Pulmonary tuberculosis diagnostic practices among people living with the human immunodeficiency virus in Lesotho.

SETTING: Twelve health facilities in Berea District, Lesotho, that participated in the Start TB Patients on ART and Retain on Treatment (START) Study, a mixed-methods cluster-randomized trial evaluating a combination intervention package to improve early initiation of antiretroviral therapy (ART) and anti-tuberculosis treatment success among patients with tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVE: To assess TB and HIV diagnostic practices among TB-HIV patients. DESIGN: A standardized survey assessed services at each facility at baseline. Routine clinical data were abstracted for all newly registered adult TB-HIV patients during the study period. Descriptive statistics were used to assess TB diagnostic practices, timing of the HIV diagnosis, and ART status at TB treatment initiation. RESULTS: Between April 2013 and March 2015, 1233 TB-HIV patients were enrolled. Among 1215 patients with available data, 87.2% had pulmonary TB, of which 34.8% were bacteriologically confirmed, 40.9% tested negative and 24.3% were not tested. Among 1138 patients with available data, 53.3% had an existing HIV diagnosis, of whom 39.3% were ART-naïve. CONCLUSIONS: The majority of pulmonary TB patients were clinically diagnosed, and many were unaware of their HIV status or were ART-naïve despite known status. The Test and Treat Strategy holds promise to prevent TB and reduce TB-related mortality among people living with HIV; however, enhanced TB diagnostic capacity and improved HIV case detection are urgently needed.

Review article: chronic viral infection in the anti-tumour necrosis factor therapy era in inflammatory bowel disease.

BACKGROUND: Anti-tumour necrosis factor (TNF) therapy is now well established in the treatment of inflammatory bowel disease and the risk of opportunistic infection is recognized. However, specific considerations regarding screening, detection, prevention and treatment of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease are not widely adopted in practice. AIM: To provide a detailed and comprehensive review of the relevance of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease. METHODS: Literature search was conducted using Medline, Pubmed and Embase using the terms viral infection, hepatitis, herpes, CMV, EBV, HPV, anti-TNF, infliximab, adalimumab, certolizumab pegol and etanercept. Hepatitis B and C and HIV had the largest literature associated and these have been summarized in Tables. RESULTS: Particular risks are associated with the use of anti-TNF drugs in patients with hepatitis B infection, in whom reactivation is common unless anti-viral prophylaxis is used. Reactivation of herpes zoster is the most common viral problem associated with anti-TNF treatment, and may be particularly severe. Primary varicella infection may present with atypical features in patients on anti-TNF. CONCLUSION: Appreciation of risks of chronic viral disease associated with anti-TNF therapy may permit early recognition, prophylaxis and treatment.

How intestinal epithelial cells tolerise dendritic cells and its relevance to inflammatory bowel disease.

Intestinal epithelial layer is an important barrier against antigen invasion. In addition to its barrier function, the immunomodulatory role of intestinal epithelium is attracting considerable attention. The intestinal epithelium may influence underlying immune cells including dendritic cells and lymphocytes and promote tolerogenic and regulatory responses in health. Breakdown of such regulatory influences may result in uncontrolled inflammation and tissue damage. The molecules mediating such regulation derived from intestinal epithelium and their interaction with immune cells may provide novel targets and therapeutic molecules that have translational potential in intestinal inflammation. Understanding the cross-talk between intestinal epithelium and immune cells has progressed from in vitro co-culture models to epithelial cell conditional knockout models.

Studies of compliance with delayed-release mesalazine therapy in patients with inflammatory bowel disease.

BACKGROUND: Non-compliance with maintenance mesalazine therapy may be a risk factor for relapse in inflammatory bowel disease, but the prevalence and determinants of non-compliance are unknown. AIM: To study the prevalence and determinants of non-compliance in patients with inflammatory bowel disease. METHODS: Out-patients receiving delayed-release mesalazine were studied. Compliance was determined by direct enquiry and by analysis of urine samples for 5-aminosalicylic acid/N-acetyl-5-aminosalicylic acid. Potential determinants of compliance were assessed. RESULTS: Ninety-eight patients were studied. Forty-two patients (43%) reported taking <80% of their prescribed dose. Logistic regression revealed the independent predictors of non-compliance to be three-times daily dosing [odds ratio (OR), 3.1; 95% confidence interval (CI), 1.8-8.4] and full-time employment (OR, 2.7; 95% CI, 1.1-6.9). Urine from 12 patients (12%) contained no detectable 5-aminosalicylic acid/N-acetyl-5-aminosalicylic acid, and 18 patients (18%) had levels below those expected. Depression was the only independent predictor of complete non-compliance (OR, 10.5; 95% CI, 1.8-79.0), and three-times daily dosing was the only independent predictor of partial non-compliance (OR, 3.7; 95% CI, 1.8-8.9). Self-reporting correctly identified 66% of patients judged to be non-compliant on urinary drug measurement. CONCLUSIONS: Non-compliance with maintenance mesalazine therapy is common in patients with inflammatory bowel disease. Three-times daily dosing and full-time employment are predictors of partial non-compliance, whilst depression is associated with complete non-compliance. Self-reporting detects most non-compliant patients.

Bilateral variation in calcaneal broadband ultrasound attenuation. Part II: as measured by three bone densitometers employing ultrasound or X-ray.

In previous study, we found a bilateral difference in broadband ultrasound attenuation (BUA) of the calcaneus, using the McCue Cubaclinical II device. The purpose of the present study was to determine whether a calcaneal bilateral difference (greater than that that would be expected from the coefficient of variation) was also found by other instruments and their technologies. Twenty-four subjects (ages 22-81) were each scanned by the same operator using three devices: the Cubaclinical (ultrasound [US], BUA), the Lunar Achilles plus (US, BUA and stiffness index), and the Pixi (dual X-ray absorptiometry, bone mineral density). To allow for the different variables used by the three devices, the following computation was applied to the data for comparison purposes (left - right) / (right). Analysis of variance showed no significant difference. We conclude that the three devices do not differ in their ability to detect a proportional difference between right and left calcanei. In an additional investigation, using the Cubaclinical, 23 subjects were scanned. The direction of the US wave between emitter and receiver transducers was reversed to determine the effect, if any, on bilateral BUA readings. In this case, the direction of the US wave was not influential.

Bilateral variation in calcaneal broadband ultrasound attenuation: part I.

A total of 1412 women of various ethnic origins ages 20-80 yr were tested for bilateral calcaneal broad-band ultrasound attenuation (BUA) with the McCue Cubaclinical ultrasound bone densitometer. A significant difference was found between nondominant and dominant measures (p < 0.0001). The magnitude of calcaneal BUA was not related to dominance. The difference was of a significant degree to have resulted in differing predictions of fracture risk depending on the side used in assessment. Forty-eight subjects (3%) would have been considered at risk of osteoporotic fracture based on the nondominant measure, whereas only 21 subjects (1.5%) would have been considered to be at risk based on the dominant measure. In concurrence with other studies, we conclude that it is essential to carry out bilateral measurements of the os calcis to avoid misleading implications for prediction of fracture risk.