Exercise in the heat causes "central fatigue", associated with reduced skeletal muscle recruitment during sustained isometric contractions. A similar mechanism may cause fatigue during prolonged dynamic exercise in the heat. The aim of this study was to determine whether centrally regulated skeletal muscle recruitment was altered during dynamic exercise in hot (35 degrees C) compared with cool (15 degrees C) environments. Ten male subjects performed two self-paced, 20-km cycling time-trials, one at 35 degrees C (HOT condition) and one at 15 degrees C (COOL condition). Rectal temperature rose significantly in both conditions, reaching maximum values at 20 km of 39.2+/-0.2 degrees C in HOT and 38.8+/-0.1 degrees C in COOL (P<0.005 HOT vs. COOL). Core temperatures at all other distances were not different between conditions. Power output and integrated electromyographic activity (iEMG) of the quadriceps muscle began to decrease early in the HOT trial, when core temperatures, heart rates and ratings of perceived exertion (RPE) were similar in both conditions. iEMG was significantly lower in HOT than in COOL at 10 and 20 km, while power output was significantly reduced in the period from 80% to 100% of the trial duration in the HOT compared with COOL condition. Thus, reduced power output and iEMG activity during self-paced exercise in the heat occurs before there is any abnormal increase in rectal temperature, heart rate or perception of effort. This adaptation appears to form part of an anticipatory response which adjusts muscle recruitment and power output to reduce heat production, thereby ensuring that thermal homeostasis is maintained during exercise in the heat.

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In this review, fatigue is described as a conscious sensation rather than a physiological occurrence. We suggest that the sensation of fatigue is the conscious awareness of changes in subconscious homeostatic control systems, and is derived from a temporal difference between subconscious representations of these homeostatic control systems in neural networks that are induced by changes in the level of activity. These mismatches are perceived by consciousness-producing structures in the brain as the sensation of fatigue. In this model, fatigue is a complex emotion affected by factors such as motivation and drive, other emotions such as anger and fear, and memory of prior activity. It is not clear whether the origin of the conscious sensation of fatigue is associated with particular localised brain structures, or is the result of electrophysiological synchronisation of entire brain activity.

Globally, about 36.7 million people were living with HIV infection at the end of 2015. The most frequent infection co-occurring with HIV-1 is Mycobacterium tuberculosis-374,000 deaths per annum are attributable to HIV-tuberculosis, 75% of those occurring in Africa. HIV-1 infection increases the risk of tuberculosis by a factor of up to 26 and alters its clinical presentation, complicates diagnosis and treatment, and worsens outcome. Although HIV-1-induced depletion of CD4 T cells underlies all these effects, more widespread immune deficits also contribute to susceptibility and pathogenesis. These defects present a challenge to understand and ameliorate, but also an opportunity to learn and optimize mechanisms that normally protect people against tuberculosis. The most effective means to prevent and ameliorate tuberculosis in HIV-1-infected people is antiretroviral therapy, but this may be complicated by pathological immune deterioration that in turn requires more effective host-directed anti-inflammatory therapies to be derived.

Inflammation, or the prolonged resolution of inflammation, contributes to death from tuberculosis. Interest in inflammatory mechanisms and the prospect of beneficial immune modulation as an adjunct to antibacterial therapy has revived and the concept of host directed therapies has been advanced. Such renewed attention has however, overlooked the experience of such therapy with corticosteroids. Areas covered: The authors conducted literature searches and evaluated randomized clinical trials, systematic reviews and current guidelines and summarize these findings. They found evidence of benefit in meningeal and pericardial tuberculosis in HIV-1 uninfected persons, but less so in those HIV-1 coinfected and evidence of harm in the form of opportunist malignancy in those not prescribed antiretroviral therapy. Adjunctive corticosteroids are however of benefit in the treatment and prevention of paradoxical HIV-tuberculosis immune reconstitution inflammatory syndrome. Expert commentary: Further high-quality clinical trials and experimental medicine studies are warranted and analysis of materials arising from such studies could illuminate ways to improve corticosteroid efficacy or identify novel pathways for more specific intervention.

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A recent international workshop, organized by the authors, analyzed the obstacles facing the ambitious goal of eliminating viral hepatitis globally. We identified several policy areas critical to reaching elimination targets. These include providing hepatitis B birth-dose vaccination to all infants within 24 hours of birth, preventing the transmission of blood-borne viruses through the expansion of national hemovigilance schemes, implementing the lessons learned from the HIV epidemic regarding safe medical practices to eliminate iatrogenic infection, adopting point-of-care testing to improve coverage of diagnosis, and providing free or affordable hepatitis C treatment to all. We introduce Egypt as a case study for rapid testing and treatment scale-up: this country offers valuable insights to policy makers internationally, not only regarding how hepatitis C interventions can be expeditiously scaled-up, but also as a guide for how to tackle the problems encountered with such ambitious testing and treatment programs.

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