Enhancing TB Case Detection: Experience in Offering Upfront Xpert MTB/RIF Testing to Pediatric Presumptive TB and DR TB Cases for Early Rapid Diagnosis of Drug Sensitive and Drug Resistant TB

Background

Diagnosis of pulmonary tuberculosis (PTB) in children is challenging due to difficulties in obtaining good quality sputum specimens as well as the paucibacillary nature of disease. Globally a large proportion of pediatric tuberculosis (TB) cases are diagnosed based only on clinical findings. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents the results from pediatric groups taking part in a large demonstration study wherein Xpert MTB/RIF testing replaced smear microscopy for all presumptive PTB cases in public health facilities across India.

Methods

The study covered a population of 8.8 million across 18 programmatic sub-district level tuberculosis units (TU), with one Xpert MTB/RIF platform established at each study TU. Pediatric presumptive PTB cases (both TB and Drug Resistant TB (DR-TB)) accessing any public health facilities in study area were prospectively enrolled and tested on Xpert MTB/RIF following a standardized diagnostic algorithm.

Results

4,600 pediatric presumptive pulmonary TB cases were enrolled. 590 (12.8%, CI 11.8–13.8) pediatric PTB were diagnosed. Overall 10.4% (CI 9.5–11.2) of presumptive PTB cases had positive results by Xpert MTB/RIF, compared with 4.8% (CI 4.2–5.4) who had smear-positive results. Upfront Xpert MTB/RIF testing of presumptive PTB and presumptive DR-TB cases resulted in diagnosis of 79 and 12 rifampicin resistance cases, respectively. Positive predictive value (PPV) for rifampicin resistance detection was high (98%, CI 90.1–99.9), with no statistically significant variation with respect to past history of treatment.

Conclusion

Upfront access to Xpert MTB/RIF testing in pediatric presumptive PTB cases was associated with a two-fold increase in bacteriologically-confirmed PTB, and increased detection of rifampicin-resistant TB cases under routine operational conditions across India. These results suggest that routine Xpert MTB/RIF testing is a promising solution to present-day challenges in the diagnosis of PTB in pediatric patients.     

Trait-Based Filtering of the Regional Species Pool to Guide Understory Plant Reintroductions in Midwestern Oak Savannas, U.S.A.

A common first step during ecological restoration is reestablishing the local species pool through active reintroduction of individual plant species. Unfortunately, the regional species pool is often far too large to be of practical use during restoration. Methods are needed to produce manageable lists of key species for directed reintroduction. We used life history traits to target species from the regional species pool ( n = 900) for reintroduction to degraded Midwestern oak savanna remnants ( n = 8) in central Iowa, U.S.A. Beginning with the full regional species pool, we first used a priori filters to remove exotic species, species that live in permanently wet habitats, and species already present at the degraded remnant savannas. Next, we created a set of filters to target species with high priority for reintroduction, based on comparisons between the degraded and regional species pools. By this process, we identified perennial forbs and grasses that may be dispersal limited (ant, passive, or heavy wind-dispersed seeds) and are conservative in habitat requirement or have affinities for high-light environments. By applying these filters, we were able to winnow down the regional species pool to a manageable number of species ( n = 111) that we recommend for initial reintroduction efforts to the degraded savanna remnants. Furthermore, we specifically targeted members of the regional species pool that could fill under-represented ecological niches at the degraded savanna remnants and discuss potential benefits of adding these species for restoring ecosystem function.     

A Novel Testing Model for Opportunistic Screening of Pre-Diabetes and Diabetes among U.S. Adults

Objective

The study aim was to evaluate the performance of a novel simultaneous testing model, based on the Finnish Diabetes Risk Score (FINDRISC) and HbA1c, in detecting undiagnosed diabetes and pre-diabetes in Americans.

Research Design and Methods

This cross-sectional analysis included 3,886 men and women (≥ 20 years) without known diabetes from the U.S. National Health and Nutrition Examination Survey (NHANES) 2005-2010. The FINDRISC was developed based on eight variables (age, BMI, waist circumference, use of antihypertensive drug, history of high blood glucose, family history of diabetes, daily physical activity and fruit & vegetable intake). The sensitivity, specificity, and the receiver operating characteristic (ROC) curve of the testing model were calculated for undiagnosed diabetes and pre-diabetes, determined by oral glucose tolerance test (OGTT).

Results

The prevalence of undiagnosed diabetes was 7.0% and 43.1% for pre-diabetes (27.7% for isolated impaired fasting glucose (IFG), 5.1% for impaired glucose tolerance (IGT), and 10.3% for having both IFG and IGT). The sensitivity and specificity of using the HbA1c alone was 24.2% and 99.6% for diabetes (cutoff of ≥6.5%), and 35.2% and 86.4% for pre-diabetes (cutoff of ≥5.7%). The sensitivity and specificity of using the FINDRISC alone (cutoff of ≥9) was 79.1% and 48.6% for diabetes and 60.2% and 61.4% for pre-diabetes. Using the simultaneous testing model with a combination of FINDRISC and HbA1c improved the sensitivity to 84.2% for diabetes and 74.2% for pre-diabetes. The specificity for the simultaneous testing model was 48.4% of diabetes and 53.0% for pre-diabetes.

Conclusions

This simultaneous testing model is a practical and valid tool in diabetes screening in the general U.S. population.     

Colonial to modern skeletal change in the U.S.A.

Eighty-two people dating from 1675 to 1879 compared with 182 modern middle-class White and Black skeletons test the myths of radical changes produced by improved diet, less disease, and nineteenth century immigration. Longevity increases and health and growth improvement is clearest in reduced juvenile deaths (census data) and deepening of true pelvis. Stature increase is minimal (though seventeenth century Londoners and modern West Africans are shorter than Colonial to Modern Americans); teeth deteriorate and for cultural reasons fractures increase. Clavicles and forearms elongate. From Old to New World Colonial samples there is a noticeable skull change (and a greater Old World to Modern contrast) but White Colonial to Modern shows strong continuity surprisingly, the key changes being increasing head height, and retraction of face with increasing nose projection, and longer mastoids, resulting from selection and mixture. Blacks change more, possibly from Indian and White mixture. Variabilities are above average. Change is much less than expected, and apparently involves heterosis and selection as well as the obvious health advance and mixtures.