Wednesday, March 31, 2010
The overall mother-to-child transmission (MTCT) rate among HIV-positive women in St. Petersburg, Russia was 6.3%, a three-year study has revealed; the shorter the duration of treatment, the fewer drugs used and the later the start, the higher the rate of transmission.
A significantly reduced transmission rate of 2.7%, seen in a minority of women (12.8% or 149) who had dual or triple antiretroviral therapy throughout their pregnancy, showed the possibility for further reductions in perinatal transmission in Russia, Susan D. Hillis and colleagues reported in a study published in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.
Over two-thirds of women started ART late in their pregnancy or not at all, and these women were more likely not to have received antenatal care, were active injection drug users and were non-residents of the city.
The authors note that their study highlights that even with ART widely available in Russia only a minority of HIV-positive pregnant women in St. Petersburg had access to a full course of ART. However given the low transmission rate among this minority the authors point to the opportunity this presents to further reduce MTCT rates in Russia.
Antiretroviral prophylaxis to prevent perinatal HIV transmission in St. Petersburg, Russia: too little, too late.
Hillis, Susan D; PhD, Elena Kuklina; Akatova, Natalia; Kissin, Dmitry M; Vinogradova, Elena N; Rakhmanova, Aza G; Stepanova, Elena; Jamieson, Denise J; Robinson, Joanna; Vitek, Charles; Miller, William C
JAIDS Journal of Acquired Immune Deficiency Syndromes: Post Author Corrections, 03 February 2010 doi: 10.1097/QAI.0b013e3181cdaba0
Link to JAIDS abstract
Misunderstandings about proper use of antibiotics have the potential to spread widely through social networks such as Twitter, according to a report in the April issue of AJIC: American Journal of Infection Control.
Researchers from Columbia University and MixedInk (New York, NY) studied the health information content of Twitter updates mentioning antibiotics to determine how people are sharing information and assess the proliferation of misinformation. The investigation explored evidence of misunderstanding or misuse of antibiotics.
"Research focusing on microblogs and social networking services is still at an early stage," Daniel Scanfeld, MS, MA, and colleagues state in the article. "Further study is needed to assess how to promote healthy behaviors and to collect and disseminate trustworthy information using these tools." The authors stress that because health information is shared extensively on such networks, it is important for health care professionals to have a basic familiarity with social networking media services, such as Twitter. They add that such services can potentially be used to gather important real-time health data and may provide a venue to identify potential misuse or misunderstanding of antibiotics, promote positive behavior change, and disseminate valid information.
Using content analysis of 52,153 Twitter status updates ("tweets") mentioning antibiotics between March 13, 2009, and July 31, 2009, researchers categorized each tweet into one of 11 groups: general use, advice/information, side effects/negative reactions, diagnosis, resistance, misunderstanding and/or misuse, positive reactions, animals, wanting/needing, cost and other.
Once categories were established, 1,000 status updates were selected randomly from the complete list of 52,153 tweets and analyzed. The full list of tweets was further explored for cases of misunderstanding or abuse with a search for the following combinations: "flu + antibiotic(s)," "cold + antibiotic(s)," "leftover + antibiotic(s)," "share + antibiotic(s)," and "extra + antibiotic(s)."
The most common category was "general use," including a range of updates about taking antibiotics, often simply mentioning the number of days remaining on a prescription and a desire that the antibiotics begin helping soon. The second most common category was "advice and information." Some updates included the transfer of personal advice or information, such as "get antibiotics if its [sic] serious" or "Garlic generally good, but not specific to strep…" The third most prevalent category was "side effects/ negative reactions," which included a variety of complaints and side effects from taking the medication. Examples of side effects ranged from the general, such as, "those antibiotics made me want to die," to the more specific, "I am on antibiotics that make me want to vomit." Negative reactions generally revolved around inconveniences, such as not being able to drink alcohol or sensitivity to the sun.
The authors also found that while the category of "misunderstanding and/or misuse" only comprised about 700 of the more than 52,000 tweets, such misunderstandings could easily spread to a large audience due to the nature of information flow through the Twitter network. The most popular word combination in this category was "flu + antibiotics," with 345 status updates including misinformation reaching a total of 172,571 followers. The next most popular word combination was "cold + antibiotics," with 302 status updates reaching a total of 850,375 followers.
"As people change how they interact, going from passive consumption to active creation of content on the Internet, social networks have become increasingly important sources of information," said Cathryn Murphy, RN, PhD, CIC, APIC 2010 president. "These findings are a reminder that we need to continue to monitor networks such as Twitter and explore ways to positively impact public health using social networks."
Dissemination of health information through social networks: Twitter and antibiotics.
Daniel Scanfeld MS, MA, Vanessa Scanfeld MPP and Elaine L. Larson RN, PhD, FAAN, CIC
American Journal of Infection Control, April 2010,; 38 (3): 182 - 188 DOI: 10.1016/j.ajic.2009.11.004
Link to AJIC abstract
Once suppressed, the risk of viral load rising to levels associated with onward transmission is extremely low in patients taking antiretroviral therapy who have maintained a long-term undetectable viral load, Danish investigators report in the online edition of HIV Medicine.
However, they found that during the first year of HIV treatment, viral load was above the threshold of 1,000 copies/ml associated with onward transmission for approximately 5% of the time.
“In this nationwide population-based cohort study of Danish HIV-infected patients on HAART [highly active antiretroviral therapy] with more than six months of suppressed viral load, we found that the risk of experiencing a viral load above 1000 copies/ml and thereby transmitting HIV sexually was very low”, comment the investigators.
There is intense debate about the risk of people with HIV taking antiretroviral therapy and who have an undetectable viral load transmitting HIV to their sex partners if they do not use condoms.
This debate was kick-started by a statement from the Swiss Federal Commission for HIV/AIDS that stated, “a seropositive person without additional sexually transmitted disease on antiretroviral treatment with suppressed viral load cannot transmit HIV sexually.”
In order to be considered uninfectious, the Swiss said that an individual must fulfill three conditions:
- Be taking a stable antiretroviral regimen with a viral load below 50 copies/ml for at least six months.
- Have good adherence to treatment.
- Be free of any untreated sexually transmitted infections.
The Swiss also noted that their recommendations were based on data obtained from heterosexual couples in reportedly monogamous relationships.
Although no country has changed its official guidance advising condom use to prevent HIV transmission, there is some evidence that HIV-positive individuals and their partners have accepted the Swiss recommendations.
Danish HIV physicians wished to assess the likelihood of viral load increasing to levels associated with onward transmission in patients taking suppressive HIV treatment.
They therefore analyzed the viral load results of 2680 patients obtained between 2000 and 2007.
The investigators defined a plasma viral load above 1000 copies/ml as being potentially infectious, and a viral load below this level as being uninfectious. This threshold was based in part on research in heterosexual couples not receiving treatment in the Rakai district of Uganda. That study showed that no infections occurred when the HIV-positive partner had a viral load below 1500 copies/ml.
Just over a third (38%) of patients reported being in a relationship, and 78% said that they always had safer sex.
Viral load tests were performed on average every three months. The patients contributed 9348 person-years of follow-up, and the investigators calculated that for 0.6% of this time, patients had a potentially infectious viral load.
The risk of transmission was especially high during the first six months of HIV therapy, when 8% of the time was spent with a viral load above 1000 copies/ml. During the next six months, viral load was at potentially infectious levels for a little over 1% of the time.
Thereafter, viral load was above the potentially infectious threshold for an average of 0.6% of the follow-up period.
However, amongst patients who had been taking suppressive HIV treatment for over five years, only 0.03% of follow-up was spent with a viral load above 1000 copies.
Analysis by subgroup did not greatly affect these results. But the researchers did notice that injecting drug users taking suppressive HIV treatment had a potentially infectious level of viral load 1.5% of the time. This was attributed to poorer treatment adherence in this population.
“Assuming that there is a viral threshold of infectiousness, our results indicate that the risk of viraemia is very low in patients on successful antiretroviral treatment”, write the investigators.
Noting that “HIV-infected patients have, however, an increased risk of abrupt viremia in not just the first six months but the first twelve months of episodes with undetectable viral load”, the investigators recommend “there would be a substantial gain in reducing the risk of infecting the sexual partner, if the time limit recommended by the Swiss…was extended from six months to at least twelve months.”
An important limitation of this study is the inability of the investigators to assess the extent to which plasma viral load differed from viral load in genital fluids, and the extent to which any divergence might be influenced either by time on therapy, drug regimen or sexually transmitted infections.
Some sexually transmitted infections have been associated with an increased likelihood of detectable virus in genital fluids even when plasma viral load is undetectable, leading some experts to argue that in populations with high rates of sexually transmitted infections, undetectable viral load may be an unreliable markers for assessing an individual's risk of transmitting HIV.
Risk of high-level viraemia in HIV-infected patients on successful antiretroviral treatment for more than 6 months.
FN Engsig, LH Omland, MV Larsen, LD Rasmussen, T Qvist, J Gerstoft, N Obel
HIV Medicine, online edition, DOI: 10. 1111/j.1468-1293.2009.00813.x, 2010 .
Link to HIV Med abstract
Tuesday, March 30, 2010
BBC News on line (March 30, 2010)
Easter eggs and other chocolate can be good for you, as long as you eat only small amounts, according to a study of over 19,000 people, published in the European Heart Journal,
It found those who ate half a bar a week had lower blood pressure. They also had a 39% lower risk of heart attacks and strokes.
The study looked at the chocolate consumption of middle-aged men and women over eight years, comparing the health of those who ate the most and least chocolate.
The difference between these two groups was just 6 grams a day, equivalent to one small square of chocolate a day.
The lead author, Dr Brian Buijsse, from the German Institute of Human Nutrition, Nuthetal said: "Our hypothesis was that because chocolate appears to have a pronounced effect on blood pressure, therefore chocolate consumption would lower the risk of strokes and heart attacks, with a stronger effect being seen for stroke."
This is, in fact, what the study found. Those who ate more chocolate cut their risk of heart attacks by around a quarter, and of stroke by nearly half, compared with those who ate the least.
But Dr Buijsse warned that it was important people ensured that eating chocolate did not increase their overall intake of calories or reduce their consumption of healthy foods.
"Small amounts of chocolate may help to prevent heart disease, but only if it replaces other energy-dense food, such as snacks, in order to keep body weight stable," he said.
The researchers believe that flavanols in cocoa may be the reason why chocolate seems to be good for people's blood pressure and heart health.
And since there is more cocoa in dark chocolate, dark chocolate may have a greater effect.
Chocolate consumption in relation to blood pressure and risk of cardiovascular disease in German adults
Brian Buijsse, Cornelia Weikert, Dagmar Drogan, Manuela Bergmann and Heiner Boeing
European Heart Journal (2010) doi: 10.1093/eurheartj/ehq068 First published online: March 30, 2010
Link to Euro Heart Journal abstract
— It is time to discard the word euthanasia because it mixes ideas and values that confuse the debate about dying, states an editorial in CMAJ (Canadian Medical Association Journal).
"The end of life debate seems particularly burdened by confusion over the term 'euthanasia'," writes Dr. Ken Flegel, Senior Associate Editor and Dr. Paul Hébert, Editor-in-Chief, Canadian Medical Association Journal. "Both sides use it to further their ideological views: one side says murder, the other mercy; the right to live versus the right to die with dignity; selfishness versus compassion."
The term, euthanasia, is from the Greek and was coined in 1646. It was intended to mean a gentle and easy death. A nuance was introduced, by 1742, referring to the means of bringing about such a death and, in 1859, to the action of inducing such a death. Modern dictionaries have a variety of definitions, but they all imply the same meaning, an intentional action to bring about death in someone who is suffering.
"Euthanasia's broad meaning has inadvertently enveloped a set of actions that also involve the relief of symptoms in dying people," write the authors. "For example giving enough narcotic to relieve pain in cancer patients and adding enough sedation to enable comfort and minimize agitation is appropriate and compassionate care, even when the amounts required increase the probability of death. It can be argued that, in such circumstances, death becomes an acceptable side-effect of effective palliation. But, in our view, it is not euthanasia."
Physicians can help by not using "euthanasia" to refer to actions taken to assist dying patients and instead, can clearly name and define each action as well as its possible repercussions.
"As physicians, we should promote honest debate; assist in defining actions and terms; avoid further polarizing this important debate with our own values and ideologies, and help educate the public to increase engagement in this very important societal issue, "conclude the authors. "Then 'euthanasia' can experience its own gentle death."
Editorial: Time to move on from the euthanasia debate
Ken Flegel MDCM MSc and Paul C. Hébert MD MHSc
Canadian Medical Association Journal CMAJ 2010. DOI:10.1503/cmaj.100338
Link to CMAJ editorial [pdf]
Monday, March 29, 2010
Science Daily (March 29, 2010)
— The rise of multidrug resistance in gonorrhea-causing bacteria is threatening to make this sexually-transmitted infection extremely difficult to treat. Professor Catherine Ison, speaking at the Society for General Microbiology's spring meeting in Edinburgh, highlighted the very real possibility that strains of Neisseria gonorrhoeae resistant to all current treatment options could emerge in the near future.
Professor Ison, from the Health Protection Agency (HPA) in London, described how some strains of the gonococcal bacteria that cause the disease are now showing decreased sensitivity to the current antibiotics used to treat them -- ceftriaxone and cefixime.
Gonorrhea is the second most common bacterial sexually-transmitted infection and if left untreated can lead to pelvic inflammatory disease, ectopic pregnancy and infertility in women. Current treatment consists of a single dose of antibiotic given in the clinic when prescribed, by mouth for cefixime and by injection for ceftriaxone.
"Choosing an effective antibiotic can be a challenge because the organism that causes gonorrhea is very versatile and develops resistance to antibiotics very quickly," explained Professor Ison. "Penicillin was used for many years until it was no longer effective and a number of other agents have been used since. The current drugs of choice, ceftriaxone and cefixime, are still very effective but there are signs that resistance particularly to cefixime is emerging and soon these drugs may not be a good choice," she said.
Bacteria isolated from patients diagnosed with gonorrhea are tested for their susceptibility to various antibiotics to monitor patterns of resistance at a local and national level. Ongoing monitoring of antimicrobial resistance is critical to ensure that first-line treatments for gonorrhea remain effective. "There are few new drugs available and so it is probable that the current use of a single dose may soon need to be revised and treatment over several days or with more than one antibiotic will need to be considered," Professor Ison warned. "If this problem isn't addressed then there is a real possibility that gonorrhea will become a very difficult infection to treat," she said.
BBC News on line (March 28, 2009)
The opportunity to save tens of thousands of HIV patients with a simple, cheap, drug treatment is being missed, say researchers.
Giving some newly-diagnosed patients an antibiotic would significantly reduce the death toll in the early stages of the disease, they say.
A major study in The Lancet medical journal found it halved mortality.
The World Health Organization already endorses the treatment, but specialists say many people are not given the drug.
Much of the focus of the pharmaceutical battle against HIV has been on antiretroviral drugs, which can greatly extend life.
However, many patients are at greatest risk in the first weeks after diagnosis, with a variety of infections ready to take advantage of their weakened immune systems.
Studies have estimated that as many as a quarter of people who enter antiretroviral drug treatment programs in sub-Saharan Africa will die in the first year.
But the addition of co-trimoxazole, an inexpensive antibiotic, to the long-term treatment plan of those with the worst affected immune systems appears to prevent many of these deaths.
The Lancet study, carried out among 3,179 Ugandan patients, suggested a fall of 59% over the first 12 weeks, and 44% between 12 and 72 weeks.
Its authors, from the Medical Research Council Clinical Trials Unit and Imperial College in London, and centers in Uganda and Zimbabwe, say the antibiotic is not available in many places.
Professor Charles Gilks, who led the study, said any arguments over the effectiveness of the antibiotics were now "well and truly answered".
He said: "Tens of thousands of lives can be saved by more universal use of the drug, costing just a few pence a day."
Co-author Professor Diana Gibb, from the Medical Research Council, said the availability and supply of the drug needed to be "ramped up", and offered to all new patients for the first 18 months.
"There is a significant benefit now - waiting to be grasped," she said.
In addition to preventing bacterial infections in HIV patients, the drug had another welcome benefit - it cut the incidence of malaria by a quarter.
Daily co-trimoxazole prophylaxis in severely immunosuppressed HIV-infected adults in Africa started on combination antiretroviral therapy: an observational analysis of the DART cohort
Dr AS Walker PhD, D Ford PhD, Prof CF Gilks FRCP, P Munderi MBChB, F Ssali MBChB, A Reid MBChB, Prof E Katabira FRCP, Prof H Grosskurth PhD, Prof P Mugyenyi FRCP, Prof J Hakim FRCP, Prof JH Darbyshire FRCP, Prof DM Gibb MD, Prof AG Babiker PhD
The Lancet, Early Online Publication, 29 March 2010 doi:10.1016/S0140-6736(10)60057-8
Link to The Lancet abstract