Drug level testing as a strategy to determine eligibility for drug resistance testing after failure of ART: a retrospective analysis of South African adult patients on second-line ART.

INTRODUCTION: When protease inhibitor (PI)-based second-line ART fails, guidelines recommend drug resistance testing and individualized third-line treatment. However, PI-resistant viral strains are rare and drug resistance testing is costly. We investigated whether less costly PI-exposure testing can be used to select those patients who would benefit most from drug resistance testing. METHODS: We performed a retrospective analysis of South African adults living with HIV experiencing failure of ritonavir-boosted-lopinavir (LPV/r)-based second-line ART for whom drug resistance testing results were available. We included patients who received plasma-based drug resistance testing at a central South African reference laboratory in 2017 and patients who received dried blood spots (DBS)-based drug resistance testing at a rural South African clinic between 2009 and 2017. PI-exposure testing was performed on remnant plasma or DBS using liquid chromatography mass spectrometry (LCMS). Additionally, a low-cost immunoassay was used on plasma. Population genotypic drug resistance testing of the pol region was performed on plasma and DBS using standard clinical protocols. RESULTS: Samples from 544 patients (494 plasma samples and 50 DBS) were included. Median age was 41.0 years (IQR: 33.3 to 48.5) and 58.6% were women. Median HIV-RNA load was 4.9 log10 copies/mL (4.3 to 5.4). Prevalence of resistance to the NRTI-backbone was 70.6% (349/494) in plasma samples and 56.0% (28/50) in DBS. Major PI-resistance mutations conferring high-level resistance to LPV/r were observed in 26.7% (132/494) of plasma samples and 12% (6/50) of DBS. PI-exposure testing revealed undetectable LPV levels in 47.0% (232/494) of plasma samples and in 60.0% (30/50) of DBS. In pooled analysis of plasma and DBS samples, detectable LPV levels had a sensitivity of 90% (84% to 94%) and a negative predictive failure of 95% (91% to 97%) for the presence of major LPV/r resistance. CONCLUSIONS: PI-exposure testing revealed non-adherence in half of patients experiencing failure on second-line ART and accurately predicted the presence or absence of clinically relevant PI resistance. PI-exposure testing constitutes a novel screening strategy in patients with virological failure of ART that can differentiate between different underlying causes of therapy failure and may allow for more effective use of limited resources available for drug resistance testing.

Role of arginine 29 and glutamic acid 81 interactions in the conformational stability of human chloride intracellular channel 1.

The ion channel protein CLIC1 exists in both a soluble conformation in the cytoplasm and a membrane-bound conformation. The conformational stability of soluble CLIC1 demonstrates pH sensitivity which may be attributable to very specific residues that function as pH sensors. These sensors could be histidine or glutamate residues with pK(a) values that fall within the physiological pH range. The role of Glu81, a member of a topologically conserved buried salt bridge in CLIC1, as a pH sensor was investigated here. The mutants E81M, R29M, and E81M/R29M were designed to break the salt bridge between Glu81 and Arg29 and examine the effect of each member on the stability of the protein. Spectroscopic studies and the solved crystal structures indicated that the global structure of CLIC1 was not affected by the mutations. Urea-induced equilibrium unfolding unexpectedly showed E81M to stabilize CLIC1 at pH 7. This was due to stabilizing hydrophobic interactions with Met81 and a water-mediated compensatory H-bond between Met81 and Arg29. R29M and E81M/R29M destabilized CLIC1 at pH 7, and the unfolding transition changed from two-state to three-state, mimicking the wild type at pH 5.5. This observation points out the significance of the salt bridge in stabilizing the native state. The total unfolding free energy change of E81M CLIC1 does not change with pH, implying that Glu81 forms one of a network of pH-sensor residues in CLIC1 responsible for destabilization of the native state. This allows detachment of the N-domain from the C-domain at low pH.

Spontaneous burrowing behaviour in the rat is reduced by peripheral nerve injury or inflammation associated pain.

Pain influences many aspects of daily living and effective analgesics should reinstate normal spontaneous daily behaviours. Experiments are described herein which show that the innate, spontaneous behaviour of burrowing by rats, which can be simply and objectively assessed by measuring the amount of gravel left in a hollow tube 1 h after presentation to the rat, is reduced by peripheral nerve injury (tibial nerve transection (TNT), L5 spinal nerve transection (SNT) and partial sciatic nerve ligation (PSNL)) and also following inflammation induced by intra-plantar injection of Complete Freund's Adjuvant (CFA). Gabapentin (100 mg/kg sc) but not at 30 mg/kg sc significantly reduced burrowing activity in naive rats. All peripheral nerve injuries and CFA reduced burrowing compared with shams and rats naive to surgery. The level of mechanical hypersensitivity in rats with peripheral nerve injury did not correlate with the deficit in burrowing indicating that different parameters of the holistic pain experience are measured in these paradigms. Gabapentin at 30 mg/kg sc, but not 100 mg/kg sc, reversed the deficit in burrowing induced by TNT and ibuprofen (30 mg/kg sc) reversed the effect of CFA on burrowing. These experiments show that measurement of burrowing is a simple, objective assay of innate rodent behaviour affected by pain that is ethologically relevant to the rat, does not rely wholly on evoking a reflex and can dissociate a selective analgesic dose of gabapentin from one inducing motor impairment in the same animal.

Transmitter content, origins and connections of axons in the spinal cord that possess the serotonin (5-hydroxytryptamine) 3 receptor.

Recent evidence suggests that serotonin has pronociceptive actions in the spinal cord when it acts through 5-hydroxytryptamine (5-HT)(3) receptors. Cells and axon terminals which are concentrated in the superficial dorsal horn possess this receptor. We performed a series of immunocytochemical studies with an antibody raised against the 5-HT(3A) subunit in order to address the following questions: 1) Are axons that possess 5-HT(3) receptors excitatory? 2) Are 5-HT(3) receptors present on terminals of myelinated primary afferents? 3) What is the chemical nature of dorsal horn cells that possess 5-HT(3) receptors? 4) Do axons that possess 5-HT(3) receptors target lamina I projection cells? Approximately 45% of 5-HT(3A) immunoreactive boutons were immunoreactive for the vesicular glutamate transporter 2 and almost 80% formed synapse-like associations with GluR2 subunits of the AMPA receptor therefore it is principally glutamatergic axons that possess the receptor. Immunoreactivity was not present on myelinated primary afferent axons labeled with the B-subunit of cholera toxin or those containing the vesicular glutamate transporter 1. Calbindin (which is associated with excitatory interneurons) was found in 44% of 5-HT(3A) immunoreactive cells but other markers for inhibitory and excitatory cells were not present. Lamina I projection cells that possessed the neurokinin-1 receptor were associated with 5-HT(3A) axons but the density of contacts on individual neurons varied considerably. The results suggest that 5-HT(3) receptors are present principally on terminals of excitatory axons, and at least some of these originate from dorsal horn interneurons. The relationship between lamina I projection cells and axons possessing the 5-HT(3) receptor indicates that this receptor has an important role in regulation of ascending nociceptive information.

Elimination of bilirubin interference in creatinine assays by routine techniques: comparisons with a high performance liquid chromatography method.

The aim of this study was to find a method for creatinine analysis unaffected by jaundice by comparing four different methods with high performance liquid chromatography (HPLC) as a reference method. The methods investigated were Kodak DTSC single slide, Boehringer alkaline picrate with and without blank correction and a Boehringer enzymatic method, the last three using the Hitachi 737 analyser. HPLC results were compared with the results of the methods studied. In addition, graphs plotting the difference from the HPLC result against the bilirubin concentration were made; the ideal method would yield a slope and intercept of zero. While all methods showed a positive bias compared with HPLC, the Kodak slide and the Boehringer alkaline picrate with blank correction methods eliminated bilirubin interference and we have changed to the latter method as a consequence of this work.

Serum creatinine assays in patients receiving the antibiotic Cefpirome (HR 810): a study of three different routine methods compared with a specific HPLC method.

Sequential timed samples were taken from patients after a single dose of a new cephalosporin--Cefpirome HR810. The patients had been recruited in a multi-centre trial over a 12-month period. Creatinine was estimated in all of these specimens by four different techniques, embodying four different analytical principles. Interference from the drug was evident in the assay depending on the Jaffe reaction. There was also interference in the enzyme-based methods, manifested as increased imprecision due to a non-specified cause thought to be related to the age of the samples. Only the HPLC method guaranteed precise results free from drug interference.

An improved cation exchange HPLC method for the measurement of serum creatinine.

An improved HPLC method for the measurement of serum creatinine is described. Separation is effected using a strong cation exchange column at pH 4.7. Analytical recovery, precision and linearity are satisfactory, and the method correlates well with a kinetic Jaffé procedure. The method provides a means of accurately measuring creatinine and may be of use in the investigation of interference in creatinine assays.

Genetic analysis of the fungus, Bremia lactucae, using restriction fragment length polymorphisms.

Restriction fragment length polymorphisms (RFLPs) were developed as genetic markers for Bremia lactucae, the biotrophic Oomycete fungus which causes lettuce downy mildew. By using 55 genomic and cDNA probes, a total of 61 RFLP loci were identified among three heterothallic isolates of B. lactucae. Of these 61 RFLP loci, 53 were heterozygous in at least one of the three strains and thus were informative for linkage analysis in at least one of two F1 crosses that were performed. Analysis of the cosegregation of these 53 RFLPs, eight avirulence loci and the mating type locus allowed the construction of a preliminary genetic linkage map consisting of 13 small linkage groups. Based on the extent of linkage detected among probes, the genome of B. lactucae can be estimated to be approximately 2000 cM. Linkage was detected between a RFLP locus and an avirulence gene, providing a potential starting point for chromosome walking to clone an avirulence gene. The high frequency of DNA polymorphism in naturally occurring isolates and the proper Mendelian segregation of loci detected by low copy number probes indicates that it will be possible to construct a detailed genetic map of B. lactucae using RFLPs as markers. The method of analysis employed here should be applicable to many other outbreeding, heterozygous species for which defined inbred lines are not available.

External quality assessment of quantitative urinary analysis.

An external quality-assessment scheme was initiated among a group of 13 clinical chemistry laboratories for the urinary analysis of calcium, chloride, creatinine, glucose, osmolality, phosphate, potassium, protein, sodium, urate and urea and also for the estimation of creatinine clearance. The greatest inter-laboratory imprecision occurred in the assay of urinary protein. The results of the survey are compared with similar schemes elsewhere and their significance discussed.

Modification of the Vickers SP120 continuous flow analyser to accommodate the Scandinavian recommended conditions of enzyme analysis for aspartate aminotransferase, lactate dehydrogenase and alkaline phosphatase.

It is important that recommendations of expert bodies for the estimation of enzymes are not undermined by laboratories at District General Hospital level adopting manufacturers' procedures. Three enzyme assay methods are presented which enable adaptation of SCE kinetic methods to the end point type of determination performed on the Vickers SP120 continuous flow analyser. Despite the differences in analytical principle, good precision and correlation was obtained.