Grief and Mourning during the COVID-19 Pandemic in Portugal

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Tuberculosis: where and how fast are stone quarry workers infected?

Background

In 2018 an annual tuberculosis (TB) screening program targeting stone quarry workers was implemented in two municipalities in Northern Portugal. These have been hotspots for TB (76 and 59 cases per 100 000 population per year in 2012-2016, well above the 18 cases per 100 000 population observed in Portugal in 2016), with 30% of active TB cases occurring among stone quarry workers. Screening in this setting is recommended by the World Health Organization, as exposure to silica and silicosis increase the risk of TB. Occupational health services, TB outpatient centers, the hospital, a laboratory, primary health care and public health services work closely together with employers, employees, municipal council and the community promoting meetings and continuous training.

Screening activities included a symptom questionnaire, chest X-ray and sputum exam; and, after exclusion of active TB, interferon-gamma release assay (IGRA) for latent tuberculosis infection (LTBI). Preventive treatment was offered.

Objective

Assess annual rate of TB infection

Methods

Workers without history of TB/LTBI were IGRA tested in 2018, and retested in 2019. Annual rate of infection was calculated as the proportion of workers IGRA negative in 2018 becoming positive in 2019.

Results

In 2018-2019, 274 workers were screened yearly. In 2018, 22 were diagnosed with LTBI and 26 had previous history of TB/LTBI. Out of 226 IGRA negative workers in 2018, 19 tested positive in 2019 (8.4% annual rate of infection). These individuals were not identified as close contacts of any new TB case and no cases of active TB were reported in their stone quarries. Some active TB cases were regular customers of specific bars.

Conclusions

Active transmission of TB seems to be occurring among stone quarry workers. Workers that converted from IGRA negative to positive had no co-workers with active TB in the study period, suggesting they could have been infected away from the workplace, possibly in community public places.

Key messages

Stone quarry workers in a high-risk TB sub-region were infected at an 8.4% annual rate, and could have been infected in community public places such as bars. Besides screening close contacts and at workplace, more efforts should be made identifying social contacts of active TB cases.

The 8-item Morisky medication adherence scale: validation of a Portuguese version in HIV patients

Background

Antiretroviral therapy (ART) has the most effective treatment for people with HIV, but its effectiveness depends on the individual medication adherence. Morisky Medication Adherence Scale (MMAS-8) is one of the most widely used scales to assess patient adherence. Thus, we aimed to validate a Portuguese version of MMAS-8 and determine its psychometric properties in HIV positive patients.

Methods

A cross-sectional survey was conducted in Centro Hospitalar Universitário São João (Porto, northern Portugal) at the infectious diseases department. After authorization to use the scale - granted by the author - and, a standard forward-backwards procedure to translate MMAS-8 to Portuguese, the questionnaire was applied to 233 patients with HIV doing ART. Reliability was assessed using Cronbach's alpha and test-retest reliability. Three levels of adherence were considered: 0 to < 6 (low), 6 to < 8 (medium), 8 (high).

Results

In the studied sample, the mean age was 45.03 years (SD = 11.63), 80.3% men, 19.3% women and 1 transgender, and 53.8% had ≤9 years of education. The mean number of prescribed ART per patient was 1.76. The mean score for the medication adherence scale was 7.29 (SD = 6.74). For the reliability analysis, 12 patients were excluded due to missing data (n = 221). Regarding the level of adherence, 22.5% were low adhering, 71.6% medium and 5.9% high. Corrected item-total correlations showed that 1 item does not correlate very well with the overall scale and was dropped. Scale reliability analysis for the remaining 7 items revealed an overall Cronbach's alpha of 0.661. Women had a protective effect on adherence (OR = 0.31;95%CI:0.15-0.66). Number of years doing ART, age of participants, and type of residence didn't show to be correlated with adherence.

Conclusions

MMAS-8 is a reliable and valid measure to detect patients at risk of non-adherence. A satisfactory Cronbach's alfa (0.661) was obtained. In general, adherence to medication was medium or high.

Key messages

This scale can be applied nationwide in other different hospitals, as it could serve as a tool for measuring adherence to ART that can allow for better health care to the ones that are low adhering. A Portuguese version of the MMAS-8 was created for measuring adherence to ART that maintained a similar structure to the original MMAS-8 and good psychometric properties.

Association of chronic inflammation and accelerated atherosclerosis among an indigenous black population with chronic kidney disease

Introduction

Inflammation plays a major role in the development of atherosclerosis and cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients. Toll-like receptor-4 (TLR4) is a major receptor for lipopolysaccharides (endotoxin) and other ligands involved in the pathogenesis of inflammation. We determined whether endotoxin levels and the presence of TLR4 polymorphisms are associated with markers of inflammation and atherosclerosis among South African CKD patients.

Materials and methods

Endotoxin, lipopolysaccharide binding protein (LBP), serum CD14 (sCD14), interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1) and carotid intima media thickness (CIMT) were measured in 160 participants (120 CKD patients and 40 controls). Associations between endotoxins and CIMT in the presence of sCD14, IL-8 and MCP-1, were assessed using odds ratios. Participants were screened for the presence of Asp299Gly and Thr399Ile TLR4 polymorphisms, and CIMT and inflammatory markers were compared between subjects with and without TLR4 polymorphisms.

Results

Endotoxin levels correlated with sCD14 (r = 0.441, p<0.001) and MCP-1 (r = 0.388, p<0.001) levels while increased CIMT was associated with MCP-1 (r = 0.448, p<0.001), sCD14 levels (r = 0.476, p<0.001), LBP (r = 0.340, p<0.001), and IL-8 (r = 0.395, p<0.001). Atherosclerosis was associated with endotoxin levels (odds ratio: 4.95; 95% confidence interval: 2.52–9.73; p<0.001), and was predicted by higher serum levels of inflammatory markers. Analysis of patients with TLR4 polymorphisms showed reduced serum levels of inflammatory markers and CIMT values compared with the patients carrying the wild type TLR4 alleles.

Conclusion

The study demonstrated associations between circulating endotoxaemia, systemic inflammation and accelerated atherosclerosis among South African CKD patients, and showed that the atherogenic predictive power of endotoxaemia was significantly increased by the presence of elevated levels of inflammatory markers. Additional findings, which must be confirmed, suggest that TLR4 polymorphisms are associated with low levels of inflammatory markers and CIMT values.

Isoniazid (INH) mono-resistance and tuberculosis (TB) treatment success: analysis of European surveillance data, 2002 to 2014

Introduction: Isoniazid (INH) is an essential drug for tuberculosis (TB) treatment. Resistance to INH may increase the likelihood of negative treatment outcome.

Aim: We aimed to determine the impact of INH mono-resistance on TB treatment outcome in the European Union/European Economic Area and to identify risk factors for unsuccessful outcome in cases with INH mono-resistant TB.

Methods: In this observational study, we retrospectively analysed TB cases that were diagnosed in 2002–14 and included in the European Surveillance System (TESSy). Multilevel logistic regression models were applied to identify risk factors and correct for clustering of cases within countries.

Results: A total of 187,370 susceptible and 7,578 INH mono-resistant TB cases from 24 countries were included in the outcome analysis. Treatment was successful in 74.0% of INH mono-resistant and 77.4% of susceptible TB cases. In the final model, treatment success was lower among INH mono-resistant cases (Odds ratio (OR): 0.7; 95% confidence interval (CI): 0.6–0.9; adjusted absolute difference in treatment success: 5.3%). Among INH mono-resistant TB cases, unsuccessful treatment outcome was associated with age above median (OR: 1.3; 95% CI: 1.2–1.5), male sex (OR: 1.3; 95% CI: 1.1–1.4), positive smear microscopy (OR: 1.3; 95% CI: 1.1–1.4), positive HIV status (OR: 3.3; 95% CI: 1.6–6.5) and a prior TB history (OR: 1.8; 95% CI: 1.5–2.2).

Conclusions: This study provides evidence for an association between INH mono-resistance and a lower likelihood of TB treatment success. Increased attention should be paid to timely detection and management of INH mono-resistant TB.

Development and Psychometric Validation of a Screening Questionnaire to Detect Excessive Menstrual Blood Loss That Interferes in Quality of Life: The SAMANTA Questionnaire

Background: Heavy menstrual bleeding (HMB) affects up to 35% of women at some point in their lives, and has an important impact on their quality of life (QoL). Current techniques to assess and quantify menstrual blood loss are inconvenient and the correlation between actual and perceived blood loss is poor. This study aimed to develop and validate a screening questionnaire in Spanish to identify HMB in women of reproductive age. Methods: The study consisted of two phases: the conceptual development of a set of items to discriminate between women with and without HMB and the assessment of the sensitivity and specificity of these items. Correlation of the screening tool with women's perception of the intensity of bleeding and the interference in their daily life activities was also assessed. Results: An initial set of 46 items were identified, from which 21 items were selected following the cognitive interviews. For the psychometric validation phase, 389 patients were enrolled, of whom 364 were assessable: 211 cases with Pictorial Blood loss Assessment Chart-confirmed excessive menstrual loss (EML) and 153 controls. Six items met entry criteria in the model and together yielded a sensitivity of 86.7% and specificity of 89.5% to identify cases and controls. These items were weighted according to their contribution to the final model to yield a tool that can be scored from 0 to 10 being 3 the cutoff point to diagnose EML that interferes in QoL. Conclusions: The 6-item SAMANTA questionnaire represents a valid screening tool to easily identify women with EML that interfere with QoL.

APOL1 Genetic Variants Are Associated with Serum-Oxidized Low-Density Lipoprotein Levels and Subclinical Atherosclerosis in South African CKD Patients

INTRODUCTION

Apolipoprotein L1 (APOL1) plays an important role in cholesterol metabolism and attenuation of low-density lipoprotein (LDL) oxidation. While protecting against Trypanosoma brucei rhodesiense infection, APOL1 risk alleles confer greater risk for CKD and cardiovascular disease among patients of African descent.

OBJECTIVES

We investigated whether APOL1 risk variants are associated with atherosclerosis and oxidized LDL (OxLDL) levels among black South African CKD patients.

METHODS

A cross-sectional study of 120 adult CKD patients and 40 controls was undertaken. DNA samples of participants were genotyped for APOL1 G1 and G2 variants. High-sensitivity C-reactive protein, serum lipids, and OxLDL levels were measured, and carotid doppler ultrasonography was performed on all participants.

RESULTS

APOL1 alleles rs73885319, rs60910145, and rs71785313 had minor allele frequencies of 9.2, 8.8, and 17.5%, respectively, in the patients, and 8.8, 8.8, and 13.8%, respectively, in the controls. Of the 9 patients with 2 APOL1 risk alleles, 77.8% were compound G1/G2 heterozygotes and 22.2% were G2 homozygotes. Carriers of at least 1 APOL1 risk allele had a 3-fold increased risk of subclinical atherosclerosis (odds ratio 3.19; 95% confidence interval: 1.64-6.19; p = 0.01) compared to individuals with no risk alleles. Patients with 1 or 2 APOL1 risk alleles showed a significant increase in OxLDL levels when compared with those without the APOL1 risk allele.

CONCLUSION

These findings suggest an increased risk for atherosclerosis in carriers of a single APOL1 risk variant, and the presence of APOL1 risk variants was associated with increased serum OxLDL levels in black South African CKD patients.

Combined Anastrozole and Antiplatelet Therapy Treatment Differentially Promotes Breast Cancer Cell Survival

Thromboembolic disorders are the second leading cause of death in breast cancer. Antiplatelet therapy combined with cancer therapy is a potential treatment strategy against cancer-associated thromboembolic disorders; however, the efficacy of such dual treatment has not been established. This study reports novel findings on the response of hormone-dependent breast cancer cell lines (MCF7/T47D) following 24 h treatment with Anastrozole, combined with Aspirin and Clopidogrel cocktail; and Atopaxar. Neutral red and lactate dehydrogenase assays were conducted to assess viability and cytotoxicity respectively. Flow cytometric Annexin-V/PI assay was used to assess the mode of cell death. Morphological alterations were studied using scanning electron microscopy. Statistical analysis was conducted using Statistica V13. Definitive outcomes were established with flow cytometric detection of phosphatidylserine exposure and propidium iodide staining, complemented with ultrastructural analysis. Results showed that a few cells were undergoing death mainly through secondary necrosis. Morphological features suggesting induced cell motility (pseudopodia/ruffled membranes) were observed in both cell lines; notably, T47D cells presented pronounced features than MCF7 cells. Overall, these findings suggest that such combined treatment may differentially promote cell survival, inducing a more aggressive breast cancer phenotype.

[COVID-19 and the Invisible Damage]

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To be or not to be hospitalised with tuberculosis in Portugal

SETTING: In Portugal, as in other countries, tuberculosis (TB) is considered a disease that should be managed on an ambulatory basis. However, hospitalisation remains important to manage some at-risk groups and complications.OBJECTIVE: To identify the possible risk factors associated with hospitalisations in TB patients in Portugal.DESIGN: Data extraction through two national databases (one for registration of TB cases and the other with hospitalisation information in public health facilities) between 2007 and 2013. Univariate and multivariate analysis of demographic and clinical variables was performed.RESULTS: We identified 4421 hospitalisations. Chronic diseases, cancer, substance abuse, a higher social/economic risk, extra-pulmonary TB, lung cavitary disease and previous uncompleted treatment were more frequent among hospitalised patients. Human immunodeficiency virus coinfection, cancer, alcohol abuse, extra-pulmonary TB and uncompleted previous TB treatment were the most important predictors of hospitalisation with TB. The hospitalisation rate among TB patients in Portugal was lower when compared with other countries with lower and higher incidences.CONCLUSION: Immune dysfunctions and progression of chronic diseases are associated with more severe forms of TB and frequent adverse effects which can be sufficiently severe to necessitate hospital admission. Despite having an intermediate TB incidence, the hospitalisation rate in Portugal is not higher than that of other countries.

Ex vivo interaction between blood components and hormone-dependent breast cancer cells induces alterations associated with epithelial-mesenchymal transition and thrombosis

The prevalence of breast cancer is steadily increasing with metastasis and thromboembolic complications identified as the most common causes of death. The acquisition of an aggressive phenotype by hormone-dependent breast cancers is mediated by Transforming Growth Factor Beta 1 (TGF-β₁) expression and is associated with epithelial-mesenchymal transition (EMT) and, potentially, increased propensity for thrombosis. We investigated this phenomenon by assessing the effect of platelet-rich plasma (PRP) and whole blood (WB) on parameters of EMT and hypercoagulation in vitro. MCF-7 breast cancer cells were cultured under standard conditions, followed by co-culture with PRP or WB. Cells were processed for real-time PCR (TGF-β₁ and vimentin), electron microscopy or immunocytochemistry (TGF-β₁). Micrographs were qualitatively assessed, and real-time PCR data analyzed with PAST Statistical Software. The addition of blood components heightened TGF-β₁ immunolocalization and significantly increased corresponding gene expression. Both PRP and WB significantly increased vimentin expression and induced a shape change from a typical epithelial phenotype to a spindle-shape morphology, indicative of EMT. Fibrin fiber, network and plaque formation indicated a hypercoagulatory environment. The results thus show that in preparation for hematogenous metastasis, hormone-dependent breast cancer cells assume an aggressive phenotype associated with EMT, simultaneously increasing the propensity for the formation of thrombo-emboli.

Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline

Background: The American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America jointly sponsored this new practice guideline on the treatment of drug-resistant tuberculosis (DR-TB). The document includes recommendations on the treatment of multidrug-resistant TB (MDR-TB) as well as isoniazid-resistant but rifampin-susceptible TB.Methods: Published systematic reviews, meta-analyses, and a new individual patient data meta-analysis from 12,030 patients, in 50 studies, across 25 countries with confirmed pulmonary rifampin-resistant TB were used for this guideline. Meta-analytic approaches included propensity score matching to reduce confounding. Each recommendation was discussed by an expert committee, screened for conflicts of interest, according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.Results: Twenty-one Population, Intervention, Comparator, and Outcomes questions were addressed, generating 25 GRADE-based recommendations. Certainty in the evidence was judged to be very low, because the data came from observational studies with significant loss to follow-up and imbalance in background regimens between comparator groups. Good practices in the management of MDR-TB are described. On the basis of the evidence review, a clinical strategy tool for building a treatment regimen for MDR-TB is also provided.Conclusions: New recommendations are made for the choice and number of drugs in a regimen, the duration of intensive and continuation phases, and the role of injectable drugs for MDR-TB. On the basis of these recommendations, an effective all-oral regimen for MDR-TB can be assembled. Recommendations are also provided on the role of surgery in treatment of MDR-TB and for treatment of contacts exposed to MDR-TB and treatment of isoniazid-resistant TB.

Endothelial dysfunction in HIV-positive patients with acute coronary syndromes

AIM

This study investigated endothelial function in HIV-positive patients with acute coronary syndrome (ACS). Flow-mediated dilatation, pulse-wave velocity, carotid intima-media thickness and endothelial biomarkers were used to non-invasively investigate endothelial dysfunction.

METHODS

Twenty HIV-positive patients with ACS (HIV+/ACS) were compared to 20 HIV-negative patients with ACS (HIV-/ACS) and 20 HIV-positive patients without ACS (HIV+/no ACS).

RESULTS

Endothelial function measured by flow-mediated dilatation (FMD) was similar in both the HIV+/ACS (5.2; IQR 1.4-13.4%) and HIV-/ACS groups (3.7; IQR 2.3-4.4%) (p = 0.78). Arterial stiffness, measured by pulse-wave velocity (PWV) was low in all three cohorts. Carotid intima-media thickness (CIMT) was also low in all three cohorts. The vascular cellular adhesion molecule-1 (VCAM-1) levels in HIV-positive patients with and without ACS were significantly higher than in the HIV-/ACS cohort (p = 0.033 and 0.024, respectively).

CONCLUSIONS

Non-invasive investigations such as FMD, CIMT and PWV did not identify patients with HIV who were at high risk of ACS. Endothelial biomarkers may be more useful markers to identify HIV-positive patients who have endothelial dysfunction and increased risk of ACS.

Tuberculin skin test and predictive host factors for false-negative results in patients with pulmonary and extrapulmonary tuberculosis

INTRODUCTION

Tuberculin skin test (TST) has been the standard test for screening for Mycobacterium tuberculosis infection for decades. Identifying persons with latent tuberculosis infection (LTBI) is crucial, as they constitute a reservoir that sustains the global tuberculosis (TB) epidemic. However, different factors, such as HIV infection, can lower the sensitivity of the test.

OBJECTIVES

The aim of this study was to determine the TST sensitivity in active TB patients and to ascertain risk factors that could be associated with false-negative results.

METHODS

Retrospective cohort study of all active TB notifications with a TST result (n = 8833), from 2008 to 2015. TST results were interpreted using a 5 mm and 10 mm cutoff. Bivariate and multivariate logistic regression analysis were used to evaluate the association of sociodemographic and clinical factors with false-negative TST results and to develop predictive risk models.

RESULTS

TST presented an overall sensitivity of 63.8% (5 mm) and 56.1% (10 mm). HIV infection was the risk factor with the strongest association with false-negative results (aOR 4.65-5 mm; aOR 5.05-10 mm). Other factors such as chronic renal failure (CRF) (aOR 1.55-5 mm; aOR 1.73-10 mm), alcohol abuse (aOR 1.52-5 mm; aOR 1.31-10 mm), drug abuse (aOR 1.90-5 mm; aOR 1.76-10 mm) or age ≥65 years (OR 1.69-5 mm and 10 mm) were also associated with a probability of false-negative results.

CONCLUSION

These results highlight the importance of knowing which factors influence TST results, such as HIV status, substance abuse or age, thus improving its usefulness as a screening method for LTBI.

The 2019 Novel Coronavirus (2019-nCoV): Novel Virus, Old Challenges

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MDR/XDR-TB management of patients and contacts: Challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network

The continuous flow of new research articles on MDR-TB diagnosis, treatment, prevention and rehabilitation requires frequent update of existing guidelines. This review is aimed at providing clinicians and public health staff with an updated and easy-to-consult document arising from consensus of Global Tuberculosis Network (GTN) experts. The core published documents and guidelines have been reviewed, including the recently published MDR-TB WHO rapid advice and ATS/CDC/ERS/IDSA guidelines. After a rapid review of epidemiology and risk factors, the clinical priorities on MDR-TB diagnosis (including whole genome sequencing and drug-susceptibility testing interpretations) and treatment (treatment design and management, TB in children) are discussed. Furthermore, the review comprehensively describes the latest information on contact tracing and LTBI management in MDR-TB contacts, while providing guidance on post-treatment functional evaluation and rehabilitation of TB sequelae, infection control and other public health priorities.

Cardiovascular disease in chronic kidney disease – a review of risk factors

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease (CVD), such that the risk of cardiovascular mortality is greater than the risk of progression to end-stage kidney disease. Despite the increased prevalence of traditional and non-traditional cardiovascular risk factors, patients with kidney disease have been mostly under-represented in previous cardiovascular outcome studies, thereby resulting in a paucity of data on the evidence-based management of CVD in CKD. In this review, we explore the evidence on the burden of CVD and its risk factors in patients with CKD, highlight various inflammatory biomarkers for predicting CVD and provide an overview on novel biomarkers for CVD.

Can environmental determinants explain Nontuberculous Mycobacteria geographic incidence?

INTRODUCTION AND OBJECTIVES

Nontuberculous mycobacteria (NTM) are opportunistic agents that have gained importance during the last decades due to their increasing incidence in high-risk populations. Their modes of transmission differ from person-toperson contact commonly described in Mycobacterium tuberculosis (MTB). In fact, NTM are frequently found in soil, natural waters and drinking-water distributions systems, emphasizing the contribution of environmental factors when discussing this disease's susceptibility. Our aim is to evaluate the incidence of NTM in Portugal and to identify the main environmental variables related to it.

MATERIAL AND METHODS

We performed a cross-sectional study centred on 2011 (date of the latest Portuguese census) from collected personal features and environmental data available in public databases. Environmental values when only known at the district level were interpolated using inverse distance weighting. A semiparametric poisson model was used to estimate NTM incidence. The non-parametric part of the model was obtained by using thin plate smoothing splines defined on the spatial component of the data.

RESULTS

359 new NTM cases were notified during a five-year period. None of the environmental determinants studied was strong enough to predict NTM geographical incidence in Portugal (p>0.05), except for population density (p<0.001). Personal characteristics such as female sex (p<0.001), age (p<0.001) and Human Immunodeficiency Virus infection and Acquired Immune Deficiency Syndrome (HIV/AIDS) incidence (p<0.001) are associated with an increase of NTM disease incidence.

CONCLUSIONS

NTM appears to be more common in elderly women, especially if they have HIV/AIDS disease or if they live in urban, highly populated areas. Overall, female sex seems to assume the most relevant role when discussing predisposition to NTM disease. However, further studies are needed to evaluate the impact on NTM geographical incidence by other environmental and personal variables not included in this one.

Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD): Current Perspectives

Despite the availability of global and regional guidelines to curtail the adverse clinical outcomes associated with chronic kidney disease–mineral and bone disorder (CKD-MBD), most CKD patients are still affected by the consequences of abnormalities of CKD-MBD. This important clinical complication of CKD continues to be studied, in order to improve the understanding and management of CKD-MBD. Some notable discoveries include the role of fibroblast growth factor 23 (FGF23) in the pathogenesis of CKD-MBD, leading to a shift from the previous well-established classic trade-off hypothesis to the updated trade-off hypothesis. More recently, there has been a shift from the treatment of CKD-MBD based on a single level of biomarkers to serial measurements of calcium, phosphate and parathyroid hormone (PTH). Furthermore, some clinical trials have emerged after the 2009 Kidney Disease-Improving Global Outcomes (KDIGO) Guidelines, leading to the 2017 KDIGO updated recommendations. Hence, this review gives an overview of the rapidly evolving trends in CKD-MBD, linking the past and current concepts of CKD-MBD.

Surveillance of adverse events in the treatment of drug-resistant tuberculosis: first global report

The World Health Organization (WHO) recommends that countries implement pharmacovigilance and collect information on active drug safety monitoring (aDSM) and management of adverse events.The aim of this prospective study was to evaluate the frequency and severity of adverse events to anti-tuberculosis (TB) drugs in a cohort of consecutive TB patients treated with new (i.e. bedaquiline, delamanid) and repurposed (i.e. clofazimine, linezolid) drugs, based on the WHO aDSM project. Adverse events were collected prospectively after attribution to a specific drug together with demographic, bacteriological, radiological and clinical information at diagnosis and during therapy. This interim analysis included patients who completed or were still on treatment at time of data collection.Globally, 45 centres from 26 countries/regions reported 658 patients (68.7% male, 4.4% HIV co-infected) treated as follows: 87.7% with bedaquiline, 18.4% with delamanid (6.1% with both), 81.5% with linezolid and 32.4% with clofazimine. Overall, 504 adverse event episodes were reported: 447 (88.7%) were classified as minor (grade 1-2) and 57 (11.3%) as serious (grade 3-5). The majority of the 57 serious adverse events reported by 55 patients (51 out of 57, 89.5%) ultimately resolved. Among patients reporting serious adverse events, some drugs held responsible were discontinued: bedaquiline in 0.35% (two out of 577), delamanid in 0.8% (one out of 121), linezolid in 1.9% (10 out of 536) and clofazimine in 1.4% (three out of 213) of patients. Serious adverse events were reported in 6.9% (nine out of 131) of patients treated with amikacin, 0.4% (one out of 221) with ethionamide/prothionamide, 2.8% (15 out of 536) with linezolid and 1.8% (eight out of 498) with cycloserine/terizidone.The aDSM study provided valuable information, but implementation needs scaling-up to support patient-centred care.

Failure to complete treatment for latent tuberculosis infection in Portugal, 2013-2017: geographic-, sociodemographic-, and medical-associated factors

There is conflicting evidence about factors associated with failure to complete treatment (FCT) for latent tuberculosis infection (LTBI). We aim to identify the geographic, sociodemographic, and medical factors associated with FCT in Portugal, highlighting the two main metropolitan areas of Porto and Lisbon. We performed a retrospective cohort study including LTBI patients that started treatment in Portugal between 2013 and 2017. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using multivariable logistic regression to identify geographic, sociodemographic, and medical factors associated with FCT. Data on completion of treatment were available for 15,478 of 17,144 patients (90.3%). Of those, 2132 (13.8%) failed to complete treatment. Factors associated with FCT were being older than 15 years (aOR, 1.65 (95% CI = 1.34-2.05) for those aged 16 to 29), being born abroad (aOR, 2.04 (95% CI = 1.19-3.50) for Asia; aOR, 1.57 (95% CI = 1.24-1.98) for Africa), having a chronic disease (aOR, 1.29 (95% CI = 1.04-1.60)), alcohol abuse (aOR, 2.24 (95% CI = 1.73-2.90)), and being intravenous drug user (aOR, 1.68 (95% CI = 1.05-2.68)). Three-month course treatment with isoniazid plus rifampicin was associated with decreased FCT when compared with 6- or 9-month courses of isoniazid-only (aOR, 0.59 (95% CI = 0.45-0.77)). In Lisbon metropolitan area, being born in Africa, and in Porto metropolitan area, alcohol abusing and being intravenous drug user were distinctive factors associated with FCT. Sociodemographic and medical factors associated with FCT may vary by geographical area and should be taken into account when planning interventions to improve LTBI treatment outcomes. This study reinforces that shorter course treatment for LTBI might reduce FCT.

Predictive factors for unfavourable treatment in MDR-TB and XDR-TB patients in Rio de Janeiro State, Brazil, 2000-2016

SETTING

The State of Rio de Janeiro stands out as having the second highest incidence and the highest mortality rate due to TB in Brazil. This study aims at identifying the factors associated with the unfavourable treatment of MDR/XDR-TB patients in that State.

METHOD

Data on 2269 MDR-TB cases reported in 2000-2016 in Rio de Janeiro State were collected from the Tuberculosis Surveillance System. Bivariate and multivariate logistic regressions were run to estimate the factors associated with unfavourable outcomes (failure, default, and death) and, specifically, default and death.

RESULTS

The proportion of unfavourable outcomes was 41.9% among MDR-TB and 81.5% among XDR-TB. Having less than 8 years of schooling, and being an Afro-Brazilian, under 40 years old and drug user were associated with unfavourable outcome and default. Bilateral disease, HIV positive, and comorbidities were associated with death. XDR-TB cases had a 4.7-fold higher odds of an unfavourable outcome, with 29.3% of such cases being not treated for multidrug resistance in the past.

CONCLUSION

About 30% of XDR-TB cases may have occurred by primary transmission. The high rates of failure and death in this category reflect the limitation of treatment options. This highlights the urgency to incorporate new drugs in the treatment.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term CAPD in South Africa

Background

Occurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).

Methods

This was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.

Results

Atherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.

Conclusion

Atherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.