DOTS implementation in a middle-income country: development and evaluation of a novel approach

BACKGROUND

DOTS is widely accepted as the most cost-effective strategy for tuberculosis (TB) control. However, there is little published information regarding methods for implementation in middle-income countries.

METHODS

Over 3 years, the Canadian Lung Association assisted the Ecuadorian TB programme to implement DOTS for over half the nation's total population. A multilevel strategy developed by a team of Ecuadorian health professionals provided initial, in-service, replica and reinforcement training at the local level, and training at national level for specialist physicians, specialist societies and medical schools. Evaluation was based on international guidelines for case finding, treatment and laboratory quality control, and costs of all implementation activities.

RESULTS

By January 2004, DOTS training had been provided to 1954 health professionals and 199 smear microscopy technicians, and DOTS was implemented in all 496 health facilities. Case detection activities at the local level increased substantially. Cure and treatment completion improved to 83% of new cases. Overall concordance of laboratory quality control readings was 98.7%. The total cost of DOTS implementation was US dollar 3 049 585.

CONCLUSIONS

To achieve international targets for TB control, DOTS implementation in a middle-income country required intensive training at the local level and at multiple other levels.

Benign proliferative nipple duct lesions frequently contain CAM 5.2 and anti-cytokeratin 7 immunoreactive cells in the overlying epidermis

Benign proliferative nipple duct lesions (PNDLs) pose a diagnostic problem for clinicians and pathologists. Clinically, they may be associated with skin changes typically present in Paget's disease of the nipple. The identification of numerous scattered cells in the epidermis that are immunoreactive for low-molecular-weight cytokeratin may lead to further confusion with Paget's disease. We studied the nipple epidermis in nine cases of PNDL and compared them with 26 histologically normal nipples from mastectomy specimens. CAM 5.2 and anticytokeratin 7 (CK7) immunoreactive cells were identified in the epidermis of seven of nine nipples associated with PNDL. The cytokeratin-positive cells appeared cytologically benign and were dispersed singly (scattered in seven of seven cases and frequent in four of seven cases) or formed small aggregates with occasional tubular structures (three of seven cases) in the basal and middle layers of the epidermis. In two of seven cases, these epidermal immunoreactive cells showed continuity with the underlying PNDL, suggesting the spread or continuation of lesional cells to the epidermis. Dispersed single immunoreactive cells were identified in small numbers (scattered) in the basal layer of the epidermis in 12 of 26 normal nipples and more frequently in 1 of 12 cases. In all cases, the intraepidermal cells were negative for carcinoembryonic antigen (CEA) and Her-2/neu. We conclude that intraepidermal CAM 5.2 and anti-CK7 immunoreactive cells, which are normally present in the nipple epidermis, may proliferate and form aggregates when there is an underlying PNDL. The presence of these cells does not imply Paget's disease when the intraepidermal cells have a bland cytologic appearance, fail to overexpress Her-2/neu, and there is no carcinoma within the PNDL or elsewhere in the breast.

Pyruvate carboxylase from Rhizobium etli: mutant characterization, nucleotide sequence, and physiological role

Pyruvate carboxylase (PYC), a biotin-dependent enzyme which catalyzes the conversion of pyruvate to oxaloacetate, was hypothesized to play an important anaplerotic role in the growth of Rhizobium etli during serial subcultivation in minimal media containing succinate (S. Encarnación, M. Dunn, K. Willms, and J. Mora, J. Bacteriol. 177:3058-3066, 1995). R. etli and R. tropici pyc::Tn5-mob mutants were selected for their inability to grow in minimal medium with pyruvate as a sole carbon source. During serial subcultivation in minimal medium containing 30 mM succinate, the R. etli parent and pyc mutant strains exhibited similar decreases in growth rate with each subculture. Supplementation of the medium with biotin prevented the growth decrease of the parent but not the mutant strain, indicating that PYC was necessary for the growth of R. etli under these conditions. The R. tropici pyc mutant grew normally in subcultures regardless of biotin supplementation. The symbiotic phenotypes of the pyc mutants from both species were similar to those of the parent strains. The R. etli pyc was cloned, sequenced, and found to encode a 126-kDa protein of 1,154 amino acids. The deduced amino acid sequence is highly homologous to other PYC sequences, and the catalytic domains involved in carboxylation, pyruvate binding, and biotinylation are conserved. The sequence and biochemical data show that the R. etli PYC is a member of the alpha4, homotetrameric, acetyl coenzyme A-activated class of PYCs.

Semen analyses in men with asymptomatic genital gonorrhoea

Thirty asymptomatic men with gonorrhoea were studied. No significant difference was seen in spermiogram (semen volume, sperm count, motility, velocity and normal morphology) and most of the seminal constituents studied (fructose, ascorbic acid, calcium, sodium, potassium, chlorides and magnesium) between this group of men and those of a normal control group. Citric acid levels were significantly lower in men with gonorrhoea (P less than 0.002). suggesting a non-acute prostatitis. No significant difference was observed in the studies before and after treatment.

[Gastric secretion in hypovolemic rats caused by acute hemorrhage]

Gastric secretion was studied in two groups of rats in which pyloric ligature with wire was previously peformed. One of the groups was acutely bled until hypovolemia. The following parameters were checked: gastric volume, acid and pepsin secretion, Pu/g of stomach, chloride, potassium, and sodium. A significant decrease in volume, acid and pepsin secretion, Pu/g of stomach and chloride and increase in potassium in the hypovolemic rats found. There was no significant change in sodium concentration. There was no significant difference in the pepsinogen concentration in gastric mucous between both groups of rats.

[Study of gastric secretion in rats with ligation of the pylorus according to the Shay and Dai methods]

A comparative study of gastric secretion in rats with pyloric ligature according to either Shays' or Dais' methods was carried on, studying in both groups gastic acid and peptic secretions, mucous pepsinogen, and Na+, K+, and Cl-. The acid-peptic output as well as gastric Pu/g were greater in Dais' method. There were no changes regarding mucous pepsinogen when comparing both methods. Cl- and Na+ determinations showed minimal changes, whereas K+ showed no difference in both methods. We explain these modifications based on the difference in the secreted volume, since the acid concentration and Pu/ml are practically the same when comparing both methods.