Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia.

The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.

La pandémie de COVID-19 et les mesures de riposte incluant des confinements et une réorientation des services de santé ont perturbé les services de santé essentiels destinés aux autres maladies comme la TB, le VIH et le paludisme. En ce qui concerne la TB, les réductions de la détection des cas dues à la pandémie de COVID-19 devrait entraîner une augmentation de la transmission, morbidité et mortalité de la TB. La recherche active des cas (ACF) de TB grâce à des approches communautaires est une stratégie potentielle visant à compenser pour les réductions de détection de la TB en écartant le besoin pour les patients de solliciter des soins dans un structure de santé. Plusieurs approches peuvent être utilisées pour réaliser l'ACF TB de façon sûre et de dépister des populations cibles désignées tout en gérant les risques de transmission du SARS-CoV-2 pour le personnel, les individus et la communauté. Nous présentons un cadre d'options et d'expériences d'adaptation des services TB ACF en réponse aux défis du COVID-19 dans notre programme à Yogyakarta, Indonésie. Les changements majeurs ont inclus une révision des priorités des populations cibles focalisée sur les contacts domiciliaires ; une réduction de la cadence de la recherche de cas ; la mise en œuvre de mesures supplémentaires de lutte contre l'infection et de précautions ; et l'intégration du dépistage de COVID-19 parmi ceux dépistés pour la TB. Notre approche pourrait informer d'autres programmes voulant adapter les services TB ACF afin d'atténuer l'impact négatif du COVID-19 sur la détection des cas de TB.

Active case-finding in contacts of people with TB.

BACKGROUND: Exposure to people with TB substantially elevates a person's risk of tuberculous infection and TB disease. Systematic screening of TB contacts enables the early detection and treatment of co-prevalent disease, and the opportunity to prevent future TB disease. However, scale-up of contact investigation in high TB transmission settings remains limited.METHODS: We undertook a narrative review to evaluate the evidence for contact investigation and identify strategies that TB programmes may consider when introducing contact investigation and management.RESULTS: Selection of contacts for priority screening depends upon their proximity and duration of exposure, along with their susceptibility to develop TB. Screening algorithms can be tailored to the target population, the availability of diagnostic tests and preventive therapy, and healthcare worker expertise. Contact investigation may be performed in the household or at communal locations. Local contact investigation policies should support vulnerable patients, and ensure that drop-out during screening can be mitigated. Ethical issues should be anticipated and addressed in each setting.CONCLUSION: Contact investigation is an important strategy for TB elimination. While its epidemiological impact will be greatest in lower-transmission settings, the early detection and prevention of TB have important benefits for contacts and their communities.

Bilateral ptosis: An unusual presentation of mid brain tuberculoma.

Central nervous system tuberculoma can have different clinical manifestations like headache, seizures, papilledema or other signs of raised intracranial pressure depending up on the site and number of tuberculoma. We report a case of 56 year old female reported with history of bilateral asymmetric ptosis of one month duration,with no other neurological defecit. Magnetic resonance imaging (MRI) brain revealed well defined ring enhancing lesion in the medial aspect of left hemi midbrain with diffuse disproportionate perilessional edema. Contrast Enhanced Computed Tomogram (CECT) of chest and abdomen revealed features of disseminated tuberculosis. She was diagnosed as a case of disseminated tuberculosis and started on antitubercular therapy with steroids and the ptosis almost resolved after 01 month of antitubercular therapy. Our case report is unique in the sense that only few cases of midbrain tuberculoma causing occulomotor abnormalities are reported in literature.

Graphene functionalized field-effect transistors for ultrasensitive detection of Japanese encephalitis and Avian influenza virus.

Graphene, a two-dimensional nanomaterial, has gained immense interest in biosensing applications due to its large surface-to-volume ratio, and excellent electrical properties. Herein, a compact and user-friendly graphene field effect transistor (GraFET) based ultrasensitive biosensor has been developed for detecting Japanese Encephalitis Virus (JEV) and Avian Influenza Virus (AIV). The novel sensing platform comprised of carboxy functionalized graphene on Si/SiO2 substrate for covalent immobilization of monoclonal antibodies of JEV and AIV. The bioconjugation and fabrication process of GraFET was characterized by various biophysical techniques such as Ultraviolet-Visible (UV-Vis), Raman, Fourier-Transform Infrared (FT-IR) spectroscopy, optical microscopy, Scanning Electron Microscopy (SEM) and Atomic Force Microscopy (AFM). The change in the resistance due to antigen-antibody interaction was monitored in real time to evaluate the electrical response of the sensors. The sensors were tested in the range of 1 fM to 1 µM for both JEV and AIV antigens, and showed a limit of detection (LOD) upto 1 fM and 10 fM for JEV and AIV respectively under optimised conditions. Along with ease of fabrication, the GraFET devices were highly sensitive, specific, reproducible, and capable of detecting ultralow levels of JEV and AIV antigen. Moreover, these devices can be easily integrated into miniaturized FET-based real-time sensors for the rapid, cost-effective, and early Point of Care (PoC) diagnosis of JEV and AIV.

The emergency response to multidrug-resistant tuberculosis in Daru, Western Province, Papua New Guinea, 2014-2017.

SETTING: A response to an outbreak of multidrug-resistant tuberculosis (MDR-TB) on Daru Island, South Fly District (SFD), Western Province, Papua New Guinea (PNG) was implemented by a national emergency response taskforce. OBJECTIVE: To describe programmatic interventions for TB in SFD and evaluate characteristics of TB case notifications, drug resistance and treatment outcomes. DESIGN: This was a retrospective cohort study based on routine programmatic data for all patients enrolled on TB treatment at Daru General Hospital from 2014 to 2017. RESULTS: The response involved high-level political commitment, joint planning, resource mobilisation, community engagement and strengthening TB case detection and treatment. Of 1548 people enrolled on TB treatment, 1208 (78%) had drug-susceptible TB (DS-TB) and 333 (21.5%) had MDR-TB. There was an increase in MDR-TB as a proportion of all TB. Treatment success rates increased over the study period from 55% to 86% for DS-TB, and from 70% to 81% for MDR-TB from 2014 to 2015. The 2014 case notification rate for TB in SFD was 1031/100 000, decreasing to 736/100 000 in 2017. CONCLUSION: The outbreak was stabilised through the response from the national and provincial governments and international partners. Additional interventions are needed to decrease the TB burden in Daru.

Drug-resistant tuberculosis diagnosis since Xpert® MTB/RIF introduction in Papua New Guinea, 2012-2017.

SETTING: Xpert® MTB/RIF was introduced in Papua New Guinea in 2012 for the diagnosis of tuberculosis (TB) and of rifampicin-resistant TB (RR-TB), a marker of multi-drug-resistant TB (MDR-TB). OBJECTIVE: To assess the concordance of Xpert with phenotypic drug susceptibility testing (DST) performed at the supranational reference laboratory and to describe the patterns of drug-resistant TB observed. DESIGN: This was a retrospective descriptive study of laboratory data collected from April 2012 to December 2017. RESULTS: In 69 months, 1408 specimens with Xpert results were sent for mycobacterial culture and DST; Mycobacterium tuberculosis was cultured from 63% (884/1408) and DST was completed in 99.4%. The concordance between Xpert and culture for M. tuberculosis detection was 98.6%. Of 760 RR-TB cases, 98.7% were detected using Xpert; 98.5% of 620 MDR-TB cases were identified using phenotypic DST. Phenotypic resistance to second-line drugs was detected in 59.4% (522/879) of specimens tested, including 29 with fluoroquinolone resistance; the majority were from the National Capital District and Daru Island. CONCLUSION: The high concordance between phenotypic DST and Xpert in identifying RR-TB cases supports the scale-up of initial Xpert testing in settings with high rates of drug resistance. However, rapid DST in addition to the detection of RR-TB is required.

Impact of GxAlert on the management of rifampicin-resistant tuberculosis patients, Port Moresby, Papua New Guinea.

SETTING: GxAlert is an automatic electronic notification service that provides immediate Xpert® MTB/RIF testing results. It was implemented for the notification of patients with rifampicin resistant-tuberculosis (RR-TB) at Port Moresby General Hospital, Port Moresby, Papua New Guinea, in May 2015. OBJECTIVE: To determine if there were differences in pre-treatment attrition, the time to treatment initiation and patient outcomes in the 12 months pre- and post-introduction of GxAlert for RR-TB patients. DESIGN: This was a retrospective cohort study. RESULTS: The median time from Xpert testing to treatment initiation decreased from 35 days [IQR 13-131] prior to GxAlert to 10 days [IQR 3-29] after GxAlert (P = 0.001), with the cumulative proportion of patients initiating treatment within 30 days increasing from 25% (95%CI 17-37) to 54% (95%CI 44-64; P < 0.001) over these periods. However, our analysis of the time to treatment prior to the introduction of GxAlert suggests that a decrease had already occurred prior to implementation. There was no difference in interim clinical outcomes between the periods. CONCLUSION: Although a decrease in time to treatment initiation cannot be attributed to GxAlert, there was a significant improvement over the 2-year period, suggesting that considerable improvements have been made in timely RR-TB patient management in Port Moresby.

Implementation of screening and management of household contacts of tuberculosis cases in Daru, Papua New Guinea.

SETTING: Daru Island, Western Province, Papua New Guinea (PNG). OBJECTIVE: To describe the implementation of a screening programme for household contacts of tuberculosis (TB) cases residing on Daru Island. DESIGN: This was a retrospective descriptive study evaluating two periods of implementation: introduction and expansion of a screening programme for household contacts of drug-resistant TB (DR-TB) cases (March 2016 to September 2017), and inclusion of drug-susceptible TB (DS-TB) cases with provision of preventive therapy for eligible contacts between October 2017 and March 2018. RESULTS: In the first period, the contact screening programme was established and strengthened by increasing coverage over time. There was a large number of contacts (median 8) in each household, and a high uptake of screening. In the second period of evaluation, respectively 412 and 223 contacts of 42 DS-TB and 25 DR-TB index cases were screened. Overall, 156 (24.6%) contacts reported TB-related symptoms and 9 (1.4%) were diagnosed with active TB. All 9 commenced TB treatment: 5 had DS-TB and 4 had DR-TB. Of 82 child contacts of DS-TB cases eligible for preventive therapy, 57 (69.5%) commenced treatment and 45 completed treatment. CONCLUSION: Community-based household contact screening and management was successfully implemented under programme conditions in this high burden TB and DR-TB setting in PNG.

The effects of decentralisation of tuberculosis services in the East New Britain Province, Papua New Guinea.

SETTING: The tuberculosis (TB) programmes at the Nonga General Hospital, Rabaul Urban Clinic and Kerevat District Hospital in East New Britain Province, Papua New Guinea. BACKGROUND: In East New Britain, TB care was mainly offered by the General Hospital, resulting in limited community-based care and poor treatment outcomes. In 2016, TB services were decentralised from the provincial to the district level by 1) training health workers, 2) increasing community awareness of TB, and 3) providing a weekly Clinical Outreach (TACO) service. OBJECTIVE: To describe the effect of TACO on the use of TB diagnostic and treatment services from 1 January 2014 to 31 December 2017. DESIGN: This was a retrospective study comparing 2014-2015 (pre-TACO) and 2016-2017 (TACO) cohorts. RESULTS: There was an increase in pre-TACO to TACO cohorts in screened cases (1581 to 2195), total registered TB cases (678 to 824) and registered cases at decentralised sites (209 to 615). Unfavourable treatment outcomes were common (pre-TACO, 46.0% vs. TACO, 40.1%). In multivariable analysis, treatment at a decentralised Basic Management Unit (aOR 0.55, 95%CI 0.42-0.74) was significantly associated with fewer unfavourable outcomes, but treatment outcomes between the pre-TACO and the TACO group were not significantly different. CONCLUSION: Strengthening decentralisation of TB services at the district level increased TB screening and case registration, with similar treatment outcomes.

Successful implementation of bedaquiline for multidrug-resistant TB treatment in remote Papua New Guinea.

SETTING: Bedaquiline (BDQ) was introduced in the multi-drug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM). OBJECTIVE: To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017. DESIGN: A retrospective cohort analysis of routine programme data. RESULTS: Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for >5 electrocardiograms and 79% for ⩾2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored. CONCLUSION: Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings.

Public-private mix for tuberculosis care and control in Myanmar: a strategy to scale up?

Setting: The public-private mix (PPM) tuberculosis (TB) project implemented by the Myanmar Medical Association (MMA) in 105 townships in Myanmar. Objectives: 1) To assess the contribution of the MMA-PPM-TB project to total TB patient notification in the project townships; 2) to evaluate the outcomes of patients treated at the MMA-PPM clinics; and 3) to identify factors associated with unfavourable treatment outcomes, from January to December 2013. Design: A retrospective cohort study. Results: The MMA-PPM-TB project contributed 7501 (12%) of 60 905 TB patient notifications to the National Tuberculosis Programme (NTP) in 105 study townships. Of 2975 TB patients diagnosed and treated at private MMA-PPM clinics, 92% had a favourable outcome (32% cured, 60% completed treatment) and 8% had an unfavourable outcome (2.9% died, 2.5% lost to follow-up, 1.9% failure, 0.6% transfer out). Patient characteristics significantly associated with an unfavourable treatment outcome were age ⩾65 years (adjusted risk ratio [aRR] 5.7, 95% confidence interval [CI] 4.20-7.68), retreatment (aRR 2.44, 95%CI 1.79-3.33) and female sex (aRR 1.44, 95%CI 1.14-1.82). Conclusion: This study supports the continuation and expansion of the MMA-PPM-TB model and/or similar PPM approaches in Myanmar that engage all health providers in the ambitious goals of achieving universal health coverage in this country in transition and ending its TB epidemic by 2035.

Contexte : Le projet mixe public-privé (PPM) pour la tuberculose (TB) mis en œuvre par l'association médicale du Myanmar (MMA) dans 105 townships, Myanmar.Objectifs : 1) Evaluer la contribution du projet TB MMA-PPM à la notification totale des patients TB dans les townships du projet ; 2) évaluer le devenir des patients traités dans les centres de santé MMA-PPM ; et 3) identifier les facteurs associés avec un résultat défavorable du traitement de janvier à décembre 2013.Schéma : Étude rétrospective de cohorte.Résultats : Le projet MMA-PPM-TB a contribué à 7501 (12%) des 60 905 notifications de patients TB au Programme National TB dans les 105 townships de l'étude. Parmi 2975 patients TB diagnostiqués et traités dans les centres privés du MMA-PPM, 92% ont eu un résultat favorable (32% de guérison, 60% d'achèvement) et 8% des patients ont eu un résultat défavorable (2,9% sont décédés, 2,5% ont été perdus de vue, 1,9% ont eu un échec du traitement et 0,6% ont déménagé). Les caractéristiques des patients significativement associées avec un résultat défavorable du traitement ont été l'âge ⩾65 ans (ratio de risque ajusté [aRR] 5,7 ; intervalle de confiance [IC] 95% 4,20­7,68), le retraitement (aRR 2,44 ; IC95% 1,79­3,33) et le sexe féminin (aRR 1,44 ; IC95% 1,14­1,82).Conclusion : Cette étude est en faveur de la poursuite et de l'expansion du modèle MMA-PPM-TB et/ou d'approches similaires public-privé au Myanmar, engageant tous les prestataires de santé, car ce pays en transition présente une vision audacieuse consistant à offrir une couverture santé universelle et à mettre fin à l'épidémie de TB d'ici 2035.

Marco de referencia: El proyecto de colaboración público-privada (PPM) en materia de tuberculosis (TB) puesta en práctica por la Asociación Médica de Myanmar (MMA) en 105 municipios de Birmania.Objetivos: 1) Evaluar la contribución del MMA-PPM-TB en Birmania al total de notificaciones de casos de TB en los municipios que participaron; 2) evaluar los desenlaces clínicos de los pacientes tratados en los consultorios participantes; y 3) definir los factores que se asociaron con los desenlaces terapéuticos desfavorables, de enero a diciembre del 2013.Método: Fue este un estudio retrospectivo de cohortes.Resultados: El MMA-PPM-TB aportó 7501 casos (12%) a las 60 905 notificaciones de pacientes al Programa Nacional contra la TB en los 105 municipios que participaron en el estudio. De los 2975 pacientes diagnosticados con TB y tratados en los consultorios del MMA-PPM-TB, el 92% logró un desenlace terapéutico favorable (32% curaciones y 60% tratamientos completos) y el 8% obtuvo un desenlace desfavorable (2,9% defunciones, 2,5% pérdidas durante el seguimiento, 1,9% fracasos y 0,6% transferencias a otros centros). Las características que se asociaron de manera significativa con un desenlace desfavorable fueron la edad ⩾65 años (riesgo relativo ajustado [RRa] 5,7; intervalo de confianza [IC] del 95% 4,20­7,68), los pacientes en retratamiento (RRa 2,44; IC95% 1,79­3,33) y el sexo femenino (RRa 1,44; IC95% 1,14­1,82).Conclusión: Los resultados del presente estudio respaldan la continuación y la ampliación del modelo de MMA-PPM-TB y de otras iniciativas equivalentes de PPM en Birmania que vinculen a todos los profesionales de salud, pues el país en un momento de transición pone en marcha una perspectiva ambiciosa de cobertura universal de salud y de erradicación de la epidemia de TB en el 2035.

Dotting the Three I's for collaborative TB-HIV activities: evaluation of a pilot programme in Kathmandu, Nepal.

Setting: The three government tertiary care hospitals providing care for people living with the human immunodeficiency virus (PLHIV) in Kathmandu, Nepal. Objectives: To assess 1) the screening cascades for intensified case finding for tuberculosis (TB), 2) isoniazid preventive therapy (IPT), including demographic and clinical factors associated with treatment interruption, and 3) TB infection control (IC) in the health facilities. Design: A cross-sectional study of new PLHIV enrolled from January 2012 to December 2014. Results: Among 572 registered PLHIV, 91% were on antiretroviral therapy. Of those registered, 561 (98%) were screened for TB and 73 (13%) were diagnosed with TB (17 [25%] sputum smear-positive, 17 [25%] smear-negative and 35 [51%] extra-pulmonary). Among the 488 (87%) PLHIV without active TB, 157 (32%) were initiated on IPT, of whom 136 (87%) completed treatment and 17 (11%) interrupted treatment. Those who experienced adverse events were 12 times more likely to interrupt IPT. TB IC showed gaps in personal control measures and supporting structures and policies. Conclusion: The implementation of the Three I's for collaborative TB-HIV activities in pilot sites in Nepal was successful and should be scaled up.

Contexte : Les trois hôpitaux d'état de niveau tertiaire offrant des soins aux personnes vivant avec le virus de l'immunodéficience humaine (PVVIH) à Katmandou, Népal.Objectifs : Evaluer 1) les étapes du dépistage pour une recherche intensifiée de cas (ICF) de tuberculose (TB) ; 2) le traitement préventif par isoniazide (TPI), y compris les facteurs démographiques et cliniques associés à l'interruption du traitement ; et 3) la lutte contre l'infection tuberculeuse (IC) dans les structures de santé.Schéma : Etude transversale auprès des nouveaux PVVIH enrôlés entre janvier 2012 et décembre 2014.Résultats : Parmi 572 PVVIH enregistrés, 91% étaient sous traitement antirétroviral. Parmi les inscrits, 561 (98%) ont eu un dépistage de TB et 73 (13%) ont eu un diagnostic de TB (17 [25%] TB à frottis positif, 17 [25%] TB à frottis négatif et 35 [51%] TB extra-pulmonaire). Parmi les 488 (87%) PVVIH sans TB active, 157 (32%) ont été mis sous TPI, 136 (87%) d'entre eux l'ont achevé et 17 (11%) ont interrompu le traitement. Ceux qui ont eu des effets secondaires ont été 12 fois plus susceptibles d'interrompre le TPI. Les mesures de lutte contre l'infection TB connaissent des lacunes en termes de mesures de protection individuelle et des structures et des politiques de soutien.Conclusion : La mise en œuvre des Trois I pour des activités collaborative TB-VIH dans des sites pilotes au Népal s'est faite avec succès et devrait être étendue.

Marco de referencia: Los tres hospitales públicos de atención terciaria que prestan servicios a las personas aquejadas de infección por el virus de la inmunodeficiencia humana (PVVIH) en Katmandú, Nepal.Objetivos: Evaluar 1) el algoritmo de detección en la búsqueda intensiva de casos de tuberculosis (TB); 2) el tratamiento preventivo con isoniazida (TPI), incluidos los factores demográficos y clínicos que se asocian con su interrupción; y 3) el control de la infección (IC) tuberculosa en los establecimientos de salud.Método: Fue este un estudio transversal de los PVVIH recién inscritos en el programa de enero del 2012 a diciembre del 2014.Resultados: De 572 PVVIH inscritos, el 91% recibía tratamiento antirretrovírico. De los pacientes registrados, en 561 se practicó la detección sistemática de la TB (98%) y se diagnosticaron 73 casos de enfermedad activa (13%) (17 obtuvieron un resultado positivo de la baciloscopia del esputo [25%], 17 un resultado negativo [25%] y ocurrieron 35 casos de TB extrapulmonar [51%]). De los 488 PVVIH sin TB activa (87%), 157 iniciaron el TPI (32%), 136 de ellos lo completaron (87%) y 17 lo interrumpieron (11%). La probabilidad de interrumpir el TPI fue 12 veces mayor en los pacientes que presentaron reacciones adversas. Al evaluar las medidas de control de las infecciones se observaron deficiencias en las medidas personales, las estructuras auxiliares y en las normas.Conclusión: La ejecución de actividades conjuntas, los Tres I's, de atención de la TB-VIH en tres centros piloto en Nepal fue eficaz y sería muy útil ampliar su escala de aplicación.

Hormone responsiveness of cultured Sertoli cells obtained from adult rats after their rapid isolation under less harsh conditions.

During adulthood, testicular Sertoli cells (Sc) coordinate all stages of germ cell (Gc) development involved in sperm production. However, our understanding about the functions of adult Sc is limited because of the difficulties involved in the process of isolating these cells from the adult testis, mainly because of the presence of large number of advanced Gc which interfere with Sc isolation at this age. Most of our knowledge about Sc function are derived from studies which used pre-pubertal rat Sc (18 ± 2-day old) as it is easy to isolate and culture Sc at this age. To this end, we established a less time consuming and less harsh procedure of isolating Sc from adult (60 days of age) rat testis for facilitating research on Sc-mediated regulation of spermatogenesis during adulthood. The cells were isolated using collagenase digestion at higher temperature, reducing the exposure time of cells to the enzyme. Step-wise digestion with intermittent removal of small clusters of tissue helped in increasing the yield of Sc. Isolated Sc were cultured and treated with FSH and testosterone (T) to evaluate their hormone responsiveness in terms of lactate, E2 , cAMP production. Adult Sc were found to be active and produced high amounts of lactate in a FSH-independent manner. FSH-mediated augmentation of cAMP and E2 production by adult Sc was less as compared with that by pre-pubertal Sc obtained from 18-day-old rats. Androgen-binding ability of adult Sc was significantly higher than pre-pubertal Sc. Although T treatment remarkably augmented expression of Claudin 11, it failed to augment lactate production by adult Sc. This efficient and rapid procedure for isolation and culture of functionally viable adult rat Sertoli cells may pave the way for determining their role in regulation and maintenance of spermatogenesis.

Two cases of medically-refractory spontaneous orthostatic headaches with normal cerebrospinal fluid pressures responding to epidural blood patching: Intracranial hypotension versus hypovolemia and the need for clinical awareness.

The diagnosis of spontaneous intracranial hypotension or cerebrospinal fluid (CSF) hypovolemia syndrome requires a high index of suspicion and meticulous history taking, demonstration of low CSF pressure and/or neuroimaging features. A 31-year-old male, presented with subacute onset moderate occipital and sub-occipital headaches precipitated by upright posture and relieved on recumbency and neck pain for 2 years. There was no trauma, cranial/spinal surgery. Clinical examination was normal and CSF opening pressure and laboratory study were normal. Magnetic resonance imaging (MRI) brain showed thin subdural hygroma. Another patient, 41-year-old male presented with 1 month of subacute onset severe bifrontal throbbing orthostatic headaches (OHs). CSF opening pressure was normal. Contrast MRI brain showed the presence of bilateral subdural hygromas, diffuse meningeal enhancement, venous distension, sagging of the brain, and tonsillar herniation. We report two cases of "spontaneous OHs" with normal CSF pressures who were successfully treated with epidural blood patching after poor response to conservative management.

Effect of long-term castration on serum biochemistry in rhesus monkeys.

BACKGROUND: Testicular failure has an effect on normal physiology. To address this issue, an experimental non-human primate model of long-term castrated rhesus monkey was chosen for this study to evaluate the influence of castration on various biochemical parameters. METHODS: Nine castrated rhesus monkeys were evaluated for changes in body weight, serum testosterone, and serum biochemical parameters as compared to those in non-castrated macaques. RESULTS: Castration caused statistically significant changes in body weight, biochemical analytes, and testosterone levels. Body weight and testosterone levels were decreased, and there were increase in alanine aminotransferase, cholesterol, serum bilirubin, phosphorous, alkaline phosphatase, urea and a decrease in serum protein, uric acid, creatinine, and triglycerides. CONCLUSIONS: This study provided essential baseline information on biochemical variables due to the effect of castration associated with declining levels of testosterone, as data are not readily accessible from the existing body of scientific literature on non-human primates.

Granulosa theca cell tumor with luteoma in the ovary of a bonnet monkey (Macaca radiata).

A mass was identified on the left caudal region of the abdomen in a 13-year-old bonnet monkey (Macaca radiata). The mass was excised and diagnosed as granulosa theca cell tumor accompanied with luteoma based on the microscopic findings. Morphologically it appeared pink, round, firm multilobulated measured approximately 5 x 3 x 2.5 cm in dimension. Histologically the luteoma composed of polyhedral cells with pale strained vacuolated cytoplasm, centrally located nuclei with distinct cytoplasmic borders. Granulosa theca cell tumor appeared as densely packed spindle shaped fusiform cells arranged in interlacing bundles and whorled pattern with neoplastic cells appearing irregular shaped solid sheets. The concomitant development of granulosa theca cell tumor with luteoma in a single ovary is very rare and is the first reported case in a bonnet macaque to our knowledge.

Sebaceous gland adenoma in a rhesus monkey (Macaca mulatta).

A tumor mass was identified below the shoulder region of a 5-year-old male rhesus monkey (Macaca mulatta). The mass was excised and diagnosed as sebaceous gland adenoma based on the microscopic findings. Morphologically it appeared as an elevated, dome-shaped, circumscribed mass of 3.6 x 2.8 x 3.2 cm in dimension with tan speckled color. Histologically, the tumor was composed of mature, sebaceous cells (sebocytes), basal cells arranged in a mass of irregular shapes and sizes, with a characteristic appearance of poly or multilobular structure. Sebocytes were well differentiated with foamy cytoplasm in the center of the lobules and poorly or undifferentiated densely staining basal cells in the periphery of the lobules. Cellular changes in the adjacent lymph node included hyperplasia of plasma cells, macrophages and lymphoid elements with typical mitosis.

Sustained activation of mitogen-activated protein kinases and activator protein 1 by the hepatitis B virus X protein in mouse hepatocytes in vivo.

Transcriptional activation of diverse cellular genes by the X protein (HBx) of hepatitis B virus (HBV) has been suggested as one of the mechanisms for HBV-associated hepatocellular carcinoma. However, such functions of HBx have been studied using transformed cells in culture and have not been examined in the normal adult hepatocytes, a natural host of HBV. Using an efficient hepatocyte-specific virus-based gene delivery system developed in our laboratory earlier, we studied the HBx action in vivo. We demonstrate that following virosome-mediated delivery of HBx DNA, a large population (>50%) of hepatocytes express the HBx protein in a dose-dependent manner, which induces a significant increase in the activity of extracellular signal-regulated kinases (ERKs) in the livers of HBx-transfected mice. Inhibition of HBx-induced ERK activation following intravenous administration of PD98059, a mitogen-activated protein kinase kinase kinase (MEK) inhibitor, confirmed the requirement for MEK in the activation of ERKs by HBx. Induction of ERK activity by HBx was sustained for up to 30 days. Interestingly, sustained activation of c-Jun N-terminal kinases (JNKs) for up to 30 days was also noted. Such constitutive ERK and JNK activation as a consequence of continued HBx expression also led to sustained stimulation of further downstream events, such as increased levels of c-Jun and c-Fos proteins along with the persistent induction of activator protein 1 binding activity. Taken together, our data suggest a critical role of these molecules in HBx-mediated cell transformation.