Perspectives for personalized therapy for patients with multidrug-resistant tuberculosis.

According to the World Health Organization (WHO), tuberculosis is the leading cause of death attributed to a single microbial pathogen worldwide. In addition to the large number of patients affected by tuberculosis, the emergence of Mycobacterium tuberculosis drug-resistance is complicating tuberculosis control in many high-burden countries. During the past 5 years, the global number of patients identified with multidrug-resistant tuberculosis (MDR-TB), defined as bacillary resistance at least against rifampicin and isoniazid, the two most active drugs in a treatment regimen, has increased by more than 20% annually. Today we experience a historical peak in the number of patients affected by MDR-TB. The management of MDR-TB is characterized by delayed diagnosis, uncertainty of the extent of bacillary drug-resistance, imprecise standardized drug regimens and dosages, very long duration of therapy and high frequency of adverse events which all translate into a poor prognosis for many of the affected patients. Major scientific and technological advances in recent years provide new perspectives through treatment regimens tailor-made to individual needs. Where available, such personalized treatment has major implications on the treatment outcomes of patients with MDR-TB. The challenge now is to bring these adances to those patients that need them most.

[Undesired side effects of tapentadol in comparison to oxycodone. A meta-analysis of randomized controlled comparative studies]. / Unerwünschte Nebenwirkungen von Tapentadol im Vergleich zu Oxycodon. Eine Metaanalyse randomisierter, kontrollierter Vergleichsstudien.

OBJECTIVE: Tapentadol is a new centrally acting analgesic with a dual mode of action as an agonist of the µ-opioid receptor and as a norepinephrine reuptake inhibitor. The aim of the present study was to evaluate the results from randomized controlled trials investigating the relative amount of adverse effects using tapentadol or oxycodone for the treatment of pain. METHODS: A quantitative systematic review was carried out according to the PRISMA recommendations on randomized controlled trials comparing tapentadol and oxycodone in pain treatment. The incidences of typical adverse side effects of opioid-based analgesic therapy (e.g. nausea, vomiting, obstipation or pruritus) were extracted and the pooled relative risks (RR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS: A total of 9 trials involving 7,948 patients were included and of these 2,810 patients were treated with oxycodone and 5,138 were treated with tapentadol in equivalent analgesic dosages as documented by an equivalent analgesic effect. The risk of typical opioid-based adverse effects, such as nausea (RR 0.61; 95% CI 0.57-0.66), vomiting (RR 0.50, 95% CI: 0.41-0.60), obstipation (RR 0.47, 95%-CI 0.40-0.56), dizziness (RR 0.86, 95% CI 0.78-0.95), somnolence (RR 0.76, 95% CI 0.67-0.86) and pruritus (RR 0.46, 95% CI 0.37-0.58) was reduced when tapentadol was used for analgesic treatment. These adverse effects were investigated in all nine trials. The risk for dryness of the mouth (6 trials, 6,218 patients, RR 1.79, 95% CI 1.40-2.29) and dyspepsia (1 trial, 646 patients, RR 2.75, 95% CI 1.09-6.94) was increased when tapentadol was used instead of oxycodone. There were no significant differences in the relative risk for any other investigated adverse effect such as dysentery, headache or fatigue. CONCLUSION: The results show that using tapentadol significantly reduces the risk of the typical opioid-based adverse effects compared with oxycodone while providing equivalent analgesic treatment.

[Prophylaxis of nausea and vomiting in the postoperative phase: relative effectiveness of droperidol and metoclopramide]. / Prophylaxe von Übelkeit und Erbrechen in der postoperativen Phase : Relative Effektivität von Droperidol und Metoclopramid.

OBJECTIVE: The aim of the present study was to conduct a meta-analysis of the results from randomized controlled trials investigating the relative efficacy of droperidol versus metoclopramide for the prevention of postoperative nausea and vomiting (PONV). METHODS: A systematic literature search for randomized controlled trials comparing droperidol and metoclopramide for the prevention of PONV was performed according to the PRISMA recommendations. The incidence of PONV within the early (0-6 h) and cumulative postoperative periods (0-48 h) was collated and the pooled relative risk (RR) with the corresponding 95% confidence interval (CI) was calculated. Results from a subgroup analysis are presented excluding the data of a Japanese group (Fujii et al.) which are given in parentheses. RESULTS: A total of 41 (30) trials with a total number of 3,491 (2,721) patients were included and of these 12 (8) trials with 1,403 (1,083) patients reported data of the early period and 32 (21) studies with 2,656 (1,836) patients comprised data of the cumulative period. A total of 1,797 (1,309) patients were treated with droperidol (0.25-5 mg) and 1,694 (1,412) with metoclopramide (5-50 mg). In the early period the risk for PONV after metoclopramide was 35% (95%-CI: 17-57%) higher than after prophylaxis with droperidol (without Fujii data: 46%; 23-73%). During the cumulative period the risk for PONV after metoclopramide was increased by 20% (95%-CI: 7-37%) compared to droperidol (without Fujii data: 25%; 4-50%). Due to heterogenous dosing of both drugs subgroup analyses with distinct dose intervals were performed with increments of 0.75 mg for droperidol and 7 mg for metoclopramide. Droperidol was superior in 17 (12) out of 19 (14) subgroup analyses. Comparing recommended doses of droperidol (0.75-1.5 mg) with low doses of metoclopramide (7-14 mg) and medium metoclopramide doses (14-21 mg) PONV was increased by 12% (95%-CI: -11% to 42%) and 32% (95%-CI: 4%-66%), respectively when metoclopramide instead of droperidol was used. When higher doses of metoclopramide (>20 mg) were used the superiority of droperidol was less pronounced and did not reach statistical significance due to the limited numbers of trials included in this analysis (3 studies, 662 patients). The risk for PONV after high-dose metoclopramide was increased by 13% (95%-CI: -21% to +61%) for the early period and by 19% (95%-CI: -11% to +57%) for the cumulative observation period. CONCLUSION: For the prevention of postoperative nausea and vomiting droperidol is significantly superior to metoclopramide doses below 20 mg. There was no obvious positive dose response with respect to increasing doses of metoclopramide. There was also a trend towards higher efficacy of droperidol compared to higher doses of metoclopramide (≥20 mg). However, there were not enough comparative studies to show a statistically significant result in this subgroup analysis. These data support the notion that droperidol in low doses may represent the more effective D(2)-antagonist for a pharmacological armamentarium to cope with PONV.

No difference in survival after HLA mismatched versus HLA matched allogeneic stem cell transplantation in Ewing sarcoma patients with advanced disease.

Patients with advanced Ewing sarcoma (AES) carry a poor prognosis. Retrospectively, we analyzed 66 AES patients treated with allogeneic stem cell transplantation (allo-SCT) receiving HLA-mismatched (group A, n = 39) versus HLA-matched grafts (group B, n = 27). Median age at diagnosis was 13 years, and 15 years (range 3-49 years) at allo-SCT. The two groups did not differ statistically in distribution of gender, age, remission status/number of relapses at allo-SCT, or risk stratum. 9/39 (23%) group A versus 2/27 (7%) group B patients developed severe acute graft versus host disease (GvHD). Of patients alive at day 100, 7/34 (21%) group A versus 9/19 (47%) group B patients had developed chronic GvHD. In group A, 33/39 (85%) versus 20/27 (74%) group B patients died of disease and 1/39 (3%) versus 1/27 (4%) patients died of complications, respectively. Altogether 12/66 (18%) patients survived in CR. Median EFS 24 months after allo-SCT was 20% in both groups, median OS was 27% (group A) versus 17% (group B), respectively. There was no difference in EFS and OS in AES patients transplanted with HLA-mismatched versus HLA-matched graft in univariate and multivariate analyses. In this analysis, CR at allo-SCT is a condition for survival (p < 0.02).

Whole genome sequencing for M/XDR tuberculosis surveillance and for resistance testing.

Whole genome sequencing (WGS) can help to relate Mycobacterium tuberculosis genomes to one another to assess genetic relatedness and infer the likelihood of transmission between cases. The same sequence data are now increasingly being used to predict drug resistance and susceptibility. Controlling the spread of tuberculosis and providing patients with the correct treatment are central to the World Health Organization's target to 'End TB' by 2035, for which the global prevalence of drug-resistant tuberculosis remains one of the main obstacles to success. So far, WGS has been applied largely to drug-susceptible strains for the purposes of understanding transmission, leaving a number of analytical considerations before transferring what has been learnt from drug-susceptible disease to drug-resistant tuberculosis. We discuss these potential problems here, alongside some of the challenges to characterizing the Mycobacterium tuberculosis 'resistome'-the optimal knowledge-base required for WGS-based assays to successfully direct individualized treatment regimens through the prediction of drug resistance and susceptibility in the future.

Treatment of relapse after allogeneic stem cell transplantation in children and adolescents with ALL: the Frankfurt experience.

Therapy for post-transplant relapse of paediatric ALL is limited. Standardised curative approaches are not available. We hereby describe our local procedure in this life-threatening situation. A total of 101 ALL patients received their first allogeneic stem cell transplantation (SCT) in our institution. After relapse, our primary therapeutic goal was to cure the patient with high-dose chemotherapy or specific immunotherapy (HDCHT/SIT) followed by a second SCT from a haploidentical donor (transplant approach). If this was not feasible, low-dose chemotherapy and donor lymphocyte infusions (LDCHT+DLI) were offered (non-transplant approach). A total of 23 patients suffered a post-transplant relapse. Eight patients received HDCHT/SIT, followed by haploidentical SCT in 7/8. Ten received LDCHT+DLI. The eight patients treated with a second transplant and the ten treated with the non-transplant approach had a 4-year overall survival of 56% and 40%, respectively (P=0.232). Prerequisites for successful treatment of post-transplant relapse by either a second transplant or experimental non-transplant approaches are good clinical condition and the capacity to achieve haematological remission by the induction treatment element.

Tracing Mycobacterium tuberculosis transmission by whole genome sequencing in a high incidence setting: a retrospective population-based study in East Greenland.

In East Greenland, a dramatic increase of tuberculosis (TB) incidence has been observed in recent years. Classical genotyping suggests a genetically similar Mycobacterium tuberculosis (Mtb) strain population as cause, however, precise transmission patterns are unclear. We performed whole genome sequencing (WGS) of Mtb isolates from 98% of culture-positive TB cases through 21 years (n = 182) which revealed four genomic clusters of the Euro-American lineage (mainly sub-lineage 4.8 (n = 134)). The time to the most recent common ancestor of lineage 4.8 strains was found to be 100 years. This sub-lineage further diversified in the 1970s, and massively expanded in the 1990s, a period of lowered TB awareness in Greenland. Despite the low genetic strain diversity, WGS data revealed several recent short-term transmission events in line with the increasing incidence in the region. Thus, the isolated setting and the uniformity of circulating Mtb strains indicated that the majority of East Greenlandic TB cases originated from one or few strains introduced within the last century. Thereby, the study shows the consequences of even short interruptions in TB control efforts in previously TB high incidence areas and demonstrates the potential role of WGS in detecting ongoing micro epidemics, thus guiding public health efforts in the future.

Nosocomial transmission of multidrug-resistant tuberculosis.

Nosocomial transmission of multidrug-resistant tuberculosis (MDR-TB) was ascertained by 24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU-VNTR) and spoligotyping at four hospitals in the Republic of Moldova, a high MDR-TB burden country. Overall, 5.1% of patients with pan-susceptible TB at baseline were identified with MDR-TB during in-patient treatment. In 75% of cases, the MDR-TB strain was genetically distinct from the non-MDR-TB strain at baseline, suggesting a high rate of nosocomial transmission of MDR-TB. The highest proportion (40.3%) of follow-up MDR-TB isolates was associated with the M. tuberculosis URAL 163-15 strain.

Cyclophilin-facilitated bradykinin inactivation in the perfused rat lung.

Cis and trans isomers of X-proline (X-Pro) bonds can influence some aspects of the kinetics of peptide metabolism. We previously used the peptidyl-prolyl cis-trans isomerase, cyclophilin, to show that angiotensin converting enzyme (ACE) preferentially hydrolyzes the trans isomer of a synthetic tripeptide that contains a C-terminal proline (Dawson et al., Am J Physiol 257:H853-H865, 1989; Merker et al., J Appl Physiol 75: 1519-1524, 1993). Bradykinin (Arg-Pro-Pro-Gly-Phe-Ser-Pro-Phe-Arg) exists as both cis and trans isomers at all three X-Pro bonds, and although its inactivation in the lung by pulmonary endothelial peptidases is extensive, commonly a small fraction of the peptide survives passage through the lung. To determine whether the presence of cis X-Pro bonds might limit the extent of bradykinin metabolism in the lung, we studied inactivation of bradykinin by the isolated perfused rat lung using the rabbit jugular vein superfused with the pulmonary venous effluent as a bioassay for bradykinin. A large fraction (> 90%) of the bradykinin in a bolus injection was inactivated in a single transit through the pulmonary circulation, but a detectable fraction emerged in the venous effluent. The addition of cyclophilin to the bradykinin in the bolus reduced the bradykinin emerging from the lungs to virtually undetectable levels. When the isomerase inhibitor cyclosporin A was included with bradykinin and cyclophilin in the injectate, this effect of cyclophilin was reversed. These observations suggest that the fraction of bradykinin that normally survives passage through the lungs contains isomers that have at least one X-Pro bond that is refractory to enzymatic inactivation and whose isomerization time constant is significantly longer than the pulmonary capillary transit time.

In situ iodination of angiotensin-converting enzyme and other pulmonary endothelial membrane proteins.

Biochemical responses of endothelial cells in culture to pharmacological or physiological stimuli are often extrapolated to define the behavior of the vascular endothelium in vivo. However, culture conditions cannot recreate the environment of endothelial cells in vivo. To compare cell functions in vivo and in vitro, we iodinated endothelial membrane proteins of both the perfused rabbit lung and cultured rabbit lung endothelial cells. Endothelial cell protein 125I-labeling in the perfused intact lung was catalyzed by lactoperoxidase and glucose oxidase immobilized on 3-10 microns polyacrylamide beads (Enzymobeads, Bio-Rad). Changes in 5-hydroxytryptamine uptake, angiotensin converting enzyme activity and perfusion pressure made before, during and/or after iodination were small, suggesting that the procedure does not grossly injury the lung. As confirmed by tissue autoradiography, iodination was confined to the vascular space. A subcellular "membrane" fraction of the whole homogenate was enriched for several iodinated proteins. Lectin binding further purified a library of putative iodinated endothelial membranes proteins, one of which was angiotensin-converting enzyme as shown by immunoprecipitation with goat anti-rabbit antibody to angiotensin-converting enzyme. Iodinated proteins of similar molecular weights were also isolated from cultured rabbit lung endothelium iodinated under the same conditions, thus confirming the endothelial lineage of proteins iodinated in the intact lung. We conclude that this technique labels endothelial surface proteins in the intact lung without causing observable tissue injury and thus should be valuable in the study of the physiology and pathophysiology of the vascular lining in vivo.

Propranolol and serotonin removal in lung injury.

Indicator dilution technique was used to study effects of reduced vascular volume or acute injury on removal of low doses of [3H]propranolol and [14C]serotonin (5-hydroxytryptamine, 5-HT) by perfused rabbit lung. Glass-bead (500 micron) embolization doubled pulmonary arterial pressure (Ppa) at flow rates of 20, 50, and 100 ml/min, decreased volume of distribution by approximately 50%, and increased pulmonary vascular resistance by at least 60%. Before embolization, (flow rate 20 ml/min) removal of [3H]propranolol and [14C] 5-HT was 89 +/- 2 and 75 +/- 5%, respectively, and was unaltered by changes in flow rate. However, after embolization, [3H]propranolol and [14C]5-HT removal decreased in a flow-dependent manner, reaching 28 +/- 4 and 1 +/- 3% (P less than 0.05), respectively, at a flow rate of 100 ml/min. When phorbol myristate acetate (PMA, 200 nM) was perfused (50 ml/min) through the lungs for 15 min, Ppa increased from 13 +/- 1 to 25 +/- 2 cmH2O (P less than 0.05), whereas [3H]propranolol removal decreased from 92 +/- 1 to 75 +/- 5% (P less than 0.05) and [14C]5-HT removal decreased from 73 +/- 3 to 46 +/- 8% (P less than 0.05). The PMA also caused vasoconstriction, which could be partially blocked by adding papaverine (500 microM) to the perfusion medium. Under the latter conditions, Ppa increased to 19 +/- 1 cmH2O and [3H]propranolol removal was unaffected. However, the combination of PMA and papaverine reduced [14C]5-HT removal from 64 +/- 4 to 19 +/- 3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction and accumulation of methylene blue by the lung.

We studied the disposition of methylene blue added to the perfusate passing through isolated perfused rabbit lungs. Experiments were carried out in a recirculating or single-pass mode, the latter with either a steady infusion or bolus injection of the dye in its blue oxidized form (MB+) or in its colorless reduced leukomethylene blue form (MBH). The recirculation experiments revealed that the dye was taken up by the lungs and that a substantial fraction (approximately 16%) of the MB+ entering the pulmonary artery was reduced before it emerged from the pulmonary veins. Sequestration of the dye by the lungs was a relatively slow process, and the blue color of the lungs at a time when there was little dye left in the perfusate suggests that much of the sequestered dye was in the oxidized form. The results from the single-pass bolus and steady infusion experiments suggest that MBH diffuses rapidly between perfusate and tissue and that it is more soluble in the tissue than in the perfusates used in the study. In this context, the concept of "solubility" includes the impact of the rapidly equilibrating associations of the dye with the perfusate albumin and tissue components. The observed characteristics of the disposition of the methylene blue within the lungs and the rapid rate of its reduction on passage through the lungs suggest that it may be useful to evaluate the possibility that changes in reduction, uptake, and/or sequestration rates may reflect alterations in the metabolic function of the lungs.

Angiotensin-converting enzyme preferentially hydrolyzes trans isomer of proline-containing substrate.

An analysis of the hydrolysis kinetics of the synthetic angiotensin-converting enzyme (ACE) substrate benzoyl-phenylalanyl-alanyl-proline (BPAP) in the intact lung suggested that 12-15% of the BPAP was in a form that could not be hydrolyzed by ACE in the time course of a single pass through the lungs [C. A. Dawson et al. Am. J. Physiol. 257 (Heart Circ. Physiol. 26): H853-H865, 1989]. BPAP has been found to exist as a mixture of cis and trans isomers in a ratio of approximately 14:86 in aqueous solution at equilibrium. Thus, one possible explanation for the incomplete hydrolysis of BPAP on passage through the intact lung is that the trans form is the preferred substrate for ACE. To examine this hypothesis, we measured BPAP hydrolysis by ACE in vitro over a range of ACE concentrations and in the presence and absence of the peptidyl-prolyl cis-trans isomerase cyclophilin. In the presence of a sufficient concentration of ACE and in the absence of cyclophilin, hydrolysis of [3H]BPAP by ACE followed biexponential progress curves, consistent with the hypothesis that the rate of hydrolysis of the majority (approximately 87%) of the substrate is proportional to ACE concentration, whereas the hydrolysis rate of the remaining substrate fraction is independent of enzyme concentration. The addition of cyclophilin resulted in an increase in the ACE-independent rate constant, an effect that was reversed by the cyclophilin inhibitor cyclosporin A. These results suggest that the enzyme-independent rate constant represents the rate of cis-trans isomerization and that the enzyme-dependent rate constant represents the hydrolysis of the trans isomer.(ABSTRACT TRUNCATED AT 250 WORDS)

A protein from the marine mollusc Aplysia californica that is hemolytic and stimulates arachidonic acid metabolism in cultured mammalian cells.

Aqueous extracts of the foot muscle of the marine mollusc Aplysia californica contain a proteins(s) that stimulates cytolysis and prostaglandin production in the C-9 rat liver cell line and hemolysis of red blood cells. Partial purification of the protein by ion exchange chromatography and fast protein liquid chromatography resulted in parallel increases in specific activity for prostaglandin production and hemolysis. Prostaglandin release occurred both at cytolytic concentrations of the protein and at lower concentrations that caused no apparent alterations in cell morphology. Differential sensitivity of a variety of cell lines to stimulation of prostaglandin production was observed; one group of cells, including the C-9 rat liver cell line, displayed a 5-fold stimulation of arachidonic acid metabolism with 1-3 micrograms of a partially purified protein preparation, while a second group was insensitive to concentrations as high as 20 micrograms protein of that preparation. Red blood cells also displayed differential sensitivity to hemolysis: rhesus and squirrel monkey red blood cells were 100-fold more sensitive to lysis by the protein than cebus monkey erythrocytes. Both activities were abolished by treatment with pepsin, trypsin or heat and both had a molecular weight of congruent to 45,000, as determined by gel filtration. Stimulation of both prostaglandin synthesis and hemolysis was Ca2+ dependent. These observations suggest, but do not prove, that the protein that causes lysis of red blood cells and the protein that stimulates arachidonic acid metabolism in the C-9 cell line is the same.

Psychiatric emergency evaluation.

This article is designed to assist the psychiatric clinical nurse specialist in the Emergency Department by defining psychiatric emergency; reviewing crisis intervention theory; exploring various nursing roles in the ED: delineating the assessment process; and outlining a decision-making process for determining client follow-up.

Uptake and nature of the intracellular binding of cyclosporin A in a murine thymoma cell line, BW5147.

In a survey of malignant cell lines including a variety of leukemias and lymphomas, BW5147, a T lymphoma from the spontaneous virus-associated thymoma in AKR mice, was found to be the most sensitive to growth inhibition by cyclosporin A (Cs A). Inhibition of growth was cell cycle phase-independent and inhibition of macromolecular precursor uptake was relatively nonspecific. Uptake of radiolabeled Cs A by these cells was characterized by two components: one that appeared saturable at low drug concentrations (0.03 to 1.0 microgram/ml), and another that was nonsaturable at higher drug concentrations (1.0 microgram/ml or higher). Most of the drug concentrated by cells (70 to 80%) was located in the cytosol (100,000 X G supernatant of lysed cells). The apparent m.w. of the drug-macromolecule complex was 15,000 to 20,000 as determined by m.w. exclusion columns. This complex could also be formed by adding drug to cytosol prepared from unexposed cells. The low m.w. complex migrated on a preparative isoelectric focusing column to form two peaks with isoelectric points of 6.8 and 8.5. A method was developed to assay for the binding component, and a sequence of m.w. exclusion columns and isoelectric focusing was used to effect partial purification of the Cs A binding component.

Endotoxin-induced exposure of pulmonary glycoproteins in an intact animal.

A method has been developed to radioiodinate luminally disposed endothelial proteins in an in situ perfused lung system without causing obvious vascular changes. The spectrum of endothelial cell proteins labeled in control animals and those treated with endotoxin for 45 min were compared. No changes in gross tissue morphology or in the distribution of radiolabel (125I-s-SHPP) were detected in control or treated lungs. Lectin affinity purification was applied to a lung membrane fraction to isolate labeled proteins, which were in turn resolved by gel electrophoresis and autoradiography. Comparisons of gel autoradiographs from control and treated lungs identified eight glycoproteins, the labeling of which was enhanced in endotoxin-treated animals. A similar lectin affinity analysis of radiolabeled effluent blood cells from the lungs identified only two proteins, neither of which were consistently changed by endotoxin pretreatment. A glycoprotein response can, therefore, be measured at the pulmonary endothelial surface on endotoxin administration to the whole animal without causing obvious lung injury.