An approach to the management of unintentional weight loss in elderly people

UNINTENTIONAL WEIGHT LOSS, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period. A variety of physical, psychological and social conditions, along with age-related changes, can lead to weight loss, but there may be no identifiable cause in up to one-quarter of patients. We review the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and a clinical approach to diagnosis. Screening tools to detect malnutrition are highlighted, and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss in older adults are discussed.Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients¹ and 27% of frail people 65 years and older.² Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred.^1,3,4 Frail elderly people,⁵ people with low baseline body weight,^5,6,7 and elderly patients recently admitted to hospital are particularly susceptible to increased mortality.^8,9 Weight loss is also associated with an increased risk of in-hospital complications,^10,11 a decline in activities of daily living or physical function,^12,13 higher rates of admission to an institution^2,8 and poorer quality of life.¹⁴     

Characterization of the PduS Cobalamin Reductase of Salmonella enterica and Its Role in the Pdu Microcompartment

Salmonella enterica degrades 1,2-propanediol (1,2-PD) in a coenzyme B₁₂ (adenosylcobalamin, AdoCbl)-dependent fashion. Salmonella obtains AdoCbl by assimilation of complex precursors, such as vitamin B₁₂ and hydroxocobalamin. Assimilation of these compounds requires reduction of their central cobalt atom from Co³⁺ to Co²⁺ to Co⁺, followed by adenosylation to AdoCbl. In this work, the His₆-tagged PduS cobalamin reductase from S. enterica was produced at high levels in Escherichia coli, purified, and characterized. The anaerobically purified enzyme reduced cob(III)alamin to cob(II)alamin at a rate of 42.3 ± 3.2 μmol min⁻¹ mg⁻¹, and it reduced cob(II)alamin to cob(I)alamin at a rate of 54.5 ± 4.2 nmol min⁻¹ mg⁻¹ protein. The apparent K_m values of PduS-His₆ were 10.1 ± 0.7 μM for NADH and 67.5 ± 8.2 μM for hydroxocobalamin in cob(III)alamin reduction. The apparent K_m values for cob(II)alamin reduction were 27.5 ± 2.4 μM with NADH as the substrate and 72.4 ± 9.5 μM with cob(II)alamin as the substrate. High-performance liquid chromatography (HPLC) and mass spectrometry (MS) indicated that each monomer of PduS contained one molecule of noncovalently bound flavin mononucleotide (FMN). Genetic studies showed that a pduS deletion decreased the growth rate of Salmonella on 1,2-PD, supporting a role in cobalamin reduction in vivo. Further studies demonstrated that the PduS protein is a component of the Pdu microcompartments (MCPs) used for 1,2-PD degradation and that it interacts with the PduO adenosyltransferase, which catalyzes the terminal step of AdoCbl synthesis. These studies further characterize PduS, an unusual MCP-associated cobalamin reductase, and, in conjunction with prior results, indicate that the Pdu MCP encapsulates a complete cobalamin assimilation system.Coenzyme B₁₂ (adenosylcobalamin, AdoCbl) is an indispensable cofactor for a variety of enzymes that are widely distributed among microbes and higher animals (2, 55). Organisms obtain AdoCbl by de novo synthesis or by assimilation of complex precursors, such as vitamin B₁₂ (cyanocobalamin, CN-Cbl) and hydroxocobalamin (OH-Cbl), which can be enzymatically converted to AdoCbl. De novo synthesis occurs only in prokaryotes, but the assimilation of complex precursors is more widespread, taking place in many microbes and in higher animals (56). A model for the assimilation of CN-Cbl and OH-Cbl to AdoCbl, based on work done in a number of laboratories, is shown in Fig. ​Fig.1.1. CN-Cbl is first reductively decyanated to cob(II)alamin (22, 30, 68). Next, cob(II)alamin is reduced to cob(I)alamin, and ATP:cob(I)alamin adenosyltransferase (ATR) transfers a 5′ deoxyadenosyl group from ATP to cob(I)alamin to form AdoCbl (10, 11, 28, 29, 35, 63, 64, 72). Studies indicate that prior to reduction cob(II)alamin binds the ATR and undergoes a transition to the 4-coordinate base-off conformer (41, 48, 59, 61, 62). Transition to the 4-coordinate state raises the midpoint potential of the cob(II)alamin/cob(I)alamin couple by about 250 mV, facilitating reduction (60). OH-Cbl assimilation occurs by a similar pathway except that the first step is reduction of OH-Cbl to cob(II)alamin by cobalamin reductase or by the reducing environment of the cell (19, 69).Open in a separate windowFIG. 1.Cobalamin assimilation and recycling pathway. Many organisms are able to take up CN-Cbl and OH-Cbl and convert them to the active coenzyme form, AdoCbl. This process involves reduction of the central cobalt atom of the corrin ring followed by addition of a 5′ deoxyadenosyl (Ado) group via a carbon-cobalt bond. The Ado group is unstable in vivo, and AdoCbl breaks down to form OH-Cbl. Consequently, cobalamin recycling is required for AdoCbl-dependent processes, and recycling uses the same pathway that functions in the assimilation of cobalamin from the environment. PPPi, triphosphate.The pathway used for the assimilation of OH-Cbl and CN-Cbl is also used for intracellular cobalamin recycling. During catalysis the adenosyl group of AdoCbl is periodically lost due to by-reactions and is usually replaced by a hydroxyl group, resulting in the formation of an inactive OH-Cbl enzyme complex (66). Cobalamin recycling begins with a reactivase that converts the inactive OH-Cbl-enzyme complex to OH-Cbl and apoenzyme (43, 44). Next, the process described in Fig. ​Fig.11 converts OH-Cbl to AdoCbl, which spontaneously associates with apoenzyme to form active holoenzyme (43, 44, 66). In the organisms that have been studied, cobalamin recycling is essential, and genetic defects in this process block AdoCbl-dependent metabolism (3, 16, 29).Salmonella enterica degrades 1,2-propanediol (1,2-PD) via an AdoCbl-dependent pathway (27). 1,2-PD is a major product of the anaerobic degradation of common plant sugars rhamnose and fucose and is thought to be an important carbon and energy source in natural environments (38, 46). Twenty-four genes for 1,2-PD utilization (pdu) are found in a contiguous cluster (pocR, pduF, and pduABB′CDEGHJKLMNOPQSTUVWX) (7, 27). This locus encodes enzymes for the degradation of 1,2-PD and cobalamin recycling, as well as proteins for the formation of a bacterial microcompartment (MCP) (7). Bacterial MCPs are simple proteinaceous organelles used by diverse bacteria to optimize metabolic pathways that have toxic or volatile intermediates (6, 13, 14, 71). They are polyhedral in shape, 100 to 150 nm in cross section (about the size of a large virus), and consist of a protein shell that encapsulates sequentially acting metabolic enzymes. Sequence analyses indicate that MCPs are produced by 20 to 25% of all bacteria and function in seven or more different metabolic processes (14). The function of the Pdu MCP is to confine the propionaldehyde formed in the first step of 1,2-PD degradation in order to mitigate its toxicity and prevent DNA damage (7, 23, 24, 51). Prior studies indicate that 1,2-PD traverses the protein shell and enters the lumen of the Pdu MCP, where it is converted to propionaldehyde and then to propionyl-coenzyme A (CoA) by AdoCbl-dependent diol dehydratase (DDH; PduCDE) and propionaldehyde dehydrogenase (PduP) (8, 33). Propionyl-CoA then exits the MCP into the cytoplasm, where it is converted to 1-propanol or propionate or enters central metabolism via the methylcitrate pathway (25, 47). The shell of the Pdu MCP is thought to limit the diffusion of propionaldehyde in order to protect cytoplasmic components from toxicity. The Pdu MCP was purified, and 14 major polypeptide components were identified (PduABB′CDEGHJKOPTU), all of which are encoded by the pdu locus (23). PduABB′JKTU are confirmed or putative shell proteins (23, 24, 51). PduCDE and PduP catalyze the first 2 steps of 1,2-PD degradation as described above (7, 8, 23, 33). The PduO and PduGH enzymes are used for cobalamin recycling. PduO is an adenosyltransferase (29), and PduGH is a homolog of the Klebsiella DDH reactivase, which mediates the removal of OH-Cbl from an inactive OH-Cbl-DDH complex (43, 44). However, a reductase which is also required for cobalamin recycling was not previously identified as a component of the Pdu MCP (23). This raises the question of how cobalamin is recycled for the AdoCbl-dependent DDH that resides within the Pdu MCP.Prior studies indicated that the PduS enzyme (which is encoded by the pdu locus) is a cobalamin reductase (52). Very recently PduS was purified from S. enterica and shown to be a flavoprotein that can mediate the reduction of 4-coordinate cob(II)alamin bound to ATR but was not further characterized (40). In this study, PduS from S. enterica is purified and more extensively characterized, including identification of its cofactor requirements and kinetic properties. In addition, we show that PduS is a component of the Pdu MCP. This finding in conjunction with prior work indicates that, in addition to 1,2-PD degradative enzymes, the Pdu MCP encapsulates a complete cobalamin recycling system.     

Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial

Background

Sport is the leading cause of injury requiring medical attention among adolescents. We studied the effectiveness of a home-based balance-training program using a wobble board in improving static and dynamic balance and reducing sports-related injuries among healthy adolescents.

Methods

In this cluster randomized controlled trial, we randomly selected 10 of 15 high schools in Calgary to participate in the fall of 2001. We then recruited students from physical education classes and randomly assigned them, by school, to either the intervention (n = 66) or the control (n = 61) group. Students in the intervention group participated in a daily 6-week and then a weekly 6-month home-based balance-training program using a wobble board. Students at the control schools received testing only. The primary outcome measures were timed static and dynamic balance, 20-m shuttle run and vertical jump, which were measured at baseline and biweekly for 6 weeks. Self-reported injury data were collected over the 6-month follow-up period.

Results

At 6 weeks, improvements in static and dynamic balance were observed in the intervention group but not in the control group (difference in static balance 20.7 seconds, 95% confidence interval [CI] 10.8 to 30.6 seconds; difference in dynamic balance 2.3 seconds, 95% CI 0.7 to 4.0 seconds). There was evidence of a protective effect of balance training in over 6 months (relative risk of injury 0.2, 95% CI 0.05 to 0.88). The number needed to treat to avoid 1 injury over 6 months was 8 (95% CI 4 to 35).

Interpretation

Balance training using a wobble board is effective in improving static and dynamic balance and reducing sports-related injuries among healthy adolescents.Adolescents commonly participate in sports.^1,2 In a survey of adolescents in Alberta, 59% reported that they took part in sports more than 5 hours per week (unpublished data). In North America, sport is the leading cause of injury requiring medical attention and visits to an emergency department among adolescents.^3,4 In Alberta 26% of youths aged 15–19 years in a survey reported sustaining a sports-related injury requiring medical attention.⁵ The impact may be lifelong, as there is evidence that knee and ankle injuries may result in an increased risk of osteoarthritis later in life.^6,7,8 In addition, each year 8% of adolescents drop out of sports activities because of injury.⁹ The reduction in physical activity resulting from sports-related injuries could have significant long-term effects on morbidity and mortality.^10,11Proprioceptive balance training is used in rehabilitation following sports-related injuries and is becoming recognized as an important element in injury prevention in sports.^{12,13,14,15,16,17,18,19} Running, jumping or pivoting on one leg relies on a sense of joint position and muscular control for joint stability. There is evidence that static balance improves following proprioceptive balance training using a wobble board.^20,21,22,23 However, most of these studies did not examine the effect of dynamic proprioceptive balance training, which may improve postural control in athletic situations and prevent some injuries.There is evidence from randomized trials that multifaceted prevention programs, including proprioceptive balance training using a wobble board, are effective in reducing injuries to the lower extremities in specific sports.^{12,13,14,15,16,17,18,19} However, the programs in these trials were multifaceted (i.e., included warm-up, flexibility, jump training, strength training, rehabilitation and sport-specific technical components), and balance was not measured. The effectiveness of balance training alone on balance ability and prevention of injury remains unclear. Moreover, the use of these techniques in adolescents and non-elite athletes has not been studied.The objectives of our study were to determine the effectiveness of a proprioceptive home-based balance-training program in improving static and dynamic balance in adolescents and to examine the effectiveness of this training program on reducing sports-related injury among adolescents.     

Malaria “epidemic” in Quebec: diagnosis and response to imported malaria

Background

Imported malaria is an increasing problem. The arrival of 224 African refugees presented the opportunity to investigate the diagnosis and management of imported malaria within the Quebec health care system.

Methods

The refugees were visited at home 3–4 months after arrival in Quebec. For 221, a questionnaire was completed and permission obtained for access to health records; a blood sample for malaria testing was obtained from 210.

Results

Most of the 221 refugees (161 [73%]) had had at least 1 episode of malaria while in the refugee camps. Since arrival in Canada, 87 (39%) had had symptoms compatible with malaria for which medical care was sought. Complete or partial records were obtained for 66 of these refugees and for 2 asymptomatic adults whose children were found to have malaria: malaria had been appropriately investigated in 55 (81%); no malaria smear was requested for the other 13. Smears were reported as positive for 20 but confirmed for only 15 of the 55; appropriate therapy was verified for 10 of the 15. Of the 5 patients with a false-positive diagnosis of malaria, at least 3 received unnecessary therapy. Polymerase chain reaction testing of the blood sample obtained at the home visit revealed malaria parasites in 48 of the 210 refugees (23%; 95% confidence interval [CI] 17%– 29%). The rate of parasite detection was more than twice as high among the 19 refugees whose smears were reported as negative but not sent for confirmation (47%; 95% CI 25%– 71%).

Interpretation

This study has demonstrated errors of both omission and commission in the response to refugees presenting with possible malaria. Smears were not consistently requested for patients whose presenting complaints were not “typical” of malaria, and a large proportion of smears read locally as “negative” were not sent for confirmation. Further effort is required to ensure optimal malaria diagnosis and care in such high-risk populations.In many industrialized countries, the incidence of imported malaria is rising because of changing immigration patterns and refugee policies as well as increased travel to malaria-endemic regions.^{1,2,3,4,5,6,7,8,9,10} Imported malaria is not rare in Canada (300–1000 cases per year),³ the United States^2,3,4 or other industrialized countries.^5,6,7,8,9,10 Malaria can be a serious challenge in these countries because of its potentially rapid and lethal course.^11,12,13,14 The task of front-line health care providers is made particularly difficult by the protean clinical presentations of malaria. Classic periodic fevers (tertian or quartan) are seen infrequently.^{9,15,16,17,18,19} Atypical and subtle presentations are especially common in individuals who have partial immunity (e.g., immigrants and refugees from disease-endemic areas) or are taking malaria prophylaxis (e.g., travellers).^9,16,17 Even when malaria is considered, an accurate diagnosis can remain elusive or can be delayed as a result of inadequate or distant specialized laboratory support.^19,20In Quebec, the McGill University Centre for Tropical Diseases collaborates with the Laboratoire de santé publique du Québec to raise awareness of imported malaria, to offer training and quality-assurance testing, and to provide reference diagnostic services. A preliminary diagnosis is typically made by the local laboratory, and smears (with or without staining) are sent to the McGill centre, where they are reviewed within 2–48 hours, depending on the urgency of the request. Initial medical decisions are usually based on local findings and interpretations. Although malaria is a reportable disease, there is no requirement to use the reference service.On Aug. 9, 2000, 224 refugees from Tanzanian camps landed in Montréal aboard an airplane chartered by Canadian immigration authorities. Over the ensuing 5 weeks, the McGill University Centre for Tropical Diseases noted an increase in demand for malaria reference services and an apparent small “epidemic” of imported malaria. This “epidemic” prompted us to investigate the performance of the health care system in the diagnosis and management of imported malaria.     

Vitamin D deficiency and whole-body and femur bone mass relative to weight in healthy newborns

Background

Vitamin D is required for normal bone growth and mineralization. We sought to determine whether vitamin D deficiency at birth is associated with bone mineral content (BMC) of Canadian infants.

Methods

We measured plasma 25-hydroxyvitamin D [25(OH)D] as an indicator of vitamin D status in 50 healthy mothers and their newborn term infants. In the infants, anthropometry and lumbar, femur and whole-body BMC were measured within 15 days of delivery. Mothers completed a 24-hour recall and 3-day food and supplement record. We categorized the vitamin D status of mothers and infants as deficient or adequate and then compared infant bone mass in these groups using nonpaired t tests. Maternal and infant variables known to be related to bone mass were tested for their relation to BMC using backward stepwise regression analysis.

Results

Twenty-three (46%) of the mothers and 18 (36%) of the infants had a plasma 25(OH)D concentration consistent with deficiency. Infants who were vitamin D deficient were larger at birth and follow-up. Absolute lumbar spine, femur and whole-body BMC were not different between infants with adequate vitamin D and those who were deficient, despite larger body size in the latter group. In the regression analysis, higher whole-body BMC was associated with greater gestational age and weight at birth as well as higher infant plasma 25(OH)D.

Conclusion

A high rate of vitamin D deficiency was observed among women and their newborn infants. Among infants, vitamin D deficiency was associated with greater weight and length but lower bone mass relative to body weight. Whether a return to normal vitamin D status, achieved through supplements or fortified infant formula, can reset the trajectory for acquisition of BMC requires investigation.In northern countries, endogenous synthesis of vitamin D is thought to be limited to the months of April through September.¹ During the winter months, dietary or supplemental vitamin D intake at values similar to the recommended intake of 200 IU/day (5 μg/day) is not enough to prevent vitamin D deficiency in young women.² Vitamin D deficiency is well documented among Canadian women^3,4,5,6,7 and young children^4,8,9,10,11 and has been reported at levels as high as 76% of women and 43% of children (3–24 months) in northern Manitoba⁴ and 48.4%–88.6% of Aboriginal women and 15.1%–63.5% of non-Aboriginal women in the Inuvik zone of the former Northwest Territories.³ Vitamin D dependent rickets in children and osteomalacia in adults are the most commonly reported features of deficiency.¹² We sought to determine whether maternal or infant vitamin D deficiency at birth is associated with BMC of Canadian infants.     

Inactivation of Vibrio anguillarum by Attached and Planktonic Roseobacter Cells

The purpose of the present study was to investigate the inhibition of Vibrio by Roseobacter in a combined liquid-surface system. Exposure of Vibrio anguillarum to surface-attached roseobacters (10⁷ CFU/cm²) resulted in significant reduction or complete killing of the pathogen inoculated at 10² to 10⁴ CFU/ml. The effect was likely associated with the production of tropodithietic acid (TDA), as a TDA-negative mutant did not affect survival or growth of V. anguillarum.Antagonistic interactions among marine bacteria are well documented, and secretion of antagonistic compounds is common among bacteria that colonize particles or surfaces (8, 13, 16, 21, 31). These marine bacteria may be interesting as sources for new antimicrobial drugs or as probiotic bacteria for aquaculture.Aquaculture is a rapidly growing sector, but outbreaks of bacterial diseases are a limiting factor and pose a threat, especially to young fish and invertebrates that cannot be vaccinated. Because regular or prophylactic administration of antibiotics must be avoided, probiotic bacteria are considered an alternative (9, 18, 34, 38, 39, 40). Several microorganisms have been able to reduce bacterial diseases in challenge trials with fish or fish larvae (14, 24, 25, 27, 33, 37, 39, 40). One example is Phaeobacter strain 27-4 (17), which inhibits Vibrio anguillarum and reduces mortality in turbot larvae (27). The antagonism of Phaeobacter 27-4 and the closely related Phaeobacter inhibens is due mainly to the sulfur-containing tropolone derivative tropodithietic acid (TDA) (2, 5), which is also produced by other Phaeobacter strains and Ruegeria mobilis (28). Phaeobacter and Ruegeria strains or their DNA has been commonly found in marine larva-rearing sites (6, 17, 28).Phaeobacter and Ruegeria (Alphaproteobacteria, Roseobacter clade) are efficient surface colonizers (7, 11, 31, 36). They are abundant in coastal and eutrophic zones and are often associated with algae (3, 7, 41). Surface-attached Phaeobacter bacteria may play an important role in determining the species composition of an emerging biofilm, as even low densities of attached Phaeobacter strain SK2.10 bacteria can prevent other marine organisms from colonizing solid surfaces (30, 32).In continuation of the previous research on roseobacters as aquaculture probiotics, the purpose of this study was to determine the antagonistic potential of Phaeobacter and Ruegeria against Vibrio anguillarum in liquid systems that mimic a larva-rearing environment. Since production of TDA in liquid marine broth appears to be highest when roseobacters form an air-liquid biofilm (5), we addressed whether they could be applied as biofilms on solid surfaces.     

Interactions of DNA with Biofilm-Derived Membrane Vesicles

The biofilm matrix contributes to the chemistry, structure, and function of biofilms. Biofilm-derived membrane vesicles (MVs) and DNA, both matrix components, demonstrated concentration-, pH-, and cation-dependent interactions. Furthermore, MV-DNA association influenced MV surface properties. This bears consequences for the reactivity and availability for interaction of matrix polymers and other constituents.The biofilm matrix contributes to the chemistry, structure, and function of biofilms and is crucial for the development of fundamental biofilm properties (46, 47). Early studies defined polysaccharides as the matrix component, but proteins, lipids, and nucleic acids are all now acknowledged as important contributors (7, 15). Indeed, DNA has emerged as a vital participant, fulfilling structural and functional roles (1, 5, 6, 19, 31, 34, 36, 41, 43, 44). The phosphodiester bond of DNA renders this polyanionic at a physiological pH, undoubtedly contributing to interactions with cations, humic substances, fine-dispersed minerals, and matrix entities (25, 41, 49).In addition to particulates such as flagella and pili, membrane vesicles (MVs) are also found within the matrices of gram-negative and mixed biofilms (3, 16, 40). MVs are multifunctional bilayered structures that bleb from the outer membranes of gram-negative bacteria (reviewed in references 4, 24, 27, 28, and 30) and are chemically heterogeneous, combining the known chemistries of the biofilm matrix. Examination of biofilm samples by transmission electron microscopy (TEM) has suggested that matrix material interacts with MVs (Fig. ​(Fig.1).1). Since MVs produced in planktonic culture have associated DNA (11, 12, 13, 20, 21, 30, 39, 48), could biofilm-derived MVs incorporate DNA (1, 39, 40, 44)?Open in a separate windowFIG. 1.Possible interactions between matrix polymers and particulate structures. Shown is an electron micrograph of a thin section through a P. aeruginosa PAO1 biofilm. During processing, some dehydration occurred, resulting in collapse of matrix material into fibrillate arrangements (black filled arrows). There is a suggestion of interactions occurring with particulate structures such as MVs (hollow white arrow) and flagella (filled white arrows) (identified by the appearance and cross-dimension of these highly ordered structures when viewed at high magnification), which was consistently observed with other embedded samples and also with whole-mount preparations of gently disrupted biofilms (data not shown). The scale bar represents 200 nm.     

Cell-Cell Spread of Human Immunodeficiency Virus Type 1 Overcomes Tetherin/BST-2-Mediated Restriction in T cells

Direct cell-to-cell spread of human immunodeficiency virus type 1 (HIV-1) between T cells at the virological synapse (VS) is an efficient mechanism of viral dissemination. Tetherin (BST-2/CD317) is an interferon-induced, antiretroviral restriction factor that inhibits nascent cell-free particle release. The HIV-1 Vpu protein antagonizes tetherin activity; however, whether tetherin also restricts cell-cell spread is unclear. We performed quantitative cell-to-cell transfer analysis of wild-type (WT) or Vpu-defective HIV-1 in Jurkat and primary CD4⁺ T cells, both of which express endogenous levels of tetherin. We found that Vpu-defective HIV-1 appeared to disseminate more efficiently by cell-to-cell contact between Jurkat cells under conditions where tetherin restricted cell-free virion release. In T cells infected with Vpu-defective HIV-1, tetherin was enriched at the VS, and VS formation was increased compared to the WT, correlating with an accumulation of virus envelope proteins on the cell surface. Increasing tetherin expression with type I interferon had only minor effects on cell-to-cell transmission. Furthermore, small interfering RNA (siRNA)-mediated depletion of tetherin decreased VS formation and cell-to-cell transmission of both Vpu-defective and WT HIV-1. Taken together, these data demonstrate that tetherin does not restrict VS-mediated T cell-to-T cell transfer of Vpu-defective HIV-1 and suggest that under some circumstances tetherin might promote cell-to-cell transfer, either by mediating the accumulation of virions on the cell surface or by regulating integrity of the VS. If so, inhibition of tetherin activity by Vpu may balance requirements for efficient cell-free virion production and cell-to-cell transfer of HIV-1 in the face of antiviral immune responses.Human immunodeficiency virus type 1 can disseminate between and within hosts by cell-free infection or by direct cell-cell spread. Cell-cell spread of HIV-1 between CD4⁺ T cells is an efficient means of viral dissemination (65) and has been estimated to be several orders of magnitude more rapid than cell-free virus infection (6, 8, 41, 64, 74). Cell-cell transmission of HIV-1 takes place at the virological synapse (VS), a multimolecular structure that forms at the interface between an HIV-1-infected T cell and an uninfected target T cell during intercellular contact (27). Related structures that facilitate cell-cell spread of HIV-1 between dendritic cells and T cells (42) and between macrophages and T cells (16, 17) and for cell-cell spread of the related retrovirus human T-cell leukemia virus type 1 (HTLV-1) (24) have also been described. Moreover, more long-range cell-cell transfer can occur via cellular projections, including filopodia (71) and membrane nanotubes (75). The VS is initiated by binding of the HIV-1 envelope glycoprotein (Env), which is expressed on the surfaces of infected T cells, to HIV-1 entry receptors (CD4 and either CXCR4 or CCR5) present on the target cell membrane (6, 22, 27, 41, 61, 73). Interactions between LFA-1 and ICAM-1 and ICAM-3 further stabilize the conjugate interface and, together with Env receptor binding, help trigger the recruitment of viral proteins, CD4/coreceptor, and integrins to the contact site (27, 28, 61). The enrichment of viral and cellular proteins at the VS is an active process, dependent on cytoskeletal remodeling, and in the infected T cell both the actin and tubulin network regulate polarization of HIV-1 proteins at the cell-cell interface, thus directing HIV-1 assembly and egress toward the engaged target cell (27, 29). Virus is transferred by budding into the synaptic cleft, and virions subsequently attach to the target cell membrane to mediate entry, either by fusion at the plasma membrane or possibly following endocytic uptake (2, 22). In this way, the VS promotes more rapid infection kinetics and may enhance HIV-1 pathogenesis in vivo.Cells have evolved a number of barriers to resist invading microorganisms. One mechanism that appears to be particularly important in counteracting HIV-1 infection is a group of interferon-inducible, innate restriction factors that includes TRIM5α, APOBEC3G, and tetherin (38, 49, 69, 79). Tetherin (BST-2/CD317) is a host protein expressed by many cell types, including CD4⁺ T cells, that acts at a late stage of the HIV-1 life cycle to trap (or “tether”) mature virions at the plasma membranes of virus-producing cells, thereby inhibiting cell-free virus release (49, 56, 81). This antiviral activity of tetherin is not restricted to HIV-1, and tetherin can also inhibit the release of other enveloped viruses from infected cells (31, 40, 54, 62). What the cellular function of tetherin is besides its antiviral activity is unclear, but because expression is upregulated following alpha/beta interferon (IFN-α/β) treatment (1) and tetherin can restrict a range of enveloped viruses, tetherin has been postulated to be a broad-acting mediator of the innate immune defense against enveloped viruses.To circumvent restriction of particle release, HIV-1 encodes the 16-kDa accessory protein Vpu, which antagonizes tetherin and restores normal virus budding (47, 78). The molecular mechanisms by which Vpu does this are not entirely clear, but evidence suggests that Vpu may exert its antagonistic function by downregulating tetherin from the cell surface, trapping it in the trans-Golgi network (10) and targeting it for degradation by the proteasome (12, 39, 81) or lysosome (9, 25, 44); however, degradation of tetherin may be dispensable for Vpu activity (13), and in HIV-1-infected T cells, surface downregulation of tetherin has been reported to be minor (45), suggesting that global removal of tetherin from the plasma membrane may not be necessary to antagonize its function.Tetherin-mediated restriction of HIV-1 and antagonism by Vpu have been the focus of much research, and inhibition of cell-free virus infection has been well documented (33, 47-49, 77, 81, 82). In contrast, less studied is the impact of tetherin on direct cell-cell dissemination. For example, it is not clear if tetherin-mediated restriction inhibits T cell-T cell spread as efficiently as cell-free release or whether tetherin affects VS formation. To address these questions, we analyzed Vpu⁺ and Vpu⁻ viruses for their ability to spread directly between Jurkat T cells and primary CD4⁺ T cells in the presence or absence of endogenous tetherin. Our data suggest that tetherin does not restrict HIV-1 in the context of cell-to-cell transmission of virus between T cells expressing endogenous tetherin. Interestingly, we also that observed that Vpu-defective virus may disseminate more efficiently by cell-cell spread at the VS. We postulate that cell-cell spread may favor viral pathogenesis by allowing HIV-1 to disseminate in the presence of tetherin during an interferon-producing innate response.