Low Etanercept Concentrations in Children With Obesity and Juvenile Idiopathic Arthritis

OBJECTIVE To evaluate the impact of obesity on etanercept (ETN) drug exposure in children with juvenile idiopathic arthritis (JIA). METHODS We conducted a pilot, cross-sectional, observational study in a real-world cohort of children with JIA receiving ETN as standard of care from a single center. We analyzed the relationship between body size and ETN plasma concentrations, adjusting for dosage. Body size was analyzed as a continuous measure using weight and body mass index (BMI) percentiles and categorically using BMI percentile classifications according to the CDC guidelines. RESULTS We enrolled a total of 29 children. Each child provided one plasma sample for ETN concentration measurement, and all participants were receiving subcutaneous ETN dosed weekly. We observed that the ETN concentration normalized for dose decreased significantly as a function of weight (p = 0.004) and BMI percentile (p = 0.04). Similarly, we observed a progressive decline in mean and median dose-normalized concentrations across higher body size categories. Because of reaching maximum ETN dosage (50 mg), 7 of 8 children (87.5%) with obesity received a weight-based dosage < 0.8 mg/kg/dose. CONCLUSIONS We found that higher body weight and BMI percentile are significantly and negatively associated with ETN drug serum concentration, accounting for differences in dosing. Our data suggest that children who are obese may be routinely under-dosed using current dosing strategies. Inadequate dosing may increase the risk for therapeutic failure and long-term morbidity in a developing child. As a result, characterizing adequate drug exposure in children of all sizes is an important step toward precision dosing.

Lost in Translation: Narrative Salience of Fear > Hope in Prevention of COVID-19

Using short, policy-image-like narratives, we explore the relationship between narrative agreement and narrative impacts in the case of COVID-19 in the US. Building upon previous research which identified attention narratives focusing on problems “stories of fear” and those focusing on solutions “stories of hope,” we use a narrative survey experiment of the general public (n=1000) to test the salience of problem and solution narratives and if they impact agreement with Center for Disease Control (CDC) prevention guidelines. Our findings are 1) fear story agreement is partisan but hope story agreement is not 2) fear story is the more salient of the two, 3) narrative agreement for both fear and hope were related to CDC safety guideline agreement, but were partisan, and 4) exposure to neither narrative impacted likelihood to agree with the guidelines as compared to a control group. Our findings are consistent with previous work indicating a Democratic party preference for stories of fear, where Democrats were more likely to support policy action. While we find that agreement with our narratives and guidelines is related, neither narrative treatment successfully altered support for CDC guidelines, suggesting a potential limit for the influence of narratives to either change or reorder existing preferences in highly salient and partisan issue areas like COVID-19 and suggesting a need for more research into the dynamics of narrative attention.

Immune Thrombocytopenic Purpura following Administration of mRNA-Based SARS-CoV-2 and MMR Vaccinations: A Cautionary Tale

We report a case of immune thrombocytopenic purpura (ITP) in an otherwise healthy 31-year-old man following coadministration of the live measles, mumps, and rubella (MMR) vaccine with the Pfizer-BioNTech mRNA SARS-CoV-2 vaccine. The patient was hospitalized briefly and treated for ITP with glucocorticoids, IVIG, and platelet transfusion. Although our patient’s clinical presentation and subsequent course are similar to those of other cases of ITP in association with SARS-CoV-2 vaccination, to our knowledge, this is the first reported case of ITP following MMR and mRNA SARS-CoV-2 vaccine coadministration. It would be impossible to conclusively prove that the patient’s thrombocytopenia was secondary to the SARS-CoV-2 vaccine alone, the MMR vaccine, or an additive effect of both vaccines. However, with the CDC guidelines recommending the coadministration of the mRNA SARS-CoV-2 vaccine without regards to timing with other vaccines, we urge further caution as there is limited evidence to inform practice. This case highlights the need for further safety data regarding the coadministration and timing of the mRNA SARS-CoV-2 vaccine with other vaccines.

The cost-effectiveness of common strategies for the prevention of transmission of SARS-CoV-2 in universities

Background Most universities that re-open in the United States (US) for in-person instruction have implemented the Centers for Disease Prevention and Control (CDC) guidelines. The value of additional interventions to prevent the transmission of SARS-CoV-2 is unclear. We calculated the cost-effectiveness and cases averted of each intervention in combination with implementing the CDC guidelines. Methods We built a decision-analytic model to examine the cost-effectiveness of interventions to re-open universities. The interventions included implementing the CDC guidelines alone and in combination with 1) a symptom-checking mobile application, 2) university-provided standardized, high filtration masks, 3) thermal cameras for temperature screening, 4) one-time entry (‘gateway’) polymerase chain reaction (PCR) testing, and 5) weekly PCR testing. We also modeled a package of interventions (‘package intervention’) that combines the CDC guidelines with using the symptom-checking mobile application, standardized masks, gateway PCR testing, and weekly PCR testing. The direct and indirect costs were calculated in 2020 US dollars. We also provided an online interface that allows the user to change model parameters. Results All interventions averted cases of COVID-19. When the prevalence of actively infectious cases reached 0.1%, providing standardized, high filtration masks saved money and improved health relative to implementing the CDC guidelines alone and in combination with using the symptom-checking mobile application, thermal cameras, and gateway testing. Compared with standardized masks, weekly PCR testing cost $9.27 million (95% Credible Interval [CrI]: cost-saving-$77.36 million)/QALY gained. Compared with weekly PCR testing, the ‘package’ intervention cost $137,877 (95% CrI: $3,108-$19.11 million)/QALY gained. At both a prevalence of 1% and 2%, the ‘package’ intervention saved money and improved health compared to all the other interventions. Conclusions All interventions were effective at averting infection from COVID-19. However, when the prevalence of actively infectious cases in the community was low, only standardized, high filtration masks clearly provided value.

Implementation of CDC Guidelines for Recess: A Formative Research Study

The American Academy of Pediatrics recognizes recess as an essential part of overall child development in schools, impacting children’s cognitive, socioemotional and physical health and development. However, recess is often removed from the school curriculum in exchange for more classroom activities. The Centers for Disease Control and Prevention (CDC) and SHAPE America developed Strategies for Recess in Schools to promote high-quality recess through specific actions, yet is not known how these are successfully implemented, particularly, in underserved settings. This formative research study examined the implementation of the CDC strategy in an urban, inner-city charter elementary school to identify barriers and facilitators to successful recess implementation from the perspective of various stakeholders. Thirteen in-depth interviews and focus group discussions were conducted with parents, teachers, recess monitors, and school administrators. Interviews were recorded, transcribed, and coded for thematic analysis, supported by group discussion and analytic memos. Results suggested that although stakeholders recognized the importance of recess, the implementation of the CDC strategy was neither uniformly understood nor implemented, suggesting that additional frameworks may be helpful in implementing the CDC strategy in schools in underserved communities.

Modifications in Orthodontic Practice Post COVID Lockdown in Pakistan

OBJECTIVE: To assess the frequency of positive changes in orthodontic practice in Pakistani governmental and private workplaces after lifting of COVID-19 lockdown. METHODOLOGY: This cross sectional questionnaire-based study was carried out on 143 Pakistani orthodontic practitioners for the duration of 3 months. A well-constructed, computerized closed ended questionnaire was designed at an online website i.e., google drive and the link was circulated through social media and e-mail. Change in dental practice was assessed by comparing the results with CDC guidelines, keeping positive response cutoff 70%. Data was analyzed by using SPSS 22, Confounders, like educational qualification, gender and workplace were controlled through stratification. Post stratification Chi square Test was applied to assess the association of dentist's response with gender, educational level, age and workplace, keeping P value < 0.05. RESULTS: There were total 143 participants (80 female and 63 male) with age range from 23 to 56 years, with a mean age of 31.24 ± 6.82 years. Majority of the participants (75.52%) belonged to the age range of 23-33 years. Most of the orthodontists were post graduate trainees (66.4%). Out of all these participants, 67 were working at orthodontic OPD, 22 at private practice and 51 worked at both. 68.5% Implementation of positive modifications in dental practice were recorded. The chi square test results were significant (P <.05) for education and workplace of orthodontist. CONCLUSION: Most orthodontists have positively modified their dental practice post COVID-19 lockdown in Pakistan, by following WHO and CDC guidelines for Covid-19 to curtail spread of infection. KEYWORDS: Changes, Orthodontics, COVID

Incidence of COVID-19 reinfection among Midwestern healthcare employees

Importance: Given the overwhelming worldwide rate of infection and the disappointing pace of vaccination, addressing reinfection is critical. Understanding reinfection, including protection longevity after natural infection, will allow us to better know the prospect of herd immunity, which hinges on the assumption that natural infection generates sufficient, protective immunity. The primary aim of this paper is to provide data on SARS-CoV-2 reinfection over a 10-month period. Objective: The primary objective of this study is to establish the incidence of reinfection of COVID-19 among healthcare employees who experienced a prior COVID-19 infection. Design: This observational cohort study followed a convenience sample of 2,625 participants who experienced a COVID-19 infection for subsequent COVID-19 infection. Setting: Healthcare employees were recruited across a large Midwestern healthcare system. Positive PCR test results were administered and recorded by the system-affiliated lab serving Illinois and Wisconsin. Participants: Adult healthcare system employees who enrolled in a research study focused on SARS-CoV-2 antibodies (N = 16,357) and had at least one positive PCR test result between March 1, 2020 and January 10, 2021 were included (N = 2,625). Exposure: Positive PCR test for SARS-CoV-2 Main Outcome(s) and Measure(s): The primary outcome is incidence of COVID-19 reinfection, defined by current CDC guidelines (i.e. subsequent COVID-19 infection ≥ 90 days from prior infection). COVID-19 recurrence, defined as subsequent COVID-19 infection after prior infection irrespective of time, is also described. Results: Of 2,625 participants who experienced at least one COVID-19 infection during the 10-month study period, 156 (5.94%) experienced reinfection and 540 (20.57%) experienced recurrence after prior infection. Median days were 126.50 (105.50-171.00) to reinfection and 31.50 (10.00-72.00) to recurrence. Incidence rate of COVID-19 reinfection was 0.35 cases per 1,000 person-days, with participants working in COVID-clinical and clinical units experiencing 3.77 and 3.57 times, respectively, greater risk of reinfection relative to those working in non-clinical units. Incidence rate of COVID-19 recurrence was 1.47 cases per 1,000 person-days. Conclusions and Relevance: This study supports the consensus that COVID-19 reinfection, defined as subsequent infection ≥ 90 days after prior infection, is rare, even among a sample of healthcare workers with frequent exposure.

Current best practice recommendations for safe dental Practice in the COVID-19 era

Methods: The researchers conducted a thorough review of the American Dental associations (ADA), Advisory Taskforce on Dental Practice Recovery, CDC (Centers for disease controls & Prevention, USA) guidelines for providing dental care during Covid-19 pandemic to protect the dental personal, OSHA’s (Occupational safety and health administration, US Government agency) supplemental interim guidelines for dental workers and employers related to control and prevention of Covid-19 & the UK’s National Health Services (NHS) proposed guidelines for standard operating procedures for urgent dental care during covid-19 pandemic. Results: Systematically laid down and concisely presented infection control, administrative and engineering control guidelines from top international organizations. Step by step guidelines beginning from pre-appointment screening, in office registration process, chairside protocols to staff protection protocols are presented. Special focus on aerosol/droplet/fomite generating procedures and prevention of infection through judicious use of PPE’s and other novel disinfection techniques including administrative and engineering controls. Conclusion: Covid-19 pandemic is a unique and once in a generation crisis for the practice of dentistry globally. Most dental professionals are limiting themselves to emergency treatments as per local guidelines. There is an urgent need to ensure state of the art and scientifically authentic guidelines are presented to the dental community to alleviate their anxiety so that they can begin to practice dentistry without the uncertainty and fear that Covid-19 has brought upon the dental fraternity. Keywords: COVID-19; dental practice; CDC guidelines; viruses.

Setting a Protocol for Identification and Detecting the Prevalence of Candida auris in Tertiary Egyptian Hospitals Using the CDC Steps

BACKGROUND: Candida is considered the most common cause of opportunistic infections in the world. Increased use of antifungal agents may have led to increasing resistance of Candida for antifungals and may be related to therapeutic failures. Recently, a multidrug-resistant Candida auris has immerged causing outbreaks in several countries all over the world. This discovered superbug is widely spread causing a broad range of health care-associated infections. AIM: This study aims to set a protocol for the identification and detection of the prevalence of C. auris in tertiary Egyptian hospitals following the center of disease and control (CDC) methodology. METHODOS: Over almost 2 years, 400 Candida isolates were collected from different wards of Cairo University Hospitals. Identification of species of all isolates was done by germ tube test followed by sub-culturing on chromogenic agar media for confirmation. Candida non-albicans isolates were further subjected to thermotolerance. Isolates that grew in 42°C were further identified by matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry for definite species identification. Antifungal susceptibility using E-test was done for isolates identified by MALDI to detect resistance patterns. RESULTS: Among the 400 isolates, 227 (56.75%) were Candida albicans while 180 (43.25%) were non-albicans Candida. Candida non-albicans was classified by Chromagar as following; 25 (13.8%) were Candida tropicalis, 43 (23.8%) were Candida krusei, and 112 (62.2%) were other Candida spp. (Candida glabrata, Candida kefyr, Candida parapsilosis, and Candida lusitaniae). Using thermotolerance, 10 isolates grew at 42°C suspecting C. auris. MALDI-TOF was used for definite and final identification; five isolates were identified as C. glabrata, four as C. krusei, and one C. kefyr. Antifungal susceptibility testing of the 10 identified isolates revealed total resistance to fluconazole. CONCLUSION: Following the set protocol for identification based on CDC guidelines, C. auris is not prevalent in Egyptian hospitals. Fluconazole resistance is on the surge among candida isolates. Further studies on a bigger scale including larger number of hospitals are recommended.

Elevator (Lift) Car Ventilation Design to Mitigate the Risk of Spread of COVID-19

Recent studies, on the airborne transmission of the SARS-CoV-2 and the new CDC guidelines confirming the aerosol transmission of the virus, make immediate attention to the airflow in elevators imperative. While several versions have been thought of for contactless rides, there is little that has been considered for lessening the anticipated viral load in the elevator car.In this paper, a two-step approach is used. The first is the risk assessment, and the second is the risk mitigation through an improved lift car ventilation design. The risk is assessed by computing the probable viral load during the journey in a lift car. It is seen that the ventilation typically provided as per the minimum permissible requirements by codes is inadequate to handle the current situation.The computations show that one-minute exposure, to a coughing high emitter in the lift car, creates a viral load to dangerous levels well above the possible acceptable level of 10,000 virus copies/m3. To come up with the risk mitigation strategies, the required ventilation in the car was computed. The main recommendation suggests the use of forced ventilation using pressure fans and 3 to 6 air changes per minute depending on the operating environment. Such a design will help us achieve our objective of bringing the density of virus copies in the lift car to an acceptable level. A properly designed ventilation system for the elevator car will benefit in both pandemic situations as well as non-pandemic situations.