Regional Differences in Rates of HIV-1 Viral Load Monitoring in Canada: Insights and Implications for Antiretroviral Care in High Income Countries

Background: Viral load (VL) monitoring is an essential component of the care of HIV positive individuals. Rates ofVL monitoring have been shown to vary by HIV risk factor and clinical characteristics. The objective of this studywas to determine whether there are differences among regions in Canada in the rates of VL testing of HIV-positiveindividuals on combination antiretroviral therapy (cART), where the testing is available without financial barriersunder the coverage of provincial health insurance programs.Methods: The Canadian Observational Cohort (CANOC) is a collaboration of nine Canadian cohorts of HIV-positiveindividuals who initiated cART after January 1, 2000. The study included participants with at least one year offollow-up. Generalized Estimating Equation (GEE) regression models were used to determine the effect ofgeographic region on (1) the occurrence of an interval of 9 months or more between two consecutive recordedVL tests and (2) the number of days between VL tests, after adjusting for demographic and clinical covariates.Overall and regional annual rates of VL testing were also reported.Results: 3,648 individuals were included in the analysis with a median follow-up of 42.9 months and a median of15 VL tests. In multivariable GEE logistic regression models, gaps in VL testing >9 months were more likely inQuebec (Odds Ratio (OR) = 1.72, p < 0.0001) and Ontario (OR = 1.78, p < 0.0001) than in British Columbia andamong injection drug users (OR = 1.68, p < 0.0001) and were less likely among older individuals (OR = 0.77 per10 years, p < 0.0001), among men having sex with men (OR = 0.62, p < 0.0001), within the first year of cART(OR = 0.15, p < 0.0001), among individuals on cART at the time of the blood draw (OR = 0.34, p < 0.0001) andamong individuals with VL < 50 copies/ml at the previous visit (OR = 0.56, p < .0001).Conclusions: Significant variation in rates of VL testing and the probability of a significant gap in testing wererelated to geographic region, HIV risk factor, age, year of cART initiation, type of cART regimen, being in the firstyear of cART, AIDS-defining illness and whether or not the previous VL was below the limit of detection

Factors Associated With the Frequency of Monitoring of Liver Enzymes, Renal Function and Lipid Laboratory Markers Among Individuals Initiating Combination Antiretroviral Therapy: A Cohort Study

Background As the average age of the HIV-positive population increases, there is increasing need to monitor patients for the development of comorbidities as well as for drug toxicities. Methods We examined factors associated with the frequency of measurement of liver enzymes, renal function tests, and lipid levels among participants of the Canadian Observational Cohort (CANOC) collaboration which follows people who initiated HIV antiretroviral therapy in 2000 or later. We used zero-inflated negative binomial regression models to examine the associations of demographic and clinical characteristics with the rates of measurement during follow-up. Generalized estimating equations with a logit link were used to examine factors associated with gaps of 12 months or more between measurements. Results Electronic laboratory data were available for 3940 of 7718 CANOC participants. The median duration of electronic follow-up was 3.5 years. The median (interquartile) rates of tests per year were 2.76 (1.60, 3.73), 2.55 (1.44, 3.38) and 1.42 (0.50, 2.52) for liver, renal and lipid parameters, respectively. In multivariable zero-inflated negative binomial regression models, individuals infected through injection drug use (IDU) were significantly less likely to have any measurements. Among participants with at least one measurement, rates of measurement of liver, renal and lipid tests were significantly lower for younger individuals and Aboriginal Peoples. Hepatitis C co-infected individuals with a history of IDU had lower rates of measurement and were at greater risk of having 12 month gaps between measurements. Conclusions Hepatitis C co-infected participants infected through IDU were at increased risk of gaps in testing, despite publicly funded health care and increased risk of comorbid conditions. This should be taken into consideration in analyses examining factors associated with outcomes based on laboratory parameters

How Strong is the Case for Dollarization in Central America? An Empirical Analysis of Business Cycles, Credit Market Imperfections and the Exchange Rate

In this paper, we contrast two different views in the debate on official dollarization. The Mundell (1961) framework of optimal currency areas and a model on boom-bust cycles, by Schneider and Tornell (2004), who take account of credit market imperfections prevalent in middle income countries. We highlight that the role of the exchange rate is strikingly different in the two models. While in the Mundell framework the exchange rate is expected to smooth the business cycle, the other model predicts that the exchange rate plays an amplifying role. We empirically evaluate both models for eight highly dollarized Central American economies, and find that the main benefit of official dollarization derives from avoiding a mismatch between foreign currency liabilities and domestic revenues, as well as the boom-bust episodes that are likely to follow from it. Using a new method of Cubadda (1999, 2007), we furthermore test for cyclical comovement and reject the hypothesis that the countries form an optimal currency area with the United States according to the Mundell definition

Gallid Alphaherpesvirus 2 in the Egyptian Turkeys:Molecular Characterization and Establishment of a Universal System for Phylogenetic Classification

Introduction: Gallid alphaherpesvirus 2 (GaHV-2) is a highly contagious oncogenic virus that causes Marek's disease in chickens and occasionally in turkeys. Among 100 genes identified in GaHV-2 genome, the Meq gene appears to involve viral virulence, oncogenicity, and genetic diversity. Despite the use of Meq gene sequences in phylogenetic classification of GaHV-2 strains circulating in many countries worldwide, no integrated system exists yet. Methods: Turkeys from 2 commercial Egyptian farms were presented with signs of dullness, dehydration, and emaciation. Samples prepared from the internal organs were examined by histopathology and immunohistochemistry. Pools of the internal organs were analyzed by PCR for identification of GaHV-2, avian leucosis virus, and reticuloendotheliosis virus. The Meq gene of an Egyptian strain was sequenced and analyzed in comparison to 40 reference strains for generation of a universal system for phylogenetic classification of GaHV-2 strains. Results: Gross and histopathological examination revealed grayish-white soft masses in the internal organs characterized by diffuse infiltration of pleomorphic neoplastic cells. All lymphoma cells were identified as T-lymphocytes of CD3+ phenotype. Samples of both farms were only positive for GaHV-2 by PCR. Sequence analysis of the Meq gene has classified the current turkey strain as related to the Egyptian strains identified in chicken in 2012. A universal phylogenetic system for classification of GaHV-2 strains into 4 clusters was proposed. The vaccine strains were all grouped in cluster 2, and most of the classical American strains belonged to cluster 4. Cluster 1 was further divided into 3 subclusters (1.1-1.3). Conclusion: GaHV-2 was identified in turkeys for the first time in Africa and the Middle East. Sequence analysis of the Meq gene of the Egyptian strain along with a wide array of the global strains has enabled the construction of a novel phylogenetic classification system

Complex single step skull reconstruction in Gorham’s disease - a technical report and review of the literature

Background: Gorham’s disease is a rare osteolytic disorder characterized by progressive resorption of bone and replacement of osseous matrix by a proliferative non-neoplastic vascular or lymphatic tissue. A standardized treatment protocol has not yet been defined due to the unpredictable natural history of the disease and variable clinical presentations. No single treatment has proven to be superior in arresting the course of the disease. Trials have included surgery, radiation and medical therapies using drugs such as calcium salts, vitamin D supplements and hormones. We report on our advantageous experience in the management of this osteolyic disorder in a case when it affected only the skull vault. A brief review of pertinent literature about Gorham’s disease with skull involvement is provided. Case presentation: A 25-year-old Caucasian male presented with a skull depression over the left fronto-temporal region. He noticed progressive enlargement of the skull defect associated with local pain and mild headache. Physical examination revealed a tender palpable depression of the fronto-temporal convexity. Conventional X-ray of the skull showed widespread loss of bone substance. Subsequent CT scans showed features of patchy erosions indicative of an underlying osteolysis. MRI also revealed marginal enhancement at the site of the defect. The patient was in need of a pathological diagnosis as well as complex reconstruction of the afflicted area. A density graded CT scan was done to determine the variable degrees of osteolysis and a custom made allograft was designed for cranioplasty preoperatively to allow for a single step excisional craniectomy with synchronous skull repair. Gorham’s disease was diagnosed based on histopathological examination. No neurological deficit or wound complications were reported postoperatively. Over a two-year follow up period, the patient had no evidence of local recurrence or other systemic involvement. Conclusions: A single step excisional craniectomy and cranioplasty can be an effective treatment for patients with Gorham’s disease affecting the skull vault only. Preoperative planning by a density graded CT aids to design a synthetic bone flap and is beneficial in skull reconstruction. Systemic involvement is variable in this patient’s population

Penetration enhancer-containing spanlastics (PECSs) for transdermal delivery of haloperidol: in vitro characterization, ex vivo permeation and in vivo biodistribution studies

Haloperidol (Hal) is one of the widely used antipsychotic drugs. When orally administered, it suffers from low bioavailability due to hepatic first pass metabolism. This study aimed at developing Hal-loaded penetration enhancer-containing spanlastics (PECSs) to increase transdermal permeation of Hal with sustained release. PECSs were successfully prepared using ethanol injection method showing reasonable values of percentage entrapment efficiency, particle size, polydispersity index and zeta potential. The statistical analysis of the ex vivo permeation parameters led to the choice of F1L – made of Span® 60 and Tween® 80 at the weight ratio of 4:1 along with 1% w/v Labrasol® – as the selected formula (SF). SF was formulated into a hydrogel by using 2.5% w/v of HPMC K4M. The hydrogel exhibited good in vitro characteristics. Also, it retained its physical and chemical stability for one month in the refrigerator. The radiolabeling of SF showed a maximum yield by mixing of 100 µl of diluted formula with 50 µl saline having 200 MBq of 99mTc and containing 13.6 mg of reducing agent (NaBH4) and volume completed to 300 µl by saline at pH 10 for 10 min as reaction time. The biodistribution study showed that the transdermal 99mTc-SF hydrogel exhibited a more sustained release pattern and longer circulation duration with pulsatile behavior in the blood and higher brain levels than the oral 99mTc-SF dispersion. So, transdermal hydrogel of SF may be considered a promising sustained release formula for Hal maintenance therapy with reduced dose size and less frequent administration than oral formula

Influence of employment and job security on physical and mental health in adults living with HIV: cross-sectional analysis

Background: In the general population, job insecurity may be as harmful to health as unemployment. Some evidence suggests that employment is associated with better health outcomes among people with HIV, but it is not known whether job security offers additional quality-of-life benefits beyond the benefits of employment alone. Methods: We used baseline data for 1660 men and 270 women who participated in the Ontario HIV Treatment Network Cohort Study, an ongoing observational cohort study that collects clinical and socio-behavioural data from people with HIV in the province of Ontario, Canada. We performed multivariable regression analyses to determine the contribution of employment and job security to health-related quality of life after controlling for potential confounders. Results: Employed men with secure jobs reported significantly higher mental health-related quality of life than those who were non-employed (β = 5.27, 95% confidence interval [CI] 4.07 to 6.48), but insecure employment was not associated with higher mental health scores relative to non-employment (β = 0.18, 95% CI -1.53 to 1.90). Thus, job security was associated with a 5.09-point increase on a 100-point mental health quality-of-life score (95% CI 3.32 to 6.86). Among women, being employed was significantly associated with both physical and mental health quality of life, but job security was not associated with additional health benefits. Interpretation: Participation in employment was associated with better quality of life for both men and women with HIV. Among men, job security was associated with better mental health, which suggests that employment may offer a mental health benefit only if the job is perceived to be secure. Employment policies that promote job security may offer not only income stability but also mental health benefits, although this additional benefit was observed only for men

Bias in published cost effectiveness studies: systematic review

Objective To investigate if published studies tend to report favourable cost effectiveness ratios (below $20 000,$50 000, and $100 000 per quality adjusted life year (QALY) gained) and evaluate study characteristics associated with this phenomenon. Design Systematic review. Studies reviewed 494 English language studies measuring health effects in QALYs published up to December 2001 identified using Medline, HealthSTAR, CancerLit, Current Content, and EconLit databases. Main outcome measures Incremental cost effectiveness ratios measured in dollars set to the year of publication. Results Approximately half the reported incremental cost effectiveness ratios (712 of 1433) were below$20 000/QALY. Studies funded by industry were more likely to report cost effectiveness ratios below $20 000/QALY (adjusted odds ratio 2.1, 95$50 000/QALY (3.2, 1.8 to 5.7), and $100 000/QALY (3.3, 1.6 to 6.8). Studies of higher methodological quality (adjusted odds ratio 0.58, 0.37 to 0.91) and those conducted in Europe (0.59, 0.33 to 1.1) and the United States (0.44, 0.26 to 0.76) rather than elsewhere were less likely to report ratios below$20 000/QALY. Conclusion Most published analyses report favourable incremental cost effectiveness ratios. Studies funded by industry were more likely to report ratios below the three thresholds. Studies of higher methodological quality and those conducted in Europe and the US rather than elsewhere were less likely to report ratios below $20 000/QALY