Analysis of Mycobacterium tuberculosis isolates from treatment failure patients living in East Timor

SETTING

In the first 2 years of the East Timor National TB Control Programme, 7960 new patients were treated (2RHZE/6HE) and 224 received a retreatment regimen (2SRHZE/1RHZE/4R3H3Z3E3).

OBJECTIVE

To determine the nature and extent of drug-resistant tuberculosis (TB) in treatment failure cases in East Timor.

METHODS

Sputum specimens from retreatment failure cases were processed and inoculated into a BACTEC MGIT960 tube and onto Löwenstein-Jensen media. Isolates were identified by Ziehl-Neelsen staining, hybridisation with nucleic acid probes and biochemical investigations. Susceptibility testing was performed using the radiometric proportion method. Pyrazinamide testing was performed using the Wayne indirect method.

RESULTS

Eighteen patients failed retreatment (0.7% of new cases) and 14 were available for analysis. Mycobacterium tuberculosis was cultured from all specimens, despite considerable transport delays. Nine (64.3%) had multiple drug resistance (MDR-TB) and four (28.6%) had other drug resistance. All MDR-TB isolates were susceptible to amikacin, capreomycin and ethionamide, with most also susceptible to ciprofloxacin and para-aminosalicylic acid (PAS).

CONCLUSIONS

An excellent TB control programme has been established in East Timor. If funds are available, East Timor provides an ideal setting for a small-scale DOTS-Plus programme to treat prevalent cases of MDR-TB, and this study could inform the second-line drug regimen.

Early carotid atherosclerosis and cardiac diastolic abnormalities in hypertensive subjects

Despite the fact that it is known that hypertension may be associated to early atherosclerosis manifestations, few data are to date available on the relationship between early carotid abnormalities and left ventricular diastolic dysfunction. To address this issue, 142 hypertensive patients (64 females and 78 males) younger than 55 years, at the first diagnosis of mild-to-moderate essential hypertension (WHO/ISH criteria), were selected from a database consisting of 3541 subjects referred to ultrasound cardiovascular laboratory in the last 5 years. Carotid intima-media thickness (IMT) was detected by high-resolution vascular ultrasound and left ventricular structure and function by the use of Doppler echocardiography. According to carotid IMT values, all patients were subgrouped into two groups consisting of 89 (62.6%) pts with IMT > or = 1 mm (A) and 53 (37.4%) pts with IMT < 1 mm (B). Our results show that isovolumic relaxation time (IVRT), deceleration time of E velocity (EDT) and left ventricular relative wall thickness (LV-RWT) were significantly (P < 0.05) higher in group A (IVRT 112 +/- 8.9 ms; EDT 288 +/- 21.8 ms; LV-RWT 0.40 +/- 0.08) than in group B (IVRT 92.3 +/- 4.6 ms; EDT 203.3 +/- 27.01 ms; LV- RWT 0.37 +/- 0.06). Moreover, the prevalence of left ventricular hypertrophy (LVH) was significantly (P < 0.01) higher in group A (30/89; 33.7%) than in group B (8/53; 15%). A positive correlation (P < 0.001) between IMT, EDT and IVRT was found only in hypertensives without LVH. These results are consistent with the indication that IMT evaluation has to be recommended both in hypertensive patients with LVH and in those without LVH, but with left ventricular diastolic dysfunction. This approach might improve the prognostic stratification of hypertensive subjects and it might be suitable to recognize the subset of patients at a higher risk of cardiovascular disease or events early.

Effects of mood induction on eating behavior and cigarette craving in dietary restrainers

Women high in dietary restraint ("restrainers") increase food intake more than nonrestrainers following emotional arousal. When restrained smokers are deprived of cigarettes during elevated mood states, nicotine craving should increase with food craving. The present study investigated the interaction of smoking and affect on food intake in 60 women, 18-25 years old, who were identified as restrainers. The study consisted of smokers and nonsmokers who viewed a domestic violence or comedy film segment, followed by exposure to snacks. Emotional arousal, regardless of valence, did not result in a difference in food consumption between smokers and nonsmokers. Furthermore, smokers showed similar levels of nicotine craving after both films. Self-report of mood changed only in the domestic violence condition, indicating the difficulty of positive mood induction. Limitations to the study and suggestions for further research are discussed.

MR findings in a case of exogastric stromal tumor of the stomach

A case of gastrointestinal stromal tumor of stomach investigated with US, CT, and MRI is reported. On imaging, the neoplasm arises from the wall of the gastric fundus and appears well circumscribed and sharply demarcated from the adjacent structures. MRI provides an excellent means of evaluating the site and extension of this neoplasm and enables accurate surgical planning. The authors stress that there has been recently widespread scientific and clinical interest in GIST (gastrointestinal stromal tumor) because its principal pathogenetic defect has been identified and a specific molecular inhibitor of GIST has been developed.

MNA predictive value in the follow-up of geriatric patients

OBJECTIVE

The aim of this study is to verify, in a sample of elderly subjects admitted to long-term care, the impact of malnutrition, according to the Mini Nutritional Assessment (MNA), on mortality and on the occurrence of Adverse Clinical Events in a 3-12 months follow-up study.

SUBJECTS

The survey included all patients admitted to a geriatric hospital--"Villa delle Querce", Nemi (Rome, Italy)--between January 1997 and April 2000, whose nutritional status we were able to monitor for over 3 months. The study comprised 167 elderly subjects, of which 125 women (74.9%) aged 83.3 8 years (60-95 years), and 42 men (25.1%) aged 79.6 9 years with an average follow-up period of 7.5 months.

METHODS

Upon admission and at every check we evaluated each subject's cognitive functions, functional status, co-morbidity, frailty, nutritional status (anthropometric and biochemical indices; MNA). During the follow-up we recorded Adverse Clinical Events. We calculated the predictive value of MNA, we correlated variations in MNA scores with variations of nutritional parameters.

RESULTS

MNA's predictive ability both upon admission and upon discharge was found to be excellent. The MNA score was found to be correlated-although not to a very high degree-with variations nutritional parameters. Even more than malnutrition, a low MNA score was found to be predictive of a greater incidence of Adverse Clinical Events during hospitalisation and of higher mortality.

Dexamethasone improves vascular hyporeactivity induced by LPS in vivo by modulating ATP-sensitive potassium channels activity

(1) Septic shock represents an important risk factor for patients critically ill. This pathology has been largely demonstrated to be a result of a myriad of events. Glucocorticoids represent the main pharmacological therapy used in this pathology. (2) Previously we showed that ATP-sensitive potassium (KATP) channels are involved in delayed vascular hyporeactivity in rats (24 h after Escherichia coli lipopolysaccharide (LPS) injection). In LPS-treated rats, we observed a significant hyporeactivity to phenylephrine (PE) that was reverted by glybenclamide (GLB), and a significant increase in cromakalim (CRK)-induced hypotension. (3) We evaluated the effect of dexamethasone (DEX 8 mg kg-1 i.p.) whether on hyporeactivity to PE or on hyperreactivity to CRK administration, in vivo, in a model of LPS (8 x 106 U kg-1 i.p.)-induced endotoxemia in urethane-anaesthetised rats. (4) DEX treatment significantly reduced, in a time-dependent manner, the increased hypotensive effect induced by CRK in LPS-treated rats. This effect was significantly (P<0.05) reverted by the glucocorticoid receptor antagonist RU38486 (6.6 mg kg-1 i.p.). (5) GLB-induced hypertension (40 mg kg-1 i.p.), in LPS-treated rats, was significantly inhibited by DEX if administered at the same time of LPS. (6) Simultaneous administration of DEX and LPS to rats completely abolished the hyporeactivity to PE observed after 24 h from LPS injection. (7) In conclusion, our results suggest that the beneficial effect of DEX in endotoxemia could be ascribed, at least in part, to its ability to interfere with KATP channel activation induced by LPS. This interaction may explain the improvement of vascular reactivity to PE, mediated by DEX, in LPS-treated rats, highlighting a new pharmacological activity to the well-known anti-inflammatory properties of glucocorticoids.

Levetiracetam: a new therapeutic option for refractory epilepsy

Levetiracetam (LEV) is the most recently licensed antiepileptic drug (AED) for adjunctive therapy of partial seizures. Its mechanism of action is uncertain but it exhibits a unique profile of anticonvulsant activity in models of chronic epilepsy. Three randomised, double-blind, placebo-controlled trials enrolling 904 patients with refractory partial epilepsy have demonstrated the efficacy of LEV as adjunctive therapy, with a responder rate (> or = 50% reduction in seizure frequency) of 28-41%. Long-term efficacy studies suggest retention rates of 60% after one year, with 13% of patients seizure-free for six months of the study and 8% seizure-free for one year. Adverse effects of LEV, including somnolence, lethargy and dizziness, were generally mild and the frequency of incidents was not significantly different between the active treatment and placebo groups in clinical trials. LEV has no clinically significant pharmacokinetic interactions (PKI) with other AEDs, or with commonly prescribed medications. Preliminary data suggest that LEV has efficacy in primary generalised epilepsy and further randomised trials are under way. The combination of potent antiepileptic properties with a relatively mild adverse effect profile makes LEV an attractive adjunctive therapy for partial seizures.

Overweight and obesity in children and adolescents: relationship with blood pressure, and physical activity

OBJECTIVE

Using body mass index (BMI) quartiles, the present study's aims were (1) to describe and evaluate the relationship between overweight/obesity with cardiovascular disease (CVD) risk factors, such as systolic blood pressure (SBP), diastolic blood pressure (DBP) and physical activity; (2) to provide information on the prevalence of high blood pressure and physical activity according to BMI quartiles; and (3) to examine the relationship of risk of obesity to adverse levels of high blood pressure and physical activity.

METHODS

The sample consisted of 1439 children (758 males and 681 females), 8-16 years old. Participants were classified as being at 'risk of obesity' according to age- and sex-adjusted fourth quartile of BMI values. Blood pressure was measured using the Dinamap monitor. An adapted version of the Weekly Activity Checklist was applied for the diagnosis of physical activity index (PAI).

RESULTS

Systolic and diastolic blood pressures were significantly (p < 0.05) and positively related to BMI, whereas no significant associations were reported between BMI and PAI in both genders. Overall, the proportion of subjects with adverse levels of blood pressure (SBP or DBP) ranged from 21.3% in the first BMI quartile (BMI-1Q) to 30.4% in BMI-4Q (p < 0.05). The PAI ranged from 24.5% in BMI-1Q to 20.6 in BMI-4Q and no significant differences were found. Children and adolescents at 'risk of obesity' were 1.5 times as likely to have at least one risk factor (high blood pressure or low level of activity).

CONCLUSIONS

Our data suggest that higher BMI is associated with higher values of SBP and DBP. Children and adolescents in the upper quartile of BMI are 1.5 times as likely to have at least one risk factor. Furthermore our data confirmed previous findings that higher levels of BMI are associated with a unfavourable risk profile for CVD risk factors.

[Epidemiological surveillance during humanitarian emergencies]

Humanitarian emergencies are complex situations that usually occur after warfare or social upheavals. They result in a dramatic increase in morbidity and mortality in the affected population. Organizations that undertake management of humanitarian emergencies must be prepared to provide comprehensive services covering all aspects of public health including preliminary evaluation, mass vaccination, water and sanitation, food supply and nutrition, shelter, medical care, control of communicable diseases, personnel training, and logistic coordination. Epidemiological surveillance is an integral part of a full-service approach to humanitarian action that should be included in the preliminary evaluation. Epidemiology is a powerful tool for detecting any health problems that might further jeopardize the victim population. By allowing measurement of the impact of humanitarian action, epidemiological data also provides a means of verifying that the victims are benefiting from aid operations. Implementation of a surveillance system should be given high priority during the start-up of a humanitarian operation. The system must have the simplicity and flexibility necessary to adapt changing, unstable situations as well as high sensitivity necessary for early detection of epidemic outbreaks.

A "proportional and objective score" for the mini nutritional assessment in long-term geriatric care

BACKGROUND

In a previous study we tested the predictive value of the Mini Nutritional Assessment (MNA) in an Italian population of frail elderly in long-term hospital care. The results of our study confirmed the MNA's excellent overall predictive value and sensitivity. Unfortunately we had a large number of false positive judgments, hence our study's low specificity, which we think was caused by two factors: 1. in most cases it was impossible to conduct a reliable subjective assessment of the patients' nutritional and health status. 2. most patients failed to respond to some of the MNA questions, which as a consequence received a "0" score. The result was an artificially low global MNA score even in well-nourished patients.

OBJECTIVE AND DESIGN

We tried to neutralize the effects of the defective answers by modifying the total score and the cut-off points of the test. Thus, we: 1. replaced the subjective assessment of health and nutritional status with an objective evaluation; 2. replaced the total score of MNA with the ratio of this value with the maximum of points that each subject can obtain without including the items for which we could not have a response. Similarly, the cut-off points (17 and 24) were replaced with the ratio of these values with the maximum of points obtainable by a complete MNA (30). Patients are classified as "malnourished" below 0.56, "at risk of malnutrition" between 0.56 and 0.79, and "well-nourished" from 0.8 up.

RESULTS

This way, the overall predictive value of MNA is increased from 80.3 to 85.4% and the specificity from 12.8 to 25%, whereas the sensitivity increase is modest (from 98 to 98.1%).

Kidney structural and ultrastructural pathological changes induced by uracoan rattlesnake (Crotalus vegrandis Klauber 1941) venom

Acute renal insufficiency related to acute tubular necrosis is the most important complication caused by crotalid bite. For structural and ultrastructural studies of renal tissue, mice injected with crude venom or C. vegrandis haemorrhagic fraction, and controls were tested. Light microscopy analysis of kidneys at 24 h after injection of crude venom showed only moderate alterations such as tubular epithelia microvacuolisation. After 120 h marked glomerular and tubular capillaries congestion and interstitial oedema were observed. At 24 h after Uracoina-1 i.p. injection, intense glomerular and peritubular capillaries congestion was observed. Electron microscopic analysis of kidneys 24 h after i.p. injection of crude venom showed, capillary endothelial cell debris and pleomorphic mitochondria. Loss of interdigitations regularity, abundant dense bodies and light widening of the basal membrane were observed. Autophagic vacuoles were present as well as endothelia unfolding to the lumen and altered forms of podocytes. At 48 h, augmented endothelia without fenestrae formation with sequestration of low optical density debris inside the protrusions were noticed. At 120 h, capillary residues with loss of the endothelium were present and the basal membrane was widened. At 15 days, the number of vesicles and vacuoles in the tubules was increased and only few interdigitations were noticed. Autophagic vacuoles and mitochondrial matrix low electron density were observed. At 120 h after injection of crude venom, vascular damage with loss of capillary cell structures and collagen fibres were observed. At 24 h of haemorrhagic fraction injection, presence of autophagic vacuoles and myelinic figures were noticed.

Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.

Fate of pesticides in tropical soils of Brazil under field conditions

The potential of pesticides for nonpoint ground water pollution depends on their dissipation and leaching behavior in soils. We investigated the fate of 10 pesticides in two tropical soils of contrasting texture in the Brazilian Cerrado region near Cuiabá during an 80-d period, employing topsoil dissipation studies, soil core analyses, and lysimeter experiments. Dissipation of pesticides was rapid, with field half-lives ranging from 0.8 to 20 d in Ustox and 0.6 to 11.8 d in Psamments soils. Soil core analyses showed progressive leaching of polar pesticides in Psamments, whereas in Ustox pesticides were rapidly transported to 40 cm soil depth regardless of their sorption properties, suggesting that leaching was caused by preferential flow. In lysimeter experiments (35 cm soil depth), cumulative leaching was generally low, with < or = 0.02% and < or = 0.19% of the applied amounts leached in Ustox and Psamments, respectively. In both soils, all pesticides but the pyrethroids were detected in percolate at 35 cm soil depth within the first 6 d after application. Cumulative efflux and mean concentrations of pesticides in percolate were dosely correlated with their Groundwater Ubiquity Score (GUS). The presence of alachlor (2-chloro-2', 6'-diethyl-N-methoxymethylacetanilide), atrazine (2-chloro-4-ethylamino-6-isopropylamino-1,3,5-triazine), metolachlor [2-chloro-N-(2-ethyl-6-methylphenyl)-N-(2-methoxy-1-methylethyl)acetamide], simazine [2-chloro-4,6-bis(ethylamino)-1,3,5-triazine], and trifluralin (2,6-dinitro-N,N-dipropyl-4-trifluoromethylaniline) throughout the soil profile and in percolate of wick lysimeters at 95 cm soil depth indicated that a nonpoint pollution of ground water resources in tropical Brazil cannot be ruled out for these substances.

Inhibition of nitric oxide synthase expression by a methanolic extract of Crescentia alata and its derived flavonols

In order to validate the use of Crescentia alata (Bignoniaceae) in the traditional medicine of Guatemala as an antiinflammatory remedy, the methanolic (MeOH) extract has been evaluated in vivo for antiinflammatory activity on carrageenin paw edema in rats and in vitro on Escherichia coli lipopolysaccharide- (LPS)-induced nitric oxide (NO) production and inducible nitric oxide synthase (iNOS) expression in J774.A1 macrophage cell line. This extract exerted in vivo a significant anti-inflammatory activity at the highest dose tested. The same extract showed in vitro an inhibitory activity on inducible nitric oxide synthase expression and on NO formation in LPS-primed J774.A1 cells. Subsequent fractionation and analysis of the extract has led to the isolation and characterization as major constituents of two flavonol glycosides: quercetin 3-O-alpha-L-rhamnopyranosyl-(1->6)-beta-D-glucopyranoside (rutin) 1, kaempferol 3-O-alpha-L-rhamnopyranosyl-(1->6)-beta-D-glucopyranoside (kaempferol 3-O-rutinoside) 2, and flavonol aglycone, kaempferol 3. Their structures were elucidated by spectral methods. The bioassay-directed analysis of flavonols 1-3 indicated that kaempferol (3) was the most active compound contained in the MeOH extract because it reduced in vitro both NO production and iNOS expression in LPS-primed J774.A1 cells, whereas rutin (1) and kaempferol 3-O-rutinoside (2) showed no significant activity. The MeOH extract and all of flavonoids tested did not show in vitro significant cytotoxic effect in J774.A1 macrophage cell line.

Molecular characterization of first human Bartonella strain isolated in Italy

The aim of this study was to characterize a Bartonella strain (BA-1) isolated from a blood culture of an Italian, human immunodeficiency virus-positive patient with bacillary angiomatosis. We analyzed the isolate using molecular biology methods such as whole-cell fatty acid analysis, PCR-restriction fragment length polymorphism analysis, type-specific 16S rRNA PCRs, sequence analysis of the 16S rRNA, pulsed-field gel electrophoresis, and arbitrarily primed PCR. The BA-1 isolate turned out to be a Bartonella quintana strain, similar but not identical to B. quintana Oklahoma, which was used as a control strain.

The integration of primary anorexia nervosa and obsessive-compulsive disorder

This paper explores the relationship between primary anorexia nervosa (PAN) and obsessive-compulsive disorder (OCD) in both their concomitant and their sequential presentation. Their clinical descriptions demonstrate the presence of obsessionality and compulsiveness that seem to interface during their course and overlap in their symptomatologies has been noted for over sixty years. However, recent research in this regard is scant. Commonalities in pathophysiology indicate disturbances in neurotransmitters, notably serotonin. Biological challenges have failed to establish a definitive correlation with PAN and OCD, whether in combination or individually. We may postulate that, with limitations, they share some anatomical pathways. The areas affected are the amygdala, cingulum and orbito-frontal cortex. Few studies, however, have been devoted to the treatment of concomitant PAN and OCD.