Mental Health Needs of Adolescent and Young Adult PrEP Users in South Africa: Implications for Sexual and Reproductive Health Programming.

PURPOSE: Poor mental health is associated with sexual and reproductive health (SRH) risks, including human immunodeficiency virus (HIV) and pre-exposure prophylaxis discontinuation. Adolescents and young people (AYP) are vulnerable to HIV and depression. This paper describes the prevalence and severity of depression and associated factors in AYP accessing SRH services in South Africa. METHODS: A cross-sectional analysis of enrollment data (January 2019 to December 2021) from a cohort of individuals receiving pre-exposure prophylaxis services at eight clinics in three provinces in South Africa was conducted. Females (n = 1,074) and males (n = 231) aged 15-24 years were included. Interviewer-administered questionnaires were conducted, and the prevalence and severity of depression assessed using the Patient Health Questionnaire-9. Multivariate analysis was used to identify factors associated with depression. RESULTS: Over 40% of participants had experienced any depression symptoms (43.7% of females, 38.5% of males). For males, experiencing intimate partner violence was the only predictor of depression symptoms (adjusted odds ratio (AOR) 8.81, 95% confidence intervals (CI) 1.03-75.44). For females, living with both parents (AOR 1.70, 95% CI 1.15-2.51), having transactional sex (AOR 1.63, 95% CI 1.00-2.65), experiencing any intimate partner violence (AOR 1.96, 95% CI 1.34-2.89), and using drugs (AOR 1.78, 95% CI 1.03-3.11) were all positively associated with depression symptoms. Resilience was a protective factor against depression symptoms for both sexes (males: AOR 0.96, 95% CI 0.93-0.98; females: AOR 0.96, 95% CI 0.95-0.97). DISCUSSION: There is a high burden of depression among AYP accessing SRH services in South Africa. Mental health screening should be integrated into SRH and HIV prevention programs for AYP.

Socio-demographic and social support factors related to substance use in South African in-school adolescents: Insights from the Girls Achieve Power (GAP Year) trial in three peri-urban settings.

Background: Substance use is a significant public health problem worldwide, with consequences including violence, risky behaviours, and even death. Substance use amongst adolescents is increasing in South Africa, and limited research on frequency, risk and protective factors means that prevention interventions are difficult to design. This paper aims to describe and discuss factors associated with substance use among school-going adolescents in three peri-urban South African settings. Methods: A cross-sectional analysis was conducted using baseline data from participants in the Girls Achieve Power (GAP Year) trial. Grade 8 learners (N=2383), aged 11-18, were recruited from 26 lowest quintile public high schools in three townships: Soweto and Thembisa in Gauteng Province, and Khayelitsha in Western Cape Province. A baseline survey gathered demographic and behavioural data. Questions relevant to substance use and social support were used for this analysis. Multivariate logistic regression analyses were conducted to identify factors associated with substance use. The final variables were included in an unadjusted and adjusted logistic regression for current substance use, and a multinomial logistic regression for frequency of substance use. Results: A total of 22.5% (534) of participants indicated they had ever used substances. Being male was strongly associated with substance use (P<0.001), and less strongly with frequency of substance use. Age significantly predicted substance use, with older adolescents being more likely to engage in substance use (P<0.001); having a parent/guardian employed was negatively associated with substance use (P=0.021). Family-related social support variables were predictive of substance use. Being able to count on friends when things went wrong was predictive of lower frequency of substance use (P=0.019). Conclusions: These results can inform the targeting of prevention interventions to males and younger learners, as well as ensuring youth interventions build family and peer support to make substance use less likely and less frequent.

Improving the accuracy of sports medicine surveillance: when is a subsequent event a new injury?

The recent increased use of injury and illness surveillance programmes has the potential to greatly advance our knowledge about risk factors and treatment effectiveness. Maximising this potential requires that data be entered in a format that can be interpreted and analysed. One remaining challenge concerns whether and when an increase in symptoms should be documented within an existing injury record (eg, exacerbation) versus a new injury record. In this review, we address this challenge using the principles of the multistate framework for the analysis of subsequent injury in sport (M-FASIS). In brief, we argue that a new injury record should be documented whenever there is an increase in symptoms due to activity-related exposures that is beyond the normal day-to-day symptom fluctuations, regardless of whether the athlete was in a 'healthy state' immediately before the event. We illustrate the concepts with concrete examples of shoulder osteoarthritis, ankle sprains and ACL tears.

Short Communication: A Recombinant Variant with Increased Envelope Entry Efficiency Emerged During Early Infection of an HIV-1 Subtype C Dual Infected Rapid Progressor.

Mutations in functionally constrained sites of the HIV envelope (Env) can affect entry efficiency and are potential targets for vaccine and drug design. We investigated Du151, a dual-infected individual with rapid disease progression. At her death 19 months postinfection (mpi), she was infected with a recombinant variant, which outgrew both parental viruses. We aimed to determine whether the recombinant virus had enhanced Env entry efficiency compared to the parental viruses and to identify the functional determinant. We generated 15 env clones at 1, 2, 8, and 19 mpi. Pseudovirus carrying a recombinant Env clone (PSV clone), C18 (19 mpi), had significantly higher entry efficiency compared to the parents, suggesting that the recombinant virus had enhanced fitness. To identify the functional determinant, we compared two recombinant PSV clones (C18 and C63)-differing in entry efficiency (2-fold) and by four and three amino acids in gp120 and gp41, respectively. The increased entry efficiency of a C18-gp41 PSV chimera indicated that the three amino acids in the C18 gp41 region were involved (K658, G671, and F717). Site-directed mutagenesis of the three amino acids of C63 showed that a single amino acid mutation, R658K, increased pseudovirion entry efficiency. The introduction of R658 into two PSV clones (C1 and C18) decreased their entry efficiency, suggesting that R658 carries a fitness cost. Thus, our data suggest that a recombinant virus emerged at 19 mpi with enhanced Env entry efficiency. Therefore, K658 in gp41 could in part be a contributing factor to the increased viral load and rapid disease progression of Du151.

Improving pain management of abdominal pain in children presenting to the paediatric emergency department: a pre-post interventional study.

BACKGROUND: In 2007, the Mater Children's Hospital Emergency Department participated in the Emergency Care Pain Management Initiative funded by the National Health and Medical Research Council National Institute of Clinical Studies (NHMRC-NICS). The findings of this NHMRC-NICS research across eleven paediatric emergency departments highlighted deficits in pain management of abdominal pain. Specifically pain assessment, timeliness of analgesia, and pain management guidelines were found to be lacking. METHODS: In response to the NICS report local practice was reviewed and a pilot research project undertaken to develop a clinical guideline for the pain management of abdominal pain in children presenting to the emergency department. The guideline was developed by an expert panel and trialled using a pre and post intervention design. RESULTS: The results demonstrated improved compliance to assessment and documentation of pain scores and assimilation of the best practice principles recommended in the guideline. CONCLUSIONS: This project raised local awareness in the pain management of abdominal pain and provides baseline information for future improvement. The guideline has been trialled in the clinical setting of paediatric emergency and has the potential to improve pain management practices in children presenting to the emergency department with abdominal pain.

Shedding the load of hypertension: the proteolytic processing of angiotensin-converting enzyme.

A number of membrane proteins are enzymatically cleaved or 'shed' from the cell surface, resulting in the modulation of biological events and opening novel pharmaceutical approaches to diverse diseases by targeting shedding. Our focus has been on understanding the shedding of angiotensin-converting enzyme (ACE), an enzyme that plays a pivotal role in blood pressure regulation. The identification of novel hereditary ACE mutations that result in increased ACE shedding has advanced our understanding of the role of ACE shedding in health and disease. Extensive biochemical and molecular analysis has helped to elucidate the mechanism of ACE shedding. These findings point to the potential therapeutic role of targeting shedding in regulating tissue ACE levels in cardiovascular disease.

An angiotensin I-converting enzyme mutation (Y465D) causes a dramatic increase in blood ACE via accelerated ACE shedding.

BACKGROUND: Angiotensin I-converting enzyme (ACE) metabolizes a range of peptidic substrates and plays a key role in blood pressure regulation and vascular remodeling. Thus, elevated ACE levels may be associated with an increased risk for different cardiovascular or respiratory diseases. Previously, a striking familial elevation in blood ACE was explained by mutations in the ACE juxtamembrane region that enhanced the cleavage-secretion process. Recently, we found a family whose affected members had a 6-fold increase in blood ACE and a Tyr465Asp (Y465D) substitution, distal to the stalk region, in the N domain of ACE. METHODOLOGY/PRINCIPAL FINDINGS: HEK and CHO cells expressing mutant (Tyr465Asp) ACE demonstrate a 3- and 8-fold increase, respectively, in the rate of ACE shedding compared to wild-type ACE. Conformational fingerprinting of mutant ACE demonstrated dramatic changes in ACE conformation in several different epitopes of ACE. Cell ELISA carried out on CHO-ACE cells also demonstrated significant changes in local ACE conformation, particularly proximal to the stalk region. However, the cleavage site of the mutant ACE--between Arg1203 and Ser1204--was the same as that of WT ACE. The Y465D substitution is localized in the interface of the N-domain dimer (from the crystal structure) and abolishes a hydrogen bond between Tyr465 in one monomer and Asp462 in another. CONCLUSIONS/SIGNIFICANCE: The Y465D substitution results in dramatic increase in the rate of ACE shedding and is associated with significant local conformational changes in ACE. These changes could result in increased ACE dimerization and accessibility of the stalk region or the entire sACE, thus increasing the rate of cleavage by the putative ACE secretase (sheddase).

Who wants to be an ICH Euro billionaire?

The ICH E9 guideline on Statistical Principles for Clinical Trials is a pivotal document for statisticians in clinical research in the pharmaceutical industry guiding, as it does, statistical aspects of the planning, conduct and analysis of regulatory clinical trials. New statisticians joining the industry require a thorough and lasting understanding of the 39-page guideline. Given the amount of detail to be covered, traditional (lecture-style) training methods are largely ineffective. Directed reading, perhaps in groups, may be a helpful approach, especially if experienced staff are involved in the discussions. However, as in many training scenarios, exercise-based training is often the most effective approach to learning. In this paper, we describe several variants of a training module in ICH E9 for new statisticians, combining directed reading with a game-based exercise, which have proved to be highly effective and enjoyable for course participants.

Fine epitope mapping of monoclonal antibody 5F1 reveals anticatalytic activity toward the N domain of human angiotensin-converting enzyme.

Angiotensin I-converting enzyme (ACE, peptidyl dipeptidase, EC 3.4.15.2) is a key enzyme in cardiovascular pathophysiology. A wide spectrum of monoclonal antibodies to different epitopes on the N and C domains of human ACE has been used to study different aspects of ACE biology. In this study we characterized the monoclonal antibody (mAb) 5F1, developed against the N domain of human ACE, which recognizes both the catalytically active and the denatured forms of ACE. The epitope for mAb 5F1 was defined using species cross-reactivity, synthetic peptide (PepScan technology) and phage display library screening, Western blotting, site-directed mutagenesis, and protein modeling. The epitope for mAb 5F1 shows no overlap with the epitopes of seven other mAbs to the N domain described previously and is localized on the other side of the N domain globule. The binding of mAb 5F1 to ACE is carbohydrate-dependent and increased significantly as a result of altered glycosylation after treatment with alpha-glucosidase-1 inhibitor, N-butyldeoxynojirimycin (NB-DNJ), or neuraminidase. Out of 17 species tested, mAb 5F1 showed strict primate ACE specificity. In addition, mAb 5F1 recognized human ACE in Western blots and on paraffin-embedded sections. The sequential part of the epitope for mAb 5F1 is created by the N-terminal part of the N domain, between residues 1 and 141. A conformational region of the epitope was also identified, including the residues around the glycan attached to Asn117, which explains the sensitivity to changes in glycosylation state, and another stretch localized around the motif 454TPPSRYN460. Site-directed mutagensis and inhibition assays revealed that mAb 5F1 inhibits ACE activity at high concentrations due to binding of residues on both sides of the active site cleft, thus supporting a hinge-bending mechanism for substrate binding of ACE.

Deglycosylation, processing and crystallization of human testis angiotensin-converting enzyme.

Angiotensin I-converting enzyme (ACE) is a highly glycosylated type I integral membrane protein. A series of underglycosylated testicular ACE (tACE) glycoforms, lacking between one and five N-linked glycosylation sites, were used to assess the role of glycosylation in tACE processing, crystallization and enzyme activity. Whereas underglycosylated glycoforms showed differences in expression and processing, their kinetic parameters were similar to that of native tACE. N-glycosylation of Asn-72 or Asn-109 was necessary and sufficient for the production of enzymically active tACE but glycosylation of Asn-90 alone resulted in rapid intracellular degradation. All mutants showed similar levels of phorbol ester stimulation and were solubilized at the same juxtamembrane cleavage site as the native enzyme. Two mutants, tACEDelta36-g1234 and -g13, were successfully crystallized, diffracting to 2.8 and 3.0 A resolution respectively. Furthermore, a truncated, soluble tACE (tACEDelta36NJ), expressed in the presence of the glucosidase-I inhibitor N -butyldeoxynojirimycin, retained the activity of the native enzyme and yielded crystals belonging to the orthorhombic P2(1)2(1)2(1) space group (cell dimensions, a=56.47 A, b=84.90 A, c=133.99 A, alpha=90 degrees, beta=90 degrees and gamma=90 degrees ). These crystals diffracted to 2.0 A resolution. Thus underglycosylated human tACE mutants, lacking O-linked oligosaccharides and most N-linked oligosaccharides or with only simple N-linked oligosaccharides attached throughout the molecule, are suitable for X-ray diffraction studies.