Antiretroviral therapy adherence among peripartum women with HIV in Kenya: an explanatory mixed methods study using dry blood spot measures and narrative interviews.

ABSTRACTAdherence to antiretroviral therapy (ART) remains sub-optimal among pregnant and postpartum women with HIV (PPWH) in high HIV prevalence low resource settings with few effective behavioral interventions. A large body of qualitative literature has established general barriers and facilitators to ART adherence in PPWH at various levels (individual, interpersonal, structural). However, research exploring the underlying behavioral mechanisms of ART adherence in PPWH with objectively verified adherence biomarkers is extremely limited. We conducted 24 in-depth interviews with postpartum women in western Kenya who had linked ART drug concentrations obtained from three dried blood spot samples across the peripartum period. Among PPWH with a low drug concentration (n = 13) compared to those with continuously high drug concentrations (n = 11), distinct themes emerged related to HIV status disclosure, social support, interactions with the health system, and health beliefs. By combining ART biomarkers with patient reported challenges, there is the potential for real-time interventions to support sustained ART adherence among PPWH and improve maternal and infant health outcomes.

Measuring ART Adherence Among Young Adults with Perinatally Acquired HIV: Comparison Between Self-report, Telephone-Based Pill Count, and Objective Pharmacologic Measures.

Tenofovir diphosphate (TVF-DP) can be quantified in red blood cells (RBCs) and dried blood spots (DBS) and can objectively measure ART adherence and predict viral suppression. Data on the association of TFV-DP with viral load are very limited in adolescents and young adults (AYA) living with perinatally-acquired HIV (PHIV), as are data comparing TFV-DP to other measures of ART adherence, such as self-report and unannounced telephone pill count. Viral load and ART adherence (self-report, TFV-DP and unannounced telephone pill count) were assessed and compared among 61 AYAPHIV recruited from an ongoing longitudinal study (CASAH) in New York City.

Tenofovir diphosphate in dried blood spots and HIV-1 resistance in South Africa.

BACKGROUND: Suboptimal antiretroviral (ART) adherence can lead to virologic failure with consequent HIV-1 resistance. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is a powerful biomarker of cumulative adherence, predictive of future viremia. It has been associated with resistance in Persons With HIV (PWH) in South Africa and the US. We explored the relationship of TFV-DP concentrations with antiretroviral drug resistance at the time of treatment failure in SA. METHODS: Adult PWH from health clinics in Cape Town, South Africa on efavirenz-based first-line ART containing tenofovir disoproxil fumarate (TDF) with an undetectable (< 50 copies/mL) HIV-1 viral load (VL) were prospectively enrolled in an observational cohort for 12 months. Monthly study visits included blood collection for HIV-1 VL and DBS for TFV-DP. The first confirmed viral breakthrough (VB) > 400 copies/mL triggered HIV-1 genotyping at the subsequent visit. An electronic adherence (EA) device monitored ART adherence in real-time, estimated as a percent for the 30-days prior to VB. Wilcoxon rank sum test was used to compare median [IQR] TFV-DP by genotype outcome. RESULTS: Of 250 individuals, (n = 195, 78% women), 21 experienced VB, with a median of 5 [4;7] months on study, and a median EA of 33.3 [13.3;53.3]%. Demographic characteristics between those with and without VB were similar. Median VL at VB was 4.0 [3.2;4.5] log copies/mL. TFV-DP concentrations trended down towards the VB visit. Median TFV-DP concentrations were significantly higher in those HIV-1 genotype did not amplify due to being virally suppressed at the subsequent visit (n = 10; 380 [227-661] fmol/punch, p = 0.035; EA 45 [24.9; 59.2]%); than in those who were successfully genotyped with evidence of drug resistance (n = 5, 241 [150-247] fmol/punch, EA 20 [6.7;36.7]%) and in individuals who did not have resistance (n = 3, 39.9 [16.6; 93.9] fmol/punch; EA 33.3 [16-38]%). Three genotype collections were not done. Only non-nucleoside reverse transcriptase inhibitor-associated mutations were identified on resistance testing. (K103N, E138K, Y118H). CONCLUSION: TFV-DP in DBS showed a step-wise inverse relationship with VB and drug resistance, with evidence of low cumulative ART adherence in PWH who developed antiretroviral resistance. Monitoring TFV-DP concentrations could be a valuable tool for predicting future VB and future resistance.

Indinavir plasma protein binding in HIV-1-infected adults.

OBJECTIVE: To quantify unbound indinavir concentrations and characterize indinavir plasma protein binding in HIV-infected adults. DESIGN: Pharmacokinetic study in antiretroviral-naive, HIV-infected persons with CD4 T lymphocytes > 100 x 10(6) cells/L and HIV-RNA in plasma >5000 copies/ml at baseline who were participating in an open-label study of zidovudine, lamivudine and indinavir therapy. METHODS: Eight men underwent 8 h intensive pharmacokinetic studies for indinavir on two occasions 6 months apart. Unbound indinavir was separated by ultra-filtration, and unbound and total concentrations were quantified by a validated high-performance liquid chromatography method. RESULTS: Overall indinavir protein binding was 61+/-6%, with a range among the profiles of 54 to 70%. Indinavir binding was higher at the 8 h post-dose concentration compared with the 1 h post-dose concentration (66 versus 57%, P = 0.0006). CONCLUSIONS: The mean 61% protein binding for indinavir in these HIV-infected persons is similar to the in vitro report of 60%. However, the fraction bound was concentration-dependent, and considerable variability in binding was present among patients. Quantification of unbound protease inhibitor concentrations opens new avenues of research to advance our understanding of the pharmacologically-relevant moieties of antiretroviral agents and thereby the pharmacotherapy of HIV infection.

Zidovudine triphosphate and lamivudine triphosphate concentration-response relationships in HIV-infected persons.

OBJECTIVE: To quantitate intracellular concentrations of zidovudine and lamivudine triphosphate and explore relationships with virologic and immunologic responses to antiretroviral therapy. DESIGN: Eight antiretroviral-naive, HIV-infected persons with CD4 T cell counts > 100 x 10(6) cells/l, and HIV RNA in plasma > 5000 copies/ml participating in a prospective, randomized, open-label study of standard dose versus concentration-controlled therapy with zidovudine, lamivudine, and indinavir. METHODS: Peripheral blood mononuclear cells and plasma were collected frequently throughout the study for quantitation of intracellular zidovudine triphosphate and lamivudine triphosphate concentrations, and zidovudine and lamivudine concentrations in plasma. CD4 T cells and HIV RNA in plasma (Roche Amplicor Ultrasensitive Assay) were measured at baseline and every 4 weeks throughout the study. Relationships among intracellular and plasma concentrations, and CD4 T cells and HIV RNA in plasma were investigated with regression analyses. RESULTS: Significant relationships were observed between the intracellular concentrations of zidovudine triphosphate and lamivudine triphosphate and the baseline level of CD4 cells. Lamivudine triphosphate concentrations were related in a linear manner to the apparent oral clearance of lamivudine from plasma. A direct linear relationship was found between the intracellular concentrations of zidovudine triphosphate and lamivudine triphosphate. The percent change in CD4 cells during therapy and the rate of decline in HIV RNA in plasma were related to the intracellular concentrations of zidovudine triphosphate and lamivudine triphosphate. CONCLUSION: These studies into the intracellular clinical pharmacology of nucleoside reverse transcriptase inhibitors illustrate potential clinical implications as determinants of therapeutic success. Moreover, these findings provide several leads and a strong impetus for future investigations with nucleoside reverse transcriptase inhibitors particularly when given in combination and sequentially.

Immunotoxins and cytokine toxin fusion proteins.

Paul Ehrlich first suggested the simple and elegant concept of creating specific cell toxins or "magic bullets" through the fusion of cell-specific antibodies and toxins. In practice it has proven difficult to create safe and effective "magic bullets." In the past several years, several immunotoxins have been applied to clinical testing. These immunotoxins have been created by the biochemical coupling of cell- or lineage-specific monoclonal antibodies to plant toxins or fragments thereof. These immunotoxins have been used to treat bone marrow transplant recipients and patients with autoimmune disorders. In recent years, another strategy has also been pursued to create hybrid toxins. Rather than use antibodies as the targeting moiety, cytokines have been used to target a select population of cells bearing a high copy number of receptors for the specific cytokine. Rather than biochemically couple a cytokine to the toxin, the cytokine and toxin are fused by a peptide bond established via genetic engineering. A prototype IL-2 diphtheria toxin-related fusion protein is now being tested in the clinic for treatment of hematopoietic malignancies and autoimmune disorders.

Peripartum heart failure: idiopathic cardiomyopathy or compounding cardiovascular events?

During a 12-year period, when more than 106,000 women were delivered, 28 women with peripartum heart failure of obscure etiology that initially was diagnosed as peripartum cardiomyopathy were studied. None had obvious underlying cardiac disease or iatrogenic fluid overload, and in all an assiduous search for underlying cardiovascular disease was launched. In 21 of these 28 women, heart failure was attributed to chronic underlying disease (chronic hypertension in 14, forme fruste mitral stenosis in four, and morbid obesity in one) or viral myocarditis. Importantly, these women also had multiple compounding cardiovascular factors--preeclampsia, cesarean section, anemia, and infection--which, when superimposed on those of pregnancy, acted in concert to cause heart failure. In seven women, the cause for cardiomegaly and global hypokinesis was not found, and peripartum cardiomyopathy was diagnosed. Compared with women with explicable causes of peripartum heart failure, these women did poorly: six had persistent cardiomegaly and heart failure, and four of these died within four months to eight years. From these observations, the authors conclude that idiopathic peripartum cardiomyopathy is uncommon, and that in most women with peripartum heart failure of obscure etiology, underlying chronic disease will be identified. Heart failure in these women ensues when the cardiovascular demands of normal pregnancy are amplified further by common pregnancy complications superimposed upon these underlying conditions that cause compensated ventricular hypertrophy.

A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections.

The objective of this article is to review and evaluate risks and benefits associated with the use of acyclovir in the treatment and prophylaxis of common manifestations of herpes simplex virus (HSV) infections in immunocompetent and immunocompromised patients. Information was found through a MEDLINE search using keywords: herpes simplex virus, genital herpes, herpes labialis, acyclovir and acyclovir. Selected articles were randomised, double-blind, placebo-controlled, clinical trials. 30 such trials involving 3364 persons were evaluated. All articles were reviewed by the authors and the data were extracted and summarised. In both immunocompetent and immunocompromised hosts, acyclovir therapy demonstrated a high degree of clinical efficacy. None of the studies reported statistically significant differences between acyclovir and placebo for mild or major adverse events. This evaluation found that acyclovir is both effective and well tolerated for treatment and prophylaxis of genital, oral and mucocutaneous HSV infections in immunocompetent and immunocompromised patients. In most clinical scenarios. the benefit of acyclovir exceeded any risks by a comfortable margin. The availability of acyclovir as a generic preparation further improves the benefit to cost ratio.

Semen and serum pharmacokinetics of zidovudine and zidovudine-glucuronide in men with HIV-1 infection.

STUDY OBJECTIVE: To characterize the concentration-time profiles of zidovudine and zidovudine-glucuronide in semen and serum of men infected with the human immunodeficiency-1 virus (HIV-1). DESIGN: Open-label observational study. SETTING: University-affiliated teaching hospital and research center. PATIENTS: Four asymptomatic HIV-1-infected men. INTERVENTIONS: Zidovudine administration was followed by an 8-hour intensive pharmacokinetic study on day 1. Over the next 8 days, a dose administration and timed single-sample strategy was employed to determine serum and semen concentration time profiles simultaneously. MEASUREMENTS AND MAIN RESULTS: Zidovudine and zidovudine-glucuronide concentrations were uniformly higher in semen than in serum except at 1 hour after the dose. The median area under the curve ratio (semen AUC0-48:serum AUC0-infinity) was 3.31 for zidovudine and 15.04 for zidovudine-glucuronide. CONCLUSION: Zidovudine and zidovudine-glucuronide reach high levels in seminal plasma relative to serum. The virologic, pharmacodynamic, and public health implications of distribution to this compartment require further study.

In vivo strain measurements collected using calcium phosphate ceramic-bonded strain gauges.

Identification of the strains and the strain changes caused by implants is critical to the understanding of bone remodeling and can identify design changes needed to prevent bone loss near orthopedic implants. Calcium phosphate ceramic (CPC) coated strain gauges have been developed to allow long-term in vivo strain measurements. Previously used cyanoacrylate-bonded gauges have uncharacterizable sensing accuracy because the adhesive is resorbed from the instant it is placed in vivo. In this study CPC-coated strain gauges were used to measure physiologically "normal" bone strains collected from the proximal femora of dogs at a series of gait speeds and the postmortem sensing accuracy of the gauges was evaluated. Three male dogs were surgically implanted with up to six wired CPC-coated strain gauges placed around the circumference of their proximal femora. The dogs were trained to run on a treadmill, and in vivo strain measurements were collected following a 12-week period. The animals were tetracyline labeled and then euthanized and their femora explanted. Gauges were attached with cyanoacrylate to the intact contralateral control femora in the same position as the CPC-coated gauges on the test femora. Both femora were tested in cantilever bending to assess the functionality of the gauges and quality of the CPC-bone bond. After testing, all bones were embedded, sectioned, and ground. Sections from each femur were stained with mineralized bone stain and examined with transmitted and ultraviolet light to assess bone formation. Additional sections were examined with backscattered electron microscopy to confirm bone bonding to coatings. Wired gauges attached with the CPC coatings measured strain patterns during gait at several treadmill speeds. Patterns were similar and peak strains the same over a 2-week period. Mechanical testing showed bonding of CPC-coated gauges, and histologic examination showed intimate contact between gauge coatings and bone surfaces. Further development of CPC-bonded strain gauges is expected to result in a measurement system that provides ease of placement, and consistent longer term bone strain measurements with characterizable accuracy.

A mechanical and histomorphometric analysis of bone bonding by hydroxyapatite-coated strain gages.

Identification of the strains controlling bone remodeling is important for determining ways to prevent bone loss due to load deprivation, or implant placement. Long-term monitoring of strains can potentially provide the best information. Glues are resorbed within 2-3 weeks. Two formulations of microcrystalline hydroxyapatite (HA) were used to attach strain gages to rat femora to assess their long-term in vivo strain measurement capability. Seven male rats received HA-coated gages, and 2 animals underwent a sham procedure. The gages were prepared using a published technique and placed on the antero-lateral aspect of the left femora. After 6-7 weeks, the animals were euthanized and both femora explanted. Gages were attached to the right femora with cyanoacrylate. All femora were tested in cantilever bending, then embedded, sectioned, and stained with mineralized bone stain. The undecalcified sections were examined using transmitted and ultraviolet light microscopy. Mechanical testing showed one HA formulation provided 70-100% bonding. Histology showed intimate contact between the gage and bone surface. Histomorphometry indicated increased bone activity under the gage compared to the remaining bone, the controls, and the shams. The results indicate that microcrystalline HAs bond to bone quickly and can allow long term in vivo measurements.

Use of RAPD-PCR to differentiate genetically defined lines of an intermediate host of Schistosoma mansoni, Biomphalaria glabrata.

The genetic differentiation among several laboratory-maintained pedigree snail lines of Biomphalaria glabrata (with different susceptibility phenotypes to Schistosoma mansoni infection) was assessed with the random amplified polymorphic DNA method. Out of the 20 primers tested, 2 (OPA-01 and OPA-06) gave reproducible markers with either individual or bulked DNA samples from resistant (BS-90, 10-R2, LAC-line) and susceptible (M-line) snails. Arbitrary primer, OPA-01, amplification of BS-90 DNA identified a 180-bp strain-specific fragment and a 400-bp marker in the susceptible M-line stock. In the 10-R2 and LAC snail lines, OPA-01 specific markers of 200 bp and 550 bp were identified. Amplification with primer OPA-06 identified several major strain-specific markers in the BS-90 (150 bp, 400 bp, 800 bp) and M-line (1,100 bp) snails. The heritability of the RAPD markers was evaluated in progeny snails derived from a cross between the BS-90 and M-line stocks. Results showed that markers were inherited in a dominant or codominant fashion. The 1,100-bp M-line marker was inherited in all susceptible progeny snails analyzed.

An experimental method for the application of lateral muscle loading and its effect on femoral strain distributions.

Experimental models that have been used to evaluate hip loading and the effect of hip implants on bone often use only a head load and abductor load. Anatomic considerations and in vivo measurements have lead several investigators to suggest that these models are inaccurate because they do not incorporate the loads imposed by additional muscles. The aim of this study was to evaluate the strains in the proximal and mid diaphysis of the femur for five hip loading models, one with a head load and abductor load only and four which incorporated lateral muscle loads as well. Head load to body weight load ratios were used to evaluate the physiologic accuracy of these models and strains were compared to determine the extent of strain changes as a function of model complexity. All models which incorporated additional lateral muscle loads more accurately simulated head load to body-weight load ratios than the simple abductor-only model. The model which incorporated a coupled vastus lateralis and iliotibial band load in addition to the abductor load provided the simplest configuration with a reasonable body-weight to head-load ratio.

Inflammatory cytokine expression on nasal polyps developed in allergic and infectious rhinitis.

To investigate the expression of cytokine mRNAs in nasal polyps and the role of allergy in the pathogenesis of nasal polyposis, we studied the expression of IL-4, IL-5, and IFN-gamma mRNAs using the RT-PCR and Southern blot. Nasal polyp specimens were obtained from 14 patients with infectious rhinitis and 5 patients with perennial allergic rhinitis. Turbinate mucosa specimens were obtained from 10 patients with allergic rhinitis and from 10 healthy subjects as controls. IL-4, IL-5 and IFN-gamma mRNA were expressed in most specimens of allergic turbinate mucosa. The expression of these cytokines was less frequent in normal healthy turbinate mucosa. The density ratios of IL-4, IL-5 and IFN-gamma to beta-actin were individually determined in both polyp and turbinate tissues. The density ratio for each cytokine was relatively higher in polyp tissues than in healthy turbinate mucosa; however, there was no significant difference in the density ratios determined for polyps associated with allergic rhinitis as compared with polyps associated with infectious rhinitis. These findings indicate that nasal polyposis may differ from allergic rhinitis in the mechanism by which IL-4 and IL-5 are increased. It is concluded that allergy may have an insignificant role in the development of nasal polyps.

Identification of pseudorabies virus-infected swine herds by evaluating the serostatus of boars or finishing pigs.

Data were collected from 39 Minnesota swine farms quarantined for pseudorabies virus (PRV) infection. Each herd was serologically evaluated for antibodies to PRV in the sows, boars, and finishing pigs. To identify PRV-seropositive swine herds, the Kappa statistic was used to estimate the effectiveness of evaluating the PRV serostatus of boars or of finishing pigs. Using the serostatus of all herd boars, the sensitivity (with 95% confidence interval) of identifying PRV-infected herds was 58 +/- 22%, and the specificity was 100 +/- 0%; Kappa statistic was 0.55. Using the serostatus of a representative sample of finishing pigs, the sensitivity of identifying PRV-infected herds (with 95% confidence interval) was 63 +/- 22%, and specificity was 87 +/- 23%; Kappa statistic was 0.40. The PRV serostatus of herd boars or of a representative sample of finishing pigs did not accurately reflect the PRV serostatus of the herd.

Factors associated with circulation of pseudorabies virus within swine herds.

Data were collected from 104 Minnesota swine farms quarantined for pseudorabies virus (PRV) infection. Each herd was serologically evaluated for the presence of antibodies to PRV in finishing pigs. Herd management practices, swine housing design, and disease profiles were described for each farm. Multiple logistic regression analysis was used to determine which factors were associated with circulation of PRV in the finishing pigs of farrow-to-finish farms. Sixty-seven (64%) of the herds had no serologic evidence of PRV circulation in the finishing section, whereas 37 herds (36%) contained at least one PRV seropositive finishing pig. The odds of a given finishing herd being seropositive for PRV were 2.85 times higher if the finishing pigs were housed in confinement (P = 0.01), 2 times higher if Actinobacillus (Haemophilus) pleuropneumoniae was a clinical problem in the herd (P = 0.03), 1.36 times less for each year that passed since the herd quarantine was issued (P = 0.01), 1.74 times higher if clinical signs of PRV were reported (P = 0.04), and 1.52 times higher if animal protein was included in at least one of the rations (P = 0.08).

Factors associated with the seroprevalence of pseudorabies virus in breeding swine from quarantined herds.

Strategies for the elimination of pseudorabies virus (PRV) from swine herds include test and removal, offspring segregation, and depopulation/repopulation. The prevalence of PRV in a herd is a major factor in selection of the most appropriate strategy. The purpose of the study reported here was to describe the prevalence of PRV in adult swine in PRV quarantined herds in Minnesota, and to determine herd factors associated with the seroprevalence. Questionnaires describing the health history of the herd, management practices, and design of the swine facilities were obtained from the owners of 142 quarantined herds. Blood was collected from 29 finishing pigs over the age of 4 months, up to 29 adult females, and all herd boars. Factors considered to be significant in a bivariate analysis were combined in a stepwise multiple logistic regression analysis. The prevalence of PRV-seropositive adults in each herd was bimodally distributed among the 142 herds. In 42 (30%) of the herds, none of the females tested was seropositive, which represented the lower mode. At least 90% of the adults tested were seropositive in 30 (21%) of the herds and represented the higher mode. The odds of the breeding swine of a given herd having a PRV seroprevalence of greater than or equal to 20% as compared with having a seroprevalence of less than 20% was 1.654 times higher per 50 adults in the herd, 13.550 times higher if the finishing pigs were seropositive, 2.378 times higher if sows were housed inside during gestation, and 1.481 times lower per number of years since the imposition of quarantine.(ABSTRACT TRUNCATED AT 250 WORDS)

Mucoid impaction following nasal intubation in a child with an upper respiratory infection.

We describe a case of mucoid impaction following nasotracheal intubation in a child with an upper respiratory infection that was successfully treated with a fiberoptic bronchoscope too large to pass through the endotracheal tube lumen. To the best of our knowledge, it is the first report in the anesthesia literature in which the placement of a nasal tracheal tube is implicated as the cause of the mucous obstruction. The physiologic changes that occur with anesthesia and that place patients at increased risk for this phenomenon, as well as the differential diagnosis, treatment, and prevention of this entity, are discussed.

Early case reports of dyslexia in the United States and Europe.

Current understanding of reading disabilities is rooted in the early observations of physicians dating as far back in history as the 17th century. This article reviews medical case study research from the United Kingdom, Germany, and the United States that identified characteristics, etiological factors, and treatment methods of reading disorders. The physicians involved provided rich descriptions of the personal struggles of individuals who lost the ability to read because of brain insult as well as of those who failed to achieve literacy because of reading disability. Although many of the theories that were advanced by these early researchers have not been supported by current investigations, others have been substantiated and withstand the test of time. This article also addresses the validity of case study research from an historic and current-day perspective.

Learning disabilities, employment discrimination, and the ADA.

The Americans with Disabilities Act (ADA) of 1990 was intended to prohibit discrimination against individuals with disabilities. Although the scope of this legislation is broad, there are aspects of Title I and Title II of the ADA that may be of particular interest to persons with learning disabilities who are preparing for employment. This article discusses those aspects and presents case studies to demonstrate how the ADA could potentially be applied to typical situations. Suggestions are given for individuals with learning disabilities, their parents, and teachers with regard to employment preparation in secondary and postsecondary settings.