Xpert MTB/RIF testing in a low tuberculosis incidence, high-resource setting: limitations in accuracy and clinical impact

BACKGROUND

Xpert MTB/RIF, the first automated molecular test for tuberculosis, is transforming the diagnostic landscape in low-income countries. However, little information is available on its performance in low-incidence, high-resource countries.

METHODS

We evaluated the accuracy of Xpert in a university hospital tuberculosis clinic in Montreal, Canada, for the detection of pulmonary tuberculosis on induced sputum samples, using mycobacterial cultures as the reference standard. We also assessed the potential reduction in time to diagnosis and treatment initiation.

RESULTS

We enrolled 502 consecutive patients who presented for evaluation of possible active tuberculosis (most with abnormal chest radiographs, only 18% symptomatic). Twenty-five subjects were identified to have active tuberculosis by culture. Xpert had a sensitivity of 46% (95% confidence interval [CI], 26%-67%) and specificity of 100% (95% CI, 99%-100%) for detection of Mycobacterium tuberculosis. Sensitivity was 86% (95% CI, 42%-100%) in the 7 subjects with smear-positive results, and 28% (95% CI, 10%-56%) in the remaining subjects with smear-negative, culture-positive results; in this latter group, positive Xpert results were obtained a median 12 days before culture results. Subjects with positive cultures but negative Xpert results had minimal disease: 11 of 13 had no symptoms on presentation, and mean time to positive liquid culture results was 28 days (95% CI, 25-47 days) compared with 14 days (95% CI, 8-21 days) in Xpert/culture-positive cases.

CONCLUSIONS

Our findings suggest limited potential impact of Xpert testing in high-resource, low-incidence ambulatory settings due to lower sensitivity in the context of less extensive disease, and limited potential to expedite diagnosis beyond what is achieved with the existing, well-performing diagnostic algorithm.

Alexithymic and somatisation scores in patients with temporomandibular pain disorder correlate with deficits in facial emotion recognition

Current studies suggest dysfunctional emotional processing as a key factor in the aetiology of temporomandibular disorder (TMD). Investigating facial emotion recognition (FER) may offer an elegant and reliable way to study emotional processing in patients with TMD. Twenty patients with TMD and the same number of age-, sex- and education-matched controls were measured with the Facially Expressed Emotion Labelling (FEEL) test, the 26-item Toronto Alexithymia Scale (TAS-26), the Screening for Somatoform Symptoms (SOMS-2a), the German Pain Questionnaire and the 21-item Hamilton Depression Rating Scale (HAMD). The patients had significantly lower Total FEEL Scores (P = 0·021) as compared to the controls, indicating a lower accuracy of FER. Furthermore, we were able to demonstrate significant group differences with respect to the following issues: patients were more alexithymic (P = 0·006), stated more somatoform symptoms (P < 0·004) and had higher depressive scores in the HAMD (P < 0·003). The factors alexithymia and somatisation could explain 31% (adjusted 27%) of the variance of the FEEL Scores in the sample. The estimation of the standardised regression coefficients suggests an equivalent influence of TAS-26 and SOMS-2a on the FEEL Scores, whereas 'group' (patients versus healthy controls) and depressive symptoms did not contribute significantly to the model. Our findings highlight FER deficits in patients with TMD, which are partially explained by concomitant alexithymia and somatisation. As suggested previously, impaired FER in patients with TMD may further point to probable aetiological proximities between TMD and somatoform disorders.

Mycobacterial disease and impaired IFN-γ immunity in humans with inherited ISG15 deficiency

ISG15 is an interferon (IFN)-α/β-inducible, ubiquitin-like intracellular protein. Its conjugation to various proteins (ISGylation) contributes to antiviral immunity in mice. Here, we describe human patients with inherited ISG15 deficiency and mycobacterial, but not viral, diseases. The lack of intracellular ISG15 production and protein ISGylation was not associated with cellular susceptibility to any viruses that we tested, consistent with the lack of viral diseases in these patients. By contrast, the lack of mycobacterium-induced ISG15 secretion by leukocytes-granulocyte, in particular-reduced the production of IFN-γ by lymphocytes, including natural killer cells, probably accounting for the enhanced susceptibility to mycobacterial disease. This experiment of nature shows that human ISGylation is largely redundant for antiviral immunity, but that ISG15 plays an essential role as an IFN-γ-inducing secreted molecule for optimal antimycobacterial immunity.

[Experimental research on mechanical behavior of human placenta]

OBJECTIVES

Determination of mechanical properties of human placenta.

PATIENTS AND METHODS

Realisation of an experimental study using 80 human placentas and modelisation of this study using a finite element numerical model. Using the inverse analysis method, research of the parameters of placenta's behavior.

RESULTS

Hyper-Visco-Elastic law written by Ogden, optimized for placenta with parameters: mu(1)=0.0001881Mpa, mu(2)=-0.000240Mpa, mu(3)=mu(4)=0Mpa and alpha(1)=2, alpha(2)=-8, alpha(3)=alpha(4)=0 in static condition.

DISCUSSION AND CONCLUSION

The parameters enable an approach of the mechanical behavior of the placenta. They could be used in numerical modelisation.

TB: screening for responses to a vile visitor

Mycobacteria, the pathogens that cause tuberculosis and leprosy, establish long-term infections in host macrophages. Recent studies, including two genetic screens reported in this issue of Cell (Kumar et al., 2010; Tobin et al., 2010), reveal that virulent mycobacteria evade the host immune system by stimulating production of anti-inflammatory molecules and inhibiting autophagy.

SAPHO syndrome with ankylosis of the temporomandibular joint

SAPHO syndrome is a rare combination of different symptoms with unknown aetiology. A complete ankylosis of the temporomandibular joint (TMJ) in a patient with SAPHO syndrome has not been described previously. The goal of this case report is to present the disease, give an overview about the frequency of mandibular involvement and describe different therapeutic strategies. The complication of an ankylosis of the TMJ is noted and the literature is reviewed. The authors report a 42-year-old patient with SAPHO syndrome and recurrent swelling of the right mandible and the soft tissue. The persisting involvement of the mandible resulted in a complete osseous ankylosis of the right TMJ and required resection with alloplastic replacement of the right condyle. SAPHO syndrome should be suspected in some cases of 'therapy resistant osteomyelitis' of the mandible. Smaller joints, such as the TMJ may also be affected. Treatment of SAPHO syndrome should include antibiotics and NSAIDs; corticosteroids may be helpful. Surgery is the ultimate treatment.

Flexural strength of experimentally filled resins made of electron beam irradiated silica fillers

This study investigated the influence of different silica fillers on the flexural strength of experimentally filled resins. Hydrophilic (non-silanated) silica, hydrophobic silica modified by organofunctional silane, and silica modified by organofunctional silane that additionally contains polymerizable carbon double bonds were assigned into further subgroups: the first subgroup was electron beam irradiated with 10 kGy (dose rate) and the second with 30 kGy, whereas the third constituted the non-irradiated control group. In total, nine experimentally filled resin blends were mixed. Rectangular specimens were constructed, and a flexural strength test was performed. Regardless of the type of silica, specimens constructed of blends containing non-irradiated fillers showed the lowest flexural strength in comparison to their corresponding irradiated groups. With increasing dose rates from 10 to 30 kGy, filler irradiation prior to blend mixing resulted in slightly increased flexural strength values for hydrophilic as well as for organofunctional silanated silica. Specimens constructed of blends with fillers that were not only modified by silane containing polymerizable carbon double bonds but were additionally irradiated showed the highest flexural strength. The results of this study indicate that the flexural strength of filled resins could be enhanced by advance preparation of silica fillers with silane coupling agents followed by electron beam irradiation.

Periodically hyperthyroid phenotype in thyroid hormone resistance is associated with mutation D322N in the thyroid hormone receptor beta gene: transcriptional properties of the mutant and the role of retinoid X receptor

We report a point mutation in the ligand-binding domain of the TR beta 1 gene in an affected patient and his daughter. The phenotype was borderline hyperthyroid with periodic aggravation of symptoms. In the cognate variant TR beta (TR beta-CN) amino acid codon 322 was exchanged from aspartic acid to asparagine. TR beta-CN revealed strongly decreased T3-binding activity. At low T3 levels TR beta-CN transactivated a palindromic thyroid hormone response element (TRE-PAL) only to a limited extend, whereas full activity was retained at a high T3 concentration. At low T3 levels, TR beta-CN exerted a dominant negative effect on wild-type TR beta, whereas this effect was diminished in the presence of high T3 concentrations. TR beta-CN could not be activated by retinoid X receptor (RXR) beta in the presence of T3, whereas addition of 9cis-retinoic acid (9c-RA) resulted in the transactivation of TRE-PAL through RXR beta independently of the presence of TR beta-CN. In conclusion, the time dependent variable THR phenotype of patient CN might be influenced by the differential expression of RXRs and the T3 and 9c-RA hormonal status.

PhoP: a missing piece in the intricate puzzle of Mycobacterium tuberculosis virulence

Inactivation of the transcriptional regulator PhoP results in Mycobacterium tuberculosis attenuation. Preclinical testing has shown that attenuated M. tuberculosis phoP mutants hold promise as safe and effective live vaccine candidates. We focused this study to decipher the virulence networks regulated by PhoP. A combined transcriptomic and proteomic analysis revealed that PhoP controls a variety of functions including: hypoxia response through DosR crosstalking, respiratory metabolism, secretion of the major T-cell antigen ESAT-6, stress response, synthesis of pathogenic lipids and the M. tuberculosis persistence through transcriptional regulation of the enzyme isocitrate lyase. We also demonstrate that the M. tuberculosis phoP mutant SO2 exhibits an antigenic capacity similar to that of the BCG vaccine. Finally, we provide evidence that the SO2 mutant persists better in mouse organs than BCG. Altogether, these findings indicate that PhoP orchestrates a variety of functions implicated in M. tuberculosis virulence and persistence, making phoP mutants promising vaccine candidates.

Liver injuries in frontal crash situations a coupled numerical - experimental approach

From clinical knowledge, it has been established that hepatic traumas frequently lead to lethal injuries. In frontal or lateral crash situations, these injuries can be induced by pure deceleration effects or blunt trauma due to belt or steering wheel impact. Concerning the liver under frontal decelerations, how could one investigate organ behaviour leading to the injury mechanisms? This work couples experimental organ decelerations measurements (with 19 tests on cadaver trunks) and finite element simulation, provides a first analysis of the liver behaviour within the abdomen. It shows the influence of the liver attachment system that leads to liver trauma and also torsion effects between the two lobes of the liver. Injury mechanisms were evaluated through the four phases of the liver kinematics under frontal impact: (1) postero-anterior translation, (2) compression and sagittal rotation, (3) rotation in the transverse plane and (4) relaxation.

Experimental composites made of electron beam irradiated reinforced fillers

This study investigated the influence of electron beam irradiated reinforced fillers on the three body wear and flexural strength of experimental composite blends. Three formulations of reinforced fillers were investigated: (A) high loaded inorganic filler composite with 60 wt.% SiO2, (B) low loaded inorganic filler composite with 40 wt.% SiO2, (C) organic filler composite (precipitated Bis-phenol-A-di-methacrylate). The fillers were assigned to two subgroups of unswollen (A, B, C) and monomer swollen (As, Bs, Cs) fillers. The experimental blends (matrix: Urethane-dimethacrylate) were mixed using un-treated, annealed (90 degrees C), or electron beam irradiated fillers with 30 and 90 kGy, respectively. All specimens were heat-cured for 20 min at 140 degrees C. Three-body abrasion and flexural strength tests were performed. The highest flexural strength was evaluated for composites made of the 30 kGy irradiated type Bs filler. The comparison with annealed fillers showed that the effect was independent of increasing temperatures during the radiation process. Blends with a SiO2 content of 60 wt.% (type A, As) had significantly less wear than blends with 40 wt.% (type B, Bs) or blends with organic fillers (type C, Cs). The flexural strength of the composite could be improved by using pre-irradiated reinforced fillers. However, wear was not affected using this procedure.

Molecular genetic analysis of two loci (Ity2 and Ity3) involved in the host response to infection with Salmonella typhimurium using congenic mice and expression profiling

Numerous genes have been identified to date that contribute to the host response to systemic Salmonella Typhimurium infection in mice. We have previously identified two loci, Ity2 and Ity3, that control survival to Salmonella infection in the wild-derived inbred MOLF/Ei mouse using a (C57BL/6J x MOLF/Ei)F(2)cross. We validated the existence of these two loci by creating congenic mice carrying each quantitative trait locus (QTL) in isolation. Subcongenic mice generated for each locus allowed us to define the critical intervals underlying Ity2 and Ity3. Furthermore, expression profiling was carried out with the aim of identifying differentially expressed genes within the critical intervals as potential candidate genes. Genomewide expression arrays were used to interrogate expression differences in the Ity2 congenics, leading to the identification of a new candidate gene (Havcr2, hepatitis A virus cellular receptor 2). Interval-specific oligonucleotide arrays were created for Ity3, identifying one potential candidate gene (Chi3l1, chitinase 3-like 1) to be pursued further. The combination of the use of congenics in QTL confirmation and fine mapping and in the identification of candidate genes by expression profiling has been successful and represents a step toward quantitative gene(s) identification.