Association between high body mass index and adverse birth outcomes by HIV and ART status in Cape Town, South Africa

Background: Tested independently, studies report that obesity and HIV infection and/or ART use in pregnancy are associated with adverse birth outcomes. However, there is limited data on the combined impact of these maternal factors on adverse birth outcomes. Given the high prevalence of obesity and HIV infection in Sub-Saharan Africa (SSA), understanding these associations is important. This study examined the association of the double burden of high maternal body mass index and HIV infection/ART use in pregnancy with adverse birth outcomes. Methods: Part A of this mini-dissertation presents the study protocol which outlines the rationale, aim and objectives of the study; the research methodology, analysis plan and ethical considerations. Part B is the literature review of studies conducted in SSA which investigated the relationship between BMI and HIV infection and adverse birth outcomes of interest. Part C is the journal-formatted manuscript which presents the results and discussion of the study findings in relation to other scholars. The referencing style used for the whole thesis is Vancouver as required by the journal chosen for the formatting of the manuscript. We used data collected from a large observational Prematurity Study that enrolled HIV-infected and HIV-uninfected women seeking antenatal care at Gugulethu MOU in Cape Town between April 2015 and October 2016. A subset of HIV-infected women who booked early (≤24weeks) was prospectively followed through delivery and was used to study gestational weight gain (GWG) and adverse birth outcomes. Data was obtained from review of medical records and study questionnaires. Logistic regression was used to compare birth outcomes by BMI status: preterm delivery (PTD), low/high birthweight (LBW/HBW) and small/large gestational age (SGA/LGA) between HIV-uninfected and -infected women; and between HIV-infected women who initiated ART before pregnancy and those who initiated ART during pregnancy. Using the subset of HIV-infected women who booked early (≤24weeks), we compared the adverse birth outcomes between low, adequate and high GWG. Results: Of the 2779 participants included in the analysis, 20% had normal BMI, 29% were overweight, 51% were obese and 39% were HIV-infected. Overall, there was no association between obese BMI and PTD (aOR 1.06, 95% CI 0.75-1.49). Instead, obese BMI was negatively associated with LBW (aOR 0.53; CI: 0.39-0.72) and SGA infants (aOR 0.55, 95% CI 0.41-0.75) compared to normal BMI women. Stratifying by HIV infection showed similar results for LBW (aOR 0.54; CI: 0.35-0.83) and SGA (aOR 0.60, 95% CI 0.38-0.94) in obese HIV-infected women compared to corresponding women with normal BMI. However, comparison of obese HIV-uninfected and obese HIV-infected women showed a higher incidence of LBW and SGA infants in obese HIV-infected women (12% vs 8%). The association of obese BMI and LBW and SGA in HIV-infected women did not differ by timing of ART initiation. In terms of HBW and LGA, overall, obese BMI was positively associated with HBW (aOR 2.00; CI: 1.13-3.57) and LGA infants (aOR 1.98, 95% CI 1.40-2.80) compared to normal BMI women. Stratifying by HIV infection also showed a positive association between obese BMI and HBW (aOR 2.54; CI: 1.17-5.53) and LGA (aOR 2.30; CI: 1.46-3.62) in HIV-uninfected women. Although a similar positive association was also obtained in obese HIV-infected women, the strength of this association was weaker for both HBW (aOR 1.41; CI: 0.59-3.34) and LGA (aOR 1.58; CI: 0.91-2.72). When the analysis was restricted to HIV-infected women by timing of ART initiation we found that obese women who initiated ART during pregnancy had 3-fold likelihood of having LGA infants (aOR 3.26; CI: 1.32-8.09) and those who initiated ART before pregnancy had a reversed effect (aOR 0.87; CI: 0.43-1.78) compared to respective normal BMI women. However, restricting the analysis to obese HIV-infected women only revealed a counter effect of the two conditions where the frequencies of both LGA and SGA are high. Abnormal gestational weight gain had no association with PTD, LBW, HBW and SGA. However, we showed that GWG lower than the IOM recommended values reduced the likelihood of having LGA infants (aOR 0.29; CI: 0.12-0.70) compared to adequate GWG. Conclusions: Obese HIV-infected women appear to be cushioned by their BMI against LBW and SGA when compared to normal BMI. However, comparison of these outcomes amongst women who are either obese or HIV-infected reveal a higher burden of both SGA and LGA infants in obese HIV-infected women, regardless of ART initiation status

The effects of plant-derived oleanolic acid on kidney function in male Sprague-Dawley rats and, in cell lines of the kidney and liver.

Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Westville, 2012.Adverse effects and increasing cost of therapeutic drugs have renewed an interest in the use of medicinal plant products for the treatment of a variety of chronic disorders. One such bioactive plant-derived compound is a pentacyclic triterpenoid, oleanolic acid (3ß-hydroxy-olea-12-en-28- oic acid, OA) present in herbs. OA possesses a variety of pharmaceutical activities and of interest in this study are the anti-diabetic properties. Diabetes is associated with disorders grouped as microvascular (retinopathy and nephropathy) and macrovascular (atherosclerotic) complications. Accordingly, this study further investigated the potential of OA in diabetes management by studying the effects of this triterpene on kidney function as well as proximal tubular Na+ handling in an effort to identify the site of action of OA. Furthermore, the study evaluated the effects of OA in kidney and liver cell lines to establish whether this triterpene exhibits any toxicity in these organs. OA was extracted using a previously validated protocol in our laboratory. Briefly, dried flower buds of Syzygium aromaticum were soaked in dichloromethane overnight, thereafter in ethyl acetate to obtain ethyl acetate solubles which contained a mixture of OA/ursolic and maslinic acid (MA). OA/MA mixture was subjected to column chromatograph and pure OA was obtained through recrystallization in methanol. The absolute stereostructure of OA was elucidated using 1H and 13C NMR spectroscopy and was comparable to previously reported data. In kidney function studies, various doses of OA (30, 60, 120 mg/kg, p.o.) were administered to male Sprague-Dawley rats twice (8h apart) every third day for five weeks. Rats administered deionised water served as controls. Measurements of body weight, food and water intake, blood pressure, Na+, K+, Cl-, urea and creatinine were taken 24 h from dosing. Renal clearance studies investigated the influence of OA on Na+ handling in the proximal tubule of anaesthetized rats using lithium clearance. Animals were given water with lithium (12mmol/l) for 48 hours following which they were anaesthetized and cannulated using a previously validated standard protocol that has been reported from our laboratories. After a 3½ h equilibration, animals were challenged with hypotonic saline for 4 h of 1 h control, 1½ h treatment and 1½ h recovery periods. OA was added to the infusate during the treatment period. In vitro effects of various OA concentrations (5, 10, 20, 40, 80 μmol/l) were investigated in HEK293, MDBK and HepG2cell lines. Cells were exposed to OA for 24, 48 and 72 h, thereafter, 3-4,5 dimethylthiazol-2-yl- 2,5diphenyltetrozolium bromide (MTT) and single cell gel electrophoresis (comet) assays were conducted. All data are presented as means ±SEM. OA significantly (p<0.05) increased urinary Na+ output from week 2 until the end of the experimental period in a dose independent manner. However, this OA-evoked natriuresis was not reflected in plasma collected at the end of the experiment as there was no change in plasma Na+ concentrations compared with control animals at the corresponding time. OA administration had no significant influence on K+ and Cl- excretion rates throughout the experiment. However, OA significantly (p<0.05) reduced plasma creatinine concentration with a concomitant increase in glomerular filtration rate (GFR). Furthermore, OA administration significantly (p<0.05) decreased mean arterial pressure from week 2 until the end of the experimental period. Intravenous infusion of OA at 90 ug/h for 1 ½ h induced a marked increase in urinary excretion rates of Na+. This increase was accompanied by concomitant increase in FENa proximal and FENa distal and FELi which persisted until the end of the experiment without any apparent changes in GFR. The cell viabilities of HepG2, HEK293 and MDBK cell lines were significantly increased after 24 h exposure, however, the viabilities of all the three cell lines dropped after 72 h exposure to values that did not achieve statistical significance in comparison to the respective controls. In addition, all OA-treated cells in the comet assay had intact DNA after exposure for 24, 48 and 72 h. Hence, the decrease in viability that was observed in the MTT assay after 72 h exposure could probably be attributed to the depletion of nutrients in the culture medium. The results of the present study, apart from confirming our previous observations of the natriuretic effects of OA in rats, indicate that this effect is in part mediated via the inhibition of proximal tubular Na+ reabsorption and increased Na+ secretion. We speculate that this increased Na+ secretion could have been due to increased tubular function and not to the toxicity of OA as indicated by MTT and comet assays. These findings suggest that OA does not exhibit toxicity in the kidney and the liver

Mechanisms of cardiovascular effects of oleanolic acid and related synthetic oleanane derivatives : an experimental study.

Ph. D. University of KwaZulu-Natal, Durban 2014.Introduction Despite the various conventional treatments that are available to treat hypertension, this disease continues to be globally responsible for approximately 9.4 million deaths each year. The high mortality can partly be attributed to side effects of available drugs or to the inaccessibility of current synthetic drugs to communities from poor socioeconomic background because of their relative high cost. This problem has resulted in a growing interest in the use of medicinal plant products because they are considered to be cheap, believed to possess few side effects and are easily accessible to the general population in developing countries. Although traditional herbal remedies are widely used in Africa for the management of various disorders including cardiovascular diseases, very little reliable data is available on their therapeutic and pharmacological effects. In search for plants with therapeutic properties for the treatment of hypertension and complications, our laboratory has scientifically evaluated several plant species. In particular, we have isolated Syzygium spp-derived triterpenes and focused on the therapeutic effects of oleanolic acid (OA) and maslinic acid (MA). In the present study, we investigated the effects of Syzygium aromaticum-derived OA and related synthetic derivatives on arterial pressure and evaluated the underlying mechanisms in Wistar, spontaneously hypertensive rats (SHR) and Dahl salt-sensitive (DSS) animals. Materials and methods OA was extracted from dried flower buds of Syzygium aromaticum using a previously validated protocol in our laboratory. Oleanolic acid methyl ester (Me-OA) and a brominated derivative of OA (Br-OA) were synthesised according to methods described by Fu and Gribble. The structures of extracted OA and synthesised derivatives were confirmed using 1H and 13C nuclear magnetic resonance (NMR) spectroscopy and were comparable to previously reported data. Acute renal clearance studies investigated the influence of OA and derivatives on mean arterial pressure (MAP) and Na+ handling in the proximal tubule of anaesthetised Wistar rats using lithium clearance. Animals were given water with lithium (12 mmol L-1) for 48 hours following which they were anaesthetised and cannulated using a previously validated standard protocol that has been reported from our laboratories. After a 3.5 h equilibration, animals were challenged with hypotonic saline for 4 h of 1 h control, 1.5 h treatment and 1.5 h recovery periods. OA, Me-OA and Br-OA were added to the infusate during the treatment period followed by measurements of arterial pressure, fluid and electrolyte handling. Sub-chronic study experiments were restricted to OA because of the low amounts of synthetic derivatives obtained during the synthetic studies to prepare the derivatives. Various doses of OA (30, 60, 120 mg kg-1, p.o.) were administered to separate groups of male Wistar, SHR and DSS rats twice (8 h apart) every third day for nine weeks. Rats given dimethyl sulphoxide (DMSO)-saline (3 mL kg-1, p.o.) acted as untreated controls. Mean arterial pressure (MAP) was monitored every third consecutive day using non-invasive tail cuff method with photoelectric sensors. Measurements of body weight, food and water intake, Na+, K+, Cl-, urea and creatinine were taken 24 h after dosing. At the end of this 9 week study, the cardiac, renal and hepatic tissues harvested from hypertensive animals were evaluated for oxidative status by measuring malonyldialdehyde (MDA, lipid peroxidation marker) and antioxidant enzymes; superoxide dismutase (SOD) and glutathione peroxidase (GPx). In addition, we evaluated the effects of OA and derivatives on aldosterone and arginine vasopressin (AVP) secretion on plasma samples from both sub-chronic and acute experimental settings. Additional Ex vivo studies to unravel the mechanisms of action of OA and derivatives were carried out in isolated ventricular cardiomyocytes and arteries. Measurements of cell shortening and Ca2+ currents were done in cells isolated from Wistar and DSS animals using edge detection and whole cell patch clamp techniques, respectively. Isometric tension measurements were done in endothelium-intact and denuded aortic rings and mesenteric arteries of Wistar and DSS rats. The influence of indomethacin (INDO), N-nitro-L-arginine methyl ester (L-NAME), glibenclamide (Gli) and 4-aminopyridine (AP) on the effects of OA and derivatives was investigated. Results The purity of the plant-derived OA was approximately 98% and the percentage yield varied from 0.79% to 1.72% of the dry plant material. The percentage yield of the synthetic derivatives, Me-OA and Br-OA was 65% and 30%, respectively, from the starting materials. Our results show that OA decreased MAP in both acute and sub-chronic experimental settings, and that the MAP lowering effect was more marked in hypertensive animals compared to normotensive rats. Similarly, the two OA derivatives, used in acute settings, also decreased MAP. OA increased urinary Na+ excretion rate under acute and sub-chronic conditions. A similar but quantitatively more marked increase was obtained with Br-OA derivative under acute conditions. Untreated hypertensive animals had elevated levels of plasma aldosterone and AVP in comparison to Wistar rats. OA treatment significantly reduced aldosterone secretion in these animals but had no influence on plasma concentrations of AVP. Compared with respective control rats, OA-treated animals exhibited significantly lower MDA levels and increased activity of the antioxidant enzymes, SOD and GPx in hepatic, cardiac and renal tissues. OA and derivatives had a positive inotropic effect on isolated ventricular cardiomyocytes in Wistar rats and had no influence on the contraction of cells from hypertensive animals. OA and derivatives caused relaxation in aortic rings and mesenteric arteries of both Wistar and DSS animals. This effect was partly inhibited by INDO and K+ channel blockers when used independently. Addition of L-NAME did not further inhibit the cyclooxygenase (COX)-resistant relaxation. The combination of INDO, Gli and AP completely abolished OA or derivatives-evoked relaxation in endothelium-intact arteries indicating involvement of both endothelium-dependent and independent mechanisms. Discussion The present study investigated the effects of OA and related synthetic derivatives (Me-OA and Br-OA) on blood pressure and thereafter examined the possible underlying mechanisms. The absolute stereo-structure of S. aromaticum-derived OA and synthetic derivatives elucidated from the spectra using 1H- and 13C-NMR was comparable to previously reported data. Our results confirm the previously reported antihypertensive properties of OA in experimental models of hypertension. However, the present study demonstrates a more marked action in SHR and DSS by comparison with non-hypertensive animals, suggesting a specifically enhanced action in disease conditions. We noticed that urinary Na+ excretion in control, untreated animals tended to spontaneously increase with time during the following 9 weeks post weanling. In both hypertensive models, no such increase with time was obtained, instead, urinary Na+ excretion tended to decrease with time after weanling in the DSS model supporting Na+ retention previously reported in these animals. To further support this theory we found increased aldosterone levels in the plasma of non-treated hypertensive rats. Our data show that OA decreased aldosterone secretion and increased urine Na+ excretion, relatively larger increases were obtained in the hypertensive models. This suggests that treatment with the drugs was accompanied by alleviation of Na+ retention in these animals. This increase in urinary Na+ output is, at least in part, mediated via inhibition of proximal tubular Na+ reabsorptions as indicated by increased Li+ clearance. Indeed, we found a positive correlation between the increase in urinary Na+ excretion rate and the decrease in MAP. However, despite the potent natriuretic effects of these triterpenes mediated by decreased aldosterone levels, the urine flow rate was not changed as supported by unchanged levels of AVP. Our experiments indicated that OA induces vasorelaxation of aortic rings and small mesenteric arteries in both normotensive and hypertensive animals. The maximum relaxation evoked by the derivatives, particularly Br-OA, was significantly larger in the mesenteric vessels although these differences were not observed in the aorta. Glibenclamide and 4-aminopyridine used allowed a complete blockade of the relaxation to OA, Br-OA and Me-OA suggesting that ATP-dependent and voltage-activated K+ channels opening mediate the endothelium-independent relaxation. Our experiments using isolated cardiomyocytes showed that OA and derivatives do not decrease but rather tend to increase myocyte shortening and had no influence on Ca2+ currents in Wistar rats. Increase cardiomyocyte contractility implies an increase in the force of cardiac tissue contraction and increase cardiac output which may be ideal for a drug which causes natriuresis. The results showed that OA-treated DSS animals had normal levels of MDA, SOD and GPx in comparison to untreated hypertensive rats. Therefore, we suggest that OA-evoked decreased reactive oxygen species (ROS) and increased antioxidant enzymes may have enhanced the production of prostanoids, thereby improving vasodilation. Hence, we speculate that antioxidant properties of OA could play a role in hypotensive mechanisms of this triterpene. Conclusion The results of this study introduce the first evidence that OA and its oleanane derivatives induce similar effects. These involve 1) increased urinary Na+ output mediated by inhibition of proximal and distal tubular Na+ reabsorption as indicated by increased Li+ clearance and decreased aldosterone levels, respectively. 2) Modulation of oxidative status in cardiac, renal and hepatic tissues in hypertensive animals. As well as 3) decreased vascular resistance via endothelium-dependent COX/prostanoids pathway and endothelium-independent opening of ATP-dependent and voltage-activated K+ channels. The results of this study are novel and clinically relevant because OA and related triterpene derivatives exert multiple blood pressure lowering mechanisms while increasing the force of cardiac contraction hence balancing the fluid volume in the circulatory system so as to avoid a state of hypotension. Limitations and direction for future studies Due to low amounts obtained for the synthetic derivatives, we were unable to study their sub-chronic effects in conscious animals, therefore this should be explored in future. OA effects on renal function seem to mimic oxytocin-like activities i.e. increase Na+ output without changing the urine flow rate, hence future studies should explore whether this hormone can have synergistic effects with OA and derivatives. This study did not evaluate the effects of these triterpenes on nitric oxide production or expression of eNOS and phosphorylation of K+ channels

Association between food intake and obesity in pregnant women living with and without HIV in Cape Town, South Africa: a prospective cohort study

Background Although global nutrition/dietary transition resulting from industrialisation and urbanisation has been identified as a major contributor to widespread trends of obesity, there is limited data in pregnant women, including those living with HIV in South Africa. We examined food-based dietary intake in pregnant women with and without HIV at first antenatal care (ANC) visit, and associations with maternal overweight/obesity and gestational weight gain (GWG). Methods In an urban South African community, consecutive women living with (n = 479) and without (n = 510) HIV were enrolled and prospectively followed to delivery. Interviewer-administered non-quantitative food frequency questionnaire was used to assess dietary intake (starch, protein, dairy, fruits, vegetables, legumes, oils/fats) at enrolment. Associations with maternal body mass index (BMI) and GWG were examined using logistic regression models. Results Among women (median age 29 years, IQR 25–34), the prevalence of obesity (BMI ≥ 30 kg/m2) at first ANC was 43% and that of excessive GWG (per IOM guidelines) was 37% overall; HIV prevalence was 48%. In women without HIV, consumption of potato (any preparation) (aOR 1.98, 95% CI 1.02–3.84) and pumpkin/butternut (aOR 2.13, 95% CI 1.29–3.49) for 1–3 days a week increased the odds of overweight/obesity compared to not consuming any; milk in tea/coffee (aOR 6.04, 95% CI 1.37–26.50) increased the odds of excessive GWG. Consumption of eggs (any) (aOR 0.52, 95% CI 0.32–0.86) for 1–3 days a week reduced the odds of overweight/obesity while peanut and nuts consumption for 4–7 days a week reduced the odds (aOR 0.34, 95% CI 0.14–0.80) of excessive GWG. In women with HIV, consumption of milk/yoghurt/maas to drink/on cereals (aOR 0.35, 95% CI 0.18–0.68), tomato (raw/cooked) (aOR 0.50, 95% CI 0.30–0.84), green beans (aOR 0.41, 95% CI 0.20–0.86), mixed vegetables (aOR 0.49, 95% CI 0.29–0.84) and legumes e.g. baked beans, lentils (aOR 0.50, 95% CI 0.28–0.86) for 4–7 days a week reduced the odds of overweight/obesity; tomato (raw/cooked) (aOR 0.48, 95% CI 0.24–0.96) and mixed vegetables (aOR 0.38, 95% CI 0.18–0.78) also reduced the odds of excessive GWG. Conclusions Diet modification may promote healthy weight in pregnant women living with and without HIV

Low Immune Activation in Early Pregnancy Is Associated With Preterm But Not Small-for-gestational-age Delivery in Women Infected With Human Immunodeficiency Virus Initiating Antiretroviral Therapy in Pregnancy: A Prematurity Immunology in HIV-infected Mothers and their Infants Study (PIMS) Case-control Study in Cape Town, South Africa.

BACKGROUND: Mechanisms underlying an association between human immunodeficiency virus (HIV) or antiretroviral therapy (ART) during pregnancy with risk of preterm delivery (PTD) and small-for-gestational-age (SGA) remain unclear. We explored the association between cellular immune activation and PTD or SGA in women with HIV initiating ART during or before pregnancy. METHODS: Women with HIV enrolled at median 15 weeks' gestation, were analyzed for immune markers, and matched on ART initiation timing (15 women initiated pre- and 15 during pregnancy). There were 30 PTD (delivery 25th percentile) as outcomes. Lymphocytes, monocytes, and dendritic cell populations and their activation status or functionality were enumerated by flow cytometry. RESULTS: PTD cases initiating ART in pregnancy showed decreased CD8+ T cell, monocyte, and dendritic cell activation; increased classical (CD14+CD16-) and intermediate (CD14+CD16+) monocyte frequencies; and decreased inflammatory monocytes (CD14dimCD16+) compared with SGA cases and term controls (all P < .05). Allowing for baseline viral load, the immune markers remained significantly associated with PTD but only in women initiating ART in pregnancy. Lower monocyte activation was predictive of PTD. TLR ligand-induced interferon-α and macrophage inflammatory protein-1β levels in monocytes were significantly lower in PTD women initiating ART in pregnancy. CONCLUSION: Low immune activation, skewing toward anti-inflammatory monocytes, and lower monocyte cytokine production in response to TLR ligand stimulation were associated with PTD but not SGA among women initiating ART in, but not before, pregnancy, suggesting immune anergy to microbial stimulation as a possible underlying mechanism for PTD in women initiating ART in pregnancy

Growth patterns of infants with in- utero HIV and ARV exposure in Cape Town, South Africa and Lusaka, Zambia

Background Infants born HIV-exposed yet remain uninfected (HEU) are at increased risk of poorer growth and health compared to infants born HIV-unexposed (HU). Whether maternal antiretroviral treatment (ART) in pregnancy ameliorates this risk of poorer growth is not well understood. Furthermore, whether risks are similar across high burden HIV settings has not been extensively explored. Methods We harmonized data from two prospective observational studies conducted in Cape Town, South Africa, and Lusaka, Zambia, to compare weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) Z-scores between infants who were HEU and HU, converting infant anthropometric measures using World Health Organisation Growth Standards adjusted for age and sex. Linear mixed effects models were fit to identify risk factors for differences in anthropometrics at 6–10 weeks and 6 months by infant HIV exposures status and by timing of exposure to maternal ART, either from conception or later in gestation. Results Overall 773 mother-infant pairs were included across two countries: women living with HIV (WLHIV), 51% (n = 395) with 65% on ART at conception and 35% initiating treatment in pregnancy. In linear mixed effects models, WAZ and WLZ at 6–10 weeks were lower among infants who were HEU vs HU [β = − 0.29 (95% CI: − 0.46, − 0.12) and [β = − 0.42 (95% CI: − 0.68, − 0.16)] respectively after adjusting for maternal characteristics and infant feeding with a random intercept for country. At 6 months, LAZ was lower [β = − 0.28 CI: − 0.50, − 0.06)] among infants who were HEU, adjusting for the same variables, with no differences in WAZ and WLZ. Within cohort evaluations identified different results with higher LAZ among infants who were HEU from Zambia at 6–10 weeks, [β = + 0.34 CI: + 0.01, + 0.68)] and lower LAZ among infants who were HEU from South Africa [β = − 0.30 CI: − 0.59, − 0.01)] at 6 months, without other anthropometric differences at either site. Conclusion Infant growth trajectories differed by country, highlighting the importance of studying contextual influences on outcomes of infants who were HEU

Neurodevelopment of HIV-exposed uninfected children in Cape Town, South Africa.

BackgroundEvidence shows that antiretroviral (ART) exposure is associated with neurodevelopmental delays in human immunodeficiency virus (HIV)-exposed uninfected (HEU) children. However, there are few insights into modifiable maternal and child factors that may play a role in improving neurodevelopment in HEU children. We used a parent-centric neurodevelopment tool, Ages & Stages Questionnaire (ASQ) to examined neurodevelopment in HEU children at 12-24 months of age, and associations with maternal and child factors.Methods505 HIV-infected women (initiated ART pre- or during pregnancy) with live singleton births attending primary health care were enrolled; 355 of their HEU children were assessed for neurodevelopment (gross motor, fine motor, communication, problem solving and personal-social domains) at 12-24 months using age-specific ASQ administered by a trained fieldworker. Associations with maternal and child factors were examined using logistic regression models.ResultsAmong mothers (median age 30 years, IQR, 26-34), 52% initiated ART during pregnancy; the median CD4 count was 436 cells/μl (IQR, 305-604). Most delayed neurodevelopment in HEU children was in gross (9%) and fine motor (5%) functions. In adjusted models, maternal socio-economic status (aOR 0.42, 95% CI 0.24-0.76) was associated with reduced odds of delayed gross-fine motor neurodevelopment. Maternal age ≥35 years (aOR 0.22, 95% CI 0.05-0.89) and maternal body mass index (BMI) ConclusionsDelayed neurodevelopment was detected in both gross and fine motor functions in this cohort of HEU children, with strong maternal predictors that may be explored as potentially modifiable factors associated with neurodevelopment at one to two years of age

Changes in Renal Function and Oxidative Status Associated with the Hypotensive Effects of Oleanolic Acid and Related Synthetic Derivatives in Experimental Animals.

The triterpene oleanolic acid (OA) is known to possess antihypertensive actions. In the present study we to compared the effects of the triterpene on mean arterial blood pressure (MAP) and kidney function following acute administration in normotensive animals with those of its related oleanane synthetic derivatives (brominated oleanolic acid, Br-OA and oleanolic acid methyl ester, Me-OA). We also used experimental models of hypertension to further explore the effects of sub-chronic oral OA treatment and evaluated influences on oxidative status.OA was extracted from dried flower buds of Syzygium aromaticum using a previously validated protocol in our laboratory. Me-OA and Br-OA were synthesized according to a method described. Rats were supplemented with lithium chloride (12 mmol L-1) prior to experimentation in order to raise plasma lithium to allow measurements of lithium clearance and fractional excretion (FELi) as indices of proximal tubular Na+ handling. Anaesthetized animals were continuously infused via the right jugular with 0.077M NaCl. MAP was measured via a cannula inserted in the carotid artery, and urine was collected through a cannula inserted in the bladder. After a 3.5 h equilibration, MAP, urine flow, electrolyte excretion rates were determined for 4 h of 1 h control, 1.5 h treatment and 1.5 h recovery periods. OA, Me-OA and Br-OA were added to the infusate during the treatment period. We evaluated sub-chronic effects on MAP and kidney function in normotensive Wistar rats and in two animal models of hypertension, spontaneously hypertensive rats (SHR) and Dahl salt-sensitive (DSS) rats, during 9-week administration of OA (p.o.). Tissue oxidative status was examined in these animals at the end of the study. Increasing evidence suggests that and renal function disturbances and oxidative stress play major roles in the pathogenesis of hypertension.Acute infusion OA and oleanane derivatives displayed qualitatively similar effects in decreasing MAP and increasing urinary Na+ outputs. The drugs increased the FENa and FELi without influencing GFR indicating that at least part of the overall natriuretic effect involved proximal tubular Na+ reabsorption. Sub-chronic OA administration (p.o.) also elicited hypotensive responses in Wistar, DSS and SHR rats. The MAP lowering effect was more marked in hypertensive animals and were positively correlated with increased urinary Na+ excretion. Compared with respective control rats, OA treatment reduced malondialdehyde (MDA, a marker of lipid peroxidation) and increased activities of antioxidant enzymes; superoxide dismutase and glutathione peroxidase in hepatic, cardiac and renal tissues.OA and oleanane derivatives have similar effects on MAP, kidney function and oxidative stress. The amelioration of oxidative stress and blood pressure lowering effects by OA are more marked in hypertensive animals and correlated with an increased urinary Na+ output.The results of this study are novel in that they show 1) a correlation between blood pressure reduction and increased urinary Na+ excretion by OA, 2) a more marked MAP reduction in hypertensive animals and 3) a drug-induced decrease in proximal tubule Na+ reabsorption. The results may also be clinically relevant because OA is effective via oral administration

Vascular Endothelium-Dependent and Independent Actions of Oleanolic Acid and Its Synthetic Oleanane Derivatives as Possible Mechanisms for Hypotensive Effects.

PURPOSE: Plant-derived oleanolic acid (OA) and its related synthetic derivatives (Br-OA and Me-OA) possess antihypertensive effects in experimental animals. The present study investigated possible underlying mechanisms in rat isolated single ventricular myocytes and in vascular smooth muscles superfused at 37°C. METHODS: Cell shortening was assessed at 1 Hz using a video-based edge-detection system and the L-type Ca2+ current (ICaL) was measured using the whole-cell patch-clamp technique in single ventricular myocytes. Isometric tension was measured using force transducer in isolated aortic rings and in mesenteric arteries. Vascular effects were measured in endothelium-intact and denuded vessels in the presence of various enzyme or channel inhibitors. RESULTS: OA and its derivatives increased cell shortening in cardiomyocytes isolated from normotensive rats but had no effect in those isolated from hypertensive animals. These triterpenes also caused relaxation in aortic rings and in mesenteric arteries pre-contracted with either phenylephrine or KCl-enriched solution. The relaxation was only partially inhibited by endothelium denudation, and also partly inhibited by the cyclooxygenase (COX) inhibitor indomethacin, with no additional inhibitory effect of the NO synthase inhibitor, N-ω-Nitro-L-arginine. A combination of both ATP-dependent channel inhibition by glibenclaminde and voltage-dependent K+ channel inhibition by 4-aminopyridine was necessary to fully inhibit the relaxation. CONCLUSION: These data indicate that the effects of OA and its derivatives are mediated via both endothelium-dependent and independent mechanisms suggesting the involvement of COX in the endothelium-dependent effects and of vascular muscle K+ channels in the endothelium-independent effects. Finally, our results support the view that the antihypertensive action of OA and its derivatives is due to a decrease of vascular resistance with no negative inotropic effect on the heart

Methods of gestational age assessment influence the observed association between antiretroviral therapy exposure, preterm delivery and small-for-gestational-age infants: a prospective study in Cape Town, South Africa

Purpose: Heterogeneous findings exist on antiretroviral treatment (ART) use in pregnancy and preterm delivery (PTD) or infants born small-for-gestational age (SGA). Whether reported differences may be explained by methods used to ascertain gestational age(GA) has not been explored. Methods: We enrolled consecutive pregnant women attending a large primary care antenatal clinic in South Africa. Public-sector midwives assessed GA by last menstrual period (LMP) and symphysis-fundal height (SFH). Separately, if clinical GA was &lt;24weeks, ultrasound (US) was performed by a research sonographer blinded to midwife assessments. In analysis, the impact of measurement error on the association between HIV/ART status and birth outcome by GA method was assessed, and factors associated with clinical GA under- or over-estimation identified. Results: In 1787 women included overall, estimated PTD incidence was 36% by LMP, 17% by SFH and 11% by US. PTD risk was higher for HIV-infected than HIV-uninfected women using US-GA (adjusted odds ratio (aOR) 1.95; 95% CI 1.10-3.46); for LMP/SFH-GA the associations were smaller and not significant. These findings persisted after adjustment for age, parity, height and previous PTD. PTD risk did not vary by timing of ART initiation (before or during pregnancy) for any method. Elevated BMI and older age were associated with decreased risk of under-estimation by both LMP and SFH; HIV status and obesity were associated with increased risk of over-estimation by SFH. There were no differences in SGA incidence across GA methods. Conclusions: Findings for an association between HIV/ART and birth outcomes are substantially influenced by GA assessment method. With growing public health interest in this association, future research efforts should seek to standardize optimal measures of gestation