Fatal Occupational Asthma in Cannabis Production - Massachusetts, 2022.

Multiple respiratory hazards have been identified in the cannabis cultivation and production industry, in which occupational asthma and work-related exacerbation of preexisting asthma have been reported. An employee working in a Massachusetts cannabis cultivation and processing facility experienced progressively worsening work-associated respiratory symptoms, which culminated in a fatal asthma attack in January 2022. This report represents findings of an Occupational Safety and Health Administration inspection, which included a worksite exposure assessment, coworker and next-of-kin interviews, medical record reviews, and collaboration with the Massachusetts Department of Public Health. Respiratory tract or skin symptoms were reported by four of 10 coworkers with similar job duties. Prevention is best achieved through a multifaceted approach, including controlling asthmagen exposures, such as cannabis dust, providing worker training, and conducting medical monitoring for occupational allergy. Evaluation of workers with new-onset or worsening asthma is essential, along with prompt diagnosis and medical management, which might include cessation of work and workers' compensation when relation to work exposures is identified. It is important to recognize that work in cannabis production is potentially causative.

Coworkers are more likely than patients to transmit SARS-CoV-2 infection to healthcare personnel.

OBJECTIVES: To compare the impact of occupational exposures to SARS-CoV-2 positive patients and SARS-CoV-2 positive coworkers, by comparing the frequency of occupational exposure incidents and the rate of healthcare personnel (HCP) who developed a positive PCR test for SARS-COV-2 after occupational exposure to the two different types of infectious individuals. METHODS: A retrospective analysis of all confirmed higher risk occupational exposure incidents that occurred in HCP from 20 March 2020 to 31 December 2020 at a large multisite US academic medical centre. Comparisons between groups for source type were performed using unpaired Student's t-test for continuous variables and the χ2 test for categorical variables, regression analysis was conducted to assess the associations between source type and risk of positive COVID-19 test after occupational exposure. RESULTS: In total, 2253 confirmed medium or high-risk occupational exposures occurred during the study period. 57% were exposures from coworker sources. Each source individual exposed a mean of 2.6 (95% CI 2.3 to 2.9) HCP; during postexposure surveillance, 4.5% of exposed HCP tested positive within 14 days. A coworker source on average exposed 2.2 (95% CI 2.01 to 2.4) other HCP and infected 0.14 (95% CI 0.1 to 0.17) HCP, while patient sources exposed a mean of 3.4 (95% CI 2.6 to 4.2) HCP but only infected 0.07 (95% CI 0.04 to 0.11) HCP. The multivariate analysis demonstrated that exposure to a coworker source carried a higher risk of testing positive compared with exposure to a patient source (OR 3.22; 95% CI 1.72 to 6.04). CONCLUSION: Occupational exposures to coworker sources were not only more frequent but also associated with triple the risk of developing COVID-19 infection, compared with exposures to patient sources.

Therapies for advanced stage hepatocellular carcinoma with macrovascular invasion or metastatic disease: A systematic review and meta-analysis.

Hepatocellular carcinoma (HCC) is a complex disease most commonly arising in the background of chronic liver disease. In the past two decades, there has been a significant increase in our understanding of both the clinical and molecular heterogeneity of HCC. There has been a robust increase in clinical trial activity in patients with poor prognostic factors, such as macrovascular invasion and extrahepatic spread (EHS). We aimed to synthesize the evidence for the treatment of patients with advanced HCC based on these baseline characteristics, including patients with both Child-Pugh (CP) scores of A and B. A comprehensive search of several databases from each database inception to February 15, 2016 any language was conducted. We included 14 studies (three randomized controlled studies [RCTs] and 11 observational studies). We included studies that compared sorafenib, transarterial bland embolization/transarterial chemoembolization, yttrium-90/radiation therapy, ablation (or combination), and no therapy. Two RCTs comparing sorafenib to best supportive care demonstrated a consistent improvement in overall survival (OS) for patients with advanced HCC and metastatic vascular invasion (MVI) and/or EHS and CP A liver disease (hazard ratio, 0.66 [95% confidence interval, 0.51-0.87]; I2 = 0%). Several observational studies evaluated locoregional therapies alone or in combination with other treatments and were limited by very-low-quality of evidence. This was true for both patients with EHS and MVI. CONCLUSION: In patients with advanced HCC and CP A liver function, sorafenib is the only treatment that has been shown to improve OS in randomized studies. High-quality data supporting the use of other treatment modalities in this setting, or in the setting of patients with less compensated (CP B) liver disease, are lacking. (Hepatology 2018;67:422-435).

Tuberculin Skin Test Conversions and Occupational Exposure Risk in US Healthcare Workers.

Background: Healthcare workers (HCWs) undergo occupational tuberculosis screening at regular intervals. However, the risk of contracting tuberculosis at the workplace in a setting with a low background tuberculosis incidence is unclear. We aimed to evaluate the risk of tuberculin skin test (TST) conversion and the risk of occupational tuberculosis infection among HCWs in such a setting. Methods: We conducted a retrospective cohort study of employees of a large tertiary medical center in the US Midwest who had undergone TST screening during the study period 1 January 1998 to 31 May 2014. Results: Among 40142 HCWs who received a TST, only 123 converted over 16.4 years. Only 9 (7%) of the converters had a suspected tuberculosis exposure at the workplace and none developed active tuberculosis. The majority of TST converters (66%) had a negative QuantiFERON-TB test at the time of the conversion. Conclusions: In one of the largest cohorts of HCWs in a low-tuberculosis-incidence setting, we demonstrated an extremely low risk of occupational tuberculosis exposure among TST converters and no resulting active tuberculosis cases. In this setting, the approach of testing HCWs at baseline and after tuberculosis exposure, rather than at regular intervals, should be considered.

Antiviral therapy in management of chronic hepatitis B viral infection in children: A systematic review and meta-analysis.

UNLABELLED: Most individuals with chronic hepatitis B viral (HBV) infection acquired the infection around the time of birth or during early childhood. We aimed to synthesize evidence regarding the effectiveness of antiviral therapy in the management of chronic HBV infection in children. We conducted a comprehensive search of multiple databases from 1988 to December 2, 2014, for studies that enrolled children (<18 years) with chronic HBV infection treated with antiviral therapy. We included observational studies and randomized controlled trials (RCTs). Two independent reviewers selected studies and extracted data. In the 14 included studies, two cohort studies showed no significant reduction in the already low risk of hepatocellular carcinoma or cirrhosis and 12 RCTs reported intermediate outcomes. In RCTs with posttreatment follow-up <12 months, antiviral therapy compared to placebo improved alanine aminotransferase normalization (risk ratio [RR] = 2.3, 95% confidence interval [CI] 1.7-3.2), hepatitis B e antigen (HBeAg) clearance/loss (RR = 2.1, 95% CI 1.5-3.1), HBV DNA suppression (RR = 2.9, 95% CI 1.8-4.6), HBeAg seroconversion (RR = 2.1, 95% CI 1.4-3.3), and hepatitis B surface antigen clearance (RR = 5.8, 95% CI 1.1-31.5). In RCTs with posttreatment follow-up ≥12 months, antiviral therapy improved cumulative HBeAg clearance/loss (RR = 1.9, 95% CI 1.7-3.1), HBeAg seroconversion (RR = 2.1, 95% CI 1.3-3.5), alanine aminotransferase normalization (RR = 1.4, 95% CI 1.1-1.7), and HBV DNA suppression (RR = 1.4, 95% CI 1.1-1.8) but not hepatitis B surface antigen clearance or seroconversion. CONCLUSION: In children with chronic HBV infection, antivirals compared to no antiviral therapy improve HBV DNA suppression and frequency of alanine aminotransferase normalization and HBeAg seroconversion.

Antiviral therapy for chronic hepatitis B viral infection in adults: A systematic review and meta-analysis.

UNLABELLED: Chronic hepatitis B viral (HBV) infection remains a significant global health problem. Evidence-based guidelines are needed to help providers determine when treatment should be initiated, which medication is most appropriate, and when treatment can safely be stopped. The American Association for the Study of Liver Diseases HBV guideline methodology and writing committees developed a protocol a priori for this systematic review. We searched multiple databases for randomized controlled trials and controlled observational studies that enrolled adults ≥18 years old diagnosed with chronic HBV infection who received antiviral therapy. Data extraction was done by pairs of independent reviewers. We included 73 studies, of which 59 (15 randomized controlled trials and 44 observational studies) reported clinical outcomes. Moderate-quality evidence supported the effectiveness of antiviral therapy in patients with immune active chronic HBV infection in reducing the risk of cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In immune tolerant patients, moderate-quality evidence supports improved intermediate outcomes with antiviral therapy. Only very low-quality evidence informed the questions about discontinuing versus continuing antiviral therapy in hepatitis B e antigen-positive patients who seroconverted from hepatitis B e antigen to hepatitis B e antibody and about the safety of entecavir versus tenofovir. Noncomparative and indirect evidence was available for questions about stopping versus continuing antiviral therapy in hepatitis B e antigen-negative patients, monotherapy versus adding a second agent in patients with persistent viremia during treatment, and the effectiveness of antivirals in compensated cirrhosis with low-level viremia. CONCLUSION: Most of the current literature focuses on the immune active phases of chronic HBV infection; decision-making in other commonly encountered and challenging clinical settings depends on indirect evidence.

Systematic review and meta-analysis of duplex ultrasound surveillance for infrainguinal vein bypass grafts.

OBJECTIVE: Duplex ultrasound (DUS) surveillance of infrainguinal vein bypass grafts is widely practiced, but the evidence of its effectiveness compared with other methods of surveillance remains unclear. METHODS: Following an a priori protocol developed by the guidelines committee from the Society for Vascular Surgery, this systematic review and meta-analysis included randomized and nonrandomized comparative studies that enrolled patients who underwent infrainguinal arterial reconstruction and received DUS surveillance for follow-up compared with any other method of surveillance. The search included MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, and Scopus through November 2016. Outcomes of interest included all-cause mortality, limb viability, and graft patency reports. Meta-analysis was performed using the random-effects model. RESULTS: We included 15 studies. Compared with ankle-brachial index and clinical examination, DUS surveillance was not associated with a significant change in primary, secondary, or assisted primary patency or mortality. DUS surveillance was associated with a nonstatistically significant reduction in amputation rate (odds ratio, 0.70 [95% confidence interval, 0.23-2.13]). The quality of evidence was low because of imprecision (small number of events and wide confidence intervals) and high risk of bias in the primary literature. CONCLUSIONS: A recommendation for routine DUS surveillance of infrainguinal vein grafts remains dependent on low-quality evidence. Considering that DUS offers the opportunity of early intervention and because of its noninvasive nature and low cost, vascular surgeons may incorporate DUS as they individualize the follow-up of lower extremity vein grafts.

Grading the quality of evidence in complex interventions: a guide for evidence-based practitioners.

Evidence-based practitioners who want to apply evidence from complex interventions to the care of their patients are often challenged by the difficulty of grading the quality of this evidence. Using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and an illustrative example, we propose a framework for evaluating the quality of evidence that depends on obtaining feedback from the evidence user (eg, guideline panel) to inform: (1) proper framing of the question, (2) judgements about directness and consistency of evidence and (3) the need for additional contextual and qualitative evidence. Using this framework, different evidence users and based on their needs would consider the same evidence as high, moderate, low or very low.

PREDICTORS OF BIOCHEMICAL REMISSION AND RECURRENCE AFTER SURGICAL AND RADIATION TREATMENTS OF CUSHING DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS.

OBJECTIVE: We conducted a systematic review and meta-analysis to synthesize the evidence about predictors that may affect biochemical remission and recurrence after transsphenoidal surgery (TSS), radiosurgery (RS), and radiotherapy (RT) in Cushing disease. METHODS: We searched multiple databases through December 2014 including original controlled and uncontrolled studies that enrolled patients with Cushing disease who received TSS (first-line), RS, or RT. We extracted data independently, in duplicates. Outcomes of interest were biochemical remission and recurrence. A meta-analysis was conducted using the random-effects model to estimate event rates with 95% confidence intervals (CIs). RESULTS: First-line TSS was associated with high remission (76% [95% CI, 72 to 79%]) and low recurrence rates (10% [95% CI, 6 to 16%]). Remission after TSS was higher in patients with microadenomas or positive-adrenocorticotropic hormone tumor histology. RT was associated with a high remission rate (RS, 68% [95% CI, 61 to 77%]; RT, 66% [95% CI, 58 to 75%]) but also with a high recurrence rate (RS, 32% [95% CI, 16 to 60%]; RT, 26% [95% CI, 14 to 48%]). Remission after RS was higher at short-term follow-up (≤2 years) and with high-dose radiation, while recurrence was higher in women and with lower-dose radiation. Remission was after RT in adults who received TSS prior to RT, and with lower radiation doses. There was heterogeneity (nonstandardization) in the criteria and cutoff points used to define biochemical remission and recurrence. CONCLUSION: First-line TSS is associated with high remission and low recurrence, while RS and RT are associated with reasonable remission rates but important recurrence rates. The current evidence warrants low confidence due to the noncomparative nature of the studies, high heterogeneity, and imprecision.

Non-pharmacological treatment of depression: a systematic review and evidence map.

BACKGROUND: The comparative effectiveness of non-pharmacological treatments of depression remains unclear. METHODS: We conducted an overview of systematic reviews to identify randomised controlled trials (RCTs) that compared the efficacy and adverse effects of non-pharmacological treatments of depression. We searched multiple electronic databases through February 2016 without language restrictions. Pairs of reviewers determined eligibility, extracted data and assessed risk of bias. Meta-analyses were conducted when appropriate. RESULT: We included 367 RCTs enrolling ∼20 000 patients treated with 11 treatments leading to 17 unique head-to-head comparisons. Cognitive behavioural therapy, naturopathic therapy, biological interventions and physical activity interventions reduced depression severity as measured using standardised scales. However, the relative efficacy among these non-pharmacological interventions was lacking. The effect of these interventions on clinical response and remission was unclear. Adverse events were lower than antidepressants. LIMITATION: The quality of evidence was low to moderate due to inconsistency and unclear or high risk of bias, limiting our confidence in findings. CONCLUSIONS: Non-pharmacological therapies of depression reduce depression symptoms and should be considered along with antidepressant therapy for the treatment of mild-to-severe depression. A shared decision-making approach is needed to choose between non-pharmacological therapies based on values, preferences, clinical and social context.

A systematic review of treatment of intermittent claudication in the lower extremities.

BACKGROUND: Peripheral arterial disease is common and is associated with significant morbidity and mortality. METHODS: We conducted a systematic review to identify randomized trials and systematic reviews of patients with intermittent claudication to evaluate surgery, endovascular therapy, and exercise therapy. Outcomes of interest were death, amputation, walking distance, quality of life, measures of blood flow, and cost. RESULTS: We included eight systematic reviews and 12 trials enrolling 1548 patients. Data on mortality and amputation and on cost-effectiveness were sparse. Compared with medical management, each of the three treatments (surgery, endovascular therapy, and exercise therapy) was associated with improved walking distance, claudication symptoms, and quality of life (high-quality evidence). Evidence supporting superiority of one of the three approaches was limited. However, blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management (low- to moderate-quality evidence). Compared with endovascular therapy, open surgery may be associated with longer length of hospital stay and higher complication rate but resulted in more durable patency (moderate-quality evidence). CONCLUSIONS: In patients with claudication, open surgery, endovascular therapy, and exercise therapy were superior to medical management in terms of walking distance and claudication. Choice of therapy should rely on patients' values and preferences, clinical context, and availability of operative expertise.

RADIOTHERAPY VERSUS RADIOSURGERY IN TREATING PATIENTS WITH ACROMEGALY: A SYSTEMATIC REVIEW AND META-ANALYSIS.

OBJECTIVE: When patients with acromegaly have residual disease following surgery, adjuvant radiation therapy is considered. Both stereotactic radiosurgery (SRS) and conventional fractionated radiotherapy (RT) are utilized. We conducted a systematic review and meta-analysis to synthesize the existing evidence and compare outcomes for SRS and RT in patients with acromegaly. METHODS: We searched Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through April 2014 for studies in which SRS or RT were used in patients with acromegaly. Outcomes evaluated were serum insulin-like growth factor-I (IGF-I) and growth hormone (GH) levels, biochemical remission, all-cause mortality, hypopituitarism, headaches, and secondary malignancies. We pooled outcomes using a random-effects model. RESULTS: The final search yielded 30 eligible studies assessing 2,464 patients. Compared to RT, SRS was associated with a nonsignificant increase in remission rate at the latest follow-up period (52% vs. 36%; P = .14) and a significantly lower follow-up IGF-I level (-409.72 µg/L vs. -102 µg/L, P = .002). SRS had a lower incidence of hypopituitarism than RT; however, the difference was not statistically significant (32% vs. 51%, respectively; P = .05). CONCLUSION: SRS may be associated with better biochemical remission, and it had a lower risk of hypopituitarism with at least 1 deficient axis when compared with RT; however, the confidence in such evidence is very low due to the noncomparative nature of the studies, high heterogeneity, and imprecision.

Influenza-Associated Outcomes and Healthcare Utilization by Race and Ethnicity in the USA: a Retrospective Cohort Study Using the National Inpatient Sample Database.

BACKGROUND: The influenza virus continues to be a public health concern every season. We aimed to evaluate influenza-associated outcomes and healthcare utilization by race and ethnicity. METHODS: We conducted a retrospective cohort study using the National Inpatient Sample across 2019 and 2020. Influenza pneumonia was selected as the principal diagnosis. Outcomes included mortality, use of respiratory support ventilation, length of stay, and total hospitalization charge. Regression models were adjusted for age, gender, Charlson Comorbidity Index, hospitals' region, bed size, teaching status, insurance status, and median income. RESULTS: We identified 73,098 individuals hospitalized with influenza pneumonia; 39,807 and 33,291 were admitted in 2019 and 2020, respectively. The sample included 49,829 (68%) White, 11,356 (15.5%) Black, 7526 (10%) Hispanic, 1860 (2.5%) Asian/Pacific, and 617 (0.84%) Native American patients. In-hospital mortality rates and respiratory support (non-invasive ventilation and invasive mechanical ventilation) in 2019 and 2020 were not significantly different across all the races. In 2019 and 2020, the adjusted odds ratios of in-patient mortality were not significantly different. Asians had higher odds of receiving NIV in 2019 but not in 2020 compared to White patients (adjusted odds ratio (aOR) 1.67, p value 0.04). The adjusted odds ratios for receiving IMV were not significantly different between the races in 2019 and 2020. CONCLUSIONS: This study contributes valuable insight into influenza-associated outcomes and healthcare utilization patterns among diverse racial and ethnic groups. Disparities in healthcare utilization were observed among younger (< 65 years) individuals of Black and Hispanic ethnicity.

Safety implications of mask use: a systematic review and evidence map.

BACKGROUND: Widespread use of respiratory protection masks has become a critical component of public health response. OBJECTIVES: This systematic review synthesises the evidence on the acute physiological, cognitive and psychological impacts associated with different types of masks and provides an evidence map of research gaps. METHODS: A comprehensive search from 2000 to 2023 was conducted across multiple databases (MEDLINE, EMBASE, Cochrane databases, Scopus and PubMed). An umbrella systematic overview was conducted for physiological outcomes using existing systematic reviews. We conducted de novo systematic reviews for cognitive and psychological outcomes. Pairs of independent reviewers determined eligibility, extracted data and assessed risk of bias. Certainty at an outcome level was appraised using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: The search resulted in 13 370 potential citations, leading to the inclusion of nine systematic reviews for physiological outcomes (87 primary studies) and 10 primary studies for cognitive and psychological outcomes (3815 participants), with the majority of participants being healthy adults. Studies evaluating physiological outcomes demonstrated that various types of masks have little to no significant difference in heart rate (surgical mask (mean difference (MD): 0.96 (-1.01 to 2.93)), N95 mask (MD: 1.63 (-2.79 to 6.05)) and cloth mask (MD: -0.94 (-6.39 to 4.52))) or respiratory rate during rest or exercise (surgical mask (MD: -1.35 (-3.00 to 0.29)), N95 mask (MD: 0.10 (-3.10 to 3.29)) and cloth mask (MD: -2.57 (-6.44 to 1.29)) (low certainty for most outcomes)). Mask use may be associated with very small changes in minute ventilation (surgical mask (MD: -13.9 (-20.30 to -7.53)) and N95 mask (MD: -16.3 (-28.7 to -3.9))), tidal volume (surgical mask (MD: -0.14 (-0.23 to -0.05)) and N95 mask (MD: -0.10 (-0.33 to 0.13))), oxygen saturation (surgical mask (MD: -0.59% (-0.87 to -0.30)), N95 mask (MD: -0.35% (-0.75 to 0.05)) and cloth mask (MD: -0.50% (-1.23; 0.24))), carbon dioxide partial pressure (surgical mask (standardised MD (SMD): 1.17 (0.70 to 1.64)) and N95 mask (SMD: 0.43 (0.08 to 0.79))) and exercise performance (surgical mask (SMD: -0.12 (-0.39 to 0.15)), N95 mask (SMD: -0.42 (-0.76 to -0.08)) and cloth mask (SMD: -0.26 (-0.54 to 0.02)) (low certainty for most outcomes)). Studies evaluating cognitive outcomes showed mixed results. Some studies reported reduced mental workload, and others showed no significant effect or decreased performance. The impact on attention, errors and reaction time was variable. These studies were small and at moderate to high risk of bias. Evidence was insufficient to estimate the effect of mask use on psychological outcomes (claustrophobia, depression and anxiety) as these studies were small, non-longitudinal and at high risk of bias. CONCLUSION: This evidence map provides a comprehensive insight into the multifaceted impact of respiratory protection mask use, and highlights the limited certainty in the available body of evidence. This evidence map supports the development of future research agenda.

Who is getting boosted? Disparities in COVID-19 vaccine booster uptake among health care workers.

COVID-19 vaccination remains one of the most effective tools to reduce the risk of SARS-CoV-2 infection. Unfortunately, vaccine hesitancy has limited primary vaccination and booster uptake among the general population and HCWs. To gain a better understanding of factors associated with booster vaccine uptake, we analyzed COVID-19 vaccine booster rates among HCWs and identified risk factors associated with nonacceptance. Of the 62,387 HCWs included in our analysis, the overall booster uptake rate was 64.8%. Older age, Non-Hispanic White racial group, early initial vaccine uptake and longer duration of employment were associated with higher booster uptake. Significant differences were observed between different job categories. This persistence of vaccine hesitancy and disparities in COVID-19 booster uptake among HCWs, almost 2 years after the rollout of the COVID-19 vaccination, call for further efforts to increase vaccine confidence among HCWs and the general population in light of the continued need for further COVID-19 protection.

Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3.

BACKGROUND: History and physical examination are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical examination findings. METHODS: This study involved a patient-intervention-control-outcome (PICO) question: (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical examination findings; and (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was assessed. RESULTS: From 6309 titles, 460 articles were retrieved, and 43 met the inclusion criteria: general neurologic examination-five studies, 869 patients, pooled sensitivity 46.8% (95% confidence interval [CI] 32.3%-61.9%, moderate certainty) and specificity 92.8% (95% CI 75.7%-98.1%, low certainty); limb weakness/hemiparesis-four studies, 893 patients, sensitivity 11.4% (95% CI 5.1%-23.6%, high) and specificity 98.5% (95% CI 97.1%-99.2%, high); truncal/gait ataxia-10 studies, 1810 patients (increasing severity of truncal ataxia had an increasing sensitivity for central etiology, sensitivity 69.7% [43.3%-87.9%, low] and specificity 83.7% [95% CI 52.1%-96.0%, low]); dysmetria signs-four studies, 1135 patients, sensitivity 24.6% (95% CI 15.6%-36.5%, high) and specificity 97.8% (94.4%-99.2%, high); head impulse test (HIT)-17 studies, 1366 patients, sensitivity 76.8% (64.4%-85.8%, low) and specificity 89.1% (95% CI 75.8%-95.6%, moderate); spontaneous nystagmus-six studies, 621 patients, sensitivity 52.3% (29.8%-74.0%, moderate) and specificity 42.0% (95% CI 15.5%-74.1%, moderate); nystagmus type-16 studies, 1366 patients (bidirectional, vertical, direction changing, or pure torsional nystagmus are consistent with a central cause of vertigo, sensitivity 50.7% [95% CI 41.1%-60.2%, moderate] and specificity 98.5% [95% CI 91.7%-99.7%, moderate]); test of skew-15 studies, 1150 patients (skew deviation is abnormal and consistent with central etiology, sensitivity was 23.7% [95% CI 15%-35.4%, moderate] and specificity 97.6% [95% CI 96%-98.6%, moderate]); HINTS (head impulse, nystagmus, test of skew)-14 studies, 1781 patients, sensitivity 92.9% (95% CI 79.1%-97.9%, high) and specificity 83.4% (95% CI 69.6%-91.7%, moderate); and HINTS+ (HINTS with hearing component)-five studies, 342 patients, sensitivity 99.0% (95% CI 73.6%-100%, high) and specificity 84.8% (95% CI 70.1%-93.0%, high). CONCLUSIONS: Most neurologic examination findings have low sensitivity and high specificity for a central cause in patients with acute vertigo or dizziness. In acute vestibular syndrome (monophasic, continuous, persistent dizziness), HINTS and HINTS+ have high sensitivity when performed by trained clinicians.

Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for the guidelines for reasonable and appropriate care in the emergency department.

BACKGROUND: Patients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness. METHODS: An electronic search was designed following patient-intervention-control-outcome (PICO) question-(P) adult patients with acute vertigo or dizziness presenting to the ED; (I) neuroimaging including computed tomography (CT), CT angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and ultrasound (US); (C) MRI/clinical criterion standard; and (O) central causes (stroke, hemorrhage, tumor, others) versus peripheral causes of symptoms. Articles were assessed in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess certainty of evidence in pooled estimates. RESULTS: We included studies that reported diagnostic test accuracy. From 6309 titles, 460 articles were retrieved, and 12 were included: noncontrast CT scan-six studies, 771 patients, pooled sensitivity 28.5% (95% confidence interval [CI] 14.4%-48.5%, moderate certainty) and specificity 98.9% (95% CI 93.4%-99.8%, moderate certainty); MRI-five studies, 943 patients, sensitivity 79.8% (95% CI 71.4%-86.2%, high certainty) and specificity 98.8% (95% CI 96.2%-100%, high certainty); CTA-one study, 153 patients, sensitivity 14.3% (95% CI 1.8%-42.8%) and specificity 97.7% (95% CI 93.8%-99.6%), CT had higher sensitivity than CTA (21.4% and 14.3%) for central etiology; MRA-one study, 24 patients, sensitivity 60.0% (95% CI 26.2%-87.8%) and specificity 92.9% (95% CI 66.1%-99.8%); US-three studies, 258 patients, sensitivity ranged from 30% to 53.6%, specificity from 94.9% to 100%. CONCLUSIONS: Noncontrast CT has very low sensitivity and MRI will miss approximately one in five patients with stroke if imaging is obtained early after symptom onset. The evidence does not support neuroimaging as the only tool for ruling out stroke and other central causes in patients with acute dizziness or vertigo presenting to the ED.

Disparities in COVID-19 vaccine uptake among health care workers.

BACKGROUND: COVID-19 vaccine uptake by healthcare workers (HCWs) is critical to protect HCWs, the patients they care for, and the healthcare infrastructure. Our study aims to examine the actual COVID-19 vaccination rate among HCWs and identify risk factors associated with vaccine nonacceptance. STUDY DESIGN AND METHODS: A retrospective analysis of COVID-19 vaccinations for HCWs at a large multi-site US academic medical center from 12/18/2020 through 05/04/2021. Comparisons between groups were performed using unpaired student t-test for continuous variables and the chi-square test for categorical variables. A logistic regression analysis was used to assess the associations between vaccine uptake and risk factor(s). RESULTS: Of the 65,270 HCWs included in our analysis, the overall vaccination rate was 78.6%. Male gender, older age, White and Asian race, and direct patient care were associated with higher vaccination rates (P <.0001). Significant differences were observed between different job categories. Physicians and advanced practice staff, and healthcare professionals were more likely to be vaccinated than nurses and support staff. CONCLUSIONS: Our data demonstrated higher initial vaccination rates among HCWs than the general population national average during the study period. We observed significant disparities among different high-risk HCWs groups, especially among different job categories, black HCWs and younger HCWs despite their high risk of contracting the infection. Interventions to address lower vaccination rate and vaccine hesitancy should be built with these disparities and differences in mind to create more targeted interventions.

Occupational exposure to severe acute respiratory coronavirus virus 2 (SARS-CoV-2) and risk of infection among healthcare personnel.

OBJECTIVE: To assess the rate and factors associated with healthcare personnel (HCP) testing positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) after an occupational exposure. DESIGN: Retrospective cohort study. SETTING: Academic medical center with sites in Minnesota, Wisconsin, Arizona, and Florida. PARTICIPANTS: HCP with a high or medium risk occupational exposure to a patient or other HCP with SARS-CoV-2. METHODS: We reviewed the records of HCP with significant occupational exposures from March 20, 2020, through December 31, 2020. We then performed regression analysis to assess the impact of demographic and occupational variables to assess their impact on the likelihood of testing positive for SARS-CoV-2. RESULTS: In total, 2,253 confirmed occupational exposures occurred during the study period. Employees were the source for 57.1% of exposures. Overall, 101 HCP (4.5%) tested positive in the postexposure period. Of these, 80 had employee sources of exposure and 21 had patient sources of exposure. The postexposure infection rate was 6.2% when employees were the source, compared to 2.2% with patient sources. In a multivariate analysis, occupational exposure from an employee source had a higher risk of testing positive compared to a patient source (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.72-6.04). Sex, age, high-risk exposure, and HCP role were not associated with an increased risk of testing positive. CONCLUSIONS: The risk of acquiring coronavirus disease 2019 (COVID-19) following a significant occupational exposure has remained relatively low, even in the prevaccination era. Exposure to an infectious coworker carries a higher risk than exposure to a patient. Continued vigilance and precautions remain necessary in healthcare settings.