Trends in rifampicin and isoniazid resistance in patients with presumptive TB

BACKGROUND: Early diagnosis of drug-resistant TB (DR-TB) is crucial in preventing the spread of the disease in the community. Introduction of upfront decentralised drug susceptibility testing to district-level as part of universal drug susceptibility testing (UDST) policy increased the feasibility of rapid and early testing for drug resistance closer to the patient and has resulted in reduced circumstances for transmission. The introduction of the first-line line-probe assay (FL-LPA), GenoType^® MTBDRplus v2, has had an extensive impact on the management of multidrug-resistant TB (MDR-TB) in India.MATERIALS and METHODS: Sputum samples of patients with presumptive TB and DR-TB from selected districts of Tamil Nadu received through National TB Elimination Programme (NTEP) were subjected to FL-LPA as per programme guidelines. In this study, we present trends in genotypic resistance to isoniazid (INH) and rifampicin (RIF) during the 4 years (2016-2019) among these patients. Band patterns were analysed as per the updated GLI (Global Laboratory Initiative) LPA interpretation and reporting guidelines.RESULTS: A total of 26,349 samples were received during the study period. Smear-positive samples (n = 20231) were directly subjected to FL-LPA; smear-negative samples were cultured in liquid media and M. tuberculosis-positive cultures were tested using FL-LPA. A total of 18,441 were MTB-positive on FL-LPA. INH monoresistance, RIF monoresistance and MDR-TB was observed in respectively 8.7%, 1.1% and 3.3% of the samples. There was a decreasing trend in all types of resistance observed particularly after 2017 (P < 0.001). MDR-TB showed a steady decrease from 5.6% to 1.8%. S531L (19.5%) and S315T (61.1%) were the most common mutations identified in the rpoB and katG genes, respectively. The percentage of inhA-c-15t promoter mutation, indicating low-level INH resistance, showed a consistent increase (P < 0.001).CONCLUSION: The impact of the UDST policy on the NTEP may have led to this decreasing trend in RIF and INH resistance observed in the study period. The increase in low-level INH resistance mutation inhA-c-15t may be associated with ethionamide/prothionamide resistance, and this should be taken into account when designing DR-TB regimen.

Factors affecting medication assisted treatment success for opioid use disorder

Background

In the United States (US) when opioid use disorder (OUD) is treated with medication assisted treatment (MAT), many patients in MAT will relapse into active opioid use during the recovery process. About 23% drop out of treatment within 3 months, and 40-50% drop out within 6 months of MAT start. Using the Anderson and Newman (2005) Framework for Health Services Utilization, 27 variables reflecting predisposing, enabling, and need factors were used to examine the impact on the number of days patients were retained in treatment.

Methods

One MAT clinic in rural Michigan used random sample of archival records (n = 390) OUD patients (DSM-V-TR code 304.00, ICD-10 code F11.20) between Jan. 1, 2014 and Nov. 21, 2018 with prescribed buprenorphine as part of MAT program. The first set of linear regressions (backward elimination) defined significant variables for each factor, and the final model included significant variables to predict length of retention in MAT.

Results

The first step identified legal issues (predisposing), MSHN insurance, distance to clinic, ability to drive, mental health diagnosis, and homelessness (enabling factors); Zung self-reporting depression score, starting dose, past suicide attempt, Hep-C status, and method of use (needs factor) as statistically significant to be used in the final model, controlling for age and gender. Starting dose (unstandardized b = 136.8, 95%CI 98.0, 175.6), driving license (b = 68.3, CI 13.2, 123.4), distance to clinic (b=-1.1, CI -2.2, -0.5) had statistical impact on the length of stay in MAT.

Discussion

This case study identified enabling factors (starting dose and access to clinic) affecting length of participation in MAT. Other factors warranting provider attention were identified for rural OUD patients.

Conclusions

Evidence based guidelines for starting doses are needed to increase MAT effectiveness. MAT services should consider distance to clinic as a factor of successful treatment.

Key messages

Evidence based guidelines for starting doses are needed to increase MAT effectiveness. Opiood treatment services should consider distance to clinic as a factor of successful treatment.

Isoniazid preventive treatment in children in two districts of South India: does practice follow policy?

SETTING

Two districts of Tamil Nadu, India

OBJECTIVES

To determine the proportion of household contacts aged <6 years of patients with tuberculosis (TB) with positive sputum microscopy results who initiated and completed isoniazid preventive treatment (IPT), and to determine reasons for non-initiation and non-completion of IPT.

DESIGN

Household visits were conducted on a random sample of adult patients registered during January-June 2012 to identify household contacts aged <6 years.

RESULTS

Among 271 children living with 691 index patients, 218 (80%) were evaluated and 9 (4%) were diagnosed with TB. Of 209 remaining contacts, 70 (33%) started IPT and 16 (22.9%) completed a full course of IPT. Of 139 contacts who did not start IPT, five developed TB disease. Reasons for non-initiation of IPT included no home visit by the field staff (19%) and no education about IPT (61%). Reasons for non-completion included isoniazid not provided (52%) and long duration of treatment (28%).

CONCLUSION

This study shows that Revised National TB Programme guidance was not being followed and IPT implementation was poor. Poor IPT uptake represents a missed opportunity to prevent future TB cases. Provision of IPT may be improved through training, improved logistics and enhanced supervision and monitoring.

The human UNP locus at 3p21.31 encodes two tissue-selective, cytoplasmic isoforms with deubiquitinating activity that have reduced expression in small cell lung carcinoma cell lines

The human Unp gene at 3p21.3 has sequence similarity to ubiquitin proteases and has been suggested to play a role in carcinogenesis of the lung (Gray et al., 1995). To investigate this possibility, we isolated cDNAs from several human tissue libraries and found evidence for two major isoforms, encoding proteins predicted to either contain an internal 47 amino acid segment or not. Both are functional in deubiquitination assays, and mutation of a critical conserved cysteine residue to alanine abolished activity. Unp specifies two closely-migrating transcripts whose relative abundance varies among human adult tissues. Antibodies specific to UNP confirm the presence of at least two endogenous protein isoforms of approximately 105-110 kDa in cell lysates, as predicted from the cDNA sequences. Cellular fractionation and immunocytochemistry revealed UNP expression localized primarily in the cytoplasm. When we examined a panel of lung-derived cell lines for both UNP mRNA and protein expression, we found reduced levels of UNP protein in all four small cell lung carcinoma cell lines tested. These findings directly contradict and offer alternative interpretations to a number of previously published observations on Unp.