Performance of Cepheid ® Xpert MTB/RIF ® and TB-Biochip ® MDR in two regions of Russia with a high prevalence of drug-resistant tuberculosis.

The purpose of this study was to assess the performance of Cepheid® Xpert MTB/RIF® ("Xpert") and TB-Biochip® MDR ("TB-Biochip"). Sputum specimens from adults with presumptive tuberculosis (TB) were homogenized and split for: (1) direct Xpert and microscopy, and (2) concentration for Xpert, microscopy, culture [Lowenstein-Jensen (LJ) solid media and Mycobacteria Growth Indicator Tube® (MGIT)], indirect drug susceptibility testing (DST) using the absolute concentration method and MGIT, and TB-Biochip. In total, 109 of 238 (45.8 %) specimens were culture-positive for Mycobacterium tuberculosis complex (MTBC), and, of these, 67 isolates were rifampicin resistant (RIF-R) by phenotypic DST and 64/67 (95.5 %) were isoniazid resistant (INH-R). Compared to culture of the same specimen, a single direct Xpert was more sensitive for detecting MTBC [95.3 %, 95 % confidence interval (CI), 90.0-98.3 %] than direct (59.6 %, 95 % CI, 50.2-68.5 %) or concentrated smear (85.3 %, 95 % CI, 77.7-91.1 %) or LJ culture (80.8 %, 95 % CI, 72.4-87.5 %); the specificity was 86.0 % (95 % CI, 78.9-91.3 %). Compared with MGIT DST, Xpert correctly identified 98.2 % (95 % CI, 91.5-99.9 %) of RIF-R and 95.5 % (95 % CI, 85.8-99.2 %) of RIF-susceptible (RIF-S) specimens. In a subset of 104 specimens, the sensitivity of TB-Biochip for MTBC detection compared to culture was 97.3 % (95 % CI, 91.0-99.5 %); the specificity was 78.1 % (95 % CI, 61.5-89.9 %). TB-Biochip correctly identified 100 % (95 % CI, 94.2-100 %) of RIF-R, 94.7 % (95 % CI, 76.7-99.7 %) of RIF-S, 98.2 % (95 % CI, 91.4-99.9 %) of INH-R, and 78.6 % (95 % CI, 52.1-94.2 %) of INH-S specimens compared to MGIT DST. Xpert and Biochip were similar in accuracy for detecting MTBC and RIF resistance compared to conventional culture methods.

[Selective effects of pulmonary surfactant on various subpopulations of alveolar macrophages in the model of experimental tuberculosis].

Pulmonary surfactant is necessary component for maintenance of high level of phagocytic activity of alveolar macrophages. Tuberculosis inflammation reduces the production of surfactant by type II cells and phagocytic activity of alveolar macrophages. The effects of exogenous pulmonary surfactant on the ultrastructural changes of various subpopulations of alveolar macrophages were studied by TEM-method. For investigations the bronchial alveolar lavage fluid from guinea pigs infected of M. tuberculosis and treated by isoniatid or isoniazid + exogenous pulmonary surfactant were used. It was shown that isoniazid + exogenous pulmonary surfactant normalizes the heterogeneous population of alveolar macrophages providing stimulating effects on their maturation and phagocytic activity more effectively than isoniazid therapy.

[Prevention of tuberculosis: current approaches to development of vaccines].

This review is focused on recent advances in development of new vaccines for the prevention of tuberculosis. The main reasons for lack of BCG vaccine efficacy in different populations and geographic regions are presented. Design of new vaccines based on live modified strains of Mycobacterium bovis BCG, attenuated strains of Mycobacterium tuberculosis, recombinant proteins and viral vectors is considered in the specific examples. The usage of the heterologous "prime-boost" vaccination strategy against tuberculosis is discussed.

[Monitoring detection and treatment of new patients with pulmonary tuberculosis].

We estimated results of detection and treatment of TB patients registered in 2006 in 15 regions of RF under supervision of the Central Research Institute of Tuberculosis. The fraction of sputum positive patients increased in comparison with 2005. It ranged from 77.1% in Orel region to 35.2% in Astrakhan region. The primary MDR rate varied significantly from 2.5% in the Republic of Mordovia to 14.7% in Mary El (estimated level 5%). The frequency of efficient chemotherapy (evaluated from sputum microscopy data) increased in 8 regions and decreased in 7 ones. The efficiency varied from 69.0 to 81.1% in 9 regions (recommended level for 2007 68.5%). It amounted to 68.5% or higher (based on sputum culturing data) in Republics of Kalmykia and Tatarstan, Nizhny Novgorod, Saratov and Ul'yanovsk regions. TB mortality rate in 2006 exceeded the acceptable level of 2.5% in 13 regions and the frequency of refusals to continue chemotherapy was higher than 5% recommended for 2010 by the Global Fund Target Project in 10 regions. The efficiency of treatment in sputum-positive patients was frequently evaluated by X-ray in 3 regions with poorly organized microbiological services. TB treatment efficiency estimated from cavity closure was higher than 60% in 10 regions; it the remaining ones it varied from 36,3% (Nizhny Novgorod) to 52.2% (Vladimir). The system of evaluation being tested permits to accurately register new TB patients, objectively estimate effectiveness of their treatment, and reveal causes of its failure. Also, it makes possible corrections of therapeutic strategy on a trimestrial basis instead of postponing them till the end of the year. Introduction of cohort analysis combined with supervision of responsibility regions by specialists of relevant research institutions would increase efficiency of TB control in each subject of Russian Federation. Supervisory management appears to be an efficacious tool for monitoring implementation of the TB control Program.

New 5-modified pyrimidine nucleoside inhibitors of mycobacterial growth.

The WHO has declared tuberculosis (TB) a global health emergency. Therefore, there is an urgent need to discover and develop new anti-TB drugs. Here we report on a new category of 5-substituted pyrimidine nucleosides as potent inhibitors of Myco-bacterium tuberculosis growth in vitro. A series of 2'-deoxy-, 3'-azido-2',3'-dideoxy-, and 3'-amino-2',3'-dideoxypyrimidine nucleoside analogues bearing lengthy flexible alkyloxymethyl substituents exhibited marked inhibitory activity against M. tuberculosis in vitro. 5-Dodecyloxymethyl-2'-deoxyuridine was found to be a potent inhibitor of M. tuberculosis propagation in vitro. In contrast, monophosphates of the tested nucleosides were devoid of antimycobacterial activity. This new class of inhibitors seems to be a promising chemotherapeutic agent against TB and merits further studies.

[Psychoemotional changes in patients with pulmonary tuberculosis during therapy using psychological and neuropsychological methods].

Therapy for pulmonary tuberculosis in patients is complicated by their negative psychoemotional state frequently deteriorated by long inpatient stay. Enhancing the efficiency of rehabilitative measures in phthisiology requires active optimization of the patients' mental state. This problem can be solved by a package of correction measures involving psychological correction with reflex therapeutic normalization of the functional state of the cortical regions of the central nervous system in patients with pulmonary tuberculosis. One hundred tuberculosis patients with decompensated mind, including 60 with OG and 40 with KG, were examined. A noticeable psychoemotional improvement was reliably detected 5 months after complex correction psychological and neuropsychological accompaniments of standard chemotherapy in the OG study.

[Comparison of radionuclide studies with pleural morphological changes in patients with tuberculosis pleurisy].

Forty-seven patients with pleurisy of tuberculous etiology underwent a radionuclide study using the reagent 99mTc-labeled technefit, the result of which was compared with the morphological changes in the pleural biopsy or resection specimens. First-degree pleural resorptive dysfunction (PRD) was ascertained in 27.6% of the patients. Morphologically, there were signs of acute edema of all pleural layers in both the area of inflammation and the proximal portions with reduced vessels in the microcirculatory bed (MCB). These patients had medical treatment. 59.6% of patients had second-degree PRD--circumscribed caseous foci and granulomas were morphologically found in the presence of progressive fibrosis with a small number of vessels in the MCB. 12.8% of patients had third-degree PRD--massive pleural fibrosis with a significant reduction in MCB vessels and lymph capillaries. Active tuberculous inflammation remained mainly in the deep layers of the pleura. Surgical treatment was performed in patients with second-third degree PRD. Thus, comparison of the results of a radionuclide study with morphological changes in the tuberculosis-afflicted pleura made it possible to establish the degree of pleural MCB impairments, to characterize the activity of a pathological process, and to define objectively treatment policy.

[Up-to-date technologies in preoperative preparation and postoperative period in patients with progressive destructive pulmonary tuberculosis].

The impact of complex pathogenetic treatment involving the latest advances of science and technology in the correction of pulmonary surfactant system (PSS) disorders, extracorporeal therapy and immunomodulation on the enhancement of efficiency of surgical treatment in patients with progressive destructive tuberculosis of the lung. The results of examinations and treatment were studied in 199 patients with progressive and complicated pulmonary tuberculosis. According to the used treatment, the patients were divided into 2 groups: a study group (n = 102) and a control one (n = 97). In the pre- and postoperative periods, the study group patients received complex pathogenetic therapy by the developed algorithm: for pharmacological activation of PSS, nebulizer aerosol therapy with lasolvan (ambroxol) was first used in various modifications by the developed algorithms. The efficiency of preoperative preparation in the study group patients in accordance with the applied methods of pathogenetic therapy indicated that the best results were achieved in the context of stabilization of a specific process, compensation of complications and comorbidity in the patients who underwent modified drug-induced PSS activation with small-volume plasmapheresis and leukinferon (LI) in 93.3% and drug-induced PSS activation with small-volume medical plasmapheresis (MI) in 81.4%. Overall, comprehensive preoperative preparation involving correction of homeostatic disorders by the developed algorithm proved to be 30.9% more effective (81.4%) than the conventional preoperative preparation in the controls (50.5%). Analysis of the results of surgical treatment depending on the methods of pathogenetic therapy used in the pre- and postoperative period showed that the efficiency of surgical treatment was observed in 25 (80%) patients receiving nebulizer aerosol therapy and MP, in 20 (86.9%) who had nebulizer aerosol therapy + MP and in only 8 (65%) treated with nebulizer aerosol therapy.

[Systemic transplantation of autologous mesenchymal stem cells of the bone marrow in the treatment of patients with multidrug-resistant pulmonary tuberculosis].

The study undertaken 3 years ago examined the effect of systemic transplantation of autologous mesenchymal stem cells (MSC) in the complex therapy of 27 patients with pulmonary tuberculosis, including 15 patients with multidrug-resistant pulmonary tuberculosis and 12 with extensive drug resistance of Mycobacterium tuberculosis. All the patients were bacteria-discharging persons with disseminated destructive processes in lung tissue, most (n=17) of them had chronic fibrocavernous tuberculosis. In all the patients, previous long specific antituberculous treatment was ineffective or inadequately effective. After systemic MSC transplantation, 16 patients were followed up for 1.5-2 years or more and the remaining 11 patients for at least 6 months. After MSC administration, a positive clinical effect was observed in all 27 cases; bacterial discharge stopped in 20 patients after 3-4 months; resolution of sustained lung tissue cavities further occurred in 11 patients. At present, a persistent remission of a tuberculous process may be stated in 9 of the 16 patients in whom MSCs were transplanted 1.5-2 years, significant positive bacteriological and morphological changes are observed in 6 patients. Thus, inclusion of transplantation of the autologous MSCs propagated in the culture into a course of antituberculous therapy may be a promising procedure for enhancing the efficiency of therapy in patients with resistant forms of pulmonary tuberculosis.

[Monitoring of the detection of new pulmonary tuberculosis cases and the efficiency of their treatment in the area supervised by the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences].

The results of the detection and treatment of new pulmonary tuberculosis cases in 2006 were assessed in 15 subjects of the Russian Federation, supervised by the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences. As compared with 2005, in 2006 the proportion of bacteria-discharging individuals increased among the new cases of pulmonary tuberculosis and ranged from 77.1% in the Oryol Region to 35.2% in the Astrakhan Region. The frequency of multidrug-resistant MBT among the new cases of pulmonary tuberculosis (the expected frequency was 5%) showed a wide scatter and varied from 0.7% in the Republic of Ingushetia to 14.7% in that of Mariy El. The higher and lower percentages of patients receiving an effective course of chemotherapy, as shown by microscopy, were noted in 8 and 7 regions, respectively. Their scatter was 42.4% in the Nizhni Novgorod Region to 81.1% in the Republic of Mordovia. The efficiency of treatment, as evidenced by sputum culture, varied from 46.3% in the Nizhni Novgorod Region to 79.0% in the Republic of Mordovia. More than 3% of those who died from tuberculosis were recorded in 10 regions and more than 5% of those who discontinued a course of chemotherapy before the appointed time were notified in 8 regions. The cavity decay closure rate ranged from 36.3% in the Nizhni Novgorod Region to 52.2% in the Vladimir Region. Quarterly monitoring of the detection and treatment allows a precise registration of identified tuberculosis patients, objective assessment of the results of treatment, elucidation of reasons for ineffective chemotherapy, and corrections of a treatment process.

[The clinical and morphological features of the course of tuberculosis in HIV infection].

The development of an acutely progressing process of varying extent to the point of total damage to both lungs is typical of a patient with tuberculosis concurrent with HIV infection due to progressive immunodeficiency. There is an apparent need for dividing patients with comorbidity into 2 groups: (1) HIV/TB, in patients HIV infection is a primary disease; (2) TB/HIV, in whom tuberculosis is accordingly primary. These groups differ in clinical manifestations, forms of tuberculosis, and pathomorphological changes. Group 1 patients are mostly typified by the primary forms of tuberculosis with involvement of lymph nodes of all groups and by miliary processes at the sites of multiple organs (the lung, abdomen, and central nervous system). Most patients from Group 1 are observed to have fever, progressive intoxication, and morphologically necrotic foci without signs of differentiation and in the absence of typical granulomas. Multiple drug resistance is noted in more than 20% of the patients; in these patients, the efficiency of an intensive therapy phase in arresting bacterial discharge is 26.9%. In Group 2 patients, comorbidity takes a less acute course, pulmonary symptoms are less marked; there is a preponderance of infiltrative, disseminated, firocavernous pulmonary tuberculosis, and caseous pneumonia. In this group, the signs of a prior tuberculous process with phenomena of a slight or moderate productive reaction and with resolution elements are morphologically detectable. In late-stage HIV infection--AIDS, the patients from both groups develop a generalized tuerculous process. Both patient groups are typified by the severe progressive course with identical clinical and pathomorphological manifestations, which results in death.

[Experience with small-volume plasmapheresis used in the correction of hemostatic disorders in patients with progressive destructive pulmonary tuberculosis].

Pulmonary tuberculosis may result from a complex of the phenomena predisposing to impaired blood coagulation. The purpose of the investigation was to study the efficiency of small-volume plasmapheresis in the correction of hemostatic disorders in patients with progressive destructive pulmonary tuberculosis. The results of examination and treatment were analyzed in 112 patients aged 18 to 65 years who had progressive destructive pulmonary tuberculosis treated at the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences, in 1994 to 2004. The patients were divided into groups: Group 1 (basic)--43 subjects receiving the standard therapy supplemented by 4 small-volume plasmapheresis sessions every 2 days and comparison groups: 2A--36 patients receiving 2 plasmapheresis sessions at a week interval and 2B--33 patients being on the standard therapy alone. In the presence of endogenous intoxication, the patients with disseminated and complicated fibrocavernous tuberculosis were ascertained to develop blood coagulative disorders typical of grades 1-2 chronic disseminated intravascular coagulation (DIC). The use of small-volume plasmapheresis in combination with antiaggregatory and anticoagulant therapy in patients with disseminated and complicated fibrocavernous pulmonary tuberculosis had a beneficial effect on the blood aggregation controlling system positive impact, prevented DIC progression, promoted improvement of blood rheological properties. With the standard therapy (including double plasmapheresis at a week interval), positive hemostatic changes were absent throughout the preoperative period.

[Pathomorphological changes in the lung in tuberculosis patients died from HIV infection at the stage of AIDS].

The authors revealed the typical morphological changes of lung tuberculous lesion in HIV infection at the stage of AIDS: these included alterative changes without typical tuberculosis granulomas; a well-defined exsudative inflammatory component with a predominance of leukocytic infiltration and a drastically decrease of and, occasionally, a complete disappearance of macrophages and lymphocytes; formation of pyonecrotic foci; the focal monomorphic pattern illustrating the loss of the signs of process indulation. These signs suggest the specific features of immunity and the course of specific inflammation as immediate hypersensitivity with the acutest progression of tuberculosis.

[Results of use of surfactant in complex therapy of patients with destructive pulmonary tuberculosis].

Many years' experience in studying the surfactant system in patients with pulmonary tuberculosis has allowed recommendation of using surfactant agents in the treatment of tuberculosis. The purpose of the study was to evaluate the efficacy of surfactant-BL (Russia) as a pathogenetic agent in chemotherapy in patients with destructive pulmonary tuberculosis. The results of treatment were compared in two groups of 70 persons in each, which were matched by gender, age, the extent of a tuberculous process, and the presence of drug resistance in the causative agent, including multidrug resistance. In the study group, the patients received surfactant inhalations (8 weeks) during chemotherapy while the control patients had only chemotherapy. Drugs were chosen on an individual basis, by taking into account the pathogen's drug sensitivity and a patient's tolerability of a drug. The cumulative dose of the surfactant was 700 mg. There were no adverse reactions to the surfactant in the study group of patients. After 2-5 surfactant inhalations, the amount of sputum increase, its discharge became easier, and cough diminished. Following 4 weeks, the level of bacterial isolation decreased in 49 (70.0%) patients from the study group and in 20 (28.6%) from the control one. Two months of treatment, bacterial isolation ceased in 82.9 and 64.3% in the study and control groups, respectively. In the study group, X-ray trend in infiltration resolution and cavernous closure was significantly better in the study group. By month 4, cavernous closure was achieved in 72.9% in the study group and in 41.4% in the control one. The changes in the cellular composition of the lung in surfactant-treated and untreated patients were analyzed by the data on broncho-alveolar lavage. The findings indicate that inhaled Surfactant-BL as a two-month therapy has a pathogenetic effect and during chemotherapy improves the efficiency of treatment reduces its time in pulmonary tuberculosis.

[Morphological signs of acute lung lesion in patients with caseous pneumonia].

The authors conducted light optical and electron microscopic studies of caseum-free resected lung parenchymal portions from 11 patients with caseous pneumonia. All cases were found to have severe vascular bed permeability impairments, developed extensive intraalveolar edema, destruction of both type 1 respiratory alveolocytes and surfactant-producing type 2 alveolocytes. Release of plasma proteins into the intraalveolar space and their interaction with extracellular phospholipoproteins gave rise to hyaline masses.

[On the morphological diagnosis of drug-resistant pulmonary tuberculosis].

The intraoperative samples taken from 15 patients with acutely progressive drug-resistant fibrocavernous pulmonary tuberculosis were studied. There were typical signs of granulomatosis inflammation, a predominance of an exudative tissue reaction, and an extensive vascular bed lesion. Two types of perifocal cellular infiltrates were identified. Mononuclear infiltrates with epithelioid cellular transformation along the periphery were defined as specified. Nonspecific infiltrates were composed of foam macrophages-lipophages and they reflected lipid metabolic disturbances. In addition, the severity of the process was determined by an extensive specific bronchial lesion of all generations. A morphological study of the samples could reveal the tissue and cellular features of respiratory organs in drug-resistant tuberculosis and identify the diagnostically significant signs of specific and nonspecific inflammation.