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IntroductionLead exposure from discharged lead dust is a recognised risk at firing ranges. We report a lead poisoning outbreak among staff and their close contacts at a UK civilian indoor 24 m firing range.MethodsA retrospective review was undertaken of data collected on all patients at risk of lead poisoning identified either by direct referral to the Clinical Toxicology clinicians at the West Midlands Poisons Unit, or via the Trace Elements Supra-Regional Assay Service Laboratory at Sandwell hospital.ResultsEighty-seven patients were identified as having possible lead exposure, either at the firing range or via close contacts. Of these, 63 patients aged between 6 months and 78 years attended for blood lead concentration (BLC) testing. The highest BLC at presentation was 11.7 µmol/L (242 µg/dL). Only nine patients reported any symptoms at presentation. Fifteen patients received lead chelation therapy with oral dimercaptosuccinic acid (or succimer) 30 mg/kg/day or intravenous sodium calcium edetate (EDTA) 75 mg/kg/day, dependent on stock availability.DiscussionThis report highlights the need for vigilance of lead poisoning as an occupational hazard in the UK, including at recreational facilities such as indoor firing ranges. It emphasises the importance of regulation of lead exposure in the workplace, particularly given the vague symptoms of lead poisoning, and proposes re-appraisal of UK legislation. This report also highlights potential issues surrounding stock availability of rarely used antidotes for uncommon presentations in the event of an outbreak of poisoning.

Males have higher tuberculosis incidence and mortality rates than females. This study aimed to assess how sex differences in tuberculosis incidence and mortality could be explained by sex differences in HIV, antiretroviral treatment (ART) uptake, smoking, alcohol abuse, undernutrition, diabetes, social contact rates, health-seeking patterns, and treatment discontinuation. We developed an age-sex-stratified dynamic tuberculosis transmission model and calibrated it to South African data. We estimated male-to-female (M:F) tuberculosis incidence and mortality ratios, the effect of the abovementioned factors on the M:F ratios and PAFs for the tuberculosis risk factors. Over the period 1990–2019, the M:F ratios for tuberculosis incidence and mortality rates persisted above 1.0, and the figures reached 1.70 and 1.65, respectively, by the end of 2019. In 2019, HIV contributed greater increases in tuberculosis incidence among females than males (54.5% vs. 45.6%); however, females experienced more reductions due to ART than males (38.3% vs. 17.5%). PAFs for tuberculosis incidence due to alcohol abuse, smoking, and undernutrition, in men were 51.4%, 29.5%, and 16.1%, respectively, higher than females (30.1%, 15.4%, and 10.7%, respectively); the PAF due to diabetes was higher in females than males (22.9% vs. 17.5%). Lower health-seeking rates in males accounted for a 7% higher mortality rate in men. The higher burden of tuberculosis in men highlights the need to improve men’s access to routine screening and ensure earlier diagnosis. Sustained efforts in providing ART remain critical in reducing HIV-associated tuberculosis. Additional interventions to reduce alcohol abuse and tobacco smoking are also needed.

Delayed linkage to tuberculosis (TB) treatment leads to poor patient outcomes and increased onward transmission. Between 12% and 25% of people diagnosed with TB are never linked to a primary health care facility for continued care. The TB health program is for creating processes that promote and facilitates easy access to care. We explored how TB patients experience TB services and how this influenced their choices around linkage to TB care and treatment. We enrolled 20 participants routinely diagnosed with TB in hospital or at primary health care facilities (PHC) in a high TB/HIV burdened peri-urban community in South Africa. Using the Western Cape Provincial Health Data centre (PHDC) which consolidates person-level clinical data, we used dates of diagnosis and treatment initiation to select participants who had been linked (immediately, after a delay, or never). Between June 2019 and January 2020, we facilitated in-depth discussions to explore both the participants' experience of their TB diagnosis and their journey around linking to TB care at a primary health care facility. We analysed the data using case descriptions. Twelve of twenty (12/20) participants interviewed who experienced a delay linking were diagnosed at the hospital. Participants who experienced delays in linking or never linked explained this as a result of lack of information and support from health care providers. Unpleasant previous TB treatment episodes made it difficult to 'face' TB again and being uncertain of their TB diagnosis. In contrast, participants said the main motivator for linking was a personal will to get better. The health care system, especially in hospitals, should focus on strengthening patient-centred care. Communication and clear messaging on TB processes is key, to prepare patients in transitioning from a hospital setting to PHC facilities for continuation of care. This should not just include a thorough explanation of their TB diagnosis but ensure that patients understand treatment processes. Former TB patients may require additional counselling and support to re-engage in care.

South Africa is a high tuberculosis (TB) burdened country. People who are newly diagnosed with TB must link to a TB treatment facility and be registered in the electronic TB notification system for ongoing care. Delayed linkage to care increases the risk of disease progression, mortality, and ongoing TB transmission. We describe lessons from a systematic tracing process aimed to support linkage to care for people diagnosed with TB. The study used the Western Cape Provincial Health Data Centre (PHDC) to identify persons newly diagnosed with TB (January-December 2020) who were not recorded as linked to care after routine linking efforts, in one peri-urban health sub-district in Cape Town, South Africa. A systematic tracing process was followed, including visits to primary health care (PHC) facilities, and home visits for those with no evidence of linkage at PHC level. Descriptive statistics were used to analyse quantitative data. Lessons learned during the process were documented. Within the PHDC, 406 persons diagnosed with TB had no evidence of being linked to TB care. Verification at PHC facilities found that 153/406 (38%) had linked to care. We traced 219 persons; of which107 (49%) could not be found. Overall, the PHDC showed 76% linkage among those traced and found and 72% among those not found. Lessons learned include the need for improved; (i) record keeping enabling the allocation of resources to patients who are truly lost to follow up, (ii) communication to improve patient understanding of timely treatment initiation and (iii) interpersonal relationships to encourage trust. The systematic tracing process was useful to understand the complexities around delayed linkage to care. To reduce ILTFU, we recommend, improving accuracy and timely recording of TB data, updating patient contact details regularly and strengthening interpersonal relations and communication between patients and healthcare workers.

Coronavirus disease (COVID-19) negatively impacted tuberculosis (TB) programs which were already struggling to meet End-TB targets globally. We aimed to quantify and compare diagnosis, treatment initiation, treatment success, and losses along this TB care cascade for drug-susceptible TB in Cape Town, South Africa, prior to and during COVID-19. This observational study used routine TB data within two predefined cohorts: pre-COVID-19 (1 October 2018-30 September 2019) and during-COVID-19 (1 April 2020-31 March 2021). The numbers of people diagnosed, treated for TB and successfully treated were received from the Western Cape Provincial Health Data Centre. Pre and post treatment loss to follow up and cascade success rates (proportion of individuals diagnosed with an outcome of treatment success) were calculated and compared across cohorts, disaggregated by sex, age, HIV status, TB treatment history and mode of diagnosis. There were 27,481 and 19,800 individuals diagnosed with drug-susceptible TB in the pre- and during-COVID-19 cohorts respectively, a relative reduction of 28% (95% CI [27.4% - 28.5%]). Initial loss to follow up increased from 13.4% to 15.2% (p<0.001), while post treatment loss increased from 25.2% to 26.1% (p < 0.033). The overall cascade success rate dropped by 2.1%, from 64.8% to 62.7% (p< 0.001). Pre- and during-COVID-19 cascade success rates were negatively associated with living with HIV and having recurrent TB. An already poorly performing TB program in Cape Town was negatively impacted by the COVID-19 pandemic. There was a substantial reduction in the number of individuals diagnosed with drug-susceptible. Increases in pre-and post-treatment losses resulted in a decline in TB cascade success rates. Strengthened implementation of TB recovery plans is vital, as health services now face an even greater gap between achievements and targets and will need to become more resilient to possible future public health disruptions.

INTRODUCTION:Biliodigestive fistula is a rare complication of cholelithiasis which can lead to gallstone ileus. The gallstone after passing into GI tract is eliminated in 85 % of the cases through the feces or vomitus. However in 15 % of the cases it gets entrapped in the GI tract most commonly in the terminal ileum. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum.CASE DESCRIPTION/METHODS:A 91 yo M presented to the hospital with one week history of nausea, vomiting and abdominal pain. He was noted to have right upper quadrant abdominal tenderness. Liver function tests were unremarkable. CT abdomen with oral contrast showed findings concerning for gastric outlet obstruction secondary to large lamellated gallstone along with a choledochoduodenal fistula. An upper GI endoscopy was done which showed a large immobile gallstone obstructing the first part of duodenum. An attempt to remove the stone endoscopically by various techniques including mechanical lithotripsy and net extraction was unsuccessful. A 7 cm gallstone partially contained in the gallbladder and extending to the duodenum was then successfully removed by open partial cholecystectomy with duodenal extraction followed by choledochoduodenal fistula repair. Patient recovered well without any complications after the surgery.DISCUSSION:Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be managed in a timely fashion. Clinically patients with this condition present with nausea, vomiting and abdominal pain. History of recent bouts of jaundice and biliary colic is seen in up to 70% of the patients. Rarely patients can present with hematemesis secondary to duodenal or celiac artery erosion. CT abdomen with contrast is the imaging of choice. Medium sized mobile stone in the duodenum can be successfully managed endoscopically by lithotripsy or net extraction. However when there is an immobile large calculus, endoscopy often fails and surgical extraction of the stone needs to be done to relieve the obstruction. Nevertheless considering the higher mortality associated with surgery, endoscopic removal of the calculus should be attempted first.

INTRODUCTION:Interventional radiology guided (IR) embolotherapy can be lifesaving when an acute gastrointestinal (GI) bleed cannot be controlled with endoscopic therapy. However, IR embolization can lead to various complications and herein we present a complication which has been published.CASE DESCRIPTION/METHODS:A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding manifesting as hematemesis. After medical optimization, the patient underwent an upper GI endoscopy (EGD) which showed large amount of frank blood in the duodenum interfering with the visualization and treatment of the bleeding site. Hence, the patient underwent an urgent IR guided arteriogram and embolization of the gastroduodenal artery by placement of vascular coils. An EGD was done 48 hours later which showed a giant non-bleeding cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. No active bleeding was noted from the ulcer. Patient had no further evidence of bleeding post embolization and was discharged. The patient presented 3 months later with abdominal pain. CT abdomen showed multiple liver abscesses. IR-guided drainage of abscesses was performed and the culture grew Streptococcus Intermedius. MRCP, ERCP and barium enema were unremarkable. The patient was treated with prolonged course of IV antibiotics and recovered without any further issues.DISCUSSION:IR guided arterial embolization can be life-saving in cases where GI bleeding cannot be controlled endoscopically, however it can lead to serious complications including endovascular coil migration into GI lumen. Endovascular coil migration can occur immediately or several years later which can result in fatal bleeding and infection. Endoscopic removal of the migrated coil with hot biopsy forceps has been reported however in most cases this complication has been conservatively followed by endoscopy. The best approach to prevent and manage migrated endovascular coils in GI lumen remains unclear.

In South Africa, low tuberculosis (TB) treatment coverage and high TB case fatality remain important challenges. Following TB diagnosis, patients must link with a primary health care (PHC) facility for initiation or continuation of antituberculosis treatment and TB registration. We aimed to evaluate mortality among TB patients who did not link to a TB treatment facility for TB treatment within 30 days of their TB diagnosis, i.e. who were “initial loss to follow-up (ILTFU)” in Cape Town, South Africa. We prospectively included all patients with a routine laboratory or clinical diagnosis of TB made at PHC or hospital level in Khayelitsha and Tygerberg sub-districts in Cape Town, using routine TB data from an integrated provincial health data centre between October 2018 and March 2020. Overall, 74% (10,208/13,736) of TB patients were diagnosed at PHC facilities and ILTFU was 20.0% (2,742/13,736). Of ILTFU patients, 17.1% (468/2,742) died, with 69.7% (326/468) of deaths occurring within 30 days of diagnosis. Most ILTFU deaths (85.5%; 400/468) occurred in patients diagnosed in hospital. Multivariable logistic regression identified increasing age, HIV positive status, and hospital-based TB diagnosis (higher in the absence of TB treatment initiation and being ILTFU) as predictors of mortality. Although hospitals account for a modest proportion of diagnosed TB patients they have high TB-associated mortality. A hospital-based TB diagnosis is a critical opportunity to identify those at high risk of early and overall mortality. Interventions to diagnose TB before hospital admission, improve linkage to TB treatment following diagnosis, and reduce mortality in hospital-diagnosed TB patients should be prioritised.