Evaluation of tuberculosis diagnostics in children: 1. Proposed clinical case definitions for classification of intrathoracic tuberculosis disease. Consensus from an expert panel

There is a critical need for improved diagnosis of tuberculosis in children, particularly in young children with intrathoracic disease as this represents the most common type of tuberculosis in children and the greatest diagnostic challenge. There is also a need for standardized clinical case definitions for the evaluation of diagnostics in prospective clinical research studies that include children in whom tuberculosis is suspected but not confirmed by culture of Mycobacterium tuberculosis. A panel representing a wide range of expertise and child tuberculosis research experience aimed to develop standardized clinical research case definitions for intrathoracic tuberculosis in children to enable harmonized evaluation of new tuberculosis diagnostic technologies in pediatric populations. Draft definitions and statements were proposed and circulated widely for feedback. An expert panel then considered each of the proposed definitions and statements relating to clinical definitions. Formal group consensus rules were established and consensus was reached for each statement. The definitions presented in this article are intended for use in clinical research to evaluate diagnostic assays and not for individual patient diagnosis or treatment decisions. A complementary article addresses methodological issues to consider for research of diagnostics in children with suspected tuberculosis.     

Anomalous coronary circulation: left anterior descending and left circumflex coronary arteries arising from the right sinus of valsalva

Approximately 1% of adults who undergo cardiac catheterization have coronary anomalies. Patients may present with chest pain, arrhythmias, presyncope, and sometimes sudden cardiac death. Multidetector computed tomography (MDCT) is an excellent tool for identifying coronary artery anomalies and defining their course and relationship to the great vessels and surrounding structures; its value is incremental to conventional angiography. We present a rare case of a coronary anomaly involving three separate ostia at the right sinus of Valsalva for the left and right coronary vessels.     

Acetyltransferases (HATs) as Targets for Neurological Therapeutics

The acetylation of histone and non-histone proteins controls a great deal of cellular functions, thereby affecting the entire organism, including the brain. Acetylation modifications are mediated through histone acetyltransferases (HAT) and deacetylases (HDAC), and the balance of these enzymes regulates neuronal homeostasis, maintaining the pre-existing acetyl marks responsible for the global chromatin structure, as well as regulating specific dynamic acetyl marks that respond to changes and facilitate neurons to encode and strengthen long-term events in the brain circuitry (e.g., memory formation). Unfortunately, the dysfunction of these finely-tuned regulations might lead to pathological conditions, and the deregulation of the HAT/HDAC balance has been implicated in neurological disorders. During the last decade, research has focused on HDAC inhibitors that induce a histone hyperacetylated state to compensate acetylation deficits. The use of these inhibitors as a therapeutic option was efficient in several animal models of neurological disorders. The elaboration of new cell-permeant HAT activators opens a new era of research on acetylation regulation. Although pathological animal models have not been tested yet, HAT activator molecules have already proven to be beneficial in ameliorating brain functions associated with learning and memory, and adult neurogenesis in wild-type animals. Thus, HAT activator molecules contribute to an exciting area of research.     

Enzyme Immunoassay: Binding of Salmonella Antigens to Activated Microtiter Plates

Abstract

A heat extract prepared from radiolabeled Salmonella cells was used to determine if covalent binding to activated surface of polystyrene plates would improve antigen retention thus contributing to increase sensitivity in an enzyme immunoassay for Salmonella antigen. The effect of treatment with ethylchloroformate on the retention of antigens passively absorbed to polyvinylchloride and polystyrene plates was also investigated. Chemically modified plates retained more radiolabeled antigens after washing than did untreated plates in which the antigens had been physically adsorbed. However, improvement of assay sensitivity depended on the type of plate used for covalent binding of antigen. N-succiniraidyl 3-(2-pyridyldlthio) propionate (SPDP), was found to be potentially useful for mediation of covalent binding of antigens to activated plates.     

Caveolin-1 regulation of store-operated Ca(2+) influx in human airway smooth muscle

Caveolae, plasma membrane invaginations with constitutive caveolin proteins, harbour proteins involved in intracellular calcium ([Ca(2+)](i)) regulation. In human airway smooth muscle (ASM), store-operated Ca(2+) entry (SOCE) is a key component of [Ca(2+)](i) regulation, and contributes to increased [Ca(2+)](i) in inflammation. SOCE involves proteins Orai1 and stromal interaction molecule (STIM)1. We investigated the link between caveolae, SOCE and inflammation in ASM. [Ca(2+)](i) was measured in human ASM cells using fura-2. Small interference RNA (siRNA) or overexpression vectors were used to alter expression of caveolin-1 (Cav-1), Orai1 or STIM1. Tumour necrosis factor (TNF)-α was used as a representative pro-inflammatory cytokine. TNF-α increased SOCE following sarcoplasmic reticulum Ca(2+) depletion, and increased whole-cell and caveolar Orai1 (but only intracellular STIM1). Cav-1 siRNA decreased caveolar and whole-cell Orai1 (but not STIM1) expression, and blunted SOCE, even in the presence of TNF-α. STIM1 overexpression substantially enhanced SOCE: an effect only partially reversed by Cav-1 siRNA. In contrast, Orai1 siRNA substantially blunted SOCE even in the presence of TNF-α. Cav-1 overexpression significantly increased Orai1 expression and SOCE, especially in the presence of TNF-α. These results demonstrate that caveolar expression and regulation of proteins such as Orai1 are important for [Ca(2+)](i) regulation in human ASM cells and its modulation during inflammation.     

Immune reconstitution inflammatory syndrome in HIV-infected patients with and without prior tuberculosis

We conducted a nested case-control study in a cohort of patients initiating antiretroviral therapy (ART) to identify risk factors and common manifestations of immune reconstitution inflammatory syndrome (IRIS) and to validate the Robertson criteria for IRIS prediction. HIV-infected patients at the Tuberculosis Research Centre clinics, Chennai and Madurai, India, initiating ART between July 2004 and June 2005 were prospectively studied. Of 97 patients (62% men, median age 32 years, median CD4 count 63 cells/μL) included, 34 developed IRIS. IRIS was more common in patients with a prior history of tuberculosis (74% versus 52%, P = 0.04), median time to development was 46 days and the sensitivity and specificity of the Robertson criteria to predict IRIS were 91% and 22%, respectively. In this population, IRIS was a common event, more so among patients with prior tuberculosis, and neither the rate of CD4 increase nor the Robertson criteria were useful in predicting its development.     

Clinical impact of the use of 16S rRNA sequencing method for the identification of "difficult-to-identify" bacteria in immunocompromised hosts

Molecular method of 16S rRNA sequencing is reported to be helpful in the accurate identification of organisms with ambiguous phenotypic profiles. We analyzed the use of 16S rRNA sequencing method to identify clinically significant, “difficult‐to‐identify” bacteria recovered from clinical specimens, and evaluated its role in patient management and consequent clinical outcome. Among the 172 “difficult‐to‐identify” bacteria recovered over a 4‐year period, 140 were gram‐positive cocci or gram‐negative bacilli; identification by 16S rRNA did not play a role in the management of patients infected with these bacteria. From 32 patients, 33 “difficult‐to‐identify” gram‐positive bacilli were identified; the organisms were mycobacteria, Nocardia, Tsukamurella, Rhodococcus, and Gordonia. In 24 patients for whom clinical data were available, results from the 16S rRNA sequencing method led to treatment change in 14 immunocompromised patients (including 7 hematopoietic stem cell recipients and 1 liver transplant recipient). Therapy was modified in 9 patients, initiated in 3 patients, and discontinued in 2 patients. Most patients’ therapy was switched to oral antibiotics with discontinuation of intravascular catheters, facilitating early hospital discharge. All 14 patients were alive 30 days after infection onset. The present study demonstrates the clinical application of 16S rRNA sequencing method to identify “difficult‐to‐identify” mycobacteria and other gram‐positive bacilli in clinical specimens, particularly in immunocompromised hosts.