Emergence of bedaquiline-resistant tuberculosis and of multidrug-resistant and extensively drug-resistant Mycobacterium tuberculosis strains with rpoB Ile491Phe mutation not detected by Xpert MTB/RIF in Mozambique: a retrospective observational study.

BACKGROUND: In 2021, an estimated 4800 people developed rifampicin-resistant tuberculosis in Mozambique, 75% of which went undiagnosed. Detailed molecular data on rifampicin-resistant and multidrug-resistant (MDR) tuberculosis are not available. Here, we aimed at gaining precise data on the determinants of rifampicin-resistant and MDR tuberculosis in Mozambique. METHODS: In this retrospective observational study, we performed whole-genome sequencing of 704 rifampicin-resistant Mycobacterium tuberculosis complex (Mtbc) strains submitted to the National Tuberculosis Reference Laboratory (NTRL) in Maputo, Mozambique, between 2015 and 2021. Phylogenetic strain classification, genomic resistance prediction, and cluster analysis were performed. FINDINGS: Between Jan 1, 2015, and July 31, 2021, 2606 Mtbc isolates with an isoniazid or rifampicin resistance were identified in the NTRL biobank, of which, 1483 (56·9%) were from men, 1114 (42·7%) from women, and nine (0·4%) were unknown. Genome-based drug-resistant prediction classified 704 Mtbc strains as rifampicin resistant. 628 (89%) of the 704 Mtbc strains were classified MDR; of those, 146 (23%) were pre-extensively drug resistant (pre-XDR; additional fluoroquinolone resistance), and 24 (4%) extensively drug resistant (XDR; combined fluoroquinolone and bedaquiline resistance). Overall, 61 (9%) of 704 strains revealed resistance to bedaquiline: five (7%) of 76 rifampicin resistant plus bedaquiline resistant, 32 (7%) of 458 MDR plus bedaquiline resistant, and 24 (100%) of 24 XDR. Prevalence of bedaquiline resistance increased from 3% in 2016 to 14% in 2021. The cluster rate (12 single-nucleotide polymorphism threshold) was 42% for rifampicin-resistant strains, 78% for MDR strains, 94% for pre-XDR strains, and 96% for XDR Mtbc strains. 31 (4%) of 704 Mtbc strains, belonging to a diagnostic escape outbreak strain previously described in Eswatini (group_56), had an rpoB Ile491Phe mutation which is not detected by Xpert MTB/RIF (no other rpoB mutation). Of these, 23 (74%) showed additional resistance to bedaquiline, 13 (42%) had bedaquiline and fluoroquinolone resistance, and two (6%) were bedaquiline, fluoroquinolone, and delamanid resistant. INTERPRETATION: Pre-XDR resistance is highly prevalent among MDR Mtbc strains in Mozambique and so is bedaquiline resistance; and the frequency of bedaquiline resistance quadrupled over time and was found even in Mtbc strains without fluoroquinolone resistance. Importantly, strains with Ile491Phe mutation were frequent, accounting for 31% (n=10) of MDR plus bedaquiline-resistant strains and 54% (n=13) of XDR Mtbc strains. Given the current diagnostic algorithms and treatment regimens, both the emergence of rifampicin resistance due to Ile491Phe and bedaquiline resistance might jeopardise MDR tuberculosis prevention and care unless sequencing-based technology is rolled out. The potential cross border spread of diagnostic escape strains needs further investigation. FUNDING: The German Ministry of Health through the Seq_MDRTB-Net project, the Deutsche Forschungsgemeinschaft under Germany's Excellence Strategy Precision Medicine in Inflammation and the Research Training Group 2501 TransEvo, the Leibniz Science Campus Evolutionary Medicine of the Lung, and the German Ministry of Education and Research via the German Center for Infection Research.

Falls and Preventive Practices among Institutionalized Older People.

The present study about falls among the older adult population essentially explores bio-physiological factors. In light of the complexity of the factors that cause these accidents, it is important to identify the safety and self-care practices of institutionalized older adults and their relationship with falls in order to introduce prevention measures and personalized cognitive-behavioral strategies. The objective of this study was to: (a) determine the frequency of falls and their recurrence among institutionalized older adults, and (b) to associate the occurrence of falls among institutionalized adults with or without cognitive impairment to communication and safety practices. This was a quantitative, correlational, and longitudinal study with 204 institutionalized older adults living in two long-term care facilities in Portugal. The Scale of Practices and Behaviors for Institutionalized Elderly to Prevent Falls was administered to the sample. The prevalence of falls at a 12-month follow-up was 41.6%, of which 38.3% were recurring episodes. Older adults with cognitive decline showed lower mean scores for safety practices. Further research with larger samples should explore the relationships between communication and safety practices and falls, their recurrence, and fear of new falls.

Gait Ability and Muscle Strength in Institutionalized Older Persons with and without Cognitive Decline and Association with Falls.

Falls are a complex problem, given their multifactorial nature, the comorbidities involved, and due to the dependency of older persons living in nursing homes. Risk, fear of falling, falls themselves, and their recurrence are the main factors behind fragility fractures, lack of independence, and increases in pain prevalence, and other comorbidities in older populations. The objectives of the present quantitative and longitudinal study were: (a) to characterize the cognitive state and fall frequency of older persons living in nursing homes; (b) to analyze the relationship between cognitive status and some fall risk factors; and (c) to associate cognitive decline, gait ability, and muscle strength of the examined institutionalized older persons with fall occurrence and recurrence over 12 months. The participants were 204 older persons who lived in Portuguese nursing homes, and data were collected from January 2019 to February 2020 by consulting medical records and applying the following instruments: the Mini-Mental State Examination, Timed Up and Go Test, and Medical Research Council Manual Muscle Testing Scale. Fall prevalence, assessed in two periods, 12 months apart, was similar in both samples (with and without cognitive decline) and close to 42%, and the annual recurrence rate was 38.3%. Older persons with no cognitive decline showed an association between gait speed and occurrence of first fall and recurrent fall (p < 0.05). Muscle strength and use of gait aid devices were not related to falls and their recurrence, regardless of mental state.

Transitional Care Management from Emergency Services to Communities: An Action Research Study.

In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin's content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution's research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients' process of returning home, and this factor must be taken into account in care planning.

Evaluation of the Ogawa-Kudoh method for tuberculosis isolation in two health units in Mozambique.

BACKGROUND: Mozambique is among the highest tuberculosis, tuberculosis-HIV and multidrug-resistant-tuberculosis burden countries. Although molecular technologies are available in-country, mycobacterial isolation through culture remains an important tool for tuberculosis diagnostics and drug susceptibility testing. OBJECTIVE: We evaluated the use of the Ogawa-Kudoh (OK) mycobacterial culture, a simple technique, to isolate Mycobacterium tuberculosis in two health units, in Maputo City, Mozambique. METHODS: From May to December 2014, 122 patient samples were collected in Chamanculo General Hospital and Polana Caniço General Hospital. The specimens were first tested in the health units using the OK method and afterwards shipped to the National Tuberculosis Reference Laboratory for mycobacterial culture using the NALC-NaOH-Citrate (NALC) decontamination method followed by inoculation in Lowenstein Jensen (LJ) solid media as the reference standard. RESULTS: Among 107 samples with valid results, 98 (91.6%) had concordant results in both methods; 9 (8.4%) had discordant results. The contamination rate was 4.1% (5/122) for the OK and 9.0% (11/122) for the NALC/LJ methods. The sensitivity of OK was 80% (95% confident interval [CI]: 51.4-94.7) and the specificity was 94% (95% CI: 85.8-97.3). The degree of agreement between both methods was moderate (Kappa: 0.68; 95% CI: 0.48-0.89). CONCLUSION: The OK method showed satisfactory sensitivity and specificity. The method also had a lower contamination rate when compared to the NALC/LJ. Similar to other studies in resource-limited settings, our findings showed that the OK method can effectively be implemented in settings with limited laboratory capacity to isolate tuberculosis bacteria by culture for further testing.

Interobserver analysis of safety practices and behaviors adopted by elderly people to prevent falls.

OBJECTIVE: determine the psychometric properties of the safety practices and behaviors dimension of the Scale of Practices and Behaviors of Institutionalized Elderly People to Prevent Falls in a sample of elderly people with cognitive decline. METHOD: methodological study, with a quantitative approach, to assess the psychometric properties of the mentioned scale in a sample with 102 elderly people with cognitive decline who lived in two long-term care institutions for the public in this age group. Internal consistency evaluation was carried out by calculating the Cronbach's alpha coefficient; interobserver reliability was expressed by Cohen's kappa coefficient; and temporal stability, by obtaining Spearman correlation. Compliance with all ethical procedures was observed. RESULTS: the dimension of safety practices and behaviors showed α = 0.895 for its 11 items. Seven out of the 11 items reached good to excellent agreement among the experts for interobserver reliability. Kappa index values indicated that the instrument is valid and reliable. Safety practices and behaviors were influenced by institutionalization time, being at least 85 years old, and gait skills. CONCLUSION: the results pointed out that the instrument has good reproducibility and is valid and reliable, which allows its use in clinical practice in elderly people with cognitive decline as well as in research.

Interobserver analysis of safety practices and behaviors adopted by elderly people to prevent falls / Análise Interobservadores das práticas e comportamentos de segurança adotados pelos idosos institucionalizados para prevenir quedas / Análisis interobservadores de prácticas y comportamientos de seguridad adoptadas por ancianos institucionalizados para prevenir caídas

Objective: determine the psychometric properties of the safety practices and behaviors dimension of the Scale of Practices and Behaviors of Institutionalized Elderly People to Prevent Falls in a sample of elderly people with cognitive decline. Method: methodological study, with a quantitative approach, to assess the psychometric properties of the mentioned scale in a sample with 102 elderly people with cognitive decline who lived in two long-term care institutions for the public in this age group. Internal consistency evaluation was carried out by calculating the Cronbach's alpha coefficient; interobserver reliability was expressed by Cohen's kappa coefficient; and temporal stability, by obtaining Spearman correlation. Compliance with all ethical procedures was observed. Results: the dimension of safety practices and behaviors showed α = 0.895 for its 11 items. Seven out of the 11 items reached good to excellent agreement among the experts for interobserver reliability. Kappa index values indicated that the instrument is valid and reliable. Safety practices and behaviors were influenced by institutionalization time, being at least 85 years old, and gait skills. Conclusion: the results pointed out that the instrument has good reproducibility and is valid and reliable, which allows its use in clinical practice in elderly people with cognitive decline as well as in research.

Objetivo: determinar as propriedades psicométricas da dimensão das práticas e dos comportamentos de segurança da Escala de Práticas e Comportamentos dos Idosos Institucionalizados para Prevenir Quedas numa amostra de idosos com declínio cognitivo. Método: estudo metodológico, com abordagem quantitativa, para a avaliação das propriedades psicométricas da escala numa amostra de 102 idosos com declínio cognitivo, residentes em duas Instituições de Longa Permanência para Idosos. A avaliação da consistência interna foi efetuada pelo α de Cronbach, a confiabilidade interobservadores, calculada pelo coeficiente de concordância Kappa de Cohen e a estabilidade temporal, pela correlação de Spearman. Todos os procedimentos éticos foram contemplados no estudo. Resultados: a dimensão das práticas e dos comportamentos de segurança da escala apresentou um α=0,895 para os seus 11 itens. Na confiabilidade interobservador, 7 dos 11 itens obtiveram de boa a excelente concordância entre os juízes. Os valores do Índice Kappa evidenciam que o instrumento é válido e fidedigno. As práticas e os comportamentos de segurança são influenciados pelo tempo de institucionalização, idade superior a 85 anos e capacidade de marcha. Conclusão: os resultados indicam uma boa reprodutibilidade, o instrumento é válido e fidedigno, permitindo a utilização do instrumento na clínica em idosos com declínio cognitivo e na investigação.

Objetivo: determinar las propiedades psicométricas de la dimensión de prácticas y conductas de seguridad de la Escala de prácticas y comportamientos de los ancianos institucionalizados para prevenir las caídas, sobre una muestra de ancianos con deterioro cognitivo. Método: estudio metodológico de abordaje cuantitativo para evaluar las propiedades psicométricas de la escala sobre muestra de 102 ancianos con deterioro cognitivo, residentes en dos hogares para ancianos. Evaluación de consistencia interna verificada por α de Cronbach, confiabilidad interobservadores calculada por coeficiente de concordancia Kappa de Cohen, estabilidad temporal comprobada por correlación de Spearman. Fueron contemplados todos los procedimientos éticos. Resultados: la dimensión de prácticas y comportamientos de seguridad de la escala expresa α=0,895 para sus 11 ítems. En confiabilidad interobservadores, 7 de los 11 ítems obtienen buena o excelente concordancia entre los evaluadores. Los valores del índice Kappa evidencian que el instrumento es válido y fidedigno. Las prácticas de comportamiento de seguridad están influidas por el tiempo de institucionalización, edad superior a 85 años y capacidad de marcha. Conclusión: los resultados demuestran buena reproductividad, el instrumento es válido y confiable, pudiéndoselo utilizar en la clínica con ancianos con deterioro cognitivo y en la investigación.

Falls in institutionalized elderly with and without cognitive decline A study of some factors.

Falls in long-stay institutions for elderly people have a high prevalence, contributing to the physical and mental deterioration of institutionalized elderly. OBJECTIVE: To determine the prevalence of falls among institutionalized elderly with and without cognitive decline, and to characterize the practices and behaviors of those with and without cognitive decline in managing fall risks, and relate them to some factors. METHODS: The present correlational study was carried out with a sample of 204 institutionalized elderly, 50% of whom had cognitive decline. RESULTS: The elderly with cognitive decline (40.2%) fell less often than those who did not have cognitive decline (42.2%) (p>0.05). Safety practices and behaviors were better in the elderly with cognitive decline (p<0.05). Most of the elderly with cognitive decline who fell took benzodiazepines (65.9%), in contrast with those without cognitive decline (32.2%). It was observed that 81.4% of the elderly without cognitive decline and 43.9% of those with cognitive decline who fell had a performance of over 12 seconds on the Timed Up and Go Test, where differences reached statistical significance in both groups of elderly. CONCLUSION: Data collected in the present study further the knowledge on risk factors in the genesis of falls and on the behavior of elderly with and without cognitive decline in maintaining their safety in self-care and accessibility.

As quedas nas instituições de longa permanência para idosos apresentam uma elevada prevalência, contribuindo para a deterioração física e mental dos idosos institucionalizados. OBJETIVO: Determinar a prevalência de quedas nos idosos institucionalizados com e sem declínio cognitivo; caracterizar as práticas e comportamentos dos idosos com e sem declínio cognitivo na gestão do risco de queda e relacionar com alguns fatores. MÉTODOS: Este estudo correlacional foi realizado numa amostra de 204 idosos institucionalizados (50% com declínio cognitivo). RESULTADOS: Os idosos com declínio (40,2%) caíram menos que os que não tem declínio (42,2%) cognitivo (p>0,05). As práticas e comportamentos de segurança são melhores nos idosos com declínio (p<0,05). O maior percentual de idosos com declínio que caem consomem benzodiazepinas (65,9%), o mesmo não se verificando com os idosos sem declínio (32,2%). Verificamos que 81,4% dos idosos sem declínio e 43,9% dos idosos com declínio que caem apresentam perfomance no Timed Up and Go Test superior a 12 segundos tendo as diferenças significado estatístico em ambos os grupos de idosos. CONCLUSÃO: Os dados contribuem para um melhor conhecimento dos fatores de risco na génese da queda e das práticas e comportamentos dos idosos com e sem declínio para manterem a sua segurança no autocuidado e a acessibilidade.

Falls in institutionalized elderly with and without cognitive decline: a study of some factors / A queda em idosos institucionalizados com e sem declínio cognitivo: estudo de alguns fatores

ABSTRACT: Falls in long-stay institutions for elderly people have a high prevalence, contributing to the physical and mental deterioration of institutionalized elderly. Objective: To determine the prevalence of falls among institutionalized elderly with and without cognitive decline, and to characterize the practices and behaviors of those with and without cognitive decline in managing fall risks, and relate them to some factors. Methods: The present correlational study was carried out with a sample of 204 institutionalized elderly, 50% of whom had cognitive decline. Results: The elderly with cognitive decline (40.2%) fell less often than those who did not have cognitive decline (42.2%) (p>0.05). Safety practices and behaviors were better in the elderly with cognitive decline (p<0.05). Most of the elderly with cognitive decline who fell took benzodiazepines (65.9%), in contrast with those without cognitive decline (32.2%). It was observed that 81.4% of the elderly without cognitive decline and 43.9% of those with cognitive decline who fell had a performance of over 12 seconds on the Timed Up and Go Test, where differences reached statistical significance in both groups of elderly. Conclusion: Data collected in the present study further the knowledge on risk factors in the genesis of falls and on the behavior of elderly with and without cognitive decline in maintaining their safety in self-care and accessibility.

RESUMO: As quedas nas instituições de longa permanência para idosos apresentam uma elevada prevalência, contribuindo para a deterioração física e mental dos idosos institucionalizados. Objetivo: Determinar a prevalência de quedas nos idosos institucionalizados com e sem declínio cognitivo; caracterizar as práticas e comportamentos dos idosos com e sem declínio cognitivo na gestão do risco de queda e relacionar com alguns fatores. Métodos: Este estudo correlacional foi realizado numa amostra de 204 idosos institucionalizados (50% com declínio cognitivo). Resultados: Os idosos com declínio (40,2%) caíram menos que os que não tem declínio (42,2%) cognitivo (p>0,05). As práticas e comportamentos de segurança são melhores nos idosos com declínio (p<0,05). O maior percentual de idosos com declínio que caem consomem benzodiazepinas (65,9%), o mesmo não se verificando com os idosos sem declínio (32,2%). Verificamos que 81,4% dos idosos sem declínio e 43,9% dos idosos com declínio que caem apresentam perfomance no Timed Up and Go Test superior a 12 segundos tendo as diferenças significado estatístico em ambos os grupos de idosos. Conclusão: Os dados contribuem para um melhor conhecimento dos fatores de risco na génese da queda e das práticas e comportamentos dos idosos com e sem declínio para manterem a sua segurança no autocuidado e a acessibilidade.

Optimized adsorption onto biosolids-based activated carbon for tartrazine removal from wastewater.

This study investigates optimized tartrazine uptake by activated carbon prepared from biosolids (BBAC). Different tartrazine concentrations (10-20 mg/L), adsorbent dosages (1.0-2.0 g), pH (2.0-4.0), and contact times (60-120 min) were tested. These independent variables formed a 24 full factorial experiment arranged as central composite rotative design (CCRD). Response surface methodology (RSM) analyzed the responses of 50 experimental runs. Tartrazine removal efficiency fluctuated between 76.2% and 99.9%. The experimental data were best fitted by a quadratic model (R2  > 0.95, p > 0.0001). All variables exerted statistically significant (p < 0.05) effects on the tartrazine uptake (initial concentration, p = 0.0011; BBAC dosage, p = 0.0004; pH, p < 0.0001; contact time, p < 0.0001). Optimized tartrazine uptake efficiency of 97.4% can happen when variables mutually correlate at 10.1 mg/L of tartrazine concentration, 1.07 g of adsorbent dosage, 2.13 of pH, and 116.9 min of contact time. PRACTITIONER POINTS: Production of biosolids-based activated carbon (BBAC) is presented. Adsorptive affinity to tartrazine in aqueous solution was experimented. Experimental conditions optimized by Response Surface Methodology.

OMNIgene.SPUTUM suppresses contaminants while maintaining Mycobacterium tuberculosis viability and obviates cold-chain transport.

Tuberculosis (TB) diagnostics are centralised, requiring long-distance transportation of specimens in most resource-limited settings. We evaluated the ability of OMNIgene.SPUTUM (OM-S) to obviate cold-chain transport of TB specimens. A two-arm (same-day and after 5 days sample processing) study was conducted to assess contamination rates and Mycobacterium tuberculosis viability in OM-S-treated samples against the standard decontamination procedure (SDP) in Mozambique, using Lowenstein Jensen (LJ) and mycobacterial growth indicator tube (MGIT) culture and molecular bacterial load assay. 270 specimens were processed using OM-S and SDP in same-day and 5-day arms. Contamination was lower in OM-S-treated than SDP-treated cultures: 12% versus 15% and 2% versus 27% in the same-day and 5-day arms, respectively. M. tuberculosis recovery in OM-S-treated LJ cultures was 10% and 56% higher in the same-day and 5-day arms, respectively, than SDP-treated cultures, but lower in MGIT (52% and 28% lower in the same-day and 5-day arms, respectively). M. tuberculosis viable count was 1log estimated CFU·mL-1 lower in 5-day OM-S-treated sputa. OM-S was more effective at liquefying sputum with a shorter sample processing time: 22 min for culture. OM-S is simple to use and has demonstrated a high potency to suppress contaminants, maintenance of viability at ambient temperatures and higher M. tuberculosis recovery, particularly in the solid LJ cultures. Optimisation of OM-S to achieve higher MGIT culture positivity and shorter time to result will increase its application and utility in the clinical management of TB.

Mozambique's journey toward accreditation of the National Tuberculosis Reference Laboratory.

BACKGROUND: Internationally-accredited laboratories are recognised for their superior test reliability, operational performance, quality management and competence. In a bid to meet international quality standards, the Mozambique National Institute of Health enrolled the National Tuberculosis Reference Laboratory (NTRL) in a continuous quality improvement process towards ISO 15189 accreditation. Here, we describe the road map taken by the NTRL to achieve international accreditation. METHODS: The NTRL adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme as a strategy to implement a quality management system. After SLMTA, the Mozambique National Institute of Health committed to accelerate the NTRL's process toward accreditation. An action plan was designed to streamline the process. Quality indicators were defined to benchmark progress. Staff were trained to improve performance. Mentorship from an experienced assessor was provided. Fulfilment of accreditation standards was assessed by the Portuguese Accreditation Board. RESULTS: Of the eight laboratories participating in SLMTA, the NTRL was the best-performing laboratory, achieving a 53.6% improvement over the SLMTA baseline conducted in February 2011 to the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) assessment in June 2013. During the accreditation assessment in September 2014, 25 minor nonconformities were identified and addressed. In March 2015, the NTRL received Portuguese Accreditation Board recognition of technical competency for fluorescence smear microscopy, and solid and liquid culture. The NTRL is the first laboratory in Mozambique to achieve ISO 15189 accreditation. CONCLUSIONS: From our experience, accreditation was made possible by institutional commitment, strong laboratory leadership, staff motivation, adequate infrastructure and a comprehensive action plan.