Decreased bioavailability of rifampin and other antituberculosis drugs in patients with advanced human immunodeficiency virus disease

We evaluated the effects of human immunodeficiency virus (HIV) disease on pharmacokinetics of antituberculosis medications by measuring concentrations of isoniazid and rifampin in blood and of pyrazinamide and ethambutol in urine. Peak concentration and exposure were reduced for rifampin, and rapid acetylators of isoniazid had lower drug levels. HIV and HIV-tuberculosis patients who have diarrhea and cryptosporidial infection exhibit decreased bioavailability of antituberculosis drugs.

Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV patients with culture confirmed pulmonary tuberculosis in India and the potential role of IL-6 in prediction

Background

The incidence, manifestations, outcome and clinical predictors of paradoxical TB-IRIS in patients with HIV and culture confirmed pulmonary tuberculosis (PTB) in India have not been studied prospectively.

Methods

HIV+ patients with culture confirmed PTB started on anti-tuberculosis therapy (ATT) were followed prospectively after anti-retroviral therapy (ART) initiation. Established criteria for IRIS diagnosis were used including decline in plasma HIV RNA at IRIS event. Pre-ART plasma levels of interleukin (IL)-6 and C-reactive protein (CRP) were measured. Univariate and multivariate logistic regression models were used to evaluate associations between baseline variables and IRIS.

Results

Of 57 patients enrolled, 48 had complete follow up data. Median ATT-ART interval was 28 days (interquartile range, IQR 14–47). IRIS events occurred in 26 patients (54.2%) at a median of 11 days (IQR: 7–16) after ART initiation. Corticosteroids were required for treatment of most IRIS events that resolved within a median of 13 days (IQR: 9–23). Two patients died due to CNS TB-IRIS. Lower CD4⁺ T-cell counts, higher plasma HIV RNA levels, lower CD4/CD8 ratio, lower hemoglobin, shorter ATT to ART interval, extra-pulmonary or miliary TB and higher plasma IL-6 and CRP levels at baseline were associated with paradoxical TB-IRIS in the univariate analysis. Shorter ATT to ART interval, lower hemoglobin and higher IL-6 and CRP levels remained significant in the multivariate analysis.

Conclusion

Paradoxical TB–IRIS frequently complicates HIV-TB therapy in India. IL-6 and CRP may assist in predicting IRIS events and serve as potential targets for immune interventions.

Age, nutritional status and INH acetylator status affect pharmacokinetics of anti-tuberculosis drugs in children

SETTING

The currently recommended dosages of rifampicin (RMP), isoniazid (INH), pyrazinamide (PZA) and ethambutol in children are extrapolated from adult pharmacokinetic studies, and have not been adequately evaluated in children.

OBJECTIVE

To describe the pharmacokinetics of RMP, INH and PZA given thrice weekly in children with tuberculosis (TB), and to relate pharmacokinetics to treatment outcomes.

METHODS

Eighty-four human immunodeficiency virus negative children with TB aged 1-12 years in Chennai and Madurai, India, were recruited. Phenotypic INH acetylator status was determined. Nutritional status was assessed using Z scores. During the intensive phase of anti-tuberculosis treatment, a complete pharmacokinetic study was performed after directly observed administration of drugs. At 2 and 6 months, drug levels were measured 2 h post-dose. Drug concentrations were measured using high performance liquid chromatography and pharmacokinetic variables were calculated. Multivariable regression analysis was performed to explore factors impacting drug levels and treatment outcomes.

RESULTS AND CONCLUSIONS

Children aged <3 years had significantly lower RMP, INH and PZA concentrations than older children, and 90% of all children had sub-therapeutic RMP Cmax (<8 μg/ml). Age, nutritional status and INH acetylator status influenced drug levels. Peak RMP and INH concentrations were important determinants of treatment outcome. Recommendations for anti-tuberculosis treatment in children should take these factors into consideration.

Model for blood collections management

BACKGROUND

A typical blood bank gets its major supply of blood from organizing blood donation camps. The quantity of blood collected in the blood donation drives is random and it might be sensible to cut off the supply at some level to reduce the wastages by overcollection.

STUDY DESIGN AND METHODS

In this paper we introduce two new cutoff level policies and compare their performance with the policy of collecting all the available supply at blood collection drives, which is quite prevalent among the blood banks. We develop a simulation model for collection that enables such comparison on the basis of shortages, wastages, and total costs.

RESULTS AND CONCLUSION

The results obtained from the simulation model for a real-life situation show that the cutoff level policies are better than the unrestricted collection policy in controlling total costs. They also result in less wastage in the system for a given level of shortages.

Efficacy of antiretroviral therapy program in children in India: prognostic factors and survival analysis

The objective of this article is to study the survival pattern and the prognostic factors for HIV-infected children on antiretroviral therapy (ART) for two and half years at the Government Hospital of Thoracic Medicine, Tambaram, Chennai, India. We studied 295 children who were initiated on ART from 1 April 2004 to 30 September 2006 at a large, public tertiary care facility in Chennai, India. Weight for age Z-score was calculated. Survival curves and Cox proportional hazard models were used to identify risk factors for mortality. The mean and median follow up was 11 and 10 months, respectively. The cumulative survival probability at 6, 12, 18, 24 and 30 months was 93, 90, 89.7, 89.7 and 89.7%, respectively. Of the children who died, about 50% died within the first month. Nearly 6% of the children had adherence less than 95%. The children who had a baseline CD4 percent less than or equal to 14% had significantly (p < 0.05) higher mortality as compared to children who had 20% or more. The children who had negative or no change in weight for age Z-score and hemoglobin had 18.9 (3.7-95.7) times significantly higher mortality as compared to children who had positive change in both variables (p < 0.001). The sensitivity, specificity and likelihood ratio of the positive test for negative change or no change in HB was 65%, 85% and 4.3, respectively. Similarly, these were 80%, 73% and 3% for negative or no change in Absolute Lymphocyte Count (ALC). These findings indicate the feasibility and effectiveness of implementing an ART program in a large government hospital in India. Simple nutritional variable hemoglobin and immunologic variable ALC could be used to monitor the progression of disease in children.

Role of LTA4H Polymorphism in Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Occurrence and Clinical Severity in Patients Infected with HIV

Background

Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is an inflammatory phenomenon complicating HIV management in coincidental tuberculosis (TB) infection, upon immune reconstitution driven by antiretroviral therapy (ART). Leukotriene A4 hydroxylase (LTA4H), an enzyme which converts LTA₄ to LTB₄, regulates the balance between the anti-inflammatory lipoxins and pro-inflammatory LTB₄, with direct implications in TB-driven inflammation. In humans, a single nucleotide polymorphism (SNP) in the LTA4H promoter which regulates its transcriptional activity (rs17525495) has been identified and described to impact clinical severity of TB presentation and response to corticosteroid therapy. Notably, the role of LTA4H on TB-IRIS has not been previously evaluated. Here, we performed an exploratory investigation testing the association of LTA4H polymorphism with respect to frequency of TB-IRIS occurrence and severity of TB-IRIS presentation in HIV-TB co-infected individuals.

Methods

Genotypic evaluation of the LTA4H enzyme from available samples was retrospectively correlated with clinical data captured in case sheets including IRIS details. The cohort included patients recruited from a prospective cohort study nested within a randomized clinical trial (NCT0933790) of ART-naïve HIV+ patients with newly diagnosed rifampicin sensitive pulmonary TB in South India. Frequency of the wild type genotype (CC), as well as of the mutant genotypes (CT or TT) in the IRIS and non-IRIS patients was estimated. Comparative analyses were performed between wild genotype (CC) and the mutant genotypes (CT or TT) and tested for association between the LTA4H polymorphisms and IRIS incidence and clinical severity.

Results

A total of 142 eligible ART-naïve patients were included in the analyses. Eighty-six individuals exhibited the wild genotype (CC) while 56 had mutant genotypes (43-CT and only 13-TT). Variant allele frequency was 0.23 and 0.26 in non-IRIS group and in IRIS group, respectively. Upon ART initiation, 51 patients developed IRIS while 91 did not. IRIS incidence was 34% and 37% in the wild (CC) and mutant type (CT/TT), respectively (p = 0.858) with a higher frequency of severe IRIS presentation in the mutant genotype group compared to the wild type genotype (p = 0.0006). A logistic regression model confirmed the association between the presence of CT/TT genotypes and occurrence of severe IRIS. Corticosteroid therapy successfully resolved IRIS in all cases irrespective of the LTA4H genotype.

Conclusion

A higher incidence of severe IRIS among patients with mutant LTA4H genotypes (CT and TT) was observed compared to the wild type, despite similar IRIS incidence and immune restoration in both groups. Steroids were effective in alleviating IRIS in all the genotypes.

Dynamics of T-Lymphocyte Activation Related to Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome in Persons With Advanced HIV

Most persons living with HIV (PLWH) experience a significant restoration of their immunity associated with successful inhibition of viral replication after antiretroviral therapy (ART) initiation. Nevertheless, with the robust quantitative and qualitative restoration of CD4⁺ T-lymphocytes, a fraction of patients co-infected with tuberculosis develop immune reconstitution inflammatory syndrome (TB-IRIS), a dysregulated inflammatory response that can be associated with significant tissue damage. Several studies underscored the role of adaptive immune cells in IRIS pathogenesis, but to what degree T lymphocyte activation contributes to TB-IRIS development remains largely elusive. Here, we sought to dissect the phenotypic landscape of T lymphocyte activation in PLWH coinfected with TB inititating ART, focusing on characterization of the profiles linked to development of TB-IRIS. We confirmed previous observations demonstrating that TB-IRIS individuals display pronounced CD4⁺ lymphopenia prior to ART initiation. Additionally, we found an ART-induced increase in T lymphocyte activation, proliferation and cytotoxicity among TB-IRIS patients. Importantly, we demonstrate that TB-IRIS subjects display higher frequencies of cytotoxic CD8⁺ T lymphocytes which is not affected by ART. Moreover, These patients exhibit higher levels of activated (HLA-DR⁺) and profilerative (Ki-67⁺) CD4⁺ T cells after ART commencenment than their Non-IRIS counterparts. Our network analysis reveal significant negative correlations between Total CD4⁺ T cells counts and the frequencies of Cytotoxic CD8⁺ T cells in our study population which could suggest the existance of compensatory mechanisms for Mtb-infected cells elimination in the face of severe CD4⁺ T cell lymphopenia. We also investigated the correlation between T lymphocyte activation profiles and the abundance of several inflammatory molecules in plasma. We applied unsupervised machine learning techniques to predict and diagnose TB-IRIS before and during ART. Our analyses suggest that CD4⁺ T cell activation markers are good TB-IRIS predictors, whereas the combination of CD4⁺ and CD8⁺ T cells markers are better at diagnosing TB-IRIS patients during IRIS events Overall, our findings contribute to a more refined understanding of immunological mechanisms in TB-IRIS pathogenesis that may assist in new diagnostic tools and more targeted patient management.

Multifocal tuberculosis-associated immune reconstitution inflammatory syndrome - a case report of a complicated scenario

BACKGROUND

Tuberculosis (TB)-associated Immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response in TB patients with advanced human immunodeficiency virus coinfection, after antiretroviral therapy commencement.

CASE PRESENTATION

We present a rare case of a 51-year-old woman living with HIV who developed a series of TB-IRIS events occurring at multiple sites sequentially, highlighting the clinical complexity in diagnosis and management.

CONCLUSION

This case illustrates how complicated a clinical scenario of successive TB-IRIS episodes can be, in terms of clinical management.

Managing bullwhip effect: two case studies

Purpose: The purpose of this paper is to present two examples based on real life experiences where the Bullwhip effect (BWE) in supply chain is considerably reduced. Both examples relate to the consumer durables industry in India. Design/methodology/approach: The first example uses enterprise resource planning and vendor managed inventory as tools to reduce the BWE. The second example uses a modification of the classical inventory control policies to eliminate BWE. Research limitations/implications: This paper could initiate research in an area which would help supply chain researchers and managers to understand why some companies are able to contain BWE and others are not. Findings: Based on these two empirical case studies, the paper argues that managing BWE is a strategic initiative by organization and the best approach is a combination of several tactical initiatives. Originality/value: This paper briefly summarizes the managerial approaches to tame BWE in two different contexts. The two examples have some similarities, differences and offer unique insights related to managing BWE.

Frequency of CXCR3+ CD8+ T-Lymphocyte Subsets in Peripheral Blood Is Associated With the Risk of Paradoxical Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome Development in Advanced HIV Disease

Background

Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a clinical aggravation of TB symptoms observed among a fraction of HIV coinfected patients shortly after the start of antiretroviral therapy (ART). Of note, TB-IRIS is characterized by exacerbated inflammation and tissue damage that occurs in response to the elevated production of CD4+ T cell-derived IFN-γ. Nevertheless, the possible participation of CD8+ T cells in TB-IRIS development remains unclear.

Methods

We performed a comprehensive assessment of the composition of CD8+ T cell memory subsets and their association with circulating inflammation-related molecules in TB-HIV coinfected patients initiating ART.

Results

We found that TB-IRIS individuals display higher frequencies of Antigen-experienced CD8+ T cells during the onset of IRIS and that the levels of these cells positively correlate with baseline mycobacterial smear grade. TB-IRIS individuals exhibited higher frequencies of effector memory and lower percentages of naïve CD8+ T cells than their Non-IRIS counterparts. In both TB-IRIS and Non-IRIS patients, ART commencement was associated with fewer significant correlations among memory CD8+ T cells and cells from other immune compartments. Networks analysis revealed distinct patterns of correlation between each memory subset with inflammatory cytokines suggesting different dynamics of CD8+ T cell memory subsets reconstitution. TB-IRIS patients displayed lower levels of memory cells positive for CXCR3 (a chemokine receptor that plays a role in trafficking activated CD8+ T cells to the tissues) than Non-IRIS individuals before and after ART. Furthermore, we found that CXCR3+ naïve CD8+ T cells were inversely associated with the risk of TB-IRIS development. On the other hand, we noticed that the frequencies of CXCR3+ effector CD8+ T cells were positively associated with the probability of TB-IRIS development.

Conclusion

Our data suggest that TB-IRIS individuals display a distinct profile of memory CD8+ T cell subsets reconstitution after ART initiation. Moreover, our data point to a differential association between the frequencies of CXCR3+ CD8+ T cells and the risk of TB-IRIS development. Collectively, our findings lend insights into the potential role of memory CD8+ T cells in TB-IRIS pathophysiology.

Regulatory Challenges and Non-profit Welfarism

The debate over non-profit organisations and then proper role in the liberalisation era continues, periodically grabbing public attention for sustainability, tax exemption, etc. However, as the non-profit sector grows in size and commercial activities, it is becoming indistinguishable from the private sector? The competition between non-profit sectors and private is made even more complex by the fact that the former are moving into activities that have previously been the domain of profit firms; and private firms are expanding into traditionally non-profit areas. To what extent this occurs is important for public policy, since the justification for subsidies, receiving donations and tax exemptions to non-profit sectors hinges on their differentiation from private firms. This is not only questioning the social welfarism philosophy, but also the one of the regulatory challenges that stand in front of us. Attention to NPOs growing commercial activity is necessary because it highlights both the difference between what society expects from them and private firms, and the similarity in the financial constraints that they face. Nevertheless this article aims to understand the available revenue factors that affect NPOs and their activities. In addition, this article also suggests regulations that affect the use of accounting procedures that minimise or eliminate taxable profit, and rules that affect commercial alliances with, or conversions into, private firms.

Financing Sustainability and Globalisation

Aid financing has an important role in the future. Yet accumulated weaknesses, defects and contradictions in the current concepts of aid and sustainability discussed in this article point to the growing need for a fundamental change in thinking to engage the whole aid relationship and fund management, embracing the role and purpose of aid, the form it takes and its place in the broader relations with different types of NPOs/donors. What is needed is not the creation of a completely new sustainability outlook, but the establishment of a firm contemporary agenda that builds on some of the proven strengths of the community-based agenda. Within this context, the thinking about sustainability in particular ought to be built on a firmer and more strategically robust foundation than available now. This article comprehensively reviews the key questions about aid and sustainability, including the changing motives for and the purposes of providing aid, the need for new aid targets, distinctions among various recipient NPOs, and the implications of globalisation. In fact, it is an attempt to understand the term in the context of globalisation through a process of transforming that understanding into organisational action. Although ‘sustainability’, ‘globalisation’ and ‘organisational action’ can stand by themselves, it may be a useful exercise to explore the sustainability concept under the globalisation setting, drawing on its own experiences and best practices from India.

Cool King Limited

This case details the decision facing Cool King Limited, one of the leading businesses in India dealing with the installation of central air conditioning. So far it has had only a token presence in the window air conditioning business, but is now looking to expand into it as explosive growth in the industry is predicted in the near future. However, this change of focus from central air conditioning to window air conditioning is likely to affect the sales of central air conditioners, which is already on the decline, and may prevent Cool King from venturing into other related businesses such as sales of refrigerators.

Prevalence of acquired MDR-TB and HIV co-infection

BACKGROUND

Mounting prevalence of primary and acquired multidrug-resistant tuberculosis in India is a sorry reminder of all round failure in our fight against tuberculosis and also of the necessity for new effective strategies.

OBJECTIVES

(1) To assess the prevalence and pattern of drug resistant pulmonary tuberculosis among treated patients or on those on treatment without adequate response and (2) to evaluate HIV seropositivity among MDR-TB patients.

METHODS

Pulmonary TB patients, who had at least six months of unsuccessful anti-tuberculous treatment were selected for the study. Their sputum specimens were examined for M. tuberculosis culture and drug sensitivity pattern and serological examinations for HIV infection were carried out.

RESULTS

Sputum specimens of 618 patients' (61.8%) of a total of 1000 examined had shown culturable M. tuberculosis. Four hundred ninty-five patients (49.5%) were found to expectorate tubercle bacilli resistant to one or more anti TB drugs. MDR-TB was detected in 339 patients (33.9%). HIV seropositivity among MDR-TB was 4.42%. Significantly, 245 patients (24.5%) had tubercle bacilli resistant to one or more reserve drugs too (ethionamide, kanamycin and/or ofloxacin).

CONCLUSIONS

Prevalence of MDR-TB was high in the study population. It is essentially an acquired condition. Its association with HIV disease was at present on the lower side, an observation contrary to published western literature. Higher rates of resistance for reserve drugs (ethionamide, kanamycin and/or ofloxacin) in patients who never had these drugs in their earlier treatment schedules suggest the possibility of emerging spontaneous drug resistant mutants.

Demographic & clinical profile of HIV infected children accessing care at Tambaram, Chennai, India

BACKGROUND & OBJECTIVE

Human immunodeficiency virus (HIV) is severely affecting the poorly educated and economically disadvantaged in Indian society. When children start developing clinical manifestations, needing treatment, they have to travel long distances for accessing care and support at tertiary institutions. This places an extra burden on patients, who are already struggling to cope with their illness. Sufficient data are needed for the government to evolve appropriate policy for providing care to the children affected with HIV. We undertook this study to present the socio-demographic characteristics, signs and symptoms, clinical profile, distance travelled and follow up pattern of HIV positive children who accessed care for the first time in a referral hospital at Chennai, India.

METHODS

Electronic medical records from patients diagnosed with HIV between 2002 and 2004 at the Government Hospital for Thoracic Medicine (GHTM) in Tambaram (Chennai) in India were analyzed to understand care-seeking behaviours. Demographic variables such as age, sex, education and occupation, data on clinical manifestations were examined together with geographic information.

RESULTS

At GHTM 1,768 new paediatric patients accessed care from 2002 to 2004. Children aged less than 5 yr were 49.9 per cent; 1115 children had (63%) tuberculosis. Significantly, 14.9 and 20.6 per cent children had extra-pulmonary TB and disseminated TB respectively. Lower respiratory infection (15.8%), Pneumocystis carinii pneumonia (15.20%), oral/oesophageal candidiasis (13.5%), wasting (6.1%) and diarrhoeal disorders (3.5%) were the common clinical manifestations. In all 47 per cent children traveled between 200-400 km from home and 14 per cent travelled over 400 km.

INTERPRETATION & CONCLUSION

Our findings showed that tuberculosis should be regarded as the indicator disease for HIV infection in children, especially when they have clinical manifestations of progressive, non pulmonary and disseminated disease. The primary and secondary health care centres should have the trained capacity to diagnose and treat HIV disease and opportunistic infections so as the children to have much needed care and support nearer to their residence.