Clinical standards for the management of adverse effects during treatment for TB.

BACKGROUND: Adverse effects (AE) to TB treatment cause morbidity, mortality and treatment interruption. The aim of these clinical standards is to encourage best practise for the diagnosis and management of AE.METHODS: 65/81 invited experts participated in a Delphi process using a 5-point Likert scale to score draft standards.RESULTS: We identified eight clinical standards. Each person commencing treatment for TB should: Standard 1, be counselled regarding AE before and during treatment; Standard 2, be evaluated for factors that might increase AE risk with regular review to actively identify and manage these; Standard 3, when AE occur, carefully assessed and possible allergic or hypersensitivity reactions considered; Standard 4, receive appropriate care to minimise morbidity and mortality associated with AE; Standard 5, be restarted on TB drugs after a serious AE according to a standardised protocol that includes active drug safety monitoring. In addition: Standard 6, healthcare workers should be trained on AE including how to counsel people undertaking TB treatment, as well as active AE monitoring and management; Standard 7, there should be active AE monitoring and reporting for all new TB drugs and regimens; and Standard 8, knowledge gaps identified from active AE monitoring should be systematically addressed through clinical research.CONCLUSION: These standards provide a person-centred, consensus-based approach to minimise the impact of AE during TB treatment.

Clinical standards for drug-susceptible pulmonary TB.

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice´ for diagnosis, treatment and management of drug-susceptible pulmonary TB (PTB).METHODS: A panel of 54 global experts in the field of TB care, public health, microbiology, and pharmacology were identified; 46 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all 46 participants.RESULTS: Seven clinical standards were defined: Standard 1, all patients (adult or child) who have symptoms and signs compatible with PTB should undergo investigations to reach a diagnosis; Standard 2, adequate bacteriological tests should be conducted to exclude drug-resistant TB; Standard 3, an appropriate regimen recommended by WHO and national guidelines for the treatment of PTB should be identified; Standard 4, health education and counselling should be provided for each patient starting treatment; Standard 5, treatment monitoring should be conducted to assess adherence, follow patient progress, identify and manage adverse events, and detect development of resistance; Standard 6, a recommended series of patient examinations should be performed at the end of treatment; Standard 7, necessary public health actions should be conducted for each patient. We also identified priorities for future research into PTB.CONCLUSION: These consensus-based clinical standards will help to improve patient care by guiding clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment for PTB.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease.

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort.

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Th22 response induced by Mycobacterium tuberculosis strains is closely related to severity of pulmonary lesions and bacillary load in patients with multi-drug-resistant tuberculosis.

The role of interleukin-22 (IL-22) in the pathogenesis or tissue repair in human tuberculosis (TB) remains to be established. Here, we aimed to explore the ex-vivo and in-vitro T helper 22 (Th22) response in TB patients and healthy donors (HD) induced by different local multi-drug-resistant (MDR) Mvcobacterium tuberculosis (Mtb) strains. For this purpose, peripheral blood mononuclear cells from drug-susceptible (S-TB) MDR-TB patients and HD were stimulated with local MDR strains and the laboratory strain H37Rv. IL-22 and IL-17 expression and senescent status were assessed in CD4+ and CD8+ cells by flow cytometry, while IL-22 amount was measured in plasma and culture supernatants by enzyme-linked immunosorbent assay (ELISA). We found lower IL-22 amounts in plasma from TB patients than HD, together with a decrease in the number of circulating T cells expressing IL-22. In a similar manner, all Mtb strains enhanced IL-22 secretion and expanded IL-22+ cells within CD4+ and CD8+ subsets, being the highest levels detected in S-TB patients. In MDR-TB, low systemic and Mtb-induced Th22 responses associated with high sputum bacillary load and bilateralism of lung lesions, suggesting that Th22 response could be influencing the ability of MDR-TB patients to control bacillary growth and tissue damage. In addition, in MDR-TB patients we observed that the higher the percentage of IL-22+ cells, the lower the proportion of programmed cell death 1 (PD-1)+ or CD57+ T cells. Furthermore, the highest proportion of senescent T cells was associated with severe lung lesions and bacillary load. Thus, T cell senescence would markedly influence Th22 response mounted by MDR-TB patients.

Point of care diagnostics for tuberculosis.

The goals of the End TB strategy, which aims to achieve a 90% reduction in tuberculosis (TB) incidence and a 95% reduction in TB mortality by 2035, will not be achieved without new tools to fight TB. These include improved point of care (POC) diagnostic tests that are meant to be delivered at the most decentralised levels of care where the patients make the initial contact with the health system, as well as within the community. These tests should be able to be performed on an easily accessible sample and provide results in a timely manner, allowing a quick treatment turnaround time of a few minutes or hours (in a single clinical encounter), hence avoiding patient loss-to-follow-up. There have been exciting developments in recent years, including the WHO endorsement of Xpert MTB/RIF, Xpert MTB/RIF Ultra, loop-mediated isothermal amplification (TB-LAMP) and lateral flow lipoarabinomannan (LAM). However, these tests have limitations that must be overcome before they can be optimally applied at the POC. Furthermore, worrying short- to medium-term gaps exist in the POC diagnostic test development pipeline. Thus, not only is better implementation of existing tools and algorithms needed, but new research is required to develop new POC tests that allow the TB community to truly make an impact and find the "missed TB cases".

The IL-17A rs2275913 single nucleotide polymorphism is associated with protection to tuberculosis but related to higher disease severity in Argentina.

Mycobacterium tuberculosis (Mtb) causes nearly 10 millions of new tuberculosis disease cases annually. However, most individuals exposed to Mtb do not develop tuberculosis, suggesting the influence of a human genetic component. Here, we investigated the association of the rs2275913 SNP (G → A) from IL-17A and tuberculosis in Argentina by a case-control study. Furthermore, we evaluated in vitro the functional relevance of this SNP during the immune response of the host against Mtb and analyzed its impact on clinical parameters of the disease. We found an association between the AA genotype and tuberculosis resistance. Additionally, within the healthy donors population, AA cells stimulated with a Mtb lysate (Mtb-Ag) produced the highest amounts of IL-17A and IFN-γ, which further support the genetic evidence found. In contrast, within the tuberculosis patients population, AA Mtb-Ag stimulated cells showed the lowest immunological parameters and we evidenced an association between the AA genotype and clinical parameters of disease severity, such as severe radiological lesions and higher bacilli burden in sputum. Overall, our findings demonstrated that the AA genotype from the IL-17A rs2275913 SNP is positively associated with protection to active tuberculosis but related to higher disease severity in the Argentinean population.

Mycobacterium tuberculosis multi-drug-resistant strain M induces IL-17+ IFNγ- CD4+ T cell expansion through an IL-23 and TGF-ß-dependent mechanism in patients with MDR-TB tuberculosis.

We have reported previously that T cells from patients with multi-drug-resistant tuberculosis (MDR-TB) express high levels of interleukin (IL)-17 in response to the MDR strain M (Haarlem family) of Mycobacterium tuberculosis (M. tuberculosis). Herein, we explore the pathways involved in the induction of Th17 cells in MDR-TB patients and healthy tuberculin reactors [purified protein derivative healthy donors (PPD+ HD)] by the M strain and the laboratory strain H37Rv. Our results show that IL-1ß and IL-6 are crucial for the H37Rv and M-induced expansion of IL-17+ interferon (IFN)-γ- and IL-17+ IFN-γ+ in CD4+ T cells from MDR-TB and PPD+ HD. IL-23 plays an ambiguous role in T helper type 1 (Th1) and Th17 profiles: alone, IL-23 is responsible for M. tuberculosis-induced IL-17 and IFN-γ expression in CD4+ T cells from PPD+ HD whereas, together with transforming growth factor (TGF-ß), it promotes IL-17+ IFN-γ- expansion in MDR-TB. In fact, spontaneous and M. tuberculosis-induced TGF-ß secretion is increased in cells from MDR-TB, the M strain being the highest inducer. Interestingly, Toll-like receptor (TLR)-2 signalling mediates the expansion of IL-17+ IFN-γ- cells and the enhancement of latency-associated protein (LAP) expression in CD14+ and CD4+ T cells from MDR-TB, which suggests that the M strain promotes IL-17+ IFN-γ- T cells through a strong TLR-2-dependent TGF-ß production by antigen-presenting cells and CD4+ T cells. Finally, CD4+ T cells from MDR-TB patients infected with MDR Haarlem strains show higher IL-17+ IFN-γ- and lower IL-17+ IFN-γ+ levels than LAM-infected patients. The present findings deepen our understanding of the role of IL-17 in MDR-TB and highlight the influence of the genetic background of the infecting M. tuberculosis strain on the ex-vivo Th17 response.

[Phthalate exposure in the neonatal intensive care unit]. / Sources d'exposition aux phtalates dans une unité de soins néonatals.

There are growing concerns on long-term health consequences, notably on fertility rates, of plasticizers such as phthalates. While di(2-ethylhexyl)phthalate (DEHP) is currently used in several medical devices, newborns in the neonatal intensive care unit are both more exposed and more vulnerable to DEHP. The objectives of this study were to identify, count, and describe possible sources of DEHP in a neonatal care unit. Our method consisted in the listing and the inspection of the information on packaging, complemented by contact with manufacturers when necessary. According to the results, 6% of all products and 10% of plastic products contained some DEHP; 71% of these involved respiratory support devices. A vast majority of the items showed no information on the content of DEHP. Further research is needed, particularly to determine the effects of such an early exposure and to study and develop safer alternatives.

Selection of appropriate Schizosaccharomyces strains for winemaking.

This paper describes the selection of Schizosaccharomyces yeasts with adequate oenological suitability and high capacity for the degradation of malic acid. Despite the almost non-existent number of commercial strains, the use of this yeast genus has recently been recommended by the International Organisation of Vine and Wine (OIV, in French). Thus, in the present study, a large number of Schizosaccharomyces strains were isolated using a selective differential medium. Initially, classic parameters of oenological interest for the use of fermentative strains of Saccharomyces cerevisiae (the most frequently used type of yeast) were assessed. Only five strains of moderate acetic acid production lower than 0.4 g/L were obtained at the end of fermentation. Other, more specific features of this yeast genus' physiology were also studied, including urease activity and the production of pyruvic acid and glycerol. Finally, oenological suitability was determined by comparing selected strains with other Schizosaccharomyces reference and S cerevisiae control strains. Schizosaccharomyces strains produced 80% less urea content, four times higher pyruvic acid levels and 1 g higher glycerol contents than the Saccharomyces reference strains. The results confirmed that it is possible to perform selective processes on microorganisms from the genus Schizosaccharomyces using methodology developed in this work to obtain strains of industrial interest.

Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis.

The broadest pattern of tuberculosis (TB) drug resistance for which a consensus definition exists is extensively drug-resistant (XDR)-TB. It is not known if additional drug resistance portends worsened patient outcomes. This study compares treatment outcomes of XDR-TB patients with and without additional resistance in order to explore the need for a new definition. Individual patient data on XDR-TB outcomes were included in a meta-analysis comparing outcomes between XDR alone and three nonmutually exclusive XDR-TB patient groups: XDR plus resistance to all the second-line injectables (sli) and capreomycin and kanamycin/amikacin (XDR+2sli) XDR plus resistance to second-line injectables and to more than one group 4 drug, i.e. ethionamide/protionamide, cycloserine/terizidone or para-aminosalicylic acid (XDR+sliG4) and XDR+sliG4 plus resistance to ethambutol and/or pyrazinamide (XDR+sliG4EZ). Of 405 XDR-TB cases, 301 were XDR alone, 68 XDR+2sli, 48 XDR+sliG4 and 42 XDR+sliG4EZ. In multivariate analysis, the odds of cure were significantly lower in XDR+2sli (adjusted OR 0.4, 95% CI 0.2-0.8) compared to XDR alone, while odds of failure and death were higher in all XDR patients with additional resistance (adjusted OR 2.6-2.8). Patients with additional resistance beyond XDR-TB showed poorer outcomes. Limitations in availability, accuracy and reproducibility of current drug susceptibility testing methods preclude the adoption of a useful definition beyond the one currently used for XDR-TB.

Difficult clinical management of anti-tuberculosis DRESS syndrome.

We describe 11 cases of anti-tuberculosis DRESS (drug-related rash with eosinophilia and systemic symptoms) syndrome, a potentially serious complication of treatment that led to interruption of treatment for prolonged periods, systemic corticosteroid use and the resumption of treatment with less effective regimens. All patients had rash and toxic hepatitis, one died of multi-organ failure and, contrary to expectations, the evolution of tuberculosis (advanced in most cases) did not progress under corticosteroid treatment. The drug most frequently involved was rifampicin, while retreatment schemes included, in most cases, levofloxacin, ethambutol, streptomycin and cycloserine.

First Report of Homothallic Isolates of Phytophthora infestans in Commercial Potato Crops (Solanum tuberosum) in the Toluca Valley, Mexico.

Phytophthora infestans causes severe symptoms of wilt disease on potato crops (Solanum tuberosum) in the Toluca Valley (Mexico) despite the use of fungicides. P. infestans oospores produced by sexual reproduction can survive in the soil for many years, resisting harsh environments. In many agroecosystems, oospores germinate in the beginning of a season, which represents the initial inoculum for epidemics. The sexual cycle of the pathogen allows the generation of recombinant genotypes that can be more pathogenic or even resistant to chemicals. This paper presents a study of 20 isolates of P. infestans collected from potato crops in the Toluca Valley within the municipality of Zinacantepec (Mexico State). Isolates were obtained from potato foliar infected tissues. The pathogen was confirmed as P. infestans on the basis of morphological characters (1). Sporangia were caducous, ovoid, limoniform, semipapillate, and were 28.4 ± 1.3 × 17.6 ± 1.2 µm (height × width). Mycelium was coenocytic with hyphal diameter of 5 to 8 µm. Five isolates were collected in 2011, and 15 in 2012. Isolates were transferred by hyphal tip to culture medium plates with V8 juice agar and incubated at 19°C. All the isolates were mated to determine the mating type with the reference isolates J104 (A1) and J204 (A2), which were provided by the Michoacana University of San Nicolás de Hidalgo (Mx). Isolates that produced oospores with both A1 and A2 testers (J104 and J204) and in a single culture were designated homothallic. Results show that two out of the five isolates collected in 2011 were homothallic and the other three were type A1. Regarding the 15 isolates collected in 2012, six were typed as A1, five as A2, and four were homothallic. The heterothallic isolates only produce oospores when mated with the opposite mating type. The homothallic isolates possessed the ability to act as A1 and A2 during heterothallic mating and were found capable of producing sexual structures (oogonia and amphigynous antheridia) in a single culture, a phenomenon not observed in isolates that are strictly A1 or A2. Oospores formed were aplerotic and measured 32.2 ± 3.3 µm in diameter. Single-sporangium progeny were produced from the six homothallic isolates to be analyzed to confirm the occurrence of the self-fertility. Assessment of 48 single-sporangium progeny from the homothallic isolates resulted in 22 homothallic, 12 A1, 10 A2, and four sterile. These results differ from those found by Grünwald et al. (3), who conducted a study with isolates collected from the Toluca Valley region in 1997 and 1998, finding a 1:1 frequency between compatibility types A1 and A2. Fernandez et al. (2) studied a broad population of 27 isolates from potato crops in the state of Michoacán (Mx), and found two homothallic isolates among heterothallic isolates; the ratio was 1:1. Also, homothallic isolates have been found in Spain and China (4). To our knowledge, this is the first report of the occurrence of homothallic P. infestans isolates in commercial potato crops (S. tuberosum) in the Toluca Valley, Mexico. References: (1) D. C. Erwin and O. K. Ribeiro, Page 346 in: Phytophthora Diseases Worldwide. The American Phytopathological Society. St. Paul, MN, 1996. (2) S. P. Fernández et al. Rev. Mexicana Fitopatol. 23:191, 2005. (3) N. J. Grünwald et al. Phytopathology 91:883, 2001. (4) M. Han et al. J. Eukaryotic Microbiol. 60:79, 2013.

Pielonefritis xantogranulomatosa: estudio retrospectivo de 8 casos / Xanthogranulomatous pyelonephritis: a retrospective study of 8 cases

Hemos revisado las características clínicas, radiológicas y patológicas de la pielonefritis xan-togranulomatosa junto con la evolución de la enfermedad y una revisión bibliográfica de la misma. Se realiza un estudio retrospectivo en nuestro centro, obteniendo una muestra de 8 casos confirmados por anatomía patológica a través de los que describimos las características clínicas y diagnósticas. De los 8 casos (1 varón y 7 mujeres), 6 de ellos debutaron como cólico renal complicado, 1 se presentó con astenia y pérdida de peso y el otro caso fue un hallazgo incidental. El diagnóstico inicial se realizó mediante ecografía en 2 casos y TC en todos los casos, siendo confirmados todos mediante estudio histopatológico.

We have revised the clinical, radiological and pathological characteristics of Xanthogranuloma-tous pyelonephritis (XGP), together with the evolution of the disease and a literature review of the same. A retrospective study was performed at our center, obtaining a sample of 8 pathologically confirmed cases which we used to describe the clinical and diagnostic features. Of the 8 cases (1 male and 7 female), 6 of them presented complicated renal colic, one presented asthenia and weight loss and the other case was an incidental finding. The initial diagnosis was achieved with ultrasonography in 2 of the cases and with CT in all of the cases, all being confirmed by a histopathological study.

First Report of Fusarium verticillioides Causing Stalk and Root Rot of Sorghum in Spain.

Sweet sorghum (Sorghum bicolor L.) is considered one of the most promising crops for bioethanol production in many countries and is a focus of bioenergy research worldwide. In July 2011, plants of the sweet sorghum cv. Suchro 506 in Oropesa (Toledo, Spain, 40.048577°N, 5.360298°W) (European Datum 1950 UTM zone 30 N) were observed with severe wilting. Upon examination, the lower internodes were found to be straw colored. When the plant was split, the internal pith was reddish, soft, and disintegrating. Small pieces of symptomatic stems and roots were surface disinfected in sodium hypochlorite (0.5% wt/vol) for 2 min and air dried. The sections were then placed on either PDA (potato dextrose agar) medium or Komada agar and incubated for 5 days at 25°C. Isolations from diseased stem and root tissue consistently yielded Fusarium verticillioides (Sacc.) Nirenberg (3). The small, hyaline, mostly single-celled, oval to club-shaped microconidia of F. verticillioides were produced in long catenate chains arising from monophialides. PCR amplification of the ITS1-5.8S-ITS2 was performed using the primers and protocols described elsewhere (4) and the fragments obtained were subsequently sequenced in both directions. Sequences were deposited in the EMBL Sequence Database (Accession Nos. HE652878, HE652879, HE652880, and HE652881). Four of the recovered F. verticilliodes isolates were tested in pathogenicity assays. One-week-old cultures of each isolate were homogenized in 400 ml of sterile water and 200 ml were used to inoculate water-growth-chamber-grown plants in 500-ml pots. Two pots each with three plants of cv. Suchro 506 were inoculated for each isolate. Water with sterile PDA was used as a control. All plants were kept at 20 to 25°C under a photoperiod of 14 h at 12,000 lux. After 21 days, above- and belowground parts were dried for 24 h at 60°C. Total length and dry weight of both sections were obtained. Inoculated plants produced root rot symptoms characteristic of F. verticillioides with dark red discolorations of the cortex of seedling roots (1), whereas the plants watered with water containing only PDA did not produce symptoms. Inoculated plants also had a decrease in dry weight for above- and belowground sections (P = 0.05) compared with the control with 43 and 47% reductions, respectively. The length of aerial parts was approximately 5% less in inoculated plants compared with control plants. F. verticillioides was reisolated from all inoculated plants. Sorghum stalk and root rot caused by F. verticillioides has been reported in different countries including India (2) and the United States (3). To our knowledge, this is the first report of F. verticillioides causing stalk and root rot of sorghum in Spain. An increase of production of this crop is expected to meet targets of the renewable energy share in Spain and any disease compromising yield may be a threat to this endeavour. References: (1) R. A. Frederiksen and G. N. Odvody. Compendium of Sorghum Diseases. The American Phytopathological Society. St. Paul, MN, 2000. (2) N. N. Khune et al. Indian Phytopathol. 37:316, 1984. (3) J. F. Leslie and B. A. Summerell. The Fusarium Laboratory Manual. Blackwell Publishing, Ames, IA, 2006. (4) T. J. White et al. PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, New York, 1990.

Comparative study of the pathogenicity of seabed isolates of Fusarium equiseti and the effect of the composition of the mineral salt medium and temperature on mycelial growth

The pathogenicity of seven strains of Fusarium equiseti isolated from seabed soil was evaluated on different host plants showing pre and post emergence damage. Radial growth of 27 strains was measured on culture media previously adjusted to different osmotic potentials with either KCl or NaCl (-1.50 to - 144.54 bars) at 15º, 25º and 35º C. Significant differences and interactive effects were observed in the response of mycelia to osmotic potential and temperature.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Fungal microbiota from rain water and pathogenicity of Fusarium species isolated from atmospheric dust and rainfall dust.

In order to determine the presence of Fusarium spp. in atmospheric dust and rainfall dust, samples were collected during September 2007, and July, August, and October 2008. The results reveal the prevalence of airborne Fusarium species coming from the atmosphere of the South East coast of Spain. Five different Fusarium species were isolated from the settling dust: Fusarium oxysporum, F. solani, F. equiseti, F. dimerum, and F. proliferatum. Moreover, rainwater samples were obtained during significant rainfall events in January and February 2009. Using the dilution-plate method, 12 fungal genera were identified from these rainwater samples. Specific analyses of the rainwater revealed the presence of three species of Fusarium: F. oxysporum, F. proliferatum and F. equiseti. A total of 57 isolates of Fusarium spp. obtained from both rainwater and atmospheric rainfall dust sampling were inoculated onto melon (Cucumis melo L.) cv. Piñonet and tomato (Lycopersicon esculentum Mill.) cv. San Pedro. These species were chosen because they are the main herbaceous crops in Almeria province. The results presented in this work indicate strongly that spores or propagules of Fusarium are able to cross the continental barrier carried by winds from the Sahara (Africa) to crop or coastal lands in Europe. Results show differences in the pathogenicity of the isolates tested. Both hosts showed root rot when inoculated with different species of Fusarium, although fresh weight measurements did not bring any information about the pathogenicity. The findings presented above are strong indications that long-distance transmission of Fusarium propagules may occur. Diseases caused by species of Fusarium are common in these areas. They were in the past, and are still today, a problem for greenhouses crops in Almería, and many species have been listed as pathogens on agricultural crops in this region. Saharan air masses dominate the Mediterranean regions. The evidence of long distance dispersal of Fusarium spp. by atmospheric dust and rainwater together with their proved pathogenicity must be taken into account in epidemiological studies.

Comparative study of the pathogenicity of seabed isolates of Fusarium equiseti and the effect of the composition of the mineral salt medium and temperature on mycelial growth.

The pathogenicity of seven strains of Fusarium equiseti isolated from seabed soil was evaluated on different host plants showing pre and post emergence damage. Radial growth of 27 strains was measured on culture media previously adjusted to different osmotic potentials with either KCl or NaCl (-1.50 to -144.54 bars) at 15°, 25° and 35° C. Significant differences and interactive effects were observed in the response of mycelia to osmotic potential and temperature.