Scoring System for the Use of Nebulizers in the Primary Care Settings: An Expert Consensus Statement.

BACKGROUND: The use of nebulizers is an important and useful method for delivering drugs to the lungs in patients with various airway and lung parenchymal disorders. They are primarily used in patients with acute symptoms and in a selected group of patients for maintenance treatment. Its use has increased, especially during the coronavirus disease 2019 (COVID-19) pandemic. To ensure the appropriate use of nebulizers by primary care physicians and to guide them, we aimed to develop a simple nebulizer use score. METHODS: An expert working group (EWG) of pulmonologists were formed who using a semi- Delphi method, developed a list of variables and a cut-off score to decide when to use nebulizers. We started with a total of 55 variables that were developed through an exhaustive review of the literature. These were further reduced to smaller numbers that had the maximum score as well as concordance with the EWG. The scores ranged from 1 to 10 (completely disagree to completely agree), and only those above 7.5 were selected. RESULTS: A total of 8 variables with the highest scores were selected (Table 1), which had a total maximum score of 40. A score of <15 was suggested to indicate no use of nebulizer and >20 to suggest definite use of nebulizer. A score between 15 and 20 was suggested for physician judgment. A separate table of 12 conditions was made where the use of nebulizers was mandatory. CONCLUSION: This first-of-its-kind nebulizer score can be used by primary care physicians to decide which patients should be put on nebulizer treatment.

Medication non-adherence: a role for the dental professional.

Medication non-adherence is a multifactorial and complex problem that poses an enormous health and economic burden. Medication non-adherence related to medication side effects, referred to as rational non-adherence, is increasingly seen in patients. This article discusses rational non-adherence with an exemplar of osteoporosis patients discontinuing their medication, mainly bisphosphonates, for fear of complications such as osteonecrosis of jaw. Also, the possible role of dental professionals in overcoming medication non-adherence in general is outlined.

Medication nonadherence: a role for the dental professional.

Medication nonadherence is a multifactorial and complex problem that poses an enormous health and economic burden. Medication nonadherence related to medication side effects, referred to as rational nonadherence is increasingly seen in patients. This article discusses rational nonadherence with an exemplar of osteoporosis patients discontinuing their medication, mainly bisphosphonates, for fear of complications such as osteonecrosis of jaw. Also, the possible role of dental professionals in overcoming medication nonadherence in general is outlined.

Atypical odontalgia--an update.

Atypical odontalgia is a commonly misdiagnosed condition that frequently leads to unnecessary dental treatments such as extraction and endodontic therapy. These treatments often worsen the pain. Despite greater recognition and understanding of this condition, proper diagnosis and treatment remains a challenge. It is believed that atypical odontalgia is a neuropathic condition. This article updates the current understanding of the etiology and pathophysiology of atypical odontalgia, and provides appropriate diagnostic and management approaches for this condition.

The role of microbial biofilms in osteonecrosis of the jaw associated with bisphosphonate therapy.

Microbial biofilms have been observed and described in bone specimens of patients with bisphosphonate (BP)-associated osteonecrosis of the jaw (BONJ) and investigators are more recently suggesting that this condition essentially represents an osteomyelitis of the jaw clinically, with greater susceptibility in some patients on BP therapy. This article explains the role of microbial biofilms in BONJ and also discusses associated factors in the disease pathogenesis, which include BP effects on bone remodeling, anti-angiogenesis, matrix necrosis, microcracks, soft tissue toxicity, and inflammation and wound healing. Recent findings suggest a key role for microbial biofilms in the pathogenesis of BONJ; this has important therapeutic implications because biofilm organisms represent a clinical target for prevention and treatment efforts aimed at reducing the significant morbidity and costs associated with this condition.

Prevalence and impact of sleep disorders and sleep habits in the United States.

PURPOSE: Epidemiologic studies on sleep disorders in the USA have mostly focused on specific disorders in specific groups of individuals. Most studies on sleep habits and sleep-related difficulties have focused on children and adolescents. The authors describe the prevalence of the three common physician-diagnosed sleep disorders (insomnia, sleep apnea, and restless legs syndrome (RLS)) by age, gender, and race in the US population. In addition, the authors describe the sleep habits and sleep-related difficulties in carrying routine daily activities. The authors also investigate the impact of the sleep disorders on performing routine daily activities. METHODS: Data from the 2005-2006 National Health and Nutrition Examination Survey for 6,139 individuals over the age of 16 was analyzed for sleep-related parameters. RESULTS: The prevalence was highest for sleep apnea (4.2%), followed by insomnia (1.2%) and RLS (0.4%). Hispanics and Whites reported longer sleep duration than Blacks by 24 to 30 min. The predominant sleep habits were snoring while sleeping (48%), feeling unrested during the day (26.5%), and not getting enough sleep (26%). Difficulty concentrating (25%) or remembering (18%) were the main sleep-related difficulties in our sample. Insomnia, sleep apnea, and RLS had the highest impact on concentration and memory. CONCLUSIONS: Our findings suggest that the prevalence of sleep disorders in the USA is much lower than previously reported in the literature suggesting under diagnosis of sleep disorders by primary care physicians.

Estimation of virological and immunological parameters in subjects from South India infected with human immunodeficiency virus type 1 clade C and correlation of findings with occurrence of neurological disease.

Several studies carried out in Western countries have demonstrated that a number of virological and immunological markers such as viral loads, cytokines, beta(2)-microglobulin, neopterin, etc., are elevated in the serum and cerebrospinal fluid (CSF) of human immunodeficiency virus (HIV)-infected individuals with neurological disease. The neurological manifestations of HIV infection noted in Indian patients is different from those reported in Western countries. Moreover, few studies have investigated the role of virological and immunological parameters with respect to the progression of HIV-1 clade C infection in India. In this study, we measured virological (HIV-1 RNA levels) and immunological parameters (CD4 cell count and inflammatory markers) in the plasma and CSF of HIV-1-infected neurologically asymptomatic and symptomatic (with opportunistic infections and/or dementia) subjects. By using clade-specific polymerase chain reaction (PCR), we ascertained that all samples used for the study were infected with HIV-1 clade C. Among the various laboratory parameters evaluated, high viral loads in the CSF, low CD4 counts, and higher levels of interleukin (IL)-1alpha, IL-6, tumor necrosis factor alpha (TNFalpha), beta(2)-microglobulin, and neopterin were noted in HIV-infected subjects with neurological disease as compared to asymptomatic subjects. These data suggest that the markers evaluated in plasma and CSF samples correlated with occurrence of neurological disease in symptomatic individuals as compared to asymptomatic HIV infected subjects.

Do men and women with HIV differ in their quality of life? A study from South India.

This paper examined gender differences in Quality of Life (QOL) among people living with HIV/AIDS in South India using the locally validated version of the WHO Quality of Life Instrument for HIV (WHOQOL-HIV 120). Participants (N = 109) were men and women with HIV1 Clade C infection participating in a cohort study. There was no gender difference in CD4 counts or use of antiretroviral therapy. Of the 29 facets of QOL, men reported significantly higher QOL in the following facets-positive feeling, sexual activity, financial resources and transport, while women reported significantly higher QOL on the forgiveness and blame facet. Of the six domains of QOL, men reported better quality of life in the environmental domain while women had higher scores on the spirituality/religion and personal beliefs domain. Understanding these gender differences may provide potentially useful information for tailoring interventions to enhance QOL among people infected with HIV/AIDS.

Clinical characteristics and diagnosis of atypical odontalgia: implications for dentists.

BACKGROUND: Atypical odontalgia (AO) is a poorly understood and commonly misdiagnosed condition for which patients often undergo multiple unsuccessful dental or surgical procedures. The authors conducted a study to determine the prevalence and describe the characteristics of patients with AO seen at the University of Southern California Orofacial Pain and Oral Medicine Center (USC OFP-OM Center), Los Angeles. METHODS: The authors conducted a retrospective record review from a database of more than 3,000 patient records from June 2003 to August 2007 to identify patients diagnosed with AO. RESULTS: The authors identified 64 patients (44 women and 20 men) between the ages of 26 and 93 years as having a diagnosis of AO. Of those 64 patients, 71 percent initially consulted a dentist regarding their pain, and 79 percent had undergone dental treatment that failed to resolve the pain. The pain of 64 percent of the patients had no known cause. CONCLUSIONS: Dentists, who often are the first health care providers to see patients with AO, must be aware of this condition and must follow the appropriate steps to determine its diagnosis. CLINICAL IMPLICATIONS: Dentists and physicians should understand the implications and importance of early diagnosis of patients with AO and of referral to pain specialists for treatment.

Prevalence of hypertension in patients with trigeminal neuralgia.

It is unclear whether hypertension (HTN) is a predisposing factor for the development of trigeminal neuralgia (TN). The purpose of this study was to determine the prevalence of HTN in TN patients and controls at the USC Orofacial Pain and Oral Medicine Center. A retrospective chart review was conducted from a database of over 3,000 patient records from 2003 to 2007. We identified patients diagnosed with TN with or without HTN. A total of 84 patients (54 females; 30 males) between the ages of 33 and 93 years were diagnosed with TN; 37% had TN with HTN and 32% of controls had HTN. The increased prevalence of HTN in the TN patients was not statistically significant (P = 0.50). Since, both TN and HTN are seen in the elderly, it is likely that HTN is simply a co-existing condition in patients with TN and not a risk factor for its development.

Xerostomia: prevalence, diagnosis, and management.

This article summarizes the common causes, clinical presentation, and complications of xerostomia and salivary gland hypofunction in the geriatric population and discusses the various management options.

Cognitive changes in asymptomatic drug-naïve human immunodeficiency virus type 1 clade C infection.

Asymptomatic human immunodeficiency virus (HIV) infection is associated with impaired cognitive functioning in both clade B and C infections. The nature of cognitive change longitudinally has not been studied in asymptomatic clade C infection. The present study evaluated changes in neuropsychological functioning over a 2(1/2)-year period in a cohort of HIV-1 clade C-infected asymptomatic individuals from South India. Participants with CD4 counts below 250 were started on highly active antiretroviral therapy (HAART) as per National AIDS Control Organisation NACO guidelines and hence excluded. The sample consisted of 68 patients (30 men and 38 women), with a mean age of 29.4 years (SD=5.6 years) and a mean education of 10.0 years (SD=2.7 years). A comprehensive neuropsychological assessment with 12 tests yielding 21 variables was used to examine cognitive functioning at baseline and subsequently at 6-monthly intervals for five follow-ups. Shift in CD4 and viral load categories measured by the McNemar's test indicated disease progression. Latent growth curve (LGC) modeling assessed the nature of change in cognition over the 2(1/2)-year study period. Ten variables representing attention, executive functions, and long-term memory fit the LGC model. Excepting visual working memory, the slope was nonsignificant for nine variables, indicating absence of deterioration in cognition over a 2(1/2)-year period. However, CD4 and viral load levels worsened, indicating disease progression. Asymptomatic individuals with HIV-1 clade C infection do not show any significant decline on individual neuropsychological functions over 2(1/2) years despite disease progression, as evidenced by immune suppression and viral loads.

Progressive dysregulation of autonomic and HPA axis functions in HIV-1 clade C infection in South India.

Human immunodeficiency virus type 1 (HIV-1) infection causes a wide spectrum of abnormalities in neurological, neuropsychological, and neuroendocrinological functions. Several studies report disturbance in autonomic nervous system (ANS) and hypothalamic pituitary-adrenal (HPA) axis function in HIV-1B infected individuals. However, no such investigations on the effect of HIV-1 clade C infection, particularly during the initial phase of the disease progression, have been reported. The present investigations were carried out longitudinally over a 2-year period at 12 monthly intervals in clinically asymptomatic HIV-1 clade C seropositive patients (n=120) and seronegative control subjects (n=29). We determined both the basal levels and the dynamic changes in plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotrophic hormone (ACTH) and cortisol (CORT). Studies were also extended longitudinally (at three separate yearly visits of each participant), to evaluate the response of autonomic and HPA axis to mirror star tracing challenge test (MSTCT) and the values were determined as area under the curve (AUC, corrected for baseline levels of NE, E, ACTH, and CORT). The findings show that the values of basal plasma NE levels, as well as NE response to MSTCT (AUC) at the first visit of HIV-1 seropositive individuals did not differ from those found in the control subjects (NE, pg/ml, HIV-1C=313.5+/-12.7 vs. controls=353.0+/-21.3; p=NS; AUC, HIV-1C=225+/-14.75 vs. controls=232.7+/-19.34; p=NS, respectively). At the subsequent two visits of HIV-1 positive patients however, NE response to MSTCT challenge was progressively attenuated (AUC=235+/-19.5 and 162.7+/-13.6; p<0.01 and 0.05, respectively) compared to that found at the first visit. On the other hand, plasma levels of E as well as E response to MSTCT at the first visit were significantly lower in HIV-1C seropositive individuals compared to those in the control subjects (pg/ml, HIV-1C=77.30+/-5.7 vs. controls=119.1+10.5; p<0.05; AUC, HIV-1C =83.29+/-7.5 vs. controls=172.3+/-18.9; p<0.001), but no further change was observed in AUC of E in response to MSTCT at the two subsequent yearly visits. The basal plasma levels of ACTH in HIV-1C seropositives were not different than in the control subjects (pg/ml: HIV-1C=20.0+/-0.9 vs. controls=23.1+/-1.6; p=NS), but ACTH response to MSTCT in HIV-1C seropositive patients at the first visit was lower than in the controls (AUC, HIV-1C=23.57+/-1.5 vs. controls=30.94+/-3.5; p<0.05), and fluctuated between high and low at the second and third visits (AUC, 28.89+/-2.3 and 21.69+/-2.36, respectively). However, the baseline plasma levels of cortisol as well as the response of cortisol to MSTCT (AUC) in HIV-1C seropositive individuals were higher than in the control subjects at the first visit (mug/dl, HIV-1C=9.83+/-0.39 vs. controls=6.3+/-0.56; p<0.05; AUC, HIV-1C=12.31+/-0.7 vs. control=9.18+/-0.9; p<0.05), and remained high at the two subsequent yearly follow up visits of HIV-1C (AUC, 11.8+/-0.86 and 11.98+/-0.77, respectively). These findings demonstrate attenuated autonomic functions, a disconnection between response of ACTH and cortisol to the MSTCT challenge, and an inverse relationship between plasma levels of catecholamine(s) and cortisol. Since plasma catecholamines and cortisol are the peripheral mediators of the autonomic and HPA axis function, the findings of this study reflect the overall adverse effect of HIV-1C infection on autonomic as well as HPA axis functions. The findings, apart from being the first to demonstrate the progressive dysregulation of autonomic nervous system and HPA axis function among HIV-1C infected seropositive individuals much ahead of the onset of acquired immunodeficiency syndrome (AIDS), also suggest that MSTCT, involving visuoconstructive cognitive abilities, is an effective stressor for unraveling the underlying dysfunctions in the neuroendocrine functions in health and disease.

Oral mucosal melanoma with unusual clinicopathologic features.

Oral mucosal melanoma (OMM) is an extremely rare malignancy, accounting for < 0.5% of all melanomas and all oral malignancies. The rarity of OMM, the heterogeneity in clinical and histopathologic appearances, and the paucity of molecular and genetic studies to date have limited our knowledge of the etiopathogenesis of these cancers. A 39-year-old Hispanic male presented for evaluation of a large, pigmented, plaque-like and nodular growth of the maxillary gingival and palatal mucosa. On presentation, a presumptive clinical diagnosis of mucosal melanoma was made, which was confirmed by incisional biopsy with subsequent histopathologic evaluation. Macroscopically, the morphology and highly pigmented nature of the tumor was suggestive of a rarer subtype of melanoma known as animal-type melanoma, also referred to as pigmented epithelioid melanocytoma. However, microscopically, the tumor showed histopathologic features consistent with a high-grade acral (mucosal) lentiginous melanoma with overt cytomorphologic features of malignancy in addition to showing prominent pigment synthesis resembling animal-type melanoma. A detailed search of the literature did not identify a previous report of OMM with prominent pigment synthesis resembling animal-type melanoma. Identification of melanoma subtypes has specific implications for therapeutic approach, and thus their recognition is important to successful patient management.

Identification of microbial biofilms in osteonecrosis of the jaws secondary to bisphosphonate therapy.

PURPOSE: Biofilm theory has emerged to explain the etiology of the chronic infections that have come to constitute between 65% to 80% of the microbial diseases treated by physicians in the developed world. The purpose of this article is to report for the first time the observation of multispecies microbial biofilms on affected bone in patients with osteonecrosis of the jaws (ONJ) secondary to bisphosphonate therapy. PATIENTS AND METHODS: A program has been established at the University of Southern California to monitor and evaluate patients with ONJ as a multidisciplinary collaboration between the School of Dentistry, Center for Biofilms, Center for Craniofacial Molecular Biology and the Keck School of Medicine. From this cohort, 4 patients with active ONJ who were scheduled for necessary treatment in the form of sequestrectomy gave informed consent for this study. Bone samples were evaluated using conventional histopathologic techniques and scanning electron microscopy, a technique applicable to biofilm characterization. RESULTS: Bone specimens from affected sites in all patients showed large areas occluded with biofilms comprising mainly bacteria, and occasionally yeast, embedded in extracellular polymeric substance. The number of bacterial morphotypes in the biofilms ranged from 2 to 15, and they included species from the genus Fusobacterium, bacillus, actinomyces, staphylococcus, streptococcus, Selenomonas, and 3 different types of treponemes. The yeast identified was consistent with Candida species. Co-aggregation was observed between different species within the biofilms. CONCLUSION: These findings have important clinical and therapeutic implications and may suggest a role for microbial biofilms in the disease process of ONJ.

Measuring salivary flow: challenges and opportunities.

BACKGROUND: Saliva is being studied extensively and is being used for risk assessment, diagnosis and monitoring high-risk behavior and disease progression. A variety of medical conditions and medications are associated with salivary gland hypofunction. The major disadvantage in the use of saliva for health-related purposes is the lack of standardization in saliva collection methods. METHODS: The authors provide a brief overview of different methods of saliva collection and the advantages and disadvantages associated with each method, as well as of how to assess the salivary flow rate. RESULTS: The authors present the complete set up and step-by-step guidelines for the collection of unstimulated and stimulated whole saliva. CONCLUSIONS: The life expectancy of people will continue to increase with advances in medicine and therapeutic modalities, and the prevalence of salivary gland hypofunction in the elderly population will increase owing to their longevity. The assessment of salivary gland hypo-function will need to be incorporated into everyday clinical practice. CLINICAL IMPLICATIONS: The saliva collection methods outlined in this article can be used by dentists to assess patients at risk of developing diseases and by scientists for scholarly activities.

Osteonecrosis of the jaws secondary to bisphosphonate therapy: a case series.

AIM: The objective of this report is to present the clinical experiences of several patients affected with osteonecrosis (ONJ) secondary to bisphosphonate (BP) therapy and to provide a discussion of the specific BPs implicated in this condition. BACKGROUND: ONJ secondary to BP therapy is becoming an increasingly reported complication following dental therapy. This is particularly true of surgical dental procedures such as extractions. BPs are a class of pharmaceuticals used in the treatment of numerous disorders affecting bone, including osteoporosis, cancer metastases to bone, hypercalcemia of malignancy, and multiple myeloma. Although ONJ is a more recently described phenomenon, it is an emerging problem that may be associated with significant morbidity such as oral dysfunction, impaired eating ability, pain, and compromised esthetics resulting in a poor quality of life in affected patients. CASE REPORT: This is a description of 13 patients affected with ONJ secondary to BP therapy managed at the Orofacial Pain & Oral Medicine Center, Special Patients Clinic, and Oral and Maxillofacial Surgery Clinic at the University of Southern California, School of Dentistry between October 2005 and April 2007, with a discussion of the specific BPs implicated in this condition, the clinical presentation, management, and follow-up. SUMMARY: Thorough reporting of every case of ONJ is important to help advance the understanding of this poorly understood condition. The authors' approach to care represents a more conservative mode to management than previously described by many investigators.

HPA axis activity and neuropathogenesis in HIV-1 clade C infection.

A disturbance in the activity of the hypothalamic-pituitary-adrenal (HPA) axis has been reported among individuals with HIV-1 infection. However, these studies have been carried out in the West where the infecting clade is clade B. HIV-1 infection is rapidly spreading in various parts of South East Asia, including India, where the HIV-1 infecting clade is largely clade C. An investigation of HPA axis activity in this type of infection is warranted since there are many structural differences between clades B and C. This study was carried out to investigate whether HIV-1 infection clade C interferes with the functions of the hippocampus and thereby affects the HPA axis. We tested the hypothesis that when hippocampus activity is disturbed, it leads to the development of neuropathogenesis in HIV-1 C-clade infected individuals. This study included asymptomatic HIV-1 seropositive individuals (n=117) and, age-matched, HIV-1 seronegative controls (n=29). Neuroendocrine function of the HPA axis was evaluated using plasma levels of cortisol, ACTH, and DHEA-S, both in the morning (0800-1000 hr) and evening (2000-2200 hr). A significant elevation of cortisol levels during A.M. and P.M. hours was observed in HIV-1 infected individuals when compared to the controls. Interestingly, no significant change in ACTH level was observed in HIV-1 seropositive subjects, either during A.M or P.M. Elevated levels of cortisol in HIV-1 seropositive subjects appear to be independent of ACTH and may be the result of a defective negative feedback mechanism. On the other hand, a significant decrease in the plasma levels of DHEA-S was observed during A.M. and P.M. hours in HIV-1 infected individuals, leading to an increased cortisol to DHEA-S ratio. Since increased levels of cortisol and decreased levels of DHEA-S are related to the development of neuropathogenesis, it is hypothesized that a study of the development of neurocognitive deficits among HIV-1 seropositive individuals in India is warranted.

Quantitation of HIV-1 RNA levels in plasma and CSF of asymptomatic HIV-1 infected patients from South India using a TaqMan real time PCR assay.

BACKGROUND: Most of the quantitation assays for HIV-1 RNA used currently are designed and optimized for HIV-1 subtype B viruses and hence may not be suitable for India, where the predominant subtype is HIV-1 subtype C. OBJECTIVES: Development and standardization of HIV-1 TaqMan real time PCR assay suitable for measuring plasma and CSF viral RNA levels in HIV subtype C infected individuals. STUDY DESIGN: A TaqMan real time PCR was developed using primers and probes selected in the gag region for detection of Indian HIV-1 subtype C strain. Plasma (n=120) and CSF samples (n=46) obtained from HIV infected subjects were used to evaluate the sensitivity and specificity of the assay. A comparative evaluation was carried out with a commercially available quantitative HIV viral load assay (Roche Amplicor Version 1.5). RESULTS: The TaqMan assay was able to amplify all HIV-1 group M subtypes except subtype E. Viral loads could be estimated in all the plasma (n=120) and 40/46 CSF samples obtained from HIV positive subjects. Sensitivity of this assay was found to be 180 copies/ml. Correlation with the commercially available viral load assay was very good (r=0.885). CONCLUSIONS: A TaqMan real time PCR was standardized for HIV-1 subtype C and it was more sensitive (180 copies/ml) than standard Amplicor monitor assay, Version 1.5 (400 copies/ml).

Plasma adenosine deaminase activity among HIV1 Clade C seropositives: relation to CD4 T cell population and antiretroviral therapy.

BACKGROUND: Plasma adenosine deaminase and its isoenzymes(s) activities have been used as diagnostic marker for intracellular parasitism, including HIV infection, and malignancy of immune cells. HIV infection being primarily targeted against CD4 cells, it would be of interest to relate the activity of total plasma ADA and isoenzymes fractions to immune status and antiretroviral therapy. METHODS: In the present study, plasma total ADA activity (ADAT) including ADA1 and ADA2 isoenzyme(s) were assayed among HIV seropositive Clade C (n=90) comprising both asymptomatic (n=71) and symptomatic (n=19) and compared with that of HIV seronegatives (n=35). RESULTS: A significant increase in the activity of ADAT (16.30+/-0.80 v/s 6.18+/-0.30) as well as ADA1 (6.50+/-0.42 v/s 2.34+/-0.16) and ADA2 (9.79+/-0.53 v/s 3.85+/-0.23) isoenzyme(s) among the asymptomatic as well as the symptomatic subjects as compared to respective controls was noted. Increase in plasma ADAT activity, including ADA1 and ADA2 isoenzyme(s), were found to have negative correlation with CD4 counts (r, -0.273; p<0.05). The increased plasma ADAT activity among the asymptomatic HIV seropositive with CD4 counts>500 (13.2+/-1.65; p<0.01) as well as those who were on antiretroviral therapy (19.31+/-1.36; p<0.001) was evident. CONCLUSIONS: These findings suggest that plasma ADA can be a sensitive marker of an ongoing biological insult to host tissues either because of infection and/or side effects of medication. Measurement of plasma ADA activity, along with serological evidence for HIV infection may provide an alternate laboratory tool to monitor intracellular parasitism including secondary infection vis a vis the after effects of therapeutic outcome.