Prevalence and clinical significance of respiratory viruses and bacteria detected in tuberculosis patients compared to household contact controls in Tanzania: a cohort study.

OBJECTIVES: To describe the prevalence of respiratory pathogens in tuberculosis (TB) patients and in their household contact controls, and to determine the clinical significance of respiratory pathogens in TB patients. METHODS: We studied 489 smear-positive adult TB patients and 305 household contact controls without TB with nasopharyngeal swab samples within an ongoing prospective cohort study in Dar es Salaam, Tanzania, between 2013 and 2015. We used multiplex real-time PCR to detect 16 respiratory viruses and seven bacterial pathogens from nasopharyngeal swabs. RESULTS: The median age of the study participants was 33 years; 61% (484/794) were men, and 21% (168/794) were HIV-positive. TB patients had a higher prevalence of HIV (28.6%; 140/489) than controls (9.2%; 28/305). Overall prevalence of respiratory viral pathogens was 20.4% (160/794; 95%CI 17.7-23.3%) and of bacterial pathogens 38.2% (303/794; 95%CI 34.9-41.6%). TB patients and controls did not differ in the prevalence of respiratory viruses (Odds Ratio [OR] 1.00, 95%CI 0.71-1.44), but respiratory bacteria were less frequently detected in TB patients (OR 0.70, 95%CI 0.53-0.94). TB patients with both respiratory viruses and respiratory bacteria were likely to have more severe disease (adjusted OR [aOR] 1.6, 95%CI 1.1-2.4; p 0.011). TB patients with respiratory viruses tended to have more frequent lung cavitations (aOR 1.6, 95%CI 0.93-2.7; p 0.089). CONCLUSIONS: Respiratory viruses are common for both TB patients and household controls. TB patients may present with more severe TB disease, particularly when they are co-infected with both bacteria and viruses.

Detection and management of drug-resistant tuberculosis in HIV-infected patients in lower-income countries.

SETTING: Drug resistance threatens tuberculosis (TB) control, particularly among human immunodeficiency virus (HIV) infected persons. OBJECTIVE: To describe practices in the prevention and management of drug-resistant TB under antiretroviral therapy (ART) programs in lower-income countries. DESIGN: We used online questionnaires to collect program-level data on 47 ART programs in Southern Africa (n = 14), East Africa (n = 8), West Africa (n = 7), Central Africa (n = 5), Latin America (n = 7) and the Asia-Pacific (n = 6 programs) in 2012. Patient-level data were collected on 1002 adult TB patients seen at 40 of the participating ART programs. RESULTS: Phenotypic drug susceptibility testing (DST) was available in 36 (77%) ART programs, but was only used for 22% of all TB patients. Molecular DST was available in 33 (70%) programs and was used in 23% of all TB patients. Twenty ART programs (43%) provided directly observed therapy (DOT) during the entire course of treatment, 16 (34%) during the intensive phase only, and 11 (23%) did not follow DOT. Fourteen (30%) ART programs reported no access to second-line anti-tuberculosis regimens; 18 (38%) reported TB drug shortages. CONCLUSIONS: Capacity to diagnose and treat drug-resistant TB was limited across ART programs in lower-income countries. DOT was not always implemented and drug supplies were regularly interrupted, which may contribute to the global emergence of drug resistance.

Characteristics of adults and children diagnosed with tuberculosis in Lilongwe, Malawi: findings from an integrated HIV/TB clinic.

OBJECTIVES: To describe initial registration characteristics of adult and paediatric TB patients at a large, public, integrated TB and HIV clinic in Lilongwe, Malawi, between January 2008 and December 2010. METHODS: Routine data on patient with TB category and TB type, stratified by HIV and ART status, were used to explore differences in proportions among TB only, TB/HIV co-infected patients not on ART and TB/HIV co-infected patients on ART using chi-square tests. Trends over time illustrate strengths and weaknesses of integrated service provision. RESULTS: Among 10 143 adults, HIV ascertainment and ART uptake were high and increased over time. The proportion of relapse was highest among those on ART (5%). The proportion of smear-positive pulmonary TB (PTB) was highest among HIV-negative patients with TB (34.9%); extra-pulmonary TB (EPTB) was lowest among TB only (16.2%). Among 338 children <15 years, EPTB and smear-positive PTB were more common among TB-only patients. Time trends showed significant increases in the proportion of adults with smear-positive PTB and the proportion of adults already on ART before starting TB treatment. However, some co-infected patients still delay ART initiation. CONCLUSIONS: HIV ascertainment and ART uptake among co-infected patients are successful and improving over time. However, delays in ART initiation indicate some weakness linking TB/HIV patients into ART during TB follow-up care. Improved TB diagnostics and screening efforts, especially for paediatric patients, may help improve quality care for co-infected patients. These results may aid efforts to prioritise TB and HIV prevention, education and treatment campaigns for specific populations.

Genetic diversity of Mycobacterium tuberculosis in Madang, Papua New Guinea.

SETTING: Madang and surroundings, Papua New Guinea (PNG). OBJECTIVE: To characterise the genetic diversity and drug susceptibility of Mycobacterium tuberculosis isolates collected in Madang and surroundings. DESIGN: M. tuberculosis was isolated from sputum samples from active pulmonary tuberculosis cases. Drug resistance profiles were obtained by drug susceptibility testing. M. tuberculosis lineages were identified by single nucleotide polymorphisms and sub-typing was performed by spoligotyping. Spoligotyping and 24 locus mycobacterial interspersed repetitive units-variable number of tandem repeats were combined to identify clustered isolates. RESULTS: The 173 M. tuberculosis isolates collected belonged predominantly to the Euro-American lineage (Lineage 4) and the East-Asian lineage (Lineage 2). Multidrug-resistant M. tuberculosis were observed in 5.2% of isolates. Lineage 2 M. tuberculosis, which includes the 'Beijing' genotype, was significantly associated with any drug resistance (OR 5.2, 95%CI 1.8-15.1). Cluster analyses showed 44% molecularly clustered isolates, suggesting transmission of M. tuberculosis in the community, including transmission of primary drug-resistant M. tuberculosis. CONCLUSION: These data provide the first insight into the molecular characteristics of M. tuberculosis in the Madang area of PNG, and indicate substantial drug resistance with evidence of ongoing transmission.

Tuberculosis in HIV programmes in lower-income countries: practices and risk factors.

BACKGROUND: Tuberculosis (TB) is a common diagnosis in human immunodeficiency virus (HIV) infected patients on antiretroviral treatment (ART). OBJECTIVE: To describe TB-related practices in ART programmes in lower-income countries and identify risk factors for TB in the first year of ART. METHODS: Programme characteristics were assessed using standardised electronic questionnaire. Patient data from 2003 to 2008 were analysed and incidence rate ratios (IRRs) calculated using Poisson regression models. RESULTS: Fifteen ART programmes in 12 countries in Africa, South America and Asia were included. Chest X-ray, sputum microscopy and culture were available free of charge in respectively 13 (86.7%), 14 (93.3%) and eight (53.3%) programmes. Eight sites (53.3%) used directly observed treatment and five (33.3%) routinely administered isoniazid preventive treatment (IPT). A total of 19 413 patients aged ≥ 16 years contributed 13,227 person-years of follow-up; 1081 new TB events were diagnosed. Risk factors included CD4 cell count (>350 cells/µl vs. <25 cells/µl, adjusted IRR 0.46, 95%CI 0.33-0.64, P < 0.0001), sex (women vs. men, adjusted IRR 0.77, 95%CI 0.68-0.88, P = 0.0001) and use of IPT (IRR 0.24, 95%CI 0.19-0.31, P < 0.0001). CONCLUSIONS: Diagnostic capacity and practices vary widely across ART programmes. IPT prevented TB, but was used in few programmes. More efforts are needed to reduce the burden of TB in HIV co-infected patients in lower income countries.

The giant anomalous Hall effect in the ferromagnet Fe3Sn2--a frustrated kagome metal.

The kagome-bilayer material Fe(3)Sn(2) has recently been shown to be an example of a rare class of magnet-a frustrated ferromagnetic metal. While the magnetism of Fe(3)Sn(2) appears to be relatively simple at high temperature, with localized moments parallel to the c-axis (T(C) = 640 K), upon cooling the competing exchange interactions and spin frustration become apparent as they cause the moments to become non-collinear and to rotate towards the kagome plane, forming firstly a canted ferromagnetic structure and then a re-entrant spin glass (T(f) approximately equal 80 K). In this work we show that Fe(3)Sn(2) possesses an unusual anomalous Hall effect. The saturated Hall resistivity of Fe(3)Sn(2) is 3.2 µΩ cm at 300 K, almost 20 times higher than that of typical itinerant ferromagnets such as Fe and Ni. The anomalous Hall coefficient R(s) is 6.7 × 10(-9) Ω cm G(-1) at 300 K, which is three orders of magnitude larger than that of pure Fe, and obeys an unconventional scaling with the longitudinal resistivity, ρ(xx), of R(s) is proportional to ρ(xx)(3.15). Such a relationship cannot be explained by either the conventional skew or side-jump mechanisms, indicating that the anomalous Hall effect in Fe(3)Sn(2) has an extraordinary origin that is presumed to be related to the underlying frustration of the magnetism. These findings demonstrate that frustrated ferromagnets, whether based on bulk materials or on artificial nanoscale structures, can provide new routes to room temperature spin-dependent electron transport properties suited to application in spintronics.

The preparation and storage of anaesthetic drugs for obstetric emergencies: a survey of UK practice.

BACKGROUND: Traditionally anaesthetic drugs for obstetrics are prepared as a contingency and stored until they are required for emergency use or have expired. Expiry is based on presumed reduction in sterility and efficacy although evidence for this is inconsistent. Preparation in advance introduces the risk of error and potential for tampering by a third party. Discarding and re-preparing drugs daily represents significant wastage with associated cost implications. We predicted that practice of drug preparation would differ widely across the UK, so conducted a national survey. METHOD: A postal questionnaire was sent to lead consultant obstetric anaesthetists at each of the 223 consultant-led UK obstetric units enquiring about the preparation of anaesthetic drugs for obstetric emergencies. RESULTS: The response rate was 75%; 87% of units routinely draw up emergency drugs, most commonly thiopental and succinylcholine. Only 10% routinely use commercially-prepared succinylcholine syringes, although a further 8% would use them if available. Thiopental is prepared by anaesthetists in 78% of units, operating department practitioners in 8% and pharmacy in <7% of cases. Drugs are changed every 24h in 80% of units and weekly in 6%. With one exception, all units changing drugs weekly use pharmacy-prepared thiopental. CONCLUSION: The majority of UK obstetric units routinely draw up emergency drugs every 24h. With conflicting evidence regarding sterility and efficacy this represents tremendous wastage and potential for drug error and tampering. We propose that nationwide introduction of commercially- and pharmacy-prepared drugs with long shelf lives would improve safety and cost effectiveness.

Non-collinearity and spin frustration in the itinerant kagome ferromagnet Fe(3)Sn(2).

Frustrated itinerant ferromagnets, with non-collinear static spin structures, are an exciting class of material as their spin chirality can introduce a Berry phase in the electronic scattering and lead to exotic electronic phenomena such as the anomalous Hall effect (AHE). This study presents a reexamination of the magnetic properties of Fe(3)Sn(2), a metallic ferromagnet, based on the two-dimensional kagome bilayer structure. Previously thought of as a conventional ferromagnet, we show using a combination of SQUID (superconducting quantum interference device) measurements, symmetry analysis and powder neutron diffraction that Fe(3)Sn(2) is a frustrated ferromagnet with a temperature-dependent non-collinear spin structure. The complexity of the magnetic interactions is further evidenced by a re-entrant spin glass transition ([Formula: see text] K) at temperatures far below the main ferromagnetic transition (T(C) = 640 K). Fe(3)Sn(2) therefore provides a rare example of a frustrated itinerant ferromagnet. Further, as well as being of great fundamental interest our studies highlight the potential of Fe(3)Sn(2) for practical application in spintronics technology, as the AHE arising from the ferromagnetism in this material is expected to be enhanced by the coupling between the conduction electrons and the non-trivial magnetic structure over an exceptionally wide temperature range.

Epidemiology of Clostridium difficile-associated disease at University Hospital Basel including molecular characterisation of the isolates 2006-2007.

A prospective study was conducted during a one-year period between 2006 and 2007 to describe the epidemiology of Clostridium difficile-associated disease (CDAD) at University Hospital Basel, Switzerland (UHBS) and to determine phenotypic and genotypic features of C. difficile strains isolated at the Microbiology Laboratory UHBS including strains from regional non-university hospitals. We prospectively identified 78 CDAD cases at UHBS with an incidence of 2.65/1,000 hospitalised patients or 2.3/10,000 patient-days. Sixteen patients (20.5%) were infected with clindamycin-resistant strains of PCR-ribotype 027 during an outbreak at the geriatric hospital. Among 124 single-patient isolates, 28 (22.6%) were resistant to moxifloxacin and 34 (27.4%) were resistant to clindamycin, but all remained susceptible to metronidazole and vancomycin. Of 102 toxigenic isolates, 19 (18.7%) had an 18-bp deletion in the tcdC gene, eight (7.8%) a 39-bp deletion, and one (1.0%) a 54-bp deletion. Genes for binary toxin were present in 27 (21.8%). PCR-ribotype 027 was associated with older age (median age 83.5 vs. 65.5 years, p < 0.0001) and longer duration of hospitalisation before onset of disease (median 15.5 vs. 9 days, p = 0.014) with a trend towards higher crude mortality, more severe disease, and previous use of macrolides compared to ribotype non-027. Overall, severe disease correlated with use of a nasogastric tube and surprisingly shorter duration of hospitalisation before onset of disease. Today, laboratory-based and epidemiological surveillance systems are required to monitor CDAD cases and emergence of new epidemic strains.

Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers.

OBJECTIVE: To evaluate the efficacy of a standardized regimen for decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers and to identify factors influencing decolonization treatment failure. DESIGN: Prospective cohort study from January 2002 to April 2007, with a mean follow-up period of 36 months. SETTING: University hospital with 750 beds and 27,000 admissions/year. PATIENTS: Of 94 consecutive hospitalized patients with MRSA colonization or infection, 32 were excluded because of spontaneous loss of MRSA, contraindications, death, or refusal to participate. In 62 patients, decolonization treatment was completed. At least 6 body sites were screened for MRSA (including by use of rectal swabs) before the start of treatment. INTERVENTIONS: Standardized decolonization treatment consisted of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days. Intestinal and urinary-tract colonization were treated with oral vancomycin and cotrimoxazole, respectively. Vaginal colonization was treated with povidone-iodine or, alternatively, with chlorhexidine ovula or octenidine solution. Other antibiotics were added to the regimen if treatment failed. Successful decolonization was considered to have been achieved if results were negative for 3 consecutive sets of cultures of more than 6 screening sites. RESULTS: The mean age (+/- standard deviation [SD]) age of the 62 patients was 66.2 +/- 19 years. The most frequent locations of MRSA colonization were the nose (42 patients [68%]), the throat (33 [53%]), perianal area (33 [53%]), rectum (36 [58%]), and inguinal area (30 [49%]). Decolonization was completed in 87% of patients after a mean (+/-SD) of 2.1 +/- 1.8 decolonization cycles (range, 1-10 cycles). Sixty-five percent of patients ultimately required peroral antibiotic treatment (vancomycin, 52%; cotrimoxazole, 27%; rifampin and fusidic acid, 18%). Decolonization was successful in 54 (87%) of the patients in the intent-to-treat analysis and in 51 (98%) of 52 patients in the on-treatment analysis. CONCLUSION: This standardized regimen for MRSA decolonization was highly effective in patients who completed the full decolonization treatment course.

Molecular epidemiology of invasive methicillin-susceptible Staphylococcus aureus strains circulating at a Swiss University Hospital.

In contrast to methicillin-resistant Staphylococcus aureus, little is known of the distribution of spa types among methicillin-susceptible S. aureus (MSSA). We have analyzed 101 nonrepetitive invasive MSSA isolates from infected patients, consecutively isolated during 14 months between 2006 and 2007 at University Hospital Basel. They were genetically characterized according to S. aureus protein A (spa) types and important virulence-associated genes. Sixty-five different spa types corresponding to nine different spa clonal complexes were observed. Analysis of different virulence genes showed a frequency of 17% for toxic-shock syndrome toxin and 5% for exfoliative toxin D. In conclusion, spa typing revealed a great genetic diversity without predominant spa type, not providing evidence for clonal spreading.

Marginal and subgingival plaque--a natural habitat of Tropheryma whipplei?

BACKGROUND: DNA of Tropheryma whipplei, the etiologic agent of Whipple's disease, has recently been detected in the saliva of healthy subjects. In this pilot study we searched for the habitat of T. whipplei within the oral cavity. MATERIALS AND METHODS: Samples from different oral sites were obtained from periodontically healthy volunteers, patients with progressive periodontitis and Chinese subjects with necrotizing ulcerative gingivitis or gingivitis. Quantitative real-time PCR was performed using T. whippleispecific primers, human beta-globin-specific primers to control for tissue DNA extraction and PCR reaction and broad-range eubacterial primers to control for bacterial DNA extraction. T. whipplei specificity of multiple amplicons was confirmed by sequencing. The detection limit of the method was 10 ag of T. whipplei DNA, corresponding to one to five bacteria under reference assay conditions. RESULTS: T. whipplei was found in the oral cavity of four out of ten healthy individuals from hospital staff and in three out of nine periodontitis patients, but in none of the individuals from China. All positive samples derived from subgingival and gingival sulcus plaque containing between 10(3) and 5 x 10(5) cells ml(-1) of plaque suspension, whereas saliva, smooth surface plaque and samples from the tongue or cheeks were negative. CONCLUSION: Our results suggest that T. whipplei colonizes the human body via the oral cavity and that bacterial plaques of the gingival crevice and the gingival sulcus/pocket may serve as a natural primary habitat.

Evidence of hepatitis in patients receiving transfusions of blood components containing antibody to hepatitis C.

When hepatitis C virus antibody (anti-HCV) enzyme immunoassay (EIA1) testing became available in 1990, we tested samples from previously transfused blood units, traced the recipients of reactive units, and evaluated the recipients for HCV infection during the 12 months after transfusion. Ten of 42 recipients of EIA1-reactive blood were anti-HCV reactive on follow-up by EIA1 and 12 were reactive by a second-generation assay (EIA2). Reverse transcriptase-polymerase chain reaction (RT-PCR) detected HCV RNA in 5 seronegative recipients. In all, 17 of 42 recipients (40%) of EIA1-reactive blood had evidence of HCV infection. In comparison, 54 surgery patients, who received either no transfusion or autologous EIA1-nonreactive blood, remained EIA1 nonreactive and RT-PCR negative for 1 year; 1 patient (1.8%) became EIA2 reactive (P < or = .01). Of the recipients of anti-HVC reactive blood transfusions (reactive by both EIA1 and a supplemental 4-antigen strip immunoblot assay [RIBA2]), 14 (93%) of the recipients had evidence of HCV infection compared with only 3 of 27 recipients (11%) of EIA1-reactive, RIBA2-nonreactive blood (P < or = .01). Thus, blood components reactive for anti-HCV EIA1 may have transmitted HCV up to 40% of the time, but blood components found reactive by both EIA1 and RIBA2 may transmit HCV with a frequency of greater than 90%.

Effect of neuraminidase on the adherence to salivary pellicle of Streptococcus sanguis and Streptococcus mitis.

Neuraminidase-sensitive adherence to experimental salivary pellicles was studied using eight strains of Streptococcus sanguis and five strains of Streptococcus mitis. Approximately 60% of the strains of each species showed significantly lower adherence to neuraminidase-treated versus untreated saliva-coated hydroxyapatite. In addition, the adherence of several of these streptococcal strains to saliva-coated hydroxyapatite and neuraminidase-treated saliva-coated hydroxyapatite was inhibited using galactose and N-acetyl-D-galactosamine. Results from these studies suggested that several salivary receptors mediate adherence of these species.

Utilization of a continuous streptococcal surface to measure interbacterial adherence in vitro and in vivo.

Cell-to-cell interactions are essential for the formation of dental plaque. A continuous layer of Streptococcus sanguis SA-1 cells fixed to a solid surface has been used to evaluate interactions among this bacterium, Haemophilus parainfluenzae, and Streptococcus sobrinus. S. sanguis cells were attached to a Falcon 3001 tissue culture plates or bovine enamel chips, coated with a biological adhesive. Scanning electron microscopy of the chips showed the streptococci as a contiguous surface. Radiolabeled bacteria were used to measure a second-species interbacterial adherence to the streptococcal-coated culture plates. Strains of H. parainfluenzae known to coaggregate (strain HP-28) and not to coaggregate (strains HP-42 and HP-80), in suspension with S. sanguis strain SA-1, were studied for adherence. Ten-fold-higher numbers of coaggregating strain HP-28 adhered in vitro to the streptococcal layer than did the non-coaggregating strains. S. sobrinus strain 6715 did not show appreciable adherence to the S. sanguis surface. Saliva did not affect the adherence of coaggregating or non-coaggregating H. parainfluenzae strains to S. sanguis strain SA-1. Bovine enamel chips, coated with streptococci, mounted on modified orthodontic appliances and placed in the mouths of three volunteers, facilitated the measurement of interbacterial adherence in vivo of streptomycin-resistant strains of H. parainfluenzae (HP-28R or HP-42R). Suspensions of bacteria were placed into the mouth, distributed throughout, and expectorated. After 15 or 120 minutes, the appliance with the chips was removed, the chips sonified, and colony-forming units (CFU) of streptomycin-resistant haemophili determined per chip.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute haematogenous osteomyelitis: II. The effect of a metaphyseal abscess on the surrounding blood supply.

Three major vessel types--metaphyseal, epiphyseal and transphyseal vessels--were identified in the region of the growth plate following perfusion of the vasculature of the chicken leg with a solution of Berlin Blue. Following the production of osteomyelitis, obstruction to the blood supply adjacent to the abscess was rapid and was clearly demonstrated due to a lack of perfusion of the involved vessels with Berlin Blue. The extent of disturbance to the blood supply was dependent on the type of vessel involved in the inflammatory process. The efficacy of bloodstream therapy is discussed in relation to these findings.