Facilitators and barriers to adolescent participation in a TB clinical trial

BACKGROUND

The inclusion of adolescents in TB drug trials is essential for the development of safe, child-friendly regimens for the prevention and treatment of TB. TB Trials Consortium Study 31/AIDS Clinical Trials Group A5349 (S31/A5349) enrolled adolescents as young as 12 years old. We assessed investigator and coordinator described facilitators and barriers to adolescent recruitment, enrollment, and retention.

METHODS

Interviews were conducted with six investigators from sites that enrolled adolescent participants and six investigators from non-enrolling sites. Additionally, two focus groups were conducted with study coordinators from enrolling sites and two focus groups with non-enrolling sites. Discussions were transcribed, analyzed, summarized, and summaries were reviewed by Community Research Advisors Group members and research group representatives for content validity.

RESULTS

Investigators and coordinators attributed the successful enrollment of adolescents to the establishment and cultivation of external partnerships, flexibility to accommodate adolescents' schedules, staff engagement, recruitment from multiple locations, dedicated recruitment staff working onsite to access potential participants, creation of youth-friendly environments, and effective communications. Non-enrolling sites were mainly hindered by regulations. Suggestions for improvement in future trials focused on study planning and site preparations.

CONCLUSION

Proactive partnerships and collaboration with institutions serving adolescents helped identify and reduce barriers to their inclusion in this trial..

Accuracy of methods for reporting inorganic element concentrations and radioactivity in oil and gas wastewaters from the Appalachian Basin, U.S. based on an inter-laboratory comparison

Accurate and precise analyses of oil and gas (O&G) wastewaters and solids (e.g., sediments and sludge) are important for the regulatory monitoring of O&G development and tracing potential O&G contamination in the environment. In this study, 15 laboratories participated in an inter-laboratory comparison on the chemical characterization of three O&G wastewaters from the Appalachian Basin and four solids impacted by O&G development, with the goal of evaluating the quality of data and the accuracy of measurements for various analytes of concern. Using a variety of different methods, analytes in the wastewaters with high concentrations (i.e., >5 mg L-1) were easily detectable with relatively high accuracy, often within ±10% of the most probable value (MPV). In contrast, often less than 7 of the 15 labs were able to report detectable trace metal(loid) concentrations (i.e., Cr, Ni, Cu, Zn, As, and Pb) with accuracies of approximately ±40%. Despite most labs using inductively coupled plasma mass spectrometry (ICP-MS) with low instrument detection capabilities for trace metal analyses, large dilution factors during sample preparation and low trace metal concentrations in the wastewaters limited the number of quantifiable determinations and likely influenced analytical accuracy. In contrast, all the labs measuring Ra in the wastewaters were able to report detectable concentrations using a variety of methods including gamma spectroscopy and wet chemical approaches following Environmental Protection Agency (EPA) standard methods. However, the reported radium activities were often greater than ±30% different to the MPV possibly due to calibration inconsistencies among labs, radon leakage, or failing to correct for self-attenuation. Reported radium activities in solid materials had less variability (±20% from MPV) but accuracy could likely be improved by using certified radium standards and accounting for self-attenuation that results from matrix interferences or a density difference between the calibration standard and the unknown sample. This inter-laboratory comparison illustrates that numerous methods can be used to measure major cation, minor cation, and anion concentrations in O&G wastewaters with relatively high accuracy while trace metal(loid) and radioactivity analyses in liquids may often be over ±20% different from the MPV.

Defining the optimal dose of rifapentine for pulmonary tuberculosis: Exposure-response relations from two phase II clinical trials

Rifapentine is a highly active antituberculosis antibiotic with treatment-shortening potential; however, exposure-response relations and the dose needed for maximal bactericidal activity have not been established. We used pharmacokinetic/pharmacodynamic data from 657 adults with pulmonary tuberculosis participating in treatment trials to compare rifapentine (n = 405) with rifampin (n = 252) as part of intensive-phase therapy. Population pharmacokinetic/pharmacodynamic analyses were performed with nonlinear mixed-effects modeling. Time to stable culture conversion of sputum to negative was determined in cultures obtained over 4 months of therapy. Rifapentine exposures were lower in participants who were coinfected with human immunodeficiency virus, black, male, or fasting when taking drug. Rifapentine exposure, large lung cavity size, and geographic region were independently associated with time to culture conversion in liquid media. Maximal treatment efficacy is likely achieved with rifapentine at 1,200 mg daily. Patients with large lung cavities appear less responsive to treatment, even at high rifapentine doses.

Reasons for non-participation in an international multicenter trial of a new drug for tuberculosis treatment

SETTING

Clinical trials can provide a high standard of patient care and contribute to scientific knowledge; however, only a fraction of the patients screened participate and receive treatment as part of a trial.

OBJECTIVE

To explore reasons why patients were not enrolled in an international tuberculosis (TB) treatment trial and to compare experiences among study sites.

DESIGN

An analysis of reasons why patients were not enrolled was conducted among patients screened for a TB clinical trial at 26 sites in North and South America, Africa, and Europe.

RESULTS

Staff at study sites screened 1119 potential candidates for the trial: 61% (n = 686) were not enrolled due to 1) failure to meet eligibility criteria (n = 405, 59%), 2) site's decision (n = 168, 24%), or 3) candidate's choice (n = 113, 16%). Study staff recorded a total of 144 reasons for why they believed patients chose not to participate, including concerns over research (28%), conflicts with work or school (21%), and lifestyle and family issues (20%). Socio-demographic and geographic factors also influenced participation.

CONCLUSION

Increased evaluation of screening outcomes and of specific interventions, such as improved education and communication about trial procedures, may increase the efficiency of screening and enrollment in clinical trials.

Effect of tissue non-specific alkaline phosphatase in maintenance of structure of murine colon and stomach

The gastrointestinal tract of mammals secretes a phospholipid-rich membrane that is enriched in alkaline phosphatase (AP) and surfactant proteins (surfactant-like particle, SLP). The production of this particle is stimulated in the small intestine by fat feeding and in cultured cells in vitro by transfection with intestinal alkaline phosphatase (IAP). To test whether tissue non-specific alkaline phosphatase (TNAP) was a factor in stimulating surfactant-like particle production in stomach and colon (tissues expressing TNAP), mice lacking this enzyme were studied. Mice were harvested at 8 days of life, when body weight of homozygous animals (TNAP -/-) was about half that of congenic controls (TNAP +/+) or heterozygotes (TNAP +/-), but before seizures had begun. No difference in content of the major SLP protein (65 kDa) by Western blotting or immunocytochemistry was seen in stomach or colon of TNAP -/- vs. TNAP +/+ animals, but the content was only about half in the IAP-expressing small bowel. Transmission electron microscopy of the TNAP -/- small bowel showed large dilated lysosomes and residual bodies. Colonocytes and gastric surface epithelial cells from the same animals showed mitochondria containing homogeneous dense inclusions, consistent with neutral lipid. In the underweight homozygous animals, there was a decrease in the neuronal content of submucosal ganglia in the jejunum and ileum and of myenteric ganglia in the jejunum of TNAP -/- animals. These findings suggest that (1) TNAP is not important in maintaining surfactant-like particle content of tissues that express TNAP, (2) normal fat absorption is important in maintaining SLP content in the small intestine, and (3) TNAP is important in the maintenance of some intestinal structures, and perhaps their function.

Measuring self-efficacy in substance abuse intervention in obstetric practices

BACKGROUND

This study presents findings on the effect of an office-based obstetrics training program (given the acronym OBIWOM) on substance use assessment, management, and referral self-efficacy among obstetricians and staff of private, community-based obstetric practices.

METHODS

Participants were obstetricians and staff from 10 of 27 available community-based, private obstetric practices in the target areas, for a practice participation rate of 37%. This study used a delayed treatment design to compare self-efficacy between practice staff randomly assigned to an immediate or delayed intervention group.

RESULTS

Self-efficacy increased significantly after intervention from baseline to first follow-up for the immediate group, while no change was shown for the delayed (control) group. The impact of the intervention on self-efficacy was replicated in the assessment construct only after the intervention for the delayed group.

CONCLUSION

This research shows that education and training can effectively improve self-efficacy in obstetricians and their staff in the management of substance use and pregnancy.

Effects of aerosolized surfactant in patients with stable chronic bronchitis: a prospective randomized controlled trial

CONTEXT

Chronic bronchitis, estimated to affect more than 13 million adults in the United States, is characterized in part by retention of airway secretions, but no approved or effective therapy for airway mucus retention in patients with chronic bronchitis has been established. Surfactant reduces sputum adhesiveness, which contributes to difficulty in clearing secretions, but surfactant has not been tested in patients with chronic bronchitis.

OBJECTIVE

To examine the effects of exogenous surfactant on sputum clearance and pulmonary function in patients with stable chronic bronchitis.

DESIGN

A prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled comparison of the effects of 2 weeks of treatment with 3 doses of aerosolized surfactant (palmitoylphosphadidylcholine [DPPC]) or saline (placebo).

SETTING

Four US teaching hospitals.

PARTICIPANTS

A total of 87 adult patients with the diagnosis of stable chronic bronchitis.

MAIN OUTCOME MEASURES

Pulmonary function, respiratory symptoms, and sputum properties before treatment (day 0), after 2 weeks of treatment (day 14), and 7 days after stopping treatment (day 21).

RESULTS

A total of 66 patients were randomized to surfactant treatment and 21 to saline treatment. Patient demographic characteristics between groups were similar at baseline. In patients who received a DPPC dose of 607.5 mg/d for 2 weeks, prebronchodilator forced expiratory volume in 1 second (FEV1) increased from 1.22 L (SEM, 0.08 L) at day 0 to 1.33 L (SEM, 0.09 L) at day 21 (P=.05), an improvement of 11.4%; postbronchodilator FEV1 improved 10.4% by days 14 and 21 (P=.02); and the ratio of residual volume to total lung capacity, a measure of thoracic gas trapping, decreased 6.2% by day 21 (P=.009). In the surfactant groups, there was a dose-dependent increase in the ability of sputum to be transported by cilia in vitro.

CONCLUSION

Aerosolized surfactant improved pulmonary function and resulted in a dose-related improvement in sputum transport by cilia in patients with stable chronic bronchitis.

Sufficient conditions for effective treatment of substance abusing homeless persons

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects (n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

Thermobrachium celere gen. nov., sp. nov., a rapidly growing thermophilic, alkalitolerant, and proteolytic obligate anaerobe

More than 40 isolates of a novel, ubiquitous, proteolytic, moderately alkaliphilic, thermophilic obligate anaerobe were obtained from geothermally and anthropogenically heated environments and mesobiotic environments located on three continents. Whole-cell protein sodium dodecyl sulfate gel electrophoresis revealed that most of these organisms are very similar. Eight of the isolates were characterized in detail; this analysis included 16S ribosomal DNA sequence analysis. The cells of those organisms are (depending on the isolate) 0.5 to 0.8 micron in diameter and 1.5 to 13 microns long, exhibit tumbling motility, and have a positive Gram stain reaction. The temperature range for growth is 43 degrees to 75 degrees C (optimum temperature, 66 degrees C), and the pH range for growth is 5.4 to 9.5 (optimum pH, 8.2); the shortest doubling time is around 10 min. Yeast extract is required for growth, and (depending on the strain) glucose, sucrose, fructose, galactose, and ribose are utilized. The fermentation products from glucose in the presence of yeast extract are CO2, H2, acetate, formate, and ethanol. The G + C content is 30 to 31 mol%. On the basis of these properties, which differentiate these strains from all alkalitolerant thermophiles described previously, and the results of a comparison of the 16S ribosomal DNA sequences of these organisms with previously described sequences, we propose that our isolates be placed in a single species of the new genus Thermobrachium; strain JW/YL-NZ35 is the type strain of the the type species, Thermobrachium celere.

Treatment outcome as a function of treatment attendance with homeless persons abusing cocaine

This research examines the influence of treatment attendance at two substance abuse outpatient treatment programs of the Birmingham Substance Abuse Homeless Project on substance abuse, homelessness, and unemployment outcomes with homeless persons abusing primarily crack cocaine. Results revealed that significant reductions across a one year period in alcohol use, cocaine use, and homelessness were more likely to occur in clients who attended an average of 4.1 treatment days per week (High attendance or Enhanced Care group) than clients who attended less than one day a week on the average (Low attendance or Usual Care and Medium attendance groups). These results are consistent with the literature suggesting that more intensive contact early in treatment results in better long-term outcome with cocaine abusers, but has now been demonstrated with homeless cocaine abusers who have additional problems associated with housing and employment.

Decremental carryover effects of sucrose ingestion in the negative anticipatory contrast procedure in rats

To test for retrospective effects of sucrose ingestion in the anticipatory contrast procedure, 4 experiments examined intake of an initial 0.15% saccharin solution as a function of the unsignaled interspersing of days in which the 2nd solution was 32% sucrose or 0.15% saccharin. In Experiment 1, rats that received alternating saccharin-saccharin days and saccharin-sucrose days drank less saccharin on saccharin-only days, and on both days they drank less saccharin than a control group that received saccharin only. In Experiment 2, rats that received randomized saccharin-saccharin and saccharin-sucrose days drank less saccharin if, and only if, a sucrose day preceded. Experiments 3 and 4 used double and quadruple alternation of saccharin and sucrose days to examine persistence of the effects of a sucrose day. The results highlighted a retrospective carryover effect of sucrose that reduced intake of the initial saccharin solution and apparently was based on sucrose memories persisting over days.

Validity of self-reported crack cocaine use among homeless persons in treatment

The validity of self-reported crack cocaine use among 131 homeless persons participating in an outpatient substance abuse treatment research demonstration project was assessed by comparing the concordance of self-report and urinalysis results. The subjects were participants in either a Usual Care outpatient program or an Enhanced Care day treatment program that included drug free contingent work therapy and housing. For all subjects across four evaluation points, the false negative classification by self-report (i.e., denied verified use) rate for crack cocaine use was 32.0%. Denied verified use was greater in Usual Care (34.9%) than in Enhanced Care clients (23.7%) and greater at follow-up as compared to treatment entry for all clients. The findings are explained in terms of social desirability and the influence of treatment contingencies and greater accountability specific to the Enhanced Care program. The need for validation of self-reported cocaine use data among homeless persons in settings where contingencies are present and in other drug treatment or research settings is recommended.

Isolation and characterization of a novel alkalitolerant thermophile, Anaerobranca horikoshii gen. nov., sp. nov

Nine moderately alkalitolerant thermophilic bacteria with similar properties were isolated from water and soil samples obtained from Yellowstone National Park. These Gram-type-positive, rod-shaped bacteria produce cells with primary branches. The cells are peritrichous and exhibit only slight tumbling motility. At 60 degrees C the pH range for growth is 6.9 to 10.3, and the optimum pH is 8.5. At pH 8.5 the temperature range for growth is 34 to 66 degrees C, with an optimum temperature of 57 degrees C. The strains are mainly proteolytic. The fermentation products from yeast extract are acetate, CO2, and H2. Fumarate added to minimal medium containing yeast extract is stoichiometrically converted to succinate, indicating that it is used as an alternative electron acceptor. The DNA G + C content is 33 to 34 mol%. On the basis of its unique properties, such as branch formation, growth at alkaline pH values at elevated temperatures, and the relative distance of its 16S rRNA sequence from those of other known bacteria, we propose that strain JW/YL-138T (T = type strain) and eight similar strains represent a new genus and species, Anaerobranca horikoshii. Strain JW/YL-138 is designated the type strain of the type species, A. horikoshii, which was named in honor of Koki Horikoshi, a pioneer in the field of alkaliphilic bacteria.

The secretion of intestinal alkaline phosphatase (IAP) from the enterocyte

Rat intestinal alkaline phosphatase exists in two separate forms, differing markedly in the carboxyterminal coding region, as well as in the 3' untranslated regions. It is secreted bound to a phospholipid-rich particle (surfactant-like particle) which appears to have unique properties, but whose role is still uncertain. Evidence is presented to suggest that intestinal alkaline phosphatase secretion is mediated by this particle. The challenge for the future is to study the biology of the surfactant-like particle, to ascertain its role in gut physiology, and to determine how the dual alkaline phosphatases are involved in this specialized secretory apparatus.

Clostridium thermoalcaliphilum sp. nov., an anaerobic and thermotolerant facultative alkaliphile

An anaerobic and thermophilic alkaliphile, strain JW/YL23-2T (T = type strain), was isolated from sewage sludge obtained from a sewage plant in Atlanta, Ga. At pH 10.1 and 50 degrees C, the doubling time of this strain was 19 min. Strain JW/YL23-2T, a motile rod-shaped bacterium with 2 to 12 peritrichous flagella, exhibited a negative Gram stain reaction but was gram-type positive as judged by the polymyxin B test. No heat-stable (85 degrees C, 15 min) endospores were detected. At 50 degrees C, growth occurred at pH values ranging from 7.0 to 11.0; the optimum pH was 9.6 to 10.1. The temperature range for growth ranged from 27 to 57.5 degrees C; the optimum temperature was 48 to 51 degrees C (pH 10.1). Dissimilatory sulfate reduction was not detected. The organism utilized glucose, fructose, sucrose, maltose, cellobiose, and Casamino Acids. The DNA G+C content was 32 mol% (as determined by chemical analysis). A 16S rRNA sequence analysis revealed a 2% inferred evolutionary distance to Clostridium paradoxum. However, the cell wall type of strain JW/YL23-2T was A4 beta (L-Orn-D-Asp), while that of C. paradoxum was A1 tau (m-diaminopimelic acid direct). On the basis of the alkaline pH values and high temperatures for optimal growth, the inability to form spores, and other characteristics different from C. paradoxum characteristics, strain JW/YL-23-2 was placed in a new species, Clostridium thermoalcaliphilum; JW/YL23-2 (= DSM 7309) is the type strain of this new species.

Caco-2 cell transfection by rat intestinal alkaline phosphatase cDNA increases surfactant-like particles

The rat enterocyte produces a particle with surfactant-like properties (including a whorled appearance, enrichment for dipalmitoyl phosphatidylcholine, and ability to lower surface tension) that also is enriched for intestinal alkaline phosphatase. Human Caco-2 cells grown on polycarbonate filters were utilized to study the secretion of these particles and exhibited whorls and strands of unilamellar membranes, particularly concentrated at the apical pole or near junctional complexes. Concentrated culture medium from these cells separated on continuous NaBr gradients revealed a fraction at density = 1.07 g/l enriched for phosphatidylcholine and intestinal alkaline phosphatase. This fraction contained membranous sheets containing alkaline phosphatase, detected by immunolocalization. Phosphatidylcholine comprised 54% of phospholipid in this fraction, compared with 20% in brush borders. When Caco-2 cells were transfected with cDNA encoding rat intestinal alkaline phosphatase, cellular phosphatase activity increased twofold, but activity in the medium increased 14-fold to > 200 (average 32)-fold. Ultrastructurally, compared with mock-transfected cells or cells transfected with human placental alkaline phosphatase, transfection with rat intestinal alkaline phosphatase cDNA led to intracellular and extracellular accumulation of surfactant-like particles. We conclude that surfactant-like particles are produced by Caco-2 cells, and their production can be enhanced by transfection with a cDNA encoding a protein known to be associated with such particles.

Deletion mutant analysis of the Staphylococcus aureus plasmid pI258 mercury-resistance determinant

Deletion mutant analysis of the mercury-resistant determinant (mer operon) from the Staphylococcus aureus plasmid pI258 was used to verify the location of the merA and merB genes and to show the existence of mercuric ion transport gene(s). ORF5 was confirmed to be a transport gene and has an amino acid product sequence homologous to the merT gene products from several gram-negative bacteria and a Bacillus species. Deletion analysis established that inactivation of merA on a broad-spectrum mer resistance determinant resulted in a mercury-hypersensitive phenotype. Gene dosage had no apparent effect on the level of resistance conferred by the intact mer operon or on the expression of an inducible phenotype, except that when the intact pI258 mer operon was on a high copy number plasmid, uninduced cells possessed a volatilization rate that was at most only 3.5-fold less than that observed for induced cells. There was no need for mercury ion transport proteins for full resistance when the mer operon was expressed in a high copy number plasmid.