cerámica que más eficientemente se comporta en los ensayos de comportamiento hídrico. Al final de la investigación se ha caracterizado el material cerámico aportando características acerca de su porosidad, capacidad de absorción, color, rugosidad y mineralogía. Así como datos de referencia de su comportamiento hídrico. Además se ha desarrollado una metodología de ensayo específica que permite evaluar la capacidad de enfriamiento eficiente de una pieza cerámica. ABSTRACT The purpose of this research is to determine the characteristics of ceramic materials having the most efficient performance in terms of evaporation and cooling, so that they can be integrated in building envelopes to reduce cooling loads. Ceramics are suitable materials for cooling through passive evaporation. After being fired at temperatures over 900 °C (1,652 °F), the capillary network of this inert porous medium turns to be excellent to retain water, which is progressively liberated by evaporation while the material surface gets colder. Research methodology has involved the following steps: Search and analysis on the state of the art in technology and research. Theoretical study on the efficiency of evaporation as passive cooling strategies in buildings. Experimental stage developed in three phases, namely: definition of parameters determining evaporative cooling in ceramic elements; ceramic selection and design of experimental tests; characterization of ceramic materials under evaporation and cooling criteria. Search and analysis on the state of the art in this field have been useful to identify technology applications and scientific research where ceramics are employed for evaporative cooling. The resulting table shows that applications are wholly focused on the design of pieces and systems. Nonetheless, there is lack of definition of material characteristics in this scope. The theoretical study on efficiency of the passive strategy applied to buildings has been realized by calculation of the percentage increase in comfort hours through direct/indirect evaporative cooling techniques (DEC/IEC). The mapping of their potential application in Spain clearly shows that comfort conditions can be reached in almost all the hours of the hottest days in many towns. In the initial phase of the experimental stage, parameters determining evaporative cooling in ceramic media have been defined. For this purpose, characterization tests and evaporation and cooling rates experiments have been carried out; the number of samples tested amounted to 12. It has been concluded that material characteristics have great influence on these rates, which supports the initial hypothesis and the need for their characterization. The first empirical phase has focused on ceramic selection and design of water behaviour experimental methods. The samples covered five different kinds of ceramic materials. Four different characterization tests and six different water behaviour experiments were carried out; the number of samples tested amounted to 123. The experimental testing procedures served to determine the most efficient types of ceramic materials in terms of evaporative cooling efficiency and, at the same time, made it necessary to change the original designed experimental test for the last phase. In the second phase, a number of varied hand-made ceramic tiles have been selected. Seven different characterization tests and five different water behaviour tests were carried out; the number of samples amounted to 197. The results of characterization served to establish a range of features in ceramic materials according to their efficiency in water behaviour experiments. Finally, ceramic materials have been characterized according to porosity, water absorption, colour, surface roughness and mineralogy. Also, reference data regarding water behaviour have been included. Moreover, an innovative and specific experimental test to evaluate cooling efficiency of ceramic tiles has been developed.