Immigration can affect the evolution of TB as an AIDS-defining disease (AIDS–TB).The Barcelona AIDS register for 1994–2005 was analyzed, and the global characteristics of AIDS–TB and AIDS–non-TB cases were compared. The Mantel-Haenszel test was used in the trend analysis, and logistic regression was used in the multivariate analysis.P = 0.02). The number of cases among immigrants remained constant over the period of study, but decreased among native residents. The sociodemographic and immunological characteristics associated with TB were male sex, age younger than 36 years, inner city residence, a record of incarceration, greater than 200 CD4+ T-cells/mm3, injecting drug use, heterosexual sex, and immigration from Latin America, the Caribbean, or sub-Saharan Africa.Of the 3600 cases studied, 1130 had both AIDS and TB. A declining trend in AIDS–TB rates was observed in both sexes among both immigrants and native residents. The percentage of AIDS–TB was significantly higher among immigrants (The incidence of TB as an AIDS-defining disease decreased in Barcelona during a recent 10-year period in both native and immigrant populations. However, immigrants remain a high-risk group for AIDS–TB and should be targeted for surveillance and control of both diseases. Mycobacterium tuberculosis.1 The high prevalence of co-infection by these 2 microorganisms in many geographical areas and in specific population groups has made TB the most common AIDS-diagnostic disease in the world.2 For these reasons, the HIV pandemic has modified the epidemiology of TB and necessitated a review of the strategies for TB prevention and control.3 One method for evaluating such strategies is to analyze trends in the incidence of TB as an AIDS-defining disease in AIDS registers.4–6The human immunodeficiency virus (HIV) is the strongest risk factor for the development of tuberculosis (TB) among individuals infected with 7 Antiretroviral therapy (ART) and trends in immigration have influenced the epidemiology of these diseases in a number of countries and regions.8–10In Spain, TB has been the most common AIDS-defining disease  since pulmonary tuberculosis was introduced as a diagnostic criterion for AIDS in 1994.The aim of the present study was to examine the factors associated with TB as an AIDS-defining disease in a context where ART is free and universally available and where more than 4 million immigrants have arrived in recent years .Barcelona, the second largest city in Spain (1 605 602 inhabitants in 2006), is located in the northern part of the east coast of the country. The city AIDS register includes all patients diagnosed with AIDS who were recorded in the Epidemiological Surveillance System, which is an active system for gathering data provided by doctors, hospital discharges, and mortality databases. The register is linked to the registers of TB patients and drug users and thus provides a comprehensive data source.7 CD4 cell count/mL at diagnosis , and date of diagnosis, which was grouped into the periods 1994–1996, 1997–2000, and 2001–2005, which corresponded to the most widely used antiretroviral treatments, ie, pre-HAART, HAART with protease inhibitors, and HAART with non-nucleoside reverse transcriptase inhibitors, respectively. The collected data for AIDS–TB cases were then compared with those for AIDS–non-TB cases. Univariate analysis for categorical and continuous variables was conducted using the chi-square test and the t test, respectively. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analysis that included variables associated with AIDS–TB cases with a P-value less than 0.2, according to a maximized log-likelihood procedure.In this observational, retrospective study of prevalence, we analyzed AIDS cases among city residents older than 13 years who were included in the register between 1994 and 2005. The variables studied were sex, age at AIDS diagnosis, geographical region of origin , place of residence (inner city or other), period in prison, route of HIV infection , AIDS-defining disease (AIDS–TB for tuberculosis and AIDS–non-TB for other),TB rates and 95% CIs for the periods 1994–1998, 1999–2001, 2002–2004, and 2005 were calculated from information provided by the Barcelona City Department of Statistics. The data were obtained from the municipal censuses of, respectively, 1996, 2001, 2004 and 2005  and were subdivided by age group, sex, and nationality. Trends were analyzed using the Mantel-Haenszel test for trend.All data were systematically collected by the AIDS Registry of Barcelona City and were handled in a strictly confidential manner according to the principles of the Declaration of Helsinki, 1964, reviewed and updated by the World Medical Organisation . This study also fulfilled the requirements of law 15/1999 on the protection of data, which stipulates that the approval of an ethics committee is not required for this type of analysis.P < 0.001). Regarding time spent in Spain, 6.2% of immigrants developed AIDS within the 1st year, 46.1% between the 1st and 5th year, 25.9% between the 6th and 10th year, and 21.8% after 10 years. The corresponding distribution was 7.7%, 52.8%, 19.0%, and 20.4% among Latin Americans, and 0%, 52.4%, 21.4%, and 26.2% among sub-Saharans.A total of 3600 AIDS cases were detected, including 1130 (31.4%) AIDS–TB cases. Localization of TB was exclusively pulmonary in 60.9% of cases (688/1130), exclusively extrapulmonary in 15.0% (169/1130), and mixed in the remaining 24.2% (273/1130). The proportion of cases with smear-positive pulmonary localization was 39.5% (380/961). The time between HIV infection and a diagnosis of AIDS was less than 1 month in 38.4% of native Spaniards and 54.2% of immigrants , but not among immigrants (Table P < 0.001). This increase was mainly accounted for by males: 5.5% of AIDS–TB cases in 1994–1996 were male immigrants, which rose to 27.5% in 2001–2005 , which decreased to 7.2 per 100 000 in 2005 . The decrease in AIDS–TB rates was constant throughout the study period: on average, the rate decreased by 20% per year among both natives and immigrants , Spain (183.5 cases per million), and Barcelona (464.3 cases per million).14 Since that year, there have been consistent decreases in both the number of cases and the incidence of AIDS. As compared with 1994 values, incidence in 2005 was 75% lower (<20 cases per million) in the European Union, 80% lower (36 cases per million) in Spain, and approximately 90% lower (68.7 cases per million) in Barcelona. The marked declines in both AIDS–TB and AIDS–non-TB cases have been attributed to improvement in the immune status of HIV-infected individuals owing to highly active antiretroviral therapies (HAART) and the effectiveness of programs for prevention and control of HIV infection and TB.11,12 The reduction in AIDS–TB rates observed in our study is likely attributable to the same causes. In Spain, ART has always been widely accessible and free, and, since 1997, approximately 70% of HIV-infected individuals have been receiving HAART.13–15 HIV prevention and control activities in the city of Barcelona have been effective, especially among IDUs.16 The tuberculosis control program is also effective and may partly explain the decline in AIDS–TB cases that occurred during the pre-HAART period.17The 1994 adoption of pulmonary TB as an AIDS-defining disease among individuals infected with HIV18 the United States (5%),19 France (10%),20 Brazil (24%),21 London (19%),4 and New York (5.3%),22 and lower than incidences observed in Eastern Europe (50%)18 and Portugal (51%),18 where the incidence of TB is higher and lower, respectively.Regarding TB as an AIDS-defining disease, Barcelona has historically had high incidences of AIDS and TB, with many cases of comorbidity, which explains why more than 30% of AIDS cases had TB as their AIDS-defining disease. This percentage is higher than those observed in Central and Western Europe ,M. tuberculosis and are associated with the same population groups: males, young people, IDUs, promiscuous heterosexuals, individuals with a history of incarceration, and immigrants from countries with a high prevalence of latent tuberculosis infection (LTBI).23,24 It should be noted that, in Barcelona, the inner city is the district with the lowest socioeconomic level and the city’s highest incidences of TB and AIDS.25 The present study shows that a level of greater than 200 CD4+ T-cells/mm3 is associated with the presence of TB, which could be due to the high prevalence of LTBI.25,26 The absence in the city of outbreaks, which are associated with the presence of individuals with severe immunosuppression, indicates that endogenous reactivation and treatment of LTBI may be important in contexts where the prevalence of co-infection is high.27,28As in previous studies, the factors predicting the presence of TB as an AIDS-defining disease are consistent with the high observed prevalences of co-infection by HIV and 8,29,30 However, the endemic nature of TB-AIDS co-infection in countries of origin may not be sufficient to explain this finding. In the case of immigrants with latent tuberculosis infection (LTI) alone, the social group into which immigrants integrate in the receiving country could determine their risk of HIV infection and, therefore, the occurrence of AIDS–TB cases.31 On arrival in Spain, some immigrants become IDUs or sell sex for money, thereby increasing the risk of HIV infection.31In the present study, immigrants from Latin America, the Caribbean, and sub-Saharan Africa were more likely to develop TB as an AIDS-defining disease—as was observed in previous studies in countries with high levels of immigration from those geographical areas—probably because of the high prevalence of TB-AIDS co-infection in their countries of origin.30 It should also be noted that access to methods of early detection of HIV infection may have been impaired among immigrants, as was observed in the present study and in other Spanish studies, perhaps due to the illegal residence status of some immigrants and the fact that HIV transmission occurred mainly among heterosexuals, a group perceived as less at risk.14,15,30,34 The proportion of AIDS–TB cases increased among immigrants because the number of cases among that population remained constant over time, which was not the case among native Spaniards. A similar tendency was observed in the Spanish HIV infection registry32 and the Lazio TB registry in Italy.33AIDS–TB rates observed among immigrants were higher than among native Spaniards, but may be overestimated because of a higher real denominator due to the existence of illegal immigration. Nonetheless, other cohort studies have also found higher rates among immigrants.12,29 These findings must be interpreted with caution, however, as an immigrant population is not normally representative of its country of origin and does not reflect its epidemiological patterns. Nonetheless, it is not difficult to imagine an exchange of infections that might occur between one group with a high prevalence of LTBI and low HIV infection (immigrants) and another with lower LTBI prevalence but a higher rate of HIV infection (natives).31 This hypothesis is supported by the fact that immigrants who had been in Spain longer had developed HIV infection in that country. It thus seems likely that approximately half the comorbid immigrants arrive in Spain with co-infection, and at least one third become co-infected while living in Spain.31Immigration in Spain has increased considerably in recent years: immigrants formed 2.3% of the population in 2000 and 8.5% in 2005 . In Barcelona, the number of immigrants rose from 29 534 in the 1996 census to 260 058 in 2005 . The vast majority come from countries with higher TB rates and lower HIV infection rates than Spain . This could explain the low impact of immigration on the rate of AIDS–TB in Spain, in contrast to trends observed elsewhere, where the decline in AIDS–TB rates has been checked by the arrival of immigrants from areas of high co-infection, particularly sub-Saharan Africa.The incidence of TB as an AIDS-defining disease decreased in Barcelona during 1994–2005 in both the native and immigrant populations. To ensure that this trend continues in the future, it is essential to intensify HIV infection and TB control programs specifically directed at those immigrant groups most at risk of HIV infection .


Parenteral nutrition (PN), including intravenous lipid administration, is a life-saving therapy but can be complicated by cholestasis and liver disease. The administration of intravenous soy bean oil (SO) has been associated with the development of liver disease, while the administration of intravenous fish oil (FO) has been associated with the resolution of liver disease. The biochemical mechanism of this differential effect is unclear. This study compares SO and FO lipid emulsions in a murine model of hepatic steatosis, one of the first hits in PN-associated liver disease.We established a murine model of hepatic steatosis in which liver injury is induced by orally feeding mice a PN solution. C57BL/6J mice were randomized to receive PN alone (a high carbohydrate diet (HCD)), PN plus intravenous FO , PN plus intravenous SO , or a chow diet. After 19 days, liver tissue was harvested from all animals and subjected to metabolomic profiling.de novo fatty acid synthesis and oxidative stress. Both FO and SO relieved some of the metabolic shift towards de novo lipogenesis, but FO offered additional advantages in terms of lipid peroxidation and the generation of inflammatory precursors.The administration of an oral HCD without lipid induced profound hepatic steatosis. SO was associated with macro- and microvesicular hepatic steatosis, while FO largely prevented the development of steatosis. 321 detectable compounds were identified in the metabolomic analysis. HCD induced in vivo.Improved lipid metabolism combined with reduced oxidative stress may explain the protective effect offered by intravenous FO  Parenteral nutrition (PN) is a life-saving therapy for many patients with a variety of intestinal failure syndromes. However, PN is associated with a severe form of hepatobiliary dysfunction: PN-associated liver disease (PNALD). The manifestations of PNALD can range from steatosis and cholestasis to hepatic fibrosis, cirrhosis, and end-stage liver disease. PNALD is estimated to affect as many as 85% of neonates and 60% of infants who are PN-dependent for their nutritional needs. PN is administered in combination with a lipid emulsion to provide additional non-protein calories and prevent essential fatty acid deficiency (EFAD). There is growing evidence that PNALD may be, in part, due to the composition of the lipid emulsion that is administered with PN. Clinically, the administration of FO-based lipid emulsions has shown promise in the prevention and reversal of PNALD. Puder and colleagues have reported that infants on FO reversed cholestasis six times faster than infants on SO. de novo fatty acid synthesis and oxidative stress; (2) Both FO and SO would offer some relief from these effects of exclusive carbohydrate provision seen with the HCD alone; and (3) FO would further decrease de novo lipogenesis, lipid peroxidation, and inflammatory precursors relative to SO.The use of a broad metabolomics platform provides the distinct advantage of analyzing dozens of metabolic pathways simultaneously, thereby allowing a systems-level approach to the complex interplay among metabolic processes. We proposed several hypotheses: (1) A high-carbohydrate, PN solution provided without lipid would demonstrate a marked increase in Animal protocols complied with the NIH Animal Research Advisory Committee guidelines and were approved by the Children’s Hospital Boston Animal Care and Use Committee.We established a murine model of hepatic steatosis in which liver injury is induced by orally feeding mice a PN solution. Male 6-week-old C57BL6/J mice  were randomized to four groups, as previously described. Group 2 received the HCD plus intravenous normal saline (designated “HCD” hereafter). Groups 3 and 4 received commercial lipid emulsions via tail vein injections every other day (2.4 g of fat/kg body weight per day). Group 3 received the HCD plus intravenous fish oil (FO) ; Group 4 received the HCD plus intravenous soy bean oil (SO) . Mice were housed five per wire-bottom cage in a barrier room with regulated temperature (21°C±1.6°C), humidity (45%±10%), and an alternating 12-hour light and dark cycle. At 19 days, the animals were euthanized with carbon dioxide inhalation, after which the liver was harvested for histology and metabolic profiling.A designated lobe of the liver was fixed in 10% formalin overnight, washed with chilled phosphate buffered saline solution, and embedded in paraffin. The sections were stained with hematoxylin and eosin to examine cellular architecture. Another portion of the liver was collected as frozen sections, placed in embedding medium , and promptly immersed in liquid nitrogen. Sections were stained at the Department of Pathology, Children’s Hospital Boston with Oil Red “O” for hepatic fat. A last portion was immediately snap-frozen in liquid nitrogen and placed on dry ice for future metabolomic analysis. The samples were stored at −80°C.The sample preparation process was carried out using the automated MicroLab STAR® system from Hamilton Company. Recovery standards were added prior to the first step in the extraction process for QC purposes. Sample preparation was conducted using a proprietary series of organic and aqueous extractions to remove the protein fraction while allowing maximum recovery of small molecules. The resulting extract was divided into two fractions: one for analysis by LC and one for analysis by GC. Samples were placed briefly on a TurboVap®  to remove the organic solvent. Each sample was then frozen and dried under a vacuum. Samples were then prepared for the appropriate instrument, either LC/MS or GC/MS.. Samples were analyzed on a Thermo-Finnigan Trace DSQ fast-scanning single-quadrupole mass spectrometer using electron impact ionization.The LC/MS portion of the platform was based on a Waters ACQUITY UPLC and a Thermo-Finnigan LTQ mass spectrometer, which consisted of an electrospray ionization (ESI) source and linear ion-trap (LIT) mass analyzer. The samples destined for GC/MS analysis were re-dried under vacuum desiccation for a minimum of 24 hours prior to being derivatized under dried nitrogen using bistrimethyl-silyl-triflouroacetamide (BSTFA). The GC column was 5% phenyl and the temperature ramp was from 40° to 300°C in a 16 minute periodThe raw data was extracted, peak-identified and QC processed. Compounds were identified by comparison to library entries of purified standards or recurrent unknown entities. This library contains the retention time/index (RI), mass to charge ratio (m/z), and chromatographic data  on all molecules present in the analysis. Furthermore, biochemical identifications were based on three criteria: retention index within a narrow RI window of the proposed identification, nominal mass match to the library +/−0.2 amu, and the MS/MS forward and reverse scores between the experimental data and authentic standards. The MS/MS scores were based on a comparison of the ions present in the experimental spectrum to the ions present in the library spectrum. While there may be similarities between these molecules based on one of these factors, the use of all three data points can be utilized to distinguish and differentiate biochemicals. More than 2400 commercially available purified standard compounds have been acquired and registered into LIMS for distribution to both the LC and GC platforms for determination of their analytical characteristics.Missing values (if any) were assumed to be below the level of detection. However, biochemicals that were detected in all samples from one or more groups but not in samples from other groups were assumed to be near the lower limit of detection in the groups in which they were not detected. In this case, the lowest detected level of these biochemicals was imputed for samples in which that biochemical was not detected. Following log transformation and imputation with minimum observed values for each compound, Welch’s two-sample t-test was used to identify biochemicals that differed significantly between experimental groups. A p-value of 0.05 was adapted as the significant level. q-values were provide but not used for significance. Volcano plots were constructed to visualize the distribution of p-values . PathwayAs previously described, the administration of an oral HCD without lipid induced profound hepatic steatosis, consistent with both a high glucose diet and EFAD . SO induThree hundred and twenty one detectable compounds were identified in the metabolomic analysis.de novo in humans. In this analysis, α-linolenic acid could not be distinguished from γ-linolenic acid. As expected, the levels of linoleate and linolenate decreased significantly in the group receiving HCD alone compared to chow . Similar decreases were observed for eicosapentaenoic acid (EPA) and docosapentaenoic acid (DPA) – derived from ALA (EPA) and LA(DPA) – in HCD compared to chow . SO increased most major fatty acids, including dihomo-gammalinolenate  derived from LA, relative to the EFA-deficient HCD alone group. Notably, SO did not increase levels of the omega-3 fatty acids docosahexaenoic Acid (DHA) and DPA, even though SO contains substantial amounts (about 7%) of ALA. Compared to SO, FO increased the ω-3 FAs – DPA (5.18) and DHA (2.61) – and decreased the ω-6 FAs – LA (0.20) and arachidonic acid (0.44) (p<0.05).The essential fatty acids – classically defined as linoleate (linoleic acid) and linolenate (linolenic acid) – are the fatty acids that cannot be synthesized The hydroxyeicosatetraenoic acids (HETEs) are major mono-hydroxylated arachidonic acid metabolites that are produced during inflammatory and immunological responses. Compared to SO, FO decreased 12-HETE (0.42) and 15-HETE (0.32) (p<0.05).Glutathione metabolism is one of the major endogenous defense systems to combat cellular oxidative stress. Relative to chow, HCD alone decreased levels of 5-oxoproline (0.72) and most of the detected γ–glutamyl amino acids: γ-glutamylvaline (0.54), γ-glutamylglutamate (0.80), γ-glutamylphenylalanine (0.54), γ-glutamylthreonine (0.26) (p<0.05), all of which suggests slower glutathione turnover in the HCD group. Compared to chow, the relative concentration of taurine in the HCD group was 1.35 (p<0.05).Both FO and SO increased the concentration of reduced glutathione relative to chow . Relative to HCD, FO increased the concentration of reduced glutathione ; the trend was that SO increased reduced glutathione relative to HCD (1.16), but the difference was not statistically significant. Both FO and SO decreased the concentration of oxidized glutathione (GSSG) compared to chow  and compared to HCD .FO decreased taurine relative to HCD , suggesting less diversion of cysteine from glutathione synthesis. Compared to SO, the relative concentrations of 5-oxoproline and opthalmate were higher in FO .9-HODE and 13-HODE are the oxidized products of linoleic acid. Relative to chow, both HCD (0.46) and FO (0.11) decreased these metabolites (p<0.05). However, SO increased the concentration of 9-HODE and 13-HODE relative to chow . Compared to HCD, SO increased the concentration of this metabolite , while FO decreased its concentration . FO dramatically decreased the concentration of these oxidation products relative to SO .12,13-hydroxyoctadec-9(Z)-enoate is a lipid peroxidation product that has neutrophil chemotactic properties. Relative to chow, both HCD (0.40) and FO (0.30) decreased this metabolite (p<0.05), while SO increased its concentration . Compared to HCD, SO increased the concentration of this metabolite (3.93), and FO trended towards a decrease in concentration (0.74), though it did not reach statistical significance. FO lowered the concentration of 12,13-hydroxyoctadec-9(Z)-enoate (0.19) as compared to SO (p<0.05).α-tocopherol is a form of Vitamin E that acts as an antioxidant in the glutathione peroxidase pathway. Compared to chow, α-tocopherol was increased in HCD (4.65) and SO (3.95), but much more dramatically in FO (21.89)(p<0.05). There was no difference between SO and HCD in terms of α-tocopherol, but FO increased α-tocopherol relative to both HCD (5.55) and SO (4.70)(p<0.05).The formation of malonyl-CoA is the committed step in FA biosynthesis. The level of malonylcarnitine normally reflects the level of malonyl-CoA. Compared to chow, both HCD (0.33) and SO (0.41) decreased the relative concentration of malonylcarnitine (p<0.05), while FO produced the concentration closest to that of chow (0.78). Compared to HCD, FO (2.36) but not SO (1.25) produced a statistically significant increase in malonylcarnitine (p<0.05). FO significantly increased malonylcarnitine relative to SO .de novo lipogenesis particularly as reflected in the increased saturated fatty acids and the monounsaturated fatty acids with an ω-9 configuration. The glycogen breakdown products maltotriose, maltotetraose, maltopentaose, and maltohexaose also decreased significantly in the HCD group compared to chow (p<0.05), consistent with reduced glyogenolysis.The levels of long-chain fatty acids (LCFAs), including myristate, myristoleate, palmitate, palmitoleate, 10-heptadecenoate, oleate, 10-nonadecenoate, eicosenoate, dihomo-linoleate, docosadienoate, and docosatrienoate were increased in HCD as compared to chow (p<0.05), suggesting greater The intermediates in the TCA cycle – malate, fumarate, succinate and succinylcarnitine – did not differ between the HCD and chow groups. These intermediates increased significantly in both SO and FO groups in relation to HCD and chow (p<0.05), which suggests improved aerobic glycolysis with the addition of lipid of either type.Carnitine transports long-chain acyl groups from fatty acids into the mitochondrial matrix, where they can be metabolized via beta-oxidation. Compared to the chow group, carnitine was reduced significantly in HCD (0.67) and SO (0.74), but there was no statistically significant difference between FO and chow. Relative to HCD, FO had a higher concentration of carnitine , while SO did not. FO had a higher concentration of carnitine compared to SO , which is indicative of increased fatty acid oxidation with FO. The levels of ascorbate were increased in both FO (1.25) and SO (1.42) as compared to HCD alone, which again is consistent with increased oxidative metabolism.Increased glycerol and decreased glycerate are indicative of increased glycerol metabolism. Compared to chow, HCD (2.22), SO (2.97), and FO (1.57) increased levels of glycerol. Both HCD (0.57) and SO (0.72) decreased levels of glycerate (p<0.05), while FO did not.Relative to chow, only SO raised glycerol 3-phosphate (G3P) levels (p<0.05), while HCD and FO did not. Relative to HCD, SO raised G3P levels , but FO did not (0.82). FO reduced glycerol (0.53) and G3P (0.57) relative to SO (p<0.05). HCD appears to increase lipogenesis, with these changes partially attenuated by FO but not SO.Phospholipids form lipid bilayers as part of cell membranes, and they are composed of three parts: a diglyceride, a phosphate group, and an organic molecule. Compared to chow, HCD, SO, and FO all had statistically significant reductions in phospholipid head groups – choline and ethanolamine– and their phosphorylated derivatives – choline phosphate and phosphoethanolamine (p<0.05). Most of the detected lysolipids, including 1-palmitoylglycerophosphocholine (0.42) and 1-stearoylglycerophosphocholine (0.39), showed significant decreases in HCD alone relative to chow (p<0.05). SO followed the same trend as HCD in most of lysolipids. However, FO reversed a significant number of changes observed in HCD alone and SO, including an increase in lysolipid levels close to that observed in the chow group. These changes are consistent with a normalization of phospholipid metabolism with FO administration compared to HCD and SO.Sphingolipids are a class of aliphatic amino alcohols that are key components of the cell membrane and important signaling mediators. The level of palmitoyl sphingomyelin increased significantly in HCD alone (1.62), SO (1.36), and FO (1.60) compared to chow (p<0.05). Compared to HCD alone, SO decreased levels of sphinganine (0.48) and sphingosine (0.42), while FO increased levels of sphinganine (2.57) and sphingosine (3.28) (p<0.05).The level of hepatic cholesterol was significantly decreased in both HCD alone (0.82) and SO (0.87) groups relative to chow (p<0.05). FO had the same concentration of cholesterol as the chow group. Squalene decreased significantly in HCD alone relative to chow (0.35) and both SO and FO increased the level significantly above that in HCD alone . 7-α-Hydroxycholesterol, a precursor for bile acids derived from cholesterol, showed progressively significant decreases in the order of HCD alone (0.68), SO (0.40) and FO (0.26) (p<0.05).Compared to SO, FO increased the levels of branched-chain amino acid (BCAA) catabolites, including 2-methylbutyroylcarnitine (1.78), isovalerylcartinine (1.84), hydroxyisovaleroyl carnitine (1.22), tiglyl carnitine (1.52), and methylglutaroylcarnitine (1.42) (p<0.05). These changes are consistent with either an increased or decreased use of branched chain amino acids for oxidation, which are primary fuels for skeletal muscle. The levels of riboflavin (1.47) and flavin adenine dinucleotide (1.23) increased in FO relative to SO, suggesting an improved capacity for energy production in response to FO supplement.de novo fatty acid synthesis and oxidative stress; (2) Both FO and SO relieved some of the metabolic shift towards de novo lipogenesis; but (3) FO offered additional advantages in terms of lipid peroxidation and the generation of inflammatory precursors.In this study, we sought to characterize global metabolic changes that occur in our mouse model of hepatic steatosis, with a focus on the effect of high-carbohydrate feeding and the differential effect of FO versus SO. Specifically, we focused on the metabolites that are critical to fatty acid synthesis and degradation, carbohydrate metabolism, triglyceride synthesis, inflammation, and oxidation. We confirmed our hypotheses: (1) HCD without lipid induced The administration of HCD alone without any source of fat resulted in a significantly decreased concentration of the EFAs LA and ALA. This is expected given the absence of dietary LA and ALA, as well as the effect of insulin (stimulated by high glucose administration) to limit adipose tissue lipolysis and therefore contain endogenous LA and ALA. Except for DHA and DPA, the SO group increased all of the other measured FA relative to the HCD group, presumably related to the dietary presence of LA and ALA. However, SO supplementation resulted in a relatively lower degree of increase of the ω-3 FAs, consistent with the lipid composition that provides ALA, which only has limited conversion to EPA and virtually no conversion to DPA and DHA. Compared to all the other groups, FO supplementation resulted in significant increases in the ω-3 FAs and decreases in the ω-6 FAs, reflecting enrichment of very long chain polyunsaturated ω-3 FAs in FO emulsion. FO reduced the level of arachidonic acid and its derivatives (12-HETE and 15-HETE), as EPA is known to inhibit the production of arachidonic acid from LA as well as substitute for arachidonic acid in tissue membranes. de novo lipogenesis may increase the liver’s susceptibility to secondary insults from reactive oxygen species, endotoxins, and adipocytokines. While the specific role of the multitude of eicosanoids in PNALD is unknown, inflammation is clearly a key part of PNALD pathogenesis. The administration of HCD in piglets has been associated with hepatic steatosis, insulin resistance, and hepatic inflammation, including increased myeloperoxidase activity and expression of proinflammatory cytokines and chemokines, particularly IL-2, CXCL2, TNFα, and IL-6. An increased burden of reactive oxygen species, combined with the inability to detoxify these products, induces oxidative stress, which results in damage to cellular proteins, lipids, and nucleic acids. PN has been previously shown to increase free radical production, in addition to decreasing liver oxidative metabolism and enzymatic antioxidant defenses, potentially as a result of saturation of liver microsomal fatty acids. There are several major cellular anti-oxidant pathways. Specifically, glutathione acts as an electron donor to reduce disulfide bonds formed between cysteine residues on cytoplasmic proteins. Glutathione is oxidized to glutathione disulfide (GSSG), which can then be converted back to reduced glutathione via glutathione reductase.This metabolomics analysis suggests that HCD impaired glutathione metabolism. Supplementation with SO showed increased levels of reduced glutathione, but FO appeared to show the largest increase in reduced glutathione. Furthermore, there were several changes that indicated FO improved the antioxidant defense system. FO reduced the levels of oxidized products from linoleate (18∶2n6) –9 and 13-HODE, which are known to be inducers of reactive oxygen species. There was a marked increase in the antioxidant α-tocopherol in the FO group that reflects the underlying composition of the lipid emulsion. The concentration of α-tocopherol in the commercial FO emulsion (150–296 mg/L) is significantly higher than the concentration of α-tocopherol in the commercial SO emulsion (38 mg/L).Our results support an improved redox state in animals supplemented with FO compared with SO. This finding is relevant for several reasons. Oxidative damage is thought to be critical in the development of PNALD, with evidence demonstrating that PN administration is associated with inhibition of the superoxide dismutase activity in hepatocytes, an increase of the malondialdehyde level, an increase in cytochrome c release from the mitochondria, and increased apoptosis. As noted in the histology, the administration of an oral HCD without lipid induced profound hepatic steatosis. SO also induced hepatic steatosis but to a lesser degree, while FO prevented the development of steatosis entirely. Our data revealed several distinct and simultaneous metabolic changes that are consistent with derangements in fatty acid synthesis in this mouse model.de novo lipogenesis. de novo lipogenesis via sterol regulatory element binding protein 1-c. de novo lipogenesis as well as enhanced FA oxidation, consistent with the protective effect of FO on development of steatosis.The formation of malonyl-CoA is the committed step in FA biosynthesis. The level of malonylcarnitine normally reflects the level of malonyl-CoA and was significantly lower in the HCD group relative to the chow group, suggesting increased FA synthesis as a consequence of high glucose administration unimpeded by dietary ω-6 or ω-3 fatty acid provision that specifically limit The intermediates in the TCA cycle increased significantly in both SO and FO groups in relation to HCD alone, indicative of an increased TCA cycle activity, more efficient energy production and less diversion of citrate for FA synthesis. Compared to the HCD alone or SO groups, levels of branched-chain amino acid (BCAA) catabolites in the FO group were significantly elevated and closer to that observed in the chow group. This observation may reflect a reduced demand for BCAA catabolites for FA synthesis in the FO group compared to the HCD alone and SO groups, and potentially reduced utilization of branched chain amino acids for oxidation by skeletal muscle.TAG accumulation is a central feature of steatosis and is the result of disordered lipid metabolism, either in the form of increased TAG synthesis, defective TAG trafficking, or decreased TAG degradation primarily through oxidation.Our analysis demonstrates that the HCD group had increased levels of glycerol and decreased levels of glycerate indicative of increased glycerol metabolism. This observation coupled with increased FA synthesis could result in increased TAG synthesis, observed histologically as the profound increase in lipid deposition. SO raised glycerol 3-phosphate levels, possibly offering some attenuation of HCD-induced increase in TAG synthesis. On the other hand, FO reduced glycerol, G3P and free LCFA levels significantly relative to the SO group. This observation could indicate a restoration of TAG synthesis to the normal level by FO and may be related to the protective effect of FO. This would be expected given the known ability of the ω-6 fatty acid LA and the ω-3 fatty acids ALA and EPA to reduce FA synthesis through effects on PPAR with the much greater impact of EPA. There were different priorities among the groups in cholesterol utilization; most notably, FO normalized hepatic cholesterol levels that were decreased in HCD alone and SO.de novo lipogenesis. This mechanistic insight is supported by existing data on the effect of HCD on FA metabolism. HCD is high in simple carbohydrate content, and overconsumption of carbohydrates (particularly simple ones) enhances lipogenesis. The supplementation of HCD with lipid reduces hepatic triglyceride synthesis, enhances FA oxidation, and increases peripheral plasma triglyceride lipolysis. There are several limitations to our study. This work is based on a mouse model of high glucose-induced hepatic steatosis, and therefore, the relevance to human PNALD is unknown. In our study, the HCD solution was administered orally to induce hepatic steatosis. Others have described an intravenous rat model of PNALD, but the duration of this model is short given the development of a high rate of sepsis in such animals. We felt that a longer duration of treatment would better simulate the metabolic changes of chronic PN dependence. Additionally, while this metabolomic approach represents a systematic and simultaneous analysis of a complex pathophysiologic state, it only provides a single snap shot, therefore limiting any conclusions about changes over time or the order of events, and a number of the changes are speculative based on static levels.in vivo. Future work is necessary to determine how the manipulation of these pathways may have therapeutic benefit in PNALD.The present data detail the global metabolic consequences of PN and lipid administration, and suggest that improved lipid metabolism combined with reduced oxidative stress may explain the protective effect offered by FO supplement We would like to thank the team at Metabolon for their services in performing the metabolomic profiling, as well as their technical advice and analysis.


Urinary tract infections (UTIs) are the most commonly treated infection among nursing home residents. Even in the absence of specific  or non-specific  signs or symptoms, residents frequently receive an antibiotic for a suspected infection. This research investigates factors associated with the use of antibiotics to treat asymptomatic bacteriuria (ASB) among nursing home residents.This was a cross-sectional study involving multi-level multivariate analyses of antibiotic prescription data for residents in four nursing homes in central Texas. Participants included all nursing home residents in these homes who, over a six-month period, received an antibiotic for a suspected UTI. We investigated what factors affected the likelihood that a resident receiving an antibiotic for a suspected UTI was asymptomatic.The most powerful predictor of antibiotic treatment for ASB was the presence of an indwelling urinary catheter. Over 80 percent of antibiotic prescriptions written for catheterized individuals were written for individuals with ASB. For those without a catheter, record reviews identified 204 antibiotic prescriptions among 151 residents treated for a suspected UTI. Almost 50% of these prescriptions were for residents with no documented UTI symptoms. Almost three-quarters of these antibiotics were ordered after laboratory results were available to clinicians. Multivariate analyses indicated that resident characteristics did not affect the likelihood that an antibiotic was prescribed for ASB. The only statistically significant factor was the identity of the nursing home in which a resident resided.We confirm the findings of earlier research indicating frequent use of antibiotics for ASB in nursing homes, especially for residents with urinary catheters. In this sample of nursing home residents, half of the antibiotic prescriptions for a suspected UTI in residents without catheters occurred with no documented signs or symptoms of a UTI. Urine studies were performed in almost all suspected UTI cases in which an antibiotic was prescribed. Efforts to improve antibiotic stewardship in nursing homes must address clinical decision-making solely on the basis of diagnostic testing in the absence of signs or symptoms of a UTI. Urinary tract infections (UTIs) are the most commonly treated infection among nursing home residents -5. In a Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and fluoroquinolone-resistant gram negative bacilli . All but a scant few of the listed infections were associated with an antimicrobial prescription, so that the infection logs essentially represent antibiotic treatment logs. For each identified episode of antibiotic treatment for a suspected UTI, the research team collected resident-level data, including resident characteristics at admission and information from the Minimum Data Set (MDS) assessment completed prior to the date of the prescription that brought them into our sample ) or 1.5°C [2.4°F] increase above baseline temperature),•new or worsening urgency, frequency, or incontinence,•suprapubic pain,•gross hematuria,•costovertebral angle (flank) tenderness,•rigors, or•delirium .The dependent variable equaled zero when any of the signs or symptoms above were noted in the medical record , and it equaled one when none of these symptoms were present .Resident characteristics were obtained using a resident’s admission MDS (version 2.0) and the most recent MDS completed prior to the date of the first suspected UTI. Information on physical functioning and cognitive patterns were used to construct established scales for activities of daily living and cognitive performance. Our model also included an indicator for potential depression, and an indicator of the presence of a problem or condition that might result relatively soon in a health decline or in death.We investigated the effects of individual health status measures on the likelihood a prescription would be written for ASB. Although the results of previous research on the impact of functional status or case-mix on certain aspects of antibiotic use is somewhat mixed ,27, we iResident demographic characteristics were included in the analysis to explore any potential differences in the presence or absence of signs and symptoms for UTIs associated with age, gender and race/ethnicity. Age was categorized into 3 groups . Given the preponderance of non-Hispanic White residents and missing observations, race/ethnicity was categorized as three variables representing non-Hispanic White, all other races/ethnicities, and missing observations. A binary variable identifying any resident with multiple courses of antibiotics for a suspected UTI was also developed. Similarly, an indicator representing the nursing home within which the suspected infection took place was included in our analyses. General data on the four nursing homes were also collected by the research consultants.Data were analyzed using SAS 9.2. We present descriptive data for the four homes and compare baseline characteristics of all non-catheterized residents who received antibiotics for a suspected UTI, categorizing those residents by whether or not they presented with signs or symptoms thought to warrant antibiotic use.One of the major predictors of the use of an antibiotic for a suspected UTI was the presence of an indwelling urinary catheter . Data foWhile the descriptive analysis focused on 151 individual residents without an indwelling catheter, the multivariate analysis was performed on 204 prescriptions for a suspected UTI for these 151 individuals. The unit of analysis for our multivariate modeling was the prescription. As our results indicate, a reasonable proportion of residents received more than one antibiotic for a suspected UTI during the study period. Very few of these were prescriptions were for a persistent UTI. We identified all prescriptions written for the same person over a period of one month. We then removed these individuals from our analyses. The results did not change, so these cases remain in the data used in our analyses.Due to the correlated nature of the prescription data, in which a resident may have had more than one episode of a suspected UTI during the study period, a generalized linear mixed effect model was used to estimate the likelihood of a resident having none of the signs or symptoms identified in the Loeb criteria among those who received an antibiotic prescription for a UTI . ResidenTwenty-three prescriptions in the study period were written for individuals with an indwelling catheter. Of these, 82.6 percent (19) were written when the resident displayed no localized or proximal symptoms of a UTI. Since the relative number of prescriptions was low, but the percent of prescription written for residents who were asymptomatic was so different from that for other residents, we did not use these cases in our further analyses. While recognizing the overwhelming role of an indwelling urinary catheter in antibiotic prescription for a suspected UTI, our analyses focus on those factors that result in treatment for ASB among residents who are not catheterized; the results discussed below involve only the prescriptions written for those residents without an indwelling catheter.Table As the results in Table Table In a multivariate analysis Table  of the lOne of the major issues in antibiotic stewardship in nursing homes is the use of antibiotics to treat suspected UTIs -40. DespSomewhat surprisingly, our results indicated that resident demographics or indicators of health and functional status did not affect the likelihood of receipt of an antibiotic despite the absence of physical symptoms for UTI. Several resident conditions such as diabetes, stroke and causes of urinary tract dysfunction were not included in these data. Nonetheless, these results imply that differences in health and functional status among residents are not a driving force behind prescribing antibiotic treatment for ASB.Our results provide evidence of the overwhelming importance of the presence or absence of an indwelling urinary catheter in the use of antibiotics for ASB. Our results from these four homes indicate that over 80 percent of the antibiotics prescribed for individuals with a catheter were written in the absence of signs or symptoms of a UTI. However, they were usually written in the presence of urinalysis results.Previously published infection surveillance criteria for UTIs in long term care facilities have given too little attention to laboratory data as part of the diagnostic paradigm . HoweverOur data highlight the need for further assessment of how the interpretation of these tests might drive prescribing decisions in this setting. The medical literature emphasizes that older persons with a UTI may present differently than younger persons -47. ThusC. difficile rates in a facility over time). Thus, the value of good antibiotic stewardship may go unrecognized by the clinician who focuses on residents sequentially, rather than as a part of a population.Given the receipt of a positive urinalysis, the attending clinician is faced with what can be viewed as a short and long-term risk assessment decision. For the clinician the calculation of risk can be almost entirely short-term. In terms of short-term risks, by not prescribing an antibiotic, the clinician may fail to treat a blossoming infection; the resident’s condition may worsen, possibly dramatically. The benefits of not prescribing an antibiotic, such as reduction in emergence of antibiotic-resistant pathogens or avoidance of adverse drug complications’ will usually be seen in rates for the entire population in the home  in College Station, TX. DKM is an assistant professor in Health Policy and Management at the HSC. OA and ON are doctoral students at the HSC. HZ is an associate professor of biostatistics at the HSC. DM is William C. Allen Professor in Family and Community Medicine at the University Of Missouri School Of Medicine in Columbia, MO. NS is the medical epidemiologist for long-term care in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta, GA.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/12/73/prepub


RPA is a single-stranded DNA binding protein that physically associates with the BLM complex. RPA stimulates BLM helicase activity as well as the double Holliday junction dissolution activity of the BLM-topoisomerase IIIα complex. We investigated the effect of RPA on the ssDNA decatenase activity of topoisomerase IIIα. We found that RPA and other ssDNA binding proteins inhibit decatenation by topoisomerase IIIα. Complex formation between BLM, TopoIIIα, and RMI1 ablates inhibition of decatenation by ssDNA binding proteins. Together, these data indicate that inhibition by RPA does not involve species-specific interactions between RPA and BLM-TopoIIIα-RMI1, which contrasts with RPA modulation of double Holliday junction dissolution. We propose that topoisomerase IIIα and RPA compete to bind to single-stranded regions of catenanes. Interactions with BLM and RMI1 enhance toposiomerase IIIα activity, promoting decatenation in the presence of RPA. BLM gene give rise to Bloom syndrome, a rare cancer predisposition disorder in humans BLM is a member of the RecQ family of helicases that safeguards genome integrity Replication Protein A (RPA) is a single-stranded DNA (ssDNA) binding protein that is indispensable in all eukaryotes E. coli SSB (Single-stranded Binding Protein) (EcSSB) RPA associates with the BLM complex. RPA co-immunoprecipitates with BLM and RMI1 in vitro system that mimics the latest stage in DHJ dissolution In this study, we investigated whether RPA modulates the second step of the dissolution reaction, the decatenation by TopoIIIα. Using a previously established E. coli topoisomerase I (EcTop1) belong to type IA family of topoisomerases Because RPA positively regulates BLM-TopoIIIα-mediated DHJ dissolution E. coli, inhibits decatenation. We incubated single-stranded catenanes with TopoIIIα or EcTop1 at concentrations at which both enzymes exhibited similar decatenase activities  residues of RMI1 disrupt the interaction between RMI1 and TopoIIIα and ablate the stimulation of TopoIIIα decatenase activity by BLM RPA, a core member of the BLM complex, specifically stimulates BLM helicase activity Since EcSSB inhibits TopoIIIα decatenase activity, we asked whether BLM and RMI1 alleviate EcSSB-mediated inhibition of TopoIIIα decatenation. We found that BLM, but not RMI1, alleviated the inhibition of TopoIIIα decatenation by EcSSB  was purchased from New England BioLabs. RPA was purchased from Enzo Life Science (ALX-201-296). EcSSB was purchased from Epicentre Biotechnologies (SSB02200).TopoIIIα and RMI1 were purified as described 2, 1 mM DTT, and 0.1 mg/ml BSA at 37°C for 30 minutes. For reactions containing BLM, 5 mM ATP was added to initiate the reactions because the stimulation of TopoIIIα decatenase activity by BLM requires ATP Single-stranded DNA decatenation assay were performed as described


Steroid therapy is very effective even at disease relapse. A Th2-dominant immune response or the activation of regulatory T cells seems to be involved in the underlying immune reaction. It is still unknown why IgG4 levels are specifically elevated in patients with this disease. IgG4 might be secondarily overexpressed by Th2 or regulatory cytokines given the lack of evidence that IgG4 is an autoantibody.IgG4 cholangiopathy can involve any level of the biliary tree which exhibits sclerosing cholangitis or pseudotumorous hilar lesions. Most cases are associated with autoimmune pancreatitis, an important diagnostic clue. Without autoimmune pancreatitis, however, the diagnosis of IgG4-cholangiopathy is challenging. Indeed such cases have been treated surgically. IgG4-cholangiopathy should be diagnosed based on serological examinations including serum IgG4 concentrations, radiological features, and histological evidence of IgG4 IgG4-related disease is a unique systemic inflammatory condition characterized by tumorous swelling of affected organs and high-serum IgG4 concentrations –3. AutoiThe relationship between IgG4-SC and autoimmune pancreatitis is summarized in Recent papers have introduced IgG4-related autoimmune hepatitis , which aIn our experience, patients with IgG4-SC usually present with obstructive jaundice due to a pancreatic head mass (autoimmune pancreatitis) or severe biliary stricture , 13. Othγ-globulinemia (observed in 50% of patients), hyper IgG (60–70%), antinuclear antibodies (40–50%), rheumatoid factor (20%), and eosinophilia (15–25%) [Patients with IgG4 disease share serological abnormalities irrespective of the organ of origin. There is no doubt that elevated serum IgG4 levels are the most specific indicator. Other sensitive but not specific markers include hyper (15–25%) , 19. Aut(15–25%) , 19. Studies on autoimmune pancreatitis have provided further data on autoantibodies which might participate in the pathogenesis. Antibodies against lactoferrin (LF) and carbonic anhydrase (CA) II are frequently detected in cases of autoimmune pancreatitis  . Interes+ plasma cells on immunostaining. Pathological features can be summarized as follows: (1) diffuse lymphoplasmacytic infiltration, (2) storiform fibrosis, (3) obliterative phlebitis, (4) eosinophilic infiltration, and (5) numerous IgG4+ plasma cells [It is not difficult to make a diagnosis of IgG4-SC if surgically resected specimens are available. The gold standard for the diagnosis of IgG4-SC is histology including characteristic features on H&E and extensive infiltration by IgG4ma cells , 23. Fea+ plasma cells is usually not necessary for cases showing typical radiological features  [+ plasma cells. Most institutions use 135 or 140 mg/dL as a cut-off point for serum IgG4 levels, with more than 300 mg/dL being highly specific for IgG4-related disease [Serology, imaging, other organ involvement, and biopsy need to be considered for the diagnosis of nonsurgical cases. Given that most patients (>90%) with IgG4-SC have autoimmune pancreatitis, it seems most important to examine changes in the pancreas. Autoimmune pancreatitis is radiologically suspected in most cases, and the diagnosis can be confirmed by the serological examination of IgG4. Histological detection of IgG4ic duct)  and high disease .+ plasma cell is recommended even if the patients have high-serum IgG4 concentrations. Three potential approaches have been proposed to detect infiltration by IgG4+ plasma cells. Vater's ampulla biopsy is least invasive and technically easiest, and especially useful for patients discovered endoscopically to have ampullary swelling [+ plasma cells infiltrating into peripheral small portal tracts [+ plasma cells but also other histological features such as storiform fibrosis and eosinophilic infiltration are detectable [+ plasma cells are used as the diagnostic threshold for biopsy samples.It is challenging to diagnose IgG4-SC not associated with pancreatitis. In fact, most patients have been surgically treated for suspected biliary malignancy . In our swelling –29. Anotl tracts , 30, 31.l tracts . The lasThere is no international consensus regarding diagnostic steroid trials for IgG4-related disease. Some institutions use steroid trials for the diagnosis –34, wher+ plasma cells or the presence of periportal “fibroinflammatory nodules [IgG4-SC must be differentiated from PSC given that the steroid responsiveness is completely different. These two entities are histologically distinct. Large bile ducts affected by IgG4-SC show transmural inflammation with storiform fibrosis and obliterative phlebitis , whereas nodules ” in need nodules , 31. It + plasma cells in explanted liver with PSC. Twenty-three of 98 livers (23%) showed more than 10 IgG4+ cells per HPF which might be less specific given that most IgG4-related lesions show more than 100 IgG4+ cells/HPF in surgical specimens. In addition, another group revealed that 2 out of 41 (5%) explanted livers with PSC showed more than 100 IgG4+ cells/HPF [+ cell infiltration (>10 cells/HPF) and rarely exhibit marked infiltration (>100 cells/HPF) around large bile duct lesions. Importantly, the other histological features of these cases were not typical of IgG4-SC but consistent with PSC [+ plasma cells.Zhang et al.  examinedells/HPF . These twith PSC , 39. The+ plasma cell infiltration or obliterative phlebitis is usually not conspicuous, different from IgG4-SC [This is a rare disease entity characterized by numerous lymphoid follicles around hilar or perihilar bile ducts , 41. Mos IgG4-SC .+ cell infiltration is needed for patients without autoimmune pancreatitis.In our experience, hilar cholangiocarcinoma is the most important and difficult differential diagnosis of IgG4-SC in the clinical field, particularly for patients without autoimmune pancreatitis. Radiological features of IgG4-SC sometimes resemble those of hilar cholangiocarcinoma . Serum IIgG4-SC responds dramatically to steroid therapy the same as other IgG4-related lesions. This is one significant difference from PSC , 13. At γ, IL-5/IFN-γ, and IL-13/IFN-γ in IgG4-related disease tissues than in tissues from patients with classical autoimmune diseases [in situ hybridization. Recent papers also showed that peripheral blood mononuclear cells collected from patients with IgG4-related disease produced predominantly Th2-type cytokines such as IL-4, IL-5, IL-10, and IL-13 after T-cell stimulation. Recent papers have provided data suggesting that the Th2-type immune response is activated in IgG4-related disease including IgG4-SC –48. Quandiseases . Lymphocβ (TGF-β), are significantly overexpressed [+CD25+Foxp3+ Tregs could be detected within affected tissues by immunohistochemistry, in numbers significantly higher than in autoimmune and nonautoimmune disease controls. The number of Foxp3+ cells was significantly correlated with the number of IgG4+ plasma cells in IgG4-related cholangitis [+CD25high Tregs was significantly higher in patients with AIP than in patients with chronic pancreatitis and was correlated with the level of IgG4 in serum [+CD25high Tregs could reflect IgG4-related disease progression [Interestingly, the number of regulatory T-cells (Tregs) is characteristically increased in both tissue and blood of patients with IgG4-related disease. Our investigation revealed that the mRNA expression of forkhead box P3  was higher in IgG4-related disease than in classical autoimmune diseases. Two regulatory cytokines, IL-10 and transforming growth factor-xpressed , 50. Furlangitis . Miyoshiin serum . The numgression . H pylori in the pathogenesis of AIP was reported in 2005 [H. pylori infection triggers AIP in genetically predisposed subjects via molecular mimicry between human CA-II and alpha-carbonic anhydrase of H. pylori [H. pylori [H. pylori in the pathogenesis of other IgG4-related lesions has not been reported so far.The possible involvement of  in 2005 . Gastric. pylori . Frullon. pylori . The amiIgG4-SC is a unique cholangiopathy which should be differentiated from classical PSC or biliary malignancy. An underlying immune response might be mediated by predominantly Th2 or regulatory cytokines.


The fragment divisions with the highest SCEDS are then used as separate template models for MR. Test cases show that where the protein contains fragments that undergo a change in juxtaposition between template model and target, SCEDS can identify fragments that lead to a lower R factor after ten cycles of all-atom refinement with REFMAC5 than the original template structure. The method has been implemented in the software Phaser.A method is described for generating protein fragments suitable for use as molecular-replacement (MR) template models. The template model for a protein suspected to undergo a conformational change is perturbed along combinations of low-frequency normal modes of the elastic network model. The unperturbed structure is then compared with each perturbed structure in turn and the structurally invariant regions are identified by analysing the difference distance matrix. These fragments are scored with SCEDS, which is a combined measure of the sphericity of the fragments, the continuity of the fragments with respect to the polypeptide chain, the equality in number of atoms in the fragments and the density of C The conformational changes of interest for this study are those involving a change in juxtaposition of fragments, where fragments are defined as spatially contiguous groupings of atoms for which all interatomic distances are effectively identical between the two conformations in the target and template, and for which the fraction of scattering is significant. These fragments may or may not correspond to definitions of protein domains such as those annotated in sequence databases such as ProDom  of the elastic network model  normal mode 7 displacement and subsequent analysis that parallels graph-theory implementations  where the packing density of atoms is low and hence where flexibility is likely to occur, (ii) where the resulting fragments are roughly the same size or at least of significant size and so represent a significant fraction of the scattering and (iii) where the atoms are packed into contiguous regions of space; hence, where to divide the structure for MR. In this study, we show that it is possible to predict fragments of proteins suitable for MR using a combination of NMA, analysis of the DDM and a function that scores the size, shape and packing density of the fragments (SCEDS). The method is conceptually similar to the way that crystallographers identify fragments for MR from visual inspection of a structure.2.Sphericity Continuity Equality Density Score) and (v) MR with the highest scoring fragments. Only one set of fragments representing the template, i.e. the set corresponding to the highest SCEDS, is used in MR at the conclusion of the analysis  NMA of the ENM of the template structure, (ii) perturbation of the template structure along low-frequency normal modes of the ENM, (iii) using the DDM between the original and perturbed template structure to find the structurally invariant fragments for each perturbation, (iv) ranking of the structurally invariant fragments generated by each DDM analysis by SCEDS  and is two by default. If the conformational change is more than a simple hinge motion then it will be necessary to generate fragment divisions for NDOM values higher than two in order for MR to succeed. SCEDS values are not comparable for analyses with different NDOM fragments and therefore the SCEDS method cannot determine an optimal number of fragments. The coordinates for the fragments written for MR searches are those of the unperturbed structure, because this structure has the unperturbed geometry.2.1.et al.  approach  will influence the exploration of conformational differences between perturbed and unperturbed structures for the DDM analysis, and sufficient modes must be explored to include at least one combination that gives the correct fragments. At the same time, the computation time expands exponentially with the number n of normal modes if all combinations are considered. See the Supplementary Material for the parameters controlling the selection of normal modes and mode combinations.After NMA, 2.3.α atoms are included in the DDM. The DDM element  for a Cα atom with coordinates aU and bU in the unperturbed structure and coordinates aP and Pb in the perturbed structure is Only Cα atoms a and b are considered for clustering if DDM is less than a given threshold. Since the absolute numerical range of the values in the DDM depends on the degree of perturbation, the threshold depends on the range of DDM values present in the matrix. In addition to the difference distance threshold, two further tests must be passed before atoms a and b are clustered. Firstly, the atoms must be separated by less than a given distance through space, which helps to filter noise in the DDM. Secondly, a minimal separation of the atoms in sequence may be applied, preventing neighbouring atoms from being clustered together and thus the undesirable clustering of atoms through linker regions between fragments. The clustering of atoms in the DDM analysis is performed for a range of DDM thresholds, distances and sequence separations. Each choice of parameters has the potential to generate different sets of DDM clusters of atoms.The DDM is analysed with a modified form of single-linkage clustering. Ca with atoms b→z and finds those meeting the three DDM-cluster criteria of DDM threshold, through-space distance and sequence separation. The atoms in the DDM cluster with a are assigned to fragment 1 by definition, with the remainder left unassigned. Atom b is then compared with atoms c→z and a set of DDM-cluster atoms are identified. This DDM cluster is assigned the fragment number of b (1) if b were previously clustered with a or if any member of the clustered subset of c→z were previously clustered with a. Otherwise, the DDM cluster of b will be assigned to fragment 2 by definition. Atom c is then compared with d→z to identify its DDM cluster. If neither c nor any members of its DDM cluster are assigned to a fragment this DDM cluster becomes fragment 3 by definition. If not, the DDM cluster is assigned the fragment number most represented in the DDM cluster. The algorithm iterates for the DDM cluster of d in e→z and so on until all atoms are assigned a fragment number.The algorithm for assigning the fragment number to each atom  first compares atom α atoms to DDM clusters is dependent on the order in which the Cα atoms are considered, i.e. the sequence order. Whilst other modifications to single-linkage clustering that are independent of sequence order could be tried in the future, the SCEDS method implemented is very fast and produced good results in our test cases.This method of assigning Cvia the chaining of atoms together in fragments, the DDM-cluster through-space distance criterion does not limit the final spatial extent of the fragments and at the end of the analysis a fragment may fill any extent in space. Similarly, application of the DDM-cluster sequence-separation criterion does not force fragments to contain sequence gaps.Note that, m contains a short intercalating fragment assigned to another fragment, the atoms in the fragment are assigned to fragment m. Fragment divisions are produced for a range of intercalating fragment-joining lengths.After the DDM analysis a fragment-joining procedure is undertaken. If fragment At the end of the DDM analysis the fragments are sorted in size by the number of atoms assigned to each fragment. The sorted order will not  be the same as the integer order of the fragments because the latter results from the sequential sampling of the polypeptide chain for seed residues; fragment 1 will not generally be the largest fragment. For illustration, consider a protein with 100 residues, with the N-terminal 39 and C-terminal 60 residues being folded fragments with a single-residue hinge between them at residue 40. Residue 1 would be in fragment 1 by definition. If NMA perturbation and DDM analysis revealed the hinge at residue 40, residues 2–39 would also be assigned to fragment 1, the hinge would be fragment 2 (with one residue) and the largest fragment, with 60 residues, would be fragment 3. The sort order for the fragments would be . After sorting the fragments by size, only the largest NDOM fragments are carried forward in the analysis and used in the SCEDS calculation. For the illustrative example above and NDOM = 2, this would be fragments 3 and 1.The DDM analysis does not restrict the number of clusters of atoms to the number NDOM requested by the user. An important corollary is that the method does not guarantee that all atoms will be allocated to one or other of the top NDOM fragments. It is not valid to use these excluded atoms as an additional single fragment because the excluded atoms will have been assigned to multiple fragments.At the conclusion of the DDM analysis step, some combinations of normal-mode perturbations and DDM analyses will result in the protein being divided into several large fragments of atoms while others will fragment the protein into many small fragments, depending on the nature of the flexibility revealed.2.4.S) of the fragments based on the maximal extents of the fragments in three orthogonal directions, the continuity (C) of the chains in the polypeptide sequence, the equality (E) in the number of amino acids in each fragment and the packing density (D) of the atoms in the fragments. Each of the four scores has a weight factor ,For the largest NDOM fragments from each perturbation and analysis of the DDM, a SCEDS is calculated. The SCEDS is the sum of four scores measuring the sphericity (2.4.1.Vd) to surface area (Ad) ratio of the fragment d.ad, bd and cd of the fragment d. Although the volume of an ellipsoid is trivially calculated from the three principal axes, there is no trivial expression for the surface area, but an approximation  and is set at 0.0071 Cα Å−3. The density term has a maximal value of 1 when the triaxial ellipsoid is tightly packed with Cα atoms.Fragments densely populated with atoms were selected by taking the product over the fragments of the packing of 2.5.Phaser using a standard MR protocol. The NDOM fragments are entered as NDOM separate ensembles. Assuming that the SCEDS fragment division is accurate, the r.m.s.d. can be accurately estimated from the sequence identity between the template and target in the same way as for a protein that does not have a conformational change between template and target  mode. If MR is successful then structure refinement  in the implementation. CPU time for the analyses of a template with different values of NDOM may be shortened by reading in the eigenvector matrix written in the first analysis. The default parameters are described in the sections below and in the Supplementary Material.3.1.The training-set proteins were selected on the basis that two conformers were present in the Protein Data Bank and the difference between the two conformers was a hinge motion between significant fractions of the polypeptide chains. There were ten proteins in the training set: alcohol dehydrogenase, cAMP-dependent protein kinase, citrate synthase, diptheria toxin, glutamine-binding protein, immunoglobulin, lactoferrin, lysine/arginine/ornithine (LAO) binding protein, maltodextrin-binding protein and thymine synthase. Three proteins were analysed in two conformers, giving 13 test cases Table 1.3.2.et al., 2002et al.  DDM analysisBy default, the range of DDM element thresholds sampled for clustering atoms together in a DDM cluster increases in five steps of a 50th of the range of values in the DDM from the minimum DDM element. The distance threshold ranges from 7 to 14 Å inclusive in steps of 1 Å and the separation threshold is either 0, or at least one trace atom. In total, 80 (5 × 8 × 2) DDM analyses are performed per normal-mode perturbation. Fragment-joining lengths range from 2 to 12% of the total polypeptide length. See the Supplementary Material for parameters controlling the DDM analysis.3.3.Sw equal to 4 by default. The continuity weight Cw is zero by default as nonzero values give poorer results in the majority of cases. This is likely to be because the N-terminus and the C-terminus of proteins are often located near one another and hence in the same fragment, and whole fragments can be inserted into loops  will significantly change the SCEDS of fragment divisions and result in markedly different fragment divisions scoring highly. See the Supplementary Material for the parameters controlling SCEDS weighting.Equality and density terms in SCEDS have weight factors of 1 by default. Sphericity is up-weighted with 4.4.1.et al., 2004The test cases for MR were selected on the basis that the protein had at least two conformations present in the Protein Data Bank and that at least one of these had structure factors available from the Uppsala Electron Density Server . The conformational change in pyruvate phosphate dikinase is more complicated than a simple hinge motion between two fragments  the template model in the inactive form had to be analysed with NDOM = 4  and for the target inactive pyruvate phosphate dikinase triple mutant (PDB entry 2r82) the template model in the active form had to be analysed with NDOM = 5 . Where MR succeeded, the fragment divisions compared well with the fragment divisions obtained from a comparison of the two experimental structures with ESCET  was also the only member of the test set that gave fragment divisions with a significant fraction of the atoms excluded. Approximately 8% of the scattering matter was not included in the fragments used for MR. This resulted in higher R values than would be expected had all residues in the template been included and correctly placed  is owing to the r.m.s.d. between the template and target for each fragment remaining high in the context of the low scattering fraction of the fragments, the quality of the data and the size of the unit cell in this case.MR failed for adenylate kinase in the open conformation in the target based on SCEDS analysis of the closed conformation. MR was partially successful for adenylate kinase in the closed conformation in the target, where two copies (corresponding to the two structures in the asymmetric unit) of the largest fragment identified from the SCEDS analysis of the open conformation with NDOM = 3 could be unequivocally placed in the asymmetric unit but the smaller fragments could not. The conformational change in adenlyate kinase has been extensively studied  identified. We have observed that often several mode combinations sharing one or more normal modes can generate similar fragments. The movement between two biological conformations is stabilized et al., 2004The test cases used here only include structures of the same sequence undergoing a conformational change. However, structures with lower sequence identity may also be subjected to this analysis and used in MR. This technique can be used in conjunction with model-editing procedures either before or after SCEDS analysis is undertaken (Schwarzenbacher The algorithm can be run with NDOM = 1. For the multi-fragment cases in this study, the single fragment output is either the whole protein with some trimming or the same as the largest fragment in the two-fragment analysis. The algorithm is biased towards assigning all atoms to the top NDOM fragments through the equality term. As currently implemented, SCEDS is therefore not suitable for locating flexible regions on the surfaces of proteins, and other loop-trimming procedures should be used for this purpose (Bunkóczi & Read, 2011α atoms fit their DDM cluster (Rousseeuw, 1987In the future, it may be possible to design a method to automatically select the optimal number of fragments. The silhouette width, which measures how well DDM-clustered CThe SCEDS method is not infallible and fragments useful for MR may not be generated. This will do no harm when the technique is used for MR, because the MR itself acts as a positive control on the accuracy of the fragment divisions, failing if they are wrong and succeeding if they are correct. We would caution against using SCEDS fragments for any structural analysis other than MR.6.Phaser. Phaser is available through the CCP4 (http://www.ccp4.ac.uk; Winn et al., 2011PHENIX (http://www.phenix-online.org; Adams et al., 2002Phaser documentation can be found at http://www.phaser.cimr.cam.ac.uk.All methods described are implemented in 10.1107/S0907444913021811/ba5209sup1.pdfSupplementary material file. DOI:


Emerging evidence provides a scientific rationale for combining treatment programs for neglected tropical diseases (NTDs) with programs for the treatment of HIV/AIDS. Engaging the major stakeholders to establish operational links between HIV/AIDS and NTD control and elimination activities, especially in sub-Saharan Africa, could increase the efficiency and cost-effectiveness of both HIV/AIDS and NTD efforts.Sub-Saharan Africa is home to more than 90% of the world's cases of onchocerciasis and schistosomiasis, about one-half the world's lymphatic filariasis and trachoma, and one-third of all global soil-transmitted helminth infections preventive chemotherapy, the United States Agency for International Development (USAID) is supporting national programs of control or elimination of the most common NTDs in multiple African countries Because of the availability of donated or generically available inexpensive drugs, it is possible through the mass drug administration (MDA) of “rapid impact” packages containing albendazole/mebendazole, ivermectin, praziquantel, and azithromycin to reduce the prevalence, and in some cases either control or eliminate these NTDs, for as little as US$0.50 per person annually HIV/AIDS and NTD co-infections are widespread in sub-Saharan Africa, and there is evidence that the high prevalence helminth infections, i.e., the three major soil-transmitted helminth infections , and schistosomiasis either promote susceptibility to the HIV virus or worsen the clinical course and progression of AIDS, while visceral leishmaniasis (VL) has emerged as an important opportunistic infection of HIV/AIDS.The relationship between HIV/AIDS and NTDs has been noted since the early 1990s. The World Health Organization has recognized that VL can present as an aggressive opportunistic infection in people living with HIV/AIDS (PLWHA). If left untreated, VL alone will cause mortality rates as high as 100% within two years Schistosoma haematobium infection) and HIV/AIDS in the large southern and East African countries of Kenya, Mozambique, South Africa, Tanzania, Zambia, and Zimbabwe, and to some extent, Cameroon in West Africa The geographic overlap between the high prevalence helminth infections and HIV/AIDS in sub-Saharan Africa is extensive. More than 100 million people in sub-Saharan Africa are infected with ascariasis, hookworm, trichuriasis, or some combination of these soil-transmitted helminth infections S. haematobium infection, increases the risk of humans acquiring HIV infection 3-fold Schistosoma mansoni infection increases the risk of new HIV acquisition in rhesus macaques These high prevalence helminth infections have an adverse, albeit largely hidden, impact on the AIDS epidemic in Africa The high prevalence of helminth infections and other NTDs in sub-Saharan Africa and their medical significance in terms of affecting Africa's AIDS epidemic demand a public health response from the established global HIV/AIDS community, in parallel with efforts to scale up NTD control. At the recent United Nations 2010 Millennium Development Goals Summit, US President Barack Obama announced a new approach to the programs that make up the United States government's Global Health Initiative. At the core of this new directive is a call for the integration of programs and investments across health priorities We support the US President's call for integration and would favor strategic planning to examine how the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the two largest global programs committed to delivering anti-retroviral drugs and other AIDS prevention measures, could advance efforts to coordinate and link the HIV/AIDS programs they support with NTD control and elimination programs As noted above, national programs of NTD control and elimination are underway in more than a dozen sub-Saharan Africa countries, with additional programs expected in the coming years. These NTD preventive chemotherapy programs deliver partial or complete rapid impact packages, together with environmental control measures or simple surgeries, under the auspices of public–private partnerships working with national health ministries Currently, both PEPFAR- and GFATM-supported programs provide treatment for deadly tuberculosis co-infections in PLWHA In terms of providing treatment, there are several areas within PEPFAR's programming that could link with NTD control efforts. Just as PEPFAR programs provide treatment options for tuberculosis co-infections and chemoprophylaxis to prevent other opportunistic infections, NTD co-infections for PLWHA that receive treatment through PEPFAR clinics could also be addressed. These facilities could be stocked with appropriate NTD medications based on regional NTD prevalence. This approach would allow PLWHA to be treated at the point of service, thus minimizing the impact of NTDs on viral replication. In addition, because many individuals who live in NTD-endemic areas are unaware of their HIV status, NTD control and elimination campaigns could be expanded to provide HIV testing and care. In this way there could be mutual and bi-directional benefit.PEPFAR antenatal clinics could actively engage in NTD control as well. Up to one-third of pregnant women in sub-Saharan Africa are infected with hookworms PEPFAR's care initiatives have two entry points for NTD control, both of which would decrease morbidity in PLWHA by building upon existing programming. PEPFAR community health care workers (CHWs) visit the homes of orphans and vulnerable children (OVC) infected and affected by HIV/AIDS to monitor growth and development. These health care workers can be trained to administer the appropriate NTD chemoprophylaxis based on prevalence mapping. Many OVCs, who are often missed by school-based deworming programs, would benefit. Similar to the OVC program, PEPFAR sends CHWs to the homes of PLWHA that are unable to travel to local clinics. PEPFAR could integrate NTD control into both the OVC and home-based care programs to respond to the risk of chronic immune activation in co-infected individuals.Operational research to evaluate the successes and failures for HIV/AIDS and NTD control are critical, as is research and development for new and improved control tools for the NTDs Integrating NTD control into a PEPFAR or GFATM framework would require careful coordination and collaboration with the USAID's NTD Program, as well as with parallel efforts supported by DFID and the Global Network for NTDs, and most importantly the health ministries in the disease-endemic countries together with public–private partnerships committed to NTD control. Embracing the control of the NTDs, the most common infections of girls and women in developing countries Evidence speaking to the biological relationship between NTDs and HIV/AIDS means that effective management of HIV/AIDS may require the control of NTDs. The past successes in integrating directly observed therapy for tuberculosis


Despite many attempts to prevent surgical site infections (SSIs), these complications are not uncommon in most hospitals while the precise determination of the burden of these infections in our country has not been performed but crude data in hospitals shows a significant cost of managements. With an estimated 27 million surgical procedures annually, and near 2–5% rate of SSIs, approximately 300,000–500,000 surgical site infections can be predicted to occur each year.[2][3] InPreoperative antibiotics and aseptic techniques are most important aspects of care in major surgical procedures but it should be emphasized that all preventive measures for surgical site infections are unrealistic due to presence of many risk factors that are largely unalterable such as comorbid diseases. So the objectives should be elimination of all potentially preventable infections by the use of evidence based actions.The center for disease control (CDC) recommends that antibiotic prophylaxis should be used for all clean contaminated procedures and some of clean procedures such as prosthetic joints or intravascular device insertions. ContaminThe benefit of antibiotic prophylaxis in all clean procedures has not been determined. Only in some invasive clean procurers, there are recommendation about antibiotic use and in minimally invasive ones there are few powerful randomized clinical trials and the benefits of their use should be outweighted by potential risks of antibiotic therapy.7]7]In this issue of journal, Hatam et al. reported on the economic burden of inappropriate antibiotic use for prophylaxis of infections in surgical wards of Shiraz University of Medical Sciences affiliated hospitals during year 2004. They found that antibiotics were prescribed for 98% procedures in which an antibiotic did not have an indication and also the cost for a 6 months period of antimicrobial prophylaxis regimen was approximately shown 4,623 USD.The reported study was completed 7 years ago and the research team is to be congratulated on this well designed survey. Those who are working in an infectious ward in university hospitals are painfully aware of inappropriate antibiotic usage in wards including surgical wards and operating rooms. We have a great problem with these unnecessary administrations and need enforcement for reduction of antimicrobial usage.The inappropriate preoperative use of antibiotics may represent a significant portion of the hospital pharmacy’s expenditure for antibiotics and the surgeons are needed to be encouraged to eliminate antibiotics given for prophylaxis in inappropriate settings. This goal can be reached by educational programs and supervision of administration by infectious disease teams.However, it seems inappropriate to evaluate antimicrobial use based on cost alone. With inappropriate usage, the over-use or under-use, the costs in terms of mortality, morbidity and resources for fighting against developed resistance microorganism or managing wound infections should be clarified. In theseTherefore, one needs to know that such a difficulty exist and cannot be determined simply by direct cost analysis methods. Those whose professional activities are on health economic policy need to design special research projects on all outcomes and direct and indirect costs produced by inappropriate antibiotic usage in hospitals.


Infection with the human immunodeficiency virus-1 (HIV) and the resulting acquired immune deficiency syndrome (AIDS) alter not only cellular immune regulation but also the bone metabolism. Since cellular immunity and bone metabolism are intimately intertwined in the osteoimmune network, it is to be expected that bone metabolism is also affected in patients with HIV/AIDS. The concerted evidence points convincingly toward impaired activity of osteoblasts and increased activity of osteoclasts in patients with HIV/AIDS, leading to a significant increase in the prevalence of osteoporosis. Research attributes these outcomes in part at least to the ART, PI, and HAART therapies endured by these patients. We review and discuss these lines of evidence from the perspective of translational clinically relevant complex systematic reviews for comparative effectiveness analysis and evidence-based intervention on a global scale. Osteoimmunology pertains to the physiological process that involves the intimate intertwining of bone metabolism and cellular immune surveillance. It is a novel interdisciplinary research field that has converged into studies of the interplay between the immune system and bone metabolism. sequelae of bone pathologies upon regulation of cell mediated immunity. Cytokines and other soluble immune factors modulate and regulate the maturation of osteoblasts responsible for bone formation, and the osteoclastic bone resorption  : 6.4), of whom 15% manifested clinical signs of osteoporosis (pooled OR : 3.7), compared to control HIV-seronegative subjects (patients  (Refer tP < .0001), which was attributable to marked differences in the study populations and interventions. Nonetheless, the sensitivity analysis showed that in two homogeneous studies , alendronate, calcium, and vitamin D markedly improved lumbar bone mineral density after one year, when compared with calcium and vitamin D alone . Of note is the clinically relevant observation that the alendronate-supplemented group did not evidence fewer fragility fractures , or osteoporosis symptomatology , and, overall, adverse occurrence of clinical outcomes was not significantly different between groups . One RTC, markedly heterogeneous with the others, demonstrated that patients with AIDS wasting showed clinically important improvement in lumbar bone mineral density following three months of testosterone enanthate treatment, compared to placebo, , whereas progressive resistance training failed to improve this outcome in the patients. Neither the testosterone nor the resistance-training group suffered adverse effects. Taken together, and as briefly outlined above, the best available evidence that has emerged from this systematic review confirmed that bisphosphonate therapy in HIV-seropositive adults, and testosterone in patients with AIDS wasting syndrome appears to be both safe and possibly effective to improve bone mineral density. Clearly, these conclusions are preliminary due to the limited number of pertinent and homogeneous studies included in this analysis [In a Cochrane systematic review, the effects of interventions aimed at increasing bone mineral density in HIV-infected adults were examined. Following a remarkable extensive search of the available evidence that included MEDLINE, EMBASE, LILACS, and The Cochrane Library as well as “gray literature such as Meeting Abstracts, AIDSTRIALS, ACTIS, Current Controlled Trials, National Institutes of Health Clinical Trials Registry, and CenterWatch, only randomized trials that compared pharmacological or nonpharmacological therapy with placebo, no treatment, or an alternative therapy, in seropositive men and women 18 years of age or older were included. The clinical outcome of interest was increasing bone mineral density. The extensive and focused nature of the systematic review yielded three RCT studies that reported examination of the role of alendronate in patients with HIV and osteopenia or osteoporosis. A meta-analysis was precluded because of excessive heterogeneity  to yield technical research synthesis reports, which are referred to as “systematic reviews”. Increasingly, research synthesis protocols involve the systematic evaluation of multiple existing systematic reviews, a process which must not remain purely technical but must strive to establish the clinical relevance of the consensus evidence: hence, the term “clinically relevant complex systematic review” .Systematic reviews and clinically relevant complex systematic reviews are used in research and analysis comparing either the effectiveness or the efficacy of treatment intervention. However, the “real world” of patient care and practice demands that comparative effectiveness and comparative efficacy research not be distinct, but in fact remain conjoined for the ultimate administration of the best treatment intervention in terms of what works, and of what is most cost-effective, beneficial, and poses the least amount of risk to the patient. Research synthesis in health care must focus on quantifying the quality of the evidence and the strength of the clinical recommendations, in a manner to our expansion of the GRADE assessment tool . Hence, we propose that the new frontier in the domain of research synthesis in health care will be the integration of these two traditionally distinct avenues into a novel perspective, which could be termed Comparative Effectiveness-Efficacy Research & Analysis for Practice (CEERAP).In conclusion, it is clear that HIV/AIDS has posed a challenge to fundamental and clinical research for decades. Surely, this is so in large part because the term actually implies to at least three distinct epidemiologies: in the Western societies, we note a substantial difference between patients with HIV/AIDS in the population of multidrug users and patients who have contracted HIV/AIDS following unsafe sexual practices. There may be some degree of overlap between these groups in some instances, but mostly they represent two distinct patient populations from the socioeconomical viewpoint. In emerging societies and in the developing world, the HIV/AIDS epidemic is different altogether, as it affects the pediatric population in greater number, it is more prominent, and causes considerably more deaths than in the West. In the heart of Africa, entire villages may be affected, a large majority of the population of certain countries  may be affected with osteoimmune and other HIV/AIDS pathologies, which calls for an even greater urgency for a globalization of CEERAP (g-CEERAP).The success of our intervention efforts to combat and defeat HIV/AIDS worldwide in the next decade will rest on g-CEERAP, we contend, along three principal domains:identification of the best available evidence for effectiveness and efficacy of treatment intervention for osteoporosis as a pathology of HIV/AIDS, dissemination in order to increase health literacy of the patient and caregiver populations, as well as the health care providers who may not be familiar with CEER analysis for practice, worldwide access via 2G or 3G to paperless CEERAP recommendations for full coverage of human information technology.