Increasing prevalence of gonorrhoea and chlamydia among female sex workers in northern Sydney, 2005-2019.

BACKGROUND: Recent reports indicate increasing gonorrhoea and chlamydia among female sex workers (FSWs) in Australia, with decreasing condom use for oral sex. METHODS: We determined trends in prevalence and positivity of gonorrhoea and chlamydia among FSWs attending our clinic from 2005 to 2019, by analysing data from medical and pathology records. We conducted a sensitivity analysis by using an alternative prevalence definition of first test result only per calendar year. RESULTS: Prevalence of gonorrhoea (all sites: pharynx, genital, rectal) increased from 1/130 (0.8%) in 2005 to 14/166 (8.4%) in 2012, to 31/257 (12.1%) in 2019; rate ratio (RR) 1.19, 95%CI 1.14-1.24, ptrend < 0.001. There were rising trends for pharyngeal (RR 1.11, 95% CI 1.05-1.17, ptrend = 0.001) and genital gonorrhoea (RR 1.17, 95% CI 1.08-1.26, ptrend < 0.001). Prevalence of chlamydia (all sites) increased from 4/130 (3.1%) in 2005 to 8/166 (4.8%) in 2012, to 20/257 (7.8%) in 2019; RR 1.05, 95%CI 1.01-1.09, ptrend = 0.006. This rise reflected predominately pharyngeal chlamydia (RR 1.16, 95%CI 1.04-1.29, ptrend = 0.004). Qualitatively similar trends with similar significant results, were seen for gonococcal and chlamydial infections in the sensitivity analyses, indicating robustness of results to potential changes in testing frequency. Gonorrhoea and chlamydia were significantly associated with FSWs born in China. Chlamydia was significantly associated with age group 18-25. In the 2015-2019 period, of 89 women with gonococcal infections, 56 (62.9%) were pharyngeal-only; of 93 with chlamydial infections, 32 (34.4%) were pharyngeal-only infections. CONCLUSIONS: FSWs require screening for pharyngeal as well as genital infections. Enhanced and sustainable health promotion is required.

Increased targeted HIV testing and reduced undiagnosed HIV infections among gay and bisexual men.

OBJECTIVES: To evaluate the impact of government HIV strategies that aimed to increase HIV testing uptake and frequency among gay and bisexual men (GBM) in New South Wales (NSW), Australia. DESIGN: We analysed HIV testing data from existing passive and sentinel surveillance systems between 2010 and 2018. METHODS: Six indicators were measured: (1) state-wide total HIV laboratory tests; (2) number of GBM attending publicly-funded clinics; (3) 12-monthly testing uptake; (4) annual testing frequency; (5) HIV testing with a STI diagnosis; and (6) HIV positivity. Mathematical modelling was used to estimate (7) the proportion of men with undiagnosed HIV. Indicators were stratified by Australian vs. overseas-born. RESULTS: Overall, 43,560 GBM attended participating clinics (22,662 Australian-born, 20,834 overseas-born) from 2010-2018. Attendees increased from 5,186 in 2010 to 16,507 in 2018. There were increasing trends (p<0.001 for all) in testing uptake (83.9% to 95.1%); testing with a STI diagnosis (68.7% to 94.0%); annual HIV testing frequency (1.4 to 2.7); and a decreasing trend (p<0.01) in HIV positivity (1.7% to 0.9%).Increases in testing were similar in Australian-born and overseas-born GBM. However, there were decreasing trends in the estimated undiagnosed HIV proportion overall (9.5% to 7.7%) and in Australian-born GBM (7.1% to 2.8%), but an increasing trend in overseas-born GBM (15.3% to 16.9%) (p<0.001 for all).

Interrogation of a longitudinal, national pharmacy claims dataset to explore factors that predict the need for add-on therapy in older and socioeconomically disadvantaged Australians with type 2 diabetes mellitus patients (T2DM).

PURPOSE: The management of type 2 diabetes mellitus (T2DM) is complex. The aim of this work is to explore factors that predict the need for add-on therapy in patients with T2DM in the community. METHODS: We accessed longitudinal, pharmacy payment claim records from the national Pharmaceutical Benefits Scheme (PBS) (Subsidises costs of medicines: government pays difference between patient co-payments, lower in concessional patients, and additional cost of drug.) for the period January 2006 to September 2014 (EREC/MI3127) from a 10% random sample of the Australian population validated to be representative of the population by the Australian Bureau of Statistics (ABS). Likely, T2DM patients were identified as those having been dispensed a single anti-hyperglycaemic drug (monotherapy). The time taken and possible factors that might lead to the addition of a second therapy were examined. An examination was made of trends in the co-prescription of either antihypertensive or anti-hyperlipidaemic agents in relation to the time (± 3 years) of initiating an anti-hyperglycaemic agent. RESULTS: Most (83%) presumed T2DM patients were initiated with metformin. The average time until the second agent was added was 4.8 years (95% CI 4.7-4.9). Satisfactory adherence, age, male gender, initiating therapy after 2012 and initiating with a sulphonylurea drug all were significant risks for add-on therapy. There was no overall trend in the initiation of antihypertensive and/or anti-hyperlipidaemic agents with respect to the time of anti-hyperglycaemic initiation. CONCLUSION: The usefulness of a longitudinal dataset of pharmacy-claim records is demonstrated. Over half of all older and socioeconmically disadvantaged T2DM patients captured in this longitudinal claims database will be prescribed a second anti-hyperglycaemic agent within 5 years of their first drug therapy. Several factors can predict the risk of prescription of add-on therapy, and these should be considered when prescribing medications to treat T2DM.

The Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI): grading disease severity and assessing responsiveness to clinical change in epidermolysis bullosa.

BACKGROUND: The lack of validated outcome measures for epidermolysis bullosa (EB) presents major barriers to evaluating disease severity and comparing the efficacy of therapies. The Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI) was recently introduced as a valid and reliable instrument for EB; however, its interpretation for use in clinical practice and clinical trials is yet to be defined. OBJECTIVE: To assess the interpretability of the EBDASI in classifying patients according to disease severity and clinical response. METHODS: A total of 53 outpatients with EB at two interstate institutions were prospectively evaluated. At each visit, the principal dermatologist completed the EBDASI and global assessments of disease severity and change. Classifications for mild, moderate and severe disease using the EBDASI were determined using receiver operating characteristic curves. Minimal clinically important differences for the EBDASI activity subscale were calculated and compared with the standard error of measurement. RESULTS: Total EBDASI score ranges of 0-42, 43-106 and 107-506 corresponded to mild, moderate and severe disease respectively. Reduction in EBDASI activity scores of greater than 9 indicated clinically significant improvement. An increase of 3 in the activity score indicated deterioration. CONCLUSION: The EBDASI is a responsive tool and may be useful in characterizing disease severity and response. The cut-offs proposed in this study provide the first practical guide for interpreting the EBDASI, further supporting its use for longitudinal patient assessment and in clinical trials.

The significance of low-level viraemia in diverse settings: analysis of the Treat Asia HIV Observational Database (TAHOD) and the Australian HIV Observational Database (AHOD).

OBJECTIVES: The aim of the study was to assess the significance of low-level viraemia (LLV) and the timing of treatment change in low/middle-income country (L/MIC) compared with high-income country (HIC) settings. METHODS: Patients with virological control following commencement of combination antiretroviral therapy (cART) were included in the study. LLV was defined as undetectable viral load (<50 HIV-1 RNA copies/mL) followed by confirmed detectable viral load < 1000 copies/mL. Virological failure was defined as viral load > 1000 copies/mL. Kaplan-Meier plots of time to virological failure by prior LLV and income category were generated. Regimen changes in the setting of LLV were compared between sites. Sensitivity analysis of rates of LLV and virological failure by person-years and number of tests was conducted for differing definitions of LLV and virological failure. RESULTS: A total of 1748 patients from HICs and 823 patients from L/MICs were included in the study. One hundred and ninety-six (11.2%) HIC participants and 36 (4.4%) L/MIC participants experienced at least one episode of LLV. Of the patients who underwent regimen switch in HIC settings, the majority changed from a nucleoside reverse transcriptase inhibitor (NRTI)/protease inhibitor (PI) regimen to an NRTI/nonnucleoside reverse transcriptase inhibitor (NNRTI) regimen (26.8%). Very few switches were made in L/MIC settings. Rates of LLV were significantly higher for HICs compared with L/MICs per 1000 person-years (28.6 and 9.9 per 1000 person-years, respectively), but not in terms of the number of tests (9.4 and 7.2 per 1000 tests, respectively). Rates of virological failure per test were significantly higher for L/MICs compared with HICs (30.7 vs. 19.6 per 1000 tests, respectively; P < 0.001). LLV was a significant predictor of virological failure at 2 years in L/MICs [0.25; 95% confidence interval (CI) 0.11-0.50; P = 0.043] but not in HICs (0.13; 95% CI 0.08-0.22; P = 0.523). CONCLUSIONS: LLV is weakly predictive of virological failure at 2 years in L/MICs but not in HICs. This suggests that interventions targeted at subjects with LLV in L/MICs would help to improve treatment outcomes.

Does use of antiretroviral therapy regimens with high central nervous system penetration improve survival in HIV-infected adults?

OBJECTIVES: The aim of the study was to determine whether combination antiretroviral therapy (cART) with high central nervous system penetration-effectiveness (CPE) rank (neurocART) is associated with increased survival benefit compared with non-neurocART. METHODS: Prospective data were examined for HIV-positive patients in the Asia Pacific HIV Observational Database who had commenced cART. CPE rank was calculated using the 2010 rankings process. NeurocART status was assigned to regimens with a CPE rank of 8 or more. Survival was analysed using Cox proportional hazards models with covariates updated at changes in cART regimen and with deaths up to 90 days after regimen cessation attributed to that regimen. Sensitivity analyses were conducted to examine the robustness of analysis assumptions. RESULTS: Among 5882 patients, 308 deaths occurred. The hazard ratio (HR) for neurocART use was 0.89 (P=0.35) when data were stratified by cohort and adjusted for age, mode of HIV exposure, hepatitis B virus coinfection, AIDS-defining illness, CD4 count (cells/µL) and regimen count. Sensitivity analyses showed similar nonsignificant results. We also examined a composite endpoint of AIDS-defining illness or death (HR=0.93; P=0.61), baseline regimen as neurocART (HR=0.95; P=0.69), CPE category (P=0.71) and prior neurocART duration (P=0.16). No association between CD4 cell count and neurocART use was observed (P=0.52). CONCLUSIONS: Our findings do not show a significant overall survival benefit associated with neurocART compared with cART. The potential benefit associated with neurocART in terms of prevention of neurocognitive impairment did not translate into an improvement in overall survival in this population. These findings were limited by the low incidence of associated mortality. Further studies and more extensive data are needed to address these limitations.

Production of recombinant anthrax toxin receptor (ATR/CMG2) fused with human Fc in planta.

Mass vaccination against anthrax with existing vaccines is costly and unsafe due to potential side effects. For post-infection treatment, passive immunotherapy measures are currently available, most based on anthrax protective antigen (PA)-specific therapeutic antibodies. Efficient against wild-type strains, these treatment(s) might fail to protect against infections caused by genetically engineered Bacillus anthracis strains. A recent discovery revealed that the von Willebrand factor A (VWA) domain of human capillary morphogenesis protein 2 (CMG2) is an exceptionally effective anthrax toxin receptor (ATR) proficient in helping to resolve this issue. Here we describe in planta production of chimeric recombinant protein (immunoadhesin) comprised of functional ATR domain fused with the human immunoglobulin Fc fragment (pATR-Fc). The fusion design allowed us to obtain pATR-Fc in plant green tissues in a soluble form making it fairly easy to purify by Protein-A chromatography. Standardized pATR-Fc preparations (purity>90%) were shown to efficiently bind anthrax PA as demonstrated by ELISA and Western blot analysis. Recombinant pATR-Fc was also shown to protect J774A1 macrophage cells against the anthrax toxin. This study confirmed that plant-derived pATR-Fc antibody-like protein is a prospective candidate for anthrax immunotherapy.

Epifluorescent and histochemical aspects of shoot anatomy of Typha latifolia L., Typha angustifolia L. and Typha glauca Godr.

Using epifluorescent and histochemical techniques, we examined anatomical differences in the shoot organs of Typha latifolia, T. angustifolia and T. glauca. The leaf lamina of T. latifolia and T. glauca had enlarged epidermal cells and a thickened cuticle above the subepidermal vascular bundles; that of T. angustifolia lacked these characteristics. Leaf sheaths were similar among the species and all lacked the epidermal thickenings found in the lamina. The fertile stems had typical scattered vascular bundles with a band of fibres that was most prominent in T. glauca. The sterile stems were only 1 cm in length and contained a multiseriate hypodermis and a uniseriate endodermis over part of their length. The rhizomes were similar except for a pronounced band of fibres surrounding the central core in T. angustifolia. The rhizome was also characterized by an outer cortical region with a large multiseriate hypodermis/exodermis and a uniseriate endodermis with Casparian bands, suberin lamellae and secondarily thickened walls.

Evidence that the entire Golgi apparatus cycles in interphase HeLa cells: sensitivity of Golgi matrix proteins to an ER exit block.

We tested whether the entire Golgi apparatus is a dynamic structure in interphase mammalian cells by assessing the response of 12 different Golgi region proteins to an endoplasmic reticulum (ER) exit block. The proteins chosen spanned the Golgi apparatus and included both Golgi glycosyltransferases and putative matrix proteins. Protein exit from ER was blocked either by microinjection of a GTP-restricted Sar1p mutant protein in the presence of a protein synthesis inhibitor, or by plasmid-encoded expression of the same dominant negative Sar1p. All Golgi region proteins examined lost juxtanuclear Golgi apparatus-like distribution as scored by conventional and confocal fluorescence microscopy in response to an ER exit block, albeit with a differential dependence on Sar1p concentration. Redistribution of GalNAcT2 was more sensitive to low Sar1p(dn) concentrations than giantin or GM130. Redistribution was most rapid for p27, COPI, and p115. Giantin, GM130, and GalNAcT2 relocated with approximately equal kinetics. Distinct ER accumulation could be demonstrated for all integral membrane proteins. ER-accumulated Golgi region proteins were functional. Photobleaching experiments indicated that Golgi-to-ER protein cycling occurred in the absence of any ER exit block. We conclude that the entire Golgi apparatus is a dynamic structure and suggest that most, if not all, Golgi region-integral membrane proteins cycle through ER in interphase cells.

The role of cholesterol and glycosylphosphatidylinositol-anchored proteins of erythrocyte rafts in regulating raft protein content and malarial infection.

Human erythrocytes are terminally differentiated, nonendocytic cells that lack all intracellular organelles. Here we show that their plasma membranes contain detergent-resistant membrane rafts that constitute a small fraction (4%) of the total membrane protein, with a complex mixture of proteins that differentially associate with rafts. Depletion of raft-cholesterol abrogates association of all proteins with no significant effect on cholesterol:protein ratios in the rest of the membrane, lipid asymmetry, deformability, or transport properties of the bilayer, indicating that cholesterol is critical for protein assembly into rafts and suggesting that rafts have little influence on several erythrocyte functions. Erythrocytes from patients with paroxysmal nocturnal hemoglobinuria, which lack glycosylphosphatidylinositol-anchored proteins, show significant elevation in raft-cholesterol but no increase in raft protein association, suggesting that raft assembly does not require glycosylphosphatidylinositol-anchored proteins, raft proteins do not bind directly to cholesterol, and only threshold levels of raft-cholesterol are critical for protein recruitment. Loss of glycosylphosphatidylinositol-anchored proteins had no effect on erythrocytic infection by malarial parasite or movement of raft markers into the parasite's vacuole. However, infection is blocked following raft-cholesterol disruption, suggesting that erythrocyte rafts can be functionally exploited and providing the first evidence for the involvement of host rafts in an apicomplexan infection.

Vacuolar uptake of host components, and a role for cholesterol and sphingomyelin in malarial infection.

Erythrocytes, which are incapable of endocytosis or phagocytosis, can be infected by the malaria parasite Plasmodium falciparum. We find that a transmembrane protein (Duffy), glycosylphosphatidylinositol (GPI)-anchored and cytoplasmic proteins, associated with detergent-resistant membranes (DRMs) that are characteristic of microdomains in host cell membranes, are internalized by vacuolar parasites, while the major integral membrane and cytoskeletal proteins are not. The internalized host proteins and a plasmodial transmembrane resident parasitophorous vacuolar membrane (PVM) protein are detected in DRMs associated with vacuolar parasites. This is the first report of a host transmembrane protein being recruited into an apicomplexan vacuole and of the presence of vacuolar DRMs; it establishes that integral association does not preclude protein internalization into the P.FALCIPARUM: vacuole. Rather, as shown for Duffy, intracellular accumulation occurs at the same rate as that seen for a DRM-associated GPI-anchored protein. Furthermore, novel mechanisms regulated by the DRM lipids, sphingomyelin and cholesterol, mediate (i) the uptake of host DRM proteins and (ii) maintenance of the intracellular vacuole in the non-endocytic red cell, which may have implications for intracellular parasitism and pathogenesis.

A comparison of the standard 12-lead electrocardiogram to exercise electrode placements.

In order to determine the effect of electrode placement and standing on the 12-lead electrocardiogram required prior to exercise testing, 104 male patients with stable coronary heart disease were studied. Electrocardiograms were recorded with two different placements of the arm electrodes commonly used for exercise testing with the patient supine and standing. These were compared to a standard ECG with the electrodes placed at the wrists and ankles with the patient supine. The four ECGs gathered on each patient were analyzed using standard visual techniques for diagnostic changes and using a computer for analysis of axis, amplitudes, and durations. There were important differences between the standard 12-lead ECG and the ECGs gathered with the pre-exercise test modifications. These differences were minimized by placing the arm electrodes as close to the shoulders as possible and by recording the ECG with the patient supine.