ERS International Congress 2021: highlights from the Respiratory Infections Assembly

The European Respiratory Society Annual Congress 2021 took place virtually for the second year running due to the coronavirus pandemic. The congress programme featured more than 400 sessions and 3000 abstract presentations, covering the entire respiratory science and medicine field. In this article, Early Career Members of the Respiratory Infections Assembly summarise a selection of sessions across a broad range of topics, including presentations on bronchiectasis, non-tuberculosis mycobacteria, tuberculosis, cystic fibrosis and COVID-19.

The Rise and Fall of SARS-CoV-2 Variants

N/a.

Insomnia and nightmare profiles during the COVID-19 pandemic in Portugal: characterization and associated factors

Objective/background

To describe and characterize insomnia symptoms and nightmare profiles in Portugal during the first six weeks of a national lockdown due to COVID-19.

Patients/methods

An open cohort study was conducted to collect information of the general population during the first wave of SARS-CoV-2/COVID-19 pandemic in Portugal. We analyzed data from 5011 participants (≥16 years) who answered a weekly questionnaire about their well-being. Two questions about the frequency of insomnia and nightmares about COVID-19 were consecutively applied during six weeks (March–May 2020). Latent class analysis was conducted and different insomnia and nightmare profiles were identified. Associations between individual characteristics and both profiles were estimated using odds ratios (ORs) and 95% confidence intervals (CI).

Results

Five insomnia (No insomnia, Stable-mild, Decreasing-moderate, Stable-severe, Increasing-severe) and three nightmares profiles (Stable-mild, Stable-moderate, Stable-severe) were identified. Being female, younger, perceiving their income as insufficient and feelings of fear towards COVID-19 were associated with higher odds of insomnia (Women: OR = 6.98 95%CI: 4.18–11.64; ≥60 years: OR = 0.30 95%CI: 0.18–0.53; Insufficient income: adjusted OR (aOR) = 8.413 95%CI: 3.93–16.84; Often presenting fear of being infected with SARS-CoV-2 infection: aOR = 9.13 95%CI: 6.36–13.11), and nightmares (Women: OR = 2.60 95%CI: 1.74–3.86; ≥60 years: OR = 0.45 95%CI: 0.28–0.74; Insufficient income: aOR = 2.60 95%CI: 1.20–5.20; Often/almost always presenting fear of being infected with SARS-CoV-2 infection: aOR = 6.62 95%CI: 5.01–8.74). Having a diagnosis of SARS-CoV-2 virus infection was associated with worse patterns of nightmares about the pandemic.

Conclusions

Social and psychological individual factors are important characteristics to consider in the development of therapeutic strategies to support people with sleep problems during the COVID-19 pandemic.

Reduced glomerular filtration rate is associated with ascending aortic dilatation in South African chronic kidney disease patients

Background: Ascending aortic dilatation (AAD) is an adverse prognostic cardiovascular marker in the general population. There are few data reporting its presence or clinical significance in chronic kidney disease (CKD) patients. The aim of this study was to evaluate ascending aorta dimensions and their correlates in a population of South African CKD patients.Methods: A total of 124 CKD patients and 40 healthy controls were enrolled. Cardiac dimensions, systolic and diastolic function indices, and aortic root diameters were assessed by transthoracic echocardiography. The ascending aorta was measured at four levels (aortic annulus, sinuses of Valsalva, sino-tubular junction, and ascending aorta) and was normalised for body surface area. The prevalence of AAD was assessed in CKD patients compared with the control group.Results: In CKD patients, the ascending aorta dimension was significantly larger than in controls at all four sites of the aorta that were measured. The prevalence of AAD was 6.5% at the annulus, 12.9% at the sinuses, 15.3% at the sino-tubular junction, and 8.9% at the ascending aorta. Overall, 29 patients (23%) had AAD. On multivariate analyses, eGFR was independently associated with AAD (odds ratio 0.980; 95% confidence interval 0.965–0.996; P = 0.014).Conclusion: AAD is a common cardiovascular phenotype in South African CKD patients. Low eGFR was independently associated with AAD, suggesting a direct link between CKD and the development of AAD in South African CKD patients. Keywords: chronic kidney disease, cardiovascular disease, ascending aortic dilatation

Profiling Biomarkers in HIV Glomerular Disease – Potential for the Non-Invasive Diagnosis of HIVAN?

Background

There is a wide spectrum of kidney pathology in human immunodeficiency virus (HIV) infection, affecting all structures of the kidney. The histology of HIV chronic kidney disease (CKD) is diverse, ranging from HIV-associated nephropathy (HIVAN) to focal glomerulosclerosis (FSGS), HIV-immune complex disease (HIV-ICD), other glomerulopathies and tubulo-interstitial nephritis. Definitive diagnosis is by kidney biopsy, an invasive procedure. However, serum and urinary biomarkers may be useful in predicting the histological diagnosis of HIVAN.

Purpose

We wished to determine the utility of serum and urinary biomarkers in predicting the histological diagnosis of HIVAN.

Patients and Methods

We measured neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, transforming growth factor (TGF)-β isoforms and bone morphogenetic protein (BMP)-7 in the serum and urine in patients with different histological forms of HIV glomerular disease.

Results

In HIVAN, we demonstrated increased levels of serum cystatin C and increased levels of serum and urinary NGAL. Urinary TGF-β1 and TGF-β2 levels were elevated in HIV-positive patients with CKD but were not significantly different in the different HIV histologies, while urinary BMP-7 levels were elevated in minimal change disease.

Conclusion

This study confirmed the presence of increased serum and urinary biomarkers of tubular injury in patients with HIVAN, and increased urinary biomarkers of fibrosis in HIV CKD, and may indicate their value as a non-invasive diagnostic tool for the diagnosis of HIVAN.

A cohort study of the relationship between anaemia, mean corpuscular volume and mortality among a CKD population in South Africa

Background

The burden of chronic kidney disease is increasing globally and prompt identification, coupled with improved management of CKD patients have increased the population of pre-dialysis patients. We, therefore, aimed to evaluate the predictors of survival among pre-dialysis CKD patients in South Africa.

Methods

We conducted a cohort study of 256 consecutive consenting Black non-dialysis requiring CKD patients attending the renal outpatient clinic of a tertiary Hospital in South Africa from 1st June 2016 to 1st December 2016. Socio-demographic and clinical information of the participants were obtained. Descriptive statistics, Kaplan-Meier curves and Cox proportional hazard regression analyses were conducted to evaluate factors affecting the survival of the participants.

Results

The mean age of the participants was 52.8±14.3 years and 48.0% were females, 52% were males. The death rate increased with worsening haemoglobin level from 0.96 among patients with mild anaemia to 4.29 per 100-person years among patients with severe anaemia. Anaemic patients with GFR < 30mls/min had significantly increased risk of death (HR 11.51, 95% CI 1.62–78.32, P < 0.001).

Conclusion

Mortality in pre-dialysis CKD patients was associated with anaemia and hyperphosphatemia. Clinical interventions targeted at preventing these conditions may improve outcomes among this group of CKD patients.

Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal

BACKGROUND

Early diagnosis and treatment of pulmonary tuberculosis (PTB) is essential for an effective control of the tuberculosis (TB) epidemic. Delayed diagnosis and treatment of TB increases the chance of complications and mortality for the patients, and enhances TB transmission in the population. Therefore, the aim of this study was to characterize patient, healthcare and total delay in diagnosing PTB and assess the effect of clinical and sociodemographic factors on the time until first contact with healthcare or reaching a PTB diagnosis.

METHODS

Retrospective cohort study that included active PTB patients notified in the National Tuberculosis Surveillance System (SVIG-TB), between 2008 and 2017. Descriptive statistics, Kaplan-Meier estimates, logrank test and Cox proportional hazards model were used to characterize patient, healthcare and total delay and estimate the effect of clinical and sociodemographic variables on these delays. Significance level was set at 0.05.

RESULTS

Median patient, healthcare and total delays was 37 days (Interquartile range (IQR): 19-71), 8 days (IQR: 1-32) and 62 days (IQR: 38-102), respectively. The median patient delay showed a constant increase, from 33 days in 2008 to 44 days in 2017. The median total delay presented a similar trend, increasing from 59 days in 2008 to 70 days in 2017. Healthcare delay remained constant during the study period. More than half of the PTB cases (82.9%) had a delay > 1 month between symptom onset and diagnosis. In the final Cox model, alcohol abuse, unemployment and being from a high TB incidence country were factors significantly associated with longer patient delay, while being female, having more than 45 years, oncologic and respiratory diseases were associated with longer healthcare delay. Being female, having more than 45 years and being from a high TB incidence country were associated with longer total delay.

CONCLUSIONS

Patient delay and total delay have increased in recent years. Older patients, patients with alcohol problems, other comorbidities, unemployed or from countries with high TB incidence would benefit from the development of specific public health strategies that could help reduce the delay in TB diagnosis observed in our study. This study emphasizes the need to promote awareness of TB in the general population and among the healthcare community, especially at ambulatory care level, in order to reduce the gap between beginning of symptoms and TB diagnosis.

Patient and healthcare delays in critical and non-critical pulmonary tuberculosis incidence areas in Portugal: are there differences?

OBJECTIVES

To characterize patient, healthcare, and total delay in diagnosing pulmonary tuberculosis (PTB) in critical (higher PTB incidence) and non-critical (lower PTB incidence) areas and their determinants considering clinical and sociodemographic factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data was retrieved from the Portuguese National Tuberculosis Surveillance System (SVIG-TB). Were included in the study all active PTB patients (n = 11,762) notified between 2008 and 2017. Spatial analysis was used to define critical and non-critical areas. Kaplan-Meier estimator, logrank test, and Cox regression were conducted, stratified by area.

RESULTS

PTB cases in critical areas (n = 6594, 56.1%) presented longer patient median delay (41 vs 31days), shorter healthcare median delay (7 vs 10 days), and longer total median delay (63 vs 61days) t.han non-critical areas. Patient and total delay increased in both areas over time, while healthcare delay only increased in non-critical areas. Icn both areas, being from a high TB incidence country and alcohol abuse were associated with longer patient delays. Being female, older age, and oncologic diseases were associated with longer healthcare delays. Respiratory diseases were only associated with a longer healthcare delay in non-critical areas. Being female, older, and from a high TB incidence country were associated with a longer total delay in both areas.

CONCLUSIONS

Patient delay was significantly longer in critical areas, and healthcare delay was significantly longer in non-critical areas. Several factors associated with longer delays have been identified, most of which are shared by critical and non-critical areas. Differences in patient and healthcare delay, for example, by sex, age, or country of birth, highlight the need for targeted public health interventions to help reduce these differences.

Metabolic syndrome and cardiovascular disease after haematopoietic cell transplantation (HCT) in adults: an EBMT cross-sectional non-interventional study

Metabolic syndrome (MetS) is associated with cardiovascular disease in the general population and is also a potential cardiovascular risk factor in survivors of haematopoietic cell transplantation (HCT). We report an EBMT cross-sectional, multi-centre, non-interventional study of 453 adult HCT patients surviving a minimum of 2 years post-transplant attending routine follow-up HCT and/or late effects clinics in 9 centres. The overall prevalence of MetS was 37.5% rising to 53% in patients >50 years of age at follow-up. There were no differences in rates of MetS between autologous and allogeneic HCT survivors, nor any association with graft-versus-host disease (GvHD) or current immunosuppressant therapy. Notably, there was a significantly higher occurrence of cardiovascular events (CVE, defined as cerebrovascular accident, coronary heart disease or peripheral vascular disease) in those with MetS than in those without MetS (26.7% versus 9%, p < 0.001, OR 3.69, 95% CI 2.09-6.54, p < 0.001), and, as expected, MetS and CVE were age-related. Unexpectedly, CVE were associated with occurrence of second malignancy. Screening for and management of MetS should be integrated within routine HCT long-term follow-up care for both allogeneic and autologous HCT survivors. Further research is warranted, including randomised controlled trials of interventional strategies and mechanistic studies of cardiovascular risk in HCT survivors.

The impact of age when screening for latent tuberculosis infection - is it a problem?

Background

Older population in developed countries represents a large reservoir of tuberculosis (TB) infection. Knowledge if age can contribute to false negative results in the immunological tests available for screening latent TB infections (LTBI) is critical to improve their usefulness in Public Health strategies for TB control. The aim of this study was to ascertain whether age was a risk factor for false negative (FN) results in the tuberculin skin test (TST) and in an interferon gamma release assay (IGRA).

Methods

Retrospective cohort study carried out using data from the Portuguese National Tuberculosis Surveillance system (2008-2015). Were included all active pulmonary TB cases with an IGRA (n = 597) and/or TST (n = 6185) result. TST outcomes were interpreted using a 5mm (TST-5mm) and 10mm (TST-10mm) cutoff. Logistic regression analysis crude and sex-adjusted was used to evaluate the association of age to the risk of FN results.

Results

Patients with a TST result presented a mean age of 42.7 years and patients with an IGRA result presented a median age of 45.5 years. TST-5mm, TST-10mm and IGRA had 36.5%, 43.9% and 24.5% FN results, respectively. Older patients presented a statistically significant association with the risk of FN TST results, regardless of using a 5mm [71-80years: OR 2.209; &gt;80years: OR 2.491; p &lt; 0.001] or 10mm [71-80years: OR 1.986; &gt;80years: OR 2.308; p &lt; 0.001] cut-off. Age was not a predictive factor for FN IGRA results. However, older patients presented a significant association with indeterminate IGRA results [71-80years: OR 3.808; &gt;80years: OR 5.214; p &lt; 0.001].

Conclusions

When using TST as part of the Public Health strategies for screening elderly patients, healthcare professionals should bear in mind that there is an increased risk of obtaining a FN result. On the other hand, age did not show an association with the occurrence of FN IGRA results, which suggests that this test could perform better when screening for LTBI in older patients.

Key messages

TST in elderly people is associated with false negative results thus, when using this test for screening for LTBI, a negative result should be interpreted with caution. IGRA was not associated with false negative results in elderly people, however indeterminate results can occur more frequently, thus performing better in this population group.

Psychological Impact of the COVID-19 Pandemic and Social Determinants on the Portuguese Population: Protocol for a Web-Based Cross-sectional Study

BACKGROUND

The COVID-19 outbreak and consequent physical distance measures implemented worldwide have caused significant stress, anxiety, and mental health implications among the general population. Unemployment, working from home, and day-to-day changes may lead to a greater risk of poor mental health outcomes.

OBJECTIVE

This paper describes the protocol for a web-based cross-sectional study that aims to address the impact of the COVID-19 pandemic on mental health.

METHODS

Individuals from the general population aged 18 years or more and living in Portugal were included in this study. Data collection took place between November 10, 2020, and February 10, 2021. An exponential, nondiscriminative, snowball sampling method was applied to recruit participants. A web-based survey was developed and shared on social media platforms (eg, Facebook, Instagram, Twitter, LinkedIn, and WhatsApp groups) and through e-mail lists for recruitment of the seeds.

RESULTS

Data analysis will be performed in accordance with the different variables and outcomes of interest by using quantitative methods, qualitative methods, or mixed methods, as applicable. A total of 929 individuals had completed the web-based survey during the 3-month period; thus, our final sample comprised 929 participants. Results of the survey will be disseminated in national and international scientific journals in 2021-2022.

CONCLUSIONS

We believe that the findings of this study will have broad implications for understanding the psychological impact of the COVID-19 pandemic on Portuguese residents, as well as aspects related to the informal economy. We also hope that the findings of this study are able to provide insights and guidelines for the Portuguese government to implement action. Finally, we expect this protocol to provide a roadmap for other countries and researchers that would like to implement a similar questionnaire considering the related conclusions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28071.

Survival of south african women with breast cancer receiving anti-retroviral therapy for HIV

PURPOSE

Breast cancer outcomes in sub-Saharan Africa is reported to be poor, with an estimated five-year survival of 50% when compared to almost 90% in high-income countries. Although several studies have looked at the effect of HIV in breast cancer survival, the effect of ARTs has not been well elucidated.

METHODS

All females newly diagnosed with invasive breast cancer from May 2015-September 2017 at Charlotte Maxeke Johannesburg Academic and Chris Hani Baragwanath Academic Hospital were enrolled. We analysed overall survival and disease-free survival, comparing HIV positive and negative patients. Kaplan-Meier survival curves were generated with p-values calculated using a log-rank test of equality while hazard ratios and their 95% confidence intervals (CIs) were estimated using Cox regression models.

RESULTS

Of 1019 patients enrolled, 22% were HIV positive. The overall survival (95% CI) was 53.5% (50.1-56.7%) with a disease-free survival of 55.8% (52.1-59.3) after 4 years of follow up. HIV infection was associated with worse overall survival (HR (95% CI): 1.50 (1.22-1.85), p < 0.001) and disease-free survival (OR (95% CI):2.63 (1.71-4.03), p < 0.001), especially among those not on ART at the time of breast cancer diagnosis. Advanced stage of the disease and hormone-receptor negative breast cancer subtypes were also associated with poor survival.

CONCLUSION

HIV infection was associated with worse overall and disease-free survival. HIV patients on ARTs had favourable overall and disease-free survival and with ARTs now being made accessible to all the outcome of women with HIV and breast cancer is expected to improve.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

Bioecological aspects of triatomines and marsupials as wild Trypanosoma cruzi reservoirs in urban, peri-urban and rural areas in the Western Brazilian Amazon

In the Amazon region, Trypanosoma cruzi transmission cycles involve a great diversity of Triatominae vectors and mammal reservoirs. Some Rhodnius spp. mainly inhabit palm trees that act as microhabitats for hosts and vectors. The current study aimed to describe aspects of the bio-ecology of the vectors and reservoirs of T. cruzi in relation to human populations resident near areas with large quantities of palm trees, in rural, peri-urban and urban collection environments, located in the Western Brazilian Amazon. Rhodnius pictipes and Didelphis marsupialis were respectively the most predominant vector and reservoir, with rates of 71% for R. pictipes and 96.5% for D. marsupialis. The vast majority of T. cruzi isolates clustered with TcI. The most prevalent haplotype was TcI COII1 (69.7%). Mauritia flexuosa and Attalea phalerata were the main ecological indicators of infestation by triatomines. Birds were the most common food source (27,71%). T. cruzi isolated from R. robustus has the haplotype HUM-13, previously detected in a chronic Chagas patient living in the same area. Our results demonstrate the relevance of this study, with the occurrence of elevated infection rates in animals, and suggest the importance of the Amazon zones where there is a risk of infection in humans.

1284Food insecurity and mental health features and behaviours in adults from Portugal

Background

COVID-19 pandemic has been affecting population’s health and economies, in which food insecurity appears as important concern, particularly considering its associations with mental health and adverse behaviours. This study explored the relationship between food insecurity and mental health features and behaviours in adults from Portugal.

Methods

A cross-sectional study using data from an online survey was performed, including Portugal’s residents aged ≥18 years. Data on sociodemographics, behaviours, mental health features and food security status were collected. Food security status was evaluated with the United States Household Food Security Survey Module: Six-item Short Form. Chi-square test or Fisher's exact test, as appropriate, were used to explore the relationship between food security status and categorical variables.

Results

Food insecurity prevalence was 6.8%; showed to be significantly higher among less educated individuals (≤12 years of schooling) (p&lt;0.001), those who were employed and remained since the beginning of the pandemic (p&lt;0.001) and among those reporting need to be careful about expenses (p&lt;0.001). Comparing to individuals who were food secure, food insecure participants were more likely to smoke (p=0.009), to report depressive symptoms (p&lt;0.001) and anxiety (p&lt;0.001), measured by the Hospital Anxiety and Depression Scale.

Conclusions

From the present study, it can be concluded that the COVID-19 pandemic can affect food security in different subpopulations.

Key messages

The findings of this study have several implications for health policy and reinforce the need for investment in contexts of populations vulnerable to food insecurity

Thrombotic events and COVID-19 vaccines

COVID-19 vaccines are considered promising agents in the control of the pandemic. Although their safety was assessed in randomised clinical trials, severe adverse events (AEs) have been reported after large-scale administration. This study aims to evaluate thromboembolic AEs reported after vaccination in a real-world context and how they led to the interruption of vaccination campaigns. We also review the benefits and risks of the vaccines approved in the European Union and provide recommendations. A review of the literature was performed using Medline/PubMed electronic database as well as institutional and pharmacovigilance official reports. Our findings show that vaccine-induced prothrombotic immune thrombocytopenia has been suggested as a very rare AE associated with viral vector vaccines. Unusual thrombotic events combined with moderate-to-severe thrombocytopenia were reported mainly in women under 60 years of age. As safety signals emerged, Vaxzevria and Janssen´s COVID-19 vaccine campaigns have been paused while investigations proceed. On the other hand, the number of deep vein thrombosis and pulmonary embolism reports have not increased. Post-marketing surveillance indicated that mRNA vaccines are safe and should continue to be used. The thrombotic events report rate is not increased in people over 60 years. As they are at greater risk for COVID-19 complications and death, no vaccine restrictions are recommended in this group. Risk factors for vaccine-induced prothrombotic immune thrombocytopenia should be established so that evidence-based decisions can be made. Systematic monitoring of COVID-19 vaccine safety is essential to ensure that the benefits of vaccination outweigh the risks.

1287Grief and mourning and its relation with anxiety and depressive symptoms during COVID-19 pandemic

Background

During these unprecedented times, individuals who experience the sudden death of a family member or friend, already miss the anticipatory grief and are now also prevented from a proper farewell. This study aimed to address prolonged grief disorder since the beginning of the COVID-19 pandemic

Methods

A virtual snowball sampling survey was disseminated through social networking channels. The study enrolled participants from general resident population in Portugal with ≥18 years. Characteristics of the sample were summarized using descriptive statistics. Anxiety and depression symptoms are described by absolute and relative frequencies and compared through the Chi-square test.

Results

A total of 929 participants completed the survey; 17.9% (n = 166) have lost someone since the beginning of the pandemic, making our final sample. Most were female (66.9%); median age of 35 years and 70.5% had a high education degree. Participants who had lost a grandparent consisted of 28.3% of the sample, father and/or mother 9.0%, and a friend 22.3%. We found a prevalence of 30.7% of anxiety symptoms and 10.2% of depression symptoms (p = 0.030). Also, 16.8% have had a high score on the PG13, which show that these people can mourned for longer periods.

Conclusions

Paying the last tribute to a loved one is a mental health gesture that allows individuals to make amends and reconcile with life.

Key messages

The need arises to give timely attention to the psychological consequences due to the COVID-19 pandemic concerning grief

Gauging the impact of the COVID-19 pandemic on tuberculosis services: a global study

The effects of the coronavirus disease 2019 (COVID-19) pandemic on tuberculosis (TB) disease and TB services emerged in the beginning of 2020 [1, 2]. Epidemiological and clinical studies, including mortality rates of the first cohort of patients with COVID-19 and TB co-infection were described [3, 4]. Several reports from individual countries suggested that the COVID-19 pandemic significantly affected TB services [5–9], including validation by modelling studies [10]. The Global Tuberculosis Network (GTN) reported that the COVID-19 pandemic affected TB services in 33 TB centres from 16 countries in the first 4 months of 2020 [11]. An increased use of telehealth during the COVID-19 pandemic was observed in some TB centres [11]. The major limitations of that study were the short period of observation (January to April 2020 compared to the same period in 2019) and the limited number of variables analysed [11–14].

This global study of 43 TB centres from 19 countries demonstrates the impact of COVID-19 pandemic on TB services. Newly diagnosed TB disease, drug-resistant TB, TB deaths, outpatient clinic attendances and newly diagnosed TB infection were reduced.https://bit.ly/3sdHbfk

Treatment outcomes and predictive factors for multidrug-resistant TB and HIV coinfection in Rio de Janeiro State, Brazil

BACKGROUND: Brazil ranks 14^th worldwide in the number of TB cases and 19^th in terms of TB-HIV co-infected cases. This study aims at identifying clinical and demographic factors associated with unsuccessful treatment outcomes (loss to follow-up, treatment failure and death) of HIV-positive patients with multidrug-resistant TB (MDR-TB) in Rio de Janeiro State, Brazil.METHODS: This was a retrospective cohort study of MDR-TB cases notified from 2000 to 2016 in RJ. Cox proportional hazard regression models were used to assess risk factors associated with unsuccessful treatment in HIV-positive patients with MDR-TB.RESULTS: Among 2,269 patients, 156 (6.9%) were HIV-positive and had a higher proportion of unsuccessful treatment outcomes (52.6%) than HIV-negative cases (43.7%). All HIV-positive cases with extensively drug-resistant TB (XDR-TB) had unsuccessful treatment outcomes. Multivariate analysis shows that previous MDR-TB treatment (HR 1.97, 95% CI 1.22-3.18) and illicit drugs use (HR 1.68, 95% CI 1.01-2.78) were associated with a greater hazard of unsuccessful treatment outcomes, while 6-month culture conversion (HR 0.48, 95% CI 0.27-0.84) and use of antiretroviral therapy (ART) (HR 0.51, 95% CI 0.32-0.80) were predictors of reduced risk.CONCLUSIONS: Unsuccessful treatment was higher among HIV patients with MDR-TB than among HIV-negative patients. Prompt initiation of ART and effective interventions are necessary to improve treatment adherence and prevent retreatment cases.

TB management in the European Union/European Economic Area: a multi-centre survey

BACKGROUND:

Essential TB care in the European Union/European Economic Area (EU/EEA) comprises 21 standards for the diagnosis, treatment and prevention of TB that constitute the European Union Standards for Tuberculosis Care (ESTC).

METHODS:

In 2017, we conducted an audit on TB management and infection control measures against the ESTC standards. TB reference centres in five EU/EEA countries were purposely selected to represent the heterogeneous European TB burden and examine geographic variability.

RESULTS:

Data from 122 patients, diagnosed between 2012 and 2015 with multidrug-resistant TB (n = 49), extensively drug-resistant TB (XDR-TB) (n = 11), pre-XDR-TB (n = 29) and drug-susceptible TB (n = 33), showed that TB diagnosis and treatment practices were in general in agreement with the ESTC.

CONCLUSION:

Overall, TB management and infection control practices were in agreement with the ESTC in the selected EU/EEA reference centres. Areas for improvement include strengthening of integrated care services and further implementation of patient-centred approaches.

Comparing the cost-effectiveness of two screening strategies for latent tuberculosis infection in Portugal

INTRODUCTION AND OBJECTIVES

Screening for latent tuberculosis infection (LTBI) in close contacts of infectious TB cases might include Tuberculin Skin Test (TST) and Interferon-Gamma Release Assays (IGRA), in combination or as single-tests. In Portugal, the screening strategy changed from TST followed by IGRA to IGRA-only testing in 2016. Our objective was to compare the cost-effectiveness of two-step TST/IGRA with the current IGRA-only screening strategy in immunocompetent individuals exposed to individuals with respiratory TB.

MATERIALS AND METHODS

We reviewed clinical records of individuals exposed to infectious TB cases diagnosed in 2015 and 2016, in two TB outpatient centers in the district of Porto. We estimated medical, non-medical and indirect costs for each screening strategy, taking into account costs of tests and health care personnel, travel distance from place of residence to screening site and employment status. We calculated the incremental cost-effectiveness ratio (ICER) as the cost difference between the two screening strategies with the difference number of LTBI diagnosis as a measure of cost-effectiveness, assuming that treating LTBI is a cost-effective intervention. We also calculated adjusted odds-ratios to test the association between diagnosis of LTBI and screening strategy and estimated the total cost for averting a potential TB case.

RESULTS

We compared 499 contacts TST/IGRA screened with 547 IGRA-only. IGRA-only strategy yielded a higher screening effectiveness for diagnosing latent tuberculosis infection (aOR 2.12, 95%CI: 1.53 - 2.94). ICER was €106 per LTBI diagnosis, representing increased effectiveness with a slightly increased cost of IGRA-only screening strategy.

CONCLUSIONS

Our data suggests that in Portugal LTBI screening with IGRA-only is more cost-effective than the two-step TST/IGRA testing strategy, preventing a higher number of cases of TB cases.

Histopathological Pattern of Kidney Diseases Among HIV-Infected Treatment-Naïve Patients in Kano, Nigeria

Introduction

Kidney biopsy in patients with HIV-associated kidney diseases allows for histopathologic diagnosis and institution of appropriate treatment as well as proper prognostication. There is a paucity of data on the histopathological pattern of HIV-associated kidney diseases in most sub-Saharan African countries. This study was aimed at evaluating the histopathologic patterns of kidney diseases seen among HIV-infected treatment-naive patients in our center as this will allow for proper diagnosis and institution of appropriate treatment.

Methods

In this cross-sectional study, consecutive patients who satisfied inclusion criteria and consented to participate were recruited. Percutaneous kidney biopsies were carried out as day procedures under real-time ultrasound guidance using an automatic spring-loaded biopsy gun as per our unit protocols. Baseline investigations including urea, creatinine, electrolytes, CD4 count, complete blood count, and glomerular filtration rate (eGFR) calculations, urinalysis and urine protein creatinine ratios were done on all the participants.

Results

Fifty-five patients who satisfied the inclusion criteria were studied. The mean age of the study population was 38.34± 9.26 years, with 32% females. Mean serum creatinine was 249.6±164.6 μmol/L, and mean CD4 count was 238 ±210 cells/mL. The commonest histological type was FSGS seen in 20 patients (37.7%), followed by HIVAN seen in 17 (32.1%) patients; chronic interstitial nephritis in 7 patients (13.2%) and 6 (11%) had no significant pathological finding. Compared to non-HIVAN, HIVAN patients tended to have higher systolic BP (p= 0.05); higher serum creatinine levels (p= 0.05); lower eGFR (0.03) and higher urine protein to creatinine ratio [uPCR; p= 0.02].

Conclusion

Kidney involvement is still a form of presentation among HIV-infected treatment-naïve patients and though a wide range of glomerular and tubulointerstitial lesions may be seen, FSGS and HIVAN are still the most common. We recommend assessment of kidney function, including urinalysis, as part of the routine evaluation of newly diagnosed HIV patients and biopsy where indicated to prognosticate and institute appropriate early treatment.

Evaluation of drug-resistant tuberculosis treatment outcome in Portugal, 2000-2016

Treatment of drug-resistant tuberculosis (TB), which is usually less successful than that of drug-susceptible TB, represents a challenge for TB control and elimination. We aimed to evaluate treatment outcomes and to identify the factors associated with death among patients with MDR and XDR-TB in Portugal. We assessed MDR-TB cases reported for the period 2000-2016, using the national TB Surveillance System. Treatment outcomes were defined according to WHO recommendations. We identified the factors associated with death using logistic regression. We evaluated treatment outcomes of 294 MDR- and 142 XDR-TB patients. The treatment success rate was 73.8% among MDR- and 62.7% among XDR-TB patients (p = 0.023). The case-fatality rate was 18.4% among MDR- and 23.9% among XDR-TB patients. HIV infection (OR 4.55; 95% CI 2.31-8.99; p < 0.001) and resistance to one or more second-line injectable drugs (OR 2.73; 95% CI 1.26-5.92; p = 0.011) were independently associated with death among MDR-TB patients. HIV infection, injectable drug use, past imprisonment, comorbidities, and alcohol abuse are conditions that were associated with death early on and during treatment. Early diagnosis of MDR-TB and further monitoring of these patients are necessary to improve treatment outcome.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Different disease, same challenges: Social determinants of tuberculosis and COVID-19

Infectious diseases, such as tuberculosis (TB) and the novel coronavirus (COVID-19) relate to environmental factors, understanding of which is essential to inform policy and practice and tackle them effectively.

The review follows the conceptual framework offered by the World Health Organization Commission on Social Determinants of Health (defined as “all those material, psychological and behavioural circumstances linked to health and generically indicated as risk factors’ in the conventional epidemiological language”). It describes the social factors behind TB and COVID-19, the commonalities between the two diseases, and what can be learned so far from the published best practices.

The social determinants sustaining TB and COVID-19 underline the importance of prioritising health and allocating adequate financial and human resources to achieve universal health coverage and health-related social protection while addressing the needs of vulnerable populations. Rapid and effective measures against poverty and other major social determinants and sources of inequality are urgently needed to develop better health in the post-COVID-19 world.

Ki67 Immunohistochemistry Quantification in Breast Carcinoma: A Comparison of Visual Estimation, Counting, and ImmunoRatio

BACKGROUND

Molecular analysis has shown that breast carcinomas can be classified into several intrinsic subtypes, with implications for management and prognosis. In the majority of pathology laboratories molecular analysis of each case is not possible and immunohistochemistry is used for subtyping. This includes analysis of hormone receptors as well as HER2-neu and Ki67. The methodology for the interpretation of the proliferation index using Ki67 remains an area of uncertainty. We investigated the degree of agreement between different methods of Ki67 interpretation.

MATERIALS AND METHODS

We analyzed 204 breast core biopsies diagnostic of breast carcinoma using visual estimation/eyeballing (EB), ImmunoRatio, and counting by 2 pathologists (CP1 and CP2). The correlation between the different methods and the interobserver agreement between the 2 pathologists was assessed. Specific analysis was also done with respect to classification of cases into low Ki67 groups (using Ki67 values<14% and <20%) since this is critical in classifying tumors into luminal A and luminal B subtypes.

RESULTS

Correlation between the different methods was best achieved comparing ImmunoRatio and CP1, and worst comparing CP1 and EB. Correlation was better when considering interobserver variability (CP1 vs. CP2). Comparing the number of cases classified as low Ki67 (<14% and <20%) the Cohen κ statistic varied from κ=0.267 to 0.814 with different methods. When limiting the analysis to cases with a Ki67 of 10% to 25% according to any method, there was greater disagreement.

CONCLUSIONS

At the higher and lower Ki67 levels, the correlation between the methods of assessment was acceptable, however, at levels close to the cut-off values for lumial A versus luminal B, several patients would be differently classified by the different methods and therefore potentially receive suboptimal management.

[A Perspective about the "Health at a Glance 2020" OECD Report]

N/a.

Tuberculosis and COVID-19 interaction: A review of biological, clinical and public health effects

Evidence is accumulating on the interaction between tuberculosis (TB) and COVID-19.

The aim of the present review is to report the available evidence on the interaction between these two infections. Differences and similarities of TB and COVID-19, their immunological features, diagnostics, epidemiological and clinical characteristics and public health implications are discussed. The key published documents and guidelines on the topic have been reviewed.

Based on the immunological mechanism involved, a shared dysregulation of immune responses in COVID-19 and TB has been found, suggesting a dual risk posed by co-infection worsening COVID-19 severity and favouring TB disease progression.

The available evidence on clinical aspects suggests that COVID-19 happens regardless of TB occurrence either before, during or after an active TB diagnosis. More evidence is required to determine if COVID-19 may reactivate or worsen active TB disease. The role of sequeale and the need for further rehabilitation must be further studied

Similarly, the potential role of drugs prescribed during the initial phase to treat COVID-19 and their interaction with anti-TB drugs require caution. Regarding risk of morbidity and mortality, several risk scores for COVID-19 and independent risk factors for TB have been identified: including, among others, age, poverty, malnutrition and co-morbidities (HIV co-infection, diabetes, etc.). Additional evidence is expected to be provided by the ongoing global TB/COVID-19 study.

Multidrug-Resistant Tuberculosis in Portugal: Patients’ Perception of the Challenges Faced during Treatment

<b><i>Introduction:</i></b> The increase in drug-resistant tuberculosis (TB) threatens global progress in eliminating TB, and constitutes a major challenge for patients, health-care workers and health services. Treatment for multidrug-resistant TB (MDR-TB) can last almost 2 years, and is more expensive, more toxic, and less effective than treating TB caused by drug-sensitive bacilli. This study aims to analyze patients’ narratives about the challenges they face during MDR-TB treatment and identify the support factors that help patients being treated in the most populous district of Portugal. <b><i>Methods:</i></b> Semi-structured interviews were conducted with patients being treated for MDR-TB. The interviews were coded using thematic analysis. They were audio-recorded, transcribed, and transported into NVivo v12 for data management and coding. <b><i>Results:</i></b> Depression, social discrimination, and the side effects of drugs are the main challenges faced by patients with MDR-TB. A good relationship of the patients with the health team, emotional support, and supervised treatment stand out as the factors that generate better adherence and treatment success. <b><i>Conclusion:</i></b> In addition to modern diagnostic techniques and new treatments, MDR-TB can be fought by focusing on the care and needs of patients. We suggest that the Lisbon Tuberculosis Program adopts the following measures: build the health-care team’s capacity to identify symptoms of depression early, increase public awareness of the disease, expand the multidisciplinary team, and expand the options for individualized social support for patients.

Breast Cancer Cells Induce a Pro-inflammatory Response to Mitigate Immune Mediation in a 3D Culture Model

BACKGROUND

Growth factors and cytokines mediate complex interactions between cells within the breast tumour microenvironment. In advanced cancer, an excess of regulatory T (T_REG) lymphocytes and lack of natural killer (NK) cells in tumour-infiltrating lymphocyte populations may reflect a shift to pro-tumorigenic adaptive immune mechanisms. To facilitate targeted assessment of the interactions between tumour and immune cells ex vivo, three-dimensional (3D) culture systems are able to better recapitulate the in vivo microenvironment, recreating the anatomy of tumours.

MATERIALS AND METHODS

We used 3D breast tumour models to determine morphological alterations, and the levels of secreted transforming growth factor-β (TGFβ) and induced cytokines. 3D luminal phenotype models and basal phenotype models were generated by culturing NK cells and CD4⁺CD25⁺ T_REG cells with MCF-7 cells and MDA-MB-231 cells respectively, in growth factor-reduced Matrigel. TGFβ was qualitatively assessed by immunolocalisation and cytokine data from culture supernatant was acquired with a multiplex cytokine assay. Traditional statistical analysis and principal component analysis were employed to unravel the cytokine response.

RESULTS AND CONCLUSION

We identified that an interleukin-6 (IL6)-chemokine axis associated with TGFβ is primarily responsible for differences detected between breast cancer models, with luminal and basal phenotype tumours responding differentially to immune mediation. Identified cytokines are implicated in facilitating tumour cell subversion of immune cell function to promote an invasive phenotype. Moreover, the disruption of the extracellular matrix and failure to form well-differentiated tumour masses/networks is indicative of enhanced malignancy. Tumour cells are implicated in promoting a pro-inflammatory microenvironment to attenuate NK cell function and in inducing a pro-tumorigenic profile that is facilitated by T_REG lymphocytes.

Completeness of TB notification in Portugal, 2015: an inventory and capture-recapture study

BACKGROUND: Despite the steady decline in the last few decades, Portugal remains the Western European country with the highest TB notification rates. The aim of this study was to estimate the completeness of notification to the National Tuberculosis Programme (NTP) Surveillance System (SVIG-TB) in 2015.METHODS: We implemented an inventory study and a three-source log-linear capture-recapture analysis using two additional data sources that were deterministic and probabilistically linked: the national notifiable diseases surveillance system (Sistema Nacional de Vigilância Epidemiológica SINAVE) and the national hospital discharge database (Grupos de Diagnósticos Homogéneos GDH).RESULTS: We identified 2328 unique probable/confirmed TB cases across the three data sources. We found a positive dependency between SVIG-TB and SINAVE (incidence rate ratio IRR 8.9, 95%CI 6.6-12.0) and between GDH and SINAVE (IRR 2.6, 95%CI 2.0-3.4). After adjusting for these dependencies, we estimated that 266 cases (95%CI 198-358) were not reported, indicating a notification (to SVIG-TB) completeness rate of 77.0%.CONCLUSION: True incidence rate of TB in Portugal in 2015 could have been as high as 26.1 per 100 000. This could be an overestimation because of false-positive cases recorded in both SINAVE and GDH or on a smaller scale, false non-matches. Studies aimed at validating potentially false-positive cases should be implemented to address these limitations.

Design and methods of the prevalence and pharmacogenomics of tenofovir nephrotoxicity in HIV-positive adults in south-western Nigeria study

BACKGROUND

Individuals of African descent are at higher risk of developing kidney disease than their European counterparts, and HIV infection is associated with increased risk of nephropathy. Despite a safe renal profile in the clinical trials, long-term use of tenofovir disoproxil fumarate (TDF) has been associated with proximal renal tubulopathy although the underlying mechanisms remain undetermined. We aim to establish the prevalence of and risk factors for TDF-induced kidney tubular dysfunction (KTD) among HIV-I and II individuals treated with TDF in south-west Nigeria. Association between TDF-induced KTD and genetic polymorphisms in renal drug transporter genes and the APOL1 (Apolipoprotein L1) gene will be examined.

METHODS

This study has two phases. An initial cross-sectional study will screen 3000 individuals attending the HIV clinics in south-west Nigeria for KTD to determine the prevalence and risk factors. This will be followed by a case-control study of 400 KTD cases and 400 matched controls to evaluate single nucleotide polymorphism (SNP) associations. Data on socio-demographics, risk factors for kidney dysfunction and HIV history will be collected by questionnaire. Blood and urine samples for measurements of severity of HIV disease (CD4 count, viral load) and renal function (creatinine, eGFR, phosphate, uric acid, glucose) will also be collected. Utility of urinary retinol binding protein (RBP) and N-acetyl-beta-D-glucosaminidase (NAG) levels as surrogate markers of KTD will be evaluated. Genomic DNA will be extracted from whole blood and SNP analyses performed using the rhAMP SNP genotyping assays. Statistical analysis including univariate and multivariate logistic regression analyses will be performed to identify factors associated with KTD.

DISCUSSION

In spite of TDF being the most commonly used antiretroviral agent and a key component of many HIV treatment regimens, it has potential detrimental effects on the kidneys. This study will establish the burden and risk factors for TDF-induced KTD in Nigerians, and explore associations between KTD and polymorphisms in renal transporter genes as well as APOL1 risk variants. This study may potentially engender an approach for prevention as well as stemming the burden of CKD in sub-Saharan Africa where GDP per capita is low and budgetary allocation for health is inadequate.

Hepcidin and GDF-15 are potential biomarkers of iron deficiency anaemia in chronic kidney disease patients in South Africa

BACKGROUND

Anaemia is a common presenting feature among patients with chronic kidney disease (CKD) and it is associated with poor clinical outcomes and quality of life. It is not clear if growth differentiation factor-15 (GDF-15) or hepcidin are useful as early markers of iron deficiency anaemia (IDA) among non-dialysis CKD patients. We therefore evaluated the diagnostic validity of GDF-15 and hepcidin as biomarkers of IDA among non-dialysis CKD patients in Johannesburg, South Africa.

METHOD

An analytic cross-sectional study was conducted among non-dialysis CKD patients (n = 312) and apparently healthy controls (n = 184) from June to December 2016 at an Academic Hospital, in Johannesburg, South Africa. An interviewer administered proforma was used to obtain the socio-biological and clinical characteristics of the participants. Serum levels of GDF-15 and hepcidin were determined. Predictive logistic regression models were built and post estimation receiver operator characteristics were determined to evaluate diagnostic validity of hepcidin and GDF-15 for absolute and functional iron deficiency anaemia.

RESULTS

About half (50.6%) of the participants were female while the participants' mean age was 49.7 ± 15.8 years. The predictive value of diagnosing absolute IDA among CKD patients using GDF-15 was 74.02% (95% CI: 67.62-80.42%) while the predictive value of diagnosing functional IDA among CKD patients using hepcidin was 70.1% (95% CI: 62.79-77.49%).There was a weak negative correlation between hepcidin levels and GFR (r = - 0.19, p = 0.04) in anaemic CKD patients, and between serum GDF-15 and haemoglobin (r = - 0.34, p = 0.001). Serum ferritin (β = 0.00389, P-value< 0.001), was a predictor of log hepcidin. MCHC (β = - 0.0220, P-value 0.005) and CKD stage (β = 0.4761, P-value < 0.001), race (β = 0.3429, P-value = 0.018) were predictors of log GDF-15. Both GDF-15 (adj OR: 1.0003, 95%CI: 1.0001-1.0005, P = 0.017) and hepcidin (adj OR: 1.003, 95%CI: 1.0004-1.0055, P = 0.023) were associated with iron deficiency anaemia after multiple linear regression modelling.

CONCLUSION

Serum GDF-15 is a potential biomarker of absolute IDA, while hepcidin levels can predict functional IDA among CKD patients.

Grief and Mourning during the COVID-19 Pandemic in Portugal

N/a.