Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

Background

Chest X-ray has been included in national tuberculosis screening algorithms as a sensitive tuberculosis screening tool among high-risk groups. However, the implementation was influenced by multiple factors. We aimed to explore facilitators and barriers to implementing chest X-ray in systematic tuberculosis screening of clinically high-risk groups in Addis Ababa, Ethiopia.

Methods

We conducted face-to-face, in-depth interviews with purposively selected participants at tertiary-level hospitals and a tuberculosis program coordinator at the Ethiopian Ministry of Health, who coordinates chest X-ray-guided systematic tuberculosis screening. A framework analysis was conducted using the consolidated framework for implementation research.

Results

We identified 11 constructs that influenced the implementation of the chest X-ray intervention. Facilitators included the relative sensitivity of chest X-ray over symptom-based screening, its potential integration into existing systems, technological advancements in the area, policies and laws supporting the screening intervention, and the quality of the evidence of the screening intervention. Barriers included implementation complexity, high costs of the intervention, knowledge gaps among healthcare providers, training gaps, low priority for chest X-ray screening at the healthcare facility level, and a lack of external support from the Ministry of Health and stakeholders.

Conclusion

This study identified contextual factors that influence the implementation of chest X-ray guided systematic tuberculosis screening among clinically high-risk groups that healthcare facilities and health ministries may use for decision-making. Addressing the barriers identified by the study would help to improve the implementation of chest X-rays for improved tuberculosis case detection and prompt treatment in clinically high-risk groups.

How Can Artificial Intelligence Be Implemented Effectively in Diabetic Retinopathy Screening in Japan?

Diabetic retinopathy (DR) is a major microvascular complication of diabetes, affecting a substantial portion of diabetic patients worldwide. Timely intervention is pivotal in mitigating the risk of blindness associated with DR, yet early detection remains a challenge due to the absence of early symptoms. Screening programs have emerged as a strategy to address this burden, and this paper delves into the role of artificial intelligence (AI) in advancing DR screening in Japan. There are two pathways for DR screening in Japan: a health screening pathway and a clinical referral path from physicians to ophthalmologists. AI technologies that realize automated image classification by applying deep learning are emerging. These technologies have exhibited substantial promise, achieving sensitivity and specificity levels exceeding 90% in prospective studies. Moreover, we introduce the potential of Generative AI and large language models (LLMs) to transform healthcare delivery, particularly in patient engagement, medical records, and decision support. Considering the use of AI in DR screening in Japan, we propose to follow a seven-step framework for systematic screening and emphasize the importance of integrating AI into a well-designed screening program. Automated scoring systems with AI enhance screening quality, but their effectiveness depends on their integration into the broader screening ecosystem. LLMs emerge as an important tool to fill gaps in the screening process, from personalized invitations to reporting results, facilitating a seamless and efficient system. However, it is essential to address concerns surrounding technical accuracy and governance before full-scale integration into the healthcare system. In conclusion, this review highlights the challenges in the current screening pathway and the potential for AI, particularly LLM, to revolutionize DR screening in Japan. The future direction will depend on leadership from ophthalmologists and stakeholders to address long-standing challenges in DR screening so that all people have access to accessible and effective screening.

Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination

In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among "high-risk" populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection-affecting up to a quarter of the global population -complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow's tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.

A Multicenter Study to Assess a Systematic Screening of Occupational Exposures in Lung Cancer Patients

Occupational lung cancer cases remain largely under-reported and under-compensated worldwide. In order to improve the detection and compensation of work-related lung cancers, we implemented a systematic screening of occupational exposures, combining a validated self-administered questionnaire to assess occupational exposures and a specialized occupational cancer consultation. After a pilot study, the present prospective, open-label, scale-up study aimed to assess this systematic screening of occupational exposures in lung cancer patients in five sites in France by associating university hospitals with cancer centers. Patients with lung cancer were sent a self-administered questionnaire to collect their job history and potential exposure to lung carcinogens. The questionnaire was assessed by a physician to determine if a specialized occupational cancer consultation was required. During the consultation, a physician assessed if the lung cancer was occupation-related and, if it was, delivered a medical certificate to claim for compensation. Patients were offered help from a social worker for the administrative procedure. Over 15 months, 1251 patients received the questionnaire and 462 returned it (37%). Among them, 176 patients (38.1%) were convened to the occupational cancer consultation and 150 patients attended the consultation. An exposure to occupational lung carcinogen was identified in 133 patients and a claim for compensation was judged possible for 90 patients. A medical certificate was delivered to 88 patients and 38 patients received compensation. Our national study demonstrated that a systematic screening of occupational exposures is feasible and will bring a significant contribution to improve the detection of occupational exposures in lung cancer patients.

Progress in screening strategies for neonatal developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is the most common congenital disease of the musculoskeletal system in newborns and encompasses a disease spectrum ranging from a stable hip with a mildly dysplastic acetabulum to complete hip dislocation. Systematic screening for infant DDH has been performed for several decades all over the world and has contributed greatly to the early detection, diagnosis and treatment of DDH. However, some cases of delayed diagnosis still occur among the screened population, or conversely, overdiagnosis or overtreatment occasionally occurs. Furthermore, screening strategies for DDH are still controversial. The aim of our study was to analyze the current literature on DDH screening, paying particular attention to DDH screening strategies and their effectiveness. We searched the DDH screening literature from 1958 to 2021 in MEDLINE and other databases using PubMed. In this study, we reviewed the history of DDH screening and the progress of screening strategies and discussed the controversies regarding clinical and ultrasound screening methods with particular emphasis on the current opinions. Given the existing scientific evidence and changes in newborn DDH screening practices, universal ultrasound screening seems to be the best option for preventing late-detected cases and can be recommended as a favorable prevention strategy.

Exploring Views and Professional Learning Needs of Comprehensive, Integrated, Three-Tiered (Ci3T) Leadership Teams Related to Universal Behavior Screening Implementation

Research conducted to date has highlighted barriers to initial adoption of universal behavior screening in schools. However, little is known regarding the experiences of those implementing these procedures and there have been no studies conducted examining the experiences of educators in different stages of implementing various tiered systems of supports. Universal screening is foundational to a successful Comprehensive, Integrated Three-Tiered (Ci3T) model of prevention-an integrated tiered system addressing academics, behavior, and social and emotional well-being. Therefore, the perspectives of Ci3T Leadership Team members at different stages of Ci3T implementation were solicited through an online survey that sought to understand (1) current school-based screening practices and (2) individual beliefs regarding those practices. A total of 165 Ci3T Leadership Team members representing five school districts from three geographic regions across the United States, all of whom were participating in an Institute of Education Sciences Network grant examining integrated tiered systems, reported the screening procedures were generally well-understood and feasible to implement. At the same time, results highlighted continuing professional learning may be beneficial in the areas of: (1) integrating multiple sources of data (e.g., screening data with other data collected as regular school practices) and (2) using those multiple data sources to determine next steps for intervention. We discuss educational implications, limitations, and directions for future inquiry.

Guiding the Catalytic Properties of Copper for Electrochemical CO2 Reduction by Metal Atom Decoration

Tuning bimetallic effects is a promising strategy to guide catalytic properties. However, the nature of these effects can be difficult to assess and compare due to the convolution with other factors such as the catalyst surface structure and morphology and differences in testing environments. Here, we investigate the impact of atomic-scale bimetallic effects on the electrochemical CO2 reduction performance of Cu-based catalysts by leveraging a systematic approach that unifies protocols for materials synthesis and testing and enables accurate comparisons of intrinsic catalytic activity and selectivity. We used the same physical vapor deposition method to epitaxially grow Cu(100) films decorated with a small amount of noble or base metal atoms and a combination of experimental characterization and first-principles calculations to evaluate their physicochemical and catalytic properties. The results indicate that the metal atoms segregate to under-coordinated Cu sites during physical vapor deposition, suppressing CO reduction to oxygenates and hydrocarbons and promoting competing pathways to CO, formate, and hydrogen. Leveraging these insights, we rationalize bimetallic design principles to improve catalytic selectivity for CO2 reduction to CO, formate, oxygenates, or hydrocarbons. Our study provides one of the most extensive studies on Cu bimetallics for CO2 reduction, establishing a systematic approach that is broadly applicable to research in catalyst discovery.

Toxic plants-Detection of colchicine in a fast systematic clinical toxicology screening using liquid chromatography-mass spectrometry

Colchicum autumnale, which can be mistaken for Allium ursinum, contains the alkaloid colchicine potentially leading to life-threatening up to fatal intoxications. We report two cases of acute intoxications with unexplained circumstances. Using the authors' systematic screening approaches, colchicine could be detected in blood plasma and urine samples using liquid chromatography coupled to linear ion trap mass spectrometry (LC-ITMSⁿ ) and high-resolution tandem mass spectrometry (LC-HRMS/MS). Metabolites of colchicine could be identified in urine for confirmation of screening results. Gas chromatography-mass spectrometry (GC-MS) analysis was also conducted, but colchicine could not be detected. Furthermore, colchicine concentration was estimated via LC-HRMS/MS in plasma samples. Results of the systematic screening indicated the ingestion of colchicine from both subjects. In both cases, the parent compound was detected in blood plasma and urine using the LC-HRMS/MS and LC-ITMSⁿ system. An O-demethylation metabolite was identified in urine samples of both subjects using LC-HRMS/MS; the N-deacetylation product was also found in urine samples of both cases via LC-HRMS/MS and LC-ITMSⁿ . The use of LC-ITMSⁿ resulted only in the detection of the O-demethylation product in case 2. Plasma concentrations were estimated at 2.5 ng/ml and 4.7 ng/ml for cases 1 and 2, respectively. We demonstrated the detection of this highly toxic alkaloid in blood plasma and urine using a time-saving and reliable clinical systematic screening. Furthermore, we identified metabolites of colchicine being rarely discussed in literature, which can be used as additional screening targets.

Systematic Severe Acute Respiratory Syndrome Coronavirus 2 Screening at Hospital Admission in Children: A French Prospective Multicenter Study

To assess the relevance of systematic SARS-CoV-2 screening of all children admitted to hospital, we conducted a prospective multicenter study including 438 consecutive hospitalized children. A symptom-based SARS-CoV-2 testing strategy failed to identify 45% (95%CI [24; 68]) of hospitalized children infected by SARS-CoV-2. To limit intra-hospital transmission, a systematic screening of children admitted to hospital should be considered.

Systematic screening for SARS-CoV-2 in pregnant women admitted for delivery in a Portuguese maternity

Objectives The burden of undocumented SARS-Cov-2 infections in Portuguese pregnant women is unknown. At our institution, routine COVID-19 testing was implemented from 19th of March on to all pregnant women who were admitted for delivery. The purpose of the study was to estimate the SARS-CoV-2 infection rate in our obstetric population admitted for delivery. Mathods Between 19th March and May 4th, 184 pregnant women were screened for SARS-CoV-2 infection upon admission. Results Eleven women were positive for SARS-CoV-2, corresponding to a global prevalence of 6.0%. Of these, only two reported symptoms at admission. The prevalence of asymptomatic infection was 4.9%. We report a lower rate of positive cass than other studies. Eighty-two percent of our cases had no symptoms at admission. Conclusions The proportion of asymptomatic infection highlights the importance of universal laboratory screening for all women admitted for delivery as opposed to symptom-based screening.

Active versus passive case finding for tuberculosis in marginalised and vulnerable populations in India: comparison of treatment outcomes

Background: Community-based active case finding (ACF) for tuberculosis (TB) implemented among marginalised and vulnerable populations in 285 districts of India resulted in reduction of diagnosis delay and prevalence of catastrophic costs due to TB diagnosis. We were interested to know whether this translated into improved treatment outcomes. Globally, there is limited published literature from marginalised and vulnerable populations on the independent effect of community-based ACF on treatment outcomes when compared to passive case finding (PCF).

Objectives: To determine the relative differences in unfavourable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) of ACF and PCF-diagnosed people.

Methods: Cohort study involving record reviews and interviews in 18 randomly selected districts. We enrolled all ACF-diagnosed people with new smear-positive pulmonary TB, registered under the national TB programme between March 2016 and February 2017, and an equal number of randomly selected PCF-diagnosed people in the same settings. We used log binomial models to adjust for confounders.

Results: Of 572 enrolled, 275 belonged to the ACF and 297 to the PCF group. The proportion of unfavourable outcomes were 10.2% (95% CI: 7.1%, 14.3%) in the ACF and 12.5% (95% CI: 9.2%, 16.7%) in the PCF group (p = 0.468). The association between ACF and unfavourable outcomes remained non-significant after adjusting for confounders available from records [aRR: 0.83 (95% CI: 0.56, 1.21)]. Due to patient non-availability at their residence, interviews were conducted for 465 (81.3%). In the 465 cohort too, there was no association after adjusting for confounders from records and interviews [aRR: 1.05 (95% CI: 0.62, 1.77)].

Conclusion: We did not find significant differences in the treatment outcomes. Due to the wide CIs, studies with larger sample sizes are urgently required. Studies are required to understand how to translate the benefits of ACF to improved treatment outcomes.

Lithium-Rich Mineral Water is a Highly Bioavailable Lithium Source for Human Consumption

SCOPE

Lithium is an important trace element in human nutrition and medicine. Mineral and medicinal waters may represent a significant source of dietary lithium intake.

METHODS AND RESULTS

The lithium concentration of 360 German mineral and 21 medicinal waters is determined. Based on a systematic screening, three different mineral waters exhibiting low (1.7 µg L^-1 ), medium (171 µg L^-1 ), and high lithium (1724 µg L^-1 ) concentrations are chosen for an acute bioavailability study in male healthy volunteers. In Germany, a north-east to south-west gradient of analyzed lithium concentrations is observed in the 381 tested waters. The lithium concentration in the water is significantly correlated with its sodium (r = 0. 810), potassium (r = 0.716), and magnesium (r = 0.361), but not with its calcium concentration. In a randomized cross-over trial, volunteers (n = 3×10 each) drink 1.5 L of the respective mineral waters, and lithium concentrations in serum and urine are monitored over 24 h. Consumption of the mineral waters with a medium and high lithium content results in a dose-dependent response in serum lithium concentrations and total urinary lithium excretion.

CONCLUSION

Lithium-rich mineral and medicinal waters may be an important and highly bioavailable lithium source for human consumption.

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe

Setting

Ten districts and three cities in Zimbabwe.

Objective

To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone.

Design

Cross-sectional study using data from the ZimACF project.

Results

A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm.

Conclusion

The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Editor's Highlight: A Genome-wide Screening of Target Genes Against Silver Nanoparticles in Fission Yeast

To identify target genes against silver nanoparticles (AgNPs), we screened a genome-wide gene deletion library of 4843 fission yeast heterozygous mutants covering 96% of all protein encoding genes. A total of 33 targets were identified by a microarray and subsequent individual confirmation. The target pattern of AgNPs was more similar to those of AgNO₃ and H₂O₂, followed by Cd and As. The toxic effect of AgNPs on fission yeast was attributed to the intracellular uptake of AgNPs, followed by the subsequent release of Ag⁺, leading to the generation of reactive oxygen species (ROS). Next, we focused on the top 10 sensitive targets for further studies. As described previously, 7 nonessential targets were associated with detoxification of ROS, because their heterozygous mutants showed elevated ROS levels. Three novel essential targets were related to folate metabolism or cellular component organization, resulting in cell cycle arrest and no induction in the transcriptional level of antioxidant enzymes such as Sod1 and Gpx1 when 1 of the 2 copies was deleted. Intriguingly, met9 played a key role in combating AgNP-induced ROS generation via NADPH production and was also conserved in a human cell line.

Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis

BACKGROUND

There is limited evidence on whether active case finding (ACF) among marginalised and vulnerable populations mitigates the financial burden during tuberculosis (TB) diagnosis.

OBJECTIVES

To determine the effect of ACF among marginalised and vulnerable populations on prevalence and inequity of catastrophic costs due to TB diagnosis among TB-affected households when compared with passive case finding (PCF).

METHODS

In 18 randomly sampled ACF districts in India, during March 2016 to February 2017, we enrolled all new sputum-smear-positive TB patients detected through ACF and an equal number of randomly selected patients detected through PCF. Direct (medical and non-medical) and indirect costs due to TB diagnosis were collected through patient interviews at their residence. We defined costs due to TB diagnosis as 'catastrophic' if the total costs (direct and indirect) due to TB diagnosis exceeded 20% of annual pre-TB household income. We used concentration curves and indices to assess the extent of inequity.

RESULTS

When compared with patients detected through PCF (n = 231), ACF patients (n = 234) incurred lower median total costs (US$ 4.6 and 20.4, p < 0.001). The prevalence of catastrophic costs in ACF and PCF was 10.3 and 11.5% respectively. Adjusted analysis showed that patients detected through ACF had a 32% lower prevalence of catastrophic costs relative to PCF [adjusted prevalence ratio (95% CI): 0.68 (0.69, 0.97)]. The concentration indices (95% CI) for total costs in both ACF [-0.15 (-0.32, 0.11)] and PCF [-0.06 (-0.20, 0.08)] were not significantly different from the line of equality and each other. The concentration indices (95% CI) for catastrophic costs in both ACF [-0.60 (-0.81, -0.39)] and PCF [-0.58 (-0.78, -0.38)] were not significantly different from each other: however, both the curves had a significant distribution among the poorest quintiles.

CONCLUSION

ACF among marginalised and vulnerable populations reduced total costs and prevalence of catastrophic costs due to TB diagnosis, but could not address inequity.

Yield of intensified tuberculosis case-finding activities using Xpert(®) MTB/RIF among risk groups in Nepal

SETTING

Twenty-two districts of Nepal, where intensified case-finding (ICF) activities for tuberculosis (TB) were implemented among risk groups under the TB REACH initiative in collaboration with the National TB Programme from July 2013 to November 2015.

OBJECTIVES

To assess the yield of TB screening using an algorithm with smear microscopy followed by Xpert(®) MTB/RIF.

DESIGN

A descriptive study using routinely collected data.

RESULTS

Of 145 679 individuals screened, 28 574 (19.6%) had presumptive TB; 1239 (4.3%) of these were diagnosed with TB and 1195 (96%) were initiated on anti-tuberculosis treatment. The yield of screening was highest among people living with the human immunodeficiency virus (PLHIV) (6.1%), followed by household contacts (3.5%) and urban slum dwellers (0.5%). Among other risk groups, such as prisoners, factory workers, refugees and individuals with diabetes, the yield was less than 0.5%. The number needed to screen to diagnose an active TB case was 17 for PLHIV, 29 for household contacts and 197 for urban slum dwellers. Of 11 525 patients from ICF and the routine programme, 112 (1%) were diagnosed with multidrug-resistant TB.

CONCLUSION

There was a substantial yield of TB cases among risk groups such as PLHIV and household contacts. Although the yield in urban slum dwellers was found to be moderate, some intervention should nonetheless be targeted because of the large population and poor access to care in this group.

Implementing a large-scale systematic tuberculosis screening program in correctional facilities in South Africa

Background.  Tuberculosis (TB) prevalence is high in correctional facilities in southern Africa. With support from local South African nongovernmental organizations, the South African Department of Correctional Services initiated a program of systematically screening newly admitted and current inmates for symptoms followed by GeneXpert Mycobacterium tuberculosis (MTB)/rifampicin (Rif) for microbiologic testing of symptomatic inmates. Methods.  We conducted a program evaluation during a 5-month window describing program reach, effectiveness, adoption within the facilities, cost, and opportunities for sustainability. This evaluation included 4 facilities (2 large and 2 smaller) with a total daily census of 20 700 inmates. Results.  During the 5-month evaluation window from May to September 2013, 7426 inmates were screened at the 4 facilities. This represents screening 87% of all new admits (the remaining new admits were screened by correctional staff only and are not included in these statistics) and 23% of the daily inmate census, reaching 55% of the overall screening target as calculated per annum. The reach ranged from 57% screened during these 5 months at one of the smaller facilities to 13% at the largest facility. Two hundred one cases of pulmonary TB were diagnosed, representing 2.1% of the screened population; 93% had documented initiation of TB treatment. The cost per TB case identified was $1513, excluding treatment costs (with treatment costs it was $1880). Conclusions.  We reached a large number of inmates with high-volume screening and effectively used GeneXpert MTB/Rif to diagnose pulmonary TB and rapidly initiate treatment. The cost was comparable to other screening programs.