Accelerated rehabilitation following thumb ulnar collateral ligament repair with suture tape augmentation: A case series of professional basketball players

STUDY DESIGN

Case series.

INTRODUCTION

Rehabilitation protocols following thumb metacarpophalangeal (MCP) ulnar collateral ligament (UCL) repair typically do not allow for return to sport until 12 weeks post-surgery. The potential for accelerated rehabilitation following thumb MCP UCL repair with suture tape augmentation has yet to be explored.

PURPOSE OF THE STUDY

To describe the accelerated rehabilitation following thumb MCP UCL repair with the suture tape augmentation in professional basketball players.

METHODS

Three professional basketball players underwent thumb MCP UCL repair with suture tape augmentation. The athletes followed an accelerated rehabilitation program post-surgery that began with range-of-motion exercises at 2-3 days, proximal strengthening at 7-10 days, grip/pinch strengthening at 1-2 weeks, followed by progressive sport specific intervention with a custom orthosis.

RESULTS

At 5-6 weeks post-surgery, active thumb MCP range of motion returned to 83%-100%, grip strength to 81%-100%, and tripod pinch strength to 73%-78% of the contralateral side. All athletes successfully returned to sport within 5-6 weeks post-surgery.

DISCUSSION/CONCLUSION

This is the first clinical application of an accelerated rehabilitation protocol in athletes following thumb MCP UCL repair. In this series, professional basketball players were able to return to sport in half the routine recovery time. Further prospective studies re-thinking current rehabilitation protocols are warranted.

Can we do it faster? accelerated rehabilitation following thumb ulnar collateral ligament repair with suture tape augmentation

Ulnar Collateral Ligament (UCL) injuries are the most common thumb metacarpophalangeal joint ligamentinjury. Rehabilitation protocols traditionally permit return to sport at 12 weeks post-surgery. In this article, we propose anacellerated rehabilitation protocol permitting return to sport at 5-6 post-surgery in the recreational athlete.

Impact of mental disorders on active TB treatment outcomes: a systematic review and meta-analysis

BACKGROUND: Comorbid mental disorders in patients with TB may exacerbate TB treatment outcomes. We systematically reviewed current evidence on the association between mental disorders and TB outcomes.METHODS: We searched eight databases for studies published from 1990 to 2018 that compared TB treatment outcomes among patients with and without mental disorders. We excluded studies that did not systematically assess mental disorders and studies limited to substance use. We extracted study and patient characteristics and effect measures and performed a meta-analysis using random-effects models to calculate summary odds ratios (ORs) with 95% confidence intervals (CIs).RESULTS: Of 7687 studies identified, 10 were included in the systematic review and nine in the meta-analysis. Measurement of mental disorders and TB outcomes were heterogeneous across studies. The pooled association between mental disorders and any poor outcome, loss to follow-up, and non-adherence were OR 2.13 (95%CI 0.85-5.37), 1.90 (95%CI 0.33-10.91), and 1.60 (95%CI 0.81-3.02), respectively. High statistical heterogeneity was present.CONCLUSION: Our review suggests that mental disorders in TB patients increase the risk of poor TB outcomes, but pooled estimates were imprecise due to small number of eligible studies. Integration of psychological and TB services might improve TB outcomes and progress towards TB elimination.

Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors

<sec id="st1"> <title>SETTING</title> A global survey of National Tuberculosis Program (NTP) directors. </sec> <sec id="st2"> <title>OBJECTIVES</title> To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. </sec> <sec id="st3"> <title>DESIGN</title> Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. </sec> <sec id="st4"> <title>RESULTS</title> Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. </sec> <sec id="st5"> <title>CONCLUSIONS</title> NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. </sec>.

High rates of exposure to tuberculosis patients among HIV-infected health care workers in Botswana

OBJECTIVE

To compare daily exposure to tuberculosis (TB) patients between HIV-infected and non-HIV-infected health care workers (HCWs), and examine the uptake of antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) among HIV-infected HCWs in Botswana.

DESIGN

We conducted a cross-sectional study among HCWs in 30 hospitals and clinics. We determined self-reported exposure frequency to TB patients and HIV status through in-person interviews. HCWs with unknown or negative HIV status were offered rapid HIV testing. Multivariable Poisson regression modeling with robust variance was used to estimate the association between HIV status and daily exposure to TB patients.

RESULTS

Of 1877 participants enrolled, 1388 (73.9%) with complete data were included in this study. Among 277 (20.0%) HIV-infected participants, 14.3% were newly diagnosed, 57.8% were on ART, and 34.3% reported previously receiving IPT. Daily exposure to TB patients was reported by respectively 48.4% and 52.9% of HIV-infected and non-infected participants. After adjusting for sex, age, occupation, and department, the rates of daily TB exposure remained similar between HIV-infected and non-HIV-infected participants (prevalence ratio 0.96, 95%CI 0.85-1.08).

CONCLUSIONS

We found similar rates of exposure to TB patients between HIV-infected and non-HIV-infected HCWs. Improved efforts are needed to reduce nosocomial exposure to TB among HIV-infected HCWs.

Isoniazid therapy for Mycobacterium tuberculosis infection in HIV clinics, Los Angeles, California

SETTING

Publicly funded human immunodeficiency virus (HIV) clinics in Los Angeles County, California, USA.

BACKGROUND

HIV-infected persons are a high priority group for targeted testing and treatment for Mycobacterium tuberculosis infection in the United States.

OBJECTIVE

To describe rates of isoniazid (INH) initiation and completion among HIV-1 and M. tuberculosis co-infected persons in Los Angeles County.

DESIGN

We conducted a cross-sectional study using routinely collected surveillance data from publicly funded HIV clinics. We examined differences in INH treatment initiation and completion between four clinic categories: the three largest clinics (Clinics A, B, and C) and 'Other' clinics (pooled data for the remaining 10 clinics).

RESULTS

During 2010-2013, 802 (5.3%) of 15 029 HIV-1-infected persons tested positive for M. tuberculosis infection. INH was initiated in 581 (72.4%) persons, of whom 457 (78.7%) completed treatment. We found significant differences between clinics in terms of treatment initiation (range 59.1-93.4%) and completion (range 58.8-82.3%). Overall, 57% (457/802) of HIV and M. tuberculosis co-infected persons completed the recommended treatment (range across clinics 34.8-76.3%).

CONCLUSION

We identified significant gaps in the treatment for M. tuberculosis infection among HIV-infected persons in Los Angeles County. Interventions are needed to improve initiation and completion of treatment for M. tuberculosis infection in this population.

Detecting selection signatures between Duroc and Duroc synthetic pig populations using high-density SNP chip

The development of high throughput genotyping techniques has facilitated the identification of selection signatures of pigs. The detection of genomic selection signals in a population subjected to differential selection pressures may provide insights into the genes associated with economically and biologically important traits. To identify genomic regions under selection, we genotyped 488 Duroc (D) pigs and 155 D × Korean native pigs (DKNPs) using the Porcine SNP70K BeadChip. By applying the F_ST and extended haplotype homozygosity (EHH-Rsb) methods, we detected genes under directional selection associated with growth/stature (DOCK7, PLCB4, HS2ST1, FBP2 and TG), carcass and meat quality (TG, COL14A1, FBXO5, NR3C1, SNX7, ARHGAP26 and DPYD), number of teats (LOC100153159 and LRRC1), pigmentation (MME) and ear morphology (SOX5), which are all mostly near or at fixation. These results could be a basis for investigating the underlying mutations associated with observed phenotypic variation. Validation using genome-wide association analysis would also facilitate the inclusion of some of these markers in genetic evaluation programs.

Dose-response association between salivary cotinine levels and Mycobacterium tuberculosis infection

SETTING

Tijuana, Mexico.

OBJECTIVE

To describe the association between salivary cotinine levels and interferon-gamma (IFN-γ) release assay results.

DESIGN

We conducted a cross-sectional study among injection drug users. Salivary cotinine levels were measured using NicAlert, a semi-quantitative dipstick assay. QuantiFERON©-TB Gold In-Tube (QFT-GIT) was used to determine Mycobacterium tuberculosis infection.

RESULTS

Among 234 participants, the prevalence of QFT-GIT positivity for NicAlert cotinine categories 0 (non-smoking), 1 (second-hand smoke exposure or low-level smoking) and 26 (regular smoking) were respectively 42.1%, 46.4% and 65.2% (Ptrend 0.012). We found increasing trends in QFT-GIT positivity (Ptrend 0.003) and IFN-γ concentrations (Spearman's r 0.200, P 0.002) across cotinine levels 0 to 6. In multivariable log-binomial regression models adjusted for education, cotinine levels were not associated with QFT-GIT positivity when included as smoking categories (1 and 26 vs. 0), but were independently associated with QFT-GIT positivity when included as an ordinal variable (prevalence ratio 1.09 per 1 cotinine level, 95%CI 1.021.16).

CONCLUSION

Our findings suggest that a dose-response relationship exists between tobacco smoke exposure and M. tuberculosis infection. Longitudinal studies that use biochemical measures for smoking status are needed to confirm our findings.

Disruption of GRM1-mediated signalling using riluzole results in DNA damage in melanoma cells

Gain of function of the neuronal receptor, metabotropic glutamate receptor 1 (Grm1), was sufficient to induce melanocytic transformation in vitro and spontaneous melanoma development in vivo when ectopically expressed in melanocytes. The human form of this receptor, GRM1, has been shown to be ectopically expressed in a subset of human melanomas but not benign nevi or normal melanocytes, suggesting that misregulation of GRM1 is involved in the pathogenesis of certain human melanomas. Sustained stimulation of Grm1 by the ligand, glutamate, is required for the maintenance of transformed phenotypes in vitro and tumorigenicity in vivo. In this study, we investigate the mechanism of an inhibitor of glutamate release, riluzole, on human melanoma cells that express metabotropic glutamate receptor 1 (GRM1). Various in vitro assays conducted show that inhibition of glutamate release in several human melanoma cell lines resulted in an increase of oxidative stress and DNA damage response markers.

Clinical characteristics, drug resistance, and treatment outcomes among tuberculosis patients with diabetes in Peru

OBJECTIVES

Diabetes is a risk factor for active tuberculosis (TB). Data are limited regarding the association between diabetes and TB drug resistance and treatment outcomes. We examined characteristics of TB patients with and without diabetes in a Peruvian cohort at high risk for drug-resistant TB. Among TB patients with diabetes (TB-DM), we studied the association between diabetes clinical/management characteristics and TB drug resistance and treatment outcomes.

METHODS

During 2005-2008, adults with suspected TB with respiratory symptoms in Lima, Peru, who received rapid drug susceptibility testing (DST), were prospectively enrolled and followed during treatment. Bivariate and Kaplan-Meier analyses were used to examine the relationships of diabetes characteristics with drug-resistant TB and TB outcomes.

RESULTS

Of 1671 adult TB patients enrolled, 186 (11.1%) had diabetes. TB-DM patients were significantly more likely than TB patients without diabetes to be older, have had no previous TB treatment, and to have a body mass index (BMI) >18.5 kg/m(2) (p<0.05). In patients without and with previous TB treatment, the prevalence of multidrug-resistant TB was 23% and 26%, respectively, among patients without diabetes, and 12% and 28%, respectively, among TB-DM patients. Among 149 TB-DM patients with DST results, 104 (69.8%) had drug-susceptible TB and 45 (30.2%) had drug-resistant TB, of whom 29 had multidrug-resistant TB. There was no association between diabetes characteristics and drug-resistant TB. Of 136 TB-DM patients with outcome information, 107 (78.7%) had a favorable TB outcome; active diabetes management was associated with a favorable outcome.

CONCLUSIONS

Diabetes was common in a cohort of TB patients at high risk for drug-resistant TB. Despite prevalent multidrug-resistant TB among TB-DM patients, the majority had a favorable TB treatment outcome.

Impact of rapid drug susceptibility testing for tuberculosis: program experience in Lima, Peru

SETTING

Programmatic implementation of decentralized rapid drug susceptibility testing (DST) in Lima, Peru.

OBJECTIVE

Pre-post analysis compared time to diagnosis, treatment outcome and survival among patients tested with direct nitrate reductase assay (NRA) vs. indirect conventional methods.

DESIGN

From 2005 to 2009, we prospectively followed all patients referred for DST before (control) and after (intervention) NRA implementation. Among those referred for DST, NRA was used for smear-positive samples of patients with no prior history of multidrug resistance or treatment for multidrug-resistant tuberculosis (TB). Data were abstracted from patient charts and laboratory registers. Endpoints were favorable outcomes, time to result and time to death.

RESULTS

Of those patients who met the criteria for NRA, 740 underwent NRA and 621 underwent conventional DST. NRA yielded test results for 78.4% of cases vs. 68.8% for conventional DST (P < 0.0001); the median time to result was 44 vs. 133 days, respectively (adjusted HR 0.64, 95%CI 0.56-0.73). Among individuals without previous anti-tuberculosis treatment, NRA was associated with a favorable treatment outcome (adjusted OR 1.39, 95%CI 1.01-1.90) and prolonged survival (adjusted HR 0.53, 95%CI 0.31-0.90).

CONCLUSION

Direct NRA significantly shortened time to test result and improved treatment outcomes and survival in certain groups.

Plant lectin can target receptors containing sialic acid, exemplified by podoplanin, to inhibit transformed cell growth and migration

Cancer is a leading cause of death of men and women worldwide. Tumor cell motility contributes to metastatic invasion that causes the vast majority of cancer deaths. Extracellular receptors modified by α2,3-sialic acids that promote this motility can serve as ideal chemotherapeutic targets. For example, the extracellular domain of the mucin receptor podoplanin (PDPN) is highly O-glycosylated with α2,3-sialic acid linked to galactose. PDPN is activated by endogenous ligands to induce tumor cell motility and metastasis. Dietary lectins that target proteins containing α2,3-sialic acid inhibit tumor cell growth. However, anti-cancer lectins that have been examined thus far target receptors that have not been identified. We report here that a lectin from the seeds of Maackia amurensis (MASL) with affinity for O-linked carbohydrate chains containing sialic acid targets PDPN to inhibit transformed cell growth and motility at nanomolar concentrations. Interestingly, the biological activity of this lectin survives gastrointestinal proteolysis and enters the cardiovascular system to inhibit melanoma cell growth, migration, and tumorigenesis. These studies demonstrate how lectins may be used to help develop dietary agents that target specific receptors to combat malignant cell growth.

Alcohol use and the management of multidrug-resistant tuberculosis in Tomsk, Russian Federation

SETTING

Alcohol use increases the risk of multidrug-resistant tuberculosis (MDR-TB) and poses challenges for successful MDR-TB treatment, including the potential for additional adverse events.

AIM

To investigate the association between alcohol consumption during MDR-TB treatment and adverse events and treatment outcomes in a cohort of patients in Tomsk, Russia.

DESIGN

From 2000 to 2004, retrospective data were collected on 407 MDR-TB patients in Tomsk. Factors associated with treatment outcomes were assessed using logistic regression.

RESULTS

Of the 407 patients, 253 (62.2%) consumed alcohol during treatment ('drinkers'), and 367 (90.2%) had at least one documented adverse advent. No significant differences were noted in frequency of adverse events in drinkers vs. non-drinkers. Drinkers had less favourable treatment outcomes (OR 0.28, 95%CI 0.18-0.45). Among drinkers, favourable treatment outcome was associated with adherence to at least 80% of prescribed doses (OR 2.89, 95%CI 1.30-6.43) and the occurrence of an adverse event requiring treatment interruption (OR 2.49, 95%CI 1.11-5.59).

CONCLUSIONS

Alcohol use did not appear to increase the risk of adverse events during MDR-TB treatment; however, alcohol consumption was associated with poor outcome. Our findings suggest that individuals who drink alcohol should receive aggressive attention to optimise treatment adherence and manage adverse events.

Hepatotoxicity during treatment for multidrug-resistant tuberculosis: occurrence, management and outcome

SETTING

Multidrug-resistant tuberculosis (MDR-TB) treatment program in Tomsk, Russia.

OBJECTIVE

To describe the incidence and management of hepatotoxicity during treatment of MDR-TB, and to assess risk factors associated with its development and impact on treatment outcomes.

DESIGN

A retrospective case series performed among 608 patients.

RESULTS

Hepatotoxicity, using American Thoracic Society (2006) definitions, was observed in 91/568 patients (16.5%). The median time to the first hepatotoxic event was 196 days post treatment commencement. Baseline factors associated with hepatotoxicity included elevated alanine aminotransferase/aspartate aminotransferase/bilirubin (OR 53.9, 95%CI 6.30-438.7), and renal insufficiency (OR 19.6, 95%CI 2.71-141.6). High treatment adherence (OR 3.25, 95%CI 2.07-5.09) and starting treatment in prison (OR 1.77, 95%CI 1.04-3.01) were associated with treatment success. Smoking (OR 0.44, 95%CI 0.21-0.92) and bilateral cavitary disease (OR 0.51, 95%CI 0.34-0.77) were associated with worse outcomes. For alcohol users, developing hepatotoxicity was associated with better outcomes (OR 4.40, 95%CI 1.79-10.81) than not (OR 0.42, 95%CI 0.25-0.68). One or more medications were permanently stopped in 10/91 patients, but in no case was treatment entirely discontinued.

CONCLUSION

MDR-TB treatment in the face of hepatotoxicity during therapy did not result in a statistically significant increase in poor outcomes.

Use of fluoroquinolone antibiotics leads to tuberculosis treatment delay in a South African gold mining community

BACKGROUND

Empiric use of fluoroquinolone (FQ) antibiotics could delay tuberculosis (TB) treatment and lead to FQ-resistant TB.

METHODS

We examined the impact of FQ use on TB outcomes, including smear status, treatment delay and FQ resistance, through a retrospective cohort study of 440 FQ-exposed and 511 non-exposed patients in a gold mining community in South Africa. We considered both recent (≤ 100 days before sputum collection) and distant exposure (≤ 1 year). We examined 201 and 180 isolates from FQ-exposed and non-exposed individuals for the presence of gyrA mutations.

RESULTS

Patients recently exposed to ≥ 5 days of FQ were less likely to be smear-positive (OR 0.27, 95%CI 0.11-0.63), with an increased time to treatment (time ratio 2.02, 95%CI 1.19-3.44). The strength of association decreased when we considered distant exposure. Adjusting for smear status nullified the effect of FQ exposure on treatment delay. We detected a gyrA mutation in one isolate (0.5%) taken from an individual exposed to FQ for 8 days.

CONCLUSION

FQ exposure is associated with treatment delay, mediated by negative smear status. Short exposures to FQ do not routinely lead to resistance encoded by gyrA mutations. We recommend prudent use of FQ in settings with a high burden of human immunodeficiency virus and TB.

Electronic laboratory system reduces errors in National Tuberculosis Program: a cluster randomized controlled trial

OBJECTIVE

To evaluate the impact of the e-Chasqui laboratory information system in reducing reporting errors compared to the current paper system.

DESIGN

Cluster randomized controlled trial in 76 health centers (HCs) between 2004 and 2008.

METHODS

Baseline data were collected every 4 months for 12 months. HCs were then randomly assigned to intervention (e-Chasqui) or control (paper). Further data were collected for the same months the following year. Comparisons were made between intervention and control HCs, and before and after the intervention.

RESULTS

Intervention HCs had respectively 82% and 87% fewer errors in reporting results for drug susceptibility tests (2.1% vs. 11.9%, P = 0.001, OR 0.17, 95%CI 0.09-0.31) and cultures (2.0% vs. 15.1%, P < 0.001, OR 0.13, 95%CI 0.07-0.24), than control HCs. Preventing missing results through online viewing accounted for at least 72% of all errors. e-Chasqui users sent on average three electronic error reports per week to the laboratories.

CONCLUSIONS

e-Chasqui reduced the number of missing laboratory results at point-of-care health centers. Clinical users confirmed viewing electronic results not available on paper. Reporting errors to the laboratory using e-Chasqui promoted continuous quality improvement. The e-Chasqui laboratory information system is an important part of laboratory infrastructure improvements to support multidrug-resistant tuberculosis care in Peru.

Recombinant human epidermal growth factor treatment of radiation-induced severe oral mucositis in patients with head and neck malignancies

Mucositis of the oral cavity and pharynx is a major dose-limiting factor in the application of radiotherapy (RT) to patients with head and neck cancer. Therefore, we evaluated the wound healing effect of human recombinant epidermal growth factor (rhEGF) in head and neck cancer and lymphoma patients with irradiation (with or without combined chemotherapy-induced oral mucositis). Patients at Asan Medical Center who had undergone definitive RT of the head and neck region with or without combined chemotherapy and who had developed severe oral mucositis (higher than the Radiation Therapy Oncology Group grade 3) were treated with topical rhEGF twice daily for 7 days. The evaluation of response with regard to oral mucositis was performed 1 week later. Of the 11 treated patients, three had nasopharyngeal carcinoma, three had carcinoma of the oropharynx, two had carcinoma of the oral cavity, one had carcinoma of the hypopharynx and two had lymphoma of the head and neck. Six patients received RT only, and five patients received concurrent chemoradiotherapy. All patients showed improvements in their oral mucositis after topical treatment with rhEGF in that the Radiation Therapy Oncology Group grade was significantly decreased (P = 0.0000). This finding suggests that rhEGF is effective and safe for the treatment of radiation-induced mucositis. Further studies are needed to determine the optimal dosage and fractionation schedule.

Neurolysis of the distal superficial radial nerve for dysaesthesia due to nerve tethering

The subcutaneous course of the superficial radial nerve over the radial border of the wrist and hand renders it very susceptible to injury. Both traumatic and iatrogenic injury can produce tethering of this nerve, presenting as dysaesthesia. This study was designed to evaluate the efficacy of neurolysis of the distal superficial radial nerve for this condition. Twenty-five cases of tethered superficial radial nerves underwent neurolysis. At final follow-up (mean 3.5 years), fourteen cases reported symptomatic resolution while eleven continued to experience dysaesthesia. Intra-operatively, evidence of external abnormality, scarring, or compression was identified in only six cases, and its presence did not correlate with symptomatic outcome. Although the majority of patients were improved postoperatively, the success rate was lower than anticipated. Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success.

Adverse reactions among patients being treated for MDR-TB in Tomsk, Russia

BACKGROUND AND SIGNIFICANCE

Treatment of multidrug-resistant tuberculosis (MDR-TB) is challenging because of the toxicity of second-line medications. Little is known about whether adverse events impact treatment outcome.

METHODS

We conducted a retrospective case series of 244 MDR-TB patients enrolled in Tomsk between 10 September 2000 and 10 September 2002. Adverse reactions were determined by laboratory data and/or clinical criteria. A multiple logistic regression model was performed to determine whether the occurrence of adverse reactions was associated with poor treatment outcome.

RESULTS

In this cohort, 76.0% were cured, 6.6% failed, 4.9% died and 11.5% defaulted. Adverse events were observed in 73.3% of patients, occurring in 74.8% of patients who were adherent (taking at least 80% of prescribed doses) and 59.1% of non-adherent individuals (P = 0.11). The impact of adverse events on outcome was modified by non-adherence; among adherent patients, the occurrence of any adverse reaction was associated with treatment cure (adjusted odds ratio 3.24, 95% confidence interval 1.56-6.70).

CONCLUSION

Adverse reactions occurred frequently in MDR-TB patients in Tomsk, Russia, but did not negatively impact treatment outcome. The occurrence of adverse reactions among adherent patients was associated with treatment cure.

Treating multidrug-resistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease

Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are diseases of poverty. Because Mycobacterium tuberculosis exists predominantly in a social space often defined by poverty and its comorbidities--overcrowded or congregate living conditions, substance dependence or abuse, and lack of access to proper health services, to name a few--the biology of this organism and of TB drug resistance is intimately linked to the social world in which patients live. This association is demonstrated in Russia, where political changes in the 1990s resulted in increased socioeconomic inequality and a breakdown in health services. The effect on TB and MDR-TB is reflected both in terms of a rise in TB and MDR-TB incidence and increased morbidity and mortality associated with the disease. We present the case example of Tomsk Oblast to delineate how poverty contributed to a growing MDR-TB epidemic and increasing socioeconomic barriers to successful care, even when available. The MDR-TB pilot project implemented in Tomsk addressed both programmatic and socioeconomic factors associated with unfavorable outcomes. The result has been a strengthening of the overall TB control program in the region and improved case-holding for the most vulnerable patients. The model of MDR-TB care in Tomsk is applicable for other resource-poor settings facing challenges to TB and MDR-TB control.

Dual enteric and respiratory tropisms of winter dysentery bovine coronavirus in calves

Although winter dysentery (WD), which is caused by the bovine coronavirus (BCoV) is characterized by the sudden onset of diarrhea in many adult cattle in a herd, the pathogenesis of the WD-BCoV is not completely understood. In this study, colostrum-deprived calves were experimentally infected with a Korean WD-BCoV strain and examined for viremia, enteric and nasal virus shedding as well as for viral antigen expression and virus-associated lesions in the small and large intestines and the upper and lower respiratory tract from 1 to 8 days after an oral infection. The WD-BCoV-inoculated calves showed gradual villous atrophy in the small intestine and a gradual increase in the crypt depth of the large intestine. The WD-BCoV-infected animals showed epithelial damage in nasal turbinates, trachea and lungs, and interstitial pneumonia. The WD-BCoV antigen was detected in the epithelium of the small and large intestines, nasal turbinates, trachea and lungs. WD-BCoV RNA was detected in the serum from post-inoculation day 3. These results show that the WD-BCoV has dual tropism and induces pathological changes in both the digestive and respiratory tracts of calves. To our knowledge, this is the first detailed report of dual enteric and respiratory tropisms of WD-BCoV in calves. Comprehensive studies of the dual tissue pathogenesis of the BCoV might contribute to an increased understanding of similar pneumoenteric CoV infections in humans.

Causes of death during tuberculosis treatment in Tomsk Oblast, Russia

SETTING

Tuberculosis (TB) incidence and mortality in Russia have risen dramatically over the past 15 years.

OBJECTIVE

To identify risk factors and causes of death among TB patients in Russia.

DESIGN

A retrospective study conducted to determine the risk factors and causes of death in patients receiving TB therapy in Tomsk, Siberia.

RESULTS

Of 1916 patients who initiated treatment between 1 January 2002 and 31 December 2003, 183 (9.6%) died during treatment, 38 (21%) in the first week of therapy. Twenty-five per cent of deaths were not directly attributable to TB. Risk factors for death included older age, previous treatment for TB, multidrug resistance and alcoholism.

CONCLUSIONS

The high death rate during TB treatment observed in this cohort likely reflects an increased risk of dying not only from TB, but also from comorbid conditions, such as alcoholism and cardiovascular disease. Overall, alcoholism and late presentation both contributed substantially to the mortality in this cohort.

Anti-inflammatory effect of jeongshintang through suppression of p38 activation in human astrocytoma, U373MG cells

Jeongshintang (JST) is a Korean herbal prescription, which has been successfully used for cerebral diseases. However, the anti-inflammatory effect of JST on Alzheimer's disease (AD) is still not fully understood. In this study, we investigated the effects of JST in attenuating the inflammatory response induced by interleukin (IL)-1beta plus beta-amyloid [1-42] fragment (A beta) in the human astrocyte cell line, U373MG. The production of IL-6, IL-8, and prostaglandin (PG)E2 was significantly increased by IL-1beta plus A beta (1-42) in a time-dependent manner (P < 0.05). JST significantly inhibited the IL-1beta plus A beta (1-42)-induced IL-6, IL-8, and PGE2 production at 24 h (P < 0.05). Maximal inhibition rate of IL-6, IL-8, and PGE2 production by JST was about 54.40%, 56.01%, and 44.06% respectively. JST (0.01-1 mg/ml) also attenuated the expression of cyclooxygenase (COX)-2 and activation of p38 MAPK induced by IL-1beta and A beta (1-42). These results demonstrated that JST has an anti-inflammatory effect, which might explain its beneficial effect in the treatment of various neurodegenerative diseases such as AD.

Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia

SETTING

Multidrug-resistant tuberculosis (MDR-TB) is a major problem in countries of the former Soviet Union in both the civilian and prison sectors.

OBJECTIVE

To evaluate outcomes of the MDR-TB treatment program (DOTS-Plus) in Tomsk, Russia.

DESIGN

Retrospective case series of all patients enrolled in this program between 10 September 2000 and 10 September 2002. The program involves both the civilian and penitentiary TB services in Tomsk. Poor treatment outcome was defined as death, default and treatment failure.

RESULTS

Among the 244 patients who received treatment, 77% were cured, 5% died, 7% failed, and 12% defaulted. In a multivariable analysis, alcohol consumption during treatment and the presence of both cavitary and bilateral disease were found to be the strongest predictors of poor treatment outcome.

CONCLUSIONS

The integration of civilian and penitentiary TB services in the Tomsk MDR-TB treatment program has resulted in high cure rates and low rates of default. However, alcohol use among patients with MDR-TB is associated with poor treatment outcomes. Better understanding and programmatic alcohol interventions are needed if large-scale treatment of MDR-TB is to be successful in areas with high rates of alcohol use disorders.

Validation of a rapid method for detection of M. tuberculosis resistance to isoniazid and rifampin in Lima, Peru

SETTING

Treatment of multidrug-resistant tuberculosis (MDR-TB) is often based on drug susceptibility testing (DST) results; for this reason, rapid, simple DST methods are sought which could be applied in resource-poor countries. One such method is a nitrate reductase colorimetric assay known as the Griess method. In Peru, where the incidence rate of TB is among the highest in South America, the National Institute of Health recently undertook the validation and implementation of the direct Griess method.

OBJECTIVE

To describe the process of validation and implemention of the direct Griess method at the Peruvian National Institute of Health.

DESIGN

Prospective study comparing the sensitivity and specificity of the direct Griess method with the Löwenstein-Jensen proportion method in determining resistance to isoniazid (INH) and rifampin (RMP) among clinical isolates.

RESULTS

Among 192 specimens, the sensitivity and specificity of the Griess method for detection of INH resistance was 99.1% and 100%, respectively. For identification of RMP resistance, the sensitivity and specificity was 93.5% and 100%, respectively.

CONCLUSIONS

In addition to its high sensitivity and specificity and rapid turn around time, the Griess method uses simple, inexpensive reagents and requires minimal laboratory space and technical expertise, thus providing an ideal screening tool for resource-poor settings with high rates of MDR-TB.

Acquisition of drug resistance in multidrug-resistant Mycobacterium tuberculosis during directly observed empiric retreatment with standardized regimens

The risk of acquiring additional drug resistance in strains of multidrug-resistant tuberculosis (MDR-TB) during failure of empiric standardized retreatment regimens is poorly defined. We sought to estimate this risk by comparing drug susceptibility profiles and RFLP patterns of paired MDR-TB isolates collected from 27 patients before and after retreatment failure. Among 23 patients with paired isolates with concordant RFLP patterns, 19 (83%) had become resistant to at least one additional drug after failed retreatment. In this limited group of MDR-TB patients, acquisition of resistance was common during failure of empiric drug regimens. Further study is needed to confirm these findings.

Mesenteric inflammatory myofibroblastic tumor mimicking a necrotized malignant mass in an adult: case report with MR findings

Inflammatory myofibroblastic tumors are lesions that usually affect young adults and children. Numerous extrapulmonary sites of these tumors have been found, but the mesentery is a very unusual location for an inflammatory myofibroblastic tumor and it is extremely rare in an older patient. Inflammatory myofibroblastic tumor of the mesentery is often demonstrated as a large and infiltrative lesion with heterogeneous enhancement. Its diagnosis is recognized as difficult and it often mimics malignant tumor. We report a case of mesenteric inflammatory myofibroblastic tumor mimicking a necrotized malignant mass in a 55-year-old man who was examined with magnetic resonance imaging. To our knowledge, this is the first report of magnetic resonance imaging of mesenteric inflammatory myofibroblastic tumor with extensive central necrosis in an older patient.

rpoBGene Mutations in Clinical Isolates of Multidrug-ResistantMycobacterium tuberculosisin Northern Lima, Peru

In many developing countries and outside hospital settings, the characteristics of endemic Mycobacterium tuberculosis strains resistant to multiple drugs remain unknown. In a community-based referral and therapy program in northern Lima, Peru, beginning in 1996, patients found to be failures on standard regimens were referred for drug-susceptibility testing of their isolates, and those found to be infected with M. tuberculosis isolates resistant to at least rifampin were treated with individualized regimens based on their infecting strains. Isolates from 42 of these patients were subjected to DNA sequencing of the rpoB gene region responsible for rifampin resistance. We determined the frequency of types of mutations in the rpoB gene among these Peruvian isolates.

Clinical and programmatic considerations in the treatment of MDR-TB in children: a series of 16 patients from Lima, Peru

SETTING

Since 2000, the directly observed treatment, short-course (DOTS) strategy has been expanded in several countries to include treatment of multidrug-resistant tuberculosis (MDR-TB). This strategy is known as DOTS-Plus. Tuberculosis is a common cause of morbidity and mortality for children throughout the developing world. Children may also be infected with MDR-TB, yet most developing countries do not specifically address pediatric MDR-TB.

OBJECTIVE

To present the intermediate outcomes of the first 16 children enrolled in the Peruvian DOTS-Plus program and to demonstrate the tolerability of second-line anti-tuberculosis drugs.

RESULTS

Three children completed therapy and are cured, one child had bacteriologic and clinical failure after 12 months of therapy and died of respiratory insufficiency, and 12 have intermediate outcomes demonstrating favorable clinical, bacteriologic, and radiographic evidence of improvement after 9-19 months of therapy.

CONCLUSIONS

Of the 16 pediatric DOTS-Plus patients, 15 have tolerated therapy well and have had favorable clinical evolution. However, the diagnosis of pediatric MDR-TB is often extremely delayed due to reliance on the adult case definition and should be changed to prevent progressive, chronic illness in such children. Programmatic changes could facilitate earlier diagnosis and treatment of pediatric MDR-TB in Peru and in other DOTS-Plus programs.

Suppressive effects of PG201, an ethanol extract from herbs, on collagen-induced arthritis in mice

OBJECTIVE

PG201 has been formulated using 12 herbs known to have anti-inflammatory and protective effects on damaged tissue and bone among other functions. The present study was done in order to assess the therapeutic effects of PG201 in collagen-induced arthritis (CIA) in mice.

METHODS

DBA/1 mice were immunized with bovine type II collagen. After a second collagen immunization, mice were treated with PG201 orally at 10 mg/kg once a day for 18 days. Paws were evaluated macroscopically for redness, swelling and deformities. The levels of TNF-alpha and IL-1beta in the ankle were examined. The severity of arthritis within the knee joints was evaluated by histological assessment of cartilage destruction and pannus formation. Molecular indicators related to CIA pathology were analysed by measuring the serum levels of matrix metalloproteinase 2 (MMP-2), tissue inhibitor of matrix metalloproteinase 2 (TIMP-2) and the anti-inflammatory cytokines interleukin (IL)-4 and IL-10.

RESULTS

Administration of PG201 significantly suppressed the progression of CIA and inhibited the production of TNF-alpha and IL-1beta in the paws. The erosion of cartilage was dramatically reduced in mouse knees after treatment with PG201. In the serum of PG201-treated mice, the level of TIMP-2 and the ratio of TIMP-2 to MMP-2 were significantly elevated, and the level of IL-4, but not of IL-10, was increased.

CONCLUSION

Administration of PG201 has therapeutic effects on CIA. Protection of cartilage was particularly prominent. PG201 is a potential therapy for rheumatoid arthritis.

Peripheral neuropathy associated with treatment for multidrug-resistant tuberculosis

OBJECTIVE

To review the incidence and management of peripheral neuropathy in patients receiving therapy for MDR-TB.

METHODS

A case series with retrospective chart review of 75 patients who initiated individualized therapy for multidrug-resistant tuberculosis (MDR-TB) in Lima, Peru, between 1 August 1996 and 31 January 1999.

RESULTS

All patients had confirmed MDR-TB and were receiving individualized therapy, comprised of an average of six drugs. Ten (13%) of these patients presented with symptoms of peripheral neuropathy, confirmed by electromyography. All symptoms were reported in the lower extremities, and all were sensory in nature. Median time to presentation from initiation of MDR-TB therapy was 9.1 months. No significant risk factors associated with development of peripheral neuropathy were identified. Management strategies depended on the severity of symptoms and included the treatment of contributing co-morbidities, medications for neuropathic pain, and adjustment of doses of possible offending agents. All patients responded to management; three patients were left with mild residual symptoms. Patients whose neuropathy resolved had symptoms for a median of 7 months.

CONCLUSIONS

Peripheral neuropathy was encountered in 13% of our cohort of MDR-TB patients. The diagnosis of peripheral neuropathy can be based on clinical presentation alone, and effective management of this side-effect is possible without sacrificing MDR-TB treatment efficacy.

Trends in immunologic and clinical status of newly diagnosed HIV-positive patients initiating care in the HAART era

OBJECTIVE

To evaluate whether the availability of highly active antiretroviral therapy (HAART) has motivated people at risk for HIV infection to be tested earlier.

METHODS

Data are from the Adult and Adolescent Spectrum of HIV Disease (ASD) Study, a chart review study of HIV-infected people receiving care. The sample comprised newly diagnosed HIV-positive persons initiating care at five ASD clinics in New York City (NYC) 1994 to 1999. CD4 + lymphocyte count and clinical status (asymptomatic, major AIDS-related symptoms, AIDS-defining opportunistic illnesses) at first visit were ascertained. Trends in these two outcomes were analyzed comparing each time period after the second half of 1996 with the aggregate period from 1994 to the first half of 1996.

RESULTS

Between 1994 and 1999, we identified 545 patients newly diagnosed as positive for HIV with a first visit to an ASD clinic. Patients were predominantly black or Hispanic (93%). The mean CD4 + count at baseline was 246 cells/microl and the median was 152 cells/microl. After adjusting for covariates, the mean CD4 + count of newly diagnosed HIV-positive patients was significantly lower ( p =.04) only during the second half of 1997. The proportion of patients who were asymptomatic at baseline ranged from 29% in the second half of 1998 to 61% in the first half of 1994 (chi 2 = 48.8; p =.0008). After adjustment for covariates, the probability of a patient having a major symptom or an opportunistic illness at baseline was significantly higher only during the second half of 1998 ( p =.001).

DISCUSSION

During most time periods, both before and after the introduction of HAART, most newly diagnosed patients at these five HIV clinics in NYC were immune suppressed and symptomatic.

High glucose levels alter angiotensin II-induced Ca(2+) uptake via PKC and cAMP pathways in renal proximal tubular cells

Although a dysfunction of the calcium metabolism occurs in diabetes mellitus, alterations of Ca(2+) uptake induced by angiotensin II (ANG II) in renal proximal tubular cells (PTCs) grown in high-glucose medium are not fully elucidated. Thus, we examined whether high glucose concentrations can induce an alteration of the ANG II effect on the Ca(2+) uptake and its action mechanism in primary cultured renal PTCs. PTCs were exposed to different glucose concentrations (5-100 mM) and time intervals (0-48 h). There was a sustained increase of Ca(2+) uptake at glucose concentrations >15 mM. Thus, we selected 25 mM glucose and incubation for 48 h to maintain a hyperglycemic condition in vitro, unlike short-time regulatin. ANG II significantly inhibited the Ca(2+) uptake in a dose-dependent manner in a 5-mM glucose medium. In addition, downregulation of ANG II receptors appeared in a glucose dose dependent manner. However, PTCs treated with 25 mM glucose for 48 h, not 12 h, did not exhibit the inhibitory effect of ANG II (10(-7) M) on Ca(2+) uptake, although the inhibitory effect of ANG II on Ca(2+) uptake occurred in the presence of 25 mM mannitol or L-glucose. Staurosporine, bisindolylmaleimide I (protein kinase C, PKC, inhibitors), 12-o-tetradecanoylphorbol 13-acetate pretreatment, SQ 22536 (an adenylate cyclase inhibitor), and myristoylated protein kinase A inhibitor amide 14-22 (a protein kinase A inhibitor) blocked the 25-mM-glucose-induced alteration of ANG II effect on Ca(2+) uptake. These results suggest that both PKC and cyclic adenosine monophosphate (cAMP) pathways are involved in the high-glucose-induced alteration of ANG II effect on Ca(2+) uptake. Indeed, 25 mM glucose increased PKC activity and cAMP contents. In conclusion, a high glucose concentration altered ANG II induced inhibition of Ca(2+) uptake via PKC and cAMP pathways in the PTCs.

Combined Chemotherapy and Radiotherapy for Primary CNS Lymphoma

PURPOSE

This study was performed in order to evaluate the effectiveness of combined chemotherapy and radiotherapy (RT) in primary central nervous system lymphoma (PCNSL).

MATERIALS AND METHODS

From January 1995 to August 1999, 21 patients with a diagnosis of PCNSL were treated with combined chemotherapy and radiotherapy. Their median age was 47 years with range of 19 to 78 years. Twelve patients were male and nine patients were female. All patients were immunocompetent and they had no evidence of systemic lymphoma. All patients underwent placement of an Ommaya reservoir and recieved a combination regimen using pre-RT systemic and intra-Ommaya methotrexate (MTX), 40 Gy whole-brain RT with a 14.4 Gy boost, and 2 courses of post-RT high-dose cytarabine. The median follow-up period of all patients and survived patients were 22 months and 36 months, respectively.

RESULTS

The median overall survival duration was 21 months and the overall two- and four-year survival rates were 51% and 43%, respectively. Complete response (CR), partial response, stable disease, and progressive disease were achieved in 12, 3, 1, and 5 patients, respectively. All nine patients without CR expired within 1-31 months (median 6 months). Two patients among the patients with CR developed recurrence after 13 and 14 months, respectively. The location of recurrent disease was within the port of radiation boost. Survival was influenced by age, performance status, and CR. There was one episode of MTX neurotoxicity and hepatotoxicity,respectively.

CONCLUSION

Combined chemotherapy and radiotherapy was an effective treatment for PCNSL, and was associated with a minimum toxicity. However, we must pay attention to the recurrence and late toxicity, particularly within two years following treatment.

Experimental induction of the two-host life cycle of Sarcocystis cruzi between dogs and Korean native calves

Eight dogs were experimentally infected with Sarcocystis by oral inoculation of cardiac muscle from naturally infected cattle. The infected dogs commenced discharging of sporocysts in the feces after 10 to 12 days of inoculation, and continued until 20 and 35 days after inoculation. Three dogs were reinfected with cardiac muscle from the naturally infected cattle. Sporocysts reappeared in the feces on 12 to 13 days after reinfection. Sarcocystis sporocysts collected from the experimentally infected dogs were fed to each of the two 30-day-old Korean native calves. The infected calves remained clinically normal, except for the high fever (> or = 40 degrees C) and decreased hematocrit values on day 30 to 40 post inoculation. Muscular cysts of Sarcocystis were found from infected calves on day 40 post inoculation. Proliferative forms of Sarcocystis were also observed in the muscle of infected calves. These results suggest that the Sarcocystis cruzi found in Korean native cattle has a 2-host life cycle with dogs as the definitive host and Korean native calves as the intermediate host.

Occurrence of serious adverse effects in patients receiving community-based therapy for multidrug-resistant tuberculosis

SETTING

A community-based treatment program for multidrug-resistant tuberculosis (MDR-TB) in an urban shantytown of Lima, Peru.

OBJECTIVES

To ascertain the occurrence of serious adverse effects associated with therapy for MDR-TB in northern Lima, Peru, where therapy was individualized according to drug-susceptibility testing of patients' infecting strains and delivered through a community-based program.

DESIGN

A retrospective record review of 60 patients who had received individualized therapy for MDR-TB between September 1996 and October 1998.

RESULTS

Although adverse effects were common, they occurred less frequently than previously reported in the literature and were rarely life-threatening. Effects occurring most frequently in this population included: mild gastritis (100%), dermatological effects (43.3%), peripheral neuropathy (16.7%), depression (18.3%), and anxiety (11.7%). These effects never resulted in the discontinuation of anti-tuberculosis therapy, and only occasionally resulted in the suspension of an agent (11.7%).

CONCLUSION

In young patients with little comorbid disease, multidrug, long-course regimens rarely caused life-threatening adverse effects. Common side effects may be managed successfully on an out-patient basis through a community-based treatment program in conjunction with MDR-TB experts, even in resource-poor settings. The very low rate of default in this cohort offers hope that strategies to manage the adverse effects may reduce the incidence of abandonment of therapy and increase rates of cure.

Peroral immunization with Helicobacter pylori adhesin protein genetically linked to cholera toxin A2B subunits

Helicobacter pylori is a major cause of gastric-associated diseases. To evaluate the efficacy of a possible vaccine antigen against H. pylori infection, the chimaeric construct adhesin--CTXA2B, derived from H. pylori adhesin genetically coupled to cholera toxin (CTX) subunits A2 and B (CTXA2B), was expressed in Escherichia coli as an insoluble recombinant chimaeric protein. The protein was then purified by denaturation, renaturation and size-exclusion chromatography. The composition of purified adhesin--CTXA2B was verified by SDS/PAGE and Western blotting with antibodies to antigenic components of adhesin and CTXB, and confirmed as a chimaeric protein with G(M1)-ganglioside binding activity and adhesin epitopes by a G(M1)-ELISA developed using antibodies to adhesin. Oral immunization of mice with adhesin--CTXA2B induced higher levels of mucosal IgA and serum IgG antibodies to H. pylori adhesin and to CTXB than in mice immunized with adhesin or CTXA2B alone. Adhesin--CTXA2B was also demonstrated to be a potential protective antigen in a mouse model of H. pylori infection. The immunization of mice with adhesin--CTXA2B protected 62.5% of mice infected with H. pylori SS1 strain, whereas adhesin immunization was not able to confer protection to mice. This protection may be correlated with high levels of mucosal IgA and serum IgG antibodies against H. pylori adhesin. Taken together, the results indicate that the genetically linked CTXA2B acts as a useful mucosal adjuvant, and that the adhesin-CTXA2B chimaeric protein could be a potential component in future H. pylori vaccine development.

2,2-Dimethyl-4,5-diaryl-3(2H)furanone derivatives as selective cyclo-oxygenase-2 inhibitors

A series of 2,2-dimethyl-5-[4-(methylsulfonyl)phenyl]-4-phenyl-3(2H)furanones was prepared and evaluated for their ability to inhibit cyclo-oxygenase-2 (COX-2).

Using treatment failure under effective directly observed short-course chemotherapy programs to identify patients with multidrug-resistant tuberculosis

SETTING

Public ambulatory care centers in three districts of northern metropolitan Lima, Peru.

OBJECTIVE

To document drug resistance patterns of isolates of Mycobacterium tuberculosis from patients identified as treatment failures under a model tuberculosis (TB) control program based on directly observed, short-course chemotherapy (DOT-SCC).

DESIGN

Case series.

RESULTS

In a referred, consecutive sample of 173 patients identified as treatment failures on DOT-SCC, 160 (92.5%) had culture-positive TB. Of those 160, 150 (93.8%) had active, pulmonary multidrug-resistant TB (MDR-TB, resistance to at least isoniazid [INH] and rifampicin [RIF]). Sixty of the 150 (40.0%) had isolates resistant to at least INH, RIF, ethambutol (EMB) and pyrazinamide (PZA), the initial first-line empiric treatment regimen used locally. Forty-four (29.3%) had isolates resistant to at least INH, RIF, EMB, PZA and streptomycin (SM), the first retreatment regimen. This series of patients had isolates resistant to a mean of 4.5 of the ten drugs tested. The local profile of multidrug resistance is very different from that obtained from national data from Peru.

CONCLUSION

In this setting, treatment failure on DOT-SCC is strongly predictive of active MDR-TB. Because of existing local drug resistance patterns in northern Lima, 89.3% of MDR-TB patients identified as treatment failures will receive ineffective therapy with two or fewer secondary TB drugs if they are given the five-drug empiric retreatment regimen endorsed by the World Health Organization. Further short-course chemotherapy for these patients would only serve to amplify ominous existing drug resistance patterns.

Trends in prescriptions for highly active antiretroviral therapy in four New York City HIV clinics

OBJECTIVE

To describe trends in prescriptions for antiretroviral therapies and factors associated with prescriptions for highly active antiretroviral therapy (HAART).

METHODS

Medical records of patients at four HIV clinics in New York City were reviewed every 6 months. For the four 6-month periods 1997 to 1998, we identified patients with a CD4+ nadir <500 cells/microl; sample sizes were 434, 432, 503, and 643, respectively. Trends in HAART prescriptions were tested by logistic regression using robust variance estimates because some patients contributed more than one time period. Associations between HAART prescriptions and patient characteristics were tested by chi2 and multiple logistic regression analysis.

RESULTS

Patients were predominantly black or Hispanic (89%-90%) and male (66%-68%), and injection drug use was the most prevalent HIV risk (38%-49%). From 1997 to 1998, HAART prescriptions increased from 54% to 89% of antiretroviral prescriptions, and the proportion that included an nonnucleoside reverse transcriptase inhibitors (NNRTI) increased from 3% to 10%. HAART prescriptions were inversely associated with CD4+ nadir group during all time periods, and in the second half of 1998, patients with CD4+ nadir between 50 and 199 cells/microl were as likely to be prescribed HAART as the most immunosuppressed patients (CD4+ nadir <50 cells/microl; 91% versus 92%). HAART prescriptions were associated with clinic, HIV risk, and other patient characteristics in some time periods but not consistently.

CONCLUSIONS

In these four HIV clinics, prescriptions for HAART increased significantly from 1997 to 1998, leveling off at 89% in the second half of 1998. Increasingly, HAART was prescribed for healthier patients and included an NNRTI.

Effect of administering short-course, standardized regimens in individuals infected with drug-resistant Mycobacterium tuberculosis strains

Presented here are the cases of three siblings with multidrug-resistant tuberculosis who demonstrated increased antituberculous-drug resistance during the periods in which they received standard regimens of directly observed, short-course chemotherapy that were administered before the susceptibility patterns of their Mycobacterium tuberculosis isolates had been checked. More specifically, they acquired resistance to drugs they received as part of ineffective standard treatment and retreatment regimens. Development of antituberculous-drug resistance through inadvertent, inadequate therapy appears to be the most likely explanation for the increased resistance seen in these three patients.

Angiotropic (intravascular) large cell lymphoma of T-cell phenotype presenting as acute appendicitis in a patient with acquired immunodeficiency syndrome

We describe a patient with acquired immunodeficiency syndrome who presented with acute appendicitis but was found to have angiotropic large cell lymphoma (ALCL) by pathologic examination of the appendectomy specimen, without acute inflammation. Very rare cases of angiotropic large cell lymphoma have been reported in patients with human immunodeficiency virus infection, and most cases of this rare lymphoma are of B-cell origin, but in this instance immunohistochemical analysis showed a T-cell phenotype.

[Development of integrated traditional Chinese and western medicine and change of medical policy in China]

"Sect of Integration of Chinese and Western Medicine" came into the world four hundred years ago when Traditional Chinese Medicine (TCM) contacted Western Medicine (WM) at the beginning of the 17th century. It collected historical experiences showing that the cooperation of TCM and WM is more efficient for the cure and prevention of disease than each of them separately. Now the recognition that the cooperation of eastern and western medicine is more efficient to cure disease is spreading widely. This study will help Korean eastern and western medicine to find their directions. First, the concept of "sect of Integration of Chinese and Western Medicine" which was established between the beginning of the 17th century and the middle of the 20th century, and Integration of Traditional Chinese and Western Medicine (ITCWM) which was formed after the middle of the 20th century will be discussed. The relationship of "sect of Integration of Chinese and Western Medicine" and ITCWM and political consideration for the establishment of ITCWM will also be discussed. Finally, the current status of ITCWM in China will be discussed. New trends of thought appeared in Chinese medicine, owing to the cultural background of modern China, the development of WM, and the academic background of the intellectual class. "Sect of Integration of Chinese and Western Medicine" and ITCWM are different in historical and social background. However, purpose, foundation of thoughts and logical idea are fundamentally the same. It can be said that "sect of Integration of Chinese and Western Medicine" provided academic mood to open the way for ITCWM and ITCWM is a succession of "sect of Integration of Chinese and Western Medicine". The concept of ITCWM has many ways of explanation. However, it can be said to build up the foundation of new medical area including Chinese special way of medical treatment and new methods of modern medicine, succeeding a legacy of TCM. ITCWM began before the establishment of People's Republic of China. Mao Ze-dong (1893-1976), a powerful politician, and Li Ding-ming (1881-1947) who had many experiences and insight for TCM and WM played important roles at this stage. The period from the New China to the Great Proletarian Cultural Revolution (1966-1975) is the term for the establishment of the shape of ITCWM. "The effort of research and development on TCM-WM integration" was adapted as one of hygienic policies for curing of epidemic disease and succession and development of the heritage of TCM to establish new medical area. TCM class for western medical doctors was opened and mass media was used to spread out ITCWM throughout China. During the period of the Great Proletarian Cultural Revolution, ITCWM had to be stepped back and stagnant. Only the TCM class of western medical doctors and some clinical applications were barely kept moving on and alive. From the period of the Great Proletarian Cultural Revolution to the end of the 1980s, there are the movement of re-preparation of ITCWM, education of successors, and the establishment of the Institute of ITCWM. Hospitals began to establish department of ITCWM. Furthermore, it was clearly indicated in the constitutional law that "We not only have to develop modern medicine but also traditional medicine". The equality of TCM and WM was legally established in this time. From the 1990s, "equality of TCM and WM" was adapted as one of the hygienic policies, and department of ITCWM was opened in traditional Chinese medical school and western medical school. ITCWM has been settled down as a new academic field through education, training, research, academic activity, and publishing text books. In conclusion, the motive of the development of ITCWM was the policy such as "the effort of research and development on TCM-WM integration" abd "equality of TCM and WM" aimed at the development of Chinese medical area. It is no doubt helpful to organize systems and policy-making for the cooperation of eastern and western medicine in Korea.

[Authors of "Classified Collection of Medical Prescriptions"]

In this study, the career and official ranks of the authors of the Sejong text (1443-1445), Sejo text (1451-1464), and Seongjong text (1475-1477) of "Classified Collection of Medical Prescriptions" were investigated. In the completion of Sejong text, Kim Rye-mong (1406-1469), Ryu Seong-won (?-1456), and Min Bohua (?) collected and arranged all medical books inside and outside of Choseon; Kim Moon (?-1448), Shin Seok-jo (1407-1459), Lee Ye (1419-1480), Kim Soo-on (1410-1481), Jeon soon-eui (?), Choi Yun (?), and Kim Yu-ji (?-1469) took part in the edition; Lee Yong (1418-1453), Lee Sa-cheol (1405-1456), Lee Sa-soon (?-1455), and Rho Joon-g-rye (?-1452) participated in the editorial supervision. Ryang Seong-ji (1415-1482), Son So (1433-1484), Ryu Yo (?), Han Chi-ryang (?), An Geuk-sang (?), Han Kye-mi (1421-1471), and Choi Young-rin (?) took part in the completion of Sejo text. Han Kye-heiu (1423-1482), Rym Won-joon (1423-1500), Kueon Chan (1430-1487), Ryu Seo (?), and Baek Soo-heui(?) participated in the completion of Seongjong text. All 96 persons participated in the completion of draft text, revision text, and first-publication text of "Classified Collection of Medical Prescriptions". 14 persons (14.58%) participated in the completion of draft text. 77 persons (80.21%) participated in revision text, and 5 persons (5.21%) participated in first-publication text. Even though "Classified Collection of Medical Prescriptions" is a medical book, civil officials participated in its completion together with medical officials. The scholars of Jiphyeonjeon (The Jade Hall of Scholars) who led the academy at those days and famous medical officials were ordered to complete it by Sejong (1419-1450), Sejo (1455-1468), and Seongjong (1470-1494) who showed special interest in their own health and the health of common people.

Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft: a biomechanic and histologic study

A new surgical technique has been recently described that involves reconstruction of the dorsal aspect of the scapholunate ligament (DSLL) with a bone-retinaculum-bone (BRB) autograft preparation from Lister's tubercle. In this study, the mechanic and histologic properties of the 2 tissues were compared. The BRB and DSLL specimens were harvested from 6 fresh-frozen human cadaveric forearms. The specimens were measured and then tested in tension with an MTS 810 servohydraulic materials testing machine at a rate of 10 mm/min. The BRB autograft was significantly weaker than the DSLL. However, because the mean cross-sectional area of the DSLL was more than 3 times as large as that of the BRB autograft, the failure stress (failure force/cross-sectional area) of the BRB autograft was not significantly different from that of the DSLL. Histologically, the DSLL and BRB autograft were also similar. These findings suggest that the BRB autograft may be appropriate graft material for scapholunate ligament reconstruction, but that structural parity with DSLL will ultimately depend on remodeling and hypertrophy during healing. This also highlights the importance of using a large BRB autograft to approximate the strength of the DSLL as much as possible, and that the BRB autograft must be protected postoperatively as it heals and remodels.

Lymphoid cell aggregates: a useful clue in the fine-needle aspiration diagnosis of follicular lymphomas

Among the various types of lymphoma, follicular lymphoma (FL) is known to have significant limitations in cytologic diagnosis by the fine-needle aspiration (FNA) method. The diagnostic accuracy (DA) for non-Hodgkin's lymphoma (NHL) by FNA was evaluated by review of 82 cases of histologically proved NHL after prior FNA. The DA for all NHLs was 66% (54/82), and that for low-grade lymphomas, including small lymphocytic lymphoma, follicular small-cleaved cell lymphoma, and follicular mixed cell lymphoma, was 71% (12/17). The DA for FL was 69% (11/16). Review of individual surgical and cytologic materials from FLs revealed a tendency to show fibrosis in the cytologically false-negative group and diffuse areas of lymphoma in the true-positive group. The presence of "aggregation" of uniform lymphoid cells, probably due to cell adhesions with the support of dendritic reticulum cells, was seen in 55% of true-positive FL (6/11). In contrast, only 28% of true-positive diffuse large cell lymphomas (5/18) showed a mild degree of aggregation, and none of 7 cases of true-positive diffuse small-cleaved cell lymphoma showed this feature. The aggregation of cells was not pathognomonic of FL, but its presence with a homogeneous cellular constituent and the paucity of tingible-body macrophages helped us to predict FL. Also, it was a feature distinguishing FL from diffuse small-cleaved cell lymphoma (P = 0.025).

Exposure of swine to Trichinella spiralis antigen as determined by consecutive ELISAs and western blot

Exposure of swine to Trichinella spiralis was evaluated using a combination of 3 consecutive enzyme-linked immunosorbent assays (ELISAs) based on larval T. spiralis excretory-secretory antigen as screening test and western blot analysis as confirmatory test. Ninety-three of 32,693 domestic swine sera collected in Georgia over a 5-yr period contained antibodies specific to T. spiralis (prevalence of exposure = 0.28%). The highest prevalence (0.52%) of exposure to T. spiralis was in samples from stockyards and salebarns. Prevalence of exposure in samples from cull sows from 1 slaughter house was 0.38% compared with 0.17% in samples obtained from farms. Pepsin-HCl digestion of diaphragms from 49 swine from 6 seropositive farms revealed 0.01 larvae/g in 4 swine from 3 farms. Determination of T. spiralis infection status of farms appears to be accurately determined with this combination of exploratory ELISAs and confirmatory western blot analysis.

Rosette-forming non-Hodgkin's lymphomas

Homer Wright rosettes, typically found in neuroblastomas and consisting of neoplastic cells surrounding an eosinophilic fibrillary centre without a lumen, have been considered as an important finding in the differential diagnosis of small round cell tumours. Rosettes in a neoplasm involving lymph nodes or bone marrow traditionally excluded a diagnosis of malignant lymphoma. In this report, we describe three cases of malignant lymphoma (two small lymphocytic and one diffuse large cell) with pronounced rosette formation. One of the two cases of small lymphocytic lymphoma was observed in the bone marrow, the other small lymphocytic lymphoma and the large cell lymphoma were in lymph nodes. The rosettes consisted of neoplastic lymphoid cells, often with participation of reactive macrophages, and ultrastructurally they had a central mass of interdigitating fibrillary cytoplasmic projections. Two cases were of B-cell lineage and one was of T-cell lineage. To the best of our knowledge, this is the first report of T-cell lymphoma with rosettes. Based on these findings, it is suggested that non-Hodgkin's lymphoma be included in the differential diagnosis of rosette-forming round cell neoplasms.

[A survey of canine heartworm infections among German shepherds in South Korea]

A survey of canine heartworm (Dirofilaria immitis) infections among German shepherds in five areas of South Korea was performed from October 1994 to August 1995 using a microfilarial test (modified Knott's test) and an antigen test (DiroCHEK, Synbiotics, USA). The infection rate of 127 German shepherds (71 males and 56 females) was 10.2% (13/127) by the microfilarial test, but was 28.3% (36/127) by the antigen test, revealing that 24 of the 36 antigen-positive dogs were microfilaria negative in the peripheral blood. All dogs that were microfilaria-positive were also antigen positive. There of the microfilaria negative and antigen positive dogs contained 4.15 adult heartworms in the heart and pulmonary arteries upon necropsy. The infection rate among German shepherds was the highest in Hoengsong-gun (Kangwon-do, 84.4%), while those of Yechon gun (Kyongsangbuk-do) and Chungwon-gun (Chungchongbuk-do) areas were 20.0% and 14.3%, respectively. None of the dogs in the Kimhae-shi (Kyongsangnam-do) and Kwangju areas was heartworm positive. The infection rates of heartworm in dogs at the age of 1-3, 4-6, and 7-11 years were 6.2%, 21.4%, and 56.4%, respectively. Based on the fact that the antigen test is more accurate than the microfilarial test, this study strongly indicates that the prevalence rate of canine heartworm in Korea may be higher than previously reported (3.1 approximately 23.0%) which utilized microfilarial tests.