Radiological manifestations of splenic tuberculosis: a 23-patient case series from India

Background & Objective: Splenic tuberculosis (TB) is a less common but important manifestation of abdominal TB, especially in India and other developing countries. Its prevalence is increasing with the epidemic of HIV-TB co-infection and subsequent rise in extrapulmonary TB. The range of radiological manifestations of splenic TB is poorly described. Here, we review the ultrasonographic and computed tomographic (CT) images of 23 cases from two large tertiary care centers in India. Methods: Radiographic images, ultrasonographic in all cases and CT in selected cases, were retrospectively analyzed in a series of 23 patients presenting to two large tertiary care centers in India, with suspected TB and with splenomegaly on physical examination. Images were assessed at baseline and when available following anti-tuberculosis therapy. Results: The ultrasound and CT findings included, in order of most common: single or multiple hypoechoic focal lesions, splenic abscess, calcifications (on CT), and isolated splenomegaly. Five of the six patients with findings of isolated splenomegaly on ultrasound were found to have lesions on CT. Interpretation & Conclusion: Ultrasonography of the spleen is an affordable, non-invasive imaging modality, which can be helpful in diagnosis of splenic TB and assessment of therapeutic response. Proper use of this imaging modality in splenic TB should help avoid unnecessary CT imaging or invasive procedures. However, this technique is operator-dependent, and, when extensive intraabdominal involvement is suspected, or the diagnosis is unclear, CT may be necessary

Persistently high HIV seroprevalence among adult tuberculosis patients at a tertiary care centre in Delhi

Background & Objective: This study was designed to estimate HIV seroprevalence among tuberculosis patients presenting to tertiary care centre in Delhi. Methods: Cross-sectional prevalence study among all patients presenting to the inpatient and outpatient departments of All India Institute of Medical Sciences (AIIMS), New Delhi, and receiving anti-tuberculosis treatment from May 2003 to April 2005. Results: Of the 448 patients who presented to the TB clinic during the study period, 23 (5.1%) were previously tested HIV-positive. An additional 21 patients (4.6%) refused testing, and 30 (6.7%) were lost to follow up. Of the remaining 374 patients who consented to testing, 31 (8.3%) were found to be HIV-positive. Risk factors for HIV seropositivity included high-risk sexual behaviours (48% in HIV-TB co-infected vs. 6% in TB infected patients, P<0.001) and history of blood transfusion (23% vs. 5%; P=0.002). Interpretation & Conclusion: Previous studies from the same hospital published in 2000 and 2003 reported HIV seroprevalence among TB patients to be 0.4 and 9.4 per cent respectively. The current study documents a persistently high seropositivity among TB patients. These results emphasize the acute need for improved detection and treatment for HIV among TB patients in northern India

Poor follow-up rates at a self-pay northern Indian tertiary AIDS clinic

<p>Abstract</p> <p>Background</p> <p>In many developing countries, out-of-pocket payment remains a primary mechanism by which patients infected with HIV access treatment. In India, this has been changing as the National AIDS Control Organization (NACO) has been rolling out free antiretroviral therapy throughout the country since 2004. The vast majority of patients, however, remain without access to free medicines.</p> <p>Methods</p> <p>A retrospective chart review was performed on data obtained from a registry of ninety-three (93) patients attending a self-pay clinic at the All India Institute of Medical Sciences in Delhi, India. Multivariable Cox proportional hazard and logistic regression models were explored to assess the relationship between lost-to-follow-up status and the predictor variables: age, sex, household income, baseline CD4 count, and distance from clinic.</p> <p>Results</p> <p>Lost-to-follow-up rates were very high; 68% (63/93) were lost-to-follow-up till the time of chart review, including 59% (55/93) who were lost within one year. In both regression models, younger age, low baseline CD4 counts, and low income level were significantly associated with increased risk of lost-to-follow-up. Additionally, there was a significant interaction between income and CD4 counts. The patients with both low CD4 counts and low income level were more likely to be lost-to-follow-up than would be predicted by each covariable alone.</p> <p>Conclusion</p> <p>In this small cohort of AIDS patients attending a self-pay antiretroviral clinic at a large tertiary care center in Delhi, India, follow-up rates were quite poor. Poorer patients tended to present to clinic with more depressed CD4 counts and were less likely to be retained in care. These findings indicate that greater strides must be taken to improve the recruitment and retention of poor patients. The expansion of free antiretrovirals is one step among many necessary to achieve this objective.</p

Improved HIV and Substance Abuse Treatment Outcomes for Released HIV-Infected Prisoners: The Impact of Buprenorphine Treatment

HIV-infected prisoners fare poorly after release. Though rarely available, opioid agonist therapy (OAT) may be one way to improve HIV and substance abuse treatment outcomes after release. Of the 69 HIV-infected prisoners enrolled in a randomized controlled trial of directly administered antiretroviral therapy, 48 (70%) met DSM-IV criteria for opioid dependence. Of these, 30 (62.5%) selected OAT, either as methadone (N = 7, 14.5%) or buprenorphine/naloxone (BPN/NLX; N = 23, 48.0%). Twelve-week HIV and substance abuse treatment outcomes are reported as a sub-study for those selecting BPN/NLX. Retention was high: 21 (91%) completed BPN/NLX induction and 17 (74%) remained on BPN/NLX after 12 weeks. Compared with baseline, the proportion with a non-detectable viral load (61% vs 63% log10 copies/mL) and mean CD4 count (367 vs 344 cells/mL) was unchanged at 12 weeks. Opiate-negative urine testing remained 83% for the 21 who completed induction. Using means from 10-point Likert scales, opioid craving was reduced from 6.0 to 1.8 within 3 days of BPN/NLX induction and satisfaction remained high at 9.5 throughout the 12 weeks. Adverse events were few and mild. BPN/NLX therapy was acceptable, safe and effective for both HIV and opioid treatment outcomes among released HIV-infected prisoners. Future randomized controlled trials are needed to affirm its benefit in this highly vulnerable population

Retention on Buprenorphine Is Associated with High Levels of Maximal Viral Suppression among HIV-Infected Opioid Dependent Released Prisoners

HIV-infected prisoners lose viral suppression within the 12 weeks after release to the community. This prospective study evaluates the use of buprenorphine/naloxone (BPN/NLX) as a method to reduce relapse to opioid use and sustain viral suppression among released HIV-infected prisoners meeting criteria for opioid dependence (OD).From 2005-2010, 94 subjects meeting DSM-IV criteria for OD were recruited from a 24-week prospective trial of directly administered antiretroviral therapy (DAART) for released HIV-infected prisoners; 50 (53%) selected BPN/NLX and were eligible to receive it for 6 months; the remaining 44 (47%) selected no BPN/NLX therapy. Maximum viral suppression (MVS), defined as HIV-1 RNA<50 copies/mL, was compared for the BPN/NLX and non-BPN/NLX (N = 44) groups.The two groups were similar, except the BPN/NLX group was significantly more likely to be Hispanic (56.0% v 20.4%), from Hartford (74.4% v 47.7%) and have higher mean global health quality of life indicator scores (54.18 v 51.40). MVS after 24 weeks of being released was statistically correlated with 24-week retention on BPN/NLX [AOR = 5.37 (1.15, 25.1)], having MVS at the time of prison-release [AOR = 10.5 (3.21, 34.1)] and negatively with being Black [AOR = 0.13 (0.03, 0.68)]. Receiving DAART or methadone did not correlate with MVS.In recognition that OD is a chronic relapsing disease, strategies that initiate and retain HIV-infected prisoners with OD on BPN/NLX is an important strategy for improving HIV treatment outcomes as a community transition strategy

Tuberculin skin test among pulmonary sarcoidosis patients with and without tuberculosis: its utility for the screening of the two conditions in tuberculosis-endemic regions

Background: Sarcoidosis is an increasingly important condition in developing countries, including those with a high prevalence of tuberculosis. The tuberculin skin test (TST) is one test used in distinguishing these two granulomatous conditions. It has been shown that a negative TST is highly sensitive for sarcoidosis. This retrospective study set out to assess the converse: the role of a positive test in the assessing the likelihood that a patient with sarcoidosis might also have tuberculosis. Methods: A retrospective chart review of 141 patients with biopsy-proved sarcoidosis, among whom there were 16 biopsy-proven sarcoidosis and tuberculosis patients and 125 sarcoidosis-only patients. The receiver operating curve was constructed by calculating the sensitivity and specificity of various levels of induration of the tuberculin skin test for the diagnosis of comorbid tuberculosis. Results: The area under the curve of the ROC did not differ from 0.5, meaning that the TST was not useful as a graded measure. This was largely due to its poor sensitivity. However, a level of greater than or equal to 10 mm induration, though insensitive, had a specificity of 97.6% for the diagnosis of tuberculosis among this population of sarcoidosis patients. Conclusions: The tuberculin skin test in sarcoid patients has a high specificity but a poor sensitivity for tuberculosis. As such, while a negative TST in the general population is a sensitive test for sarcoidosis, a positive TST among sarcoidosis patients is a specific test for indicating tuberculosis. A positive TST in a patient suspected to suffer from sarcoidosis should therefore be an absolute indication for a thorough work-up for tuberculosis

The role of temporal cues in conspecific vocal recognition: rhesus monkey orienting asymmetries to reversed calls.

An understanding of the acoustic cues that animals use to categorize their vocalizations has important implications for the way we design neuroethological investigations of auditory function. Compared to other species, we know relatively little about the kinds of acoustic features used by nonhuman primates to recognize and categorize vocalizations. To further our understanding, this study explores the role of temporal features in recognition of conspecific vocalizations by rhesus macaques (Macaca mulatta). Experiments were designed to extend an earlier set of findings showing that adult rhesus macaques selectively turn with the right ear leading when a conspecific vocalization is played 180° behind them, but turn left or not at all when a non-conspecific signal is played. Two call types were used as stimuli: shrill barks (alarm call) and harmonic arches (food call). We found that for normal calls, rhesus macaques turned to the right – supporting earlier findings – but for time- reversed shrill barks and harmonic arches, subjects oriented to the left. These results suggest that for at least a subset of calls, rhesus macaques use temporal cues to recognize conspecific vocal signals. The asymmetry of the behavioral response, and the corresponding asymmetry in the time-amplitude waveform, may have important implications for studies of temporal coding in the primate auditory system

Temporal cues in the perception of long calls by cotton-top tamarins.

In primates, long-range communication is often mediated by the use of ‘long’ (or ‘loud’) calls. Beyond the acoustic classification of these calls and descriptions of the behavioural context in which they are produced, few experimental studies have examined how species-typical information is encoded in the structure of these signals. We present the results of eight experimental conditions designed to isolate the mechanisms underlying the perception of long calls in cottontop tamarins, Saguinus oedipus. Our procedure involved presenting a combination of naturally produced and experimentally manipulated long calls to individuals isolated from their group, and then recording the relationship between signal design and the production of antiphonal long calls by the test subject. Tamarins did not distinguish between normal calls and time-reversed or pitch-shifted long calls, but normal response rates did require the species-typical amplitude envelope. Furthermore, there was suggestive evidence that the number of syllables and the syllable rate may also influence antiphonal calling responses. We discuss these results in terms of the mechanisms of vocal recognition in primates and other taxa

Compromising comprehensive AIDS management will lead to failure

This article does not have an abstract

Tubercular oesophagocutaneous fistula

A case of oesophageal tuberculosis complicated by an oesophagocutaneous fistual is reported. We subsequently review the literature of this exceedingly rare condition