Nonalcoholic fatty liver disease is associated with a risk of coronary artery disease . We evaluated whether nonalcoholic hepatic steatosis is associated with high-risk plaques as assessed by multidetector computed tomography (CT).This retrospective study involved 414 participants suspected of having coronary artery disease. Nonalcoholic hepatic steatosis was defined as a liver-to-spleen fat ratio of <1.0 and the presence and appropriate characteristics of coronary-artery plaques as assessed by coronary CT angiography. High-risk plaques were identified, as were low-density plaques, positive remodeling, and spotty calcification.vs. 44%, p<0.01), positive remodeling , and spotty calcification . The number of high-risk plaques in patients with nonalcoholic hepatic steatosis was greater than in those without nonalcoholic hepatic steatosis (p<0.01). Patients with nonalcoholic hepatic steatosis were more likely to have high-risk plaques than were those with only an elevated level of visceral adipose tissue . Multivariate analyses that included nonalcoholic hepatic steatosis, amount of visceral adipose tissue, and the presence/absence of traditional risk factors demonstrated that nonalcoholic hepatic steatosis was an independent predictor of high-risk plaques .Compared with patients who did not have nonalcoholic hepatic steatosis, patients with nonalcoholic hepatic steatosis had more low-density plaques (21% Diagnosis of nonalcoholic hepatic steatosis may be of value when assessing the risk of coronary artery disease. Nonalcoholic fatty liver disease (NAFLD) is the most frequent cause of abnormal liver function, as documented in an urban population in the USA . NAFLD iVisceral adipose tissue (VAT) has also been shown to be independently associated with metabolic syndrome, diabetes mellitus, coronary artery disease (CAD), and CAD-related deaths . The extBefore the present study, the impact of NAFLD on the presence and characteristics of coronary-artery plaques had not been investigated in detail. The purpose of this study was to determine whether NAFLD is associated with high-risk plaques as assessed by MDCT. However, the diagnosis of NAFLD by liver biopsy is difficult to apply for all patients undergoing MDCT. In the present study, nonalcoholic hepatic steatosis as defined by MDCT was evaluated for the association between NAFLD and high-risk coronary plaques.The initial population surveyed was 602 patients who had been evaluated consecutively at Okayama University Hospital  between August 2011 and March 2013 using 64-slice MDCT because of suspected CAD. Patients with implanted coronary-artery stents (n = 37) or who had coronary artery bypass graft surgery (n = 10) were excluded. Patients who had unevaluated coronary-artery segments owing to motion artifacts or inadequate contrast-medium filling were also excluded (n = 17). In addition, individuals who consumed >20 g of alcohol per day (n = 73), those with known liver disease , or who were currently using oral corticosteroids (n = 27) and/or amiodarone (n = 3) were excluded. Such exclusion criteria left 414 subjects for assessment .The present study was approved by the Ethics Committee of Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences . This study was conducted according to the principles expressed in the Declaration of Helsinki. All patients provided written informed consent to be included in the study.CT images were acquired using a SOMATOM Definition Flash instrument  as described previously . A CT acWe used axial and curved multiplanar reformatted images to evaluate the morphology of coronary-artery plaques with commercially available cardiac reconstruction software   15]. On. On15]. Before cardiac imaging, an abdominal non-contrast CT scan was carried out at the umbilical level. Waist circumference was calculated automatically at this level . VAT and2 areas that did not include large vessels or biliary structures) [Hepatic and splenic Hounsfield attenuations were measured in the largest possible regions of interest  . Regionsuctures) .2 test for categorical variables and Student’s t-test for continuous variables. We defined “higher VAT” as >74 cm2. This cutoff value was determined according to analyses of receiver operator characteristic curves for discrimination of high-risk plaques. Multivariate logistic regression analyses were adjusted for age, sex, hypertension, dyslipidemia, diabetes mellitus, smoking, higher VAT, nonalcoholic hepatic steatosis, medication use. p<0.05 was considered significant. All statistical analyses were undertaken using SPSS v17.0 for Windows .Categorical variables are the number of patients (percentage). Continuous variables are the mean ± the standard deviation (SD). Levels of triglyceride, high-sensitivity C-reactive protein (CRP), and Agatston scores are reported as medians (interquartile range). Differences between any two groups were evaluated using Pearson’s χAll patients had suspected CAD and were diagnosed clinically before coronary CT angiography as follows: effort angina (n = 171), silent myocardial ischemia (n = 221), vasospastic angina (n = 15) and acute coronary syndrome (n = 7). Of the 414 participants , 64 (15%) had nonalcoholic hepatic steatosis. Compared with patients who did not have nonalcoholic hepatic steatosis, more patients with nonalcoholic hepatic steatosis were male, used dipeptidyl peptidase-4 inhibitors and had: a higher prevalence of hypertension and diabetes mellitus; higher levels of triglyceride and LDL-cholesterol; lower level of HDL-cholesterol; higher level of hemoglobin A1c; higher level of high-sensitivity CRP; . With reCharacteristics of subjects according to the presence or absence of high-risk plaques are shown in vs. 70%, p = 0.13). However, patients with nonalcoholic hepatic steatosis had significantly more non-calcified plaques than patients who did not have nonalcoholic hepatic steatosis , positive remodeling , low-density plaques , spotty calcification , and high-risk plaques . vs. 52%, p<0.01), non-calcified plaques , positive remodeling , low-density plaques , spotty calcification , and high-risk plaques . A significant difference in the Agatston score was found for high- and low-VAT patients (37 (216) vs. 0.5 (151), p<0.01), but not for patients with and without nonalcoholic hepatic steatosis (25 (152) vs. 9 (192), p = 0.64).vs. 1.3±1.8, p = 0.03), low-density plaques , and high-risk plaques  than those who did not have nonalcoholic hepatic steatosis. Patients with higher VAT had more calcified plaques , non-calcified plaques , mixed plaques , and high-risk plaques  than those with lower VAT. No significant difference was found for coronary-artery stenosis when nonalcoholic hepatic steatosis and VAT classifications were compared.According to the univariate analysis, nonalcoholic hepatic steatosis was correlated significantly with high-risk plaques after patients had been adjusted independently for age, sex, hypertension, dyslipidemia, type-2 diabetes mellitus, smoking habits, as well as use of antihypertensive agents, statins, and hypoglycemic agents . MultivaThe main finding of the present study was a strong correlation between nonalcoholic hepatic steatosis and high-risk coronary-artery plaques independent of VAT according to multivariate logistic analyses. Nonalcoholic hepatic steatosis, therefore, is a valuable predictor of high-risk plaques.NAFLD has been suggested to be a risk factor for CAD . Non-diaPreviously, we reported that large accumulation of VAT is an independent predictor of high-risk plaques as determined by CT angiography . HoweverIn the present study, nonalcoholic hepatic steatosis was diagnosed by CT, not by liver biopsy. Recent studies have shown that, in patients with biopsy-proven NAFLD, greater thickness of epicardial fat is associated with the severity of liver fibrosis . The assThree reports have addressed the relationship between NAFLD and the characteristics of coronary plaques. Akabame and colleagues reported that plaques with lipid cores are independently associated with NAFLD after adjustment for covariates (including body mass index) for 298 patients suspected of having CAD . A smallvia increased levels of proinflammatory cytokines. Our study showed a significant difference in levels of high-sensitivity CRP for patients with nonalcoholic hepatic steatosis and in those who did not have nonalcoholic hepatic steatosis. Chronic, low-grade systemic inflammation may account for the increased prevalence of coronary plaques [The mechanism underlying the link between NAFLD and CAD is incompletely understood. NAFLD is associated with obesity, particularly with visceral obesity , 28. How plaques , 30. In  plaques  and add  plaques . HoweverSeveral population-based cohort studies have reported that NAFLD, as diagnosed by ultrasonography, is an independent predictor of cardiovascular events with an increased relative risk compared with a control population –35. Our In the present study, the prevalence of diabetes mellitus in patients with nonalcoholic hepatic steatosis was significantly higher than that in patients who did not have nonalcoholic hepatic steatosis. Nonalcoholic hepatic steatosis has been reported to be a cause of insulin resistance and diabetes mellitus , whereasOur study had limitations. First, the cross-sectional design made determination of the causal or temporal relationships between nonalcoholic hepatic steatosis and high-risk plaques difficult. Prospective studies are required to confirm our findings and to assess potential interactions between NAFLD and high-risk plaques. Second, CT results may not be sufficient for the diagnosis of NAFLD. A liver biopsy has been the gold standard for the diagnosis of NAFLD  and histIn conclusion, nonalcoholic hepatic steatosis, as assessed by the L/S attenuation ratio determined by MDCT, is strongly correlated with coronary artery plaques  independent of VAT. NAFLD may, therefore, be a relevant predictor of acute coronary syndrome.


The character of central nervous system (CNS) HIV infection and its effects on neuronal integrity vary with evolving systemic infection. Using a cross-sectional design and archived samples, we compared concentrations of cerebrospinal fluid (CSF) neuronal biomarkers in 143 samples from 8 HIV-infected subject groups representing a spectrum of untreated systemic HIV progression and viral suppression: primary infection; four groups of chronic HIV infection neuroasymptomatic (NA) subjects defined by blood CD4+ T cells of >350, 200–349, 50–199, and <50 cells/µL; HAD; treatment-induced viral suppression; and ‘elite’ controllers. Samples from 20 HIV-uninfected controls were also examined. The neuronal biomarkers included neurofilament light chain protein (NFL), total and phosphorylated tau , soluble amyloid precursor proteins alpha and beta  and amyloid beta (Aβ) fragments 1–42, 1–40 and 1–38. Comparison of the biomarker changes showed a hierarchy of sensitivity in detection and suggested evolving mechanisms with progressive injury. NFL was the most sensitive neuronal biomarker. Its CSF concentration exceeded age-adjusted norms in all HAD patients, 75% of NA CD4<50, 40% of NA CD4 50–199, and 42% of primary infection, indicating common neuronal injury with untreated systemic HIV disease progression as well as transiently during early infection. By contrast, only 75% of HAD subjects had abnormal CSF t-tau levels, and there were no significant differences in t-tau levels among the remaining groups. sAPPα and β were also abnormal (decreased) in HAD, showed less marked change than NFL with CD4 decline in the absence of HAD, and were not decreased in PHI. The CSF Aβ peptides and p-tau concentrations did not differ among the groups, distinguishing the HIV CNS injury profile from Alzheimer's disease. These CSF biomarkers can serve as useful tools in selected research and clinical settings for patient classification, pathogenetic analysis, diagnosis and management. Infection of the central nervous system (CNS) develops early during systemic human immunodeficiency virus type 1 (HIV) infection active, ongoing brain injury from static impairment related to earlier, but now inactive pathologies Much of the understanding of the effects of HIV on the CNS derives from clinical descriptions and staging A complementary approach to characterizing CNS infection and resultant active brain injury in HIV infection uses CSF biomarkers for more accurate clinical diagnosis, assessment of treatment effects and understanding of evolving pathobiology in different stages of HIV-infection, and can be attained at a single sampling rather than relying on longitudinal observation elite controllersnd, 40th and 38th amino acid of the protein .In this cross-sectional study we compared changes in a panel of neuronal biomarkers with respect to their capacity to detect and characterize neuronal injury across the spectrum of untreated systemic disease progression from early or ‘primary’ HIV infection (PHI), through systemic progression with falling blood CD4+ T cells, to the presentation with overt HAD. We also assessed these neuronal biomarkers in antiretroviral-treated patients with plasma viral suppression and in a small group of individuals with endogenous HIV control, so-called NFL, the light subunit of the neurofilament protein, is a major structural component of myelinated axons and its CSF measurement has proved to be a sensitive indictor of CNS axonal injury in a variety of neurodegenerative diseases Amyloid precursor protein (APP) is ubiquitously expressed in neurons and undergoes sequential proteolytic cleavage by secretases, resulting in metabolites that have been linked to a variety of neuropathological consequences In this study we compared changes in these neuronal biomarkers in archived samples from pre-defined patient groups representing essential stages of HIV disease progression and viral suppression in order to establish a broad overview of neuronal change with evolving HIV infection.The background clinical, laboratory and demographic data for each subject group are summarized in a priori comparisons that relate to particular facets of HIV-related CNS injury with evolving infection and treatment. We also examined broad correlations across the entire dataset and across the subjects in the six viremic HIV groups.Our main analytic focus was on differences in the CSF biomarker concentrations across the subject groups, first considering all groups and then exploring selected Groups and neuronal biomarkers with significant statistical comparisons using Kruskal-Wallis with Dunn's multiple comparison tests are listed in The highest levels of CSF NFL were noted in the HAD group with a median value more than ten-fold higher than the HIV negative controls and the laboratory upper limit of normal . When coa priori whether there is an increase in CSF NFL during PHI compared to uninfected controls) showed a statistical difference (p = 0.003) consistent with previous findings in a larger group The PHI group also showed low-level CSF NFL elevation with 42 percent of subjects having concentrations above the age-adjusted laboratory norm, though in a comparison with all other groups by Kruskal-Wallis and Dunn's multiple comparison tests this did not prove statistically significant. However, an isolated Mann-Whitney comparison of these groups . To assess the mild elevation of p-tau in HAD in relation to t-tau, we analyzed the ratio of p-tau to t-tau  which shHAD was associated with a reduction in CSF sAPPα and sAPPβ, most notably in the latter  D and E Because the concentration of CSF sAPPα and sAPPβ in PHI showed a trend to elevation rather than depression as noted with advancing CD4+ cell loss, we explored the ratio of NFL and t-tau to sAPPβ as shown in We also explored the broader correlations among the neuronal biomarkers across the entire sample set and among the six groups of untreated viremic subjects, along with their correlations with the major background biomarkers. The significant correlations of the variables among the viremic HIV-infected subjects  are highlighted in Of the CSF neuronal biomarkers, NFL correlated most commonly and strongly with the background biomarkers, negatively with blood CD4 and CD8 cell counts and with QNPZ-4 and positively with the plasma and CSF HIV RNA levels and albumin ratio . sAPPβ hThis exploratory survey provides a broad view of the changes in the neuronal injury biomarkers over the course of HIV infection and treatment. The six viremic study groups were chosen to represent distinct epochs in evolving untreated systemic infection from PHI, through progressive systemic disease with CD4+ T cell loss, to the presentation with clinically overt HAD. Treatment and host endogenous (elite) viral control were also represented to assess the CNS in two types of viral control. These results extend previous findings, place them in a broader context, and both confirm the presence of neuronal injury before overt symptoms and provide a comparison of different classes of neuronal biomarkers. The changes in neuronal biomarkers across the subject groups provide a preliminary ‘reconstructed’ sequential picture of the impact of evolving infection and immunosuppression on the CNS. The aggregate findings suggest a hierarchy of injury and its detection that not only have pathogenetic implications but also potential application in the clinical evaluation and staging of HIV-related neuronal injury and response to therapy.Among these CSF neuronal biomarkers, NFL was the most sensitive to injury and indeed demonstrated the presence of active axonal damage not only in the symptomatic HAD patients but in many of those with less apparent disease in the presence of reduced blood CD4 cells as well as during the first year of PHI. Discernable alterations in tau metabolism were largely restricted to those with HAD, while CSF amyloid proteins were also altered with reduction of sAPPβ and to a lesser degree sAPPα. The combined view of these neuronal biomarkers provides a novel characterization of the profile and evolution of neuronal injury across progressive systemic disease and viral suppression.http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/0/).In some PHI patients early CNS viral invasion was accompanied by relatively mild injury reflected in the increase in median CSF NFL concentrations with 42 percent reaching abnormal levels. This increase in CSF NFL during PHI compared to HIV-uninfected subjects has been reported in more detail elsewhere The four chronically infected NA groups were defined by blood CD4+ T cell counts into four biologically meaningful groups in order to examine neuronal changes as systemic disease progressed. Samples were chosen from our archived experience on the basis of blood CD4+ T cell counts without reference to other clinical or laboratory variables. The higher CD4+ groups reflected earlier landmarks used to guide treatment initiation while the lower CD4+ groups related to risks of opportunistic infections and death CD4 >200 cells per µL ; those from the <50 and 50–199 groups with normal CSF NFL (designated NFL-); and those from these same two low CD4 groups with CSF NFL above the age-related laboratory cutoff (designated NFL+). This importantly separated the subjects without and with detectable active axonal injury. We then compared these new groups and the HAD group for differences in the neuronal biomarkers and background variables as shown in In order to further examine the character of injury in NA patients, we examined CSF biomarker profiles after re-sorting the NA subjects on the basis of both CD4 and NFL into three new redefined groups: subjects with blood As anticipated by the definitions used in the re-grouping, CSF NFL concentrations were high in the NFL+ group, and lower but not significantly different from the HAD subjects . PerhapsExamination of the background variables after this regrouping also emphasized some of the salient features of the NFL+ group and its distinction from the NFL- groups, on the one hand, and HAD, on the other. The NFL+ group was distinguished by low CSF WBC counts  which weGiven some of the similarities of the NFL+ and HAD groups, it might be questioned whether there was really any difference between these groups and that their clinical distinction was simply a matter of under-recognition. However, in addition to their different clinical presentations which determined the differences in diagnosis prior to the study, there were distinct biological differences that distinguished the HAD group from the NFL+ group, including significantly elevated CSF t-tau, lower sAPPα and sAPPβ, elevated CSF WBCs, and raised albumin ratios. These indicate a clear difference in both neuronal biomarker profiles and in the levels of inflammation and altered blood-brain permeability. The comparison between the NFL+ and HAD groups suggests two forms or severities of major brain injury, one with a paucity of inflammation and the other more inflammatory. In HAD the background neural injury related to infection may be augmented by more robust inflammation and breakdown of the blood-brain barrier leading to neuronal body injury or death with t-tau release and the clinical presentation of subacute neurological deterioration. A simple pathway to these two types of injury is diagrammed in The samples for this patient group were selected on the basis of sustained blood viral suppression. Their CSF neural biomarker concentrations were normal except for 3 subjects with age-corrected concentrations just above the normative cutoff resulting in a higher median concentration than controls, though not statistically significant. Elsewhere, in an analysis of a larger sample, it has been suggested that CSF NFL in treated patients may remain above age-adjusted controls, though still within the normal laboratory limits The small group of elite controllers included in this study performed relatively poorly on QNZP-4 testing with a median score of −1.1. Whether this was a consequence of HIV and its control by host mechanisms is uncertain The differences in the CSF neuronal biomarkers in the various subject groups indicate a hierarchy in their capacity to detect CNS injury, with NFL > sAPPs > t-tau. An important question is whether these differences reflect mainly test sensitivity related to their CSF metabolism  and signal properties (measurement sensitivity and accuracy), or whether they indicate a hierarchy of HIV-related injury pathways. We cannot definitely answer this question from our data, though measurements of the markers were within the quantitative range of the assays and the differences in biomarker ratios among some of the groups may favor the latter.NFL was clearly the most sensitive of the CSF neuronal biomarkers and thus the most valuable for detecting HIV-related neurodegeneration over the course of infection. Not only were NFL concentrations abnormally high in all of the HAD patients, they revealed a substantial prevalence of less evident or subclinical injury in the NA groups with low blood CD4 T-cell counts as well as during the early phase of infection. In that sense, NFL serves as a standard for detecting and measuring active CNS injury in untreated HIV infection. Indeed, this was the basis of its use in regrouping the NA subjects with <200 CD4+ T cells into the NFL+ and NFL- groups. Of course, elevations of CSF NFL concentrations are not specific to HIV-related brain injury; CSF NFL concentrations have been shown to be a sensitive indictor of CNS axonal injury in a variety of neurological diseases NFL is the light subunit of the neurofilament protein, a major structural component of myelinated axons that is essential for molecular transport over the length of the axon and for normal nerve conduction CSF t-tau concentrations were frequently increased in the HAD group but not in those with low blood CD4+ T cell levels initially categorized as NA who had increased CSF NFL. P-tau was mainly present in normal concentrations in all of the subject groups, with low-level elevation in the HAD group that likely was secondary to the elevated t-tau and, in fact, was ‘disproportionately’ low in relation to t-tau compared to the other groups. These finding are compatible with previous reports, with differences related mainly to variations in diagnostic criteria, treatment status and interpretation Enhanced leakage of t-tau into CSF without a concomitant increase in p-tau in HAD likely signaled non-specific damage of cortical axons and neurons rather than a primary or selective effect on t-tau metabolism. This is similar to findings in other infections CNS amyloid metabolism was also altered by HIV infection with significant reductions in CSF sAPPβ and to a lesser extent sAPPα concentrations in HAD without substantial parallel changes in Aβ peptides , Table 3These sAPP changes contrasted with the normal CSF levels of three different Aβ peptides . Concentrations of these Aβ peptides were similar in all the studied groups, with Aβ42 actually increasing somewhat with CD4 progression across the NA and HAD groups unexpectedly correlating directly with CSF t-tau concentrations. While reported changes in CSF Aβ peptides have been varied As previously hypothesized, the current findings suggest that CNS HIV infection alters APP processing or transport The CSF neuronal biomarkers applied to this study also may be useful in selected HIV clinical research and clinical management settings, including in the identification and classification of patients with active CNS injury and in differential diagnosis of patients presenting with neurological deterioration.Since NFL is the most sensitive of the neuronal biomarkers studied in detecting the presence of active HIV-related CNS injury, it should be the most useful in assessing the presence and magnitude of active HIV-related injury. Settings where this might be clinically useful include untreated patients with background confounders that obscure whether neurological signs and symptoms are explained by active HIV-induced CNS disease. NFL may also reveal truly asymptomatic and therefore subclinical active CNS disease. In the research setting, this may be used to classify patients for studies that assess CNS efficacy of different treatment regimens or other issues related to neuronal injury.In treated patients, elevated NFL may also be useful in characterizing and managing those with symptomatic CNS escapes While CSF NFL is the most sensitive of these biomarkers, the others neuronal biomarkers may be useful for differential diagnosis, particularly for diagnosing Alzheimer's disease in an HIV-infected patient. This issue is likely to become more common as treatment extends the longevity of infected patients. Since HIV is not associated with notable elevation of CSF p-tau or depression in Aβ42 that characterize Alzheimer's disease, these biomarkers can be used to identify the latter in HIV patients suffering deteriorating cognition and help to monitor any increase in Alzheimer's disease prevalence in treated HIV infection.There are a number of limitations to this study. While the overall number of subjects was relatively large, individual groups were limited in size, particularly the important HAD group and the minor elite group that were restricted by their low incidence and availability. Analysis included many comparisons of both the biomarkers and the groups, potentially resulting in both false positive and negative associations. For this reason some of the results should be considered more exploratory than definitive. They provide a broad overview of some essential aspects of disease progression and are helpful in formulating more targeted studies. The study used cross-sectional samples to reconstruct a longitudinal process. While longitudinal study would clearly be more desirable, logistically this will become increasingly difficult as guidelines call for earlier and broader treatment. The low proportion of women in the study across all the study groups also means that the results cannot yet be clearly applied to women with HIV infection. Despite these limitations, the study raises a number of interesting points, including:There was a seeming hierarchy of detection of neuronal injury with the sensitivity of CSF NFL > CSF sAPPs (particularly sAPPβ) > CSF t-tau as CD4 fell and HAD developed. This may reflect difference in injury mechanisms, patterns, or distributions, or alternatively in the catabolism and other properties of these biomarkers after release into the CSF compartment.NFL detected mild injury during PHI and in an increasing proportion of individuals as CD4 counts were reduced in the absence of overt HAD, and in those with overt HAD.The pattern of biomarker abnormalities in PHI with elevated CSF NFL but without depressed sAPPs may suggest a different mechanism of injury during this stage than in later infection.HAD was characterized not only by higher CSF NFL, but by t-tau elevation and both elevated CSF WBC counts and blood-brain barrier breakdown that distinguished it biologically from nonHAD neuronal injury detected in the low-CD4+ NFL+ group.Altered tau metabolism in HAD (high CSF t-tau with relatively reduced p-tau) likely reflects nonspecific injury of nonmyelinated proximal axons and neuronal cell bodies, differing from AD with the latter's associated neurofibrillary tangles.The profile of CSF biomarker changes in HIV-related CNS injury is quite different from that of Alzheimer's disease and can be used to distinguish these dementing conditions. There was no reduction in Aβ42 or the other measured Aβ fragments despite the reduction in sAPPβ, nor was there a distinct elevation of p-tau in any of the HIV-infected groups, including HAD, consistent with other evidence that HAD brain injury is very different from that of Alzheimer's disease.CSF sAPPs showed an intermediate pattern of reduction, less common and marked than NFL elevation with reduced blood CD4+ counts in the absence of HAD, but trending downward. Reduced CSF sAPPs may reflect a later more severe phase in brain injury than detected by NFL elevation but may also result in part from the difficulty of detecting an overall reduction compared to an increase in the release of a neuronal metabolite.Treatment-induced viral suppression was associated with normal or near normal CSF NFL. Since the individuals in this group experienced low CD4 nadirs, it is likely that some had suffered subclinical CSF NFL elevations in the past, and hence this had normalized with treatment ; the Regional Ethics Committée Gothenburg, the IRB used by the Sahlgrenska Hospital and University of Gothenburg; and University of California Davis Institutional Review Board (the IRB of UC Davis). All CSF and blood samples were performed with written consent of subjects under one these IRB-approved protocols.PHI, defined as within the first twelve months after initial HIV-1 infection) neuroasymptomatic (NA) and divided by blood CD4+ T cell counts into those with >350, 200–349, 50–199, and CD4 <50 cells per µL; and a group presenting with clinically overt HAD. All of these subjects were either naïve to treatment or off treatment for at least 6 months at the time of sampling. Also included was a group of treated HIV+ subjects with ≥1 year of plasma virus suppression to below 50 copies/mL of HIV RNA (Rx suppressed) and a small group of untreated patients with documented HIV infection but plasma HIV RNA levels below 50 copies/mL . A group of uninfected (HIV-) volunteer subjects, confirmed by serological testing at study visit, were recruited from the San Francisco community for research assessments to provide comparison data for the HIV-infected subjects.CSF along with blood samples for assessment of background HIV status were included from 8 defined HIV-infected subject groups: early or ‘primary’ HIV infection , Cobas TaqMan RealTime HIV-1  or the Abbott RealTime HIV-1 assay . All recorded viral loads that were below the lower limit of quantitation (40 copies per mL) were standardized to a defined ‘floor’ value of 39 copies per mL for descriptive purposes. Each study visit included assessments by local clinical laboratories using routine methods to measure CSF white blood cell (WBC) count, CSF and blood albumin, and blood CD4+ and CD8+ T lymphocyte counts by flow cytometry. Some of the background characteristics of these subjects have been reported previously All subjects underwent routine clinical bedside screening for symptoms or signs of CNS opportunistic infections or other conditions that might impact CSF biomarker concentrations. Diagnosis of HAD was based on clinicians' assessment at presentation which was characteristically subacute, and met American Academy of Neurology criteria Neuronal biomarkers were assessed by enzyme-linked immunosorbent assays (ELISAs). CSF neurofilament light chain protein concentrations were measured using a sensitive sandwich method . T-tau, p-tau181 and Aβ42 were measured using the INNOTEST ELISAs . Concentrations of sAPPα and sAPPβ were determined using the MSD sAPPα/sAPPβ Multiplex Assay . To further explore Aβ fragments, we also measured three separate cleavage products  using the Abeta Triplex assay by MSD; unlike the INNOTEST antibody combination that is directed against the full Aβ1-42 molecule recognizing amino acids 1 and 42 in the sandwich, these recognize the specific C-terminal portions in combination with an N-terminal antibody (6E10) that reacts with amino acids 4 to 9. All samples were analyzed in a single run in the Laboratory of Neurochemistry at the University of Gothenburg by board-certified laboratory technicians blind to clinical data using a single batch of reagents for each assay; intra-assay coefficients of variation were below 10% for all analyses. Previously described laboratory cutoffs for CSF NFL, Aβ1-42, t-tau, and p-tau were used for descriptive analysis a priori questions used non-parametric methods including Mann-Whitney to compare two groups and Kruskal-Wallis with Dunn's post hoc test to compare three or more groups. These methods were used to focus on characteristics of these pathobiologically important subject groups representing different phases or states of HIV-infected individuals. Biomarker associations were analyzed across the entire sample set using Spearman's rank correlation. Descriptive statistics generally used medians with intraquartile ranges and the exploratory statistical comparisons used nonparametric methods because of the skewed distributions and inclusion of values below the quantitative ranges of some of the variables. All statistics were performed with GraphPad Prism .Comparison of biomarker concentrations between all and selected subject groups to address the S1 TableFull set of the data included in the analysis.(XLSX)Click here for additional data file.


Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County.We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission.Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available “always” or “sometimes”. Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including “before eating” (80 % rinsing vs. 7 % washing with soap) and “before preparing/cooking food” (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone.Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions. Overcrowded conditions, poor nutrition, and limited water, sanitation, and hygiene (WASH) facilities put refugees at high risk for communicable disease outbreaks, especially diseases transmitted by the fecal-oral route such as diarrhea and viral hepatitis A and E. In one meta-analysis, handwashing with soap has been shown to reduce diarrhea risk by 31 % and acute respiratory infection risk by 21 % .Studies on handwashing frequency, motivators, and barriers have primarily been performed in stable developing country contexts . Curtis Maban County, Upper Nile State, South Sudan experienced an influx of refugees escaping violence and civil unrest in Sudan beginning in November 2011. As of December 2013, approximately 124,000 registered refugees lived in four camps in Maban County: Kaya, Yusuf Batil, Doro, and Gendrassa , 9. In 2The four camps varied in size and demographics. Doro was predominantly Christian while Kaya, Batil, and Gendrassa were predominantly Muslim. The hepatitis E outbreak disproportionately affected individuals in Batil and what is now Kaya camp due to their physical locations in a floodplain. Different organizations were in charge of WASH activities for each camp and, thus, some camps had more handwashing stations built, others had better family:latrine ratios, and clean water provision was a priority in all camps. Latrines and, if present, handwashing stations, were shared among multiple compounds of families in each camp. The hygiene promotion also varied from camp to camp in response to the outbreak. While all agencies focused on improving access to clean water, other interventions included posters depicting important times to wash hands with soap, community health workers who provided family and school level messaging regarding handwashing, and increasing latrine and handwashing station access. The amount of soap distributed to each household monthly increased equally amongst all camps.In this study, we sought to describe the knowledge, attitudes, and practices among the refugees in three camps in Maban County 1 year after the scale up of hygiene education, increased soap distribution, and improved sanitation measures in response to the HEV outbreak. We also sought to examine the motivators and barriers to handwashing with soap including access to latrines and soap and beliefs about disease risk and transmission. Finally, we aimed to compare self-reported practices with the observed rates of handwashing with soap and rinsing with water at critical times for pathogen transmission to assess the validity of self-reported handwashing behavior compared to directly observed behavior.From November 22 through December 19, 2013, during the dry season, we conducted cross-sectional surveys of women over 18 years in each of three refugee camps . Households were selected by systematic random sampling from the UNHCR list of registered refugees of each camp. We aimed for a sample size of 200 per camp based on the following assumptions: 50 % of households would have bar soap and water at the handwashing station near the latrine; precision based on 95 % confidence interval of +/− 7 %. We increased the sample size to 230 households for Kaya and Batil and to 250 for Doro to account for non-response rate seen in the prior two camps.Eligible respondents were adult females, preferably female heads of household; if an adult female member of the household was not present, we returned at least one additional time to attempt to identify an eligible respondent. If still not present, another household on the sample list was chosen. Due to low literacy levels, verbal informed consent was obtained from all participants after an explanation of the study objectives. Participants were informed of their right to refuse to participate or answer individual questions.We developed a standardized questionnaire in English and translated it into Arabic with the enumerators. The questionnaire was piloted in Arabic and changes were made based on field testing. We collected information about demographics, handwashing knowledge, practices, and preferences, and HEV and diarrhea transmission knowledge. Questions regarding important times to use soap and when the respondent used soap were asked in both open-ended and closed-ended formats. Availability of soap and water was directly observed at latrine handwashing stations and in the household compound.We sought to conduct structured observation among a subset of 50 households per camp identified by systematic random sampling from the selected sample list of households from the UNHCR list. We felt structured observation was a critical complement to the survey as self-reported practices are known to be biased. A trained data collector observed the routine household activities and handwashing events for three hours, aiming to capture handwashing behavior–none, water alone, or soap and water– during critical events, such as before preparing or cooking food, before eating, before feeding a child, after toileting, after cleaning a child’s bottom, and after disposing a child’s feces using methods as previously described . The agehttp://opendatakit.org/; University of Washington, Seattle, WA), an open-source platform for data entry.Enumerators were trained to enter data directly into an electronic tablet using Open Data Kit . Each camp was considered a stratum. Sampling weights were created based on the inverse probability of selection. For the analysis, stratification and sample weights were used to calculate weighted point estimates and sampling errors.Structured observation analyses primarily evaluated handwashing behavior after toileting events and before food handling events.Two wealth indices were created to examine the wealth or socioeconomic status (SES) of the survey households; one based on assets owned prior to relocation to Maban and a second for assets owned after relocating. Index values were generated for each participant and participants were assigned into quartiles.Events observed during a structured observation within a household were not independent and, thus, household clustering was taken into account in the inferential statistics. SAS complex survey procedures with Taylor series linearization for variance estimation were used to take into account clustering, stratification, and unequal sample weights for both the survey and structured observation. Prevalence ratios were calculated using the Cox proportional hazards model for sample survey data via the SURVEYPHREG procedure in SAS. Significance tests were determined by chi-square test with p-value less than 0.05 considered as significant; 95 % confidence intervals were calculated.We completed 195 interviews from the randomly selected list of the first 220 in Kaya. In Batil, the list of 230 was exhausted to yield 200. In Doro, we stopped after 205 interviews due to the civil unrest that erupted on December 15 2013 and the subsequent evacuation of several team members. Therefore, the total sample was 600 households with mean household size of seven with a mean of two children under five years old (range 0–9) per household. Of the 600 respondents, the median age was 28 years . Of those respondents who could remember, nearly all (99 %) arrived in Maban in 2011 and 2012 and were thus present in the camps for at least 1 year. Households selected for structured observation were not different from the survey population with regard to household size, number of children under five years of age, soap and water access, or receipt of handwashing promotion messaging , 38 % of events. Overall, 71 % of individuals were observed rinsing hands with water at these two critical times, 23 % were observed washing hands with soap, and 6 % of individuals were observed not washing at all.Among household members observed “before food preparation/cooking”, 23 % washed hands with soap while an additional 72 % rinsed hands with water (Table p = 0.002). Similarly, compared to those under 15 years of age, the prevalence ratio for washing hands or rinsing before preparing, cooking, or eating food was 1.37 (p = <.0001) for those over 15 years of age.Age was the only factor found to be associated with hand cleansing, including both rinsing and handwashing with soap—those over 15 years old performed more hand cleansing than those 15 years and younger. With 15 and under as the referent group, the prevalence ratio for washing hands with soap or rinsing hands after toileting for those aged over 15 years was 1.27 , which does not take into account locally relevant beliefs. Didactic instructional messaging may be less effective than messages appealing to the emotive factors that can help shape behavior change, such as “disgust” and “comfort” . QualitaThe open-ended format of the self-report questions regarding times at which hands were washed with or without soap may have caused a lower response rate for some categories. That is, women were expected to name the times they wash hands with soap, rather than choose from a list, or be asked specifically about each critical time. This may account for the discrepancy between women who reported handwashing with soap before feeding a child and the women who were observed washing their hands. Another factor may be that the analysis was not limited to women with children under two years old as this information was not collected.Structured observation is subject to the reactivity in which the circumstance of being observed may influence the participants’ behavior (Hawthorne effect) . It is lAdditionally, we observed all individuals of those present in the household at the time of the observation while the survey requested information on handwashing practices from a single individual; therefore, the low observed handwashing may not have correlated with the reported behavior. However, limiting the observations to women from the household (who were more likely to be the survey respondent) did not change the percentage of observed handwashing with soap events (data not presented). We were also not able to assess whether they washed their hands inside the latrine by bringing in an ibrik, however the small size of the latrine enclosure makes this less likely.Due to logistical constraints, we stopped sampling when we reached 200 in Doro households and 195 in Kaya, which may have introduced some bias in that the sampling list of 250 and 230, respectively, were not completely sampled.The knowledge about when to use soap was high among the refugee population in Maban and a high proportion of individuals rinsed hands with water, which does confer some benefit . A substRefugee camps are a high risk setting for infectious diseases with epidemic potential. Diarrhea is a major cause of morbidity and mortality in emergencies besides the need to provide sufficient and safe water, there is a need to promote hand hygiene and provide soap that will be used for that activity . Refugee


Background: When exogenous testosterone or treatments to elevate testosterone (human chorionic gonadotropin [HCG] or Clomid) are prescribed for men who have antecedent thrombophilia, deep venous thrombosis and pulmonary embolism often occur and may recur despite adequate anticoagulation if testosterone therapy is continued. Case Presentation: A 55-year-old white male was referred to us because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis. In 2009, despite low-normal serum testosterone 334 ng/dL , he was given testosterone (TT) cypionate (50 mg/week) and human chorionic gonadotropin  for presumed hypogonadism. Ten months later, with supranormal serum T  and estradiol (E2) 45 pg/mL (UNL 41 pg/mL), he had a pulmonary embolus (PE) and was then anticoagulated for 2 years . Four years later, on TT-HCG, he had his first deep venous thrombosis (DVT). TT was stopped and HCG continued; he was anticoagulated . One year after his first DVT, on HCG, still on fondaparinux, he had a second DVT (5/315), was anticoagulated (enoxaparin + warfarin), with a Greenfield filter placed, but 8 days later had a second PE. Thrombophilia testing revealed the lupus anticoagulant. After stopping HCG, and maintained on warfarin, he has been free of further DVT-PE for 9 months. Conclusion: When DVT-PE occur on TT or HCG, in the presence of thrombophilia, TT-HCG should be stopped, lest DVT-PE reoccur despite concurrent anticoagulation. A white male, age 55, was referred to us  because of 4 thrombotic events, 3 despite adequate anticoagulation over a 5-year period. We assessed interactions between thrombophilia, exogenous testosterone therapy, and recurrent thrombosis.A previously healthy 55-year-old skilled welder developed acromegaly and had removal of a growth-hormone secreting pituitary adenoma in 2002. Seven years later (July 2009), after complaints of fatigue and increasing muscle weakness, he was found to have low-normal serum testosterone 334 ng/dL  and high estradiol [E2] 45 pg/mL , and despite these findings, he was started on 50 mg intramuscular testosterone therapy (TT) cypionate/week and intramuscular human chorionic gonadotropin (HCG) 250 IU twice/week. On TT-HCG, both serum total T and E2 became supranormal .Ten months after starting TT-HCG, in May 2010, he sustained multiple pulmonary embolus PE . SonograOn TT-HCG , his serum E2 was high , and total T was normal .In May 2014, 4 years from the initial PE, on TT-HCG but no anticoagulation, DVT #1 in the right leg was diagnosed. TT was stopped, but HCG was continued . AnticoaOn May 3, 2015, 1 year after his first DVT, despite having been on enoxaparin, then warfarin, then apixaban, and then fondaparinux, while still on HCG, his second DVT occurred . Venous We evaluated the patient for the first time in Cincinnati on May 28, 2015. Five years from his first PE, our tests of thrombophilia and hypofibrinolysis revealed the presence of the lupus anticoagulant, measured while on warfarin, with DRVVT 57.9 seconds (reference <55) and hexagonal phospholipid neutral 14.Being off the HCG for 2 weeks and off TT for a year, serum T was normal , and E2 was normal .1 without consideration of risks.2 As in this case, many men given TT do not meet well-defined diagnostic and therapeutic criteria.3 Before TT-HCG, our patient was found to have low-normal serum T  and high E2 . Despite these findings, he was started on 50 mg testosterone cypionate and HCG 500 IU per week. On TT-HCG serum total T became supranormal , and serum E2 was high , both speculatively contributing to his DVT-PE events, interacting with his lupus anticoagulant.TT is often indiscriminately prescribed4 In these 36 patients, E2 was supranormal (>42.6 pg/mL) before TT in 6%, and on TT in 14%. Conventional TT can lead to supranormal T and E2 in hypogonadal patients.In 36 hypogonadal patients in our center studied before and on conventional TT (50-60 mg gel/day) 11% developed supranormal serum T (>800 ng/mL) on TT.6 who sustained a first venous thromboembolic event (VTE) and then, while continuing TT, and despite adequate anticoagulation, sustained a second VTE. Moreover, of these 11 patients, with TT further continued, 6 men46 had a third VTE, despite continuing adequate anticoagulation. Recurrent PEs and DVTs despite anticoagulation in our current case when TT-HCG or HCG alone were continued parallels our previous 11 patients’46 recurrent thrombotic events. After stopping HCG, with continuation of warfarin, in the current study, the subject had no further DVT-PE over the subsequent 9 months of follow-up.We have previously described 11 of 67 patients with thrombophilia given exogenous TT8 However, the lupus anticoagulant can be transient and should be remeasured over time for optimal confirmation.In the current case, the sole thrombophilia identified was the lupus anticoagulant, which was present during warfarin anticoagulation. Recent studies have suggested that despite concurrent warfarin, the lupus anticoagulant can be detected by dilute Russel’s Viper Venom time.9 and Canada Health,10 based on postmarketing data, required manufacturers to add a warning to testosterone product labels about the potential risks of VTE, including DVT and PE. As a result, there is now broad public concern regarding this issue.In 2014, both the US Food and Drug Administration11 High serum E2 is common during TT therapy13 via aromatization from exogenous T and may provide a direct stimulus to thrombosis, particularly when, as in the current case, TT supplementation leads to supranormal serum T, and subsequently to supranormal E2. TT can also promote VTE via increased blood pressure,14 polycythemia,16 decrements in high-density lipoprotein cholesterol,16 blood hyperviscosity, and platelet aggregation.1618 Intramuscular TT increases platelet thromboxane A2 receptor density and platelet aggregation,19 increasing adhesion to the coronary artery endothelium and thrombus formation, with subsequent plaque rupture and acute coronary syndrome.20 Dihydrotestosterone can promote acute coronary events through enhanced monocyte activation.22TT and/or HCG are conventionally used in the treatment of hypogonadism.23 Despite the example of thrombotic and cardiovascular events related to sex-hormone therapy in postmenopausal women from the Women’s Health Initiative,25 TT is rapidly increasing, often indiscriminately, without understanding of its long-term effects.26From 2001 to 2011, androgen use in men age ≥40 has increased more than 3-fold.3 However, T levels fall with age,28 with chronic disease,30 and with obesity29 but not with smoking.32 With aging, accumulation of obesity, and development of diabetes, more and more men have lower T, but do not meet diagnostic criteria3 for hypogonadism. Moreover, most normal ranges come from healthy younger men.33 Differences in T assay methods35 and adverse muscle symptoms at different T levels further interfere with efficient diagnosis.36Use of TT in young men with classic forms of hypogonadism is considered effective and there is little disagreement regarding its use in this patient population.38 where low T has no definable etiology beyond aging and/or chronic disease, is controversial, with concerns over its effectiveness and safety.3942 Indiscriminate use of TT for LOH is a real issue,4345 as this form of therapy is administered to almost 1 in 25 American men over the age of 60.46Use of TT in men affected by late onset hypogonadism (LOH),4750 and cardiovascular ramifications.52 Adverse or intermediate cardiovascular disease (CVD) outcomes have been widely reported after TT was started.4154 In contrast, 2 studies demonstrated significant CVD event reduction on TT.40 A placebo-controlled clinical trial demonstrated that in patients age 65 or older, raising low testosterone to mid-normal range improved sexual function, mood, and symptoms of depression, but failed to improve vitality and walking distance.55 The sample size was too small provide conclusions about TT risks.55Increasing use of TT may have thrombotic4 after starting TT to 76 controls, not taking TT, who sustained DVT/PE. Of the 67 VTE TT patients, 16 (24%) were found to be heterozygous for the factor V Leiden mutation versus 7 of the 76 (7%) VTE controls not on TT, P = .004. The 67 patients with VTE on TT also were more likely than the 76 VTE no-TT controls to have the lupus anticoagulant, 9/64 (14%) versus 2/76, 3%, P = .023.4 When screening men4 for thrombophilia before starting TT, we suggest that minimal tests include the factor V Leiden mutation and the lupus anticoagulant, while more extensive tests would also include PCR for the G20210A prothrombin gene mutation, factors VIII and XI, and homocysteine.We have compared 67 patients who sustained VTE4 in an observational population study by Baillargeon et al,56 TT use was not associated with increased VTE events. Having filled a prescription for TT was not significantly associated with increased risk of VTE.56 In a retrospective study of male adults with low serum T at a low-moderate baseline risk of DVT/PE, and after excluding men with prior history of DVT/PE, cancer, hypercoagulable state, and chronic anticoagulation, Sharma et al57 did not detect a significant association between TT and risk of DVT/PE. However, almost all of our 67 subjects4 with VTE after starting TT would have been excluded by Sharma et al57 because of antecedent DVT/PE, hypercoagulable state, and chronic anticoagulation, biasing against recognizing a significant association4 between TT and DVT-PE events.57In contrast to our clinical case-control series,44 revealed that personal and family history were nonspecific and insensitive to effectively identify subjects in whom TT and estrogen replacement therapy should not be given, prescreening for thrombophilia is realistic. However, it is expensive, with average laboratory costs in our center $1200. On the other hand, direct hospital costs for VTE events are about $15 000,58 and higher for re-admission, and there are high direct and indirect costs of post–phlebitic syndrome. It would be valuable to do a pharmacoeconomic study of the number of quality of life years realized by prescreening for coagulation factors before starting TT, and the balance between the cost of hospitalization for VTE and dollars saved by prescreening. This analysis should provide an incremental cost-effectiveness ratio within a society willingness-to-pay threshold.Particularly since our recent retrospective study of men and women hospitalized for VTEWhy TT induces VTE in thrombophilic patients despite correct use of anticoagulation is unknown, but we speculate that testosterone with subsequent aromatization to estradiol must interact with underlying coagulation factors to overwhelm the expected protection from the anticoagulant.59 and therefore we do not know that it was present during the entire time frame that the patient was studied. Even if the lupus anticoagulant was only transient, based on this case and in 11 similar cases (of 67 previously reported),4 we would never continue TT despite concurrent anticoagulants in patients with previous VTE, particularly if they had familial thrombophilia or repetitively demonstrated lupus anticoagulant.A limitation of our study is that there is only one set of lupus anticoagulant data. The lupus anticoagulant may be transient,48 given exogenous TT and/or HCG, and especially in the presence of thrombophilia-hypofibrinolysis,46 we believe that continued or subsequent use of TT is contraindicated. As in this case, and in the presence of thrombophilia, continuation of anticoagulation therapy during TT repetitively fails to prevent recurrent DVT-PE, and to date, the only solution is to stop the TT. Moreover, we suggest that screening for thrombophilia be done before starting TT in order to avoid interaction of TT with underlying thrombophilia with resultant VTE. If thrombophilia is found before starting TT, this substantially changes estimations of risk-benefit ratios related to TT.When DVT-PE occurs in men or women


Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory’s data to describe the current distribution of – and trends in – transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization’s Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network. Organización Nacional de Trasplantes.In May 2004 the World Health Assembly adopted resolution WHA57.18, in recognition of the global increase in transplantation activities, the associated risks to patient safety, the trafficking of organs for transplantation and the trafficking of human beings as sources of such organs. This resolution urged the World Health Organization’s (WHO’s) Member States to implement “effective national oversight of the procurement, processing and transplantation of human cells, tissues and organs” and requested the collection of global data on practices in allogeneic transplantation and their outcomes.In this article, we used Global Observatory data to investigate the current distribution of global transplantation activities and the temporal trends in rates of solid organ transplantation for each Global Burden of Disease region.,International variation in transplantation activities is recognized to be largely unrelated to the actual distribution of medical need – correlating instead with the resources available for health-care provision.,Previous studies on this topic have focused on the number of kidney transplants per million population per year as the outcome.Box 1No local transplantation activity – either reported to the Global Observatory on Donation and Transplantation between 2006 and 2011 or detected by additional investigation.At least one kidney transplant centre – with the capacity to perform living donor nephrectomy, kidney transplantation and post-transplant management of recipients – within the country’s borders. No deceased donor activity reported to the Global Observatory on Donation and Transplantation between 2006 and 2011.Countries that have commenced deceased donor kidney transplantation within their own borders. Sufficient local capacity – including local medical expertise – exists to perform kidney recovery surgery from deceased and living donors, kidney transplantation and recipient management. Activities may also include liver transplantation and isolated cases of heart and lung transplantation.Deceased donor kidney and liver transplantation have been performed for at least five years. Heart and lung transplantation also available, either locally or via formal international cooperative organ-sharing agreements such as Eurotransplant and Scandiatransplant. Legislation permits and regulates organ donation and transplantation.An established multi-organ deceased donor transplant programme exists that is capable of providing kidney, liver, heart, lung and pancreas transplantation either locally or via formal international cooperative organ-sharing agreements. The transplant programme has been providing multi-organ deceased donor transplants consistently for at least five years, with an overall rate of transplantation in 2010 above 30 solid organ transplants per million population. The country has a government-recognized authority that is responsible for oversight of organ donation and transplantation activities.a Levels of health system capacity proposed during the WHO Madrid Consultation in 2010.n = 6020), India (n = 5482), Turkey (n = 3044), Mexico (n = 1894), Egypt (n = 1867), Japan (n = 1850), Brazil (n = 1748), Republic of Korea (n = 1620), Islamic Republic of Iran (n = 1545) and the United Kingdom of Great Britain and Northern Ireland (n = 1063). The 10 Member States with the highest deceased donor transplant numbers were the United States (n = 23 368), China (n = 6806), Brazil (n = 5097), France (n = 4634), Germany (n = 4064), Spain (n = 3886), the United Kingdom (n = 3048), Italy (n = 3020), Canada (n = 1738) and Poland (n = 1446).Counts for living and deceased donor kidney, liver, pancreas, heart, lung and small bowel transplants performed between 2006 and 2011 were obtained from the Global Observatory database.In Australasia, the rate of deceased donor transplantation increased after 2008, coinciding with the establishment of an official authority responsible for the national coordination of donation and transplantation systems.,The centralization of the coordination of organ donation and transplantation under an officially recognized authority, the reorientation of organ recovery around transplant coordinators and the systematization of donor identification and organ recovery are all key components of the frequently cited “Spanish Model” of organ donation and transplantation.Declining rates of living donor transplantation were observed in south Asia and south-east Asia, where these trends were largely driven by reduced activity in Pakistan and the Philippines, respectively. The declining rate of deceased donor transplantation observed in east Asia was driven by reduced activity in China. Pakistan signed into law the Ordinance on Human Cell and Tissue Transplantation in 2010, thus criminalizing organ sales.As at 31 December, 2011, the Global Observatory had recorded activity of at least one organ transplant in 100 Member States, including deceased donor transplantation activity in 69 Member States in the year 2011. Another 11 Member States – Bahrain, Bosnia and Herzegovina, Honduras, Iraq, Jamaica, Kazakhstan, Montenegro, Serbia, Trinidad and Tobago, Ukraine and Viet Nam – were identified, via expert review or literature and web-based searches, as currently being engaged in transplantation activity. Therefore, most (57%) of the WHO’s Member States were engaged in some level of organ transplantation activity between 2006 and 2011, and over a third (36%) reported deceased donor transplantation activity in 2011.Major geographical disparities in access to transplantation persist: 62% of the 112 939 solid organ transplants reported in 2011 were performed in high-income Member States, while only 28%, 9% and less than 1% were performed in upper-middle-, lower-middle- and low-income Member States, respectively. It is, however, noteworthy that, although the majority of organ transplantation takes place in high-income Member States, the practice of organ transplantation has now diffused across all income strata and has reached the populations of low-income Member States including Bangladesh, Kenya, Kyrgyzstan, Myanmar, Nepal and Tajikistan.n = 34), defined as having one or more centres providing living kidney transplantation, tended to have higher per capita income and notably higher physician-to-patient ratios compared with level 1 Member States. Exceptions included Bangladesh, Ghana, Kenya, Nepal, Nigeria, Pakistan and Sudan. The 23 Member States that were assigned to level 3, based on deceased donor transplantation activity, tended to have higher per capita incomes than level 2 Member States. Most level 4 Member States (n = 21) had per capita incomes and physician-to-population ratios above the global means – the exceptions being China, Colombia, South Africa and Thailand. Thirty-two of the 33 Member States assigned to level 5 had two or more physicians per thousand population and gross national incomes that exceeded 12 000 international dollars per capita – the only exception was the Islamic Republic of Iran. In logistic regression analyses of these data, higher physician-to-population ratio – but not higher gross national income per capita – was found to be significantly associated with the existence of any transplantation activity  a legal framework and regulatory oversight, (ii) an adequately resourced deceased donor programme, (iii) a waiting list of candidates who are allocated organs irrespective of gender, ethnicity or social status, (iv) an ethical living donor programme; and (v) clinical practices consistent with international standards.Box 2Even where transplantation capacity does not currently exist, epidemiological, demographic and economic transitions are increasing the demand for organ transplantation. Therefore, prospective health policies addressing the role of living and deceased donor transplantation in the health system, beginning with appropriate legislative frameworks, are warranted for all countries.For those countries seeking to improve rates of deceased donor transplantation, the efficacy of the Spanish Model of organ donation and transplantation has now been demonstrated across a diverse range of countries. The model’s key reforms include centralization of the coordination of organ donation and transplantation under an official authority, reorientation of organ recovery around transplant coordinators and the systematization of donor identification and organ recovery.Low- and lower-middle-income countries are capable of providing living donor transplantation programmes, given a willingness to allocate resources and personnel to this goal and the existence of one or more highly trained individuals. The transition from a transplant programme based only on living donors to one that also includes deceased donor transplantation requires a substantially greater investment of resources. It is also dependent on engagement with policy-makers to remove legal impediments to the recovery of organs from dead donors, and engagement with the public to increase public acceptance of deceased donation.For health systems that are underdeveloped and for countries where out-of-pocket and private payments for health-care services are high, there is a particular need for health policies that uphold the principles of equity and transparency in the provision of transplantation, and for legislation prohibiting unethical practices.Governments are accountable for the implementation of transplantation programmes in which the opportunity to benefit is shared equitably across the population. Achieving this requires: (i) appropriate legislation, regulation and oversight, (ii) registries to monitor activities and outcomes and to ensure transparency of practices; and (iii) the optimization of activities – consistent with competing demands on health resources – by focusing on specialist training, particularly the training of transplant coordinators and the implementation of a structured professional network that incorporates continuous training and performance assessment.Finally, in presenting overall regional trends, we have not commented on intraregional variation in transplantation activities or on the spatial, socioeconomic, racial and gender disparities in access to transplantation that exist within individual Member States. As the diffusion of the practice of transplantation continues, equity of access will be a major challenge. Catch-up growth, market integration, increased personal income and savings and epidemiological and demographic transitions – all of which have combined to increase the burden of organ failure in developing countries while simultaneously increasing the wealth of upper-income households – have the potential both to increase demand for transplantation and to exacerbate inequities in access within low- and middle-income countries.


Human cytomegalovirus (HCMV) infection is associated with cardiovascular disease (CVD) but the role of this virus in CVD progression remains unclear. We aimed to examine the HCMV serostatus in Russian patients (n = 90) who had undergone carotid endarterectomy (CEA) and controls (n = 82) as well as to determine the prevalence of HCMV immediate early (IE) and late (LA) antigens in carotid atherosclerotic plaques obtained from 89 patients. In addition, we sought to determine whether HCMV infection was associated with inflammatory activity in the plaque by quantifying infiltrating CD3 and CD68 positive cells and 5-LO immunoreactivity.t test was performed to connote the significance level of mean optical density between patients and controls.HCMV serology was assessed with ELISA and immunohistochemistry staining was performed to detect HCMV antigens, CD3, CD68 and 5-LO reactivity. The Fisher’s exact test was used to compare i) seroprevalence of HCMV IgG between patients and controls and ii) HCMV-positive or –negative to that of CD3, CD68 and 5-LO immunoreactive cells in plaque samples. The student-The seroprevalence for HCMV IgG was high in both patients and controls . Controls had significantly higher IgG titers for HCMV compared with patients (p = 0.0148). Strikingly, we found a high prevalence of HCMV antigens in atherosclerotic plaques; 57/89 (64%) and 47/87 (54%) were HCMV IE and LA positive, respectively. Most plaques had rather low HCMV reactivity with distinct areas of HCMV-positive cells mainly detected in shoulder regions of the plaques, but also in the area adjacent to the necrotic core and fibrous cap. In plaques, the cellular targets for HCMV infection appeared to be mainly macrophages/foam cells and smooth muscle cells. HCMV-positive plaques trended to be associated with increased numbers of CD68 positive macrophages and CD3 positive T cells, while 5-LO reactivity was high in both HCMV-positive and HCMV-negative plaques.In Russian patients undergoing CEA, HCMV proteins are abundantly expressed in carotid plaques and may contribute to the inflammatory response in plaques via enhanced infiltration of CD68 and CD3 cells. Herpesviridae[Chlamydia pneumonia, Helicobacter pylori and certain periodontal pathogens or viruses, such as herpes simplex virus and HCMV in the pathogenesis of CVD [Chlamydia pneumonia provide the strongest evidence of a link to CVD through seroepidemiological, clinical and experimental models [Human cytomegalovirus (HCMV) is a DNA virus that belongs to the family esviridae. It is aesviridae. HCMV isesviridae. Accumulesviridae. For exas of CVD ,4. Amongl models -7.HCMV has been proposed to influence various cardiovascular disease processes ,8,9. HCMInflammation is a well-established atherogenesis promoter that increases CVD risk and contributes to plaque rupture ,22. AmonBoth sera (n = 90) and human atherosclerotic plaque tissue samples (n = 89) were obtained from Russian patients with CEA that were stored in St. Petersburg Investigation of Carotid Endarterectomies (SPICE) Biobank Table . The EthHCMV IgM titers were determined by ELISA  and IgG by an in-house anti-CMV/IgG ELISA assay, Karolinska University Hospital, Sweden). This assay is used for routine clinical diagnostics at the accredited Clinical Virology Laboratory at the Karolinska University Hospital. We obtained comparable results by using this method and two commercial kits . The anti-CMV/IgM ELISA was assayed in duplicates according to the manual’s instruction. For the anti-CMV/IgG ELISA, an in-house prepared 96-well plate coated with CMV/control antigens was washed 3 times with washing buffer (0.9% NaCl/0.05% Tween 20), incubated at 37°C, 60 mins with plasma (1:500), thereafter washed 4 times and incubated with polyclonal rabbit anti-human IgG conjugated to horseradish peroxidase , 1:5000 in 1% BSA/PBS for 5 mins on a shaker at RT and thereafter for 60 mins at 37°C. After 4 washings, reactivity was detected using o-phenylenediamine. The reaction was stopped with 2.5 M sulphuric acid . The O.D. was read at 492 nm. The cut-off value for positivity was an O.D. > 0.2.IHC was performed with 8–10 μm thick acetone/methanol-fixed cryosections using ImmPRESS detection system. After endogenous peroxidase quenching, sections were sequentially incubated with protein block, Fc receptor blocker, followed by normal horse serum, all for 20 mins at RT. Primary antibodies, mouse anti-HCMV immediate early , mouse anti-HCMV late proteins , mouse anti-human CD68 , mouse anti-human CD3  and rabbit anti-5-LO  were applied and incubated overnight at 4°C. Negative controls were prepared by omitting the primary antibody (TBS only) or with isotype controls. HCMV VR1814-infected endothelial cells served as positive controls. Immunoreactivity was detected with diaminobenzidine (DAB) and counterstained with hematoxylin before microscope viewing. The staining was graded according to the estimated percentage of positive cells with grade I denoting <25%; grade II, 25-50%; grade III, 51-75% and grade IV, >75% as previously described .6 IU of HCMV in 1 ml of nuclease-free water was subjected to DNA extraction using QIAamp MinElute Virus Spin Kits (Qiagen) and the DNA was eluted with 100 μl of nuclease-free water. A standard curve was then generated using a serial of ten-fold dilution with two microliter of each dilution was used in a total volume of 10 μl reaction.Tissue plaques samples were cut into small pieces, incubated with Proteinase K overnight and DNA was extracted using DNeasy Blood & Tissue kit (Qiagen). The primers and probe sequences used for the HCMV IE DNA detection were as previously described . The Taqt test was performed to connote the significance level of mean optical density between patients and controls. A p value < 0.05 was considered statistically significant.All statistical analysis was performed using GraphPad Prism 5 software. The Fisher’s exact test was used to compare i) seroprevalence of HCMV IgG between patients and controls and ii) HCMV-positive or –negative to that of CD3, CD68 and 5-LO immunoreactive cells in plaque samples. The student-Table in vitro were positive for HCMV IE and LA  and 47/87 (54%) were positive for HCMV IE and LA, respectively Figure A. MinimaA Figure E.9 IU/ml). The non-template control consisting of water was consistently negative. The sensitivity limit of our assay was determined to be 765 IU/ml using the WHO International Standard for HCMV. We failed to extract RNA from 10 samples (each 10 tissues section slices) that was sufficient in both quantity and quality to perform TaqMan PCR as assessed by NanoDrop 2000 (Thermo Scientific).To confirm the presence of HCMV nucleic acids in plaques, we randomly selected 9 samples from HCMV IHC-positive and 9 samples of IHC-negative tissue plaques, isolated DNA and performed TaqMan PCR analysis for HCMV. We detected 4/9 (44%) samples positive for IE DNA, while none of nine IHC-negative plaques was positive for HCMV IE Table . We usedTo quantify HCMV immunoreactivity in CEA samples, we graded positive staining Figure F-2G as pTo address the question whether any association exists between HCMV IgG titers and viral burden in carotid plaques, we combined the results obtained from the serology and viral IE antigens staining analyses. Among 51 patients who were positive for HCMV IE, 10 20%) patients had O.D. < 1 and 41 (80%) patients had O.D. > 1. Among 30 HCMV IE negative patients, 6 (20%) had O.D. < 1 and 25 (80%) had O.D. > 1 , 79/82 (96%) and 84/84 (100%) of the CEA plaques were positive for 5-LO, CD3 and CD68, respectively  of the inflammatory markers. We found no statistically significant difference in the grade of inflammatory markers between those that were low HCMV IE vs. high HCMV IE reactivity: IE vs. 5-LO (p = 1.0000); IE vs. CD68 (p = 0.3408) and IE vs. CD3 (p = 0.0920). However, we observed a trend for higher immunoreactivity among HCMV-positive plaques for CD3 and CD68 compared to that of HCMV-negative plaques  of the HCMV antigen positive plaques while no HCMV IE DNA existed in HCMV antigen negative plaques (n = 9). In 75 arterial vascular tissues, a similar detection rate of HCMV DNA was reported . As we fTo our knowledge, only two earlier reports examined the presence of HCMV protein expression in atherosclerotic plaques with reasonably large sample cohorts ,38. ChiuElevated antibody levels against HCMV was shown by others to correlate positively with atherosclerosis , coronarThe concept of a low grade infection is in line with emerging views that there is an association between chronic low grade inflammation or infection and the slow process of arteriosclerosis . HCMV inIn summary, HCMV IE and LA antigens are abundantly expressed in carotid atherosclerotic plaques obtained from Russian patients. The seroprevalence of HCMV was very high in both Russian patients with CEA as well as in controls, but the IgG titers were significantly lower among patients than controls. There was abundant 5-LO expression and a substantial infiltration of CD68-positive macrophages in plaques, but relatively less prevalent infiltration of CD3-positive T cells. We observed a trend for increased infiltration of CD3-positive T cells and macrophages in HCMV-positive plaques, suggesting that this virus may influence the inflammatory activity in atherosclerotic plaques.HCMV: Human cytomegalovirus; IE: Immediate early proteins; TBS: Tris-buffered saline; CEA: Carotid endartectomy; DAB: 3, 3-diaminobenzidine; SD: Standard deviation; 5-LO: 5-lipoxygenase; SPICE: St. Petersburg Investigation of Carotid Endarterectomies; CVD: Cardiovascular disease; O.D.: Optical density.The authors declare that they have no competing interests.KCY and CSN conceived and designed the study. KCY, CT, AAM and BD performed all the experiments, analyses and generated figures. OO, ES, OR and AK provided materials crucial for the study. KCY wrote the manuscript. CSN, VW, AR, LB and AA participated in the analyses and helped in drafting the manuscript. All authors have read and approved the final manuscript.


Tube thoracostomy (TT) is widely used to resolve a number of pleural conditions. Few data are available on the complications of TT performed for non-traumatic conditions, especially in low income setting. The aim of this study is to analyse the indications and complications of TT performed for both traumatic and non-traumatic conditions of the chest in a low-income environment.This retrospective study conducted over a four years period in a the Regional Hospital, Limbe in South-West Cameroon analyses the rate and nature of complications after TT performed for both traumatic and non-traumatic conditions. Different factors related to complications are analysed.We analysed 134 patients who had 186 chest tubes inserted. After placement, tubes were either connected to a water seal system (40%) or submitted to suction (60%). Most (91%) procedures were performed for a non-traumatic condition. Non-infectious pleural effusion in patients with HIV infection or pulmonary tuberculosis was the most common indication. Sixty six per-cents of procedures were carried out by a general surgeon. The complication rate was 19.35%. The most common complications included tube dislocation and pneumothorax. Most complications were solved by replacement of the tube. The nature of operator  was a significant predictor of outcome (p < 0.01). No procedure related death was recorded.TT is a safe and efficient procedure to drain pleural collections of both traumatic and non-traumatic origins, even in low-income settings. The incidence of complications could be reduced by a better training of general practitioners on this procedure. Pneumocystis carinii infection, Kaposi's sarcoma and pneumonia [Tube thoracostomy (TT) is one of the most important modalities of treatment of pleural diseases of traumatic and non-traumatic origin. In thoracic injuries, this procedure is the most commonly used modality of treatment for hemothorax and pneumothorax –5. The nneumonia , 9.TT is known to be associated with a number of complications such as wrong placement, damage to lungs or mediastinal organs, bleeding or pain , 11, 12.This retrospective observational study was conducted in the general surgery unit of Regional Hospital Limbe, a level III institution located in the South West region of Cameroon. The study covered a period of 4 years, from January 1st 2006 to December 31st 2009. During this period, every patient, irrespective of age and sex, who had a chest tube inserted and was admitted in a ward or observed in the hospital for a minimum period of 48 hours, was included in the study. We excluded all patients who left the ward or the hospital before 48 hours for various reasons . We also excluded all patients with an encysted pleural fluid collection. For each patient included, we used a standard data collection sheet to gather information regarding patient's background, indication for TT, previous thoracocentesis, location of chest tube insertion, technique of drainage, quality of operator, duration of drainage, complications recorded and outcome. Data were analysed using Epi-info 2000 and Chi-square test were used to compare proportions. P ≤ 0.05 was considered statistically significant.A total of 203 chest tubes were inserted in 151 patients during the study period. 17 patients (11.26%) were excluded for the following reasons: discharge before 48 hours (n = 13) and death within less than 48 hours (n = 4). 134 patients who had 186 chest tubes inserted could finally be analysed. Two patients had a bilateral tube. 43 patients (32%) had TT performed more than once.Their ages ranged from 2 to 67 (mean: 34.4 ± 7.6); the male to female ratio was 0.72. All patients were symptomatic at the time of placement of chest tube; chest pain and dyspnoea at various degrees were the most common symptoms.Fifty seven patients had TT performed after a previous needle thoracocentesis performed. Of these patients, 18 (31.57%) had an associated pneumothorax on standard chest X-ray. The TT was performed by a surgeon 124 times (66.66%) and by a general practitioner in the remaining cases. It was performed in the operative room 153 times, the emergency department 21 times and in the ward 12 times.®, Tyco Healthcare). Almost all tubes were placed laterally in the 4th or 5th intercostal space. Once placed, the chest tube was connected to a water seal system 73 times (39.25%). All the remaining other chest tubes (60.75%) were submitted to a negative intra-thoracic pressure (suction) every day. All chest tubes were removed under continuous suction. No prophylactic antibiotic were administered.There was an only one make-up chest tube available in our institution during the study period; this was a steel trocard tube . As shown on One case of post-removal pneumothorax was symptomatic and required another TT. One case of non functional tube was treated with re-placement successfully; the second case failed and required referral for thoracotomy.Thoracotomy was necessary for 5 patients (3.73%). These included two cases of failure of TT defined as continuous drainage after 20 days, one case of TT related empyema thoracis and the two cases of continuous drainage after removal of the drain. No procedure related mortality was recorded.Tube thoracostomy (TT) is widely used to solve a variety of pleural conditions. The medical literature about the outcome of chest tube performed for traumatic chest conditions is rich , 19–21, HIV and tuberculous infections have been largely associated with increased risk of development of a pleural effusion , 9. The The rate of complications of chest tubes does not generally seem to be influenced by the nature of the lesion (trauma vs non-trauma) , 21, 22.In non-trauma related situations, tuberculosis and HIV infection seem to play a major role , 23, 24.The utility of needle thoracocentesis have been recently reassessed in many studies, especially when this procedure is performed using a small bore catheter to reduce the risk of iatrogenic pneumothorax , 22, 27.Our choice to perform almost all our procedures in the lateral aspect of the chest is justified by the fact that there is no difference between anterior and lateral approaches in terms of functional malposition , though The nature of the operator seems to be a clear predictor of outcome , 21, 22.Emergency department and operative room seem to be safer than inward for TT , 19. PosOur present policy of control X-ray will probably need to be revised. The immediate post-operative X-ray and the post-removal X-ray could be skipped without major risk in most patients , 35, 36.The management of these complications still relies on conservative measures such as replacement of the tube, preferably under guidance , 15. OneWhen performed with caution, TT is a safe procedure to drain pleural collections of both traumatic and non-traumatic origins, even in low-income settings. It is more useful and cause fewer complications than needle thoracocentesis, especially in the management of large pleural effusions in the context of high prevalence of HIV and pulmonary tuberculosis. However, a significant number of complications could still occur of which positional complications are the most frequent. Their real incidence is likely to be higher if appropriate investigations such as CT scan are made available to help diagnose them. The overall complication rate in settings such as ours is likely to be reduced by a better training of general practitioners on the insertion of chest tubes, as it is probable that we will still need to rely on them for a significant number of procedures. It is also likely to be reduced by standardizing the management of chest tubes by the use of guidelines with predefined criteria , 39. The