Beyond multidrug-resistant tuberculosis in Europe: a TBNET study

The emergence of drug-resistant tuberculosis (TB) is a challenge to TB control in Europe. We evaluated second-line drug susceptibility testing in Mycobacterium tuberculosis isolates from patients with multidrug-resistant, pre-extensively drug-resistant (pre-XDR-TB) and XDR-TB at 23 TBNET sites in 16 European countries. Over 30% of bacilli from patients with pre-XDR-TB showed resistance to any fluoroquinolone and almost 70% to any second-line injectable drug. Respectively >90% and >80% of the XDR-TB strains tested showed phenotypic resistance to pyrazinamide and ethambutol. Resistance to prothionamide/ethionamide was high in bacilli from pre-XDR-TB patients (43%) and XDR-TB patients (49%).

Why does it take so long? The reasons behind tuberculosis treatment delay in Portugal

INTRODUCTION

Delayed diagnosis and treatment of tuberculosis contributes to the spread of the disease. In this study, we aimed to determine the patient and healthcare system delay among tuberculosis patients in Portugal and identify associated factors at individual and contextual level.

METHODS

We analysed all TB cases notified in Portugal between 2010 and 2014 using data from the national surveillance system. Patient and healthcare system delay were computed, log-transformed, and used as outcomes. Adjusted generalized linear models were fitted to identify sociodemographic, contextual and clinical determinants.

RESULTS

The study included 6838 patients. The median of patient and healthcare system were 33 and 17 days, respectively. Adjusted regression models revealed that higher patient delay occurred in foreign patients (exponentiated beta: 1.177, 95%CI 1.091-1.270) and those addicted to alcohol (1.169, 1.072-1.276) and drugs (1.153, 1.027-1.295). Higher healthcare system delay was observed among patients with extra-pulmonary TB (2.067, 1.885-2.268) and pulmonary comorbidities - lung cancer (2.391, 1.656-3.452), sarcoidosis (3.316, 1.370-8.022) and COPD (1.295, 1.059-1.584) - and in patients residing further from a healthcare service (1.040, 1.018-1.062).

CONCLUSION

We found that various individual and contextual factors affect the time delay in tuberculosis treatment. Our findings indicate that some strategies, such as facilitating the access to healthcare services among foreign patients and patients with addictions and increasing the awareness towards TB among healthcare professionals, may result in better TB control.

Tuberculosis among the homeless: should we change the strategy?

BACKGROUND

Tuberculosis (TB) is a major concern among high-risk populations such as the homeless.

OBJECTIVES

To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless.

DESIGN

This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression.

RESULTS

TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection.

CONCLUSION

TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.

Impact of the COVID-19 pandemic on tuberculosis services

BACKGROUND

In Portugal, Outpatient Tuberculosis Centres (OTBC) are responsible for the diagnosis, treatment, screening and prevention of tuberculosis (TB), and only severe or resistant cases are hospitalized.

AIM

To understand how infection control norms and standards were applied and how these centres responded during the pandemic.

METHOD

We sent an electronic questionnaire to all coordinators of OTBC. The questionnaire included questions on infection control during the COVID-19 pandemic and evaluation of the functioning of the OTBC in two periods: during the 1st National State of Emergency and after 1 year.

RESULTS

Thirty-two responses were obtained (52.5%). The infection control norms were globally applied; diagnosis, treatment, and prevention were kept, and contact screening was only affected during the 1st State of Emergency. However, half of the respondents (53.1%) believed that there were diagnostic delays during the 1st State of Emergency, rising to 68.8% after 1 year. Only 31.3% performed Directly Observed Therapy (DOT) in all patients during the 1st State of Emergency, and 59.4% after 1 year. Half the inquiries expected an increase in TB incidence in the near future.

CONCLUSION

The pandemic affected OTBC functioning, although the services were kept open; diagnostic delay and DOT appliance were the most affected.

Phospholipase A2 isoforms are altered in chronic pancreatitis

OBJECTIVE

To determine if phospholipase A2 (PLA2) type II and type IV mRNA expression and protein are altered in chronic pancreatitis.

SUMMARY BACKGROUND DATA

PLA2s have an important regulatory function in several signaling pathways, especially in inflammation. In this study, we examined the expression of three PLA2 isoforms (type I, type II, and type IV) in chronic pancreatitis.

METHODS

The distribution of PLA2 was studied in 15 pancreas samples obtained from patients with chronic pancreatitis using immunohistochemical, Northern blot, and in situ hybridization techniques. Normal pancreas obtained from healthy organ donors served as control.

RESULTS

Northern blot analysis revealed enhanced mRNA levels of PLA2 type II (5.7-fold) and type IV (5.1-fold) in chronic pancreatitis (p < 0.01) versus normal pancreas. In normal pancreas, intense PLA2 type I immunostaining was present in acinar cells, whereas PLA2 type II immunostaining was visible only in some acinar cells. In chronic pancreatitis, PLA2 type II immunostaining was present more frequently and with higher intensity in acinar cells. Furthermore, PLA2 type II immunoreactivity was more abundant in metaplastic ductal cells in the chronic pancreatitis samples. By in situ hybridization, areas with ductal metaplasia in chronic pancreatitis exhibited intense PLA2 type IV mRNA signals. All chronic pancreatitis tissues with concomitantly increased mRNA expression for PLA2 type II and type IV exhibited a higher degree of degeneration, ductal metaplasia, and fibrosis.

CONCLUSIONS

Upregulation of PLA2 types II and IV in areas with more histologic damage suggests that these PLA2 isoforms might contribute to the morphologic changes that occur in chronic pancreatitis.

Biomechanical evaluation of different reconstructive techniques of proximal tibia in revision total knee arthroplasty: An in-vitro and finite element analysis

BACKGROUND

Bone loss and subsequent defects are often encountered in revision total knee arthroplasty. In particular, when the cortical rim of proximal tibia is breached, the surgical decision on the reconstructive options to be taken is challenging due to the variety of defects and the lack of data from clinical or experimental studies that can support it. The purpose of this study is to assess how different reconstructive techniques, when applied to an identical defect and bone condition, can be associated to dissimilar longevity of the revision procedure, and the role of a stem in this longevity.

METHODS

Proximal cortex strains and implant stability were measured in ten reconstructive techniques replicated with synthetic tibiae. The cancellous bone strains under each construct were assessed with finite element models which were validated against experimental strains.

FINDINGS

The measured strains and stability showed that the proximal cortex is not immune to the different reconstructive techniques when applied to an identical defect. The largest cancellous strain differences between modular and non-modular techniques indicate a distinct risk between reconstructive techniques, associated to the supporting capacity of cancellous bone at long term.

INTERPRETATION

The main finding of the present study is the observation that modular augments increases, on a long term basis, the potential risk of bone resorption relative to the non-modular techniques. In addition, the use of a press-fit stem in the scope of non-modular techniques can lead to improved stability and load transfer, which can contribute positively to the life expectancy of these techniques.

Genetic polymorphism in Trypanosoma cruzi I isolated from Brazilian Northeast triatomines revealed by low-stringency single specific primer-polymerase chain reaction

Different molecular markers have been employed for typing Trypanosoma cruzi strains from endemic areas of Chagas disease. The low-stringency single specific primer-polymerase chain reaction (LSSP-PCR) has been a sensitive and informative technique that uses the variable region of kinetoplast DNA minicircles as a genetic marker, allowing detection of DNA sequence variation. In the present study, we analyzed the intra-lineage genetic variability of the T. cruzi strains obtained from triatomine feces collected on filter paper FTA card by LSSP-PCR. The hybridization of the PCR products with a probe for the subgenus Schizotrypanum and a clone-specific probe from Dm28c confirmed the subgenus as T. (S.) cruzi and respective lineages as T. cruzi I. Phenetic analysis showed the presence of three clusters that diverged by different coefficients of similarity. Thirteen T. cruzi I genotypes were observed circulating among Triatoma pseudomaculata and Rhodnius nasutus from peridomiciliary and natural environments in five peri-urban and urban localities of Jaguaruana, Ceará, Brazil. These data indicate the importance of the circulation of T. cruzi I genotypes among T. pseudomaculata and R. nasutus in different environments and the possible risk of Chagas disease domestic transmission.

Allogeneic hematopoietic stem cell transplantation in solid organ transplant recipients: a retrospective, multicenter study of the EBMT

We conducted a questionnaire survey of the 565 European Society for Blood and Marrow Transplantation centers to analyze the outcome of allogeneic hematopoietic stem cell transplantation (alloSCT) in recipients of solid organ transplantation (SOT). We investigated 28 patients with malignant (N = 22) or nonmalignant diseases (N = 6), who underwent 31 alloSCT procedures: 12 after kidney, 13 after liver and 3 after heart transplantation. The incidence of solid organ graft failure at 60 months after first alloSCT was 33% (95% confidence interval [CI], 16-51%) for all patients, 15% (95% CI, 2-40%) for liver recipients and 50% (95% CI, 19-75%) for kidney recipients (p = 0.06). The relapse rate after alloSCT (22%) was low following transplantation for malignant disorders, despite advanced stages of malignancy. Overall survival at 60 months after first alloSCT was 40% (95% CI, 19-60%) for all patients, 51% (95% CI, 16-86%) for liver recipients and 42% (95% CI, 14-70%) for kidney recipients (p = 0.39). In summary, we show that selected SOT recipients suffering from hematologic disorders may benefit from alloSCT and experience enhanced long-term survival without loss of organ function.

Conserved cis-elements bind a protein complex that regulates Drosophila ras2/rop bidirectional expression

The Drosophila ras2 promoter region exhibits bidirectional activity, as has been demonstrated for the human c-Ha-ras1 and the mouse c-Ki-ras. Here we address a unique case of ras regulation, as Drosophila ras2 provides the only example to date in which the flanking gene (rop) and its product have been isolated. A linking mechanism of control suggests a mutual interaction between the two gene products. Our studies indicate that the Drosophila ras2 promoter region shares with the human c-Ha-ras1 promoter a CACCC box and an AP-1-like sequence. A 14 bp promoter fragment which holds a CACCC element is demonstrated to interact with a specific transcription factor (factor B). This CACCC promoter element represents a stretch of imperfect palindrome. We present evidence that this factor can form a complex with another specific DNA-binding protein (factor A). The binding sites (A + B) for these protein factors are essential for 95% expression of both genes flanking the promoter (ras2 and rop). Region A consists of four overlapping consensus sequences: a TATA-like element, a DSE-like motif (the core sequence of the serum response element), a DRE octamer, which has been shown to play a role in cell proliferation, and a 5 bp direct repeat representing the GATA consensus sequence. Factor A has a very weak affinity to the full promoter region, but when complexed with factor B binding efficiency is enhanced. We also show that alterations of DNA-protein binding specificities can be achieved by supplementing the growth media with different sera.

TBNET - Collaborative research on tuberculosis in Europe

Networking is a key feature of scientific success. The Tuberculosis Network European Trialsgroup (TBNET) was founded in 2006 as a non-profit, non-governmental peer-initiated scientific organization to collaboratively address research priorities in the area of tuberculosis in Europe. Today, TBNET is the largest tuberculosis research organization in Europe with nearly 500 members from 22 EU countries and 49 countries worldwide (www.tb-net.org). Apart from small multicenter basic research studies, a particular strength of TBNET is the performance of large collaborative projects, pan-European multicenter studies and database projects. In recent years, research from TBNET has substantially contributed to the understanding of the management, risk and prognosis of patients with multidrug (MDR) and extensively drug-resistant (XDR) tuberculosis and led to a better understanding of the clinical value of novel tests for the identification of adults and children with tuberculosis and latent infection with Mycobacterium tuberculosis. In 2009, two branches of TBNET were founded to specifically address tuberculosis in the pediatric population (ptbnet) and non-tuberculous mycobacterial diseases (NTM-NET). In addition to the research activities, TBNET is developing expert consensus documents for clinical management and provides training and capacity building especially for members from Eastern European countries, where tuberculosis is still a prevalent health problem.

Aetiology of acute diarrhoea in hospitalized children in Rio de Janeiro City, Brazil

Enteropathogens were investigated in 406 children aged 0-3 years with diarrhoea attending the Salles Neto Municipal Hospital. Enteric bacterial pathogens were isolated from 49 per cent of the children. Enterotoxigenic Escherichia coli (ETEC) (20.9 per cent), enteropathogenic E. coli (EPEC) (16.5 per cent), rotavirus (11.6 per cent), and Campylobacter (9.9 per cent) were the most common agents. Among clinical features, vomiting and fever were significantly associated with Rotavirus isolation (50.0 per cent), respiratory infection with Adenovirus (14.3 per cent), bloody diarrhoea with Campylobacter (12.5 per cent), and dehydration with EPEC (71.6 per cent).

Team approach to manage difficult-to-treat TB cases: Experiences in Europe and beyond

As recommended by the World Health Organization (WHO), optimal management of MDR-TB cases can be ensured by a multi-speciality consultation body known as 'TB Consilium'. This body usually includes different medical specialities, competences and perspectives (e.g., clinical expertise both for adults and children; surgical, radiological and public health expertise; psychological background and nursing experience, among others), thus lowering the risk of making mistakes - or managing the patients inappropriately, in order to improve their clinical outcomes. At present, several high MDR-TB burden countries in the different WHO regions (and beyond) have introduced TB Consilium-like bodies at the national or subnational level to reach consensus on the best treatment approach for their patients affected by TB. In addition, in countries/settings where a formal system of consultation does not exist, specialized staff from MDR-TB reference centres or international organizations usually spend a considerable amount of their working time responding to phone or e-mail clinical queries on how to manage M/XDR-TB cases. The aim of this manuscript is to describe the different experiences with the TB Consilia both at the international level (European Respiratory Society - ERS/WHO TB Consilium) and in some of the countries where this experience operates successfully in Europe and beyond. The Consilium experiences are described around the following topics: (1) history, aims and focus; (2) management and funding; (3) technical functioning and structure; (4) results achieved. In addition a comparative analysis of the TB Consilia in the different countries has been performed.

A randomized clinical trial comparing metabolic parameters after 48 weeks of standard- and low-dose stavudine therapy and tenofovir disoproxil fumarate therapy in HIV-infected South African patients

OBJECTIVES

Low-dose stavudine therapy may have a lower toxicity profile compared with standard dose. A randomized controlled trial comparing these two doses of stavudine with tenofovir disoproxil fumarate (tenofovir DF) was performed to assess the effects on anthropometry, markers of inflammation, and lipid and glucose metabolism in Black South African patients.

METHODS

Sixty patients were randomized 1:1:1 to either standard-dose (30-40 mg) or low-dose (20-30 mg) stavudine or tenofovir DF (300 mg), each combined with lamivudine and efavirenz, for 48 weeks. Anthropometry, markers of inflammation, and lipid and glucose metabolism were assessed using standard techniques.

RESULTS

In all three treatment arms, there was a significant increase in lipid levels over the study period. At 48 weeks, fasting glucose level (P < 0.005) and homeostasis model assessment (HOMA) score (P < 0.05) increased significantly in the standard-dose stavudine arm, as did insulin and C-peptide levels in both the standard- and low-dose stavudine arms. At week 48, a significant decrease (P < 0.05) in adiponectin was noted in the standard-dose stavudine arm, but there was an increase (P < 0.005) in the tenofovir DF arm. In both the stavudine arms, significant increases in anthropometric measures occurred at 24 weeks but these decreased by week 48. Mitochondrial toxicities occurred in both the stavudine arms. Immunological and virological outcomes were similar for all three arms.

CONCLUSIONS

This study highlights the occurrence of metabolic abnormalities with both stavudine and tenofovir DF treatment. Awareness of the potential increased cardiovascular risk should be of concern with the use of both these therapies.

Breast cancer cell-induced platelet activation is compounded by tamoxifen and anastrozole in vitro

Platelet-tumour cell interaction is implicated in the initiation of breast cancer-associated thrombosis, with hormone-therapy (Tamoxifen/Anastrozole), increasing this risk. However, recent in vitro research indicates that Tamoxifen inhibits platelet activation, while the effects of Anastrozole on platelet activation are not well characterised. This study investigated platelet activation caused by Tamoxifen or Anastrozole-treated breast cancer cells in vitro. MCF7 and T47D cells were pre-treated with Tamoxifen or Anastrozole to mimic the effects of the drugs in vivo, and co-cultured with whole blood. Platelet activation was determined using flow cytometry. Platelet (CD41a⁺CD62P⁺) was determined using an interval gating strategy. Platelet morphology was visualised using scanning electron microscopy. Our results support clinical findings, showing that hormone-therapy is associated with platelet activation. Tamoxifen-treated MCF7 cells increased P-selectin expression, with ultrastructural analysis showing fully spread platelets. Conversely, Tamoxifen-treated T47D cells decreased P-selectin expression with platelets showing signs of early aggregation. Anastrozole pre-treatment decreased P-selectin expression, with treated MCF7 cells inducing platelet membrane folds and lamellipodia extension, and treated T47D cells inducing platelet aggregation and fibrin network formation indicating hypercoagulation. The findings support clinical studies. Hormone-therapy augments tumour cell-induced platelet activation, which may be linked to cell phenotype. This may have clinical implications for treatment strategies.

Thrombotic events and COVID-19 vaccines

COVID-19 vaccines are considered promising agents in the control of the pandemic. Although their safety was assessed in randomised clinical trials, severe adverse events (AEs) have been reported after large-scale administration. This study aims to evaluate thromboembolic AEs reported after vaccination in a real-world context and how they led to the interruption of vaccination campaigns. We also review the benefits and risks of the vaccines approved in the European Union and provide recommendations. A review of the literature was performed using Medline/PubMed electronic database as well as institutional and pharmacovigilance official reports. Our findings show that vaccine-induced prothrombotic immune thrombocytopenia has been suggested as a very rare AE associated with viral vector vaccines. Unusual thrombotic events combined with moderate-to-severe thrombocytopenia were reported mainly in women under 60 years of age. As safety signals emerged, Vaxzevria and Janssen´s COVID-19 vaccine campaigns have been paused while investigations proceed. On the other hand, the number of deep vein thrombosis and pulmonary embolism reports have not increased. Post-marketing surveillance indicated that mRNA vaccines are safe and should continue to be used. The thrombotic events report rate is not increased in people over 60 years. As they are at greater risk for COVID-19 complications and death, no vaccine restrictions are recommended in this group. Risk factors for vaccine-induced prothrombotic immune thrombocytopenia should be established so that evidence-based decisions can be made. Systematic monitoring of COVID-19 vaccine safety is essential to ensure that the benefits of vaccination outweigh the risks.

Spontaneous rupture of renal allograft

Spontaneous rupture of a renal allograft was encountered in 3 male patients among 75 consecutive renal transplants over a three-year period. In 1 patient, the transplant was from a living related donor, while the other two were cadaveric kidneys from pediatric donors. In 2 patients, allograft rupture followed steroid-resistant rejection, while in the third with cadaveric kidney transplant, the rupture was associated with renal vein thrombosis. Two patients presented with classic symptoms of renal allograft rupture: sudden onset of severe pain and swelling over the allograft and hypotension, while in the third the rupture was found during exploration of the allograft with clinical diagnosis of renal artery thrombosis. Transplant nephrectomy was done in 2 patients, while successful surgical repair was performed in the third patient with living related transplant.

Severe infections after single umbilical cord blood transplantation in adults with or without the co-infusion of CD34+ cells from a third-party donor: results of a multicenter study from the Grupo Español de Trasplante Hematopoyético (GETH)

BACKGROUND

Umbilical cord blood transplantation (CBT) is an established alternative source of stem cells in the setting of unrelated transplantation. When compared with other sources, single-unit CBT (sCBT) is associated with a delayed hematologic recovery, which may lead to a higher infection-related mortality (IRM). Co-infusion with the sCBT of CD34+ peripheral blood stem cells from a third-party donor (TPD) (sCBT + TPDCD34+) has been shown to markedly accelerate leukocyte recovery, potentially reducing the IRM. However, to our knowledge, no comparative studies have focused on severe infections and IRM with these 2 sCBT strategies.

METHODS

A total of 148 consecutive sCBT (2000-2010, median follow-up 4.5 years) were included in a multicenter retrospective study to analyze the incidence and risk factors of IRM and severe viral and invasive fungal infections (IFIs). Neutrophil engraftment occurred in 90% of sCBT (n = 77) and 94% sCBT + TPDCD34+ (n = 71) recipients at a median of 23 and 12 days post transplantation, respectively (P < 0.01).

RESULTS

The 4-year IRM was 24% and 20%, respectively (P = 0.7), with no differences at day +30 (5% and 4%, respectively) and day +100 (10% and 8%, respectively). In multivariate analysis early status of the underlying malignancy, cytomegalovirus (CMV)-seronegative recipient and high CD34+ cell content in the cord blood unit before cryostorage (≥1.4 × 10(5) /kg) were protective of IRM. Among the causes of IRM, bacterial infections and IFIs were more common in sCBT (15% vs. 4%), while CMV disease and parasitic infections were more common in the sCBT + TPDCD34+ cohort (5% vs. 16%).

CONCLUSION

These data show that sCBT supported with TPDCD34(+) cells results in much shorter periods of post-transplant leukopenia, but the short- and long-term rates of IRM were comparable to those of sCBT, presumably because immune recovery is equally delayed in both graft types.