Radiological manifestations of splenic tuberculosis: a 23-patient case series from India.

BACKGROUND & OBJECTIVE: Splenic tuberculosis (TB) is a less common but important manifestation of abdominal TB, especially in India and other developing countries. Its prevalence is increasing with the epidemic of HIV-TB co-infection and subsequent rise in extrapulmonary TB. The range of radiological manifestations of splenic TB is poorly described. Here, we review the ultrasonographic and computed tomographic (CT) images of 23 cases from two large tertiary care centers in India. METHODS: Radiographic images, ultrasonographic in all cases and CT in selected cases, were retrospectively analyzed in a series of 23 patients presenting to two large tertiary care centers in India, with suspected TB and with splenomegaly on physical examination. Images were assessed at baseline and when available following anti-tuberculosis therapy. RESULTS: The ultrasound and CT findings included, in order of most common: single or multiple hypoechoic focal lesions, splenic abscess, calcifications (on CT), and isolated splenomegaly. Five of the six patients with findings of isolated splenomegaly on ultrasound were found to have lesions on CT. INTERPRETATION & CONCLUSION: Ultrasonography of the spleen is an affordable, non-invasive imaging modality, which can be helpful in diagnosis of splenic TB and assessment of therapeutic response. Proper use of this imaging modality in splenic TB should help avoid unnecessary CT imaging or invasive procedures. However, this technique is operator-dependent, and, when extensive intraabdominal involvement is suspected, or the diagnosis is unclear, CT may be necessary.

Persistently high HIV seroprevalence among adult tuberculosis patients at a tertiary care centre in Delhi.

BACKGROUND & OBJECTIVE: This study was designed to estimate HIV seroprevalence among tuberculosis patients presenting to tertiary care centre in Delhi. METHODS: Cross-sectional prevalence study among all patients presenting to the inpatient and outpatient departments of All India Institute of Medical Sciences (AIIMS), New Delhi, and receiving anti-tuberculosis treatment from May 2003 to April 2005. RESULTS: Of the 448 patients who presented to the TB clinic during the study period, 23 (5.1%) were previously tested HIV-positive. An additional 21 patients (4.6%) refused testing, and 30 (6.7%) were lost to follow up. Of the remaining 374 patients who consented to testing, 31 (8.3%) were found to be HIV-positive. Risk factors for HIV seropositivity included high-risk sexual behaviours (48% in HIV-TB co-infected vs. 6% in TB infected patients, P<0.001) and history of blood transfusion (23% vs. 5%; P=0.002). INTERPRETATION & CONCLUSION: Previous studies from the same hospital published in 2000 and 2003 reported HIV seroprevalence among TB patients to be 0.4 and 9.4 per cent respectively. The current study documents a persistently high seropositivity among TB patients. These results emphasize the acute need for improved detection and treatment for HIV among TB patients in northern India.

The potential role of buprenorphine in the treatment of opioid dependence in HIV-infected individuals and in HIV infection prevention.

Untreated opioid dependence is a major obstacle to the successful treatment and prevention of human immunodeficiency virus (HIV) infection. In this review, we examine the interwoven epidemics of HIV infection and opioid dependence and the emerging role of buprenorphine in improving HIV treatment outcomes among infected individuals, as well as its role in primary and secondary prevention. This article addresses some of the emerging issues about integrating buprenorphine treatment into HIV clinical care settings and the various strategies that must be considered. Specifically, it addresses the role of buprenorphine in improving HIV treatment outcomes through engagement in care, access to antiretroviral therapy and preventive therapies for opportunistic infections, and the potential benefits of and pitfalls in integrating buprenorphine into HIV clinical care settings. We discuss the key research questions regarding buprenorphine in the area of improving HIV treatment outcomes and prevention, including a review of published studies of buprenorphine and antiretroviral treatment and currently ongoing studies, and provide insight into and models for integrating buprenorphine into HIV clinical care settings. Dialogue among practitioners and policy makers in the HIV care and substance abuse communities will facilitate an effective expansion of buprenorphine and ensure that these beneficial outcomes are achieved.

Impact of enhanced services on virologic outcomes in a directly administered antiretroviral therapy trial for HIV-infected drug users.

BACKGROUND: Directly administered antiretroviral therapy (DAART) is a promising intervention for improving HIV outcomes among active drug users, but the elements associated with successful DAART programs remain largely unknown. This study aimed to assess the impact of colocated medical, case management, and referral to substance abuse services (DAART-Plus) among the subjects receiving DAART as part of a larger randomized controlled trial comparing DAART with self-administered therapy. METHODS: The health services utilization of 72 subjects receiving DAART was analyzed for its impact on changes in HIV-1 RNA levels at 6 months. The primary outcome was virologic success, defined as achieving an HIV-1 RNA level /=1.0 log10 reduction in HIV-1 RNA level. A second analysis consisted of linear regression assessing the effect of covariates on log10 HIV-1 RNA reduction from baseline to 6 months. RESULTS: In multivariate analyses, achieving virologic success at 6 months was associated with high medical services utilization [adjusted odds ratio [AOR] = 10.0 (1.4, 73.9); P = 0.02] and with the use of case management services [AOR = 5.8 (1.1, 30.5); P = 0.04]. Both services resulted in a larger reduction in log10 HIV-1 RNA from baseline (difference in slopes: -0.9 and -1.0, respectively; P = 0.02 for both). Referral to off-site substance abuse services treatment did not significantly predict either virologic outcome. CONCLUSIONS: Among individuals who receive DAART, the utilization of on-site medical and case management services was independently associated with improved virologic outcomes. These results suggest the potential utility of integrating these services into DAART interventions (DAART-Plus) targeting HIV-infected drug users with problematic adherence.

Diagnostic accuracy of ascitic fluid IFN-gamma and adenosine deaminase assays in the diagnosis of tuberculous ascites.

In this study, we evaluated the diagnostic accuracy and cost-effectiveness of ascitic fluid interferon-gamma (IFN-gamma) and adenosine deaminase (ADA) assays in the diagnosis of tuberculous ascites. Ascitic fluid from patients with proven tuberculosis (TB) (n = 31) and non-TB ascites (n = 88) was analyzed for IFN-gamma and ADA levels. Areas under the receiver operative characteristic (ROC) curves (AUCs) for the two biologic markers were compared. Levels of ascitic fluid IFN-gamma, median (range): 560 (104-1600) pg/mL vs. 4.85 (0-320) pg/mL (p < 0.001), and ADA, median (range): 58 (16-331) IU/L vs. 10 (0-59) IU/L (p = 0.001), were significantly different between TB and non-TB groups. IFN-gamma and ADA assays showed equal sensitivity (0.97) and differed marginally in specificity (0.97 vs. 0.94). Difference in AUCs was not significant (0.99 vs. 0.98, p < 0.62). For differentiating TB from non-TB ascites, optimal cutoff points were 112 pg/mL for IFN-gamma and 37 IU/L for ADA. The accuracy of the ADA assay was similar to that of the IFN-gamma assay in differentiating of TB from non-TB ascites. Because both material and human costs of the ADA assay are far less than those of the IFN-gamma assay, the former is probably the most appropriate diagnostic test for analysis of peritoneal fluid in resource- limited settings.

Models for integrating buprenorphine therapy into the primary HIV care setting.

Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. We describe the following 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. The key barriers against effective integration of buprenorphine maintenance therapy and primary HIV services are discussed, and we suggest several mechanisms to overcome such obstacles.

Tubercular oesophagocutaneous fistula.

A case of oesophageal tuberculosis complicated by an oesophagocutaneous fistual is reported. We subsequently review the literature of this exceedingly rare condition.

Tuberculin skin test among pulmonary sarcoidosis patients with and without tuberculosis: its utility for the screening of the two conditions in tuberculosis-endemic regions.

BACKGROUND: Sarcoidosis is an increasingly important condition in developing countries, including those with a high prevalence of tuberculosis. The tuberculin skin test (TST) is one test used in distinguishing these two granulomatous conditions. It has been shown that a negative TST is highly sensitive for sarcoidosis. This retrospective study set out to assess the converse: the role of a positive test in the assessing the likelihood that a patient with sarcoidosis might also have tuberculosis. METHODS: A retrospective chart review of 141 patients with biopsy-proved sarcoidosis, among whom there were 16 biopsy-proven sarcoidosis and tuberculosis patients and 125 sarcoidosis-only patients. The receiver operating curve was constructed by calculating the sensitivity and specificity of various levels of induration of the tuberculin skin test for the diagnosis of comorbid tuberculosis. RESULTS: The area under the curve of the ROC did not differ from 0.5, meaning that the TST was not useful as a graded measure. This was largely due to its poor sensitivity. However, a level of greater than or equal to 10 mm induration, though insensitive, had a specificity of 97.6% for the diagnosis of tuberculosis among this population of sarcoidosis patients. CONCLUSIONS: The tuberculin skin test in sarcoid patients has a high specificity but a poor sensitivity for tuberculosis. As such, while a negative TST in the general population is a sensitive test for sarcoidosis, a positive TST among sarcoidosis patients is a specific test for indicating tuberculosis. A positive TST in a patient suspected to suffer from sarcoidosis should therefore be an absolute indication for a thorough work-up for tuberculosis.

HIV testing in correctional institutions: evaluating existing strategies, setting new standards.

Before introducing an HIV testing protocol into correctional facilities, the unique nature of these environments must be taken into account. We analyze three testing strategies that have been used in correctional settings--mandatory, voluntary, and routine "opt out" testing--and conclude that routine testing is most likely beneficial to inmates, the correctional system, and the outside community. The ethics of pre-release testing, and the issues surrounding segregation, confidentiality, and linking prisoners with community-based care, also play a role in determining how best to establish HIV testing strategies in correctional facilities. Testing must be performed in a manner that is not simply beneficial to public health, but also enhances the safety and health status of individual inmates. Longer-stay prison settings provide ample opportunities not just for testing but also for in-depth counseling, mental health and substance abuse treatment, and antiretroviral therapy. Jails present added complexities because of their shorter stay with respect to prisons, and testing, treatment, and counseling policies must be adapted to these settings.