Association of age with mortality and virological and immunological response to antiretroviral therapy in rural South African adults

Objective

To assess whether treatment outcomes vary with age for adults receiving antiretroviral therapy (ART) in a large rural HIV treatment cohort.

Design

Retrospective cohort analysis using data from a public HIV Treatment & Care Programme.

Methods

Adults initiating ART 1^st August 2004 - 31^st October 2009 were stratified by age at initiation: young adults (16–24 years) mid-age adults (25–49 years) and older (≥50 years) adults. Kaplan-Meier survival analysis was used to estimate mortality rates and age and person-time stratified Cox regression to determine factors associated with mortality. Changes in CD4 cell counts were quantified using a piecewise linear model based on follow-up CD4 cell counts measured at six-monthly time points.

Results

8846 adults were included, 808 (9.1%) young adults; 7119 (80.5%) mid-age adults and 919 (10.4%) older adults, with 997 deaths over 14,778 person-years of follow-up. Adjusting for baseline characteristics, older adults had 32% excess mortality (p = 0.004) compared to those aged 25–49 years. Overall mortality rates (MR) per 100 person-years were 6.18 (95% CI 4.90–7.78); 6.55 (95% CI 6.11–7.02) and 8.69 (95% CI 7.34–10.28) for young, mid-age and older adults respectively. In the first year on ART, for older compared to both young and mid-aged adults, MR per 100 person-years were significantly higher; 0–3 months (MR: 27.1 vs 17.17 and 21.36) and 3–12 months (MR: 9.5 vs 4.02 and 6.02) respectively. CD4 count reconstitution was lower, despite better virological response in the older adults. There were no significant differences in MR after 1year of ART. Baseline markers of advanced disease were independently associated with very early mortality (0–3 months) whilst immunological and virological responses were associated with mortality after 12months.

Conclusions

Early ART initiation and improving clinical care of older adults are required to reduce high early mortality and enhance immunologic recovery, particularly in the initial phases of ART.     

Fishing directly selects on growth rate via behaviour: implications of growth-selection that is independent of size

Size-selective harvest of fish and crustacean populations has reduced stock numbers, and led to reduced growth rates and earlier maturation. In contrast to the focus on size-selective effects of harvest, here, we test the hypothesis that fishing may select on life-history traits (here, growth rate) via behaviour, even in the absence of size selection. If true, then traditional size-limits used to protect segments of a population cannot fully protect fast growers, because at any given size, fast-growers will be more vulnerable owing to bolder behaviour. We repeatedly measured individual behaviour and growth of 86 crayfish and found that fast-growing individuals were consistently bold and voracious over time, and were subsequently more likely to be harvested in single- and group-trapping trials. In addition, there was some indication that sex had independent effects on behaviour and trappability, whereby females tended to be less active, shyer, slower-growing and less likely to be harvested, but not all these effects were significant. This study represents, to our knowledge, the first across-individual support for this hypothesis, and suggests that behaviour is an important mechanism for fishing selectivity that could potentially lead to evolution of reduced intrinsic growth rates.     

Induction of macrophage migration through lactose-insensitive receptor by elastin-derived nonapeptides and their analog.

Elastin, one of the extracellular matrix components, is present in tissues requiring extensibility and resilience such as the aorta, lungs, ligaments and skin. Degradation of elastin is observed in diseases such as atherosclerosis, emphysema and metastasis. It has been suggested that degraded elastin-derived peptides interact with a variety of cell types and are involved in development of diseases. Two nonapeptides, Ala-Gly-Val-Pro-Gly-Leu-Gly-Val-Gly (AGVPGFGVG) and Ala-Gly-Val-Pro-Gly-Phe-Gly-Val-Gly (AGVPGFGVG), exist in hydrophobic regions of elastin. In this paper, we characterized these elastin-derived nonapeptides by macrophage migration assay. Both nonapeptides induced a maximal migration at 10(-8) M and elicited the same degree of responsiveness. To investigate the role of the sixth residue of the nonapeptides, seven analog peptides in which Leu or Phe is substituted by Ile, Val, Ala, Gly, Pro, Lys or Glu were synthesized and their macrophage migration activity tested. Among the nonapeptide analogs, only Ala-Gly-Val-Pro-Gly-Ile-Gly-Val-Gly induced the migration of macrophages at the optimal concentration of 10(-9) M and its responsiveness was the same as that of parent nonapeptide AGVPGFGVG. Results of the deactivation tests and the effect of lactose on macrophage migration showed that a lactose-insensitive receptor which mainly recognizes Ala-Gly-Val-Pro-Gly-Ile-Gly-Val-Gly is presumably present on the membrane of macrophages in addition to the elastin-binding protein (EBP) sensitive to lactose. These results suggest that Leu, Phe and Ile residues at the sixth position of elastin-derived nonapeptides are crucial for inducing macrophage migration and in particular, Ile residue is important for the recognition by receptor insensitive to lactose.     

Environmental correlates, plasticity, and repeatability of differences in performance among blacknose dace (Rhinichthys atratulus) populations across a gradient of urbanization

Urbanization alters stream and watershed hydrology so that fish from urban stream systems are confronted with extreme flows during storms and runoff events. To test whether residence in urban streams is associated with altered swimming ability, we compared sprint and endurance swimming performances of eight populations of blacknose dace (Rhinichthys atratulus) from different watersheds along an urban/rural gradient. Watershed impervious surface cover, a measure of urbanization, was significantly correlated with sprint performance in dace from all stream types and endurance swimming performance (U(crit)) when only fish from urban streams were analyzed. Three estimators of water flow in a stream system, watershed area, mean annual discharge, and base-flow current speed, were all related to U(crit) in fish from nonurban streams. The U(crit) was significantly repeatable after 6 mo in the laboratory, but dace populations with exceptional U(crit) values lost ability under no-flow, "detraining" conditions. Sprint performance changed substantially in individual dace after 10 wk under no-flow conditions and was a significant function of the animal's original performance. Animals with high sprint performance tended to lose ability, whereas those with poor performance gained ability. Interpopulation differences in both sprint and endurance swimming were robust over multiple years of collection from the same sites.     

Adenoviral overexpression of the glutamylcysteine ligase catalytic subunit protects pancreatic islets against oxidative stress

The catalytic subunit of glutamylcysteine ligase (GCLC) primarily regulates de novo synthesis of glutathione (GSH) in mammalian cells and is central to the antioxidant capacity of the cell. However, GCLC expression in pancreatic islets has not been previously examined. We designed experiments to ascertain whether GCLC is normally expressed in islets and whether it is up-regulated by interleukin-1 beta (IL-1 beta). GCLC expression levels were intermediate compared with other metabolic tissues (kidney, liver, muscle, fat, and lung). IL-1 beta up-regulated GCLC expression (10 ng/ml IL-1 beta, 3.76 +/- 0.86; 100 ng/ml IL-1 beta, 4.22 +/- 0.68-fold control) via the p38 form of mitogen-activated protein kinase and NF kappa B and also increased reactive oxygen species levels (10 ng/ml IL-1 beta, 5.41 +/- 1.8-fold control). This was accompanied by an increase in intraislet GSH/GSSG ratio (control, 7.1 +/- 0.1; 10 ng/ml IL-1 beta, 8.0 +/- 0.5; 100 ng/ml IL-1 beta, 8.2 +/- 0.5-fold control; p < 0.05). To determine whether overexpression of GCLC increases the antioxidant capacity of the islet and prevents the adverse effects of IL-1 beta on glucose-induced insulin secretion, islets were infected with an adenovirus encoding GCLC. IL-1 beta significantly decreased glucose-stimulated insulin secretion (control, 123.8 +/- 17.7; IL-1 beta, 40.2 +/- 3.9 microunits/ml insulin/islet). GCLC overexpression increased intraislet GSH levels and partially prevented the decrease in glucose-stimulated insulin secretion caused by IL-1 beta. These data provide the first report of GCLC expression in the islet and demonstrate that adenoviral overexpression of GCLC increases intracellular GSH levels and protects the beta cell from the adverse effects of IL-1 beta.     

Descriptive Epidemiology of Typhoid Fever during an Epidemic in Harare,Zimbabwe, 2012

Background

Typhoid fever remains a significant public health problem in developing countries. In October 2011, a typhoid fever epidemic was declared in Harare, Zimbabwe - the fourth enteric infection epidemic since 2008. To orient control activities, we described the epidemiology and spatiotemporal clustering of the epidemic in Dzivaresekwa and Kuwadzana, the two most affected suburbs of Harare.

Methods

A typhoid fever case-patient register was analysed to describe the epidemic. To explore clustering, we constructed a dataset comprising GPS coordinates of case-patient residences and randomly sampled residential locations (spatial controls). The scale and significance of clustering was explored with Ripley K functions. Cluster locations were determined by a random labelling technique and confirmed using Kulldorff''s spatial scan statistic.

Principal Findings

We analysed data from 2570 confirmed and suspected case-patients, and found significant spatiotemporal clustering of typhoid fever in two non-overlapping areas, which appeared to be linked to environmental sources. Peak relative risk was more than six times greater than in areas lying outside the cluster ranges. Clusters were identified in similar geographical ranges by both random labelling and Kulldorff''s spatial scan statistic. The spatial scale at which typhoid fever clustered was highly localised, with significant clustering at distances up to 4.5 km and peak levels at approximately 3.5 km. The epicentre of infection transmission shifted from one cluster to the other during the course of the epidemic.

Conclusions

This study demonstrated highly localised clustering of typhoid fever during an epidemic in an urban African setting, and highlights the importance of spatiotemporal analysis for making timely decisions about targetting prevention and control activities and reinforcing treatment during epidemics. This approach should be integrated into existing surveillance systems to facilitate early detection of epidemics and identify their spatial range.     

MENTAL HEALTH—A Discussion of Various Program Approaches Used in California and the Basic Assumptions Involved

The nation''s Number One health problem, mental illness, compels careful reevaluation of past and current methods of attack. It also invites consideration of the ways and means of integrating preventive measures that emphasize the conservation of mental health with prophylactic efforts that stress the avoidance of mental illnesses.A review of the development of both local and statewide mental health programs in California reveals that three fundamentally different approaches have been used: (1) The traditional approach which confines itself to the protection of society from the “insane” by the state, and to the treatment of those who are not legally insane through “private enterprise”; (2) the public health approach which seeks to minimize the causes and/or spread of selected types of psychiatric disorder regarded as mass phenomena; and (3) the sociological approach which stresses the importance of social factors both in the causation and in the rehabilitation of those mental conditions that are considered to be symptomatic of a “sick” society.An approach that combines the theoretical and practical implications of all three viewpoints offers some new solutions to the problems of (1) fitting mental health programs to populations; (2) financing; and (3) balancing preventive and clinical services.Mental illness is not a single disease-entity but a long list of distinctly different conditions. The causes and manifestations are multiple. Biological, psychological and social components in either mental health or mental illness cannot be dissociated in any attempt to understand and deal with so wide a range of illnesses and states of comparative health. Therefore, many professions and multiple public and private agencies are involved in planning, developing and administering a mental health program.     

Does Antibiotic Resistance Evolve in Hospitals?

Nosocomial outbreaks of bacteria are well documented. Based on these incidents, and the heavy usage of antibiotics in hospitals, it has been assumed that antibiotic resistance evolves in hospital environments. To test this assumption, we studied resistance phenotypes of bacteria collected from patient isolates at a community hospital over a 2.5-year period. A graphical model analysis shows no association between resistance and patient information other than time of arrival. This allows us to focus on time-course data. We introduce a hospital transmission model, based on negative binomial delay. Our main contribution is a statistical hypothesis test called the Nosocomial Evolution of Resistance Detector (NERD). It calculates the significance of resistance trends occurring in a hospital. It can inform hospital staff about the effects of various practices and interventions, can help detect clonal outbreaks, and is available as an R package. We applied the NERD method to each of the 16 antibiotics in the study via 16 hypothesis tests. For 13 of the antibiotics, we found that the hospital environment had no significant effect on the evolution of resistance; the hospital is merely a piece of the larger picture. The p-values obtained for the other three antibiotics (cefepime, ceftazidime, and gentamicin) indicate that particular care should be taken in hospital practices with these antibiotics. One of the three, ceftazidime, was significant after accounting for multiple hypotheses, indicating a trend of decreased resistance for this drug.