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Background: Identifying and treating tuberculosis infection (TBI) among refugees at elevated risk for developing TB disease is crucial for TB prevention and elimination in the United States (U.S.). However, current evidence is limited by small sample sizes, inclusion of refugees from only a single country, and/or reliance solely on the tuberculin skin test (TST). Methods: Refugees in a large cohort study from 10 U.S. sites underwent evaluation for TBI using three available tests: the TST and two interferon-gamma release assays (IGRAs). This study calculated TBI prevalence and assessed tuberculosis preventive treatment (TPT) completion among refugees, defining TBI prevalence as positive results on at least two tests. Results: Among 8960 refugees enrolled July 2012 through May 2017, TBI prevalence was 23.2% (95% confidence interval [CI]: 22.4%-24.1%). Completion of TPT was 81.2% (95% CI: 79.6%-82.7%). Shorter treatment regimens of 3 months were associated with higher treatment completion compared to regimens of 6 months or longer. Conclusion: The high TBI prevalence among refugees is a concern, but their high TPT acceptance and completion rates offer an opportunity. IGRA-based tests are preferred in this population; however, limited resources underscore the need for more precise screening approaches to better identify high-risk individuals who truly require TPT.

Objective: This pilot study compared muscle activity during lateral reaching tasks between mobile and stable sitting using a novel therapy chair in people after stroke and healthy controls. Design: Observational pilot study. Setting: This study was conducted in a rehabilitation center for people after stroke and at the university's movement laboratory for healthy participants. Participants: A total of eleven people after stroke and fifteen healthy people (N=26) took part. Interventions: Lateral reaching exercises to the ipsilateral and contralateral sides were performed on a mobile and a stable seat. Main Outcome Measure: Muscular activity of the multifidus, erector spinae and external oblique was measured bilaterally. A within-subject linear mixed model was applied to analyze the effects of seat condition, task, muscle side, and group. Results: A seat condition effect was found for the multifidus and external oblique that was dependent on the muscle side and task. During ipsilateral reaching, the activity of the multifidi decreased for people after stroke on the mobile seat, while increasing for healthy participants. The erector spinae showed no condition effect. Decreased activity of the external oblique was found for both groups on the mobile seat. Conclusions: Mobile sitting influences muscular activity. However, these preliminary results should be further investigated in order to generate recommendations for rehabilitation.

Background: In 2019, the World Health Organization released guidelines reflecting major changes in multidrug-resistant tuberculosis (MDR-TB) management—prioritizing fluoroquinolones, bedaquiline, and linezolid (LZD) while de-emphasizing previously favored injectable agents. In some cases, linezolid use is associated with gastrointestinal intolerance, mitochondrial toxicity, and significant drug interactions. CDC’s Division of Tuberculosis Elimination supports a network of regional TB Centers of Excellence, which provide medical consultation to healthcare providers. Consultations are documented in a medical consultation database (MCD) enabling evaluation of management questions and recommendations. We describe the scope of clinical inquiries and responses specific to linezolid use for MDR-TB in the US. Research Question: What are the major themes of provider and patient challenges regarding the use of linezolid for the treatment of MDR-TB in the US? Methods: We queried MCD consults categorized as “MDR/XDR-TB” from 1/1/2013 to 12/31/2018. Only linezolid-specific consultations were included; incomplete and duplicate entries were excluded as were those citing linezolid historically or theoretically. Subgroup characteristics were assessed (e.g., Center, year, provider type). A descriptive coding scheme was developed through inductive thematic analysis. Results: In 2013–2018 of the 1889 consults regarding MDR/XDR-TB, 934 MDR-TB consults referenced linezolid; 137 met inclusion criteria, representing between 4 and 10% of MDR-TB consults annually. Four main themes emerged: adverse effects (71.5%); concerns about linezolid use due to co-morbidities or concurrent medication use (15.3%); dosing adjustments (8.8%); and monitoring and maintenance logistics (4.4%). Interpretations: Linezolid consults consistently exceeded 4% of all consults annually over the 6-year period, suggesting a need for access to expert opinion for providers using linezolid to manage MDR-TB. While only a snapshot of MDR-TB in the US, this evaluation summarizes major provider concerns regarding particular adverse effects, and highlights a need for evidence-based guidance regarding linezolid dosing and toxicity management.

PurposeThe COVID-19 lockdown interrupted normal daily activities, which may have led to an increase in sedentary behavior (Castelnuovo et al., 2020). The aim of this study was to investigate the effect of the COVID-19 pandemic on the level of physical activity among Swiss office workers.MethodsOffice workers from two Swiss organizations, aged 18–65 years, were included. Baseline data from January 2020 before the COVID-19 pandemic became effective in Switzerland were compared with follow-up data during the lockdown phase in April 2020. Levels of physical activity were assessed using the International Physical Activity Questionnaire. Paired sample t-tests or Wilcoxon signed-rank test were performed for statistical analysis.ResultsData from 76 participants were analyzed. Fifty-four participants were female (71.1%). The mean age was 42.7 years (range from 21.8 to 62.7) at baseline. About 75% of the participants met the recommendations on minimal physical activity, both before the COVID-19 pandemic and during the lockdown. Weak statistical evidence for a decline in total physical activity in metabolic equivalent of task minutes per week (MET min/week) was found (estimate = −292, 95% CI from – ∞ to 74, p-value = 0.09), with no evidence for a decrease in the three types of activity: walking (estimate = −189, 95% CI from – ∞ to 100, p-value = 0.28), moderate-intensity activity (estimate = −200, 95% CI from – ∞ to 30, p-value = 0.22) and vigorous-intensity activity (estimate = 80, 95% CI from – ∞ to 460, p-value = 0.74). Across the three categories “high,” “moderate,” and “low” physical activity, 17% of the participants became less active during the lockdown while 29% became more active.ConclusionThe COVID-19 pandemic did not result in a reduction in total physical activity levels among a sample of Swiss office workers during the first weeks of lockdown. Improved work-life balance and working times may have contributed to this finding.Clinical Trial Registrationwww.ClinicalTrials.gov, NCT04169646. Registered 15 November 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04169646.

Setting: Delays in diagnosing Tuberculosis (TB) are associated with increased transmission. TB may present as a clinical syndrome that mimics community-acquired pneumonia (CAP). Objective: To determine frequency of TB among patients with CAP at a referral hospital in Gaborone, Botswana. Design: We performed a retrospective study of adults presenting with CAP from April 2010- October 2011 to the Emergency Department (ED); we matched this cohort to the National Botswana Tuberculosis Registry (NBTR) to identify individuals subsequently diagnosed with TB. We assessed demographics, time to TB diagnosis, clinical outcomes and performed logistic regressions to identify factors associated with TB diagnosis. Results: We identified 1,305 individuals presenting with CAP; TB was subsequently diagnosed in 68 (5.2%). The median time to TB diagnosis was 9.5 days. Forty percent were AFB sputum smear positive. The HIV positive rate was 87%. Conclusion: Subsequent diagnosis of TB is common among individuals with CAP at our ED, suggesting that TB may be present at the time of CAP presentation. Given the lack of distinguishing clinical factors between pulmonary TB and CAP, adults presenting with CAP should be evaluated for active TB in Botswana.

According to established guidelines from high-income countries, computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana, meningitis in HIV-infected patients is common but CT is not widely available. Objective: Develop a rational, evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence. Methods: Emergency center (EC) staff at Princess Marina Hospital in Gaborone, Botswana, reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses, and to specialists in other hospital departments for review and comment before finalization. Result: Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT, in contradiction to established guidelines. Discussion: The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources.

Introduction: Sepsis is a common cause of morbidity and mortality in populations with a high prevalence of HIV, but the full package of early goal directed therapy (EGDT) for sepsis is not feasible in most low and middle-income countries. The objective was to develop emergency adult sepsis care guidelines for Botswana appropriate to available resources and local epidemiology in referral hospitals and in lower levels of care. Methods: The individual components of guidelines from the Surviving Sepsis Campaign were compared with available resources for their applicability in a tertiary referral hospital in Botswana. Antibiotics were chosen based on the hospital antibiogram, national antibiotic guidelines, and the cost and availability of antibiotics. The preliminary algorithm was presented to emergency centre medical officers in a referral hospital for feasibility and acceptability of implementation. The referral hospital guideline was further modified as part of a National Guidelines Project for suitability to all levels of care. Results: An acceptable and feasible sepsis algorithm was developed and implemented in a referral hospital in Botswana in accordance with the established hospital process. In turn, it served as the basis for the development of a national guideline. Discussion: The principles of EGDT are adaptable to Botswana, and are likely to be adaptable to a variety of low- and middle-income countries on the basis of local resources and epidemiology. Further research is needed to study adherence and outcome related to the modified guidelines.