Enteric fever and COVID-19 co-infection in a teenager returning from Pakistan

As SARS-CoV-2 has become widespread around the globe, co-infection with other endemic infectious diseases will occur. Here we present the first reported case of enteric fever and COVID-19 co-infection, in a teenager returning from travel to Pakistan and describe his clinical course.

Interleukin-6 in Covid-19: A systematic review and meta-analysis

Coronaviruses may activate dysregulated host immune responses. As exploratory studies have suggested that interleukin-6 (IL-6) levels are elevated in cases of complicated Covid-19, we undertook a systematic review and meta-analysis to assess the evidence in this field. We systematically searched MEDLINE and EMBASE for studies investigating the immunological response in Covid-19; additional grey literature searches were undertaken. Study selection and data abstraction was undertaken independently by two authors. Meta-analysis was undertaken using random effects models to compute ratios of means with 95% confidence intervals (95%CIs). Eight published studies and two preprints (n = 1798) were eligible for inclusion. Meta-analysis of mean IL-6 concentrations demonstrated 2.9-fold higher levels in patients with complicated Covid-19 compared with patients with noncomplicated disease (six studies; n = 1302; 95%CI, 1.17-7.19; I² = 100%). Consistent results were found in sensitivity analyses exclusively restricted to studies comparing patients requiring ICU admission vs no ICU admission (two studies; n = 540; ratio of means = 3.24; 95%CI, 2.54-4.14; P < .001; I² = 87%). Nine of ten studies were assessed to have at least moderate risk of bias. In patients with Covid-19, IL-6 levels are significantly elevated and associated with adverse clinical outcomes. Inhibition of IL-6 may be a novel target for therapeutics for the management of dysregulated host responses in patients with Covid-19 and high-quality studies of intervention in this field are urgently required.

Interleukin-6 in Covid-19: A systematic review and meta-analysis

Coronaviruses may activate dysregulated host immune responses. As exploratory studies have suggested that interleukin-6 (IL-6) levels are elevated in cases of complicated Covid-19, we undertook a systematic review and meta-analysis to assess the evidence in this field. We systematically searched MEDLINE and EMBASE for studies investigating the immunological response in Covid-19; additional grey literature searches were undertaken. Study selection and data abstraction was undertaken independently by two authors. Meta-analysis was undertaken using random effects models to compute ratios of means with 95% confidence intervals (95%CIs). Eight published studies and two preprints (n = 1798) were eligible for inclusion. Meta-analysis of mean IL-6 concentrations demonstrated 2.9-fold higher levels in patients with complicated Covid-19 compared with patients with noncomplicated disease (six studies; n = 1302; 95%CI, 1.17-7.19; I² = 100%). Consistent results were found in sensitivity analyses exclusively restricted to studies comparing patients requiring ICU admission vs no ICU admission (two studies; n = 540; ratio of means = 3.24; 95%CI, 2.54-4.14; P < .001; I² = 87%). Nine of ten studies were assessed to have at least moderate risk of bias. In patients with Covid-19, IL-6 levels are significantly elevated and associated with adverse clinical outcomes. Inhibition of IL-6 may be a novel target for therapeutics for the management of dysregulated host responses in patients with Covid-19 and high-quality studies of intervention in this field are urgently required.

Social media and vaccine hesitancy: new updates for the era of COVID-19 and globalized infectious diseases

Despite major advances in vaccination over the past century, resurgence of vaccine-preventable illnesses has led the World Health Organization to identify vaccine hesitancy as a major threat to global health. Vaccine hesitancy may be fueled by health information obtained from a variety of sources, including new media such as the Internet and social media platforms. As access to technology has improved, social media has attained global penetrance. In contrast to traditional media, social media allow individuals to rapidly create and share content globally without editorial oversight. Users may self-select content streams, contributing to ideological isolation. As such, there are considerable public health concerns raised by anti-vaccination messaging on such platforms and the consequent potential for downstream vaccine hesitancy, including the compromise of public confidence in future vaccine development for novel pathogens, such as SARS-CoV-2 for the prevention of COVID-19. In this review, we discuss the current position of social media platforms in propagating vaccine hesitancy and explore next steps in how social media may be used to improve health literacy and foster public trust in vaccination.

A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly spread globally since being identified as a public health emergency of major international concern and has now been declared a pandemic by the World Health Organization (WHO). In December 2019, an outbreak of atypical pneumonia, known as COVID-19, was identified in Wuhan, China. The newly identified zoonotic coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is characterized by rapid human-to-human transmission. Many cancer patients frequently visit the hospital for treatment and disease surveillance. They may be immunocompromised due to the underlying malignancy or anticancer therapy and are at higher risk of developing infections. Several factors increase the risk of infection, and cancer patients commonly have multiple risk factors. Cancer patients appear to have an estimated twofold increased risk of contracting SARS-CoV-2 than the general population. With the WHO declaring the novel coronavirus outbreak a pandemic, there is an urgent need to address the impact of such a pandemic on cancer patients. This include changes to resource allocation, clinical care, and the consent process during a pandemic. Currently and due to limited data, there are no international guidelines to address the management of cancer patients in any infectious pandemic. In this review, the potential challenges associated with managing cancer patients during the COVID-19 infection pandemic will be addressed, with suggestions of some practical approaches. IMPLICATIONS FOR PRACTICE: The main management strategies for treating cancer patients during the COVID-19 epidemic include clear communication and education about hand hygiene, infection control measures, high-risk exposure, and the signs and symptoms of COVID-19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case-by-case basis. Minimizing outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure. More research is needed to better understand SARS-CoV-2 virology and epidemiology.

In Reply

This letter to the editor remarks on additional considerations for the management of febrile neutropenia during the COVID‐19 pandemic, in response to the letter by Boutayeb et al.

Distal transradial access for cardiac catheterization: A systematic scoping review

OBJECTIVE

Systematically review the literature for cardiac catheterization and coronary angiography via distal transradial access (dTRA) and its outcomes.

BACKGROUND

dTRA, via anatomical snuffbox, may have several advantages over conventional transradial access (cTRA) for percutaneous cardiac procedures, including easier left-sided access for aorto-coronary grafts, future proximal radial artery preservation, and patient and operator comfort. However, its procedural characteristics and safety profile remain unclear.

METHODS

Ovid MEDLINE and EMBASE were searched from inception to September 2018. Two authors independently performed two-stage selection and data extraction. Reports assessing the dTRA approach for cardiac intervention in adults reporting any outcomes were eligible. Descriptive summary statistics were calculated from pooled data.

RESULTS

A total of 19 publications comprising 4,212 participants undergoing dTRA were included. Mean age was 63.8 years, and 23.0% were female. dTRA was primarily undertaken for assessment of stable coronary artery disease (87.6%), with 41.7% for diagnostic procedures and 46.9% undergoing percutaneous coronary intervention. The overall success rate for undertaking the dTRA approach was 95.4% (69-100%). Complications occurred in 2.4% of cases, of which the leading complications were bleeding/hematoma (18.2%). Complication rates did not significantly differ between dTRA and cTRA. The occurrence of radial artery occlusion in patients undergoing dTRA was low (1.7%).

CONCLUSIONS

Observational data demonstrate that dTRA is a safe and feasible method for percutaneous cardiac procedures, with high rates of procedural success and low rates of complication. As data comparing dTRA with cTRA remain limited, future high-quality randomized comparative studies are required.

Temporal trends in anti-vaccine discourse on Twitter

Despite vaccination's role in preventing communicable diseases, misinformation threatens uptake. Social media may disseminate such anti-vaccination messages. We characterized trends in pro- and anti-vaccination discourse on Twitter. All tweets between 2010 and 2019 containing vaccine-related hashtags were identified. Pro- and anti-vaccine tweets and users per quarter (3-months) were tabulated; discussion subcommunities were identified with network analysis. 1,637,712 vaccine-related tweets were identified from 154 pro-vaccine and 125 anti-vaccine hashtags, with 86% of users posting exclusively pro-vaccine and 12% posting exclusively anti-vaccine hashtags. Pro-vaccine tweet volumes are larger than anti-vaccine tweets and consistently increase over time. In contrast, anti-vaccine tweet volumes have decreased since 2014, despite an increasing anti-vaccine user-base. Users infrequently responded across pro/anti-vaccine alignment (0.2%). Despite greater volumes of pro-vaccination discourse in recent years, and the anti-vaccination content userbase being smaller, the anti-vaccine community continues to grow in size. This finding coupled with the minimal inter-communication between communities suggests possible ideological isolation.

Skin cancer screening after solid organ transplantation: Survey of practices in Canada

Guidelines recommend annual dermatology screening after solid organ transplantation to facilitate early detection of keratinocyte carcinoma (nonmelanoma skin cancer), the most common posttransplant malignancy. There are limited data on adherence levels and barriers to screening. We conducted a cross-sectional survey of 477 physicians and nurses providing posttransplant care in Canada. The questionnaire asked about skin cancer screening and education practices, including the perceived importance and barriers. Whereas care providers viewed skin cancer screening as important for adult patients (median rating of 10/10, interquartile range 8-10), only 53% ensured annual screening for white adult transplant recipients. Having a screening policy in place (adjusted odds ratio 6.78, 95% confidence interval 3.12-14.74) and a dermatologist present at the transplant center (adjusted odds ratio 2.19, 95% confidence interval 1.03-4.67) were independently associated with higher adherence. Long wait times, lack of specialized transplant dermatologists, long travel distances, and insufficient priority were cited as the most common barriers for access to dermatologic care. Skin cancer education was provided to patients by over three quarters of care providers. Given the self-reported lack of adherence to annual skin cancer screening, there is need to develop, evaluate, and implement interventions that improve screening rates and skin cancer outcomes.

Information on Cardiovascular Disease in the Digital Era: Results From a Cross-Sectional Patient Survey

Public health strategies to reduce cardiovascular disease (CVD) rely on the effective dissemination of evidence-based information to at-risk populations. An improved understanding of the information sources patients use can facilitate content development and promote awareness of effective interventions for CVD prevention, monitoring, and management. We therefore sought to determine the contemporary patterns of CVD information source usage via a prospective, cross-sectional survey study of CVD information sources in a primary care centre in Ontario, Canada. Primary source(s) used for CVD information were defined as: traditional media (television or print media), Internet-based sources, or community resources (community agencies and health care providers). Of 4682 consecutively screened patients aged > 18 years 3189 (68%) participated in the survey. The mean age of the survey respondents was 37 ± 14 years and 54.4% were female. Traditional media (71%) were used more frequently than Internet-based sources (45%) or community health services (23%). Only 20% of respondents identified health care providers as the source of information for CVD. Compared with respondents aged ≥ 55 years, the adjusted odds of Internet-based source use were significantly higher among younger age groups, whereas the adjusted odds of print media and health services usage was lowest among ages 25-34 years. Although traditional print and electronic media remain the primary resource for CVD-related information, younger individuals increasingly rely on Internet-based sources. These findings have important implications for public health policy and resource allocation, highlighting the importance of maintaining traditional media presence in addition to the development of high-quality Internet-based sources of CVD information.

Efficacy of Cidofovir in Treatment of BK Virus-Induced Hemorrhagic Cystitis in Allogeneic Hematopoietic Cell Transplant Recipients

BK virus-associated hemorrhagic cystitis (BK-HC) is a common complication after allogeneic hematopoietic stem cell transplantation (allo-HCT), with incidences up to 70%. Cidofovir is an antiviral agent with growing evidence as a therapeutic intervention. To assess the safety profile and efficacy of intravenous and intravesical cidofovir in allo-HCT patients with BK-HC, a retrospective study was undertaken of the allo-HCT cohort who received cidofovir for symptomatic BK-HC (hematuria with BK viruria or viremia) from January 2010 until March 2017 in a single transplant center in Ontario, Canada. The primary outcome measure was a reduction in BK-HC severity (graded from 1 to 4); secondary outcomes included overall survival, BK virus titers, and the onset of acute kidney injury. Twelve allo-HCT patients received cidofovir for BK-HC, with pretreatment clinical severity of 3 (50%) or 4 (50%). Cidofovir was administered via intravenous (33%), intravesical (58%), or both modalities (8%). After a median cumulative dose of 10 mg/kg (range, 1 to 37), mean BK-HC grade decreased significantly by 1.8 (3.5 precidofovir, 1.7 postcidofovir, P < .01). Sixty-six percent of patients had at least partial response to cidofovir, with similar response rates between intravenous (66%) and intravesical (62%) administration. Sixty-seven percent of patients died, and 33% of patients experienced renal toxicity, including 2 patients receiving intravesical therapy. In this retrospective series, there was a significant reduction in BK-HC severity after cidofovir administration; most patients achieved at least partial response after cidofovir administration. Even with intravesical instillation, acute kidney injury remains a potential complication of cidofovir. Although cidofovir may be an efficacious therapy for BK-HC, albeit with potential demonstrated toxicities, further prospective trials are needed.

An efficient strategy allowed English-speaking reviewers to identify foreign-language articles eligible for a systematic review

OBJECTIVE

To assess English-speaking reviewers' accuracy in determining the eligibility of foreign-language articles for a systematic review.

STUDY DESIGN AND SETTINGS

Systematic review of randomized controlled trials of therapy for fibromyalgia. Guided by 10 questions, English-speaking reviewers screened non-English-language articles for eligibility. Teams of two native-language speakers provided reference standard judgments of eligibility.

RESULTS

Of 15,466 potentially eligible articles, we retrieved 763 in full text, of which 133 were published in 19 non-English languages; 53 trials published in 11 languages other than English proved eligible. Of the 53 eligible articles, English-language reviewers guided by the 10 questions mistakenly judged 6 as ineligible; of the 80 ineligible articles, 8 were incorrectly judged eligible by English-language reviewers (sensitivity=0.89; specificity=0.90). Use of a simple three-step rule (excluding languages with less than three articles, reviewing titles and abstracts for clear indications of eligibility, and noting the lack of a clearly reported statistical analysis unless the word "random" appears) led to accurate classification of 51 of 53 articles (sensitivity=0.96; specificity=0.70).

CONCLUSION

Our findings show promise for limiting the need for non-English-language review teams in systematic reviews with large numbers of potentially eligible non-English-language articles.

Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol

BACKGROUND

Fibromyalgia is associated with substantial socioeconomic loss and, despite considerable research including numerous randomized controlled trials (RCTs) and systematic reviews, there exists uncertainty regarding what treatments are effective. No review has evaluated all interventional studies for fibromyalgia, which limits attempts to make inferences regarding the relative effectiveness of treatments.

METHODS/DESIGN

We will conduct a network meta-analysis of all RCTs evaluating therapies for fibromyalgia to determine which therapies show evidence of effectiveness, and the relative effectiveness of these treatments. We will acquire eligible studies through a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, PsychINFO, PapersFirst, ProceedingsFirst, and the Cochrane Central Registry of Controlled Trials. Eligible studies will randomly allocate patients presenting with fibromyalgia or a related condition to an intervention or a control. Teams of reviewers will, independently and in duplicate, screen titles and abstracts and complete full text reviews to determine eligibility, and subsequently perform data abstraction and assess risk of bias of eligible trials. We will conduct meta-analyses to establish the effect of all reported therapies on patient-important outcomes when possible. To assess relative effects of treatments, we will construct a random effects model within the Bayesian framework using Markov chain Monte Carlo methods.

DISCUSSION

Our review will be the first to evaluate all treatments for fibromyalgia, provide relative effectiveness of treatments, and prioritize patient-important outcomes with a focus on functional gains. Our review will facilitate evidence-based management of patients with fibromyalgia, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.