Health and illness beliefs in adults with tuberculosis infection during the COVID-19 pandemic in the UK.

Background: COVID-19 disrupted the TB prevention programme in the UK, especially for TB infection (TBI) care. We explore whether experience of the COVID-19 pandemic impacted on patients' perceptions of TBI and its treatment. Methods: Semi-structured interviews were conducted as part of the Research to Improve Detection and Treatment of TBI (RID-TB) programme, exploring perceptual and practical barriers to TBI treatment. Nineteen people diagnosed with TBI were interviewed between August 2020 and April 2021. Recordings were transcribed and analysed using a constant comparative approach, allowing for a dynamic and iterative exploration of themes. Themes are organised using the Perceptions and Practicalities Approach. Findings: Some participants perceived TBI as a risk factor for increased susceptibility to COVID-19, while some thought that treatment for TBI might protect against COVID-19 or mitigate its effects. Adaptations to TB services (e.g., remote follow-up) and integrated practices during the COVID-19 restrictions (e.g., medication being posted) addressed some practical barriers to TBI treatment. However, we identified beliefs about TBI and COVID-19 that are likely to act as barriers to engagement with TBI treatment, including: interpreting service delays as an indication of TBI not being serious enough for treatment and concerns about contracting COVID-19 in TB clinics. Interpretation: COVID-19 and TBI service delays influence people's perceptions and practical barriers to TBI treatment adherence. Failure to address these beliefs may lead to people's concerns about their treatment not being fully addressed. Utilised service adaptations like remote consultations to address practical barriers may be relevant beyond COVID-19. Funding: NIHR RID-TB Program (RP-PG-0217-20009).

Variations in airborne pollen and spores in urban Guangzhou and their relationships with meteorological variables.

Airborne pollen causes various types of allergies in humans, and the extent of allergic infection is related to the presence of different types of sporo-pollen and existing meteorological conditions in a certain area. Therefore, an aeropalynological study of 72 airborne samples with a hydrofluoric acid (HF) treatment was conducted in the Haizhu district of Guangzhou, China, in 2016, to identify the temporal variations in airborne sporo-pollen and the relationship between airborne sporo-pollen concentrations and different meteorological variables in Guangzhou, China. Forty-five types of airborne pollen, seven types of airborne spores, and some undetermined sporo-pollen taxa were identified with two separate plant habitats occurring during this period (from January to December 2016): arboreal pollen (tree-based) and non-arboreal pollen (herb, shrub, aquatic, liane, etc.). Furthermore, the daily records of four key meteorological variables (temperature, precipitation, relative humidity, and wind speed) were acquired to distinguish the pollen seasons and correlated with Spearman's rho test to establish a pollen-weather data book with the seasonal variations. The two leading seasons were identified based on pollen abundance: spring and autumn. Among them, the primary dominant sporo-pollen families during the spring season were Poaceae, Pinaceae, Euphorbiaceae, Moraceae, Microlepia sp., and Polypodiaceae. Conversely, Artemisia sp., Asteraceae, Cyperaceae, Poaceae, Alnus sp., Corylus sp., Myrtaceae, and Rosaceae were the dominant pollen species during autumn. However, few pollen grains were identified in January, May-July, and December. The statistical analysis revealed that temperature had both positive and negative correlations with sporo-pollen concentrations. However, precipitation and relative humidity had a strong impact on the sporo-pollen dispersion and exhibited a negative correlation with the sporo-pollen concentrations. The wind speed had a positive but strong correlation with the sporo-pollen concentration during the study period. Some inconsistent results were found due to environmental variations, vegetation type, and climate change around the study area. This study will facilitate the identification of pollen seasons to prevent the occurrence of pollen-related allergies in the Guangzhou city area.

Guillain-Barré syndrome associated with SARS-CoV-2 infection: A case report with long term follow up.

A 50-years old male presented with quadriplegia and paresthesia and was diagnosed as Guillain-Barré syndrome (GBS). He was found positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) six weeks prior to the onset of weakness. GBS disability score was 4. Electrophysiology showed acute inflammatory demyelinating polyradiculopathy. Anti-SARS-CoV-2 IgG was found positive. Immunological tests for Campylobacter jejuni, Zika virus, Hepatitis E virus, Herpes Simplex virus, Haemophilus influanzae and Mycoplasma pneumoniae were negative. Patient received standard dose of intravenous immunoglobulin and after six months had almost complete recovery of muscle power. This case represents possible association of SARS-CoV-2 infection and GBS with good clinical outcome.

Diagnostic pitfalls of urogenital tuberculosis.

OBJECTIVES: To describe characteristics, details of diagnosis and outcomes of urogenital tuberculosis (UGTB) in a low-prevalence country. METHODS: We conducted a retrospective observational study of 37 consecutive patients diagnosed with UGTB between 1st January 2014 and 31st October 2019 in an East London hospital. RESULTS: 68% (25/37) of patients were male and the median age was 42 years (IQR 34-55). 89% (33/37) of patients were born outside the United Kingdom with 65% (24/37) born in the South Asian region. Renal (32.4%), epididymal (24.3%) and endometrial TB (21.6%) were the most prevalent forms of UGTB. Only 13.5% of UGTB patients had concurrent pulmonary TB. The median length of time from symptom onset to treatment was 163 days, while endometrial TB had an average delay to diagnosis of 564 days. Approximately half of patients with UGTB were culture positive (51.4%). However, 70% of early morning urines (EMUs) sent in urinary TB were culture positive. 11 patients (30.6%) underwent two or more invasive procedures, such as biopsy to obtain specimen samples. The mean treatment length for all UGTB cases was 7.3 months (SD 3.1). Notably, 25% of patients with endometrial TB required surgery despite antituberculous treatment. CONCLUSIONS: UGTB is challenging to diagnose as early disease is often asymptomatic. Clinicians faced with non-specific symptoms, or features suggestive of urogenital malignancy amongst patients from TB-endemic areas, should maintain a high suspicion of UGTB.

"You have to change your whole life": A qualitative study of the dynamics of treatment adherence among adults with tuberculosis in the United Kingdom.

Maintaining adherence to treatment for tuberculosis (TB) is essential if the disease is to be eliminated. As part of formative research to develop an intervention to improve adherence, we documented the lived experiences of adults receiving anti-TB treatment (ATT) in three UK cities and examined how personal, social, and structural circumstances interacted to impact on individuals' adherence to treatment. Using a topic guide that explored social circumstances and experiences of TB care, we conducted in-depth interviews with 18 adults (six women) who were being or had been treated for TB (patients) and four adults (all women) who were caring for a friend, relative, or partner being treated for TB (caregivers). We analysed transcripts using an adapted framework method that classified factors affecting adherence as personal, social, structural, health systems, or treatment-related. Eleven of 18 patients were born outside the UK (in South, Central, and East Asia, and Eastern and Southern Africa); among the seven who were UK-born, four were Black, Asian, or Minority Ethnic and three were White British. TB and its treatment were often disruptive: in addition to debilitating symptoms and side effects of ATT, participants faced job insecurity, unstable housing, stigma, social isolation, worsening mental health, and damaged relationships. Those who had a strong support network, stable employment, a routine that could easily be adapted, a trusting relationship with their TB team, and clear understanding of the need for treatment reported finding it easier to adhere to ATT. Changes in circumstances sometimes had dramatic effects on an individual's ability to take ATT; participants described how the impact of certain acute events (e.g., the onset of side effects or fatigue, episodes of stigmatisation, loss of income) were amplified by their timing or through their interaction with other elements of the individual's life. We suggest that the dynamic and fluctuating nature of these factors necessitates comprehensive and regular review of needs and potential problems, conducted before and during ATT; this, coupled with supportive measures that consider (and seek to mitigate) the influence of social and structural factors, may help improve adherence.

Extraspinal articular tuberculosis: An 11-year retrospective study of demographic features and clinical outcomes in East London.

OBJECTIVES: To describe demographic features, clinical outcomes and diagnostic delay amongst patients with extra-spinal articular tuberculosis (TB) in a low-incidence setting. METHODS: Cases of TB treated at our institution between 2004 and 2014 were identified via the London TB register (LTBR). Demographic features of extra-spinal articular TB cases were compared to controls with TB at all other sites. For articular cases (excluding individuals <16 years or with spinal TB without peripheral joint involvement) clinical data were retrospectively collected. RESULTS: 6,146 TB patients were identified over the study period; 146 (2.4%) cases had extra-spinal articular infection. There was no difference in median age between extra-spinal articular TB cases and controls with TB at other sites (31 vs 32 years, p = 0.57). Articular cases were more likely to be male (70.6% vs 59.5%, p = 0.007), Bangladeshi (28.7% vs 18.0%) or Pakistani (24.0% vs 16.1%) and were less likely to be Black-African (9.5% vs 19.8%) (p < 0.001). 93 cases were included in the case series; 85 (88.5%) were migrants and 83 (89.2%) were South Asian. Knee and elbow joints were affected in 22 (23.7%) and 18 (19.4%) cases respectively. The median durations of pre-healthcare and healthcare associated delay were 16 and 6 weeks respectively. Where mycobacterial culture was performed, 57/75 (76%) were positive for Mycobacterium tuberculosis. 86 (92.5%) cases received standard quadruple therapy for a median of 6 months (IQR 6-9). Recurrence of TB infection occurred in 4 (4.3%) cases and there were no TB related deaths. Seven (7.6%) cases required surgical intervention. CONCLUSIONS: Extra-spinal articular TB more commonly affected men and people of South Asian ethnicity. Significant diagnostic delays were identified, including avoidable healthcare-associated delays.

Anthropogenic effect on heavy metal contents in surface sediments of the Bengal Basin river system, Bangladesh.

Heavy metals (Sc, Cr, Co, Ni, Cu, Ga, Ge, Nb, Mo, Cd, In, Hf, Ta, W, Tl, Pb, Bi, Th, and U) in the surface sediments of the Ganges-Brahmaputra-Meghna (GBM) river system of the Bengal Basin (BB) were measured to evaluate the heavy metal contamination and anthropogenic influence. The average concentration levels of most of the heavy metals (except Mo and Tl) were above the average crustal and shale values. Contamination indices, including the contamination factor, pollution load index, enrichment factor, and geo-accumulation index, and multivariate statistical analyses indicated that the GBM is slightly polluted by heavy metals with some considerable pollution from Bi, Th, Ta, Cd, Nb, Pb, In, and U. Among the four individual rivers, the Brahmaputra River and Ganges-Brahmaputra (GB) confluence river sediments contain higher heavy metal concentrations than do the Ganges and Meghna Rivers, which may be caused by the effects of local municipal discharge, industrial or urban wastes, and ferry crossing activities.

Breast tuberculosis in East London: A 13-year retrospective observational study.

SETTING: Breast tuberculosis (TB) is rare in Western Europe, and its diagnosis may be delayed through lack of awareness of presenting features. Our institution serves a large East London population with a high incidence of TB. OBJECTIVE: To characterize presenting features and avoidable diagnostic delay in breast TB patients. DESIGN: We conducted a 13-year retrospective study of breast TB patients treated at our institution including demographic, clinical, microbiology, and pathology data. RESULTS: Forty-seven cases were included; 44 (94%) were female, with a median age of 33 years (IQR 28.5-39.5). The main presenting feature was a breast lump in 41 cases (87%); which were predominantly solitary unilateral lesions (25, 61%) and frequently located in the upper outer quadrant (28, 68%). Where performed, Mycobacterium tuberculosis was cultured in 15/36 (42%) cases. Granulomata were present on biopsy or aspirate in 21 (47%) and 17 (36%) cases, respectively. The median duration between symptom onset and treatment was 20 weeks (IQR 15-30). Forty-six (98%) completed treatment successfully and one relapsed. CONCLUSION: A high index of suspicion for TB is required for individuals presenting with breast symptoms from countries where TB is endemic. Development of standardized pathways may improve detection and management of breast TB may reduce diagnostic delay.

Managing severe tuberculosis and its sequelae: from intensive care to surgery and rehabilitation.

Multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) continue to challenge physicians and public health specialists. Global treatment outcomes continue to be unsatisfactory, positive outcomes being achieved in only 54% of patients. Overall outcomes are even worse in patients infected with highly resistant strains. Treating MDR-/XDR-TB is difficult because of frequent adverse events, the long duration of drug regimens, the high costs of second-line drugs, chronic post-infectious sequelae, and loss of organ function. Ongoing research efforts (studies and trials) have various aims: increasing the rates of treatment success; understanding the potentialities of new and repurposed drugs; shortening the treatment duration; and reducing the rates of adverse events. It is hoped that better access to rapid diagnostics, increased awareness, and treatments that are more effective will reduce the rate of complications and of lung function impairment. This article aims to discuss the management of severe tuberculosis (defined as that which is potentially life threatening, requiring higher levels of care) and its sequelae, from intensive care to the postoperative period, rehabilitation, and recovery. We also discuss the nonpharmacological interventions available to manage chronic sequelae and improve patient quality of life. Because the majority of MDR-/XDR-TB cases evolve to lung function impairment (typically obstructive but occasionally restrictive), impaired quality of life, and low performance status (as measured by walk tests or other metrics), other interventions (e.g., smoking cessation, pulmonary rehabilitation, vaccination/prevention of secondary bacterial infections/exacerbations, complemented by psychological and nutritional support) are required.

Detection of changes and trends in climatic variables in Bangladesh during 1988-2017.

Due to the importance of climatic variability, an assessment detecting the changes and trends has been carried out over different time series of major climatic variables from the records of meteorological stations over Bangladesh from 1988-2017. Linear regression, the Mann-Kendall test, and Sen's slope method were used to analyze the significant trends and magnitude of the variables' changes, while the Pearson and Spearman rho correlation test have been applied to correlate between the variables. The results show that the average monthly maximum temperature (T max ) and minimum temperature (T min ) have increased significantly by 0.35 °C/decade and 0.16 °C/decade, respectively. However, the increase in T max is comparatively higher than T min and caused significant increases in the monthly temperature range (MTR) at a higher rate in winter than in the monsoon season. The trend patterns of T max , T min , and MTR reveal that most of the regions of the country (especially the south-eastern and north-eastern) have been colder during winter and hotter during the monsoon. In contrast, the wind speed (WS) has decreased significantly all over the country and decreased by a higher rate in the north-western (NW) region (monsoon, 0.60 and annual, 0.51 kt/decade) than other regions, while the monsoonal and annual precipitation have decreased by 87.35 mm/decade and 107 mm/decade, respectively. The monsoonal T max and T min (0.47 °C/decade and 0.38 °C/decade, respectively) have increased significantly in the NW; consequently, this region has been warmed by 0.27 °C/decade. The increase in temperature and decrease in WS may cause a decrease in rainfall in the NW region. Humidity changes are not significant except in the monsoon season across the country. Precipitation, WS, and humidity are negatively correlated with the temperature variables. The declination of WS may influence the rising trend in temperature and the falling trend in precipitation and humidity, suggesting the need for further advanced study on the negative effects of climate change in Bangladesh.

Necrotizing pneumonia (aetiology, clinical features and management).

PURPOSE OF REVIEW: Necrotizing pneumonia is a severe form of community-acquired pneumonia characterized by rapid progression of consolidation to necrosis and cavitation which may lead to pulmonary gangrene. Morbidity and mortality are high and chronic sequelae are frequent. The lack of guidance supports the review of the latest recommendations in the management of these pneumonias. RECENT FINDINGS: Antibiotic therapy alone may not be enough to alter the course of the infection, and regimens, adjunctive therapies like intravenous immunoglobulins, surgery may be required to alter the course of the disease especially with pulmonary gangrene. SUMMARY: The causative agents, clinical features and management of necrotizing pneumonias are discussed.

Managing severe tuberculosis and its sequelae: from intensive care to surgery and rehabilitation / Tratamento da tuberculose grave e suas sequelas: da terapia intensiva à cirurgia e reabilitação

ABSTRACT Multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) continue to challenge physicians and public health specialists. Global treatment outcomes continue to be unsatisfactory, positive outcomes being achieved in only 54% of patients. Overall outcomes are even worse in patients infected with highly resistant strains. Treating MDR-/XDR-TB is difficult because of frequent adverse events, the long duration of drug regimens, the high costs of second-line drugs, chronic post-infectious sequelae, and loss of organ function. Ongoing research efforts (studies and trials) have various aims: increasing the rates of treatment success; understanding the potentialities of new and repurposed drugs; shortening the treatment duration; and reducing the rates of adverse events. It is hoped that better access to rapid diagnostics, increased awareness, and treatments that are more effective will reduce the rate of complications and of lung function impairment. This article aims to discuss the management of severe tuberculosis (defined as that which is potentially life threatening, requiring higher levels of care) and its sequelae, from intensive care to the postoperative period, rehabilitation, and recovery. We also discuss the nonpharmacological interventions available to manage chronic sequelae and improve patient quality of life. Because the majority of MDR-/XDR-TB cases evolve to lung function impairment (typically obstructive but occasionally restrictive), impaired quality of life, and low performance status (as measured by walk tests or other metrics), other interventions (e.g., smoking cessation, pulmonary rehabilitation, vaccination/prevention of secondary bacterial infections/exacerbations, complemented by psychological and nutritional support) are required.

RESUMO A tuberculose multirresistente e a tuberculose extensivamente resistente ainda são um desafio para médicos e especialistas em saúde pública. Os desfechos globais do tratamento ainda são insatisfatórios; apenas 54% dos pacientes têm um desfecho positivo. Os desfechos globais são ainda piores em pacientes infectados por cepas altamente resistentes. O tratamento da tuberculose multirresistente/extensivamente resistente é difícil em virtude dos eventos adversos frequentes, da longa duração dos esquemas terapêuticos, do alto custo dos medicamentos de segunda linha, das sequelas pós-infecciosas crônicas e da perda da função orgânica. Esforços de pesquisa (estudos e ensaios) estão em andamento e têm diversos objetivos: aumentar as taxas de sucesso do tratamento; compreender o potencial de medicamentos novos e reaproveitados; encurtar o tratamento e reduzir as taxas de eventos adversos. Espera-se que melhor acesso ao diagnóstico rápido, maior conhecimento e terapias mais eficazes reduzam as complicações e o comprometimento da função pulmonar. O objetivo deste artigo é discutir o tratamento da tuberculose grave (potencialmente fatal, que necessita de níveis maiores de atenção) e suas sequelas, desde a terapia intensiva até o pós-operatório, reabilitação e recuperação. São também discutidas as intervenções não farmacológicas disponíveis para tratar sequelas crônicas e melhorar a qualidade de vida dos pacientes. Como a maioria dos casos de tuberculose multirresistente/extensivamente resistente resulta em comprometimento da função pulmonar (obstrução principalmente, mas às vezes restrição), qualidade de vida prejudicada e desempenho reduzido (medido por meio de testes de caminhada ou outros), são necessárias outras intervenções (cessação do tabagismo, reabilitação pulmonar, vacinação e prevenção de infecções bacterianas secundárias/exacerbações, por exemplo, complementadas por apoio psicológico e nutricional).

The cursed duet today: Tuberculosis and HIV-coinfection.

The tuberculosis (TB) and HIV syndemic continues to rage and are a major public health concern worldwide. This deadly association raises complexity and represent a significant barrier towards TB elimination. TB continues to be the leading cause of death amongst HIV-infected people. This paper reports the challenges that lay ahead and outlines some of the current and future strategies that may be able to address this co-epidemic efficiently. Improved diagnostics, cheaper and more effective drugs, shorter treatment regimens for both drug-sensitive and drug-resistant TB are discussed. Also, special topics on drug interactions, TB-IRIS and TB relapse are also described. Notwithstanding the defeats and meagre investments, diagnosis and management of the two diseases have seen significant and unexpected improvements of late. On the HIV side, expansion of ART coverage, development of new updated guidelines aimed at the universal treatment of those infected, and the increasing availability of newer, more efficacious and less toxic drugs are an essential element to controlling the two epidemics. On the TB side, diagnosis of MDR-TB is becoming easier and faster thanks to the new PCR-based technologies, new anti-TB drugs active against both sensitive and resistant strains (i.e. bedaquiline and delamanid) have been developed and a few more are in the pipeline, new regimens (cheaper, shorter and/or more effective) have been introduced (such as the "Bangladesh regimen") or are being tested for MDR-TB and drug-sensitive-TB. However, still more resources will be required to implement an integrated approach, install new diagnostic tests, and develop simpler and shorter treatment regimens.