Background Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)‐recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis ( ). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review. Objectives To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin‐resistant tuberculosis. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction. Selection criteria Randomized trials, cross‐sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture‐based drug susceptibility testing or MTBDR plus for rifampicin resistance. Data collection and analysis Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS‐2 and performed meta‐analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random‐effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing. Main results We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen. Tuberculosis detection Of the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias. Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high‐certainty evidence). We found similar accuracy when ...

Editorial group: Cochrane Infectious Diseases Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 2, 2021.

Coronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity, and diabetes. We examined the association between hypertension, obesity, and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak. RESEARCH DESIGN AND METHODS Data were collected from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, LA from 30 March to 5 April 2020. MetS was identified per World Health Organization criteria. RESULTS Among 287 patients (mean age 61.5 years; female, 56.8%; non-Hispanic black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR] 3.42 [95% CI 1.52-7.69]), intensive care unit (ICU) (aOR 4.59 [CI 2.53-8.32]), invasive mechanical ventilation (IMV) (aOR 4.71 [CI 2.50-8.87]), and acute respiratory distress syndrome (ARDS) (aOR 4.70 [CI 2.25-9.82]) compared with non-MetS. Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR 2.18 [CI, 1.25-3.81]), ARDS (aOR 2.44 [CI 1.28-4.65]), and IMV (aOR 2.36 [CI 1.33-4.21]). Diabetes was associated with ICU (aOR 2.22 [CI 1.24-3.98]) and IMV (aOR 2.12 [CI 1.16-3.89]). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, CRP, and lactate dehydrogenase (LDH) were associated with mortality (CRP [aOR 3.66] [CI 1.22-10.97] and LDH [aOR 3.49] [CI 1.78-6.83]). CONCLUSIONS In predominantly black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as MetS increased the odds of mortality compared with these comorbidities individually. Coronavirus disease 2019 (COVID-19), first described in Wuhan, China in December 2019, is caused by the severe acute respiratory syndrome coronavirus 2 (1). It has spread rapidly worldwide, infecting .7 million people as of 18 June 2020, with the U.S. leading the world both in number of cases (;2 million) and fatalities (.100,000) (2). New Orleans, LA was an early epicenter, with the highest death rate per capita in the U.S. (37.93 per 100,000 people) noted in early April (3). One-third of individuals hospitalized for COVID-19 have severe pneumonia requiring admission to an intensive

<b>OBJECTIVE</b> Coronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity and diabetes mellitus. We examined the association between hypertension, obesity and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak. <p><b>RESEARCH DESIGN AND METHODS</b> Data were collected from 287 consecutive COVID-19 patients hospitalized at two hospitals in New Orleans, Louisiana from March 30^th to April 5^th, 2020. MetS was identified per WHO criteria.</p> <p><b>RESULTS</b> Among 287 patients (mean age, 61.5 years; female, 56.8%; non-Hispanic Black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR]: 3.42, 95% confidence interval [CI]: 1.52-7.69), ICU (aOR: 4.59, CI: 2.53-8.32), invasive mechanical ventilation (IMV) (aOR: 4.71, CI: 2.50-8.87) and acute respiratory distress syndrome (ARDS) (aOR: 4.70, CI: 2.25-9.82), compared with non-MetS. Multivariable analyses of hypertension, obesity and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR, 2.18, CI, 1.25-3.81), ARDS (aOR, 2.44, CI, 1.28-4.65), and IMV (aOR, 2.36, CI, 1.33-4.21). Diabetes was associated with ICU (aOR, 2.22, CI, 1.24-3.98) and IMV (aOR, 2.12, CI, 1.16-3.89). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, C-reactive protein (CRP) and lactate dehydrogenase (LDH) were associated with mortality [CRP (aOR, 3.66, CI, 1.22-10.97), LDH (aOR, 3.49, CI, 1.78-6.83)].</p> <p><b>CONCLUSIONS</b> In predominantly Black patients hospitalized for COVID-19, the clustering of hypertension, obesity and diabetes as MetS increased the odds of mortality compared to these comorbidities individually. </p>

Objective Coronavirus disease 2019 (COVID‐19) has disproportionately impacted the African American community. This study aims to identify the risk factors for severe COVID‐19 disease in African American patients. Methods This was a retrospective cross‐sectional analysis of African American patients with COVID‐19 treated between March 12 and April 9, 2020, at a single tertiary center. The primary outcome of interest was severe disease defined as those requiring intensive care unit (ICU) admission. Results The study included 158 consecutive patients. The mean age was 57 years, and 61% were women. The mean (SD) of BMI was 33.2 (8.6) kg/m2. Overall, patients admitted to the ICU were older (62 vs. 55 years, P = 0.003) and had higher BMI (36.5 kg/m2 vs. 31.9 kg/m2, P = 0.002). In unadjusted and adjusted analysis, the factors most associated with ICU admission in this sample were age (adjusted odds ratio [aOR]: 1.073; 95% CI: 1.033‐1.114), BMI (aOR: 1.115; 95% CI: 1.052‐1.182), and lung disease (aOR: 3.097; 95% CI: 1.137‐8.437). Conclusions This study identified risk factors for severe disease in COVID‐19, specifically in an African American population. Further inclusive research aimed at optimizing clinical care relevant to the African American population is critical to ensure an equitable response to COVID‐19.

Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.

Supplemental Digital Content is available in the text

Introduction: Markers of monocyte/macrophage activation and vascular inflammation are associated with HIV-related cardiovascular diseases (CVD) and mortality. We compared these markers among African people living with HIV (PLWH) and HIV-negative adults, and examined risk factors associated with elevated biomarkers (>75th percentile) in PLWH on antiretroviral therapy (ART). Design: Cross-sectional study. Methods: We measured serum concentrations of a gut integrity biomarker (intestinal-fatty acid binding protein), monocyte/macrophage activation biomarkers (soluble CD14 and CD163), and vascular inflammation biomarkers [soluble intercellular adhesion molecule 1 (sICAM-1) and soluble vascular adhesion molecule 1 (sVCAM-1)]. We assessed the relationship of these inflammatory parameters with HIV, using logistic regression adjusting for traditional CVD risk factors. Results: Among the 541 participants, median age was 43 years and half were female. Among 275 PLWH, median CD4+ T-cell count and duration of ART use was 509 cells/μl and 8 years, respectively. PLWH had significantly higher prevalence of elevated inflammatory biomarkers compared with HIV-negative individuals even after adjustment for traditional CVD risk factors. Compared with individuals without HIV, the prevalence of elevated biomarkers was highest among persons with detectable viral load and CD4+ T-cell counts 200 cells/μl or less. In a subanalysis among PLWH, nadir CD4+ T-cell count 200 cells/μl or less was associated with elevated soluble CD14 (sCD14); dyslipidemia with elevated sCD14, sICAM-1, and sVCAM-1; and overweight/obesity with reduced sCD14. Longer ART exposure (>4 years) was associated with reduced sVCAM-1 and sICAM-1. Conclusion: HIV and not traditional CVD risk factors is a primary contributor of monocyte/macrophage activation and inflammation despite ART. Anti-inflammatory therapies in addition to ART may be necessary to reduce these immune dysregulations and improve health outcomes of African PLWH.