Influenza vaccine effectiveness against hospitalizations associated with influenza A(H3N2) in Hong Kong children aged 9 months to 17 years, June-November 2023.

A test negative study was carried out from 13 June through to 15 November 2023 enrolling 3183 children hospitalized with acute respiratory illness in Hong Kong. Influenza A and B viruses were detected in 528 (16.6%) children, among which 419 (79.4%) were influenza A(H3N2). The overall vaccine effectiveness against hospitalization associated with any influenza virus infection was estimated as 22.4% (95% CI: -11.7%, 46.1%), and against influenza A(H3N2) specifically was 14.3% (95% CI: -29.2%, 43.2%). Despite the moderate to low VE estimated here, which could be a result of waning immunity and antigenic drift, influenza vaccination remains an important approach to reduce the impact of influenza in children.

Influenza Vaccine Effectiveness Against Influenza-Associated Hospitalization in Hong Kong Children Aged 9 Months to 17 Years, March-June 2023.

In March-June 2023, we conducted a test-negative study in 1671 children who were hospitalized with acute respiratory illness in Hong Kong. Two hundred and eighty-six children (17.2%) were tested positive for influenza virus including 188 with A(H1N1). We estimated influenza vaccine effectiveness against influenza-associated hospitalization as 69.6% (95% confidence interval: 49.3%, 81.7%).

Effectiveness of social distancing measures and lockdowns for reducing transmission of COVID-19 in non-healthcare, community-based settings.

Social distancing measures (SDMs) are community-level interventions that aim to reduce person-to-person contacts in the community. SDMs were a major part of the responses first to contain, then to mitigate, the spread of SARS-CoV-2 in the community. Common SDMs included limiting the size of gatherings, closing schools and/or workplaces, implementing work-from-home arrangements, or more stringent restrictions such as lockdowns. This systematic review summarized the evidence for the effectiveness of nine SDMs. Almost all of the studies included were observational in nature, which meant that there were intrinsic risks of bias that could have been avoided were conditions randomly assigned to study participants. There were no instances where only one form of SDM had been in place in a particular setting during the study period, making it challenging to estimate the separate effect of each intervention. The more stringent SDMs such as stay-at-home orders, restrictions on mass gatherings and closures were estimated to be most effective at reducing SARS-CoV-2 transmission. Most studies included in this review suggested that combinations of SDMs successfully slowed or even stopped SARS-CoV-2 transmission in the community. However, individual effects and optimal combinations of interventions, as well as the optimal timing for particular measures, require further investigation. This article is part of the theme issue 'The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence'.

Nonpharmaceutical interventions for managing SARS-CoV-2.

PURPOSE OF REVIEW: Initial response strategies to the COVID-19 pandemic were heavily reliant on nonpharmaceutical interventions (NPIs), a set of measures implemented to slow or even stop the spread of infection. Here, we reviewed key measures used during the COVID-19 pandemic. RECENT FINDINGS: Some NPIs were successful in reducing the transmission of SARS-CoV-2. Personal protective measures such as face masks were widely used, and likely had some effect on transmission. The development and production of rapid antigen tests allowed self-diagnosis in the community, informing isolation and quarantine measures. Community-wide measures such as school closures, workplace closures and complete stay-at-home orders were able to reduce contacts and prevent transmission. They were widely used in the pandemic and contributed to reduce transmission in the community; however, there were also negative unintended consequences in the society and economy. SUMMARY: NPIs slowed the spread of SARS-CoV-2 and are essential for pandemic preparedness and response. Understanding which measures are more effective at reducing transmission with lower costs is imperative.

Infant deaths from respiratory syncytial virus in Lusaka, Zambia from the ZPRIME study: a 3-year, systematic, post-mortem surveillance project.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infections and a key driver of childhood mortality. Previous RSV burden of disease estimates used hospital-based surveillance data and modelled, rather than directly measured, community deaths. Given this uncertainty, we conducted a 3-year post-mortem prevalence study among young infants at a busy morgue in Lusaka, Zambia-the Zambia Pertussis RSV Infant Mortality Estimation (ZPRIME) study. METHODS: Infants were eligible for inclusion if they were aged between 4 days and less than 6 months and were enrolled within 48 h of death. Enrolment occurred mainly at the University Teaching Hospital of the University of Zambia Medical School (Lusaka, Zambia), the largest teaching hospital in Zambia. We extracted demographic and clinical data from medical charts and official death certificates, and we conducted verbal autopsies with the guardian or next of kin. RSV was identified using reverse transcriptase quantitative PCR and stratified by age, time of year, and setting (community vs facility deaths). By combining the PCR prevalence data with syndromic presentation, we estimated the proportion of all infant deaths that were due to RSV. FINDINGS: The ZPRIME study ran from Aug 31, 2017, to Aug 31, 2020, except for from April 1 to May 6, 2020, during which data were not collected due to restrictions on human research at this time (linked to COVID-19). We enrolled 2286 deceased infants, representing 79% of total infant deaths in Lusaka. RSV was detected in 162 (7%) of 2286 deceased infants. RSV was detected in 102 (9%) of 1176 community deaths, compared with 10 (4%) of 236 early facility deaths (<48 h from admission) and 36 (5%) of 737 late facility deaths (≥48 h from admission). RSV deaths were concentrated in infants younger than 3 months (116 [72%] of 162 infants), and were clustered in the first half of each year and in the poorest and most densely populated Lusaka townships. RSV caused at least 2·8% (95% CI 1·0-4·6) of all infant deaths and 4·7% (1·3-8·1) of community deaths. INTERPRETATION: RSV was a major seasonal cause of overall infant mortality, particularly among infants younger than 3 months of age. Because most RSV deaths occurred in the community and would have been missed through hospital-based surveillance, the global burden of fatal RSV has probably been underestimated. FUNDING: Bill & Melinda Gates Foundation.

Risk Factors for Respiratory Syncytial Virus-Associated Community Deaths in Zambian Infants.

BACKGROUND: Respiratory syncytial virus (RSV) is a major cause of infant deaths. Its epidemiology in low- and middle-income countries is poorly understood. Risk factors associated with RSV-associated infant deaths that occur in community settings are incompletely known. METHODS: Community deaths for infants aged 4 days to 6 months were identified during a 3-year postmortem RSV prevalence study at the main city morgue in Lusaka, Zambia, where 80% of deaths are registered. This analysis focuses on the subset of deaths for which an abbreviated verbal autopsy was available and intended to sort deaths into respiratory or nonrespiratory causes by clinical adjudication. Posterior nasopharyngeal swab samples were collected within 48 hours of death and tested for RSV using quantitative reverse-transcription polymerase chain reaction. Associations between potential risk factors were determined as relative risks with 95% confidence intervals (CIs). RESULTS: We prospectively enrolled 798 community infant deaths with verbal autopsies and RSV laboratory results, of which 62 results were positive. The mean age of the infants was 10 weeks, and 41.4% of them were male. Of all deaths, 44% were attributed to respiratory causes. RSV was detected in 7.8% of the community infants and was significantly associated with respiratory deaths (risk ratio, 4.0 [95% CI, 2.2-7.1]). Compared with older infants, those aged 0-8 weeks had a 2.83 (95% CI, 1.30-6.15) increased risk of dying with RSV. The risk of RSV for the 0-8-week age group increased to 5.24 (1.56-33.14) with adjustment for demographics, parental education, and geography. RSV deaths were increased with domiciliary overcrowding and were concentrated in poor and dense neighborhoods in Lusaka (risk ratio, 2.00 [95% CI, 1.22-3.27]). CONCLUSION: RSV is a significant contributor to community respiratory deaths in this population, particularly in the first 3 months of life and in the more poor and dense parts of Lusaka.

Association of Respiratory Syncytial Virus Infection and Underlying Risk Factors for Death Among Young Infants Who Died at University Teaching Hospital, Lusaka Zambia.

BACKGROUND: Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections and child mortality. While RSV disease burden is highest in low- and middle-income countries, most knowledge about risk factors for fatal RSV disease comes from high-income settings. METHODS: Among infants aged 4 days to <6 months who died at University Teaching Hospital in Lusaka, Zambia, we tested nasopharyngeal swabs obtained postmortem for RSV using reverse transcriptase-quantitative polymerase chain reaction. Through a systematic review of death certificates and hospital records, we identified 10 broad categories of underlying medical conditions associated with infant deaths. We used backward-selection models to calculate adjusted and unadjusted risk ratios (RRs) for the association between each underlying condition and RSV status. RESULTS: From 720 infant deaths, 6% (44) were RSV-positive, 70% were <4 weeks old, and 54% were male. At least 1 underlying condition was found in 85% of infants, while 63% had ≥2. Prematurity/low birth weight (53% [384]) and complications of labor and delivery (32% [230]) were the most common conditions. Congenital cardiac conditions were significantly associated with an increased risk of RSV infection (4%, 32; adjusted RR: 3.57; 95% CI: 1.71-7.44). No other underlying conditions were significantly associated with RSV. CONCLUSIONS: Other than congenital cardiac conditions, we found a lack of association between RSV and underlying risk factors. This differs from high-income settings, where RSV mortality is concentrated among high-risk infants. In this population, birth-related outcomes are the highest mortality risk factors. Improved neonatal care remains crucial in the fight against neonatal mortality.

The Effect of Magnesium Supplementation on Endothelial Function: A Randomised Cross-Over Pilot Study.

Evidence supports an association between low magnesium (Mg) intake and coronary heart disease and between Mg intake and endothelial function. The aim of this study was to assess the effect of one week of Mg supplementation on endothelial function, assessed by flow mediated dilatation (FMD). Nineteen healthy men and women completed this cross-over pilot study in which participants were randomised to take an over-the-counter magnesium supplement for one week or to follow their usual diet. Weight, FMD and blood pressure (BP) were taken on completion of each intervention and 24 h urine collections and blood samples were taken to assess compliance. Baseline serum Mg was within normal range for all participants. Urinary Mg and urinary magnesium-creatinine ratio (Mg/Cr) significantly increased between interventions, (p = 0.03, p = 0.005, respectively). No significant differences in FMD or BP were found between the interventions. A significant negative correlation was seen between age and FMD (r = -0.496, p = 0.031). When adjusted for age, saturated fat was negatively associated with FMD (p = 0.045). One week of Mg supplementation did not improve FMD in a healthy population.

The Acute Effect of Magnesium Supplementation on Endothelial Function: A Randomized Cross-Over Pilot Study.

Magnesium (Mg) deficiency might be a catalyst in the process of endothelial dysfunction, an early event in the pathogenesis of atherosclerosis. The aim of this study was to determine the acute effect of an oral Mg supplement as compared to control on endothelial function assessed by flow-mediated dilatation (FMD). Nineteen participants (39 years, body mass index (BMI) 22.9 kg/m2) completed this randomized cross-over study. Blood pressure (BP) and FMD were measured and blood samples were taken before participants drank 200 mL water, with or without an over the counter Mg supplement (450 mg and 300 mg for men and women). Measurements were repeated at 60 and 120 min. There was a statistically significant two-way interaction between treatment and time on serum Mg (p = 0.037). A difference of -0.085 mm in FMD was observed 60-min post drink in the control group, as compared to baseline FMD, and no difference was observed in the supplement group as compared to baseline. Despite the non-significant interaction between treatment and time on FMD, once adjusted for baseline, the difference seen in the control group and the lack of change in the supplement group at 60 min post-drink suggests that Mg might attenuate the reduction in FMD post-prandially.

The Incubation Period Distribution of Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

Incubation period is an important parameter to inform quarantine period and to study transmission dynamics of infectious diseases. We conducted a systematic review and meta-analysis on published estimates of the incubation period distribution of coronavirus disease 2019, and showed that the pooled median of the point estimates of the mean, median and 95th percentile for incubation period are 6.3 days (range, 1.8-11.9 days), 5.4 days (range, 2.0-17.9 days), and 13.1 days (range, 3.2-17.8 days), respectively. Estimates of the mean and 95th percentile of the incubation period distribution were considerably shorter before the epidemic peak in China compared to after the peak, and variation was also noticed for different choices of methodological approach in estimation. Our findings implied that corrections may be needed before directly applying estimates of incubation period into control of or further studies on emerging infectious diseases.

Streamlining an existing hip fracture patient pathway in an acute tertiary adult Irish hospital to improve patient experience and outcomes.

OBJECTIVE: To improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway. DESIGN: A pre-post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery. SETTING: A 600-bed teaching hospital in Ireland. PARTICIPANTS: Nursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management. INTERVENTIONS: LSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators. MAIN OUTCOME MEASURES: Access to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment. RESULTS: The percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral. CONCLUSIONS: Hip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes.

What does the Internet teach the obstetric patient about labor analgesia? / O que a internet ensina à paciente obstétrica sobre a analgesia de parto?

Abstract Background and objectives: It has been observed a general public increased search on the Internet for health information, including Anesthesiology. The objective of this study was to evaluate the information available to the lay person in Portuguese on the Internet about labor analgesia for the Brazilian population. Method: Using the term "labor anesthesia", the first 20 sites found on Google in November 2014 were evaluated by two resident physicians and classified as medical and non-medical. Legibility and Design - accessibility, reliability and navigability-were compared using Flesch Reading Ease Score (FRESH) and Minervation validation tool for healthcare websites (LIDA) tools. The websites' content was confronted with that of the medical literature. Results: Medical and non-medical websites were considered difficult to read according to FRESH. Regarding the design, there was no difference between groups regarding navigability, however, accessibility was considered superior in non-medical websites (p = 0.042); while reliability was higher in medical websites (p = 0.019). Conclusions: With the increased search for health information on the Internet and concern about improving the quality of childbirth care, it is fundamental that the content available to the layperson about labor analgesia is of quality and well understood. This study demonstrated that both medical and non-medical websites are difficult to read and that non-medical websites are more accessible while the medical ones are more accurate.

Resumo Justificativa e objetivos: Observa-se um crescimento da busca de informação no público geral sobre temas médicos na internet, inclusive em anestesiologia. O objetivo deste estudo foi avaliar a informação existente ao leigo na internet em língua portuguesa sobre analgesia de parto para a população brasileira. Método: Com o uso do termo "anestesia de parto", os 20 primeiros sites encontrados no Google em novembro de 2014 foram avaliados por dois médicos residentes e classificados como médicos e não médicos. Legibilidade e desenho - acessibilidade, confiabilidade e navegabilidade - foram comparados por meio das ferramentas Fresh (Flesch Reading Ease Score) e Lida (Minervation Validation Tool for Healthcare Websites). O conteúdo dos sites foi confrontado em relação à literatura médica. Resultados: Sites médicos e não médicos foram considerados de difícil leitura de acordo com o Fresh. Em relação ao desenho, não houve diferença entre os grupos quanto à navegabilidade. Entretanto, a acessibilidade foi considerada superior em sites não médicos (p= 0,042); enquanto que a confiabilidade foi maior em sites médicos (p= 0,019). Conclusões: Com aumento da busca de informações em saúde na internet e aumento da preocupação de melhorar a qualidade de assistência ao parto, é fundamental que o conteúdo disponível ao leigo sobre analgesia de parto seja de qualidade e compreendido. Este estudo demonstrou que tanto sites médicos como não médicos são de difícil leitura; e que os sites não médicos são mais acessíveis, enquanto os médicos são mais precisos.

[What does the Internet teach the obstetric patient about labor analgesia?] / O que a internet ensina à paciente obstétrica sobre a analgesia de parto?

BACKGROUND AND OBJECTIVES: It has been observed a general public increased search on the Internet for health information, including Anesthesiology. The objective of this study was to evaluate the information available to the lay person in Portuguese on the internet about labor analgesia for the Brazilian population. METHOD: Using the term "labor anesthesia", the first 20 sites found on Google in November 2014 were evaluated by two resident physicians and classified as medical and non-medical. Legibility and Design - accessibility, reliability and navigability-were compared using Flesch Reading Ease Score (FRESH) and Minervation validation tool for healthcare websites (LIDA) tools. The websites' content was confronted with that of the medical literature. RESULTS: Medical and non-medical websites were considered difficult to read according to FRESH. Regarding the design, there was no difference between groups regarding navigability, however, accessibility was considered superior in non-medical websites (p = 0.042); while reliability was higher in medical websites (p = 0.019). CONCLUSIONS: With the increased search for health information on the Internet and concern about improving the quality of childbirth care, it is fundamental that the content available to the layperson about labor analgesia is of quality and well understood. This study demonstrated that both medical and non-medical websites are difficult to read and that non-medical websites are more accessible while the medical ones are more accurate.

The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis.

INTRODUCTION: The influence that different concentrations of labour epidural local anesthetic have on assisted vaginal delivery (AVD) and many obstetric outcomes and side effects is uncertain. The purpose of this meta-analysis was to determine whether local anesthetics utilized at low concentrations (LCs) during labour are associated with a decreased incidence of AVD when compared with high concentrations (HCs). METHODS: We searched PubMed, Ovid EMBASE, Ovid MEDLINE, CINAHL, Scopus, clinicaltrials.gov, and Cochrane databases for randomized controlled trials of labouring patients that compared LCs (defined as ≤ 0.1% epidural bupivacaine or ≤ 0.17% ropivacaine) of epidural local anesthetic with HCs for maintenance of analgesia. The primary outcome was AVD and secondary outcomes included Cesarean delivery, duration of labour, analgesia, side effects (nausea and vomiting, motor block, hypotension, pruritus, and urinary retention), and neonatal outcomes. The odds ratios (OR) or weighted mean differences (WMD) and 95% confidence intervals (CI) were calculated using random effects modelling. An OR < 1 or a WMD < 0 favoured LCs. RESULTS: Eleven studies met our criteria (eight bupivacaine and three ropivacaine studies), providing 1,145 patients in the LCs group and 852 patients in the HCs group for analysis of the primary outcome. Low concentrations were associated with a reduction in the incidence of AVD (OR = 0.70; 95% CI 0.56 to 0.86; P < 0.001). There was no difference in the incidence of Cesarean delivery (OR 1.05; 95% CI 0.82 to 1.33; P = 0.7). The LCs group had less motor block (OR 3.9; 95% CI 1.59 to 9.55; P = 0.003), greater ambulation (OR 2.8; 95% CI 1.1 to 7.14; P = 0.03), less urinary retention (OR 0.42; 95% CI 0.23 to 0.73; P = 0.002), and a shorter second stage of labour (WMD -14.03; 95% CI -27.52 to -0.55; P = 0.04) compared with the HCs group. There were no differences between groups in pain scores, maternal nausea and vomiting, hypotension, fetal heart rate abnormalities, five-minute Apgar scores, and need for neonatal resuscitation. One-minute Apgar scores < 7 favoured the HCs group (OR 1.53; 95% CI 1.07 to 2.21; P = 0.02), and there was more pruritus in the LCs group (OR 3.36; 95% CI 1.00 to 11.31; P = 0.05). CONCLUSION: When compared with HCs of local anesthetics, the use of LCs for labour epidural analgesia reduces the incidence of AVD. This may be due to a reduction in the amount of local anesthetic used and the subsequent decrease in motor blockade. We therefore recommend the use of LCs of local anesthetics for epidural analgesia to optimize obstetric outcome.

Airway management and oxygenation in obese patients.

PURPOSE: The purpose of this Continuing Professional Development module is to describe anatomic and physiologic challenges in obese patients, review their effects on oxygenation and airway management, and propose strategies for perioperative management. PRINCIPAL FINDINGS: The combination of excess adipose tissue deposition, increased oxygen consumption, reduced lung volumes, and increased airway resistance in obese patients increases the risk of a difficult airway and rapid oxygen desaturation in the perioperative period. Preoxygenation can be optimized by a head-up or reverse Trendelenburg position, continuous positive airway pressure, and pressure support ventilation. Difficulties in bag and mask ventilation may occur. Laryngeal exposure during direct laryngoscopy is best achieved with the patient in the "ramped" position. Tracheal tube introducers or intubating stylets can assist tracheal intubation when suboptimal laryngeal views are obtained, and video laryngoscopy may help improve the glottic view and success of tracheal intubation. New generation double-lumen supraglottic airway devices provide higher leak pressures and may be safer in obese patients, and they can also provide a conduit for bronchoscopic intubation. In patients with anticipated difficult airways, preparations should be made for awake tracheal intubation. Intraoperatively, ventilatory strategies, such as recruitment maneuvers with positive end-expiratory pressure, may reduce atelectasis and improve oxygenation. Tracheal extubation in the head-up position and continuous positive airway pressure reduce postoperative hypoxemia. Following a difficult tracheal intubation, extubation over an airway exchange catheter should be considered. CONCLUSIONS: Rapid oxygen desaturation may occur in obese patients. Potential difficulties in airway management should be assessed and anticipated, and oxygenation, ventilation, and airway management strategies should be optimized perioperatively.

Elective cesarean delivery in non-dialyzed parturient with chronic renal failure.

Chronic renal failure is rare in pregnancy and often results in significant maternal and neonatal morbidity. When possible, preoperative dialysis is useful to optimize fluid and electrolyte balance. We describe the perioperative management of a parturient who persistently refused dialysis, had an uneventful cesarean delivery under graded epidural anesthesia.

Transversus abdominis plane block for analgesia in renal transplantation: a randomized controlled trial.

BACKGROUND: The transversus abdominis plane (TAP) block has proven effective in reducing opioid requirements and pain scores for some procedures involving the lower abdominal wall. In this study we assessed its efficacy in patients with end-stage renal failure undergoing cadaveric renal transplantation. METHODS: Sixty-five adult renal transplant recipients were prospectively randomized to receive a standard general anesthetic technique supplemented with levobupivacaine 0.375% 20 mL TAP block or sham block with 20 mL 0.9% saline. Both groups received patient-controlled morphine analgesia and acetaminophen. Patient assessment occurred in the postanesthetic care unit and at 2, 4, 6, 12, and 24 hours. The primary outcome was total morphine consumption in the first 24 hours after renal transplantation. Other outcomes assessed included pain scores, presence of nausea or vomiting, excessive sedation, and respiratory depression. RESULTS: Morphine requirements did not differ between the 2 groups, 31.6 ± 5.6 mg in the TAP group and 32.6 ± 5.5 mg in the control group (95% confidence interval [CI], -8.96 to 7.09, P = 0.817). Pain scores also did not differ significantly at any time point after surgery. Nausea was reported in 53% of the TAP group and 24% of the control group. The relative risk of nausea associated with treatment was 2.2 (95% CI, 1.1 to 4.3, P = 0.017). No patient exhibited excessive sedation or respiratory depression. CONCLUSIONS: The addition of a TAP block to the analgesia regimen for renal transplantation did not reduce morphine requirements.