Antimicrobial resistance in leprosy: results of the first prospective open survey conducted by a WHO surveillance network for the period 2009-15.

OBJECTIVES: Antimicrobial resistance (AMR) is a priority for surveillance in bacterial infections. For leprosy, AMR has not been assessed because Mycobacterium leprae does not grow in vitro. We aim to obtain AMR data using molecular detection of resistance genes and to conduct a prospective open survey of resistance to antileprosy drugs in countries where leprosy is endemic through a WHO surveillance network. METHODS: From 2009 to 2015, multi-bacillary leprosy cases at sentinel sites of 19 countries were studied for resistance to rifampicin, dapsone and ofloxacin by PCR sequencing of the drug-resistance-determining regions of the genes rpoB, folP1 and gyrA. RESULTS: Among 1932 (1143 relapse and 789 new) cases studied, 154 (8.0%) M. leprae strains were found with mutations conferring resistance showing 182 resistance traits (74 for rifampicin, 87 for dapsone and 21 for ofloxacin). Twenty cases showed rifampicin and dapsone resistance, four showed ofloxacin and dapsone resistance, but no cases were resistant to rifampicin and ofloxacin. Rifampicin resistance was observed among relapse (58/1143, 5.1%) and new (16/789, 2.0%) cases in 12 countries. India, Brazil and Colombia reported more than five rifampicin-resistant cases. CONCLUSIONS: This is the first study reporting global data on AMR in leprosy. Rifampicin resistance emerged, stressing the need for expansion of surveillance. This is also a call for vigilance on the global use of antimicrobial agents, because ofloxacin resistance probably developed in relation to the general intake of antibiotics for other infections as it is not part of the multidrug combination used to treat leprosy.

Effects of heat stress and insulin sensitizers on pig adipose tissue.

Heat stress (HS) negatively impacts several swine production variables, including carcass fat quality and quantity. Pigs reared in HS have more adipose tissue than energetically predicted, explainable, in part, by HS-induced hyperinsulinemia. Study objectives were to evaluate insulin's role in altering fat characteristics during HS via feeding insulin-sensitizing compounds. Forty crossbred barrows (113 ± 9 kg BW) were randomly assigned to one of five environment by diet treatments: 1) thermoneutral (TN) fed ad libitum (TNAL), 2) TN and pair-fed (TNPF), 3) HS fed ad libitum (HSAL), 4) HS fed ad libitum with sterculic oil (SO) supplementation (HSSO; 13 g/d), and 5) HS fed ad libitum with dietary chromium (Cr) supplementation (HSCr; 0.5 mg/d; Kemin Industries, Des Moines, IA). The study consisted of three experimental periods (P). During P0 (2 d), all pigs were exposed to TN conditions (23 ± 3 °C, 68 ± 10% RH) and fed ad libitum. During P1 (7 d), all pigs received their respective dietary supplements, were maintained in TN conditions, and fed ad libitum. During P2 (21 d), HSAL, HSSO, and HSCr pigs were fed ad libitum and exposed to cyclical HS conditions (28 to 33 °C, 58 ± 10% RH). The TNAL and TNPF pigs remained in TN conditions and were fed ad libitum or pair-fed to their HSAL counterparts. Rectal temperature (TR), respiration rate (RR), and skin temperature (TS) were obtained daily at 0600 and 1800 h. At 1800 h, HS exposed pigs had increased TR, RR, and TS relative to TNAL controls (1.13 °C, 48 bpm, and 3.51 °C, respectively; P < 0.01). During wk 2 and 3 of P2, HSSO pigs had increased 1800 h TR relative to HSAL and HSCr (~0.40 and ~0.42 °C, respectively; P ≤ 0.05). Heat stress decreased ADFI and ADG compared to TNAL pigs (2.24 vs. 3.28 and 0.63 vs. 1.09 kg/d, respectively; P < 0.01) and neither variable was affected by SO or Cr supplementation. Heat stress increased or tended to increase moisture content of abdominal (7.7 vs. 5.9%; P = 0.07) and inner s.c. (11.4 vs. 9.8%; P < 0.05) adipose depots compared to TNAL controls. Interestingly, TNPF pigs also had increased adipose tissue moisture content and this was most pronounced in the outer s.c. depot (15.0 vs. 12.2%; P < 0.01) compared to TNAL pigs. Heat stress had little or no effect on fatty acid composition of abdominal, inner, and outer s.c. adipose tissue depots. In summary, the negative effects of HS on fat quality do not appear to be fatty acid composition related, but may be explained by increased adipose tissue moisture content.

Preclinical safety evaluation of recombinant human interleukin-10.

Escherichia coli-derived recombinant human interleukin-10 (rhuIL-10) has been evaluated in an extensive series of in vivo and in vitro nonclinical safety studies, including genetic toxicology, single- and repeat-dose systemic toxicity and toxicokinetics, reproductive toxicity, and specialized irritation studies. The primary test species in the toxicology studies were the mouse and monkey based on rhuIL-10 activity in receptor binding and ex vivo cytokine assays. Supported by a detailed preclinical program of therapeutic and prophylactic animal models in autoimmune diseases, the initial clinical development program has focused on investigating the therapeutic potential of rhuIL-10 (Tenovil) in Crohn's disease and rheumatoid arthritis. The results of the subcutaneous toxicity studies, up to 3 months dosing duration in mice and 6 months dosing duration in monkeys, support the development of rhuIL-10 for present and future clinical indications by the subcutaneous route of administration.

Vitamin-mineral supplementation and accelerated chilling effects on quality of pork from pigs that are monomutant or noncarriers of the halothane gene.

We examined the effects of vitamin and mineral supplementation of the finishing diet on growth and accelerated chilling of carcasses on carcass and muscle traits of halothane gene carrier and noncarrier pigs. Barrows and gilts that were either monomutants (MON, n = 49) or noncarriers (NON, n = 28) of the halothane gene were fed a standard finishing diet until they reached 86 kg. They then were randomly assigned to one of four finishing diets formulated to contain 11 IU/kg vitamin E (0), 311 IU/kg vitamin E plus additional vitamins and minerals (300), 611 IU/kg vitamin E plus additional vitamins and minerals (600), or 911 IU/kg vitamin E plus additional vitamins and minerals (900) until they were slaughtered (118 kg). Alternating carcass sides were assigned either a normal chilling procedure (NC, 4 degrees C for 24 h) or an accelerated chilling procedure (AC, -20 degrees C for 1.5 h and then 4 degrees C for 22.5 h). Supplementing vitamin E in the finishing diet increased (P < 0.05) the concentration of vitamin E in the longissimus muscle. Supplementing vitamin E in the diets of MON pigs did not affect color, firmness, or cooking losses of loins or color and firmness of hams. For the NON genotype, increasing the level of vitamin E in the diet decreased (P < 0.05) the percentage of PSE loins and hams. Color and firmness scores of the gluteus medius and longissimus muscles were improved 0.4 unit (P < 0.005) by AC compared with NC of carcasses. Loin chop juiciness and flavor were improved (P < 0.05) in the MON genotype for AC compared to NC. Accelerated chilling reduced (P < 0.05) the percentage of PSE loins from 38 to 17% and PSE hams from 32 to 10% for the MON genotype, but percentage of PSE was not affected (P > 0.05) by chilling treatment for the NON genotype. No interaction between diet and chill treatments existed for muscle quality traits (P > 0.05). Supplementing finishing diets of NON pigs with at least 600 IU/kg vitamin E, in addition to other vitamins and minerals, or accelerated chilling of MON carcasses can reduce the incidence of PSE pork.

Sociocultural and community factors influencing the use of Native Hawaiian healers and healing practices among adolescents in Hawai'i.

Recently, there has been much emphasis placed on both alternative approaches to health care and the provision of culturally competent care. Despite these trends, few studies have examined the use of alternative therapies on the part of adolescents. Even fewer studies have been done focusing on traditional Hawaiian approaches to health care. This is essential, especially in Hawai'i, where Hawaiians have not attained health parity with other majority ethnic populations, despite significant efforts and funding to achieve this end. This study examines the sociocultural and community factors influencing the use of traditional Native Hawaiian healers and healing practices by adolescents in Hawai'i. The Hawaiian High Schools Health Survey was administered at five high schools on three islands in Hawai'i during the 1993-1994 school year. The sample included 1,321 high school students who preferred either an allopathic or alternative practitioner. Ethnicity, gender, community access, healer preference, health status, level of education, and health insurance status were used to predict healer use and participation in healing practices. Community access and healer preference predicted both healer use and participation in native healing practices. Mental health predicted healer use (i.e., seeing a Native Hawaiian healer in the past six months), but did not predict taking part in native healing practices, such as ho'oponopono and lomilomi. Hawaiian ethnicity, female gender, and a measure of health insurance predicted participation in native healing practices, but not healer use. These results suggest that native healing practices and traditional healers are being used in Native Hawaiian communities and this is perhaps not due to a lack of health insurance. Given the general separation between Western and Native Hawaiian health services, traditional healing practices should be made available in Native Hawaiian communities to see whether a collaboration between Western practitioners and traditional healers can have a greater positive impact on the health of Native Hawaiians, particularly for adolescents.

Sociocultural factors influencing adolescent preference and use of native Hawaiian healers.

OBJECTIVE: Few studies have examined the use of alternative therapies among adolescents. This study examines the predictors of Native Hawaiian healer preference in the treatment of physical or emotional problems as well as the predictors of healer use. DESIGN: This study is a longitudinal cross-sectional design. SETTING: The survey was conducted in five high schools in Hawai'i. PARTICIPANTS: 1,322 high school students selected preference for and/or use of allopathic or alternative practitioners. MAIN OUTCOME MEASURES: Grade level, gender, ethnicity and cultural identity were used to predict healer preference. Healer preference, socioeconomic status and health status were used to predict healer use. RESULTS: Identification with the Hawaiian culture was the strongest predictor of healer preference for both Hawaiian and non-Hawaiian adolescents. Mental health was also predictive of healer preference for non-Hawaiians. Healer use by Native Hawaiian adolescents was also predicted by Hawaiian cultural identity. Gender, grade level, and socioeconomic variables were not predictive of healer preference or use. CONCLUSION: Cultural identity plays a significant role in the preference and use of alternative practitioners, especially for minority adolescent populations.

Failure of treatment with cephalexin for Lyme disease.

CONTEXT: Lyme disease typically presents with a skin lesion called erythema migrans (EM), which though often distinctive in appearance may be confused with cellulitis. The first-generation cephalosporin, cephalexin monohydrate, is effective for treating bacterial cellulitis but has not been recommended or studied for treating Lyme disease because of poor in vitro activity. OBJECTIVE: To describe the outcome of patients with EM who were treated with cephalexin. PATIENTS AND METHODS: Patients presenting with EM to the Lyme Disease Diagnostic Center in Westchester, NY (May 1992-September 1997). A 2-mm punch biopsy specimen of the leading edge of the EM lesion and/or blood was cultured for Borrelia burgdorferi. RESULTS: Eleven (2.8%) of 393 study patients had been initially treated with cephalexin prior to our evaluation; 9 (82%) were originally diagnosed with cellulitis. Cephalexin was administered for 8.6 days (range, 2-21 days) prior to presentation. All 11 patients had clinical evidence of disease progression, including 8 whose rash enlarged, 2 who developed seventh-nerve palsy (1 with new EM lesions), and 1 who developed new EM lesions. Borrelia burgdorferi grew in cultures from 5 patients despite a mean of 9.8 days of treatment with cephalexin (range, 5-21 days). CONCLUSION: Cephalexin should not be used to treat early Lyme disease and should be prescribed with caution during the summer months for patients believed to have cellulitis in locations where Lyme disease is endemic.

Is an outpatient appointment required for patients referred for a minor operation under local anaesthetic?

The necessity of an outpatient (OP) consultation for patients referred for minor surgery under local anaesthetic (LA) was examined. Two separate prospective studies were performed. The first comprised 107 patients referred for minor surgery, who were assessed in the outpatient department (OPD), before being booked for minor operations. The second study comprised 106 patients whose names were placed directly on a minor operations list on the basis of the GP referral letter alone. In the first study, 97 (91 per cent) patients went on to undergo minor surgery. Five were not suitable for LA and in five an operation was considered unnecessary. Patients not suitable for LA included children, neck swellings, pre-auricular swellings and swellings described as lymph nodes. In the second study, the GP referral letters were screened to exclude the above and of 106 referrals 93 (88 per cent) underwent a minor operation. The benefit of the second study was twofold. First, 106 OP slots were available for other referrals and secondly, patients avoided the OP waiting list and did not lose time from work as a result of the OP visit. There were no adverse effects demonstrated during the second study. We believe the OP consultation can be avoided if the referral letters are carefully screened.

Structure, distribution, and functional expression of the phosphofructokinase C isozyme.

To elucidate the structure, tissue-specific expression, and allosteric properties of phosphofructokinase-C (PFK-C), we cloned the cDNA for PFK-C from a rat hypothalamic cDNA library. The cDNA is 2643 base pairs long and encodes a protein of 765 amino acids. The deduced amino acid sequence is highly homologous to PFK-M (muscle) and PFK-L (liver), 69 and 65% amino acid identity, respectively, especially at substrate binding and catalytic sites, while the allosteric binding sites are less conserved. Tissue-specific expression of PFK-C was investigated by Northern blot analysis. PFK-C mRNA was detected in several brain regions and the anterior pituitary but not in liver, skeletal muscle, or several other tissues. In situ hybridization showed that PFK-C is expressed at a higher level in higher brain regions such as the cortex, compared with the midbrain and basal ganglia, while PFK-L is expressed at approximately equal levels throughout the brain. Expression plasmids containing PFK-C and PFK-L coding sequences were constructed and expressed by transient transfection into CMT cells. Expression of transfected PFKs was demonstrated by PFK enzymatic activity and by Western blotting with anti-rat brain and liver PFK antisera. Allosteric regulatory properties of PFK-C and PFK-L expressed in CMT cells were compared. Fructose 2,6-bisphosphate, a potent activator of PFK, decreased the Km of PFK-C for fructose 6-phosphate from 200 to 60 microM while decreasing that of PFK-L from 300 to 55 microM. The properties of PFK-C and PFK-L expressed in CMT cells clearly demonstrate the allosteric differences between the different PFK isozymes.

Ceftriaxone therapy of chronic inflammatory arthritis. A double-blind placebo controlled trial.

To determine whether chronic inflammatory arthritis may respond to antibiotic therapy (implying a bacterial origin), we conducted a placebo-controlled, double-blind study. Sixty patients with inflammatory arthritis and antibody titers to Borrelia burgdorferi 1:64 or more were randomized to receive placebo (n = 20) or 2 g/d of ceftriaxone intravenously (n = 40) for 2 weeks. Two of 20 placebo- and 19 of 40 antibiotic-treated patients improved. At 1 month, the placebo-treated patients could elect to receive ceftriaxone. Altogether, 58 patients were treated with ceftriaxone and followed up for 13 to 24 months. Improvement was noted in 27 of the 58 antibiotic-treated patients. Patients with a wide diversity of inflammatory arthritis were studied. Response to ceftriaxone was seen in all groups, including 5 of 12 with rheumatoid arthritis, 5 of 8 with psoriatic arthritis, 3 of 5 with vasculitis, and 14 of 33 with less well-differentiated chronic inflammatory arthritis. In 16 of the 27 who responded to the antibiotic, the arthritis worsened 6 to 18 months after the initial response to ceftriaxone. Previous improvement of arthritis after oral antibiotic was a better predictor of response to ceftriaxone than either duration of disease or Lyme antibody titer. Side effects to ceftriaxone were frequent and included diarrhea (29/60) and acute allergic reactions (9/58). We conclude that some patients may have an occult bacterial infection underlying their chronic inflammatory arthritis, and may respond to antibiotic therapy. The response to ceftriaxone in patients with even weakly reactive Lyme titers encourages further prospective placebo-controlled studies of antibiotics in various subsets of chronic arthritis.

Subnormal concentrations of serum selenium and plasma carnitine in chronically tube-fed patients.

Forty-seven tube-fed nursing home patients were investigated with regard to serum or plasma selenium (Se), carnitine, and red blood cell (RBC) glutathione peroxidase (GSH-Px). Thirty-six patients were tube fed with Isocal, and 11 were tube fed with Compleat B, an L-carnitine-containing formula. Eighteen elderly nursing home patients and 10 young adults served as controls. Serum Se and plasma carnitine were lowest (p less than 0.05) in the Isocal patients. In all 36 Isocal subjects, Se was below normal, and in 26% of Isocal patients RBC GSH-Px was also below normal. Free and total carnitine were below normal in most Isocal subjects. All 11 Compleat B patients had subnormal serum Se, but most had normal carnitine concentrations. These data suggest that enteral formulae in nursing homes should contain greater than 100 micrograms Se and on the order of a mmol carnitine/1600 kcal.

Dietary supplementation of undernourished rats with soy or safflower oil: effects on myelin polyunsaturated fatty acids.

Undernourished suckling rats were administered, by gastric intubation, either soy oil (which is rich in both linoleic and linolenic acids) or safflower oil (which is rich in linoleic acid but deficient in linolenic acid) to determine (1) if dietary supplementation would offset the hypomyelination characteristic of the undernourished, developing brain and (2) to compare myelin fatty acids in normal, undernourished, and oil-supplemented rats. Myelin recovery was not increased by supplementation with either oil. The proportions of C22:4 and C22:6 fatty acids were reduced in myelin of the undernourished rats. Undernourished rats supplemented with either soy or safflower oil had higher than normal proportions of polyunsaturated fatty acids (C20:4 and C22:6). The triene-tetraene ratio in the oil-supplemented rats was lower than in normal controls, indicating that the oil-supplemented rats were not deficient in essential fatty acids. No significant differences were observed between the oil-supplemented groups.

Interaction of Treponema pallidum (Nichols strain) with cultured mammalian cells: effects of oxygen, reducing agents, serum supplements, and different cell types.

Cultured mammalian cells extend the time of survival of Treponema pallidum (Nichols strain). Various parameters that have been previously shown to enhance treponemal survival in vitro were examined for influences on the interaction of T. pallidum with cultured cells. With cells derived from normal rabbit testes, the time of retention of treponemal virulence was extended in an atmosphere containing reduced concentrations of oxygen. Glutathione and cysteine, when added to the basal tissue culture medium, prolonged treponemal survival. In an assessment of various tissue culture medium supplements, normal rabbit serum was equivalent to fetal bovine serum and superior to bovine serum albumin fraction V (BSA), fatty acid-poor BSA, and lipid-pooed for TRK-2, HSE, NRK, and C6 cells. Dithiotreitol, as an additional reducing agent, sharply enhanced treponemal survival. With SF1Ep NBL-11 cells and basal tissue culture medium containing glutathione, cysteine, and dithiothreitol, in an atmosphere of approximately 3% oxygen, T. pallidum was maintained without detectable decreases in the number of virulent organisms for 6 days.

The lipids of four unusual non-pathogenic host-associated spirochetes.

The lipid compositions of two spirochetes isolated from the human oral cavity and two isolated from pig feces were examined. These isolates were unusual in that they did not require long-chain fatty acids for growth, as do the other host-associated spirochetes, but rather required isobutyric and valeric acids. Therefore, they could be cultured in a medium free of serum or fatty acid - albumin supplements. The major fatty acids synthesized were normal and iso fatty acids with 14 and 16 carbons. No unsaturated fatty acids were detected, nor were chain lengths longer than 16 carbons. The major complex lipids found were monogalactosyl diglyceride, phosphatidyl glycerol, and bis-phosphatidyl glycerol. Nitrogenous phospholipids, present in Treponema and Leptospira, were not synthesized by these novel strains. The data indicate an intermediate position of these isolates between Treponema and free-living Spriochaeta.

Failure to infect gnotobiotic colostrum-deprived, and normal piglets with Treponema pallidum (Nichols).

Normal piglets kept at 16 degrees C. and gnotobiotic piglets kept at 32 degrees C. rapidly destroyed Treponema pallidum, while gnotobiotic piglets kept at 26 degrees C. showed slightly slower clearance. No infections were established. The high body temperature of the piglets has an important influence on the survival of T. pallidum.