Choice of Initial Combination Antiretroviral Therapy in Individuals With HIV Infection: Determinants and Outcomes.

BACKGROUND Current guidelines give recommendations for preferred combination antiretroviral therapy (cART). We investigated factors influencing the choice of initial cART in clinical practice and its outcome. METHODS We analyzed treatment-naive adults with human immunodeficiency virus (HIV) infection participating in the Swiss HIV Cohort Study and starting cART from January 1, 2005, through December 31, 2009. The primary end point was the choice of the initial antiretroviral regimen. Secondary end points were virologic suppression, the increase in CD4 cell counts from baseline, and treatment modification within 12 months after starting treatment. RESULTS A total of 1957 patients were analyzed. Tenofovir-emtricitabine (TDF-FTC)-efavirenz was the most frequently prescribed cART (29.9%), followed by TDF-FTC-lopinavir/r (16.9%), TDF-FTC-atazanavir/r (12.9%), zidovudine-lamivudine (ZDV-3TC)-lopinavir/r (12.8%), and abacavir/lamivudine (ABC-3TC)-efavirenz (5.7%). Differences in prescription were noted among different Swiss HIV Cohort Study sites (P < .001). In multivariate analysis, compared with TDF-FTC-efavirenz, starting TDF-FTC-lopinavir/r was associated with prior AIDS (relative risk ratio, 2.78; 95% CI, 1.78-4.35), HIV-RNA greater than 100 000 copies/mL (1.53; 1.07-2.18), and CD4 greater than 350 cells/μL (1.67; 1.04-2.70); TDF-FTC-atazanavir/r with a depressive disorder (1.77; 1.04-3.01), HIV-RNA greater than 100 000 copies/mL (1.54; 1.05-2.25), and an opiate substitution program (2.76; 1.09-7.00); and ZDV-3TC-lopinavir/r with female sex (3.89; 2.39-6.31) and CD4 cell counts greater than 350 cells/μL (4.50; 2.58-7.86). At 12 months, 1715 patients (87.6%) achieved viral load less than 50 copies/mL and CD4 cell counts increased by a median (interquartile range) of 173 (89-269) cells/μL. Virologic suppression was more likely with TDF-FTC-efavirenz, and CD4 increase was higher with ZDV-3TC-lopinavir/r. No differences in outcome were observed among Swiss HIV Cohort Study sites. CONCLUSIONS Large differences in prescription but not in outcome were observed among study sites. A trend toward individualized cART was noted suggesting that initial cART is significantly influenced by physician's preference and patient characteristics. Our study highlights the need for evidence-based data for determining the best initial regimen for different HIV-infected persons.

The role of bradykinin B(1) and B(2) receptors for secondary brain damage after traumatic brain injury in mice.

Inflammatory mechanisms are known to contribute to the pathophysiology of traumatic brain injury (TBI). Since bradykinin is one of the first mediators activated during inflammation, we investigated the role of bradykinin and its receptors in posttraumatic secondary brain damage. We subjected wild-type (WT), B(1)-, and B(2)-receptor-knockout mice to controlled cortical impact (CCI) and analyzed tissue bradykinin as well as kinin receptor mRNA and protein expression up to 48 h thereafter. Brain edema, contusion volume, and functional outcome were assessed 24 h and 7 days after CCI. Tissue bradykinin was maximally increased 2 h after trauma (P<0.01 versus sham). Kinin B(1) receptor mRNA was upregulated up to four-fold 24 h after CCI. Immunohistochemistry showed that B(1) and B(2) receptors were expressed in the brain and were significantly upregulated in the traumatic penumbra 1 to 24 h after CCI. B(2)R(-/-) mice had significantly less brain edema (-51% versus WT, 24 h; P<0.001), smaller contusion volumes ( approximately 50% versus WT 24 h and 7 d after CCI; P<0.05), and better functional outcome 7 days after TBI as compared with WT mice (P<0.05). The present results show that bradykinin and its B(2) receptors play a causal role for brain edema formation and cell death after TBI.

The pneumonia severity index: a decade after the initial derivation and validation

The prognosis of community-acquired pneumonia ranges from rapid resolution of symptoms and full recovery of functional status to the development of severe medical complications and death. The pneumonia severity index is a rigorously studied prediction rule for prognosis that objectively stratifies patients into quintiles of risk for short-term mortality on the basis of 20 demographic and clinical variables routinely available at presentation. The pneumonia severity index was derived and validated with data on >50,000 patients with community-acquired pneumonia by use of well-accepted methodological standards and is the only pneumonia decision aid that has been empirically shown to safely increase the proportion of patients given treatment in the outpatient setting. Because of its prognostic accuracy, methodological rigor, and effectiveness and safety as a decision aid, the pneumonia severity index has become the reference standard for risk stratification of community-acquired pneumonia

The spared nerve injury model of neuropathic pain.

The spared nerve injury (SNI) model mimics human neuropathic pain related to peripheral nerve injury and is based upon an invasive but simple surgical procedure. Since its first description in 2000, it has displayed a remarkable development. It produces a robust, reliable and long-lasting neuropathic pain-like behaviour (allodynia and hyperalgesia) as well as the possibility of studying both injured and non-injured neuronal populations in the same spinal ganglion. Besides, variants of the SNI model have been developed in rats, mice and neonatal/young rodents, resulting in several possible angles of analysis. Therefore, the purpose of this chapter is to provide a detailed guidance regarding the SNI model and its variants, highlighting its surgical and behavioural testing specificities.

NPK fertilization on initial growth of physic nut seedlings in Quartzarenic Neossol

Balanced fertilization is important for plant growth. There is little information on physic nut (Jatropha curcas L.) and tests with the fertilization of the species are very recent. This study evaluated the initial growth of physic nut seedlings in response to NPK rates to Quartzarenic Neossol in a greenhouse and estimated P and K critical soil levels and N, P and K in shoot dry matter after 120 days of evaluation. The treatments were arranged in a randomized, fractional factorial design (4 x 4 x 4)½, totalizing 32 treatments with three replicates, 96 experimental plots and N rates (0, 75, 150 and 300 mg dm-3) as urea; P rates (0, 45, 90 and 180 mg dm-3) as triple superphosphate and K rates (0, 50, 100 and 200 mg dm-3) as potassium chloride. After 120 days, the plants were harvested and some variables evaluated: plant height, stem diameter, shoot and root dry weight, macro and micronutrient levels in plant shoots, and soil chemical properties. The physic nut seedlings responded to NPK fertilizer in the initial growth phase; the response to N was negative. The recommended P and K rates were 25 and 67 mg dm-3, respectively. The critical levels, corresponding to the recommended P rate were 13 and 74 mg dm-3 for K in soil (Mehlich-1). The N, P and K levels in the shoot dry matter of physic nut were 37.4, 2.1 and 35.7 g kg-1, respectively.

Initial state of ultrarelativistic heavy ion collision

A model for energy, pressure, and flow velocity distributions at the beginning of ultrarelativistic heavy ion collisions is presented, which can be used as an initial condition for hydrodynamic calculations. Our model takes into account baryon recoil for both target and projectile, arising from the acceleration of partons in an effective field F mu nu produced in the collision. The typical field strength (string tension) for RHIC energies is about 512 GeV/fm, which allows us to talk about string ropes. The results show that a quark-gluon plasma forms a tilted disk, such that the direction of the largest pressure gradient stays in the reaction plane, but deviates from both the beam and the usual transverse flow directions. Such initial conditions may lead to the creation of antiflow or third flow component [L. P. Csernai and D. Rhrich, Phys. Rev. Lett. B 458, 454 (1999)].

Decay of unstable states in the presence of colored noise and random initial conditions. I. Theory of nonlinear relaxation times

The general theory of nonlinear relaxation times is developed for the case of Gaussian colored noise. General expressions are obtained and applied to the study of the characteristic decay time of unstable states in different situations, including white and colored noise, with emphasis on the distributed initial conditions. Universal effects of the coupling between colored noise and random initial conditions are predicted.

Decay of unstable states in the presence of colored noise and random initial conditions. II. Analog experiments and digital simulations

The decay of an unstable state under the influence of external colored noise has been studied by means of analog experiments and digital simulations. For both fixed and random initial conditions, the time evolution of the second moment ¿x2(t)¿ of the system variable was determined and then used to evaluate the nonlinear relaxation time. The results obtained are found to be in excellent agreement with the theoretical predictions of the immediately preceding paper [Casademunt, Jiménez-Aquino, and Sancho, Phys. Rev. A 40, 5905 (1989)].

Incidence and mechanisms of cerebral ischemia in early clinical head injury.

Antemortem demonstration of ischemia has proved elusive in head injury because regional CBF reductions may represent hypoperfusion appropriately coupled to hypometabolism. Fifteen patients underwent positron emission tomography within 24 hours of head injury to map cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), and oxygen extraction fraction (OEF). We estimated the volume of ischemic brain (IBV) and used the standard deviation of the OEF distribution to estimate the efficiency of coupling between CBF and CMRO2. The IBV in patients was significantly higher than controls (67 +/- 69 vs. 2 +/- 3 mL; P < 0.01). The coexistence of relative ischemia and hyperemia in some patients implies mismatching of perfusion to oxygen use. Whereas the saturation of jugular bulb blood (SjO2) correlated with the IBV (r = 0.8, P < 0.01), SjO2 values of 50% were only achieved at an IBV of 170 +/- 63 mL (mean +/- 95% CI), which equates to 13 +/- 5% of the brain. Increases in IBV correlated with a poor Glasgow Outcome Score 6 months after injury (rho = -0.6, P < 0.05). These results suggest significant ischemia within the first day after head injury. The ischemic burden represented by this "traumatic penumbra" is poorly detected by bedside clinical monitors and has significant associations with outcome.

Renal arteries: navigator-gated balanced fast field-echo projection MR angiography with aortic spin labeling: initial experience.

A cardiac-triggered free-breathing three-dimensional balanced fast field-echo projection magnetic resonance (MR) angiographic sequence with a two-dimensional pencil-beam aortic labeling pulse was developed for the renal arteries. For data acquisition during free breathing in eight healthy adults and seven consecutive patients with renal artery disease, real-time navigator technology was implemented. This technique allows high-spatial-resolution and high-contrast renal MR angiography and visualization of renal artery stenosis without exogenous contrast agent or breath hold. Initial promising results warrant larger clinical studies.

Microbial biomass and activity in litter during the initial development of pure and mixed plantations of Eucalyptus grandis and Acacia mangium

Studies on microbial activity and biomass in forestry plantations often overlook the role of litter, typically focusing instead on soil nutrient contents to explain plant and microorganism development. However, since the litter is a significant source of recycled nutrients that affect nutrient dynamics in the soil, litter composition may be more strongly correlated with forest growth and development than soil nutrient contents. This study aimed to test this hypothesis by examining correlations between soil C, N, and P; litter C, N, P, lignin content, and polyphenol content; and microbial biomass and activity in pure and mixed second-rotation plantations of Eucalyptus grandis and Acacia mangium before and after senescent leaf drop. The numbers of cultivable fungi and bacteria were also estimated. All properties were correlated with litter C, N, P, lignin and polyphenols, and with soil C and N. We found higher microbial activity (CO2 evolution) in litter than in soil. In the E. grandis monoculture before senescent leaf drop, microbial biomass C was 46 % higher in litter than in soil. After leaf drop, this difference decreased to 16 %. In A. mangium plantations, however, microbial biomass C was lower in litter than in soil both before and after leaf drop. Microbial biomass N of litter was approximately 94 % greater than that of the soil in summer and winter in all plantations. The number of cultivable fungi and bacteria increased after leaf drop, especially so in the litter. Fungi were also more abundant in the E. grandis litter. In general, the A. mangium monoculture was associated with higher levels of litter lignin and N, especially after leaf drop. In contrast, the polyphenol and C levels in E. grandis monoculture litter were higher after leaf drop. These properties were negatively correlated with total soil C and N. Litter in the mixed stands had lower C:N and C:P ratios and higher N, P, and C levels in the microbial biomass. This suggests more effective nutrient cycling in mixed plantations in the long term, greater stimulation of microbial activity in litter and soil, and a more sustainable system in general.

La "satisfaction" du médecin lors d'une première consultation diffère-t-elle selon l'origine du patient? Une étude prospective. [Does physician's satisfaction with an initial consultation differ according to the patient's origin? A prospective study].

Difficulties in the doctor-patient relationship may arise because of differences in socio-cultural background. The aim of this study was to evaluate the doctors' satisfaction in an ambulatory care setting when confronted with 3 different cultural groups (Swiss, foreign residents, refugees) and to review some preconceived ideas. Actually, the foreign population did not consult more often in emergencies than the Swiss population, nor did it present more frequently with somatizations in first interview. However, the doctors felt globally less satisfied with the refugees than with the other patients, mainly because of communication difficulties and therefore a less satisfying doctor-patient relationship. Nevertheless, the doctors felt they had the same diagnostic accuracy in the 3 groups. Studies on the satisfaction of primary care doctors are important, because the quality of the doctor-patient relationship directly influences the quality of medical care.

Combination of MRI and dynamic FET PET for initial glioma grading.

AIM: MRI and PET with 18F-fluoro-ethyl-tyrosine (FET) have been increasingly used to evaluate patients with gliomas. Our purpose was to assess the additive value of MR spectroscopy (MRS), diffusion imaging and dynamic FET-PET for glioma grading. PATIENTS, METHODS: 38 patients (42 ± 15 aged, F/M: 0.46) with untreated histologically proven brain gliomas were included. All underwent conventional MRI, MRS, diffusion sequences, and FET-PET within 3±4 weeks. Performances of tumour FET time-activity-curve, early-to-middle SUVmax ratio, choline / creatine ratio and ADC histogram distribution pattern for gliomas grading were assessed, as compared to histology. Combination of these parameters and respective odds were also evaluated. RESULTS: Tumour time-activity-curve reached the best accuracy (67%) when taken alone to distinguish between low and high-grade gliomas, followed by ADC histogram analysis (65%). Combination of time-activity-curve and ADC histogram analysis improved the sensitivity from 67% to 86% and the specificity from 63-67% to 100% (p < 0.008). On multivariate logistic regression analysis, negative slope of the tumour FET time-activity-curve however remains the best predictor of high-grade glioma (odds 7.6, SE 6.8, p = 0.022). CONCLUSION: Combination of dynamic FET-PET and diffusion MRI reached good performance for gliomas grading. The use of FET-PET/MR may be highly relevant in the initial assessment of primary brain tumours.