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The Complications in Medical Aesthetics Collaborative (CMAC) is a nonprofit organization established to promote best patient outcomes through educating clinicians in the prevention, diagnosis, and management of complications that can arise following nonsurgical cosmetic procedures. The organization is a global community sharing information, learning, experience, and data to promote best practices. There is no reliable data on the risk or incidence of acute infection following a nonsurgical cosmetic procedure, but it is considered to be a rare complication. This article explores the evidence base for precautions and best practice standards, including an examination of the rational for standard aftercare advice and guidance on prevention, diagnosis, and management protocols.

The Complications in Medical Aesthetics Collaborative (CMAC) is a not-for-profit organization established to promote best patient outcomes through educating clinicians who perform nonsurgical cosmetic procedures in the prevention, diagnosis, and management of complications that can arise. The organization is a global community sharing information, learning, experience, and data to promote best practice. Herpes simplex is common in the general population. The risk of reactivation due to trauma is acknowledged in the literature. Reactivation of herpes simplex 1 following cosmetic procedures is considered rare, but there are no reliable data on the incidence. Although self-limiting, symptoms can be painful and distressing for patients who have undergone a procedure to improve their appearance. Clinicians should document the steps they've taken to avoid reactivation, and should be confident in their management plan and patient care if a patient suffers a reactivation. The authors have referred to the available literature and experience to provide a user-friendly guideline to reduce risk of herpes simplex 1 reactivation through appropriate patient screening, promote accurate diagnosis and an understanding of differentials, and provide management plans for prophylaxis to minimize adverse sequalae. In cases of post-procedure outbreak, the guideline explains the management options, including patient education and support when prescription medications are not indicated.

The response to the coronavirus disease 2019 (COVID-19) pandemic has been hampered by lack of an effective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antiviral therapy. Here we report the successful use of remdesivir in a patient with COVID-19 and the prototypic genetic antibody deficiency X-linked agammaglobulinaemia (XLA). Despite evidence of complement activation and a robust T cell response, the patient developed persistent SARS-CoV-2 pneumonitis, without progressing to multi-organ involvement. His unusual clinical course identifies a key role for SARS-CoV-2 antibodies in both viral clearance and progression to severe disease. In the absence of these confounders, we took an experimental medicine approach to examine the in vivoutility of remdesivir. Over two independent courses of treatment, we observed a dramatic, temporally correlated clinical and virological response, leading to clinical resolution and viral clearance, with no evidence of acquired drug resistance. We therefore provide unambiguous evidence for the antiviral efficacy of remdesivir in vivo, and its potential benefit in selected patients.

Background In April 2014 the UK government launched the ‘NHS Visitor and Migrant Cost Recovery Programme Implementation Plan’ which set out a series of policy changes to recoup costs from ‘chargeable’ (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced. Methods There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP. Results We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13–1.66, p value 0.001). Conclusion Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

Background Emergency Department (ED) presentations could present a valuable opportunity to identify high-risk individuals with latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease. We aimed to investigate the prevalence and cost-effectiveness of screening for LTBI and pulmonary TB disease among migrants and under-served groups attending London EDs. Methods We recruited adults attending EDs (18/7/2013–25/5/2017) who were either recent entrants from high TB-incidence countries; or had a history of homelessness, imprisonment, or substance use disorder. We assessed the yield of screening for LTBI (using an interferon-gamma release assay; IGRA) and active pulmonary TB (with a symptom screen, followed by chest radiograph and sputum Xpert MTB/RIF if positive). A cost-effectiveness analysis was performed by calculating cost per true-positive LTBI test. Results A total of 1420 participants were screened for LTBI. Median age was 45 years (IQR 34–60), and the majority were born outside the UK (1,162/1,420; 81.8%). A total of 241/1,420 participants (17.0%) had a history of either substance use disorder, homelessness or imprisonment. Of those with available IGRA results, 214/1,246 (17.2%) were positive. Male sex, age >35 years, non-UK country of birth, and previous TB contact were independent risk factors for being IGRA-positive. Of the 214 with a positive IGRA, 120 (56%) were followed-up by health record review for evidence of progression to TB disease; 5/120 (4.2%) were diagnosed with TB disease (median interval to TB 162 days (IQR 55–108.5)). In the economic analysis, the average cost per patient recruited of correctly diagnosing an LTBI case was £834 (compared to an estimated £1007 per LTBI case diagnosed through primary care). Only 14/513 (2.7%) participants screened for active TB had a positive symptom screen so were eligible for further testing. No cases of active TB were diagnosed. Conclusions Targeted LTBI screening in EDs could be considered to complement the primary care LTBI screening programme. In contrast, active TB screening in EDs using our symptom screen-led algorithm should not be pursued as the yield is likely to be minimal. Other active TB screening models (e.g. routine, automated reviews of ED chest radiographs) could be considered as a focus of future research.

Background: Paradoxical reactions (PR) are recognised phenomena in the management of tuberculosis (TB). They are defined as the worsening of clinical or radiological features following initial improvement with anti-TB medication in the absence of any other possible causes for deterioration. PR commonly been reported in HIV patients, there is very little evidence available to identify those at risk of developing a PR in HIV patients. Method: We looked at retrospective case series of PR patients identified in a large tertiary UK centre over a period of 6 years. 17 cases of PR were identified as having a documented diagnosis Results: The resuts are present in table 1. The average time of treatment prior the paradoxical reaction was 57 days (IQR 33-72). There was a noted to be a mild increase in the lymphocyte count 0.44, 95% CI 0.21-0.94. The monocyte: lymphocyte ratio was noted to have decreased but this was not statistically significant (-0.146, 95% CI -0.38 to + 0.09 n=10). 16 patients had good clinical improvement of their PR with one death which was TB related. Concluison: Disseminated disease and extra pulmonary TB may be implicated as a risk factor for developing PR and symptoms often manifests within the intensive phase of treatment. Further prospective studies are warranted with a particular focus on cytokine profiling and immunophenotyping of non-HIV patients.

Background: The collaborative tuberculosis strategy 2015-2020 published by Public Health England (PHE) currently recommends screening all migrants aged 16-35 who entered the UK less than 5 years ago arriving from a high incidence country (≥150/100,000 or Sub-Saharan Africa (SSA)). Methods: A retrospective analysis of all active TB cases notified in Newham 2011-2016. We evaluated the number of active cases in migrants from high incidence countries or SSA which may have been prevented by screening using the PHE criteria, and with extended criteria (age 16-50, and up to 10 and 15 years in the UK). Results: A total of 1409 cases were notified in Newham from 2011 to 2016. 923 were male, 485 were female. Of these, 1092 came from countries eligible for screening under PHE guidelines (incidence ≥150/100,000, or SSA). 369 of these active cases fulfilled the additional PHE criteria for age and years since UK entry, and could potentially have been prevented by the screening programme. With all other parameters kept constant, extending screening to those up to the age of 50 may have prevented an additional 51 cases. 152 cases may have been prevented by extending screening to those who had been in the country for up to 10 years. Conclusion: Further work is needed to evaluate whether current LTBI screening guidelines should be extended to migrants up to 50 years or who have been in the UK more than 5 years. Figure 1: Active TB cases in eligible migrants that may have been prevented under different screening protocols.

Introduction: The aim of this study was to compare outcomes of NTM infection in those with COPD and control groups. Methods: A retrospective analysis of patients meeting ATS criteria for NTM lung disease was performed using electronic patient databases from January 2011 to March 2016. Patients with COPD were identified and compared to those with bronchiectasis and, in a separate analysis, compared to all non-COPD patients (including those with bronchiectasis). Results: 57 patients were identified as having NTM lung disease. 30 (52.6%) had COPD, 16 (28.1%) had bronchiectasis, one (1.8%) had lung cancer, one (1.8%) had sarcoid and 8 (14.0%) had no known respiratory illnesses. Patients with COPD were older at diagnosis of NTM (72 years) than those with bronchiectasis (58 years) and all non-COPD (58 years)(p Patients with COPD had a lower mean FEV1 (52.8% predicted) and mean FVC (86.3% predicted), compared to patients with bronchiectasis (FEV1 84.8% predicted, p=0.0001; FVC 108.0% predicted, p=0.017), and all non-COPD patients (FEV1 88.4% predicted, p 17 (58.62%) patients with COPD and a diagnosis of NTM lung disease had radiological changes compared to the 6 (40%) patients with bronchiectasis (p=0.42). 8 (28.6%) COPD patients died compared to 2 (13.3%) patients with bronchiectasis (p=0.508) and 4 (16%) of the combined non-COPD patients (p=0.337). Conclusion: The majority of NTM lung disease observed was in the context of COPD. NTM disease presents at an older age in patients with COPD compared to other patients. There was a trend towards higher mortality in those with COPD and NTM disease that warrants further investigation.

Introduction: Spinal Tuberculosis (TB) accounts for 1% of all TB cases and if left untreated can cause severe morbidity and mortality. Surgical intervention may often be required in extreme cases. Our Trust has now in place a clinic in which patients are reviewed jointly by Spinal surgeons Respiratory physicians and Radiologists. Methodology: We performed a retrospective cohort study on patients with spinal TB over a period of 5 years identified from the national registry. Results: The results are present in figure 1. 99 patients were documented to have spinal TB of which 78 patients completed treatment (5 migrated, 2 non TB related deaths, 4 incomplete data and 10 lost to follow up). 80 patients presented with back pain, 32 with neurological symptoms, 5 had spinal cord compression. 7 patients had a cough and 34 patients had constitutional symptoms. 63/78 patients received TB chemotherapy for a period of 12 months or more and 12 patients required surgical intervention along with medical management. 45 patients received steroid treatment. 11 patients developed an ADR related to chemotherapy or steroids. There were no grade 3 or 4 serious adverse events. 4 patients have on going neurological disability with 20 patients having minimal to mild back pain after 12 months from diagnosis. Conclusion: Coordinated Management of Spinal TB between Physicians and Surgeons may improve clinical outcomes.

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

Introduction: Although disseminated infection with Mycobacterium tuberculosis (TB) implies a major failure in the immune response, most patients with disseminated TB have no identifiable cause of immunodeficiency. Th2 inflammation, associated with asthma and allergy, inhibits Th1 and Th17 responses, both necessary for effective immune responses to TB. Th2 inflammation is known associated with disseminated Cryptococcal and Histoplasmosa infections. We therefore reviewed our cohort of HIV negative patients with disseminated TB for asthma or blood eosinophilia as a biomarker of unsuppressed Th2 inflammation. Methods: Our TB Registry was examined for cases of disseminated TB at Royal London and Newham Hospitals over the last 5 years. Full blood counts (with eosinophil counts) preceding diagnosis and commencement of anti-TB therapy were recorded, along with history of asthma or steroid therapy. Results: Full blood counts preceding anti-TB therapy were available in 31 patients with miliary/disseminated TB. 24 had undetectable eosinophils and only 3 a low-grade eosinophilia (0.4-0.5). 2 patients had asthma. 2 patients were on inhaled steroids (and 1 on oral steroids). Conclusion: We could find no evidence of frequent asthma or heightened Th2 immunity (high blood eosinophils) in disseminated TB. It is possible that measuring blood counts at time of presentation is too late to detect any eosinophilia present earlier when they first acquired TB and failed to mount an early effective immune response. The eosinopaenia in these patients may reflect Th1 immune responses suppressing Th2 responses, and there is limited evidence that BCG vaccination may be able to suppress asthmatic inflammation.

Introduction More than Seventy percent of active Tuberculosis (TB) cases in England are in patients born outside the United Kingdom (UK). Lack of access to primary healthcare is often cited as a barrier to TB control. We considered how patients with TB referred directly to outpatient services initially access healthcare. Method A retrospective cohort analysis of all patients with active TB on the London TB register (LTBR) between April 2014 and April 2015 at a large urban tertiary referral centre. The route of referral to TB services was confirmed by a review of electronic patient records. We compared demographic, disease and outcome variables between groups as recorded in the LTBR. We excluded those requiring admission; identified through contact tracing; referrals from other secondary care outpatient services and those with inadequate data. Chi squared or Exact tests were used in the analysis. Results We compared patients diagnosed with TB who were referred directly to outpatient services from General Practice (GP) (97 patients) and the Emergency Department (ED) (35 patients). There was no significant difference in age or sex between groups. Of those patients born outside the UK (105), 78 percent (82/105) were referred to clinic from their GP compared to only 56 percent (15/27) of those born within the UK (15/27). This difference was statistically significant (p Comparing disease between the groups, there was a higher proportion of multisite disease amongst those referred from ED compared to GP (23% [8/35] vs 14% [14/97], p Conclusion Amongst patients with active TB referred directly to outpatient services, those born outside the UK were more likely to have been referred by their GP than UK-born patients.