Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

ECG monitoring in STREAM Stage 1: can we identify those at increased risk of QT prolongation?

BACKGROUND: STREAM (Standardised Treatment Regimen of Anti-tuberculosis Drugs for Patients with Multidrug-resistant Tuberculosis) Stage 1 was a randomised trial of a Short (9-month) regimen for rifampicin-resistant TB (RR-TB). QT or QTcF prolongation ≥500 ms occurred in 31 (11%) of 282 Short regimen participants. The frequent ECG monitoring employed might be challenging for treatment programmes. This analysis aimed to determine whether those at higher risk of severe QT prolongation could be identified early for more targeted monitoring.METHODS: Data from the first month of treatment were used to investigate whether participants were at risk of developing QT/QTcF ≥500 ms. QTcF increases from baseline at different time points were examined. Absolute QTcF measurements were categorised in 5 ms increments at each time-point. The most discriminating time points and QTcF cut-offs were combined to optimise sensitivity and specificity.RESULTS: Absolute QTcF values were more discriminating than magnitude of increase from baseline. More participants who developed QT/QTcF ≥500 ms had a QTcF of respectively ≥425 ms and ≥430 ms at 4 h and Week 3 (P < 0.05) than those who did not. By combining QTcF values ≥425 ms at 4 h and ≥430 ms at Week 3, we identified high-risk participants with 97% sensitivity and 99% negative predictive value.CONCLUSION: Reduced ECG monitoring may be possible for many Short regimen participants.

Global availability of susceptibility testing for second-line anti-tuberculosis agents

BACKGROUND: The continued development of new anti-TB agents brings with it a demand for accompanying treatment regimens to prevent the development of resistance. Effectively meeting this demand requires an understanding of the pathogen´s susceptibility to various treatment options, which in turn makes access to antibiotic susceptibility testing (AST) a paramount consideration in the global treatment of TB.METHODS: A 12-question, quantitative and qualitative survey was developed to gauge global capacity and access to AST. The survey was disseminated to members of the Global Laboratory Initiative, Global Drug-resistant TB Initiative, and the TB section of the International Union Against Tuberculosis and Lung Disease to solicit responses from pertinent stakeholders.RESULTS: A total of 323 complete responses representing 84 countries and all WHO Regions were collected. AST capacity for fluoroquinolones and second-line injectables was high in all WHO Regions. AST capacity for the new and repurposed drugs is highest in the European Region, Region of the Americas and the Western Pacific Region, but quite limited in the African and Eastern Mediterranean Regions. The AST turnaround time for second-line drugs was delayed compared to that for first-line drugs as samples needed to be sent farther for analysis. Common barriers to AST for second-line drugs were lack of specimen transportation infrastructure, high costs, and lack of specialised laboratory workers and specialised laboratory facilities.CONCLUSION: Without expanding global access to AST, the growing availability of new treatment options will likely be threatened by accompanying increase in resistance. There is an earnest and pressing need to improve capacity and access to AST alongside treatment options.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Investigation of the efficacy of the short regimen for rifampicin-resistant TB from the STREAM trial

BACKGROUND

The STREAM trial demonstrated that a 9-11-month "short" regimen had non-inferior efficacy and comparable safety to a 20+ month "long" regimen for the treatment of rifampicin-resistant tuberculosis. Imbalance in the components of the composite primary outcome merited further investigation.

METHODS

Firstly, the STREAM primary outcomes were mapped to alternatives in current use, including WHO programmatic outcome definitions and other recently proposed modifications for programmatic or research purposes. Secondly, the outcomes were re-classified according to the likelihood that it was a Failure or Relapse (FoR) event on a 5-point Likert scale: Definite, Probable, Possible, Unlikely, and Highly Unlikely. Sensitivity analyses were employed to explore the impact of informative censoring. The protocol-defined modified intention-to-treat (MITT) analysis population was used for all analyses.

RESULTS

Cure on the short regimen ranged from 75.1 to 84.2% across five alternative outcomes. However, between-regimens results did not exceed 1.3% in favor of the long regimen (95% CI upper bound 10.1%), similar to the primary efficacy results from the trial. Considering only Definite or Probable FoR events, there was weak evidence of a higher risk of FoR in the short regimen, HR 2.19 (95%CI 0.90, 5.35), p = 0.076; considering only Definite FoR events, the evidence was stronger, HR 3.53 (95%CI 1.05, 11.87), p = 0.030. Cumulative number of grade 3-4 AEs was the strongest predictor of censoring. Considering a larger effect of informative censoring attenuated treatment differences, although 95% CI were very wide.

CONCLUSION

Five alternative outcome definitions gave similar overall results. The risk of failure or relapse (FoR) may be higher in the short regimen than in the long regimen, highlighting the importance of how loss to follow-up and other censoring is accounted for in analyses. The outcome of time to FoR should be considered as a primary outcome for future drug-sensitive and drug-resistant TB treatment trials, provided sensitivity analyses exploring the impact of departures from independent censoring are also included.

Progress in global rollout of new multidrug-resistant tuberculosis treatments

SETTING: The global multidrug-resistant tuberculosis (MDR-TB) epidemic has grown over the past decade and continues to be difficult to manage. In response, new drugs and treatment regimens have been recommended.OBJECTIVE: In 2017 and again in 2018, the International Union Against Tuberculosis and Lung Disease (The Union) drug-resistant (DR) TB Working Group collaborated with RESIST-TB to implement an internet survey to members of The Union around the world to assess access to these new treatment strategies.DESIGN: A nine-question survey was developed using SurveyMonkey^®. The survey was open for participation to all members of The Union registered under the TB Section. Two reminders were sent during each survey. The responses were analyzed taking into account the WHO Region to which the respondent belonged.RESULTS: The 2018 survey showed a global increase in implementation of the shorter (9-month) MDR-TB regimen (from 33% to 56% of respondents, P < 0.001) and an increase in the use of bedaquiline and/or delamanid (from 25% to 41% of respondents, P < 0.001) compared to 2017. There were substantial variations in roll-out between WHO regions.CONCLUSION: These results demonstrate improvement in global implementation of the new treatment strategies over a 1-year period.

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

QTc and anti-tuberculosis drugs: a perfect storm or a tempest in a teacup? Review of evidence and a risk assessment

SUMMARY

Multidrug-resistant (MDR) and extensively drug-resistant tuberculosis (XDR-TB) are global concerns, with stagnant treatment success rates of roughly 54% and 30%, respectively. Despite adverse events associated with several DR-TB drugs, newly developed drugs and shorter regimens are bringing hope; recent concern has focused on drugs that prolong the corrected QT interval (QTc). QTc prolongation is a risk factor for torsades de pointe (TdP), a potentially lethal cardiac arrhythmia. While QTc prolongation is used in research as a surrogate marker for drug safety, the correlation between QTc and TdP is not perfect and depends on additional risk factors. The electrocardiogram (ECG) monitoring that has been recommended when new drugs are used has created alarm among clinicians and National Tuberculosis Programmes (NTPs). ECG monitoring is often challenging in high-burden settings where treatment alternatives are limited. According to a review of studies, the prevalence of sudden death directly attributable to TdP by QTc-prolonging DR-TB drugs is likely less than 1%. The risk of death from an ineffective MDR-TB/XDR-TB regimen thus far exceeds the risk of death from arrhythmia. In patients with QTc prolongation who develop cardiac events, other significant risk factors in addition to the drugs themselves are nearly always present. Clinicians and NTPs should be aware of and manage all possible circumstances that may trigger an arrhythmia (hypopotassaemia and human immunodeficiency virus infection are probably the most frequent in DR-TB patients). We present the limited but growing evidence on QTc prolongation and DR-TB management and propose a clinical approach to achieve an optimal balance between access to life-saving drugs and patient safety.

Insights into drug-resistant tuberculosis treatment: results of The Union DR-TB Working Group Survey, 2017

The past 4 years have seen the introduction of new regimens and new drugs to treat multidrug-resistant tuberculosis (MDR-TB). To identify implementation trends over time, the DR-TB Working Group of the International Union Against Tuberculosis and Lung Disease (The Union), in collaboration with RESIST-TB, launched an online survey to Union members around the world. Survey results showed substantial diversity in treatment roll-out: 36% of respondents stated that their country is using the 9-month regimen for MDR-TB treatment; 41% are using bedaquiline and delamanid, but not the 9-month regimen; 28% are using both; and 22% of respondents indicated that their country does not currently offer either of these treatment options. Survey respondents also identified specific challenges to the introduction of shorter MDR-TB regimens and new drugs, including access to rapid diagnosis of fluoroquinolone resistance and case management. The results of this survey are intended to help identify research and implementation gaps while highlighting the importance of global implementation of scalable regimens for the treatment of MDR-TB.

Gatifloxacin for short, effective treatment of multidrug-resistant tuberculosis

The 9-month regimen for the treatment of multidrug-resistant tuberculosis (MDR-TB) piloted in Bangladesh and used, with modifications, in Cameroon and Niger, has achieved treatment success in a very large proportion of patients; gatifloxacin (GFX) is likely to have played a critical role in this success. Two months after the publication of a study reporting that GFX and not moxifloxacin (MFX) was associated with dysglycaemia, the manufacturer announced the withdrawal of GFX from the market. The findings of that study may have less significance for the majority of MDR-TB patients living in high-incidence countries who are much younger, have a lower risk of dysglycaemia and suffer from a highly fatal condition. The problem of dysglycaemia is not limited to GFX use and may occur with other fluoroquinolones; furthermore, GFX-associated dysglycemia was manageable among those MDR-TB patients in Bangladesh and Niger in whom it occurred. GFX has now become unavailable in Bangladesh, Cameroon, Niger and other countries piloting the shorter MDR-TB regimens, depriving resource-poor countries of an efficacious, effective and inexpensive drug with a demonstrated good safety profile for the given indication. There is little reason not to make GFX available for MDR-TB treatment as long as the superiority of non-GFX-based MDR-TB regimens is not demonstrated.

Risk factors for unfavourable treatment outcome among new smear-positive pulmonary tuberculosis cases in China

Setting: Three projects of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. Objectives: To assess unfavourable treatment outcomes (UTOs), including failure, died, loss to follow-up (LTFU), transferred out and unknown outcome, and to identify risk factors associated with UTOs. Design: This was a cross-sectional study using routine programme data. Results: Of 30 277 new smear-positive tuberculosis (TB) patients, 4261 (14.1%) had UTOs: 2048 (6.8%) LTFU, 1418 (4.7%) transferred out, 390 (1.3%) died, 340 (1.1%) failed and 65 (0.2%) had an unknown outcome. Risk factors for LTFU (including LTFU, transfer out and unknown outcome) were residing in Anhui, age > 55 years, service delay > 10 days, patient delay < 30 days, directly observed treatment (DOT) provided by a family member or others and unknown DOT provider. The outcome of 'died' was associated with residing in Shaanxi, age > 55 years, male sex, patient delay > 30 days and unknown DOT provider. 'Failed' was associated with having unlimited access to health services, patient delay of >30 days and unknown DOT provider. Conclusion: This study highlights the predominance of lost patients among UTOs. Patients with family members or other non-medical DOT providers or unknown DOT providers had a high risk of a UTO. There is an urgent need to address these service-related factors.

Dynamic Internet-Mediated Team-Based Case Management of High-Frequency Emergency Department Users

Introduction

We assessed whether a strategy using dynamic, internet-mediated, team-based case management could reduce the number of subsequent emergency department (ED) visits by frequent ED users.

Methods

Patients who attended the ED three or more times within 72 hours in June 2010 were identified. These cases were divided into the pain management or chronic disease group according to their chief complaint. Patients were assessed by expert panels, and initial care plans were developed and posted on an internal website. Thereafter, each emergency physician could follow or adjust the care plans dynamically via the internal website according to the patient's condition and use the website to communicate results. Care plans were revised by the team according to the patient's clinical situation as it changed. Patient ED visits over the subsequent six months were monitored.

Results

Fourteen cases were enrolled in the study, seven in each group. The mean number of visits per patient per month in the pain management and chronic disease groups decreased from 14.9 to 5.79 (p=0.031) and 6.1 to 2.9 (p<0.001) visits per month after the intervention, respectively. The overall mean number of visits per patient per month decreased from 10.5 to 4.36 (p=0.004), a decrease of 6.14 visits (58.27%).

Conclusions

Dynamic internet-mediated team-based case management may help to reduce subsequent visits in patients who frequently visit the ED. (Hong Kong j.emerg.med. 2014;21:161-166)

Does enhanced diabetes management reduce the risk and improve the outcome of tuberculosis?

SETTING

The Bureau of National Health Insurance (NHI) has implemented a pay-for-performance (p4p) programme for diabetes mellitus (DM) in Taiwan.

OBJECTIVE

To investigate whether patients with DM enrolled in the p4p programme (DM-p4p) are less likely to develop tuberculosis (TB) and whether they have a better outcome than patients with DM not enrolled in the p4p programme (DM-non-p4p) if they do develop TB.

DESIGN

A random sample of 79,471 DM-p4p, 100,000 DM-non-p4p and 100,000 non-diabetic patients (non-DM) was obtained from the 2008-2009 NHI database, and the patients were matched with the National TB Registry to determine whether they had developed TB by the end of 2010.

RESULTS

The average annual incidence of TB was respectively 259.9 (95%CI 230.2-293.4), 137.5 (95%CI 116.4-162.5) and 74.1 (95%CI 59.0-93.0) per 100,000 population among DM-non-p4p, DM-p4p and non-DM patients. The relative risk of death over treatment success was 1.79 (95%CI 1.05-3.04) among DM-non-p4p and 1.69 (95%CI 0.84-3.40) among non-DM patients, relative to DM-p4p patients.

CONCLUSIONS

Enhanced case management of DM reduced risk and improved outcomes of TB among patients with DM.

Integrative proteomic profiling of ovarian cancer cell lines reveals precursor cell associated proteins and functional status

A cell line representative of human high-grade serous ovarian cancer (HGSOC) should not only resemble its tumour of origin at the molecular level, but also demonstrate functional utility in pre-clinical investigations. Here, we report the integrated proteomic analysis of 26 ovarian cancer cell lines, HGSOC tumours, immortalized ovarian surface epithelial cells and fallopian tube epithelial cells via a single-run mass spectrometric workflow. The in-depth quantification of >10,000 proteins results in three distinct cell line categories: epithelial (group I), clear cell (group II) and mesenchymal (group III). We identify a 67-protein cell line signature, which separates our entire proteomic data set, as well as a confirmatory publicly available CPTAC/TCGA tumour proteome data set, into a predominantly epithelial and mesenchymal HGSOC tumour cluster. This proteomics-based epithelial/mesenchymal stratification of cell lines and human tumours indicates a possible origin of HGSOC either from the fallopian tube or from the ovarian surface epithelium.

High-grade serous ovarian cancer is the most common and aggressive ovarian cancer, with uncertain cell of origin. Here, the authors undertake a mass spectrometric analysis of 26 cancer cell lines and identify a protein signature that classifies ovarian cancer tissues into epithelial and mesenchymal groups.

Western Pacific Regional Green Light Committee: progress and way forward

•

The Western Pacific Regional Green Light Committee (rGLC WPR) was established in 2011 to promote scale-up of programmatic management of drug-resistant tuberculosis (PMDT).

•

rGLC WPR has generated greater awareness of regional challenges and has encouraged local solutions to regional problems.

•

PMDT should be part and parcel of routine TB programme activity.

•

Challenges and bottlenecks have varied according to the different stages of PMDT implementation, requiring different types of technical assistance.

•

Regional initiatives should be dynamic and responsive to the needs of countries.

The Western Pacific Regional Green Light Committee (rGLC WPR) was established in 2011 to promote the rational scale-up of programmatic management of drug-resistant tuberculosis (PMDT). We reflect on its achievements, consider the challenges faced, and explore its potential future role. Achievements include the supervision and support of national PMDT action plans, increased local ownership, contextualized guidance, and a strong focus on regional capacity building, as well as a greater awareness of regional challenges. Future rGLC activities should include (1) advocacy for high-level political commitment; (2) monitoring, evaluation, and supervision; (3) technical support and contextualized guidance; and (4) training, capacity building, and operational research. Regional activities require close collaboration with both national and global efforts, and should be an important component of the new Global Drug-resistant TB Initiative.

Recurrence of bilateral atypical femoral fractures associated with the sequential use of teriparatide and denosumab: a case report

We report that a postmenopausal woman with osteoporosis developed bilateral incomplete atypical femoral fractures (AFFs) after seven years of bisphosphonate therapy. Cessation of the bisphosphonate and treatment with teriparatide was associated with near complete radiological resolution of the AFFs. After 12 months without treatment, denosumab was commenced to prevent structural deterioration. Six months later she developed recurrent bilateral AFFs. This case highlights the management dilemma in patients with ongoing bone loss but prone to stress fractures associated with antiresorptive therapy. Stopping the antiresorptive is recommended but structural decay will recur predisposing to fragility fractures. If the antiresorptive is continued, bone material composition will be further compromised predisposing to atypical fractures. Teriparatide may assist healing of stress fractures and improvement in bone matrix composition. Later antiresosrptive therapy to preserve bone microstructure may compromise material composition.

Caring stress, suicidal attitude and suicide care ability among family caregivers of suicidal individuals: a path analysis

ACCESSIBLE SUMMARY

What is known on the subject? Suicide is a global mental health issue. Taking care of suicidal individuals is a substantial challenge. Most studies emphasize the suicidal individual. Few studies have emphasized the family caregivers of suicidal individuals. No study has explored the relationship between family caregivers' caring stress with suicidal attitudes and suicide care ability. What this paper adds to existing knowledge? The main results indicated that the older family caregivers tended to have a more negative attitude towards suicidal individuals. Female family caregivers' stress was higher than that of male family caregivers. A mild level of caring stress would help family caregivers have a more positive attitude towards suicidal individuals. Furthermore, a positive attitude would help family caregivers improve their caring ability. What are the implications for practice? Mental health nurses could help family caregivers, especially female family caregivers, reduce their holistic caring burden by looking for support resources and enhancing their coping strategies. Mental health nurses could help family caregivers promote positive attitudes towards suicidal relatives by understanding suicidal individuals' suffering.

INTRODUCTION

Suicide is a global mental health issue. Family caregivers play a key role in preventing suicide attempts.

AIMS

The aim of this study was to examine the relationship among stress due to the family caregiver's role, suicidal attitude of the family caregiver and suicide care ability among family caregivers. Additionally, instruments of caring stress, attitudes towards suicidal relatives and caring abilities used in the study were tested to measure construct validity.

METHODS

A cross-sectional correlational study was conducted with 164 family caregivers of people who are suicidal. The following three questionnaires were used: the Caring Stress Scale, the Suicidal Attitudes Scale and the Suicidal Caring Ability Scale. Structural equation modelling was performed using SPSS AMOS 19.0 to examine the path relationships among variables.

RESULTS

Bivariate analyses showed that age was negatively correlated with suicidal attitude. In the final path model, caring stress had a positive effect on suicidal attitudes. Suicidal attitude and suicide care ability were highly positively correlated. Gender had a direct effect on caring stress, which indicated that female family caregivers experienced more stress from their role.

IMPLICATIONS FOR PRACTICE

Mental health nurses could help family caregivers become aware of the emotional pain that suicidal people experience and then promote their positive attitudes towards their suicidal relatives. Furthermore, family caregivers could increase their ability to care for their suicidal relatives, which could reduce the numbers of suicides.

Patient delay in the diagnosis and treatment of tuberculosis in China: findings of case detection projects

OBJECTIVE

1) To assess patient delay among new smear-positive pulmonary tuberculosis (PTB) patients in accessing health services in seven FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) projects from 2003 to 2008 in China; 2) to compare treatment delay by province; and 3) to assess factors associated with delay.

METHOD

Records of new smear-positive PTB patients were reviewed. Data sources were the consultation book, laboratory register, patient record, treatment card and the PWLAHS (people with limited access to health services) evaluation form. Data were collected using a standard questionnaire, cross-checked by staff from the sites and by the International Union Against Tuberculosis and Lung Disease (The Union) and analysed by The Union.

RESULTS

Of the 75 401 new smear-positive PTB patients included in the study, 63-89% were PWLAHS. The average gross domestic product of the project sites and at national level were respectively US$557 and US$998. The median patient delay was 93 days (range 68-128). Delays were longer among females, older patients, rural residents and PWLAHS. Delayed access to health services was significantly associated with a greater number of symptoms.

CONCLUSION

Patient delay in accessing health care in China was lengthy; TB care and control needs to be improved.

A smoking cessation intervention among tuberculosis patients in rural China

OBJECTIVE

To assess the integration of a smoking cessation intervention into routine tuberculosis (TB) services.

METHOD

Consecutive TB patients registered from 1 March to 31 August 2010 were enrolled in an intervention for self-reported smoking to promote tobacco cessation during treatment for TB. Information on the harmful health effects of tobacco smoke and smoking and TB were provided to TB patients who self-reported as current smokers. Smoking status was reassessed at every follow-up visit during anti-tuberculosis treatment with reinforced health messages and advice to quit.

RESULTS

Of 800 TB patients enrolled, 572 (71.5%) were male and 244 (30.5%) were current smokers. Females were more likely to be non-smokers (100% vs. 35.8%, P < 0.001). Of the 244 current smokers, 144 (59.0%) started smoking at <20 years, 197 (80.7%) consumed ⩾20 cigarettes per day, 211 (86.5%) had perceived smoking dependence and 199 (81.6%) had made no attempt to quit before the diagnosis of TB. Of the 244 current smokers, 234 (95.9%) were willing to quit, and 156 (66.7%) reported abstinence at month 6. Challenges to implementing smoking cessation intervention were identified.

CONCLUSION

The majority of current smokers among TB patients were willing to quit and remained abstinent at the end of anti-tuberculosis treatment. This intervention should be scaled up nationwide.

Mobilising elementary and secondary school students for tuberculosis case finding in Anhui, China

OBJECTIVES

To evaluate the implementation of a FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) project in Anhui Province, China.

DESIGN

A survey card was designed for students to identify individuals who might have tuberculosis (TB) in their family. Teachers provided health education on TB before distributing the survey cards. Survey cards identifying individuals with respiratory symptoms for ≥3 weeks were sent by the teachers to village doctors who were trained to visit symptomatic individuals and advise them to undergo sputum examination. Data were routinely collected in the implementation of the FIDELIS project, and quarterly reports from the National Tuberculosis Programme were analysed. The detection of new smear-positive TB cases before and after FIDELIS, as well as with and without FIDELIS, were compared.

RESULTS

In the first year, a total of 2 387 405 students were involved and 23 079 symptomatic individuals were examined, among whom 2307 (10.3%) were diagnosed with smear-positive TB. Case detection in FIDELIS counties increased by a factor of 3.5 during the FIDELIS period compared with before FIDELIS, and that in non-FIDELIS counties by a factor of 3.1 (P = 0.001).

CONCLUSION

It was feasible to massively mobilise students for TB case finding through collaboration between the health care and education systems.

Management of asthma in resource-limited settings: role of low-cost corticosteroid/β-agonist combination inhaler

The management of asthma requires medicines that are effective in relaxing airway smooth muscles and in reducing airway inflammation. Rapid-acting β₂ agonist is a bronchodilator that provides quick symptom relief in patients with asthma. However, it does not effectively address the underlying problem of airway inflammation. Excess use of inhaled bronchodilators alone for symptom relief may result in delay in seeking health care, which in turn may result in delayed use of anti-inflammatory agents. Inhaled corticosteroid (ICS) is critical in the treatment of airway inflammation; it reduces the risk of life-threatening asthma attacks and the need for hospitalisation. ICS is underused, however, and a substantial proportion of patients with persistent asthma in resource-limited settings have no access to affordable ICS for long-term treatment. International guidelines recommend the use of rapid-acting β-agonists as needed as rescue treatment when symptoms occur. Studies have shown that the use of both ICS and rapid-acting β-agonist as needed for symptom relief might be a better option. The combination of ICS and rapid-acting bronchodilator in a single inhaler is currently too expensive and is not affordable for the poor. Although ICS and short-acting β₂ agonist (SABA) for rescue treatment can be obtained to a certain extent by using separate ICS and SABA inhalers, the first step is to ensure access to affordable, quality-assured essential asthma medicine in resource-limited settings.

Abstract AS23: Microenvironment mediated downregulation of miR-193b promotes ovarian cancer metastasis

The cross-talk between ovarian cancer cells with the microenvironment of the site of metastasis is an essential determinant of successful metastatic colonization. microRNAs have been well established to play critical roles in various stages of cancer progression, including metastasis. However, the role of the signals from the microenvironment in regulating key microRNAs in metastasizing cancer cells has not been studied. Using a 3D culture model mimicking the human omentum, one of the principal sites of ovarian cancer metastasis, we have identified the microenvironment-induced downregulation of a tumor suppressor microRNA miR-193b in the metastasizing ovarian cancer cells. The direct interaction of the ovarian cancer cells with the mesothelial cells covering the surface of the omentum caused DNA methyltransferase 1 (DNMT1) mediated methylation and decreased expression of miR-193b. The reduction in miR-193b enabled the metastasizing cancer cells to invade and proliferate in the omentum both in vitro and in a mouse xenograft model of ovarian cancer metastasis. The functional effects of miR-193b were mediated at least partly through the concomitant increased expression of its target urokinase-type plasminogen activator (uPA). Our findings link paracrine signals from the microenvironment with the regulation of a key microRNA in cancer cells that is essential for the initial steps of ovarian cancer metastatic colonization. Targeting miR-193b would be a promising approach to treat ovarian cancer metastasis.

Citation Format: AK Mitra, CY Chiang, P Tiwari, ME Peter, E Lengyel. Microenvironment mediated downregulation of miR-193b promotes ovarian cancer metastasis [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr AS23.

A Salvia miltiorrhiza ethanol extract ameliorates tissue destruction caused by experimental periodontitis in rats

BACKGROUND AND OBJECTIVE

Salvia miltiorrhiza Bunge (Labiatae), or Danshen, is a Chinese medicine used for treatment of cardiac diseases by improving blood circulation and inhibiting inflammatory responses. In this study, we aimed to determine whether an ethanol extract of S. miltiorrhiza can ameliorate tissue damage caused by periodontitis.

MATERIAL AND METHODS

An ethanolic extract of S. miltiorrhiza roots was prepared, and its major constituents were determined by HPLC analysis, by comparison with known standards for the major bioactive components. The activity of the extract was evaluated in a rat model in which periodontitis was induced by ligation of a silk suture around the neck of molar teeth. The effects of the S. miltiorrhiza extract on periodontitis were assessed by dental radiography, micro-computed tomography and histology.

RESULTS

The cemento-enamel junction-bone distances among the four different groups of rats were significantly different: the distance was shorter in groups treated with ligation + S. miltiorrhiza extract than in the group treated with ligation only, but was longer than in the nonligated group, regardless of the radiographic methods used. Histology and histometry also indicated a similar trend of less gingival inflammation and alveolar bone destruction in the histological sections from the S. miltiorrhiza extract groups than in those from the ligation group.

CONCLUSION

Because the S. miltiorrhiza extract reduced tissue damage and bone loss caused by ligation-induced periodontitis in rats, we suggest that the S. miltiorrhiza extract might have an ameliorative effect on periodontal tissue destruction during the process of periodontitis.

Microenvironment-induced downregulation of miR-193b drives ovarian cancer metastasis

The cross-talk between ovarian cancer (OvCa) cells and the metastatic microenvironment is an essential determinant of successful colonization. Micro(mi)RNAs play several critical roles during metastasis; however, the role of microenvironmental cues in the regulation of miRNAs in metastasizing cancer cells has not been studied. Using a 3D culture model that mimics the human omentum, one of the principal sites of OvCa metastasis, we identified and characterized the microenvironment-induced downregulation of a tumor suppressor miRNA, miR-193b, in metastasizing OvCa cells. The direct interaction of the OvCa cells with mesothelial cells, which cover the surface of the omentum, caused a DNA methyltransferase 1 (DNMT1) mediated decrease in the expression of miR-193b. The reduction in miR-193b enabled the metastasizing cancer cells to invade and proliferate into human omental pieces ex vivo and into the omentum of a mouse xenograft model of OvCa metastasis. The functional effects of miR-193b were mediated, in large part, by the concomitant increased expression of its target, urokinase-type plasminogen activator (uPA), a known tumor-associated protease. These findings link paracrine signals from the microenvironment with the regulation of a key miRNA that is essential for the initial steps of OvCa metastatic colonization. Targeting miR-193b could prove effective in the treatment of OvCa metastasis.

Indoor air pollution from solid fuel and tuberculosis: a systematic review and meta-analysis

OBJECTIVE

To conduct an updated systematic review and meta-analysis on the association between indoor air pollution and tuberculosis (TB).

DESIGN

We searched for English or Chinese articles using PubMed and EMBASE up to 28 February 2013. We aimed to identify randomised controlled trials and observational epidemiological studies that reported the association between domestic use of solid fuel and TB. Two reviewers independently extracted the information from included studies and assessed the risk of bias of these studies using pre-defined criteria. The effect sizes of eligible studies were pooled using a random-effects model; the heterogeneity across studies was quantified using I(2) statistics.

RESULTS

We identified 15 studies on solid fuel use and active TB and one on solid fuel use and latent tuberculous infection. The summary odds ratios from case-control and cross-sectional studies were respectively 1.17 (95%CI 0.83 - 1.65) and 1.62 (95%CI 0.89 - 2.93), with substantial between-study heterogeneity (I(2) 56.2% and 80.5%, respectively). Subgroup analysis and meta-regression analysis did not identify any study-level factors that could explain the heterogeneity observed.

CONCLUSION

The level of evidence for the association between domestic use of solid fuels and TB was very low. High-quality studies are badly needed to clarify this association and to estimate the magnitude of the problem.

Standard case management of asthma in Sudan: a pilot project

SETTING

A pilot project for asthma management in selected hospitals in Khartoum and Gezira States, Sudan.

OBJECTIVE

To assess standard case management of asthma in 2007-2008.

DESIGN

Local adaptation of guidelines, followed by situational analysis, pre-intervention study, training and implementation. Treatment outcome was assessed 1 year after patient enrolment.

RESULTS

Situational analysis revealed that inhaled beclometasone was not available in the public sector. During the project, 2068 patients were enrolled: severity of asthma was intermittent in 185 (9.0%), mild persistent in 231 (11.2%), moderate persistent in 640 (31.0%), severe persistent in 812 (39.3%) and unclassified in 200 (9.7%). Of the 1654 patients with persistent asthma who were treated with inhaled corticosteroids, 1157 (70.0%) had treatment cards available for outcome assessment. Of these, 652 (56.4%) did not attend their annual evaluation, among whom 1 (0.1%) died and 651 (56.3%) were lost to follow-up. Of the 505 patients who attended their annual evaluation, 417 (82.6%) improved, 32 (6.3%) were stable and 56 (11.1%) were worse. The frequency of emergency visits and hospitalisation decreased substantially among those who presented for the 1 year follow-up assessment.

CONCLUSION

The results of standard case management of asthma were encouraging; however, a high proportion of patients did not return for long-term management.

Proficiency of drug susceptibility testing for Mycobacterium tuberculosis in Taiwan, 2007-2011

SETTING

Authorised clinical mycobacteriology laboratories in Taiwan.

OBJECTIVE

To evaluate the impact of external quality assessment (EQA) on the quality of drug susceptibility testing (DST) in 2007-2011.

DESIGN

Panels consisting of 20-30 Mycobacterium tuberculosis strains were used. Efficiency of 95% in detecting resistance to both isoniazid (INH) and rifampicin (RMP), and of 90% to ethambutol (EMB) and streptomycin (SM) was used to define a competent laboratory.

RESULTS

The proportion of laboratories that fulfilled the competency criteria for all first-line drugs was 16.7% in 2007, increasing to 85.7% in 2008, 86.1% in 2009, 82.4% in 2010, and to 96.8% in 2011 (P < 0.01). The mean efficiency in detecting resistance to INH and RMP reached >99% during 2008-2011 (P = 0.90 for INH and P = 0.82 for RMP), and for EMB it increased from 82.0% in 2007 to 92.2% in 2008 and 99.5% in 2011 (P < 0.01), while that for resistance to SM increased from 82.0% in 2007 to 98.1% in 2008 and 99.5% in 2011 (P < 0.01). Preparations of inoculum for DST and detection of EMB resistance were the main reasons for non-competence.

CONCLUSION

The EQA programme was effective in improving the competency of clinical laboratories in performing DST for tuberculosis.

Management of asthma in Benin: the challenge of loss to follow-up

SETTING

An asthma pilot project in Benin.

OBJECTIVE

To assess the implementation of standard case management of asthma at three referral centres and three primary care centres.

METHODS

The project began with local adaptation of international asthma guidelines, followed by situation analysis, pre-intervention, training and intervention. The initial dosage of inhaled beclometasone was determined by asthma severity. Outcome of treatment was assessed annually, starting from one year after enrolment.

RESULTS

Of 103 asthma patients identified during situation analysis, only 11 (11%) were prescribed inhaled corticosteroids. After health worker training, a total of 430 asthma patients were identified in 2008, of whom 273 (63.5%) returned after initial management with 7-day oral prednisolone. Of the 273 patients, 261 (95.6%) had persistent asthma, 231 (86.2%) had peak flow measurement variability of ≥20%, and 155 (56.8%) had had one or more unplanned visits to health facilities in the previous year. Outcome at one year evaluation was as follows: 63 (24.1%) had improved, 48 (18.4%) remained stable, 14 (5.4%) were worse and 136 (52.4%) were lost to follow-up.

CONCLUSION

It is feasible to train health workers to manage asthma patients in a standardised manner. However, a high proportion of patients were lost to follow-up during treatment.

Involvement of ATP in noxious stimulus-evoked release of glutamate in rat medullary dorsal horn: a microdialysis study

Our electrophysiological studies have shown that both purinergic and glutamatergic receptors are involved in central sensitization of nociceptive neurons in the medullary dorsal horn (MDH). Here we assessed the effects of intrathecal administration of apyrase (a nucleotide degrading enzyme of endogenous adenosine 5-triphosphate [ATP]), a combination of apyrase and 1,3-dipropyl-8-cyclopentylxanthine (DPCPX, an adenosine A1 receptor antagonist), or 2,3-O-2,4,6-trinitrophenyl-adenosine triphosphate (TNP-ATP, a P2X1, P2X3, P2X2/3 receptor antagonist) on the release of glutamate in the rat MDH evoked by application of mustard oil (MO) to the molar tooth pulp. In vivo microdialysis was used to dialyse the MDH every 5 min, and included 3 basal samples, 6 samples after drug treatment and 12 samples following application of MO. Tooth pulp application of MO induced a significant increase in glutamate release in the MDH. Superfusion of apyrase or TNP-ATP alone significantly reduced the MO-induced glutamate release in the MDH, as compared to vehicle. Furthermore, the suppressive effects of apyrase on glutamate release were reduced by combining it with DPCPX. This study demonstrates that application of an inflammatory irritant to the tooth pulp induces glutamate release in the rat MDH in vivo that may be reduced by processes involving endogenous ATP and adenosine.

Asthma as a hidden disease in rural China: opportunities and challenges of standard case management

OBJECTIVE

To assess the implementation of standard case management of asthma in Huaiyuan County, Anhui Province, China, in 2008.

DESIGN

The study project began with the local adaptation of international asthma guidelines, followed by a situation analysis, pre-intervention study, training and intervention. Inhaled beclomethasone (US$15 for a 200-puff [250 µg/puff] inhaler) was prescribed for patients with persistent asthma. Treatment outcome was assessed at 1 year after enrolment.

RESULTS

Asthma was never diagnosed in the participating facilities before the project was introduced. Of the 95 patients diagnosed with persistent asthma, 72 (75.8%) were prescribed inhaled beclomethasone, and 23 (24.2%) were not, because they either refused to use inhaled beclomethasone or did not return after the initial visit. At 1 year evaluation, of the 72 patients with persistent asthma treated with inhaled corticosteroids, 12 (16.7%) improved, 7 (9.7%) remained stable, none were worse, 1 (1.4%) had died, and 52 (72.2%) were lost to follow-up. Of the 52 patients lost to follow-up, 25 (48%) were found to be alive but had stopped using inhaled beclomethasone.

CONCLUSION

Asthma is more frequently disabling and costly than had been recognised earlier. Asthma patients can be provided the care that they require, but affordable access to inhaled corticosteroids remains a challenge.

Systemic pregabalin attenuates sensorimotor responses and medullary glutamate release in inflammatory tooth pain model

Our previous studies have demonstrated that application of inflammatory irritant mustard oil (MO) to the tooth pulp induces medullary glutamate release and central sensitization in the rat medullary dorsal horn (MDH), as well as nociceptive sensorimotor responses in craniofacial muscles in rats. There is recent evidence that anticonvulsant drugs such as pregabalin that influence glutamatergic neurotransmission are effective in several pain states. The aim of this study was to examine whether systemic administration of pregabalin attenuated glutamate release in the medulla as well as these nociceptive effects reflected in increased electromyographic (EMG) activity induced by MO application to the tooth pulp. Male adult rats were anesthetized with isofluorane (1.0-1.2%), and jaw and tongue muscle EMG activities were recorded by needle electrodes inserted bilaterally into masseter and anterior digastric muscles and into the genioglossus muscle, and also the medullary release of glutamate was assessed by in vivo microdialysis. Pregabalin or vehicle control (isotonic saline) was administered 30 min before the pulpal application of MO or vehicle control (mineral oil). Application of mineral oil to the maxillary first molar tooth pulp produced no change in baseline EMG activity and glutamate release. However, application of MO to the pulp significantly increased both the medullary release of glutamate and EMG activity in the jaw and tongue muscles for several minutes. In contrast, pre-medication with pregabalin, but not vehicle control, significantly and dose-dependently attenuated the medullary glutamate release and EMG activity in these muscles after MO application to the tooth pulp (analysis of variance (ANOVA), p<0.05). These results suggest that pregabalin may attenuate the medullary release of glutamate and associated nociceptive sensorimotor responses in this acute inflammatory pulpal pain model, and that it may prove useful for the treatment of orofacial inflammatory pain states.

Effect of cyclosporine-A on orthodontic tooth movement in rats

OBJECTIVE

The objective of this study is to examine the effect of cyclosporine-A (CsA) on the rate of orthodontic tooth movement in rats.

SETTING AND SAMPLE POPULATION

This is a randomized controlled trial with a split-mouth design in Sprague-Dawley rats.

MATERIAL AND METHODS

Eighteen rats, divided at random in two groups, were fed with 8 mg/kg CsA (experiment) or mineral oil (control) daily after initial healing of bilateral maxillary second molar removal. All rats received orthodontic coil springs (10 cN) secured to the maxillary incisors and first molars at the rights side, while no springs were placed at the left. Distances between first and third molars were measured on days 0, 3, 6, and 12. After sacrificing on day 12, the alveolar ridges of the maxillae were sectioned and blood samples were collected for serum tartrate-resistant acid phosphatase (TRAP)-5b level detection and for histology, respectively.

RESULTS

Significantly larger changes in intermolar distances were found after orthodontic force application in the CsA group at days 3 and 12 when compared with the control group. The inter-radicular dental alveolus of CSA-fed rats was osteopenic. Significantly increased TRAP-5b serum level was noted in the CsA group when compared with the control group.

CONCLUSIONS

We suggest that CsA enhanced the rate of orthodontic tooth movement. The osteopenia and the increased osteoclastic activity could be the underlying factors.

Cyclosporine-A inhibits MMP-2 and -9 activities in the presence of Porphyromonas gingivalis lipopolysaccharide: an experiment in human gingival fibroblast and U937 macrophage co-culture

BACKGROUND AND OBJECTIVE

Studies have shown that bacterial plaque and the associated gingival inflammation increase the severity of gingival overgrowth induced by cyclosporine-A (CsA). This in vitro study aimed to evaluate the effect of CsA on the activities of MMPs from the co-culture of human gingival fibroblasts and U937 macrophages in the presence or absence of Porphyromonas gingivalis lipopolysaccharide (LPS).

MATERIAL AND METHODS

Activities of pro-MMP-2, MMP-2 and pro-MMP-9 in the supernatants of independent cultures and co-cultures were examined by zymography. RT-PCR was selected to evaluate the expression of mRNA for membrane type-1 (MT1) MMP in the co-cultures.

RESULTS

Activities of MMPs in the co-cultures were significantly greater when compared with any of the independent cultures. Lipopolysaccharide significantly increased the MMP activities in a dose-dependent manner in the co-cultures, whereas CsA inhibited these activities. In the presence of both CsA and LPS, the MMP activities inhibited by CsA could still be observed in the co-cultures. In the individual cultures, in contrast, the CsA-inhibited MMP activities, in the presence of LPS, were minimally detected. The mRNA expression of MT1-MMP was significantly enhanced after LPS treatment; however, this enhancement was inhibited by CsA.

CONCLUSION

This study demonstrated that, in co-cultures of human gingival fibroblasts and U937 macrophages, CsA could inhibit MMP activities in the presence of P. gingivalis LPS. It might be part of the underlying reason for the persistent overgrowth of gingiva seen when bacterial plaque and local inflammation are present during CsA therapy.

Modulation of astroglial glutamine synthetase activity affects nociceptive behaviour and central sensitization of medullary dorsal horn nociceptive neurons in a rat model of chronic pulpitis

Previous studies indicate that the astroglial glutamate-glutamine shuttle may be involved in acute pulpal inflammatory pain by influencing central sensitization induced in nociceptive neurons in the trigeminal subnucleus caudalis [the medullary dorsal horn (MDH)] by application of an inflammatory irritant to the rat tooth pulp. The aim of this study was to test if intrathecal application to the rat medulla of the astroglial glutamine synthetase inhibitor methionine sulfoximine (MSO) can influence the central sensitization of MDH nociceptive neurons and the animal's associated behaviour that are manifested in a model of chronic pulpitis pain induced by exposure of a mandibular molar pulp. This model was found to be associated with nocifensive behaviour and enhanced reflex activity evoked by mechanical stimulation of the rat's facial skin and with immunocytochemical evidence of astroglial activation in the MDH. These features were apparent for up to 28 days post-operatively. During this post-operative period, the nocifensive behaviour and enhanced reflex activity were significantly attenuated by intrathecal application of MSO (5 μL, 10 mM) but not by vehicle application. In electrophysiological recordings of nociceptive neuronal activity in the MDH, central sensitization was also evident in pulp-exposed rats but not in intact rats and could be significantly attenuated by MSO application but not by vehicle application. These behavioural and neuronal findings suggest that the astroglial glutamate-glutamine shuttle is responsible for the maintenance of inflammation-induced nocifensive behavioural changes and the accompanying central sensitization in MDH nociceptive neurons in this chronic pulpitis pain model.

The FIDELIS initiative: innovative strategies for increased case finding

SETTING

Low-income, high tuberculosis (TB) burden countries.

OBJECTIVE

To compare case finding of new smear-positive pulmonary TB patients in projects funded to apply innovative approaches.

DESIGN

Prospective application of innovative approaches to case finding within routine services to determine the numbers of additional cases detected and the cost per additional case detected, according to the type of approach applied.

RESULTS

Between 2003 and 2007, 51 FIDELIS projects were implemented in 18 countries; 273,239 cases were reported, of which 85,267 were additional to the number reported in the previous year. The median cost per additional case was US$103. The interventions employed were: 1) social mobilisation and information, education and communication; 2) engagement of the private sector; 3) innovative approaches for microscopy services; 4) enhanced or semi-active case finding; 5) health systems strengthening; and 6) use of incentives. None of these was significantly more likely to detect additional cases or to have a lower cost per additional case than any of the others.

CONCLUSION

While there was a substantial increase in cases detected, at a moderate cost per additional case, we were unable to show that any single intervention had an advantage over the others.

Mixed infection with Beijing and non-Beijing strains in pulmonary tuberculosis in Taiwan: prevalence, risk factors, and dominant strain

Patients with pulmonary tuberculosis (TB) can be simultaneously infected with different strains of Mycobacterium tuberculosis (mixed infection). We investigated the prevalence and risk factors of mixed infection by Beijing and non-Beijing strains in pulmonary TB patients in Taiwan. We developed a quantitative PCR method to simultaneously detect the presence of Beijing and non-Beijing strains. A total of 868 pretreatment samples (from 868 patients), including 563 sputum samples smear-positive for acid-fast bacilli and 305 liquid medium samples culture-positive for mycobacteria, were tested. Medical records of patients with culture-confirmed pulmonary TB were reviewed. The detection limit of our quantitative PCR method was five copies of target sequences. With mycobacterial culture result as the reference standard, the sensitivity and specificity of our quantitative PCR method were 95% and 98%, respectively. M. tuberculosis strains were isolated in 466 samples, of which 231 (49.6%) were infected with a Beijing strain. Another 14 patients (3.0%) had mixed infection, with the Beijing strain being the dominant strain in 13 (93%). Age <25 years with pulmonary cavities was associated with mixed infection. In patients infected with non-Beijing strains, the bacterial load of non-Beijing strains was lower among those with mixed infection than among those without. Our quantitative PCR method was accurate in detecting Beijing and non-Beijing strains in smear-positive sputum and culture-positive liquid medium samples. Mixed infection was present in pulmonary TB patients (3.0%), especially in those aged <25 years with pulmonary cavities. Beijing strains seem to be more dominant than non-Beijing strains in patients with mixed infection.

Exposure to combustion of solid fuel and tuberculosis: a matched case-control study

The present study was conducted in Benin to ascertain the association between exposure to combustion of solid fuel (coal and biomass) and tuberculosis. Cases were consecutive, sputum smear-positive tuberculosis patients never previously treated for tuberculosis for as long as 1 month. Two controls were selected from the neighbourhood of each case, matched by age and sex by a predefined procedure. A total of 200 new smear-positive cases and 400 neighbourhood controls were enrolled. In univariate analysis, using solid fuel for cooking (OR 1.7, 95% CI 1.1-2.8), ever smoking (OR 5.5, 95% CI 3.1-9.8), male sex (OR 10.5, 95% CI 1.6-71.1), daily use of alcoholic beverages (OR 2.3, 95% CI 1.2-4.2) and having a family member with tuberculosis in the previous 5 yrs (OR 30.5, 95% CI 10.8-85.8) were all significantly associated with tuberculosis cases. When all significant variables were entered into a multivariate conditional logistic regression model, the association between using solid fuel for cooking and tuberculosis cases was no longer statistically significant (adjusted OR 1.4, 95% CI 0.7-2.7). In conclusion, the association between exposure to combustion of solid fuel and tuberculosis was relatively weak and not statistically significant.

Inconsistent dosing of anti-tuberculosis drugs in Taipei, Taiwan

SETTING

Taipei City, Taiwan.

OBJECTIVES

To evaluate prescribing practices for anti-tuberculosis drugs in the treatment of tuberculosis (TB).

METHOD

Medical audit of the medical charts of all patients notified and treated for TB in Taiwan in 2003 to determine the treatment regimens prescribed and to compare these with recommended dosages.

RESULTS

A total of 24 different anti-tuberculosis regimens were prescribed. Of 1700 patients notified, 1096 (64.5%) had their body weight recorded. Of 506 patients prescribed a three-drug fixed-dose combination (FDC), the dosage was adequate in 374 (73.9%), too low in 100 (19.8%) and too high in 32 (6.3%). Of 75 patients prescribed a two-drug FDC, the dosage was adequate in 57 (76.0%), too low in 15 (20.0%) and too high in 3 (4.0%). Of 481 patients prescribed rifampicin, the dosage was adequate in 302 (62.8%), too low in 152 (31.6%) and too high in 27 (5.6%). Of 451 patients prescribed isoniazid, the dosage was adequate in 396 (87.8%), too low in 29 (6.4%) and too high in 26 (5.8%).

CONCLUSION

The prescribing practices for anti-tuberculosis drugs were substandard and need improvement. These findings imply that the National TB Programme needs strengthening.

Molecular epidemiology of multidrug-resistant Mycobacterium tuberculosis in Eastern Taiwan

Taiwan initiated a multidrug-resistant tuberculosis (MDR-TB) programme in May 2007. Seventy-seven MDR-TB patients were enrolled from May 2007 to February 2009 in Eastern Taiwan. Isolates of 73 (94%) patients were available for genotyping using spoligotyping and MIRU-VNTR (mycobacterial interspersed repetitive unit-variable number of tandem repeats). Spoligotyping results indicated the Beijing strain as the predominant genotype (n = 48, 66%). Of the 73 isolates, 28 (38.4%) had a unique pattern and 45 (61.6%) were clustered pattern strains. Epidemiological links could be established in 21 (46.7%) of the 45 patients with a clustered pattern strain. The proportion of MDR-TB patients with a clustered pattern strain in Eastern Taiwan was high.