Loss to follow-up among youth accessing outpatient HIV care and treatment services in Kisumu,Kenya

Youth are particularly vulnerable to acquiring HIV, yet reaching them with HIV prevention interventions and engaging and retaining those infected in care and treatment remains a challenge. We sought to determine the incidence rate of loss to follow-up (LTFU) and explore socio-demographic and clinical characteristics associated with LTFU among HIV-positive youth aged 15–21 years accessing outpatient care and treatment clinics in Kisumu, Kenya. Between July 2007 and September 2010, youth were enrolled into two different HIV care and treatment clinics, one youth specific and the other family oriented. An individual was defined as LTFU when absent from the HIV treatment clinic for ≥?4 months regardless of their antiretroviral treatment status. The incidence rate of LTFU was calculated and Cox regression analysis used to identify factors associated with LTFU. A total of 924 youth (79% female) were enrolled, with a median age of 20 years (IQR 18–21). Over half, (529 (57%)), were documented as LTFU, of whom 139 (26%) were LTFU immediately after enrolment. The overall incidence rate of LTFU was 52.9 per 100 person-years (p-y). Factors associated with LTFU were pregnancy during the study period (crude HR 0.68, 95% CI 0.53–0.89); CD4 cell count >350 (adjusted hazard ratios (AHR) 0.59, 95% CI 0.39–0.90); not being on antiretroviral therapy (AHR 4.0, 95% CI 2.70–5.88); and non-disclosure of HIV infection status (AHR 1.43, 95% CI 1.10–1.89). The clinic of enrolment, age, marital status, employment status, WHO clinical disease stage and education level were not associated with LTFU. Interventions to identify and enrol youth into care earlier, support disclosure, and initiate ART earlier may improve retention of youth and need further investigation. Further research is also needed to explore the reasons for LTFU from care among HIV-infected youth and the true outcomes of these patients.     

Volume-dependent compliance in ARDS: proposal of a new diagnostic concept

Objective: Adaptation of ventilator settings to the individual's respiratory system mechanics requires information about the pressure-volume relationship and the change of compliance which is dependent on inflated volume. Unfortunately, established methods of obtaining this information are invasive and time-consuming, and, therefore, not well suited for clinical routine. We propose a new standardized diagnostic concept based on the recently developed slice method. This multiple linear regression method (MLR) determines volume-dependent respiratory system compliance (C_SLICE) within the tidal volume (V_T) during ongoing mechanical ventilation. The impact of a ventilator strategy, recommended by a consensus conference, on the course of compliance within V_T was investigated in patients with the acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).¶Design: Prospective observational study.¶Setting: Intensive care unit of a university hospital.¶Patients: 14 ARDS patients, 2 patients with ALI.¶Interventions: None.¶Measurements and results: After measurement of flow and airway pressure and calculation of tracheal pressure, C_SLICE was determined. The resulting course of C_SLICE within V_T was estimated using a mathematical algorithm. C_SLICE data were compared to those obtained by standard MLR. We found decreasing C_SLICE mainly in the upper part of V_T in all patients. In 7 patients, we found an additional increasing C_SLICE mainly in the lower part of V_T.¶Conclusions: C_SLICE was not constant in patients with ARDS/ALI whose lungs were ventilated according to consensus conference recommendations. The proposed diagnostic concept may serve as a new tool to obtain a standardized estimation of respiratory system compliance within V_T non-invasively without interfering with ongoing mechanical ventilation.     

Analysis of p53 mutations in a large series of lymphoid hematologic malignancies of childhood

p53 mutations are found in a wide variety of cancers, including hematologic malignancies. These alterations apparently contribute to development of the malignant phenotype. We analyzed a large series of lymphoid (330 cases) and a smaller series of myeloid (29 cases) malignancies of childhood for p53 mutations by single-strand conformational polymorphism (SSCP) following polymerase chain reaction. Samples with abnormal SSCP were reamplified and analyzed by direct sequencing method. p53 mutations were detected within the known mutational hotspots (exons 5 to 8) in 8 of 330 lymphoid malignancies, and in none of 29 myeloid malignancies, showing that the frequency of p53 mutations in childhood lymphoid malignancies was very low (8 of 330 cases [2%]). Four of these patients had very aggressive, fatal acute lymphocytic leukemia (ALL). None of 13 infants and none of 48 patients with T-lineage leukemia had detectable p53 mutations in their ALL cells. Exceptionally, p53 mutations were comparatively frequent in a small sample of B-cell non-Hodgkin's lymphomas (2 of 8 cases). Mutations were detected in samples from two patients with ALL at relapse; these were not detected in samples at initial diagnosis from the same patients, suggesting that p53 mutations may be associated with progression to a more malignant phenotype. Seven of eight alterations of p53 were missense mutations, and seven of eight samples may be heterozygous for the mutant p53, indicating that p53 protein may act in a dominant negative fashion.     

Proteolysis of the N-methyl-d-aspartate receptor by calpain in situ

N-Methyl-D-aspartate (NMDA) receptors are calcium-permeable glutamate receptors that play putative roles in learning, memory, and excitotoxicity. NMDA receptor-mediated calcium entry can activate the calcium-dependent protease calpain, leading to substrate degradation. The major NMDA receptor 2 (NR2) subunits of the receptor are in vitro substrates for calpain at selected sites in the C-terminal region. In the present study, we assessed the ability of calpain-mediated proteolysis to modulate the NR1a/2A subtype in a heterologous expression system. Human embryonic kidney (HEK293t) cells, which endogenously express calpain, were cotransfected with NR1a/2A in addition to the calpain inhibitor calpastatin or empty vector as control. Receptor activation by glutamate and glycine as co-agonists led to calpain activation as measured by succinyl-L-leucyl-L-leucyl-L-valyl-L-tyrosyl-aminomethyl coumarin (Suc-LLVY-AMC). Calpain activation also resulted in the degradation of NR2A and decreased binding of (125)I-MK-801 ((125)I-dizocilpine) to NR1a/2A receptors. No stable N-terminal fragment of the NMDA receptor was formed after calpain activation, suggesting calpain regulation of NMDA receptor levels in ways distinct from that previously observed with in vitro cleavage. NR2 subunit constructs lacking the final 420 amino acids were not degraded by calpain. Agonist-stimulated NR1a/2A-transfected cells also had decreased calcium uptake and produced lower changes in agonist-stimulated intracellular calcium compared with cells cotransfected with calpastatin. Calpastatin had no effect on either calcium uptake or intracellular calcium levels when the NR2A subunit lacked the final 420 amino acids. These studies demonstrate that NR2A is a substrate for calpain in situ and that this proteolytic event can modulate NMDA receptor levels.     

Older people with impaired mobility have specific loci of periventricular abnormality on MRI.

BACKGROUND: Recent investigations using MRI suggest that older persons with mobility impairment have a greater volume of abnormal cerebral white matter compared with persons with normal mobility, thus raising the possibility that those with impairment have lesions in areas critical for the control of mobility. OBJECTIVE: To utilize automated image analysis methods to localize the specific regions of abnormal white matter that distinguish subjects with lower mobility from subjects with higher mobility. METHODS: Tissue classification was performed on subjects' dual-echo long repetition time spin-echo MRI using computer algorithms operating on intensity criteria integrated with anatomic information. Statistical analysis of group differences was obtained after spatially normalizing each brain to a standard reference brain. RESULTS: Four discrete periventricular regions, including bilaterally symmetric frontal and bilateral occipitoparietal regions, were identified as being sensitive (frontal) or specific (occipitoparietal) in discriminating the subjects with lower mobility from subjects with higher mobility. The symmetry of these lesions in individual subjects suggested pathology other than arteriolar infarction. CONCLUSIONS: These results suggest that damage to discrete frontal and occipitoparietal periventricular white matter locations may be associated with a mobility disorder of aging.     

Functional MRI with variable echo time acquisition

A new functional MRI protocol that integrates variable echo time (TE) acquisition and a block-design paradigm is proposed and evaluated with finger-tapping motor task. Simulations and experimental data show that the blood oxygenation level-dependent (BOLD) sensitivity achieved with this approach is comparable to that achieved using a conventional constant-TE protocol. The proposed variable-TE fMRI protocol provides valuable information that cannot be obtained with the constant-TE protocol. First, a field inhomogeneity map can be derived from the multi-TE data and used to correct EPI geometric distortions. Second, changes of T2* values due to the BOLD effect can be quantified. Third, for brain regions with pronounced susceptibility field gradients, the reduced BOLD sensitivity may be compensated for when the acquired multi-TE data are processed appropriately (e.g., with weighted summation). Fourth, large venules and veins may possibly be identified (depending on the vessel orientation and volume fraction) by evaluating the phase values of the multi-TE data. Finally, magnetic field drift over time can be measured from dynamic field maps available with this protocol.