A natural experiment during lockdown and on-going care-home COVID-19 outbreaks showed a single dose of vaccine reduced hospitalisation and deaths of care-home residents in North West England.

OBJECTIVE: To examine the effectiveness of one dose of the COVID-19 vaccine on care-home residents. STUDY DESIGN: Natural experiment. METHODS: We compared the effectiveness of single doses of Pfizer/BioNTech BNT162b2 (effective at 10 days) and AstraZeneca ChAdOx1 (effective at 14 days) vaccines in vaccinated and control (unvaccinated) homes. Using routine data, all care-homes reporting COVID-19 outbreaks between 11/12/2020 and 12/3/2021 in a sub-region of North West England were included. RESULTS: Of 126 care-homes (4042 residents), with outbreaks, 55 (44%, 1686 residents) reported onset dates before vaccination commenced; 38 (30%, 1304 residents) reported onset < 10 (BNT162b2) and < 14 days (ChAdOx1) after vaccine administration; and 33 (26%, 1052 residents) reported onset > 10 (BNT162b2) and > 14 (ChAdOx1) days after vaccination. Eighty-nine (71%) homes used ChAdOx1 vaccine. A single dose of vaccine before the outbreak onset significantly lowered the risk of symptoms (reduced by 48%), positivity (by 65%), hospitalisation (by 68%), and death (by 81%). Some vaccine effectiveness was also noted in care-homes that received one dose of vaccine within 10-14 days of outbreak onset. The number needed to vaccinate to prevent one resident from COVID-19-related hospitalisation was 34, and death was 17. CONCLUSIONS: This real-world, natural experiment adds to the evidence of COVID-19 vaccine effectiveness from different studies using varying designs. In the context of lockdown's impact on infection rates and on-going care-home outbreaks, a single dose of either ChAdOx1 or BNT162b2 vaccine had a significant impact on reducing COVID-19 related hospitalisation and death in care-home residents. Natural experiments should be used more in public health.

Effect of socioeconomic deprivation on uptake of measles, mumps and rubella vaccination in Liverpool, UK over 16 years: a longitudinal ecological study.

Suboptimal uptake of the measles, mumps and rubella (MMR) vaccine by certain socioeconomic groups may have contributed to recent large measles outbreaks in the UK. We investigated whether socioeconomic deprivation was associated with MMR vaccine uptake over 16 years. Using immunization data for 72,351 children born between 1995 and 2012 in Liverpool, UK, we examined trends in vaccination uptake. Generalized linear models were constructed to examine the relative effect of socioeconomic deprivation and year of birth on MMR uptake. Uptake of MMR1 by age 24 months ranged between 82·5% in 2003 [95% confidence interval (CI) 81·2-83·7] and 93·4% in 2012 (95% CI 92·7-94·2). Uptake of MMR2 by age 60 months ranged between 65·3% (95% CI 64·4-67·4) in 2006 and 90·3% (95% CI 89·4-91·2) in 2012. In analysis adjusted for year of birth and sex, children in the most deprived communities were at significantly greater risk of not receiving MMR1 [risk ratio (RR) 1·70, 95% CI 1·45-1·99] and MMR2 (RR 1·36, 95% CI 1·22-1·52). Higher unemployment and lower household income were significantly associated with low uptake. Contrary to concerns about lower MMR uptake in affluent families, over 16 years, children from the most socioeconomically deprived communities have consistently had the lowest MMR uptake. Targeted catch-up campaigns and strategies to improve routine immunization uptake in deprived areas are needed to minimize the risk of future measles outbreaks.

Community-level variation in TB testing history in Blantyre, Malawi.

SETTING: Equitable access to TB testing is vital for achieving global diagnosis and treatment targets, but access to diagnostic services is often worse in poorer communities. The SCALE (Sustainable Community-wide Active case-finding for Lung hEalth) survey estimated TB prevalence in Blantyre City, Malawi, and recorded previous engagement with TB services.OBJECTIVE: To explore local variation in the prevalence of ever-testing for TB in Blantyre and investigate potential socio-economic drivers.DESIGN: We fit a mixed-effects model to self-reported prior TB testing from survey participants across 72 neighbourhood clusters, adjusted for sex, age and HIV status and with cluster-level random intercepts. We then evaluated to what extent cluster-level variation was explained by two alternate poverty indicators.RESULTS: We observed substantial variation between clusters in previous TB testing, with little correlation between neighbouring clusters. Individuals residing in less affluent households, on average, had lower odds of having undergone prior testing. However, adjusting for poverty did not explain the cluster-level variations observed.CONCLUSION: Despite a decade of increased active case-finding efforts, access to TB testing is inconsistent across the population of Blantyre. This likely reflects health inequities that also apply to TB testing in many other settings, and motivates collection and analysis of TB testing data to identify the drivers behind these inequities.

Patterning of microspheres and microbubbles in an acoustic tweezers.

We describe the construction of an ultrasonic device capable of micro-patterning a range of microscopic particles for bioengineering applications such as targeted drug delivery. The device is formed from seven ultrasonic transducers positioned around a heptagonal cavity. By exciting two or three transducers simultaneously, lines or hexagonal shapes can be formed with microspheres, emulsions and microbubbles. Furthermore, phase control of the transducers allows patterning at any desired position in a controlled manner. The paper discusses in detail direct positioning of functionalised microspheres, emulsions and microbubbles. With the advantages of miniaturization, rapid and simple fabrication, ultrasonic tweezers is a potentially useful tool in many biomedical applications.

Deletion of Sod1 in Motor Neurons Exacerbates Age-Related Changes in Axons and Neuromuscular Junctions in Mice.

Whole-body knock-out of Cu,Zn superoxide dismutase (Sod1KO) results in accelerated, age-related loss of muscle mass and function associated with neuromuscular junction (NMJ) breakdown similar to sarcopenia. In order to determine whether altered redox in motor neurons underlies this phenotype, an inducible neuron-specific deletion of Sod1 (i-mnSod1KO) was compared with wild-type (WT) mice of different ages (adult, mid-age, and old) and whole-body Sod1KO mice. Nerve oxidative damage, motor neuron numbers and structural changes to neurons and NMJ were examined. Tamoxifen-induced deletion of neuronal Sod1 from two months of age. No specific effect of a lack of neuronal Sod1 was seen on markers of nerve oxidation (electron paramagnetic resonance of an in vivo spin probe, protein carbonyl, or protein 3-nitrotyrosine contents). i-mnSod1KO mice showed increased denervated NMJ, reduced numbers of large axons and increased number of small axons compared with old WT mice. A large proportion of the innervated NMJs in old i-mnSod1KO mice displayed a simpler structure than that seen in adult or old WT mice. Thus, previous work showed that neuronal deletion of Sod1 induced exaggerated loss of muscle in old mice, and we report that this deletion leads to a specific nerve phenotype including reduced axonal area, increased proportion of denervated NMJ, and reduced acetyl choline receptor complexity. Other changes in nerve and NMJ structure seen in the old i-mnSod1KO mice reflect aging of the mice.

Direct patterning of mammalian cells in an ultrasonic heptagon stencil.

We describe the construction of a ultrasonic device suitable for micro patterning particles and cells for tissue engineering applications. The device is formed by seven transducers shaped into a heptagon cavity. By exciting two and three transducers simultaneously, lines or hexagonal shapes can be formed with beads and cells. Furthermore, phase control of the transducers allows shifting the standing waves and thus patterning at different positions on a surface in a controlled manner. The paper discusses direct patterning of mammalian cells by ultrasound "stencil".

Missed opportunities for diagnosis and treatment in patients with TB symptoms: a systematic review.

BACKGROUND: The identification of patients with symptoms is the foundation of facility-based TB screening and diagnosis, but underdiagnosis is common. We conducted this systematic review with the hypothesis that underdiagnosis is largely secondary to patient drop out along the diagnostic and care pathway. METHODS: We searched (up to 22 January 2019) MEDLINE, Embase, and Cinahl for studies investigating patient pathway to TB diagnosis and care at health facilities. We used Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) to assess risk of bias. We reported proportions of patients with symptoms at each stage of the pathway from symptom screening to treatment initiation. RESULTS: After screening 3,558 abstracts, we identified 16 eligible studies. None provided data addressing the full cascade of care from clinical presentation to treatment initiation in the same patient population. Symptom screening, the critical entry point for diagnosis of TB, was not done for 33-96% of participants with symptoms in the three studies that reported this outcome. The proportion of attendees with symptoms offered a diagnostic investigation (data available for 15 studies) was very low with a study level median of 38% (IQR 14-44, range 4-84). CONCLUSIONS: Inefficiencies of the TB symptom screen-based patient pathway are a major contributor to underdiagnosis of TB, reflecting inconsistent implementation of guidelines to ask all patients attending health facilities about respiratory symptoms and to offer diagnostic tests to all patients promptly once TB symptoms are identified. Better screening tools and interventions to improve the efficiency of TB screening and diagnosis pathways in health facilities are urgently needed.

CONTEXTE: L'identification des patients symptomatiques est à la base du dépistage et du diagnostic de la TB en centres de soins, mais les sous-diagnostics sont fréquents. Nous avons réalisé cette revue systématique en émettant l'hypothèse que le sous-diagnostic était bien moins important que la perte de vue des patients tout au long du parcours diagnostique et thérapeutique. MÉTHODES: Nous avons interrogé les bases de données MEDLINE, Embase et Cinahl (jusqu'au 22 janvier 2019) pour identifier les études ayant évalué le parcours diagnostique et thérapeutique des patients atteints de TB en centres de soins. Nous avons utilisé le QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) afin d'évaluer le risque de biais. Nous avons rapporté les proportions de patients présentant des symptômes à chaque stade du parcours, du dépistage symptomatique à l'instauration du traitement. RÉSULTATS: Après avoir passé en revue 3 558 résumés, nous avons identifié 16 études éligibles. Aucune ne fournissait, dans une même population de patients, de données sur l'ensemble de la cascade de soins, de la présentation clinique à l'instauration du traitement. Le dépistage symptomatique (point de départ essentiel du diagnostic de la TB) n'avait pas été réalisé pour 33­96% des participants symptomatiques dans les trois études ayant rapporté ce résultat. La proportion de personnes symptomatiques consultant à qui un examen diagnostique a été proposé (données disponibles pour 15 études) était très faible, avec une médiane de 38% (IQR 14­44 ; écart 4­84). CONCLUSIONS: Le manque d'efficacité du parcours patient fondé sur le dépistage symptomatique de la TB est un facteur contributif majeur du sous-diagnostic de la maladie. Cette inefficacité reflète une mise en œuvre incohérente des recommandations qui stipulent de demander à tous les patients consultant en centres de soins s'ils présentent des symptômes respiratoires et de proposer rapidement des tests diagnostiques à tous les patients une fois les symptômes de TB identifiés. De meilleurs outils et interventions de dépistage permettant d'améliorer l'efficacité du parcours de dépistage et de diagnostic de la TB en centres de soins sont urgemment nécessaires.

Determining the value of TB active case-finding: current evidence and methodological considerations.

Active case-finding (ACF) is an important component of the End TB Strategy. However, ACF is resource-intensive, and the economics of ACF are not well-understood. Data on the costs of ACF are limited, with little consistency in the units and methods used to estimate and report costs. Mathematical models to forecast the long-term effects of ACF require empirical measurements of the yield, timing and costs of case detection. Pragmatic trials offer an opportunity to assess the cost-effectiveness of ACF interventions within a 'real-world´ context. However, such analyses generally require early introduction of economic evaluations to enable prospective data collection on resource requirements. Closing the global case-detection gap will require substantial additional resources, including continued investment in innovative technologies. Research is essential to the optimal implementation, cost-effectiveness, and affordability of ACF in high-burden settings. To assess the value of ACF, we must prioritize the collection of high-quality data regarding costs and effectiveness, and link those data to analytical models that are adapted to local settings.

Does tuberculosis screening improve individual outcomes? A systematic review.

BACKGROUND: To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review). METHODS: Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative. FINDINGS: Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened. INTERPRETATION: We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice. FUNDING: WHO and EDCTP.

Psychosocial and pharmacologic interventions for methamphetamine addiction: protocol for a scoping review of the literature.

BACKGROUND: Methamphetamine use and harms are rising rapidly. Management of patients with methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU) is challenging, with no clearly established best approach; both psychosocial and pharmacologic interventions have been described. Furthermore, given the diversity of individuals that use methamphetamines, there is a need to assess evidence for treatments for subgroups including youths; gay, bisexual, and other men who have sex with men; individuals with mental health comorbidities; and individuals in correction services. Establishing awareness of the messages regarding treatment from recent clinical practice guidelines (CPG) in the field is also of value. The first study objective will be to establish a greater understanding of the methods, populations, and findings of controlled studies for psychosocial and pharmacologic treatments for MUD and PMU. Investigation of this information can help establish the potential for advanced syntheses of the evidence (such as network meta-analysis) to compare therapies for this condition and to identify gaps related to key populations where more primary research is needed. Summarizing the recommendations regarding treatment of MUD/PMU from recent CPGs and systematic reviews will be an important secondary objective. METHODS: A scoping review will be performed. Using the OVID platform, MEDLINE, Embase, PsycINFO, and relevant Cochrane databases from EBM Reviews will be searched (from databases' inception onwards). Eligibility criteria will include individuals described as having MUD or PMU, with designs of interest including randomized trials, non-randomized trials, and controlled cohort studies with three or more months of follow-up; systematic reviews and CPGs will also be sought. Two reviewers (with support from automation tools) will independently screen all citations, full-text articles, and chart data. Different approaches to handling and summarizing the data will be implemented for each type of study design. Tables and graphics will be used to map evidence sources and identify evidence gaps. DISCUSSION: This research will enhance awareness of evidence addressing the effects of psychosocial and pharmacologic interventions for MUD/PMU overall and in sub-populations, both in terms of recent CPGs/reviews and primary studies; inspection of the latter will also help establish the feasibility of future syntheses to compare treatments, such as network meta-analysis. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: Open Science Framework ( https://osf.io/9wy8p ).

Discordance in HIV-1 viral loads and antiretroviral drug concentrations comparing semen and blood plasma.

OBJECTIVES: For individuals not on antiretroviral therapy, the risk of heterosexual transmission of HIV appears negligible when blood plasma (BP) viral loads are <1500 HIV-1 RNA copies/mL. It is not clear whether this observation can be extrapolated to individuals on highly active antiretroviral therapy (HAART). Because of differential tissue penetration, antiretroviral drug concentrations may be sufficient to maintain an undetectable viral load in the BP yet not achieve adequate levels to suppress HIV in the genital tract. Therefore, we wanted to correlate HIV viral loads and drug concentrations in semen plasma (SP) and BP. METHODS: Thirty-three men were included. All were on combination antiretroviral therapy with an undetectable BP viral load for at least 1 year. Blood and semen samples were collected within 2 h of each other and tested for HIV RNA by the NucliSens QT (bioMerieux, St Laurent, QC, Canada) method; drug concentrations were determined by liquid chromatography tandem mass spectrometry. RESULTS: Two of the 33 patients (6.1%) with BP viral loads below detection had time-matched HIV viral loads in SP > or =700 copies/mL. Both patients were on efavirenz, the SP concentrations of which were < or =10% of the levels in BP and well below the minimal therapeutic drug monitoring target concentration required to suppress HIV. CONCLUSIONS: Because, at least in part, of poor drug penetration into the genital tract, an undetectable HIV viral load in the BP does not guarantee an undetectable viral load in semen. In view of this, caution should be taken in concluding that patients on HAART with suppressed viraemia are sexually non-infectious.

Targeting the E1 replication protein to the papillomavirus origin of replication by complex formation with the E2 transactivator.

The mechanism by which transcription factors stimulate DNA replication in eukaryotes is unknown. Bovine papillomavirus DNA synthesis requires the products of the viral E1 gene and the transcriptional activator protein encoded by the E2 gene. Experimental data showed that the 68-kilodalton (kD) E1 protein formed a complex with the 48-kD E2 transcription factor. This complex bound specifically to the viral origin of replication, which contains multiple binding sites for E2. Repressor proteins encoded by the E2 open reading frame failed to complex with E1 suggesting that the 162-amino acid region of E2 that participates in transactivation contained critical determinants for interaction with E1. The physical association between a replication protein and a transcription factor suggests that transcriptional activator proteins may function in targeting replication initiator proteins to their respective origins of replication.

Contacts of underserved tuberculosis patients have higher odds of TB disease in North West England: a cohort study.

OBJECTIVE: To investigate the association between patients' social risk factors and the risk of tuberculous infection and TB disease among their contacts in England. DESIGN: This was a cohort study of all TB cases from North West England diagnosed between 27 March 2012 and 28 June 2016. The social risk factors of TB cases were evaluated to estimate their need for enhanced case management (ECM), from 0 (standard of care) to 3 (intensive social support). RESULTS: A total of 2139 cases and their 10 019 contacts met the eligibility criteria. Being a contact of a patient with smear-positive TB with high ECM or being of Black Caribbean ethnicity was independently associated with greater odds of active TB disease (smear-positive vs. smear-negative, OR 5.3, 95%CI 3.2-8.7; ECM-3 vs. ECM-0, OR 2.2, 95%CI 1.01-5.0; Black Caribbean vs. White, OR 7.4, 95%CI 2.1-25). Being a contact of a patient with smear-positive TB or of Black Caribbean ethnicity was also independently associated with greater odds of tuberculous infection (smear-positive vs. smear-negative, OR 5.3, 95%CI 3.8-7.3; and Black Caribbean vs. White, OR 6.7, 95%CI 2.0-25). CONCLUSIONS: The social complexity and ethnicity of patients were associated with tuberculous infection and TB disease in their contacts.

Completion of isoniazid preventive therapy among human immunodeficiency virus positive adults in urban Malawi.

SETTING: Despite worldwide scale-up of human immunodeficiency virus (HIV) care services, relatively few countries have implemented isoniazid preventive therapy (IPT). Among other programmatic concerns, IPT completion tends to be low, especially when not fully integrated into HIV care clinics. OBJECTIVE: To estimate non-completion of 6-month IPT and its predictors among HIV-positive adults aged 16 years. DESIGN: A prospective cohort study nested within a cluster-randomised trial of TB prevention was conducted between February 2012 and June 2014. IPT for 6 months was provided with pyridoxine at study clinics. Non-completion was defined as loss to follow-up (LTFU), death, active/presumptive TB or stopping IPT for any other reason. Random-effects logistic regression was used to determine predictors of non-completion. RESULTS: Of 1284 HIV-positive adults initiated on IPT, 885/1280 (69.1%) were female; the median CD4 count was 337 cells/µl (IQR 199-511); 320 (24.9%) did not complete IPT. After controlling for antiretroviral treatment status, IPT initiation year, age and sex, non-completion of IPT was associated with World Health Organization stage 3/4 (aOR 1.76, 95%CI 1.22-2.55), CD4 count 100-349 cells/µl (aOR 1.93, 95%CI 1.10-3.38) and any reported side effects (aOR 22.00, 95%CI 9.45-46.71). CONCLUSION: Completion of IPT was suboptimal. Interventions to further improve retention should target immunosuppressed HIV-positive adults and address side effects.

Processing of O6-methylguanine by mismatch correction in human cell extracts.

Human cell extracts perform an aberrant form of DNA synthesis on methylated plasmids [1], which represents processing of O6-methylguanine (O6-meG). Here, we show that extracts of colorectal carcinoma cells with defects in the mismatch repair proteins that normally correct replication errors do not carry out this synthesis. hMSH2-defective LoVo cell extracts (hMSH for human MutS homologue) performed O6-meG-dependent DNA synthesis only after the addition of the purified hMutS alpha mismatch recognition complex. Processing of O6-meG by mismatch correction requires PCNA and therefore probably DNA polymerase delta and/or epsilon. Mismatch repair-defective cells withstand O6-meG in their DNA [2], making them tolerant to methylating agents. Methylation-tolerant HeLaMR clones, with a mutator phenotype and a defect in either mismatch recognition or correction in vitro, also performed little O6-meG-dependent DNA synthesis. Assays of pairwise combinations of tolerant and colorectal carcinoma cell extracts identified hMLH1 as the missing mismatch repair function in a group of tolerant clones. The absence of processing by extracts of methylation-tolerant cells provides the first biochemical evidence that lethality of DNA O6-meG derives from its interaction with mismatch repair.

Elevated amounts of a 7S nuclear RNA with sequence homology to a tumor virus promoter in transformed and tumorigenic cells.

A small nuclear RNA (7S-K) from cultured mammalian cells has been shown, in previous studies, to have the characteristics expected of a gene regulatory molecule, i.e., a tissue- and species-specific stimulatory activity for initiation of transcription of protein-coding genes. Moreover, in simian virus 40 (SV40)-transformed mouse cells, this RNA was shown, by S1-analysis, to bear an extensive homology to the SV40 promoter, suggesting that it acts by base-pairing to DNA in this region to facilitate the formation of the transcription-initiation complex. In order to investigate whether or not this homology is restricted to SV40-transformed cells and in any way related to transformation, a series of normal and transformed cell lines were examined for the degree of homology between their 7S-K RNAs and the SV40 promoter. Results show that the amount of 7S-K RNA hybridizable to the promoter varies as a direct function of the established degree of tumorigenic activity of the cells and is not dependent on the presence of SV 40 sequences. Taken together with the known overexpression of some cellular oncogenes in tumor tissues, these results suggest that this particular RNA may be involved in stimulating transcription of, at least, some of these genes.

Coregulation of the human O6-methylguanine-DNA methyltransferase with two unrelated genes that are closely linked.

The loss of expression of the enzyme O6-methylguanine-DNA methyltransferase (the Mex- phenotype), which often results from cellular transformation, confers hypersensitivity to alkylating agents. We have observed two unrelated examples in which human cell lines have undergone a spontaneous alteration in their Mex phenotype during propagation in vitro. The change was reversible and was not the result of mutation. In both cases a loss of methyltransferase expression was accompanied by a simultaneous loss of expression of two metabolically unrelated enzymes: thymidine kinase and galactokinase. "Reversion" to methyltransferase expression was accompanied by simultaneous reexpression of both kinase activities. A third example of this coordinate gene regulation was seen with the Burkitt's lymphoma cell line Raji which expresses methyltransferase, thymidine kinase, and galactokinase at high levels. A thymidine kinase- Raji cell line derived by bromodeoxyuridine mutagenesis that is also Mex- was found to be galactokinase-. It appears that methyltransferase expression may in some instances be coordinately regulated with the tk and glk loci which are closely linked on human chromosome 17.

Epigenetic regulation of the MGMT and hMSH6 DNA repair genes in cells resistant to methylating agents.

We investigated the relationship between DNA cytosine methylation and the expression of two genes associated with resistance to DNA methylation damage. Variants of RajiMex- cells acquired resistance to N-methyl-N-nitrosourea by either reactivating a previously silent O6-methylguanine-DNA methyltransferase (MGMT) gene or by repressing the hMSH6 mismatch repair gene. DNA sequencing and measurements of mRNA and enzyme levels revealed that MGMT activity was not correlated with methylation of the core MGMT promoter. Treatment with the demethylating agent 5-azadeoxycytidine reduced MGMT mRNA and enzyme levels, indicating that methylation of some nonpromoter sequences may be required for MGMT gene expression. In contrast, both hMSH6 mRNA and protein levels were increased by 5-azadeoxycytidine treatment of an N-methyl-N-nitrosourea-resistant variant that did not express detectable hMSH6, which implies that this gene was transcriptionally silenced by cytosine methylation. This could be substantiated by in vitro modification of the CpG sites in the hMSH6 promoter with restriction methylase M.SssI, which abolished the transcription of a reporter gene under its control in a transient transfection assay. Taken together, our data show that treatment with chemical methylating agents alters gene expression patterns through increased CpG methylation of genomic DNA, and thereby permits the emergence and selection of clones that are resistant to these agents due to increased repair or tolerance of O6-methylguanine.

High mortality and prevalence of HIV and tuberculosis in adults with chronic cough in Malawi: a cohort study.

BACKGROUND: Adults with suspected tuberculosis (TB) in health facilities in Africa have a high risk of death. The risk of death for adults with suspected TB at community-level is not known but may also be high. METHODS: Adults reporting cough of ⩾ 2 weeks (coughers) during a household census of 19,936 adults in a poor urban setting in Malawi were randomly sampled and age-frequency matched with adults without cough ⩾ 2 weeks (controls). At 12 months, participants were traced to establish vital status, offered human immunodeficiency virus (HIV) testing and investigated for TB if symptomatic (sputum for Xpert(®) MTB/RIF, smear microscopy and culture). RESULTS: Of 345 individuals with cough, 245 (71%) were traced, as were 243/345 (70.4%) controls. TB was diagnosed in 8.9% (16/178) of the coughers and 3.7% (7/187) of the controls (P = 0.039). HIV prevalence among coughers was 34.6% (56/162) and 18.8% (32/170) in controls (P = 0.005); of those who were HIV-positive, respectively 26.8% and 18.8% were newly diagnosed. The 12-month risk of death was 4.1% (10/245) in coughers and 2.5% (6/243) in controls (P = 0.317). CONCLUSION: Undiagnosed HIV and TB are common among adults with chronic cough, and mortality is high in this urban setting. Interventions that promote timely seeking of HIV and TB care are needed.

Equitable tuberculosis care in the North West of England: analysis of tuberculosis cohort review data.

BACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown. METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models. RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27-19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10-2.62). In multivariable analysis, there were no significant associations. CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.