Transformation of serum-susceptible Escherichia coli O111 with p16Slux plasmid to allow for real-time monitoring of complement-based inactivation of bacterial growth in bovine milk

Complement activity has only recently been characterized in raw bovine milk. However, the activity of this component of the innate immune system was found to diminish as milk was subjected to heat or partitioning during cream separation. Detection of complement in milk relies on a bactericidal assay. This assay exploits the specific growth susceptibility of Escherichia coli O111 to the presence of complement. Practical application of the assay was demonstrated when a reduction in complement activity was recorded in the case of pasteurized and reduced-fat milks. This presented an opportunity to improve the functionality of the bactericidal assay by incorporating bioluminescence capability into the target organism. Following some adaptation, the strain was transformed by correctly integrating the p16Slux plasmid. Growth properties of the transformed strain of E. coli O111 were unaffected by the modification. The efficacy of the strain adaptation was correlated using the LINEST function analysis [r=0.966; standard error of prediction (SEy)=0.957] bioluminescence with that of bactericidal assay total plate counts within the range of 7.5 to 9.2 log cfu/mL using a combination of raw and processed milk samples. Importantly, the transformed E. coli O111 p16Slux strain could be identified in milk and broth samples using bioluminescence measurement, thus enabling the bactericidal assay-viability test to be monitored in real time throughout incubation.

Optically isolated, 2 kHz repetition rate, 4 kV solid-state pulse trigger generator

This paper presents the design and operation characteristics of a solid-state high voltage pulse generator. Its primary utilization is aimed at triggering a gaseous spark gap with high repeatability. Specifically, the trigger generator is designed to achieve a risetime on the order of 0.1 kV/ns to trigger the first stage, trigatron spark gap of a 10-stage, 500 kV Marx generator. The major design components are comprised of a 60 W constant current DC-DC converter for high voltage charging, a single 4 kV thyristor, a step-up pulse transformer, and magnetic switch for pulse steepening. A risetime of <30 ns and pulse magnitude of 4 kV is achieved matching the simulated performance of the design.

Tuberculosis and diabetes mellitus in the Republic of Kiribati: a case-control study

OBJECTIVES

To better inform local management of TB-diabetes collaborative activities, we aimed to determine the prevalence of diabetes among persons with and without TB and to determine the association between TB and diabetes in Kiribati, a Pacific Island nation.

METHODS

We compared consecutively enrolled TB cases to a group of randomly selected community controls without evidence of TB. Diabetes was diagnosed by HbA1c, and clinical and demographic data were collected. A tuberculin skin test was administered to controls. The chi-square test was used to assess significance in differences between cases and controls. We also calculated an odds ratio, with 95% confidence intervals, for the odds of diabetes among cases relative to controls. Unweighted multivariate logistic regression was performed to adjust for the effects of age and sex.

RESULTS

A total of 275 TB cases and 499 controls were enrolled. The diabetes prevalence in cases (101, 37%) was significantly greater than in controls (94, 19%) (adjusted odds ratio: 2.8; 95% CI 2.0-4.1). Fifty-five percent (108) of all diabetic diagnoses were new; this proportion was higher among controls (64.8%) than cases (46.5%). Five patients with TB were screened to detect one patient with diabetes.

CONCLUSIONS

There is a strong association between TB and diabetes in Kiribati and bidirectional screening should be conducted in this setting.

Effect of diabetes on tuberculosis presentation and outcomes in Kiribati

OBJECTIVES

To determine the association between diabetes and the clinical features and treatment outcomes of TB in Kiribati.

METHODS

We enrolled consecutive patients with TB who presented from August 2010 to February 2012 and compared clinical features and TB treatment outcomes for patients with and without diabetes, as measured by haemoglobin A1c assay. Poor outcome was defined as death, default or treatment failure, and good outcome as treatment success or cure.

RESULTS

Two hundred and seventy-five eligible persons with TB disease were enrolled; 101 (37%) had diabetes. TB patients with diabetes were more likely to have acid-fast bacilli (AFB) seen on sputum smear microscopy (RR: 1.3; 95% CI: 1.03-1.62). The risk of poor outcome did not differ between patients with or without diabetes (RR: 1.1; 95% CI: 0.5-2.7).

CONCLUSION

TB patients with diabetes are more likely than those without to have sputum with AFB on microscopy. This could increase transmission in the community. Early detection of TB by screening patients with diabetes, and the converse, could be important public health interventions where diabetes and TB are prevalent.

The anti-inflammatory potential of a moderately hydrolysed casein and its 5 kDa fraction in in vitro and ex vivo models of the gastrointestinal tract

Bioactive peptides from milk can impart a wide range of physiological benefits without the allergies and intolerance associated with the consumption of whole milk.

Diagnostic nanoparticle targeting of the EGF-receptor in complex biological conditions using single-domain antibodies

For effective localization of functionalized nanoparticles at diseased tissues such as solid tumours or metastases through biorecognition, appropriate targeting vectors directed against selected tumour biomarkers are a key prerequisite. The diversity of such vector molecules ranges from proteins, including antibodies and fragments thereof, through aptamers and glycans to short peptides and small molecules. Here, we analyse the specific nanoparticle targeting capabilities of two previously suggested peptides (D4 and GE11) and a small camelid single-domain antibody (sdAb), representing potential recognition agents for the epidermal growth factor receptor (EGFR). We investigate specificity by way of receptor RNA silencing techniques and look at increasing complexity in vitro by introducing increasing concentrations of human or bovine serum. Peptides D4 and GE11 proved problematic to employ and conjugation resulted in non-receptor specific uptake into cells. Our results show that sdAb-functionalized particles can effectively target the EGFR, even in more complex bovine and human serum conditions where targeting specificity is largely conserved for increasing serum concentration. In human serum however, an inhibition of overall nanoparticle uptake is observed with increasing protein concentration. For highly affine targeting ligands such as sdAbs, targeting a receptor such as EGFR with low serum competitor abundance, receptor recognition function can still be partially realised in complex conditions. Here, we stress the value of evaluating the targeting efficiency of nanoparticle constructs in realistic biological milieu, prior to more extensive in vivo studies.

Congenital-infantile fibrosarcoma of the foot--avoidance of amputation

Congenital-infantile fibrosarcoma is a rare entity with a five year survival rate of over 90%. Surgery is still the most common treatment modality with amputation often necessary. There have been reports supporting the use of neoadjuvant chemotherapy to debulk the tumour in an effort to facilitate limb sparing surgery. We report a case of a newborn who presented with a life threatening haemorrhage from a fibrosarcoma of the foot, successfully treated with Vincristine, Actinomycin and Cyclophosphamide (VAC) chemotherapy alone.

The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis

BACKGROUND

Pediatric orthopaedic surgery owes its development to many pioneering individuals, and the studies that these individuals have undertaken form the basis for the clinical decisions made on the modern pediatric orthopaedic service. The aim of our study was to use citation analysis to identify the top 100 papers in pediatric orthopaedic surgery.

METHODS

Using the Thomson Reuters Web of Knowledge, we searched for citations of all papers relevant to pediatric orthopaedics. The number of citations, authorship, year of publication, journal of publication, and country and institution of origin were recorded for each paper.

RESULTS

The most cited paper was found to be the classic paper from 1963 by Salter and Harris that introduced the now-eponymous classification system for physeal injuries in the skeletally immature patient. The second most cited was Salter's paper describing the widely used osteotomy for the treatment of developmental dysplasia of the hip, and the third most cited was Catterall's description of the natural history of Legg-Calvé-Perthes disease. Most papers originated in the U.S., and most were published in this journal. A number of authors including Salter, Ponseti, Graf, and Loder had more than one paper in the top-100 list.

DISCUSSION

This paper's identification of the classic papers of pediatric orthopaedic surgery gives us a unique insight into the development of pediatric orthopaedic surgery in the twentieth and early twenty-first centuries and identifies those individuals who have contributed the most to the body of knowledge used to guide evidence-based clinical decision-making in pediatric orthopaedics today.

Enzymatic hydrolysis of heat-induced aggregates of whey protein isolate

The effects of heat-induced denaturation and subsequent aggregation of whey protein isolate (WPI) solutions on the rate of enzymatic hydrolysis was investigated. Both heated (60 °C, 15 min; 65 °C, 5 and 15 min; 70 °C, 5 and 15 min, 75 °C, 5 and 15 min; 80 °C, 10 min) and unheated WPI solutions (100 g L(-1) protein) were incubated with a commercial proteolytic enzyme preparation, Corolase PP, until they reached a target degree of hydrolysis (DH) of 5%. WPI solutions on heating were characterized by large aggregate formation, higher viscosity, and surface hydrophobicity and hydrolyzed more rapidly (P < 0.001) than the unheated. The whey proteins exhibited differences in their susceptibility to hydrolysis. Both viscosity and surface hydrophobicity along with insolubility declined as hydrolysis progressed. However, microstructural changes observed by light and confocal laser scanning microscopy (CLSM) provided insights to suggest that aggregate size and porosity may be complementary to denaturation in promoting faster enzymatic hydrolysis. This could be clearly observed in the course of aggregate disintegration, gel network breakdown, and improved solution clarification.

Precipitation Fluctuations over Northern Hemisphere Land Areas Since the Mid-19th Century

An extensive array of measurements extending back to the mid-19th century was used to investigate large-scale changes in precipitation over Northern Hemisphere land areas. Significant increases in mid-latitude precipitation and concurrent decreases in low-latitude precipitation have occurred over the last 30 to 40 years. Although these large-scale trends are consistent with general circulation model projections of precipitation changes associated with doubled concentrations of atmospheric carbon dioxide, they should be viewed as defining large-scale natural climatic variability. Additional work to refine regional variations and address potential network inhomogeneitics is needed. This study attempts to show secular precipitation fluctuations over hemispheric and continental-scale areas of the Northern Hemisphere.

Transmissibility of 2009 pandemic influenza A(H1N1) in New Zealand: effective reproduction number and influence of age, ethnicity and importations

The first wave of pandemic influenza A(H1N1) has subsided in New Zealand as in other southern hemisphere countries. This study aimed to estimate the effective reproduction number (R) of 2009 pandemic influenza A(H1N1) taking into account imported cases. It also aimed to show the temporal variation of R throughout the New Zealand epidemic, changes in age- and ethnicity-specific cumulative incidence, and the effect of school holidays. Using a new modelling method to account for imported cases, we have calculated the peak R during the containment phase of the pandemic as 1.55 (95% confidence interval: 1.16 to 1.86). This value is less than previously estimated in the country early in the pandemic but in line with more recent estimates in other parts of the world. Results also indicated an increase in the proportion of notifications among school-age children after the school holiday (3-19 July 2009). This finding provides support for the potential effectiveness of timely school closures, although such disruptive interventions need to be balanced against the severity of the pandemic.

Transmissibility of 2009 pandemic influenza A(H1N1) in New Zealand: effective reproduction number and influence of age, ethnicity and importations

Binary file ES_Abstracts_Final_ECDC.txt matches

Pulmonary tuberculosis, impaired lung function, disability and quality of life in a high-burden setting

SETTING

Tuberculosis treatment clinic in Papua, Indonesia.

OBJECTIVE

To document the impact of pulmonary tuberculosis (PTB) on lung function, exercise tolerance and quality of life (QOL).

DESIGN

A prospective cohort study of 115 patients with smear-positive PTB followed for 6 months. Demographics, disease history, sputum microbiology, spirometry, 6-minute weight.walk distance (6MWWD) and QOL (modified St George's Respiratory Questionnaire) were measured at diagnosis and at 2 and 6 months. Analysis was restricted to the 69/115 (60%) subjects who attended all follow-up visits.

RESULTS

Subjects who attended all visits were less likely than the full cohort to be of Papuan ethnicity (P < 0.05), were more likely to be cured (P < 0.001) and had better lung function at diagnosis (P < 0.05). Significant lung function impairment (forced expiratory volume in 1 second [FEV(1)] <60% predicted) was found in 27/69 (39%) at diagnosis. Although this fell during treatment (P < 0.01), 17/69 (24.6%) had persisting significant lung function impairment at treatment completion. As lung function recovered, exercise tolerance (6MWWD) rose by 12.3% (P < 0.001) and QOL improved (P < 0.001).

CONCLUSION

In a high-burden setting, PTB causes prolonged, significant impairment of lung function, exercise tolerance and QOL. Current measures of disease burden are likely to underestimate the true impact of disease. Earlier diagnosis and disease-modifying treatments may reduce the long-term impact of PTB.

Chicken faeces garden fertilizer: possible source of human avian influenza H5N1 infection

Avian influenza H5N1 infection in humans is typically associated with close contact with infected poultry or other infected avian species. We report on human cases of H5N1 infection in Indonesia where exposure to H5N1-infected animals could not be established, but where the investigation found chicken faeces contaminated with viable H5N1 virus in the garden fertilizer. Human cases of avian influenza H5N1 warrant extensive investigations to determine likely sources of illness and to minimize risk to others. Authorities should regulate the sale and transportation of chicken faeces as fertilizer from areas where H5N1 outbreaks are reported.

An ethnographic study of barriers to and enabling factors for tuberculosis treatment adherence in Timor Leste

BACKGROUND

Tuberculosis (TB) is a major public health problem in Timor Leste; treatment adherence was identified by the National TB Control Programme (NTP) as an impediment to TB control.

OBJECTIVE

To identify barriers to and enabling factors for the successful implementation of the DOTS strategy in Timor Leste.

METHOD

Qualitative research was carried out in the two districts (one rural and one urban) with the lowest treatment completion rates. Semi-structured interviews and focus group discussions were conducted with patients, health workers and community members in eight villages.

RESULT

Good knowledge of TB, including a correct understanding of how it is cured, together with the provision of incentives, were important factors contributing to treatment completion. Defaulting patients and community members had less knowledge of TB. TB nurses had a good understanding of, and a high level of commitment to implementing the DOTS strategy. Obstacles to treatment completion included preference for traditional medicine, economic difficulties and geographic remoteness.

CONCLUSION

Local cultural practices and knowledge as well as socio-economic factors contribute to less than optimal adherence to TB treatment. This study has assisted Timor Leste's NTP in modifying its DOTS expansion strategies to overcome barriers to treatment completion.

Ethical challenges in TB control in the era of XDR-TB

Tuberculosis (TB) is the second leading cause of preventable illness worldwide and arguably the most important neglected topic in bioethics. This paper 1) explains the ethical importance of TB, 2) documents its neglect in bioethics discourse, 3) maps the terrain of ethical issues associated with TB, and 4) calls for ethicists, activists and socially concerned health professionals to raise and debate the full range of ethical issues associated with TB.

A public-private partnership for TB control in Timika, Papua Province, Indonesia

SETTING

A district-level tuberculosis (TB) control programme in Papua Province, Indonesia.

OBJECTIVE

To describe a successful partnership between the District Health Department, a private company and non-governmental health care providers.

METHODS

Routinely collected surveillance data were analysed. A conceptual model was constructed to describe TB control in the district. Data were compared with the National TB Control Programme (NTP) performance indicators.

RESULTS

Funding for the programme's TB clinic is provided by a private company (PT Freeport Indonesia). The NTP provides the policy framework, treatment guidelines and some supplies. TB clinic staff are included in training programmes and the TB laboratory in the provincial quality assurance system. TB clinic staff are responsible for diagnosis, treatment, default tracing, recording and reporting, health education and community mobilisation. The largest proportion of TB patient referrals came from the community hospital (41%). The TB notification rate (311/100000), TB-HIV (human immunodeficiency virus) co-infection (12%) and multidrug-resistant (MDR) TB (2%) are significantly higher in Mimika, but the treatment success rate for smear-positive patients (91%) is similar to Indonesian national figures.

CONCLUSIONS

For true progress in attaining the United Nations Millennium Development Goals for TB in Indonesia, innovative local solutions utilising public-private partnerships are essential. The Mimika model is one such solution that should be tested elsewhere.

Tuberculosis control in conflict-affected East Timor, 1996-2004

SETTING

East Timor has undergone major political changes in the past 10 years. Tuberculosis (TB) control has flourished, despite chronic low tension conflict, a brief but intense period of high-level conflict and post-conflict reconstruction.

OBJECTIVE

To assess TB control in East Timor from 1996 to 2004.

DESIGN

Data were collected from a variety of sources. Key TB programme indicators were analysed with reference to WHO targets to assess the performance of the three TB control programmes that operated during the study period.

RESULTS

Before 1999, a non-governmental TB control programme was established in several districts in parallel with the government TB programme, and showed optimistic results. External donor funds, technical assistance and local control strategies were key components. In 1999, conflict led to complete disruption of both programmes. In 2000, a National Tuberculosis Control Programme (NTP) was established from the non-governmental programme in collaboration with other partners. The smear-positive TB case notification rate of 108 per 100000 population is the highest in the region and reflects high population coverage. The cure rate of 81% is close to reaching the WHO target.

CONCLUSION

High-quality TB control has been introduced in conflict-affected East Timor. Further research is needed to examine Timorese approaches to inform other, similar settings.

Effect of milk protein standardization using different methods on the composition and yields of Cheddar cheese

Two sets of Cheddar cheese were made in which the milk protein level (%, wt/wt) was increased from 3.3 (Control A, CA) to 3.6 (set A) or from 3.3 (control B, CB) to 4.0 (set B) by the addition of phosphocasein (PC), milk protein concentrate (MPC), or freshly prepared ultrafiltered milk retentate (UFR). The cheeses were denoted CA, PCA, MPCA, and UFRA from set A, and CB, PCB, MPCB, and UFRB, from set B, respectively. The level of cheese moisture decreased significantly on increasing milk protein level from 3.3 to 3.6 or 4.0% (wt/wt), but was not affected significantly by the method of protein standardization. The percentage milk fat recovered to cheese increased significantly on increasing the level of milk protein from 3.3 to 3.6% (wt/wt) with PC, and from 3.3 to 4.0% (wt/wt) with PC, MPC, and UFR. Increasing milk protein level from 3.3 to 4.0% (wt/wt) with PC significantly increased the percentage of milk protein recovered to cheese. Actual cheese yield increased significantly with milk protein level. The yield of cheese per 100 kg of milk normalized to reference levels of fat (3.4%, wt/wt) and casein (2.53%, wt/wt) indicated no significant effects of protein content or standardization treatment on yield. However, the moisture-adjusted yield per 100 kg of milk with reference levels of fat and casein increased significantly on increasing the protein content from 3.3 to 3.6% (wt/wt) with MPC and from 3.3 to 4.0% (wt/wt) with PC, MPC, and UFR.

Transforming growth factor-beta (TGF-β) in acute injuries of the spinal cord

Injuries to the spinal cord may be associated with increased healing of fractures. This can be of benefit, but excessive bone growth can also cause considerable adverse effects.

We evaluated two groups of patients with fractures of the spinal column, those with neurological compromise (n = 10) and those without (n = 15), and also a control group with an isolated fracture of a long bone (n = 12). The level of transforming growth factor-beta (TGF-β), was measured at five time points after injury (days 1, 5, 10, 42 and 84).

The peak level of 142.79 ng/ml was found at day 84 in the neurology group (p < 0.001 vs other time points). The other groups peaked at day 42 and had a decrease at day 84 after injury (p ≤ 0.001).

Our findings suggest that TGF-β may have a role in the increased bone turnover and attendant complications seen in patients with acute injuries to the spinal cord.

An alternative method for sputum storage and transport for mycobacterium tuberculosis drug resistance surveys

SETTING

A district level tuberculosis (TB) programme in Indonesia.

OBJECTIVE

To evaluate whether a single sputum specimen could be stored by refrigeration for an extended period of time, then transported to a reference laboratory and successfully cultured for Mycobacterium tuberculosis.

METHODS

Single sputum specimens were collected from newly diagnosed smear-positive pulmonary TB patients, refrigerated at the study site without addition of 1% cetylpyridinium chloride, batched and sent to the reference laboratory, where they were decontaminated and inoculated into BACTEC MGIT 960 liquid media.

RESULTS

One hundred and seven patients were enrolled. The median specimen storage time was 12 days (range 1-38) and median transportation time was 4 days (2-12). The median time from specimen collection until processing was 18 days (4-42). Only 4 (3.7%) specimens failed to grow Mycobacterium species and M. tuberculosis was isolated from 101 (94.4%) specimens. Six specimens with breakthrough contamination successfully grew M. tuberculosis after a second decontamination procedure.

CONCLUSIONS

Single sputum specimens collected at a remote setting, refrigerated for relatively long periods without preservatives and transported without refrigeration to a reference laboratory can yield a high positive culture rate. These findings offer potential logistic simplification and cost savings for drug resistance surveys in low-resource countries.

A community-based TB drug susceptibility study in Mimika District, Papua Province, Indonesia

SETTING

A district level tuberculosis (TB) control programme in Papua Province, Indonesia.

OBJECTIVE

To determine the nature and extent of drug-resistant TB in newly diagnosed sputum smear-positive patients.

METHODS

Sputum was collected from previously untreated smear-positive pulmonary TB patients diagnosed in the district over a 10-month period. Sputum specimens were processed and inoculated into a BACTEC MGIT960 tube. Isolates were identified by Ziehl-Neelsen staining, hybridisation with nucleic acid probes and biochemical investigations. Susceptibility testing was performed using the radiometric proportion method. Pyrazinamide testing was performed using the Wayne indirect method.

RESULTS

One hundred and seven patients had sputum sent to a reference laboratory; 101 (94.4%) were culture-positive for Mycobacterium tuberculosis, with 87 (86.1%) fully sensitive to first-line anti-tuberculosis drugs. Two per cent were multidrug-resistant (MDR-TB) and 12 (11.9%) had other drug resistance. Each of the MDR-TB isolates was susceptible to amikacin, capreomycin, ciprofloxacin and para-aminosalicylic acid (PAS), but were resistant to rifabutin. One isolate was also resistant to ethionamide.

CONCLUSIONS

MDR-TB is present in Indonesia but is not a major problem for TB control in this district. Generalisability to other districts in Indonesia, particularly large urban areas, needs to be confirmed by future studies.

Seroprevalence of Burkholderia pseudomallei in East Timorese refugees: implications for healthcare in East Timor

Melioidosis is a disease with protean clinical manifestations caused by the bacterium Burkholderia pseudomallei. It is endemic in countries surrounding the newly independent East Timor, but has yet to be isolated or demonstrated serologically in that country. One illness that can be clinically indistinguishable from melioidosis is pulmonary tuberculosis, a condition with a very high prevalence in East Timor. We used an indirect hemagglutination test (IHA) to measure antibodies to B. pseudomallei in 407 East Timorese evacuated to Darwin, Australia, in September 1999. Assuming a positive IHA titer as > or = 1:40, the overall seroprevalence rate was 17.0%, in keeping with other seroprevalence studies from the region. The IHA titres ranged up to 1:320. After adjusting for age, females were 2.5 times more likely to be seropositive than males (p = 0.0001). There was an inverse relationship between seropositivity and age. This study shows that exposure to B. pseudomallei occurs in East Timor melioidosis is also likely to occur. Due to the lack of laboratory facilities at present, it may be some time before a laboratory-confirmed case proves that melioidosis occurs. In the meantime, clinicians in East Timor should include melioidosis in the differential diagnosis of the many conditions that it may mimic.

Analysis of Mycobacterium tuberculosis isolates from treatment failure patients living in East Timor

SETTING

In the first 2 years of the East Timor National TB Control Programme, 7960 new patients were treated (2RHZE/6HE) and 224 received a retreatment regimen (2SRHZE/1RHZE/4R3H3Z3E3).

OBJECTIVE

To determine the nature and extent of drug-resistant tuberculosis (TB) in treatment failure cases in East Timor.

METHODS

Sputum specimens from retreatment failure cases were processed and inoculated into a BACTEC MGIT960 tube and onto Löwenstein-Jensen media. Isolates were identified by Ziehl-Neelsen staining, hybridisation with nucleic acid probes and biochemical investigations. Susceptibility testing was performed using the radiometric proportion method. Pyrazinamide testing was performed using the Wayne indirect method.

RESULTS

Eighteen patients failed retreatment (0.7% of new cases) and 14 were available for analysis. Mycobacterium tuberculosis was cultured from all specimens, despite considerable transport delays. Nine (64.3%) had multiple drug resistance (MDR-TB) and four (28.6%) had other drug resistance. All MDR-TB isolates were susceptible to amikacin, capreomycin and ethionamide, with most also susceptible to ciprofloxacin and para-aminosalicylic acid (PAS).

CONCLUSIONS

An excellent TB control programme has been established in East Timor. If funds are available, East Timor provides an ideal setting for a small-scale DOTS-Plus programme to treat prevalent cases of MDR-TB, and this study could inform the second-line drug regimen.

Tuberculosis in east timorese refugees: implications for health care needs in East Timor

SETTING

East Timorese refugees evacuated to Darwin, Australia, September 1999.

OBJECTIVE

Presentation of the process and results of tuberculosis (TB) screening in a previously unscreened refugee population.

DESIGN

Screening for TB by clinical examination (all persons) and chest X-ray (CXR) (persons over 12 years of age and those of any age with respiratory symptoms) and sputum microscopy and mycobacterial culture (abnormal CXR).

RESULTS

Seventy-six patients were diagnosed with TB (38 culture-positive for Mycobacterium tuberculosis, including 11 sputum smear-positive). Of 89 positive mycobacterial cultures, 51 were non-tuberculous mycobacteria (NTM). Of the M. tuberculosis isolates, 82.2% were fully sensitive, 17.2% were resistant to isoniazid and 8.6% were resistant to isoniazid and streptomycin. Fifty-three consecutively diagnosed patients with TB were HIV-negative. The TB burden in this population was very high (point prevalence of 542/100,000 for smear-positive and 2,060/100,000 for culture-positive cases). Rates of culture for NTM were also high. Information from this study assisted the implementation of a National TB Control Programme for East Timor in February 2000.

CONCLUSION

The challenges for public health authorities in East Timor to provide a successful TB control programme are enormous. The apparently low prevalence of drug resistance and HIV co-infection in the population is encouraging.

Quality control Lactobacillus strains for use with the API 50CH and API ZYM systems at 37 degrees C

The API 50CH and API ZYM systems fulfil an important role in the polyphasic taxonomic identification of lactobacilli. When the API 50CH fermentation profile of the quality control Lactobacillus casei var. alactosus (Lb. paracasei subsp. paracasei) strain NCFB 206 was determined at 37 degrees C, it was found to differ from that determined at 30 degrees C by BioMéreiux SA (Montalieu Vercieu, France) and the National Collection of Food Bacteria (Aberdeen, Scotland). In addition, the API 50CH fermentation and API ZYM profiles of Lb. casei strain ATCC 334T determined at 37 degrees C differed from those determined at 30 degrees C by Lee and Simard (1984). Strains NCFB 206 and ATCC 334T were thus assumed to exhibit temperature-dependent variation in fermentation profile, a phenomenon recently described by Nigatu et al. (2000). In contrast, Lb. rhamnosus strain ATCC 243T did not exhibit temperature-dependent variation in fermentation profile. Moreover, the fermentation profile obtained at 37 degrees C differed in only one respect (positive beta-gentiobiose utilisation) from that published by Collins et al. (1989). In addition, Lactobacillus strain GG produced a stable and reproducible API ZYM profile at 37 degrees C, although some variation in the level of enzyme activity was evident. Thus, strain NCFB 206 was replaced by strain ATCC 243T as the quality control strain of choice for use with the API 50CH fermentation system, and Lactobacillus strain GG adopted for use as a quality control strain with the API ZYM system for strain identification of lactobacilli at 37 degrees C. The API 50CH and API ZYM profiles of the commercially important Lactobacillus strains NCFB 1748, GG, KLD, F19, and ACA-DC 212.3 were determined at 37 degrees C after anaerobic growth in MRS broth. The fermentation and enzyme profiles of strain NCFB 1748 were almost identical to those of Lb. crispatus ATCC 33820T, those of strain GG were found to be more similar to those of Lb. rhamnosus strain 243T than Lb. zeae strain ATCC 15820T, those of strain KLD were most similar to those of Lb. fermentum DSM 20052T, while those of strains F19 and ACA-DC 212.3 were similar to those of Lb. casei strain ATCC 334T.

Gradient diffusion antibiotic susceptibility testing of potentially probiotic lactobacilli

Minimum inhibitory contentrations (MICs) of selected inhibitors of cell wall synthesis (benzylpenicillin, ampicillin, and vancomycin), protein synthesis (gentamicin, streptomycin, tetracycline, chloramphenicol, and erythromycin), and nucleic acid synthesis (co-trimoxazole, rifampicin, and metronidazole) were determined by gradient diffusion (E test; AB Biodisk, Solna, Sweden) on deMan, Rogosa, Sharpe (MRS) agar for Lactobacillus strain GG and 11 closely related, rapidly growing, facultatively anaerobic, potentially probiotic Lactobacillus rhamnosus strains. All strains were resistant to vancomycin (MIC90 > or = 256 microg/ml), co-trimoxazole (MIC90 > or = 32 microg/ml), metronidazole (MIC90 > or = 32 microg/ml), gentamicin (MIC90 > or = 128 microg/ml), and streptomycin (MIC90 > or = 256 microg/ml), and sensitive to pencillin G (MIC90 > 0.375 microg/ml), ampicillin (MIC90 > 0.750 microg/ml), rifampicin (MIC90 > 0.375 microg/ml), tetracycline (MIC90 > 1.5 microg/ml), chloramphenicol (MIC90 > 8 microg/ml), and erythromycin (MIC90 > 2 microg/ml). E test MICs were also determined for L. acidophilus National Collection of Food Bacteria (NCFB) 1748 and L. reuteri Deutsche Sammlung von Mikroorganismen 20016T by the inoculum application method recommended by the manufacturer (swabbing), with and without antibiotic prediffusion for 1 h at room temperature, and by an alternative inoculum application (agar overlay) method, without antibiotic prediffusion. Antibiotic prediffusion increased the MICs for penicillin G, ampicillin, tetracycline, and chloramphenicol by up to 2 log2 MIC dilutions without changing antibiotic susceptibility category. Agar overlay application also increased the MICs for these antibiotics as well as for gentamicin by up to 3 log2 MIC dilutions without changing antibiotic susceptibility category. Exact agreement between MICs determined by swab and agar overlay application without antibiotic prediffusion was strain dependent: 54.5% for strain DSM 20016T and 72.7% for strain NCFB 1748. The swab and agar overlay gradient diffusion methods provide a reliable basis for antibiotic susceptibility testing of rapidly growing, facultatively anaerobic lactobacilli, using MRS agar as test medium and are readily applicable for testing individual isolates as needed.

Bioavailability of n-3 polyunsaturated fatty acids (PUFA) in foods enriched with microencapsulated fish oil

OBJECTIVE

Incorporation of fish oil into food products provides a means of increasing n-3 fatty acid intake, particularly in populations where fish consumption remains low. The aim of the present study was to evaluate the bioavailability of n-3 PUFA in microencapsulated fish-oil-enriched foods compared with an equal amount of n-3 PUFAs contained in fish oil capsules.

METHODS

Twenty-five healthy female volunteers were randomly assigned to one of two groups for the 4-week intervention: one group received 0.9 g of n-3 PUFA/day as fish oil capsule (capsule group), while the second group (food group) received an equal amount of n-3 PUFA/day from enriched foods. Baseline and post-intervention samples were analysed for platelet fatty acid composition.

RESULTS

There was no significant difference in the change in platelet arachidonic acid (AA), eicosapentaenoic acid (EPA), or docosahexaenoic acid (DHA) between the two groups following the intervention.

CONCLUSIONS

The results indicate that n-3 PUFA from microencapsulated fish-oil-enriched foods are as bioavailable as n-3 PUFA in a capsule. Fortification of foods with microencapsulated fish oil, therefore, offers an effective way of increasing n-3 PUFA intakes and status in line with current dietary recommendations.

Local problems, local solutions: improving tuberculosis control at the district level in Malawi

OBJECTIVE

To examine the causes of a low cure rate at the district level of a tuberculosis (TB) control programme and to formulate, implement, and evaluate an intervention to improve the situation.

METHODS

The study setting was Mzuzu (population 60,000), where the annual smear-positive pulmonary TB incidence was 160 per 100,000 and the human immunodeficiency virus (HIV) seroprevalence was 67% among TB patients. There is one TB treatment unit, but several other organizations are involved with TB control. An examination of case-holding activities was carried out, potential areas for improvement were identified, and interventions performed.

FINDINGS

In 1990-91, the cure rate was 24% among smear-positive cases (29% among survivors to end of treatment). Problems identified included a fragmented TB control programme; inadequate training and supervision; suboptimal recording of patients' addresses; and nonadherence to national TB control programme protocols. These problems were addressed, and in 1992-93 the cure rate rose to 68% (relative risk (RR) = 2.85 (95% confidence interval (CI) = 1.63, 4.96)) and to 92% among survivors to the end of treatment (RR = 3.12 (95% CI = 1.84, 5.29)). High cure rates are therefore achievable despite high HIV prevalence.

CONCLUSIONS

Simple, inexpensive, local programmatic interventions can dramatically improve TB case holding. This study demonstrates the need for evaluation, training, and supervision at all levels of the programme.

Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve

We describe a clinical sign for identification of the superficial peroneal nerve. Flexion of the fourth toe accentuates the subcutaneous course of the cutaneous branches of the superficial peroneal nerve. Thirty feet from 15 volunteers were examined for presence of this sign. Twenty-six of 30 feet had a positive sign that was confirmed by infiltrating the observed nerve with 1% lignocaine and correlating the consequent area of hypoaesthesia with the known distribution of the superficial peroneal nerve.

Effect of conjugated bile salts on antibiotic susceptibility of bile salt-tolerant Lactobacillus and Bifidobacterium isolates

Virtually every antibiotic may cause in vivo alterations in the number, level, and composition of the indigenous microbiotae. The degree to which the microbiotae are disturbed depends on many factors. Although bile may augment antibiotic activity, studies on the effect of bile on the antibiotic susceptibility of indigenous and exogenous probiotic microorganisms are lacking. It was against this background that the antibiotic susceptibility of 37 bile salt-tolerant Lactobacillus and 11 Bifidobacterium isolates from human and other sources was determined in the presence of 0.5% wt/wt oxgall (conjugated bile salts). Oxgall did not affect the intrinsic resistance of lactobacilli to metronidazole (5 microg), vancomycin (30 microg), and cotrimoxazole (25 microg), whereas it resulted in a complete loss of resistance to polymyxin B (300 microg) and the aminoglycosides gentamicin (10 microg), kanamycin (30 microg), and streptomycin (10 microg) for most strains studied (P < 0.001). Oxgall did not affect the intrinsic resistance of bifidobacteria to metronidazole and vancomycin, whereas polymyxin B and co-trimoxazole resistance was diminished (P < 0.05) and aminoglycoside resistance was lost (P < 0.001). Seven lactobacilli, but no bifidobacteria strain, showed unaltered intrinsic antibiotic resistance profiles in the presence of oxgall. Oxgall affected the extrinsic susceptibility of lactobacilli and bifidobacteria to penicillin G (10 microg), ampicillin (10 microg), tetracycline (30 microg), chloramphenicol (30 microg), erythromycin (15 microg), and rifampicin (5 microg) in a source- and strain-dependent manner. Human strain-drug combinations of lactobacilli (P < 0.05) and bifidobacteria (P < 0.01) were more likely to show no change or decreased susceptibility compared with other strain-drug combinations. The antimicrobial activity spectra of polymyxin B and the aminoglycosides should not be considered limited to gram-negative bacteria but extended to include gram-positive genera of the indigenous and transiting microbiotae in the presence of conjugated bile salts. Those lactobacilli (7 of 37) that show unaltered intrinsic and diminished extrinsic antibiotic susceptibility in the presence of oxgall may possess greater upper gastrointestinal tract transit tolerance in the presence of antibiotics.

HIV and tuberculosis in rural sub-Saharan Africa: a cohort study with two year follow-up

The objective was to examine the effect of HIV seropositivity on outcomes in tuberculosis (TB) patients in a rural African setting, including rates of TB relapse, other morbid events and mortality. The study setting was a district level hospital in Mzuzu, Malawi. Adult TB patients presenting between November 1991 and May 1993 were included in the study. Treatment was given according to national guidelines. Patients with smear-positive TB received 8 months of rifampicin-containing short-course chemotherapy. Patients with smear-negative or extrapulmonary TB received 12 months of 'standard' treatment. Subjects were followed until they died or until the study concluded (December 1994). There were 225 eligible patients; 187 were tested for HIV and enrolled in the study (66.8% HIV seropositive). Ninety-four percent had complete follow-up information. The cure rate in smear-positive patients who survived to the end of treatment was over 90% and not significantly affected by HIV. Disorders of the gastrointestinal, neurological and dermatological systems were significantly more common in HIV-seropositive patients. HIV had a significant effect on the risk of relapse of TB (hazard ratio [HR] = 10.55 [95% CI 1.38, 80.93]) and on all-cause mortality (HR = 2.81 [95% CI 1.63, 4.64]). Despite high HIV prevalence, high rates of TB cure are achievable using the usual treatment protocols. However, excess TB relapse, other illnesses and mortality associated with HIV seropositivity have serious implications for TB control. There is an urgent need to identify effective intervention strategies aimed at prevention, early diagnosis and treatment of these illnesses.

A new, clinically-based algorithm for the diagnosis of HIV in African tuberculosis patients: cross-sectional analysis from Mzuzu, Malawi

We aimed to create an improved, clinically-based algorithm for the diagnosis of HIV in tuberculosis (TB) patients. Cross-sectional analysis was performed on data from adult TB patients consecutively diagnosed at a Malawian district level hospital. Of 225 patients, 187 with valid HIV results were included in the study. Sixty-seven per cent were HIV seropositive. Urban address, history of skin rash and sexually transmitted diseases (STDs) and, on examination, oral candidiasis and lymphadenopathy, were associated with HIV co-infection. Using these clinical characteristics, a case definition for HIV was constructed. The Mzuzu clinical case definition was highly sensitive (86%). The area under the receiver operating characteristic (ROC) curve was 0.81, significantly larger than existing World Health Organization (WHO) clinical case definitions. The Mzuzu definition is proposed for further evaluation in settings where HIV serological testing is not readily available.

Antibiotic susceptibility of potentially probiotic Lactobacillus species

In recent years, the time-honored reputation of lactobacilli as promoters of gastrointestinal and female urogenital health has been qualified. This has occurred due to a rare association with human infection in the presence of certain predisposing factors and their potential to act as a source of undesirable antibiotic resistance determinants to other members of the indigenous microbiota. This necessitates greater caution in their selection for use in microbial adjunct nutrition and disease management (prophylaxis and therapy). It was against this background that 46 Lactobacillus strains from human and dairy sources were assayed for susceptibility to 44 antibiotics. All strains were resistant to a group of 14 antibiotics, which included inhibitors of cell wall synthesis (cefoxitin [30 microg] and aztreonam [30 microg]), protein synthesis (amikacin [30 microg], gentamicin [10 microg], kanamycin [30 microg], and streptomycin [10 microg]), nucleic acid synthesis (norfloxacin [10 microg], nalidixic acid [30 microg], sulphamethoxazole [100 microg], trimethoprim [5 microg], co-trimoxazole [25 microg], and metronidazole [5 microg]), and cytoplasmic membrane function (polymyxin B [300 microg] and colistin sulphate [10 microg]). All strains were susceptible to tetracycline (30 microg), chloramphenicol (30 microg), and rifampicin (5 microg). Four human strains and one dairy strain exhibited atypical resistance to a penicillin, bacitracin (10 microg), and/or nitrofurantoin (300 microg). One human strain was also resistant to erythromycin (15 microg) and clindamycin (2 microg). These resistances may have been acquired due to antibiotic exposure in vivo, but conclusive evidence is lacking in this regard. Seven microorganism-drug combinations were evaluated for beta-lactamase activity using synergy and nitrocefin tests. The absence of activity suggested that cell wall impermeability appeared responsible for beta-lactam resistance. The occurrence of a minority of lactobacilli with undesirable, atypical resistance to certain antibiotics demonstrates that not all strains are suitable for use as probiotics or bacteriotherapeutic agents. The natural resistance of lactobacilli to a wide range of clinically important antibiotics may enable the development of antibiotic/probiotic combination therapies for such conditions as diarrhea, female urogenital tract infection, and infective endocarditis.

Solitary fibrous tumour of the prostate

Solitary fibrous tumours are rare, benign neoplasms that are most commonly found in the pleura and less commonly on other serosal surfaces. Their cell of origin and aetiology are uncertain. A case of solitary fibrous tumour of the prostate is presented. We believe this to be the first case of this lesion to arise in this gland. Solitary fibrous tumours of the prostate may be confused with granulomatous prostatitis or carcinoma as all three may present with a nodule on rectal examination and appear as a hypoechoic nodule on transrectal ultrasound.

Antibiotic susceptibility of potentially probiotic Bifidobacterium isolates from the human gastrointestinal tract

Sixteen Bifidobacterium isolates from the human gastrointestinal tract were assayed for susceptibility to 44 antibiotics by soft agar overlay disc diffusion on TPY agar. Five isolates (3/7 B. bifidum and 2/3 B. breve) exhibited atypical antibiotic susceptibility profiles. Poor growth in the agar overlay accounted for susceptibility of B. bifidum but not B. breve isolates. All other isolates were resistant to cefoxitin (30 micrograms), aztreonam (30 micrograms), vancomycin (30 micrograms), amikacin (30 micrograms), gentamicin (10 micrograms), kanamycin (30 micrograms), streptomycin (10 micrograms), fusidic acid (10 micrograms), trimethoprim (5 micrograms), norfloxacin (10 micrograms), nalidixic acid (30 micrograms), metronidazole (5 micrograms), polymyxin B (300 micrograms) and colistin sulphate (10 micrograms), and they were susceptible to the six penicillins studied, cephalothin (30 micrograms), cefuroxime (30 micrograms), cefaclor (30 micrograms), ceftizoxime (30 micrograms), cefotaxime (30 micrograms), bacitracin (10 micrograms), chloramphenicol (30 micrograms), erythromycin (15 micrograms), clindamycin (2 micrograms), rifampicin (5 micrograms) and nitrofurantoin (300 micrograms). In addition, they varied in their susceptibility to cephradine (30 micrograms), cephazolin (30 micrograms), cefoperazone (75 micrograms), ceftriaxone (30 micrograms), ofloxacin (5 micrograms) and furazolidone (15 micrograms). They were resistant, or only marginally moderately susceptible, to ceftazidime (30 micrograms), netilmicin (10 micrograms), sulphamethoxazole (100 micrograms), cotrimoxazole (25 micrograms) and ciprofloxacin (5 micrograms), and susceptible or marginally moderately susceptible to tetracycline (30 micrograms). All B. bifidum isolates were susceptible to cefixime (5 micrograms). Four microorganism-drug combinations were evaluated for beta-lactamase activity but its absence suggested that cell wall impermeability was responsible for cephalosporin resistance among bifidobacteria. The antibiotic susceptibility of B. animalis 25527T was similar to that of the human isolates.

Development and application of an in vitro methodology to determine the transit tolerance of potentially probiotic Lactobacillus and Bifidobacterium species in the upper human gastrointestinal tract

An in vitro methodology which mimics in vivo human upper gastrointestinal transit was developed. The transit tolerance of potentially probiotic Lactobacillus and Bifidobacterium species was determined by exposing washed cell suspensions at 37 degrees C to a simulated gastric juice (pH 2.0), containing pepsin (0.3% w/v) and sodium chloride (0.5% w/v), and a simulated small intestinal juice (pH 8.0), containing pancreatin USP (1 g l-1) and sodium chloride (5 g l-1), and monitoring changes in total viable count periodically. The methodology was also employed to determine the effect of adding milk proteins (1 g l-1), hog gastric mucin (1 g l-1) and soyabean trypsinchymotrypsin inhibitor [SBTCI] (1 g l-1) on transit tolerance. The majority (14 of 15) of isolates lost > 90% viability during simulated gastric transit. Only one isolate, Lactobacillus fermentum KLD, was considered intrinsically resistant. The addition of milk proteins, singly and in combination, generally improved gastric transit tolerance. In this regard, two isolates, Lact. casei 212.3 and Bifidobacterium infantis 25962, exhibited 100% gastric transit tolerance in the presence of milk proteins. In general, the addition of hog gastric mucin did not influence simulated gastric transit tolerance of lactobacilli but tended to increase that of bifidobacteria. However, it increased that of Lact. casei 242 and Lact. salivarius 43338 but diminished that of B. bifidum 2715 and B. animalis Bo. Selected bile salts-resistant isolates were intrinsically tolerant to simulated small intestinal transit. Only Lact. casei F19 and B. adolescentis 15703T showed significant reduction in viability after 240 min. In general, the addition of milk proteins and SBTCI did not affect simulated small intestinal transit tolerance. However, they significantly improved the intrinsic resistance of Lact. casei F19 but diminished that of B. breve 15700T. It is concluded that, whereas the majority of bile salts-resistant lactobacilli and bifidobacteria may be intrinsically sensitive to gastric transit, they are intrinsically resistant to small intestinal transit. In addition, it is postulated that milk proteins and mucin may function as both buffering agents and inhibitors of digestive protease activity in vivo, thereby protecting ingested bacterial strains during upper gastrointestinal transit.