Age, sex, and nutritional status modify the CD4+ T-cell recovery rate in HIV-tuberculosis co-infected patients on combination antiretroviral therapy.

BACKGROUND: Baseline age and combination antiretroviral therapy (cART) were examined as determinants of CD4+ T-cell recovery during 6 months of tuberculosis (TB) therapy with/without cART. It was determined whether this association was modified by patient sex and nutritional status. METHODS: This longitudinal analysis included 208 immune-competent, non-pregnant, ART-naive HIV-positive patients from Uganda with a first episode of pulmonary TB. CD4+ T-cell counts were measured using flow cytometry. Age was defined as ≤24, 25-29, 30-34, and 35-39 vs. ≥40 years. Nutritional status was defined as normal (>18.5kg/m(2)) vs. underweight (≤18.5kg/m(2)) using the body mass index (BMI). Multivariate random effects linear mixed models were fitted to estimate differences in CD4+ T-cell recovery in relation to specified determinants. RESULTS: cART was associated with a monthly rise of 15.7 cells/µl (p<0.001). Overall, age was not associated with CD4+ T-cell recovery during TB therapy (p = 0.655). However, among patients on cART, the age-associated CD4+ T-cell recovery rate varied by sex and nutritional status, such that age <40 vs. ≥40 years predicted superior absolute CD4+ T-cell recovery among females (p=0.006) and among patients with a BMI ≥18.5kg/m(2) (p<0.001). CONCLUSIONS: TB-infected HIV-positive patients aged ≥40 years have a slower rate of immune restoration given cART, particularly if BMI is >18.5kg/m(2) or they are female. These patients may benefit from increased monitoring and nutritional support during cART.

Missed opportunity for tuberculosis case detection in household contacts in a high burden setting.

Contact investigation remains an essential component of tuberculosis (TB) control, yet missed opportunities to trace, medically examine, and treat close contacts of newly diagnosed index TB cases persist. We report a new case of active TB in a 21 year-old woman who was a household contact of a known TB index case in Kampala, Uganda. She was identified during a house-to-house TB case finding survey using chronic cough (≥2 weeks). This case study re-emphasizes two important public health issues in relation to TB control in developing countries; the need to promote active contact investigations by National TB programs and the potential complementary role of active case finding in minimizing delays in TB detection especially in high burden settings like Uganda.

Improving malaria control in West Africa: interruption of transmission as a paradigm shift.

With the paradigm shift from the reduction of morbidity and mortality to the interruption of transmission, the focus of malaria control broadens from symptomatic infections in children ≤5 years of age to include asymptomatic infections in older children and adults. In addition, as control efforts intensify and the number of interventions increases, there will be decreases in prevalence, incidence and transmission with additional decreases in morbidity and mortality. Expected secondary consequences of these changes include upward shifts in the peak ages for infection (parasitemia) and disease, increases in the ages for acquisition of antiparasite humoral and cellular immune responses and increases in false-negative blood smears and rapid diagnostic tests. Strategies to monitor these changes must include: (1) studies of the entire population (that are not restricted to children ≤5 or ≤10 years of age), (2) study sites in both cities and rural areas (because of increasing urbanization across sub-Saharan Africa) and (3) innovative strategies for surveillance as the prevalence of infection decreases and the frequency of false-negative smears and rapid diagnostic tests increases.

Treatment Options for HIV-Associated Tuberculosis.

The vicious interaction between the human immunodeficiency virus (HIV) infection and tuberculosis (TB) pandemics poses special challenges to national control programs and individual physicians. Although recommendations for the treatment of TB in HIV-infected patients do not significantly differ from those for HIV-uninfected patients, the appropriate management of HIV-associated TB is complicated by health system issues, diagnostic difficulties, adherence concerns, overlapping adverse-effect profiles and drug interactions, and the occurrence of paradoxical reactions after the initiation of effective antiretroviral therapy. In this article, recommended treatment strategies and novel approaches to the management of HIV-associated TB are reviewed, including adjuvant treatment and options for treatment simplification. A focused research agenda is proposed in the context of the limitations of the current knowledge framework.

Optical imaging of temporal integration in human auditory cortex.

Behavioral and physiological studies have indicated the existence of a temporal window of auditory integration (TWI), within which similar sounds are perceptually grouped. The current study exploits the combined temporal and spatial resolution of fast optical imaging (the event-related optical signal, EROS) to show that brain activity elicited by sounds within and outside the TWI differs in location and latency. In a previous event-related brain potential (ERP) study [Sable, Gratton, and Fabiani (2003) European Journal of Neuroscience, 17, 2492-2496], we found that the mismatch negativity (MMN; a brain response to acoustic irregularities) elicited by deviations in stimulus onset asynchronies (SOAs) had a unique shape when the deviant SOA was within the TWI. In the present study, we extended these ERP results using EROS. Participants heard trains of five tones. The first four tones had SOAs of 96, 192, 288 or 384 ms. The SOA of the fourth and fifth tones was either the same (standard) or one of the other three (deviant) SOAs. With a deviant SOA of 96 ms, the cortical response was approximately 2 cm anterior to responses to longer SOA deviants, and was followed by a later response that was absent in the other conditions. Similarly to the electrical MMN, the optical mismatch response amplitudes were proportional to the magnitude of interval deviance. These results, in combination with our previous findings, indicate that the temporal integration of sounds is reflected in cortical mismatch responses that differ from the typical response to interval deviance.