Yellow fever - An old foe with new developments.

INTRODUCTION: Yellow fever is caused by an RNA flavivirus. Immunisation in conjunction with vector control is at the forefront of yellow fever control and elimination. OBJECTIVE: This narrative review describes the impact and importance of yellow fever vaccinations for northern Australian health practitioners. DESIGN: Selected key policies, studies and medical guidelines are reviewed and presented. FINDING: Large yellow fever outbreaks, associated with vector spread, have occurred in the last decade in Africa and South America, increasing the risk of international spread of the virus. Mobile populations, like travellers or migrant workers, continue to be at risk of yellow fever. Quality assurance, including yellow fever centre accreditation and initiatives to decrease fraudulent yellow fever vaccination documentation, has evolved in the past few years. Fractional dosing of yellow fever vaccines has been shown to provide protection for 1 year in outbreak scenarios, but further studies are needed. DISCUSSION: Although Australia is yellow fever-free, the disease could be introduced by viraemic persons as a competent Aedes mosquito vector is present in northern Australia. In addition to surveillance and vector control, health education and yellow fever vaccination remain the best lines of defence. In the event of an outbreak, a response via fractional dosing could prove to be effective in controlling the virus. CONCLUSION: Health care providers in northern Australia should be aware of the risks of yellow fever and its introduction to northern Australia and be able to discuss vaccination status with their clients when needed.

Mucosal delivery of ESX-1-expressing BCG strains provides superior immunity against tuberculosis in murine type 2 diabetes.

Tuberculosis (TB) claims 1.5 million lives per year. This situation is largely due to the low efficacy of the only licensed TB vaccine, Bacillus Calmette-Guérin (BCG) against pulmonary TB. The metabolic disease type 2 diabetes (T2D) is a risk factor for TB and the mechanisms underlying increased TB susceptibility in T2D are not well understood. Furthermore, it is unknown if new TB vaccines will provide protection in the context of T2D. Here we used a diet-induced murine model of T2D to investigate the underlying mechanisms of TB/T2D comorbidity and to evaluate the protective capacity of two experimental TB vaccines in comparison to conventional BCG. Our data reveal a distinct immune dysfunction that is associated with diminished recognition of mycobacterial antigens in T2D. More importantly, we provide compelling evidence that mucosal delivery of recombinant BCG strains expressing the Mycobacterium tuberculosis (Mtb) ESX-1 secretion system (BCG::RD1 and BCG::RD1 ESAT-6 ∆92-95) are safe and confer superior immunity against aerosol Mtb infection in the context of T2D. Our findings suggest that the remarkable anti-TB immunity by these recombinant BCG strains is achieved via augmenting the numbers and functional capacity of antigen presenting cells in the lungs of diabetic mice.

Disparate Effects of Metformin on Mycobacterium tuberculosis Infection in Diabetic and Nondiabetic Mice.

Comorbid type 2 diabetes poses a great challenge to the global control of tuberculosis. Here, we assessed the efficacy of metformin (MET), an antidiabetic drug, in mice infected with a very low dose of Mycobacterium tuberculosis In contrast to diabetic mice, infected nondiabetic mice that received the same therapeutic concentration of MET presented with significantly higher disease burden. This warrants further studies to investigate the disparate efficacy of MET against tuberculosis in diabetic and nondiabetic individuals.

Delayed Sputum Culture Conversion in Tuberculosis-Human Immunodeficiency Virus-Coinfected Patients With Low Isoniazid and Rifampicin Concentrations.

Background: The relationship between concentrations of antituberculosis drugs, sputum culture conversion, and treatment outcome remains unclear. We sought to determine the association between antituberculosis drug concentrations and sputum conversion among patients coinfected with tuberculosis and human immunodeficiency virus (HIV) and receiving first-line antituberculosis drugs. Methods: We enrolled HIV-infected Ugandans with pulmonary tuberculosis. Estimation of first-line antituberculosis drug concentrations was performed 1, 2, and 4 hours after drug intake at 2, 8, and 24 weeks of tuberculosis treatment. Serial sputum cultures were performed at each visit. Time-to-event analysis was used to determine factors associated with sputum culture conversion. Results: We enrolled 268 HIV-infected patients. Patients with low isoniazid and rifampicin concentrations were less likely to have sputum culture conversion before the end of tuberculosis treatment (hazard ratio, 0.54; 95% confidence interval, .37-.77; P = .001) or by the end of follow-up (0.61; .44-.85; P = .003). Patients in the highest quartile for area under the rifampicin and isoniazid concentration-time curves for were twice as likely to experience sputum conversion than those in the lowest quartile. Rifampicin and isoniazid concentrations below the thresholds and weight <55 kg were both risk factors for unfavorable tuberculosis treatment outcomes. Only 4.4% of the participants had treatment failure. Conclusion: Although low antituberculosis drug concentrations did not translate to a high proportion of patients with treatment failure, the association between low concentrations of rifampicin and isoniazid and delayed culture conversion may have implications for tuberculosis transmission. Clinical Trials Registration: NCT01782950.

Determinants of antiretroviral adherence among HIV positive children and teenagers in rural Tanzania: a mixed methods study.

BACKGROUND: Around 3.3 million children worldwide are infected with HIV and 90% of them live in sub-Saharan Africa. Our study aimed to estimate adherence levels and find the determinants, facilitators and barriers of ART adherence among children and teenagers in rural Tanzania. METHODS: We applied a sequential explanatory mixed method design targeting children and teenagers aged 2-19 years residing in Ifakara. We conducted a quantitative cross sectional study followed by a qualitative study combining focus group discussions (FGDs) and in-depth interviews (IDIs). We used pill count to measure adherence and defined optimal adherence as > =80% of pills being taken. We analysed determinants of poor adherence using logistic regression. We held eight FGDs with adolescent boys and girls on ART and with caretakers. We further explored issues emerging in the FGDs in four in-depth interviews with patients and health workers. Qualitative data was analysed using thematic content analysis. RESULTS: Out of 116 participants available for quantitative analysis, 70% had optimal adherence levels and the average adherence level was 84%. Living with a non-parent caretaker predicted poor adherence status. From the qualitative component, unfavorable school environment, timing of the morning ART dose, treatment longevity, being unaware of HIV status, non-parental (biological) care, preference for traditional medicine (herbs) and forgetfulness were seen to be barriers for optimal adherence. CONCLUSION: The study has highlighted specific challenges in ART adherence faced by children and teenagers. Having a biological parent as a caretaker remains a key determinant of adherence among children and teenagers. To achieve optimal adherence, strategies targeting the caretakers, the school environment, and the health system need to be designed.

Incidence and risk factors for travellers' diarrhoea among short-term international adult travellers from high-income countries: a systematic review with meta-analysis of cohort studies.

BACKGROUND: Travellers' Diarrhoea (TD) continues to be the most common travel-related medical event in international travellers. Updated incidence and risk factor data will improve pre-travel medical advice for travellers from high-income countries (HIC), providing an opportunity for disease prevention, and appropriate disease management. METHODS: A systematic search for cohort studies of TD incidence published between 1 January 1997 and 2 March 2023 was performed using Ovid Medline, SCOPUS, and Google Scholar databases. Study quality was assessed with a modified Newcastle-Ottawa scale (NOS). We extracted incidence data for adults travelling less than 100 days from HIC and available risk factor data. The overall random-effects pooled incidence and the corresponding 95% confidence intervals (95% CI) were estimated. Heterogeneity was assessed using the I2 statistic, tau and the 95% prediction intervals. Subgroup analyses were conducted to identify sources of heterogeneity. Risk factor studies were reviewed qualitatively and described. RESULTS: Ten studies were included in the meta-analysis, containing 8478 participants. Two of the studies measured as high quality and eight as good quality as assessed by the modified NOS. The TD incidence was 36.1% (95% CI 24-41%; I2 94%), with a prediction interval ranging from 20.3% to 55.8%. The pooled incidence of mild, moderate, and severe TD was 23.6%, 8.1% and 2.9%, respectively. Subgroup analysis showed that the incidence increased with increasing average data collection period. Risk factors for TD in travellers from HIC identified include younger age, longer travel periods, low and middle-income destinations, travelling for tourism, backpacking travel styles and pre-travel health status. CONCLUSION: It is estimated that between 20 to 56% of international travellers can expect to develop TD in travel of under 100 days. While most cases are mild, approximately 3% of all travellers will experience a disease that prevents usual activities or requires medical attention.

Cardiac cystic echinococcosis-A systematic review and analysis of the literature.

Human cystic echinococcosis (CE) is a parasitic infection caused by the larval stage of the tapeworm Echinococcus granulosus sensu lato, primarily affecting the liver and lungs. Although the heart is affected in only 0.02-2% of all CE cases, a considerable number of cases have been, and continue to be, published. However, due to the rare occurrence of cardiac CE and the resulting lack of clinical trials, knowledge about various aspects of the disease remains limited. To obtain a clearer picture of anatomical, clinical, diagnostic as well as therapeutic aspects of cardiac CE, we systematically reviewed the literature published between 1965 and 2022. The anatomical pattern of the affected cardiac structures follows the extension of the supplying capillary bed. The majority of patients (82.7%) are symptomatic and present with prolonged non-specific symptoms such as dyspnoea, chest pain and palpitations. Acute complications generally derive from cyst rupture, occur in 18.3% of cases and manifest as embolism, pericardial tamponade, or anaphylactic reaction in 83.2%, 17.8% and 10.9% of these cases, respectively. As for CE cysts localized in other organs, the diagnosis of cardiac CE is made by imaging. Serology plays a minor role due to its limited sensitivity. Unlike abdominal CE cysts, cardiac CE cysts are usually resected independent of their stage (active/inactive), because their presence impairs cardiac performance and carries the risk of long-term sequelae. More than 80% of patients are treated with a single surgical intervention. We found a disease-related case fatality rate of 11.1%. Since local recurrence was reported up to 108 months and secondary CE up to 72 months after surgery, patients should be followed up for a minimum of 10 years.

Uridine adenosine tetraphosphate: a novel endothelium- derived vasoconstrictive factor.

Beyond serving as a mechanical barrier, the endothelium has important regulatory functions. The discovery of nitric oxide revolutionized our understanding of vasoregulation. In contrast, the identity of endothelium-derived vasoconstrictive factors (EDCFs) remains unclear. The supernatant obtained from mechanically stimulated human endothelial cells obtained from dermal vessels elicited a vasoconstrictive response in an isolated perfused rat kidney. A purinoceptor blocker had a greater effect than an endothelin receptor blocker in decreasing endothelially derived vasoconstriction in the isolated perfused rat kidney. The nucleotide uridine adenosine tetraphosphate (Up(4)A) was isolated from the supernatant of stimulated human endothelium and identified by mass spectrometry. Up(4)A is likely to exert vasoconstriction predominantly through P2X1 receptors, and probably also through P2Y2 and P2Y4 receptors. Plasma concentrations of Up(4)A that cause vasoconstriction are found in healthy subjects. Stimulation with adenosine 5'-triphosphate (ATP), uridine 5'-triphosphate (UTP), acetylcholine, endothelin, A23187 and mechanical stress releases Up(4)A from endothelium, suggesting that Up(4)A contributes to vascular autoregulation. To our knowledge, Up(4)A is the first dinucleotide isolated from living organisms that contains both purine and pyrimidine moieties. We conclude that Up(4)A is a novel potent nonpeptidic EDCF. Its vasoactive effects, plasma concentrations and its release upon endothelial stimulation strongly suggest that Up(4)A has a functional vasoregulatory role.

Systematic review and meta-analysis of diagnostic tests for diagnosis of melioidosis.

OBJECTIVES: Melioidosis is an emerging tropical disease caused by B. pseudomallei that can rapidly prove fatal and require prompt and appropriate antibiotic treatment. Diagnosis currently relies on culture; however, this delays appropriate antibiotics and contributes to mortality as results can take up to one week or more. Several non-culture based diagnostic tests are available; however, their role remains a point of contention. This review was performed to characterise the accuracy of various diagnostic tests. METHODS: Medline/Pubmed, CINAHL, Informit, Scopus, The Cochrane Library, Web of Science and Embase databases were searched from inception to April 2020. Clinical trials investigating diagnostic tests capable of providing results in ≤48 hours using samples from suspected human cases; with bacterial culture as the reference test, and reporting sensitivity and specificity were eligible for inclusion. Data was pooled using bivariate analysis for diagnostic tests reported in ≥4 studies. RESULTS: 22 publications comprising 10963 individual tests were included. Meta-analysis was able to be performed for immunofluorescence assay (sensitivity 63.8% [95% CI, 45.6-78.7%]; specificity 99.4% [95% CI, 97.2-99.9%]), polymerase chain reaction (sensitivity 77.1 [95% CI, 20.8%-97.8%]; specificity 99.8 [95% CI, 91.6%-100.0%]) and lateral flow immunoassay (sensitivity 58.2% [95% CI, 34.1%-78.9%]; specificity 95.0% [95% CI, 93.3%-96.3%]). Measures of sensitivity were overall similar although specificity of immunofluorescence assay was statistically superior to lateral flow immunoassay. There was a trend for reduced sensitivity of direct detection methods applied to blood samples compared to other sample types, although statistically insignificant. Serological methods were unable to be meta-analysed due to an insufficient number of studies, but their sensitivities were generally higher than direct detection methods (median 84% [IQR 71.5-88%] vs 51% [IQR 39-79%]), however they lacked specificity compared to direct detection (median 82% [IQR 70-86%] vs 98% [IQR 95-100%]). CONCLUSIONS: Overall, no method showed sensitivity and specificity which would allow it to substitute culture. Serological tests may play a role in ruling out infection in endemic regions given their higher sensitivity, with direct detection methods being used for diagnostic confirmation. Further research into cost-effectiveness and implementation studies are required before diagnostic tests can be introduced clinically in the detection of melioidosis.

Policy and Linkages in the Application of a One Health System for Reporting and Controlling African Trypanosomiasis and Other Zoonotic Diseases in Zambia.

The capacity to detect, control and manage emerging and re-emerging zoonotic diseases in Africa has been limited by a lack of utilisation of available reporting structures and policies to support programmes at national and local levels. This study explored the impact of the Zambian government policies on animal and human disease reporting and management and on One Health opportunities. An in-depth review and analysis of strengths, weaknesses, opportunities, and threats in the existing policies and reporting structures in the departments responsible for Veterinary Services, Health, and Wildlife, was conducted. According to our findings, sub-optimal implementation of existing policies related to the control of zoonotic diseases was impacting disease reporting, and reporting structures play an important role in effective and sustainable reporting of zoonotic diseases. Further, the study explored capacities and strategies in trypanosomiasis control as a case study that could prompt effective adoption of a One Health approach, and as such, the study suggests measures that could help to assess the performance of a One Health system in the control of African trypanosomiasis and other zoonotic diseases.

Challenges in the Diagnostic Performance of Parasitological and Molecular Tests in the Surveillance of African Trypanosomiasis in Eastern Zambia.

African animal trypanosomiasis (AAT) control programs rely on active case detection through the screening of animals reared in disease endemic areas. This study compared the application of the polymerase chain reaction (PCR) and microscopy in the detection of trypanosomes in cattle blood in Mambwe, a rural district in eastern Zambia. Blood samples were collected from 227 cattle and tested for infection with trypanosomes using microscopy and Ribosomal RNA Internal Transcribed Spacers (ITS)-PCR. Microscopy on the buffy coat detected 17 cases, whilst thin and thick smears detected 26 cases and 28 cases, respectively. In total, microscopy detected 40 cases. ITS-PCR-filter paper (FP) on blood spots stored on FP detected 47 cases, and ITS-PCR-FTA on blood spots stored on Whatman FTA Classic cards detected 83 cases. Using microscopy as the gold standard, ITS-PCR-FTA had a better specificity (SP) and sensitivity (SE) (SP = 72.2%; SE = 77.5%; kappa = 0.35) than ITS-PCR-FP (SP = 88%; SE = 60%; kappa = 0.45). The prevalence of Trypanosoma brucei s.l. was higher on ITS-PCR-FTA (19/227) than on ITS-PCR-FP (0/227). Our results illustrate the complexities around trypanosomiasis surveillance in rural Africa and provide evidence of the impact that field conditions and staff training can have on diagnostic results, which in turn impact the success of tsetse and trypanosomiasis control programs in the region.

Insights into the Control and Management of Human and Bovine African Trypanosomiasis in Zambia between 2009 and 2019-A Review.

Tsetse transmitted trypanosomiasis is a fatal disease commonly known as Nagana in cattle and sleeping sickness in humans. The disease threatens food security and has severe economic impact in Africa including most parts of Zambia. The level of effectiveness of commonly used African trypanosomiasis control methods has been reported in several studies. However, there have been no review studies on African trypanosomiasis control and management conducted in the context of One Health. This paper therefore seeks to fill this knowledge gap. A review of studies that have been conducted on African trypanosomiasis in Zambia between 2009 and 2019, with a focus on the control and management of trypanosomiasis was conducted. A total of 2238 articles were screened, with application of the search engines PubMed, PubMed Central and One Search. Out of these articles, 18 matched the required criteria and constituted the basis for the paper. An in-depth analysis of the 18 articles was conducted to identify knowledge gaps and evidence for best practices. Findings from this review provide stakeholders and health workers with a basis for prioritisation of African trypanosomiasis as an important neglected disease in Zambia and for formulation of One Health strategies for better control and/or management of the disease.

HIV and AIDS in Bangladesh.

Bangladesh initiated an early response to the HIV epidemic starting in the mid-1980s. Since then, the response has been enhanced considerably, and many HIV-prevention interventions among the most at-risk populations and the general youth are being undertaken. Alongside prevention activities, gathering of data has been a key activity fostered by both the Government and individual development partners. This paper reviews available sources of data, including routine surveillance (HIV and behavioural among most at-risk populations), general population surveys, and various research studies with the aim to understand the dynamics of the HIV epidemic in Bangladesh. Available data show that the HIV epidemic is still at relatively low levels and is concentrated mainly among injecting drug users (IDUs) in Dhaka city. In addition, when the passively-reported cases were analyzed, another population group that appears to be especially vulnerable is migrant workers who leave their families and travel abroad for work. However, all sources of data confirm that risk behaviours that make individuals vulnerable to HIV are high--this is apparent within most at-risk populations and the general population (adult males and youth males and females). Based on the current activities and the sources of data, modelling exercises of the future of the HIV epidemic in Dhaka suggest that, if interventions are not enhanced further, Bangladesh is likely to start with an IDU-driven epidemic, similar to other neighbouring countries, which will then move to other population groups, including sex workers, males who have sex with males, clients of sex workers, and ultimately their families. This review reiterates the often repeated message that if Bangladesh wants to be an example of how to avert an HIV epidemic, it needs to act now using evidence-based programming.

Phenylacetic acid and arterial vascular properties in patients with chronic kidney disease stage 5 on hemodialysis therapy.

BACKGROUND: Phenylacetic acid (PAA) is a recently described uremic toxin that inhibits inducible nitric oxide synthase expression and plasma membrane calcium ATPase and may therefore also be involved in remodeling of arteries. Such vascular effects have not been evaluated yet in patients with chronic kidney disease stage 5. METHOD: We prospectively measured the plasma concentrations of PAA using nuclear magnetic resonance spectroscopy in 50 patients with chronic kidney disease stage 5 (37 men, 13 women) on maintenance hemodialysis. Arterial vascular properties were quantified by the reflective index obtained from digital photoplethysmography. RESULTS: During the hemodialysis session the plasma PAA concentration was reduced from 3.38 +/- 0.24 mmol/l (mean +/- SEM; median, 2.85 mmol/l; interquartile range, 2.02-4.52 mmol/l) to 2.25 +/- 0.11 mmol/l (median, 2.06 mmol/l; interquartile range, 1.62-2.86 mmol/l; n = 50; p < 0.001). There was a significant correlation between the PAA concentration and the reflective index before the start of the hemodialysis session. CONCLUSION: The study demonstrates an association of PAA and arterial vascular properties in patients with chronic kidney disease stage 5.

Cohort profile of a study on outcomes related to tuberculosis and antiretroviral drug concentrations in Uganda: design, methods and patient characteristics of the SOUTH study.

PURPOSE: Tuberculosis (TB) is a leading cause of death among people living with HIV in sub-Saharan Africa. Several factors influence the efficacy of TB treatment by leading to suboptimal drug concentrations and subsequently affecting treatment outcome. The aim of this cohort is to determine the association between anti-TB drug concentrations and TB treatment outcomes. PARTICIPANTS: Patients diagnosed with new pulmonary TB at the integrated TB-HIV outpatient clinic in Kampala, Uganda, were enrolled into the study and started on first-line anti-TB treatment. FINDINGS TO DATE: Between April 2013 and April 2015, the cohort enrolled 268 patients coinfected with TB/HIV ; 57.8% are male with a median age of 34 years (IQR 29-40). The median time between the diagnosis of HIV and the diagnosis of TB is 2 months (IQR 0-22.5). The majority of the patients are antiretroviral therapy naive (75.4%). Our population is severely immunosuppressed with a median CD4 cell count at enrolment of 163 cells/µL (IQR 46-298). Ninety-nine per cent of the patients had a diagnosis of pulmonary TB confirmed by sputum microscopy, Xpert/RIF or culture and 203 (75.7%) have completed TB treatment with 5099 aliquots of blood collected for pharmacokinetic analysis. FUTURE PLANS: This cohort provides a large database of well-characterised patients coinfected with TB/HIV which will facilitate the description of the association between serum drug concentrations and TB treatment outcomes as well as provide a research platform for future substudies including evaluation of virological outcomes. TRIAL REGISTRATION NUMBER: NCT01782950; Pre-results.

Diguanosine pentaphosphate: an endogenous activator of Rho-kinase possibly involved in blood pressure regulation.

OBJECTIVE: Rho-kinase activity is increased in cardiovascular disease and in the pathophysiology of hypertension. Few endogenous factors are known that activate the Rho-kinase pathway. Stimulation of P2Y receptors activates the Rho-kinase pathway. Recently identified diguanosine pentaphosphate (Gp5G) possibly activates P2Y receptors. In this study, Gp5G was identified and quantified in human plasma. The influence of Gp5G on vascular tone was studied. METHODS: Gp5G in human plasma was purified to homogeneity by several steps. Gp5G was quantified and identified by matrix-assisted laser desorption/ionization mass spectrometry and enzymatic analysis. The vasoactive effects of Gp5G were studied in the isolated perfused rat kidney and after intra-aortic application. Activation of Rho-kinase was measured using western blot analysis. RESULTS: The plasma level of Gp5G in healthy donors is 9.47 +/- 4.97 nmol/l. Gp5G increases contractile responses induced by angiotensin II in a dose-dependent way [ED50 (-log mol) angiotensin II: 10.9 +/- 0.1; angiotensin II plus Gp5G (100 nmol/l): 11.5 +/- 0.1]. P2 receptor antagonists inhibited the Gp5G-induced increase in angiotensin II vasoconstriction. MRS2179, a selective P2Y1 receptor antagonist, had no effect on Gp5G-mediated angiotensin II potentiation. Rho-kinase inhibition by Y27632 abolished the Gp5G-induced increase of contractile responses to angiotensin II. Concentrations of 10 nmol/l Gp5G activated the translocation of RhoA from the cytosolic to the membranous fraction indicating the activation of Rho-kinase. The intra-aortic application of 100 pmol Gp5G significantly increased mean arterial blood pressure by 13.5 +/- 4.2 mmHg. CONCLUSION: Gp5G is an endogenous activator of Rho-kinase, which might affect vascular tone control by Rho-kinase at physiological levels. Gp5G activates P2Y4&6 receptors, and might play a role in physiological and pathophysiological vascular tone control.

Identification and quantification of diadenosine polyphosphate concentrations in human plasma.

OBJECTIVE: Diadenosine polyphosphates have been demonstrated to be involved in the control of vascular tone as well as the growth of vascular smooth muscle cells and hence, possibly, in atherogenesis. In this study we investigated the question of whether diadenosine polyphosphates are present in human plasma and whether a potential source can be identified that may release diadenosine polyphosphates into the circulation. METHODS AND RESULTS: Plasma diadenosine polyphosphates (ApnA with n=3 to 6) were purified to homogeneity by affinity-, anion exchange-, and reversed phase-chromatography from deproteinized human plasma. Analysis of the homogeneous fractions with matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) revealed molecular masses ([M+H]+) of 757, 837, 917, and 997 d. Comparison of the postsource decay matrix-assisted laser desorption/ionization mass spectrometry mass spectra of these fractions with those of authentic diadenosine polyphosphates revealed that these isolated substances were identical to Ap3A, Ap4A, Ap5A, and Ap6A. Enzymatic analysis showed an interconnection of the phosphate groups with the adenosines in the 5'-positions of the ribose moieties. The mean total plasma diadenosine polyphosphate concentrations (micromol/L; mean +/- SEM) in cubital veins of normotensive subjects amounted to 0.89+/-0.59 for Ap3A, 0.72+/-0.72 for Ap4A, 0.33+/-0.24 for Ap5A, and 0.18+/-0.18 for Ap6A. Cubital venous plasma diadenosine polyphosphate concentrations from normotensives did not differ significantly from those in the hypertensive patients studied. There was no significant difference between arterial and venous diadenosine polyphosphate plasma concentrations in 5 hemodialysis patients, making a significant degradation by capillary endothelial cells unlikely. Free plasma diadenosine polyphosphate concentrations are considerably lower than total plasma concentrations because approximately 95% of the plasma diadenosine polyphosphates were bound to proteins. There were no significant differences in the diadenosine polyphosphate plasma concentrations depending on the method of blood sampling and anticoagulation, suggesting that platelet aggregation does not artificially contribute to plasma diadenosine polyphosphate levels in significant amounts. The ApnA (with n=3 to 6) total plasma concentrations in adrenal veins were significantly higher than the plasma concentrations in both infrarenal and suprarenal vena cava: adrenal veins: Ap3A, 4.05+/-1.63; Ap4A, 6.18+/-2.08; Ap5A, 0.53+/-0.28; Ap6A, 0.59+/-0.31; infrarenal vena cava: Ap3A, 1.25+/-0.66; Ap4A, 0.91+/-0.54; Ap5A, 0.25+/-0.12; Ap6A, 0.11+/-0.06; suprarenal vena cava: Ap3A, 1.40+/-0.91; Ap4A, 1.84+/-1.20; Ap5A, 0.33+/-0.13; Ap6A, 0.11+/-0.07 (micromol/L; mean +/- SEM; each P<0.05 (concentration of adrenal veins versus infrarenal or suprarenal veins, respectively). CONCLUSIONS: The presence of diadenosine polyphosphates in physiologically relevant concentrations in human plasma was demonstrated. Because in adrenal venous plasma significantly higher diadenosine polyphosphate concentrations were measured than in plasma from the infrarenal and suprarenal vena cava, it can be assumed that, beside platelets, the adrenal medulla may be a source of plasma diadenosine polyphosphates in humans.

Cure of tuberculosis despite serum concentrations of antituberculosis drugs below published reference ranges.

PRINCIPLES: Therapeutic target serum concentrations of first-line antituberculosis drugs have not been well defined in clinical studies in tuberculosis (TB) patients. METHODS: We retrospectively investigated the estimated maximum serum concentrations (eC max) of antituberculosis drugs and clinical outcome of TB patients with therapeutic drug monitoring performed between 2010-2012 at our institution, and follow-up until March 2014. The eC max was defined as the highest serum concentration during a sampling period (2, 4 and 6 hours after drug ingestion). We compared the results with published eC max values, and categorised them as either "within reference range", "low eC max", or "very low eC max".Low/very low eC max-levels were defined as follows: isoniazid 2-3/<2 mg/l, rifampicin 4-8/<4 mg/l, rifabutin 0.2-0.3/<0.2 mg/l, ethambutol 1-2/<0.1 mg/l and pyrazinamide <20 mg/l. RESULTS: Concentrations of antituberculosis drugs in 175 serum samples of 17 patients with TB were analysed. In 12 (71%) patients, multiple therapeutic drug monitoring samples were collected over time, in 5 (29%) patients only one sample was available for therapeutic drug monitoring. Overall, 94% of all patients had at least one low antituberculosis drug concentration. Overall, 64% of all eC max levels were classified as "low" or "very low". The eC max was below the relevant reference range in 80% of isoniazid, 95% of rifampicin, 30% of pyrazinamide, and 30% of ethambutol measurements. All but one patient were cured of tuberculosis. CONCLUSIONS: Although many antituberculosis drug serum concentrations were below the widely used reference ranges, 16 of 17 patients were cured of tuberculosis. These results challenge the use of the published reference ranges for therapeutic drug monitoring.

[Limitations of medicine:diagnosis and therapy of <> back pain]. / Grenzen der Medizin: Diagnostik und Therapie von <> Ruckenschmerzen.

A 34-year-old man from Ethiopia had been suffering from inflammatory lower backpain for five months. The imaging showed multiple osteolytic lesions histologically corresponding to a granulomatous inflammation. Detection of multiresistant Mycobacteria Tuberculosis (MDR-TB) was delayed because of initially negative microbiological findings. During the therapy of MDR-TB, the patient developed different side effects. In this article we focus on the challenge to diagnose and treat MDR-TB also in a resource-rich setting as it is the case for Switzerland.

Low isoniazid and rifampicin concentrations in TB/HIV co-infected patients in Uganda.

INTRODUCTION: There is limited data available on exposure to anti-tuberculosis (TB) drugs in this region. Peloquin has described reference ranges [1] however some studies have demonstrated that patients actually achieve concentrations below these ranges [2]. There is limited data about exposure to anti-TB drugs in the HIV/TB co-infected population in Sub-Saharan Africa. Our objective is to describe the concentration of anti-TB drug levels in a well characterized prospective cohort of adult patients starting treatment for pulmonary TB. METHODS: This study is an ongoing study carried out in the TB/HIV integrated clinic at the Infectious Diseases Institute in Kampala, Uganda. Sputum culture and microscopy was done for all patients. We performed pharmacokinetic blood sampling of anti-TB drugs for 1 hour, 2 hours and 4 hours post dose at 2 weeks, 8 weeks and 24 weeks after initiation of anti-TB treatment using ultraviolet high-performance liquid chromatography (UV-HPLC). We described the maximum concentration (Cmax) of isoniazid (H), rifampicin (R), ethambutol (E) and pyrazinamide (Z) and compare them with the values observed by Peloquin et al. referenced in other studies. RESULTS: We started 113 HIV infected adults on a fixed dose combination of HREZ. The median age of our population was 33 years, of which 52% were male with a median BMI of 19 kg/m(2) and a median CD4 cell count of 142 cells/µL. In 90% of the participants, the diagnosis of TB was based on microscopy and or cultures. The boxplot graph shows the median Cmax and IQR of H and R. CONCLUSION: We observed lower concentrations of isoniazid and rifampicin in our study population of HIV/TB co-infected patients. The implications of these findings are not yet clear. We therefore need to correlate our findings with the response to TB treatment.