Effect of antiretroviral therapy on the diagnostic accuracy of symptom screening for intensified tuberculosis case finding in a South African HIV clinic.

BACKGROUND: Current symptom screening algorithms for intensified tuberculosis case finding or prior to isoniazid preventive therapy (IPT) in patients infected with human immunodeficiency virus (HIV) were derived from antiretroviral-naive cohorts. There is a need to validate screening algorithms in patients on antiretroviral therapy (ART). METHODS: We performed cross-sectional evaluation of the diagnostic accuracy of symptom screening, including the World Health Organization (WHO) algorithm, to rule out tuberculosis in HIV-infected individuals pre-ART and on ART undergoing screening prior to IPT. RESULTS: A total of 1429 participants, 54% on ART, had symptom screening and a sputum culture result available. Culture-positive tuberculosis was diagnosed in 126 patients (8.8%, 95% confidence interval [CI], 7.4%-10.4%). The WHO symptom screen in the on-ART compared with the pre-ART group had a lower sensitivity (23.8% vs 47.6%), but higher specificity (94.4% vs 79.8%). The effect of ART was independent of CD4(+) count in multivariable analyses. The posttest probability of tuberculosis following a negative WHO screen was 8.9% (95% CI, 7.4%-10.8%) and 4.4% (95% CI, 3.7%-5.2%) for the pre-ART and on-ART groups, respectively. Addition of body mass index to the WHO screen significantly improved discriminatory ability in both ART groups, which was further improved by adding CD4 count and ART duration. CONCLUSIONS: The WHO symptom screen has poor sensitivity, especially among patients on ART, in a clinic where regular tuberculosis screening is practiced. Consequently, a significant proportion of individuals with tuberculosis would inadvertently be placed on isoniazid monotherapy despite high negative predictive values. Until more sensitive methods of ruling out tuberculosis are established, it would be prudent to do a sputum culture prior to IPT where this is feasible

Noise induced rupture process: Phase boundary and scaling of waiting time distribution

A bundle of fibers has been considered here as a model for composite materials, where breaking of the fibers occur due to a combined influence of applied load (stress) and external noise. Through numerical simulation and a mean-field calculation we show that there exists a robust phase boundary between continuous (no waiting time) and intermittent fracturing regimes. In the intermittent regime, throughout the entire rupture process avalanches of different sizes are produced and there is a waiting time between two consecutive avalanches. The statistics of waiting times follows a Gamma distribution and the avalanche distribution shows power law scaling, similar to what have been observed in case of earthquake events and bursts in fracture experiments. We propose a prediction scheme that can tell when the system is expected to reach the continuous fracturing point from the intermittent phase.Comment: 6 pages, 8 figure

Dynamic instabilities of fracture under biaxial strain using a phase field model

We present a phase field model of the propagation of fracture under plane strain. This model, based on simple physical considerations, is able to accurately reproduce the different behavior of cracks (the principle of local symmetry, the Griffith and Irwin criteria, and mode-I branching). In addition, we test our model against recent experimental findings showing the presence of oscillating cracks under bi-axial load. Our model again reproduces well observed supercritical Hopf bifurcation, and is therefore the first simulation which does so

Predicting the long-term impact of antiretroviral therapy scale-up on population incidence of tuberculosis.

OBJECTIVE: To investigate the impact of antiretroviral therapy (ART) on long-term population-level tuberculosis disease (TB) incidence in sub-Saharan Africa. METHODS: We used a mathematical model to consider the effect of different assumptions about life expectancy and TB risk during long-term ART under alternative scenarios for trends in population HIV incidence and ART coverage. RESULTS: All the scenarios we explored predicted that the widespread introduction of ART would initially reduce population-level TB incidence. However, many modelled scenarios projected a rebound in population-level TB incidence after around 20 years. This rebound was predicted to exceed the TB incidence present before ART scale-up if decreases in HIV incidence during the same period were not sufficiently rapid or if the protective effect of ART on TB was not sustained. Nevertheless, most scenarios predicted a reduction in the cumulative TB incidence when accompanied by a relative decline in HIV incidence of more than 10% each year. CONCLUSIONS: Despite short-term benefits of ART scale-up on population TB incidence in sub-Saharan Africa, longer-term projections raise the possibility of a rebound in TB incidence. This highlights the importance of sustaining good adherence and immunologic response to ART and, crucially, the need for effective HIV preventive interventions, including early widespread implementation of ART

Void Formation and Roughening in Slow Fracture

Slow crack propagation in ductile, and in certain brittle materials, appears to take place via the nucleation of voids ahead of the crack tip due to plastic yields, followed by the coalescence of these voids. Post mortem analysis of the resulting fracture surfaces of ductile and brittle materials on the $\mu$m-mm and the nm scales respectively, reveals self-affine cracks with anomalous scaling exponent $\zeta\approx 0.8$ in 3-dimensions and $\zeta\approx 0.65$ in 2-dimensions. In this paper we present an analytic theory based on the method of iterated conformal maps aimed at modelling the void formation and the fracture growth, culminating in estimates of the roughening exponents in 2-dimensions. In the simplest realization of the model we allow one void ahead of the crack, and address the robustness of the roughening exponent. Next we develop the theory further, to include two voids ahead of the crack. This development necessitates generalizing the method of iterated conformal maps to include doubly connected regions (maps from the annulus rather than the unit circle). While mathematically and numerically feasible, we find that the employment of the stress field as computed from elasticity theory becomes questionable when more than one void is explicitly inserted into the material. Thus further progress in this line of research calls for improved treatment of the plastic dynamics.Comment: 15 pages, 20 figure

Dynamical stability of the crack front line

Dynamical stability of the crack front line that propagates between two plates is studied numerically using the simple two-dimensional mass-spring model. It is demonstrated that the straight front line is unstable for low speed while it becomes stable for high speed. For the uniform model, the roughness exponent in the slower speed region is fairly constant around 0.4 and there seems to be a rough-smooth transition at a certain speed. For the inhomogeneous case with quenched randomness, the transition is gradual.Comment: 14 pages, 7 figure

Cleaved surface of i-AlPdMn quasicrystals: Influence of the local temperature elevation at the crack tip on the fracture surface roughness

Roughness of i-AlPdMn cleaved surfaces are presently analysed. From the atomic scale to 2-3 nm, they are shown to exhibit scaling properties hiding the cluster (0.45 nm) aperiodic structure. These properties are quantitatively similar to those observed on various disordered materials, albeit on other ranges of length scales. These properties are interpreted as the signature of damage mechanisms occurring within a 2-3 nm wide zone at the crack tip. The size of this process zone finds its origin in the local temperature elevation at the crack tip. For the very first time, this effect is reported to be responsible for a transition from a perfectly brittle behavior to a nanoductile one.Comment: 8 page

The Influence of Fallback Foods on Great Ape Tooth Enamel

Lucas and colleagues recently proposed a model based on fracture and deformation concepts to describe how mammalian tooth enamel may be adapted to the mechanical demands of diet (Lucas et al.: Bioessays 30[2008] 374-385). Here we review the applicability of that model by examining existing data on the food mechanical properties and enamel morphology of great apes (Pan, Pongo, and Gorilla). Particular attention is paid to whether the consumption of fallback foods is likely to play a key role in influencing great ape enamel morphology. Our results suggest that this is indeed the case. We also consider the implications of this conclusion on the evolution of the dentition of extinct hominins

Fracture in teeth—a diagnostic for inferring bite force and tooth function

Teeth are brittle and highly susceptible to cracking. We propose that observations of such cracking can be used as a diagnostic tool for predicting bite force and inferring tooth function in living and fossil mammals. Laboratory tests on model tooth structures and extracted human teeth in simulated biting identify the principal fracture modes in enamel. Examination of museum specimens reveals the presence of similar fractures in a wide range of vertebrates, suggesting that cracks extended during ingestion or mastication. The use of ‘fracture mechanics’ from materials engineering provides elegant relations for quantifying critical bite forces in terms of characteristic tooth size and enamel thickness. The role of enamel microstructure in determining how cracks initiate and propagate within the enamel (and beyond) is discussed. The picture emerges of teeth as damage-tolerant structures, full of internal weaknesses and defects and yet able to contain the expansion of seemingly precarious cracks and fissures within the enamel shell. How the findings impact on dietary pressures forms an undercurrent of the study

Advancing newborn health: The Saving Newborn Lives initiative

Until recently, newborn health was virtually absent from the global health agenda. Now, assistance agencies, national governments and non-governmental organisations are increasingly addressing this previously neglected issue of close to four million newborns dying every year. The experience of the Saving Newborn Lives initiative documents some of the progress that has been made and the challenges and opportunities that lie ahead. Since the start of the initiative in 2000, targeted research, focused on overcoming the key barriers to improved newborn survival, has demonstrated low-cost, community-based interventions and strategies that can significantly reduce newborn mortality. Building on what has been learned from this and other efforts to date, the challenge now is to reach the millions of newborns still at risk