Horizontal HIV transmission to children of HIV-uninfected mothers: A case series and review of the global literature.

BACKGROUND: Vertical transmission is the predominant route for acquisition of HIV infection in children, either in utero, intrapartum or postnatally through breast feeding. Less frequently, children may acquire HIV by horizontal transmission. Horizontal transmission may be healthcare-associated (infusion of HIV-contaminated blood products, use of contaminated needles, syringes and medical equipment, or through ingestion of HIV in expressed breastmilk). Community-acquired HIV transmission to children may occur following surrogate breastfeeding, pre-mastication of food, and sexual abuse. METHODS: Children with suspected horizontally acquired HIV infection were identified by retrospective folder review of existing patients (2004-2014) and by prospective interview and examination of new patients (from 2009 onwards), at a hospital-based paediatric antiretroviral clinic in Cape Town, South Africa. The global literature on horizontal HIV transmission to children (1 January 1986-1 November 2019) was reviewed, to contextualize the local findings. RESULTS: Among the 32 children with horizontal HIV transmission (15 identified retrospectively and 17 prospectively), the median age at first diagnosis was 79 months (interquartile range 28.5-91.5); most children (90.6%) had advanced HIV disease at presentation. HIV transmission was considered healthcare-associated in 15 (46.9%), community-associated in ten (31.3%), possibly healthcare or community-associated in five (15.6 %); and unknown in two children (6.3%). CONCLUSION: Horizontal HIV transmission to children is an important public health issue, with prevention efforts requiring intervention at healthcare facility- and community-level. Greater effort should be made to promptly identify and comprehensively investigate each horizontally HIV-infected child to establish possible routes of transmission and inform future prevention strategies.

Microinjection and electroporation of embryonic kidney explants: an improved method.

Embryonic kidney explants are routinely used to study the molecular regulation of kidney development. One of the major technical challenges has been the need to express transgenes at high levels for prolonged periods of time. Existing protocols derived from work with the chick have used microinjection and electroporation with low voltage and long pulse time. In this study, we show that a high voltage with a short pulse time is preferable for mouse kidney explants. Using these conditions, gene expression is enhanced 10-fold over a 96-h period in culture with minimal toxicity. Furthermore, by modifying the site of microinjection, the ureteric bud or the metanephric mesenchyme can be targeted. We suggest that our described conditions will make microinjection and electroporation a more effective method to study gene function in the developing mouse kidney.

Overexpression of RET leads to vesicoureteric reflux in mice.

RET, a tyrosine kinase receptor essential for kidney development, has recently been shown to be important for the formation of the urinary tract. When RET is overexpressed in the HoxB7/Ret transgenic mouse, kidneys are small and cystic, and in some of the mice, the ureters are grossly dilated. Here, we report that the observed ureteral dilatation is associated with the urinary tract abnormality vesicoureteric reflux (VUR), in which urine flows retrogradely from the bladder to the ureter. Reflux was determined in vitro by injecting methylene blue into the bladders of HoxB7/Ret and wild-type mice. At postnatal day 1, 30% of HoxB7/Ret mice had VUR compared with 4% of wild-type mice (P < 0.05). The length of the intravesical ureteral tunnel was shorter in HoxB7/Ret mice compared with wild-type mice, on both the right and the left sides (P < 0.05), suggesting a basis for the higher incidence of VUR in these mutants. At embryonic day 11, the ureteric bud was found to exit more caudally from the mesonephric duct in HoxB7/Ret mice, and this may predispose them to VUR (P < 0.05). Wild-type and HoxB7/Ret mice were tested for reflux at embryonic day 17, and both showed a high frequency of VUR (59 and 75%, respectively). These results suggest that VUR may occur transiently during normal urinary tract development before the ureter has completed its insertion into the bladder. In the HoxB7/Ret mouse, overexpression of RET appears to delay the maturation of the distal ureter, resulting in postnatal VUR. The HoxB7/Ret mouse is thus an important model in which to examine how vesicoureteric reflux arises during urinary tract development.

Smad expression during kidney development.

Signaling by the transforming growth factor (TGF)-beta superfamily is important during kidney development. Here, we describe the spatial and temporal expression patterns of the Smads, the transcription factors that translate TGF- signals into gene expression. RT-PCR data and in situ hybridization analysis showed that the receptor-regulated (R) Smads (Smad1, -2, -3, -5, and -8), the common partner Smad (Smad4), and the inhibitory (I) Smads (Smad6 and -7) were all expressed during mouse kidney development from embryonic day 12 until the end of nephrogenesis at postnatal day 15. Each Smad had a distinct spatial distribution. All were expressed by mesenchymal cells in the nephrogenic zone and were downregulated once these cells began to epithelialize. The common partner Smad, Smad4, was present in uninduced mesenchymal cells and at ureteric bud tips. The bone morphogenetic-responsive R-Smads, Smad1, -5, and -8, were mainly expressed in the nephrogenic zone, whereas the TGF-- responsive R-Smads were predominantly noted in the medullary interstitium. Expression of the I-Smad Smad7 was also seen in mesenchymal cells in the interstitium. Based on the observed patterns of expression, we speculate that individual or combinations of Smads may play specific roles in cell-fate determination during kidney development.

Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial.

BACKGROUND: Bolus fibrinolytic therapy facilitates early efficient institution of reperfusion therapy. Tenecteplase is a genetically engineered variant of alteplase with slower plasma clearance, better fibrin specificity, and high resistance to plasminogen-activator inhibitor-1. We did a double-blind, randomised, controlled trial to assess the efficacy and safety of tenecteplase compared with alteplase. METHODS: In 1021 hospitals, we randomly assigned 16,949 patients with acute myocardial infarction of less than 6 h duration rapid infusion of alteplase (< or = 100 mg) or single-bolus injection of tenecteplase (30-50 mg according to bodyweight). All patients received aspirin and heparin (target activated partial thromboplastin time 50-75 s). The primary outcome was equivalence in all-cause mortality at 30 days. FINDINGS: Covariate-adjusted 30-day mortality rates were almost identical for the two groups--6.18% for tenecteplase and 6.15% for alteplase. The 95% one-sided upper boundaries of the absolute and relative differences in 30-day mortality were 0.61% and 10.00%, respectively, which met the prespecified criteria of equivalence (1% absolute or 14% relative difference in 30-day mortality, whichever difference proved smaller). Rates of intracranial haemorrhage were similar (0.93% for tenecteplase and 0.94% for alteplase), but fewer non-cerebral bleeding complications (26.43 vs 28.95%, p=0.0003) and less need for blood transfusion (4.25 vs 5.49%, p=0.0002) were seen with tenecteplase. The rate of death or non-fatal stroke at 30 days was 7.11% with tenecteplase and 7.04% with alteplase (relative risk 1.01 [95% CI 0.91-1.13]). INTERPRETATION: Tenecteplase and alteplase were equivalent for 30-day mortality. The ease of administration of tenecteplase may facilitate more rapid treatment in and out of hospital.

A single amino acid substitution in transmembrane helix VI results in overexpression of the human GnRH receptor.

OBJECTIVE: Construction of constitutively active mutants of the GnRH receptor, a member of the G-protein coupled receptor superfamily, would facilitate investigation of the mechanism of receptor activation. DESIGN: Point mutations were introduced in the human GnRH receptor in positions corresponding to those which caused constitutive activity in other G-protein coupled receptors. The effects of these mutations on ligand binding, receptor intracellular signaling and receptor expression were determined. METHODS: Wild type and mutated receptor cDNAs were expressed in COS-1 cells. Basal and agonist-stimulated inositol phosphate production and ligand binding were determined. In addition, receptor mRNA levels, cell surface receptor stability and rate of internalization were measured. RESULTS AND CONCLUSIONS: Although none of the mutant receptors exhibited constitutive activity, mutation of Phe-2 72 in transmembrane helix VI to Leu increased cell surface receptor numbers, with unchanged affinities for radiolabeled agonist, superagonist and antagonist peptides compared with wild type receptor. The cell surface receptor stability and rate of internalization were similar for wild type and F272L GnRH receptors. Thus a single amino acid mutation in transmembrane helix VI causes an increase in cell surface receptor numbers, which appears to result from an increased rate of receptor protein translation, processing or insertion into membranes.

Alanine-261 in intracellular loop III of the human gonadotropin-releasing hormone receptor is crucial for G-protein coupling and receptor internalization.

Gonadotropin-releasing hormone (GnRH) is a decapeptide that regulates reproductive function via binding to the GnRH receptor, which is a G-protein-coupled receptor (GPCR). For several members of this family, the C-terminal domain of intracellular loop III is important in ligand-mediated coupling to G-proteins; mutations in that region can lead to constitutive activity. A specific alanine residue is involved in certain GPCRs, the equivalent of which is Ala-261 in the GnRH receptor. Mutation of this residue to Leu, Ile, Lys, Glu or Phe in the human GnRH receptor did not result in constitutive activity and instead led to complete uncoupling of the receptor (failure to support GnRH-stimulated inositol phosphate production). When this residue was mutated to Gly, Pro, Ser or Val, inositol phosphate production was still supported. All the mutants retained the ability to bind ligand, and the affinity for ligand, where measured, was unchanged. These results show that Ala-261 cannot be involved in ligand binding but is critical for coupling of the receptor to its cognate G-protein. Coupling is also dependent on the size of the residue in position 261. When the amino acid side chain has a molecular mass of less than 40 Da efficient coupling is still possible, but when its molecular mass exceeds 50 Da the receptor is uncoupled. Internalization studies on the Ala261-->Lys mutant showed a marked decrease in receptor internalization compared with the wild type, indicating that coupling is necessary for effective receptor internalization in the GnRH receptor system. Activation of protein kinase C (with PMA), but not protein kinase A (with forskolin) markedly increased the internalization of the mutant receptor while having a small effect on the wild-type receptor.

Antioxidant vitamins and coronary artery disease risk in South African males.

Decreased antioxidant-vitamin nutritional status may increase lipid peroxidation and susceptibility of low-density lipoprotein (LDL) to oxidative modification. The aim of this study was to evaluate the vitamin nutritional status of coronary artery disease (CAD) patients and to assess the risk of CAD related to each individual antioxidant vitamin. The study was performed as a case-control study with 41 patients with angiographically demonstrated CAD and 41 apparently healthy age- and smoking status-matched controls. Plasma vitamin E, C and A concentrations were significantly decreased in CAD patients compared with controls (p < 0.001) after correcting for significant covariates. Per quartile decrease in vitamin A and E concentrations was associated with increased risk of CAD, even after adjusting for CAD risk factors, while per quartile decrease in vitamin C concentrations was not associated with significant CAD risk after adjusting for CAD risk factors. Decreased vitamin A and E concentrations are independently associated with increased risk of CAD independent from other CAD risk factors in white male South Africans and dietary intervention strategies are advocated.

Efficacy and tolerability of nisoldipine coat-core formulation in the treatment of essential hypertension: The South African Multicenter ANCHOR Study. Ambulatory Nisoldipine Coat-Core Hypertension Outpatient Response (ANCHOR) Investigators.

A double-blind, placebo-controlled, multicenter trial was undertaken to assess the antihypertensive efficacy and tolerability of a controlled-release (Coat-Core [CC] tablet) formulation of the second-generation dihydropyridine calcium channel antagonist, nisoldipine. Of the 208 patients with mild-to-moderate essential hypertension, two were excluded from the main efficacy analysis, and the rest randomized into one of four treatment groups, to receive either placebo, or nisoldipine CC at doses of 10, 20, or 30 mg once daily for 6 weeks, following a 4-week placebo run-in period. Blood pressure measurements (supine, standing, diastolic, and systolic) were taken at trough plasma levels, 24 h after previous dosing at 2-week intervals throughout the study. Adverse events and laboratory parameters (plasma lipid and glucose levels, and thyroid function) were monitored. All three doses of nisoldipine CC lowered blood pressure, as compared with placebo, 24 h after dosing. At endpoint (after 6 weeks) mean changes in supine blood pressure from baseline were (systolic/diastolic) 0.9/-2.3, -8.0/-5.5, -16.9/-9.0, and -15.0/-10.3 mm Hg for the groups assigned to placebo and nisoldipine CC 10, 20, and 30 mg, respectively. The response rates were 35%, 47%, and 63% for nisoldipine CC 10, 20, and 30 mg, respectively. Twenty-four-hour ambulatory blood pressure monitoring showed that nisoldipine CC effectively controlled blood pressure throughout the dosing interval. No change in heart rate was seen for all three doses of nisoldipine CC over the 24-h dosing interval. Nisoldipine CC was at least as effective in black patients as in whites. Generally adverse events were not increased, except for peripheral edema, with rates of 7% in placebo, and 6%, 9%, and 19%, respectively, in those receiving nisoldipine CC 10, 20, or 30 mg daily. There were no clinically significant changes in blood lipids, blood glucose, or thyroid function. In conclusion, once-daily nisoldipine CC at doses of 10 to 30 mg was an effective and well tolerated antihypertensive agent, providing 24-h control of blood pressure without any increase in heart rate.

Incorporation of an additional glycosylation site enhances expression of functional human gonadotropin-releasing hormone receptor.

Mutation ofN-glycosylation sites in the mouse gonadotropin-releasing hormone receptor was previously shown to impair its expression in COS-1 cells. We therefore investigated the effects of adding an extra glycosylation site to the human gonadotropin-releasing hormone receptor, as a means for increasing its expression. Covalent labeling of the mutant receptor expressed in COS-1 cells with a gonadotropin-releasing hormone (GnRH) photoreactive analog demonstrated a shift in apparent molecular weight, indicating that the new site was in fact glycosylated. The receptor with extra glycosylation site displayed normal binding affinities for agonists buserelin and [D: -Ala(6)-Pro(9)-NHEt]-GnRH, and the antagonist antide, and a slightly increased affinity for GnRH. Receptor number was increased by 1.7-fold in membrane preparations from cells expressing the mutant receptor, compared with wild-type. Photoaffinity labeling of cell-surface receptors in intact cells demonstrated a 1.8-fold increase in binding sites on the cell surface. The GnRH receptor (GnRHR) with extra glycosylation site conferred a markedly enhanced signaling response to agonist. Dose-response curves for GnRH-stimulated inositol phosphate production were left-shifted by an average of 4.4-fold, and maximal inositol phosphate responses were increased by 1.2 fold, in cells transfected with mutant compared with wild-type receptor, indicating that the increase in binding sites represented functional receptors. These results demonstrate that addition of an extra glycosylation site enhances expression of the human GnRHR, a strategy that may be applicable to other cell-surface receptors.

Post-exercise time-course analysis of ST segment and T wave changes: an important contribution to the role of stress electrocardiography in aircrew.

Flight surgeons recognize that ongoing vigilance is necessary to detect coronary artery disease (CAD) in aircrew. Regular physical examinations with only a resting electrocardiogram, albeit having a very low predictive value for detection of CAD in asymptomatic subjects, are now widely practised. Routine stress electrocardiography has been criticized for yielding too many so-called "false positive" results because ST/T changes that develop during and after exercise are prevalent. Recent studies in our institution indicate, however, that the time-course behavior patterns of these ST/T configurational "abnormalities" after exercise are different from those reflecting myocardial ischemia due to epicardial CAD. Time-course analysis increases the predictive value of exercise testing and has dramatically decreased the number of asymptomatic aircrew being subjected to coronary arteriography in our institution. Routine exercise electrocardiography provides a reliable, cost-effective means of detecting aircrew with CAD and a baseline for comparison at subsequent examination, and we strongly recommend that it be universally reinstated.

A comparative study of atenolol, nifedipine and their combination in the treatment of hypertension.

The antihypertensive effects, as assessed by clinical and ambulatory blood pressure measurement, of nifedipine slow-release (SR), atenolol and the two in combination were evaluated in 28 known hypertensives in a placebo-controlled, double-blind, randomised cross-over trial. Clinical blood pressure was significantly lower on combination therapy (P less than 0.025) than on either agent alone, although all therapeutic agents reduced blood pressure significantly when compared with placebo (P less than 0.01). All ambulatory blood pressure measurements obtained on any therapeutic agent were significantly lower than those obtained on placebo (P less than 0.01). The mean daytime (08h00-17h00) ambulatory blood pressure measurement as well as the percentage of this monitoring period during which patients were hypertensive were significantly lower (P less than 0.01) on combination therapy than on nifedipine SR. A similar pattern was observed for 24-hour ambulatory blood pressure measurements. Headache was the most significant adverse effect. This was most common with nifedipine SR, less common with combination therapy and least common with atenolol. Combination therapy with nifedipine SR and atenolol is therefore a viable therapeutic alternative in the treatment of patients with benign essential hypertension.

Observer accuracy and confirmation of the important role of abnormal ST/T time course behavior in the evaluation of stress electrocardiograms.

Routine exercise electrocardiography has been criticized for yielding too many so-called "false-positive" results. Recent studies in our institution indicate that evaluation of the time course behavior of ST segment and T wave (ST/T) changes after cessation of exercise differentiates ischemic from non-ischemic ("false-positive") stress electrocardiograms (SEs). Our method of assessing time course behavior is clarified. The principal aim of this study was to determine the accuracy of experienced observers in making this differentiation. Records of consecutive patients undergoing coronary arteriography over a 2 year period were reviewed and 30 with SEs judged positive for ischemia by the widely accepted ST/T configurational criteria alone were selected at random for the investigation. Sixteen subjects had normal coronary angiograms and had therefore previously been regarded as having false-positive SEs. Fourteen patients had at least one significantly (> 70%) stenosed coronary artery which was our yardstick for ruling that true myocardial ischemia, due to epicardial coronary artery disease (CAD), was present. Five observers, familiar with post-exercise ST/T time course patterns, independently and "blindly" analyzed all 30 configurationally abnormal SEs. Observers were informed only of the patient's age and sex; they were thus unaware of symptoms, exercise variables, coronary anatomy and the number of patients in the 2 groups. The observer consensus for ischemia of SEs using time course analysis was: total test accuracy 87%, sensitivity 79%, specificity 94%, positive predictive value 92% and negative predictive value 83%. Because all 30 patients had ST/T abnormalities, results of the sample for ischemia based on configurational criteria alone were sensitivity 100%, specificity 0% and positive predictive value 47%. We concluded that time course analysis plays a crucial role in evaluating SEs and that exercise electrocardiography remains a safe, cost-effective and reliable method of screening many asymptomatic, as well as symptomatic, subjects for CAD.

Evaluation of the post-exercise time-course behaviour of ST-segment and T-wave changes in the elimination of the false-positive stress ECG.

Routine stress ECG has been criticised for yielding too many so-called false-positive results because ST-segment and T-wave (ST/T) changes that develop during and after exercise are prevalent. Recent studies in our institutions indicate that the time-course behaviour patterns of ST/T configurational abnormalities after exercise reflecting myocardial ischaemia are different from those that do not. The epicardial coronary arteries of 111 patients, who had positive stress tests for ischaemia based on ST/T configurational changes alone but were considered non-ischaemic when the ST/T time-course behaviour was analysed, were assessed. Of these patients, 102 had normal coronary arteries, 7 had insignificant stenoses and only 2 had significant coronary artery diseases. ST/T abnormalities on stress testing with a non-ischaemic time-course pattern should be regarded in the same category as ST segments that remain normal as far as the detection of myocardial ischaemia due to epicardial coronary artery disease is concerned. This policy has resulted in an improved predictive value of exercise testing and has considerably decreased the number of patients subjected to coronary arteriography in our institutions. The assessment of the post-exercise stress ECG remains the most practical and cost-effective method for detecting ischaemic heart disease.

The aeromedical implications of atrial fibrillation.

A retrospective study was undertaken to determine the incidence of spontaneous atrial fibrillation (AF) in a group of asymptomatic pilots. The electrocardiograms of 13,037 aircrew members accumulated between 1964 and 1986 were reviewed and those coded for AF were extracted. In each case an attempt was made to investigate factors relating to the onset, course, and prognosis of the AF. Eight subjects (mean age 50.1 years) were found to have AF. Of this group, two had a single isolated episode of AF for which a specific precipitating factor was implicated, three had recurrent paroxysmal AF of which one progressed to chronic persistent AF, and three had chronic persistent AF from the outset. The mean follow-up period for the eight subjects was 13.6 years. The two pilots who had isolated attacks of AF have thus far had no subsequent episodes of AF. Five of the remaining six have been completely well, while one required treatment for an embolus to his left leg. Concerning the aeromedical implications, we believe that pilots demonstrating single isolated episodes of AF in the presence of a normal heart, and in whom recovery is complete, should be allowed to return to full aviation duties on a waiver clause. Patients with chronic AF, lone AF, or paroxysmal AF should be excluded from all flying duties.

Long-term efficacy and safety of sustained-release diltiazem in the treatment of hypertension.

The long-term efficacy and safety of sustained-release diltiazem (Tilazem; Parke-Davis) were evaluated. A total of 27 young, physically active patients with hypertension were followed up for 17 months. On a dosage of 90 mg twice daily, adequate blood pressure reduction was obtained in 23 patients (85%). No adverse effects were noted.

Effects of therapy with diet and simvastatin on atherosclerosis in hypercholesterolemic patients.

We evaluated the effect of cholesterol reduction on atherosclerotic coronary artery lesions using diet and simvastatin, a potent HMG CoA reductase inhibitor. Fifteen subjects aged 28-69 years (mean 44), each of whom demonstrated significant (greater than 50%) narrowing of a coronary artery and a baseline cholesterol level greater than 278 mg/dl, were studied. Coronary arteriography was performed prior to and after 20 +/- 2.5 months of therapy. A 42% reduction in total serum cholesterol, a 52% reduction in LDL cholesterol, and an 87% increase in the HDL/LDL cholesterol ratio (p less than 0.01) were achieved. Pretreatment and posttreatment angiograms were reviewed by three experienced angiographers with temporal order masked. Improvement in the overall status of coronary atherosclerotic lesions was demonstrated in two patients (13%), while deterioration occurred in one patient (7%). No overall change was found in the remaining 12 patients (80%). We conclude that a cholesterol-lowering regimen using a nonatherogenic diet and simvastatin therapy may at least stabilize coronary atherosclerosis.

Left anterior hemiblock in South African aircrew.

Serial ECGs and clinical records were examined to determine the prevalence, associated ECG abnormalities and outcome of left anterior hemiblock (LAH) in 13,037 airmen. The prevalence of LAH was 0.72% and it was not related to underlying cardiac disease. LAH should be regarded as a benign finding in healthy individuals.

Bezafibrate and simvastatin (MK-733) in the treatment of primary hypercholesterolaemia.

Simvastatin, a new 3-hydroxy-3-methylglutaryl co-enzyme A reductase inhibitor, was compared to bezafibrate, a fibric acid derivative, in an open cross-over placebo-controlled study. Bezafibrate was administered as a 200 mg dose 3 times daily, while simvastatin dosage ranged from 10 mg to 40 mg once daily at night. Bezafibrate produced a non-significant 13.1% (P = 0.113) decrease in total cholesterol (TC), a 20.7% (P less than 0.05) decrease in low-density lipoprotein cholesterol (LDL-C), an increase of 26.5% (P less than 0.01) in high-density lipoprotein cholesterol (HDL-C) and an improvement in the HDL:LDL ratio of 77.3% (P less than 0.01). Simvastatin 10 mg and 20 mg daily reduced TC by 18.6% and 22.6%, respectively, and LDL-C by 23.9% and 28.6% respectively (P less than 0.01), while no significant increase was noted in HDL-C. Simvastatin 40 mg daily reduced TC and LDL-C by 27.1% and 37.6%, respectively (P less than 0.01), increased HDL-C by 32.0% (P less than 0.05) and improved on the HDL:LDL ratio by 130.8% (P less than 0.01). This showed improvements over bezafibrate of 13.5% for TC, 18.9% for LDL-C, 6.0% for HDL-C and 55.8% for HDL:LDL ratio. It was concluded that simvastatin was well tolerated and had significant hypocholesterolaemic effects when taken once daily.

Safety, tolerability and efficacy of acipimox in type II hyperlipidaemia.

Twenty-one patients with type II hyperlipidaemia were treated with the nicotinic acid analogue, acipimox (Olbetam; Farmitalia), for 6 months. Total cholesterol decreased by 10% and the high-density lipoprotein: low-density lipoprotein cholesterol ratio increased by 13%. Triglycerides were unaltered. Two patients stopped the drug after developing gastro-intestinal side-effects. Acipimox therapy warrants ongoing use and further investigation.