Pre-ART nutritional status and its association with mortality in adult patients enrolled on ART at Fiche Hospital in North Shoa,Oromia region,Ethiopia: a retrospective cohort study

Background

Human immunodeficiency virus (HIV) compromises the nutritional status of infected individuals and in turn, malnutrition worsens the effects of the infection itself by weakening the immune system consequently accelerating disease progression and death. However, few studies have examined the association between nutritional status at antiretroviral therapy (ART) initiation and early mortality. Therefore, this study assesses pre-ART nutritional status and other baseline characteristics and mortality among adult patients on ART at Fiche Hospital, Ethiopia.

Methods

A retrospective cohort study was conducted among 489 ART enrolled adult patients between August 01, 2006 and September 30, 2013 in Fiche Hospital. Study participants were selected by using systematic random sampling method. Actuarial table was used to estimate survival of patients after ART initiation and log rank test was used to compare the survival curves. Cox proportional-hazard regression was used to determine independent predictors of time to death.

Results

Most of the study subjects were females 254 (51.9%). A total of 489 patients were included in the analysis, of whom 87 died during a median study follow-up of 22 months. The estimated mortality among malnourished was 21, 28, 33, and 38% at 5, 10, 15, and 25 months respectively with mortality incidence density of 5.63 deaths per 100 person years. The independent predictors of mortality were: BMI <18.5 kg/m² (AHR = 5.4 95% CI 3.03–9.58), baseline ambulatory functional status (AHR = 3.84; 95% CI 2.19–6.74), bedridden functional status (AHR = 4.78; 95% CI 2.14–10.65), WHO clinical stage III (AHR 2.21; 95% CI 1.16–4.21), WHO clinical stage IV (AHR 4.05; 95% CI 1.50–10.97) and CD4 count less than 200 cells/μl (AHR = 2.95; 95% CI 1.48–5.88), two and more opportunistic infections (AHR 2.30; 95% CI 1.11–4.75).

Conclusions

Undernutrition at the time of ART initiation was associated with increased risk of death, particularly during the first 3 months after ART initiation. Interventions to promote earlier HIV diagnosis and treatment and integrating nutrition counseling at all stages of ART implementation may improve ART outcomes in this vulnerable population.

     

Risk factors of peripheral arterial disease: a case control study in Sri Lanka

Background

Peripheral artery disease (PAD) is an important global health problem and contributes to notable proportion of morbidity and mortality. This particular manifestation of systemic atherosclerosis is largely under diagnosed and undertreated. For sustainable preventive strategies in a country, it is mandatory to identify country-specific risk factors. We intended to assess the risk factors of PAD among adults aged 40–74 years.

Methods

This case control study was conducted in 2012–2013 in Sri Lanka. Seventy-nine cases and 158 controls in the age group of 40–74 years were selected for the study in order to have case to control ratio 1:2. The criterion for selecting cases and control was based on Ankle brachial pressure index (ABPI). Cases were selected from those who had ABPI 0.85 or less (ABPI ≤0.85) in either lower limb. Controls were selected from those ABPI score between 1.18 and 1.28 in both lower limbs. Only newly identified individuals with PAD were selected as cases. Controls were selected from the same geographical location and within the 5 year age group as cases.

Results

The history of diabetes mellitus more than 10 years (OR 5.8, 95% CI 2.2–14.2), history of dyslipidemia for more than 10 years (OR 4.9, 95% CI 2.1–16.2), history of hypertension for more than 10 years (OR 3.8, 95% CI 1.8–12.7) and smoking (OR 2.9, 95% CI 1.2–6.9), elevated HsCRP (OR 3.7, 95% CI 1.2–12.0) and hyperhomocysteinemia (OR 3.0, 95% CI 1.1–8.1) were revealed as country specific significant risk factor of PAD.

Conclusions

Diabetes mellitus, hypertension, dyslipidemia, smoking as well as elevated homocysteine and HsCRP found as risk factors of PAD. Longer the duration or higher level exposure to these risk factors has increased the risk of PAD. These findings emphasis the need for routine screening of PAD among patients with the identified risk factors.

     

A Two-Stage Adaptive Targeted Clinical Trial Design for Biomarker Performance-Based Sample Size Re-Estimation

Biomarker-directed targeted clinical trial is aimed at developing pharmaceutical agents for a targeted patient subpopulation sharing a specific disease etiology. Biomarker plays a key role in patient enrichment for targeted trials. Biomarker performance substantially impacts heterogeneity of a targeted study population and consequently trial efficiency, statistical power, information accumulation, and early stopping decision-making (Simon and Maitournam in Clinical Cancer Res 10:6759-6763, 2004; Maitournam and Simon in Stat Med 24:329-339, 2005; Gao et al. in Contemp Clin Trials 42:119-131, 2015). Hence, accurate assessment of biomarker performance is crucial to sample size calculation in planning of targeted trials. However, prior knowledge of biomarker performance is often limited at the planning stage due to inadequacy of biomarker validation, differences between study populations in demographic characteristics and trial settings, etc. Under this circumstance, adaptive design would be useful in updating biomarker performance and re-estimating sample sizes when a targeted trial is ongoing. In this paper, we propose a two-stage adaptive design that provides flexibility in biomarker performance-based sample size adaption for targeted trials. The design can facilitate a targeted trial to achieve planned statistical power by re-assessment of actual biomarker performance and subsequent sample size adaption while preserving desired type-1 error.     

Impacts of Predictive Genomic Classifier Performance on Subpopulation-Specific Treatment Effects Assessment

We consider three (strong, moderate and mild) predictive biomarker scenarios with varying prevalence. As such, there is no treatment effect in the biomarker negative (g ^?) patient subpopulation. Relative to g ^?, there is a four-fold profound treatment effect in the biomarker positive (g ⁺) patient subpopulation, a strongly predictive scenario; a three-fold large g ⁺ subpopulation treatment effect, a moderately predictive scenario; and a two-fold modest g ⁺ subpopulation treatment effect, a mildly predictive scenario. In this paper, we focus on binary endpoint in prescribing treatment effect. Using a Breiman’s (Mach. Learn. 24:123–140, 1996) machine learning voting algorithm via a k-fold cross-validated approach applied by Freidlin et al. (Clin. Cancer Res. 16:691–698, 2010), a predictive biomarker may be developed. We consider development or discovery of a genomic biomarker using microarray gene expressions data in randomized controlled trials and validate the biomarker’s predictive performance in an independent data set.We investigate the classification performance characteristics of a binary genomic composite biomarker (expected to be predictive of treatment effects) including sensitivity, specificity, accuracy, positive predictive value and negative predictive value as a function of true sensitive prevalence. In doing so, we report the finding based on three representative tuning parameter sets with varying degree of rigor in their choices of the parameters ranging from highly rigorous, moderately rigorous to mildly rigorous. We articulate the rationales on the choices of tuning parameter sets. We also study the impacts of misclassification of genomic biomarker classifiers on their assessment of treatment effects in the positive and negative patient subpopulations, and all-comer patients.We elucidate via simulation studies on approaches to improve sensitivity when a biomarker is highly specific but poorly sensitive, a scenario that is most likely to lead to an incorrect test conclusion of an applicable significant treatment effect in a specific patient subpopulation or both positive and negative subpopulations. We explore when it will be beneficial to develop a binary predictive biomarker and conclude that hypothesis test inferences for the g ⁺ subpopulation treatment effect in the dual hypotheses setting (all-comer and g ⁺ alone) cannot be relied upon if the biomarker classifier is only highly specific and poorly sensitive or resulting in poor negative predictive value. The converse dual hypotheses (all-comer and g ^? alone) have the same concern, viz. highly sensitive and poorly specific or resulting in poor positive predictive value. In addition, we compare the predictive performance of a biomarker classifier between use of direct selection and selection from a candidate pool shedding favorable lights of direct selection approach where biological or mechanistic plausibility can be relied upon. Further research is needed if accurate classifier is required irrespective of prevalence level.     

A reliability and validity study for Scolioscan: a radiation-free scoliosis assessment system using 3D ultrasound imaging

Background

Radiographic evaluation for patients with scoliosis using Cobb method is the current gold standard, but radiography has radiation hazards. Several groups have recently demonstrated the feasibility of using 3D ultrasound for the evaluation of scoliosis. Ultrasound imaging is radiation-free, comparatively more accessible, and inexpensive. However, a reliable and valid 3D ultrasound system ready for clinical scoliosis assessment has not yet been reported. Scolioscan is a newly developed system targeted for scoliosis assessment in clinics by using coronal images of spine generated by a 3D ultrasound volume projection imaging method. The aim of this study is to test the reliability of spine deformity measurement of Scolioscan and its validity compared to the gold standard Cobb angle measurements from radiography in adolescent idiopathic scoliosis (AIS) patients.

Methods

Prospective study divided into two stages: 1) Investigation of intra- and inter- reliability between two operators for acquiring images using Scolioscan and among three raters for measuring spinal curves from those images; 2) Correlation between the Cobb angle obtained from radiography by a medical doctor and the spine curve angle obtained using Scolioscan (Scolioscan angle). The raters for ultrasound images and the doctors for evaluating radiographic images were mutually blinded. The two stages of tests involved 20 (80 % females, total of 26 angles, age of 16.4?±?2.7 years, and Cobb angle of 27.6?±?11.8°) and 49 (69 % female, 73 angles, 15.8?±?2.7 years and 24.8?±?9.7°) AIS patients, respectively. Intra-class correlation coefficients (ICC) and Bland-Altman plots and root-mean-square differences (RMS) were employed to determine correlations, which interpreted based on defined criteria.

Results

We demonstrated a very good intra-rater and intra-operator reliability for Scolioscan angle measurement with ICC larger than 0.94 and 0.88, respectively. Very good inter-rater and inter-operator reliability was also demonstrated, with both ICC larger than 0.87. For the thoracic deformity measurement, the RMS were 2.5 and 3.3° in the intra- and inter-operator tests, and 1.5 and 3.6° in the intra- and inter-rater tests, respectively. The RMS differences were 3.1, 3.1, 1.6, 3.7° in the intra- and inter-operator and intra- and inter-rater tests, respectively, for the lumbar angle measurement. Moderate to strong correlations (R²?>?0.72) were observed between the Scolioscan angles and Cobb angles for both the thoracic and lumbar regions. It was noted that the Scolioscan angle slightly underestimated the spinal deformity in comparison with Cobb angle, and an overall regression equation y?=?1.1797x (R²?=?0.76) could be used to translate the Scolioscan angle (x) to Cobb angle (y) for this group of patients. The RMS difference between Scolioscan angle and Cobb angle was 4.7 and 6.2°, with and without the correlation using the overall regression equation.

Conclusions

We showed that Scolioscan is reliable for measuring coronal deformity for patients with AIS and appears promising in screening large numbers of patients, for progress monitoring, and evaluation of treatment outcomes. Due to it being radiation-free and relatively low-cost, Scolioscan has potential to be widely implemented and may contribute to reducing radiation dose during serial monitoring.

     

cljam: a library for handling DNA sequence alignment/map (SAM) with parallel processing

Background

Next-generation sequencing can determine DNA bases and the results of sequence alignments are generally stored in files in the Sequence Alignment/Map (SAM) format and the compressed binary version (BAM) of it. SAMtools is a typical tool for dealing with files in the SAM/BAM format. SAMtools has various functions, including detection of variants, visualization of alignments, indexing, extraction of parts of the data and loci, and conversion of file formats. It is written in C and can execute fast. However, SAMtools requires an additional implementation to be used in parallel with, for example, OpenMP (Open Multi-Processing) libraries. For the accumulation of next-generation sequencing data, a simple parallelization program, which can support cloud and PC cluster environments, is required.

Results

We have developed cljam using the Clojure programming language, which simplifies parallel programming, to handle SAM/BAM data. Cljam can run in a Java runtime environment (e.g., Windows, Linux, Mac OS X) with Clojure.

Conclusions

Cljam can process and analyze SAM/BAM files in parallel and at high speed. The execution time with cljam is almost the same as with SAMtools. The cljam code is written in Clojure and has fewer lines than other similar tools.

     

Glymphatic distribution of CSF-derived apoE into brain is isoform specific and suppressed during sleep deprivation

Background

Apolipoprotein E (apoE) is a major carrier of cholesterol and essential for synaptic plasticity. In brain, it’s expressed by many cells but highly expressed by the choroid plexus and the predominant apolipoprotein in cerebrospinal fluid (CSF). The role of apoE in the CSF is unclear. Recently, the glymphatic system was described as a clearance system whereby CSF and ISF (interstitial fluid) is exchanged via the peri-arterial space and convective flow of ISF clearance is mediated by aquaporin 4 (AQP4), a water channel. We reasoned that this system also serves to distribute essential molecules in CSF into brain. The aim was to establish whether apoE in CSF, secreted by the choroid plexus, is distributed into brain, and whether this distribution pattern was altered by sleep deprivation.

Methods

We used fluorescently labeled lipidated apoE isoforms, lenti-apoE3 delivered to the choroid plexus, immunohistochemistry to map apoE brain distribution, immunolabeled cells and proteins in brain, Western blot analysis and ELISA to determine apoE levels and radiolabeled molecules to quantify CSF inflow into brain and brain clearance in mice. Data were statistically analyzed using ANOVA or Student’s t- test.

Results

We show that the glymphatic fluid transporting system contributes to the delivery of choroid plexus/CSF-derived human apoE to neurons. CSF-delivered human apoE entered brain via the perivascular space of penetrating arteries and flows radially around arteries, but not veins, in an isoform specific manner (apoE2?>?apoE3?>?apoE4). Flow of apoE around arteries was facilitated by AQP4, a characteristic feature of the glymphatic system. ApoE3, delivered by lentivirus to the choroid plexus and ependymal layer but not to the parenchymal cells, was present in the CSF, penetrating arteries and neurons. The inflow of CSF, which contains apoE, into brain and its clearance from the interstitium were severely suppressed by sleep deprivation compared to the sleep state.

Conclusions

Thus, choroid plexus/CSF provides an additional source of apoE and the glymphatic fluid transporting system delivers it to brain via the periarterial space. By implication, failure in this essential physiological role of the glymphatic fluid flow and ISF clearance may also contribute to apoE isoform-specific disorders in the long term.

     

A biomechanical analysis on the impact of episiotomy during childbirth

Episiotomy is still a controversy issue among physicians, despite the enormous growth of clinical research. Therefore, the potential of numerical modeling of anatomical structures to simulate biomechanical processes was exploited to realize quantitatively the real effects of the episiotomy and its consequences on the pelvic floor muscle. As such, a numerical model was used composed of pelvic floor muscles, a surface delimiting the anterior region, and a fetus body. A normal vaginal delivery without and with different episiotomies was simulated with the fetus in vertex presentation and occipitoanterior position. According to our numerical results, a mediolateral episiotomy has a protective effect, reducing the stress on the muscles, and the force required to delivery successfully up to 52.2 %. The intervention also has benefits on muscle injury, reducing the damage to a small zone. This study demonstrates the feasibility of using a computational modeling approach to study parturition, namely the capability to isolate and evaluate the mechanical significance of a single feature. It must, however, be taken into account that the numerical model does not assess problems that may occur as blood loss, infections and others, so it is necessary to examine whether the benefits of an intervention outweigh the risks.