Universal nevirapine upon presentation in labor to prevent mother-to-child HIV transmission in high prevalence settings

OBJECTIVE: To assess the uptake of and adherence to nevirapine to prevent mother-to-child HIV transmission among women of unknown HIV serostatus presenting in labor. We also assessed preliminary efficacy of the approach. DESIGN: Women of unknown HIV serostatus presenting in labor were offered single-dose nevirapine in a prospective cohort study. Two additional contemporaneous comparison populations were also studied. METHODS: We measured uptake by counting the number of women that accepted enrollment when offered. We measured adherence with cord blood nevirapine assay. We measured preliminary efficacy with HIV DNA polymerase chain reaction of infant blood spots at 4-6 weeks of life. RESULTS: Of 1591 women approached in labor, 634 (40%) took up the intervention and received nevirapine, of whom 185 (29%) were HIV infected. Of 179 cord blood specimens from HIV-exposed infants that could be evaluated, 178 (99.4%) had nevirapine detected. This was higher than the 73 of 98 (74%) adherence rate observed in a comparison cohort in which women self-administered nevirapine before presenting to the labor ward (P < 0.001). Of 145 available infant specimens, 17 (11.7%) showed evidence of infection at 4-6 weeks, compared with 12 of 60 (20%) infants born immediately prior to study commencement whose HIV-infected mothers did not receive nevirapine (P < 0.05). CONCLUSIONS: Nevirapine without HIV testing upon presentation in labor was accepted by two-fifths of women. Because therapy is directly observed, adherence is nearly perfect. Labor ward dosing to enhance nevirapine coverage should be considered as an adjunct to antenatal nevirapine administration for prevention of mother-to-child transmission of HIV.     

Validation of a simplified method for using molecular markers to predict sulfadoxine-pyrimethamine treatment failure in African children with falciparum malaria

Surveillance of molecular markers for key mutations in Plasmodium falciparum dihydrofolate reductase (DHFR) and dihydropteroate synthetase (DHPS) has been proposed as a means of predicting sulfadoxine/ pyrimethamine (SP) treatment outcomes in Africa. This study assessed the association between DHFR and DHPS mutations and standardized clinical outcomes in children treated with SP for uncomplicated malaria in Kampala, Uganda. Two mutations (DHFR Asn-108 and Ile-51) were too common to be useful predictors. Three other mutations (DHFR Arg-59, DHPS Gly-437, and DHPS Glu-540) were associated with clinical treatment failure after 14 days, although associations were not significant. When follow-up was extended to 28 days and genotyping was used to distinguish recrudescence from new infections, associations were significantly strengthened. The presence of both the DHFR Arg-59 and DHPS Glu-540 mutations had the strongest association with clinical treatment failure (odds ratio = 10.7, P = 0.009). These results support a previously proposed method of predicting clinical outcomes based on the prevalence of these two mutations.     

Statins and their increased risk of inducing diabetes

Introduction: Statins are evidence-based drugs to prevent cardiovascular (CV) disease. However, their benefits have been disputed by a statin-related increased risk of new onset diabetes (NOD) in randomized controlled trials and meta-analyses.

Areas covered: This review provides an update based on recent outstanding evidence on the statin effect on the risk of diabetes. It also describes mechanisms potentially explaining adverse effects of statins on glucose homeostasis. PubMed was searched for original articles and reviews published from January 2010 (inclusive) to May 2015 (inclusive), which include the Search terms statins, diabetes, glucose, and insulin. NOD risk seems to be more relevant with high-intensity rather than with low-intensity statin treatment. Also, this risk is particularly increased in patients at risk for the development of diabetes. It appears that statins adversely affect glucose homeostasis in parallel with their 3-hydroxy-3-methylglutaryl-coenzyme A inhibition capacity. It was suggested that lipophilic statins are more diabetogenic than the hydrophilic ones. Mechanisms explaining statin diabetogeneicity include impaired insulin secretion by pancreatic β cells together with increased insulin resistance of various tissues.

Expert opinion: The CV outcome benefits from statin use outweigh the diabetes menace. However, patients at risk for the development of diabetes should be prescribed statins with caution.     

Characterization and regulations of the receptor for insulin-like growth factor-I in the FRTL-5 rat thyroid follicular cell line

In previous studies we have shown that insulin-like growth factor I (IGF-I) has a mitogenic effect in a line of rat thyroid follicular cells, the FRTL-5. In view of this effect, we undertook studies to identify and characterize some physicochemical and binding properties of the receptor for IGF-I in these cells and to determine what role it plays in the mitogenic activity of insulin and insulin-like growth factors in the FRTL-5 cell. Binding of 125I-labeled IGF-I (biosynthetic Thr59-IGF-I) to FRTL-5 was a function of time, temperature, and pH and was completely inhibited by high concentrations of unlabeled IGF-I. Scatchard plots of four saturation studies revealed a single apparent binding site with an average Ka of 4.2 +/- 0.6 X 10(9) M-1 (mean +/- SD) and an average maximum binding capacity of 20 +/- 2 pm/100 micrograms cellular protein. Rat IGF-II (rIGF-II) and insulin were far less potent that IGF-I in inhibiting the binding of [125I] IGF-I, and bovine TSH was without effect. 125I-Labeled IGF-II also bound to FRTL-5 cells. Binding was completely inhibited by unlabeled rIGF-II and, with lesser potency, by IGF-I. Even at high concentrations, insulin failed to inhibit the binding of [125I]IGF-II. Disuccinimidyl suberate cross-linked [125I]IGF-I to a moiety in FRTL-5 that had an apparent mol wt of approximately 135,000, as judged from sodium dodecyl sulfate-polyacrylamide gel electrophoresis under reducing conditions. Cross-linking of [125I]IGF-I was inhibited in a dose-dependent manner by unlabeled IGF-I and, with far lower potency, by rIGF-II and insulin. All three peptides stimulated the incorporation of [3H]thymidine into the DNA of FRTL-5 cells, IGF-I being the most potent, followed in decreasing order of potency of rIGF-II and insulin. The mitogenic activities of these polypeptides correlated well with their abilities to inhibit the binding of [125I]IGF-I. These data indicate that the FRTL-5 cell possesses a receptor for IGF-I that resembles in its binding and physicochemical properties the receptor for IGF-I in other tissues (type I IGF receptor) and that mediates the mitogenic response to IGF-I and insulin in these cells. FRTL-5 cells also contain a receptor for IGF-II (type II IGF receptor), but its role vis-à-vis that of the type I IGF receptor in relation to the mitogenic effect of IGF-II in these cells is uncertain.     

Oncogenes and growth factors in thyroid carcinogenesis

Normal and neoplastic thyroid tissues express a variety of oncogenes, growth factors, and growth factor receptors. The increased expression of a mutated form or forms of c-myc and c-ras appears to be associated with some epithelial and medullary thyroid carcinomas. In some cases the presence of these oncogenes correlates with less favorable histologic appearance. The possibility of cooperation between oncogene products (myc and ras) in neoplastic development is raised by studies on transformed thyroid cells in culture. Moreover, a tissue-specific oncogene associated with papillary carcinoma recently has been described. The role of excessive growth factor or growth factor receptor expression in thyroid carcinoma also has been discussed and may, as with other tumor types, be linked to specific oncogene products (e.g., c-erb-B encoding for the EGF receptor). However, the regulation of oncogenes in various stages of differentiation of thyroid tissues is not well understood. In addition to describing these associations with thyroid carcinoma and putative unchecked growth factor action in the development of neoplasia, more direct demonstrations of a causal relationship are necessary. Thus, one needs to overexpress oncogenes/growth factors in normal cell lines (as has been described in this review) and observe whether cellular transformation or dedifferentiation or both occur. The ability to specifically block oncogene or growth factor expression in neoplastic cell lines at the RNA or protein level (with antisense oligonucleotides or monoclonal antibodies, respectively) should provide important information about the pathogenetic importance of these factors. It may be anticipated that reversing the overexpression of certain oncogenes can lead to normal cellular proliferation, morphology, and differentiation. The knowledge obtained from investigating the associations of oncogenes and growth factors with thyroid cancer should provide insight into the mechanisms involved in cell growth and differentiation and in the biochemical steps involved in neoplastic transformation. New insights into these processes may lead to specific therapeutic measures designed to block aberrant expression of the cellular products involved in neoplasia. A more complete understanding of the role of oncogenes in thyroid cancer also may lead to the development of specific tumor markers that may be useful in the early diagnosis of thyroid cancer and the follow-up of therapeutic maneuvers. If specific markers can be identified, analysis of fine-needle aspiration specimens of the thyroid or imaging techniques (using for example, oncogene-specific monoclonal antibodies) could be added to the diagnostic armamentarium for thyroid disease.     

Molecular defects in mucosal serotonin content and decreased serotonin reuptake transporter in ulcerative colitis and irritable bowel syndrome

BACKGROUND & AIMS: Serotonin (5-HT) is a critical signaling molecule in the gut. 5-HT released from enterochromaffin cells initiates peristaltic, secretory, vasodilatory, vagal, and nociceptive reflexes. Despite being pathophysiologically divergent, ulcerative colitis (UC) and irritable bowel syndrome (IBS) are both associated with clinical symptoms that include alterations in the normal patterns of motility, secretion, and sensation. Our aim was to test whether enteric 5-HT signaling is defective in these disorders. METHODS: Rectal biopsy specimens were obtained from healthy controls and patients with UC, IBS with diarrhea (IBS-D), and IBS with constipation (IBS-C). Key elements of 5-HT signaling, including measures of 5-HT content, release, and reuptake, were analyzed with these samples. RESULTS: Mucosal 5-HT, tryptophan hydroxylase 1 messenger RNA, serotonin transporter messenger RNA, and serotonin transporter immunoreactivity were all significantly reduced in UC, IBS-C, and IBS-D. The enterochromaffin cell population was decreased in severe UC samples but was unchanged in IBS-C and IBS-D. When 5-HT release was investigated under basal and mechanical stimulation conditions, no changes were detected in any of the groups relative to controls. CONCLUSIONS: These data show that UC and IBS are associated with similar molecular changes in serotonergic signaling mechanisms. While UC and IBS have distinct pathophysiologic properties, these data suggest that shared defects in 5-HT signaling may underlie the altered motility, secretion, and sensation. These findings represent the first demonstration of significant molecular alterations specific to the gut in patients with IBS and support the assertion that disordered gastrointestinal function in IBS involves changes intrinsic to the bowel.     

Intravascular brachytherapy for native coronary ostial in-stent restenotic lesions

OBJECTIVES: We analyzed the effects of vascular brachytherapy (VBT) on ostial in-stent restenosis (ISR). BACKGROUND: In-stent restenosis has a high recurrence rate after percutaneous reintervention. The recurrence rate of ostial ISR lesions and the impact of VBT remain unknown. METHODS: We evaluated 133 patients with native coronary ostial ISR from a pooled database of 990 patients enrolled in randomized VBT trials. Independent quantitative angiography was performed at baseline and follow-up in 45 gamma, 27 beta, and 61 placebo patients. RESULTS: Binary restenosis was significantly higher in placebo than radiated patients (75.4% vs. 17.8% in gamma vs. 22.2% in beta, p < 0.0001). The treatment effect of both gamma (odds ratio [OR] 0.06; 95% confidence interval [CI] 0.02 to 0.17) and beta VBT (OR 0.10; 95% CI 0.03 to 0.31) was maintained after controlling for differences in baseline lesion length. Proximal and distal radiation edge restenosis rates were similar among the groups. Vascular brachytherapy of true aorto-ostial lesions (n = 34) was similarly beneficial: restenosis rates of placebo versus gamma or beta patients of 83.3% versus 6.7% versus 28.6%, p = 0.0002. CONCLUSIONS: Conventional treatment of ostial ISR is associated with a recurrence rate of over 75%. Vascular brachytherapy with either gamma or beta sources results in significant and similar reductions in restenosis compared with placebo. Similar benefits after VBT prevail in true aorto-ostial lesions.