Impact of Biologic Therapy on Key Cardiovascular Risk Parameters in a Psoriatic Cohort-a Retrospective Review.

BACKGROUND: Psoriasis is a risk factor for cardiovascular disease. Biologic agents have revolutionised psoriatic skin control. This study aims to assess the change in cardiovascular risk factors in a cohort of patients treated with 1 year of continuous biologic treatment. METHODS: A retrospective medical record review was conducted of consecutive patients receiving biologic therapy for chronic plaque psoriasis in a single dermatology centre at a major tertiary hospital in Australia. The effect of biologic therapy on psoriasis was assessed using a psoriasis area severity index (PASI). Cardiovascular risk factors included systolic blood pressure (SBP), diastolic BP (DBP), heart rate (HR) and body mass index (BMI). Measurements at baseline and 1-year follow-up were compared using paired t-tests. RESULTS: A total of 106 patients were reviewed with a median age of 44 years, and 63% of the patients were male. At baseline, mean BMI was 30 (SD 7), mean SBP was 129 (SD 17), mean DBP was 81 (SD 9) and mean HR was 82 (SD 14). Over 12 months, the PASI was reduced from 17.4 (SD 8.5) to 1.4 (SD 1.7, p < 0.001) indicating skin improvement. There was no significant difference from baseline in SBP (difference 2.3 mmHg, 95% CI - 1.4-5.9), DBP (0.6 mmHg, 95% CI - 1.2-2.5), BMI (difference - 0.1 kg/m2, 95% CI - 0.9-0.7) or HR (difference 1.3, 95% CI - 3.9-6.4). CONCLUSION: In patients with psoriasis, markers of cardiovascular disease risk did not improve after 1 year of biologic therapy despite significant improvements in psoriasis skin severity.

How Real-Time Case-Based Malaria Surveillance Helps Zanzibar Get a Step Closer to Malaria Elimination: Description of Operational Platform and Resources.

Testing and treating asymptomatic populations have the potential to reduce the population's parasite reservoir and reduce malaria transmission. Zanzibar's malaria case notification (MCN) platform collects detailed sociodemographic and epidemiological data from all confirmed malaria cases to inform programmatic decision-making. We describe the design and operationalization process of the platform and other malaria surveillance resources that are enabling Zanzibar's progress toward malaria elimination.The MCN platform consists of an interactive short message service (SMS) system for case notification, a software application for Android mobile devices, a visual question set and workflow manager, a back-end database server, and a web browser-based application for data analytics, configuration, and management. Malaria case data were collected from August 2012 to December 2021 and reported via SMS from all public and private health facilities to a central database and then to district malaria surveillance officers' mobile devices. Data included patient names, shehia (administrative area), and date of diagnosis, enabling officers to track patients, ideally within 24 hours of reporting. Patients' household members were tested for malaria using conventional rapid diagnostic tests (RDTs). Treatment using artemisinin-based combination therapy was provided for persons testing positive.Between 2012 and 2021, a total of 48,899 index malaria cases were confirmed at health facilities, 22,152 (45.3%) within 24 hours of reporting; 41,886 (85.7%) cases were fully investigated and followed up to the household level. A total of 111,811 additional household members were tested with RDTs, of whom 10,602 (9.5%) were malaria positive.The MCN platform reports malaria case data in near real time, enabling prompt follow-up of index cases and prompt testing and treatment of members in index case households. Along with routine testing and treatment and other preventive interventions, the MCN platform is foundational to the programmatic efforts in further reducing malaria and ultimately eliminating autochthonous malaria transmission in Zanzibar.

Trends of insecticide resistance monitoring in mainland Tanzania, 2004-2020.

BACKGROUND: Insecticide resistance is a serious threat to the continued effectiveness of insecticide-based malaria vector control measures, such as long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS). This paper describes trends and dynamics of insecticide resistance and its underlying mechanisms from annual resistance monitoring surveys on Anopheles gambiae sensu lato (s.l.) populations conducted across mainland Tanzania from 2004 to 2020. METHODS: The World Health Organization (WHO) standard protocols were used to assess susceptibility of the wild female An. gambiae s.l. mosquitoes to insecticides, with mosquitoes exposed to diagnostic concentrations of permethrin, deltamethrin, lambdacyhalothrin, bendiocarb, and pirimiphos-methyl. WHO test papers at 5× and 10× the diagnostic concentrations were used to assess the intensity of resistance to pyrethroids; synergist tests using piperonyl butoxide (PBO) were carried out in sites where mosquitoes were found to be resistant to pyrethroids. To estimate insecticide resistance trends from 2004 to 2020, percentage mortalities from each site and time point were aggregated and regression analysis of mortality versus the Julian dates of bioassays was performed. RESULTS: Percentage of sites with pyrethroid resistance increased from 0% in 2004 to more than 80% in the 2020, suggesting resistance has been spreading geographically. Results indicate a strong negative association (p = 0.0001) between pyrethroids susceptibility status and survey year. The regression model shows that by 2020 over 40% of An. gambiae mosquitoes survived exposure to pyrethroids at their respective diagnostic doses. A decreasing trend of An. gambiae susceptibility to bendiocarb was observed over time, but this was not statistically significant (p = 0.8413). Anopheles gambiae exhibited high level of susceptibility to the pirimiphos-methyl in sampled sites. CONCLUSIONS: Anopheles gambiae Tanzania's major malaria vector, is now resistant to pyrethroids across the country with resistance increasing in prevalence and intensity and has been spreading geographically. This calls for urgent action for efficient malaria vector control tools to sustain the gains obtained in malaria control. Strengthening insecticide resistance monitoring is important for its management through evidence generation for effective malaria vector control decision.

Spatiotemporal dynamics of malaria in Zanzibar, 2015-2020.

BACKGROUND: Despite high coverage of malaria interventions, malaria elimination in Zanzibar remains elusive, with the annual number of cases increasing gradually over the last 3 years. OBJECTIVE: The aims of the study were to (1) assess the spatiotemporal dynamics of malaria in Zanzibar between 2015 and 2020 and (2) identify malaria hotspots that would allow Zanzibar to develop an epidemiological stratification for more effective and granular intervention targeting. METHODS: In this study, we analysed data routinely collected by Zanzibar's Malaria Case Notification (MCN) system. The system collects sociodemographic and epidemiological data from all malaria cases. Cases are passively detected at health facilities (ie, primary index cases) and through case follow-up and reactive case detection (ie, secondary cases). Analyses were performed to identify the spatial heterogeneity of case reporting at shehia (ward) level during transmission seasons. RESULTS: From 1 January 2015 to 30 April 2020, the MCN system reported 22 686 index cases. Number of cases reported showed a declining trends from 2015 to 2016, followed by an increase from 2017 to 2020. More than 40% of cases had a travel history outside Zanzibar in the month prior to testing positive for malaria. The proportion of followed up index cases was approximately 70% for all years. Out of 387 shehias, 79 (20.4%) were identified as malaria hotspots in any given year; these hotspots reported 52% of all index cases during the study period. Of the 79 hotspot shehias, 12 were hotspots in more than 4 years, that is, considered temporally stable, reporting 14.5% of all index cases. CONCLUSIONS: Our findings confirm that the scale-up of malaria interventions has greatly reduced malaria transmission in Zanzibar since 2006. Analyses identified hotspots, some of which were stable across multiple years. Malaria efforts should progress from a universal intervention coverage approach to an approach that is more tailored to a select number of hotspot shehias.

Production and optimization of l-asparaginase by Streptomyces koyangensis SK4 isolated from Arctic sediment.

Actinomycetes isolated from the Arctic sediment were evaluated for the production of the enzyme l-asparaginase, an enzyme used to treat acute lymphoblastic leukemia. The most potent strain Streptomyces koyangensis SK4 was selected for l-asparaginase enzyme production by submerged fermentation. The effect of various fermentation parameters on enzyme production was analyzed statistically using the Plackett-Burman design and response surface method. Effects of eight parameters including temperature, pH, incubation time, inoculum size, agitation speed, the concentration of starch, l-asparagine, and yeast extract were studied on l-asparaginase production by the Arctic isolate S. koyangensis SK4. Factors such as temperature, pH, incubation time, agitation speed, and l-asparagine concentration were found to be important factors influencing  l-asparaginase production. Maximum enzyme activity of 136 IU/ml was obtained at 20°C on the seventh day of incubation in the asparagine dextrose broth maintained at pH 7.5, agitation speed 125 rpm, and l-asparagine concentration of 7.5 g/L. The statistical optimization method described in this study proved effective for increasing the l-asparaginase production by Arctic actinomycetes.

Improvements in malaria surveillance through the electronic Integrated Disease Surveillance and Response (eIDSR) system in mainland Tanzania, 2013-2021.

BACKGROUND: Tanzania has made remarkable progress in reducing malaria burden and aims to transition from malaria control to sub-national elimination. In 2013, electronic weekly and monthly reporting platforms using the District Health Information System 2 (DHIS2) were introduced. Weekly reporting was implemented through the mobile phone-based Integrated Disease Surveillance and Response (eIDSR) platform and progressively scaled-up from 67 to 7471 (100%) public and private health facilities between 2013 and 2020. This study describes the roll-out and large-scale implementation of eIDSR and compares the consistency between weekly eIDSR and monthly DHIS2 malaria indicator data reporting, including an assessment of its usefulness for malaria outbreak detection and case-based surveillance (CBS) in low transmission areas. METHODS: The indicators included in the analysis were number of patients tested for malaria, number of confirmed malaria cases, and clinical cases (treated presumptively for malaria). The analysis described the time trends of reporting, testing, test positivity, and malaria cases between 2013 and 2021. For both weekly eIDSR and monthly DHIS2 data, comparisons of annual reporting completeness, malaria cases and annualized incidence were performed for 2020 and 2021; additionally, comparisons were stratified by malaria epidemiological strata (parasite prevalence: very low < 1%, low 1 ≤ 5%, moderate 5 ≤ 30%, and high > 30%). RESULTS: Weekly eIDSR reporting completeness steadily improved over time, with completeness being 90.2% in 2020 and 93.9% in 2021; conversely, monthly DHIS2 reporting completeness was 98.9% and 98.7% in 2020 and 2021, respectively. Weekly eIDSR reporting completeness and timeliness were highest in the very low epidemiological stratum. Annualized malaria incidence as reported by weekly eIDSR was 17.5% and 12.4% lower than reported by monthly DHIS2 in 2020 and 2021; for both 2020 and 2021, annualized incidence was similar across weekly and monthly data in the very low stratum. CONCLUSION: The concurrence of annualized weekly eIDSR and monthly DHIS2 reporting completeness, malaria cases and incidence in very low strata suggests that eIDSR could be useful tool for early outbreak detection, and the eIDSR platform could reliably be expanded by adding more indicators and modules for CBS in the very low epidemiological stratum.

Destructive therapies for cutaneous warts: A review of the evidence.

BACKGROUND AND OBJECTIVES: Non-genital warts are benign cutaneous growths caused by infection with the human papillomavirus. Although warts can resolve spontaneously, patients might seek treatment due to discomfort or social ostracism. This review summarises high-quality studies investigating the efficacy of chemical and physical destructive wart therapies. METHOD: We performed a literature review (up to June 2021) of published articles for wart management from MEDLINE and Embase databases. We considered systematic reviews, randomised controlled trials (RCTs), cohort studies and case series. We included studies that investigated chemical or physical destructive therapies. RESULTS: Fifteen therapies were evaluated and included salicylic acid, cryotherapy, silver nitrate, phenol, cantharidin, glycolic acid, pyruvic acid, citric acid, formic acid, trichloroacetic acid, monochloroacetic acid, zinc, laser, surgery and electrocautery. Very few treatment options have been studied through RCTs. DISCUSSION: To attenuate transmission, hygienic practices need to be adopted in conjunction with any treatment. Important considerations when treating patients with warts include the location of the wart, the evidence supporting the proposed treatment and potential adverse effects of treatment.

Hypocholesterolaemia as a prognostic factor in venomous snakebite: a retrospective study from a single centre in Kerala, India.

BACKGROUND: Studies have suggested a association between serum cholesterol values and severity of envenoming. The objective of the study was to correlate the serum cholesterol levels with severity of envenoming in victims of snakebite, across snake species in our patient population. METHODS: Retrospective secondary data analysis of health records of a cohort of snakebite victims treated at Little Flower Hospital, Angamaly, Kerala during June 2006-January 2008 was performed. The cholesterol values were assessed in 205 consecutive patients admitted with snakebite envenoming, within 24 h of admission and 10 h of overnight fasting. Lipid fractions were estimated from fasting serum through the standard CHOD-PAP method on a Hitachi analyzer. The cholesterol level was compared between victims with mild and serious envenoming to assess the proportion among each category with a low cholesterol (defined as ≤150 mg/dl as per institutional criteria). In addition, low cholesterol as a marker of severity was compared with other laboratory parameters suggesting severe envenoming such as low fibrinogen, low platelet count, neutrophilia, elevated creatinine, d-dimer, hepatic transaminases and albuminuria. RESULTS: Of the 146 victims with serious degree of snakebite envenoming 116 (79%) had low cholesterol values ≤150 mg%, while 30 (21%) had values >150 mg%. Of the patients with low cholesterol, 116 (78%) had serious envenoming, while 22% had mild envenoming. By contrast, 30 patients (21%) had values >150 mg%. The risk of moderate-severe envenoming with low cholesterol was 2.7 times (170%) that of victims with normal or high cholesterol on admission. CONCLUSIONS: A low cholesterol on admission in victims of snake envenoming suggested a more severe degree of envenoming and likelihood of complications.

Prevention and management of acneiform rash associated with EGFR inhibitor therapy: A systematic review and meta-analysis.

INTRODUCTION: Epidermal growth factor receptor (EGFR) inhibitors are established therapies for advanced lung, colorectal, and head and neck cancers. They commonly cause acneiform eruptions that affect patient quality of life and may lead to discontinuation of therapy. METHODS: A systematic review and meta-analysis was undertaken to assess strategies for the prevention and reactive management of acneiform rash associated with EGFR inhibitor therapy for advanced lung, colorectal, and head and neck cancers. A systematic Medline, Embase, and EBM Reviews database search was conducted on the 2nd of January 2021. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed and the studies were critically appraised. Studies were selected if they focused on preventing or treating acneiform eruptions in adults being treated for advanced lung cancer, colorectal cancer, and head and neck cancers with EGFR inhibitors. RESULTS: Oral antibiotics had the greatest efficacy in preventing grade 2 or higher acneiform eruptions with a relative risk reduction of 40% (RR = .6, 95% CI .46-.79, p < .01). Other treatment modalities did not have statistically significant results. Topical antibiotics had a total relative risk reduction of 19% (RR = .81, 95% CI .45-1.48, p = .5). Vitamin K1 cream did not reduce the relative risk (RR = 1.08, 95% CI .45-1.48, p = .50). Sunscreen had a total relative risk reduction of 25% (RR = .75, 95% CI .49-1.14, p = .18). CONCLUSIONS: The results of this meta-analysis reinforce the fact that oral tetracycline antibiotics are the most efficacious prophylactic option for acneiform eruptions in EGFR inhibitors. They should be offered to suitable patients commencing treatment and used with a general skin-care routine involving emollients and avoidance of irritants.

Point-of-care viral load testing among adolescents and young adults living with HIV in Haiti: a randomized control trial.

HIV viral load (VL) monitoring can reinforce antiretroviral therapy (ART) adherence. Standard VL testing requires high laboratory capacity and coordination between clinic and laboratory which can delay results. A randomized trial comparing point-of-care (POC) VL testing to standard VL testing among 150 adolescents and young adults, ages 10-24 years, living with HIV in Haiti determined if POC VL testing could return faster results and improve ART adherence and viral suppression. Participants received a POC VL test with same-day result (POC arm) or a standard VL test with result given 1 month later (SOC arm). POC arm participants were more likely to receive a test result within 6 weeks than SOC arm participants (94.7% vs. 80.1%; p1000 copies/ml and low self-reported ART adherence was stronger in the POC arm (OR: 6.57; 95%CI: 2.12-25.21) than the SOC arm (OR: 2.62; 95%CI: 0.97-7.44) suggesting more accurate self-report in the POC arm. POC VL testing was effectively implemented in this low-resource setting with faster results and is a pragmatic intervention that may enable clinicians to identify those with high VL to provide enhanced counseling or regimen changes sooner.Trial registration: ClinicalTrials.gov identifier: NCT03288246.

Dermatology inpatient consultations in a tertiary hospital - a retrospective analysis.

BACKGROUND: Dermatology consultation has been shown to have a significant beneficial impact on admitted hospital patients with concurrent or newly diagnosed skin conditions. This study aimed to determine the change in diagnosis and management after dermatology consultation in a tertiary Australian referral hospital. METHODS: A retrospective analysis of dermatology consultations for hospital inpatients from June 1, 2018, through November 11, 2019, was performed. Demographic and clinical data were extracted from electronic medical records, and a chi-squared test was used to analyze categorical variables. RESULTS: There were 306 consultations during the period of interest. The male to female ratio was 1:1 with a median age of 63. Consultations were most often requested by medical teams (69%), and the majority of patients seen in the emergency department were discharged home (86%). In 44% of cases, the requesting team did not provide a diagnosis; in the cases where it did provide a diagnosis, it was changed 57.9% of the time. The most commonly misdiagnosed conditions were dermatitis and skin infections. Dermatologists established or changed management in 82% of cases, and a total of 676 suggestions were made for management. CONCLUSION: The results of this review reinforce the value of dermatology input in the diagnosis and management of hospital in patients. Ensuring maintained presence of hospital-based dermatologists has the potential to improve diagnosis and management of cutaneous issues early on; by extension, this can minimize unnecessary investigations, improve the quality of healthcare, reduce hospital burden, and facilitate outpatient follow-up.

Surgical demonstration of pressure differential through an optic disc pit.

PURPOSE: To demonstrate intraoperative dynamic flow through an optic disc pit. METHODS: Retrospective interventional case report. RESULTS: Surgical management of an optic disc pit involved standard 25-gauge pars plana vitrectomy, induction of posterior hyaloid separation with triamcinolone stain, temporal peripapillary laser and SF6 gas. Intraoperatively a remnant of stained vitreous at the optic disc head prolapsed into the optic disc pit with higher intraocular pressure but was drawn back into the vitreous cavity as the intraocular pressure was lowered. This clearly demonstrated a pressure differential across the pit. CONCLUSION: Communication between the vitreous cavity and the perineural space of the optic nerve is described histologically. Our case demonstrated dynamic flow through the optic disc pit with intraoperative fluctuation of intraocular pressure.

Risk factors associated with malaria infection identified through reactive case detection in Zanzibar, 2012-2019.

BACKGROUND: Over the past two decades, Zanzibar substantially reduced malaria burden. As malaria decreases, sustainable improvements in control interventions may increasingly depend on accurate knowledge of malaria risk factors to further target interventions. This study aimed to investigate the risk factors associated with malaria infection in Zanzibar. METHODS: Surveillance data from Zanzibar's Malaria Case Notification system from August 2012 and December 2019 were analyzed. This system collects data on malaria cases passively detected and reported by all health facilities (index cases), and household-based reactive case detection (RCD) activities linked to those primary cases. All members of households of the index cases were screened for malaria using a malaria rapid diagnostic test (RDT). Individuals with a positive RDT were treated with artemisinin-based combination therapy. Univariate and multivariate logistic regression analyses were done to investigate the association between RDT positivity among the household members and explanatory factors with adjustment for seasonality and clustering at Shehia level. RESULTS: A total of 30,647 cases were reported of whom household RCD was completed for 21,443 (63%) index case households and 85,318 household members tested for malaria. The findings show that younger age (p-value for trend [Ptrend] < 0.001), history of fever in the last 2 weeks (odds ratio [OR] = 35.7; 95% CI 32.3-39.5), travel outside Zanzibar in the last 30 days (OR = 2.5; 95% CI 2.3-2.8) and living in Unguja (OR = 1.2; 95% CI 1.0-1.5) were independently associated with increased odds of RDT positivity. In contrast, male gender (OR=0.8; 95% CI 0.7-0.9), sleeping under an LLIN the previous night (OR = 0.9; 95% CI 0.7-0.9), having higher household net access (Ptrend < 0.001), and living in a household that received IRS in the last 12 months (OR = 0.8; 95% CI 0.7-0.9) were independently associated with reduced odds of RDT positivity. A significant effect modification of combining IRS and LLIN was also noted (OR = 0.7; 95% CI 0.6-0.8). CONCLUSIONS: The findings suggest that vector control remains an important malaria prevention intervention: they underscore the need to maintain universal access to LLINs, the persistent promotion of LLIN use, and application of IRS. Additionally, enhanced behavioural change and preventive strategies targeting children aged 5-14 years and travellers are needed.

Infantile haemangiomas: Identifying high-risk lesions in primary care.

BACKGROUND: Infantile haemangiomas (IHs) are benign vascular tumours that affect up to 10% of infants and arise in the first few weeks-to-months of life. Some are associated with an increased risk of complications and poor cosmetic outcomes. General practitioners (GPs) are ideally placed to identify high-risk IHs and coordinate their management. OBJECTIVE: The aim of this article is to outline strategies to identify high-risk IHs and when to involve a multidisciplinary team. DISCUSSION: IHs that involve the lower face or neck can be associated with airway obstruction. Having five or more IHs is associated with hepatic haemangiomas, high-output cardiac failure and hypothyroidism. IHs that involve the eyes or mouth can cause functional impairments such as amblyopia and feeding difficulties, respectively. Large segmental IHs maybe associated with syndromic presentations including PHACE syndrome when on the lower face, PELVIS syndrome when on the perineum and LUMBAR syndrome when on the lower back.

Adherence to suggestions after dermatology consultation in a tertiary hospital - a retrospective analysis.

Dermatology consultation is a valuable inpatient service in Australian hospitals. Adherence rates to consultative advice in international literature range between 67.4% and 93%. This study identifies that adherence rates to suggested investigations and management in a tertiary Australian hospital are at the lower end of the range reported in previous literature.