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Objectives: Despite improvements in survival of people with HIV admitted to the intensive care unit (ICU), late diagnosis continues to contribute to in‐ICU mortality. We quantify the population attributable fraction (PAF) of in‐ICU mortality for recent late diagnosis among people with HIV admitted to a London ICU. Methods: Index ICU admissions among people with HIV were considered from 2000 to 2019. Recent late diagnosis was a CD4 T‐cell count < 350 cells/μL and/or AIDS‐defining illness at/within 6 months prior to ICU admission. Univariate comparisons were conducted using Wilcoxon rank‐sum/Cochran–Armitage/χ2/Fisher's exact tests. We used Poisson regression (robust standard errors) to estimate unadjusted/adjusted (age, sex, calendar year of ICU admission) risk ratios (RRs) and regression standardization to estimate the PAF. Results: In all, 207 index admissions were included [median (interquartile range) age: 46 (38–53) years; 72% male]; 58 (28%) had a recent late diagnosis, all of whom had a CD4 count < 350 cells/μL, and 95% had advanced HIV (CD4 count < 200 cells/μL and/or AIDS at admission) as compared with 57% of those who did not have a recent late diagnosis (p < 0.001). In‐ICU mortality was 27% (55/207); 38% versus 22% in those who did and did not have a recent late diagnosis, respectively (p = 0.02). Recent late diagnosis was independently associated with increased in‐ICU mortality risk (adjusted RR = 1.75) (95% confidence interval: 1.05–2.91), with 17.08% (16.04–18.12%) of deaths being attributable to this. Conclusions: There is a need for improved public health efforts focused on HIV testing and reporting of late diagnosis to better understand potentially missed opportunities for earlier HIV diagnosis in healthcare services. [ABSTRACT FROM AUTHOR]

Background: It is widely acknowledged that inadequate handovers are associated with putting patients at risk in clinical settings; however, handover practices have received little attention in other 24‐hr settings such as long‐stay residential care facilities. Aim: This study aimed to explore the perceived purpose and organisational processes involved in the handover of information between shifts of staff caring for older residents in five care homes in England. Methods: The study took an ethnographic approach to fieldwork, undertaken between February and June 2016. It consisted of observations of handovers (n = 12) and interviews with managers, Registered Nurses (RNs) and care assistants (n = 27) working day and night shifts. Interview transcripts and observation notes were analysed within NVivo using a matrix approach. Results: Handovers were highly variable in all five care homes in relation to their timings, locations, content and participants. Managers and RNs highlighted handovers as an opportunity for risk assurance, supervision, team building, staff education and monitoring of residents' clinical status. In comparison, care assistants considered the purpose of handovers to be prepared for the responsibilities of working a shift. The discussion addresses implications of these findings, particularly consideration of how best use can be made of RN skills and knowledge in handovers. Conclusion: Research is needed to identify whether care home resident safety can be linked to handover practices and how the presence of RNs in handovers in care homes affects this. Implications for practice: Care home managers, RNs and care workers may find this research useful in practice when considering how best to organise handovers and deploy staff in care homes for older people. [ABSTRACT FROM AUTHOR]

The article offers information on screening for latent tuberculosis infection (LTBI) among tuberculosis (TB) contacts that is an important component of TB control, aiming toward pre-elimination. Topics include examines that new-generation QuantiFERON launched, adding a second TB antigen tube that incorporates short peptides designed to stimulate a CD81 T-cell response, in addition to the CD41-response tube (TB1) included in previous versions.

Purpose: The purpose of this paper is to investigate the content, purpose and effectiveness of the handover of information between care home staff beginning and completing a shift. Design/methodology/approach: This was an exploratory study drawing on ethnographic methods. A total of 27 interviews with a range of care home staff, including managers, registered nurses, senior care workers and care workers were undertaken in five care homes selected to give a good contrast in terms of size, ownership, shift patterns and type of handover. Findings: Most handovers were short – lasting 15 min or so – and were held in the office or secluded area in which staff could talk privately. They lasted longer in one home in which the incoming and outgoing shifts physically visited each resident's room and the communal spaces. Staff felt that handovers were important for the efficient running of the home as well as to alert everyone to changes in a resident's health or important events, such as a hospital appointment. In one home, handheld devices enabled staff to follow a resident's care plan and update what was happening in real time. Research limitations/implications: This was a small scale study based on data from a limited number of care homes. Practical implications: The increasing popularity of 12 h shifts means that many homes only hold two short handovers early in the morning and in the evening when the night staff arrive. There appears to be a trend to reduce the number of staff paid to attend handover. Despite this, handovers remain an important component of the routine of a care home. The information contained in handover relates to the running of the care home, as well as residents' wellbeing, suggesting that, while their content overlaps with written records in the home, they are not superfluous. Originality/value: Although the literature on handovers in hospitals is extensive, this appears to be the first published study of handover practices in care homes. [ABSTRACT FROM AUTHOR]

This article explores how people consider their relationships to the previous inhabitants of their homes. While homes are conventionally imagined in terms of an ideal of exclusive ownership and residence, privacy and familial intimacy, the sense of home as shared with strangers who once lived there often has to be negotiated in the everyday senses of home. Drawing on qualitative case studies undertaken in England with those whose interest in the past of their home ranged from active research to more everyday reflections, this article explores the varied ways in which people reflect on and experience pre-inhabitation in terms of senses of dwelling, selfhood and relatedness to those who once lived in their homes. Our engagement with the practices of making relations with distant and recent residents, imaginatively and through more direct social interactions, is framed by a combined focus on domestic dwelling and geographies of relatedness. We argue that understandings of home and home making can be enriched through a focus on the genealogical imaginaries and idioms that are mobilised and negotiated in how people define themselves and make home relationally. [ABSTRACT FROM AUTHOR]

Introduction: Urban homeless populations in the UK have been shown to have high rates of active tuberculosis, but less is known about the prevalence of latent tuberculosis infection (LTBI). This study aimed to estimate the prevalence of LTBI among individuals using homeless hostels in London.Methods: We performed a cross-sectional survey with outcome follow-up in homeless hostels in London. Our primary outcome was prevalence of LTBI. Recruitment for the study took place between May 2011 and June 2013. To estimate an LTBI prevalence of 10% with 95% CIs between 8% and 13%, we required 500 participants.Results: 491/804 (61.1%) individuals agreed to be screened. The prevalence of LTBI was 16.5% (81/491; 95% CI 13.2 to 19.8). In UK-born individuals, a history of incarceration was associated with increased risk of LTBI (OR 3.49; 95% CI 1.10 to 11.04; P=0.018) after adjusting for age, length of time spent homeless and illicit drug use. Of the three subjects who met English treatment guidelines for LTBI at the time of the study, none engaged with services after referral for treatment. Prevalence of past hepatitis B infection was 10.4% (51/489; 95% CI 7.7 to 13.1), and 59.5% (291/489; 95% CI 55.1 to 63.9) of individuals were non-immune. Prevalence of current hepatitis C infection was 10.4% (51/489; 95% CI 7.8 to 13.1).Conclusions: This study demonstrates the high prevalence of LTBI in homeless people in London and the associated poor engagement with care. There is a large unmet need for LTBI and hepatitis C infection treatment, and hepatitis B vaccination, in this group. [ABSTRACT FROM AUTHOR]

Background: The rising incidence of pulmonary Mycobacterium avium-intracellulare complex (MAI) infection is unexplained but parallels the growing world-wide epidemic of allergic disease. We hypothesized an association between pulmonary MAI infection and Th2-type immune responses as seen in allergy.Methods: Biomarkers of patient Th2-type immune responses (peripheral blood eosinophil counts and serum IgE levels) were compared between patients with positive pulmonary samples for tuberculosis and non-tuberculous mycobacterial (NTM) infection. A further comparison of clinical characteristics, including respiratory co-morbidities, and biomarkers, was conducted between patients culturing MAI NTM and those culturing NTM other than MAI.Results: Patients culturing NTM from pulmonary samples had significantly higher peripheral blood eosinophil levels than those culturing Mycobacterium tuberculosis. Furthermore, patients culturing MAI compared to those culturing NTM other than MAI had higher eosinophil counts (mean 0.29x109/L vs 0.15x109/L, p = 0.010) and IgE levels (geometric mean 138kU/L vs 47kU/L, p = 0.021). However there was no significant difference in the frequency of asthma between the two NTM groups.Conclusions: There is an association between biomarkers of Th2-type immune responses and pulmonary MAI. Prospective and translational research could identify the direction of causation; and so determine whether our finding may be utilized within future management strategies for MAI. [ABSTRACT FROM AUTHOR]

Objectives: Detailed information regarding treatment practices and outcomes of MDR-TB treatment in the UK is required as a baseline for care improvements.Methods: 100 consecutive cases between 2008 and 2014 were reviewed retrospectively at 4 MDR-TB treatment centres in England to obtain information on drug treatment choices, hospital admission duration and outcomes for MDR-TB.Results: Initial hospital admission was long, median 62.5 (IQR 20-106, n = 92) days, and 13% (12/92) of patients lost their home during this period. Prolonged admission was associated with pulmonary cases, cavities on chest radiograph, a public health policy of waiting for sputum culture conversion (CC) and loss of the patient's home. Sputum CC occurred at a median of 33.5 (IQR 16-55, n = 46) days. Treatment success was high (74%, 74/100) and mortality low (1%, 1/100). A significant proportion of the cohort had "neutral" results due to deportation and transfer overseas (12%, (12/100)). 14% (14/100) had negative outcomes for which poor adherence was the main reason (62%, 9/14).Conclusions: Successful outcome is common in recognised centres and limited by adherence rather than microbiological failure. Duration of hospital admission is influenced by lack of suitable housing and some variation in public health practice. Wider access to long-term assisted living facilities could improve completion rates. [ABSTRACT FROM AUTHOR]

Background: The largest outbreak of isoniazid-resistant (INH-R) Mycobacterium tuberculosis in Western Europe is centred in North London, with over 400 cases diagnosed since 1995. In the current study, we evaluated the genetic variation in a subset of clinical samples from the outbreak with the hypothesis that these isolates have unique biological characteristics that have served to prolong the outbreak.Methods: Fitness assays, mutation rate estimation, and whole-genome sequencing were performed to test for selective advantage and compensatory mutations.Results: This detailed analysis of the genetic variation of these INH-R samples suggests that this outbreak consists of successful, closely related, circulating strains with heterogeneous resistance profiles and little or no associated fitness cost or impact on their mutation rate.Conclusions: Specific deletions and SNPs could be a peculiar feature of these INH-R M. tuberculosis isolates, and could potentially explain their persistence over the years. [ABSTRACT FROM AUTHOR]

Background: The incidence of non-tuberculous mycobacteria (NTM) isolation from humans is increasing worldwide. In England, Wales and Northern Ireland (EW&NI) the reported rate of NTM more than doubled between 1996 and 2006. Although NTM infection has traditionally been associated with immunosuppressed individuals or those with severe underlying lung damage, pulmonary NTM infection and disease may occur in people with no overt immune deficiency. Here we report the incidence of NTM isolation in EW&NI between 2007 and 2012 from both pulmonary and extra-pulmonary samples obtained at a population level.Methods: All individuals with culture positive NTM isolates between 2007 and 2012 reported to Public Health England by the five mycobacterial reference laboratories serving EW&NI were included.Results: Between 2007 and 2012, 21,118 individuals had NTM culture positive isolates. Over the study period the incidence rose from 5.6/100,000 in 2007 to 7.6/100,000 in 2012 (p < 0.001). Of those with a known specimen type, 90 % were pulmonary, in whom incidence increased from 4.0/100,000 to 6.1/100,000 (p < 0.001). In extra-pulmonary specimens this fell from 0.6/100,000 to 0.4/100,000 (p < 0.001). The most frequently cultured organisms from individuals with pulmonary isolates were within the M. avium-intracellulare complex family (MAC). The incidence of pulmonary MAC increased from 1.3/100,000 to 2.2/100,000 (p < 0.001). The majority of these individuals were over 60 years old.Conclusion: Using a population-based approach, we find that the incidence of NTM has continued to rise since the last national analysis. Overall, this represents an almost ten-fold increase since 1995. Pulmonary MAC in older individuals is responsible for the majority of this change. We are limited to reporting NTM isolates and not clinical disease caused by these organisms. To determine whether the burden of NTM disease is genuinely increasing, a standardised approach to the collection of linked national microbiological and clinical data is required. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to summarise the findings of a desk-based international review investigating the checking of staff and volunteers working with adults who are vulnerable or at risk (or similarly defined) receiving social care in their own homes, or in day centres or residential care. Design/methodology/approach – In England, as part of the government’s attempts to prevent harm to vulnerable people, employers must check if their staff or volunteers are barred from working with vulnerable adults in the health and care sectors or if they have a relevant criminal record. This review sought to explore practices elsewhere, with a view to informing policy and practice debates. The review was undertaken in winter 2014-2015. It mainly involved a search of internet-based material and databases. This was further informed by communications with experts and practitioners from different countries. Findings – The review found a variety of practices, ranging from no checks to substantial checks involving fingerprinting. Reasons for checks identified in different national contexts extend from efforts to stop fraudulent use of government subsidies to minimising the risk of harm to vulnerable adults, and more positively to enhance user and public trust in care providers. A small number of countries place particular emphasis on the rights of individuals to privacy and rehabilitation and this moral imperative overrides other policy goals. This review highlighted a lack of clarity in publicly available documents about the potentially multiple policy goals of different schemes and suggests that there may be advantages to clarifying the options available from other countries. Research limitations/implications – This review was confined to English language material and to material located through internet searching. Some material may not have been updated on internet sites. Originality/value – The details of the processes have not previously been collated to the best of the authors’ knowledge. [ABSTRACT FROM AUTHOR]

Introduction The impact of TB disease on survival in people living with HIV in high resource settings is not well documented in the antiretroviral treatment (ART) era. We calculated TB incidence rates and compared the mortality of persons with and without HIV-TB in a UK HIV cohort in the post-ART era, to determine the impact of HIV-TB on survival in the UK. Methods We linked the national cohort of persons (aged =15 years) diagnosed with HIV between 2000 and 2008 in England, Wales and Northern Ireland with the national TB register and deaths from the Office of National Statistics. We compared all-cause and AIDS-specific mortality in patients with and without TB by estimating HRs using Cox regression modelling allowing for potential predictors. Results Overall, 3188 (7.2%) individuals developed TB infection among a cohort of 44 050 HIV-diagnosed persons and 149 663 person-years. The cumulative TB incidence rate was 2.13 per 100 person-years with a spike within the first 6 months after HIV diagnosis. TB coinfected patients comprised 18% of the 1880 deaths during follow-up and 79% of deaths (n=967) in the year following HIV diagnosis. TB coinfection (HR 4.77, 95% CI 4.11 to 5.54) was significantly associated with increased all-cause mortality. Analysis of AIDS-related survival showed similar results. Discussion The unexpected high mortality in patients with HIV-TB in a population with good healthcare access and ART availability highlights the importance of improving active and latent TB case-finding among patients with HIV, and HIV-testing among patients with TB, to ensure appropriate and prompt treatment initiation for both diseases. [ABSTRACT FROM AUTHOR]

The article presents a study conducted by 90 members if the General Practitioner Research Group in England to investigate the psychiatric aspects of hypertension. Four cases of hypertension have been recorded by each researcher, which produced four forms consisting demographic data, symptom self-rating scale, life situation, and physician's report. Psychiatric symptoms have been assessed on a five-point severity scale, including not present, mild, moderate, severe, and extremely severe. In effect, psychological factors were found to play a part in the aetiology of hypertension. However, it is inferred that such evidence has not reflected a causal relationship between anxiety and hypertension. Positive findings have been found, which is an increased pulse rate in the hypertension.

Background: Previous studies have estimated the prevalence of tuberculosis and HIV infection in population subgroups in the UK. This study was undertaken to describe recent trends in the proportion of individuals with HIV infection among reported cases of tuberculosis in England and Wales, and to review the implications for clinical and public health core. Methods: A population-based matching study using national surveillance databases was used to investigate all persons aged 15 years and over reported with a diagnosis of tuberculosis to the Health Protection Agency in England and Wales in 1999-2003. Record linkage was used to match the national tuberculosis and HIV/AIDS surveillance databases to identify all cases of tuberculosis and determine the proportion of patients with tuberculosis co-infected with HIV. The distribution and characteristics of the cases were determined and the trend examined by year. Results: Of 30 670 cases of tuberculosis reported in England and Wales between 1999 and 2003, an estimated 1743 (5.7%) were co-infected with HIV. There was a year on year increase in the proportion from 3.1% (169/5388) in 1999 to 8.3% (548/6584) in 2003 (p for trend <0.0001). Co-infected patients contributed to almost a third of the increase in the number of cases of tuberculosis during the 5 year period. Patients co-infected with HIV were predominantly those born abroad. 18.5% (n = 323) of co-infected patients had not been reported as active cases of tuberculosis on the national tuberculosis database. Conclusion: The proportion of patients with tuberculosis co-infected with HIV in England and Wales is increasing, with the greatest impact on those born abroad regardless of their ethnic origin. With HIV infection contributing substantially to the increase in the number of cases of tuberculosis, close cooperation in the clinical management and accurate notification of patients is vital if appropriate care and public health action is to be achieved. [ABSTRACT FROM AUTHOR]

Background: A description is given of a major outbreak of isoniazid monoresistant tuberculosis (TB) chiefly in north London, including prisons. The earliest case was diagnosed in 1995 with most cases appearing after 1999.Methods: Confirmation of a local cluster of cases was confirmed by restriction fragment length polymorphism (RFLP IS6110) typing or "rapid epidemiological typing" (RAPET). Further cases were found by retrospective analysis of existing databases, prospective screening of new isolates, and targeted epidemiological case detection including questionnaire analysis.Results: By the end of 2001, 70 confirmed cases in London had been linked with a further 13 clinical cases in contacts and nine epidemiologically linked cases outside London. The epidemic curve suggests that the peak of the outbreak has not yet been reached. Cases in the outbreak largely belong to a social group of young adults of mixed ethnic backgrounds including several individuals from professional/business backgrounds. Compared with other cases of TB reported to the enhanced surveillance scheme in London during 1999-2001, the cases are more likely to be of white (26/70 (37%) v 1308/7666 (17%)) or black Caribbean ethnicity (17/70 (24%) v 312/7666 (4%)), born in the UK (41/70 (59%) v 1335/7666 (17%)), and male (52/70 (74%) v 4195/7666 (55%)). Drug misuse and/or prison detention are factors common to many cases.Conclusions: The investigation of the outbreak revealed significant problems on an individual patient and population based level including difficulties with contact tracing, compliance, and the risk of developing multidrug resistance. This incident has demonstrated the value of molecular strain typing in investigating an extensive outbreak of TB. This is the first documented outbreak involving a UK prison. [ABSTRACT FROM AUTHOR]

The article relates how the Palestine Exploration Fund was founded on June 22, 1865 at Willis' Rooms in Saint James, England. The society's objective was to study the facts concerning the Holy Land using scientific principles to help in understanding the Bible. A background on its founder, George Grove, editor of "Grove's Dictionary of Music and Musicians" and first principal of the Royal College of Music is provided. Grove organized the society by persuading representatives of various sectors, factions and religions to participate in the society.

Anti-tuberculosis drug regimens are efficacious, but drug intolerance can be severe and may impact on treatment completion rates. The Enhanced Tuberculosis Surveillance (ETS) system is a case register of all new notifications of tuberculosis in England, Wales and Northern Ireland. We conducted a cohort study to estimate the incidence of, and risk factors for, drug intolerance reported through ETS between 2001 and 2010 and to assess its relationship with treatment non-completion. Reports of drug intolerance were found for 868/67 547 (1.28%) patients in the cohort, and important risk factors were female sex, older age, later case report year and white ethnicity. Drug intolerance was associated with an approximate fivefold increased odds of treatment noncompletion ( p<0.001). These results highlight the need for better-tolerated drug regimens and close case management of patients at risk of drug intolerance to improve treatment completion rates and contribute to more effective disease control. [ABSTRACT FROM AUTHOR]

The article focuses on the influence of topography on the development of a congregation. Until about 1820 most of London Jewry lived in the city, the Whites chapel area to the East and the area around the Strand to the West. It is said that Bayswater, New South Wales had taken a whole congregation from Great Portland Street, New South Wales. The main axis of the congregation lay along Westbourne Terrace, but a considerable number lived in the most fashionable area of all, to the east of Leinster Square and Cleveland Square. Very few, about 5 per cent, still lived in the central area around Great Portland Street. The Maida Vale, London in England, area attracted a considerable middle-class Jewish settlement. The decline in the proportion of members living in Maida Vale continued between 1914 and 1933, as conditions in the Maida Vale area became less attractive. With some rebuilding and rehabilitation in Maida Vale and the general trend for those who could to move back into inner London, the number of residents of Maida Vale had increased to 226 or 40 per cent of the total.

WHO standards for tuberculosis (TB) control require monitoring and evaluation of TB control programmes. In London, TB rates have stabilised at 44 per 100 000 since 2005. In 38 urban areas outside London with TB rates above the national average, these continued to rise after 2004, to 28 per 100 000 in 2008 (15% increase). London has the highest proportion of TB cases in certain risk groups, but these are increasing rapidly outside London. Many TB control efforts focus on the capital, but with rates rising elsewhere in the country, this strategy is likely to fail in the long term. INSET: Box 1 Local areas outside London with a tuberculosis rate…. [ABSTRACT FROM AUTHOR]

Despite much recent effort, there has been little change in national rates of tuberculosis (TB). Outside of the UK, the brief, structured review of the management, contact investigation and outcome of each TB case during their treatment (cohort review, CR) has improved TB control. North Central London (NCL) TB Service has piloted this approach. To date, 525 subjects with active TB have been discussed at four cohort reviews. Each "cohort" of patients were reviewed 6-9 months from start of treatment. A single case is usually reviewed within 3 min. Here we compare key outcomes relating to case management and contact tracing between an NCL TB population notified and treated prior to CR (Quarter 3 2009, n=158) and following CR implementation (Quarter 3, 2010, 1 year from start, n=125). Treatment completion rates rose (82%-90%). The proportion of cases lost to follow-up reduced (2.5%-0%). The proportion of smear positive pulmonary cases with at least one risk factor on Directly Observed Therapy increased from 42% to 67%. Uptake of HIV testing rose (71%-89%). The proportion of pulmonary TB cases with at least 1 and >5 contacts identified both increased (64%-84% and 50%-67%, respectively). In conclusion, within a short space of time cohort review has led to an improved index case management and contact tracing process in our service. It improves accountability, enhances patient management and facilitates staff education. Accurate, comprehensive and prompt data underpin this success. If this is sustained, we believe that cohort review will result in improved patient outcomes. It provides, also, an excellent structure within which advances such as the National Strain Typing project may be introduced to achieve maximal clinical impact. [ABSTRACT FROM AUTHOR]

The authors comment on the collaborative five year tuberculosis strategy launched by Public Health England and National Health Service (NHS) England. They say that the strategy is politically astute but should not deflect from the importance of guaranteeing that the future for tuberculosis is not one of continuously failing to learn from past mistakes. They also discuss the World Health Organization's End Tuberculosis strategy and the need to improve access to health and social care.

Setting and Methods London has high rates and large numbers of TB notifications. Treatment completion is generally <85% (the figure recommended by the WHO to achieve effective control). NICE TB guidelines (2011) advise using risk assessment to identify those individuals most likely to non-adhere to therapy and hence who require enhanced case management, including directly observed therapy (DOT), to complete treatment successfully. The North Central London TB Network piloted a risk assessment tool, derived from reported risk factors predisposing to non-adherence plus information from a patient profile study undertaken across London, in a cohort of 306 TB patients starting treatment between June and December 2008. On the basis of the individual's risk of non-adherence score they were broadly allocated to DOT or self-administered therapy (SAT). Here we evaluate treatment outcomes (completion and need for re-treatment) using the London TB register (LTBR) and individual case records. Results Subjects receiving SAT had excellent treatment completion rates (91%), with 3% lost to TB service follow-up (Abstract P51 table 1). Those on DOT had a lower completion rate--which at 80% was less than the international standard. Ten per cent of DOT subjects were lost to follow-up (all after transfer out of NCL TB service care). Death rates were threefold higher in the DOT group. After 20 months median follow-up post treatment completion, 3 SAT and 0 DOT patients had been re-treated for TB. Conclusions The risk assessment tool appears to discriminate those patients who can receive SAT; though it should be noted that retreatment was only required in this group--suggesting possible poor adherence with therapy in some individuals. Subjects on DOT did well within NCL TB service, but were too often lost to follow-up if transferred elsewhere. It is unclear whether this reflects inadequate local data collection and communication by, and with, our service, or genuine loss from healthcare. Either way, this requires urgent attention. The planned introduction of enhanced case management within the London TB model of care may improve this. [ABSTRACT FROM AUTHOR]

The article focuses on a retrospective case-note review of patients treated for active tuberculosis at a hospital in London, England. It examines the impact of increasing national rates of tuberculosis or human immunodeficiency virus (HIV) on guidelines for the treatment of tuberculosis in Great Britain. It notes that hepatotoxicity associated with antituberculosis therapy is an issue because guidelines recommend baseline liver function tests treatment.

Background: The clinical utility of interferon-γ release assays (IGRAs) for diagnosis of active tuberculosis is unclear, although they are commonly used in countries with a low incidence of tuberculosis. We aimed to resolve this clinical uncertainty by determining the accuracy and utility of commercially available and second-generation IGRAs in the diagnostic assessment of suspected tuberculosis in a low-incidence setting.Methods: We did a prospective cohort study of adults with suspected tuberculosis in routine secondary care in England. Patients were tested for Mycobacterium tuberculosis infection at baseline with commercially available (T-SPOT.TB and QuantiFERON-TB Gold In-Tube [QFT-GIT]) and second-generation (incorporating novel M tuberculosis antigens) IGRAs and followed up for 6-12 months to establish definitive diagnoses. Sensitivity, specificity, positive and negative likelihood ratios, and predictive values of the tests were determined.Findings: Of the 1060 adults enrolled in the study, 845 were included in the analyses and 363 were diagnosed with tuberculosis. Sensitivity of T-SPOT.TB for all tuberculosis diagnosis, including culture-confirmed and highly probable cases, was 81·4% (95% CI 76·6-85·3), which was higher than QFT-GIT (67·3% [62·0-72·1]). Second-generation IGRAs had a sensitivity of 94·0% (90·0-96·4) for culture-confirmed tuberculosis and 89·2% (85·2-92·2) when including highly probable tuberculosis, giving a negative likelihood ratio for all tuberculosis cases of 0·13 (95% CI 0·10-0·19). Specificity ranged from 86·2% (95% CI 82·3-89·4) for T-SPOT.TB to 80·0% (75·6-83·8) for second-generation IGRAs.Interpretation: Commercially available IGRAs do not have sufficient accuracy for diagnostic evaluation of suspected tuberculosis. Second-generation tests, however, might have sufficiently high sensitivity, low negative likelihood ratio, and correspondingly high negative predictive value in low-incidence settings to facilitate prompt rule-out of tuberculosis.Funding: National Institute for Health Research. [ABSTRACT FROM AUTHOR]