Prolonged tuberculosis-associated immune reconstitution inflammatory syndrome: characteristics and risk factors

Includes bibliographical referencesBackground: In a proportion of patients with HIV-associated tuberculosis who develop paradoxical immune reconstitution inflammatory syndrome (IRIS), the clinical course of IRIS is prolonged necessitating substantial health care utilization for diagnostic and therapeutic interventions. This phenomenon has not been systematically studied to date. We aimed to determine the proportion of patients with prolonged TB-IRIS, as well as the clinical characteristics and risk factors for prolonged TB-IRIS. Methods: We pooled data from two prospective observational studies and a randomized controlled trial that enrolled patients with paradoxical TB-IRIS using the same diagnostic approach and clinical case definitions in Cape Town, South Africa. Prolonged TB-IRIS was defined as TB-IRIS symptoms lasting > 90 days. Risk factors for TB-IRIS were analysed using Wilcoxon rank sum test, Fisher's exact test, multivariate logistic regression and Cox proportional hazards model. In a separate set of analyses, risk factors for relapsing after a 4-week course of prednisone for treatment of TB-IRIS were analysed. Results: Two-hundred and sixteen patients with TB-IRIS were included. The median duration of TB-IRIS symptoms was 71.0 days (IQR=41.0-113.2). In 73/181 patients with sufficient follow-up (40.3%) IRIS duration was > 90 days. Six patients (3.3%) had IRIS duration > 1 year, mainly with nodal involvement. In univariate logistic regression analysis, the following were significantly associated with IRIS duration > 90 days: lymph node involvement at initial TB diagnosis (p=0.02), drug-resistant TB (p=0.02), lymph node TB-IRIS (p=0.0005) and not being hospitalized at time of TB-IRIS diagnosis (p=0.004). The association with lymph node TB-IRIS (p=0.02) and hospitalization status (p=0.05) remained significant in the multivariate logistic regression model. In the Cox proportional hazards model, IRIS lymph node involvement was independently associated with lower hazards of IRIS resolution (HR 0.55, 95%CI=0.38-0.78). In univariate analysis those patients with lesser reductions in liver function abnormalities during prednisone treatment had a higher risk of relapse after stopping prednisone, but no significant associations remained in multivariate analysis. Conclusions: Around 40% of patients with TB-IRIS have symptoms for more than 90 days. Lymph node IRIS involvement is an independent risk factor for a prolonged course and in the small proportion of patients (3%) with symptoms more than one year this usually manifests with lymph node involvement. Whether earlier recognition and treatment of lymph node TB-IRIS could reduce the risk of prolonged TB-IRIS needs to be evaluated. Trial registration: The randomized controlled trial was registered with Current Controlled Trials ISRCTN21322548

Utility of cardiovascular magnetic resonance in pregnancy

Pregnant women with known or suspected cardiovascular disease (CVD) often require cardiovascular imaging during pregnancy. Decisions about imaging in pregnancy are premised on understanding the physiology of pregnancy, understanding basic concepts of different imaging modalities, the clinical manifestations of existent CVD in pregnancy and features of new CVD. Cardiovascular magnetic resonance (CMR) imaging is safe in pregnancy and is not associated with any adverse foetal effects, provided there are no general contra-indications to magnetic resonance (MR) imaging. CMR also does not involve any ionising radiation. In pregnancy, CMR is useful to confirm diagnosis of CVD, assess disease severity, to stratify risk and prognosticate, to plan appropriate management, and to assess response to therapy. Use of any imaging test in pregnancy needs to have safety considerations balanced against the importance of accurate diagnosis and thorough assessment of the pathological condition. This review summarises the evolving role of CMR in evaluation of known or suspected new CVD in pregnancy

COVID-19 and impact of psychological stress on cardiovascular disease

COVID-19 has caused a global pandemic of anxiety, fear and uncertainty. National lockdowns, high mortality, social isolation, economic recession, job losses and food insecurity resulting from COVID-19 are potent drivers of increased stress levels, anxiety and depression, and have placed a substantial strain on healthcare and economic systems. Depression, anxiety and physical isolation are strongly linked to incident cardiovascular disease (CVD) as well as poorer outcomes in established CVD – including coronary artery disease, stroke and heart failure. Acute stress-related disorders such as post-traumatic stress disorder, have been robustly and independently associated with multiple phenotypes of CVD, particularly in the first year after the psychiatric diagnosis. Unprecedented psychological stress imposed by COVID-19 on the global population bears the potential to cause a parallel epidemic of mental health disorders and a subsequent surge in CVD, warranting strategic planning by healthcare services to mitigate its impact. This potential for a mental health crisis would require both large-scale psychosocial interventions, and incorporation of mental healthcare into disaster management plans. Anxiety and depression, as the dominant emotional responses to the outbreak, warrant adequate training of healthcare personnel and the optimal use of technological advances to deliver acute mental healthcare interventions which are time-limited and culturally sensitive

Learners’ access to tools and experience with technology at the University of the South Pacific: readiness for e-learning

Technology in higher education has become exceedingly popular and useful; however, a digital divide generally applies to the use of technology in education in many developing countries. The Pacific Island countries differ in their technological capacities and infrastructure, with the Fijian capital Suva being most technologically and infrastructurally advanced compared with other towns in Fiji and in other Pacific Island countries. This led the researchers to investigate access to e-learning tools and experience with technology amongst a group of 92 students, ranging from 18 to over 55 years of age, enrolled in postgraduate courses in education at the University of the South Pacific. A survey consisting of questions on age, gender, qualification, professional experience, ethnicity and access to and experience with technology was carried out for one cohort. The findings indicate an encouraging level of readiness for e-learning

Additional file 1: Figure S1. of Prolonged tuberculosis-associated immune reconstitution inflammatory syndrome: characteristics and risk factors

Distribution of TB-IRIS duration. This graph shows the number and proportion of patients who had a duration of TB-IRIS symptoms within each of the specified duration categories (in days) displayed on the x-axis. The graph includes only the 172 patients who had a known TB-IRIS start and end date, and thus excludes 2 patients who had a duration >365 days but in whom IRIS was ongoing at last visit. (DOCX 174 kb