Performance of Mali's biosafety level 3 laboratory in the external quality assessment in preparedness of laboratory accreditation and support to clinical trials.

Background: The external quality assessment (EQA) or external quality control is an evaluation conducted by a certified external organization to inquire about the quality of the results provided by a laboratory. The primary role of EQA is to verify the accuracy of laboratory results. This is essential in research because research data should be published in international peer-reviewed journals, and laboratory results must be repeatable. In 2007, the University Clinical Research Center (UCRC's) biosafety level 3 (BSL-3) laboratory joined the EQA program with the College of American Pathologists in acid-fast staining and culture and identification of mycobacteria as per laboratory accreditation preparedness. Thus, after 11 years of participation, the goal of our study was to evaluate the performance of our laboratory during the different interlaboratory surveys. Methods: We conducted a descriptive retrospective study to evaluate the results of UCRC mycobacteriology laboratory from surveys conducted during 2007 and 2017. Results: Of the 22 evaluations, the laboratory had satisfactory (100% of concordance results) in 18 (81.8%) and good (80% of concordance results) in 4 (18.2%). Overall, the laboratory was above the commended/accepted limits of 75%. Conclusion: So far, UCRC's BSL-3 performed well during the first 11 years of survey participation, and efforts should be deployed to maintain this high quality in the preparedness for laboratory accreditation and support to clinical trials.

Diabetes Mellitus among new tuberculosis patients in Bamako, Mali.

INTRODUCTION: Diabetes Mellitus (DM) increases worldwide, mostly in low- and middle-income countries. In Mali, the prevalence in the adult population is estimated at 1.8%, but tuberculosis (TB) patients are not systematically screened. The goal of our study was to determine the prevalence of DM among newly diagnosed TB patients. METHODS: We conducted a cross sectional study and a pilot prospective cohort study in four health centers in Bamako. All patients underwent fasting capillary-blood glucose (FCBG) test at Day 0, and repeated after one-week of TB treatment. Venous FBG test was performed for discrepancies between the two FCBG results. Thereafter, FCBG was performed for pilot study at month-2 (M2) and M5 of TB treatment. RESULTS: Two hundred and one patients were enrolled in this study. Impaired fasting blood glucose was identified in 17 (8.5%), of whom 11 (5.5%) had DM (VFBG >7 mmol/L). Among patients with DM, seven (63.6%) had successful TB treatment outcome, versus 142 (74.7%) of those without DM (p = 0.64), and (OR: 1.69, 95%CI 0.47-6.02). CONCLUSION: The prevalence of DM among TB patients in Bamako exceeds that of the general population and screening at TB diagnosis suffices to identify those with DM. Systematic screening of both diseases will allow better treatment.

Clinical characteristics of non-tuberculous mycobacterial pulmonary infections in Bamako, Mali.

The global spread of non-tuberculous mycobacteria (NTM) may be due to HIV/AIDS and other environmental factors. The symptoms of NTM and tuberculosis (TB) disease are indistinguishable, but their treatments are different. Lack of research on the epidemiology of NTM infections has led to underestimation of its prevalence within TB endemic countries. This study was designed to determine the prevalence and clinical characteristics of pulmonary NTM in Bamako. A cross-sectional study which include 439 suspected cases of pulmonary TB. From 2006 to 2013 a total of 332 (76%) were confirmed to have sputum culture positive for mycobacteria. The prevalence of NTM infection was 9.3% of our study population and 12.3% of culture positive patients. The seroprevalence of HIV in NTM group was 17.1%. Patients who weighed <55 kg and had TB symptoms other than cough were also significantly more likely to have disease due to NTM as compared to those with TB disease who were significantly more likely to have cough and weigh more than 55 kg (OR 0.05 (CI 0.02-0.13) and OR 0.32 (CI 0.11-0.93) respectively). NTM disease burden in Bamako was substantial and diagnostic algorithms for pulmonary disease in TB endemic countries should consider the impact of NTM.

Performance of microscopic observation drug susceptibility for the rapid diagnosis of tuberculosis and detection of drug resistance in Bamako, Mali.

OBJECTIVES: In Mali early detection and treatment of multidrug-resistant tuberculosis (MDR-TB) are still challenging due to the cost, time and/or complexity associated with regular tests. Microscopic Observation Drug Susceptibility (MODS) is a low-cost assay validated by WHO in 2010. It is a liquid-culture-based assay to detect the 'cording' characteristic of Mycobacterium tuberculosis complex and to assess susceptibility to both isoniazid and rifampicin defining multidrug-resistant tuberculosis (MDR-TB). In this study we aimed to evaluate the performance of MODS as diagnostic tool compared with a validated method-Mycobacteria Growth Indicator Tube/Antimicrobial Susceptibility Testing/Streptomycin, Isoniazid, Rifampicin and Ethambutol (MGIT/AST/SIRE). METHODS AND RESULTS: Between January 2010 and October 2015 we included 98 patients with suspected TB in an observational cohort study. The sensitivity and specificity of MODS assay for detecting TB were respectively 94.12% and 85.71% compared with the reference MGIT/7H11 culture, with a Cohen κ coefficient of 0.78 (95% CI 0.517-1.043). The median time to culture positivity for MODS assay and MGIT (plus interquartile range, IQR) was respectively 8 days (IQR 5-11) and 6 days (IQR 5-6). In detecting patients with MDR-TB, the sensitivity and specificity of MODS assay were respectively 100% and 95.92%. The positive predictive value and negative predictive value were, respectively, 66.7% and 100%. The median turnaround times for obtaining MDR-TB results using MODS assay and MGIT/AST/SIRE was respectively 9 days and 35 days. Hence, the MODS assay rapidly identifies MDR-TB in Mali compared with the MGIT/AST/SIRE. CONCLUSION: As an easy, simple, fast and affordable method, the MODS assay could significantly improve the management of TB.

Establishing Reference Ranges of Hematological Parameters from Malian Healthy Adults.

INTRODUCTION: Measurement of immuno-hematological parameters has been historically helpful in the diagnosis and treatment monitoring of many infectious diseases and cancers. However, these parameters have not yet been established in many developing countries where patient care strongly relies on such low-cost tests. This study describes the immuno-hematological parameter ranges for Malian healthy adults. METHODS: A cross sectional study was conducted from August 2004 to May 2013. We included 213 healthy volunteers (173 male and 40 female), aged between 18-59 years. Median, 2.5 and 97.5 percentile ranges for each immuno-hematological parameter are presented. RESULTS: In our study population, the hematological parameters' ranges were mostly different to the universal established ranges. We found in our population a Median white blood cell (WBC) count of 5200 cells/µL [3237.5-11900], Red Blood Cell (RBC) count of 4.94 10^6 [3.56-6.17], hemoglobin (Hb) of 14.2 g/dL [12.2-17.38], platelet count (Plt) of 275 10^3/µL [145.4-614.4], lymphocytes 2050/µL [1200-3800], neutrophils 2200/µL [1040-6220]; monocytes 200/µL [100-660]; eosinophils 131/µL [0-1026]; CD4 902 cells/µL [444-1669] and CD8 485 cells/µL [0-1272]. We found significant gender differences in RBC, Hb level and MPV. However, RBC and Hb were higher in males median values compared to females (median values) (p<0.001), whereas the Mean platelet volume lower values (MPV) in males than females (P<0.047). The hemoglobin level for some West African countries (Mali, Burkina Faso, Togo, and Nigeria) ranged from 13.5 to 15.1 g/dL for males and 12 to 13 g/dL for females. However in East and Southern Africa, the values were anywhere from 14.1 to 16.1 for males and 11.2 to 14.4 for females. CONCLUSION: Our data may help physicians to better define hematological abnormalities in patients. They may also be used to define new "normal hematological values" in Malian population or in the whole West African population.

Tuberculosis drug resistance in Bamako, Mali, from 2006 to 2014.

BACKGROUND: Although Drug resistance tuberculosis is not a new phenomenon, Mali remains one of the "blank" countries without systematic data. METHODS: Between 2006 and 2014, we enrolled pulmonary TB patients from local TB diagnostics centers and a university referral hospital in several observational cohort studies. These consecutive patients had first line drug susceptibility testing (DST) performed on their isolates. A subset of MDR was subsequently tested for second line drug resistance. RESULTS: A total of 1186 mycobacterial cultures were performed on samples from 522 patients, including 1105 sputa and 81 blood samples, yielding one or more Mycobacterium tuberculosis complex (Mtbc) positive cultures for 343 patients. Phenotypic DST was performed on 337 (98.3%) unique Mtbc isolates, of which 127 (37.7%) were resistant to at least one drug, including 75 (22.3%) with multidrug resistance (MDR). The overall prevalence of MDR-TB was 3.4% among new patients and 66.3% among retreatment patients. Second line DST was available for 38 (50.7%) of MDR patients and seven (18.4%) had resistance to either fluoroquinolones or second-line injectable drugs. CONCLUSION: The drug resistance levels, including MDR, found in this study are relatively high, likely related to the selected referral population. While worrisome, the numbers remained stable over the study period. These findings prompt a nationwide drug resistance survey, as well as continuous surveillance of all retreatment patients, which will provide more accurate results on countrywide drug resistance rates and ensure that MDR patients access appropriate second line treatment.

Exposure assessment of a mercury spill in a Nevada school -- 2004.

BACKGROUND: Although mercury is toxic, few studies have measured exposure in children who handled elemental mercury briefly. In 2004, a student spilled approximately 60 milliliters of mercury at a Nevada school. Within 12 hours, all students were removed from the source of exposure. We conducted an exposure assessment at the school. METHODS: We administered questionnaires and obtained urine samples from students. Using two-sample t-tests, we compared urine mercury levels from students who self-reported exposure to mercury levels of other students. RESULTS: Two-hundred students participated, including 55/62 (89%) who were decontaminated. The students' geometric mean urine mercury level was 0.36 microg/L (95% confidence interval 0.32-0.40 microg/L). The student who brought the mercury to school was the only one to have an elevated urine mercury level (11.4 microg/L). CONCLUSION: Despite environmental contamination, mercury exposure may have been minimized because of rapid identification of the elemental mercury spill and decontamination.

Short-cycle structured intermittent treatment of chronic HIV infection with highly active antiretroviral therapy: effects on virologic, immunologic, and toxicity parameters.

Although continuous highly active antiretroviral therapy (HAART) is effective for many HIV-infected patients, it can be toxic and prohibitive in cost. By decreasing the total amount of time patients receive medications, intermittent HAART could reduce toxicity and cost. Therefore, we initiated a pilot study in which 10 HIV-infected individuals receiving effective therapy that resulted in levels of HIV RNA <50 copies per ml of plasma and CD4(+) T cell counts >300 cells per mm(3) of whole blood received repeated cycles of 7 days on HAART followed by 7 days off of HAART. Patients maintained suppression of plasma viremia for 32-68 weeks. There was no significant increase in HIV proviral DNA or replication-competent HIV in peripheral CD4(+) T cells or HIV RNA in peripheral blood or lymph node mononuclear cells. There was no significant change in CD4(+) T cell counts, no significant increase in CD4(+) or CD8(+) T cells expressing activation markers or producing IFN-gamma in response to HIV, no increase in CD4(+) T cell proliferation to p24 antigen, and no evidence for the development of resistance to HAART medications. There was a significant decrease in serum cholesterol and triglyceride levels. Thus, in this proof-of-concept study, short-cycle intermittent HAART maintained suppression of plasma viremia as well as HIV replication in reservoir sites while preserving CD4(+) T cell counts. In addition, there was a decrease in serum cholesterol and triglyceride levels. Intermittent therapy may be an important strategy to reduce cost and toxicity for HIV-infected individuals.

Beta-adrenergic antagonist exposures in children.

Since limited toxicological data exists for beta-adrenergic antagonist (BA) exposures in children, a survey to describe triage practices by regional poison centers nationwide and to characterize clinical manifestations of unintentional pediatric BA exposures was sent to 49 poison centers. A 7-y retrospective review of acute BA exposures in children aged < 7years from 1 regional poison center was also undertaken. Thirty-three centers (67%) responded: 19/33 (58%) had no established BA triage guideline for young children. The 14/33 remaining centers (42%) most often referred these children to a hospital if any BA was ingested. In the 1-center review, metoprolol (28%) and atenolol (27%) exposures were most common, but = 1 tablet of BA was involved in 83% of the exposures. Symptoms occurred in 8 children; 2/378 had lethargy and 6/378 had bradycardia and/or hypotension. Immediate-release preparations were ingested by 7/8 symptomatic patients (median time to onset of symptoms = 3.0 h, range 45 min to 3.5 h). Of 280 children with definitive follow-up, 272 had no clinical effects, 4 had minor effects, and 4 had moderate effects. Regional poison centers commonly refer children exposed to any amount of BA to the hospital. The majority of BA exposures involved a small amount and significant clinical effects were rare. The range of toxicity for BA in children needs to be established.

Calcium channel blocker ingestions in children.

UNLABELLED: Limited data exists regarding toxicity of calcium channel blockers (CCBs) in children. The purpose of this study was to determine the frequency, the range of toxicity, the appropriate observation time, and to assess effective interventions for CCB ingestions in children. A 6-year retrospective review of CCB ingestions in children younger than 7 years of age reported to one regional poison center was undertaken. Patients with coingestants with recognized cardiovascular or central nervous system (CNS) effects were excluded. Two hundred eighty-three patients met criteria for review. The mean age was 27 months with 52% of all patients being boys. Nifedipine (38%), verapamil (34%), and amlodipine (14%) were most commonly ingested. Seventy-five percent of ingestions reportedly involved < or =1 pill. Symptoms occurred in 16/283 (6%): 4 had vomiting, and 12 had CNS or cardiovascular effects. The mean time to onset of symptoms for regular-release and for sustained-release (SR) CCB preparations were 1.5 hours (range 0.5 to 3 hr) and 4.5 hours (range 1 to 14 hr) respectively. OUTCOME: 74% of patients had no clinical effects, 4% minor effects, 2% moderate effects, and 20% other. No deaths or major effects were reported. TREATMENT: 88% of patients evaluated in an emergency department received gastric decontamination, usually one dose of charcoal. Calcium chloride was given in three verapamil SR cases. Five of six patients had reversal of hypotension with IV fluids and decontamination alone. Most pediatric CCB ingestions involve ingestions of small amounts of drug with no effects. Asymptomatic children in this study group who were known to have ingested <12 mg/kg of verapamil SR or <2.7 mg/kg of nifedipine SR could have been monitored at home. Of the children requiring evaluation and monitoring in a health care facility, an observation period for regular-release and SR-CCBs for 3 and 14 hours respectively would have been appropriate. There were insufficient cases with symptoms to draw conclusions for optimal therapeutic interventions.

CD40 ligand trimer and IL-12 enhance peripheral blood mononuclear cells and CD4+ T cell proliferation and production of IFN-gamma in response to p24 antigen in HIV-infected individuals: potential contribution of anergy to HIV-specific unresponsiveness.

It has been suggested that CD4+ T cell proliferative responses to HIV p24 Ag may be important in the control of HIV infection. However, these responses are minimal or absent in many HIV-infected individuals. Furthermore, while in vitro and in vivo responses to non-HIV recall Ags improve upon administration of highly active antiretroviral therapy, there does not appear to be a commensurate enhancement of HIV-specific immune responses. It is possible that CD4+ p24-specific T cells are deleted early in the course of infection. However, it is also possible that a discrete unresponsiveness, or anergy, contributes to the lack of proliferation to p24. To evaluate the possible contribution of unresponsiveness to the lack of CD4+ T cell proliferation to p24 in HIV-infected individuals, we attempted to overcome unresponsiveness. CD40 ligand trimer (CD40LT) and IL-12 significantly increased PBMC and CD4+ T cell proliferative responses to p24 Ag in HIV-infected, but not uninfected, individuals. No increase in proliferative response to CMV Ag was observed. CD40LT exerted its effect through B7-CD28-dependent and IL-12- and IL-15-independent mechanisms. Finally, the increase in proliferation with CD40LT and IL-12 was associated with an augmented production of IFN-gamma in most, but not all, individuals. These data suggest the possible contribution of HIV-specific unresponsiveness to the lack of CD4+ T cell proliferation to p24 Ag in HIV-infected individuals and that clonal deletion alone does not explain this phenomenon. They also indicate the potential for CD40LT and IL-12 as immune-based therapies for HIV infection.

The utility of toxicologic analysis in children with suspected ingestions.

OBJECTIVE: To evaluate the usefulness of toxicologic studies on the management of children with suspected ingestions. DESIGN: Prospective, consecutive case series. SETTING: Two tertiary care children's hospital emergency departments. PATIENTS: All children < or =18 years of age presenting with a suspected ingestion. STUDY DESIGN: Pediatric emergency physicians completed a 14-point questionnaire on each identified patient that included demographics, signs, and symptoms, and if applicable, the extent of drug analysis performed. Pre-test and post-test utility values were determined by the ordering physician using an 11-point scale (0 = least valuable, 10 = most valuable). Physicians also assessed how positive or negative drug analyses affected patient management. RESULTS: Two hundred twenty patients met study criteria. Median age was 5 years, with males making up 53% of patients. Drug analysis was ordered in 72% (158/220) of cases, with 59% of these tests obtained for a history of ingestion and 27% obtained for altered mental status (AMS). The most common suspected ingestions were acetaminophen and cold preparations. Seventy-eight of 158 (49%) patients had positive toxicology tests, with 17 unsuspected findings. Patient management was affected in 53/158 (34%; 95% CI, 27-41%) cases. Unsuspected findings affecting management were found in only 4/158 (3%; 95% CI, 1-6%) cases. Significant differences in pre-test and post-test utility values occurred for serum assays (mean difference +0.4, P = 0.008), patients presenting with AMS (mean difference -0.8, P = 0.005), and patients having a negative drug test (mean difference -0.5, P = 0.003). Although negative drug analysis gave the physician reassurance in 39/80 (49%; 95% CI, 38-60%) cases, patient management was altered in only 8/80 (10%; 95% CI, 5-18%) cases. CONCLUSIONS: Seventy-two percent of children presenting with suspected drug ingestions had toxicologic analysis performed as part of their evaluation. Analysis was most valuable to physicians when evaluation of overdoses required serum drug levels. Qualitative urine drug screens provided minimal useful information. Unexpected findings on urine drug screening leading to changes in management were uncommon.

Utility of comprehensive toxicologic screens in children.

This study was undertaken to evaluate the clinical utility and cost-effectiveness of the limited component versus the high performance liquid chromatography (HPLC) component of comprehensive toxicologic screens in children. A retrospective patient series was studied at the emergency department (ED) of Hughes Spalding Children's Hospital, an urban, tertiary-care ED, consisting of all patients younger than 19 years of age who had a comprehensive toxicologic screen between January 1994 and July 1995. The comprehensive test included a broad-spectrum HPLC component as well as a limited component that examined serum for ethanol, aspirin, and acetaminophen and urine for benzodiazepines, barbiturates, amphetamines, cocaine, phencyclidine, and opiates. All toxicologic screens were reviewed for the presence of exogenous toxins, followed by a chart review of all patients with positive screens and a selection of negative screens. Toxins were categorized as (1) iatrogenic or noniatrogenic, (2) clinically or nonclinically suspected by history and physical, and (3) clinically or nonclinically significant. Comprehensive toxicology screens were performed in 463 cases during the study period; 234 (51%) were positive for exogenous toxins. In 227 of 234 positive screens (97%), toxins were either suspected by history and/or physical, were present on the limited portion of the toxicology screen, or were clinically insignificant. The remaining 7 of the 234 positive screens (3%) were clinically significant and detected solely by the broad-spectrum HPLC portion of the comprehensive screen. However, in none of these 7 cases was patient management clinically altered as a result of the positive screen. The total additional cost for the HPLC component was $16,205 ($35x463), an average distributive charge of $2,315 per patient in whom the HPLC portion provided additional clinical information ($16,205/7). Although adding significant charges to the evaluation of suspected toxic exposures in children, the HPLC component of the comprehensive drug screen was of no additional clinical benefit compared with its limited component alone.

Ultracentrifuge schlieren photographs: automatic analysis.

Schlieren photographs can be digitized and stored in a computer's memory. A computer program then interprets and measures the Schlieren curve and calculates molecular properties.