Tuberculosis in children from diagnosis to decision to treat

SETTING

Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

OBJECTIVE

Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

DESIGN

A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

RESULTS

We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

CONCLUSION

TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.

Effect of ionizing radiation on antioxidant compounds present in cork wastewater

A preliminary study of the gamma radiation effects on the antioxidant compounds present in cork cooking water was carried out. Radiation studies were performed using radiation between 20 and 50 kGy at 0.4 and 2.4 kGy h(-1). The radiation effects on organic matter content were evaluated by chemical oxygen demand. The antioxidant activity was measured by ferric reducing power assay. The total phenolic content was studied using the Folin-Ciocalteau method. Results show that gamma radiation increases both the amount of phenolic compounds and antioxidant capacity of cork cooking water. These results highlight the potential of this technology for increasing the added value of cork waters.

Radiolytic degradation mechanism of gallic acid and its end-products

Gallic acid is one of the most representative biorecalcitrant phenolic compounds present in cork processing wastewater. In this communication, chemical oxidation of gallic acid was studied by gamma irradiation as an advanced oxidation process. This technology turns out to be an advantageous tool for the degradation of gallic acid. The results obtained by UV-Vis and electrospray ionization mass spectrometry (ESI-MS) techniques are in agreement concerning the suitability of this technique to degrade gallic acid. ESI-MS and ESI-MS(2) monitoring of the non-irradiated and irradiated gallic acid solutions leads to the identification of the main intermediate products. Based on the overall results obtained a consistent mechanism of radiolytic degradation of gallic acid is proposed. The application of radiation as a tool to increase the biodegradability of wastewaters is an important issue from the perspective of Green Chemistry.

Radiolytic degradation of gallic acid and its derivatives in aqueous solution

Polyphenols, like gallic acid (GA) released in the environment in larger amount, by inducing some unwanted oxidations, may constitute environmental hazard: their concentration in wastewater should be controlled. Radiolytic degradation of GA was investigated by pulse radiolysis and final product techniques in dilute aqueous solution. Subsidiary measurements were made with 3,4,5-trimethoxybenzoic acid (TMBA) and 3,4,5-trihydroxy methylbenzoate (MGA). The hydroxyl radical and hydrogen atom intermediates of water radiolysis react with the solute molecules yielding cyclohexadienyl radicals. The radicals formed in GA and MGA solutions in acid/base catalyzed water elimination decay to phenoxyl radicals. This reaction is not observed in TMBA solution. The hydrated electron intermediate of water decomposition adds to the carbonyl oxygen, the anion thus formed protonates on the ring forming cyclohexadienyl radical or on the carbonyl group forming carbonyl centred radical. The GA intermediates formed during reaction with primary water radicals in presence of oxygen transform to non-aromatic molecules, e.g., to aliphatic carboxylic acids.

Quantitative imaging and sigmoidoscopy to assess distribution of rectal microbicide surrogates

Understanding the distribution of microbicide and human immunodeficiency virus (HIV) within the gastrointestinal tract is critical to development of rectal HIV microbicides. A hydroxyethylcellulose-based microbicide surrogate or viscosity-matched semen surrogate, labeled with gadolinium-DTPA (diethylene triamine pentaacetic acid) and 99mTechnetium-sulfur colloid, was administered to three subjects under varying experimental conditions to evaluate effects of enema, coital simulation, and microbicide or semen simulant over 5 h duration. Quantitative assessment used single photon emission computed tomography (SPECT)/computed tomography (CT) and magnetic resonance imaging (MRI) imaging, and sigmoidoscopic sampling. Over 4 h, radiolabel migrated cephalad in all studies by a median (interquartile range) of 50% (29-102%; P<0.001), as far as the splenic flexure (approximately 60 cm) in 12% of studies. There was a correlation in concentration profile between endoscopic sampling and SPECT assessments. HIV-sized particles migrate retrograde, 60 cm in some studies, 4 h after simulated ejaculation in our model. SPECT/CT, MRI, and endoscopy can be used quantitatively to facilitate rational development of microbicides for rectal use.

Toward the prediction of the activity of antioxidants: experimental and theoretical study of the gas-phase acidities of flavonoids

The relative gas-phase acidities were determined for eight flavonoids, applying the kinetic method, by means of electrospray-ion trap mass spectrometry. The experimental acidity order, myricetin > luteolin > quercetin > (+/-)-taxifolin > kaempferol > apigenin > (+)-catechin > (+/-)-naringenin shows good agreement with the order obtained by theoretical calculations at the B3LYP/6-311 + G(2d,2p)//HF/6-31G(d) level. Moreover, these calculations provide the gas-phase acidities of the different OH groups for each flavonoid. The calculated acidity values (Delta(ac)H), corresponding to the most favorable deprotonation, cover a narrow range, 314.8-330.1 kcal/mol, but the experimental method is sensitive enough to differentiate the acidity of the various flavonoids. For all the flavones and the flavanol, catechin, the 4'-hydroxyl group is the most favored deprotonation site whereas for the flavanones studied, taxifolin and naringenin, the most acidic site is the 7-hydroxyl group. On the other hand, the 5-hydroxyl, in flavones and naringenin, and the 3-hydroxyl, in taxifolin and catechin, are always the less acidic positions. The acidity pattern observed for this family of compounds mainly depends on the following structural features: The ortho-catechol group, the 2,3 double bond and the 4-keto group.

Improved positron emission tomography quantification by Fourier-based restoration filtering

Positron emission tomography (PET) images are characterized by both poor spatial resolution and high statistical noise. Conventional methods to reduce noise, such as local weighted averaging, produce further deteriorations in spatial resolution, while the use of deconvolution to recover resolution typically amplifies noise to unacceptable levels. We studied the use of two-dimensional Fourier filtering to simultaneously increase quantitative recovery and reduce noise. The filter was based on inversion of the scanner's measured transfer function, coupled with high frequency roll-off. In phantom studies, we found improvements in both "hot" and "cold" sphere quantification. Compared with ramp-only filtering, improvements in hot spot recovery for the highest accuracy filter averaged 13.6% +/- 6.6% for spheres larger than 15 mm; improvements in cold spot recovery averaged 30.7% +/- 4.7%. At the same time, the noise was reduced by a factor of 3 compared with randomly filtering. Fourier-based image restoration filtering is thus capable of improving both accuracy and precision in PET.

Measurement of radiotracer concentration in brain gray matter using positron emission tomography: MRI-based correction for partial volume effects

Accuracy in in vivo quantitation of brain function with positron emission tomography (PET) has often been limited by partial volume effects. This limitation becomes prominent in studies of aging and degenerative brain diseases where partial volume effects vary with different degrees of atrophy. The present study describes how the actual gray matter (GM) tracer concentration can be estimated using an algorithm that relates the regional fraction of GM to partial volume effects. The regional fraction of GM was determined by magnetic resonance imaging (MRI). The procedure is designated as GM PET. In computer simulations and phantom studies, the GM PET algorithm permitted a 100% recovery of the actual tracer concentration in neocortical GM and hippocampus, irrespective of the GM volume. GM PET was applied in a test case of temporal lobe epilepsy revealing an increase in radiotracer activity in GM that was undetected in the PET image before correction for partial volume effects. In computer simulations, errors in the segmentation of GM and errors in registration of PET and MRI images resulted in less than 15% inaccuracy in the GM PET image. In conclusion, GM PET permits accurate determination of the actual radiotracer concentration in human brain GM in vivo. The method differentiates whether a change in the apparent radiotracer concentration reflects solely an alteration in GM volume or rather a change in radiotracer concentration per unit volume of GM.

Correction of PET data for partial volume effects in human cerebral cortex by MR imaging

Due to the limited spatial resolution of positron emission tomography (PET), the accuracy of quantitative measurements of regional metabolism or neuroreceptor concentration is influenced by partial volume averaging of brain with CSF, bone, and scalp. This effect is increased in the presence of cortical atrophy, as in patients with Alzheimer disease (AD). Correction for this underestimation in PET measurements is necessary for the comparison of AD patients and normal controls. We have developed a method for three-dimensional correction of human PET data using magnetic resonance (MR) imaging. A composite brain tissue image is created by summing the binary representation of nine MR images, weighted to the PET z-axis line-spread function. This composite tissue image is convolved to the resolution of the PET image. The original PET image is divided by the convolved tissue image on a pixel-by-pixel basis, resulting in an atrophy-corrected PET image in which count density represents activity per volume of brain tissue rather than spatial volume. This has been performed in [11C]carfentanil mu-opiate receptor PET studies of the temporal cortex in two AD patients and one normal volunteer. After correction, average regional increases in count density were 11% (range = 4-21%) in the normal and 46% (range = 28-99%) and 48% (range = 14-109%) in the patient studies. The accuracy of this method of partial volume correction was estimated using a spherical phantom.

Anatomical localization for PET using MR imaging

Accurate localization of an imaging plane of interest is often needed prior to a positron emission tomographic (PET) study. We have developed a simple method for accurate and reproducible selection of an imaging plane for PET using magnetic resonance (MR) imaging. This method is useful when optimal sampling of specific brain structures, such as small subcortical nuclei, or when a specific imaging angle is required for the PET study. An external localizing device, consisting of a series of tubes visible on MR, is affixed to an individually fitted thermoplastic mask. This mask system is worn by the patient during both the MR and PET studies. A plane of interest is planned from the sagittal MR image and defined by its relation to the localizing device and to the MR scanner's "landmark" or reference position. This plane is transferred to the mask by means of a calibrated alignment laser. The coplanar acquisition of MR and PET images allows individualized analysis of brain structure-function relationships. Phantom studies demonstrated the accuracy and reproducibility of imaging plane selection by this method to be within 1 mm and 1 degree. Application of the localization protocol in a human subject is also presented.