Finding the missing children for TB care and prevention in Kenya.

SETTING: One hundred high TB burden facilities in nine counties in Kenya.OBJECTIVES: 1) To increase uptake of TB preventive therapy (TPT) among child contacts aged <5 years, and 2) to increase TB diagnosis in children aged <15 years presenting to health facilities for routine care.DESIGN: For objective 1, a clinic-based child contact management strategy incorporating transport/healthcare cost reimbursement, monitoring and evaluation tools, and healthcare worker education was utilized. For objective 2, community health screeners were established in pediatric outpatient departments to perform verbal screening, flagging symptomatic children for further evaluation.RESULTS: Over 15 months, identification of 8,060 individuals diagnosed with bacteriologically confirmed TB led to 2,022 child contacts. Of these, 1,848 (91%) were evaluated; 149 (8%) were diagnosed with TB disease, leaving 1,699 (92%) eligible for TPT; 1,613 (95%) initiated TPT and 1,335 (83%) completed TPT. In outpatient settings, 140,444 children were screened; 54,236 (39%) had at least two TB symptoms; 2,395 (4%) were diagnosed with TB diseaseCONCLUSION: Health system strengthening supporting a clinic-based child contact management program increased the number of children initiating TPT. Systematic screening in outpatient clinics can lead to increased TB case notifications; however, optimal screening tools and clearer diagnostic pathways for the evaluation of these children are needed.

Improving TB case notification and treatment coverage through data use.

BACKGROUND: This was a study on national TB data. OBJECTIVE: To assess improvement in TB case notification and treatment coverage through improved data use for action in Nigeria. DESIGN: We analysed pre- and post-intervention secondary TB programme data comprising data on increased supervisory visits, incentives for health workers, DOTS expansion, outreaches and geo-code monitoring. Trend analysis was performed using Cochran-Armitage χ2 test for linear trends. RESULTS: Case-finding increased from 104,904 cases in 2017 to 138,591 in 2020. There was an increase of 2.0% from 2017 to 2018, 13.0% in 2018 to 2019 and 15.0% in 2019 to 2020 (P < 0.001). Facility DOTS coverage increased from 7,389 facilities in 2017 to 17,699 in 2020. There was an increase of 30.0% in 2018, 31.0% in 2019 and 40.0% in 2020 (P < 0.001). The number of reporting facilities increased from 5,854 in 2017 to 12,775 in 2020. Compared with 2017, there were an increase of 20.0% in 2018, 38.0% in 2019 and 32.0% in 2020 (P < 0.001). Treatment coverage rate increased from 24% in 2018 to 27% in 2019 and 30% in 2020. CONCLUSION: TB service expansion, improved monitoring and the use of data for decision making are key in increasing TB treatment coverage.

CONTEXTE: Il s'agit d'une étude sur les données nationales relatives à la TB. OBJECTIF: Évaluer l'amélioration de la notification des cas de TB et de la couverture du traitement grâce à une meilleure utilisation des données pour l'action au Nigéria. MÉTHODE: Nous avons analysé les données du programme secondaire de lutte contre la TB avant et après l'intervention, y compris les données sur l'augmentation des visites de supervision, les mesures incitatives pour les travailleurs de la santé, l'expansion du système DOTS, les activités de proximité et la surveillance des codes géographiques. L'analyse des tendances a été réalisée à l'aide du test du χ2 de Cochran-Armitage pour les tendances linéaires. RÉSULTATS: La recherche de cas est passée de 104 904 cas en 2017 à 138 591 en 2020. On observe une augmentation de 2,0% de 2017 à 2018, de 13,0% de 2018 à 2019 et de 15,0% de 2019 à 2020 (P < 0,001). La couverture DOTS des établissements est passée de 7 389 établissements en 2017 à 17 699 en 2020. On observe une augmentation de 30,0% en 2018, 31,0% en 2019 et 40,0% en 2020 (P < 0,001). Le nombre d'installations déclarantes est passé de 5 854 en 2017 à 12 775 en 2020. Par rapport à 2017, il y a eu une augmentation de 20,0% en 2018, 38,0% en 2019 et 32,0% en 2020 (P < 0,001). Le taux de couverture du traitement est passé de 24% en 2018 à 27% en 2019 et 30% en 2020. CONCLUSION: L'expansion des services de lutte contre la TB, l'amélioration de la surveillance et l'utilisation des données pour la prise de décision sont essentielles pour augmenter la couverture du traitement de la TB.

TB training in Kenya: building capacity for care and prevention.

BACKGROUND: Devolution of healthcare services in Kenya resulted in a large number of newly recruited tuberculosis (TB) coordinators. We describe a unique collaboration between a national tuberculosis program (NTP), a local, and an international non-governmental organization to build human resource capacity in TB care and prevention. METHODS: From 2016 to 2021, the Kenya Division of National Tuberculosis, Leprosy and Lung Disease Program, Centre for Health Solutions-Kenya, and the International Union Against Tuberculosis and Lung Disease developed and conducted a series of 7-day training courses. A key focus of training was the introduction of TBData4Action, an approach involving the local use of routinely available data to strengthen decision-making and support supervision. RESULTS: Implementation outcomes included training 331 (96%) coordinators out of 344, representing all 47 counties, 37 national officers and 21 other stakeholders using the country-tailored curriculum, including hands-on group work by county teams and field practicals. Thirty-five national facilitators were identified and mentored as local faculty. Training costs were reduced by 75% compared with international alternatives. CONCLUSION: The collaboration resulted in the training of the majority of the coordinators in a standardized approach to TB care. A sustainable approach to capacity building in local data use was found feasible; the model could be adapted by other NTPs.

CONTEXTE: La décentralisation des services de santé au Kenya a conduit au recrutement d'un grand nombre de nouveaux coordinateurs TB. Nous décrivons une collaboration unique entre un programme national de lutte contre la TB (NTP), une organisation non gouvernementale locale et une organisation non gouvernementale internationale visant à renforcer les capacités humaines en matière de prévention et de soins de la TB. MÉTHODES: De 2016 à 2021, la division kényane du programme national de lutte contre la tuberculose, la lèpre et les maladies respiratoires, le Centre for Health Solutions-Kenya et l'Union internationale contre la tuberculose et les maladies respiratoires ont développé et dispensé une série de formations en 7 jours. La formation mettait l'accent sur l'introduction de l'approche TBData4Action, qui promeut une utilisation locale des données disponibles en routine afin de renforcer la prise de décision et d'épauler les activités de supervision. RÉSULTATS: Les résultats de la mise en place de cette formation comprenaient la formation de 331 (96%) coordinateurs sur 344, représentant l'ensemble des 47 pays, 37 administrateurs nationaux et 21 autres acteurs formés à l'aide du programme adapté aux besoins du pays concerné (dont travail de groupe pratique par les équipes nationales et travaux pratiques sur le terrain). Trente-cinq facilitateurs nationaux ont été identifiés et formés comme enseignants locaux. Les coûts de la formation ont été réduits de 75% par rapport aux alternatives internationales. CONCLUSION: La collaboration a permis de former la majorité des coordinateurs à l'aide d'une approche standardisée de soins de la TB. Une approche durable de renforcement des capacités en matière d'utilisation des données locales s'est avérée réalisable. Ce modèle peut être adapté à d'autres NTP.

Can isoniazid preventive therapy be scaled up rapidly? Lessons learned in Kenya, 2014-2018.

BACKGROUND: TB is the leading cause of mortality among people living with HIV (PLHIV), for whom isoniazid preventive therapy (IPT) has a proven mortality benefit. Despite WHO recommendations, countries have been slow in scaling up IPT. This study describes processes, challenges, solutions, outcomes and lessons learned during IPT scale-up in Kenya.METHODS: We conducted a desk review and analyzed aggregated Ministry of Health (MOH) IPT enrollment data from 2014 to 2018 to determine trends and impact of program activities. We further analyzed IPT completion reports for patients initiated from 2015 to 2017 in 745 MOH sites in Nairobi, Central, Eastern and Western Kenya.RESULTS: IPT was scaled up 75-fold from 2014 to 2018: the number of PLHIV covered increased from 9,981 to 749,890. The highest percentage increases in the cumulative number of PLHIV on IPT were seen in the quarters following IPT pilot projects in 2014 (49%), national launch in 2015 (54%), and HIV treatment acceleration in 2016 (158%). Among 250,069 patients initiating IPT from 2015 to 2017, 97.5% completed treatment, 0.2% died, 0.8% were lost to follow-up, 1.0% were not evaluated, and 0.6% discontinued treatment.CONCLUSIONS: IPT can be scaled up rapidly and effectively among PLHIV. Deliberate MOH efforts, strong leadership, service delivery integration, continuous mentorship, stakeholder involvement, and accountability are critical to program success.

Variability in distribution and use of tuberculosis diagnostic tests in Kenya: a cross-sectional survey.

BACKGROUND: Globally, 40% of all tuberculosis (TB) cases, 65% paediatric cases and 75% multi-drug resistant TB (MDR-TB) cases are missed due to underreporting and/or under diagnosis. A recent Kenyan TB prevalence survey found that a significant number of TB cases are being missed here. Understanding spatial distribution and patterns of use of TB diagnostic tests as per the guidelines could potentially help improve TB case detection by identifying diagnostic gaps. METHODS: We used 2015 Kenya National TB programme data to map TB case notification rates (CNR) in different counties, linked with their capacity to perform diagnostic tests (chest x-rays, smear microscopy, Xpert MTB/RIF®, culture and line probe assay). We then ran hierarchical regression models for adults and children to specifically establish determinants of use of Xpert® (as per Kenyan guidelines) with county and facility as random effects. RESULTS: In 2015, 82,313 TB cases were notified and 7.8% were children. The median CNR/100,000 amongst 0-14yr olds was 37.2 (IQR 20.6, 41.0) and 267.4 (IQR 202.6, 338.1) for ≥15yr olds respectively. 4.8% of child TB cases and 12.2% of adult TB cases had an Xpert® test done, with gaps in guideline adherence. There were 2,072 microscopy sites (mean microscopy density 4.46/100,000); 129 Xpert® sites (mean 0.31/100,000); two TB culture laboratories and 304 chest X-ray facilities (mean 0.74/100,000) with variability in spatial distribution across the 47 counties. Retreatment cases (i.e. failures, relapses/recurrences, defaulters) had the highest odds of getting an Xpert® test compared to new/transfer-in patients (AOR 7.81, 95% CI 7.33-8.33). Children had reduced odds of getting an Xpert® (AOR 0.41, CI 0.36-0.47). HIV-positive individuals had nearly twice the odds of getting an Xpert® test (AOR 1.82, CI 1.73-1.92). Private sector and higher-level hospitals had a tendency towards lower odds of use of Xpert®. CONCLUSIONS: We noted under-use and gaps in guideline adherence for Xpert® especially in children. The under-use despite considerable investment undermines cost-effectiveness of Xpert®. Further research is needed to develop strategies enhancing use of diagnostics, including innovations to improve access (e.g. specimen referral) and overcoming local barriers to adoption of guidelines and technologies.

Impact of a national nutritional support programme on loss to follow-up after tuberculosis diagnosis in Kenya.

SETTING: Undernourishment is prevalent among tuberculosis (TB) patients. Nutritional support is given to TB patients to prevent and treat undernourishment; it is also used to improve treatment outcomes and as an incentive to keep patients on treatment. OBJECTIVE: To determine whether nutritional support is associated with a reduction in the risk of loss to follow-up (LTFU) among TB patients in Kenya. DESIGN: This was a retrospective cohort study using national programmatic data. Records of 362 685 drug-susceptible TB patients from 2012 to 2015 were obtained from Treatment Information from Basic Unit (TIBU), a national case-based electronic data recording system. Patients who were LTFU were compared with those who completed treatment. RESULTS: Nutrition counselling was associated with an 8% reduction in the risk of LTFU (RR 0.92, 95%CI 0.89-0.95), vitamins were associated with a 7% reduction (adjusted RR [aRR] 0.93, 95%CI 0.90-0.96) and food support was associated with a 10% reduction (aRR 0.90, 95%CI 0.87-0.94). Among patients who received food support, the addition of nutrition counselling was associated with a 23% reduction in the risk of LTFU (aRR 0.77, 95%CI 0.67-0.88). CONCLUSION: Nutritional support was associated with a reduction in the risk of LTFU. Providing nutrition counselling is important for patients receiving food support.

Diabetes and pre-diabetes in tuberculosis patients in western Kenya using point-of-care glycated haemoglobin.

Setting: The tuberculosis (TB) clinics of five health facilities in western Kenya. Objective: To assess the prevalence and associated determinants of diabetes mellitus (DM) and pre-diabetes hyperglycaemia among adult TB patients using point-of-care DCA Vantage glycated haemoglobin (HbA1c) devices. Design: This was a cross-sectional study. Results: Of 454 patients, 272 (60%) were males, the median age was 34 years, 175 (39%) were co-infected with the human immunodeficiency virus (HIV), and the median duration of anti-tuberculosis treatment was 8 weeks; 180 (40%) patients reported at least one classical symptom suggestive of DM. The prevalence of DM (HbA1c ⩾6.5%) was 5.1% (95%CI 3.2-7.5), while that of pre-diabetes (HbA1c 5.7-6.4%) was 37.5% (95%CI 33.1-42.2). The number needed to screen (NNS) was 19.6 for DM and 2.7 for pre-diabetes. Combined, 42.6% (95%CI 38.0-47.3) of the patients had either pre-diabetes or DM (NNS 2.3). Seven of the 23 patients with DM knew their prior DM status. Higher rates of DM were associated with age ⩾40 years and a family history of DM, but not obesity, type of TB, HIV status or suggestive symptoms. Conclusions: High rates of pre-diabetes and DM were found in adult TB patients. This study supports the need for routine screening of all patients with TB for DM in Kenya.

Contexte: Centres tuberculose (TB) de cinq structures de santé dans l'Ouest du Kenya.Objectif: Evaluer la prévalence et les déterminants associés du diabète (DM) et de l'hyperglycémie pré-diabète chez des patients adultes atteints de TB grâce aux appareils DCA Vantage de dosage d'hémoglobine glyquée (HbA1c) utilisés sur place.Schéma: Une étude transversale.Résultats: Sur 454 patients, 272 (60%) ont été des hommes, leur âge médian a été de 34 ans et 175 (39%) ont été co-infectés par le virus de l'immunodéficience humaine (VIH) ; la durée médiane du traitement de la TB a été de 8 semaines et 180 (40%) patients ont fait état d'au moins un symptôme classique suggérant un DM. La prévalence du DM (HbA1c ⩾ 6,5%) a été de 5,1% (IC95% 3,2­7,5) tandis que celle du pré-diabète (HbA1c 5,7­6,4%) a été de 37,5% (IC95% 33,1­422). Le nombre de dépistages requis (NNS) a été de 19,6 pour diagnostiquer un DM et de 2,7 pour un pré-diabète. En combinant les deux, 42,6% (IC95% 38,0­47,3) des patients avaient soit un pré-diabète soit un DM (NNS 2,3). Sept des 23 patients atteints de DM étaient au courant de leur statut. Des taux de DM plus élevés ont été associés avec un âge ⩾ 40 ans et des antécédents de DM dans la famille, mais pas avec l'obésité, le type de TB, le statut du VIH ou des symptômes suggestifs du VIH.Conclusions: Des taux élevés de pré-diabète et de DM ont été découverts chez des patients TB adultes. Cette étude est en faveur du dépistage de routine du DM chez tous les patients atteints de TB au Kenya.

Marco de referencia: Los consultorios de atención de la tuberculosis (TB) en cinco establecimientos de salud en el occidente de Kenya.Objetivo: Evaluar la prevalencia de diabetes (DM) e hiperglucemia prediabética y los factores determinantes asociados en los pacientes adultos con diagnóstico de TB, mediante la utilización de dispositivos de diagnóstico (DCA Vantage) que determinan la glucohemoglobina (HbA1c) en el lugar de atención.Método: Un estudio transversal.Resultados: De los 454 pacientes, 272 fueron de sexo masculino (60%), la mediana de la edad fue 34 años, 175 (39%) sufrían coinfección por el virus de la inmunodeficiencia humana (VIH), la mediana de la duración del tratamiento antituberculoso fue 8 semanas y 180 pacientes notificaron por lo menos un síntoma patognomónico de DM (40%). La prevalencia de DM (HbA1c ⩾ 6,5%) fue 5,1% (IC 95% 3,2­7,5) y la prevalencia de pre-diabetes (HbA1c 5,7­6,4%) fue 37,5% (IC95% 33,1­42,2). El número de pacientes que es necesario cribar (NNC) para detectar un caso de DM fue 19,6 y 2,7 para un caso de prediabetes. Combinados, el 42,6% de los pacientes presentaba ya sea prediabetes o DM (NNC 2,3; IC95% 38,0­47,3). Siete de los 23 pacientes con DM conocían ya su diagnóstico. Las tasas más altas de DM se asociaron con una edad de 40 años o más y el antecedente familiar de DM, pero no con la obesidad, el tipo de TB, la situación frente al VIH ni la presencia de síntomas indicativos.Conclusión: Se encontraron altas tasas de prediabetes y DM en los pacientes adultos con diagnóstico de TB. El presente estudio respalda la práctica de la detección sistemática de la DM en los pacientes con TB en Kenya.

Virus-induced gene silencing in Catharanthus roseus by biolistic inoculation of tobacco rattle virus vectors.

Catharanthus roseus constitutes the unique source of several valuable monoterpenoid indole alkaloids, including the antineoplastics vinblastine and vincristine. These alkaloids result from a complex biosynthetic pathway encompassing between 30 and 50 enzymatic steps whose characterisation is still underway. The most recent identifications of genes from this pathway relied on a tobacco rattle virus-based virus-induced gene silencing (VIGS) approach, involving an Agrobacterium-mediated inoculation of plasmids encoding the two genomic components of the virus. As an alternative, we developed a biolistic-mediated approach of inoculation of virus-encoding plasmids that can be easily performed by a simple bombardment of young C. roseus plants. After optimisation of the transformation conditions, we showed that this approach efficiently silenced the phytoene desaturase gene, leading to strong and reproducible photobleaching of leaves. This biolistic transformation was also used to silence a previously characterised gene from the alkaloid biosynthetic pathway, encoding iridoid oxidase. Plant bombardment caused down-regulation of the targeted gene (70%), accompanied by a correlated decreased in MIA biosynthesis (45-90%), similar to results obtained via agro-transformation. Thus, the biolistic-based VIGS approach developed for C. roseus appears suitable for gene function elucidation and can readily be used instead of the Agrobacterium-based approach, e.g. when difficulties arise with agro-inoculations or when Agrobacterium-free procedures are required to avoid plant defence responses.

Effects of a selective histamine H4R antagonist on inflammation in a model of carrageenan-induced pleurisy in the rat.

The histamine H4 receptor (H4R), recently cloned and identified, is a G-protein coupled histamine receptor family expressed in immune cells which plays an important role in inflammation. Recent data evidentiated that H4R antagonists can decrease airway inflammation and hyperreactivity in animal models of asthma. In the present study we evaluated the effect of the selective H4R antagonist JNJ7777120 (JNJ) in carrageenan-induced pleurisy, an in vivo model of inflammation, well characterized for cellular and molecular mechanisms. Intra-pleural administration of λ-carrageenan (1% w/v in 0.2 ml sterile saline) determined an intense recruitment of leucocytes in pleural exudates and in lung tissues, activated inducible nitric oxide (NO) synthase and cyclooxygenase-2, thus increasing the generation of harmful autacoids such as NO and pro-inflammatory prostaglandins, PgE2 and 6-ketoPgF(1α), increased cellular and DNA oxidative stress, measured as malondialdehyde and 8-OH-deoxyguanosine and the local generation of IL-1ß and TNF-α. Moreover, the activity of caspase-3, an early marker of apoptosis was also activated by λ-carrageenan injection. The pre-treatment with JNJ (5-10 mg Kg⁻¹ b.wt., given intrapleurally), 60 min before carrageenan markedly reduced all the studied parameters. This study clearly demonstrated that histamine H4R antagonists have anti-inflammatory effects and could have potential therapeutic application for the treatment of inflammatory diseases.

A selective antagonist of histamine H4 receptors prevents antigen-induced airway inflammation and bronchoconstriction in guinea pigs: involvement of lipocortin-1.

BACKGROUND AND PURPOSE: Among the pathogenic mechanisms of asthma, a role for oxidative/nitrosative stress has been well documented. Recent evidence suggests that histamine H4 receptors play a modulatory role in allergic inflammation. Here we report the effects of compound JNJ 7777120 (JNJ), a selective H4 receptor antagonist, on antigen-induced airway inflammation, paying special attention to its effects on lipocortin-1 (LC-1/annexin-A1), a 37 kDA anti-inflammatory protein that plays a key role in the production of inflammatory mediators. EXPERIMENTAL APPROACH: Ovalbumin (OA)-sensitized guinea pigs placed in a respiratory chamber were challenged with antigen. JNJ (5, 7.5 and 10 mg.kg⁻¹) was given i.p. for 4 days before antigen challenge. Respiratory parameters were recorded. Bronchoalveolar lavage (BAL) fluid was collected and lung specimens taken for further analyses 1 h after antigen challenge. In BAL fluid, levels of LC-1, PGD2 , LTB4 and TNF-α were measured. In lung tissue samples, myeloperoxidase, caspase-3 and Mn-superoxide dismutase activities and 8-hydroxy-2-deoxyguanosine levels were measured. KEY RESULTS: OA challenge decreased LC-1 levels in BAL fluid, induced cough, dyspnoea and bronchoconstriction and increased PGD2 , LTB4 and TNF-α levels in lung tissue. Treatment with JNJ dose-dependently increased levels of LC-1, reduced respiratory abnormalities and lowered levels of PGD2 , LTB4 and TNF-α in BAL fluid. CONCLUSIONS AND IMPLICATIONS: Antigen-induced asthma-like reactions in guinea pigs decreased levels of LC-1 and increased TNF-α and eicosanoid production. JNJ pretreatment reduced allergic asthmatic responses and airway inflammation, an effect associated with LC-1 up-regulation.

Antagonism of histamine H4 receptors exacerbates clinical and pathological signs of experimental autoimmune encephalomyelitis.

BACKGROUND AND PURPOSE: The histamine H4 receptor has a primary role in inflammatory functions, making it an attractive target for the treatment of asthma and refractory inflammation. These observations suggested a facilitating action on autoimmune diseases. Here we have assessed the role of H4 receptors in experimental autoimmune encephalomyelitis (EAE) a model of multiple sclerosis (MS). EXPERIMENTAL APPROACH: We induced EAE with myelin oligodendrocyte glycoprotein (MOG35-55 ) in C57BL/6 female mice as a model of MS. The histamine H4 receptor antagonist 5-chloro-2-[(4-methylpiperazin-1-yl)carbonyl]-1H-indole (JNJ7777120) was injected i.p. daily starting at day 10 post-immunization (D10 p.i.). Disease severity was monitored by clinical and histopathological evaluation of inflammatory cells infiltrating into the spinal cord, anti-MOG35-55 antibody production, assay of T-cell proliferation by [(3) H]-thymidine incorporation, mononucleate cell phenotype by flow cytometry, cytokine production by elisa assay and transcription factor quantification of mRNA expression. KEY RESULTS: Treatment with JNJ7777120 exacerbated EAE, increased inflammation and demyelination in the spinal cord of EAE mice and increased IFN-γ expression in lymph nodes, whereas it suppressed IL-4 and IL-10, and augmented expression of the transcription factors Tbet, FOXP3 and IL-17 mRNA in lymphocytes. JNJ7777120 did not affect proliferation of anti-MOG35-55 T-cells, anti-MOG35-55 antibody production or mononucleate cell phenotype. CONCLUSIONS AND IMPLICATIONS: H4 receptor blockade was detrimental in EAE. Given the interest in the development of H4 receptor antagonists as anti-inflammatory compounds, it is important to understand the role of H4 receptors in immune diseases to anticipate clinical benefits and also predict possible detrimental effects.

Outcomes of isoniazid prophylaxis among HIV-infected children attending routine HIV care in Kenya.

SETTING: Three human immunodeficiency virus (HIV) care clinics in Eastern Province, Kenya. OBJECTIVES: To establish rates of treatment completion, loss to follow-up, adverse drug reactions, tuberculosis (TB) disease and mortality among 606 HIV-infected children during 6 months of isoniazid preventive therapy (IPT). DESIGN: Retrospective record review. RESULTS: Of 606 HIV-infected children started on IPT, 556 (91.7%) successfully completed treatment, while 20 (3.3%) completed with interruptions. Cumulatively, 30 children (4.9%) did not complete IPT: 4 (0.7%) were lost to follow-up, 4 (0.7%) discontinued because of treatment interruptions, 2 (0.3%) developed adverse drug reactions, 1 developed a chronic cough, 1 was transferred to a non-IPT facility and 18 (3%) developed TB, including 2 who eventually died. TB disease was diagnosed in a median of 3 weeks (interquartile range [IQR] 2-16) post-IPT initiation. The median CD4 cell count for those aged 1-4 years who developed TB disease was 1023 cells/mm(3) (IQR 375-1432), while for those aged 5-14 years it was 149 cells/mm(3) (IQR 16-332). Isoniazid resistance was not detected in the four culture-confirmed TB cases. CONCLUSION: The high treatment completion, low loss to follow-up rate and few adverse drug reactions affirm the feasibility of IPT provision to children in HIV care clinics.

Heterogeneous expression of cyclooxygenase-2 and inducible nitric oxide synthase within colorectal tumors: correlation with tumor angiogenesis.

BACKGROUND: Recent studies have shown that the cyclooxygenase (COX) and the inducible nitric oxide synthase (iNOS) pathways are involved in the development of tumor angiogenesis in human cancers. AIMS: To investigate whether a different pattern of COX-2 and iNOS expression/activity exists within different areas of colorectal tumors and to analyze the relationship between these two enzymes and tumor angiogenesis. METHODS: Microvessel density (MVD) and COX-2, iNOS, vascular endothelial growth factor (VEGF) and VEGF receptor-2 (VEGFR-2) protein expression were evaluated at both the invasive front (IF) and the tumor center (TC) in 46 human colorectal cancer specimens. We also investigated the concentration of PGE2 and NO at the same sites. RESULTS: COX-2 and iNOS protein expression and activity were significantly higher within the IF than the TC of the tumor specimens. Similarly, MVD and VEGF/VEGFR-2 expression significantly increased from the TC to the IF. Only COX-2 expression was significantly correlated with MVD and VEGF/VEGFR-2 expression at both the TC and the IF. CONCLUSION: Our study shows a heterogeneous expression of COX-2 and iNOS in colorectal cancer. The up-regulation of COX-2 at the IF parallels an increase in vessel density and VEGF/VEGFR-2 expression, thus supporting the hypothesis that the tumor periphery is the most aggressive portion of a colorectal tumor.

Supraspinal inactivation of mitochondrial superoxide dismutase is a source of peroxynitrite in the development of morphine antinociceptive tolerance.

Effective treatment of chronic pain with morphine is limited by decreases in the drug's analgesic action with chronic administration (antinociceptive tolerance). Because opioids are mainstays of pain management, restoring their efficacy has great clinical importance. We have recently reported that formation of peroxynitrite (ONOO(-), PN) in the dorsal horn of the spinal cord plays a critical role in the development of morphine antinociceptive tolerance and have further documented that nitration and enzymatic inactivation of mitochondrial superoxide dismutase (MnSOD) at that site provides a source for this nitroxidative species. We now report for the first time that antinociceptive tolerance in mice is also associated with the inactivation of MnSOD at supraspinal sites. Inactivation of MnSOD led to nitroxidative stress as evidenced by increased levels of products of oxidative DNA damage and activation of the nuclear factor poly (ADP-ribose) polymerase in whole brain homogenates. Co-administration of morphine with potent Mn porphyrin-based peroxynitrite scavengers, Mn(III) 5,10,15,20-tetrakis(N-ethylpyridinium-2-yl)porphyrin (MnTE-2-PyP5+) and Mn(III) 5,10,15,20-tetrakis(N-n-hexylpyridinium-2-yl)porphyrin (MnTnHex-2-PyP5+) (1) restored the enzymatic activity of MnSOD, (2) attenuated PN-derived nitroxidative stress, and (3) blocked the development of morphine-induced antinociceptive tolerance. The more lipophilic analogue, MnTnHex-2-PyP5+ was able to cross the blood-brain barrier at higher levels than its lipophylic counterpart MnTE-2-PyP5+ and was about 30-fold more efficacious. Collectively, these data suggest that PN-mediated enzymatic inactivation of supraspinal MnSOD provides a source of nitroxidative stress, which in turn contributes to central sensitization associated with the development of morphine antinociceptive tolerance. These results support our general contention that PN-targeted therapeutics may have potential as adjuncts to opiates in pain management.

Activation of cannabinoid receptors prevents antigen-induced asthma-like reaction in guinea pigs.

In this study we evaluated the effects of the CB1/CB2 cannabinoid receptor agonist CP55, 940 (CP) on antigen-induced asthma-like reaction in sensitized guinea pigs and we tested the ability of the specific CB2 receptor antagonist SR144528 (SR) and CB1 receptor antagonist AM251 (AM) to interfere with the effects of CP. Ovalbumin-sensitized guinea pigs placed in a respiratory chamber were challenged with the antigen given by aerosol. CP (0.4 mg/kg b.wt.) was given i.p. 3 hrs before ovalbumin challenge. Sixty minutes before CP administration, some animals were treated i.p. with either AM, or SR, or both (0.1 mg/kg b.wt.). Respiratory parameters were recorded and quantified. Lung tissue specimens were then taken for histopathological and morphometric analyses and for eosinophilic major basic protein immunohistochemistry. Moreover, myeloperoxidase activity, 8-hydroxy-2-deoxyguanosine, cyclic adenosine monophosphate (cAMP) and guanosine monophosphate (cGMP) levels, and CB1 and CB2 receptor protein expression by Western blotting were evaluated in lung tissue extracts. In the bronchoalveolar lavage fluid, the levels of prostaglandin D2 and tumour necrosis factor-alpha TNF-alpha were measured. Ovalbumin challenge caused marked abnormalities in the respiratory, morphological and biochemical parameters assayed. Treatment with CP significantly reduced these abnormalities. Pre-treatment with SR, AM or both reverted the protective effects of CP, indicating that both CB1 and CB2 receptors are involved in lung protection. The noted treatments did not change the expression of cannabinoid receptor proteins, as shown by Western blotting. These findings suggest that targeting cannabinoid receptors could be a novel preventative therapeutic strategy in asthmatic patients.