Renal function of MDR-TB patients treated with kanamycin regimens or concomitantly with antiretroviral agents

SETTING

To compare renal insufficiency among multidrug-resistant tuberculosis (MDR-TB) patients treated with kanamycin (KM) based regimens and those treated concomitantly with tenofovir disoproxil fumarate (TDF) or other antiretroviral therapy (ART) regimens in Namibia.

DESIGN

Retrospective review of the treatment records and laboratory tests of patients initiated on MDR-TB treatment (January-December 2014). The glomerular filtration rates (eGFR) estimated pre- and post-treatment were compared using the analysis of variance test. Renal insufficiency was defined as an eGFR of <60 ml/min/1.73 m2. Use of KM or TDF and association with renal insufficiency was assessed using Kaplan-Meier plots and Cox proportional hazards analysis.

RESULTS

The baseline mean eGFR for the three groups was similar (P = 0.24): 139.3 ± 25.6 ml/min for the KM group (n = 68), 131.1 ± 25.7 ml/min for the KM+TDF group (n = 44) and 134.2±34.4 ml/min for the KM+Other group (n = 23). After 8 months, the values had declined significantly to respectively 104.8 ± 37.5 ml/min (P < 0.001), 101.5 ± 38.3 ml/min (P < 0.001) and 111.5 ± 41.7 ml/min (P = 0.01). Co-treatment with KM+ART was associated with an increased risk of renal insufficiency (hazard ratio [HR] 1.8, 95%CI 0.7-4.1, P = 0.20 for KM+TDF, and HR 3.5, 95%CI 1.4-8.2, P = 0.005 for KM+Other ART).

CONCLUSION

Renal function declined at a similar rate in MDR-TB patients treated with KM-based regimens compared with patients treated concomitantly with TDF-based or other ART. The risk of renal insufficiency was greater for patients on ART.

Mixed-methods assessment of surgical capacity in two regions in Ethiopia

Background

Surgery is among the most neglected parts of healthcare systems in low- and middle-income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement.

Methods

A mixed-methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing.

Results

Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non-physician clinicians, with little continuing education available. All hospitals tracked patient-level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care.

Conclusion

Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved.

Assessment of recovery, dreaming, hemodynamics, and satisfaction in postcardiac surgery patients receiving supplementary propofol sedation with S(+)-ketamine

BACKGROUND

S(+)-ketamine is an analgesic and sedative drug with dissociative attributes. When it is used without sedatives, nightmares have been described. The aim of this study was to assess the effects of postoperative analgosedation with propofol and S(+)-ketamine when compared to standard propofol analgosedation in terms of recovery, dreaming, hemodynamics, and patient satisfaction.

METHODS

Forty-eight patients were sedated with propofol (1-3 mg/kg/h) after coronary artery bypass grafting and allocated randomly on admission to the intensive care unit to receive either S(+)ketamine (2 mg mg/kg/h; group A) or 0.9% saline as a placebo (group B) in a double-blind fashion. If necessary, boli of 3.75 mg piritramide (an opioid) were given in both groups.

RESULTS

Patients receiving S(+)-ketamine had significantly higher satisfaction for pain management (Visual Analog Scale [VAS] = group A: median 10 [range 9-10]; group B: median 9 [range 6-10]) despite their lower piritramide consumption. Patients receiving S(+)ketamine showed significantly faster eye opening (82+/-51 vs 156+/-110 min) but dreamed significantly more often (at 2 h, 67% in group A vs 29% in group B; at 24 h, 43% in group A vs 10% in group B), whereas no significant differences were detected in the incidence of nightmares at 2 h, 14% in group A vs 10% in group B; at 24 h, 5% in group A vs 5% in group B.

CONCLUSIONS

Patients receiving S(+)-ketamine showed higher satisfaction for pain management and dreamed more often, but they did not have more nightmares.

Comparison of the effects of gelatin and a modern hydroxyethyl starch solution on renal function and inflammatory response in elderly cardiac surgery patients

BACKGROUND

The effects of hydroxyethylstarch (HES) 130/0.4 6% and gelatin 4% on inflammation, endothelial integrity, and renal function after cardiac surgery were compared.

METHODS

Sixty patients aged >80 yr undergoing cardiac surgery were randomized to receive gelatin (n=30) or HES 130/0.4 (n=30). The colloid was used in the priming of the cardiopulmonary bypass circuit (500 ml) and for volume replacement until the second postoperative day (POD). Serum creatinine, creatinine clearance, IL-6, IL-10, intercellular adhesion molecule-1 (sICAM-1), urinary glutathione transferase-alpha, and neutrophil gelatinase-associated lipocalin (NGAL) were measured perioperatively. Serum creatinine was also reported approximately 60 days after discharge.

RESULTS

The mean(sd) volume of gelatin infused was 4180(440) ml, which was greater than the volume of HES infused 2910(330) ml (P=0.002). The mean(sd) volume of serum creatinine on the first POD was 151(24) micromol litre(-1) in the gelatin group and 126(13) micromol litre(-1) in the HES group (P=0.004). Values for the second POD were 161(0.26) and 133(16) micromol litre(-1), respectively (P=0.004). Creatinine clearance was lower in the gelatin group on the first POD [37(7) vs 46(8) ml min(-1) 1.73 m2 (P=0.004)] and the second POD [32(8) vs 45(10) ml min(-1) 1.73 m2 (P=0.002)]. Kidney function approximately 60 days after discharge did not differ between the groups. IL-6, IL-10, and sICAM-1 were significantly lower in the HES group than in the gelatin group on the first and second PODs. Urinary alpha-GST increased in both groups to a comparable extent. Urinary NGAL concentrations were higher in the gelatin than in the HES patients 5 h after surgery and on the first and second PODs.

CONCLUSIONS

In cardiac surgery patients aged >80 years, volume therapy with HES 130/0.4 6% was associated with less marked changes in kidney function and a less marked endothelial inflammatory response than gelatin 4%.

The impact of a medium molecular weight, low molar substitution hydroxyethyl starch dissolved in a physiologically balanced electrolyte solution on blood coagulation and platelet function in vitro

BACKGROUND AND OBJECTIVES

Hydroxyethyl starches (HES) may have the potential to impact negatively on haemostasis. Recent findings suggest that side-effects on haemostasis stem not only from the physicochemical differences between HES, but also from the composition of the solvent. We compared the effects of a newly developed medium molecular weight (MW) and low molar substitution (MS) HES dissolved in a physiologically balanced electrolyte solution (MW 130, MS 0.42; B-HES) with a commercially available non-balanced HES (MW 130, MS 0.4; NB-HES), and with Ringer's lactate (RL) solution in vitro.

MATERIALS AND METHODS

Activated partial thromboplastin time (APTT), factor VIII clotting activity (F VIII:C) and von Willebrand factor (vWF) activity were investigated in 48 healthy individuals. Platelet function as measured by turbidimetric platelet aggregometry and whole blood impedance aggregometry induced by adenosine diphosphate (ADP), collagen and thrombin receptor activating peptide (TRAP), and by ADP and TRAP-induced expression of activated platelet fibrinogen receptor glycoprotein (GP) IIb/IIIa was determined in 24 participants. Haemodilution (25% and 50%, v/v for blood coagulation analyses and 20% and 40%, v/v for platelet function studies) was performed using the two HES preparations and RL.

RESULTS

APTT was significantly longer and F VIII and vWF significantly lower at 25% and 50% dilutions with NB-HES compared to B-HES and RL. At 20% and 40% dilutions, ADP and TRAP-induced expression of activated platelet surface GP IIb/IIIa was significantly increased by B-HES compared to NB-HES and RL. Percentages of platelet GP IIb/IIIa expression were also significantly greater in samples diluted with B-HES than in undiluted blood. Neither the diluent (B-HES, NB-HES and RL) nor the degree of dilution (undiluted, 20% and 40% dilution) had any significant influence on ADP, collagen or TRAP-induced turbidimetric platelet aggregation or impedance platelet aggregation.

CONCLUSIONS

In contrast to a non-balanced 130 kDa, MS 0.4 HES (NB-HES), a 130 kDa, MS 0.42 HES preparation dissolved in a physiologically balanced electrolyte solution (B-HES) does not affect APTT, F VIII:C and vWF in vitro. Both types of HES do not affect platelet aggregation induced by ADP, collagen or TRAP. B-HES but not NB-HES increases the expression of activated platelet GP IIb/IIIa induced by ADP or TRAP.

First Report of Endophytic Candida ipomoeae Isolated from Ovules of Upland Cotton in Mississippi

Cotton is grown on approximately 34.5 million ha worldwide to provide fiber, food oil, and animal feed. To our knowledge, this report is the first of Candida ipomoeae on cotton, and this yeast was found on ovules of the most commercially important cotton species in a major cotton-growing region. The yeast was isolated from ovules of upland cotton grown in vitro. A culture (NRRL Y-48065) was sent to Microbial ID Inc. (Newark, DE) where a partial 176-bp sequence for the D2 domain of the large subunit rDNA was obtained. A BLAST search on the GenBank database ( www.ncbi.nih.gov/Genbank/index.html ) found a 100% match between our sequence and accessions from two strains of C. ipomoeae (Accession Nos. AF050148 and AF050149). In addition, the distinctive colony morphology (white pseudomycelium with a raised stellate to lobate edge) was consistent with previous descriptions of C. ipomoeae (1). No growth was observed at 37°C for the current and previously described isolates. C. ipomoeae is a recently described asexual species (1) that has been isolated from morning glory (Ipomoea spp.) flowers and their insect visitors in Hawaii and the Americas (2). C. ipomoeae has also been found on insects that have visited flowers of the indigenous wild Hawaiian cotton species, Gossypium tomentosum (2) but it has not been isolated previously from cotton per se. Endogenous microbes are common in field-grown upland cotton and can be an impediment to obtaining aseptic plant tissue cultures. During August and September 2005, as part of an effort to rescue interspecific cotton hybrids, ovules were cultured in vitro for 4 days after pollination from plants grown in a field at Stoneville, MS. Fruit were washed in soap and water, surface sterilized in a laminar flow hood by immersion in an aqueous solution of 2.6% sodium hypochlorite and 0.1% Tween 20 for 10 min with intermittent shaking, followed by immersion in ethanol for 10 min, and then allowed to air dry. This surface sterilization protocol is >99% effective on greenhouse-grown fruit. For each fruit, ovules were placed on a single 100 × 25-mm petri dish containing 25 ml of modified Murashige and Skoog media with Gambourg's B5 vitamins (M0404; Sigma-Aldrich, St. Louis, MO) plus 1.9 g l^-1 KNO₃, 0.5 g l^-1 asparagine, 1.0 g l^-1 glutamine, 20.0 g l^-1 glucose, 0.25 g l^-1 cefotaxime, and 2.2 g l^-1 gelrite, with a pH of 5.8. Plated ovules were incubated at 30°C with 12 h of fluorescent light each day. C. ipomoeae was first observed on ovules of the cv. Deltapine 90 crossed with G. arboreum; other fungal contaminants were also observed but all of these contaminants originated from ovules within 2 weeks of culture, indicating that the contaminants were endogenous. Subsequently, ovules from the self-pollination of cv. FiberMax 832 were grown on media containing 50 mg l^-1 benomyl. On the benomyl-containing plates, the only fungal contaminant observed was C. ipomoeae and it was found on 22 of 120 plates. On plates with or without benomyl, C. ipomoeae grew slowly but caused the infected ovules to become necrotic and die, in contrast to uninfected ovules. Over time, the cultured ovules were completely overrun by the C. ipomoeae colonies. By identifying the contaminant as C. ipomoeae, pursuit of a targeted strategy for controlling it in cotton tissue cultures will now be possible. References: (1) M. A. Lachance et al. Can J. Microbiol. 44:718, 1998. (2) M. A. Lachance et al. FEMS (Fed. Eur. Microbiol. Soc.) Yeast Res. 1:1, 2001.

Seasonal variation in the parasite burden and body condition of working donkeys in East Shewa and West Shewa regions of Ethiopia

A survey of donkeys arriving at markets in three localities in East and West Shewa regions of central Ethiopia was carried out during 2002. Total faecal worm egg counts and body condition scores were measured for a total of 963 donkeys over a 12-month period. Total faecal worm egg counts did not differ significantly between localities but there was significant (p < 0.001) seasonal variation within localities. Levels of helminth infection closely followed rainfall patterns, being lowest (956 eggs per gram of faeces, e.p.g.) at the end of the long dry season (February) and highest (2022 e.p.g.) in the middle of the long wet season (August). Body condition score was associated closely with level of helminth infection (Goodman-Kruskal measure of association 0.60-0.80). Seasonal variation in body condition score reflected the temporal changes in worm burden and the availability of forage. It is suggested that a body condition score of 3 or less could be used as a simple means of identifying donkeys that require therapeutic treatment with anthelmintic. It is further proposed that economically viable strategic control of helminths in donkeys could be achieved by administering a single annual dose of avermectin-based anthelmintic at the start of the long rainy season (May-June). This may allow donkeys to recover body condition when available forage is most abundant and nutritious. It is also recommended that protein-rich feed supplementation be provided during the later part of the dry season (November-January). This may help maintain body condition when forage is scarce and the helminth challenge is at its lowest.

The effect of providing feed supplementation and anthelmintic to donkeys during late pregnancy and lactation on live weight and survival of dams and their foals in central Ethiopia

Anthelmintic treatment (A), feed supplementation (F), anthelmintic and feed supplementation (A+F) or traditional management (Control) was given to 166 pregnant female donkeys in three localities (Holetta, Debre Zeit and Adami Tulu) in Ethiopia during an on-farm study. Treatments started during the last trimester of pregnancy and continued until 6 months after parturition when the foals were weaned. The same treatments were administered to foals once they reached 1 month of age. Live weights of adults and foals were measured throughout the study along with work output of adult donkeys and survival to weaning of the foals. Faecal worm egg counts (FEC) and blood packed cell volumes (PCV) were recorded monthly. When applied alone, anthelmintic treatment (A) or feed supplementation (F) had no significant effect on live weight gain or foal survival. However, when combined, anthelmintic and feed supplementation (A+F) significantly (p<0.05) improved both live weight gain in adults and foals and foal survival. Workout was not affected by any of the treatments. Treatments A and A+F resulted in a highly significant (p<0.001) reduction in FEC in all three localities during the course of study and for at least 6 months after the last dose of anthelmintic in one of the study areas (Holetta). None of the treatments had any significant effect on PCV. Donkey owners in Ethiopia should be encouraged to adopt both anthelmintic treatment and feed supplementation if they expect tangible benefits in animal performance.

Bacterial isolates from indigenous weaning foods in rural Ethiopian setting, Jimma Zone, south west Ethiopia

A community based bacteriological study of weaning foods was conducted from November 1994 to August 1995 in six peasant associations, Jimma Zone. The households in the study community were found to be in poor sanitary conditions with cattle and pets living in the same room with humans, and the community gets water from unprotected sources. The predominant weaning foods in the study community were cereals. These and other foods given to weaning age children were found to be grossly contaminated, aerobic mesophilic bacterial counts being 10(5) cfu/ml of sample. The most frequent bacterial isolates were Enterobacter sp, Gram positive cocci including Staphylococcus aureus, Klebsiella sp., Citrobacter sp., and Escherichia coli in that order. Various factors such as unsafe water, unhygienic handling of food, storage of food at ambient temperature for a long time, poor domestic and personal hygiene may have contributed for the gross contamination of weaning foods in the study community. This calls for educating the community on the relationship between contamination of weaning foods and diarrhoeal diseases, and promoting measures such as reheating of weaning foods which have been kept at ambient temperature for a long time before serving infants and children.