Pathogenesis and management of emphysema in people with HIV.

INTRODUCTION: Since early in the HIV epidemic, emphysema has been identified among people with HIV (PWH) and has been associated with increased mortality. Smoking cessation is key to risk reduction. Health maintenance for PWH and emphysema should ensure appropriate vaccination and lung cancer screening. Treatment should adhere to inhaler guidelines for the general population, but inhaled corticosteroid (ICS) should be used with caution. Frontiers in treatment include targeted therapeutics. Major knowledge gaps exist in the epidemiology of and optimal care for PWH and emphysema, particularly in low and middle-income countries (LMIC). AREAS COVERED: Topics addressed include risk factors, pathogenesis, current treatment and prevention strategies, and frontiers in research. EXPERT OPINION: There are limited data on the epidemiology of emphysema in LMIC, where more than 90% of deaths from COPD occur and where the morbidity of HIV is most heavily concentrated. The population of PWH is aging, and age-related co-morbidities such as emphysema will only increase in salience. Over the next 5 years, the authors anticipate novel trials of targeted therapy for emphysema specific to PWH, and we anticipate a growing body of evidence to inform optimal clinical care for lung health among PWH in LMIC.

The COVID-19 Healthcare Personnel Study (CHPS): Overview, Methods, and Preliminary Findings.

INTRODUCTION: The COVID-19 Healthcare Personnel Study (CHPS) was designed to assess adverse short-term and long-term physical and mental health impacts of the coronavirus disease-2019 (COVID-19) pandemic on New York's physicians, nurse practitioners, and physician assistants. METHODS: Online population-based survey. Survey-weighted descriptive results, frequencies, proportions, and means, with 95% confidence intervals (95% CI). Odds ratios (ORs) for association. RESULTS: Over half (51.5%; 95% CI: 49.1, 54.0) of respondents worked directly with COVID-19 patients; 27.3% (95% CI: 22.5, 32.2) tested positive. The majority (57.6%; 95% CI: 55.2, 60.0) reported a negative impact on their mental health. Negative mental health was associated with COVID-19 symptoms (OR=1.7, 95% CI: 1.3, 2.1) and redeployment to unfamiliar functions (OR=1.3, 95% CI: 1.1, 1.6). CONCLUSIONS: A majority of New York health care providers treated COVID-19 patients and reported a negative impact on their mental health.

Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis.

BACKGROUND: Xpert MTB/RIF and Xpert MTB/RIF Ultra (Xpert Ultra) are World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in people with signs and symptoms of tuberculosis. This review builds on our recent extensive Cochrane Review of Xpert MTB/RIF accuracy. OBJECTIVES: To compare the diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for the detection of pulmonary tuberculosis and detection of rifampicin resistance in adults with presumptive pulmonary tuberculosis. For pulmonary tuberculosis and rifampicin resistance, we also investigated potential sources of heterogeneity. We also summarized the frequency of Xpert Ultra trace-positive results, and estimated the accuracy of Xpert Ultra after repeat testing in those with trace-positive results. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, LILACS, Scopus, the WHO ICTRP, the ISRCTN registry, and ProQuest to 28 January 2020 with no language restriction. SELECTION CRITERIA: We included diagnostic accuracy studies using respiratory specimens in adults with presumptive pulmonary tuberculosis that directly compared the index tests. For pulmonary tuberculosis detection, the reference standards were culture and a composite reference standard. For rifampicin resistance, the reference standards were culture-based drug susceptibility testing and line probe assays. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a standardized form, including data by smear and HIV status. We assessed risk of bias using QUADAS-2 and QUADAS-C. We performed meta-analyses comparing pooled sensitivities and specificities, separately for pulmonary tuberculosis detection and rifampicin resistance detection, and separately by reference standard. Most analyses used a bivariate random-effects model. For tuberculosis detection, we estimated accuracy in studies in participants who were not selected based on prior microscopy testing or history of tuberculosis. We performed subgroup analyses by smear status, HIV status, and history of tuberculosis. We summarized Xpert Ultra trace results. MAIN RESULTS: We identified nine studies (3500 participants): seven had unselected participants (2834 participants). All compared Xpert Ultra and Xpert MTB/RIF for pulmonary tuberculosis detection; seven studies used a paired comparative accuracy design, and two studies used a randomized design. Five studies compared Xpert Ultra and Xpert MTB/RIF for rifampicin resistance detection; four studies used a paired design, and one study used a randomized design. Of the nine included studies, seven (78%) were mainly or exclusively in high tuberculosis burden countries. For pulmonary tuberculosis detection, most studies had low risk of bias in all domains. Pulmonary tuberculosis detection Xpert Ultra pooled sensitivity and specificity (95% credible interval) against culture were 90.9% (86.2 to 94.7) and 95.6% (93.0 to 97.4) (7 studies, 2834 participants; high-certainty evidence) versus Xpert MTB/RIF pooled sensitivity and specificity of 84.7% (78.6 to 89.9) and 98.4% (97.0 to 99.3) (7 studies, 2835 participants; high-certainty evidence). The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at 6.3% (0.1 to 12.8) for sensitivity and -2.7% (-5.7 to -0.5) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have pulmonary tuberculosis, Xpert Ultra will miss 9 cases, and Xpert MTB/RIF will miss 15 cases. The number of people wrongly diagnosed with pulmonary tuberculosis would be 40 with Xpert Ultra and 14 with Xpert MTB/RIF. In smear-negative, culture-positive participants, pooled sensitivity was 77.5% (67.6 to 85.6) for Xpert Ultra versus 60.6% (48.4 to 71.7) for Xpert MTB/RIF; pooled specificity was 95.8% (92.9 to 97.7) for Xpert Ultra versus 98.8% (97.7 to 99.5) for Xpert MTB/RIF (6 studies). In people living with HIV, pooled sensitivity was 87.6% (75.4 to 94.1) for Xpert Ultra versus 74.9% (58.7 to 86.2) for Xpert MTB/RIF; pooled specificity was 92.8% (82.3 to 97.0) for Xpert Ultra versus 99.7% (98.6 to 100.0) for Xpert MTB/RIF (3 studies). In participants with a history of tuberculosis, pooled sensitivity was 84.2% (72.5 to 91.7) for Xpert Ultra versus 81.8% (68.7 to 90.0) for Xpert MTB/RIF; pooled specificity was 88.2% (70.5 to 96.6) for Xpert Ultra versus 97.4% (91.7 to 99.5) for Xpert MTB/RIF (4 studies). The proportion of Ultra trace-positive results ranged from 3.0% to 30.4%. Data were insufficient to estimate the accuracy of Xpert Ultra repeat testing in individuals with initial trace-positive results. Rifampicin resistance detection Pooled sensitivity and specificity were 94.9% (88.9 to 97.9) and 99.1% (97.7 to 99.8) (5 studies, 921 participants; high-certainty evidence) for Xpert Ultra versus 95.3% (90.0 to 98.1) and 98.8% (97.2 to 99.6) (5 studies, 930 participants; high-certainty evidence) for Xpert MTB/RIF. The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at -0.3% (-6.9 to 5.7) for sensitivity and 0.3% (-1.2 to 2.0) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have rifampicin resistance, Xpert Ultra will miss 5 cases, and Xpert MTB/RIF will miss 5 cases. The number of people wrongly diagnosed with rifampicin resistance would be 8 with Xpert Ultra and 11 with Xpert MTB/RIF. We identified a higher number of rifampicin resistance indeterminate results with Xpert Ultra, pooled proportion 7.6% (2.4 to 21.0) compared to Xpert MTB/RIF pooled proportion 0.8% (0.2 to 2.4). The estimated difference in the pooled proportion of indeterminate rifampicin resistance results for Xpert Ultra versus Xpert MTB/RIF was 6.7% (1.4 to 20.1). AUTHORS' CONCLUSIONS: Xpert Ultra has higher sensitivity and lower specificity than Xpert MTB/RIF for pulmonary tuberculosis, especially in smear-negative participants and people living with HIV. Xpert Ultra specificity was lower than that of Xpert MTB/RIF in participants with a history of tuberculosis. The sensitivity and specificity trade-off would be expected to vary by setting. For detection of rifampicin resistance, Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity. Ultra trace-positive results were common. Xpert Ultra and Xpert MTB/RIF provide accurate results and can allow rapid initiation of treatment for rifampicin-resistant and multidrug-resistant tuberculosis.

BMI is Associated with Coronavirus Disease 2019 Intensive Care Unit Admission in African Americans.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has disproportionately impacted the African American community. This study aims to identify the risk factors for severe COVID-19 disease in African American patients. METHODS: This was a retrospective cross-sectional analysis of African American patients with COVID-19 treated between March 12 and April 9, 2020, at a single tertiary center. The primary outcome of interest was severe disease defined as those requiring intensive care unit (ICU) admission. RESULTS: The study included 158 consecutive patients. The mean age was 57 years, and 61% were women. The mean (SD) of BMI was 33.2 (8.6) kg/m2 . Overall, patients admitted to the ICU were older (62 vs. 55 years, P = 0.003) and had higher BMI (36.5 kg/m2 vs. 31.9 kg/m2 , P = 0.002). In unadjusted and adjusted analysis, the factors most associated with ICU admission in this sample were age (adjusted odds ratio [aOR]: 1.073; 95% CI: 1.033-1.114), BMI (aOR: 1.115; 95% CI: 1.052-1.182), and lung disease (aOR: 3.097; 95% CI: 1.137-8.437). CONCLUSIONS: This study identified risk factors for severe disease in COVID-19, specifically in an African American population. Further inclusive research aimed at optimizing clinical care relevant to the African American population is critical to ensure an equitable response to COVID-19.

Family as the primary caregiver: palliative care in the Golan Heights.

Palliative care is recognised by the WHO as an essential component of care for the seriously ill. Geographically isolated and historically underserved communities, particularly from ethnic minority groups, face obstacles in obtaining adequate palliative care. This case involves the care of a 26-year-old Druze man suffering from a terminal cancer in his Golan Heights village. Local physicians were able to train the patient's father in a palliative care capacity. In the effort of capacity building, the physician and palliative care team also aided the aggrieved family in the process of coping. Robust support networks, both at state and community levels, facilitated the care provided. In showcasing the role of the national and local safety net in activating and building community resources to address a dearth of palliative care services in disadvantaged regions, this case models a potentially effective community-based approach to palliative care for patients from underserved populations.

Teaching corner: an undergraduate medical education program comprehensively integrating global health and global health ethics as core curricula : student experiences of the medical school for international health in Israel.

The Medical School for International Health (MSIH) was created in 1996 by the Faculty of Health Sciences at Ben-Gurion University of the Negev in affiliation with Columbia University's Health Sciences division. It is accredited by the New York State Board of Education. Students complete the first three years of the program on the Ben-Gurion University campus in Be'er-Sheva, Israel, while fourth-year electives are completed mainly in the United States (at Columbia University Medical Center and affiliates as well as other institutions) along with a two-month global health elective at one of numerous sites located around the world (including Canada, Ethiopia, India, Israel, Kenya, Nepal, Peru, the Philippines, Sri Lanka, Uganda, the United States, and Vietnam). The unique four-year, American-style curriculum is designed not only to prepare physicians who will be able to work at both an individual and community level but also at both of these levels anywhere in the world. In this way, it combines elements of medical and public health curricula not limited to an American perspective.

Landmines in the Golan Heights: a patient's perspective.

Fifteen years after the Ottawa Mine Ban Treaty, landmines continue to negatively impact global public health. Recent estimates attribute 11-12 daily casualties to landmines and explosive remnants of war. The majority of these casualties are civilians. Children are disproportionately affected by landmine injuries. In this report, we examine the case and recovery of a child severely injured in a 1982 Golan Heights landmine accident, illustrating the danger landmines pose to civilians and their long-term health implications.

Modified Rives-Stoppa technique for repair of complex incisional hernias in 59 patients.

Incisional hernias develop in 2% to 11% of patients who undergo laparotomy. Prosthetic mesh repair provides more strength, tension-free closure, and decreased recurrence rates as compared to primary tissue repairs. Complications-fistula formation, adhesions, skin erosion, and seroma/abscess formation-however, include increased rates of infection, sometimes requiring complete mesh removal. The Rives-Stoppa repair for complex incisional hernias confers the benefits of prosthetic repair and lower recurrence rates, but decreases certain complications by preventing direct mesh contact with the bowel. A total of 89 consecutive patients (mean age, 58.1) underwent a modified Rives-Stoppa repair for purposes of this review, all the patients who lost to follow-up before 6 months postoperatively were excluded from the study. Of the remaining 59 patients, 32.2% (n = 19) had expanded polytetrafluoroethylene mesh, and 67.8% (n = 40) had polypropylene mesh. Average range of follow-up was 40.0 months. Hernia recurred in 1 patient (1.7%). Infection requiring explantation of the prosthesis occurred in 3 patients (5.1%). The Rives-Stoppa repair is reportedly the best open technique for complex incisional hernias with comparatively lower recurrence rates. Additionally, patients with inflammatory bowel disease (64.4% of our series), who often require later reoperation for their primary disease, may benefit from this technique of herniorrhaphy where no interface exists between intrabdominal contents and the prosthesis. This lack of interface decreases intrabdominal adhesions and facilitates re-entry if future surgery is needed for inflammatory bowel disease.