Reduced Risk of Serious Pneumococcal Infection Up to 10 Years After 7-Valent Pneumococcal Conjugate Vaccine in Arthritis Patients

Background: To examine rates of serious pneumococcal infections up to 10 years after vaccination with 7-valent conjugated pneumococcal vaccine (PCV7) in patients with arthritis compared to non-vaccinated arthritis patients.Methods: In total, 595 adult arthritis patients (rheumatoid arthritis; RA=342, 80% women and spondylarthropathy; SpA=253, 45% women) received one dose of PCV7. Mean age/disease duration were 62/16 and 51/14 years, respectively. For each patient, 4 matched reference subjects were identified.At vaccination, 420 patients received bDMARDs (anti-TNF=330, tocilizumab=15, abatacept=18, anakinra=1, rituximab=56). Methotrexate was given as monotherapy (n=86) or in combination with bDMARD (n=220). 89 SpA patients received NSAIDs without DMARD. The Skåne Healthcare Register was searched for ICD-10 diagnostic codes for pneumococcal infections (pneumonia, lower respiratory tract infection, septicemia, meningitis, septic arthritis) between January 2000 and December 2018. Frequency of infections after vs before vaccination were calculated (relative risks). Relative risk ratio (RRR) and relative risk reduction (1-RRR) were calculated comparing patients vs non-vaccinated references. Kaplan-Meier and Cox regression were used to investigate time to first event and predictors of infections.Results: Among vaccinated RA and SpA patients, there was a significant relative risk reduction of pneumonia and all serious infections; 53% and 46%, respectively. There was no significant difference in time to first pneumonia or all serious infections after vaccination between patients and references. Higher age, RA diagnosis and concomitant prednisolone were associated with infections.Conclusion: One dose of pneumococcal conjugate vaccine may decrease risk of serious pneumococcal infection up to 10 years in patients with arthritis receiving immunomodulating treatment. Clinical trial registration number: EudraCT EU 2007-006539-29 and NCT 00828997

Antimicrobial Photodynamic Coatings Reduce the Microbial Burden on Environmental Surfaces in Public Transportation - a Field Study in Buses

Millions of people use public transportation daily worldwide and frequently touch surfaces, thereby producing a reservoir of microorganisms on surfaces increasing the risk of transmission. Constant occupation makes sufficient cleaning difficult to achieve. Thus, an autonomous, perma-nent antimicrobial coating (AMC) could keep down the microbial burden on such surfaces. A photodynamic AMC was applied to frequently touched surfaces in buses. The microbial burden (colony forming units, cfu) was determined weekly and compared to equivalent surfaces in buses without AMC (references). The microbial burden ranged from 0 – 209 cfu/cm² on references and from 0 – 54 cfu/cm² on AMC. The means were 13.4 ± 29.6 cfu/cm² on references and 4.5 ± 8.4 cfu/cm² on AMC (p<0.001). The difference of microbial burden on AMC and references was al-most constant throughout the study. Considering a hygiene benchmark of 5 cfu/cm², the data yield an absolute risk reduction of 22.6 % and a relative risk reduction of 50.7 %. In conclusion, photo-dynamic AMC kept down the microbial burden, reducing the risk of transmission of microor-ganisms. AMC permanently and autonomously contributes to hygienic conditions on surfaces in public transportation. Photodynamic AMC therefore are suitable for reducing the microbial load and closing hygiene gaps in public transportation.

Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery

Background and objectivesAKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery.Design, setting, participants, & measurementsPubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed.ResultsTwenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap.ConclusionsCurrent evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.

Role of Colchicine in Prevention of Contrast Induced Nephropathy in Patient Undergoing Primary Percutaneous Coronary Intervention

Background Contrast-induced nephropathy (CIN) is a frequent complication after intravascular contrast media administration. The incidence of CIN in STEMI patients undergoing primary PCI is around 19.8%. The pathophysiologic basis of CIN includes an oxidative stress and inflammatory process, and colchicine has been used as an anti-inflammatory and anti-oxidant agent to improve cardiovascular outcomes, hence the aim of the current study is to demonstrate the effect of colchicine on CIN in patients undergoing primary PCI. Patients and methods 100 STEMI patients planned for primary PCI were enrolled in this study. They were randomized into two groups of fifty patients: A control group receiving standard guideline based medical treatment alone and a study group receiving same treatment in addition to colchicine. CIN was defined based on serum creatinine that was measured repeatedly over 3 days, with absolute rise of 0.5mg/dl or relative rise of 25% or more from baseline signifying CIN. Results There was a trend towards lower CIN incidence, although not statistically significant, in patients receiving colchicine, in whom CIN incidence was 8%, in comparison to incidence of 20 in those receiving standard guideline-based therapy alone % (χ2 = 2.99 & p = 0.083) with relative risk reduction of 60%. The reduction of CIN incidence was found to be statistically significant in diabetic subgroup, with CIN incidence of 32% in those receiving standard guideline-based therapy alone, in comparison to incidence of 7% in those receiving colchicine with p = 0.033. Multiple regression analysis including colchicine as a covariable concluded that colchicine use was the most important CIN risk lowering factor in the current study (β = -0.223 and p = 0.039). Conclusion There was a trend towards lower incidence of CIN in patients undergoing primary PCI receiving colchicine, although not statistically significant. However, this trend became significant when studied in diabetic subgroup.

Consumption of cranberry as adjuvant therapy for urinary tract infections in susceptible populations: A systematic review and meta-analysis with trial sequential analysis

The efficacy of cranberry (Vaccinium spp.) as adjuvant therapy in preventing urinary tract infections (UTIs) remains controversial. This study aims to update and determine cranberry effects as adjuvant therapy on the recurrence rate of UTIs in susceptible groups. According to PRISMA guidelines, we conducted a literature search in Web of Science, PubMed, Embase, Scopus, and the Cochrane Library from their inception dates to June 2021. We included articles with data on the incidence of UTIs in susceptible populations using cranberry-containing products. We then conducted a trial sequential analysis to control the risk of type I and type II errors. This meta-analysis included 23 trials with 3979 participants. We found that cranberry-based products intake can significantly reduce the incidence of UTIs in susceptible populations (risk ratio (RR) = 0.70; 95% confidence interval(CI): 0.59 ~ 0.83; P<0.01). We identified a relative risk reduction of 32%, 45% and 51% in women with recurrent UTIs (RR = 0.68; 95% CI: 0.56 ~ 0.81), children (RR = 0.55; 95% CI: 0.31 ~ 0.97) and patients using indwelling catheters (RR = 0.49; 95% CI: 0.33 ~ 0.73). Meanwhile, a relative risk reduction of 35% in people who use cranberry juice compared with those who use cranberry capsule or tablet was observed in the subgroup analysis (RR = 0.65; 95% CI: 0.54 ~ 0.77). The TSA result for the effects of cranberry intake and the decreased risk of UTIs in susceptible groups indicated that the effects were conclusive. In conclusion, our meta-analysis demonstrates that cranberry supplementation significantly reduced the risk of developing UTIs in susceptible populations. Cranberry can be considered as adjuvant therapy for preventing UTIs in susceptible populations. However, given the limitations of the included studies in this meta-analysis, the conclusion should be interpreted with caution.

Implementation of an acute tonsillitis management protocol within a clinical decisions unit

Introduction With tonsillectomy surgery subject to increasingly strict commissioning criteria over the past 20 years in the UK, the total number of admissions for acute tonsillitis has been rising steadily. Multiple single-centre studies have demonstrated how introduction of a standardised management protocol can be effective in improving the delivery of treatment for acute tonsillitis in the emergency department. Methods Using a novel approach, we aimed to implement an acute tonsillitis management protocol within a formal clinical decisions unit (CDU) pathway. Following a retrospective baseline audit, we carried out two post-intervention cycles of data collection to assess safety and efficacy. Results The median number of initial treatments increased significantly from two of five at baseline, to three of five in both the first (U = 86, p = 0.004) and second (z = 2.959, p = 0.003) audit cycles. Admission rate was reduced from 0.79 to 0.44 in the first cycle, representing a 44.6% relative risk reduction [95% confidence interval (CI) 0.304–1.012; p = 0.0547]. Admission rate remained reduced at 0.48 in the second cycle, with a relative risk reduction of 39.2% compared with baseline (95% CI 0.380–0.972; p = 0.038). Conclusions Utilisation of the CDU led to an improvement in the delivery of initial treatment, an extended period of observation and subsequently a greater percentage of patients being discharged. An acute tonsillitis management protocol within a CDU appears to be a safe and effective model and is now standard practice in our hospital.

Polygenic risk score and statin relative risk reduction for primary prevention in a real-world population

Background Randomized-controlled trials demonstrate that high coronary heart disease (CHD) polygenic risk score modifies statin CHD relative risk reduction, but it is unknown if the association extends to statin users undergoing routine care. Objectives The primary objective was to determine how statin effectiveness is modified by CHD polygenic risk score in a real-world cohort of primary prevention participants. Methods We determined polygenic risk scores in participants of the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort. Cox regression models were used to compare the risk of the cardiovascular outcomes between statin users and matched nonusers. Results The hazard ratio (HR) for statin effectiveness on incident myocardial infarction was similar within 10-year atherosclerotic cardiovascular disease (ASCVD) risk score groups at 0.65 (95% confidence interval [CI] 0.39-1.08; P=0.10), 0.65 (95% CI 0.56-0.77; P=2.1E-7), and 0.67 (95% CI 0.57-0.80; P=4.3E-6) for borderline, intermediate, and high ASCVD groups, respectively. In contrast, statin effectiveness by polygenic risk was largest in the high polygenic risk score group (HR 0.62, 95% CI 0.50-0.77; P=1.4E-5), intermediate in the intermediate polygenic risk score group (HR 0.70, 95% CI 0.61-0.80; P=5.7E-7), and smallest in the low polygenic risk score group (HR 0.86, 95% CI 0.65-1.16; P=0.33). ASCVD risk and statin LDL-C lowering did not differ across polygenic risk score groups. Conclusions In primary prevention patients undergoing routine care, CHD polygenic risk modified statin relative risk reduction of incident myocardial infarction independent of statin LDL-C lowering. Our findings extend prior work by identifying a subset of patients with attenuated clinical benefit from statins.

NO INCREASE IN RELATIVE MORTALITY RATES FOR THOSE WITHOUT A COLLEGE DEGREE DURING COVID-19: AN ANOMALY

American mortality rates have diverged in recent years between those with and without a four-year college degree, and there are many reasons to expect the education-mortality gradient to have steepened during the pandemic. Those without a BA are more likely to work in frontline occupations, to rely on public transportation, and to live in crowded quarters, all of which are associated with an increase in infection risk, a risk that was zero prior to the pandemic. We use publicly available data from the National Center for Health Statistics on deaths by age, sex, education and race/ethnicity to assess the protective effect of a BA in 2020 compared to 2019. While the BA was strongly protective during 2020, the ratio of mortality rates between those with and without a degree was little changed relative to pre-pandemic years. Among 60 groups (gender by race/ethnicity by age) that are available in the data, the relative risk reduction associated with a BA fell for more than half the groups between 2019 and 2020, and increased by more than 5 percentage points for only five groups. Our main finding is not that the BA was protective against death in 2020, which has long been the case, but that the protective effect was little different than in 2019 and earlier years, in spite of the change in the pattern of risk by occupation and income. The virus maintained the mortality-education gradient that existed pre-pandemic, at least through the end of 2020. Our results suggest that changes in the risk of infection were less important in structuring mortality than changes in the risk of death conditional on infection.