A systematic review of rapid diagnostic tests for the detection of tuberculosis infection

Current advancements in nanoparticles for vaccines and drug delivery for the treatment of tuberculosis

Since the early centuries until the present, tuberculosis has been a global illness with no cure. However, the sickness remains dormant in the afflicted individuals in certain circumstances. Due to the thick lipid mycobacterial wall and the challenging medication delivery into the bacterial cell, treatment is complex at this point. Over the past utics., there has been a growth in the function of nanomaterials in tuberculosis (TB) management, especially in the domains of early diagnosis, vaccine, and therapy. It has been demonstrated that nanomaterials are effective in quickly and accurately identifying tuberculosis germs. Additionally, novel nanocarriers have shown great promise for improved medication delivery and immunization, possibly increasing drug concentrations in target organs while lowering the frequency of treatments. Furthermore, the engineering of antigen carriers is a promising area of tuberculosis research that may lead to the successful creation of a novel class of potent TB vaccines. This article addresses tuberculosis infection diagnosis, pathophysiology, immunology, and advanced nanoparticles to deliver TB vaccines and anti-TB drugs. The challenges and prospects for the future in creating secure and functional nanoparticles for tuberculosis treatment and diagnosis for the good health and well-being of the patient are also discussed.

Characteristics of women on opioid substitution therapy in primary healthcare in Tshwane (South Africa): a retrospective observational study

BACKGROUND

Women who use drugs face specific challenges compared with men such as higher rates of HIV infection, unsafe injecting practices, and intimate partner violence (IPV). However, this population's access to drug dependence treatment and gender-sensitive interventions remains limited, leading to unmet needs and increased vulnerability.

AIM

To investigate the characteristics of and associations with retention in care among women on opioid substitution therapy (OST) in a community-based primary care setting.

DESIGN & SETTING

A descriptive observational study within the Community Orientated Substance Use Programme in Tshwane, South Africa.

METHOD

Data from 199 women (aged >18 years) on OST was extracted from an electronic database and paper-based files. Data were analysed descriptively, and inferential analysis looked for association of variables with retention on OST for ≥6 months.

RESULTS

The majority of participants were unemployed, with 44.3% aged 20-29 years. During the initiation and course of OST, 39.2% of women had an intimate partner of which 37.2% reported IPV, and 19.2% were pregnant. Retention on OST was significantly associated with increasing age at initiation (P = 0.047), knowledge of HIV status (P = 0.029), an increase in the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) score (P = 0.023), and methadone dose (P<0.001). Factors such as race, employment status, health-system level, pregnancy, intimate partner using substances, IPV, route of administering opioids, and having tuberculosis and/or hepatitis C exposure did not show a significant relationship with retention on OST (P>0.05).

CONCLUSION

This study reveals specific vulnerabilities in women receiving OST, emphasising the need for the integration of interventions to address reproductive health, violence mitigation, infectious disease, and polydrug use into care.

Porous Silicon on Paper: A Platform for Quantitative Rapid Diagnostic Tests

Porous silicon (PSi) thin films on silicon substrates have been extensively investigated in the context of biosensing applications, particularly for achieving label-free optical detection of a wide range of analytes. However, mass transport challenges have made it difficult for these biosensors to achieve rapid response times and low detection limits. In this work, we introduce an approach for improving the efficiency of molecule transport in PSi by using open-ended PSi membranes atop paper substrates in a flow-through sensor scheme. The paper substrate provides structural support as well as an efficient means of draining solutions from the PSi membrane without the use of an external pump and microfluidic channels. Distinct changes in the reflectance properties of the PSi membrane are measured when molecules are captured in the membrane. A concentration-dependent response of the sensor for protein detection is demonstrated. Factors influencing the interaction time of molecules in the PSi membrane and the drying time of the membrane, which directly affect the detection sensitivity and overall testing time, are discussed. The demonstrated performance of the PSi-on-paper sensor establishes the feasibility of a platform for low-cost rapid diagnostic tests with a highly sensitive, quantitative readout.

New diagnostic techniques for diagnosing facture-related infections

The diagnosis of fracture-related infections (FRI) is challenging and requires interdisciplinary efforts. Many diagnostic approaches are based on the algorithms established for prosthetic joint infections (PJI). Data specific to FRI are limited. Microbiological diagnostics include tissue culture, sonication, and molecular methods. Novel metagenomic analyses are increasingly being used in clinical diagnostic practice. In addition to bacterial detection, the study of host tissue factors has the potential to transform the diagnostics of FRI by facilitating the assesment of clinical significance in clinical samples. The integration of host tissue analysis into microbiology reports has great potential to improve the diagnosis of FRI. This mini-review describes the potential improvement of diagnostic techniques by integrating new approaches into the diagnostic algorithm of fracture-related infections.

Impact of dual sensory impairment on the risk of incident dementia: a protocol for a systematic review and meta-analysis

INTRODUCTION

Strong evidence supports the importance of potentially modifiable risk factors for dementia, with sensory loss, particularly visual and hearing impairment, being prominent among them. While single sensory impairment has been widely investigated, the influence of concomitant visual and hearing impairment is still not clear. Thus, in this systematic review, we aim to evaluate the risk of developing all-cause dementia due to dual sensory (visual and hearing) impairment and to comprehensively explore possible sources of heterogeneity.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 statement and has been registered on the PROSPERO international prospective register of systematic reviews. Our literature search will include two databases: MEDLINE-PubMed and Embase. The search strategy will consist of terms tailored for each database. We will include peer-reviewed longitudinal cohort studies reporting HRs. Screening and selection of articles will be performed independently by at least two reviewers using the Covidence systematic review manager. Discrepancies will be resolved by consensus. Data will be collected on study design, location, study setting, follow-up years, baseline demographics, sensory impairment and dementia diagnosis ascertainment, and number of adjusted covariates. The quality of the included studies will be evaluated using the Newcastle-Ottawa Scale for cohort studies. If meta-analysis is possible, we will perform DerSimonian-Laird random-effects models of HRs using the most adjusted model from each study. Subgroup analyses and meta-regressions are planned as a function of study setting, geographical location, sensory impairment and dementia diagnosis ascertainment, follow-up years and number of adjusted covariates.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study involves data already published by other authors. Our findings will be disseminated by a peer-reviewed publication and presentations at relevant scientific conferences. The results will support the understanding of dementia's modifiable risk factors and may motivate the development of screening interventions to prevent dementia.

PROSPERO REGISTRATION NUMBER

CRD42023493401.

Decoding the hidden realm: Molecular pioneering unravelling osteoarticular tuberculosis diagnosis

Osteoarticular tuberculosis (TB), a form of extrapulmonary tuberculosis, refers to the involvement of Mycobacterium tuberculosis (M.tb) in the bones and joints. While pulmonary tuberculosis is the most common form, osteoarticular TB represents a relatively rare but significant manifestation, accounting for approximately 1-3% of all TB cases. Accurate and timely diagnosis plays a pivotal role in the management of osteoarticular TB. Conventional diagnostic methods for osteoarticular TB, such as acid-fast bacilli smear microscopy and culture, have limitations in terms of sensitivity, specificity, and turnaround time. The purpose of this review is to comprehensively evaluate and synthesize the existing literature on molecular pioneering in osteoarticular TB diagnosis. Molecular techniques, such as nucleic acid amplification tests and gene-based assays, have emerged as promising tools for diagnosing TB. These techniques target specific genetic sequences of M.tb, enabling rapid and sensitive detection of the pathogen. However, the diagnostic accuracy, advantages, and limitations of these molecular techniques in the context of osteoarticular TB diagnosis require further investigation and consolidation of evidence. Furthermore, this review aims to identify areas for future research and development in the field of molecular diagnostics for osteoarticular TB.

Cost-Effectiveness of Community-Based Active Case Finding Strategy for Tuberculosis: Evidence From Shenzhen, China

BACKGROUND

Active case finding (ACF) is a potentially promising approach for the early identification and treatment of tuberculosis patients. However, evidence on its cost-effectiveness, particularly in low- and middle-income countries, remains limited. This study evaluates the cost-effectiveness of a community-based ACF practice in Shenzhen, China.

METHODS

We employed a Markov model-based decision analytic method to assess the costs and effectiveness of 3 tuberculosis detection strategies: passive case finding (PCF), basic ACF, and advanced ACF. The analysis was conducted from a societal perspective on a dynamic cohort over a 20-year horizon, focusing on active tuberculosis (ATB) prevalence and the incremental cost-effectiveness ratio (ICER).

RESULTS

Compared to the PCF strategy, the basic and advanced ACF strategies effectively reduced ATB cases by 6.8 and 10.2 per 100 000 population, respectively, by the final year of this 20-year period. The ICER for the basic and advanced ACF strategies were ¥14 757 and ¥8217 per quality-adjusted life-year, respectively. Both values fell below the cost-effectiveness threshold.

CONCLUSIONS

Our findings indicate that the community-based ACF screening strategy, which targets individuals exhibiting tuberculosis symptoms, is cost-effective. This underscores the potential benefits of adopting similar community-based ACF strategies for symptomatic populations in tuberculosis-endemic areas.

Orbital tuberculosis: a case report and update on the role of imaging in treatment

Orbital tuberculosis is a manifestation of extra-pulmonary tuberculosis that is challenging to diagnose and treat. Here, we describe the pivotal role of serial imaging in the diagnosis and treatment of orbital tuberculosis. A 28-year-old male presented with recurrent right upper eyelid swelling and a supraduction deficit associated with a firm painless orbital mass, seen on initial computed tomography to be an extensive superomedial lesion producing mass effect. Biopsy revealed a tuberculosis-like granulomatous inflammation, which, coupled with a positive QuantiFERON gold test, led to empiric anti-tuberculin treatment. Serial radiologic imaging following initiation of treatment showed progressive reduction in mass size, supporting the diagnosis and determining the length of treatment. This rare case demonstrates the utility of serial radiologic exams in the diagnosis and treatment of orbital tuberculosis.

Cost-effectiveness analysis of two interventions to promote physical activity in a multiethnic population at high risk of diabetes: an economic evaluation of the 48-month PROPELS randomized controlled trial

INTRODUCTION

Physical activity (PA) is protective against type 2 diabetes (T2D). However, data on pragmatic long-term interventions to reduce the risk of developing T2D via increased PA are lacking. This study investigated the cost-effectiveness of a pragmatic PA intervention in a multiethnic population at high risk of T2D.

MATERIALS AND METHODS

We adapted the School for Public Health Research diabetes prevention model, using the PROPELS trial data and analyses of the NAVIGATOR trial. Lifetime costs, lifetime quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each intervention (Walking Away (WA) and Walking Away Plus (WA+)) versus usual care and compared with National Institute for Health and Care Excellence's willingness-to-pay of £20 000-£30 000 per QALY gained. We conducted scenario analyses on the outcomes of the PROPELS trial data and a threshold analysis to determine the change in step count that would be needed for the interventions to be cost-effective.

RESULTS

Estimated lifetime costs for usual care, WA, and WA+ were £22 598, £23 018, and £22 945, respectively. Estimated QALYs were 9.323, 9.312, and 9.330, respectively. WA+ was estimated to be more effective and cheaper than WA. WA+ had an ICER of £49 273 per QALY gained versus usual care. In none of our scenario analyses did either WA or WA+ have an ICER below £20 000 per QALY gained. Our threshold analysis suggested that a PA intervention costing the same as WA+ would have an ICER below £20 000/QALY if it were to achieve an increase in step count of 500 steps per day which was 100% maintained at 4 years.

CONCLUSIONS

We found that neither WA nor WA+ was cost-effective at a limit of £20 000 per QALY gained. Our threshold analysis showed that interventions to increase step count can be cost-effective at this limit if they achieve greater long-term maintenance of effect.

TRIAL REGISTRATION NUMBER

ISRCTN registration: ISRCTN83465245: The PRomotion Of Physical activity through structuredEducation with differing Levels of ongoing Support for those with pre-diabetes (PROPELS)https://doi.org/10.1186/ISRCTN83465245.

Detection of tuberculosis-associated compounds from human skin by GCxGC-TOFMS

Tuberculosis (TB) remains a global health concern. This study aimed to investigate the potential of human skin volatile organic compounds (VOCs) as prospective biomarkers for TB diagnosis. It employed a non-invasive approach using a wearable silicone rubber band for VOC sampling, comprehensive gas chromatography - time of flight mass spectrometry (GCxGC-TOFMS), and chemometric techniques. Both targeted and untargeted biochemical screening was utilized to explore biochemical differences between healthy individuals and those with TB infection. Results confirmed a correlation between compounds found in this study, and those reported for TB from other biofluids. In a comparison to known TB-associated compounds from other biofluids our analysis established the presence of 27 of these compounds emanating from human skin. Additionally, 16 previously unreported compounds were found as potential biomarkers. The diagnostic ability of the VOCs selected by statistical methods was investigated using predictive modelling techniques. Artificial neural network multi-layered perceptron (ANN) yielded two compounds, 1H-indene, 2,3 dihydro-1,1,3-trimethyl-3-phenyl; and heptane-3-ethyl-2-methyl, as the most discriminatory, and could differentiate between TB-positive (n = 15) and TB-negative (n = 23) individuals with an area under the receiver operating characteristic curve (AUROC) of 92 %, a sensitivity of 100 % and a specificity of 94 % for six targeted features. For untargeted analysis, ANN assigned 3-methylhexane as the most discriminatory between TB-positive and TB- negative individuals. An AUROC of 98.5 %, a sensitivity of 83 %, and a specificity of 88 % were obtained for 16 untargeted features as chosen by high performance variable selection. The obtained values compare highly favourable to alternative diagnostic methods such as breath analysis and GeneXpert. Consequently, human skin VOCs hold considerable potential as a TB diagnostic screening test.

Accuracy of Xpert® MTB/RIF in diagnosing extrapulmonary tuberculosis in Indian children

Background Diagnosing extrapulmonary tuberculosis (EPTB) can be challenging because of a variety of presentations. We assessed the accuracy of the Xpert MTB/RIF assay in diagnosing EPTB in children. Methods Of the 255 children diagnosed to have tuberculosis (TB) who underwent testing by the Xpert MTB/ RIF assay at the TB clinic from December 2014 to April 2017, 182 had EPTB and were included in the study. The diagnostic accuracy, specificity and sensitivity of the Xpert assay were calculated with Mycobacterium growth indicator tube (MGIT) as a reference standard. Results Lymph node TB was present in 58 (32%) children, 37 (20%) had neurological TB, 36 (20%) had bone TB, 31 (17%) had pleural TB, 15 (8%) had abdominal TB, 2 (1%) had abscess, 2 (1%) had congenital TB and disseminated TB was seen in 1 (0.4%) child. Xpert MTB/RIF assay was positive in 84 (46.2%) patients. The sensitivity and specificity of the Xpert MTB/RIF assay were 72% and 72.04%, respectively. Compared to MGIT, a kappa coefficient of 0.44 shows moderate agreement between the Xpert assay and MGIT. The sensitivity of Xpert MTB/RIF assay in abdominal TB, bone TB, lymph node TB, neurological TB and pleural TB was 50% (15%-85%), 72.7% (15.9%- 86.9%), 80.8% (62.1%-91.5%), 75% (50.5%-90%) and 25% (4.6%-70%), respectively. The specificity of abdominal TB, bone TB, lymph node TB, neurological TB and pleural TB was 83.3% (43.7%-97%), 69.2% (42.4%- 87.3%), 55.2% (37.6%-71.6%), 85% (64%-94.8%) and 82.6% (62.9%-93%), respectively. Forty-seven (26%) patients had drug-resistant TB (DR-TB), of which 15 (8%) were rifampicin-resistant (RR), 2 (1%) were polyresistant, 14 (8%) had multi-DR (MDR), 15 (8%) had pre-extremely DR (XDR) and 1 (1%) had XDR-TB. Of the 15 patients with MDR-TB, Xpert MTB/RIF assay detected only 10 (71%) as RR (p=0.06). Of the 15 pre-XDR cases, Xpert MTB/RIF detected only 8 (53%) as RR (p=0.02). Conclusion Xpert MTB/RIF assay is useful in the diagnosis of EPTB. It shows good concordance with MGIT. However, it may be negative in patients with DR-TB.

Evaluation of pulmonary abnormalities in recipients of hematopoietic cell transplants and cellular therapies

Hematopoietic cell transplant (HCT) and chimeric antigen receptor T-cell (CAR-T) therapy recipients are susceptible to multiple pulmonary complications that are caused by infectious and noninfectious processes. Numerous variables can be associated with specific pulmonary diseases including time from transplantation, presence of graft versus host disease (GVHD), underlying disease, and prolonged neutropenia and lymphocytopenia. Most pulmonary complications are infectious in origin, with bacterial pneumonia remaining the most common pulmonary infection, particularly before neutrophil engraftment. Invasive fungal infections continue to affect this patient population even when antifungal prophylaxis is used. Noninfectious pulmonary complications include a wide differential of pathologies in this population, and as clinical presentations of these various pulmonary disorders often overlap, clinicians frequently will use a multidisciplinary approach in diagnosing these abnormalities. Radiography, particularly with chest computed tomography (CT) imaging, is an essential tool in identifying pulmonary pathology and potential sources. While standard microbiological cultures of respiratory specimens are still utilized, their role is limited by low sensitivity and diagnostic yield. The likelihood of obtaining a diagnosis can be improved by using other microbiological assays, including fungal antigen tests and molecular diagnostic methods, particularly if specimens are collected via bronchoscopy. This review will highlight the more common causes of pulmonary diseases encountered after HCT and CAR-T and will examine the different methods in their diagnosis.

The Use of Xpert MTB/RIF Ultra Testing for Early Diagnosis of Tuberculosis: A Retrospective Study from a Single-Center Database

Tuberculosis (TB) is a multisystemic contagious disease produced by Mycobacterium tuberculosis complex bacteria (MTBC), with a prevalence of 65:100,000 inhabitants in Romania (six times higher than the European average). The diagnosis usually relies on the detection of MTBC in culture. Although this is a sensitive method of detection and remains the "gold standard", the results are obtained after several weeks. Nucleic acid amplification tests (NAATs), being a quick and sensitive method, represent progress in the diagnosis of TB. The aim of this study is to assess the assumption that NAAT using Xpert MTB/RIF is an efficient method of TB diagnosis and has the capacity to reduce false-positive results. Pathological samples from 862 patients with TB suspicion were tested using microscopic examination, molecular testing and bacterial culture. The results show that the Xpert MTB/RIF Ultra test has a sensitivity of 95% and a specificity of 96.4% compared with 54.8% sensitivity and 99.5% specificity for Ziehl-Neelsen stain microscopy, and an average of 30 days gained in the diagnosis of TB compared with bacterial culture. The implementation of molecular testing in TB laboratories leads to an important increase in early diagnostics of the disease and the prompter isolation and treatment of infected patients.

Protocol for a qualitative study exploring the lived experience of hearing loss and patient reported experience in the UK: the HeLP study

INTRODUCTION

Worldwide, hearing loss is a significant public health issue and one of the most common chronic health conditions experienced by older adults. Hearing loss is associated with communication difficulties, social withdrawal, isolation and lower quality of life. Although hearing aid technology has improved significantly, the workload of managing hearing aids has increased. The aim of this qualitative study is to develop a novel theory of people's lived experience of hearing loss across the lifespan.

METHODS

Eligible participants will be young people and adults aged 16 years and above who have a hearing loss and carers/family members of people with a hearing loss. This study will use individual, in-depth face-to-face or online interviews. With participants' permission, interviews will be audio-recorded and transcribed verbatim. A grounded theory approach to concurrent data gathering and analysis will develop grouped codes and categories and link these to provide a novel theory to describe the experience of hearing loss.

ETHICS AND DISSEMINATION

The study was approved by the West of Scotland Research Ethics Service (approval date: 6 May 2022 ref: 22/WS/0057) and the Health Research Authority and Health and Care Research Wales Approval (approval date: 14 June 2022; IRAS project ID: 308816). The research will inform the development of a Patient Reported Experience Measure to improve the information and support given to patients. Findings will be disseminated through peer-reviewed articles and at academic conferences, as well as to our patient and public involvement groups, healthcare professionals, audiology services and local commissioners.

The Collaborative Ocular Tuberculosis Study (COTS) calculator-a consensus-based decision tool for initiating antitubercular therapy in ocular tuberculosis

OBJECTIVE

To introduce the Collaborative Ocular Tuberculosis Study (COTS) Calculator, an online clinical scoring system for initiating antitubercular therapy (ATT) in patients with ocular tuberculosis (TB).

METHOD

The COTS Calculator was derived from COTS Consensus (COTS CON) data, which has previously published consensus guidelines. Using a two-step Delphi method, 81 experts evaluated 486 clinical scenario-based questions, ranking their likelihood of initiating ATT in each specific scenario. Each scenario was a permutation of the results and/or availability of five following components-clinical phenotype, endemicity, two immunological (tuberculin skin test, interferon-γ release assay) and one radiological (chest X-Ray) test results-and a sixth component further stratifying three of the clinical phenotypes. The median scores and interquartile ranges (IQR) of each scenario were tabulated, representing the expert consensus on whether to initiate ATT in that scenario. The consensus table was encoded to develop the COTS Calculator.

RESULTS

The COTS Calculator can be accessed online at: https://www.oculartb.net/cots-calc . The attending physician can select the conditions present in the patient, which will generate a median score from 1 to 5. 114 out of 486 scenarios (24%) deliberated had a median score of 5 indicating expert consensus to initiate ATT.

CONCLUSION

The COTS Calculator is an efficient, low-cost, evidence and experience-based clinical tool to guide ATT initiation. While it holds substantial promise in improving standard-of-care for ocular-TB patients, future validation studies can help to as certain its clinical utility and reliability.

Comparative analysis of cartridge-based nucleic acid amplification test (CBNAAT) with conventional methods in the diagnosis of pediatric tuberculosis at a tertiary care center

BACKGROUND

Tuberculosis is an important cause of morbidity and mortality among children. Early diagnosis and treatment in children are challenging, more so in resource-limited, tuberculosis-endemic countries. In 2017, the WHO endorsed the use of CBNAAT for tuberculosis diagnosis. We have undertaken this study to evaluate the diagnostic value of CBNAAT in pediatric tuberculosis in comparison to other methods like microscopic detection of acid-fast bacilli and detection of mycobacteria-by-mycobacteria growth indicator tube (MGIT).

MATERIAL AND METHODS

This hospital-based, cross-sectional, observational prospective study was conducted in the department of pediatrics, at a tertiary care center. A detailed history, general physical examination, and relevant physical examination were performed systematically and the findings were noted in the proforma. All necessary basic investigations like CBC, ESR, X-Ray, etc., and advanced investigations like MRI, CT, and FNAC were done as per the requirement of the subjects and the results were mentioned in the study proforma. Sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy were calculated for various methods. A comparison between the two methods was done using the Mc Nemar test. p-value ≤0.05 was taken as statistically significant. All statistical analyses were done using Epi info version 7.2.1.0 statistical software.

RESULTS

Among 102 children suspected to be suffering from tuberculosis, the maximum number of TB cases were found in the age group of 11-16 years (43.2%), there were 58.2% of females, 58.8% belonged to the rural population, fever (78.4%) was the most common presenting symptom and 35.3% had a history of contact. In the present study, CBNAAT and ZN staining had equal sensitivity (60.8%) and specificity (100%) while the yield for MGIT culture was quite low (sensitivity 37.3%, specificity 100%).

CONCLUSIONS

CBNAAT as a test was found to be useful, especially for early diagnosis and detection of rifampicin resistance in pediatric tuberculosis against MGIT culture. Since MGIT results become available only after 42 days and have a relatively lower yield so they can be utilized only in a selected clinical situation or in patients with high suspicion of tuberculosis where another test is not able to detect the organisms.

Effectiveness of social prescribing for chronic disease prevention in adults: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Social prescribing (SP) enables healthcare professionals to link patients with non-medical interventions available in the community to address underlying socioeconomic and behavioural determinants. We synthesised the evidence to understand the effectiveness of SP for chronic disease prevention.

METHODS

A systematic literature search was conducted using five databases and two registries. Eligible studies included randomised controlled trials of SP among community-dwelling adults recruited from primary care or community setting, investigating any chronic disease risk factors defined by the WHO (behavioural factors: smoking, physical inactivity, unhealthy diet and excessive alcohol consumption; metabolic factors: raised blood pressure, overweight/obesity, hyperlipidaemia and hyperglycaemia). Random effect meta-analyses were performed at two time points: completion of intervention and follow-up after trial.

RESULTS

We identified nine reports from eight trials totalling 4621 participants. All studies evaluated SP exercise interventions which were highly heterogeneous regarding the content, duration, frequency and length of follow-up. Majority of studies had some concerns for risk of bias. Meta-analysis revealed that SP likely increased physical activity (completion: mean difference (MD) 21 min/week, 95% CI 3 to 39, I²=0%; follow-up ≤12 months: MD 19 min/week, 95% CI 8 to 29, I²=0%). However, SP may not improve markers of adiposity, blood pressure, glucose and serum lipid. There were no eligible studies that primarily target unhealthy diet, smoking and excessive alcohol drinking behaviours.

CONCLUSIONS

SP exercise interventions probably increased physical activity slightly; however, no benefits were observed for metabolic factors. Determining whether SP is effective in modifying the determinants of chronic diseases and promotes sustainable healthy behaviours is limited by the current evidence of quantification and uncertainty, warranting further rigorous studies.

PROSPERO REGISTRATION NUMBER

CRD42022346687.

Communication of anticancer drug benefits and related uncertainties to patients and clinicians: document analysis of regulated information on prescription drugs in Europe

OBJECTIVE

To evaluate the frequency with which relevant and accurate information about the benefits and related uncertainties of anticancer drugs are communicated to patients and clinicians in regulated information sources in Europe.

DESIGN

Document content analysis.

SETTING

European Medicines Agency.

PARTICIPANTS

Anticancer drugs granted a first marketing authorisation by the European Medicines Agency, 2017-19.

MAIN OUTCOME MEASURES

Whether written information on a product addressed patients' commonly asked questions about: who and what the drug is used for; how the drug was studied; types of drug benefit expected; and the extent of weak, uncertain, or missing evidence for drug benefits. Information on drug benefits in written sources for clinicians (summaries of product characteristics), patients (patient information leaflets), and the public (public summaries) was compared with information reported in regulatory assessment documents (European public assessment reports).

RESULTS

29 anticancer drugs that received a first marketing authorisation for 32 separate cancer indications in 2017-19 were included. General information about the drug (including information on approved indications and how the drug works) was frequently reported across regulated information sources aimed at both clinicians and patients. Nearly all summaries of product characteristics communicated full information to clinicians about the number and design of the main studies, the control arm (if any), study sample size, and primary measures of drug benefit. None of the patient information leaflets communicated information to patients about how drugs were studied. 31 (97%) summaries of product characteristics and 25 (78%) public summaries contained information about drug benefits that was accurate and consistent with information in regulatory assessment documents. The presence or absence of evidence that a drug extended survival was reported in 23 (72%) summaries of product characteristics and four (13%) public summaries. None of the patient information leaflets communicated information about the drug benefits that patients might expect based on study findings. Scientific concerns about the reliability of evidence on drug benefits, which were raised by European regulatory assessors for almost all drugs in the study sample, were rarely communicated to clinicians, patients, or the public.

CONCLUSIONS

The findings of this study highlight the need to improve the communication of the benefits and related uncertainties of anticancer drugs in regulated information sources in Europe to support evidence informed decision making by patients and their clinicians.

Advances in TB testing

Globally, tuberculosis (TB) was the leading cause of death from a single infectious agent until the coronavirus (COVID-19) pandemic. In 2020, an estimated 10 million people fell ill with TB and a total of 1.5 million people died from the disease. About one-quarter of the global population, almost two billion people, is estimated to be latently infected with Mycobacterium tuberculosis (MTB). Although latent TB infection (LTBI) is asymptomatic and noncontagious, about 5-10% of LTBI patients have a lifetime risk of progression to active TB. The diagnosis and treatment of active cases are extremely vital for TB control programs. However, achieving the End TB goal of 2035 without the ability to identify and treat the pool of latently infected individuals will be a big challenge. To do so, improved technology to provide more accurate diagnostic tools and accessibility are crucial. Therefore, this chapter covers the current WHO-endorsed tests and advances in diagnostic and screening tests for active and latent TB.

Manhal GA, Mahmmoud Fadelallah Eljack M, Tahir MJ. The pattern of neurological manifestations of tuberculosis among adult patients attending multineurological centres and hospitals in Sudan: A hospital-based cross-sectional study

Background

Tuberculosis (TB) can involve almost any organ of the body. In the central nervous system (CNS), it can cause Pott's disease, meningitis, tuberculoma, abscess, or other manifestations. Tuberculosis is rampant in the developing world and has become a significant public health menace with the human immunodeficiency virus (HIV) dissemination. This study aimed to determine the frequency of neurological manifestations of tuberculosis among adult Sudanese patients.

Methodology

A hospital-based cross-sectional study carried out in the period from September to December 2020 at multineurological centers and hospitals in Khartoum State, including Ibrahim Malik Teaching Hospital, Alshaab Teaching Hospital, Bashier, Abu Anga, Omdurman Teaching Hospitals, included adult patients diagnosed with tuberculosis-associated neurological manifestations. The data were collected by predesigned questionnaire, and then analyzed by computer using SPSS-version 25.

Results

A total of 43 patients were evaluated, male patients were 24 (55.8%) and female patients were 19 (44.2%). About 31 (72.1%) of the participants had extra-pulmonary TB and 12 (27.9%) had pulmonary and extrapulmonary TB. The neurological manifestations of tuberculosis include Pott's disease in 29 (67.4%) patients (with thoracic spine most affected part), tuberculoma was second-most, occurring in 8 (18.7%) patients (with a single lesion in most of the patients), whereas tuberculous meningitis was found in 6 (13.9%). Clinical presentation was headache in 14 (32.6%) patients, convulsions in 10 (23.3%), loss of consciousness in 9 (20.9%), hemiparesis in 7 (16.3%) patients, and paraparesis in 23 (53.5%). Cranial nerve affected in 5 (11.6%) patients. All patients received antituberculosis medication and steroids, and 10 (23.2%) received anticonvulsants.

Conclusions

Neurological tuberculosis should be ruled out in any young male from an endemic area who exhibits abnormalities in motor, sensory, special sense, or higher mental function. To avoid potentially fatal complications, diagnoses and treatments should be initiated as soon as possible.

B21 DNA vaccine expressing ag85b, rv2029c, and rv1738 confers a robust therapeutic effect against latent Mycobacterium tuberculosis infection

Latent tuberculosis infection (LTBI) treatment is known to accelerate the decline in TB incidence, especially in high-risk populations. Mycobacterium tuberculosis (M. tb) expression profiles differ at different growth periods, and vaccines protective and therapeutic effects may increase when they include antigenic compositions from different periods. To develop a post-exposure vaccine that targets LTBI, we constructed four therapeutic DNA vaccines (A39, B37, B31, and B21) using different combinations of antigens from the proliferation phase (Ag85A, Ag85B), PE/PPE family (Rv3425), and latent phase (Rv2029c, Rv1813c, Rv1738). We compared the immunogenicity of the four DNA vaccines in C57BL/6j mice. The B21 vaccine stimulated the strongest cellular immune responses, namely Th1/Th17 and CD8⁺ cytotoxic T lymphocyte responses. It also induced the generation of strengthened effector memory and central memory T cells. In latently infected mice, the B21 vaccine significantly reduced bacterial loads in the spleens and lungs and decreased lung pathology. In conclusion, the B21 DNA vaccine can enhance T cell responses and control the reactivation of LTBI.

Surgical implementation gap: an interrupted time series analysis with interviews examining the impact of surgical trials on surgical practice in England

Objectives

Landmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects.

Design

A sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings.

Setting

Changes in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online.

Data and participants

The six surgical trials were funded and published by England’s National Institute for Health Research’s Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area.

Results

The quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data.

Conclusion

While practice does not always change in the direction indicated by clinical trials, our results suggest that individuals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.

A comparative study of a rabbit spinal tuberculosis model constructed by local direct infection via the posterior lateral approach

The present study aims to establish a method of constructing a New Zealand rabbit spinal tuberculosis model by direct local infusion of M. tuberculosis H37Rv strain into the intervertebral disc space through the posterior lateral approach. Sixty-six New Zealand rabbits were pretreated with complete Freund's adjuvant and randomly divided into 4 group: the posterolateral approach model group (Group A, 25), ventral transverse process approach model group (Group B, 25), control group (Group C, 10), and blank group (Group D, 6). In Groups A and B, the bone holes were filled with gelatin sponge after drilling, and the local area was directly infused with 0.1 ml of M. tuberculosis H37Rv strain suspension. In Group C, the gelatin sponge was filled through the posterolateral approach and the local area was infused with 0.1 ml of normal saline suspension. In Group D, No specific treatment was performed. The general conditions of the experimental rabbits in each group were compared to those of a control group; the degree of vertebral body exposure, incision length, and complications of the two methods were compared; and the tuberculosis models were evaluated by imaging, histopathology, and bacterial culture. In Group A, the lateral side of the vertebral body was well exposed, the damage was mild, and no peritoneal rupture or gastrointestinal complications were observed. In Group B, the ventral side of the vertebral body and the intervertebral disc were exposed, and abdominal complications were more likely to occur. The survival rates of the experimental rabbits at 8 weeks after surgery were 92.0% in Group A, 88.00% in Group B, 90.0% in Group C, and 100% in Group D. MRI examinations showed that in Group A, the positive rate of radiographic bone findings was 86.9% at 4 weeks after surgery and 100% at 8 weeks after surgery; in Group B, the positive rate of radiographic bone findings was 78.2% at 4 weeks after surgery and 95.4% at 8 weeks after surgery. There was no significant difference between Groups A and B in the radiographic bone findings rate detected by the same imaging method at the same time point (P > 0.05). Eight weeks after surgery, bone destruction, paravertebral abscess, and caseous necrosis occurred in the vertebral bodies of surviving rabbits in Groups A and B. The BacT/ALERT 3D rapid culture system was used to culture the pus in the lesion, and the results showed that the positive rate of tuberculosis was 52.17% in Group A and 54.54% in Group B, and the difference was not statistically significant (P > 0.05). After pretreatment with complete Freund's adjuvant, direct infusion of the H37Rv strain of M. tuberculosis into the intervertebral disc space of New Zealand rabbits via the posterolateral approach and the ventral transverse process approach can successfully establish rabbit spinal tuberculosis models.

What factors are important to whom in what context, when adults are prescribed hearing aids for hearing loss? A realist review protocol

INTRODUCTION

Hearing aids are the gold standard treatment to help manage hearing loss. However, not everyone who needs them has them, and of those who do, a significant proportion of people do not use them at all, or use them infrequently. Despite literature reviews listing key barriers and enablers to the uptake and use of hearing aids, there is little evidence to describe how this varies by population and context. This review will describe what factors are important to whom in what context when considering the provision of hearing aids for hearing loss in adults.

METHODS AND ANALYSIS

The aims of this review are as follows: (1) To iteratively review and synthesise evidence surrounding the provision of hearing aids for hearing loss in adults. (2) To generate a theory-driven understanding of factors that are important, for whom, and in what context. (3) To develop a programme theory describing contexts that can support the provision of hearing aids to result in improved outcomes for adults with hearing loss. A scoping literature search will aid the development of programme theories, to explain how the intervention is expect to work, for whom, in what circumstances and in which contexts. We will locate evidence in the following databases: CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMED, Web of Science with no date restrictions. A realist analytic approach will be used to refute and refine these initial programme theories. Throughout the review, relevant key stakeholders (eg, patients and clinicians) will be consulted to test and refine the programme theories.

ETHICS AND DISSEMINATION

This study was approved by the University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee: (FMHS 95-0820) and the London Brent NHS Research Ethics Committee (Ref: 21/PR/0259). The review will be reported according to the RAMESES guidelines and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021282049.

Immuno-Diagnosis of Active Tuberculosis by a Combination of Cytokines/Chemokines Induced by Two Stage-Specific Mycobacterial Antigens: A Pilot Study in a Low TB Incidence Country

Active tuberculosis (aTB) remains a major killer from infectious disease, partially due to delayed diagnosis and hence treatment. Classical microbiological methods are slow and lack sensitivity, molecular techniques are costly and often unavailable. Moreover, available immuno-diagnostic tests lack sensitivity and do not differentiate between aTB and latent TB infection (LTBI). Here, we evaluated the performance of the combined measurement of different chemokines/cytokines induced by two different stage-specific mycobacterial antigens, Early-secreted-antigenic target-6 (ESAT-6) and Heparin-binding-haemagglutinin (HBHA), after a short in vitro incubation of either peripheral blood mononuclear cells (PBMC) or whole blood (WB). Blood samples were collected from a training cohort comprising 22 aTB patients, 22 LTBI subjects and 17 non-infected controls. The concentrations of 13 cytokines were measured in the supernatants. Random forest analysis identified the best markers to differentiate M. tuberculosis-infected from non-infected subjects, and the most appropriate markers to differentiate aTB from LTBI. Logistic regression defined predictive abilities of selected combinations of cytokines, first on the training and then on a validation cohort (17 aTB, 27 LTBI, 25 controls). Combining HBHA- and ESAT-6-induced IFN-γ concentrations produced by PBMC was optimal to differentiate infected from non-infected individuals in the training cohort (100% correct classification), but 2/16 (13%) patients with aTB were misclassified in the validation cohort. ESAT-6-induced-IP-10 combined with HBHA-induced-IFN-γ concentrations was selected to differentiate aTB from LTBI, and correctly classified 82%/77% of infected subjects as aTB or LTBI in the training/validation cohorts, respectively. Results obtained on WB also selected ESAT-6- and HBHA-induced IFN-γ concentrations to provided discrimination between infected and non-infected subjects (89%/90% correct classification in the training/validation cohorts). Further identification of aTB patients among infected subjects was best achieved by combining ESAT-6-induced IP-10 with HBHA-induced IL-2 and GM-CSF. Among infected subjects, 90%/93% of the aTB patients were correctly identified in the training/validation cohorts. We therefore propose a two steps strategy performed on 1 mL WB for a rapid identification of patients with aTB. After elimination of most non-infected subjects by combining ESAT-6 and HBHA-induced IFN-γ, the combination of IP-10, IL-2 and GM-CSF released by either ESAT-6 or HBHA correctly identifies most patients with aTB.

Development of DNA Aptamers to Visualize Release of Mycobacterial Membrane-Derived Extracellular Vesicles in Infected Macrophages

Extracellular vesicles (EVs) have emerged into a novel vaccine platform, a biomarker and a nano-carrier for approved drugs. Their accurate detection and visualization are central to their utility in varied biomedical fields. Owing to the limitations of fluorescent dyes and antibodies, here, we describe DNA aptamer as a promising tool for visualizing mycobacterial EVs in vitro. Employing SELEX from a large DNA aptamer library, we identified a best-performing aptamer that is highly specific and binds at nanomolar affinity to EVs derived from three diverse mycobacterial strains (pathogenic, attenuated and avirulent). Confocal microscopy revealed that this aptamer was not only bound to in vitro-enriched mycobacterial EVs but also detected EVs that were internalized by THP-1 macrophages and released by infecting mycobacteria. To the best of our knowledge, this is the first study that detects EVs released by mycobacteria during infection in host macrophages. Within 4 h, most released mycobacterial EVs spread to other parts of the host cell. We predict that this tool will soon hold huge potential in not only delineating mycobacterial EVs-driven pathogenic functions but also in harboring immense propensity to act as a non-invasive diagnostic tool against tuberculosis in general, and extra-pulmonary tuberculosis in particular.

Pleural Tuberculosis

Pleural tuberculosis (TB) is common and often follows a benign course but may result in serious long-term morbidity. Diagnosis is challenging because of the paucibacillary nature of the condition. Advances in Mycobacterium culture media and PCR-based techniques have increased the yield from mycobacteriologic tests. Surrogate biomarkers perform well in diagnostic accuracy studies but must be interpreted in the context of the pretest probability in the individual patient. Confirming the diagnosis often requires biopsy, which may be acquired through thoracoscopy or image-guided closed pleural biopsy. Treatment is standard anti-TB therapy, with optional drainage and intrapleural fibrinolytics or surgery in complicated cases.

Graphene Oxide Based Electrochemical Genosensor for Label Free Detection of Mycobacterium tuberculosis from Raw Clinical Samples

Background

Mycobacterium tuberculosis’ rapid detection is still a formidable challenge to have control over the lethal disease. New diagnostic methods such as LED fluorescence microscopy, Genexpert, Interferon Gamma Release Assay (IGRA) are limited on efficacy spectrum owing to their high cost, time-intensive and laborious nature, in addition their low sensitivity hinders their robustness and portability. Electroanalytical methods are now being considered as an excellent alternative, being currently employed for efficient detection of the analytes with the potential of being portable. This report suggests label-free electrochemical detection of Mycobacterium tuberculosis (Mtb) via its marker, insertion sequence (IS6110).

Methods

In this pursuit, graphene oxide-chitosan nanocomposite (GO-CHI), a biocompatible matrix, having a large electroactive area with an overall positively charged surface, is fabricated and characterized. The obtained GO-CHI nanocomposite is then immobilized on the ITO surface to form a positively functionalized electrochemical sensor for the detection of Mtb. DNA probe, specific for the IS6110, was electrostatically anchored on a positively charged electrode surface and the resistance of charge transfer was investigated for the sensitive and specific (complementary vs non-complementary) detection of Mtb by cyclic voltammetry and differential pulse voltammetry techniques.

Results

The cyclic voltammetry was found to be diffusion controlled facilitating the absorption of analyte on the electrode surface. The label-free “genosensor” was found to detect a hybridization efficiency with a limit of detection of 3.4 pM, and correlation coefficient R²=0.99 when analysed over a range of concentrations of DNA from 7.86 pM to 94.3pM. The genosensor was also able to detect target DNA from raw sputum samples of clinical isolates without DNA purification.

Conclusion

This electrochemical genosensor provides high sensitivity and specificity; thus offering a promising platform for clinical diagnosis of TB and other infectious diseases in general.

Facilitators of and barriers to buprenorphine initiation for people with opioid use disorder in the emergency department: protocol for a scoping review

INTRODUCTION

Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation.

METHODS AND ANALYSIS

We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation.

ETHICS AND DISSEMINATION

This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.

Is the outcome of fitting hearing aids to adults affected by whether an audiogram-based prescription formula is individually applied? A systematic review protocol

INTRODUCTION

Hearing aids are typically programmed using the individual's audiometric thresholds. Developments in technology have resulted in a new category of direct-to-consumer devices, which are not programmed using the individual's audiometric thresholds. This review aims to identify whether programming hearing aids using the individual's audiogram-based prescription results in better outcomes for adults with hearing loss.

METHODS AND ANALYSIS

The methods of this review are reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. On 23 August 2020, eight different databases were systematically searched without any restrictions: EMBASE, MEDLINE, PubMed, PsycINFO, Web of Science, Cochrane Library, Emcare and Academic Search Premier. To ensure that this review includes the most recent evidence, the searches will be repeated at the final write-up stage. The population of interest of this review will be adults with any degree or type of hearing loss. The studies should compare hearing aids programmed using an audiogram-based prescription (and verified in the real ear) with those not programmed on the basis of the individual's audiogram. The primary outcome of interest is consumers' listening preferences. Hearing-specific health-related quality of life, self-reported listening ability, speech intelligibility of words and sentences in quiet and noisy situations, sound quality ratings and adverse events are the secondary outcomes of interest. Both randomised and non-randomised controlled trials will be included. The quality of each individual study and the overall evidence will be assessed using Downs and Black's checklist and the Grading of Recommendations, Assessment, Development and Evaluations tool, respectively.

ETHICS AND DISSEMINATION

We will only retrieve and analyse data from published studies, so no ethical approval is required. The review findings will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020197232.

Tuberculosis presenting as arthritis of the ankle: A case report

Tuberculosis presenting as monoarticular involvement in immunocompetent patients is rare. Here, we report a Sri Lankan patient presenting with ankle swelling due to tuberculosis with no other extrapulmonary or pulmonary involvement. Magnetic resonance imaging showed destruction of articular cartilage of the ankle joint with chronic inflammation of the subtalar joint. The diagnosis was confirmed by synovial tissue culture which was positive for Mycobacterium tuberculosis. The patient recovered uneventfully with anti-tuberculosis treatment. Therefore, a high degree of suspicion is necessary to diagnose extrapulmonary tuberculosis when patients are presenting with atypical monoarthritis.

Deep learning-assisted (automatic) diagnosis of glaucoma using a smartphone

BACKGROUND/AIMS

To validate a deep learning algorithm to diagnose glaucoma from fundus photography obtained with a smartphone.

METHODS

A training dataset consisting of 1364 colour fundus photographs with glaucomatous indications and 1768 colour fundus photographs without glaucomatous features was obtained using an ordinary fundus camera. The testing dataset consisted of 73 eyes of 73 patients with glaucoma and 89 eyes of 89 normative subjects. In the testing dataset, fundus photographs were acquired using an ordinary fundus camera and a smartphone. A deep learning algorithm was developed to diagnose glaucoma using a training dataset. The trained neural network was evaluated by prediction result of the diagnostic of glaucoma or normal over the test datasets, using images from both an ordinary fundus camera and a smartphone. Diagnostic accuracy was assessed using the area under the receiver operating characteristic curve (AROC).

RESULTS

The AROC with a fundus camera was 98.9% and 84.2% with a smartphone. When validated only in eyes with advanced glaucoma (mean deviation value < -12 dB, N=26), the AROC with a fundus camera was 99.3% and 90.0% with a smartphone. There were significant differences between these AROC values using different cameras.

CONCLUSION

The usefulness of a deep learning algorithm to automatically screen for glaucoma from smartphone-based fundus photographs was validated. The algorithm had a considerable high diagnostic ability, particularly in eyes with advanced glaucoma.

A Longitudinal Model-Based Biomarker Analysis of Exposure Response in Adults with Pulmonary Tuberculosis

The identification of sensitive, specific, and reliable biomarkers that can be quantified in the early phases of tuberculosis treatment and predictive of long-term outcome is key for the development of an effective short-course treatment regimen. Time to positivity (TTP), a biomarker of treatment outcome against Mycobacterium tuberculosis, measures longitudinal bacterial growth in mycobacterial growth indicator tube broth culture and may be predictive of standard time to stable culture conversion (TSCC). In two randomized phase 2b trials investigating dose-ranging rifapentine (Studies 29 and 29X), 662 participants had sputum collected over 6 months where TTP, TSCC, and time to culture conversion were quantified. The goals of this post hoc study were to characterize longitudinal TTP profiles and to identify individual patient characteristics associated with delayed time to culture conversion. In order to do so, a nonlinear mixed-effects model describing longitudinal TTP was built. Independent variables associated with increased bacterial clearance (increased TTP), assessed by subject-specific and population-level trajectories, were higher rifapentine exposure, lower baseline grade of sputum acid-fast bacillus smear, absence of productive cough, and lower extent of lung infiltrates on radiographs. Importantly, sensitivity analysis revealed that major learning milestones in phase 2b trials, such as significant exposure-response and covariate relationships, could be detected using truncated TTP data as early as 6 weeks from start of treatment, suggesting alternative phase 2b study designs. The TTP model built depicts a novel phase 2b surrogate endpoint that can inform early assessment of experimental treatment efficacy and treatment failure or relapse in patients treated with shorter and novel TB treatment regimens, improving efficiency of phase 2 clinical trials. (The studies discussed in this paper have been registered at ClinicalTrials.gov under identifiers NCT00694629 and NCT01043575.)

A Review on Nuclear Imaging as a Promising Modality for Efficient Diagnosis of Tuberculosis

Tuberculosis (TB) is an infectious disease and is declared a global health issue by the World Health Organization in 1993. Due to the complex pathophysiology of Mycobacterium tuberculosis, it remains a global threat. This article reviews the conventional diagnostic modalities for tuberculosis, their limitations to detect latent TB, multiple drug-resistant TB, human immunodeficiency virus co-infected TB lesions, and TB in children. Moreover, this review illustrates the importance of nuclear medicine imaging for early, non-invasive diagnosis of TB to detect disease stages and monitor therapy response. Currently, single-photon emission computed tomography and positron emission tomography with their specific radionuclides have been extensively used for a thorough assessment of TB.

Combined structure-function analysis in glaucoma screening

AIM

To assess the applicability of a structure-function (S-F) analysis combining spectral-domain optical coherence tomography (SD-OCT) and standard automated perimetry (SAP) in glaucoma screening in a middle-aged population.

METHODS

A randomised sample of 3001 Caucasian participants aged 45-49 years of the Northern Finland Birth Cohort Eye Study was examined. We performed an eye examination, including 24-2 SAP, optic nerve head (ONH) and retinal nerve fibre layer (RNFL) photography and SD-OCT of the peripapillary RNFL. The S-F report was generated by Forum Glaucoma Workplace software. OCT, SAP and the S-F analysis were evaluated against clinical glaucoma diagnosis, that is, the positive '2 out of 3' rule based on the clinician's evaluation of ONH and RNFL photographs and visual fields (VFs).

RESULTS

At a specificity of 97.5%, the sensitivity for glaucomatous damage was 26% for abnormal OCT, 35% for SAP and 44% for S-F analysis. Estimated areas under the curve were 0.74, 0.85 and 0.76, and the corresponding positive predictive values were 8 %, 10% and 12%, respectively. By applying a classification tree approach combining OCT, SAP and defect localisation data, a sensitivity of 77% was achieved at 90% specificity. In a localisation analysis of glaucomatous structural and functional defects, the correlation with glaucoma increased significantly if the abnormal VF test points were located on borderline or abnormal OCT zones.

CONCLUSION

SAP performs slightly better than OCT in glaucoma screening of middle-aged population. However, the diagnostic capability can be improved by S-F analysis.

Treatment Dilemmas in Disseminated Nontuberculous Mycobacterial Infections With Interferon-gamma Autoantibodies

Disseminated Mycobacterium avium complex (dMAC) is typically seen in individuals with impaired cell-mediated immunity and is best described in those with HIV. Recently, cases have been described in otherwise healthy individuals with neutralizing antibodies to interferon-gamma (nIFNγ-autoAb), especially in patients of Southeast Asian descent. Treatment is often refractory to mycobacterial therapies, and the use of rituximab and other immunomodulatory agents has been explored. We report 3 cases of dMAC with nIFN-γ-autoAb and review the available literature on treatment strategies to provide a framework for the management of patients with refractory infections in the context of neutralizing antibodies to interferon-gamma.

Metabolic labeling probes for interrogation of the host-pathogen interaction

Bacterial infections are still one of the leading causes of death worldwide; despite the near-ubiquitous availability of antibiotics. With antibiotic resistance on the rise, there is an urgent need for novel classes of antibiotic drugs. One particularly troublesome class of bacteria are those that have evolved highly efficacious mechanisms for surviving inside the host. These contribute to their virulence by immune evasion, and make them harder to treat with antibiotics due to their residence inside intracellular membrane-limited compartments. This has sparked the development of new chemical reporter molecules and bioorthogonal probes that can be metabolically incorporated into bacteria to provide insights into their activity status. In this review, we provide an overview of several classes of metabolic labeling probes capable of targeting either the peptidoglycan cell wall, the mycomembrane of mycobacteria and corynebacteria, or specific bacterial proteins. In addition, we highlight several important insights that have been made using these metabolic labeling probes.

Value of Xpert MTB/RIF Using Bronchoalveolar Lavage Fluid for the Diagnosis of Pulmonary Tuberculosis: a Systematic Review and Meta-analysis

The performance of Xpert MTB/RIF using bronchoalveolar lavage fluid (BAL) for the diagnosis of pulmonary tuberculosis (PTB) remains unclear. Therefore, a systematic review/meta-analysis was conducted. Studies published before 31 December 2019 were retrieved from the PubMed, Embase, and Web of Science databases using the keywords "pulmonary tuberculosis," "Xpert MTB/RIF," and "BAL." Two independent evaluators extracted the data and assessed the bias risk of the included studies. A random-effects model was used to calculate the overall sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR, respectively), diagnostic odds ratio (DOR), and the area under the curve (AUC), as well as the respective 95% confidence intervals (CIs). Nineteen trials involving 3,019 participants met the inclusion criteria. Compared to the culture method, the pooled sensitivity, specificity, PLR, NLR, DOR, and the AUC with 95% CIs of Xpert MTB/RIF were 0.87 (0.84 to 0.90), 0.92 (0.91 to 0.93), 10.21 (5.78 to 18.02), 0.16 (0.12 to 0.22), 78.95 (38.59 to 161.53), and 0.9467 (0.9462 to 0.9472), respectively. Relative to the composite reference standard, the observed values were 0.69 (0.65 to 0.72), 0.98 (0.98 to 0.99), 37.50 (18.59 to 75.62), 0.30 (0.21 to 0.43), 171.98 (80.82 to 365.96), and 0.9691 (0.9683 to 0.9699), respectively. All subgroups, except children, showed high sensitivity and specificity. In conclusion, the use of Xpert MTB/RIF in the context of BAL samples has a high diagnostic performance for PTB (except for children) and may serve as an alternative rapid diagnostic tool.

Xpert MTB/RIF Ultra and Xpert MTB/RIF assays for extrapulmonary tuberculosis and rifampicin resistance in adults

BACKGROUND

Xpert MTB/RIF Ultra (Xpert Ultra) and Xpert MTB/RIF are World Health Organization (WHO)-recommended rapid nucleic acid amplification tests (NAATs) widely used for simultaneous detection of Mycobacterium tuberculosis complex and rifampicin resistance in sputum. To extend our previous review on extrapulmonary tuberculosis (Kohli 2018), we performed this update to inform updated WHO policy (WHO Consolidated Guidelines (Module 3) 2020).

OBJECTIVES

To estimate diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for extrapulmonary tuberculosis and rifampicin resistance in adults with presumptive extrapulmonary tuberculosis.

SEARCH METHODS

Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, 2 August 2019 and 28 January 2020 (Xpert Ultra studies), without language restriction.

SELECTION CRITERIA

Cross-sectional and cohort studies using non-respiratory specimens. Forms of extrapulmonary tuberculosis: tuberculous meningitis and pleural, lymph node, bone or joint, genitourinary, peritoneal, pericardial, disseminated tuberculosis. Reference standards were culture and a study-defined composite reference standard (tuberculosis detection); phenotypic drug susceptibility testing and line probe assays (rifampicin resistance detection).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and applicability using QUADAS-2. For tuberculosis detection, we performed separate analyses by specimen type and reference standard using the bivariate model to estimate pooled sensitivity and specificity with 95% credible intervals (CrIs). We applied a latent class meta-analysis model to three forms of extrapulmonary tuberculosis. We assessed certainty of evidence using GRADE.

MAIN RESULTS

69 studies: 67 evaluated Xpert MTB/RIF and 11 evaluated Xpert Ultra, of which nine evaluated both tests. Most studies were conducted in China, India, South Africa, and Uganda. Overall, risk of bias was low for patient selection, index test, and flow and timing domains, and low (49%) or unclear (43%) for the reference standard domain. Applicability for the patient selection domain was unclear for most studies because we were unsure of the clinical settings. Cerebrospinal fluid Xpert Ultra (6 studies) Xpert Ultra pooled sensitivity and specificity (95% CrI) against culture were 89.4% (79.1 to 95.6) (89 participants; low-certainty evidence) and 91.2% (83.2 to 95.7) (386 participants; moderate-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 168 would be Xpert Ultra-positive: of these, 79 (47%) would not have tuberculosis (false-positives) and 832 would be Xpert Ultra-negative: of these, 11 (1%) would have tuberculosis (false-negatives). Xpert MTB/RIF (30 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 71.1% (62.8 to 79.1) (571 participants; moderate-certainty evidence) and 96.9% (95.4 to 98.0) (2824 participants; high-certainty evidence). Of 1000 people where 100 have tuberculous meningitis, 99 would be Xpert MTB/RIF-positive: of these, 28 (28%) would not have tuberculosis; and 901 would be Xpert MTB/RIF-negative: of these, 29 (3%) would have tuberculosis. Pleural fluid Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity against culture were 75.0% (58.0 to 86.4) (158 participants; very low-certainty evidence) and 87.0% (63.1 to 97.9) (240 participants; very low-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 192 would be Xpert Ultra-positive: of these, 117 (61%) would not have tuberculosis; and 808 would be Xpert Ultra-negative: of these, 25 (3%) would have tuberculosis. Xpert MTB/RIF (25 studies) Xpert MTB/RIF pooled sensitivity and specificity against culture were 49.5% (39.8 to 59.9) (644 participants; low-certainty evidence) and 98.9% (97.6 to 99.7) (2421 participants; high-certainty evidence). Of 1000 people where 100 have pleural tuberculosis, 60 would be Xpert MTB/RIF-positive: of these, 10 (17%) would not have tuberculosis; and 940 would be Xpert MTB/RIF-negative: of these, 50 (5%) would have tuberculosis. Lymph node aspirate Xpert Ultra (1 study) Xpert Ultra sensitivity and specificity (95% confidence interval) against composite reference standard were 70% (51 to 85) (30 participants; very low-certainty evidence) and 100% (92 to 100) (43 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 70 would be Xpert Ultra-positive and 0 (0%) would not have tuberculosis; 930 would be Xpert Ultra-negative and 30 (3%) would have tuberculosis. Xpert MTB/RIF (4 studies) Xpert MTB/RIF pooled sensitivity and specificity against composite reference standard were 81.6% (61.9 to 93.3) (377 participants; low-certainty evidence) and 96.4% (91.3 to 98.6) (302 participants; low-certainty evidence). Of 1000 people where 100 have lymph node tuberculosis, 118 would be Xpert MTB/RIF-positive and 37 (31%) would not have tuberculosis; 882 would be Xpert MTB/RIF-negative and 19 (2%) would have tuberculosis. In lymph node aspirate, Xpert MTB/RIF pooled specificity against culture was 86.2% (78.0 to 92.3), lower than that against a composite reference standard. Using the latent class model, Xpert MTB/RIF pooled specificity was 99.5% (99.1 to 99.7), similar to that observed with a composite reference standard. Rifampicin resistance Xpert Ultra (4 studies) Xpert Ultra pooled sensitivity and specificity were 100.0% (95.1 to 100.0), (24 participants; low-certainty evidence) and 100.0% (99.0 to 100.0) (105 participants; moderate-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 100 would be Xpert Ultra-positive (resistant): of these, zero (0%) would not have rifampicin resistance; and 900 would be Xpert Ultra-negative (susceptible): of these, zero (0%) would have rifampicin resistance. Xpert MTB/RIF (19 studies) Xpert MTB/RIF pooled sensitivity and specificity were 96.5% (91.9 to 98.8) (148 participants; high-certainty evidence) and 99.1% (98.0 to 99.7) (822 participants; high-certainty evidence). Of 1000 people where 100 have rifampicin resistance, 105 would be Xpert MTB/RIF-positive (resistant): of these, 8 (8%) would not have rifampicin resistance; and 895 would be Xpert MTB/RIF-negative (susceptible): of these, 3 (0.3%) would have rifampicin resistance.

AUTHORS' CONCLUSIONS

Xpert Ultra and Xpert MTB/RIF may be helpful in diagnosing extrapulmonary tuberculosis. Sensitivity varies across different extrapulmonary specimens: while for most specimens specificity is high, the tests rarely yield a positive result for people without tuberculosis. For tuberculous meningitis, Xpert Ultra had higher sensitivity and lower specificity than Xpert MTB/RIF against culture. Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity for rifampicin resistance. Future research should acknowledge the concern associated with culture as a reference standard in paucibacillary specimens and consider ways to address this limitation.

Clinical features of adult patients with a definite diagnosis of central nervous system tuberculosis in an endemic country: A 13-year retrospective review

Rationale

Objectives

Methods

Measurements and main results

Conclusions

Management of TB/HIV co-infection: the state of the evidence

Tuberculosis (TB) and HIV are strongly linked. There is a 19 times increased risk of developing active TB in people living with HIV than in HIV-negative people with Sub-Saharan Africa being the hardest hit region. According to the WHO, 1.3 million people died from TB, and an additional 300,000 TB-related deaths among people living with HIV. Although some progress has been made in reducing TB-related deaths among people living with HIV due to the evolution of diagnostics, treatment and antiretroviral HIV treatment, multi drug resistant TB is becoming a source of worry. Though significant progress has been made at the national level, understanding the state of the evidence and the challenges will better inform the national response of the opportunities for improved patient outcomes.

FUNDING

None.

Does probe-tube verification of real-ear hearing aid amplification characteristics improve outcomes in adult hearing aid users? A protocol for a systematic review

INTRODUCTION

Using a probe-tube microphone to measure and adjust the real-ear performance of the hearing aid to match the prescription target is recommended and widely used in clinical practice. Hearing aid fitting software can approximately match the amplification characteristics of the hearing aid to the prescription without real-ear measurements (REMs), but using REM improves the match to the prescribed target. What is unclear is if the improved match results in a better patient-reported outcome. The primary objective of this review is to determine whether the use of REM improves patient-reported outcomes in adult hearing aid users.

METHODS AND ANALYSIS

The review's methods are in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science and CENTRAL via Cochrane Library will be searched to identify relevant studies. The review's population of interest will include adults with any degree of sensorineural or mixed hearing loss who have been prescribed with acoustic hearing aids. The included studies should compare REM fitting to the initial fit provided by the manufacturer's fitting software. Hearing-specific health-related quality of life is the primary outcome but secondary outcomes include self-reported listening ability, speech recognition scores, generic health-related quality of life, hours of use, number of required follow-up sessions and adverse events. Randomised and non-randomised controlled trials will be included. The risk of bias in the included studies will be evaluated using Down and Black's checklist. The quality of the overall evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations tool.

ETHICS AND DISSEMINATION

Ethical approval will not be sought because this systematic review will only retrieve and analyse data from published studies. Review results will be published in a peer-reviewed journal and presented at relevant scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020166074.

The development and use of Actiphage® to detect viable mycobacteria from bovine tuberculosis and Johne's disease-infected animals

Here, we describe the development of a method that exploits bacteriophage D29 as a lysis agent for efficient DNA extraction from low numbers of mycobacterial cells. This method (Actiphage® ) used in combination with PCR achieved rapid and sensitive (LOD ≤ 10 cell ml-1 ) detection and identification of viable, pathogenic mycobacteria in blood samples within 6 h. We demonstrate that mycobacteriophage D29 can be used to detect a range of mycobacteria from clinical blood samples including both Mycobacterium tuberculosis complex and Mycobacterium avium subsp. paratuberculosis without the need for culture and confirms our earlier observations that a low-level bacteraemia is associated with these infections in cattle. In a study of M. bovis-infected cattle (n = 41), the sensitivity of the Actiphage® method was 95 % (95 % CI; 0.84-0.99) and specificity was 100 % (95% CI; 0.92-1). We further used Actiphage® to demonstrate viable Mycobacterium avium subsp. paratuberculosis is present in the blood of Johne's infected cattle. This method provides a revolutionary new tool for the study of infections caused by these difficult to grow pathogens.

Accelerated partner therapy (APT) partner notification for people with Chlamydia trachomatis: protocol for the Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) APT cross-over cluster randomised controlled trial

INTRODUCTION

Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics and STI self-sampling kits to deliver to their sex partner(s). The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity programme aims to determine the effectiveness of APT in heterosexual women and men with chlamydia and determine whether APT could affect Chlamydia trachomatis transmission at population level.

METHODS AND ANALYSIS

This protocol describes a cross-over cluster randomised controlled trial of APT, offered as an additional PN method, compared with standard PN. The trial is accompanied by an economic evaluation, transmission dynamic modelling and a qualitative process evaluation involving patients, partners and healthcare professionals. Clusters are 17 sexual health clinics in areas of England and Scotland with contrasting patient demographics. We will recruit 5440 heterosexual women and men with chlamydia, aged ≥16 years.The primary outcome is the proportion of index patients testing positive for C. trachomatis 12-16 weeks after the PN consultation. Secondary outcomes include: proportion of sex partners treated; cost effectiveness; model-predicted chlamydia prevalence; experiences of APT.The primary outcome analysis will be by intention-to-treat, fitting random effects logistic regression models that account for clustering of index patients within clinics and trial periods. The transmission dynamic model will be used to predict change in chlamydia prevalence following APT. The economic evaluation will use mathematical modelling outputs, taking a health service perspective. Qualitative data will be analysed using interpretative phenomenological analysis and framework analysis.

ETHICS AND DISSEMINATION

This protocol received ethical approval from London-Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences.

TRIAL REGISTRATION NUMBER

ISRCTN15996256.

Diagnosis of extrapulmonary tuberculosis using the MPT64 antigen detection test in a high-income low tuberculosis prevalence setting

BACKGROUND

Extrapulmonary tuberculosis (EPTB) poses diagnostic challenges due to the paucibacillary nature of the disease. The immunochemistry-based MPT64 antigen detection test (MPT64 test) has shown promising results for diagnosing EPTB in previous studies performed in low-resource settings, with higher sensitivity than microscopy and culture. The aim of this study was to investigate the performance of the MPT64 test in a routine clinical setting in a high-income low TB prevalence country.

METHODS

Extrapulmonary samples sent for TB diagnostics to microbiology and pathology laboratories at three regional tertiary care hospitals in Norway in a one-year period were included and subjected to the MPT64 test in parallel to the routine TB diagnostic tests.

RESULTS

Samples from 288 patients were included and categorised as confirmed TB cases (n = 26), clinically diagnosed TB cases (n = 5), non-TB cases (n = 243) and uncategorised (n = 14), using a composite reference standard (CRS). In formalin-fixed biopsies, the sensitivity (95% CI) of the MPT64 test, microscopy, PCR-based tests pooled, and culture was 37% (16-62), 20% (4-48), 37% (16-62) and 50% (23-77), respectively, against the CRS. The MPT64 test showed a good positive predictive value (88%) and an excellent specificity (99, 95% CI 92-100) in formalin-fixed biopsies. In fine-needle aspirates, pus and fluid samples, the test performance was lower.

CONCLUSIONS

The MPT64 test was implementable in pathology laboratories as part of routine diagnostics, and although the sensitivity of the MPT64 test was not better than culture in this setting, the test supplements other rapid diagnostic methods, including microscopy and PCR-based tests, and can contribute to strengthen the diagnosis of EPTB in formalin-fixed biopsies in the absence of culture confirmation.

Diagnostic performance of modern imaging instruments in glaucoma screening

AIM

To evaluate the applicability of imaging devices (spectral-domain optical coherence tomography (Cirrus SD-OCT), scanning laser polarimetry (GDx) and scanning laser ophthalmoscopy (Heidelberg Retinal Tomograph, HRT3)) for glaucoma screening in a middle-aged unselected population.

METHODS

Participants of the population-based Northern Finland Birth Cohort Eye Study, aged 45 to 49 years, underwent a comprehensive eye examination including modern imaging with five methods (retinal nerve fibre layer (RNFL) and macular ganglion cell layer +inner plexiform layer (GCIPL) analysis and their combination with SD-OCT, GDx and HRT). The performance of the automated classification of the imaging devices was assessed using a clinical glaucoma diagnosis as reference, that is, the '2 out of 3' rule based on the evaluation of optic nerve head and RNFL photographs and visual fields.

RESULTS

We examined 6060 eyes of 3039 subjects; in the clinical evaluation, glaucomatous damage was found in 33 subjects (1.1%) in 43 eyes. The following sensitivities were obtained; RNFL analysis (53%), GCIPL analysis (50%), OCT combination analysis (61%), GDx (56%) and HRT (31%) with corresponding specificities of 95%, 92%, 90%, 88% and 96%. The area under the curve values were 0.76, 0.73, 0.75, 0.75 and 0.73, respectively. Post-test probabilities of glaucoma after positive imaging finding with each of these methods in this unselected population were 11%, 7%, 6%, 5% and 7%, respectively.

CONCLUSION

Screening capabilities of the OCT, GDx and HRT were rather similar. The accuracy of all evaluated parameters was only moderate and thus screening with these parameters alone is not reliable.

Cost-utility analysis of transcranial direct current stimulation (tDCS) in non-treatment-resistant depression: the DISCO randomised controlled study protocol

INTRODUCTION

Depression is among the most widespread psychiatric disorders in France. Psychiatric disorders are associated with considerable social costs, amounting to €22.6 billion for treatment and psychotropic medication in 2011. Treatment as usual (TAU), mainly consisting of pharmacotherapy and psychotherapy, is effective for only a third of patients and in most cases fails to prevent treatment resistance and chronicity. Transcranial direct current stimulation (tDCS) consists in a non-invasive and painless application of low-intensity electric current to the cerebral cortex through the scalp. Having proved effective in depressed patients, it could be used in combination with TAU to great advantage. The objective is to compare, for the first time ever, the cost-utility of tDCS-TAU and of TAU alone for the treatment of a depressive episode that has been refractory to one or two drug treatments.

METHODS AND ANALYSIS

This paper, based on the DISCO study protocol, focuses on the design of a prospective, randomised, controlled, open-label multicentre economic study to be conducted in France. It will include 214 patients with unipolar or bipolar depression, assigning them to two parallel arms: group A (tDCS-TAU) and group B (TAU alone). The primary outcome is the incremental cost-effectiveness ratio, that is, the ratio of the difference in cost between each strategy to the difference in their effects. Their effects will be expressed as numbers of quality-adjusted life-years, determined through administration of the EuroQol Five-Dimension questionnaire over a 12-month period to patients (EQ-5D-5L). Expected benefits are the reduction of treatment resistance and suicidal ideation as well as social and professional costs of depression. Should depression-related costs fall significantly, tDCS might be considered an efficient treatment for depression.

ETHICS AND DISSEMINATION

This protocol has been approved by a French ethics committee, the CPP--Est IV (Comité de Protection des Personnes-Strasbourg). Data are to be published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

RCB 2018-A00474-51; NCT03758105.