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BACKGROUND: We conducted the first national TB prevalence survey to provide accurate estimates of bacteriologically confirmed pulmonary TB disease among adults aged ≥15 years in 2014.METHODS: A TB symptoms screen and chest X-ray (CXR) were used to identify presumptive TB cases who submitted two sputum samples for smear microscopy, liquid and solid culture. Bacteriological confirmation included acid-fast bacilli smear positivity confirmed using Xpert® MTB/RIF and/or culture. Prevalence estimates were calculated using random effects logistic regression with multiple imputations and inverse probability weighting.RESULTS: Of 43,478 eligible participants, 33,736 (78%) were screened; of these 5,820 (17%) presumptive cases were identified. There were 107 (1.9%) bacteriologically confirmed TB cases, of which 23 (21%) were smear-positive. The adjusted prevalences of smear-positive and bacteriologically confirmed TB disease were respectively 82/100,000 population (95% CI 47-118/100,000) and 344/100,000 (95% CI 268-420/100,000), with an overall all-ages, all-forms TB prevalence of 275/100,000 population (95% CI 217-334/100,000). TB prevalence was higher in males, and age groups 35-44 and ≥65 years. CXR identified 93/107 (87%) cases vs. 39/107 (36%) using the symptom screen.CONCLUSION: Zimbabwe TB disease prevalence has decreased relative to prior estimates, possibly due to increased antiretroviral therapy coverage and successful national TB control strategies. Continued investments in TB diagnostics for improved case detection are required.

The goal of the heart and lungs is to deliver oxygen at a tissue level, and this is determined by cardiac output (CO) and the oxygen content of arterial blood (CaO2), DO2 = CO × CaO2. ¹ The heart and lungs share the same intrathoracic space: mechanically this is akin to having a pump within a pump.2 Cardiopulmonary interactions refer to the relationship between airway pressures, lung volumes, and CO. ³ In health, the effect of cardiopulmonary interactions is minimal. It is important to look at each part of the heart separately as phasic changes in intrathoracic pressures (ITP) have differing effects. In a spontaneously breathing person, a negative ITP is transmitted to the right atrium. The flow of blood to the right atrium is governed by Ohm’s law, flow = ΔP/R, where ΔP is the driving pressure to the right atrium and R is the resistance of the capacitance vessels.4 With positive pressure ventilation (PPV) the increased ITP is transmitted to the right atrium, which results in a reduction of the driving pressure and ultimately the venous return (VR). The right ventricle afterload is the pressure that the heart must work against to eject blood during systole, and this is determined by the pulmonary vascular resistance (PVR). PVR is determined by the extra-alveolar vessels and the intra-alveolar vessels. The total PVR is the addition of the two and lowest at functional residual capacity.5 The left ventricle preload is essentially equal to the right ventricle output. There is a time lag as blood must traverse the pulmonary circulation. Left ventricle afterload can be expressed as left ventricular (LV) wall stress. Afterload increases as transmural pressure and vascular resistance increase. Positive pressure reduces the transmural pressure needed for the ejection of the stroke volume. With negative ITP there is a pressure pulling outwards as the ventricle attempts to eject its stroke volume, therefore higher transmural pressures are needed.4 Knowing how the heart and lungs work in the normal physiological state will help guide decision-making about heart-lung interactions in critically ill patients therefore mitigating any adverse consequences. [ABSTRACT FROM AUTHOR]

The syndromic paediatric airway poses a potentially difficult airway due to the anatomical and functional difficulties that are seen in the management of this paediatric airway.1 A difficult airway is described as one where a trained anaesthesiologist experiences difficulty with face mask ventilation or difficulty with tracheal intubation, or both.2 The Mallampati scoring system for airway assessment is not always reliable in the paediatric population, therefore some clinicians prefer to use the Colorado Paediatric Airway Score (COPUR) since it is more detailed and possibly more reliable.2 The syndromes can be divided into conditions associated with hypoplasia of the mandible (micrognathia), which can result in a difficult intubation; midface hypoplasia, which can result in difficult bag-mask ventilation; macroglossia, which can cause difficult bag-mask ventilation and difficult intubation. Syndromes related to cervical spine abnormalities may cause difficulties with laryngoscopy and intubation. Syndromes associated with: Micrognathia - include Pierre Robin sequence, Treacher Collins, Goldenhar Midface hypoplasia - Apert syndrome, Crouzon, Pfeiffer Macroglossia - Hurler's syndrome, Beckwith-Wiedemann syndrome and Down syndrome Cervical spine abnormalities - Klippel-Feil, Turner and Noonan's syndrome In the syndromic patient, proper planning and preparation are key in order to reduce the mortality and morbidity associated with the management of the difficult airway.3 The entire theatre team needs to be briefed on the plan for managing the airway. A thorough history and examination should be conducted on the patient, taking special note of any upper airway obstruction and its severity. Different airway equipment such as supraglottic devices, video laryngoscopes and fibreoptic bronchoscopes should be available in theatre depending on the cases, available resources and expertise of the airway manager.4 The primary goal for tackling the difficult airway is to keep the patient breathing spontaneously and to achieve a deep plane of anaesthesia before airway instrumentation. Knowledge of the difficult airway algorithm is key, as it allows one to manage the difficult airway in a stepwise approach. [ABSTRACT FROM AUTHOR]

Cardiovascular mechanical support includes the use of devices such as the intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs). These are used in cardiogenic shock (CS) as a bridge to decision (BTD), bridge to transplantation (BTT) or destination therapy (DT). CS is associated with significant morbidity and mortality.¹ It is a state of low cardiac output associated with hypotension and end-organ hypoperfusion. It includes a systolic blood pressure (SBP) < 90 mmHg or the requirement of vasopressor support to maintain an SBP of at least 90 mmHg, and some signs of end-organ hypoperfusion such as altered mental state, oliguria and a rising lactate.² Other advanced haemodynamic parameters include a cardiac index (CI) < 1.8 l/min/m² without support or < 2.2 l/min/m² with support and an elevated left ventricular enddiastolic pressure (LVEDP) > 18 mmHg.² Maximal medical therapy may no longer be seen as the end point for refractory circulatory shock, especially in well-resourced settings.³ The goal of mechanical circulatory support (MCS) is to move blood from an insufficient ventricle into the aorta or pulmonary artery with the aim of restoring cardiac output.4 MCS can be achieved with either short-term devices that are placed temporarily or long-term devices. It is not without complications and these need to be managed by a multidisciplinary team. The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles are used to stratify patients with heart failure into the New York Heart Association (NYHA) functional class III or class IV into one of seven distinct profiles. Based on this profile, a practitioner is able to reasonably gauge how quickly to intervene in terms of placement of a mechanical circulatory device from hours or days to months. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend MCS as a class I therapy as BTT.5 [ABSTRACT FROM AUTHOR]

Households affected by tuberculosis have syndemic vulnerability, reflecting a concentration of and interactions between multiple biomedical, psychosocial, and structural determinants of health. Traditional approaches to tuberculosis screening do not address pre-existing risks, such as undernutrition and other chronic conditions, or the indirect effects of tuberculosis, such as loss of livelihood. These pre-existing risks and consequences not only perpetuate the global tuberculosis epidemic but, for those affected, lead to poor health and deepen poverty. We propose reimagining tuberculosis screening as an opportunity to deliver a contextually relevant package of services that address the needs of households affected by tuberculosis. This approach puts people and their rights at the centre of efforts to end tuberculosis, and has equity at the core. This approach could support progress towards universal health coverage, benefiting communities and health systems. Leadership, flexibility in funding allocation, and innovative care models will be required to realise this approach at scale., Competing Interests: Declaration of interests CJC and RAF acknowledge funding from the Wellcome Trust. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe., Methods: We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs., Results: A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1])., Conclusion: The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs., (© 2021 John Wiley & Sons Ltd.)

Introduction: Zimbabwe is one of the 30 countries globally with a high burden of multidrug-resistant TB or rifampicin-resistant TB. The World Health Organization recommended that patients diagnosed with multidrug-resistant TB be treated with 20-24 month standardized second-line drugs since 2010. However, factors associated with mortality and treatment success have not been systematically evaluated in Zimbabwe. The Objective of the study was to assess factors associated with Mortality and treatment success among multidrug-resistant-TB patients registered and treated under the National Tuberculosis programme in Zimbabwe., Methods: the study was conducted using secondary data routinely collected from the National tuberculosis (TB) programme. Categorical variables were summarised using frequencies and a generalized linear model with a log-link function and a Poisson distribution was used to assess factors associated with mortality and treatment success. The level of significance was set at P-Value < 0.05., Results: patient antiretroviral therapy (ART) status was a significant associated factor of treatment success or failure (RRR = 3.92, p < 0.001). Patients who were not on ART had a high risk of death by 3.92 times compared to patients who were on ART. In the age groups 45 - 54 years (relative risk ratios (RRR) = 1.41, p = 0.048), the risk of death was increased by 1.41 times compared to other age groups. Patients aged 55 years and above (RRR = 1.55, p = 0.017), had a risk of dying increased by 1.55 times compared to other age groups. Diagnosis time duration of 8 - 30 days (RRR = 0.62, p = 0.022) was found to be protective, a shorter diagnosis time duration between 8 to 30 days reduced the risk of TB deaths by 0.62 times compared to longer periods. Missed TB doses of > 10% (RRR = 2.03, p < 0.001) increased the risk of MDR/RR-TB deaths by 2.03 times compared to missing TB doses of ≤ 10%., Conclusion: not being on ART when HIV positive was a major significant predictor of mortality. Improving ART uptake among those ART-naïve and strategies aimed at improving treatment adherence are important in improving treatment success rates., Competing Interests: The authors declare no competing interests., (Copyright: Ronnie Matambo et al.)

Introduction: an estimated 25% of the world population is infected with Mycobacterium tuberculosis. In 2017, new tuberculosis cases were estimated at 10 million, while 1.6 million tuberculosis related deaths were recorded, 25% residing in Africa. Treatment outcomes of multi drug resistant Tuberculosis patients in Zimbabwe has been well documented but the role of bacteriological monitoring on treatment outcomes has not been systematically evaluated. The objective of the study was to determine the role of bacteriological monitoring using culture and drug susceptibility tests on treatment outcomes among patients with multi drug resistant tuberculosis., Methods: a retrospective, secondary data analysis was conducted using routinely collected data of patients with multi drug resistant TB in Zimbabwe. Frequencies were used to summarize categorical variables and a generalized linear model with a log-link function and a Poisson distribution was used to assess factors associated with unfavourable outcomes. The level of significance was set at P-Value<0.05., Results: about the study collected data from 473 records of patients with an average age of 36.35 years. Forty-nine percent (49%) were male and 51% were female. Results showed that when a patient has baseline culture result missing, has no culture conversion result, regardless of having a follow up culture and drug susceptibility test result, the risk of developing unfavourable outcomes increase by 3.9 times compared to a patient who has received all the three (3) bacteriological monitoring tests., Conclusion: results highlights the need for consistent bacteriological monitoring of patients to avert unfavourable treatment outcomes., Competing Interests: The authors declare no competing interests., (Copyright: Ronnie Matambo et al.)

Background: Zimbabwe is one of the thirty countries globally with a high burden of multidrug-resistant tuberculosis (TB) or rifampicin-resistant TB (MDR/RR-TB). Since 2010, patients diagnosed with MDR/RR-TB are being treated with 20-24 months of standardized second-line drugs (SLDs). The profile, management and factors associated with unfavourable treatment outcomes of MDR/RR TB have not been systematically evaluated in Zimbabwe., Objective: To assess treatment outcomes and factors associated with unfavourable outcomes among MDR/RR-TB patients registered and treated under the National Tuberculosis Programme in all the district hospitals and urban healthcare facilities in Zimbabwe between January 2010 and December 2015., Methods: A cohort study using routinely collected programme data. The 'death', 'loss to follow-up' (LTFU), 'failure' and 'not evaluated' were considered as "unfavourable outcome". A generalized linear model with a log-link and binomial distribution or a Poisson distribution with robust error variances were used to assess factors associated with "unfavourable outcome". The unadjusted and adjusted relative risks were calculated as a measure of association. A 𝑝value< 0.05 was considered statistically significant., Results: Of the 473 patients in the study, the median age was 34 years [interquartile range, 29-42] and 230 (49%) were males. There were 352 (74%) patients co-infected with HIV, of whom 321 (91%) were on antiretroviral therapy (ART). Severe adverse events (SAEs) were recorded in 118 (25%) patients; mostly hearing impairments (70%) and psychosis (11%). Overall, 184 (39%) patients had 'unfavourable' treatment outcomes [125 (26%) were deaths, 39 (8%) were lost to follow-up, 4 (<1%) were failures and 16 (3%) not evaluated]. Being co-infected with HIV but not on ART [adjusted relative risk (aRR) = 2.60; 95% CI: 1.33-5.09] was independently associated with unfavourable treatment outcomes., Conclusion: The high unfavourable treatment outcomes among MDR/RR-TB patients on standardized SLDs were coupled with a high occurrence of SAEs in this predominantly HIV co-infected cohort. Switching to individualized all oral shorter treatment regimens should be considered to limit SAEs and improve treatment outcomes. Improving the ART uptake and timeliness of ART initiation can reduce unfavourable outcomes., Competing Interests: The authors have declared that no competing interests exist

Objective: To determine the prevalence of resistance to rifampicin alone; rifampicin and isoniazid, and second-line anti-TB drugs among sputum smear-positive tuberculosis patients in Zimbabwe., Design: A health facility-based cross-sectional survey., Results: In total, 1114 (87.6%) new and 158 (12.4%) retreatment TB patients were enrolled. MTB was confirmed by Xpert MTB/RIF among 1184 (93%) smear-positive sputum samples. There were 64 samples with Xpert MTB/RIF-determined rifampicin resistance. However, two were rifampicin susceptible on phenotypic drug susceptibility testing. The prevalence of RR-TB was [4.0% (95% CI, 2.9, 5.4%), n=42/1043) and 14.2% (95% CI, 8.9, 21.1%; n=20/141) among new and retreatment patients, respectively. The prevalence of MDR-TB was 2.0% (95% CI, 1.3, 3.1%) and 6.4% (95% CI, 2.4, 10.3%) among new and retreatment TB patients, respectively. Risk factors for RR-TB included prior TB treatment, self-reported HIV infection, travel outside Zimbabwe for ≥one month (univariate), and age <15 years. Having at least a secondary education was protective against RR-TB., Conclusion: The prevalence of MDR-TB in Zimbabwe has remained stable since the 1994 subnational survey. However, the prevalence of rifampicin mono-resistance was double that of MDR-TB., (Copyright © 2019. Published by Elsevier Ltd.)

Objectives: To determine the proportion of rifampicin-resistant tuberculosis (RR-TB) patients who accessed second-line drug susceptibility testing (SL-DST) results following introduction of the Hain technology in southern provinces, Zimbabwe., Design: Cohort study using secondary data., Results: Xpert MTB/RIF results were used to identify 133 RR-TB patients for this study. Their mean age (SD) was 37.9 (11.1) years, 83 (62%) were males and 106 (80%) were HIV-infected. There were 6 (5%) participants who had pre-treatment attrition. Of the 133 pulmonary TB (PTB) patients, 117 (80%) had additional sputum specimens collected; 96 (72%) specimens reached the National TB Reference Laboratory (NTBRL); 95 (71%) were processed; 68 (51%) had SL-DST results. Only 53 (40%) SL-DST results reached the peripheral facilities. Median time from specimen reception at the NTBRL to SL-DSTs was 40 days, interquartile range (IQR: 28-67). Median time from presumptive diagnosis of RR-TB by health care worker to SL-DST results was 50days (IQR: 39-80), and increased to 79days (IQR: 39-101) in facilities >250km from the NTBRL. The proportion with any fluoroquinolone resistance was 9 (13.2%)., Conclusion: Although RR-TB patients with PTB were initiated timely on treatment, access to SL-DSTs by facilities needs improvement. Health inequities exist as remote areas are less likely to get SL-DST results in time., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

1,4-Diols resulting from the double addition of ArCCLi (Ar = Ph, substituted phenyl, 2-thienyl) to ortho-C6H4(CHO)2 undergo cascades to tetracenes on simple admixture of LiHDMS, CS2 and MeI. Acene formation proceeds by [3,3]-sigmatropic rearrangement of xanthate anions followed by 6π electrocyclisations. The reactions are terminated by E2 or anionic Chugaev-type eliminations. Structural packing motifs and electronic properties are reported for the tetracenes.

Background: Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB., Methods: A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days., Results: Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045]., Conclusion: Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays.