Chronic high level parasitemia in HIV-infected individuals with or without visceral leishmaniasis in an endemic area in North-West Ethiopia: potential superspreaders?

BACKGROUND: HIV patients with recurrent visceral leishmaniasis (VL) could potentially drive Leishmania transmission in areas with anthroponotic transmission such as East-Africa, but studies are lacking. Leishmania parasitemia has been used as proxy for infectiousness. METHODS: This study is nested within the PreLeish prospective cohort study, following a total of 490 HIV infected individuals free of VL at enrollment for upto 24-37 months in North-West Ethiopia. Blood Leishmania PCR was done systematically. This case series reports on ten HIV-coinfected individuals with chronic VL (≥3 VL episodes during follow-up) for upto 37 months, and three individuals with asymptomatic Leishmania infection for upto 24 months. RESULTS: All ten chronic VL cases were male, on antiretroviral treatment, with 0-11 relapses before enrollment. Median baseline CD4 counts were 82 cells/µL. They displayed three to six VL treatment episodes over a period upto 37 months. Leishmania blood PCR levels were strongly positive for almost the entire follow-up time (median Ct value 26 (IQR 23-30), including during periods between VL treatment. Additionally, we describe three HIV-infected individuals with asymptomatic Leishmania infection and without VL history, with equally strong Leishmania parasitemia over a period of upto 24 months without developing VL. All were on antiretroviral treatment at enrollment, with baseline CD4 counts ranging from 78 to 350 cells/µL. CONCLUSION: These are the first data on chronic parasitemia in HIV-infected individuals from L donovani endemic areas. HIV patients with asymptomatic and symptomatic Leishmania infection could potentially be highly infectious and constitute Leishmania superspreaders. Xenodiagnosis studies are required to confirm infectiousness.

Breathing pattern disorder in chronic rhinosinusitis with severe asthma: nasal obstruction and polyps do not increase prevalence.

OBJECTIVES: Chronic rhinosinusitis (CRS) with severe asthma are associated with breathing pattern disorder (BPD). Mouth breathing is a sign of breathing pattern disorder, and nose breathing a fundamental part of breathing pattern retraining for BPD. The prevalence of BPD in relation to CRS subtypes and the relationship of nasal obstruction to BPD in CRS and associated severe asthma is unknown. The breathing pattern assessment tool (BPAT) can identify BPD. Our objective was to thus investigate the prevalence of BPD, nasal airflow obstruction and measures of airway disease severity in CRS with (CRSwNP) and without nasal polyps (CRSsNP) in severe asthma. METHODS: We determined whether CRS status, peak nasal inspiratory flow (PNIF) or polyp disease increased BPD prevalence. Demographic factors, measures of airway function and breathlessness in relation to BPD status and CRS subtypes were also evaluated. RESULTS: 130 Patients were evaluated (n = 69 had BPD). The prevalence of BPD in CRS with severe asthma was 53.1%. There was no difference between BPD occurrence between CRSwNP and CRSsNP. The mean polyp grade and PNIF were not statistically different between the BPD and non-BPD group. The presence of nasal polyps did not increase breathlessness. CONCLUSIONS: BPD and CRS are commonly co-associated. CRS status and nasal obstruction per se does not increase BPD prevalence.

Long-Term Progression-Free Survival of a Pre-Treated Patient with Metastatic Colorectal Cancer Receiving Trifluridine/Tipiracil.

Trifluridine/tipiracil is approved for the use in later or last-line setting in previously treated metastatic colorectal cancer (mCRC) patients who progressed on standard anti-tumor drugs including 5-fluorouracil (5-FU), irinotecan, oxaliplatin, anti-VEGF and anti-EGFR antibodies, or who are not considered candidates for those standard therapies. In this report, we describe a 67-year-old male patient with KRAS-mutated mCRC and metachronous liver and lung metastasis who failed prior 5-FU- and irinotecan-containing regimens, but then showed long-term disease control for 31 months on single-agent trifluridine/tipiracil given as second-line treatment. According to our experience, trifluridine/tipiracil is a feasible and effective treatment option in earlier but not necessarily last-line therapy in mCRC patients who are not considered candidates for doublet or triplet chemotherapy. Besides its efficacy, it is associated with maintained quality of life and a manageable toxicity profile. Considering increasing age of mCRC patients and their wish for maintaining an independent lifestyle, further research on the use of trifluridine/tipiracil in earlier lines of systemic mCRC therapy is warranted.

How people with tinnitus-related insomnia experience group CBT-for-insomnia (CBTi): a thematic analysis.

Objective: Although insomnia often compounds tinnitus, sleeping problems in people experiencing tinnitus are rarely treated. This study investigates the experiences of participants receiving Cognitive Behavioural Therapy for insomnia (CBTi) as part of a randomised controlled trial for managing tinnitus-related insomnia. The aim of this study is to gain detailed insight into participants' perceptions and experiences of this treatment.Design: Semi-structured interviews were conducted via phone or in-person by one of the two clinical psychologists who facilitated the CBTi sessions. Reflexive thematic analysis with semantic inductive approach was used for analysis to keep the research question theoretically flexible.Study samples: Eight participants (three females, age range 32-69 years) were interviewed six months after CBTi completion.Results: Three superordinate themes were identified: "Common humanity and transcending individual distress," "Changing the things I can" and "Accepting the things I cannot change." The group environment helped participants to normalise their experiences. Reliable tinnitus/sleep information and robust behavioural change techniques helped participants to respond and relate to their condition differently.Conclusion: Generally, participants reported long-term benefits from CBTi to treat tinnitus-related insomnia, particularly increased confidence, and getting on with life. CBTi is multi-component, so clinicians need to respond to individual preferences and lifestyles.

Assessing the robustness of COVID-19 vaccine efficacy trials: systematic review and meta-analysis, January 2023.

BackgroundVaccines play a crucial role in the response to COVID-19 and their efficacy is thus of great importance.AimTo assess the robustness of COVID-19 vaccine efficacy (VE) trial results using the fragility index (FI) and fragility quotient (FQ) methodology.MethodsWe conducted a Cochrane and PRISMA-compliant systematic review and meta-analysis of COVID-19 VE trials published worldwide until 22 January 2023. We calculated the FI and FQ for all included studies and assessed their associations with selected trial characteristics using Wilcoxon rank sum tests and Kruskal-Wallis H tests. Spearman correlation coefficients and scatter plots were used to quantify the strength of correlation of FIs and FQs with trial characteristics.ResultsOf 6,032 screened records, we included 40 trials with 54 primary outcomes, comprising 909,404 participants with a median sample size per outcome of 13,993 (interquartile range (IQR): 8,534-25,519). The median FI and FQ was 62 (IQR: 22-123) and 0.50% (IQR: 0.24-0.92), respectively. FIs were positively associated with sample size (p < 0.001), and FQs were positively associated with type of blinding (p = 0.023). The Spearman correlation coefficient for FI with sample size was moderately strong (0.607), and weakly positive for FI and FQ with VE (0.138 and 0.161, respectively).ConclusionsThis was the largest study on trial robustness to date. Robustness of COVID-19 VE trials increased with sample size and varied considerably across several other important trial characteristics. The FI and FQ are valuable complementary parameters for the interpretation of trial results and should be reported alongside established trial outcome measures.

Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: a randomised controlled trial.

Insomnia is a significant difficulty and is reported by large proportion of people with tinnitus. Although cognitive behavioural therapy for insomnia (CBTi) might be an effective treatment, no controlled studies had been conducted to date. This randomised controlled trial evaluated the benefits of CBTi on a sample of 102 people with tinnitus-related insomnia. Participants were randomised to 1) CBTi, 2) Audiology-Based Care (ABC) or 3) Sleep Support Group (SSG). Primary outcomes included insomnia, sleep efficiency and total sleep time. Secondary outcomes measured sleep onset latency, sleep quality, tinnitus distress, psychological distress, functioning and quality of life. CBTi was superior at reducing insomnia and increasing sleep efficiency compared to ABC post-intervention and at 6-month follow-up. ABC was superior at reducing insomnia and increasing sleep efficiency compared to SSG. Both CBTi and ABC reported increased total sleep time compared to SSG at 6-month follow. More than 80% of participants in the CBTi group reported clinically meaningful improvements compared to 47% in ABC and 20% for those receiving social support. CBTi was more effective in reducing tinnitus distress and improving sleep quality, functioning and some aspects of mental health. CBTi and ABC offer effective treatments for tinnitus-related sleep disorder but CBTi offers a sizeable benefit.

Investigating COVID-19 transmission in a tertiary hospital in Hanoi, Vietnam using social network analysis.

OBJECTIVES: In March 2020, a COVID-19 outbreak in a major referral hospital in Hanoi, Vietnam led to 7664 patients and staff being sent into lockdown for 2 weeks, and more than 52,200 persons across 49 provinces being quarantined. We assessed SARS-CoV-2 transmission patterns during this to-date largest hospital outbreak in Vietnam using social network analysis (SNA). METHODS: We constructed a directed relational network and calculated network metrics for 'degree', 'betweenness', 'closeness' and 'eigenvector' centrality to understand individual-level transmission patterns. We analysed network components and modularity to identify sub-network structures with disproportionately big effects. RESULTS: We detected 68 connections between 46 confirmed cases, of whom 27 (58.7%) were ancillary support staff, 7 (15.2%) caregivers, 6 (13%) patients and 2 (4.4%) nurses. Among the 10 most important cases selected by each SNA network metric, transmission dynamics clustered in 17 cases, of whom 12 (70.6%) cases were ancillary support staff. Ancillary support staff also constituted 71.1% of cases in the dominant sub-network and 68.8% of cases in the three largest sub-communities. CONCLUSIONS: We identified non-clinical ancillary support staff, who are responsible for room service and food distribution in hospital wards in Vietnam, as a group with disproportionally big impacts on transmission dynamics during this outbreak. Our findings call for a holistic approach to nosocomial outbreak prevention and response that includes both clinical and non-clinical hospital staff. Our work also shows the potential of SNA as a complementary outbreak investigation method to better understand infection patterns in hospitals and similar settings.

Assessing the mental effects of COVID-19-related work on depression among community health workers in Vietnam.

BACKGROUND: Community health workers (CHWs) involved in the COVID-19 response might be at increased risk of developing depression, though evidence is scarce. We investigated effects of COVID-19-related work on changes in depression levels among CHWs in Vietnam and identified sub-groups among CHWs who are at particular risk of developing severe depression. METHODS: We conducted a cross-sectional online survey among 979 CHWs who were involved in the COVID-19 response in Vietnam, in particular during the 2021 Tet holiday outbreak between January and March 2021. Respondents were asked to report depression symptoms at two-time points, before the start of the COVID-19 pandemic (average June to December 2019) and during the 2021 Tet holiday outbreak using the PHQ-9 mental health questionnaire. We estimated depression levels at both time points and developed univariate and multivariable logistic regression models to estimate odds ratios and 95% confidence intervals (95% CIs) to explore the association between deterioration to high depression levels and selected risk factors. RESULTS: Median depression levels among CHWs in Vietnam doubled from 3 (IQR = 2-7) before COVID-19 to 6 (IQR = 3-9) on the PHQ-9 scale during the Tet holiday outbreak. The proportion with normal/minimal levels decreased from 77.1% (95% CI = 74.4-79.7) to 50.9% (95% CI = 47.7-54) (p-value < 0.001), while the proportion of CHWs with moderate, moderately severe, and severe depression levels increased 4.3, 4.5, and five-fold, respectively. Less sleep and poor sleep quality, working in unfavorable work environments, and being involved in contact tracing and the organization of quarantine for suspected cases were associated with an increased risk of deterioration to high depression levels. CONCLUSIONS: We found a substantial increase in overall depression levels among CHWs in Vietnam due to their COVID-19 related work and a particularly worrisome rise in CHWs suffering from severe depression. CHWs are an indispensable yet often overlooked cadre of work in many low- and middle-income countries and shoulder a heavy psychological burden during the COVID-19 pandemic. Targeted psychological support for CHWs is needed to improve their mental health and to ensure the sustainability of community-based health interventions during COVID-19 and future epidemics.

Timeliness of contact tracing among flight passengers during the COVID-19 epidemic in Vietnam.

BACKGROUND: International air travel plays an important role in the global spread of SARS-CoV-2, and tracing of close contacts is an integral part of the public health response to COVID-19. We aimed to assess the timeliness of contact tracing among airline passengers arriving in Vietnam on flights containing COVID-19 cases and investigated factors associated with timeliness of contact tracing. METHODS: We included data from 2228 passengers on 22 incoming flights between 2 and 19 March 2020. Contact tracing duration was assessed separately for the time between the date of index case confirmation and date of contact tracing initiation (interval I), and the date of contact tracing initiation and completion (interval II). We used log-rank tests and multivariable Poisson regression models to identify factors associated with timeliness. RESULTS: The median duration of interval I and interval II was one (IQR: 1-2) and 3 days (IQR: 2-5), respectively. The contact tracing duration was shorter for passengers from flights where the index case was identified through mandatory testing directly upon arrival (median = 4; IQR: 3-5) compared to flights with index case detection through self-presentation at health facilities after arrival (median = 7; IQR: 5-8) (p-value = 0.018). Cumulative hazards for successful tracing were higher for Vietnamese nationals compared to non-Vietnamese nationals (p < 0.001). CONCLUSIONS: Contact tracing among flight passengers in the early stage of the COVID-19 epidemic in Vietnam was timely though delays occurred on high workload days. Mandatory SARS-CoV-2 testing at arrival may reduce contact tracing duration and should be considered as an integrated screening tool for flight passengers from high-risk areas when entering low-transmission settings with limited contact tracing capacity. We recommend a standardized risk-based contact tracing approach for flight passengers during the ongoing COVID-19 epidemic.

Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study.

BACKGROUND: Asylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital. METHODS: We performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups. RESULTS: A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1-2) in the asylum-seeking and 2 (IQR 1-4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (> 15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients. CONCLUSIONS: Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

Transmission of SARS-CoV 2 During Long-Haul Flight.

To assess the role of in-flight transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), we investigated a cluster of cases among passengers on a 10-hour commercial flight. Affected persons were passengers, crew, and their close contacts. We traced 217 passengers and crew to their final destinations and interviewed, tested, and quarantined them. Among the 16 persons in whom SARS-CoV-2 infection was detected, 12 (75%) were passengers seated in business class along with the only symptomatic person (attack rate 62%). Seating proximity was strongly associated with increased infection risk (risk ratio 7.3, 95% CI 1.2-46.2). We found no strong evidence supporting alternative transmission scenarios. In-flight transmission that probably originated from 1 symptomatic passenger caused a large cluster of cases during a long flight. Guidelines for preventing SARS-CoV-2 infection among air passengers should consider individual passengers' risk for infection, the number of passengers traveling, and flight duration.

Preventable admissions and emergency-department-visits in pediatric asylum-seeking and non-asylum-seeking patients.

BACKGROUND: Migrant health has become an essential part of public health. According to the World Health Organization, many health systems in Europe have not yet adapted adequately to the needs of asylum-seekers, which might result in untimely and inefficient health care for asylum-seeking patients. The aim of this study was to assess the number of preventable hospital admissions and emergency department visits in asylum-seeking and non-asylum-seeking pediatric patients. METHODS: This is a retrospective, hospital-based study. The study was done at the University Children's Hospital Basel in Switzerland. Patients admitted or presenting to the emergency department were included and split into the groups of asylum-seeking and non-asylum-seeking patients. All admissions and emergency-department visits were extracted from the administrative electronic health records from 1st Jan 2016-31st Dec 2017. The main outcome was the proportion of admissions due to ambulatory-care-sensitive conditions (which refer to conditions for which admission can be prevented by early interventions in primary care) in asylum-seeking and non-asylum-seeking patients. Ambulatory-care-sensitive conditions were defined by a validated list of ICD-10 codes. The secondary objective was to assess the number of preventable emergency-department visits by asylum-seeking patients defined as proportion of visits with a non-urgent triage score. RESULTS: A total of 75'199 hospital visits were included, of which 63'405 were emergency department visits and 11'794 were admissions. Ambulatory-care-sensitive conditions accounted for 12.1% (18/149) of asylum-seeking and 10.9% (1270/11645) of non-asylum seeking patients' admissions. Among the emergency department visits by asylum-seeking patients, non-urgent conditions accounted for 82.2% (244/297). CONCLUSIONS: Admissions due to ambulatory-care-sensitive conditions are comparable in asylum-seeking and non-asylum-seeking children, suggesting few delayed presentations to ambulatory care facilities. Strategies to prevent non-urgent visits at pediatric emergency department facilities are needed.

Correction to: Suspected paracetamol overdose in Monrovia, Liberia: a matched case-control Study.

An amendment to this paper has been published and can be accessed via the original article.

Suspected paracetamol overdose in Monrovia, Liberia: a matched case-control study.

BACKGROUND: A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children's caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case-control study. METHODS: The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case-control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community). RESULTS: Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1-21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 µg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two. CONCLUSIONS: In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.

Cognitive behavioural therapy for tinnitus-related insomnia: evaluating a new treatment approach.

OBJECTIVE: Insomnia frequently occurs alongside distressing tinnitus, and greater tinnitus severity is associated with more sleep disturbance. Insomnia and tinnitus probably share common underlying processes and sleep studies show striking similarities between primary and tinnitus-related insomnia. This is the first study to evaluate outcomes following insomnia-specific Cognitive Behavioural Therapy (CBTi) for tinnitus-related insomnia in a "real world" clinic. DESIGN: Treatment was six-sessions of group-based CBTi. Measures of insomnia, sleep diaries, tinnitus distress, psychological distress, anxiety and depression were completed pre-intervention, post-intervention and at six-weeks follow up. STUDY SAMPLE: Participants were 24 adults with chronic, distressing tinnitus and associated sleep disturbance. Twenty-two completed treatment. RESULTS: CBTi was associated with significant improvements from pre-intervention to post-intervention maintained at follow up in insomnia, sleep-diary measures, tinnitus distress, psychological distress, anxiety and depression, largely maintained at follow-up. Reliable improvements were reported in insomnia (by 67% of patients), tinnitus distress (by 50% of patients) and psychological distress (by 38% of patients) post-intervention. CONCLUSIONS: The results suggest that CBTi is associated with reduced insomnia and distress for patients reporting chronic and distressing tinnitus with related insomnia. Further research into CBTi for this population, using utilising robust, randomised controlled designs, is warranted.

Mindfulness-Based Cognitive Therapy for Chronic Tinnitus: Evaluation of Benefits in a Large Sample of Patients Attending a Tinnitus Clinic.

OBJECTIVES: Mindfulness-based approaches may benefit patients with chronic tinnitus, but most evidence is from small studies of nonstandardized interventions, and there is little exploration of the processes of change. This study describes the impact of mindfulness-based cognitive therapy (MBCT) in a "real world" tinnitus clinic, using standardized MBCT on the largest sample of patients with chronic tinnitus to date while exploring predictors of change. DESIGN: Participants were 182 adults with chronic and distressing tinnitus who completed an 8-week MBCT group. Measures of tinnitus-related distress, psychological distress, tinnitus acceptance, and mindfulness were taken preintervention, postintervention, and at 6-week follow-up. RESULTS: MBCT was associated with significant improvements on all outcome measures. Postintervention, reliable improvements were detected in tinnitus-related distress in 50% and in psychological distress in 41.2% of patients. Changes in mindfulness and tinnitus acceptance explained unique variance in tinnitus-related and psychological distress postintervention. CONCLUSIONS: MBCT was associated with significant and reliable improvements in patients with chronic, distressing tinnitus. Changes were associated with increases in tinnitus acceptance and dispositional mindfulness. This study doubles the combined sample size of all previously published studies. Randomized controlled trials of standardized MBCT protocols are now required to test whether MBCT might offer a new and effective treatment for chronic tinnitus.

The Risk and Predictors of Visceral Leishmaniasis Relapse in Human Immunodeficiency Virus-Coinfected Patients in Ethiopia: A Retrospective Cohort Study.

BACKGROUND: East Africa, where Leishmania donovani is prevalent, faces the highest burden world-wide of visceral leishmaniasis (VL) and human immunodeficiency virus (HIV) coinfection. However, data on the risk and predictors of VL relapse are scarce. Such information is vital to target medical follow-up and interventions to those at highest risk. METHODS: We conducted a retrospective cohort study at a Médecins Sans Frontières-supported health center in northwest Ethiopia. We included adult VL-HIV coinfected patients treated for VL and discharged cured between February 2008 and February 2013. The risk of relapse was calculated using Kaplan-Meier methods, and predictors were determined using Cox regression models. RESULTS: Of the 146 patients included, 140 (96%) were male and the median age was 31 years. At the index VL diagnosis, 110 (75%) had primary VL, 57 (40%) were on antiretroviral therapy (ART), and the median CD4 count was 149 cells/µL. The median follow-up time after cure was 11 months, during which 44 (30%) patients relapsed. The risk of relapse was 15% at 6 months, 26% at 12 months, and 35% at 24 months. Predictors of relapse were: not being on ART at VL diagnosis, ART not initiated during VL treatment, and high tissue parasite load (parasite grade 6+) at VL diagnosis. CONCLUSIONS: The risk of VL relapse in coinfected patients was high, particularly in those not on ART or presenting with a high tissue parasite load. These patients should be preferentially targeted for secondary prophylaxis and/or regular medical follow-up. Timely ART initiation in all coinfected patients is crucial.

Accuracy of a Modified Lactate Minimum Test and Reverse Lactate Threshold Test to Determine Maximal Lactate Steady State.

Wahl, P, Manunzio, C, Vogt, F, Strütt, S, Volmary, P, Bloch, W, and Mester, J. Accuracy of a modified lactate minimum test and reverse lactate threshold test to determine maximal lactate steady state. J Strength Cond Res 31(12): 3489-3496, 2017-This study evaluated the accuracy of a modified lactate minimum test (mLMT), a modified reverse lactate threshold test (mRLT), compared with 2 established threshold concepts (onset of blood lactate accumulation [OBLA] and modified maximal deviation method [mDmax]) to determine power output at maximal lactate steady state (MLSS) in cycling. Nineteen subjects performed an mLMT, mRLT, graded exercise test (100 W start, +20 W every 3 minutes) and 3 or more constant-load tests of 30 minutes to determine power output at MLSS. The mLMT and mRLT both consisted of an initial lactate priming segment, followed by a short recovery phase. Afterward, the initial load of the subsequent incremental or reverse segment was calculated individually and was increased or decreased by 10 W every 90 seconds, respectively. The mean difference to MLSS was +2 ± 7 W (mLMT), +5 ± 10 W (mRLT), +9 ± 21 W (OBLA), and +6 ± 14 W (mDmax). The correlation between power output at MLSS and mLMT was highest (r = 0.99), followed by mRLT (r = 0.98), mDmax (r = 0.95), and OBLA (r = 0.90). Because of the higher accuracy of the mLMT and the mRLT to determine MLSS compared with OBLA and mDmax, we suggest both tests as valid and meaningful concepts to estimate power output at MLSS in one single test in moderately trained to well-trained athletes. Additionally, our modified tests provide anaerobic data and do not require detailed knowledge of the subjects' training status compared with previous LMT or RLT protocols.

Environmental Contamination and Persistence of Ebola Virus RNA in an Ebola Treatment Center.

BACKGROUND: Ebola viruses (EBOVs) are primarily transmitted by contact with infected body fluids. Ebola treatment centers (ETCs) contain areas that are exposed to body fluids through the care of patients suspected or confirmed to have EBOV disease. There are limited data documenting which areas/fomites within ETCs pose a risk for potential transmission. This study conducted environmental surveillance in 2 ETCs in Freetown, Sierra Leone, during the 2014-2016 West African Ebola outbreak. METHODS: ETCs were surveyed over a 3-week period. Sites to be swabbed were identified with input from field personnel. Swab samples were collected and tested for the presence of EBOV RNA. Ebola-positive body fluid-impregnated cotton pads were serially sampled. RESULTS: General areas of both ETCs were negative for EBOV RNA. The immediate vicinity of patients was the area most likely to be positive for EBOV RNA. Personal protective equipment became positive during patient care, but chlorine solution washes rendered them negative. CONCLUSIONS: Personal protective equipment and patient environs do become positive for EBOV RNA, but careful attention to decontamination seems to remove it. EBOV RNA was not detected in general ward spaces. Careful attention to decontamination protocols seems to be important in minimizing the presence of EBOV RNA within ETC wards.

The Contribution of Ebola Viral Load at Admission and Other Patient Characteristics to Mortality in a Médecins Sans Frontières Ebola Case Management Centre, Kailahun, Sierra Leone, June-October 2014.

This paper describes patient characteristics, including Ebola viral load, associated with mortality in a Médecins Sans Frontières Ebola case management centre (CMC).Out of 780 admissions between June and October 2014, 525 (67%) were positive for Ebola with a known outcome. The crude mortality rate was 51% (270/525). Ebola viral load (whole-blood sample) data were available on 76% (397/525) of patients. Univariate analysis indicated viral load at admission, age, symptom duration prior to admission, and distance traveled to the CMC were associated with mortality (P < .05). The multivariable model predicted mortality in those with a viral load at admission greater than 10 million copies per milliliter (P < .05, odds ratio >10), aged ≥ 50 years (P = .08, odds ratio = 2) and symptom duration prior to admission less than 5 days (P = .14). The presence of confusion, diarrhea, and conjunctivitis were significantly higher (P < .05) in Ebola patients who died.These findings highlight the importance viral load at admission has on mortality outcomes and could be used to cohort cases with viral loads greater than 10 million copies into dedicated wards with more intensive medical support to further reduce mortality.