Impact of intensified case-finding strategies on childhood TB case registration in Nepal.

SETTING: Seven intervention districts with intensified childhood tuberculosis (TB) case-finding strategies implemented by a non-governmental organisation and seven control districts under the National Tuberculosis Programme, Nepal. OBJECTIVES: To assess the differences in childhood TB case registrations and case registration rates per 100 000 population between two time periods (Year 1 = March 2012-March 2013 and Year 2 = March 2013-March 2014) in intervention and control districts. DESIGN: Retrospective record review using routinely collected data. RESULTS: Childhood TB cases increased from 271 to 360 between Years 1 and 2 in the intervention districts (case registration rate from 18.2 to 24.2/100 000) and from 97 to 113 in the control districts (13.4 to 15.6/100 000): the increases were significantly higher in the intervention districts compared with the control districts. The increases were also significantly higher in children aged 0-4 years and in those with smear-negative pulmonary TB and extra-pulmonary TB. Of the various case-finding strategies, household contact screening, private-public mix services and mobile health chest camps produced the highest yield of TB. CONCLUSION: A package of intensified case-finding strategies in children was associated with an increase in childhood TB case registrations in Nepal. Additional diagnostic approaches to increase case registrations also need to be considered.

Contexte : Sept districts d'intervention avec des stratégies intensifiées de recherche active des cas de tuberculose (TB) mis en œuvre par une organisation non gouvernementale et sept districts témoins gérés par le Programme National Tuberculose au Népal.Objectifs : Evaluer les différences en termes d'enregistrement des cas de TB de l'enfant et de taux d'enregistrement pour 100 000 population entre deux périodes (année 1 = mars 2012 à mars 2013 et année 2 = mars 2013 à mars 2014) dans les districts d'intervention et les districts témoins.Schéma : Revue de dossiers rétrospective grâce aux données recueillies en routine.Résultats : Les cas de TB de l'enfant ont augmenté de 271 à 360 entre l'année 1 et l'année 2 dans les districts d'intervention (le taux d'enregistrement est passé de 18,2 à 24,2/100 000) et de 97 à 113 dans les districts témoins (13,4 à 15,6/100 000) : les augmentations ont été significativement plus importantes dans les districts d'intervention par rapport aux districts témoins. Les augmentations ont également été plus importantes chez les enfants de 0 à 4 ans et chez ceux qui ont eu une TB pulmonaire à frottis négatif et extra-pulmonaire. Parmi diverses stratégies de recherche des cas, le dépistage des contacts familiaux, les services conjoints privés-publics et les camps de santé mobiles pour la TB ont été les plus performants.Conclusion : Un paquet de stratégies intensifiées de recherche des cas a été associé à une augmentation des enregistrements de cas de TB de l'enfant au Népal. Il faut également envisager des approches diagnostiques supplémentaires pour augmenter encore l'enregistrement des cas.

Marco de referencia: Siete distritos de intervención en los cuales una organización no gubernamental aplica estrategias de búsqueda intensificada de casos de tuberculosis (TB) en los niños y siete distritos testigos del Programa Nacional contra la Tuberculosis de Nepal.Objetivos: Evaluar las diferencias en el registro de los casos de TB en la niñez y la tasa de registro de TB por 100 000 habitantes, en dos períodos (el primer año, de marzo del 2012 a marzo del 2013 y el segundo, de marzo del 2013 a marzo del 2014) en los distritos de intervención y los distritos testigos.Método: Fue este un estudio retrospectivo en el cual se analizaron los datos recogidos de manera sistemática.Resultados: Los casos de TB en la niñez aumentaron de 271 a 360 durante los períodos del estudio en los distritos de intervención (tasa de registro de casos de 18,2 a 24,2/100 000) y de 97 a 113 en los distritos testigos (de 13,4 a 15,6/100 000) y el incremento de los casos fue significativamente mayor en los distritos de intervención. Se observó un aumento con significación estadística en los niños del grupo de 0 a 4 años de edad, en los niños con TB pulmonar y baciloscopia negativa y con TB extrapulmonar. De las diferentes estrategias de búsqueda de casos, la detección sistemática de los contactos domiciliarios, los servicios mixtos público y privado y los puestos móviles de campaña de salud respiratoria alcanzaron el mayor rendimiento diagnóstico de TB.Conclusión: La introducción de un conjunto de estrategias de búsqueda intensificada de casos en los niños se asoció con un aumento en el registro de los casos de TB en Nepal. Se precisa también examinar la posibilidad de aplicar nuevos enfoques diagnósticos con el propósito de mejorar el registro de casos.

Spread of imipenem-resistant Acinetobacter baumannii co-expressing OXA-23 and GES-11 carbapenemases in Lebanon.

OBJECTIVES: The acquisition of carbapenemases by Acinetobacter baumannii is reported increasingly worldwide, but data from Lebanon are limited. The aims of this study were to evaluate the prevalence of imipenem-resistant A. baumannii in Lebanon, identify resistance determinants, and detect clonal relatedness. METHODS: Imipenem-resistant A. baumannii were collected from nine Lebanese hospitals during 2012. Antimicrobial susceptibility, the cloxacillin effect, and ethylenediaminetetraacetic acid (EDTA) synergy were determined. Genes encoding carbapenemases and insertion sequence ISAba1 were screened via PCR sequencing. ISAba1 position relative to genes encoding Acinetobacter-derived cephalosporinases (ADCs) and OXA-23 was studied by PCR mapping. Clonal linkage was examined by enterobacterial repetitive intergenic consensus PCR (ERIC-PCR). RESULTS: Out of 724 A. baumannii isolated in 2012, 638 (88%) were imipenem-resistant. Of these, 142 were analyzed. Clavulanic acid-imipenem synergy suggested carbapenem-hydrolyzing extended-spectrum ß-lactamase. A positive cloxacillin test indicated ADCs, while EDTA detection strips were negative. Genotyping indicated that 90% of isolates co-harbored blaOXA-23 and blaGES-11. The remaining strains had blaOXA-23, blaOXA-24, blaGES-11, or blaOXA-24 with blaGES-11. ISAba1 was located upstream of blaADC and blaOXA-23 in 97% and 100% of isolates, respectively. ERIC-PCR fingerprinting revealed 18 pulsotypes spread via horizontal gene transfer and clonal dissemination. CONCLUSION: This survey established baseline evidence of OXA-23 and GES-11-producing A. baumannii in Lebanon, indicating the need for further surveillance.

Countrywide spread of OXA-48 carbapenemase in Lebanon: surveillance and genetic characterization of carbapenem-non-susceptible Enterobacteriaceae in 10 hospitals over a one-year period.

OBJECTIVES: To detect, characterize, and assess the genetic clonality of carbapenem-non-susceptible Enterobacteriaceae in 10 Lebanese hospitals in 2012. METHODS: Selected Enterobacteriaceae isolates with reduced susceptibility to carbapenems were subject to phenotypic study including antibiotic susceptibility, cloxacillin effect, modified Hodge test, and activity of efflux pump inhibitor. Carbapenemase genes were detected using PCR; clonal relatedness was studied by pulsed field gel electrophoresis. RESULTS: Out of 8717 Enterobacteriaceae isolated in 2012, 102 (1.2%) showed reduced susceptibility to carbapenems. Thirty-one (70%) of the 44 studied clinical isolates harbored blaOXA-48, including 15 Klebsiella pneumoniae, eight Escherichia coli, four Serratia marcescens, three Enterobacter cloacae, and one Morganella morganii. The majority of OXA-48 producers co-secreted an extended-spectrum beta-lactamase, while one had an acquired AmpC of the ACC type. In the non-OXA-48 producers, carbapenem resistance was attributed to the production of acquired AmpC cephalosporinases of MOX or CIT type, outer membrane impermeability, and/or efflux pump overproduction. DNA fingerprints revealed that OXA-48 producers were different, except for clonal relatedness among four K. pneumoniae, two E. coli, two E. cloacae, and three S. marcescens. CONCLUSIONS: Nosocomial carbapenem-non-susceptible Enterobacteriaceae are moderately spread in Lebanon and the predominant mechanism is OXA-48 production.

Calcitriol (1,25-dihydroxycholecalciferol) enhances mast cell tumour chemotherapy and receptor tyrosine kinase inhibitor activity in vitro and has single-agent activity against spontaneously occurring canine mast cell tumours.

Calcitriol potentiates the effect of multiple chemotherapy agents in a variety of tumour models. In this study, we examine whether calcitriol increases chemotherapy or tyrosine kinase inhibitor in vitro cytotoxicity in canine mastocytoma C2 cells. We also evaluate the in vivo effect of DN101, a highly concentrated oral formulation of calcitriol designed specifically for cancer therapy, as a single-agent therapy in dogs with mast cell tumours (MCTs). Calcitriol exhibits synergistic, antiproliferative activity when used in combination with CCNU, vinblastine, imatinib or toceranib in vitro. The concentrations required for 50% growth inhibition were generally two- to six-fold lower when the drugs were used in combination than when used individually. High-dose oral calcitriol induced remission in 4 of 10 dogs (one complete remission, three partial remissions), although the majority experienced toxicity, necessitating discontinuation of the trial. Further evaluation of calcitriol in combination therapy for dogs with MCTs is warranted.

Phase II open-label study of single-agent hydroxyurea for treatment of mast cell tumours in dogs.

This prospective study evaluated the efficacy and safety of hydroxyurea (HU) in dogs with measurable mast cell tumours (MCTs). Dogs were treated with HU at 60 mg kg(-1)per os q24h for 14 days then 30 mg kg(-1) q24h thereafter or until MCT recurrence. Forty-six dogs were enrolled. The overall response rate was 28%. Two dogs had a complete response (CR) for 256 and 448 days, respectively. Eleven dogs had a partial response for a median duration of 46 days (range, 28-189 days). Grade 2 to 4 neutropenia occurred in eight dogs and grade 4 thrombocytopenia in two. Grade 3-4 anaemia occurred in seven dogs; overall, there was a significant decrease in haematocrit after treatment with HU. The median drop in haematocrit was 10%. This study demonstrated that HU has activity in the treatment of MCTs with mild anaemia being the primary adverse event.

Evaluation of dexamethasone as a chemoprotectant for CCNU-induced bone marrow suppression in dogs.

In mice and people, administering corticosteroids before chemotherapy can reduce the severity of myelosuppression without reducing antitumour effects. This study investigated whether pretreatment with dexamethasone would reduce the incidence of grade 4 neutropenia in dogs receiving CCNU. Twenty-five dogs received dexamethasone [0.1 mg kg(-1) per os (PO) every 12 h] for 5 days and on the sixth day received CCNU (90 mg m(-2) PO). Historical dogs (n = 67) received CCNU alone (90 mg m(-2) PO). Forty-five percent of historical dogs had grade 4 neutropenia, while 64% of dogs pretreated with dexamethasone had grade 4 neutropenia (P = 0.16). Dexamethasone plasma levels were quantified by enzyme-linked immunosorbent assay in three healthy dogs. Peak plasma concentrations after a single oral 0.1-mg kg(-1) dose were <80 ng mL(-1), the minimum level associated with chemoprotective effects of dexamethasone in people. Pretreatment with dexamethasone did not reduce the incidence of grade 4 neutropenia in dogs receiving CCNU.

Combination of CCNU and DTIC chemotherapy for treatment of resistant lymphoma in dogs.

BACKGROUND: Pleotropic-glycoprotein (P-gp)-mediated resistance is the usual cause of relapse in dogs with lymphoma. 1-(2-chloroethyl)3-cyclohexyl-1-nitrosurea (CCNU) and 5-(3,3-dimethyl-1-triazeno)-imidazole-4-carboxamide (DTIC) are alkylating agents that are not affected by P-gp and lack cross-resistance to each other. A combination protocol offers the advantage of improved summation dose and synergistic activity. HYPOTHESIS: A combination of CCNU and DTIC that is well tolerated can be used to treat dogs with lymphoma that developed resistance or failed to respond to previously administered chemotherapy. ANIMALS: Fifty-seven dogs with lymphoma that were resistant to treatment with standard chemotherapy (L-CHOP; L-asparaginase, cyclophosphamide, doxorubicin, vincristine, prednisone). METHODS: Prospective phase I and II trials were performed. CCNU was given PO immediately before a 5-h IV infusion of DTIC. Concurrent antiemetics and prophylactic antibiotics were used. Treatments were administered every 4 weeks. RESULTS: Based on the results of 8 dogs in the phase I study, CCNU at 40 mg/m(2) PO combined with DTIC at 600 mg/m(2) IV was used to treat 57 dogs with resistant lymphoma. Thirteen (23%) dogs had a complete response (CR) for a median of 83 days and 7 (12%) had a partial response for a median of 25 days. The median L-CHOP CR duration of the dogs that did not respond to CCNU-DTIC was significantly longer than that of the dogs that did achieve remission with CCNU-DTIC (225 days versus 92 days, P= .02). The principal toxic event was neutropenia; the median neutrophil count 7 days after treatment was 1,275 cells/microL. Increases in alanine transaminase activity, possibly associated with hepatotoxicity, were detected in 7 dogs. CONCLUSIONS AND CLINICAL IMPORTANCE: A combination of CCNU and DTIC can be an effective option to rescue dogs with resistant lymphoma.

Use of carboplatin for treatment of dogs with malignant melanoma: 27 cases (1989-2000).

OBJECTIVE: To evaluate response rate and duration of malignant melanomas in dogs treated with carboplatin. DESIGN: Retrospective study. ANIMALS: 27 client-owned dogs with spontaneously occurring measurable malignant melanomas. PROCEDURE: Records of dogs with melanomas treated with carboplatin from October 1989 to June 2000 were reviewed. Carboplatin was administered IV at doses of 300 or 350 mg/m2 of body surface area. Response to treatment and evidence of drug toxicity were determined. RESULT: Response to treatment could be evaluated in 25 dogs. Of those, overall response rate was 28%. One dog had a complete response, 6 (24%) dogs had a partial response (> 50% reduction in tumor burden). Median duration of partial response was 165 days. Eighteen dogs had stable disease (n = 9; 36%) or progressive disease (9; 36%). Response to treatment was significantly associated with carboplatin dose on a milligram per kilogram basis (15.1 mg/kg 16.9 mg/lb] of body weight vs 12.6 mg/kg [5.7 mg/lb]). Evidence of gastrointestinal toxicosis could be assessed in 27 dogs. Mean body weight of 5 dogs that developed gastrointestinal toxicosis was significantly less than that of 22 dogs without gastrointestinal toxicosis (9.9 kg [21.8 lb] vs 19.3 kg [42.5 lb]). CONCLUSIONS AND CLINICAL RELEVANCE: Carboplatin had activity against macroscopic spontaneously occurring malignant melanomas in dogs and should be considered as an adjunctive treatment for microscopic local or metastatic tumors. Gastrointestinal toxicosis was associated with body weight. Because small dogs are more likely to have adverse gastrointestinal effects, gastrointestinal protectants should be considered for these patients.

A prospective study of radiation therapy for the treatment of grade 2 mast cell tumors in 32 dogs.

Surgery, chemotherapy, and irradiation have been used singly or in combination to treat dogs with cutaneous grade-2 mast cell tumors (MCT). However, optimal treatment has not been established. At The Animal Medical Center, 32 dogs with grade 2, stage 0 MCT received cobalt radiation treatment to a dose of 54 Gy; 94% had a disease-free interval of 1 year. The 2-,3-,4-, and 5-year disease-free intervals were 86%. Survival rates were 100% for 1 year and 96% for 2 to 5 years, with only 1 death caused by MCT. Primary site was not a prognostic factor for survival in this study. Minimal toxicity was observed and was limited to acute cutaneous reactions. Late-term reactions to radiation therapy were mild and considered acceptable in all cases. No deaths occurred due to treatment, and no dog was eliminated from the study because of radiation therapy toxicity. Radiation therapy appears to be an effective treatment for dogs with grade 2, stage 0 MCT.

Radioprotection of DNA in isolated nuclei by naturally occurring thiols at intermediate oxygen tension.

Incubation of isolated Chinese hamster ovary cell nuclei, equilibrated in an atmosphere containing 2% O2, with glutathione, cysteine, or cysteamine resulted in a decrease in the number of X-ray-induced DNA double-strand breaks (DSBs), determined by pH 9.0 filter elution. In the absence of exogenous thiol, no sensitization was observed with the addition of N-ethylmaleimide, indicating that endogenous thiols were not present at significant levels. Protection by 0.3 mM glutathione was not enhanced by the addition of exogenous glutathione S-transferases or by glutathione peroxidase. The data were analyzed according to a simple competition model with various hypotheses. Cysteamine was more than an order of magnitude more effective than the other thiols tested, on a molar basis, in preventing DSB formation. Depending on the hypothesis used to evaluate the data, glutathione was either much less effective, on a molar basis, in preventing the bulk of the DSBs or was capable of preventing only approximately 55% of the damage, regardless of concentration. These data suggest that natural thiols other than glutathione may contribute to cellular radioprotection even if their concentration is much lower than that of glutathione. The data also suggest that despite the relative inefficiency of glutathione as a radioprotector, some areas of oxygenated tissues--where the oxygen tension falls below 2%--may be protected by glutathione concentrations in the physiological range of 3-20 mM.

Elevation of mouse kidney thiol content following administration of glutathione.

We have found that kidney glutathione and cysteine content in C3H mice can be increased by intraperitoneal administration of either glutathione (GSH) or glutathione disulfide (GSSG). Kidney thiol content is maximal 20-60 min after administration of 1000 mg/kg glutathione and returns to normal values by 2 h. The same time-course of thiol perturbation was observed when acivicin, an inhibitor of gamma-glutamyl transpeptidase, was administered 15 min prior to GSSG administration. The increase in kidney thiols after GSSG administration appears to saturate, with little additional increase as the administered dose is increased above 750 mg/kg. There was no significant change in liver GSH or cysteine after GSSG administration. We suggest that glutathione administration may provide a strategy for selective radioprotection or chemoprotection of specialized cells which can effectively utilize systemic GSH precursors.