Tackling tuberculosis in sub-Saharan Africa: EDCTP achievements and the road ahead

The European and Developing Countries Clinical Trials Partnership (EDCTP) was established in 2003 to accelerate the development of medical interventions for tuberculosis (TB), human immunodeficiency virus (HIV) and malaria, with a particular focus on Phase II and III clinical trials. Between 2003 and 2015, the first EDCTP programme committed €65.6 million to research on TB and TB-HIV co-infection. The programme made a significant contribution to the first three elements of the DOTS TB control strategy, which mobilised European and African funding for TB-related research and generated important evidence on TB diagnostics and treatment regimens. As well as informing the development of international policy on TB diagnosis and treatment, the programme also significantly enhanced the capacity of countries in sub-Saharan Africa to undertake clinical trials and associated clinical research. The lessons learned from the first EDCTP programme have informed the development of a second, expanded EDCTP programme, EDCTP2, which was launched in 2014, and is due to run until 2024. One key lesson is the need for continued partnerships to fight the global threat of TB.

A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT)

BACKGROUND

Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children.

OBJECTIVES

To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX.

METHODS

Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg^-1 per week) or CyA (4 mg kg^-1 per day).

RESULTS

The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation.

CONCLUSIONS

This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.

Oral agents for the treatment of type 2 diabetes mellitus: pharmacology, toxicity, and treatment

Currently available oral agents for the treatment of type 2 diabetes mellitus include a variety of compounds from 5 different pharmacologic classes with differing mechanisms of action, adverse effect profiles, and toxicities. The oral antidiabetic drugs can be classified as either hypoglycemic agents (sulfonylureas and benzoic acid derivatives) or antihyperglycemic agents (biguanides, alpha-glucosidase inhibitors, and thiazolidinediones). In this review, a brief discussion of the pharmacology of these agents is followed by an examination of the adverse effects, drug-drug interactions, and toxicities. Finally, treatment of sulfonylurea-induced hypoglycemia is described, including general supportive care and the management of pediatric sulfonylurea ingestions. The adjunctive roles of glucagon, diazoxide, and octreotide for refractory hypoglycemia are also discussed.

Dichloroacetate stabilizes the mutant E1alpha subunit in pyruvate dehydrogenase deficiency

OBJECTIVE

To determine whether dichloroacetate (DCA) treatment can increase pyruvate dehydrogenase (PDH) activity in PDH-deficient cell lines harboring pathogenic mutations in the PDH E1alpha gene.

BACKGROUND

PDH deficiency is a nuclear-encoded mitochondrial disorder and a major recognized cause of neonatal encephalomyopathies associated with primary lactic acidosis. Over the last decade, DCA has been used therapeutically, but it has not been clear which patients might benefit. Recent studies suggest that chronic DCA treatment may act by increasing the stability of mutant E1alpha polypeptide. The relative effects of DCA treatment on PDH-deficient cell lines with E1alpha mutations primarily affecting polypeptide stability or catalytic activity were determined and the mechanism of enhancement of residual PDH activity explored.

METHODS

The effect of chronic 5-day DCA treatment on PDH activity was assessed in PDH-deficient cell lines containing the R378H, R141Q, K387(FS), and R302C E1alpha mutations. PDH subunit turnover and steady-state E1alpha levels before and after DCA treatment were measured in the R378H mutant line.

RESULTS

Chronic DCA treatment resulted in 25% (p = 0.0434), 31% (p = 0.0014) increases in PDH activity in the K387(FS) and R378H cell lines, both of which are associated with decreased mutant polypeptide stability. In the R378H mutant cell line, chronic DCA treatment increased steady-state E1alpha levels and slowed the rate of E1alpha turnover twofold. In contrast, PDH activity did not change in the chronically DCA-treated R302C mutant line, in which the mutant polypeptide has normal stability and reduced catalytic activity.

CONCLUSIONS

Chronic DCA treatment can increase PDH activity in PDH-deficient cell lines harboring mutations that affect E1alpha stability, suggesting a biochemical criterion by which DCA-responsive patients might be selected.

The malarial fever response--pathogenesis, polymorphism and prospects for intervention

It is estimated that over 200 million people each year suffer debilitating attacks of malarial fever, and roughly 2 million of these episodes are fatal. The fever is caused by tumour necrosis factor (TNF) and other pyrogenic cytokines that are released by the host immune system response to products of schizont rupture. TNF has anti-parasitic properties but excessive TNF production is thought to play an important role in the pathogenesis of cerebral malaria. This review summarizes recent attempts to achieve molecular characterization of the parasite components that stimulate the host TNF response, and to define the host and parasite factors that affect the level of TNF production. Of particular interest are host polymorphisms that may regulate TNF gene expression, and naturally acquired antibodies that prevent the parasite from inducing TNF, both of which correlate with the clinical severity of infection. Our understanding of these processes, which are potentially of considerable therapeutic relevance, remains very limited at both the molecular and the epidemiological level.

Cytoskeletal architecture and components involved in the attachment of Trypanosoma congolense epimastigotes

Scanning and transmission electron microscopy of Trypanosoma congolense epimastigotes attached to a plastic substratum shows them to elaborate a complex flagellum filament system and plaque with a highly organized structure. Non-ionic detergent extraction of these cells shows that the resulting cytoskeletons remain attached to the plaque. The subpellicular corset of microtubules can be removed by salt or Ca2+ treatment leaving the axoneme, paraflagellar rod, associated filaments and the plaque. Neither of these treatments therefore removed the plaque-associated material from the substratum. Analysis of these fractions by SDS-polyacrylamide gel electrophoresis reveals an abundant 70 kDa protein that is highly enriched in the salt extracted 'minimal plaque' structures and appears likely to be a major constituent of this structure. These studies reveal that the complex filament and microtubule systems of the cytoskeleton involved the attachment of trypanosomes to substrata and have established a method of biochemical fractionation of the structures and components involved.

Strain variation in tumor necrosis factor induction by parasites from children with acute falciparum malaria

A small proportion of individuals infected with Plasmodium falciparum develop cerebral malaria. Why it affects some infected individuals but not others is poorly understood. Since tumor necrosis factor (TNF) has been implicated strongly in the pathogenesis of cerebral malaria, here we have compared different parasite isolates for their ability to induce TNF production by human mononuclear cells in vitro. Wild isolates were collected from 34 Gambian children with cerebral malaria and 66 children with uncomplicated malaria fever. Cerebral malaria isolates tended to stimulate more TNF production than mild malaria isolates, but there was considerable overlap between the two groups, and the present data provide only limited support for the hypothesis that cerebral malaria is caused by strains of P. falciparum inducing high levels of TNF. However, it is notable that the amounts of TNF induced by different wild isolates from a single locality differed by over 100-fold. The biological significance of this polymorphism deserves further scrutiny in view of the central role that TNF is believed to play in host defense and in the clinical symptomatology of human malaria.

Biobehavioral factors affecting pain and disability in low back pain: mechanisms and assessment

Patients with recurrent or persistent low back pain (LBP) and disability represent a formidable challenge to physical therapists. Classic models of disease and pain mechanisms do not adequately explain the commonly observed discrepancies between the extent of pathology and reported pain, or the level of pain and disability. Research over the past decade that considers the interactive role of biological, environmental, and psychological processes in pain and disability has supported the involvement of a number of biobehavioral factors in these conditions. Physical therapists and other health care providers have become more aware of these factors and their impact on the evaluation, treatment, and management of LBP. Despite this recognition, little information is available that translates the implications of this research to direct care within physical therapy practice. The purposes of this article are (1) to provide an operational definition of biobehavioral factors; (2) to review the role of these factors in the clinical presentation of LBP, functional limitation, and disability; (3) to identify commonly used approaches for their recognition and quantification; (4) to illustrate how an understanding of biobehavioral factors can assist the physical therapist in evaluation and treatment of patients with LBP; and (5) to identify certain gaps in current knowledge of the role of biobehavioral factors and their application in physical therapy. Given the central role assumed by many physical therapists in the management of LBP, acknowledging and addressing these factors in clinical practice should assist in the prevention of chronic LBP and disability, as well as potentially improve physical therapy interventions and management.

Cloning and sequencing of four structural genes for the Na(+)-translocating NADH-ubiquinone oxidoreductase of Vibrio alginolyticus

Oligonucleotide probes based on the N-terminal amino acid sequences of the NqrA and NqrC subunits were used to clone genes for the Na(+)-dependent NADH-ubiquinone oxidoreductase complex from Vibrio alginolyticus. Four consecutive ORFs were identified encoding subunit proteins of 48.6, 46.8, 27.7 and 22.6 kDa, respectively (NqrA-D). A further ORF, showing 71% homology to the BolA protein of Escherichia coli, was located upstream. From sequence comparisons, we conclude that the Na(+)-dependent NADH-ubiquinone oxidoreductase complex of V. alginolyticus is clearly distinct from the corresponding H(+)-dependent enzymes of both prokaryotes and eukaryotes.

Issues in determining treatment effectiveness of manual therapy

The purpose of this article is to examine issues pertinent to the study of the clinical effectiveness of manual therapy. The need for complete operational definitions of treatment procedures, criteria for altering treatment, and criteria for subject selection is discussed. The need for studies that examine the relationship among impairment, functional limitations, and disability is also discussed. Considerations for selecting relevant outcome measures are presented. The use of a clinical decision-making model to direct the design of clinical studies on manual therapy is described. This article concludes with a discussion of alternative ways for clinicians to contribute to the manual therapy literature.

The use of an eclectic approach for the treatment of low back pain: a case study

The purposes of this case report are (1) to describe an examination approach that relates identification of an impairment to a disability and (2) to describe an eclectic treatment approach for an individual with low back pain (LBP). The individual described in this case report is an intercollegiate athlete who, because of chronic LBP, was unable to perform his sport of pole vaulting. The findings of the physical therapy examination suggested that an impairment of lumbar motion prevented the patient from assuming the spinal position necessary for pole vaulting. The goals of the treatment consisted of increasing the patient's lumbar motion to that required for pole vaulting and to have the patient pole vault without pain or stiffness. The treatment approach that was used combined procedures described by Maitland, McKenzie, and others. The rationale for the use of these procedures and their limitations are discussed.

The frequency and incidence of low back pain/sciatica in an urban population

The frequency, incidence and severity of low back pain was assessed by a random telephone survey of 314 urban New Zealanders. Relationships between the severity and frequency of low back pain and referred lower extremity pain and other variables such as occupation, recreation, age, sex and predominant working posture was analysed. Point incidence was 17.5%, weekly incidence 33.4%, yearly incidence 63.7% and total incidence 79%. Some 28.3% get frequent minor episodes and 6.4% get frequent severe episodes of low back pain. Nearly 50% suffer the initial episode before the age of 30 years. Of those suffering low back pain within the last seven days, 14.3% experience reference below the knee and the total incidence of below knee pain was 13.7%. Over half (51.6%) have pain that has lasted seven days or less, but a third have had pain for longer than seven weeks. No correlation between the incidence of low back pain and referred pain and occupational posture was found. In conclusion, this telephone survey established that the incidence of low back pain in New Zealand is similar to that reported in overseas studies. The survey could not establish differences in low back pain characteristics across different social groupings, nor could a relationship between occupational posture and low back pain be established.

Validity of derived measurements of leg-length differences obtained by use of a tape measure

Determining the difference in the length of an individual's legs is often an important component of a musculoskeletal examination. Although measurements are easily obtained with a tape measure, the validity of these measurements is not known. The purpose of this study was to examine the validity of determinations of leg-length differences (LLDs) obtained by use of a specified tape measure method (TMM). Leg-length differences using the TMM and a radiographic technique were determined for 10 subjects who were candidates for clinical leg-length measurements and for 9 healthy control subjects. Validity of the TMM measurements was determined by assessing the degree of agreement between TMM-obtained LLDs and those obtained by the radiographic method. Validity estimates as determined by intraclass correlation coefficients (ICCs) were .770 for patients, .359 for healthy subjects, and .683 for all subjects. When the means of the two values obtained by use of the TMM were compared with the radiographic measurements, the ICCs were .852 for the patient group, .637 for the healthy subjects, and .793 for all subjects. This study suggests that TMM-derived LLD measurements are valid indicators of leg-length inequality and that the estimates of validity are improved by using the average of two determinations rather than a single determination.

Structure and mapping of the DNA of human parvovirus B19

DNA from human parvovirus B19 was prepared from infected serum and examined by electron microscopy. Double-stranded molecules were seen, often with characteristic 'fold-back' ends that were assumed to be due to the inverted terminal repeats of the genome DNA. This double-stranded DNA was mapped with 13 restriction enzymes. More than 40 isolates, including the virus from the original B19 serum, were compared. Although isolates could be grouped by this method, there was no correlation between a particular restriction endonuclease map and any of the several disease presentations of the virus.

Reliability of the attraction method for measuring lumbar spine backward bending

The distraction method is one method used to measure forward bending of the spine. Although this technique, which requires the use of a tape measure held over the spine and the location of anatomical landmarks, appears to be highly practical, previous studies have not examined its use for measuring backward bending. The purpose of our study was to determine the reliability of a similar technique, the attraction method, for measuring backward bending of the lumbar spine and to examine whether subjects with low back pain (LBP) could perform similar motion as subjects without LBP. Two groups composed of 100 subjects each, one with "significant" limiting low back pain (SLBP) and the other without "significant" limiting low back pain (NSLBP), were evaluated twice by a physical therapist to assess intrarater reliability. To assess interrater reliability, 11 subjects from the NSLBP Group were evaluated by a second therapist. For the total sample of 200 subjects, the intraclass correlation coefficient (ICC) for intrarater reliability was .95; for the SLBP Group, the ICC was .93; and for the NSLBP Group, the ICC was .90. For the sample of 11 NSLBP Group subjects examined for interrater reliability, the ICC was .94. Using a Kolmogorov-Smirnov test, we found the distribution for backward bending of the two groups to be significantly different. The attraction method, thus, appears to be a reliable method for measuring backward bending of the lumbar spine.

Structure of mouse major urinary protein genes: different splicing configurations in the 3′-non-coding region

The multigene family which codes for the mouse major urinary proteins (MUPs) consists of approximately 35 genes. Most of these are members of two different groups, Group 1 and Group 2, which can be distinguished by nucleic acid hybridisation. Here we describe the structure of a Group 1 gene and show that two size classes of MUP mRNA which are found in mouse liver result from different splicing events in the 3'-non-coding region and contain different polyadenylation sites. Short mRNA is approximately 750 nucleotides long, contains six exons, and is the main product of the Group 2 genes. Long mRNA is approximately 880 nucleotides long, contains seven exons and is the main product of the Group 1 genes. Five exons and part of the sixth are common to long and short mRNA and contain the coding region. This codes for an acidic protein of 180 amino acids containing an 18 residue signal peptide. A comparison of the mouse sequence with a homologous rat alpha 2u-globulin sequence shows that the rate of evolutionary divergence of the two proteins has been high. Silent sites have diverged four times more rapidly than replacement sites, showing that there has been selection against change in the protein sequence.