A Five-Year Prospective Evaluation of Anticholinergic Cognitive Burden and Falls in the Malaysian Elders Longitudinal Research (MELoR) study

Acknowledgements This third-wave follow-up interviews were funded by the Ministry of Higher Education Fundamental Research Grant Scheme (FRGS/1/2019/SKK02/UM/01/1). The Malaysian Elders Longitudinal Research study is now part of the Transforming Cognitive Frailty into Later-Life Self-Sufficiency (AGELESS) study which merges two existing longitudinal studies of ageing and is funded by the Ministry of Higher Education Long-Term Research Grant Scheme (LRGS/1/2019/UM/01/1/1). We would also like to acknowledge the hard work and dedication of the MELoR investigators and research team.Peer reviewedPostprin

A randomized double blind control trial comparing filgrastim and pegfilgrastim in cyclophosphamide peripheral blood hematopoietic stem cell mobilization

There are few randomized trials comparing filgrastim and pegfilgrastim in peripheral blood stem cell mobilization (PBSCM). None of the trials studied the effects of the timing of pegfilgrastim administration on the outcomes of mobilization. We conducted a randomized triple blind control trial comparing the outcomes of filgrastim 5 microg/kg daily from day 3 onwards, 'early' pegfilgrastim 6 mg on day 3 and 'delayed' pegfilgrastim 6 mg on day 7 in cyclophosphamide PBSCM in patients with no previous history of mobilization. Peripheral blood (PB) CD34+ cell count was checked on day 8 and day 11 onward. Apheresis was started when PB CD34+ >/= 10/microl from day 11 onward. The primary outcome was the successful mobilization rate, defined as cumulative collection of >/=2 x 10(6)/kg CD34+ cells in three or less apheresis. The secondary outcomes were the day of neutrophil and platelet engraftment post transplantation. There were 156 patients randomized and 134 patients' data analyzed. Pegfilgrastim 6 mg day 7 produced highest percentage of successful mobilization, 34 out of 48 (70.8%) analyzed patients, followed by daily filgrastim, 28 out of 44 (63.6%) and day 3 pegfilgrastim, 20 out of 42 (47.6%) (p = 0.075). Pegfilgrastim day 7 and daily filgrastim reported 1.48 (p = 0.014) and 1.49 (p = 0.013) times higher successful mobilization rate respectively as compared to pegfilgrastim day 3 after adjusting for disease, gender and exposure to myelotoxic agent. Multiple myeloma patients were three times more likely to achieve successful mobilization as compared to acute leukemia or lymphoma patients. Pegfilgrastim avoided the overshoot of white cells compared to filgrastim. There was no difference in the duration of both white cells and platelet recovery post transplantation between the three interventional arms

Endotoxemia Is Associated with Altered Innate and Adaptive Immune Responses in Untreated HIV-1 Infected Individuals

BACKGROUND: Microbial translocation may contribute to the immunopathogenesis in HIV infection. We investigated if microbial translocation and inflammation were associated with innate and adaptive immune responses in adults with HIV. METHODOLOGY/PRINCIPAL FINDINGS: This was an observational cohort study. Sera from HIV-infected and HIV-uninfected individuals were analyzed for microbial translocation (soluble CD14, lipopolysaccharides [LPS], endotoxin core antibody, and anti-α-galactosyl antibodies) and inflammatory markers (high sensitivity C-reactive protein, IL-6, IL-1 receptor antagonist, soluble tumor necrosis factor receptor II, and IL-10) with enzyme-linked immunosorbent assays. Peripheral blood mononuclear cells (PBMC) from HIV-infected persons and healthy controls (primed with single-stranded HIV-1-derived RNA) were stimulated with LPS, and cytokine production was measured. Finally, HIV-infected patients were immunized with Prevnar 7vPnC±CpG 7909 followed by Pneumo Novum PPV-23. Effects of microbial translocation and inflammation on immunization were analyzed in a predictive regression model. We included 96 HIV-infected individuals, 76 on highly active antiretroviral therapy (HAART), 20 HAART-naive, and 50 healthy controls. Microbial translocation and inflammatory markers were higher among HIV-infected persons than controls. Cytokine levels following LPS stimulation were increased in PBMCs from HAART-naive compared to HAART-treated HIV-infected persons. Further, RNA-priming of PBMCs from controls acted synergistically with LPS to augment cytokine responses. Finally, high serum LPS levels predicted poor vaccine responses among HAART-naive, but not among HAART-treated HIV-infected individuals. CONCLUSIONS/SIGNIFICANCE: LPS acts synergistically with HIV RNA to stimulate innate immune responses in vitro and increasing serum LPS levels seem to predict poor antibody responses after vaccination among HAART-naive HIV-infected persons. Thus, our results suggest that microbial translocation may be associated with innate and adaptive immune dysfunction in untreated HIV infection

Differential Expression of CD163 on Monocyte Subsets in Healthy and HIV-1 Infected Individuals

CD163, a haptoglobin-hemoglobin (Hp-Hb) scavenger receptor, expressed by monocytes and macrophages, is important in resolution of inflammation. Age-related non-AIDS co-morbidities in HIV-infected individuals, particularly dementia and cardiovascular disease, result in part from effects of HIV-1 infection on monocyte and macrophage biology. CD163 co-expression on CD14+CD16++ monocytes has been proposed as a useful biomarker for HIV-1 disease progression and the presence of HIV associated dementia. Here we investigated CD163 expression on monocyte subsets ex vivo, on cultured macrophages, and soluble in plasma, in the setting of HIV-1 infection. Whole blood immunophenotyping revealed CD163 expression on CD14++CD16- monocytes but not on CD14+CD16++ monocytes (P = 0.004), supported by CD163 mRNA levels. Incubation with M-CSF induced CD163 protein expression on CD14+CD16++ monocytes to the same extent as CD14++CD16− monocytes. CD163 expression on CD14++CD16+ monocytes from HIV-infected subjects was significantly higher than from uninfected individuals, with a trend towards increased expression on CD14++CD16− monocytes (P = 0.019 and 0.069 respectively), which is accounted for by HIV-1 therapy including protease inhibitors. Shedding of CD163 was shown to predominantly occur from the CD14++CD16− subset after Ficoll isolation and LPS stimulation. Soluble CD163 concentration in plasma from HIV-1 infected donors was similar to HIV-1 uninfected donors. Monocyte CD163 expression in HIV-1 infected patients showed a complicated relationship with classical measures of disease progression. Our findings clarify technical issues regarding CD163 expression on monocyte subsets and further elucidates its role in HIV-associated inflammation by demonstrating that CD163 is readily lost from CD14++CD16− monocytes and induced in pro-inflammatory CD14+CD16++ monocytes by M-CSF. Our data show that all monocyte subsets are potentially capable of differentiating into CD163-expressing anti-inflammatory macrophages given appropriate stimuli. Levels of CD163 expression on monocytes may be a potential biomarker reflecting efforts by the immune system to resolve immune activation and inflammation in HIV-infected individuals

Clinical Predictors of Immune Reconstitution following Combination Antiretroviral Therapy in Patients from the Australian HIV Observational Database

A small but significant number of patients do not achieve CD4 T-cell counts >500 cells/µl despite years of suppressive cART. These patients remain at risk of AIDS and non-AIDS defining illnesses. The aim of this study was to identify clinical factors associated with CD4 T-cell recovery following long-term cART.Patients with the following inclusion criteria were selected from the Australian HIV Observational Database (AHOD): cART as their first regimen initiated at CD4 T-cell count <500 cells/µl, HIV RNA<500 copies/ml after 6 months of cART and sustained for at least 12 months. The Cox proportional hazards model was used to identify determinants associated with time to achieve CD4 T-cell counts >500 cells/µl and >200 cells/µl.501 patients were eligible for inclusion from AHOD (n = 2853). The median (IQR) age and baseline CD4 T-cell counts were 39 (32-47) years and 236 (130-350) cells/µl, respectively. A major strength of this study is the long follow-up duration, median (IQR) = 6.5(3-10) years. Most patients (80%) achieved CD4 T-cell counts >500 cells/µl, but in 8%, this took >5 years. Among the patients who failed to reach a CD4 T-cell count >500 cells/µl, 16% received cART for >10 years. In a multivariate analysis, faster time to achieve a CD4 T-cell count >500 cells/µl was associated with higher baseline CD4 T-cell counts (p<0.001), younger age (p = 0.019) and treatment initiation with a protease inhibitor (PI)-based regimen (vs. non-nucleoside reverse transcriptase inhibitor, NNRTI; p = 0.043). Factors associated with achieving CD4 T-cell counts >200 cells/µl included higher baseline CD4 T-cell count (p<0.001), not having a prior AIDS-defining illness (p = 0.018) and higher baseline HIV RNA (p<0.001).The time taken to achieve a CD4 T-cell count >500 cells/µl despite long-term cART is prolonged in a subset of patients in AHOD. Starting cART early with a PI-based regimen (vs. NNRTI-based regimen) is associated with more rapid recovery of a CD4 T-cell count >500 cells/µl

Differential Expression of CD163 on Monocyte Subsets in Healthy and HIV-1 Infected Individuals

CD163, a haptoglobin-hemoglobin (Hp-Hb) scavenger receptor, expressed by monocytes and macrophages, is important in resolution of inflammation. Age-related non-AIDS co-morbidities in HIV-infected individuals, particularly dementia and cardiovascular disease, result in part from effects of HIV-1 infection on monocyte and macrophage biology. CD163 co-expression on CD14+CD16++ monocytes has been proposed as a useful biomarker for HIV-1 disease progression and the presence of HIV associated dementia. Here we investigated CD163 expression on monocyte subsets ex vivo, on cultured macrophages, and soluble in plasma, in the setting of HIV-1 infection. Whole blood immunophenotyping revealed CD163 expression on CD14++CD16- monocytes but not on CD14+CD16++ monocytes (P = 0.004), supported by CD163 mRNA levels. Incubation with M-CSF induced CD163 protein expression on CD14+CD16++ monocytes to the same extent as CD14++CD16− monocytes. CD163 expression on CD14++CD16+ monocytes from HIV-infected subjects was significantly higher than from uninfected individuals, with a trend towards increased expression on CD14++CD16− monocytes (P = 0.019 and 0.069 respectively), which is accounted for by HIV-1 therapy including protease inhibitors. Shedding of CD163 was shown to predominantly occur from the CD14++CD16− subset after Ficoll isolation and LPS stimulation. Soluble CD163 concentration in plasma from HIV-1 infected donors was similar to HIV-1 uninfected donors. Monocyte CD163 expression in HIV-1 infected patients showed a complicated relationship with classical measures of disease progression. Our findings clarify technical issues regarding CD163 expression on monocyte subsets and further elucidates its role in HIV-associated inflammation by demonstrating that CD163 is readily lost from CD14++CD16− monocytes and induced in pro-inflammatory CD14+CD16++ monocytes by M-CSF. Our data show that all monocyte subsets are potentially capable of differentiating into CD163-expressing anti-inflammatory macrophages given appropriate stimuli. Levels of CD163 expression on monocytes may be a potential biomarker reflecting efforts by the immune system to resolve immune activation and inflammation in HIV-infected individuals

The global distribution of fatal pesticide self-poisoning: Systematic review

<p>Abstract</p> <p>Background</p> <p>Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown.</p> <p>Methods</p> <p>We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990–2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning.</p> <p>Results</p> <p>We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm.</p> <p>Conclusion</p> <p>Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.</p

Biological determinants of long-term immune reconstitution following combination antiretroviral therapy (cART)

CD4+ T-cell reconstitution following suppressive combination antiretroviral therapy (cART) is highly variable and is an important determinant of long-term clinical outcomes in HIV-infected patients. In this thesis we explored the relative importance on long-term CD4+ T-cell recovery of two mechanisms that have different effects on T-cell homeostasis namely; microbial translocation driven immune activation and genetic factors associated with IL-7 mediated homeostasis,. The association of these factors with CD4+ T-cell recovery was assessed using a Kaplan Meier approach where a clinically relevant outcome of time to achieve CD+ T-cell counts >500 cells/µl was used as the study endpoint. In a largely Caucasian cohort, we found the IL-7Rα haplotype 2 which is associated with lower sIL-7Rα levels, was associated with faster CD4+ T-cell recovery, while levels of lipopolysaccharide (LPS) and soluble CD14 (sCD14) on treatment were not. Additionally, pre-cART factors including higher baseline CD4 T-cell counts, lower pre-cART LPS and IL-7, higher pre-cART sCD14 and younger age at cART initiation, were all associated with faster recovery. Using a kinetic model with LPS and sCD14 data from patients receiving up to 11 years of suppressive cART, we predicted LPS and sCD14 levels will eventually normalize in patients receiving long-term cART and do not contribute to impaired CD4+ T-cell recovery. In a replicate study involving African patients however, we were unable to find a similar association between the IL-7Rα haplotype 2 and CD4+ T-cell recovery, although haplotype 2 in Africans was also associated with lower concentrations of sIL-7Rα compared to non-haplotype 2 carriers as previously described in Caucasians. The reason for the lack of the same genetic association is not entirely clear but may be due to differences in linkage disequilibrium patterns in the IL-7Rα gene between Africans and Caucasians which may lead to different gene-gene interactions no solely reflected by sIL-7Rα levels. Additionally, there were differences in the immunological characteristics of the two cohorts studied including the difference in the degree of immunological suppression at cART initiation and the duration on cART. Our method of analysis using a Kaplan Meier approach was then validated in a separate large clinic-based cohort receiving prolonged cART. In this study, we assessed clinical factors associated with CD4+ T-cell recovery and again found higher baseline CD4+ T-cell counts and younger age to be associated with faster CD4+ T-cell recovery. Additionally, we found patients initiating cART with a PI-based regimen was also associated with faster recovery. In summary, we have identified multiple biological and clinical factors that are associated with CD4+ T-cell recovery. We have also highlighted the importance of performing replicate genetic studies in cohorts of different ethnicities. This is particularly important as we start to consider immune-based therapies as additional therapy to improve CD4+ T-cell recovery in patients who continue to experience immune suppression despite receiving standard cART regimens

Biological determinants of long-term immune reconstitution following combination antiretroviral therapy (cART)

CD4+ T-cell reconstitution following suppressive combination antiretroviral therapy (cART) is highly variable and is an important determinant of long-term clinical outcomes in HIV-infected patients. In this thesis we explored the relative importance on long-term CD4+ T-cell recovery of two mechanisms that have different effects on T-cell homeostasis namely; microbial translocation driven immune activation and genetic factors associated with IL-7 mediated homeostasis,. The association of these factors with CD4+ T-cell recovery was assessed using a Kaplan Meier approach where a clinically relevant outcome of time to achieve CD+ T-cell counts >500 cells/µl was used as the study endpoint. In a largely Caucasian cohort, we found the IL-7Rα haplotype 2 which is associated with lower sIL-7Rα levels, was associated with faster CD4+ T-cell recovery, while levels of lipopolysaccharide (LPS) and soluble CD14 (sCD14) on treatment were not. Additionally, pre-cART factors including higher baseline CD4 T-cell counts, lower pre-cART LPS and IL-7, higher pre-cART sCD14 and younger age at cART initiation, were all associated with faster recovery. Using a kinetic model with LPS and sCD14 data from patients receiving up to 11 years of suppressive cART, we predicted LPS and sCD14 levels will eventually normalize in patients receiving long-term cART and do not contribute to impaired CD4+ T-cell recovery. In a replicate study involving African patients however, we were unable to find a similar association between the IL-7Rα haplotype 2 and CD4+ T-cell recovery, although haplotype 2 in Africans was also associated with lower concentrations of sIL-7Rα compared to non-haplotype 2 carriers as previously described in Caucasians. The reason for the lack of the same genetic association is not entirely clear but may be due to differences in linkage disequilibrium patterns in the IL-7Rα gene between Africans and Caucasians which may lead to different gene-gene interactions no solely reflected by sIL-7Rα levels. Additionally, there were differences in the immunological characteristics of the two cohorts studied including the difference in the degree of immunological suppression at cART initiation and the duration on cART. Our method of analysis using a Kaplan Meier approach was then validated in a separate large clinic-based cohort receiving prolonged cART. In this study, we assessed clinical factors associated with CD4+ T-cell recovery and again found higher baseline CD4+ T-cell counts and younger age to be associated with faster CD4+ T-cell recovery. Additionally, we found patients initiating cART with a PI-based regimen was also associated with faster recovery. In summary, we have identified multiple biological and clinical factors that are associated with CD4+ T-cell recovery. We have also highlighted the importance of performing replicate genetic studies in cohorts of different ethnicities. This is particularly important as we start to consider immune-based therapies as additional therapy to improve CD4+ T-cell recovery in patients who continue to experience immune suppression despite receiving standard cART regimens