Drug resistant epilepsy and associated factors among children with epilepsies in tanzania: a cross-sectional study

BACKGROUND

Epilepsy contributes to high morbidity among children and adolescents in developing countries. A quarter of all children with epilepsy will be resistant to anti-seizure medications (ASMs), with associated neurocognitive impairments and risk of higher mortality. This study aimed to estimate and characterize drug-resistant epilepsy (DRE) (defined as failure to achieve sustained remission after adequate trials of two tolerated and appropriately chosen ASMs) and its associated factors among children and adolescents with epilepsies attending the pediatric neurology clinic at Muhimbili National Hospital (MNH), Dar es Salaam Tanzania.

METHODS

This cross-sectional study was conducted from June 2020 to June 2021. Children with epilepsies and who had been treated with ASMs for at least 3 months were eligible for inclusion. Exclusion criteria included children whose caregivers denied consent and those who exhibited acute medical conditions necessitating admission on the scheduled visit day. Data on demographic characteristics, perinatal history, detailed history of the seizures semiology, drug history, magnetic resonance imaging (MRI), and electroencephalography (EEG) results were obtained from caregivers and medical records available during recruitment. Seizures and epilepsies were classified using the 2017 International League Against Epilepsy (ILAE) classification. Logistic regression was used to determine factors associated with DRE.

RESULTS

A total of 236 children and adolescents aged between 4 months and 15 years (Median age 72 months (IQR = 42-78)) were enrolled in this study. We found the proportion of DRE to be 14.8% in this cohort. Of the thirty-five patients with DRE, 60% had generalized epilepsy and almost 25% had a diagnosis of an epilepsy syndrome, the most common being Lennox-Gastaut syndrome (LGS). Structural abnormalities on brain MRI were seen in almost 80% of all patients with DRE, the most prevalent being cystic encephalomalacia, which was observed in 34% of patients. Patients using both ASMs and alternative therapies accounted for 9% of this cohort. The onset of seizures during the first month of life (aOR = 1.99; 95%CI 1.7-4.6; p = 0.031) and high initial seizure frequency (aOR = 3.6; 95%CI 1.6-8;p = 0.002) were found to be independently associated with DRE.

CONCLUSION

The proportion of DRE in Tanzania is high. Patients with neonatal onset seizures and high initial seizure frequency should be followed up closely to ensure early diagnosis of DRE.

EGFR suppression contributes to growth inhibitory activity of G-quadruplex ligands in non-small cell lung cancers

Non-small cell lung carcinomas (NSCLCs) commonly harbor activating mutations in the epidermal growth factor receptor (EGFR). Drugs targeting the tyrosine kinase activity of EGFR have shown effectiveness in inhibiting the growth of cancer cells with EGFR mutations. However, the development of additional mutations in cancer cells often leads to the persistence of the disease, necessitating alternative strategies to overcome this challenge. We explored the efficacy of stabilizing the G-quadruplex structure formed in the promoter region of EGFR as a means to suppress its expression and impede the growth of cancer cells with EGFR mutations. We revealed that the carbazole derivative BMVC-8C3O effectively suppressed EGFR expression and demonstrated significant growth inhibition in EGFR-mutated NSCLC cells, both in cell culture and mouse xenograft models. Importantly, the observed repression of EGFR expression and growth inhibition were not exclusive to carbazole derivatives, as several other G-quadruplex ligands exhibited similar effects. The growth-inhibitory activity of BMVC-8C3O is attributed, at least in part, to the repression of EGFR, although it is possible that additional cellular targets are also affected. Remarkably, the growth-inhibitory effect was observed even in osimertinib-resistant cells, indicating that BMVC-8C3O holds promise for treating drug-resistant NSCLC. Our findings present a promising and innovative approach for inhibiting the growth of NSCLC cells with EGFR mutations by effectively suppressing EGFR expression. The demonstrated efficacy of G-quadruplex ligands in this study highlights their potential as candidates for further development in NSCLC therapy.

Tuberculosis cases related to tertiary care cardiac center experiences in the last 10 years

Background

Tuberculosis (TB) is one of the oldest and deadliest infectious diseases known to affect human health, which is gaining renewed importance today.

Methods

In our center, which is a tertiary research hospital, the data of patients hospitalized due to TB between 2011 and 2022 were retrospectively identified by searching the database.

Results

Six women (30.0%) and 14 men (70.0%) were included in the study. When analyzed by age grouping, four patients between the ages of 19 and 34 years (20.0%), five patients between the ages of 38 and 58 years (25.0%), five patients aged 61-69 years (25.0%), and six patients aged 70-81 years (30.0%). Radiographs showed cavitation in 9 (45.0%) patients, and 11 (55.0%) patients had no radiologic findings. The ARS results of the participants showed that there were 7 (35.0%) patients positive and 13 (65.0%) patients negative. When the TB culture variables of the participants were analyzed, it was found that there were 5 (25.0%) people with no growth and 15 (75.0%) people with growth. Concurrent diseases were noted in patients including 5 (25.0%) with organ transplantation, 3 (15.0%) with diabetes mellitus, 2 (%10) with cancer, and 2 (10%) with chronic renal failure according to the chart records. The distribution of cases was as follows: 19 (95.0%) pulmonary TB and 1 (5.0%) pleural TB. It was found that there were 5 (25.0%) people with a history of TBC and 15 people (75.0%) without a history of TBC. Moreover, drug susceptibility tests showed that 5 (25%) patients of the isolates were identified as multidrug resistant with first-line drug susceptibility testing.

Conclusion

The study was not financially supported by any individual/organization, and the authors have no vested interests.

Differential gene expression analysis combined with molecular dynamics simulation study to elucidate the novel potential biomarker involved in pulmonary TB

Tuberculosis (TB) is a lethal multisystem disease that attacks the lungs' first line of defense. A substantial threat to public health and a primary cause of death is pulmonary TB. This study aimed to identify and investigate the probable differentially expressed genes (DEGs) primarily involved in Pulmonary TB. Accordingly, three independent gene expression data sets, numbered GSE139825, GSE139871, and GSE54992, were utilized for this purpose. The identified DEGs were used for bioinformatics-based analysis, including physical gene interaction, Gene Ontology (GO), network analysis and pathway studies using the Kyoto Encyclopedia of Genes and Genomes pathway (KEGG). The computational analysis predicted that TNFAIP6 is the significant DEG in the gene expression profiling of TB datasets. According to gene ontology analysis, TNFAIP6 is also essential in injury and inflammation. Further, TNFA1P6 is strongly linked to arsenic poisoning, evident from the results of NetworkAnalyst, a comprehensive and interactive platform for gene expression profiling via network visual analytics. As a result, the TNFAIP6 gene was ultimately chosen as a candidate DEG and subsequently employed for in silico structural characterization studies. The tertiary structure of TNFAIP6 was modelled using the ROBETTA server, followed by validation with SAVES and ProSA webserver. Additionally, structural dynamic studies, including molecular dynamics simulation (MDS) and essential dynamics analysis, including principal component (PC) based free energy landscape (FEL) analysis, was used for checking the stability of TNFAIP6 models. The dynamics result established the structural rigidity of modelled TNFAIP6 through RMSD, RMSF and RoG results. The FEL analysis revealed the restricted conformational flexibility of TNFAIP6 by displaying a single minimum energy basin in the contour plot. The comprehensive computational analysis established that TNFAIP6 could serve as a viable biomarker to assess the severity of pulmonary TB.

P110α inhibitor alpelisib exhibits a synergistic effect with pyrotinib and reverses pyrotinib resistant in HER2+ breast cancer

Human epidermal growth factor receptor 2 (HER2) plays a critical role in breast cancer progression in patients with HER2 overexpression, thereby driving the development of targeted drugs and advancing therapy strategies targeting this gene. Pyrotinib is a novel irreversible pan-ErbB kinase inhibitor, primarily suppresses the downstream MAPK and PI3K/AKT pathways. Alpelisib, a selective PI3K p110α inhibitor, has been approved for clinical application in HR+, HER2-, PIK3CA mutated breast cancers and is also being developed for use in other breast cancer subtypes. In this study, we hypothesised that combining pyrotinib with alpelisib would yield superior results compared to single-drug treatment. Our data demonstrated that the combination of alpelisib and pyrotinib exhibited a synergistic effect in HER2+ breast cancer both in vitro and in vivo. This combination led to decreased cell proliferation and migration, G0-G1 cell cycle arrest, and increased apoptosis rates. Additionally, the deactivation of ErbB receptors and sustained activation of PI3K/AKT pathway by upstream compensatory pathways induced acquired pyrotinib resistant cells resistant to pyrotinib treatment, thus alpelisib combined with pyrotinib showed a tremendous synergistic effect and reverse pyrotinib resistance in acquired pyrotinib resistant cells by suppressing the activated PI3K/AKT pathway. Our results revealed a combination of pyrotinib and alpelisib as an effective therapeutic strategy in treating HER2+ breast cancer, whether sensitive or resistant to pyrotinib treatment.

Deep brain stimulation for autism spectrum disorder

Deep brain stimulation (DBS) is a medical treatment that aims to obtain therapeutic effects by applying chronic electrical impulses in specific brain structures and neurological circuits. Over the years, DBS has been studied for the treatment of many psychiatric disorders. Scientific research on the use of DBS in people with autism has focused this interest mainly on treatment-resistant obsessive-compulsive disorder, drug-resistant epilepsy, self-injurious behaviors (SIB), and aggressive behaviors toward the self. Autism spectrum disorder (ASD) includes a group of developmental disabilities characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills and the presence of repetitive and stereotyped behaviors as well as restricted interests. People with autism often have numerous medical and psychiatric comorbidities that worsen the quality of life of patients and their caregivers. Obsessive-compulsive symptoms can be found in up to 81.3% of people with autism. They are often severe, refractory to treatment, and particularly difficult to treat. SIB has a high prevalence in severely retarded individuals and is often associated with autism. Drug treatment of both autism and SIB presents a therapeutic challenge. To describe the current state of the art regarding the efficacy of DBS in people with ASD, a literature search was conducted for relevant studies using the PubMed database. Thirteen studies have been considered in this paper. Up to date, DBS has been used for the stimulation of the nucleus accumbens, globus pallidus internus, anterior limb of the internal capsule, ventral anterior limb of the internal capsule, basolateral amygdala, ventral capsule and ventral striatum, medial forebrain bundle, and posterior hypothalamus. In the total sample of 16 patients, 4 were adolescents, and 12 were adults. All patients had symptoms resistant to multiple drug therapy. Many patients taken into consideration by the studies showed clinical improvements as evidenced by the scores of the psychopathological scales used. In some cases, clinical improvements have varied over time, which may require further investigation. Among the new therapeutic perspectives, DBS could be a valid option. However, further, and more in-depth research is needed in this field.

Design, synthesis and biological evaluation of phosphoroxy quinazoline derivatives as potential EGFRT790M/C797S inhibitors

Owing to the urgency and importance of developing fourth-generation EGFR inhibitors that can effectively overcome C797S site mutation in NSCLC, Brigatinib was used in this work as a lead compound to modify its structure to obtain a series of phosphoroxy quinazoline derivatives. Biological study indicated that the inhibitory activity and selectivity of the target compounds on EGFR^{L858R/T790M/C797S}/EGFR^{Del19/T790M/C797S} enzymes and EGFR^{Del19/T790M/C797S} overexpressed Ba/F3 cells were significantly better than those of Brigatinib. Among the target compounds, 8a exhibited the best biological activity in vitro. More importantly, 8a presented acceptable pharmacokinetic behaviors and showed potent anti-tumor efficacy in the Ba/F3-EGFR^{Del19/T790M/C797S} subcutaneous xenograft mice model with the tumor growth inhibition value of 82.60% at a dose of 30 mg/kg. These results indicated that 8a, as a drug candidate of the novel fourth-generation EGFR small-molecule inhibitor, has high potentials to treat with NSCLC on EGFR with C797S mutation.

Novel antifungal triazoles with alkynyl-methoxyl side chains: Design, synthesis, and biological activity evaluation

Previous work led to the rational design, synthesis and testing of novel antifungal triazole analogues bearing alkynyl-methoxyl side chains. Tests of in vitro antifungal activity showed Candida albicans SC5314 and Candida glabrata 537 gave MIC values of ≤0.125 μg/mL for most of the compounds. Among these, compounds 16, 18, and 29 displayed broad-spectrum antifungal activity against seven human pathogenic fungal species, two fluconazole-resistant C. albicans isolates and two multi-drug resistant Candida auris isolates. Moreover, 0.5 μg/mL of 16, 18, and 29 was more effective than 2 μg/mL of fluconazole at inhibiting fungal growth of the strains tested. The most active compound (16) completely inhibited the growth of C. albicans SC5314 at 16 μg/mL for 24 h, affected biofilm formation and destroyed the mature biofilm at 64 μg/mL. Several Saccharomyces cerevisiae strains, overexpressing recombinant Cyp51s or drug efflux pumps, indicated 16, 18, and 29 targeted Cyp51 without being significantly affected by a common active site mutation, but were susceptible to target overexpression and efflux by both MFS and ABC transporters. GC-MS analysis demonstrated that 16, 18, and 29 interfered with the C. albicans ergosterol biosynthesis pathway by inhibition at Cyp51. Molecular docking studies elucidated the binding modes of 18 with Cyp51. The compounds showed low cytotoxicity, low hemolytic activity and favorable ADMT properties. Importantly, compound 16 showed potent in vivo antifungal efficacy in the G. mellonella infection model. Taken together, this study presents more effective, broad-spectrum, low toxicity triazole analogues that can contribute to the development of novel antifungal agents and help overcome antifungal resistance.

Neutrophil membrane-coated nanoparticles exhibit increased antimicrobial activities in an anti-microbial resistant K. pneumonia infection model

OBJECTIVE

To investigate the efficacy and safety of neutrophil membrane-coated nanoparticles mediated KLA peptides (KLAKLAKKLAKLAK) and gentamicin in the targeted therapy of anti-microbial resistant Klebsiella pneumoniae (K. pneumonia) lung infection.

METHODS

The characteristics of KLA-neutrophils nanoparticles (NNPs) are identified via dynamic light scattering (DLS), transmission electron microscope (TEM), SDS-PAGE, Western blot, quantitative flow cytometry (QFCM) and confocal microscopy. The safety of KLA-NNPs both in vitro and in vivo is evaluated by hemolysis test, platelet α granule membrane protein concentration, protein adsorption capacity, in vitro macrophage phagocytosis, weight change, liver function indicators, blood biochemical indicators, and pathological changes of vital organs in mice. The efficacy of KLA-NNPs is determined by time-kill assay, fluorescent label test, intracellular bacterial content, caspase-1 activity, survival rate, and HE staining both in vitro and in vivo.

RESULTS

The prepared KLA-NNPs have a typical "core-shell" structure, uniform nanometer size, and retain the membrane proteins on the neutrophil membrane that achieve functional effects. In vitro safety analysis showed that KLA-NNPs have good blood compatibility and can inhibit macrophage phagocytosis in vitro. KLA-NNPs can effectively release KLA and significantly reduce intracellular bacteria and caspase-1 activity. In vivo safety analysis and efficacy analysis revealed that KLA-NNPs have good biocompatibility and could effectively improve the survival rate of mice.

CONCLUSION

The prepared KLA-NNPs have good nano-medicine chemical and physical properties and safety. It can evade immune system clearance, achieve high-efficiency targeted aggregation and drug delivery to bacterial infection sites, and effectively inhibit the development of pneumonia induced by drug-resistant K. pneumonia.

Mesoporous silica nanoparticles as carrier to overcome bacterial drug resistant barriers

Antibiotic resistance has become a global threat to health due to abuse of antibiotics. Lots of existing antibiotics have lost their effect on drug resistant bacteria. Moreover, the discovery of novel antibiotics becomes more and more difficult. It is necessary to develop new strategies to fight against antibiotic resistance. Nano-drug delivery systems endow old antibiotics with new vitality to defeat the antibiotic resistant barrier by protecting antibiotics against hydrolysis, increasing uptake and circumventing efflux pump. Among them, mesoporous silica nanoparticles (MSNs) are one of the most extensively investigated as carrier of antibiotics due to large drug loading capability, tunable physicochemical characteristics, and biocompatibility. MSNs can improve the delivery of antibiotics to bacteria greatly by reducing size, modifying surface, and regulating shapes. Furthermore, MSNs hybridized metal ions or metal nanoparticles exert stronger antibacterial effect by controlling the release of metal ions or increasing active oxygen species. In addition, metal capped MSNs are also able to load antibiotics to exert synergistic antibacterial effect. This paper firstly reviewed the current application of various nanomaterials as antibacterial agents, and then focused on the MSNs including the introduction of MSNs and various approaches for improving antibacterial effect of MSNs.

S100A11: A Potential Carcinogen and Prognostic Marker That Correlates with the Immunosuppressive Microenvironment in Pan-Cancer

S100 calcium-binding protein A11 (S100A11) has been proved to be an oncogene of most tumors. However, its role in the tumor microenvironment (TME) in pan-cancer stills remains poorly understood. This study used public data from The Cancer Genome Atlas (TCGA) and the Genotype-Tissue Expression (GTEx) database to evaluate the expression of S100A11. The R package "GSVA" was used for Gene set variation analysis (GSVA) of S100A11. The R package "ESTIMATE" was used to further explore the relationship between S100A11 and TME. The Genomics of Drug Sensitivity in Cancer database was used to investigate the effect of S100A11 on the efficiency of anticancer drugs. We found S100A11 expression was upregulated in most tumors and predicted a poor prognosis. Furthermore, S100A11 expression was closely associated with immune regulation-related pathways. Moreover, S100A11 expression in pan-cancer was significantly related to most immunosuppressive cells, such as tumor-associated macrophages (TAM), tumor-associated fibroblasts (TAF), and Treg cells. The expression of S100A11 was significantly related to immunosuppressive genes and immune checkpoints in most tumor types. Additionally, the upregulation of S100A11 expression made patients with cancer resistant to the treatment of most anticancer drugs, such as sorafenib. In brief, our study showed that S100A11 could be used as a potential carcinogen and prognostic marker for most tumor types. The increased expression of S100A11 was closely related to tumor immunosuppressive TME. The upregulation of S100A11 expression made patients with cancer resistant to sorafenib treatment.

Treatment of chronic relapsing urinary tract infection with antibiotics selected by AtbFinder

We report the case of a 46-year-old patient who, after renal cancer surgery, developed a recurrent urinary tract infection that lasted for more than 2 years. Despite repeated antibiotic courses, including broad-spectrum drugs chosen using conventional antibiotic susceptibility testing, multiple reinfections followed. The patient was successfully treated once antibiotics were selected with AtbFinder. Unlike routine antimicrobial susceptibility methods, which select antibiotics effective only against a "lead bacterial pathogen," AtbFinder identifies antibiotics that target the mixture of bacteria at the infection site. This case demonstrates the ability of AtbFinder to successfully select antibiotics for the treatment of relapsing urinary tract infections.

Effective degradation of Chlortetracycline using dual bio catalyst

Chlortetracycline (CTC) degradation using potential microbial consortia or individual bacterial strains was useful method for improving bioremediation potential. The co-culture (Klebsiella pneumoniae CH3 and Bacillus amyloliquefaciens CS1) of bacterial strains have the ability to degrade chlortetracycline (91.8 ± 1.7%), followed by sulfamethoxazole (62.1 ± 1.2%) and amoxicillin (73.9 ± 3.3%). It was observed that the degradation potential was maximum after 10 days incubation, 8-10% inoculum, pH 7.5, and antibiotic concentration ranged from 150 to 200 mg/L. The initial concentrations of CTC significantly affected CTC degradation. In strain CH3, maximum biodegradation of CTC (99.4 ± 2.3%) was observed at 200 mg/L initial CTC concentrations. In CS1, maximum biodegradation of CTC was obtained at 150 mg/L concentration (80.5 ± 3.2%) after 10 days of culture. Alkaline pH was found to be suitable for the degradation of antibiotic than acidic range. After initial optimization by one factor at a time approach in free cells, the bacterial strains (CH3 and CS1) were co-immobilized. The co-immobilized bacterial cells showed improved degradation potential than free cells. To determine the biodegradation potential of immobilized cells, the selected strains were immobilized in polymer beads and treated with CTC with 175 mg/L initial concentration. The experimental results revealed that after 3 days of treatment the residual CTC concentration was 150.1 ± 3.2 mg/L and it decreased as 1.28 ± 0.01 mg/L after 10 days of treatment. The present study confirmed the effectiveness and feasibility of biodegradation ability of K. pneumoniae CH3 and B. amyloliquefaciens CS1 immobilized for CTC degradation in wastewater.

Methicillin and multidrug resistant pathogenic Staphylococcus aureus associated sepsis in hospitalized neonatal infections and antibiotic susceptibility

BACKGROUND

Neonatal infection is infection of the newborn or neonate acquired in first four weeks of life or during prenatal development. Microorganism associated neonatal infections caused severe mortality in recent years. It is developed either prenatally or within 28 days of neonatal period. This infection is mainly transmitted from mother to child through placenta. It has been well associated with the premature rupture of membranes which markedly enhances the risk of neonatal sepsis.

METHODS

The present experiment was designed to analyze bacteria, their antibiotic resistance pattern and possible risk factors among neonatal patients with sepsis. The neonates specimen was subjected for the isolation of bacteria and antibiotic susceptibility test. Neonates were analyzed with previous clinical history such as, previous admission in hospitals, mode of delivery, birth weight, and feeding type in accordance with questionnaire.

RESULTS

Gram-positive bacteria isolates were found to be high (79 strains, 64.22%) than the Gram-negative bacteria (44 strains, 32.5%). Staphylococcus aureus (33 strains, 26.9%) was the major Gram-positive groups of bacteria. Multidrug resistance analysis accounted more S. aureus (26.9%) and 5 strains (15.15%) showed methicillin resistance, whereas 84.9% were found to be sensitive to methicillin.

CONCLUSION

In this study, S. aureus and K. pneumoniae were the highest frequency of isolates. The overall percentage of multidrug resistant isolates was high in this study. Highest degree of resistance was observed in ampicillin against all isolates. Hence much attention is required while diagnosing sepsis among neonates. To analyze the risk for neonatal sepsis, it is not preferable for caesarian mode of delivery. Moreover, frequent screening of mother, suitable prenatal care of newborns with proper clinical interventions isthe key elements to control sepsis.

MEFAS, a hybrid of artesunate-mefloquine active against asexual stages of Plasmodium vivax in field isolates, inhibits malaria transmission

Human malaria continues to be a public health problem and an important cause of morbidity and mortality in the world. Malaria control is achieved through both individual protection against mosquito bites and drug treatment, which is hampered by the spread of Plasmodium falciparum resistance to most antimalarials, including artemisinin derivatives. One of the key pharmacological strategies for controlling malaria is to block transmission of the parasites to their mosquito vectors. Following this rational, MEFAS, a synthetic hybrid salt derived from artesunate (AS) and mefloquine has been previously reported for its activity against asexual P. falciparum parasites in vitro, in addition to a pronounced reduction in the viability of mature gametocytes. Herein, MEFAS was tested against asexual forms of Plasmodium vivax and for its ability to block malaria transmission in Anopheles darlingi mosquitoes in a membrane feeding assay using P. vivax field isolates. MEFAS demonstrated high potency, with a IC50 of 6.5 nM against asexual forms of P. vivax. At 50 μM, MEFAS completely blocked oocyst formation in mosquitoes, regardless of the oocyst number in the control group. At lower doses, MEFAS reduced oocyst prevalence by greater than 20%. At equivalent doses, AS irregularly reduced oocyst formation and caused only slight inhibition of mosquito infections. These results highlight the potential of MEFAS as a novel transmission-blocking molecule, as well as its high blood schizonticidal activity against P. vivax and P. falciparum field isolates, representing a starting point for further development of a new drug with dual antimalarial activity.

Determinants of drug resistant & drug sensitive tuberculosis patients from North India-a case control study

BACKGROUND AND OBJECTIVE

The burden of drug resistant tuberculosis (DRTB) has posed a huge challenge to for the governments, throughout the world. India has 27% of the global DRTB burden with incidence of 130,000 cases. India has kept an ambitious target of elimination of tuberculosis by 2025 which requires understanding and mitigating various determinants of DRTB.

METHODS

The retrospective case control study was undertaken from May to September 2019 among drugresistant (cases) and drug sensitive (controls) tuberculosis patients from two districts of Himachal Pradesh, India. A total of 211 participants were recruited in the study, which includes all 102 cases and randomly selected, age and sex matched 109 controls. A semi structured questionnaire, adapted from a study by Lobo et al, was used for assessing the determinants of DRTB and DSTB. The data collection was undertaken from district and block level health care facilities followed by home visits to patients. Multivariate logistic regression was used to determine risk factors associated with DRTB.

RESULTS

Diagnostic delay (aOR-7.72, p value 0.000), history of treatment default (aOR-2.97, self history of tuberculosis (aOR 1.42, p value 0.01), migration (aOR-4.84, p value 0.000), smoking (aOR-2.70, p value 0.014), and belonging to rural area (aOR-2.62, p value- 0.013) were found as independent risk factors for the occurrence of DRTB.

CONCLUSION

The risk factors identified in the study should be prioritized by the policy makers, implementators and educators for framing appropriate policies in TB control programme in India. The diagnostic delay as a risk factor merits active case finding of TB patients and educating health care staff and community.

Drug resistant tuberculosis cases from the Copperbelt province and Northern regions of Zambia: Genetic diversity, demographic and clinical characteristics

Tuberculosis (TB) caused by Mycobacterium tuberculosis remains a major cause of death worldwide. Diverse genotypes have been demonstrated to drive the epidemiology of drug resistant (DR-) TB globally. Currently, there is limited knowledge on the genotypes and transmission dynamics of M. tuberculosis in Zambia. This study aimed to describe the genotypes of DR-TB from the Copperbelt and Northern regions of Zambia. Molecular typing tools of insertion sequence 6110-restriction fragment length polymorphism (IS6110-RFLP) and spacer oligonucleotide typing (spoligotyping) were applied. We demonstrate that diverse genotypes are associated with DR-TB in Zambia. The predominant genotype was lineage 4; other strains belonged to lineage 2 and 3. Genotypes previously identified as driving the epidemiology of drug susceptible TB have been identified as drivers of DR-TB. Genotyping analysis showed clustering of strains among patients from different regions of the country; suggesting that DR-TB is widespread. Molecular findings combined with phenotypic and epidemiologic findings play a critical role in identifying circulating genotypes and possible transmission chains. Clustering of drug resistant strains was demonstrated to be 48% and 86% according to IS6110-RFLP and spoligotyping, respectively. However, gaps in clinical and demographic data skew the interpretation, and call for data collection policy improvements.

Treatment outcomes of drug resistant tuberculosis patients with multiple poor prognostic indicators in Uganda: A countrywide 5-year retrospective study

BACKGROUND

Comorbid conditions and adverse drug events are associated with poor treatment outcomes among patients with drug resistant tuberculosis (DR - TB). This study aimed at determining the treatment outcomes of DR - TB patients with poor prognostic indicators in Uganda.

METHODS

We reviewed treatment records of DR - TB patients from 16 treatment sites in Uganda. Eligible patients had confirmed DR - TB, a treatment outcome in 2014-2019 and at least one of 15 pre-defined poor prognostic indicators at treatment initiation or during therapy. The pre-defined poor prognostic indicators were HIV co-infection, diabetes, heart failure, malignancy, psychiatric illness/symptoms, severe anaemia, alcohol use, cigarette smoking, low body mass index, elevated creatinine, hepatic dysfunction, hearing loss, resistance to fluoroquinolones and/or second-line aminoglycosides, previous exposure to second-line drugs (SLDs), and pregnancy. Tuberculosis treatment outcomes were treatment success, mortality, loss to follow up, and treatment failure as defined by the World Health Organisation. We used logistic and cox proportional hazards regression analysis to determine predictors of treatment success and mortality, respectively.

RESULTS

Of 1122 DR - TB patients, 709 (63.2%) were male and the median (interquartile range, IQR) age was 36.0 (28.0-45.0) years. A total of 925 (82.4%) had ≥2 poor prognostic indicators. Treatment success and mortality occurred among 806 (71.8%) and 207 (18.4%) patients whereas treatment loss-to-follow-up and failure were observed among 96 (8.6%) and 13 (1.2%) patients, respectively. Mild (OR: 0.57, 95% CI 0.39-0.84, p = 0.004), moderate (OR: 0.18, 95% CI 0.12-0.26, p < 0.001) and severe anaemia (OR: 0.09, 95% CI 0.05-0.17, p < 0.001) and previous exposure to SLDs (OR: 0.19, 95% CI 0.08-0.48, p < 0.001) predicted lower odds of treatment success while the number of poor prognostic indicators (HR: 1.62, 95% CI 1.30-2.01, p < 0.001), for every additional poor prognostic indicator) predicted mortality.

CONCLUSION

Among DR - TB patients with multiple poor prognostic indicators, mortality was the most frequent unsuccessful outcomes. Every additional poor prognostic indicator increased the risk of mortality while anaemia and previous exposure to SLDs were associated with lower odds of treatment success. The management of anaemia among DR - TB patients needs to be evaluated by prospective studies. DR - TB programs should also optimise DR - TB treatment the first time it is initiated.

Validation of an indigenous assay for rapid molecular detection of rifampicin resistance in presumptive multidrug-resistant pulmonary tuberculosis patients

Background & objectives:

There is a need for an affordable, easy, high-sensitivity test usable at the peripheral health facility for diagnosis of drug-resistant (DR) tuberculosis (TB) to interrupt disease transmission. Nucleic acid amplification tests (NAATs) for early detection of DR-TB are ideal to bring testing near to the patient. Truenat™ MTB (Mycobacterium tuberculosis) and Truenat™ MTB-RIF (rifampicin) is an indigenous chip-based real-time polymerase chain reaction (PCR) based test for detection of multidrug-resistant (MDR) TB. The test involves extraction of DNA using automated, battery operated Trueprep instrument and real-time PCR performed on the Truelab analyzer. We report here multicentric validation of Truenat MTB-RIF for detection of DR-TB in suspected DR-TB patients.

Methods:

Consecutive patients aged 18-65 yr, with symptoms suggestive of TB and with a history of previous treatment, reporting to the National TB Elimination Programme (NTEP) clinics under four national institutes, namely AIIMS (All India Institute of Medical Sciences, New Delhi), NITRD (National Institute of Tuberculosis and Respiratory Diseases, New Delhi), NIRT (National Institute for Research in Tuberculosis, Chennai) and ICMR-National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra, were included in the study. Two sputum samples (one spot and one morning) were collected from each patient, after obtaining informed written consent. The samples were subjected to smear, GeneXpert and MGIT 960 culture (and drug susceptibility testing to RIF) (surrogate for MDR-TB) to serve as reference tests. The samples were coded to ensure blinding and subjected to Truenat MTB-RIF. Truenat MTB-RIF Version 1.5 was used for testing 1084 samples for RIF resistance, while Version 2.0 was used to test another 1201 samples.

Results:

Truenat MTB-RIF Version 1.5 in comparison with comprehensive laboratory reference standards yielded sensitivity and specificity of 76.2 and 94.7 per cent, respectively for the detection of RIF resistance in 1084 samples, collected across four sites. Based on the analysis of discordant samples, Version 2.0 of Truenat was developed by the manufacturer and this was further tested on additional 1201 samples, yielding a sensitivity of 87.5 per cent and specificity of 99.5 per cent.

Interpretation & conclusions:

Multicentric trial of Truenat™ MTB-RIF demonstrated a great potential of this point of care NAAT for detection of MDR-TB. The test would be useful in limited resource settings and inaccessible areas without need for any additional infrastructure.

A novel bicyclic 2,4-diaminopyrimidine inhibitor of Streptococcus suis dihydrofolate reductase

Streptococcus suis is a Gram-positive bacterial pathogen of pigs and an emerging zoonotic pathogen. It has become increasingly resistant to multiple classes of antibiotics. New drug candidates and knowledge of their targets are needed to combat antibiotic-resistant S. suis. In this study, the open-source Pathogen Box compound library was screened. Thirty hits that effectively inhibited S. suis growth at 10 µM were identified. Among the most potent hits, MMV675968 (a diaminoquinazoline analog) was shown to target S. suis dihydrofolate reductase (SsDHFR) via (1) growth inhibition of an E. coli surrogate whose growth is dependent on exogenously expressed SsDHFR and (2) inhibition of in vitro SsDHFR activity. Thymidine supplement is able to reverse growth inhibition by MMV675968 in both E. coli surrogate and S. suis, indicating that a thymidine-related pathway is a major target of MMV675968. Comparison of MMV675968 with seven DHFR inhibitors representing different core structures revealed that bicyclic 2,4-diaminopyrimidines with long and flexible side chains are highly effective in inhibiting SsDHFR and S. suis growth. MMV675968 and related compounds thus may serve as starting points for developing antibiotics against drug resistant S. suis.

[Significance of Lipopolysaccharide Lipid A Gene Mutation of Extensively Drug-resistant Acinetobacter baumanii on Polymyxin Resistance and Its Influence on Treatment]

OBJECTIVE

To explore the significance of the resistance to polymyxin resistance of the extensively drug resistant Acinetobacter baumannii (XDRAB) lipopolysaccharide (LPS) lpx A, lpx C, lpx D and to screen appropriate combination therapy.

METHODS

In the past two years, 72 XDRAB in the secretions of our patients were selected as the research object. According to the minimum inhibitory concentration (MIC) of the XDRAB strain on polymyxin, they were included in the drug resistance group and the sensitive group. The gene sequences of strains lpx A, lpx C, lpx D were compared with the standard strains to analyze gene mutations and compared the mutation rates in the drug resistant group and the sensitive group. The efficacy of the combination drugs was evaluated by microcheckerboard dilution method, including polymyxin+imipenem group, polymyxin+meropenem group, polymyxin+cefoperazone/sulbactam group, polymyxin+levofloxacin group, and polymyxin+fosfomycin group. Calculated the fractional inhibitory concentration (FIC) index of the combined medication regimen and compared the percentage of strains that exhibited synergistic, additive, irrelevant, and antagonistic effects.

RESULTS

Tentyone were in the drug resistant group, accounting for 21 (29.17%,) and 51 were in the sensitive group, accounting for 70.83%. Some strains had mutations in lpx A, lpx C, lpx D genes. The mutation rate in the drug resistant group was 90.48%, which was significantly higher than 11.76% in the sensitive group, the difference was statistically significant ( P<0.05). The combined drug sensitivity test showed, compared with the polymyxin+fosfomycin group, the mycotin+fosfomycin group had a higher percentage of strains with synergistic FIC index in the polymyxin+imipenem group, the difference was statistically significant ( P<0.01).

CONCLUSION

XDRAB is resistant to polymyxin, which is related to mutations in LPS lipid A biosynthesis genes lpx A, lpx C, lpx D. Clinical treatment should adopt a combination of polymyxin+imipenem/meropenem and other drug combination to reduce the secondary infection of drug resistant bacteria.

Identification and differential expression of serotransferrin and apolipoprotein A-I in the plasma of HIV-1 patients treated with first-line antiretroviral therapy

Background

Plasma proteins are known to interfere the drug metabolism during therapy. As limited information is available regarding the role of plasma proteins in HIV drug resistance during ART in HIV/AIDS patients, the present study aimed to identify and characterize the differentially expressed plasma proteins in the drug resistant and drug respondent groups of HIV-1 infected patients with > 6 years of first line ART.

Methods

Four-drug resistant (treatment failure) and four-drug respondent (treatment responder) patients were selected for plasma proteomic analysis based on viral load and drug resistance associated mutations from a cohort study designed on the first line ART patients who were enrolled in the antiretroviral therapy center, Sarojini Naidu Medical College, Agra, India from December 2009 to November 2016.

After depleting high abundant proteins, plasma proteins were resolved using two-dimensional gel electrophoresis on IPG strips, pH range of 3–10. Spots were selected in the gel based on the density of staining which was common in the drug resistant and drug respondent groups separately. The fold change of each spot was calculated using image-J. Each protein spot was identified using the matrix assisted laser desorption/ionization-time of flight/time of flight (MALDI-TOF/TOF) after tryptic digestion. Peptide peaks were identified through flex analysis version 3.3, and a search against a protein data base using the internal Mascot. Gene ontology study was completed through STRING v.11 and Panther15.0.

Results

Out of eight spots from 2D gel samples analyzed by MALDITOF/TOF, two proteins were found to have significant score (> 56) after Flex analysis. These two proteins were identified to be apolipoprotein A1 and serotransferrin. The fold change expression of these two proteins were analyzed in drug resistant and drug respondent group. Apolipoprotein-A1 and serotransferrin were observed to be expressed 1.76 and 1.13-fold more respectively in drug respondent group compared to drug resistant group. The gene ontology analysis revealed the involvement of these two proteins in various important physiological processes.

Conclusion

Apolipoprotein A-I and serotransferrin were found to be expressed more in drug respondent group compared to drug resistant group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05610-6.

Performance analysis of EEG seizure detection features

Automatic detection of epileptic seizures can serve as a valuable clinical tool which involves a more objective and computationally efficient method for the analysis of EEG data in order to generate increasingly accurate and reliable results. Automatic seizure detection is also an important component of closed-loop responsive cortical stimulation systems. The goal of this study is to evaluate EEG-based features recently proposed for seizure detection to discover the optimum ones for a reliable seizure detection system. We extracted seizure detection features from intracranial EEG signals that were recorded during invasive pre-surgical epilepsy monitoring of people with drug resistant focal epilepsy at the Epilepsy Center of the University Hospital of Freiburg. Features from time, frequency and phase space domains as well as similarity/dissimilarity features were considered. The performance of each feature was investigated using the statistical test ANOVA. Performance analysis was conducted separately on the recordings from the channels within the seizure-onset zone (SOZ-in) and the recordings from the channels outside the seizure-onset zone (SOZ-out). Similarity/dissimilarity features that measure dynamic properties of the EEG signal and the evolving phenomena of the seizures could significantly separate ictal (during seizure) states from pre-ictal (before seizure) states (p < 0.01). Among them, our proposed feature, Bhattacharyya-based dissimilarity index (BBDI), successfully passed Tukey's post-hoc test as well suggesting that it can distinguish both pre-ictal and post-ictal (after seizure) periods from ictal period. BBDI was further applied to detect epileptic seizures and achieved area under the curve of the receiver-operator characteristic (ROC) equal to 0.96 and 0.94 for SOZ-in and SOZ-out channels, respectively. No significant difference (p = 0.59) was observed in the performance of features between SOZ-in recordings and SOZ-out recordings. The discriminative value of EEG seizure detection features was determined by statistical tests. As a result, the best features to be selected for a reliable seizure detection system designed for people with drug-resistant focal epilepsy were suggested, which include similarity/dissimilarity indices.

Characterization of biofilm formed by multidrug resistant Pseudomonas aeruginosa DC-17 isolated from dental caries

The present work reports with the screening of biofilm-producing bacteria from the dental caries. The dental pathogens showed resistance against various antibiotics and biofilm forming ability at various levels. Among the bacterial strain, Pseudomonas aeruginosa DC-17 showed enhanced biofilm production. Extracellular polymeric substance (EPS) was synthesized by the selected bacterial isolate considerably and contributed as the major component of biofilm. EPS composed of eDNA, proteins and lipids. The total protein content of the EPS was found to be 1.928 mg/mL and was the major component than carbohydrate and DNA. Carbohydrate content was 162.3 mg/L and DNA content of EPS was 4.95 μg/mL. These macromolecules interacted in the matrix to develop dynamic and specific interactions to signalling biofilm to differentiating various environments. Also, the isolated bacteria showed resistant against various commercially available antibiotics. The isolates showed more resistance against penicillin (98%) and were sensitive against amoxicillin. Among the factors, temperature, pH and sugar concentration influenced biofilm formation. Biofilm forming ability of the selected bacterial stain was tested at various pH values and alkaline pH was favoured for biofilm production. Biofilm production was found to be maximum at 40 °C and 8% sucrose enhanced biofilm formation. Biofilm formed by P. aeruginosa DC-17 was resistant against various tested antimicrobials and chemicals.

Transcriptional activation of cyclin D1 via HER2/HER3 contributes to EGFR-TKI resistance in lung cancer

Several different mechanisms are implicated in the resistance of lung cancer cells to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), and only few have been functionally investigated. Here, using genetically knocked out EGFR and TKI-resistant lung cancer cells, we show that loss of wild-type EGFR attenuates cell proliferation, migration and 3D-spheroid formation, whereas loss of mutant EGFR or resistance to TKIs reinforces those processes. Consistently, disruption of wild-type EGFR leads to suppression of HER2/HER3, while mutant EGFR ablation or resistance to TKIs increases HER2/HER3 expression, compensating for EGFR loss. Furthermore, HER2/HER3 nuclear translocation mediates overexpression of cyclin D1, leading to tumor cell survival and drug resistance. Cyclin D1/CDK4/6 inhibition resensitizes erlotinib-resistant (ER) cells to erlotinib. Analysis of cyclin D1 expression in patients with non-small cell lung carcinoma (NSCLC) showed that its expression is negatively associated with overall survival and disease-free survival. Our results provide biological and mechanistic insights into targeting EGFR and TKI resistance.

Review of automated DNA extraction systems for sequencing-based solutions for drug-resistant tuberculosis detection

Robust clinical specimen nucleic acid extraction instrumentation and methods are critical to the performance of downstream molecular diagnostics for the diagnosis of drug-resistant tuberculosis (DR-TB). Currently, there is a high level of interest in sequencing-based solutions for rapid and comprehensive DR-TB testing from primary specimens (i.e., sputum). However, there is no standardized or fully automated sputum extraction system that has been widely implemented for use with Mycobacterium tuberculosis complex-containing sputum specimens. For sequencing-based technologies to be widely adopted in clinical laboratory settings in low- and middle-income countries, automated extraction technologies will be important to enhance scalability and reliability and to standardize performance of the downstream assays. Additionally, the ease of automatic technologies allows for faster uptake in laboratories currently without the expertise or infrastructure to perform manual extractions at the same automated throughput. This work is intended to provide an initial specification comparison of available automated DNA extraction systems that could serve as front-end components for existing and future sequencing approaches and provide the framework for future evaluations.

Potential effect of Allium sativum bulb for the treatment of biofilm forming clinical pathogens recovered from periodontal and dental caries

Biofilm producing clinical bacterial isolates were isolated from periodontal and dental caries samples and identified as, Lactobacillus acidophilus, Streptococcus sanguis, S. salivarius, S. mutansand Staphylococcus aureus. Among the identified bacterial species, S. aureus and S. mutansshowed strong biofilm producing capacity. The other isolated bacteria, Streptococcus sanguis, S. salivarius showed moderate biofilm formation. These pathogens were subjected for the production of extracellular polysaccharides (EPS) in nutrient broth medium and the strain S. aureus synthesized more amounts of EPS (610 ± 11.2 µg/ml) than S. sanguis (480 ± 5.8 µg/ml).EPS production was found to be less in S. salivarius (52 ± 3.8 µg/ml).The solvent extract of A. sativum bulb showed the phytochemicals such as, carbohydrate, total protein, alkaloids, saponins, flavonoids, tannins and sterioids. The solvent extract of A. sativum bulb showed wide ranges of activity against the selected dental pathogens. The difference in antibacterial activity of the solvent extract revealed differences in solubility of phytochemicals in organic solvents. Ethanol extract was highly active againstS. aureus (25 ± 2 mm). The Minimum Inhibitory Concentration (MIC) of crude garlic bulb varied widely and this clearly showed that bacteria exhibits different level of susceptibility to secondary metabolites. MIC value ranged between 20 ± 2 mg/ml and 120 ± 6 mg/ml and Minimum Bactericidal Concentration (MBC) value ranged from 60 ± 5 mg/l to 215 ± 7 mg/ml. To conclude, A. sativum bulb can be effectively used to treat periodontal and dental caries infections.

Biological characteristics and genetic evolutionary analysis of emerging pathogenic Bacillus cereus isolated from Père David's deer (Elaphurus davidianus)

Bacillus cereus (B. cereus) is widely distributed in the environment. It is one of the most common opportunistic food-borne pathogens associated with food poisoning, not only being majorly reported to cause fatal infections of the gastrointestinal tract, but also responsible for abdominal distress and vomiting. The current study was undertaken to evaluate the biological characteristics and the genetic evolution of B. cereus isolated from infected organs of dead Elaphurus davidianus (E. davidianus). B. cereus was characterized through antibiotic sensitivity tests, mouse lethality assay, whole genome sequencing analysis, and genome annotation. The results revealed that the isolated B. cereus strain was highly resistant to rifampicin, lincomycin, sulfamethoxazole, erythromycin, and ampicillin, with a high pathogenicity phenotype. KEGG annotation revealed that "metabolic pathways" had the largest number of unigenes, followed by "biosynthesis of secondary metabolites" and "biosynthesis of antibiotics". GO analysis resulted in 8039 unigenes categorized. Meanwhile, 54,779 unigenes were annotated and grouped into 23 categories based on COG functional classifications. Moreover, one gene (codY) was found to be related to the host in conformity with the analysis done on PHI-base. Other tests led to the identification of 16 B. cereus virulence factor genes and five resistance types, with potential resistance against bacitracin, penicillin, and fosfomycin. We isolated a highly drug-resistant and pathogenic B. cereus strain from E. davidianus, showing that a variety of antimicrobial drugs should be avoided in clinical treatments. Furthermore, to the best of our knowledge, this is the first study to report whole genome sequencing of a emergence of food-borne B. cereus strain isolated from E. davidianus deer; it will be helpful to extensively investigate the genetic and molecular mechanisms of drug resistance and pathogenesis about B. cereus in both humans and animals.

Adverse drug reactions in tuberculosis and management

BACKGROUND

Treatment of drug susceptible tuberculosis (DS-TB) requires regimens containing first line drugs (FLDs') whereas drug resistant tuberculosis (DR-TB) are treated with regimens comprising combination of both second line drugs (SLDs') and few FLDs'. Adverse drug reactions (ADRs') to these anti-tubercular drugs are quite common as they are being used for longer duration. ADRs' may cause associated morbidity and even mortality if not recognized early. There are major concerns regarding treatment of DR-TB patients particularly with SLDs' in that they are expensive, have low efficacy and more toxic as compared to FLDs'. There may be a severe impact on adherence and higher risk of default and treatment failure affecting outcome overall if such ADRs' are not properly managed.

METHODS

A search strategy was adopted involving principal electronic databases (Pubmed, EMBASE, Google and Google scholar) of English language articles from 1990 till now, using various terms in combination. All articles with resulting titles, abstract and full text, when available were read and kept for reference.

RESULTS

101 articles including 4 systematic reviews have been identified. The overall prevalence of ADRs' with FLDs' and SLDs' are estimated to vary from 8.0% to 85% and 69% to 96% respectively. Most ADRs' are observed in the intensive phase as compared to continuation phase. No difference in frequency of ADRs' was reported with intermittent or daily intake of anti-tubercular drugs. The occurrence of ADRs' may be influenced by multiple factors and may range from mild gastrointestinal disturbances to serious hepatotoxicity, ototoxicity, nephrotoxicity peripheral neuropathy, cutaneous ADRs', etc. Most of ADRs' are minor and can be managed without discontinuation of treatment. Some ADRs' can be major or severe causing life-threatening experience leading to either modification or discontinuation of regimen and even mortality if not recognized and treated promptly.

CONCLUSION

Early recognition by active surveillance and appropriate management of these ADRs' might improve adherence and treatment success.

Treatment outcome of multidrug-resistant tuberculosis with modified DOTS-plus strategy: A 2 years' experience

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a global health problem with notoriously difficult and challenging treatment. This study determined treatment outcome in patients of MDR-TB with modified DOTS-Plus strategy.

METHODS

Ninety-eight consecutive MDR-TB patients treated with standardized regimen according to modified DOTS-Plus strategy aligned to the existing national DOTS-Plus guidelines with relevant modifications proposed by Chennai consensus were analyzed prospectively. Treatment included monthly follow-up with clinical, radiological, and bacteriological assessment (sputum smear advised monthly till conversion then quarterly; culture for Mycobacterium tuberculosis at 0, 4, 6, 12, 18, and 24 months), ensuring adherence, intense health education, and monitoring of adverse events (AEs). Patients' outcome was considered as cure when at least two of the last three cultures (all three or last two) were negative and as failure when the same were positive.

RESULTS

Favorable and unfavorable outcomes in this cohort were reported to be 71/98 (72.4%) and 27/98 (27.6%) (failure - 10 [10.2%], default - 7 [7.1%], and expiry - 10 [10.2%]), respectively. Sputum smear and culture conversion rate were 75/81 (92.5%) and 71/81 (87.7%), respectively. Major AEs were experienced in only 17.4% of patients.

CONCLUSIONS

MDR-TB can be cured successfully with modified DOTS-Plus strategy and requires much effort from both the patients and health-care workers. It can be an alternative model for treating MDR-TB patients in private sector.

Precision medicine in resistant Tuberculosis: Treat the correct patient, at the correct time, with the correct drug

Human genomic mapping has advanced molecular medicine health care and created a transformative paradigm shift towards Precision Medicine. In 2015, President Obama launched the PM initiative, encapsulated as "unique individualized data-driven treatments". Since then, this field is rapidly advancing both curative treatment and disease prevention by accounting for both individual and environmental variability. While a substantial evidence for accelerating adoption of Precision Medicine in other spheres of medicine exists, application of Precision Medicine in infectious diseases is far more complex. One of the most warranted applications of precision healthcare is in the management and treatment of Drug-resistant Tuberculosis. Application of Precision Medicine to Drug-resistant Tuberculosis could potentially change the landscape of treatment and prevention of a disease affecting vulnerable patients in impoverished communities. Poorly diagnosed and treated Drug-resistant Tuberculosis not only leads to increased mortality and morbidity but also increased transmission of DR-TB strains, fuelling ongoing high incidence rates and further infection. A Precision medicine model using individual clinical case histories used in conjunction with Mycobacterium Tuberculosis infection genomic data will better guide health care practitioners in more appropriate drug selection, and an individualized management approach. This viewpoint deliberates the intricacies of adopting a PM approach in the management of DR-TB. If applied correctly, we postulate that the research, application, and deployment of PM in DR-TB management may address the fundamental rule of PM in infectious disease: to treat the correct patient, at the correct time, with the correct drug.

Intractable Generalized Epilepsy: Therapeutic Approaches

PURPOSE OF REVIEW

To summarize recent developments in therapeutic options, both medical and surgical, for patients with drug-resistant generalized epilepsy syndromes, which continue to be a multifaceted challenge for patients and physicians.

RECENT FINDINGS

Newer generation pharmaceutical options are now available, such as brivaracetam, rufinamide, lacosamide, perampanel, and cannabidiol. Less restrictive dietary options appear to be nearly as effective as classic ketogenic diet for amelioration of seizures. The latest implantable devices include responsive neurostimulation and deep brain stimulation. Corpus callosotomy is an effective treatment for some seizure types, and newer and less invasive approaches are being explored. Resective surgical options have demonstrated success in carefully selected patients despite generalized electrographic findings on electroencephalogram. The current literature reflects a widening range of clinical experience with newer anticonvulsant medications including cannabinoids, dietary therapies, surgical approaches, and neurostimulation devices for patients with intractable generalized epilepsy.

The Global Fight Against Tuberculosis

An estimated 1.7 billion (23%) of the world's population is infected with Mycobacterium tuberculosis leading to more than 10 million new tuberculosis (TB) cases each year. TB is one of the top 10 causes of death globally and is the leading cause of death from a single infectious disease agent. The World Health Organization's ambitious End TB Strategy aims to achieve a 95% reduction in TB deaths and 90% reduction in TB incidence rates by 2035.

Association between SCN1A polymorphism rs3812718 and valproic acid resistance in epilepsy children: a case-control study and meta-analysis

Resistance to valproic acid (VPA), a first-line antiepileptic drug (AED), is occurring at an alarming rate, particularly in children. Signal nucleotide polymorphisms are considered crucial in this process. Therefore, we investigated whether the SCN1A polymorphism rs3812718 could be associated with VPA resistance. A total of 231 children with epilepsy who were solely administered VPA were enrolled. DNA was extracted from the peripheral blood samples and was genotyped by the Mass Array method. Furthermore, a meta-analysis was conducted between the drug responsive and resistant patients who were exposed to voltage-gated sodium channels. Results revealed that the TT genotype was associated with a higher risk of developing drug resistance (OR = 2.636, 95% CI 1.08–6.433, P = 0.033). After adjusting for the risk factors, a significant difference was still observed between the responsive and resistant groups (OR = 2.861, 95% CI 1.141–7.174, P = 0.025). Moreover, the recessive model was associated with a decreased drug resistance (OR = 0.402, 95% CI 0.167–0.968, P = 0.042) after correcting the risk factors. Meta-analysis of nine studies revealed similar results. In conclusion, our results proved that the rs3812718 TT genotype was associated with a high risk of developing drug resistance, and the recessive model could decrease the risk of VPA resistance.

Identification of putative non-host essential genes and novel drug targets against Acinetobacter baumannii by in silico comparative genome analysis

Acinetobacter baumannii, the gram-negative bacteria emerged as an extremely critical pathogen causing nosocomial and different kinds of infections. A. baumannii exhibit resistivity towards various classes of antibiotics that shows that there is a dire need to search more drug targets by exploiting the full genome of the bacteria. In doing so, a strategy is made with the combination of computational biology, pathogen informatics and cheminformatics. Comparative genomics analysis, modeling and docking studies have been performed for the prediction of non-host essential genes and novel drug candidates against A. baumannii. Among 37 unique and 82 common metabolic pathways, 92 genes were predicted as non-host genes. Similarly, using homology search between A. baumannii genome and essential genes of different bacteria, 293 genes were predicted as essential genes of A. baumannii. Among these predicted non-host and essential genes, 86 genes were predicted as non-host essential genes which could serve as potential novel drug and vaccine targets. Additional drug-target like physicochemical properties were estimated such as the molecular weight, subcellular localization and druggability potential. On the structural part, the crystal structures of all the non-host essential genes of A. baumannii were found except the three genes. Out of these three, a homology model of Undecaprenyl-diphosphatase was built using a PDB template by MODELLER [version 9.18]. The quality of the model was assessed by the ProSA and RAMPAGE. The built model was subjected as a receptor for the molecular docking with Adenosine diphosphate (ADP) as a ligand. The molecular docking was performed by AutoDock4 and the best conformation with lowest binding energy (-4.39 kcal/mol) was obtained. The LigPlot was used to identify the close interactions between the ligand the receptor's residues. This study will further aid for the selection of putative inhibitors against a novel drug target identified against A. baumannii and hence could lead to the better therapeutics.

Cunaniol-elicited seizures: Behavior characterization and electroencephalographic analyses

This study aimed at describing the characteristics and properties of seizures induced by cunaniol, a polyacetylenic alcohol isolated from the Clibadium genus, which is ubiquitous in the Amazon biodiversity and its potential use as a convulsant model. Wistar rat behavior was assessed upon cunaniol administration and animals were evaluated for neural activity through electroencephalographic records whereby epidural electrodes were positioned over the motor cortex under cunaniol-elicited seizures and seizure's control using three anticonvulsant agents, namely phenytoin, phenobarbital and diazepam. Cunaniol-induced seizures displayed a cyclic development of electrocorticographic seizures, presenting interictal-like spike and ictal period, which correlates to the behavioral observations and is in line with acute seizures induced by pentylenetetrazole. Cunaniol-elicited seizures were intractable by phenytoin treatment and controlled under the GABAergic activities of phenobarbital and diazepam. The results indicate that the cunaniol-induced changes show characteristics of seizure activity, making this plant compound a suitable animal convulsant model for seizure-related studies that could be used to assist in the development of novel anticonvulsant agents.

Synthesis and antitumor activity of bis(hydroxymethyl)propionate analogs of pterostilbene in cisplatin-resistant human oral cancer cells

The aim of this study was to develop a new drug substance with low toxicity and effective inhibitory activity against cisplatin-resistant oral cancer. The naturally produced pterostilbene was selected as the lead compound for design and synthesis of a series of bis(hydroxymethyl)propionate-based prodrugs. All derivatives were screened for antiproliferative effects against the cisplatin-resistant oral squamous (CAR) cell line and the results indicated that several compounds demonstrated superior inhibitory activity compared with pterostilbene and resveratrol. Among them, the most promising compound, 12, was evaluated for in vivo antitumor activity in a CAR xenograft nude mouse model. Obvious antitumor activity was observed at the lowest oral dose (25 mg/kg/day). Increasing the dose of 12 to 100 mg/kg/day reduced the tumor size to 22% of the control group. Based on these findings as well as the extremely low toxicity seen in the in vivo studies, we believe that compound 12 could serve as a new lead for further development.

Management of Idiopathic Overactive Bladder Syndrome: What Is the Optimal Strategy After Failure of Conservative Treatment?

CONTEXT

A considerable number of patients affected by the overactive bladder syndrome (OAB) do not respond to pharmacotherapy and bladder training due to unsatisfactory response or intolerability.

OBJECTIVE

To review the available literature assessing therapeutic effect of the available third-line treatment modalities for OAB.

EVIDENCE ACQUISITION

PubMed, Medline, and Cochrane databases were searched for all studies comparing outcomes of the available third-line treatment modalities for OAB.

EVIDENCE SYNTHESIS

Several minimally invasive surgical procedures are available for patients with refractory OAB. These therapies include intravesical botulinum toxin type A, posterior tibial nerve stimulation, and sacral neuromodulation.

CONCLUSIONS

None of the mentioned therapeutic modalities shows strong superiority over another. If the results of one therapy are not satisfactory, switching to another third-line treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns. All these factors should be taken into consideration before initiation of treatment.

PATIENT SUMMARY

In the management of drug-resistant overactive bladder syndrome, the different minimally invasive treatments that are available are equal. If the results of one therapy are not satisfactory, switching to another treatment can be attempted. The treatment algorithm is dependent on several factors, including age, comorbidity, patient preference, surgical expertise, and financial concerns.

Growth Suppression of Glioma Cells Using HDAC6 Inhibitor, Tubacin

In cancer research, autophagy has been revealed as one of the major ways to maintain the metabolism of cancer cells, including glioma cells, through protein degradation. Meanwhile, autophagy is also regarded as a kind of mechanism to protect glioma cells from a harmful stimulus, such as chemical and radiation treatment. So, the inhibition of autophagy may be very helpful in curing glioma. This study aimed to determine the effect of autophagic inhibition on glioma cells using tubacin, a specific inhibitor of histone deacetylase 6(HDAC6). According to the results, tubacin inhibited the growth of both U251 and LN229 cells, which was accompanied by lower HDAC6 activity and accumulated autophagosome. The inhibition of HDCA6 also led to accumulation of autophagosome and death of glioma cells. Moreover, the combined treatment of tubacin and temozolomide, an alkylating agent used to treat glioblastoma, induced more severe glioma cell death. Thus, it can be concluded that inhibition of HDAC6 suppressed growth and drug resistance of glioma cells in-vitro through autophagic suppression and blocking of fusion of autophagosome and lysosome.

[Serotype distribution and antimicrobial resistance of Salmonella isolates from retail chicken carcasses in six provinces of China]

Objective: To obtain the serotype diversity and antimicrobial resistance of Salmonella isolates recovered from retail chicken carcasses for sale in six regions of China. Methods: From August 2010 to March 2012, each month 20 retail chicken carcasses including freshly slaughtered, chilled and frozen samples were collected from supermarkets and farmer's markets in 7 monitoring sites in Beijing, Jilin province, Inner Mongolia Autonomous, Shanxi province, Jiangsu province and Guangdong province, respectively. Samples were routinely collected for 12 months for each site. 1 680 chicken carcasses were collected in total and 2 629 Salmonella strains were isolated by PCR and biochemical method. Luminex xMAP method and classical slide agglutination method were carried out to determine isolates' serotypes. Minimal inhibitory concentrations (MICs) of 10 classes of antimicrobials including 14 agents were determined using broth micro-dilution method. Mocular methods were used to determine antimicrobial resistance genes of CIP-CTX-CT co-resistant isolates. Results: In all, 2 629 Salmonella isolates, there were 17 seorgroups and 58 serotypes, B and D1 were the dominant serogroups with rates of 34.7% (n=913) and 31.0% (n=815), Enteritidis (30.8%, n=810), Indiana (17.6%, n=463), Infantis (10.6%, n=278) were the top three serovars. We found 224 CIP-CTX co-resistant S. Indiana containing 3 colistin resistant strains, one of them carrying mcr-1 gene and being ESBLs positive, which demonstrated a nine multi drug resistance against 11 antimicrobials tested. Conclusion: These data began to describe the complicated serovar diversity and heavy antimicrobial resistance of Salmonella isolates recovered from retail chicken carcasses in six regions of China. The findings highlight the emergence of ciprofloxacin and cefotaxime co-resistant S. Indiana and also a mcr-1 positive S. Indiana with heavy multi drug resistance.

Tumor-targeting Salmonella typhimurium A1-R is a highly effective general therapeutic for undifferentiated soft tissue sarcoma patient-derived orthotopic xenograft nude-mouse models

Undifferentiated soft tissue sarcoma (USTS) is a recalcitrant and heterogeneous subgroup of soft tissue sarcoma with high risk of metastasis and recurrence. Due to heterogeneity of USTS, there is no reliably effective first-line therapy. We have generated tumor-targeting Salmonella typhimurium A1-R (S. typhimurium A1-R), which previously showed strong efficacy on single patient-derived orthotopic xenograft (PDOX) models of Ewing's sarcoma and follicular dendritic cell sarcoma. In the present study, tumor resected from 4 patients with a biopsy-proven USTS (2 undifferentiated pleomorphic sarcoma [UPS], 1 undifferentiated sarcoma not otherwise specified [NOS] and 1 undifferentiated spindle cell sarcoma [USS]) were grown orthotopically in the biceps femoris muscle of mice to establish PDOX models. One USS model and one UPS model were doxorubicin (DOX) resistant. One UPS and the NOS model were partially sensitive to DOX. DOX is first-line therapy for these diseases. S. typhimurium A1-R arrested tumor growth all 4 models. In addition to arresting tumor growth in each case, S. typhimurium A1-R was significantly more efficacious than DOX in each case, thereby surpassing first-line therapy. These results suggest that S. typhimurium A1-R can be a general therapeutic for USTS and possibly sarcoma in general.

Identifying drug resistant cancer cells using microbubble well arrays

Drug resistance is a characteristic of tumor initiating cells that can give rise to metastatic disease. In this work we demonstrate the use of microbubble well arrays as a cell culture platform to enumerate and characterize drug resistant cells in a human derived tumorigenic squamous cell carcinoma cell line. The spherical architecture and compliant hydrophobic composition of the microbubble well favors single cell survival, clonal proliferation and formation of spheres that do not grow on standard tissue culture plastic and are resistant to cisplatin. Spheres form in isolation and in microbubble wells containing proliferating cells and to some degree they stain positive for common stem cell markers CD44 and CD133. Spheres are also observed in cellularized primary human tumors cultured in microbubble arrays. This proof-of-concept study illustrates the potential for microbubble array technology to enumerate cancer cells resistant to standard care drugs with the ability to test alternative drug combinations. This capability can be developed for designing patient specific treatment strategies. Recovery of drug-resistant cells will allow a more full characterization of their gene expression profile thereby expanding our fundamental knowledge and ability to develop new targets to fight metastatic disease.

Drug-resistant Spinal Tuberculosis

Drug-resistant spinal tuberculosis (TB) is an emerging health problem in both developing and developed countries. In this review article, we aim to define management protocols for suspicion, diagnosis, and treatment of such patients. Spinal TB is a deep-seated paucibacillary lesion, and the demonstration of acid-fast bacilli on Ziehl-Neelsen staining is possible only in 10%-30% of cases. Drug resistance is suspected in patients showing the failure of clinicoradiological improvement or appearance of a fresh lesion of osteoarticular TB while on anti tubercular therapy (ATT) for a minimum period of 5 months. The conventional culture of Mycobacterium tuberculosis remains the gold standard for both bacteriological diagnosis and drug sensitivity testing (DST); however, the high turn around time of 2-6 weeks for detection with added 3 weeks for DST is a major limitation. To overcome this problem, rapid culture methods and molecular methods have been introduced. From a public health perspective, reducing the period between diagnosis and treatment initiation has direct benefits for both the patient and the community. For all patients of drug-resistant spinal TB, a complete Drug-O-Gram should be prepared which includes details of all drugs, their doses, and duration. Patients with confirmed multidrug-resistant TB strains should receive a regimen with at least five effective drugs, including pyrazinamide and one injectable. Patients with resistance to additional antitubercular drugs should receive individualized ATT as per their DST results.

Retention of perampanel in adults with pharmacoresistant epilepsy at a single tertiary care center

RATIONALE

Observational data on antiepileptic drugs (AEDs) inform about their use in clinical practice. We describe our clinical experience with perampanel (PER) in a large UK tertiary epilepsy center.

METHODS

Adults initiated on PER between October 2012 and March 2015 were followed until they discontinued PER or 10 September 2016. Data on epilepsy syndrome, duration, seizure types, concomitant and previous AED use, PER dosing, efficacy and side effects were recorded. Efficacy was categorized as temporary or ongoing (at last follow-up) seizure freedom, ≥50% seizure reduction, or other benefit (e.g. No convulsions or daytime seizures). These categories were mutually exclusive except for people with temporary seizure freedom.

RESULTS

391 received a PER prescription, five of whom never took it. No follow-up data were available for ten. 83% had focal epilepsy. People were prescribed PER in addition to 1-7 (Interquartile range [IQR] 2, 2, 3) AEDs and had previously used up to 18 (IQR 5, 7, 10) AEDs. Total exposure was 639patient/years. Retention rates were 60.4% at one year, 48.3% at two years, and 42.7% at three years. 19 (5%) people reported seizure free periods lasting at least six months. A ≥50% reduction in seizures lasting at least six months was reported by 76 people (20%), and marked improvement for ≥6months was seen in 52 (14%). Five (1%) were taken off other AEDs and continued on PER monotherapy for 4-27months. Seizures were aggravated in 57 (15%). Somatic side effects were reported by 197 (52%), mostly CNS. Mood changes, irritability or challenging behavior were reported by 137 (36%). PER was discontinued by 211 (56%) due to adverse effects (39%), inefficacy (26%), or both (35%). No idiosyncratic adverse events were seen.

CONCLUSION

PER resulted in some benefit in 40% of those exposed. Adverse effects on mental health and on balance were common and should be discussed with people before initiating PER.

Drug-resistant tuberculosis coexisting with invasive candidiasis in an immunocompetent 30-year-old woman: A case report

Invasive candidiasis coexisting with drug-resistant Mycobacterium tuberculosis (DR-TB) in the immunocompetent patient is a rare entity. We report a 30-year-old woman, nondiabetic, who presented to us with complaints of acute onset cough, breathlessness, and fever since 20 days. On thorough investigations, she was diagnosed to be suffering from coexisting drug-resistant tuberculosis and invasive candidiasis. Prompt treatment initiated at right time helped us in saving her life. The unique presentation of this case and that too in an immunocompetent female makes it an interesting case.

Preclinical Screening for Treatments for Infantile Spasms in the Multiple Hit Rat Model of Infantile Spasms: An Update

Infantile spasms are the typical seizures of West syndrome, an infantile epileptic encephalopathy with poor outcomes. There is an increasing need to identify more effective and better tolerated treatments for infantile spasms. We have optimized the rat model of infantile spasms due to structural etiology, the multiple-hit rat model, for therapy discovery. Here, we test three compounds administered after spasms induction in the multiple hit model for efficacy and tolerability. Specifically, postnatal day 3 (PN3) male Sprague-Dawley rats were induced by right intracerebral injections of doxorubicin and lipopolysaccharide. On PN5 p-chlorophenylalanine was given intraperitoneally (i.p.). Daily monitoring of weights and developmental milestones was done and rats were intermittently video monitored. A blinded, randomized, vehicle-controlled study design was followed. The caspase 1 inhibitor VX-765 (50-200 mg/kg i.p.) and the GABA_B receptor inhibitor CGP35348 (12.5-100 mg/kg i.p.) each was administered in different cohorts as single intraperitoneal injections on PN4, using a dose- and time-response design with intermittent monitoring till PN5. 17β-estradiol (40 ng/g/day subcutaneously) was given daily between PN3-10 and intermittent monitoring was done till PN12. None of the treatments demonstrated acute or delayed effects on spasms, yet all were well tolerated. We discuss the implications for therapy discovery and challenges of replication trials.

Evaluation of 4-thiazolidinone derivatives as potential reverse transcriptase inhibitors against HIV-1 drug resistant strains

Rapid emergence of drug resistance is crucial in management of HIV infection limiting implementation of efficacious drugs in the ART regimen. Designing new molecules against HIV drug resistant strains is utmost essential. Based on the anti-HIV-1 activity, we selected four 4-thiazolidinone derivatives (S009-1908, S009-1909, S009-1911, S009-1912) and studied their interaction with reverse transcriptase (RT) from a panel of 10 clinical isolates (8 nevirapine resistant and two susceptible) using in silico methods, and inhibition pattern using in vitro cell based assays. On the basis of binding affinity observed in in silico analysis, 2-(2-chloro-6-nitrophenyl)-3-(4, 6-dimethylpyridin-2-yl) thiazolidin-4-one (S009-1912) was identified as the lead molecule followed by S009-1908, S009-1909 and S009-1911. The in vitro activity against the same panel was assessed using TZM-bl assay (IC50: 0.4-11.44µg/ml, TI: 4-126) and subsequently in PBMC assay against a nevirapine resistant clinical isolate (IC50: 0.8-6.65µg/ml, TI: 8.31-11.43) and standard strain from NIH ARRRP (IC50: 0.95-3.6µg/ml, TI: 9-26). The study shows analogue with pyrimidin-2-yl amino substitution at N-3 position of thiazolidin-4-one ring (S009-1908, S009-1909, S009-1911) exhibited enhanced activity as compared to pyridin-2-yl substituted derivatives (S009-1912), suggesting the use 4-thiazolidinones for developing potent inhibitors against HIV-1 drug resistant strains.

Combination of intensity modulated radiotherapy followed treatment with p38 MAPK activation inhibitor inhibits the proliferation of MCF-7 breast cancer cells

The present study was aimed to investigate the effect of intensity modulated radiotherapy (IMRT) followed by treatment with inhibitor for p38 MAPK, SB203580 on the rate of proliferation in drug resistant MCF-7 breast cancer cells. Interestingly, the results from immuno histochemistry and western blot assays revealed higher level of distribution of activated p38 MAPK in the drug resistant breast cancer tissues compared to the primary tissues. Treatment of the drug resistant MCF-7 cells with SB203580 led to a significant decrease in the phosphorylation of p38 MAPK. Exposure to IMRT caused a significant decrease in the rate of proliferation in drug resistant MCF-7breast cancer cells (P < 0.05). MCF-7 cells were subjected to IMRT for 45 min followed by treatment with SB203580 for 12 h. The results from MTT assay revealed inhibition in the rate of proliferation of MCF-7 cells more efficiently compared to the IMRT or SB203580 when used separately (P < 0.02). The effect of IMRT and SB203580 on inhibition of MCF-7 cell proliferation showed synergistic relation. Since MAPK signaling pathway plays an important role in the development of drug resistance, therefore, inhibition of p38 MAPK activation by the combination of IMRT followed by treatment with inhibitor for p38 MAPK can be a promising strategy for breast cancer treatment. Thus combination of IMRT exposure and treatment with SB203580 can be used for the inhibition of drug resistant breast cancer.

Cathodal transcranial direct-current stimulation for treatment of drug-resistant temporal lobe epilepsy: A pilot randomized controlled trial

Objective

To investigate the effect of cathodal transcranial direct‐current stimulation (c‐tDCS) on seizure frequency in patients with drug‐resistant temporal lobe epilepsy (TLE).

Method

Twenty‐nine patients with drug‐resistant TLE participated in this study. They were randomized to experimental or sham group. Twenty participants (experimental group) received within‐session repeated c‐tDCS intervention over the affected temporal lobe, and nine (sham group) received sham tDCS. Paired‐pulse transcranial magnetic stimulation was used to assess short interval intracortical inhibition (SICI) in primary motor cortex ipsilateral to the affected temporal lobe. SICI was measured from motor evoked potentials recorded from the contralateral first dorsal interosseous muscle. Adverse effects were monitored during and after each intervention in both groups. A seizure diary was given to each participant to complete for 4 weeks following the tDCS intervention. The mean response ratio was calculated from their seizure rates before and after the tDCS intervention.

Results

The experimental group showed a significant increase in SICI compared to the sham group (F = 10.3, p = 0.005). None of the participants reported side effects of moderate or severe degree. The mean response ratio in seizure frequency was −42.14% (standard deviation [SD] 35.93) for the experimental group and −16.98% (SD 52.41) for the sham group.

Significance

Results from this pilot study suggest that tDCS may be a safe and efficacious nonpharmacologic intervention for patients with drug‐resistant TLE. Further evaluation in larger double‐blind randomized controlled trials is warranted.