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In situ measurements with a four-channel stratospheric condensation particle counter (CPC) were conducted at up to 20 km altitude on board the aircraft M-55 Geophysica from Kiruna, Sweden, in January through March (EUPLEX 2003, RECONCILE 2010) and in December (ESSenCe 2011). During all campaigns air masses from the upper stratosphere and mesosphere were subsiding inside the Arctic winter vortex, thus initializing a transport of refractory aerosol into the lower stratosphere (Θ < 500 K). The strength and extent of this downward transport varied between the years depending on the dynamical evolution of the vortex. Inside the vortex and at potential temperatures Θ ≥ 450 K around 11 submicron particles per cm3 were generally detected. Up to 8 of these 11 particles per cm3 were found to contain thermo-stable (at 250 °C) residuals with diameters of 10 nm to about 1 μm. Particle mixing ratios (150 mg−1) and fractions of non-volatile particles (75% of totally detected particles) exhibited highest values in air masses having the lowest content of nitrous oxide (70 nmol mol−1 of N2O). This indicates that refractory aerosol originates from the upper stratosphere or the mesosphere. Derived from the mixing ratio of the simultaneously measured long-lived tracer N2O, an empirical index serves to differentiate probed air masses according to their origin: inside the vortex, the vortex edge region, or outside the vortex. Previously observed high fractions of refractory submicron aerosol in the 2003 Arctic vortex were ascribed to unusually strong subsidence during that winter. However, measurements under perturbed vortex conditions in 2010 and during early winter in December 2011 revealed similarly high values. Thus, the abundance of refractory aerosol in the lower stratosphere within the Arctic vortices appears to be a regular feature rather than the exception. During December, the import from aloft into the lower stratosphere appears to be developing; thereafter the abundance of refractory aerosol inside the vortex reaches its highest levels in March. The correlations of refractory aerosol with N2O suggest that, apart from mean subsidence, diabatic dispersion inside the vortex significantly contributes to the transport of particles to the Arctic lower stratosphere. A measurement-based estimate of the total mass of refractory aerosol inside the vortex is provided for each campaign. Based on the derived increase of particle mass in the lower stratospheric vortex (100–67 hPa pressure altitude) by a factor of 4.5 between early and late winter, we estimate the total mass of mesospheric particles deposited over the winter 2009/2010 in the entire Arctic vortex to range between 77 × 103 and 375 × 106 kg. This estimate is compared with the expected atmospheric influx of meteoritic material (110 ± 55 × 103 kg per day). Such estimates at present still hold considerable uncertainties, which are discussed in this article. Nevertheless, the results enable placing constraints on the shape of the so far unknown size distribution of refractory aerosol within the vortex.

✓ The authors report on a 31-year-old man with spontaneous craniocervical osseous fusion secondary to cervical dystonia (CD). After an 8-year history of severe CD, the patient developed a fixed rotation of his head to the right. Three-dimensional computerized tomography reconstructions revealed rotation and fixation of the occiput and C-1 relative to C-2, which was similar to that seen in atlantoaxial rotatory fixation. There was abnormal ossification of the odontoid facet joints and ligaments. Additional ossification was observed in the cervical soft tissue bridging the lateral mass of C-1 and the occiput. The patient underwent partial myectomy of the dystonic left sternocleidomastoid muscle and selective posterior ramisectomy of the right posterior neck muscles; postoperatively he experienced relief of his neck pain. In patients with CD refractory to conservative treatment, the appropriate timing of surgical treatment is important.

NPR1/NIM1 is a key regulator of systemic acquired resistance (SAR) in Arabidopsis. Using the yeast two-hybrid system, we have identified three novel genes, NIMIN-1, NIMIN-2 and NIMIN-3 (NIMIN for NIM1-interacting) that encode structurally related proteins interacting physically with NPR1/NIM1. NIMIN-1 and NIMIN-2 both bind strongly to NPR1/NIM1 via a common binding motif interacting with the C-terminal moiety of NPR1/NIM1, whereas NIMIN-3 interacts with NPR1/NIM1 via the N-terminal part of NPR1/NIM1. In addition, NIMIN-1, NIMIN-2, and NIMIN-3 are able to interact via NPR1/NIM1 with basic leucine zipper transcription factors of the TGA family in a yeast tri-hybrid system. A mutant protein of NPR1/NIM1, npr1-2, which has been shown to be severely impaired in induction of SAR gene expression, failed to bind the NIMIN proteins. The NIMIN genes are expressed in Arabidopsis plants in response to SAR-inducing treatments, and the NIMIN proteins, like NPR1/NIM1, carry functional nuclear localization signals as revealed by expression of fusion proteins in yeast and in transgenic plants. Taken together, these data indicate that the NIMIN proteins, via physical interaction with NPR1/NIM1, are part of the signal transduction pathway leading to SAR gene expression in Arabidopsis.

In higher plants, as-1-like cis elements mediate auxin- and salicylic acid-inducible transcription. Originally found in viral and T-DNA promoters, they are also functional elements of plant promoters activated during the defence response against pathogens. Tobacco bZIP transcription factor TGA1a was the first recombinant protein shown to bind to as-1. cDNAs for two novel tobacco as-1-binding bZIP proteins (TGA2.1 and TGA2.2) were isolated. Revealing a high degree of amino acid identity in the bZIP domain (89%) and the C-terminus (79%), the two TGA2 factors differ remarkably with respect to the length of the N-terminus (170 amino acids in TGA2.1 versus 43 amino acids in TGA2.2). TGA2.1 and TGA2.2, but not TGA1a, interacted with ankyrin repeat protein NPR1, a central activator of the plant defence response. In contrast, TGA2.1 and TGA1a, but not TGA2.2, functioned as transcriptional activators in yeast. Apart from conferring transcriptional activation, the N-terminal domain of TGA2.1 led to reduced in vitro as-1-binding activity and almost completely abolished binding to one half site of this bifunctional element. When being part of a heterodimer with TGA2.2, TGA2.1 was efficiently recruited to a single half site, though double occupancy of the element was still preferred. In contrast, TGA1a preferred to bind to only one palindrome, a feature that was also maintained in heterodimers between TGA1a and TGA2.1 or TGA2.2.

Peripheral neuropathy (PN) is common in the setting of antiretroviral (ARV) programmes in resource-limited settings and poses significant challenges in assessment and management. A retrospective analysis was undertaken of prevalence and management of PN in a cohort of 3341 patients on highly active antiretroviral therapy. A first line ARV regimen containing stavudine (D4T) is used for clinically eligible patients. Amitriptyline is prescribed for symptom relief and in cases of persistent or escalating symptoms zidovudine (AZT) is substituted for D4T. Leg pain or numbness was reported in 1173 patients (35%). However, only 428 (13%) were given a diagnosis of PN, 228 (7%) were prescribed amitriptyline and 200 (6%) were switched to AZT. A recent pharmokinetic study in this population showed a high Cmaxof D4T with the generic combination triomune (D4T 40 mg). This could account for the high prevalence of PN. The optimum time for switch to a non-D4T containing regimen is unknown.

Intracranial pressure monitoring has a key role in the management of patients developing increased intracranial pressure (ICP). We adopted the Camino fiberoptic system for intracranial pressure measurement in 1993 in our neurosurgical department. The aim of this study was to investigate reliability, handling characteristics and complication rate of the Camino intracranial pressure device. In an eighteen month period, we prospectively investigated 118 patients with intracranial pathology undergoing Camino fiberoptic intraparenchymal or intraventricular ICP monitoring. The assessment of reliability of ICP monitoring according to patients clinical condition, to cranial computed tomography (CCT) findings and ICP waveform was carried out. Position of the probe and intracranial bleeding complications related to probe insertion were confirmed by CCT. Technical complications, as well as infections due to the device, were documented. In vivo recalibration was performed in 22 patients. At the end of the measuring period the drift of the probe was evaluated and the accuracy of the fiberoptic device was measured by performing a two point calibration. Recordings of intracranial pressure were carried out with 136 Camino devices (104 parenchymal, 32 ventricular) in 118 patients with an average measuring time of 94.1 +/- 79.1 hrs. One hundred and fifteen Camino intracranial pressure devices (85.2%) demonstrated reliability according to the predetermined clinical parameters. The actual mean drift after removal of the devices was 3.4 mmHg +/- 3.2 with an actual daily drift of 3.2 +/- 17.2 mmHg. Recorded complications included infection (0.7%), intraparenchymal haematoma (5.1%), and a high complication rate (23.5%) with regard to technical aspects. The Camino intracranial pressure system offers reliable ICP measurements in an acceptable percentage of devices, and the advantage of in vivo recalibration. The high incidence of technical complications identifies a need for improvement in the fiberoptic cable and the fixation system.

The pattern of reoccurrence of symptoms after discontinuation of deep brain stimulation (DBS) has not been systematically studied in dystonia. Eight patients (mean age (SD) 53.8 (14.4) years) with segmental dystonia at a mean follow-up of 11.3 (4.2) months were studied after implantation of bilateral DBS electrodes in the internal globus pallidus using a standard video protocol and clinical rating scales, immediately and at 2 and 4 h after switching off DBS. Dystonic signs returned sequentially, with a rapid worsening of phasic and a slower worsening of tonic dystonic components. In all patients, phasic dystonic features appeared within a few minutes, whereas the tonic elements of dystonia reoccurred with a more variable delay. Differential clinical effects when withdrawing DBS might reflect its influence on different pathophysiological mechanisms in dystonia.

Within the frame of the European Aerosol Cloud Climate and Air Quality Interactions (EUCAARI) project the Météo-France aircraft ATR-42 performed 22 research flights, over central Europe and the North Sea during the intensive observation period in May 2008. For the campaign, the ATR-42 was equipped in order to study aerosol physical, chemical and optical properties, as well as cloud microphysics. During the campaign, continental air masses from Eastern and Western Europe were encountered, along with polar and Scandinavian air masses. For the 22 research flights, retroplume analyses along the flight tracks were performed with FLEXPART in order to classify air masses into five sectors of origin which allows for a qualitative evaluation of emission influence on the respective air parcel. In the polluted boundary layer (BL), typical concentrations of particles with diameters larger than 10 nm (N10) are of the order of 5000–6000 cm−3, whereas N10 concentrations of clean air masses were lower than 1300 cm−3. The detection of the largest particle number concentrations occurred in air masses coming from Polar and Scandinavian regions for which an elevated number of nucleation mode (25–28 nm) particles was observed and attributed to new particle formation over open sea. In the free troposphere (FT), typical observed N10 are of the order of 900 cm−3 in polluted air masses and 400–600 cm−3 in clean air masses, respectively. In both layers, the chemical composition of submicron aerosol particles is dominated by organic matter and nitrate in polluted air masses, while, sulphate and ammonium followed by organics dominate the submicron aerosols in clean air masses. The highest CCN/CN ratios were observed within the polar air masses while the CCN concentration values are the highest within the polluted air masses. Within the five air mass sectors defined and the two layers (BL and FT), observations have been distinguished into anticyclonic (first half of May 2008) and cyclonic conditions (second half of May 2008). Strong relationships between meteorological conditions and physical, chemical as well as optical properties are found.

Background\ud Smear-positive pulmonary TB is the most infectious form of TB. Previous studies on the effect of HIV and antiretroviral therapy on TB treatment outcomes among these highly infectious patients demonstrated conflicting results, reducing understanding of important issues.\ud \ud Methods\ud All adult smear-positive pulmonary TB patients diagnosed between 2008 and 2010 in Malawi’s largest public, integrated TB/HIV clinic were included in the study to assess treatment outcomes by HIV and antiretroviral therapy status using logistic regression.\ud \ud Results\ud Of 2,361 new smear-positive pulmonary TB patients, 86% had successful treatment outcome (were cured or completed treatment), 5% died, 6% were lost to follow-up, 1% failed treatment, and 2% transferred-out. Overall HIV prevalence was 56%. After adjusting for gender, age and TB registration year, treatment success was higher among HIV-negative than HIV-positive patients (adjusted odds ratio 1.49; 95% CI: 1.14–1.94). Of 1,275 HIV-infected pulmonary TB patients, 492 (38%) received antiretroviral therapy during the study. Pulmonary TB patients on antiretroviral therapy were more likely to have successful treatment outcomes than those not on ART (adjusted odds ratio : 1.83; 95% CI: 1.29–2.60).\ud \ud Conclusion\ud HIV co-infection was associated with poor TB treatment outcomes. Despite high HIV prevalence and the integrated TB/HIV setting, only a minority of patients started antiretroviral therapy. Intensified patient education and provider training on the benefits of antiretroviral therapy could increase antiretroviral therapy uptake and improve TB treatment success among these most infectious patients.

Background: In Malawi, as in other sub-Saharan African countries, nurses manage patients of all ages on antiretroviral treatment (ART). Nurse management of children is rarely studied.We compare ART prescribing between nurses and clinical officers during routine clinic visits at an urban, public clinic to inform policy in paediatric ART management. Methods: Caregivers of children on first-line ART provided information about visit dates, pill counts, ART dosage and formulation to a nurse and, subsequently, to a clinical officer. Nurses and clinical officers independently calculated adherence, dosage based on body weight, and set next appointment date. Clinical officers, but not nurses, accessed an electronic data system that made the calculations for them based on information from prior visits, actual and expected pill consumption, and standard drug supplies. Nurses calculated with pen and paper. For numerical variables, Bland-Altman graphs plot differences of each nurse clinical officer pair against the mean, show the 95% limits of agreement (LoA), and also show the mean difference across all reviews. Kappa statistics assess agreement for categorical variables. Results: A total of 704 matched nurse-clinical officer reviews of 367 children attending the ART clinics between March and July 2010 were analyzed. Eight nurses and 18 clinical officers were involved; two nurses and five clinical officers managed 100 visits or more. Overall, there was a good agreement between the two cadres. Differences between nurses and clinical officers were within narrow LoA and mean differences showed little deviation from zero, indicating little skewing towards one cadre. LoA of adherence and morning and evening ART dosages varied from -24% to 24%, -0.4 to 0.4 and -0.41 to 0.40 tablets, respectively, with mean differences (95% CI) of 0.003 (-0.9, 0.91), -0.005 (-0.02, 0.01) and -0.009 (-0.02, 0.01). Next appointment calculations differed more between cadres with LoA from -40 to 42 days [mean difference: 0.96 days (95% CI:-0.6 to 2.5)], but agreement in the ART formulation prescribed was very good (kappa 0.93). Conclusions: Nurses’ ART prescribing practices and calculations of adherence and next appointments are similar to clinical officers, although clinical officers used an electronic system. Our findings support the decision of Malawi’s health officials to utilize nurses to manage paediatric ART patients. Keywords: antiretroviral therapy; child; HIV; task shifting; nurse; adherence; medication safety; Malawi; sub-Saharan Africa (Published: 17 August 2012) To access the supplementary material to this article: Examples for calculation of adherence and next appointment Dosing charts for adult split Triomune tablets and Triomune baby tablets Bland Altman graphs plotting the differences in responses between nurses and clinicians against the mean of both cadres at each visit please see Supplementary Files in the column to the right (under Article Tools). Weigel R et al. Journal of the International AIDS Society 2012, 15 :17432 http://www.jiasociety.org/index.php/jias/article/view/17432 | http://dx.doi.org/10.7448/IAS.15.2.17432

In 2004, Malawi began scaling up its national antiretroviral therapy (ART) program. Because of limited treatment options, population-level surveillance of acquired human immunodeficiency virus drug resistance (HIVDR) is critical to ensuring long-term treatment success. The World Health Organization target for clinic-level HIVDR prevention at 12 months after ART initiation is ≥ 70%. In 2007, viral load and HIVDR genotyping was performed in a retrospective cohort of 596 patients at 4 ART clinics. Overall, HIVDR prevention (using viral load ≤ 400 copies/mL) was 72% (95% confidence interval [CI], 67%-77%; range by site, 60%-83%) and detected HIVDR was 3.4% (95% CI, 1.8%-5.8%; range by site, 2.5%-4.7%). Results demonstrate virological suppression and HIVDR consistent with previous reports from sub-Saharan Africa. High rates of attrition because of loss to follow-up were noted and merit attention.

HIV-infected women identified through antenatal care (ANC) often fail to access antiretroviral treatment (ART), leaving them and their infants at risk for declining health or HIV transmission. We describe results of measures to improve uptake of ART among eligible pregnant women.Between October 2006 and December 2009, interventions implemented at ANC and ART facilities in urban Lilongwe aimed to better link services for women with CD4 counts250/μl. A monitoring system followed women referred for ART to examine trends and improve practices in referral completion, on-time ART initiation and ART retention.Six hundred and twelve women were ART eligible: 604 (99%) received their CD4 result, 344 (56%) reached the clinic, 286 (47%) started ART while pregnant and 261 (43%) were either alive on ART or transferred out after 6 months. Between 2006 and 2009, the median (IQR) time between CD4 blood draw and ART initiation fell from 41 days (17, 349) to 15 days (7,42) (P = 0.183); the proportion of eligible individuals starting ART while pregnant and retained for 6 months improved from 17% to 65% (P 0.001). Delays generally shortened within the continuum of care from 2006 to 2009; however, time from CD4 blood draw to ART referral increased from 7 to 14 days.Referrals between facilities and delays through CD4 count measurements create bottlenecks in patient care. Retention improved over time, but delays within the linkage process remained. ART initiation at ANC plus use of point-of-care CD4 tests may further enhance ART uptake.

BACKGROUND: Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa. METHODS: Treatment naïve children aged RESULTS: A total of 17 990 children (range, 238–8975) were followed for 36 181 person-years. At ART initiation, most children were underweight (50%) and stunted (66%). Lower baseline WAZ, HAZ, and WHZ were the most important determinants of faster catch-up growth on ART. WAZ and WHZ increased rapidly in the first year and stagnated or reversed thereafter, whereas HAZ increased continuously over time. Three years after starting ART, WAZ ranged from −2.80 (95% confidence interval [CI]: −3.66 to −2.02) to −1.98 (95% CI: −2.41 to −1.48) in children with a baseline z score < −3 and from −0.79 (95% CI: −1.62 to 0.02) to 0.05 (95% CI: −0.42 to 0.51) in children with a baseline WAZ ≥ −1. For HAZ, the corresponding range was −2.33 (95% CI: −2.62 to −2.02) to −1.27 (95% CI: −1.58 to −1.00) for baseline HAZ < −3 and −0.24 (95% CI: −0.56 to 0.15) to 0.84 (95% CI: 0.53 to 1.16) for HAZ ≥ −1. CONCLUSIONS: Despite a sustained growth response and catch-up growth in children with advanced HIV disease treated with ART, normal weights and heights are not achieved over 3 years of ART.

Within the European Aerosol Cloud Climate and Air Quality Interactions (EUCAARI) project, the Meteo France research aircraft ATR-42 was operated from Rotterdam airport during May 2008, to perform scientific flights dedicated to the investigation of aerosol-cloud interactions. Therein, the objective of this study is to illustrate the impact of cloud processing on the aerosol particles physical and chemical properties. The presented results are retrieved from measurements during a double-flight mission from Rotterdam (Netherlands) to Newcastle (UK) and back using data measured with compact Time of Flight Aerosol Mass Spectrometer (cToF-AMS) and Scanning Mobility Particle Sizer (SMPS). Cloud-related measurements during these flights were performed over the North Sea within as well as in close vicinity of a marine stratocumulus cloud layer. Particle physical and chemical properties observed in the close vicinity (V), below and above the stratocumulus cloud show strong differences. Firstly, measurements at constant altitude above the cloud layer show decreasing mass concentrations with decreasing horizontal distance (210–0 km) to the cloud layer by a factor up to 7, whereas below the cloud and by same means of distance, the mass concentrations merely decrease by a factor of 2 on average. Secondly, the averaged aerosol size distributions, observed above and below the cloud layer, are of bimodal character with pronounced minima between Aitken and accumulation mode which is potentially the consequence of cloud processing. Finally, the chemical composition of aerosol particles is strongly dependent on the location relative to the cloud layer (vicinity or below/above cloud). In general, the nitrate and organic fractions decrease with decreasing distance to the cloud, in the transit from cloud–free conditions towards the cloud boundaries. The decrease of nitrate and organic compounds ranges at a factor of three to ten, affecting sulfate and ammonium compounds to be increasingly abundant in the aerosol chemical composition while approaching the cloud layer. Finally, the chemical composition of non-refractory evaporated cloud droplets measured within the cloud shows increased fractions of nitrate and organics (with respect to concentrations found below clouds), but also large amounts of sulfate, thus, related to activation of particles, made up of soluble compounds.

Background Although the World Health Organization (WHO) provides information on the number of TB patients categorised as “other”, there is limited information on treatment regimens or treatment outcomes for “other”. Such information is important, as inappropriate treatment can lead to patients remaining infectious and becoming a potential source of drug resistance. Therefore, using a cohort of TB patients from a large registration centre in Lilongwe, Malawi, our study determined the proportion of all TB re-treatment patients who were registered as “other”, and described their characteristics and treatment outcomes. Methods This retrospective observational study used routine program data to determine the proportion of all TB re-treatment patients who were registered as “other” and describe their characteristics and treatment outcomes between January 2006 and December 2008. Results 1,384 (12%) of 11,663 TB cases were registered as re-treatment cases. Of these, 898 (65%) were categorised as “other”: 707 (79%) had sputum smear-negative pulmonary TB and 191 (21%) had extra pulmonary TB. Compared to the smear-positive relapse, re-treatment after default (RAD) and failure cases, smear-negative “other” cases were older than 34 years and less likely to have their HIV status ascertained. Among those with known HIV status, “other” TB cases were more likely to be HIV positive. Of TB patients categorised as “other”, 462 (51%) were managed on the first-line regimen with a treatment success rate of 63%. Conclusion A large proportion of re-treatment patients were categorised as “other”. Many of these patients were HIV-infected and over half were treated with a first-line regimen, contrary to national guidelines. Treatment success was low. More attention to recording, diagnosis and management of these patients is warranted as incorrect treatment regimen and poor outcomes could lead to the development of drug resistant forms of TB.

Aim: Genetic polymorphisms have the potential to influence drug metabolism and vary among ethnic groups. This study evaluated the correlation of genetic polymorphisms with nevirapine pharmacokinetics exposure in Malawians. Materials & methods: CYP450 2B6, 2D6, 3A4 and 3A5, ABCB1 and constitutive androstane receptor and pregnane X receptor, were analyzed for polymorphisms in 26 subjects. Results: Allele frequencies (variant) were: CYP2B6 514G>T (0.31) CYP2D6*4 (0.02); CYP2D6*17 (0.35); CYP3A4*1B (0.77); CYP3A5*3 (0.25); ABCB1 2677G>T (0.0), ABCB1 3435C>T (0.21), NR1I3 13711152T>C (0.02), NR1I2 44477T>C (0.10), NR1I2 63396C>T (0.33), NR1I2 6-bp indel (del: 0.17). CYP2B6 516G>T (non-wild-type/wild-type) correlated with nevirapine pharmacokinetic parameters; geometric mean ratios (95% CI): 1.75 (1.27–2.40) for area under the concentration time curve (AUC)0–12 h, 1.58 (1.03–2.42) for C0, and 0.53 (0.31–0.91) for clearance. In a multivariable model, nevirapine AUC increased by 1.5% per year of age (p < 0.0001), CYP2B6 516 T allele increased AUC by 92% (p < 0.0001), and CYP3A5*3 decreased AUC by 31% (p = 0.0027). Conclusion: Allele frequencies were similar to other sub-Saharan African populations. The T allele for CYP2B6 516 was significantly associated with nevirapine exposure. Original submitted 15 June 2010; Revision submitted 5 July 2011

Evaluating treatment failure is critical when deciding to modify antiretroviral therapy (ART). Virologic Assessment Forms (VAFs) were implemented in July 2008 as a prerequisite for ordering viral load. The form requires assessment of clinical and immunologic status.Using the Electronic Medical Record (EMR), we retrospectively evaluated patients who met 2006 WHO guidelines for immunologic failure (≥15 years old; on ART ≥6 months; CD4 countbaseline OR CD4 count50% drop from peak OR CD4 persistently100 cells) at the Lighthouse Trust clinic from December 2007 to December 2009. We compared virologic screening, VAF implementation and ART modification during the same period using Fisher's exact tests and unpaired t-tests as appropriate.Of 7000 enrolled ART patients ≥15 years old with at least two CD4 counts, 10% had immunologic failure with a median follow-up time on ART of 1.4 years (IQR: 0.8-2.3). Forty (6%) viral loads were ordered: 14 (35%) were detectable (400 HIV RNA copies/mL) and one (7%) patient was switched to second-line therapy. Overall, 259 VAFs were completed: 67% for immunologic failure and 33% for WHO Stage 4 condition. Before VAF implementation, 1% of patients had viral loads drawn during routine care, whereas afterwards, 8% did (P0.0001; 95% CI: 0.03-0.08).Clinicians did not identify a large proportion of immunologic failure patients for screening. Implementation of VAFs produced little improvement in virologic screening during routine care. Better training and monitoring systems are needed.

Detailed investigations of the chemical and microphysical properties of atmospheric aerosol particles were performed at the puy-de-Dôme (pdD) research station (1465 m) in autumn (September and October 2008), winter (February and March 2009), and summer (June 2010) using a Time-of-Flight Aerosol Mass Spectrometer. Over the three campaigns, the average mass concentrations of the non-refractory submicron particles ranged from 10 μg m−3 up to 27 μg m−3. Highest nitrate and ammonium mass concentrations were measured during the winter and during periods when marine modified airmasses were arriving at the site, whereas highest concentrations of organic particles were measured during the summer and during periods when continental airmasses arrived at the site. The measurements reported in this paper show that atmospheric particle composition is strongly influenced by both the season and the origin of the airmass. The total organic mass spectra were analysed using positive matrix factorisation to separate individual organic components contributing to the overall organic particle mass concentrations. These organic components include a low volatility oxygenated organic aerosol particle (LV-OOA) and a semi-volatile organic aerosol particle (SV-OOA). Correlations of the LV-OOA components with fragments of m/z 60 and m/z 73 (mass spectral markers of wood burning) during the winter campaign suggest that wintertime LV-OOA are related to aged biomass burning emissions, whereas organic aerosol particles measured during the summer are likely linked to biogenic sources. Equivalent potential temperature calculations, gas-phase, and LIDAR measurements define whether the research site is in the planetary boundary layer (PBL) or in the free troposphere (FT)/residual layer (RL). We observe that SV-OOA and nitrate particles are associated with air masses arriving from the PBL where as particle composition measured from RL/FT airmasses contain high mass fractions of sulphate and LV-OOA. This study provides unique insights into the effects of season and airmass variability on regional aerosol particles measured at an elevated site.

One of the still open issues for the development of superconducting insertion devices is the understanding of the heat load induced by the beam passage. With the aim of measuring the beam heat load to a cold bore and in order to gain a deeper understanding in the beam heat load mechanisms, a cold vacuum chamber for diagnostics is under construction. We plan to have access with the same set-up to a number of different diagnostics, so we are implementing: i) retarding field analysers to measure the electron flux, ii) temperature sensors to measure the total heat load, iii) pressure gauges, iv) and mass spectrometers to measure the gas content. The inner vacuum chamber will be removable in order to test different geometries and materials. COLDDIAG is built to fit in a short straight section at ANKA, but we are proposing its installation in different synchrotron light sources with different energies and beam characteristics. A first installation in DIAMOND is planned in June 2011. Here we describe the technical design report of this device and the planned measurements with beam.

Airborne in-situ observations of ClO in the tropics were made during the TROCCINOX (Aracatuba, Brazil, February 2005) and SCOUT-O3 (Darwin, Australia, November/December 2005) field campaigns. While during most flights significant amounts of ClO (≈10–20 parts per trillion, ppt) were present only in aged stratospheric air, instances of enhanced ClO mixing ratios of up to 40 ppt – significantly exceeding those expected from gas phase chemistry – were observed in air masses of a more tropospheric character. Most of these observations are associated with low temperatures or with the presence of cirrus clouds (often both), suggesting that cirrus ice particles and/or liquid aerosol at low temperatures may promote significant heterogeneous chlorine activation in the tropical upper troposphere lower stratosphere (UTLS). In two case studies, particularly high levels of ClO observed were reproduced by chemistry simulations only under the assumption that significant denoxification had occurred in the observed air. However, to reproduce the ClO observations in these simulations, O3 mixing ratios higher than observed had to be assumed, and at least for one of these flights, a significant denoxification is in contrast to the observed NO levels, suggesting that the coupling of chlorine and nitrogen compounds in the tropical UTLS may not be completely understood.

New particle formation (NPF), which generates nucleation mode aerosol, was observed in the tropical Upper Troposphere (UT) and Tropical Tropopause Layer (TTL) by in situ airborne measurements over South America (January–March 2005), Australia (November–December 2005), West Africa (August 2006) and Central America (2004–2007). Particularly intense NPF was found at the bottom of the TTL. Measurements with a set of condensation particle counters (CPCs) with different dp50 (50% lower size detection efficiency diameter or "cut-off diameter") were conducted on board the M-55 Geophysica in the altitude range of 12.0–20.5 km and on board the DLR Falcon-20 at up to 11.5 km altitude. On board the NASA WB-57F size distributions were measured over Central America in the 4 to 1000 nm diameter range with a system of nucleation mode aerosol spectrometers. Nucleation mode particle concentrations (NNM) were derived from these measurements which allow for identifying many NPF events with NNM in the range of thousands of particles per cm3. Over Australia and West Africa, we identified NPF in the outflow of tropical convection, in particular of a Mesoscale Convective System (MCS). Newly formed particles with NNM > 1000 cm−3 were found to coexist with ice cloud particles (dp > 2 μm) as long as cloud particle concentrations remained below 2 cm−3. The occurrence of NPF within the upper troposphere and the TTL was generally confined within 340 K to 380 K potential temperature, but NPF was of particular strength between 350 K and 370 K (i.e. ~1–4 km below the cold point tropopause). Analyses of the aerosol volatility (at 250 °C) show that in the TTL on average 75–90% of the particles were volatile, compared to typically only 50% in the extra-tropical UT, indicative for the particles to mainly consist of H2SO4-H2O and possibly organic compounds. Along two flight segments over Central and South America (24 February 2005 and 7 August 2006, at 12.5 km altitude) in cloud free air, above thin cirrus, particularly high NNM were observed. Recent lifting had influenced the probed air masses, and NNM reached up to 16 000 particles cm−3 (ambient concentration). A sensitivity study using an aerosol model, which includes neutral and ion induced nucleation processes, simulates NNM in reasonable agreement with the in situ observations of clear-air NPF. Based on new, stringent multi-CPC criteria, our measurements corroborate the hypothesis that the tropical UT and the TTL are regions supplying freshly nucleated particles. Our findings narrow the altitude of the main source region to the bottom TTL, i.e. to the level of main tropical convection outflow, and, by means of measurements of carbon monoxide, they indicate the importance of anthropogenic emissions in NPF. After growth and/or coalescence the nucleation mode particles may act as cloud condensation nuclei in the tropical UT, or, upon ascent into the stratosphere, contribute to maintain the stratospheric background aerosol.

Background Loss to follow-up is a major challenge of antiretroviral treatment (ART) programs in sub-Saharan Africa. Our objective was to a) determine true outcomes of patients lost to follow-up (LTFU) and b) identify risk factors associated with successful tracing and deaths of patients LTFU from ART in a large public sector clinic in Lilongwe, Malawi. Methods Patients who were more than 2 weeks late according to their last ART supply and who provided a phone number or address in Lilongwe were eligible for tracing. Their outcomes were updated and risk factors for successful tracing and death were examined. Results Of 1800 patients LTFU with consent for tracing, 724 (40%) were eligible and tracing was successful in 534 (74%): 285 (53%) were found to be alive and on ART; 32 (6%) had stopped ART; and 217 (41%) had died. Having a phone contact doubled tracing success (adjusted odds ratio, aOR = 2.1, 95% CI 1.4-3.0) and odds of identifying deaths [aOR = 1.8 (1.2-2.7)] in patients successfully traced. Mortality was higher when ART was fee-based at initiation (aOR = 2.3, 95% CI 1.1-4.7) and declined with follow-up time on ART. Limiting the analysis to patients living in Lilongwe did not change the main findings. Conclusion Ascertainment of contact information is a prerequisite for tracing, which can reveal outcomes of a large proportion of patients LTFU. Having a phone contact number is critical for successful tracing, but further research should focus on understanding whether phone tracing is associated with any differential reporting of mortality or LTFU.

BackgroundEvaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up.Methods and findingsTreatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes.ConclusionsNaïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.

Aerosol properties were studied during an intensive airborne measurement campaign that took place at Rotterdam in Netherlands in May 2008 within the framework of the European Aerosol Cloud Climate and Air Quality Interactions project (EUCAARI). The objective of this study is to illustrate seven events of new particle formation (NPF) observed with two Condensation Particle Counters (CPCs) operated on board the ATR-42 research aircraft in airsectors around Rotterdam, and to provide information on the spatial extent of the new particle formation phenomenon based on 1-s resolution measurements of ultra-fine particle (in the size range 3–10 nm diameter, denoted N3-10 hereafter) concentrations. The results show that particle production occurred under the influence of different air mass origins, at different day times and over the North Sea as well as over the continent. The number concentration of freshly nucleated particles (N3-10) varied between 5000 and 100 000 cm−3 within the boundary layer (BL). Furthermore the vertical extension for all nucleation events observed on the ATR-42 never exceeded the upper limit of the BL. The horizontal extent of N3-10 could not be delimited due to inflexible flight plans which could not be modified to accommodate real-time results. However, the NPF events were observed over geographically large areas; typically the horizontal extension was about 100 km and larger.

To determine the proportion of patients returning to antiretroviral treatment (ART) and factors associated with their return in a resource-limited setting.Between September 2006 and March 2009, at two ART-providing facilities in Lilongwe, Malawi, we identified patients who had missed clinic appointments by more than 3 weeks and therefore would have run out of antiretroviral drugs. We traced these individuals, documented reasons for missed appointments and, where appropriate, arranged another ART clinic appointment.Between April 2006 and March 2009, 2653 patients on ART had missed 3098 scheduled appointments. We successfully traced 85%, of whom 30% had died. Of the 1580 patients found alive, 25% had transferred to another ART clinic, 21% had collected drugs from other sources, 11% had treatment gaps; 40% had stopped taking drugs, 1% had not started taking drugs despite collecting them and 2% refused to be interviewed. Of the 1158 LTFU patients who had not died, transferred out or declined to be interviewed, 89% promised to return to their ART clinic and 74% actually did. The probability of returning to the clinic was significantly associated with being women, aged over 39 at ART initiation and having either treatment gaps or uninterrupted therapy. The B2C project reduced the proportion of patients finally classified as LTFU by 59%.Early active follow-up of LTFU patients resulted in marked improvement in known patient outcomes and improved retention in the treatment programme.

Objectives: The Malawi antiretroviral therapy (ART) programme uses the public health approach to identify ART failure. Advanced disease progression may occur before switching to second-line ART. We report outcomes for patients evaluated and initiated on second-line treatment in Malawi. Methods: Patients meeting Malawi immunological or clinical criteria for ART failure in two large urban ART clinics were evaluated for virological failure (viral load >400 HIV-1 RNA copies/mL) and if failure was confirmed initiated on second-line ART (zidovudine/lamivudine/tenofovir/lopinavir/ritonavir). Patients were seen monthly and laboratory evaluations were performed quarterly and as needed. We performed logistic regression modelling to identify factors associated with mortality mortality or new HIV illnesses and virological suppression at 12 months. Results: Of the 109 patients with confirmed virological failure five patients died prior to initiation three declined switching and 101 patients initiated second-line treatment. Over 12 months 10 additional patients died 34 patients experienced 45 HIV-related events and 19 patients experienced grade 3 or 4 toxicities. Among survivors 85.2% had HIV-1 RNA

Background The aim of this study was to evaluate the pharmacokinetics of lamivudine (3TC), stavudine (d4T) and nevirapine (NVP) in HIV-infected Malawian children receiving quartered tablet multiples of Triomune 40™ (generic tablet [GT]) compared with individual generic liquid (GL) and trade liquid (TL). Methods This was a prospective randomized three-way crossover study. Patients (8–0 h), area under the curve (AUC)0-6 h, maximum plasma concentration (Cmax) and time to Cmax were generated for each antiretroviral treatment. Results A total of 7 males and 11 females (6 in each GT dosing group) with a median (range) age of 7.2 years (1.3– 13.6), weight of 19 kg (9.0–30.5) and height of 109 cm (75–132) were recruited. Combining all patients, no difference in pharmacokinetics was noted among the formulations for all drugs. However, patients in the one-quarter GT dosing group (8–0-6 h 1,102, 1,720 and 2,060 h•ng/ml, respectively; P0 h (10 of 13 occasions versus the one-half and three-quarter tablet groups). Compared with Western paediatric cohorts, Malawians had concentrations 30–40% lower for 3TC and d4T and 50% higher for NVP. Conclusions Quartered multiples of Triomune 40™ are appropriate for children 18–

Background The HIV prevalence in Malawi is 12% and Kamuzu Central Hospital (KCH), in the capital Lilongwe, is the main provider of adult and paediatric HIV services in the central region. The Lighthouse at KCH offers opt-in HIV testing and counselling (HTC) for adults and children. In June 2004, Lighthouse was the first clinic to provide free antiretroviral treatment (ART) in the public sector, but few children accessed the services. In response, provider-initiated HIV testing and counselling (PITC) and an ART clinic were introduced at the paediatric department at KCH in Quarter 4 (Q4) 2004. Methods We analysed prospectively collected, aggregated data of quarterly reports from Q1 2003 to Q4 2006 from HTC centre registers, ART registers and clinic registrations at the ART clinics of both Lighthouse and the paediatric department. By comparing data of both facilities before (Q1 2003 to Q3 2004), and after the introduction of the services at the paediatric department (Q4 2004 to Q4 2006), we assessed the effect of this intervention on the uptake of HIV services for children at KCH. Results Overall, 3971 children were tested for HIV, 2428 HIV-infected children were registered for care and 1218 started ART. Between the two periods, the median (IQR) number of children being tested, registered and starting ART per quarter rose from 101 (53-109) to 358 (318-440), 56 (50-82) to 226 (192-234) and 18 (8-23) to 139 (115-150), respectively. The median proportion of tested clients per quarter that were children rose from 3.8% (2.7-4.3) to 9.6% (8.8 to 10.0) (p = 0.0009) and the proportion of ART starters that were children rose from 6.9% (4.9-9.3) to 21.1% (19.2-24.2) (p = 0.0036). The proportion of registered children and adults starting ART each quarter increased similarly, from 26% to 53%, and 20% to 52%, respectively. Conclusions Implementation of PITC and integration of ART services within the paediatric ward are likely to be the main reasons for improved access to HTC and ART for children at KCH, and can be recommended to other hospitals with paediatric inpatients in resource limited settings with high HIV prevalence.

Objective The pathophysiology of neuropathic pain is still poorly understood. Studies in experimental animals showed that neurotrophic factors such as glial cell line-derived neurotrophic factor (GDNF), brain-derived neurotrophic factor (BDNF), ciliary neurotrophic factor (CNTF), and nerve growth factor (NGF) might be involved in the pathophysiology of neuropathic pain. On the basis of these findings it is conceivable that neurotrophic factors also play a role in pain processing in man. Thus far, it remains unknown whether neurotrophic factors are altered in the cerebrospinal fluid (CSF) of patients with different pain syndromes. Here, we analyzed the concentrations of neurotrophic factors in the CSF of patients with chronic neuropathic pain in comparison to controls with nociceptive pain or hydrocephalus. Methods The concentrations of GDNF, BDNF, CNTF, and NGF were analyzed in the lumbar CSF of 10 patients with chronic neuropathic pain, in 20 patients with lumbar back pain undergoing myelography, and in 10 patients with normal pressure hydrocephalus, by using enzymes-linked immunosorbent assay techniques. Results The CSF concentrations of CNTF, BDNF, and NGF did not differ between the 3 patient cohorts. For GDNF a trend toward lower concentrations in neuropathic pain versus nociceptive back pain (P=0.17) was found. Discussion We did not detect any difference between patients with neuropathic versus nociceptive pain and nonpainful controls for spinal CNTF, BDNF, and NGF levels. Lower GDNF concentrations found in neuropathic pain patients might be associated with increased receptor expression. Possible alterations of neurotrophic factors at spinal relays, however, might not be reflected adequately in changes of CSF concentrations.

Background Ensuring good adherence is critical to the success of anti-retroviral treatment (ART). However, in resource-poor contexts, where paediatric HIV burden is high there has been limited progress in developing or adapting tools to support adherence for HIV-infected children on ART and their caregivers. We conducted formative research to assess children's adherence and to explore the knowledge, perceptions and attitudes of caregivers towards children's treatment. Methods All children starting ART between September 2002 and January 2004 (when ART was at cost in Malawi) were observed for at least 6 months on ART. Their adherence was assessed quantitatively by asking caregivers of children about missed ART doses during the previous 3 days at monthly visits. Attendance to clinic appointments was also monitored. In June and July 2004, four focus group discussions, each with 6 to 8 caregivers, and 5 critical incident narratives were conducted to provide complementary contextual data on caregivers' experiences on the challenges to and opportunities of paediatric ART adherence. Results We followed prospectively 47 children who started ART between 8 months and 12 years of age over a median time on ART of 33 weeks (2–91 weeks). 72% (34/47) never missed a single dose according to caregivers' report and 82% (327/401) of clinic visits were either as scheduled, or before or within 1 week after the scheduled appointment. Caregivers were generally knowledgeable about ART and motivated to support children to adhere to treatment despite facing multiple challenges. Caregivers were particularly motivated by seeing children begin to get better; but faced challenges in meeting the costs of medicine and transport, waiting times in clinic, stock outs and remembering to support children to adhere in the face of multiple responsibilities. Conclusion In the era of rapid scale-up of treatment for children there is need for holistic support strategies that focus on the child, the caregiver and the health worker and which are situated within the reality of fragile health systems. The findings highlight the need for cost-free and less complex paediatric ART regimes and culturally appropriate tools to support children's adherence.

Summary Objectives In antiretroviral therapy (ART) scale-up programmes in sub-Saharan Africa viral load monitoring is not recommended. We wanted to study the impact of only using clinical and immunological monitoring on the diagnosis of virological ART failure under routine circumstances. Methods Clinicians in two urban ART clinics in Malawi used clinical and immunological monitoring to identify adult patients for switching to second-line ART. If patients met clinical and/or immunological failure criteria of WHO guidelines and had a viral load

Background: Malawi is making good progress scaling up antiretroviral therapy (ART), but we do not know the levels of access of high-risk, disadvantaged groups such as prisoners. The aim of this study was to measure access and treatment outcomes of prisoners on ART at the national level. Methodology: A retrospective cohort study was conducted examining patient follow-up records from all 103 public sector ART clinics in Malawi, and observations were censored on December 31, 2006. Results: By December 31, 2006, a total of 81,821 patients had been started on ART. Of these, 103 (0.13%) were prisoners. At ART initiation, 93% of prisoners were in World Health Organization (WHO) clinical stage 3 or 4 while 7% started in stage 1 or 2 with a CD4-lymphocyte count of ≤250/mm3. Treatment outcomes by the end of December 2006 were as follows: 66 (64%) alive and on ART at their registration facility; 9 (9%) dead; 8 (8%) lost to follow-up; and 20 (19%) transferred out to another facility. The probability of being alive and on ART at 6 and 12 months was 82.5% and 77.7%. Conclusions: In spite of the rapid scale-up of ART, only a small number of HIV-positive prisoners had accessed ART by the end of 2006. Treatment outcomes were good. Initiatives are now needed to improve access to HIV testing and ART in Malawi’s prisons.

A national survey was carried out in all the 103 public sector and 38 private sector facilities in Malawi providing antiretroviral therapy (ART) to determine uptake of ART and subsequent treatment outcomes in police force personnel. All patients registered for ART and their subsequent treatment outcomes were censored on December 31st 2006. There were 85168 patients started on ART in both public and private sectors, of whom 463 (0.6%) were police force personnel. Of police force personnel starting ART, 17% were in WHO clinical stage 1 or 2 with a CD4-lymphocyte count of ≤250 cells/μL and 83% were in stage 3 or 4. Treatment outcomes of police force personnel by the end of December 2006 were 302 (65%) alive and on ART at their registration facility, 59 (13%) dead, 30 (7%) lost to follow-up, 1 stopped treatment and 71 (15%) transferred to another facility. Their probability of being alive on ART at 6-, 12- and 18-months was 83.2%, 78.6% and 76.7% respectively. There has been a good access of police force personnel to ART since national scale up commenced with good treatment outcomes, and this should serve as an example for other police forces in the region. Malawi Medical Journal Vol. 20 (1) 2008 pp. 23-27

Object Stimulation of dorsal nerve roots or dorsal root ganglia was reported to alleviate neuropathic pain in selected patients during the early postoperative period. A prospective study was initiated to investigate long-term outcome in patients with neuropathic pain of the lower extremities or groin who were treated with selective nerve root stimulation. Methods The study included patients with dermatomally distributed neuropathic pain who were > 18 years of age and in whom the pain was refractory to medical treatment. The patients were prospectively evaluated using a visual analog scale (VAS) for pain and ratings for quality of life, activities of daily living, and depression preoperatively, and after defined intervals postoperatively. Implantation of electrodes was performed via foraminotomy or interlaminar fenestration in an awake procedure. An implantable pulse generator (IPG) was implanted in a second operation after successful test stimulation performed over several days. Results Three patients were included in the study before it was stopped. The mean maximum pain score preoperatively was 9.3. All patients had successful test stimulation with > 50% pain relief prior to implantation of the IPG (mean maximum VAS Score 3.6). The beneficial effect, however, was lost within the next few months despite adjustment of stimulation settings. With higher amplitudes, side effects such as pain attacks or motor phenomena occurred. They disappeared after stopping stimulation, but neuropathic pain recurred to its full extent. The study was stopped 18 months after the first implantation, when the third and last IPG of this series was explanted. Due to the overall short-term effect of stimulation, no relevant changes in ratings for quality of life, activities of daily living, or depression were detected. Conclusions Spinal nerve root stimulation proved to be effective on short-term follow-up in 3 patients with neuropathic pain in a dermatomal distribution. Long-term stimulation, however, was disappointing because of the loss of effectiveness and the occurrence of side effects.

AIDS-associated Kaposi's sarcoma (KS) is the most common AIDS-related malignancy in sub-Saharan Africa, with a generally unfavourable prognosis. We report on six-month and 12-month cohort treatment outcomes of human immunodeficiency virus (HIV)-positive KS patients and HIV-positive non-KS patients treated with antiretroviral therapy (ART) in public sector facilities in Malawi. Data were collected from standardized antiretroviral (ARV) patient master cards and ARV patient registers. Between July and September 2005, 7905 patients started ART-488 (6%) with a diagnosis of KS and 7417 with a non-KS diagnosis. Between January and March 2005, 4580 patients started ART-326 (7%) with a diagnosis of KS and 4254 with a non-KS diagnosis. At six-months and 12-months, significantly fewer KS patients were alive and significantly more had died or defaulted compared to non-KS patients. HIV-positive KS patients on ART in Malawi have worse outcomes than other patients on ART. Methods designed to improve these outcomes must be found.

Study design We report on a 46-year-old man with atlantoaxial rotatory subluxation and cranio-cervical osseous fusion secondary to cervical dystonia (CD) and concomitant ankylosing spondylitis (AS). Objective To describe treatment of CD under these unusual circumstances. Summary of background data CD may cause several complications due to enhanced spinal degeneration. Primary and secondary nonresponders to conservative treatment may benefit from neurosurgical procedures including denervation procedures or functional stereotactic neurosurgery. However, if spinal fixation has occurred, usually, treatment of dystonia is considered to be not appropriate. Nevertheless, in the rare case, neurosurgical intervention may still be useful to improve dystonic pain. Methods After a 4-year history of severe CD, the head was rotated to the left in a rigidly fixed position. Three-dimensionally rendered computed tomography imaging studies revealed fixed rotation of the occiput and the C1 vertebra at an angle of 45 degrees to the C2 vertebra. There was abnormal ossification of the facet joints and the ligaments of the odontoid. Results The patient experienced marked relief of his neck pain after deactivation of the dystonic right sternocleidomastoid muscle by partial myectomy and the left posterior neck muscles by selective posterior ramisectomy. Conclusion Although rare, the concomitant occurrence of AS and CD should alert treating physicians and result in timely treatment of dystonia.

Background HIV/AIDS affects all sectors of the population and the defence forces are not exempt. A national survey was conducted in all public and private sectors in Malawi that provide antiretroviral therapy (ART) to determine the uptake of ART by army personnel, their outcomes while on treatment, and the impact of ART on mortality in the Malawi Defence Force. Methodology/Principal Findings A retrospective cohort analysis was carried out, collecting data on access and retention on treatment from all 103 public and 38 private sector ART clinics in Malawi, using standardised patient master cards and clinic registers. Observations were censored on December 31st 2006. Independent data on mortality trends in army personnel from all causes between 2002 and 2006 were available from army records. By December 31st 2006, there were 85,168 patients ever started on ART in both public and private sectors, of whom 547 (0.7%) were army personnel. Of these, 22% started ART in WHO clinical stage 1 or 2 with a CD4-lymphocyte count of ≤250/mm3 and 78% started in stage 3 or 4. Treatment outcomes of army personnel by December 31st 2006 were:−365 (67%) alive and on ART at their registration facility, 98 (18%) transferred out to another facility, 71 (13%) dead, 9 (2%) lost to follow-up, and 4 (

Salicylic acid (SA) is a plant signaling molecule that mediates the induction of defense responses upon attack by a variety of pathogens. Moreover, it antagonizes gene induction by the stress signaling molecule jasmonic acid (JA). Several SA-responsive genes are regulated by basic/leucine zipper-type transcription factors of the TGA family. TGA factors interact with NPR1, a central regulator of many SA-induced defense responses including SA/JA antagonism. In order to identify further regulatory proteins of SA-dependent signaling pathways, a yeast protein interaction screen with tobacco TGA2.2 as bait and an Arabidopsis thaliana cDNA prey library was performed and led to the identification of a member of the glutaredoxin family (GRX480, encoded by At1g28480). Glutaredoxins are candidates for mediating redox regulation of proteins because of their capacity to catalyze disulfide transitions. This agrees with previous findings that the redox state of both TGA1 and NPR1 changes under inducing conditions. Transgenic Arabidopsis plants ectopically expressing GRX480 show near wild-type expression of standard marker genes for SA- and xenobiotic-inducible responses. In contrast, transcription of the JA-dependent defensin gene PDF1.2 was antagonized by transgenic GRX480. This, together with the observation that GRX480 transcription is SA-inducible and requires NPR1, suggests a role of GRX480 in SA/JA cross-talk. Suppression of PDF1.2 by GRX480 depends on the presence of TGA factors, indicating that the GRX480/TGA interaction is effective in planta.

OBJECTIVE: Deep brain stimulation (DBS) has emerged as a useful therapeutic option for patients with insufficient benefit from conservative treatment. METHODS: Nine patients with chronic DBS who suffered from cervical dystonia (4), generalized dystonia (2), hemidystonia (1), paroxysmal dystonia (1) and Meige syndrome (1) were available for formal follow-up at three years postoperatively, and beyond up to 10 years. All patients had undergone pallidal stimulation except one patient with paroxysmal dystonia who underwent thalamic stimulation. RESULTS: Maintained improvement was seen in all patients with pallidal stimulation up to 10 years after surgery except in one patient who had a relative loss of benefit in dystonia ratings but continued to have improved disability scores. After nine years of chronic thalamic stimulation there was a mild loss of efficacy which was regained when the target was changed to the pallidum in the patient with paroxysmal dystonia. There were no major complications related to surgery or to chronic stimulation. Pacemakers had to be replaced within 1.5 to 2 years, in general. CONCLUSION: DBS maintains marked long-term symptomatic and functional improvement in the majority of patients with dystonia.

We report on the effect of multifocal deep brain stimulation for the treatment of posttraumatic peripherally-induced dystonia.A 34-year-old woman presented with an 8-year history of painful tonic dystonia starting in her left leg after injury of the third metatarsal bone. She did not benefit from right-sided pallidal stimulation by an electrode misplaced in the globus pallidus externus in another hospital.Quadripolar deep brain stimulation electrodes were placed in the globus pallidus internus and the ventrolateral thalamus by computed tomographic-guided stereotactic surgery and microelectrode recording contralateral to the side of dystonia. The Burke-Fahn-Marsden motor score of 34 did not improve with chronic pallidal or thalamic stimulation.Although deep brain stimulation is received with great enthusiasm, it is important to identify its limitations in certain subtypes of dystonia.

Background:In October 2001, a paying antiretroviral therapy service was introduced at a Central Hospital in Malawi using stavudine 40 mg/lamivudine 150 mg/nevirapine 200 mg (triomune). The objective of this study was to determine characteristics of patients seeking antiretroviral therapy, retention in care, clinical outcomes, and outlines for program improvement. Methods: Retrospectively, all patients seeking anti-retroviral therapy initiation (October 2001 to October 2002; follow-up through April 2003) were evaluated for laboratory results, retention in care, toxicity, and mortality. Hazard ratios for factors associated with dropout were determined. Results: Of 757 patients seeking evaluation, 625 began treatment. Documented mortality rate was 61 of 757. Total dropout rate was 50%. Factors associated with dropout include CD4 count 3 and Kaposi's sarcoma. Twenty-seven of 625 patients discontinued therapy for toxicity. Conclusions: The paying antiretroviral therapy program showed an unacceptable dropout rate associated with advanced baseline disease. Severe toxicity rate was low. Areas for improved program performance include lower cost, wide and earlier access to antiretroviral therapy, and targeted retention strategies.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has proved to be effective for tremor in Parkinson’s disease (PD). Most of the recent studies used only clinical data to analyse tremor reduction. The objective of our study was to quantify tremor reduction by STN DBS and antiparkinsonian medication in elderly PD patients using an objective measuring system. Amplitude and frequency of resting tremor and re-emergent resting tremor during postural tasks were analysed using an ultrasound-based measuring system and surface electromyography. In a prospective study design nine patients with advanced PD were examined preoperatively off and on medication, and twice postoperatively during four treatment conditions: off treatment, on STN DBS, on medication, and on STN DBS plus medication. While both STN DBS and medication reduced tremor amplitude, STN DBS alone and the combination of medication and STN DBS were significantly superior to pre- and postoperative medication. STN DBS but not medication increased tremor frequency, and off treatment tremor frequency was significantly reduced postoperatively compared to baseline. These findings demonstrate that STN DBS is highly effective in elderly patients with advanced PD and moderate preoperative tremor reduction by medication. Thus, with regard to the advanced impact on the other parkinsonian symptoms, STN DBS can replace thalamic stimulation in this cohort of patients. Nevertheless, medication was still effective postoperatively and may act synergistically. The significantly superior efficacy of STN DBS on tremor amplitude and its impact on tremor frequency in contrast to medication might be explained by the influence of STN DBS on additional neural circuits independent from dopaminergic neurotransmission.

✓ Propriospinal myoclonus is a rare form of spinal myoclonus. In most cases the cause has remained unclear. Secondary propriospinal myoclonus has been described secondary to various disorders including trauma, tumor, and infection. Thus far, propriospinal myoclonus caused by cervical disc herniation has not been reported. In the present report, the authors describe the case of a 53-year-old man who presented with radicular symptoms of the right C-6 nerve root and myoclonic twitches predominantly affecting the abdominal muscles but spreading to adjacent muscles. The spread was triggered and enforced by certain movements. Magnetic resonance imaging studies revealed a C-6 nerve root compression at the C5–6 level on the right side but no cervical myelopathy. Electromyography studies confirmed the diagnosis of propriospinal myoclonus. After discectomy and cage-augmented fusion via an anterior approach, the myoclonic movement disorder gradually subsided. To the authors' knowledge, this is the first report on successful treatment of propriospinal myoclonus by spinal disc surgery.

The aim of the study was to determine the source of vascular endothelial growth factor (VEGF) in hematoma fluid of patients suffering from chronic subdural hematoma (CSH) and to identify the level of gene expression of the pro-angiogenic factors angiopoietin 1 (ANG-1) and ANG-2 in hematoma membranes. Samples of venous blood, hematoma fluid, and outer membrane were obtained during surgery for CSH. The numbers of mononuclear cells were determined in hematoma fluid and in venous blood samples taken from 11 patients. The concentration of VEGF was measured by ELISA technique in hematoma fluid and in plasma. RT-PCR methodology was used to study the expression of different mRNA species in 11 patients. The mRNA species analyzed include VEGF and its receptors, VEGFR-1 and VEGFR-2, and ANG-1, ANG-2 and their receptor, Tie-2. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) served as housekeeping gene and was used for semiquantitative analysis. The VEGF concentration was several hundred fold higher in the hematoma fluid than in corresponding plasma samples. A significant correlation was found between the number of neutrophils and the VEGF content in the hematoma fluid. The expression levels of VEGF, mainly VEGF165 and VEGF121 mRNA were highest in cells obtained from the hematoma fluid. In membrane samples, mRNA encoding for VEGF and its receptors was only inconsistently detected while the mRNA species encoding for ANG-1, ANG-2, and Tie-2 were found throughout all samples. The mean ratio of ANG-1/ANG-2 mRNA expression was 0.48 as opposed to 1.9 in a normal human brain tissue sample. The results suggest that the hematoma cells are the primary source of VEGF. A marked increase in the expression of ANG-2 mRNA over ANG-1 mRNA demonstrates a pro-angiogenic pattern in the hematoma membranes. Persistent activation of the ANG/Tie-2 system in addition to high levels of VEGF may keep the vasculature in a destabilized condition and may account for the continuous formation of new and immature blood vessels resulting in massive plasma extravasation and repeated bleeding episodes. Thus, the present study provides new evidence in favor of pro-angiogenic mechanisms playing an important role in the pathophysiology of CSH.

A 67-year-old man with risperidone-responsive segmental dystonia underwent bilateral deep brain stimulation (DBS) of the globus pallidus internus. Prospectively, the authors assessed the Burke–Fahn–Marsden Dystonia Rating Scale in medication (M) and stimulation (S) “on”/“off” states. With DBS at 9 months, the score improved by 86% to 8.5 in M-“on”/S-“on” and 12.5 in M-“off”/S-“on.” Studies of the effects of DBS and concomitant medication may be warranted in selected patients treated by DBS for dystonia.