Early mortality during rifampicin-resistant TB treatment.

BACKGROUND: Data suggest that treatment with newer TB drugs (linezolid [LZD], bedaquiline [BDQ] and delamanid [DLM]), used in Khayelitsha, South Africa, since 2012, reduces mortality due to rifampicin-resistant TB (RR-TB).METHODS: This was a retrospective cohort study to assess 6-month mortality among RR-TB patients diagnosed between 2008 and 2019.RESULTS: By 6 months, 236/2,008 (12%) patients died; 12% (78/651) among those diagnosed in 2008-2011, and respectively 8% (49/619) and 15% (109/738) with and without LZD/BDQ/DLM in 2012-2019. Multivariable analysis showed a small, non-significant mortality reduction with LZD/BDQ/DLM use compared to the 2008-2011 period (aOR 0.79, 95% CI 0.5-1.2). Inpatient treatment initiation (aOR 3.2, 95% CI 2.4-4.4), fluoroquinolone (FQ) resistance (aOR 2.7, 95% CI 1.8-4.2) and female sex (aOR 1.5, 95% CI 1.1-2.0) were also associated with mortality. When restricted to 2012-2019, use of LZD/BDQ/DLM was associated with lower mortality (aOR 0.58, 95% CI 0.39-0.87).CONCLUSIONS: While LZD/BDQ/DLM reduced 6-month mortality between 2012 and 2019, there was no significant effect overall. These findings may be due to initially restricted LZD/BDQ/DLM use for those with high-level resistance or treatment failure. Additional contributors include increased treatment initiation among individuals who would have otherwise died before treatment due to universal drug susceptibility testing from 2012, an effect that also likely contributed to higher mortality among females (survival through to care-seeking).

Implementing novel regimens for drug-resistant TB in South Africa: what can the world learn?

Worldwide uptake of new drugs in the treatment of rifampicin-resistant tuberculosis (RR-TB) has been extremely low. In June 2018, ahead of the release of the updated WHO guidelines for the management of RR-TB, South Africa announced that bedaquiline (BDQ) would be provided to virtually all RR-TB patients on shorter or longer regimens. South Africa has been the global leader in accessing BDQ for patients with RR-TB, who now represent 60% of the global BDQ cohort. The use of BDQ within a shorter modified regimen has generated the programmatic data underpinning the most recent change in WHO guidelines endorsing a shorter, injectable-free regimen. Progressive policies on access to new drugs have resulted in improved favourable outcomes and a reduction in mortality among RR-TB patients in South Africa. This supported global policy change. The strategies underpinning these bold actions include close collaboration between the South African National TB Programme and partners, introduction of new TB diagnostic tools in closely monitored conditions and the use of locally generated programmatic evidence to inform country policy changes. In this paper, we summarise a decade´s work that led to the bold decision to use a modified, short, injectable-free regimen with BDQ and linezolid under carefully monitored programmatic conditions.

Analysis of CD34-positive cells in bone marrow from patients with myelodysplastic syndromes and acute myeloid leukemia and in normal individuals: a comparison between FACS analysis and immunohistochemistry.

In patients with myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML), expression of the hematopoietic stem cell marker CD34 has been associated with a poorer prognosis. CD34 is usually analyzed by flow cytometry (FC), but may also be analyzed using immunohistochemistry (IH). The present study was undertaken to compare these 2 methods. Bone marrow from 16 patients with MDS and 12 with AML and from 12 healthy young volunteers was studied. The expression of CD34 was analyzed with FC on fresh bone marrow cells and with IH on sections of paraffin-embedded bone marrow. The correlation between FC and IH was good both for patients with MDS (p<0.0001) and AML (p<0.01). However, in patients with a high number of CD34-positive cells, the FC method seemed to result in a higher percentage of positive cells compared to the IH method. In normal bone marrow, the ratio between the percentage of CD34-positive cells and the percentage of bone marrow blasts was approximately 0.8. In the whole group of MDS patients, this ratio was 1:1, while in patients with refractory anemia (RA) and ring sideroblastic anemia (RAS) it was 1.6. Patients with MDS differed significantly from patients with de novo AML, who showed a ratio of only 0.23 (p<0.01). We conclude that the FC and IH methods for measuring expression of CD34 are well-correlated in MDS and reasonably well correlated in AML. A stem cell phenotype is more commonly expressed on precursor cells from patients with MDS than from patients with AML.

Peripheral blood neutrophil morphology reflects bone marrow dysplasia in myelodysplastic syndromes.

Dysplastic features of cells in peripheral blood and bone marrow were studied in 51 patients with myelodysplastic syndromes (MDS) to evaluate the significance of the degree of neutrophil granulation (G-score) and the percentage of pelgeroid polymorphs (ppp) in the peripheral blood, as indices of dysplastic changes in the bone marrow. There was a good correlation between peripheral blood and bone marrow findings, both for G-score figures (r = 0.92, P < 0.01) and ppp (r = 0.82, P < 0.01). Significantly lower G-score figures were found among patients with an increased percentage of bone marrow blasts (P < 0.05), while high ppp correlated with the presence of ring sideroblasts, the degree of bone marrow fibrosis, and findings of complex chromosomal abnormalities. Patients with a high degree of bone marrow dysplasia had significantly lower G-score (P < 0.01) and significantly higher ppp (P < 0.05) figures, than those with less pronounced myelodysplasia. In addition, extreme hypogranulation (G-score < 150) or very high ppp (> or = 20%) was generally a sign of bi- and tri-lineage dysplasia in the bone marrow. The results thus show that quantitative estimation of peripheral blood polymorph dysplasia by G-score figures and ppp seems to reflect the total degree of bone marrow dysplasia in MDS and may serve as a complement to bone marrow evaluation when the diagnosis of MDS is difficult.

Low-dose ara-C in myelodysplastic syndromes (MDS) and acute leukemia following MDS: proposal for a predictive model.

Patients with myelodysplastic syndromes (MDS) comprise an extremely heterogeneous group. There is a need for decision models both for predicting the natural course of the disease and the outcomes of different treatment alternatives. In 102 consecutive patients with MDS or acute myelogenous leukemia (AML) following MDS, pre-treatment variables were studied in relation to the response to treatment with low-dose ara-C. Thirty patients (29%) responded with either a complete remission or a significant rise in the hemoglobin level. For the remaining 71%, the treatment was ineffective and in some cases hazardous. The factors associated with a poor response to treatment could be divided into two groups: one included low platelet counts and the presence of chromosomal aberrations, both signs of progressive MDS with a short survival, and the other comprised morphological findings, indicating ineffective hemopoiesis. Patients with platelet counts > 150 x 10(9)/l had a response rate of 55%, compared to 24% in patients with subnormal platelet counts. Logistic regression identified low bone marrow cellularity, absence of ring sideroblasts and < 2 chromosomal aberrations as predictors of a favourable response in patients with platelet counts < 150 x 10(9)/l. These factors and the platelet count were combined in a predictive model which divided patients into three groups with different probabilities of response: one favourable (38% of the patients), with a response rate of > 50%; a second, intermediate group (33% of the patients), with a response rate of 24%; and a third, unfavourable group (29% of the patients) with only 3% responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver fibrosis quantified by image analysis in methotrexate-treated patients with psoriasis.

BACKGROUND: Histopathologic monitoring of the liver is mandatory during methotrexate (MTX) treatment. Fibrosis is an important histologic feature of liver damage. OBJECTIVE: Our purpose was to supply an independent measure to histopathologic grading of hepatic changes in MTX-treated patients with psoriasis. METHODS: Forty-six liver biopsy specimens from 26 patients with psoriasis evaluated for or treated with MTX were histopathologically classified and their collagen content quantified by image analysis after staining with Sirius Red F3BA. RESULTS: Fibrosis in normal liver biopsy specimens (controls) amounted to 0.9% +/- 0.1% and in patients with psoriasis varied between 9.3% +/- 1.4% and 24.0% +/- 4.9%. An effect of MTX on liver fibrosis was not discerned. No correlation was obtained between fibrosis and histologic grades, intake of alcohol, lean tissue mass, or age of the patient. CONCLUSION: Two changes occurred in the psoriatic liver; the collagen content was increased at least tenfold when compared with controls, and significant heterogeneity in collagen content was present among patients (p < 0.001).

A predictive model for the clinical response to low dose ara-C: a study of 102 patients with myelodysplastic syndromes or acute leukaemia.

The response to treatment with low-dose ara-C was studied in 102 consecutive patients; 79 with myelodysplastic syndrome (MDS) and 23 with acute myelogenous leukaemia (AML) following MDS. The aim was to find variables that could predict the response to treatment. All patients had clinical symptoms related to cytopenia. Peripheral blood values, bone marrow morphology histology and chromosomes were analysed before the start of treatment. The median survival of the patients was 9 months and a poor survival was predicted by advanced age, low platelet counts, the presence of pseudo-Pelger morphology and > or = 2 chromosomal aberrations. Thirty patients (29%) responded with either a complete remission or a significant increase in haemoglobin level. For the remaining 71%, the treatment was ineffective and in some cases hazardous. The factors associated with a poor response to treatment could be divided into two groups: one included low platelet counts and the presence of chromosomal aberrations, both signs of progressive MDS with a short survival, and the other comprised morphological findings, indicating ineffective haemopoiesis. Patients with platelet counts > 150 x 10(9)/l had a response rate of 55% compared to 23.5% in patients with subnormal platelet counts. Logistic regression identified low bone marrow cellularity, absence of ring sideroblasts and < 2 chromosomal aberrations as predictors of a favourable response in patients with platelet counts < 150 x 10(9)/l. These factors and the platelet count were combined in a predictive model which can divide patients into three groups with different probabilities of response: a favourable group, 38.6% of the patients, with a response rate of > 50%, an intermediate group, 32.7% of the patients, with a response rate of 24%, and an unfavourable group, 28.7% of the patients, with only 3% responses. While low-dose ara-C is an effective treatment for some patients, it is ineffective and hazardous for others. We present a model that can facilitate therapeutic decision making in two-thirds of patients with MDS and MDS-AML by identifying patients who should not be treated with low-dose ara-C as well as patients with a relatively high probability of response.

Cell proliferation of the normal esophagus of mice harbouring a squamous cell neoplasia in the uterine cervix.

Some human tumors have been found to induce proliferative lesions in the squamous epithelium in organs remote from the primary tumor. This phenomenon was explored in the present animal model. After a single injection of 3H-thymidine, the proportion of DNA synthesizing basal and parabasal esophageal cells as well as the pace of intraepithelial cell migration was assessed in 124 C57Bl mice. The uterine cervix of 57 animals had been painted topically with 3,4 benzo(a)pyrene for 5 months, or with the vehicle acetone (44 animals), while 23 animals remained untreated. Groups of animals were killed from 8 hours to 10 days following a single pulse labelling. The proportion of DNA synthesizing basal and parabasal esophageal cells and of their daughter cells (as deduced by observations at various time intervals) was similar in animals harbouring neoplasias of the uterine cervix, in those treated with benzo(a)pyrene but having histologically normal cervical epithelium, in acetone treated as well as in untreated controls. Thus, in the model used herein, we failed to demonstrate increased cell proliferation in the esophageal mucosa of animals having a squamous cell neoplasia in the uterine cervix. The method appears, however, sensitive enough to register ongoing cell proliferation patterns and will be applied to the study of other experimentally induced tumors.

In vitro suspension culture reactions to 1,25 dihydroxyvitamin D3 in relation to bone marrow morphology and prognosis in patients with myelodysplastic syndromes.

Thirty-four patients with MDS or AML following MDS were studied with regard to survival, peripheral blood values and bone marrow morphology. The effects of 1,25 dihydroxyvitamin D3 (D3) on differentiation (NBT positivity) and proliferation (3H-thymidine incorporation) were studied in suspension cultures of bone marrow cells. Twelve bone marrow donors served as controls. Normal cells showed spontaneous differentiation in vitro, but only 2/12 were induced to differentiation by D3. Myelodysplastic cells did not differentiate spontaneously, but cells from 18/34 patients differentiated after incubation with D3. Normal cells showed increased proliferation, myelodysplastic cells showed a heterogeneous response and leukemic cells reacted with decreased proliferation after D3 incubation. Poor survival was associated with low platelet counts, high percentage of bone marrow blasts (BM blast %), low spontaneous in vitro proliferation and absence of hypogranulation of myeloid cells. Platelet counts and hypogranulation retained their predictive value in a multi-variate analysis. Progression to AML was predicted by a high BM blast % and low scores for erythroid and total dysplasia. In conclusion, the pattern of in vitro proliferation showed prognostic value while the pattern of vitamin D3-induced differentiation failed to correlate to other parameters. An estimation of bone marrow dysplasia can be used to predict the development of AML. Our results add to the information about the biology of MDS and may be important for the evaluation of therapeutic trials.

Studies on the distribution of abnormal cells in cytological smears. VII. Cervical brush versus plastic and wooden spatulas.

A model system of exfoliated normal human cervicovaginal squamous cells, exfoliated rodent tumor cells, and acellular, viscous, mucuslike material was used to investigate cell deposition on smear preparations made with three different instruments: plastic spatulas, wooden spatulas, and brush-tipped collectors. The total number of exfoliated cells and the total number of tumor cells present within the randomly distributed holes were then recorded for 41 smear preparations. For smears done with the brush, a total of 47,146 exfoliated cells were recorded; with wooden spatulas, 4517 cells; and with plastic spatulas, 7648 cells. When the brush was used, 6905 tumor cells were recorded. When wooden or plastic spatulas were applied, 563 and 1132 tumor cells were found, respectively. Thus, the brush yielded 12.2 and 6.1 times more tumor cells than plastic and wooden spatulas, respectively.

A quantitative method of estimating inflammation in the rectal mucosa. IV. Ulcerative colitis in remission.

Histological preparations of the rectal mucosa were analyzed quantitatively in 61 patients with ulcerative colitis in remission (UCR). Four histological variables were recorded: the diameter (minor axis) of the lumen of 10 consecutive (transversally cut) glands, the interglandular linear distance between 10 consecutive glands, the number of glands at high-power field examination, and the number of nuclei in 10 consecutive areas of lamina propria. The most important feature to differentiate UCR patients from non-colitic patients was the distance between glands and the number of glands per area. The sum of the values of the four variables demonstrated that 84% of the patients with UCR had scores of 22 or more, whereas only 1 of 124 non-colitic patients (that is, 0.8%) had similar scores.

Studies on the distribution of abnormal cells in cytologic preparations. VI. Pressure exerted by the gynecologist during smearing.

A model system consisting of exfoliated abnormal cells and acellular viscous, mucus-like material was used to investigate the effect of the pressure exerted during smearing on the number of abnormal cells present in the preparations. Smears were made with a cotton swab applicator from left to right with parallel strokes, without overlapping smearing and without rotating the instrument of cell collection. Light and heavy pressures done during smearing procedure were recorded by the aid of an automatic scale. By means of the smearing technique, a gradual decrease in the total number of cells was recorded along the pathway of smearing. By using heavy pressure, however, cell accumulation also occurred at the end of the pathway of the last smearing strokes. Smears made with heavy pressure contained 13% more tumor cells than those made with light pressure. It is concluded that the pressure exerted by the operator during smearing may be an important parameter influencing both the number and the distribution of abnormal cells on smear preparations. These considerations may be of significance in screening programs for tumor cell detection.

A quantitative method of estimating inflammation in the rectal mucosa. II. Normal limits in symptomatic patients.

Quantitative analysis of histological preparations of the rectal mucosa were carried out in 52 patients with gastrointestinal symptoms. Follow-up investigation demonstrated no signs of chronic inflammatory bowel disease. The variables recorded in the histological preparations in the 52 patients were the diameter (minor axis) of 10 consecutive, transversally cut glands, the space of lamina propria between glands, the number of glands per high-power field, and the number of nuclei in 10 consecutive areas of lamina propria (between glands). The histological state of the rectal mucosa in individual patients was quantitatively defined as the score resulting from the sum of the values in each of the above-mentioned variables. Similarly to the rectal mucosa from asymptomatic patients, the rectal mucosa from the 52 symptomatic patients had scores of 21 or less. These composite data form the basis for a comparative quantitative study of the rectal mucosa from patients with various chronic inflammatory conditions of the rectum.

A quantitative method of estimating inflammation in the rectal mucosa. III. Chronic ulcerative colitis.

Histological preparations of the rectal mucosa were analyzed quantitatively in 51 patients with chronic ulcerative colitis. Four histological variables were recorded: the diameter (minor axis) of the lumen of 10 consecutive (transversally cut) glands, the interglandular linear distance between 10 consecutive glands, the number of glands at high power field examination, and the number of nuclei in 10 consecutive areas of lamina propria. The most important feature found to differentiate colitic from noncolitic patients was the diameter of the lumen of the rectal glands. The sum of the values of the four variables has demonstrated that 94% of the colitic patients had scores of 22 or more. Previous work showed that only 0.8% of 124 noncolitic patients had a similar score.

Kinetics of cell replication of the uterine cervix. V. Behavior of DNA-replicating tumor cells in invasive squamous carcinomas in mice.

The intratumoral migration of tritiated thymidine ([3H]dThd)-labeled cells was recorded at various intervals (from 1 to 240 hr) in squamous invasive carcinomas of the cervix in 25 inbred C57Bl mice. Carcinomas were induced by local application of benzo[a]pyrene for 5 months. This treatment was discontinued 7 days before the animals were killed. Cells were labeled by a single ip injection of 6 muCi [3H]dThd/g body weight. The tumors were divided by the aid of an ocular scale into three equal compartments: a peripheral zone, an intermediate zone, and a central zone. Many densely (initially) labeled cells were present in the peripheral and intermediate zones 1-48 hours after the injection of isotope, but these cells decreased in number in the intermediate zone and had disappeared from the peripheral zone by 96 hours. Conversely, densely labeled cells were absent in the center of the tumor during the first 24 hours, but they were recorded in large numbers at 48 hours. It was concluded that in addition to already known mechanisms of cell migration in solid tumors (e.g., invasion of the surrounding normal tissue, intravascular migration, migration toward the center of individual tumor nests, and cell exfoliation), there is intratumoral migration of cells toward the center in cervical carcinomas in mice.

Studies on the distribution of abnormal cells in cytologic preparations. V. The gradient of cell deposition on slides.

A model system of exfoliated normal human cervicovaginal squamous cells, exfoliated rodent tumor cells, and acellular, viscous, mucus-like material was used to investigate the gradient of cell deposition on smear preparations. Smears were made from left to right with parallel strokes, without overlapping smearing and without rotating the instrument of cell collection. With this technique a gradual decrease in the total number of cells was recorded along the pathway of the smear. The proportion of tumor cells, however, increased halfway along the smearing pathway. The midway increase was significant for wooden spatulas or cotton swab applicators but less marked for plastic spatulas. It would appear that normal squamous cervicovaginal cells, because of their large flat surface, attach readily to the flat surface of the slide and become "consumed" from the material carried by the instrument. On the other hand, the relatively smaller round tumor cells are "pushed" forward by the instrument during the smearing procedure. These considerations may be of significance in screening programs for tumor cell detection.

A digital quantitative method of estimating inflammation in the rectal mucosa. I. The normal limits in asymptomatic patients.

Histological preparations of the rectal mucosa from 72 rheumatic patients without gastrointestinal symptoms were quantitatively analysed. The variables recorded were the diameter (minor axis) of ten consecutive transversally cut glands, the space of lamina propria between the glands, the number of glands per high-power field, and the number of nuclei in ten consecutive areas (of lamina propria) between the glands. The digitals resulting from the sum of the values in each variable were considered characteristic of the histological state of the rectal mucosa in individual patients. In most biopsies (i.e. 99%) scores of 21 or less were recorded. The data obtained serve as a basis for comparative studies of the histological state of the rectal mucosa from patients with various chronic inflammatory conditions of the rectum.

Acute gastric erosions in the rat. II. Viability of the gastric mucosa.

The autoradiographic appearance of the gastric mucosa, 5 hours after administration of indomethacin, was investigated in 29 adult rats. Indomethacin induced superficial gastric erosions. Autoradiography demonstrated the presence of viable gastric cells (as deduced by their ability to incorporate 3H-cytidine, an RNA precursor) not only in the mucosa without erosions, but also in the mucosa underneath the superficial erosions. The results indicate that indomethacin induced gastric erosions are not the superficial expression of the necrotic process taking place in the full thickness of the gastric mucosa at a particular site. A lumen-borne mechanism appears to be responsible for the formation of erosive areas in the mucosa.

Studies on the distribution of abnormal cells in cytologic preparations. III. Making the smear with a plastic spatula.

A model system of 15% exfoliated tumor (Ehrlich ascites) cells and 85% exfoliated cervicovaginal human squamous cells and acellular viscous mucuslike material was used to investigate the distribution of tumor cells on smear preparations. The smears were taken by the same individual, with plastic spatulas, using traditional smearing motions. The presence or absence of normal squamous cervicovaginal cells and tumor cells was recorded in 400 randomly distributed areas. Smears done with circular motions contained the largest number of tumor cells and those done with back-and-forth strokes, the least. Circular motions apparently should be preferred if the purpose is to transfer to slides the largest possible number of tumor cells. Independently of the motion employed, the largest total number of tumor cells was found in ring 9 and the lowest, in ring 5. When the various motions were taken into account, the largest number of tumor cells was found in ring 9 for smears done with zigzag strokes; the lowest, in ring 5 with clockwise circular motions. Despite these differences, comparative studies indicate that plastic spatuls may induce a more even distribution of tumor cells onto slides than wooden spatulas or cotton swab applicators. We have been unable to confirm that plastic spatuals induce better cytologic preparations than do wooden spatulas or cotton swab applicators.