Polio cases reported in Afghanistan, Chad, and DR Congo

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Three countries reported new polio cases this week, according to the latest update from the Global Polio Eradication Initiative (GPEI).

In Afghanistan, one wild poliovirus type 1 (WPV1) case was reported in Nangarhar province, bringing the number of reported cases in 2023 to six. GPEI notes that Nangarhar was covered during the subnational immunization days in May and July, as part of an intensified effort to disrupt persistent local WPV1 transmission in the area.

Chad reported 3 cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) in Logone Oriental, Mayo Kebbi Est, and Dar Sila provinces, bringing the number of 2023 cases to 36. The Democratic Republic of the Congo reported 1 cVDPV2 case, in Tshopo province, bringing its 2023 total to 90.

Not included in the GPEI update is a WPV1 case in an 18-month-old girl in Islamabad, Pakistan. That case was confirmed by Pakistan's National Polio Laboratory, according to reporting by Pakistani news channel ARY News. It's the country's third polio case this year.

Study suggests higher risk of new-onset post-COVID autoimmune, autoinflammatory disorders

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Hair in hairbrush
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Today in JAMA Network OpenSouth Korean researchers identify a significantly higher risk of multiple new-onset autoimmune and autoinflammatory connective-tissue disorders after COVID-19 infection, some associated with illness severity, but vaccination lowers the risk.

For the retrospective study, researchers analyzed nationwide data from the Korea Disease Control and Prevention Agency COVID-19 National Health Insurance Service on COVID-19 patients from October 2020 to December 2021. A control group was made up of uninfected people identified through the National Health Insurance Service of Korea.

The average age of the 354,527 COVID-19 patients was 52.2 years, and 50.5% were women. Among the 6,134,940 controls, the average age was 52.1 years, and 50.1% were women. The average follow-up time for the COVID-19 and control groups were 120 and 121 days, respectively.

"Possible associations of COVID-19 with autoimmune diseases… have been suggested, because SARS-CoV-2 appears to perturb self-tolerance and trigger autoimmune reactions via cross-reactivity that may lead to the development of autoimmune diseases," the study authors wrote.

Vaccinated participants at lower risk

Relative to controls, COVID-19 patients had significantly higher risks of alopecia areata (adjusted hazard ratio [aHR], 1.12), alopecia totalis (aHR, 1.74), antineutrophil cytoplasmic antibody–associated vasculitis (aHR, 2.76), Crohn disease (aHR, 1.68), and sarcoidosis (aHR, 1.59).

These findings suggest that autoimmune and autoinflammatory connective tissue disorders may manifest as post–COVID-19 sequelae, highlighting the potential long-term health ramifications associated with COVID-19.

The risks of alopecia totalis, psoriasis, vitiligo, vasculitis, Crohn disease, ulcerative colitis, rheumatoid arthritis, adult-onset Still disease, Sjogren syndrome, ankylosing spondylitis, and sarcoidosis were associated with increasing COVID-19 severity.

In subgroup analyses, unvaccinated participants were at greater risk of autoimmune diseases such as alopecia areata, alopecia totalis, and Crohn disease, as well as for COVID-associated cardiovascular control outcomes. But in vaccinated participants, the increased risks were lower for both autoimmune and cardiovascular control outcomes. The risk of psoriasis was slightly higher in a COVID-19 subgroup made up of men and those who had severe COVID-19. 

"These findings suggest that autoimmune and autoinflammatory connective tissue disorders may manifest as post–COVID-19 sequelae, highlighting the potential long-term health ramifications associated with COVID-19," the researchers wrote.

Heart attacks outside of hospitals increased, were deadlier during pandemic

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heart attack
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Today in JAMA Network Open, a new study shows that the incidence of out-of-hospital cardiac arrest (OHCA) increased during the  pandemic, and survival decreased. Rather than being directly linked to acute COVID-19 infections, the authors said the changes were linked to emergency medical services (EMS) use during the pandemic.

The findings were based on OHCA among adults attended by EMS in Seattle and King County, Washington, from January 1, 2018, to December 31, 2021.

During the study period, there were 13,081 EMS-attended patients with OHCA, 7,102 (54%) of whom were dead on arrival (DOA) and 5,979 (46%) of whom received attempted resuscitation. The average age was 64 years, and 64.6% were men.

"Of the 5,979 EMS-treated cases, 2,837 occurred during prepandemic years and 3,142 occurred during pandemic years, representing a 10.8% increase," the authors said. "We also observed a 27.2% increase in EMS-attended DOA patients, from 3,126 during prepandemic years to 3,976 during the pandemic period."

Indirect pandemic factors at play

Only 194 patients (6.2%) during the pandemic years were acutely infected with SARS-CoV-2.

According to the authors, however, there were lower proportions of OHCA survival outcomes during the pandemic compared with the prepandemic period, including survival to hospital admission (1,122 patients [35.7%] vs 1,209 patients [42.6%]), survival to hospital discharge (483 patients [15.4%] vs 544 patients [19.2%]), and survival with favorable neurologic status (432 patients [13.7%] vs 489 patients [17.2%]).

The findings suggest that a substantial proportion of the increase in OHCA incidence and the decrease in OHCA survival was not due specifically to acute COVID-19.

The unadjusted odds ratio of survival to hospital discharge during the pandemic period compared with the prepandemic period was 0.77 (95% confidence interval, 0.67 to 0.88).

"The findings suggest that a substantial proportion of the increase in OHCA incidence and the decrease in OHCA survival was not due specifically to acute COVID-19, but rather indirect factors that more generally challenged OHCA prevention and treatment," the authors concluded.

Diagnostic stewardship intervention linked to drop in catheter-associated UTIs

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A diagnostic stewardship intervention at a large urban hospital was associated with a significant reduction in catheter-associated urinary tract infections, researchers reported today in the American Journal of Infection Control.

The intervention at NYC Health + Hospitals/Kings County, implemented in April 2022, included an educational session for hospitalists and medical residents regarding the protocol for patients with indwelling urinary catheters (IUCs). The protocol emphasized replacing any IUCs that had been in place for more than 14 days before sending urinary studies, sending a urinalysis first, and ordering a urine culture only when urinalysis and clinical scenario suggested a urinary tract infection.

In addition, all pending urine cultures on patients with IUCs were reviewed 5 days a week, and a mediation was performed for cultures that didn't meet the recommended protocol.  The intervention supplemented ongoing standard CAUTI protocols.

Fewer inappropriately ordered urine cultures

In the 15 months prior to the intervention (January 2021 to April 2022), there were 16 CAUTIs with 5,536 catheter days, for a rate of 3.0 infections per 1,000 catheter-days. During the intervention period (May 2022 to April 2023), there were 4 CAUTIs during 4,233 catheter-days, for a rate of 0.94 infections/1,000 catheter days. Of the 38 mediations performed during the intervention period, 20 resulted in the culture being discontinued.

"During our pre-intervention period, a substantial proportion of patients with reported CAUTIs had cultures inappropriately ordered (e.g., IUCs were in for > 14 days) or had fevers attributed to another etiology (and the culture was not treated)," researchers from NYC Health + Hospitals/Kings Country wrote. "Our intervention, aimed to encourage only appropriately ordered urine cultures as part of a 'fever work-up,' was successful in decreasing the number of reported CAUTIs."

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