Variation in missed doses and reasons for discontinuation of anti-tuberculosis drugs during hospital treatment for drug-resistant tuberculosis in South Africa.

BACKGROUND: Updated World Health Organization (WHO) treatment guidelines prioritize all-oral drug-resistant tuberculosis (DR-TB) regimens. Several poorly tolerated drugs, such as amikacin and para-aminosalicylic acid (PAS), remain treatment options for DR-TB in WHO-recommended longer regimens as Group C drugs. Incomplete treatment with anti-TB drugs increases the risk of treatment failure, relapse, and death. We determined whether missed doses of individual anti-TB drugs, and reasons for their discontinuation, varied in closely monitored hospital settings prior to the 2020 WHO DR-TB treatment guideline updates. METHODS: We collected retrospective data on adult patients with microbiologically confirmed DR-TB between 2008 and 2015 who were selected for a study of acquired drug resistance in the Western Cape Province of South Africa. Medical records through mid-2017 were reviewed. Patients received directly observed treatment during hospitalization at specialized DR-TB hospitals. Incomplete treatment with individual anti-TB drugs, defined as the failure to take medication as prescribed, regardless of reason, was determined by comparing percent missed doses, stratified by HIV status and DR-TB regimen. We applied a generalized mixed effects model. RESULTS: Among 242 patients, 131 (54%) were male, 97 (40%) were living with HIV, 175 (72%) received second-line treatment prior to first hospitalization, and 191 (79%) died during the study period. At initial hospitalization, 134 (55%) patients had Mycobacterium tuberculosis with resistance to rifampicin and isoniazid (multidrug-resistant TB [MDR-TB]) without resistance to ofloxacin or amikacin, and 102 (42%) had resistance to ofloxacin and/or amikacin. Most patients (129 [53%]) had multiple hospitalizations and DST changes occurred in 146 (60%) by the end of their last hospital discharge. Incomplete treatment was significantly higher for amikacin (18%), capreomycin (18%), PAS (17%) and kanamycin (16%) than other DR-TB drugs (P<0.001), including ethionamide (8%), moxifloxacin (7%), terizidone (7%), ethambutol (7%), and pyrazinamide (6%). Among the most frequently prescribed drugs, second-line injectables had the highest rates of discontinuation for adverse events (range 0.56-1.02 events per year follow-up), while amikacin, PAS and ethionamide had the highest rates of discontinuation for patient refusal (range 0.51-0.68 events per year follow-up). Missed doses did not differ according to HIV status or anti-TB drug combinations. CONCLUSION: We found that incomplete treatment for second-line injectables and PAS during hospitalization was higher than for other anti-TB drugs. To maximize treatment success, interventions to improve person-centered care and mitigate adverse events may be necessary in cases when PAS or amikacin (2020 WHO recommended Group C drugs) are needed.

Bedaquilina para pacientes com tuberculose resistentes à rifampicina, multirresistentes e extensivamente resistentes a medicamentos / Bedaquiline for tuberculosis-resistant patients rifampicin, multi-resistant and extensively resistant to medicines

INTRODUÇÃO: A tuberculose (TB), conhecida anteriormente como tísica, é uma doença que pode ser causada por sete espécies do gênero do complexo Mycobacterium sendo a mais importante, do ponto de vista de saúde pública, a M. tuberculosis. Globalmente cerca de 10 milhões de pessoas tiveram TB no ano de 2018. No Brasil, em 2018, foram diagnosticados 72.788 casos novos de TB o que representa uma incidência de 34,8 casos por 100 mil habitantes. A TB pode ser classificada como pulmonar e extrapulmonar, sendo a primeira forma mais prevalente. Além disso, a TB pode ser classificada conforme a resistência à medicamentos, tais como: RR-TB, MDR-TB e XDR-TB. PERGUNTA DE PESQUISA: A bedaquilina (BDQ) associada ao tratamento padrão para pacientes adultos com RR-TB, MDR-TB ou XDR-TB, é mais eficaz, efetiva e segura comparado ao tratamento padrão utilizado pelo SUS (levofloxacino, moxifloxacino, amicacina, capreomicina, etionamida, terizidona, linezolida, clofazimina, pirazinamida, etambutol, isoniazida, rifampicina e paraminossalicílico) ou placebo? TECNOLOGIA: Bedaquilina (Sirturo®). EVIDÊNCIAS CIENTÍFICAS: A revisão sistematizada recuperou nove estudos (uma revisão sistemática [RS] com meta-análise em rede [network meta-analysis - NMA], um ensaio clínico randomizado [ECR] com dois relatos e sete estudos de coorte [seis retrospectivas e uma prospectiva]). A RS, com NMA, avaliou a BDQ em comparação aos medicamentos delamanida, metronidazol, moxifloxacino e levofloxacino. A RS avaliou os desfechos conversão de cultura do escarro e aceitabilidade, e não foram verificados resultados estatisticamente significantes. Os estudos de coorte avaliaram a BDQ em comparação aos mais diversos tratamentos disponíveis para RR-TB, MDR-TB e XDR-TB. As coortes avaliaram os seguintes desfechos: sobrevida sucesso no tratamento, tratamento completo, cura, conversão da cultura do escarro e mortalidade. Os resultados não foram estatisticamente significantes na meta-análise de modelo de efeitos randomizados para todos os desfechos avaliados, porém os resultados dos efeitos fixos demostraram resultados estatisticamente significantes favorecendo o tratamento com BDQ em comparação ao tratamento sem BDQ. Vale salientar que foram realizadas análises de subgrupos com o ECR, TMC207, que avaliou eficácia e segurança da BDQ associado ao tratamento padrão em comparação ao grupo placebo associado ao tratamento padrão em até 120 semanas para os desfechos de conversão da cultura do escarro, cura e segurança (mortalidade), porém não mudaram a direção dos resultados nas duas modelagem da meta-análise. AVALIAÇÃO ECONÔMICA (AE): Os tratamentos com BDQ comparado aos tratamentos do SUS mostraram-se dominados na avaliação de custo-efetividade, para o desfecho paciente curado. Assim, os tratamentos do SUS para RR-TB, MDR-TB e XDR-TB dominaram todos os tratamentos com BDQ, ou seja, todos os tratamentos com BDQ foram menos efetivos e mais caros que os tratamentos do SUS para obter a cura dos indivíduos com RR-TB, MDR-TB e XDR-TB. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO (AIO): A AIO, para os pacientes com RR-TB, variou entre um custo incremental R$ 936 mil no caso base a uma economia de -R$ 1 milhão ao final do quinto ano no cenário alternativo; para MDR-TB variou entre uma economia de -R$44 mil no caso base a um gasto de R$ 110 mil ao final do quinto ano no cenário alternativo; e para XDR-TB variou entre um custo incremental de R$ 188 mil no caso base a R$ 4 mil no cenário alternativo ao final do quinto ano. MONITORAMENTO DO HORIZONTE TECNOLÓGICO (MHT): Cinco medicamentos foram detectados no MHT para pacientes com MDR-TB e XDR-TB (canamicina, cicloserina, sutezolida, pretomanide e protionamida). CONSIDERAÇÕES FINAIS: Há resultados conflitantes nas evidências encontradas no relatório. O ECR, analisado como de alto risco de viés (Risk of Bias 2.0) mostrou que a BDQ associada ao tratamento padrão é eficaz em comparação ao grupo de tratamento placebo associado ao tratamento padrão, porém com maior número de mortes e episódios de náusea em comparação ao grupo de tratamento sem a BDQ. Os resultados da RS, com NMA, de qualidade moderada, não demonstraram diferenças estatisticamente significantes entre as tecnologias avaliadas. Os resultados das meta-análises dos estudos de coorte de baixa qualidade metodológica (Newcastle-Ottawa Scale), em combinação com o ECR da BDQ, foram demonstrados em efeitos fixos e randomizados. Os desfechos sucesso no tratamento, tratamento completo, cura, conversão da cultura do escarro e mortalidade não foram estatisticamente significantes no modelo de efeito randomizados na meta-análise. No entanto, foram estatisticamente significantes no modelo de efeito fixos da metaanálise, e favoreceram o tratamento com BDQ em comparação aos pacientes não tratados sem BDQ. A AE demonstrou que os tratamentos com BDQ foram dominados em relação aos tratamentos disponibilizados no SUS sem BDQ, para o desfecho paciente tratado, sendo, portanto, mais custosos e menos efetivos. A AIO, para pacientes com RR-TB, variou entre R$ 936 mil no caso base a uma economia de -R$ 1 milhão no cenário alternativo ao final do quinto ano, para MDRTB variou entre uma economia de -R$44 mil no caso base a um custo de R$ 110 mil ao final do quinto ano no cenário alternativo e para XDR-TB variou entre um custo adicional de R$ 188 mil no caso base a um custo adicional de R$ 4 mil ao final do quinto ano no cenário alternativo. RECOMENDAÇÃO PRELIMINAR DA CONITEC: A Conitec, em sua 87ª reunião ordinária, realizada nos dias 03 e 04 de junho de 2020, deliberou que a matéria fosse disponibilizada em consulta pública com recomendação preliminar favorável à incorporação no SUS da bedaquilina para pacientes com tuberculose resistente à rifampicina (RR-TB), a tuberculose multirresistente (MDR-TB) e para tuberculose extensivamente resistente a medicamentos (XDR-TB), condicionada ao monitoramento e apresentação dos dados de vida real, efetividade e segurança, da utilização da bedaquilina pela população brasileira e conforme critérios estabelecidos em protocolo do Ministério da Saúde. CONSULTA PÚBLICA: A Consulta Pública nº 24/2020 foi realizada entre os dias 22/06/2020 a 13/07/2020. Foram recebidas 66 contribuições no total, das quais 19 (29%) foram pelo formulário para contribuições técnico-científicas e 47 (71%) pelo formulário para contribuições sobre experiência ou opinião de pacientes, familiares, amigos ou cuidadores de pacientes, profissionais de saúde ou pessoas interessadas no tema. Das 19 contribuições de cunho técnico-científico, 95% submeteram a contribuição com opinião concordando totalmente com a recomendação preliminar da comissão. Apenas uma contribuição discordou da recomendação preliminar da Conitec, mas foi uma contribuição equivocada e se tratava de outro tema de consulta pública, portanto, foi excluída da análise. Das 47 contribuições recebidas sobre experiência ou opinião, apenas 15 foram analisadas, pois 32 estavam em branco, se tratavam de outro tema ou foram preenchidas inadequadamente. As 15 contribuições remanescentes concordaram 100% com a decisão preliminar da comissão. Após a apreciação das contribuições encaminhadas na consulta pública nº 24/2020, o plenário da Conitec considerou que: I) Foi apresentado um novo preço de USD 340 da bedaquilina pela Johnson & Johnson, sendo proposto um desconto de 15% no preço utilizado no relatório de recomendação preliminar (USD 400); II) Foram enviadas novas estimativas de incidência para pacientes com tuberculose multirresistente, bem como evidência de possíveis limitações na análise de impacto orçamentário; III) A nova análise de impacto orçamentário, utilizando os novos parâmetros enviados na consulta pública, aponta para economia de recursos na população com tuberculose multirresistente e um custo incremental com tuberculose resistente à rifampicina e tuberculose extensivamente resistente no cenário sem taxa de difusão gradual da bedaquilina (100% no primeiro ano de incorporação). No entanto, ao adotarmos o cenário com taxa difusão gradual da bedaquilina, 30% no primeiro ano de incorporação a 70% no quinto ano, os resultados mudam e proporcionam economia de recursos para pacientes com tuberculose resistente à rifampicina e um custo incremental para pacientes com tuberculose multirresistente e tuberculose extensivamente resistente. RECOMENDAÇÃO FINAL DA CONITEC: Os membros da Conitec presentes na 89ª reunião ordinária, no dia 05 de agosto de 2020, deliberaram por unanimidade recomendar a incorporação da bedaquilina para pacientes com tuberculose resistentes à rifampicina, multirresistentes e extensivamente resistente a medicamentos, condicionado a apresentação de dados de vida real e conforme preconizado pelo Ministério da Saúde. Foi assinado o Registro de Deliberação nº 538/2020. DECISÃO: Incorporar a bedaquilina para pacientes com tuberculose resistentes à rifampicina, multirresistentes e extensivamente resistente a medicamentos, condicionado a apresentação de dados de vida real e conforme preconizado pelo Ministério da Saúde, no âmbito do Sistema Único de Saúde - SUS, conforme Portaria nº 36, publicada no Diário Oficial da União nº 168, seção 1, página 77, em 01 de setembro de 2020.

No Benefit of Concomitant 5-Aminosalicylates in Patients With Ulcerative Colitis Escalated to Biologic Therapy: Pooled Analysis of Individual Participant Data From Clinical Trials.

OBJECTIVES: 5-aminosalicylates (5-ASA) are frequently continued in patients with moderate-severe ulcerative colitis (UC), even after escalation to biologic agents, without evaluation of the benefit of this approach. We conducted an individual participant data (IPD) pooled analysis of trials of infliximab and golimumab in UC, to evaluate whether concomitant use of 5-ASA modifies clinical outcomes among anti-tumor necrosis factor (TNF)-α-treated patients. METHODS: We included IPD from five trials of infliximab and golimumab in patients with moderate-severe UC (ACT-1 and -2, PURSUIT-SC, PURSUIT-M, NCT00336492). Patients treated with infliximab or golimumab were categorized as receiving concomitant 5-ASA or not at time of trial entry. Primary outcome was clinical remission (Mayo Clinic Score < 3) at last follow-up for each trial; secondary outcomes were clinical response and mucosal healing. Using multivariable logistic regression analysis, we evaluated association between concomitant 5-ASA and clinical remission, after adjusting for sex, smoking, baseline disease activity, disease extent, biochemical variables (C-reactive protein, albumin, hemoglobin), and concomitant prednisone and immunomodulators. RESULTS: We included 2183 infliximab-treated or golimumab-treated patients (1715 [78.6%] on 5-ASA). Concomitant use of 5-ASA was not associated with odds of achieving clinical remission (adjusted OR, 0.67 [95% CI, 0.45-1.01], p = 0.06), clinical response (aOR, 0.89 [0.60-1.33], p = 0.58) or mucosal healing (aOR, 1.12 [0.82-1.51], p = 0.48). These results were consistent in trials of induction and maintenance therapy, and in trials of infliximab and golimumab. CONCLUSIONS: Based on IPD pooled analysis, in patients with moderate-severe UC who are escalated to anti-TNF therapy, continuing 5-ASA does not improve clinical outcomes.

Efficacy and safety of Kangfuxin liquid combined with aminosalicylic acid for the treatment of ulcerative colitis: A systematic review and meta-analysis.

BACKGROUND: To systematically evaluate the clinical efficacy and safety of Kangfuxin liquid (KFXL) combined with aminosalicylic acid (ASA) in treating ulcerative colitis (UC). METHODS: The PubMed, Cochrane Library, Embase, CBM, Wan fang, the Chinese Scientific Journal Database (VIP), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched for randomized controlled trials of KFXL combined with ASA for UC from the inception dates to March 3, 2017. Two researchers independently screened the literature, extracted data, and evaluated the methodological quality according to the inclusion criteria. The meta-analysis was performed using Review Manager software (RevMan, Version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014), and the risk of bias was assessed using the Cochrane Collaboration Tool. RESULTS: A total of 39 randomized controlled trials (RCTs) involving 3204 patients fulfilled the inclusion criteria. Compared with ASA alone, KFXL combined with ASA significantly improved the clinical effectiveness rate [RR = 1.19, 95% CI: (1.16, 1.23), P < .00001], reduced the relapse rate [RR = 0.26, 95% CI: (0.18, 0.38), P < .00001], reduced the inflammation factor levels of TNF-a, IL-1, IL-6, IL-8, and C-reactive protein, reduced the coagulation index of fibrinogen, increased the coagulation index of prothrombin time, and mean platelet volume, and reduced the clinical symptoms of abdominal pain, diarrhoea, pus and bloody stool, and tenesmus. However, KFXL combined with ASA did not increase the adverse event incidence [RR = 0.74, 95% CI (0.42, 1.32), P = .31], and no severe adverse events were reported. CONCLUSION: KFXL combined with ASA has good therapeutic effect for UC and might be a safe approach in managing UC. More high-quality, multicenter randomized, double-blind trials with a large sample size are required to generate a high level of clinical evidence.

Resistance to first- and second-line antituberculosis drugs in Southern Taiwan: Implications for empirical treatment.

BACKGROUND: Multidrug-resistant and extensively drug-resistant tuberculosis infections cause public health concerns worldwide. Local epidemiologic data about the drug resistance of Mycobacterium tuberculosis isolate (Mtb) is critical to guide appropriate empirical therapy to cure patients and restrain the spread of tuberculosis. METHODS: Antituberculosis susceptibility testing was performed for 287 Mtbs, including 63 MDR-Mtbs collected in southern Taiwan from 2011 to 2015. Tuberculosis patients were classified into newly diagnosed cases and previously treated cases based on patients' medical history. RESULTS: Almost no resistance was found to the tested second-line antituberculosis drugs in non-MDR-Mtbs. Higher resistance rates to ethambutol, ofloxacin, and streptomycin were observed in MDR-Mtbs compared to non-MDR-Mtbs. Among 63 MDR-Mtbs, 61.9% of patients were newly diagnosed and 38.1% were previously treated cases. For MDR-Mtb, the drug-resistance rates in previously treated cases were significantly higher for ethambutol, pyrazinamide, ofloxacin, moxifloxacin, streptomycin, and p-aminosalicylic acid. When MDR-Mtbs are identified in previously treated cases, empirical administration of ethambutol, pyrazinamide, ofloxacin, or moxifloxacin may not provide effective treatment. The resistance rates to these drugs were all more than 50%. Furthermore, 25% of MDR-Mtbs from previously treated patients were resistant to p-aminosalicylic acid. CONCLUSION: We observed almost no resistance to the tested second-line antituberculosis drugs among non-MDR-Mtbs. Anti-tuberculosis regimen with pyrazinamide, ethambutol, fluoroquinolone, kanamycin, cycloserine and p-aminosalicylic acid can be empirically used for newly diagnosed MDR-TB cases. For previously treated MDR-TB patients, empirical ethambutol, pyrazinamide, ofloxacin, or moxifloxacin may not provide effective treatment because the resistance rates to these drugs were all >50%.

Synthesis and Evaluation of a Sodium Alginate-4-Aminosalicylic Acid Based Microporous Hydrogel for Potential Viscosupplementation for Joint Injuries and Arthritis-Induced Conditions.

A microporous hydrogel was developed using sodium alginate (alg) and 4-aminosalicylic acid (4-ASA). The synthesized hydrogel was characterized using various analytical techniques such as Fourier transform infrared spectroscopy (FTIR), Carbon-13 nuclear magnetic resonance (13C-NMR), X-ray powder diffraction (XRD), scanning electron microscopy (SEM), and differential scanning calorimetry (DSC). Additonal carboxyl and hydroxyl functional groups of 4-ASA provided significant lubrication and stress-triggered sol-gel transition to the conjugated hydrogel. In addition, cytotoxicity analysis was undertaken on the conjugated hydrogel using human dermal fibroblast-adult (HDFa) cells, displaying non-toxic characteristics. Drug release profiles displaying 49.6% in the first 8 h and 97.5% within 72 h, similar to the native polymer (42.8% in first 8 h and 90.1% within 72 h). Under applied external stimuli, the modified hydrogel displayed significant gelling properties and structure deformation/recovery behaviour, confirmed using rheological evaluation (viscosity and thixotropic area of 8095.3 mPas and 26.23%, respectively). The modified hydrogel, thus, offers great possibility for designing smart synovial fluids as a biomimetic aqueous lubricant for joint-related injuries and arthritis-induced conditions. In addtion, the combination of thixotropy, non-toxicity, and drug release capabilities enables potential viscosupplementation for clinical application.

Interactions of linezolid and second-line anti-tuberculosis agents against multidrug-resistant Mycobacterium tuberculosis in vitro and in vivo.

OBJECTIVES: The objectives of this study were to evaluate the interactions between linezolid (LZD) and second-line anti-tuberculosis (TB) agents in susceptible and multidrug-resistant (MDR) TB in vitro, and to validate the in vitro results in a murine TB model. METHODS: The minimum inhibitory concentrations of LZD and seven second-line anti-TB drugs against H37Rv and three multidrug-resistant clinical isolates were determined by Alamar Blue assay, and the interaction patterns of LZD and the seven second-line anti-TB agents against the four isolates were studied using a dynamic checkerboard method. The activities of these combinations against Mycobacterium tuberculosis were evaluated in a murine model of TB. RESULTS: The combination of LZD + capreomycin exhibited partial synergism for three of four isolates, LZD + para-aminosalicylic acid exhibited partial synergism for two of four isolates, and LZD + levofloxacin and LZD + amikacin exhibited partial synergism for one of four isolates; all other combinations showed indifference or an additive effect in vitro. The activities of six combinations and the standard regimen rifampicin + isoniazid + pyrazinamide were investigated in a murine model of TB (infection with H37Rv). Significant reductions in colony-forming units (CFU) were found in LZD + capreomycin and LZD + clofazimine groups when the CFU in the lungs on day 0 (the day of beginning treatment) was compared with the CFU in the lungs after 2 months of treatment. CONCLUSIONS: These combinations of LZD and second-line anti-TB drugs were all active against MDR-TB with indifference or an additive effect, except LZD + capreomycin, which showed partial synergy.

Therapies for crohn's disease: a clinical update / Terapia farmacológica em portadores de doença de Crohn. Atualização clínica

ABSTRACT The main objectives of clinical therapy in Crohn's disease are clinical and endoscopic remission without the use of corticosteroids for long periods of time, prevention of hospitalization and surgery, and improvement of quality of life. The main limitation of drug therapy is the loss of response over the long term, which makes incorporation of new drugs to the therapeutic arsenal necessary. This review analyses the main drugs currently used in clinical treatment of Crohn's disease.

RESUMO Os principais objetivos da terapia clínica na doença de Crohn são a remissão clínica e endoscópica por tempo prolongado, sem o uso de corticosteroides, além de evitar hospitalizações e cirurgias, e melhorar a qualidade de vida. A principal limitação da terapêutica medicamentosa é a perda de reposta a longo prazo, o que faz com que a incorporação de novas drogas ao arsenal terapêutico seja necessária. Esta revisão aborda os principais medicamentos utilizados atualmente no tratamento clínico da doença de Crohn.

THERAPIES FOR CROHN'S DISEASE: a clinical update.

The main objectives of clinical therapy in Crohn's disease are clinical and endoscopic remission without the use of corticosteroids for long periods of time, prevention of hospitalization and surgery, and improvement of quality of life. The main limitation of drug therapy is the loss of response over the long term, which makes incorporation of new drugs to the therapeutic arsenal necessary. This review analyses the main drugs currently used in clinical treatment of Crohn's disease.

Long-term therapeutic effectiveness of maintenance enteral nutrition for Crohn's disease.

BACKGROUND: Long-term effectiveness of enteral nutrition for maintaining remission in pediatric Crohn's disease (CD) is poorly documented. The aim of this study was therefore to examine the long-term effectiveness of enteral nutrition with aminosalicylates as maintenance therapy for those in whom remission was primarily induced by total parenteral nutrition or exclusive enteral nutrition with aminosalicylates. METHODS: We retrospectively analyzed data for 58 pediatric patients with newly diagnosed CD during a median follow-up period of 50 months (range, 12-216 months). Data for remission-induced patients in whom enteral nutrition with aminosalicylates was used as maintenance therapy were analyzed with particular reference to time to first relapse and time to first intestinal surgery. RESULTS: Twenty-five (43.1%) of the patients relapsed with a median duration of remission of 32.4 months (range, 6-73.2 months). The cumulative rates of continuous remission were 0.88 (95%CI: 0.79-0.96) at 1 year, 0.73 (95%CI: 0.61-0.85) at 2 years, and 0.52 (95%CI: 0.35-0.68) at 5 years. None of the patients received corticosteroids, immunomodulators or anti-tumor necrosis factor agents until relapse. Disease location had no impact on timing of relapse, but with regard to disease behavior there was a trend towards earlier relapse in patients with penetrating type. Only six of the 58 patients (10.3%) needed intestinal surgery. There was a trend towards need for surgery in patients with ileal disease and with stricturing type. CONCLUSIONS: Enteral nutrition therapy with aminosalicylates is effective for maintaining remission and decreasing the rate of intestinal surgery in pediatric CD.

Protective effects of sodium p-aminosalicylic acid on learning and memory via increasing the number of basal forebrain choline acetyltransferase neurons in manganese-exposed rats.

This study was conducted to investigate the protective effects of sodium p-aminosalicylic acid (PAS-Na) on learning and memory via increasing the number of basal forebrain choline acetyltransferase (ChAT) neurons in manganese (Mn)-exposed rats. Male Sprague Dawley rats were divided into following groups: the normal control I, II, and III groups, the model I, II, and III groups, low- and high-dose PAS-Na treatment (L- and H-PAS) group, PAS-Na prevention (PAS-P) group, and PAS-Na treatment (PAS-T) group. The model I, II, and III groups, L- and H-PAS, and PAS-T groups received intraperitoneal (i.p.) injection of 15 mg/kg manganese chloride tetrahydrate (MnCl2·4H2O) for 3 or 12 weeks, while the normal control I, II, and III groups received i.p. injection of an equal volume of saline; L- and H-PAS and PAS-T groups received back subcutaneous (s.c.) injection of PAS-Na (100 and 200 mg/kg) for the next 5 or 6 weeks, whereas model I and II group received back s.c. injection of an equal volume of saline. However, PAS-P group received back s.c. injection of 200 mg/kg PAS-Na + i.p. injection of 15 mg/kg MnCl2·4H2O for 12 weeks. Mn exposure significantly reduced the ability of spatial learning and memory capability, while PAS-Na prevention recovered it. Mn decreased the number of ChAT-positive neurons in vertical limb nucleus of the basal forebrain diagonal band/horizontal limb nucleus of the basal forebrain diagonal band and ChAT protein activity and treatment or prevention with PAS-Na restored those comparable with control. In brief, our results showed that PAS-Na may have protective effects on learning and memory against Mn via increasing the number of ChAT-positive neurons and activity of ChAT protein.

Pharmacokinetics of para-aminosalicylic acid in HIV-uninfected and HIV-coinfected tuberculosis patients receiving antiretroviral therapy, managed for multidrug-resistant and extensively drug-resistant tuberculosis.

The emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Mycobacterium tuberculosis prompted the reintroduction of para-aminosalicylic acid (PAS) to protect companion anti-tuberculosis drugs from additional acquired resistance. In sub-Saharan Africa, MDR/XDR tuberculosis with HIV coinfection is common, and concurrent treatment of HIV infection and MDR/XDR tuberculosis is required. Out of necessity, patients receive multiple drugs, and PAS therapy is frequent; however, neither potential drug interactions nor the effects of HIV infection are known. Potential drug-drug interaction with PAS and the effect of HIV infection was examined in 73 pulmonary tuberculosis patients; 22 (30.1%) were HIV coinfected. Forty-one pulmonary MDR or XDR tuberculosis patients received 4 g PAS twice daily, and in a second crossover study, another 32 patients were randomized, receiving 4 g PAS twice daily or 8 g PAS once daily. A PAS population pharmacokinetic model in two dosing regimens was developed; potential covariates affecting its pharmacokinetics were examined, and Monte Carlo simulations were conducted evaluating the pharmacokinetic-pharmacodynamic index. The probability of target attainment (PTA) to maintain PAS levels above MIC during the dosing interval was estimated by simulation of once-, twice-, and thrice-daily dosing regimens not exceeding 12 g daily. Concurrent efavirenz (EFV) medication resulted in a 52% increase in PAS clearance and a corresponding >30% reduction in mean PAS area under the concentration curve in 19 of 22 HIV-M. tuberculosis-coinfected patients. Current practice recommends maintenance of PAS concentrations at ≥1 µg/ml (the MIC of M. tuberculosis), but the model predicts that at only a minimum dose of 4 g twice daily can this PTA be achieved in at least 90% of the population, whether or not EFV is concomitantly administered. Once-daily dosing of 12 g PAS will not provide PAS concentrations exceeding the MIC over the entire dosing interval if coadministered with EFV, while 4 g twice daily ensures concentrations exceeding MIC over the entire dosing interval, even in HIV-infected patients who received EFV.

[Evaluation of the influence of tianeptine on the psychosomatic status of patients with ulcerative colitis in remission]. / Ocena wplywu tianeptyny na stan psychosomatyczny.

UNLABELLED: In order to maintain ulcerative colitis (UC) in remission, chronic use of aminosalicylates is recommended. All patients have a fear of the recurrence of symptoms, which makes their mental state and quality of life worse. Because of this a number of patients are recommended to use different sorts of anxiolytic drugs and antidepressants. AIM OF THE STUDY: Evaluation of the influence of tianeptine (selective serotonin reuptake enhancer) on the mental and somatic status in the group of patients. MATERIAL AND METHOD: The research was conducted in two groups of thirty patients, with benign form of ulcerative colitis in remission, aged 24-46 years. Patients, during a period of 12 months, were given aminosalicylates in a daily doses 2 x 1.0 g and tianeptine in a doses 3 x 12.5 mg (group I) or placebo (group II). During the treatment every three months anxiety (Hamilton Anxiety Rating Scale-HARS), depression (Back Depression Inventory-BDI), The Mayo Clinic Disease Activity Index (MCDAI), hemoglobin and C-reactive protein (CRP) level were evaluated. RESULTS: After 12 months in a group of patients who took tianeptine decrease in anxiety (from 20.35 +/- 4.03 to 12.65 +/- 3.78 points) and depression (from 19.95 +/- 4.49 points to 9.60 +/- 2.76 points) was obtained; difference compared with placebo was statistically significant (p < 0.01). At the same time significant decrease compared with placebo (p < 0.05) of disease activity index (respectively 3.05 +/- 1.36 and 4.65 +/- 1.69), insignificantly lower level of CRP (7.00 5.65 and 9.41 +/- 10.12) and higher level of hemoglobin (11.93 +/- 0.83 and 11.0 +/- 0.70) was observed. CONCLUSIONS: Tianeptine has a positive influence on mental and somatic status of patients with UC. Results give the support for tianeptine apllication in UC as adjuvant drug.

Extensively drug-resistant tuberculosis: New Zealand's first case and the challenges of management in a low-prevalence country.

In 2010, an immigrant from Burma was the first person to be diagnosed in New Zealand with extensively drug-resistant tuberculosis (XDR-TB). The strain of Mycobacterium tuberculosis is the most resistant reported to date in Australasia. Key difficulties of managing this disease in a low-prevalence country were delays from drug-susceptibility testing and in acquiring appropriate medicines, and a lack of evidence-based guidelines. Solutions are needed for New Zealand and the wider region as more cases of XDR-TB are likely to be encountered in the future.

Extensively drug resistance (XDR) tb is not always fatal.

The chance of incidence of XDR TB is on the rise due to improper use of second line anti-tubercular drugs. XDR-TB is very difficult to treat successfully and is often referred to as "virtually untreatable form of TB". We herein report a case of XDR TB confirmed by bacteriological examination in a WHO recognised laboratory who after 12 months of regular treatment improved both clinically and radiologically with sputum smear conversion. To the best of our knowledge, there has been no previous report of any similar case in literature.

Chelation therapy of manganese intoxication with para-aminosalicylic acid (PAS) in Sprague-Dawley rats.

Para-aminosalicylic acid (PAS), an FDA-approved anti-tuberculosis drug, has been used successfully in the treatment of severe manganese (Mn)-induced Parkinsonism in humans [Jiang Y-M, Mo X-A, Du FQ, Fu X, Zhu X-Y, Gao H-Y, et al. Effective treatment of manganese-induced occupational Parkinsonism with p-aminosalicylic acid: a case of 17-year follow-up study. J Occup Environ Med 2006;48:644-9]. This study was conducted to explore the capability of PAS in reducing Mn concentrations in body fluids and tissues of Mn-exposed animals. Sprague-Dawley rats received daily intraperitoneally (i.p.) injections of 6mg Mn/kg, 5 days/week for 4 weeks, followed by a daily subcutaneously (s.c.) dose of PAS (100 and 200mg/kg as the PAS-L and PAS-H group, respectively) for another 2, 3 or 6 weeks. Mn exposure significantly increased the concentrations of Mn in plasma, red blood cells (RBC), cerebrospinal fluid (CSF), brain and soft tissues. Following PAS-H treatment for 3 weeks, Mn levels in liver, heart, spleen and pancreas were significantly reduced by 25-33%, while 3 weeks of PAS-L treatment did not show any effect. Further therapy with PAS-H for 6 weeks reduced Mn levels in striatum, thalamus, choroid plexus, hippocampus and frontal cortex by 16-29% (p<0.05). Mn exposure greatly increased iron (Fe) and copper (Cu) concentrations in CSF, brain and liver. Treatment with PAS-H restored Fe and Cu levels comparable with control. These data suggest that PAS likely acts as a chelating agent to mobilize and remove tissue Mn. A high-dose and prolonged PAS treatment appears necessary for its therapeutic effectiveness.

Outcome of multi-drug resistant tuberculosis cases treated by individualized regimens at a tertiary level clinic.

AIM: To determine the clinical, radiological and drug resistance profile as well as the factors associated with treatment outcome of Multi-Drug Resistant Tuberculosis (MDR-TB). MATERIAL AND METHODS: All newly diagnosed patients with pulmonary MDR-TB from August 2002 to December 2004 enrolled at New Delhi Tuberculosis Centre, were included in the study. They were followed up clinically, radiologically and bacteriologically by sputum smear, culture and Drug Susceptibility Testing (DST) at regular intervals. According to their DST pattern and previous history of Anti-Tubercular Treatment (ATT), individualized treatment regimens were tailored for each patient. RESULTS: Out of total 27 bacteriologically proven cases of MDR-TB included in this study, 19 were males (mean age and weight 38.5 years and 52.6 kgs, respectively) and eight females (mean age and weight 34.3 years and 40.7 kgs, respectively). A majority (18) were residents of Delhi and the rest hailed from different parts of North India. All of them had a history of previous treatment ranging from six to 34 months. Cavity on chest X-rays was seen in 81%, while 44% showed extensive involvement. The patients received at least four "second line drugs" during their treatment with a mean of 6.2 anti-tubercular drugs during their intensive phase. Of the 27 patients, 13 were cured, 10 defaulted, one died, one is still on treatment and two were referred for surgery. Radiological improvement was observed in two third of cases and chest X-ray of two patients showed a complete resolution. Six predictors were identified for successful outcome of MDR-TB. They include weight gain at six months, culture conversion, radiological improvement during treatment, disease with M. tuberculosis strains exhibiting resistance to less than or up to three anti-tubercular drugs, use of less than or up to three second line drugs in treatment and no change of regimen during treatment. CONCLUSION: Default from treatment was observed to be a major challenge in the treatment of MDR-TB due to long duration and expense of ATT.

Selective chemical probe inhibitor of Stat3, identified through structure-based virtual screening, induces antitumor activity.

S3I-201 (NSC 74859) is a chemical probe inhibitor of Stat3 activity, which was identified from the National Cancer Institute chemical libraries by using structure-based virtual screening with a computer model of the Stat3 SH2 domain bound to its Stat3 phosphotyrosine peptide derived from the x-ray crystal structure of the Stat3beta homodimer. S3I-201 inhibits Stat3.Stat3 complex formation and Stat3 DNA-binding and transcriptional activities. Furthermore, S3I-201 inhibits growth and induces apoptosis preferentially in tumor cells that contain persistently activated Stat3. Constitutively dimerized and active Stat3C and Stat3 SH2 domain rescue tumor cells from S3I-201-induced apoptosis. Finally, S3I-201 inhibits the expression of the Stat3-regulated genes encoding cyclin D1, Bcl-xL, and survivin and inhibits the growth of human breast tumors in vivo. These findings strongly suggest that the antitumor activity of S3I-201 is mediated in part through inhibition of aberrant Stat3 activation and provide the proof-of-concept for the potential clinical use of Stat3 inhibitors such as S3I-201 in tumors harboring aberrant Stat3.

[Comparative randomized open study of the efficacy and tolerance of enemas with 2 gr of 4-amino-salicylic acid (4-ASA) and 1 gr of 5-amino-salicylic acid (5-ASA) in distal forms of hemorrhagic rectocolitis]. / Etude comparative ouverte randomisée de l'efficacité et de la tolérance de lavements de 2 g d'acide 4-amino-salicylique (4-ASA) et de 1 g d'acide 5-amino-salicylique (5-ASA) dans les formes basses de rectocolite hémorragique.

OBJECTIVES AND METHODS: The aim of this multicentre, randomized open trial was to compare the efficacy and tolerance of 4-ASA vs 5-ASA enemas in the treatment of distal moderately active ulcerative colitis. Fifty patients were randomized to receive enemas in 100 mL suspension of 4-ASA (2 g, n = 26), or 5-ASA (1 g, n = 24). The subjects filled a daily questionnaire on enema retention duration, and tolerance. Clinical and endoscopic evaluations were performed at baseline and after 2 and 4 weeks. RESULTS: Significant clinical and endoscopic improvements occurred in both groups. Efficacy and enema retention time did not differ between groups. Tolerance was significantly better for 4-ASA: score 0.46 +/- 0.77 vs 1.00 +/- 0.73, P = 0.03. CONCLUSIONS: Efficacy of both treatments was equivalent, but 4-ASA enemas were better tolerated than 5-ASA in this open trial.