Does less frequent routine monitoring of patients on a stable, fully suppressed cART regimen lead to an increased risk of treatment failure?

OBJECTIVE: To investigate whether HIV-infected patients on a stable and fully suppressive combination antiretroviral therapy (cART) regimen could safely be monitored less often than the current recommendations of every 3 months. DESIGN: Two thousand two hundred and forty patients from the EuroSIDA study who maintained a stable and fully suppressed cART regimen for 1 year were included in the analysis. METHODS: Risk of treatment failure, defined by viral rebound, fall in CD4 cell count, development of new AIDS-defining illness, serious opportunistic infection or death, in the 12 months following a year of a stable and fully suppressed regimen was assessed. RESULTS: One hundred thirty-one (6%) patients experienced treatment failure in the 12 months following a year of stable therapy, viral rebound occurred in 99 (4.6%) patients. After 3, 6 and 12 months, patients had a 0.3% [95% confidence interval (CI) 0.1-0.5], 2.2% (95% CI 1.6-2.8) and 6.0% (95% CI 5.0-7.0) risk of treatment failure, respectively. Patients who spent more than 80% of their time on cART with fully suppressed viraemia prior to baseline had a 38% reduced risk of treatment failure, hazard ratio 0.62 (95% CI 0.42-0.90, P = 0.01). CONCLUSION: Patients who have responded well to cART and are on a well tolerated and durably fully suppressive cART regimen have a low chance of experiencing treatment failure in the next 3-6 months. Therefore, in this subgroup of otherwise healthy patients, it maybe reasonable to extend visit intervals to 6 months, with cost and time savings to both the treating clinics and the patients.

Platelet-activating factor causes ventilation-perfusion mismatch in humans

We hypothesized that platelet-activating factor (PAF), a potent inflammatory mediator, could induce gas exchange abnormalities in normal humans. To this end, the effect of aerosolized PAF (2 mg/ml solution; 24 micrograms) on ventilation-perfusion (VA/Q) relationships, hemodynamics, and resistance of the respiratory system was studied in 14 healthy, nonatopic, and nonsmoking individuals (23 +/- 1 [SEM]yr) before and at 2, 4, 6, 8, 15, and 45 min after inhalation, and compared to that of inhaled lyso-PAF in 10 other healthy individuals (24 +/- 2 yr). PAF induced, compared to lyso-PAF, immediate leukopenia (P < 0.001) followed by a rebound leukocytosis (P < 0.002), increased minute ventilation (P < 0.05) and resistance of the respiratory system (P < 0.01), and decreased systemic arterial pressure (P < 0.05). Similarly, compared to lyso-PAF, PaO2 showed a trend to fall (by 12.2 +/- 4.3 mmHg, mean +/- SEM maximum change from baseline), and arterial-alveolar O2 gradient increased (by 16.7 +/- 4.3 mmHg) (P < 0.02) after PAF, because of VA/Q mismatch: the dispersion of pulmonary blood flow and that of ventilation increased by 0.45 +/- 0.1 (P < 0.01) and 0.29 +/- 0.1 (P < 0.04), respectively. We conclude that in normal subjects, inhaled PAF results in considerable immediate VA/Q inequality and gas exchange impairment. These results reinforce the notion that PAF may play a major role as a mediator of inflammation in the human lung.

Platelet-activating factor causes ventilation-perfusion mismatch in humans

We hypothesized that platelet-activating factor (PAF), a potent inflammatory mediator, could induce gas exchange abnormalities in normal humans. To this end, the effect of aerosolized PAF (2 mg/ml solution; 24 micrograms) on ventilation-perfusion (VA/Q) relationships, hemodynamics, and resistance of the respiratory system was studied in 14 healthy, nonatopic, and nonsmoking individuals (23 +/- 1 [SEM]yr) before and at 2, 4, 6, 8, 15, and 45 min after inhalation, and compared to that of inhaled lyso-PAF in 10 other healthy individuals (24 +/- 2 yr). PAF induced, compared to lyso-PAF, immediate leukopenia (P < 0.001) followed by a rebound leukocytosis (P < 0.002), increased minute ventilation (P < 0.05) and resistance of the respiratory system (P < 0.01), and decreased systemic arterial pressure (P < 0.05). Similarly, compared to lyso-PAF, PaO2 showed a trend to fall (by 12.2 +/- 4.3 mmHg, mean +/- SEM maximum change from baseline), and arterial-alveolar O2 gradient increased (by 16.7 +/- 4.3 mmHg) (P < 0.02) after PAF, because of VA/Q mismatch: the dispersion of pulmonary blood flow and that of ventilation increased by 0.45 +/- 0.1 (P < 0.01) and 0.29 +/- 0.1 (P < 0.04), respectively. We conclude that in normal subjects, inhaled PAF results in considerable immediate VA/Q inequality and gas exchange impairment. These results reinforce the notion that PAF may play a major role as a mediator of inflammation in the human lung.

Virological and immunological responses to efavirenz or boosted lopinavir as first-line therapy for patients with HIV.

BACKGROUND: Efavirenz and lopinavir boosted with ritonavir are both recommended as first-line therapies for patients with HIV when combined with two nucleoside reverse transcriptase inhibitors. It is uncertain which therapy is more effective for patients starting therapy with an advanced infection. METHODS: We estimated the relative effect of these two therapies on rates of virological and immunological failure within the Swiss HIV Cohort Study and considered whether estimates depended on the CD4(+) T-cell count when starting therapy. We defined virological failure as either an incomplete virological response or viral rebound after viral suppression and immunological failure as failure to achieve an expected CD4(+) T-cell increase calculated from EuroSIDA statistics. RESULTS: Patients starting efavirenz (n=660) and lopinavir (n=541) were followed for a median of 4.5 and 3.1 years, respectively. Virological failure was less likely for patients on efavirenz, with the adjusted hazard ratio (95% confidence interval) of 0.63 (0.50-0.78) then multiplied by a factor of 1.00 (0.90-1.12) for each 100 cells/mm(3) decrease in CD4(+) T-cell count below the mean when starting therapy. Immunological failure was also less likely for patients on efavirenz, with the adjusted hazard ratio of 0.68 (0.51-0.91) then multiplied by a factor of 1.29 (1.14-1.46) for each 100 cells/mm(3) decrease in CD4(+) T-cell count below the mean when starting therapy. CONCLUSIONS: Virological failure is less likely with efavirenz regardless of the CD4(+) T-cell count when starting therapy. Immunological failure is also less likely with efavirenz; however, this advantage disappears if patients start therapy with a low CD4(+) T-cell count.

Re-Engineering CTE in Iowa: Aligning Career and Technical Education Reform, Workforce Development and Economic Development, August 2007

Iowa is a relatively small state and is on the rebound economically. It has an overall population that is stable, but which is shifting within the state from more rural areas to suburban and urban centers. There is a very tight labor market with high levels of employment. Iowa now has a time-sensitive opportunity to exert global leadership in renewable energy, while maintaining its leadership in other key industries like finance and agriculture.

Reaktive Thymushyperplasie infolge der Therapie ACTH-produzierender Tumoren [Reactive thymus dysplasia following therapy for ACTH-producing tumors]

Surgical or conservative treatment of ACTH-producing tumors results in acute drop of the previously excessively high cortisol levels. The following associated pathophysiological changes also occur in the organism's recovery from stress, such as trauma, operation or chemotherapy of tumors. Both cases result in a regeneration of the immune system, which might even be exalted. The corresponding radiographic feature is the "rebound" enlargement of the thymus occurring about six months after remission of hypercortisolism. Histological examination reveals benign thymus hyperplasia. Especially in cases of still unknown primary tumor the appearance of this anterior mediastinal mass can lead to misdiagnosis. We present the cases of two patients with diffuse thymic hyperplasia following surgical and medical correction of hypercortisolism. One patient suffered from classic Cushing's disease responding to transsphenoidal resection of an ACTH-secreting pituitary microadenoma. Six months later CT of the chest incidentally demonstrated an anterior mediastinal mass known as thymic hyperplasia. The second patient presented with an ectopic, still unkown source of ACTH-production. Six months after medical correction of hypercortisolism CT of the thorax showed an enlargement of the anterior mediastinum. Thymectomy was performed in order to exclude thymus carcinoid. Histological examination revealed benign thymus hyperplasia with negative immunostaining. CONCLUSION: Radiologists and clinicians should be familiar with the pathophysiological changes resulting from precipitously dropping cortisol levels in order to prevent diagnostic errors and unnecessary operations.

Physical determinants of tennis performance in competitive teenage players

It is unclear how physical attributes influence tennis-specific performance in teenage players. The aims of this study were (a) to examine the relationships between speed, explosive power, leg stiffness, and muscular strength of upper and lower limbs; and (b) to determine to what extent these physical qualities relate to tournament play performance in a group of competitive teenage tennis players. A total of 12 male players aged 13.6 +/- 1.4 years performed a series of physical tests: a 5-m, 10-m, and 20-m sprint; squat jump (SJ); countermovement jump (CMJ); drop jump (DJ); multi-rebound jumps; maximum voluntary contraction of isometric grip strength; and plantar flexor of the dominant and nondominant side. Speed (r = 0.69, 0.63, and 0.74 for 5-, 10-, and 20-m sprints, respectively), vertical power abilities (r = -0.71, -0.80 and -0.66 for SJ, CMJ, and DJ, respectively), and maximal strength in the dominant side (r = -0.67 and -0.73 for handgrip and plantar flexor, respectively) were significantly correlated with tennis performance. However, strength in the nondominant side (r = -0.29 and -0.42 for handgrip and plantar flexor) and leg stiffness (r = -0.15) were not correlated with the performance ranking of the players. It seems that physical attributes have a strong influence on tennis performance in this age group and that an important asymmetry is already observed. By monitoring regularly such physical abilities during puberty, the conditioning coach can modify a program to compensate for the imbalances. This would in turn minimize the risks of injuries during this critical period.

How to Improve the Use of Proton Pump Inhibitors

Introduction: Proton pump inhibitors (PPI) are one of the most prescribed medications in the world with proven efficacy. However, several studies showed that their use often doesn't respect indications, leading to over-consumption, thus exposing patients to drug interactions and adverse events (for example pneumonias). Interruption of PPIs can induce a rebound phenomenon. This generates costs for health systems.Methods: This is a prospective interventional study performed in two hospitals: La Chaux-de-Fonds (CDF, cases) and Neucha^tel (NE, control) during two six-month periods, comparing use of PPIs before and after intervention. We elaborated recommendations (PPI doses and treatment duration) based on recent medical literature that we summarized on A6 cards and gave out to all prescribing doctors in the hospital of CDF and held a 30-minute information session for the departments of surgery, medicine and anesthesiology in March 2010. Doctors were asked to apply our recommendations as often as possible, leaving space for their own assessment. No information was given to the doctors of the control hospital. The number of PPI tablets that the pharmacy sent to each careunit in both hospitals was counted and adjusted to the number of patientdays from April to September 2009 (before intervention) and April to September 2010 (after intervention). The number of other antacids that were used in both hospitals was counted during the same periods. General practitioners (GP) in the region around CDF received an explanation letter to avoid re-introduction, after discharge from the hospital, of PPI treatment stopped during the stay. The number of gastro-duodenal ulcers and upper digestive hemorrhages was counted from April to December 2009 and the same period in 2010 in both hospitals.Results: In 2010, in the hospital of CDF, the use of PPIs per 100 patient-days decreased by 36% in the surgical and medical departments compared to 2009. In the control hospital the use of PPIs per 100 patient-days increased by 10% in the surgical department and decreased by 5% in the medical department during the same periods. The decrease from 2009 to 2010 of PPI utilization in CDF comparing to NE is statistically significant: p<0.0001. Use of other antacids didn't change, ulcers or digestive hemorrhages decreased slightly from 2009 to 2010 in both hospitals. Conclusions: The study showed that with a very low-cost intervention, it is possible to decrease considerably the use of PPIs in a hospital, without taking any risk for gastro-intestinal complications.

Sustained sleep fragmentation induces sleep homeostasis in mice.

STUDY OBJECTIVES: Sleep fragmentation (SF) is an integral feature of sleep apnea and other prevalent sleep disorders. Although the effect of repetitive arousals on cognitive performance is well documented, the effects of long-term SF on electroencephalography (EEG) and molecular markers of sleep homeostasis remain poorly investigated. To address this question, we developed a mouse model of chronic SF and characterized its effect on EEG spectral frequencies and the expression of genes previously linked to sleep homeostasis including clock genes, heat shock proteins, and plasticity-related genes. DESIGN: N/A. SETTING: Animal sleep research laboratory. PARTICIPANTS: Sixty-six C57BL6/J adult mice. INTERVENTIONS: Instrumental sleep disruption at a rate of 60/h during 14 days. MEASUREMENTS AND RESULTS: Locomotor activity and EEG were recorded during 14 days of SF followed by recovery for 2 days. Despite a dramatic number of arousals and decreased sleep bout duration, SF minimally reduced total quantity of sleep and did not significantly alter its circadian distribution. Spectral analysis during SF revealed a homeostatic drive for slow wave activity (SWA; 1-4 Hz) and other frequencies as well (4-40 Hz). Recordings during recovery revealed slow wave sleep consolidation and a transient rebound in SWA, and paradoxical sleep duration. The expression of selected genes was not induced following chronic SF. CONCLUSIONS: Chronic SF increased sleep pressure confirming that altered quality with preserved quantity triggers core sleep homeostasis mechanisms. However, it did not induce the expression of genes induced by sleep loss, suggesting that these molecular pathways are not sustainably activated in chronic diseases involving SF.

Childhood Overweight - Predictors, Consequences and Prevention

Childhood overweight has become more prevalent during the past three decades. The aim of the present study was to examine possible predictors of childhood overweight and to evaluate the effect of individualised, biannual dietary and lifestyle counselling, with onset in infancy and primary aim at decreasing serum LDLcholesterol, on the development of overweight and related comorbidities. The study was part of the Special Turku coronary Risk factor Intervention Project (STRIP), in which 7-month-old children were randomised into an intervention group (N=540) or to a control group (N=522). The children in the control group were followed up along with the intervention group but they did not receive the individualised counselling. At the age of 15 years, 11.9 % of girls and 13.7 % of boys were overweight. The most important predictors of overweight at age 15 years were paternal weight status at the child’s age 7 months, rapid weight gain during the first two years of life, and early adiposity rebound. Leptin, a protein secreted by adipocytes, did not predict the development of overweight. Homozygosity for the overweight-associated FTO gene variant was associated with increased BMI and risk of overweight in children older than 7 years of age. The intervention given in the STRIP trial was not intense enough to overcome the effect of the FTO genotype. Although the intervention given in the STRIP trial had no significant effect on the proportion of overweight girls and boys, it did reduce the number and clustering of overweight-related cardiometabolic risk factors. This study showed that parental weight status, rapid weight gain early in life, and having two risk alleles in the FTO gene are strongly associated with overweight in adolescence. Biannual dietary and lifestyle counselling is not intense enough to prevent overweight but it has beneficial effects on the overweight-related cardiometabolic risk.

Expressional regulation of key hepatic enzymes of intermediary metabolism in European seabass (Dicentrarchus labrax) during food deprivation and refeeding

We hypothesized that the analysis of mRNA level and activity of key enzymes in amino acid and carbohydrate metabolism in a feeding/fasting/refeeding setting could improve our understanding of how a carnivorous fish, like the European seabass (Dicentrarchus labrax), responds to changes in dietary intake at the hepatic level. To this end cDNA fragments encoding genes for cytosolic and mitochondrial alanine aminotransferase (cALT; mALT), pyruvate kinase (PK), glucose 6-phosphate dehydrogenase (G6PDH) and 6-phosphogluconate dehydrogenase (6PGDH) were cloned and sequenced. Measurement of mRNA levels through quantitative real-time PCR performed in livers of fasted seabass revealed a significant increase in cALT (8.5-fold induction)while promoting a drastic 45-fold down-regulation of PK in relation to the levels found in fed seabass. These observations were corroborated by enzyme activity meaning that during food deprivation an increase in the capacity of pyruvate generation happened via alanine to offset the reduction in pyruvate derived via glycolysis. After a 3-day refeeding period cALT returned to control levels while PK was not able to rebound. No alterations were detected in the expression levels of G6PDH while 6PGDH was revealed to be more sensitive specially to fasting, as confirmed by a significant 5.7-fold decrease in mRNA levels with no recovery after refeeding. Our results indicate that in early stages of refeeding, the liver prioritized the restoration of systemic normoglycemia and replenishment of hepatic glycogen. In a later stage, once regular feeding is re-established, dietary fuel may then be channeled to glycolysis and de novo lipogenesis.

Expressional regulation of key hepatic enzymes of intermediary metabolism in European seabass (Dicentrarchus labrax) during food deprivation and refeeding

We hypothesized that the analysis of mRNA level and activity of key enzymes in amino acid and carbohydrate metabolism in a feeding/fasting/refeeding setting could improve our understanding of how a carnivorous fish, like the European seabass (Dicentrarchus labrax), responds to changes in dietary intake at the hepatic level. To this end cDNA fragments encoding genes for cytosolic and mitochondrial alanine aminotransferase (cALT; mALT), pyruvate kinase (PK), glucose 6-phosphate dehydrogenase (G6PDH) and 6-phosphogluconate dehydrogenase (6PGDH) were cloned and sequenced. Measurement of mRNA levels through quantitative real-time PCR performed in livers of fasted seabass revealed a significant increase in cALT (8.5-fold induction)while promoting a drastic 45-fold down-regulation of PK in relation to the levels found in fed seabass. These observations were corroborated by enzyme activity meaning that during food deprivation an increase in the capacity of pyruvate generation happened via alanine to offset the reduction in pyruvate derived via glycolysis. After a 3-day refeeding period cALT returned to control levels while PK was not able to rebound. No alterations were detected in the expression levels of G6PDH while 6PGDH was revealed to be more sensitive specially to fasting, as confirmed by a significant 5.7-fold decrease in mRNA levels with no recovery after refeeding. Our results indicate that in early stages of refeeding, the liver prioritized the restoration of systemic normoglycemia and replenishment of hepatic glycogen. In a later stage, once regular feeding is re-established, dietary fuel may then be channeled to glycolysis and de novo lipogenesis.

Sedimentology of the Sixteen Mile Creek Lagoon, Niagara Peninsula, Ontario, Canada

The effec s of relative water level changes in Lake Ontario were detected in the ysical, chemical and biological characteristics of the sediments of the Fifteen, Sixteen and Twenty Mile Creek lagoonal complexes. Regional environmental changes have occurred resulting in the following sequence of sediments in the three lagoons and marsh. From the base up they are; (I) Till,(2) Pink Clay, (3) Bottom Sand, (4) Gyttja, (5) Orange Sandy Silt, (6) Brown Clay and (7) Gray Clay. The till was only encountered in the marsh and channel; however, it is presumed to occur throughout the entire area. The presence of diatoms and sponge spicules, the vertical and ongitudinal uniformity of the sediment and the stratigr ic position of the Pink Clay indicate that it has a glacial or post-glacial lacustrine origin. Overl ng the Pink Clay or Till is a clayey, silty sand to gravel. The downstream fining and unsorted nature of this material indicate that it has a fluvial/deltaic origin. Water levels began rising in the lagoon 3,250 years ago resulting in the deposition of the Gyttja, a brown, organic-rich silty clay probably deposited in a shallow, stagnant environment as shown by the presence of pyrite in the organic material and relatively high proportions of benthic diatoms and grass pollen. Increase in the rate of deposition of the Gyttja on Twenty Mile Creek and a decrease in the same unit on Sixteen Mile Creek is possibly the result of a capture of the Sixteen Mile Creek by the Twenty Mile Creek. The rise in lake level responsible for the onset and transgression of this III unit may have been produced by isostatic rebound; however, the deposition also corresponds closely to a drop in the level of Lake Huron and increased flow through the lower lakes. The o ange Sandy Silt, present only in the marsh, appears to be a buried soil horizon as shown by oxidized roots, and may be the upland equivalant to the Gyttja. Additional deepening resulted in the deposition of Brown Clay, a unit which only occurs at the lakeward end of the three lagoons. The decrease in grass pollen and the relatively high proportion of pelagic diatoms are evidence for this. The deepening may be the result of isostatic rebound; however, the onset of its deposition at 1640 years B.P. is synchronous in the three lagoons and corresponds to the end of the subAtlantic climatic episode. The effects of the climatic change in southern Ontario is uncertain. Average deposition rates of the Brown Clay are similar to those in the upper Gyttja on Sixteen Mile Creek; however, Twenty Mile Creek shows lower rates of the Brown Clay than those in the upper Gyttja. The Gray Clay covers the present bottom of the three lagoons and also occurs in the marsh It is inter1aminated wi sand in the channels. Increases in the rates of deposi ion, high concentrations of Ca and Zn, an Ambrosia rise, and an increase in bioturbation possibly due to the activities of the carp, indicate th this unit is a recent deposit resulting from the activities of man.

The sedimentology of the lower Silurian whirlpool sandstone in subsurface Lake Erie, Ontario

The lower Silurian Whirlpool Sandstone is composed of two main units: a fluvial unit and an estuarine to transitional marine unit. The lowermost unit is made up of sandy braided fluvial deposits, in shallow valleys, that flowed towards the northwest. The fluvial channels are largely filled by cross-bedded, well sorted, quartzose sands, with little ripple crosslaminated or overbank shales. Erosionally overlying this lower unit are brackish water to marine deposits. In the east, this unit consists of estuarine channels and tidal flat deposits. The channels consist of fluvial sands at the base, changing upwards into brackish and tidally influenced channelized sandstones and shales. The estuarine channels flowed to the southwest. Westwards, the unit contains backbarrier facies with extensive washover deposits. Separating the backbarrier facies from shoreface sandstone facies to the west, are barrier island sands represented by barrier-foreshore facies. The barrier islands are dissected by tidal inlets characterized by fining upward abandonment sequences. Inlet deposits are also present west of the barrier island, abandoned by transgression on the shoreface. The sandy marine deposits are replaced to the west by carbonates of the Manitoulin Limestone. During the latest Ordovician, a hiatus in crustal loading during the Taconic Orogeny led to erosional offloading and crustal rebound, the eroded material distributed towards the west, northwest and north as the terrestrial deposits of the fluvial Whirlpool. The "anti-peripheral bulge" of the rebound interfered with the peripheral bulge of the Michigan Basin, nulling the Algonquin Arch, and allowing the detritus of the fluvial Whirlpool to spread onto the Algonquin Arch. The Taconic Orogeny resumed in the earliest Silurian with crustal loading to the south and southeast, and causing tilting of the surface slope in subsurface Lake Erie towards the ii southwest. Lowstand terrestrial deposits were scoured into the new slope. The new crustal loading also reactivated the peripheral bulge of the Appalachian Basin, allowing it to interact with the bulge of the Michigan Basin, raising the Algonquin Arch. The crustal loading depressed the Appalachian basin and allowed transgression to occur. The renewed Algonquin Arch allowed the early Silurian transgression to proceed up two slopes, one to the east and one to the west. The transgression to the east entered the lowstand valleys and created the estuarine Whirlpool. The rising arch caused progradation of the Manitoulin carbonates upon shoreface facies of the Whirlpool Sandstone and upon offshore facies of the Cabot Head Formation. Further crustal loading caused basin subsidence and rapid transgression, abandoning the Whirlpool estuary in an offshore setting.

Longitudinal changes in HIV-specific IFN-? secretion in subjects who received Remune™ vaccination prior to treatment interruption

Affiliation: Maude Loignon, Lise Cyr & Emil Toma : Département de microbiologie et immunologie, Faculté de médecine, Université de Montréal