Introduction Disruption to tuberculosis (TB)-control programmes caused by restricted and virtual access to healthcare during the COVID-19 pandemic remains to be fully characterised. Objectives To evaluate performance and patient outcomes of the reconfigured virtual rapid access TB (RATB) service at Leicester (UK), comparing periods before, during and after the pandemic. Methods Retrospective analysis of patient referrals to Leicester RATB services and outcomes between 1st April and 31stMarch, in 2019/2020 (pre-pandemic); 2020/2021 (lockdown period); and 2021/22 (post-lockdown). Results Overall, TB was diagnosed in 270/772 patients. In the lockdown period, the median number of in-person clinic appointments fell, with a corresponding rise in virtual reviews that persisted post-lockdown. There was a decrease in the proportion of UK-origin patients diagnosed and increase in South-Asian patients. There was also a change in the source of referral, with an increased contribution from contact tracing, radiology and in-patients during the lockdown period, likely reflecting limited access to healthcare services and a higher rate of significant household exposure. Although overall interval from symptom onset to starting antituberculous therapy (ATT) was unchanged in the lockdown period, time to starting treatment increased for pulmonary TB (PTB) and fell for extrapulmonary TB (EPTB), likely reflecting attribution of symptoms to COVID-19 for PTB and possible cancer for EPTB in virtually assessed patients. Importantly, interval to starting ATT after symptom onset increased in the post lockdown period that is partially explained by delayed patient presentation, likely reflecting incomplete recovery of primary healthcare services. ATT completion rates were highest (97.7%) during the lockdown period, when case-manager support was facilitated by restricted patient mobility, but dropped post-lockdown (86.3%) with more patients lost to follow-up. Conclusions Our data provides evidence for changes to TB presentation during the pandemic. Expected delays in PTB diagnosis and treatment were observed during lockdown, however these were attributable to delayed presentation to services. A virtual RATB model, with intensive case-manager support provided effective care. Delayed diagnosis and falling treatment completion rates are observed post-lockdown, supporting prioritisation of recovery from COVID-19 in the TB action plan (2021–26).1 Reference https://www.gov.uk/government/publications/tuberculosis-tb-action-plan-for-england/tuberculosis-tb-action-plan-for-england-2021-to-202

Prolonged surgical stress and advanced malignant disease lead to systemic catabolism characterized by depletion of muscle protein and oxidation of skeletal muscle BCAA. BCAA oxidation provides energy for muscle and other organs and is the precursor for amino acid synthesis to replenish alanine and glutamine depleted in catabolic states. Persistent excessive catabolism leads to skeletal muscle wasting, negative nitrogen balance, and immune compromise. BCAAs, especially leucine, stimulate protein synthesis, inhibit proteolysis (in cell culture models and in animals), and promote glutamine synthesis. A number of small and diverse clinical trials studied the effects of BCAA-enriched nutritional support in moderately to severely stressed surgical and cancer patients. The findings of these clinical trials have been inconsistent; some show improved nitrogen balance, increased skeletal muscle protein synthesis, and reduced skeletal muscle catabolism whereas others show no significant improvement. The value of these trials is compromised by small sample size, heterogeneous patients, poor study design, varying degrees of metabolic stress, and inappropriate endpoints. More recent trials that evaluate clinical outcomes in hepatocellular carcinoma patients show promising results; in addition to improving metabolic parameters, BCAAenriched oral supplementation improved morbidity and quality of life in patients undergoing major liver resection and chemo-embolization. In summary, the role of BCAAs in the nutritional support of stressed surgical and cancer patients remains to be clearly defined, despite their potential beneficial biological properties. J. Nutr. 136: 314S–

Choudry, Haroon MD; Meng, QingHe MD, MS; Souba, Wiley MD, ScD; Vary, Thomas PhD; Lin, ChengMao PhD; Karinch, Anne PhD; Pan, Ming MB, PhD Author Information