Tuberculosis treatment intermittency in the continuation phase and mortality in HIV-positive persons receiving antiretroviral therapy

BACKGROUND

Some tuberculosis (TB) treatment guidelines recommend daily TB treatment in both the intensive and continuation phases of treatment in HIV-positive persons to decrease the risk of relapse and acquired drug resistance. However, guidelines vary across countries, and treatment is given 7, 5, 3, or 2 days/week. The effect of TB treatment intermittency in the continuation phase on mortality in HIV-positive persons on antiretroviral therapy (ART), is not well-described.

METHODS

We conducted an observational cohort study among HIV-positive adults treated for TB between 2000 and 2018 and after enrollment into the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet; Brazil, Chile, Haiti, Honduras, Mexico and Peru). All received standard TB therapy (2-month initiation phase of daily isoniazid, rifampin or rifabutin, pyrazinamide ± ethambutol) and continuation phase of isoniazid and rifampin or rifabutin, administered concomitantly with ART. Known timing of ART and TB treatment were also inclusion criteria. Kaplan-Meier and Cox proportional hazards methods compared time to death between groups. Missing model covariates were imputed via multiple imputation.

RESULTS

2303 patients met inclusion criteria: 2003(87%) received TB treatment 5-7 days/week and 300(13%) 2-3 days/week in the continuation phase. Intermittency varied by site: 100% of patients from Brazil and Haiti received continuation phase treatment 5-7 days/week, followed by Honduras (91%), Peru (42%), Mexico (7%), and Chile (0%). The crude risk of death was lower among those receiving treatment 5-7 vs. 2-3 days/week (HR = 0.68; 95% CI = 0.51-0.91; P = 0.008). After adjusting for age, sex, CD4, ART use at TB diagnosis, site of TB disease (pulmonary vs. extrapulmonary), and year of TB diagnosis, mortality risk was lower, but not significantly, among those treated 5-7 days/week vs. 2-3 days/week (HR 0.75, 95%CI 0.55-1.01; P = 0.06). After also stratifying by study site, there was no longer a protective effect (HR 1.42, 95%CI 0.83-2.45; P = 0.20).

CONCLUSIONS

TB treatment 5-7 days/week was associated with a marginally decreased risk of death compared to TB treatment 2-3 days/week in the continuation phase in multivariable, unstratified analyses. However, little variation in TB treatment intermittency within country meant the results could have been driven by other differences between study sites. Therefore, randomized trials are needed, especially in heterogenous regions such as Latin America.

HIV-related tuberculosis: mortality risk in persons without vs. with culture-confirmed disease

BACKGROUND

Tuberculosis (TB) diagnosis in human immunodeficiency virus (HIV) positive persons is difficult, particularly in resource-limited settings. The relationship between TB culture status and mortality in HIV-positive persons treated for TB is unclear.

METHODS

We evaluated HIV-positive adults treated for TB at or after their first HIV clinic visit in Argentina, Brazil, Chile, Honduras, Mexico or Peru from 2000 to 2015. Anti-tuberculosis treatment included 2 months of isoniazid, rifampicin (RMP)/rifabutin (RBT), pyrazinamide ± ethambutol, followed by continuation phase treatment with isoniazid + RMP/RBT.

RESULTS

Of 759 TB-HIV patients, 238 (31%) were culture-negative, 228 (30%) had unknown culture status or did not undergo culture and 293 (39%) were culture-positive. The median CD4 at TB diagnosis was 96 (interquartile range 40-228); 636 (84%) received concurrent antiretroviral therapy (ART) and anti-tuberculosis treatment. There were 123 (16%) deaths: 90/466 (19%) with TB culture-negative, unknown or not performed vs. 33/293 (11%) who were TB culture-positive (P = 0.005). In Kaplan-Meier analysis, mortality in TB patients without culture-confirmed disease was higher (P = 0.002). In a Cox model adjusted for age, sex, CD4, ART timing, disease site and stratified by study site, mortality in persons without culture-confirmed TB was not significantly increased compared to those with culture-positive TB (hazard ratio 1.39, 95%CI 0.89-2.16, P = 0.15).

CONCLUSION

Most HIV-positive patients treated for TB did not have culture-confirmed TB, and mortality tended to be higher in patients without culture-confirmed disease, although the association was not statistically different after adjusting for other variables. Accurate TB diagnosis in HIV-positive persons is crucial.

A systematic approach to the hip-spine relationship and its applications to total hip arthroplasty

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Outcomes of HIV-positive patients with cryptococcal meningitis in the Americas

BACKGROUND

Cryptococcal meningitis (CM) is associated with substantial mortality in HIV-infected patients. Optimal timing of antiretroviral therapy (ART) in persons with CM represents a clinical challenge, and the burden of CM in Latin America has not been well described. Studies suggest that early ART initiation is associated with higher mortality, but data from the Americas are scarce.

METHODS

HIV-infected adults in care between 1985-2014 at participating sites in the Latin America (the Caribbean, Central and South America network (CCASAnet)) and the Vanderbilt Comprehensive Care Clinic (VCCC) and who had CM were included. Survival probabilities were estimated. Risk of death when initiating ART within the first 2 weeks after CM diagnosis versus initiating between 2-8 weeks was assessed using dynamic marginal structural models adjusting for site, age, sex, year of CM, CD4 count, and route of HIV transmission.

FINDINGS

340 patients were included (Argentina 58, Brazil 138, Chile 28, Honduras 27, Mexico 34, VCCC 55) and 142 (42%) died during the observation period. Among 151 patients with CM prior to ART 56 (37%) patients died compared to 86 (45%) of 189 with CM after ART initiation (p=0.14). Patients diagnosed with CM after ART had a higher risk of death (p=0.03, log-rank test). The probability of survival was not statistically different between patients who started ART within 2 weeks of CM (7/24, 29%) vs. those initiating between 2-8 weeks (14/53, 26%) (p=0.96), potentially due to lack of power.

INTERPRETATION

In this large Latin-American cohort, patients with CM had very high mortality rates, especially those diagnosed after ART initiation. This study reflects the overwhelming burden of CM in HIV-infected patients in Latin America.

Retrieval analysis of squeaking ceramic implants: are there related specific features?

INTRODUCTION

Ceramic-on-ceramic total hip arthroplasty is routinely used for young and active patients with end stage of hip osteoarthritis. However, squeaking noise is a recently identified problem with such bearing surface. Many in vivo and in vitro studies have been conducted trying to find the potential causes of this phenomenon. However, we are not aware of any study analyzing retrieved ceramic implants for squeaking.

HYPOTHESIS

Our primary hypothesis was that the surface analysis of retrieved ceramic implants with squeaking would present interesting deteriorations that could explain the squeaking noise.

MATERIALS AND METHODS

Nine retrieved squeaking implants from ceramic-on-ceramic total hip arthroplasty that were retrieved for various reasons (two exclusively for squeaking, four for recurrent dislocation, one for aseptic loosening and two for instability) were analyzed. Implant positioning was calculated, macroscopic damages were noticed and microscopic roughness was analyzed. The retrieved implants were then tested on a hip simulator reproducing flexion/extension motions in several situations in lubricated and non-lubricated conditions in order to reproduce squeaking.

RESULTS

Five cups were considered with borderline insufficient anteversion. Gross impingement damage was visible on seven implants. All the retrieved heads had visible metal transfer on their surface. Eight implants had visible stripe wear. Microscopic analysis showed roughness higher than six microns on the retrieved heads. Squeaking was reproduced in vitro in dry conditions. In lubricated conditions, squeaking did not occur for the retrieved hips.

DISCUSSION

This retrieval analysis suggests that problems of cup orientation and design which can lead to impingement can generate lubrication problems because of metal transfer plus/minus stripe wear which is a common theme in ceramic-on-ceramic bearings that squeak.

Ionic currents and spontaneous firing in neurons isolated from the cerebellar nuclei

Neurons of the cerebellar nuclei fire spontaneous action potentials both in vitro, with synaptic transmission blocked, and in vivo, in resting animals, despite ongoing inhibition from spontaneously active Purkinje neurons. We have studied the intrinsic currents of cerebellar nuclear neurons isolated from the mouse, with an interest in understanding how these currents generate spontaneous activity in the absence of synaptic input as well as how they allow firing to continue during basal levels of inhibition. Current-clamped isolated neurons fired regularly ( approximately 20 Hz), with shallow interspike hyperpolarizations (approximately -60 mV), much like neurons in more intact preparations. The spontaneous firing frequency lay in the middle of the dynamic range of the neurons and could be modulated up or down with small current injections. During step or action potential waveform voltage-clamp commands, the primary current active at interspike potentials was a tetrodotoxin-insensitive (TTX), cesium-insensitive, voltage-independent, cationic flux carried mainly by sodium ions. Although small, this cation current could depolarize neurons above threshold voltages. Voltage- and current-clamp recordings suggested a high level of inactivation of the TTX-sensitive transient sodium currents that supported action potentials. Blocking calcium currents terminated firing by preventing repolarization to normal interspike potentials, suggesting a significant role for K(Ca) currents. Potassium currents that flowed during action potential waveform voltage commands had high activation thresholds and were sensitive to 1 mm TEA. We propose that, after the decay of high-threshold potassium currents, the tonic cation current contributes strongly to the depolarization of neurons above threshold, thus maintaining the cycle of firing.

Stress-induced neuroendocrine modulation of viral pathogenesis and immunity

Physical restraint (RST) was used to examine the interactions among the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic nervous system, and the immune response to infection. In these studies, mice were infected with either herpes simplex virus (HSV) or influenza A/PR8 virus so that the impact of neuroendocrine activation could be assessed on disease pathophysiology and anti-viral immunity. RST suppressed lymphadenopathy in draining lymph nodes, reduced mononuclear cellular infiltration in the lungs, and suppressed virus-specific cytokine and cytolytic T-cell responses. Blockade of type II glucocorticoid receptors (by RU486) restored cellularity and cytokine responses to both organs in restraint-stressed, infected mice. Thus, the HPA axis modulated cell trafficking and T-cell cytokine responses. However, RU486 treatment failed to restore cytolytic T-cell responses. Blockade of beta-adrenergic receptors (by nadolol), in combination with RU486 treatment, fully restored cytolytic T-cell responses, suggesting that catecholamines were involved in suppressing the virus-specific CD8+ cytolytic T-cell response. RST also modulated the local development or expression of antibody-secreting cells (ASC) in the lungs draining lymph nodes, and spleen following infection of restrained mice. RST significantly suppressed the number of virus-specific ASC (IgM, IgG and subclasses IgG1 and IgG2a) in the lungs, mediastinal (MLN) lymph nodes and spleen, while it enhanced the responses in the superficial cervical (SCV) lymph nodes. This observation of differential modulation of ASC responses in the MLN and SCV lymph nodes supports the concept of tissue-specific immunoregulation in response to stress.

Parasitic infections in sickle cell crisis: Nigerian experience

Data collected on 150 sickle cell patients in Nigeria were analyzed to determine the frequency of parasitic infections in clinical and hematologic crisis. Fifty-three adult and 97 pediatric patients (mean age: 27.6 years and 9.7 years, respectively) were studied. Of these patients, 82 were males and 68 females. One hundred thirty-nine had the SS and 11 the SC genotype. Blood samples collected from patients on admission for sickle cell-related illnesses were examined microscopically for evidence of Plasmodium sp, and stool samples were analyzed for presence of any helminth. A total of 102 parasitic infections associated with clinical cases of sickle cell crisis were recorded (malaria, 36[35.3%]; helminths, 49 ([48%]; and malaria and helminths together, 17 [16.7%]). Of the 49 helminthic infections, 26 (53.1%) were due to Ascaris lumbricoides, 15 (30.6%) were due to hookworms, 7 (14.3%) were due to Trichuris trichiura, and 1 (2%) was due to Strongyloides stercoralis. The mean hemoglobin levels during clinical crisis were 7.1 g/dL for helminths, 6.4 g/dL for malaria, and 6.1 g/dL for malaria and helminths together. Reticulocyte counts were 1.4% for helminths, 1.5% for malaria, and 1.2% for both malaria and helminths together. Severity and duration of the clinical crisis were longer for events associated with a single parasitic organism infection than for those with multiple organisms. Routine blood smear examination for malaria and stool analysis should be included in the laboratory evaluation of individuals with sickle cell anemia in developing countries as these infestations could play an important role in precipitating a crisis.

Nursing specialty practice guidelines: the implications for clinical scholarship and early intervention practice. American Nurses' Association

Specialty practice guidelines provide the nursing profession with the opportunity to examine, document, and revise practice, thus contributing to clinical scholarship and nursing science. The development and evaluation of one particular specialty practice guideline, the Children with Special Health Care Needs Guidelines, and the implications for early intervention practice are described. Recommendations for clinical research and usage for the Education of the Handicapped Act Amendment of 1986 (Public Law 99-457) are included.

Somatizing distress: hospital treatment of psychiatric co-morbidity and the limitations of biomedicine

Analysis reveals that treatment of psychiatric co-morbidity in hospitals has a somatizing effect. The patients typically have long, costly hospital stays marked by numerous nonpsychiatric consultations. When consulted, psychiatrists are constrained by their role within the hospital social system and tend to employ somatopsychic approaches which are compatible with the orientation of their physician consultees. Case studies illustrate the inadequacy of these treatment modes and highlight the significance of social and economic problems as etiologic factors in psychiatric co-morbidity. Applying a critical approach from the field of medical anthropology, we argue that the ultimate solution to many patients' problems lies outside of the realm of biomedicine and depends on changes in social policies. Thus, the limitations of biomedicine are seen as due both to its predisposition toward somatic treatment and to larger social forces which cause its practitioners to be part of the problem rather than part of the solution.

Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus

A meta-analysis of the literature of controlled studies of educational and psychosocial interventions in the treatment of diabetes mellitus yielded 93 studies of 7451 patients testing the effects of eight intervention types: (1) didactic education, (2) enhanced education, (3) diet instruction, (4) exercise instruction, (5) self-monitoring instruction, (6) social learning/behavior modification, (7) counseling, and (8) relaxation training. An overall mean effect size (ES) of +0.51 +/- 0.11 was found moderate but significant (P less than 0.05) improvements for all intervention subjects. Physical outcome and knowledge gain were most affected, followed by psychological status and compliance. Diet instruction and social learning interventions showed the strongest (ES = +0.68 +/- 0.58 and ES = +0.57 +/- 0.42, respectively) and relaxation training the weakest (ES = +0.30 +/- 0.74) effects. Associations between study and sample characteristics and mean ES values were explored with type of setting and methodological weaknesses such as single group design and non-random assignment achieving statistical significance. Neither intervention type, number of visits, sex, age, nor type of diabetes were significantly correlated with mean ES values. Implications of these findings for clinical treatment and future research are discussed.