Pharmaceuticals and personal care products in water streams: Occurrence, detection, and removal by electrochemical advanced oxidation processes.

Pharmaceutical and personal care products (PPCPs) are part of the emerging contaminants (ECs) in the environment due to their known or suspected adverse effects in aquatic and terrestrial organisms, as well as in human health. Presence of PPCPs in aquatic and terrestrial ecosystems has been mainly attributed to the effluents of wastewater treatment plants (WWTPs). Although several PPCPs have been detected in wastewater, their removal from wastewater via biological processes is limited. Removal of PPCPs depends on their chemical structure, concentration, solubility, and technology used to treat the wastewater. Electrochemical Advanced Oxidation Processes (EAOPs) are some of the most sought-after methods for dealing with organic pollutants in water including PPCPs, due to generation of strong oxidants such as •OH, H2O2 and O3- by using directly or indirectly electrochemical technology. This review is focused on the removal of main PPCPs via EAOPs such as, anodic oxidation, electro-Fenton, photoelectron-Fenton, solar photoelectron-Fenton, photoelectrocatalysis and sonoelectrochemical processes. Although more than 40 PPCPs have been identified through different analytical approaches, antibiotics, anti-inflammatory and antifungal are the main categories of PPCPs detected in different water matrices. Application of EAOPs has been centered in the removal of antibiotics and analgesics of high consumption by using model media, e.g. Na2SO4. Photoelectrocatalysis and Electro-Fenton processes have been the most versatile EAOPs applied for PPCPs removal under a wide range of operating conditions and a variety of electrodes. Although EAOPs have gained significant scientific interest due to their effectiveness, low environmental impact, and simplicity, further research about the removal of PPCPs and their by-products under realistic concentrations and media is needed. Moreover, mid-, and long-term experiments that evaluate EAOPs performance will provide knowledge about key parameters that allow these technologies to be scaled and reduce the potential risk of PPCPs in aquatic and terrestrial ecosystem.

Analysis of loss to follow-up in 4099 multidrug-resistant pulmonary tuberculosis patients.

Loss to follow-up (LFU) of ≥2 consecutive months contributes to the poor levels of treatment success in multidrug-resistant tuberculosis (MDR-TB) reported by TB programmes. We explored the timing of when LFU occurs by month of MDR-TB treatment and identified patient-level risk factors associated with LFU.We analysed a dataset of individual MDR-TB patient data (4099 patients from 22 countries). We used Kaplan-Meier survival curves to plot time to LFU and a Cox proportional hazards model to explore the association of potential risk factors with LFU.Around one-sixth (n=702) of patients were recorded as LFU. Median (interquartile range) time to LFU was 7 (3-11) months. The majority of LFU occurred in the initial phase of treatment (75% in the first 11 months). Major risk factors associated with LFU were: age 36-50 years (HR 1.3, 95% CI 1.0-1.6; p=0.04) compared with age 0-25 years, being HIV positive (HR 1.8, 95% CI 1.2-2.7; p<0.01) compared with HIV negative, on an individualised treatment regimen (HR 0.7, 95% CI 0.6-1.0; p=0.03) compared with a standardised regimen and a recorded serious adverse event (HR 0.5, 95% CI 0.4-0.6; p<0.01) compared with no serious adverse event.Both patient- and regimen-related factors were associated with LFU, which may guide interventions to improve treatment adherence, particularly in the first 11 months.

Clinical and epidemiological features of extrapulmonary tuberculosis in a high incidence region.

OBJECTIVE: To describe the clinical features of extrapulmonary tuberculosis (EXPTB) and to evaluate epidemiological data to search for potential explanations for its high frequency in the state of Aguascalientes, Mexico. MATERIALS AND METHODS: Clinical records of all patients with tuberculosis seen in Aguascalientes in 2008 were reviewed, and official databases were analyzed. RESULTS: EXPTB comprised 60.5% of the 86 cases evaluated, being lymph nodes the main site affected. Patients with EXPTB were younger and more obese than subjects with pulmonary tuberculosis (PTB). One third of cases in either group had diabetes, a frequency much higher than expected. Epidemiological analysis showed that PTB incidence, but not EXPTB incidence, decreases as geographical altitude increases, and had a descendent trend from 1997 to 2011. CONCLUSIONS: The lower frequency of PTB (due to its inverse relationship with altitude and its descendent trend in last years) might explain the high frequency of EXPTB. Obesity appeared to protect against developing pulmonary involvement, and diabetes was more frequent than expected among PTB and EXPTB cases.

Clinical and epidemiological features of extrapulmonary tuberculosis in a high incidence region / Características clínicas y epidemiológicas de la tuberculosis extrapulmonar en una región de alta incidencia

Objective. To describe the clinical features of extrapulmonary tuberculosis (EXPTB) and to evaluate epidemiological data to search for potential explanations for its high frequency in the state of Aguascalientes, Mexico. Materials and methods. Clinical records of all patients with tuberculosis seen in Aguascalientes in 2008 were reviewed, and official databases were analyzed. Results. EXPTB comprised 60.5% of the 86 cases evaluated, being lymph nodes the main site affected. Patients with EXPTB were younger and more obese than subjects with pulmonary tuberculosis (PTB). One third of cases in either group had diabetes, a frequency much higher than expected. Epidemiological analysis showed that PTB incidence, but not EXPTB incidence, decreases as geographical altitude increases, and had a descendent trend from 1997 to 2011. Conclusions. The lower frequency of PTB (due to its inverse relationship with altitude and its descendent trend in last years) might explain the high frequency of EXPTB. Obesity appeared to protect against developing pulmonary involvement, and diabetes was more frequent than expected among PTB and EXPTB cases.

Objetivo. Describir las características clínicas de la tuberculosis extrapulmonar (TBEXP) y evaluar datos epidemiológicos para buscar posibles explicaciones de su alta frecuencia en Aguascalientes, México. Material y métodos. Se revisaron expedientes de todos los pacientes con tuberculosis atendidos en Aguascalientes en 2008 y se analizaron bases de datos oficiales. Resultados. La TBEXP constituyó 60.5% de los 86 casos evaluados, con afectación más común en ganglios linfáticos. Los pacientes con TBEXP fueron más jóvenes y más obesos que aquéllos con tuberculosis pulmonar (TBP). Un tercio de cada grupo tenía diabetes, una frecuencia muy superior a la esperada. El análisis epidemiológico mostró que la incidencia de TBP, pero no de TBEXP, es menor conforme aumenta la altitud geográfica y además está disminuyendo (l997-2011). Conclusiones. La menor incidencia de TBP (por su relación inversa con la altitud y por su tendencia a disminuir en los últimos años) podría explicar la alta frecuencia de TBEXP. La obesidad parece proteger contra la afectación pulmonar, y la diabetes fue más frecuente de lo esperado tanto en TBP como en TBEXP.

Multidrug resistant pulmonary tuberculosis treatment regimens and patient outcomes: an individual patient data meta-analysis of 9,153 patients.

BACKGROUND: Treatment of multidrug resistant tuberculosis (MDR-TB) is lengthy, toxic, expensive, and has generally poor outcomes. We undertook an individual patient data meta-analysis to assess the impact on outcomes of the type, number, and duration of drugs used to treat MDR-TB. METHODS AND FINDINGS: Three recent systematic reviews were used to identify studies reporting treatment outcomes of microbiologically confirmed MDR-TB. Study authors were contacted to solicit individual patient data including clinical characteristics, treatment given, and outcomes. Random effects multivariable logistic meta-regression was used to estimate adjusted odds of treatment success. Adequate treatment and outcome data were provided for 9,153 patients with MDR-TB from 32 observational studies. Treatment success, compared to failure/relapse, was associated with use of: later generation quinolones, (adjusted odds ratio [aOR]: 2.5 [95% CI 1.1-6.0]), ofloxacin (aOR: 2.5 [1.6-3.9]), ethionamide or prothionamide (aOR: 1.7 [1.3-2.3]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.3 [1.3-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 2.7 [1.7-4.1]). Similar results were seen for the association of treatment success compared to failure/relapse or death: later generation quinolones, (aOR: 2.7 [1.7-4.3]), ofloxacin (aOR: 2.3 [1.3-3.8]), ethionamide or prothionamide (aOR: 1.7 [1.4-2.1]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.7 [1.9-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 4.5 [3.4-6.0]). CONCLUSIONS: In this individual patient data meta-analysis of observational data, improved MDR-TB treatment success and survival were associated with use of certain fluoroquinolones, ethionamide, or prothionamide, and greater total number of effective drugs. However, randomized trials are urgently needed to optimize MDR-TB treatment. Please see later in the article for the Editors' Summary.

Mycobacterial infections in the elderly.

In 2008, elderly subjects accounted for more than 262,000 cases of smear-positive tuberculosis worldwide, reaching the highest age-adjusted rates in some regions. Elders are at a greater risk for reactivation of latent tuberculosis or acquisition of new infection, especially if they live in long-term care facilities or are smokers. Once overt clinical tuberculosis appears, they are at increased risk of hospitalization and death. Pulmonary tuberculosis presentation may be atypical in elderly people, as they tend to have lower prevalence of fever, sweating, or hemoptysis, and their chest x-rays show less cavities and more lower lung field involvement. Compared with younger patients, tuberculous elders seem to have lower frequency of positive PPD, but differences in sputum smear positivity are not clear. Regimen recommended for treating new cases of pulmonary tuberculosis is not different from other age groups: a two-month bactericidal phase with daily oral administration of isoniazid, rifampin, pyrazinamide, and ethambutol, and a continuation phase with isoniazid and rifampin daily during four months, though some variations are allowed. Directly observed strategy is highly recommended in the initial phase. Elders with pulmonary tuberculosis may require longer time to become smear negative and seem to have worse outcomes than younger patients.

[Analgesic effect of intra-artcular fentanyl in knee arthroscopy to treat patellofemoral lateral hyperpressure syndrome]. / Efecto analgésico del fentanyl intraarticular en artroscopía de rodilla para el síndrome de hiperpresión lateral patelofemoral.

INTRODUCTION: During arthroscopy for the treatment of patellofemoral lateral hyper-pressure syndrome (LHS), intra-articular morphine or its derivatives (fentanyl) may reduce postoperative pain when combined with anesthetics. We therefore decided to determine whether adding fentanyl to epinephrine and bupivacaine produced an increased analgesia. MATERIAL AND METHODS: We randomly distributed 40 patients into two groups. The experimental group (n=20) was given 0.5% bupivacaine (2 mg/kg), epinephrine (100 microg) and fentanyl (2.5 microg/kg). The control group (n=20) received 0.5% bupivacaine (2 mg/kg) and epinephrine (100 microg). Patients underwent chondroplasty and retinacular release, and we assessed pain, time of analgesia and postoperative range of motion at postoperative hours 6 and 24. RESULTS: The age and the grade of patellofemoral chondromalacia (PFC) were similar in both groups (p > 0.05). No differences were found in pain and ranges of motion intraoperatively and at postoperative hours 6 and 24 (p > 0.05) between both groups. The postoperative analgesia time was similar (p > 0.05). CONCLUSIONS: Adding intra-articular fentanyl to the combination of epinephrine plus bupivacaine did not decrease pain, and did not increase neither the analgesia time nor the range of motion in patients with LHS undergoing knee arthroscopy.

[Pleural mesothelioma in a Mexican population: clinical and radiological similarities among histopathologic patterns]. / Mesotelioma pleural. Similitudes clínico-radiológicas entre estirpes.

OBJECTIVE: To describe clinical and radiological features of patients with pleural mesothelioma, according to main histological types. METHODS: Clinical records of inpatients admitted with diagnosis of pleural mesothelioma to the Instituto Nacional de Enfermedades Respiratorias in the last 11 years, were reviewed. RESULTS: We analyzed 85 cases confirmed by immunohistochemistry. The most frequent histological type was epithelial (84.7 %), followed by sarcomatous (12.9 %) and mixed (2.4 %) types. Comparison between epithelial and sarcomatous types showed no differences in age (53.7 +/- 13.1 vs. 55.9 +/- 11.0 years, respectively), male : female ratio (2.3 : 1 vs. 1.8 : 1), history of asbestos exposure (34.7 vs. 27.2 %), tobacco habit (54.2 vs 45.4 %), occupation, evolution time (4.8 +/- 3.3 vs. 4.4 +/- 3.7 months), pain, dyspnea and cough, right-side predominance (55.6 vs. 81.8 %), radiological image with pleural effusion (59.7 vs. 36.4 %) or pleural thickening (38.9 vs. 63.6 %), and diagnostic efficiency of closed pleural biopsy (58.3 vs. 27.2 %). CONCLUSIONS: Our results suggest that clinical and radiological features of epithelial and sarcomatous histological types are very similar. Additionally, we found a high frequency of epithelial mesothelioma, which contrasts with findings from other countries, suggesting that the type of asbestos or other factors involved in the development of pleural mesothelioma differ from those existing in other regions of the world.

[Thoracocentesis in patients with pleural effusion and chronic alcoholic liver disease]. / Toracentesis on pacientes con derrame pleural asociado a enfermedad hepática alcohólica.

BACKGROUND: chronic alcoholic liver disease (EHAC) associates to recurrent pleural effusion. Generally thoracocentesis is not performed for considering this fluid a trasudate. Our objective was to determine the usefulness of thoracocentesis and causes of recurrent pleural effusion. METHODS: we analyzed samples of pleural fluid of patients with chronic alcoholic liver disease, recurrent pleural effusion and respiratory failure. Blood tests, chest x-rays and pleural fluid analyses were evaluated. RESULTS: we included 27 cases. Mean age of patients was >60 year old, mean evolution time of liver disease was approximately 4 years. 55.6% were exudates and 44.4% trasudates. Causes of recurrent pleural effusion were portal hypertension in 12 (44.4%) cases. In patients with exudate, the origin was infectious in 8 (29.6%) cases; in 4 (14.8%) the cause was malignancy; one more with pulmonary embolism, and in other two patients the cause was not identified. CONCLUSIONS: we found that more than half of patients with chronic alcoholic liver disease and recurrent pleural effusion was an exudate, thus thoracocentesis should be frequently performed in these patients.

[Lipid profile in household contacts of patients with pulmonary tuberculosis]. / Perfil de lípidos en contactos convivientes de pacientes con tuberculosis pulmonar.

BACKGROUND: we have recently published the hypothesis that hypocholesterolemia might be a risk factor for the development of pulmonary tuberculosis. In this sense, albeit patients with pulmonary tuberculosis often have total cholesterol levels lower than the general population, it is not known if the latter have had a recent exposure to Mycobacterium tuberculosis. OBJECTIVE: to evaluate serum lipids in subjects exposed to mycobacteria. METHODS: we studied 25 pulmonary tuberculosis patients and 44 household contacts, and compared their serum lipid profile. RESULTS: We found that total cholesterol, LDL and triglycerides concentrations increased with age in contacts but not in pulmonary tuberculosis patients, with statistically significant differences in regression lines (age versus lipid level). Multiple linear regression analysis confirmed that being a household contact was associated with higher levels of total cholesterol, LDL, HDL and triglycerides. CONCLUSIONS: We conclude that lipid profile differed between pulmonary tuberculosis patients and their household contacts, thus supporting that low cholesterol levels might be a risk factor for developing pulmonary tuberculosis.

Appetite and tuberculosis: is the lack of appetite an unidentified risk factor for tuberculosis?

Different risk factors have been identified as associated with tuberculosis (TB), an important and common one is malnutrition, however, the causes of malnutrition have not been studied in detail, the lack of food and poverty are among the most frequent in developing countries but others are yet to be identified. We hypothesized that chronic lack of appetite can be one of the causes of malnutrition associated to TB and therefore be a potential independent risk factor for latent tuberculosis infection (LTBI) or TB disease. If this is true, contact subjects with LTBI who have poor appetite will be at higher risk for getting the disease and people with the disease will be at risk for poor treatment outcomes.

A propósito de: Tratamiento de la tuberculosis multifarmacorresistente, ¿esquema estandarizado o individualizado?" / Treatment of multidrug-resistant pulmonary TB: standardized or individual therapy?

La implementación de un tratamiento empírico en los pacientes con tuberculosis multifarmacorresistente, sin pruebas de cultivo y de farmacosensibilidad, lleva a un gran número de fracasos. Diversos estudios han demostrado que el retratamiento de segunda línea estandarizado no logra la curación en un alto porcentaje y es en principio un régimen empírico, por lo que no parece ser la mejor conducta terapéutica y es, definitivamente, más conveniente que estos pacientes sean tratados con un esquema individualizado por médicos expertos en esta forma especial de la tuberculosis.

The implementation of an empirical treatment in patients with muitidrug resistant (MDR) tuberculosis (TB) without sputum culture and drug-susceptibility tests leads to a high number of failures. Several studies have shown that standardized second line retreatment does not provide a high cure rate and is an empirical regime. Therefore, this does not appear to be the best therapeutic choice; MDRTB patients should be treated with an individualized treatment by physicians expert in this very special form of tuberculosis.

Hypocholesterolemia: a major risk factor for developing pulmonary tuberculosis?

Although one-third of the world's population is infected by Mycobacterium tuberculosis, only approximately 10% will develop the overt clinical disease due to a yet undefined risk factor. We hypothesize that hypocholesterolemia might constitute such a factor, because: (a) cholesterol is an important molecule for the good functioning of an immune system, and is necessary for macrophages to uptake and engulf mycobacteria, (b) tuberculous patients often have hypocholesterolemia, in comparison with the general population and household contacts, (c) cholesterol has a beneficial effect against pulmonary tuberculosis, since a cholesterol-rich diet accelerates the bacteriological sterilization of sputum, and (d) many conditions traditionally considered major risk factors for tuberculosis are accompanied by hypocholesterolemia. If this hypothesis proves to be true, cholesterol might be given to hypocholesterolemic subjects who are at high risk for developing pulmonary tuberculosis.