Crosssectional study to evaluate factors associated with adherence to antiretroviral therapy by Brazilian HIV-infected patients.

ABSTRACT Antiretroviral therapy success is highly dependent on the ability of the patient to fully adhere to the prescribed treatment regimen. We present the results of a cross-sectional study that evaluates the predictive value of a self-administered questionnaire of adherence to antiretroviral (ARV) therapy. Study participants were interviewed using a 36-item Patient Medication Adherence Questionnaire (PMAQ) designed to assess knowledge about ARV therapy, motivation to adhere to treatment, and behavioral skills. Plasma HIV-1 RNA levels were correlated with the results obtained from the PMAQ. Of the 182 study participants, 82 (45%) were receiving their initial ARV regimen. Of the remaining patients, 39 (21%) and 61 (34%) were on a second or additional ARV regimen, respectively. An undetectable viral load was documented in 47/62 (76%) patients on their first regimen who reported missing medication on less than 4 days in the last 3 months. The PMAQ had a higher predictive value of plasma viral suppression for patients in the initial regimen than for patients in salvage therapy. The overall predictive value of the PMAQ to identify adherence was 74%, and 59% for nonadherence, with an overall efficacy of 64%. Of the 74 patients (45%) who did not understand the concept of antiretroviral therapy, 80% were failing or had previously failed the ARV treatment. Of 35 patients with doubts about their HIV status or skeptical of the benefits of ARV therapy, 29 (84%) were nonadherent. Despite the positive predictive value of PMAQ in identifying adherence, self-reported adherence is not a sufficiently precise predictor of treatment success to substitute for viral load monitoring. On the other hand, the use of such an instrument to identify factors associated with nonadherence provides an excellent opportunity to apply early intervention designed to specifically address factors that might be contributing to the lack of adherence prior to regimen failure

The stellar metallicities of massive quiescent galaxies at 1.0 < z < 1.3 from KMOS+VANDELS

We present a rest-frame UV-optical stacked spectrum representative of massive quiescent galaxies at $1.010.8$. The stack is constructed using VANDELS survey data, combined with new KMOS observations. We apply two independent full-spectral-fitting approaches, measuring a total metallicity, [Z/H]=$-0.13\pm0.08$ with Bagpipes, and [Z/H]=$0.04\pm0.14$ with Alf, a fall of $\sim0.2-0.3$ dex compared with the local Universe. We also measure an iron abundance, [Fe/H] =$-0.18\pm0.08$, a fall of $\sim0.15$ dex compared with the the local Universe. We measure the alpha enhancement via the magnesium abundance, obtaining [Mg/Fe]=$0.23\pm$0.12, consistent with similar-mass galaxies in the local Universe, indicating no evolution in the average alpha enhancement of log$(M_*/\rm{M_\odot})=11$ quiescent galaxies over the last $\sim8$ Gyr. This suggests the very high alpha enhancements recently reported for several bright $z\sim1-2$ quiescent galaxies are due to their extreme masses, log$(M_*/\rm{M_\odot})\gtrsim11.5$, rather than being typical of the $z\gtrsim1$ population. The metallicity evolution we observe with redshift (falling [Z/H], [Fe/H], constant [Mg/Fe]) is consistent with recent studies. We recover a mean stellar age of $2.5^{+0.6}_{-0.4}$ Gyr, corresponding to a formation redshift, z_\rm{form}=2.4^{+0.6}_{-0.3}. Recent studies have obtained varying average formation redshifts for $z\gtrsim1$ massive quiescent galaxies, and, as these studies report consistent metallicities, we identify different star-formation-history models as the most likely cause. Larger spectroscopic samples from upcoming ground-based instruments will provide precise constraints on ages and metallicities at $z\gtrsim1$. Combining these with precise JWST $z>2$ quiescent-galaxy stellar-mass functions will provide an independent test of formation redshifts derived from spectral fitting.Comment: 16 pages, 3 figures, accepted for publication in Ap

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

The Low-redshift Lyman Continuum Survey. II. New Insights into LyC Diagnostics

International audienceThe Lyman continuum (LyC) cannot be observed at the epoch of reionization (z ≳ 6) owing to intergalactic H I absorption. To identify LyC emitters (LCEs) and infer the fraction of escaping LyC, astronomers have developed various indirect diagnostics of LyC escape. Using measurements of the LyC from the Low-redshift Lyman Continuum Survey (LzLCS), we present the first statistical test of these diagnostics. While optical depth indicators based on Lyα, such as peak velocity separation and equivalent width, perform well, we also find that other diagnostics, such as the [O III]/[O II] flux ratio and star formation rate surface density, predict whether a galaxy is an LCE. The relationship between these galaxy properties and the fraction of escaping LyC flux suggests that LyC escape depends strongly on H I column density, ionization parameter, and stellar feedback. We find that LCEs occupy a range of stellar masses, metallicities, star formation histories, and ionization parameters, which may indicate episodic and/or different physical causes of LyC escape

The Low-Redshift Lyman Continuum Survey I: New, Diverse Local Lyman-Continuum Emitters

The origins of Lyman continuum (LyC) photons responsible for the reionization of the universe are as of yet unknown and highly contested. Detecting LyC photons from the epoch of reionization is not possible due to absorption by the intergalactic medium, which has prompted the development of several indirect diagnostics to infer the rate at which galaxies contribute LyC photons to reionize the universe by studying lower-redshift analogs. We present the Low-redshift Lyman Continuum Survey (LzLCS) comprising measurements made with HST/COS for a z=0.2-0.4 sample of 66 galaxies. After careful processing of the FUV spectra, we obtain a total of 35 Lyman continuum emitters (LCEs) detected with 97.725% confidence, nearly tripling the number of known local LCEs. We estimate escape fractions from the detected LyC flux and upper limits on the undetected LyC flux, finding a range of LyC escape fractions up to 50%. Of the 35 LzLCS LCEs, 12 have LyC escape fractions greater than 5%, more than doubling the number of known local LCEs with cosmologically relevant LyC escape.Comment: ApJS, accepted. 28 pages, 19 figures, 8 tables. Full machine readable tables will be made available by the publisher at the time of publicatio

The Low-redshift Lyman Continuum Survey. I. New, Diverse Local Lyman Continuum Emitters

The origins of Lyman continuum (LyC) photons responsible for the reionization of the universe are as of yet unknown and highly contested. Detecting LyC photons from the Epoch of Reionization is not possible due to absorption by the intergalactic medium, which has prompted the development of several indirect diagnostics to infer the rate at which galaxies contribute LyC photons to reionize the universe by studying lower-redshift analogs. We present the Low-redshift Lyman Continuum Survey (LzLCS) comprising measurements made with the Hubble Space Telescope Cosmic Origins Spectrograph for a z = 0.2-0.4 sample of 66 galaxies. After careful processing of the far-UV spectra, we obtain a total of 35 Lyman continuum emitters (LCEs) detected with 97.725% confidence, nearly tripling the number of known local LCEs. We estimate escape fractions from the detected LyC flux and upper limits on the undetected LyC flux, finding a range of LyC escape fractions up to 50%. Of the 35 LzLCS LCEs, 12 have LyC escape fractions greater than 5%, more than doubling the number of known local LCEs with cosmologically relevant LyC escape

Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus.METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis.RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (<45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]).CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791