Is increased screening and early antiretroviral treatment for HIV-1 worth the investment? An analysis of the public health and economic impact of improvement in the UK.

OBJECTIVES: Early treatment of HIV-1 infection at all CD4 levels has demonstrated clinical and public health benefits. This analysis examined the costs, health outcomes, and cost-effectiveness of increased HIV-1 screening and early treatment initiation in the UK. METHODS: A Markov model followed theoretical cohorts of men who have sex with men (MSM), heterosexuals, and people who inject drugs (PWID) with initially undiagnosed HIV-1 infection over their remaining lifetimes. The analysis examined increased HIV-1 screening (resulting in 10-50% improvements in diagnosis rates) versus current screening in sexual health services (SHS) and other settings, with all individuals initiating treatment within 3 months of diagnosis. Health status was modelled by viral load and CD4 cell count as individuals progressed to diagnosis and treatment. Individuals accrued quality-adjusted life-years (QALYs), incurred costs for screening and HIV-related clinical management, and were at risk of transmitting HIV-1 infection to their partners. Input parameter data were taken primarily from UK-specific published sources. All outcomes were discounted at 3.5% annually. RESULTS: The model estimated that increased screening and early treatment resulted in fewer onward HIV transmissions, more QALYs, and higher total costs. For SHS, incremental cost-effectiveness ratios (ICERs) for heterosexuals (~£22 000/QALY gained) were within typical UK willingness-to-pay thresholds and were well below these thresholds for MSM (~£9500/QALY gained) and PWID (~£6500/QALY gained). Sensitivity analysis showed that model results were robust. CONCLUSIONS: Increased HIV-1 screening and early treatment initiation may be a cost-effective strategy to reduce HIV transmission and improve health for MSM, heterosexuals, and PWID in the UK.

C5a is important in the tubulointerstitial component of experimental immune complex glomerulonephritis.

Interstitial injury is the hallmark of glomerulonephritis which is progressing to end-stage renal disease (ESRD). In humans and experimental animals, we have shown that interstitial disease is accompanied by up-regulation of complement components in tubular epithelial cells. Glomerulonephritis was induced in mice by the intraperitoneal injection of horse spleen apoferritin (HSA) and lipopolysaccharide (LPS). In addition to wild-type C57/B6 mice, animals in which the C5a receptor had been deleted (C5aR KO) were used. Animals were killed after 3 or 6 weeks, and kidneys harvested. At three weeks, both groups had evidence of mild mesangial matrix expansion and increased cellularity; there were no crescents, sclerotic lesions, or interstitial disease. At six weeks, glomerular lesions were advanced, but identical in the two groups. Both groups had evidence of an identical pattern of C3 gene expression in the tubular epithelium by in situ hybridization. There was a marked difference, however, in the extent of interstitial injury. Wild-type animals had significantly greater numbers of infiltrating interstitial cells, greater expansion of the peritubular space, more tubular atrophy, and more apoptotic tubular cells than did C5aR KOs. The anaphylotoxic fragment of C5, C5a, is not likely to be important in the glomerular component of this model of progressive glomerulonephritis. On the other hand, the interstitial component is markedly attenuated in knockout animals. These data support a role for complement in the interstitial component of this glomerulonephritis model. They are consistent with our hypotheses of a role for complement in the progression of some forms of glomerulonephritis to ESRD.

C1 inhibitor: analysis of the role of amino acid residues within the reactive center loop in target protease recognition.

Previous analysis of a naturally occurring C1 inhibitor P2 mutant (Ala(443)-->Val) indicated a role for P2 in specificity determination. To define this role and that of other reactive center loop residues, a number of different amino acids were introduced at P2, as well as at P6 (Ala(439)) and P8'/9' (Gln(452)Gln(453)). Ala(439)-->Val is a naturally occurring mutant observed in a patient with hereditary angioedema. Previous data suggested that Gln(452)Gln(453) might be a contact site for C1s. Reactivity of the inhibitors toward target (C1s, C1r, kallikrein, beta factor XIIa, and plasmin) and nontarget proteases (alpha-thrombin and trypsin) were studied. Substitution of P2 with bulky or charged residues resulted in decreased reactivity with all target proteases. Substitution with residues with hydrophobic or polar side chains resulted in decreased reactivity with some proteases, but in unaltered or increased reactivity with others. Second order rate constants for the reaction with C1s were determined for the mutants with activities most similar to the wild-type protein. The three P2 mutants showed reductions in rate from 3.35 x 10(5) M(-1)s(-1) for the wild type to 1.61, 1.29, and 0.63 x 10(5) for the Ser, Thr, and Val mutants, respectively. In contrast, the Ala(439)-->Val and the Gln(452)Gln(453)-->Ala mutants showed little difference in association rates with C1s, in comparison with the wild-type inhibitor. The data confirm the importance of P2 in specificity determination. However, the P6 position appears to be of little, if any, importance. Furthermore, it appears unlikely that Gln(452)Gln(453) comprise a portion of a protease contact site within the inhibitor.

Effects of entorhinal cortex lesions on sensory integration and spatial learning.

BACKGROUND: The entorhinal cortex provides sensory information to the hippocampus for memory and learning. Damage to the entorhinal cortex is common in patients who experience traumatic brain injury, stroke, and Alzheimer's disease. Entorhinal damage is assumed to interfere with sensory integration; however, substantive knowledge of behavioral patterns is lacking. OBJECTIVES: To describe specific behavioral deficits associated with entorhinal cortex injury related to special senses identification, sensory integration, and spatial learning. METHOD: Adult male rats received bilateral entorhinal cortex damage (n = 19) or sham surgery (n = 11) with a subset randomized to participate in special senses identification, exploration, and sensory integration testing. Spatial learning was examined using a water maze. RESULTS: Lesion and control animals were similar in special senses identification testing. Sensory integration was markedly impaired in lesion animals over 3 days for all integration tasks; however, travel deficit persisted for 4 days. By day 5 sensory integration ability was equal. Lesion animals were significantly impaired across all days of spatial learning for swim time (p = .0001) and directional heading error (p = .03). Control animals exposed to sensory testing demonstrated significantly more efficient learning (p = .005) on swim days 2 and 3 versus control animals not exposed to sensory testing. CONCLUSIONS: Early and prolonged behavioral changes are evident following entorhinal cortex damage including sensory integration deficits and persistent spatial learning impairment.

The C5a receptor is expressed by human renal proximal tubular epithelial cells.

The C5a receptor is expressed by a variety of cell types. These studies demonstrate by immunohistochemistry that the receptor is present on the surface of proximal and distal tubular epithelial cells from normal kidney. In addition, the receptor was detected on transitional epithelial cells of the ureter and bladder. Primary proximal tubular cultures and a proximal tubular cell line both also expressed the C5a receptor, as demonstrated by immunofluorescence and by FACS analysis. The presence of mRNA encoding the receptor was confirmed by reverse transcriptase-polymerase chain reaction analysis. As opposed to its effect on glomerular mesangial cells, the receptor did not mediate a proliferative response by the proximal tubular cells. C5a also did not enhance the synthesis/secretion of transforming growth factor-beta 1, monocyte chemoattractant protein-1, platelet-derived growth factor-AB or tumour necrosis factor-alpha by cultured proximal tubular cells. Therefore, although the C5a receptor clearly is expressed by proximal tubular cells, clarification of its functional relevance on this cell type awaits further studies.

Neck mass caused by an intraluminal jugular paraganglioma.

Paragangliomas can develop in a number of head and neck sites, the most common being the carotid body paragangliomas and glomus jugulare tumours. This is a case of a paraganglioma confined entirely within the lumen of the jugular vein.

Mechanisms of traumatic brain injury: biomechanical, structural and cellular considerations.

Traumatic brain injury (TBI) is a public health problem of great concern, because it affects more than 2 million individuals each year. TBI occurs as a result of motor vehicle crashes, falls, and sports-related events. Biomechanical mechanisms occurring at the time of the injury initiate primary and secondary injuries that evolve over several days. In this article the relationship between an blunt injury event and the subsequent damage produced is addressed. Mechanisms of brain injury from biomechanics to cellular pathobiology are presented. Primary and secondary injuries are differentiated, and specific focal and diffuse clinical syndromes are described. Cellular mechanisms responsible for injury are also addressed, because they provide the unifying concepts across the many clinical syndromes so often discussed separately in reviews of traumatic brain injury.

Cognitive impairments following traumatic brain injury. Etiologies and interventions.

Brain injury is a dynamic process that continues for weeks. Recovery is also a lengthy process, proceeding in overlapping stages along with injury. The outcome for many patients with TBI is an inability to fully participate in life events because of cognitive impairments. Physiologic responses throughout the injury and recovery are punctuated by neuroprotective and neuroplastic events. The time course of these injury and recovery activities requires that medical and nursing therapies are targeted across the trajectory of injury as damage and recovery processes are occurring. Prevention of secondary injury using medical and nursing strategies should be of paramount importance. Altering the environment by providing meaningful yet novel sensory stimulation may enhance plasticity and lead to reorganization of structures that support cognitive processes. Administration of neuroprotective agents in an effort to control damage from neurochemical processes should proceed as these agents become approved for clinical use. Active participation in rehabilitation programs and neuropsychologic testing provide additional avenues for identifying and addressing cognitive impairments. The complex relationship between injury and cognitive impairment is slowly being unraveled. Through an understanding of the brain structures and networks associated with information processing as well as the pathophysiologic consequences of brain injury, critical care nurses can design evidence-based regimens of care that preserve cognitive function and result in improvement of long-term cognitive outcomes and fuller participation in everyday life activities.

The promoter of the C1 inhibitor gene contains a polypurine.polypyrimidine segment that enhances transcriptional activity.

The C1 inhibitor (C1INH) promoter is unusual in two respects: 1) It contains no TATA sequence, but instead contains a TdT-like initiator element (Inr) at nucleotides -3 to +5; 2) it contains a polypurine.polypyrimidine tract between nucleotides -17 and -45. Disruption of the Inr by the introduction of point mutations reduced promoter activity by 40%. A TATA element inserted at nucleotide -30 in the wild-type promoter and in promoter constructs containing the mutated Inr led to a 2-fold increase in basal promoter activity. Previous studies suggested that the potential hinged DNA-forming polypurine.polypyrimidine tract might be important in the regulation of C1INH promoter activity. The present studies indicate that this region is capable of such intramolecular triple helix formation. Disruption of the polypurine.polypyrimidine sequence by substitution of 5 of the 23 cytosine residues with adenine prevented triple helix formation. Site-directed mutagenesis experiments demonstrate that the regulation of promoter activity is independent of hinged DNA-forming capacity but requires an intact AC box (ACCCTNNNNNACCCT) or the overlapping PuF binding site (GGGTGGG). The C1INH gene also contains a number of potential regulatory elements, including an Sp-1 and an hepatocyte nuclear factor-1 binding site and a CAAT box. The role of these elements in regulation of the C1INH promoter was examined. Elimination of the hepatocyte nuclear factor-1 site at nucleotides -94 to -81 by truncation reduced the activity of the promoter by approximately 50%. Similarly, site-directed mutations that disrupt this site reduce promoter activity by 70%.

Cultured human glomerular mesangial cells express the C5a receptor.

BACKGROUND: While the association of complement activation and glomerulonephritis has been recognized for decades, the pathogenic mechanisms of complement-mediated glomerular damage are incompletely understood. Expression of the C5a receptor in the kidney suggests that C5a could play a direct role in initiating or promoting glomerulonephritis. METHODS: Expression of the C5a receptor by cultured human glomerular mesangial cells (HGMC) was examined by immunofluorescence, by FACS analysis and by reverse transcriptase-polymerase chain reaction (RT-PCR). Potential mitogenic effects were examined by analysis of neutral red dye uptake after treatment with recombinant C5a (rC5a). The production of cytokines [interleukin-1 (IL-1), interleukin-8 (IL-8), and monocyte chemoattractant protein-1 (MCP-1)] and growth factors [transforming growth factor-beta (TGF-beta) and platelet-derived growth factor (PDGF-AB)] by mesangial cells stimulated with rC5a was examined by ELISA of cell culture supernatants. RESULTS: Expression of the C5a receptor by the cultured HGMC was demonstrated by both immunofluorescence and FACS. The presence of mRNA encoding the receptor was confirmed by RT-PCR. Treatment of HGMC in vitro with rC5a resulted in mild cellular proliferation. No IL-1 was detected despite stimulation with up to 100 nM rC5a. Concentrations of IL-8 and TGF-beta did not increase beyond basal levels in control samples at any level of stimulation. Mean MCP-1 concentrations and PDGF-AB concentrations increased by 40% and 70% above control values 48 hours post-stimulation (P = 0.01 and P = 0.003, respectively). CONCLUSIONS: These data indicate that the C5a receptor is expressed on HGMC in vitro, and may play a role in mediating glomerular injury by promoting cellular proliferation and the production of cytokines and growth factors.

Regulation of C1 inhibitor synthesis.

The primary biologic roles of C1 inhibitor (C1-INH) are the regulation of activation of the classical complement pathway and of the contact system of kinin formation. Heterozygosity for deficiency or dysfunction of C1-INH results in hereditary angioedema (HAE). This deficiency results in loss of homeostasis with unregulated complement and contact system activation. Due to the consequent C1-INH consumption, plasma levels of C1-INH in patients with HAE are decreased below 50% of normal. In addition, diminished synthesis contributes to the lowered levels in some patients. The hepatocyte is the primary source of C1-INH, although a number of other cell types, including peripheral blood monocytes, microglial cells, fibroblasts, endothelial cells, the placenta, and megakaryocytes also synthesize and secrete the protein both in vivo and in vitro. Interferon-gamma and alpha (IFN), colony stimulating factor-1, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) all induce C1-INH synthesis in a variety of cell types. The IFN-response elements in the 5'-flanking region and in the first intron have been partially characterized, as have several of the promoter elements that direct basal transcription of the gene. However, although androgen therapy, in vivo, results in an increase in C1-INH plasma levels, a direct effect of androgens on C1-INH synthesis has not been convincingly demonstrated. Although the C1-INH gene contains a potential glucocorticoid/androgen response element, this element does not appear to respond to androgen. Continued analysis of the transcriptional regulation of the C1-INH gene may lead to new approaches to therapy of HAE.

Role of the P2 residue of complement 1 inhibitor (Ala443) in determination of target protease specificity: inhibition of complement and contact system proteases.

A dysfunctional C1 inhibitor (C1 INH) from a family in whom the propositus presented with systemic lupus erythematosus but without angioedema previously was shown to have diminished inhibitory activity toward isolated C1r and C1s, and intact C1. The mutation was identified as replacement of Ala443 (P2) with Val. This study further analyzed the reactivity of this mutant and characterized two mutants with Ser or Asp at this position. Ser at P2 does not interfere with binding of target proteases. However, the mutant with Asp at this position is unable to bind C1r and beta factor XIIa, and also has a decreased rate of reaction with C1s and kallikrein. Therefore, alteration of polarity alone had no effect on binding, while a bulky and/or charged side chain was not tolerated. Although defective in inhibition of C1r and C1s, the P2 A-->V mutant had acquired the ability to complex with trypsin. It also completely retained the ability to complex with kallikrein and factor XIIa. None of the 10 individuals expressing this mutant protein has ever had angioedema. This observation, combined with normal inhibition of contact system proteases and defective inhibition of complement proteases, suggests that angioedema is caused by bradykinin generated from contact system activation.

Molecular defects in hereditary angioneurotic edema.

Thirty-eight previously unreported, unrelated patients with hereditary angioneurotic edema were studied, and each was found to have a single mutation in the C1 inhibitor gene. On the basis of serine protease inhibitor crystal structure, these and published mutations affect critical domains in the reactive center loop, alpha-helices A, B, C, E, and F, and beta-sheets A and C. Almost all mutations, other than in the reactive center loop, occur at residues that are highly conserved among serine protease inhibitors, and the others are likely to interfere with molecular movement. These mutations begin to identify residues critical for molecular function of the C1 inhibitor molecule.

Retinoic acid increases cellular retinol binding protein II mRNA and retinol uptake in the human intestinal Caco-2 cell line.

Cellular retinol binding protein II (CRBPII) is an abundant small intestinal protein that facilitates vitamin A trafficking and metabolism. The magnitude of retinol uptake and metabolism correlate to CRBPII levels in the human intestinal Caco-2 cell line. To investigate the importance of retinoic acid receptor response elements in the promoter of the CRBPII gene, retinoic acid regulation of CRBPII expression and vitamin A absorption was studied in differentiated Caco-2 cells. All-trans- or 9-cis-retinoic acid increased CRBPII mRNA levels two- to threefold. This was associated with a 50% increase in retinol absorption. Retinoic acid receptor beta and apolipoprotein A1 regulatory protein-1, two nuclear receptors that bind to the CRBPII promoter, were also induced, whereas other retinoid and orphan receptors were not. Thus, retinoic acid may regulate CRBPII expression directly or by selectively changing levels of nuclear receptors or other factors. These studies are the first to demonstrate that retinoic acid can modulate endogenous CRBPII mRNA levels and retinol absorption in Caco-2 cells and suggest that human intestinal vitamin A absorption may be regulated by retinoids.

Syncytium formation induced by human immunodeficiency virus type 1 isolates correlates with affinity for CD4.

Different strains of human immunodeficiency virus type 1 (HIV-1) show considerable divergence in genetic content and biological properties. One property that has been closely correlated with clinical prognosis is the ability to induce syncytia formation in susceptible cells. This ability had been correlated with the V3 loop sequence of major envelope glycoprotein, gp120, but recent reports have questioned this connection. We investigated the contributions of different regions of the env gene to syncytia induction using chimeric viruses that contain part of the genome of a strain that lacks this ability (HIV-1(Ba-L)) within the genome of a virus that can form syncytia (HIV-1(HXB-2)). When tested in two cell lines susceptible to both parental viruses, as well as in primary cells, these chimeric viruses demonstrated that the ability to induce syncytia formation was determined by regions of env outside the V3 loop, which encompass residues that contribute to the binding of CD4 by gp120. Further investigation failed to show any difference in the expression of gp120 on the cell surface or cell adhesion molecules by cells infected with SI or NSI variants that would explain the observed differences in the ability to form syncytia. Assays of relative affinity for CD4 indicated that gp120 from SI variants showed a significantly higher affinity for CD4 than gp120 from NSI variants. These observations suggest that areas of the HIV-1 env gene contributing to the CD4 binding site may also contribute to the determination of syncytium-inducing (SI) and non-syncytium-inducing (NSI) phenotypes.

Characterization of the IFN-gamma-responsive element in the 5' flanking region of the C1 inhibitor gene.

Treatment of a variety of cell lines with IFN-gamma leads to enhanced synthesis and secretion of C1 inhibitor (C1inh). The induction of C1inh synthesis by IFN-gamma is primarily regulated at the transcriptional level, and is controlled by elements in the 5' flanking region and the first intron of the C1inh gene. Hep3B cells transfected with reporter constructs containing truncated segments between -738 and -81 of the 5' flanking region and stimulated with IFN-gamma expressed increased levels of chloramphenicol acetyl transferase. These data as well as the data obtained from studies using constructs with mutated IFN-gamma-activated sequence (GAS) indicate that the most proximal GAS element (GAS 4) that mapped to nucleotides -126 to -118 is responsible for this IFN-gamma responsiveness. Electrophoretic mobility shift assays using GAS 4 yielded a single band that appeared within 5 min after stimulation with IFN-gamma. In competition experiments, both GAS 4 and consensus GAS probes, but not a mutated GAS probe, competed for the GAS binding protein present in Hep3B and U-937 cell extracts. The identity of the GAS binding protein was confirmed using anti-STAT-1alpha Abs in supershift assays. The results indicate that STAT-1alpha binds to GAS 4, which is the primary element in the 5' flanking region responsible for IFN-gamma induction of the C1inh gene.

Resistance of human immunodeficiency virus type 1 to neutralization by natural antisera occurs through single amino acid substitutions that cause changes in antibody binding at multiple sites.

The ability of human immunodeficiency virus type 1 (HIV-1) to replicate in the presence of strong immune responses to the virus may be due to its high mutation rate, which provides envelope gene variability for selection of neutralization-resistant variants. Understanding neutralization escape mechanisms is therefore important for the design of HIV-1 vaccines and our understanding of the disease process. In this report, we analyze mutations at amino acid positions 281 and 582 in the HIV-1 envelope, where substitutions confer resistance to broadly reactive neutralizing antisera from seropositive individuals. Neither of these mutations lies within an antibody-binding site, and therefore the mechanism of immune escape in both cases is by alteration of the shape of the envelope proteins. The conformation of the CD4-binding site is shown to be critical with regard to presentation of other discontinuous epitopes. From our analysis of the neutralization of these variants, we conclude that escape from polyclonal sera occurs through alterations at several different epitopes, generally resulting from single amino acid substitutions which influence envelope conformation. Experiments on a double mutant showed that the combination of both mutations is not additive, suggesting that these variants utilized alternate pathways to elicit similar alterations of the HIV-1 envelope structure.

Antibody to C1-inhibitor in a patient receiving C1-inhibitor infusions for treatment of hereditary angioneurotic edema with systemic lupus erythematosus reacts with a normal allotype of residue 458 of C1-inhibitor.

Patients with hereditary C4 deficiency are likely to have severe lupus erythematosus. A patient with hereditary angioneurotic edema (HANE) and systemic lupus erythematosus (SLE) had a chronic deficiency in C4 because the hereditary deficiency in C1-inhibitor allowed the C1 in her serum to become activated and then inactivate C4. An attempt was made to repair the C4 deficiency as well as the deficiency in C1-inhibitor by giving infusions of human C1-inhibitor in the hope of inducing remissions of both HANE and SLE. During treatment, antibody to C1-inhibitor developed in the patient; this cleared when the infusions were stopped. During subsequent treatment with danazol alone, measurable C1-inhibitor developed in the patient's serum, but levels of C4 were never significantly increased. Antibody to normal C1-inhibitor was not expected to develop in the patient because she is heterozygous for this autosomal dominant trait. A normal allotype (VAL or MET 458), which would have been in the preparation used but which the patient does not synthesize because she can produce only one allotype (MET 458), appears to have been immunogenic. The antibody isolated from the patient's serum reacted with C1-inhibitor from a normal individual known to be homozygous for 458-VAL but not with one from a homozygote for MET-458.