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What's new in the medical literature

Updated 24 November 2023


Cochrane Library





Other journals



Risk of pericardiocentesis in patients with pulmonary hypertension
Case series suggest that patients with pulmonary hypertension (PH) may be at risk for hemodynamic collapse during pericardiocentesis, but data are limited and conflicting. A National Inpatient Sample database study of over 95,000 adults (including nearly 8000 with PH) who underwent pericardiocentesis assessed in-hospital outcomes [19]. Patients with PH had higher adjusted rates of in-hospital mortality and postprocedure shock than patients without PH. These findings suggest that hemodynamic monitoring during pericardiocentesis is particularly important in patients with PH. (See "Pericardial effusion: Approach to management", section on 'Pulmonary hypertension'.)

Investigational transdermal formulation of abaloparatide for the treatment of osteoporosis
In individuals with osteoporosis, the bone anabolic agent abaloparatide increases bone mineral density (BMD) and reduces fracture risk but requires daily subcutaneous injections. Noninjectable formulations may facilitate use of anabolic therapy for the treatment of osteoporosis. In a 12-month trial in 511 postmenopausal women with osteoporosis, participants were randomly assigned to daily treatment with an investigational, transdermal formulation of abaloparatide or subcutaneous abaloparatide. Transdermal abaloparatide increased BMD at the lumbar spine, although not as robustly as subcutaneous abaloparatide (mean increase of 7.14 versus 10.86 percent, respectively) [17]. Transdermal abaloparatide similarly led to a smaller increase in BMD at the total hip (mean increase of 1.97 versus 3.7 percent with subcutaneous abaloparatide). Further studies are needed to determine whether transdermal abaloparatide reduces fracture risk. (See "Parathyroid hormone/parathyroid hormone-related protein analog therapy for osteoporosis", section on 'Dosing'.)

Adverse effects with piperacillin-tazobactam versus cefepime
Observational data have raised concerns for nephrotoxicity with piperacillin-tazobactam (when given with vancomycin) and neurotoxicity with cefepime. In an open-label trial of over 2500 patients randomly assigned to piperacillin-tazobactam versus cefepime, the incidence of major kidney events was comparable between groups (9 versus 10 percent), including among the 1900 patients who also received vancomycin [9]. Median antibiotic use was three days. Although the incidence of neurotoxicity (primarily delirium) was higher with cefepime (21 versus 17 percent), imbalances in baseline delirium rates reduce confidence in that finding. These data reduce concern for nephrotoxicity with short-term coadministration of piperacillin-tazobactam and vancomycin (eg, for initial empiric therapy). For those who warrant prolonged therapy with vancomycin plus an antipseudomonal agent, we weigh the uncertain risks of nephrotoxicity and neurotoxicity when choosing between piperacillin-tazobactam and cefepime. (See "Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects", section on 'Renal reactions'.)

Sulbactam-durlobactam for Acinetobacter infections
Antibiotic options for infections due to Acinetobacter spp are limited due to high rates of resistance. The US Food and Drug Administration recently approved a new beta-lactam/beta-lactamase inhibitor antibiotic, sulbactam-durlobactam. In an international randomized trial of 125 patients with carbapenem-resistant Acinetobacter infection (mainly hospital-acquired or ventilator-associated pneumonia), sulbactam-durlobactam resulted in a trend toward lower all-cause mortality that was not statistically significant (19 versus 32 percent) and a higher clinical cure rate (62 versus 40 percent) compared with colistin [10]. We reserve this agent for patients with hospital-acquired pneumonia or bacteremia due to susceptible Acinetobacter baumannii complex isolates that are resistant to other first-line agents (ie, other beta-lactams, carbapenems, and fluoroquinolones). (See "Acinetobacter infection: Treatment and prevention", section on 'First-line antibiotics'.)

Early metformin treatment of gestational diabetes mellitus
Usual initial gestational diabetes mellitus (GDM) care (ie, medical nutritional therapy, exercise) may result in a few weeks of hyperglycemia before a need for pharmacotherapy is established. In a randomized trial evaluating whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care, the metformin group had a lower rate of insulin initiation and favorable trends in mean fasting glucose, gestational weight gain, and excessive fetal growth, but more births <2500 grams [1]. Rates of preeclampsia, neonatal intensive care unit admission, and neonatal hypoglycemia were similar for both groups. Given these mixed results, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. (See "Gestational diabetes mellitus: Glucose management and maternal prognosis", section on 'Does early metformin initiation improve glycemic control and reduce need for insulin?'.) 

Vacuum-induced intrauterine tamponade for treatment of postpartum hemorrhage
Intrauterine tamponade (with a balloon, packing, or vacuum) may be used to manage patients with postpartum hemorrhage (PPH) resulting from uterine atony that is not controlled by uterotonic medications and uterine massage. However, outcome data regarding vacuum-induced tamponade are limited. A study of data from a postmarketing registry of over 500 patients with PPH and isolated atony treated with vacuum-induced tamponade reported that the device controlled bleeding without treatment escalation or bleeding recurrence in 88 percent following cesarean birth and 96 percent following vaginal birth, usually within five minutes [23]. These data are consistent with previously published outcomes. Given its efficacy and ease of use, vacuum-induced tamponade is an important option for managing PPH in centers where this device is available. (See "Postpartum hemorrhage: Use of intrauterine tamponade to control bleeding", section on 'Vacuum-induced tamponade'.)

Risk of pregnancy-associated venous and arterial thrombosis in sickle cell disease
Sickle cell disease (SCD) and pregnancy both confer an increased risk of venous thromboembolism (VTE), but the magnitude of the risk is unclear. In a new administrative claims data study involving >6000 people with SCD and >17,000 age- and race-matched controls who were followed for one year postpartum, the risk of VTE was 11.3 percent in the patients with SCD, versus 1.2 percent in controls [24]. Arterial thromboembolism was also increased (5.2 percent, versus 0.6 percent in controls). This study emphasizes the value of postpartum VTE prophylaxis in people with SCD and the need for vigilance in evaluating suggestive symptoms. (See "Sickle cell disease: Obstetric considerations", section on 'Maternal risks'.)

Tebentafusp and uveal melanoma
In patients with human leukocyte antigen (HLA)-A*02:01-positive metastatic uveal melanoma, a randomized trial previously showed an improvement in overall survival (OS) with tebentafusp compared with clinician's choice of systemic therapy at a median follow-up of 14 months. Now, with longer follow-up of 36 months, improvements in OS persist (three-year OS 27 versus 18 percent; median OS 22 versus 17 months) [42,43]. Improvements were also seen in progression-free survival (median 3.4 versus 2.9 months) and objective response rates (11 versus 5 percent). Adverse events were similar to previous reports. With the longer follow-up of this trial, tebentafusp remains the recommended first-line therapy for patients with HLA-A*02:01-positive metastatic uveal melanoma. (See "Metastatic uveal melanoma", section on 'Tebentafusp'.)

Written exposure therapy for posttraumatic stress disorder
Many effective psychotherapies for posttraumatic stress disorder (PTSD), such as prolonged exposure therapy, are time- and resource-intensive; written exposure therapy (WET) is emerging as an alternative brief intervention. In a randomized trial, WET resulted in largely similar improvements in PTSD symptoms compared with prolonged exposure therapy and had a lower dropout rate (13 versus 36 percent) [17]. In addition to an earlier study in which WET compared favorably with cognitive processing therapy, these findings suggest that WET may be a viable psychotherapeutic option for individuals with PTSD who cannot participate in more intensive options. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Efficacy of exposure therapy'.)

Timing of appendectomy for uncomplicated appendicitis
Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [5]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy'.)

Negative pressure wound therapy for contaminated surgical wounds
Prophylactic negative pressure wound therapy (NPWT) is used on clean surgical wounds, but it may also be useful for contaminated surgical wounds. In a randomized trial that compared NPWT with standard wound care in 69 patients who underwent surgery for gastrointestinal perforation and had fascial closure, NPWT reduced rates of surgical site infection (18 versus 61 percent) and fascial dehiscence (9 versus 48 percent), increased the rate of delayed primary skin closure (91 versus 48 percent), and decreased median time to wound healing (19 versus 26 days) [11]. The results of this small trial are encouraging, and, in the absence of contraindications, we use NPWT over intact fascia to expedite closure of contaminated surgical wounds. (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

Tranexamic acid for burn wound excision
Randomized trials have established that tranexamic acid (TXA) reduces blood loss and transfusion requirements in various surgical settings, but data in burn surgery are limited. In a meta-analysis of observational studies evaluating intravenous and topical TXA in burn surgery, use of TXA was associated with reductions in blood loss, use of intraoperative transfusion, and number of units transfused but no change in venous thromboembolism or mortality rates [19]. Based on this review and data from other surgical settings, we routinely administer intravenous TXA for burn wound excisions over 20 percent of total body surface area. (See "Overview of the management of the severely burned patient", section on 'Coagulopathy'.)



Australian evidence‐based guidelines for the prevention and management of diabetes‐related foot disease: a guideline
Main recommendations: This article summarises the most relevant of the 98 recommendations made across six new guidelines for the general medical audience, including:

  • prevention — screening, education, self‐care, footwear, and treatments to prevent DFD;
  • classification — classifications systems for ulcers, infection, ischaemia and auditing;
  • peripheral artery disease (PAD) — examinations and imaging for diagnosis, severity classification, and treatments;
  • infection — examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments;
  • offloading — pressure offloading treatments for different ulcer types and locations; and
  • wound healing — debridement, wound dressing selection principles and wound treatments for non‐healing ulcers.

MJA 13 November 2023

Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in Australia: a narrative review

  • Extracorporeal cardiopulmonary resuscitation (ECPR) in patients with prolonged or refractory out‐of‐hospital cardiac arrest (OHCA) is likely to be beneficial when used as part of a well developed emergency service system.
  • ECPR is technically challenging to initiate and resource‐intensive, but it has been found to be cost‐effective in hospital‐based ECPR programs.
  • ECPR expansion within Australia has thus far been reactive and does not provide broad coverage or equity of access for patients.
  • Newer delivery strategies that improve access to ECPR for patients with OHCA are being trialled, including networked hospital‐based ECPR and pre‐hospital ECPR programs. The efficacy, scalability, sustainability and cost‐effectiveness of these programs need to be assessed.
  • There is a need for national collaboration to determine the most cost‐effective delivery strategies for ECPR provision along with its place in the OHCA survival chain.

MJA 13 November 2023

Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia
Changes in management as a result of this statement:

  • Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended.
  • High quality evidence supports the use of child‐specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults.
  • Red flags that indicate serious underlying conditions requiring investigation or referral should be identified.
  • Early and effective treatment of chronic wet/productive cough in children is critical.
  • Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted.
  • If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.

MJA 20 November 2023



Covid-19 vaccine effectiveness against post-covid-19 condition among 589 722 individuals in Sweden: population based cohort study
The results of this study suggest a strong association between covid-19 vaccination before infection and reduced risk of receiving a diagnosis of PCC. The findings highlight the importance of primary vaccination against covid-19 to reduce the population burden of PCC. BMJ 22 November 2023

Paracetamol use in adults
What you need to know

  • Short term use of paracetamol can be effective for acute pain, but is unlikely to offer relief for chronic pain
  • Consider adjusting dose or dose frequency for patients with low body weight, who consume alcohol regularly, have liver disease, or who are frail
  • Overdose resulting in liver damage can occur in patients who accidentally take too much paracetamol or multiple paracetamol-containing products

BMJ 16 November 2023

Developmental dysplasia of the hip in infants and children
What you need to know

  • Developmental dysplasia of the hip (DDH) is a spectrum of conditions, ranging from a shallow acetabulum with or without instability to a completely dysplastic, unstable, or dislocated hip
  • Diagnostic accuracy of clinical examination in the newborn period and at the 6-8 week check is low
  • Signs suggestive of DDH vary according to age, and use of ultrasound increases detection
  • Late diagnoses increase the need for operative intervention and have long term implications for patients and their families
  • Whether to screen infants selectively or universally with ultrasound remains controversial, and the body of evidence to support universal ultrasound screening is growing

BMJ 23 November 2023

Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis
Compared with coronary angiography guided percutaneous coronary intervention, intravascular imaging guided percutaneous coronary intervention was associated with significantly reduced cardiac death and cardiovascular outcomes in patients with coronary artery disease. The estimated absolute effects of intravascular imaging guided percutaneous coronary intervention showed a proportional relation with baseline risk, driven by the severity and complexity of coronary artery disease. BMJ 16 November 2023

Autism intervention meta-analysis of early childhood studies (Project AIM): updated systematic review and secondary analysis
The available evidence on interventions to support young autistic children has approximately doubled in four years. Some evidence from randomized controlled trials shows that behavioral interventions improve caregiver perception of challenging behavior and child social emotional functioning, and that technology based interventions support proximal improvements in specific social communication and social emotional skills. Evidence also shows that developmental interventions improve social communication in interactions with caregivers, and naturalistic developmental behavioral interventions improve core challenges associated with autism, particularly difficulties with social communication. However, potential benefits of these interventions cannot be weighed against the potential for adverse effects owing to inadequate monitoring and reporting. BMJ 14 November 2023

Advances in the understanding and management of alcohol-related liver disease
An increasing understanding of the mechanisms by which alcohol causes liver disease in susceptible individuals offers the prospect of new therapeutic targets for disease-modifying drugs. Successful translation will require significant public and private investment in a disease area which has traditionally been underfunded when compared to its overall prevalence. BMJ 20 November 2023

Vitamin B12
What you need to know

  • The clinical picture is the most important factor in assessing the significance of results of blood tests assessing cobalamin (B12) status because there is no “gold standard” test to define deficiency
  • Neurological symptoms resulting from B12 deficiency may take several months or even years to resolve completely
  • Measuring serum biomarkers such as B12 or methylmalonic acid is neither helpful nor indicated in assessing or monitoring clinical improvement, neither is titration of injection frequency based on biomarker assessment
  • Self-administration of intramuscular B12 injections can lead to greater patient satisfaction and better health outcomes

BMJ 20 November 2023

Chronic prostatitis (chronic pelvic pain syndrome)
What you need to know

  • Chronic prostatitis, also known as chronic pelvic pain syndrome, is defined as pelvic pain with variable associated urinary symptoms and sexual dysfunction for at least three months
  • Explore important differentials such as urological and rectal cancer, bacterial infection, benign prostatic enlargement, and neurological conditions
  • Empower patients with knowledge about the condition and consider psychosocial and quality of life issues early on

BMJ 17 November 2023

Proton pump inhibitors
What you need to know

  • Discuss with patients the importance of lifestyle modification for the long term management of acid reflux disorders
  • Discuss with patients that a prescription may be stopped even if it has improved symptoms
  • Side effects of PPIs include gastrointestinal disturbance, higher rate of fractures, and increased susceptibility to Clostridium difficile infection
  • Review new prescriptions of proton pump inhibitors (PPIs) at four weeks, and regularly thereafter, assessing for improvement in symptoms and quality of life

BMJ 17 November 2023

Cirrhosis in over 16s: assessment and management—updated summary of NICE guidance
What you need to know

  • Non-selective beta blockers (NSBBs) are likely to prevent or delay decompensation in people with cirrhosis and clinically significant portal hypertension
  • NSBBs can be used safely in people with cirrhosis but need to be used with caution and should be started at low doses
  • NSBBs are as effective as endoscopic variceal band ligation for preventing oesophageal variceal bleeding, and are more cost effective
  • Routine prophylactic antibiotics are unlikely to be effective in preventing spontaneous bacterial peritonitis

BMJ 22 November 2023



A placebo-controlled trial of Percutaneous Coronary Intervention for Stable Angina
Among patients with stable angina who were receiving little or no antianginal medication and had objective evidence of ischemia, Percutaneous coronary intervention (PCI)resulted in a lower angina symptom score than a placebo procedure, indicating a better health status with respect to angina. NEJM 16 November 2023

Apixaban for stroke prevention in Subclinical Atrial Fibrillation
Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. NEJM 12 November 2023

Liver transplantation – a review article
Liver transplantation will probably remain the treatment of last resort for life-threatening liver disease for some years to come. The evolution of new treatments for serious liver disease or, more fundamentally, a reduction in the social influences that drive the two liver diseases known to be related to consumption (MASLD and ALD) would reduce the demand for transplantation. Better tools for identifying patients with ALD who are likely to recover without transplantation, better instruments for predicting future drinking, and studies of alcohol use disorder in patients with ALD will advance the care of patients. NEJM 16 November 2023

Erdafitinib or Chemotherapy in advanced or metastatic urothelial carcinoma
Erdafitinib therapy resulted in significantly longer overall survival than chemotherapy among patients with metastatic urothelial carcinoma and FGFR alterations after previous anti–PD-1 or anti–PD-L1 treatment. NEJM 23 November 2023

Transcatheter Aortic-Valve Replacement in low-risk patients at five years
Among low-risk patients with severe, symptomatic aortic stenosis who underwent TAVR or surgery, there was no significant between-group difference in the two primary composite outcomes. NEJM 23 November 2023 



Effect of dietary sodium on blood pressure: A crossover trial
Dietary sodium reduction significantly lowered BP in the majority of middle-aged to elderly adults. The decline in BP from a high- to low-sodium diet was independent of hypertension status and antihypertensive medication use, was generally consistent across subgroups, and did not result in excess adverse events. JAMA 11 November 2023

The role of socioeconomic position in the association between mental disorders and mortality: A systematic review and meta-analysis
This study did not find a sufficient body of evidence that socioeconomic position (SEP) moderated the relative association between mental disorders and mortality, but the underlying mortality rates may differ by SEP group, despite having scarcely been reported. This information gap, together with our findings related to SEP and a possible differential risk between natural and external causes of death in individuals with specific types of mental disorders, warrants further research. JAMA 15 November 2023

Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps
The findings of this quality improvement study performed with interprofessional teammates suggest that organizationally sponsored labeled surgical caps was associated with improved teamwork, indicated by increased name use and role recognition in perioperative areas. JAMA 17 November 2023

Risk of bleeding following non–vitamin K antagonist oral anticoagulant use in patients with acute ischemic stroke treated with Alteplase
In this cohort study with meta-analysis, compared to no treatment with anticoagulants, treatment with non–vitamin K antagonist oral anticoagulants (NOACs) prior to stroke was not associated with a higher risk of intracranial hemorrhage, major bleeding, or mortality in patients receiving intravenous alteplase for acute ischemic stroke. JAMA 20 November 2023

Risk of suicidal ideation and behavior in individuals with Parkinson Disease: A systematic review and meta-analysis
Patients with PD may be at elevated risks of both suicidal ideation and behavior, and physicians ought to maintain a high index of suspicion for early detection and appropriate management. JAMA 13 November 2023

Operative vs nonoperative management of Acute Cholecystitis during the different trimesters of pregnancy
These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC. JAMA 15 November 2023


Other journals

To vaccinate or not to vaccinate? The interplay between pro- and against- vaccination reasons
Knowing the reasons that drive people’s decision about such an important choice can suggest new communication insights to reduce possible negative reactions toward vaccination and people's hesitancy. Results are discussed considering results of other national and international studies. BMC public health 9 November 2023

The global economic burden of health anxiety/hypochondriasis- a systematic review
This systematic review suggests that existing studies underestimate the costs of hypochondriasis due to missing information on indirect costs. Furthermore, there is no uniform data collection of the costs and definition of the disease, so that the few existing data are not comparable and difficult to evaluate. There is a need for standardised data collection and definition of hypochondriasis in future studies to identify major cost drivers as potential target point for interventions. BMC public health 13 November 2023

Understanding and explaining the link between anthroposophy and vaccine hesitancy: a systematic review
Continuing to further knowledge of vaccine beliefs in anthroposophic communities is particularly important in view of increasing measles rates and potential sudden reliance on vaccines for emerging diseases. However, popular assumptions about vaccine beliefs in anthroposophic communities are challenged by the data presented in this systematic review. BMC public health 13 November 2023

Trends in deaths and disability-adjusted life-years of stroke attributable to low physical activity worldwide, 1990–2019
Globally, deaths and Disability-Adjusted Life Years (DALYs) of stroke attributable to Low physical activity (LPA) were on the rise, although their age-standardized rates presented downward over the past three decades; the burden of stroke attributable to LPA showed upward trends especially in those aged ≥ 70 and females in the regions of East Asia, North Africa, and the Middle East, which need more attention to the effects of physical activity on health interventions. BMC public health 14 November 2023

Respiratory syncytial virus-associated hospitalisation in adults with comorbidities in two European countries: a modelling study
The findings of this study provide important evidence for identifying risk groups and assisting health authorities in RSV vaccination policymaking. Journal of infectious diseases 16 November 2023

Psychological resilience and quality of life among middle-aged and older adults hospitalized with chronic diseases: multiple mediating effects through sleep quality and depression
Sleep quality and depression mediate the relationship between psychological resilience and quality of life in middle-aged and older adults hospitalized with chronic diseases. Therefore, healthcare professionals and stakeholders should be concerned about the sleep status and mental health of middle-aged and older adults hospitalized with chronic diseases, strengthen their attention to psychological resilience, and provide interventions and treatment measures for hospitalized patients who have sleep problems and depressive tendencies. BMC geriatrics 17 November 2023

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study
These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting. BMC health services research 16 November 2023

The optimal dose of mobilisation therapy in the ICU: a prospective cohort study
A mobilisation duration of more than 40 min positively impacts functional outcomes at ICU discharge. However, the maximum level achieved during ICU stay was the most crucial factor regarding adequate dosage, as higher duration did not show an additional benefit in patients with already high mobilisation levels. Journal of intensive care 20 November 2023

Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: a retrospective cohort study
This study demonstrated that prolonged use of NMBAs was associated with an increased risk of long-term mortality in critically ill patients requiring mechanical ventilation. Further studies are needed to validate these findings. Journal of intensive care 17 November 2023

Preoperative moderate to severe anemia is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications: a propensity score-matched analysis in hip fracture surgery patients over 80 years old
Moderate to severe preoperative anemia (< 11 g/dl) is associated with increased postoperative major adverse cardiac and cerebral events and pulmonary complications. Additionally, in-hospital mortality was not significant but was higher in the preoperative moderate to severe anemia cohort. Preoperative assessment and correction of hemoglobin level to above 11 g/dl might reduce MACCE, PPCs, and in-hospital mortality in hip fracture patients over 80 years old. Perioperative medicine 10 November 2023



COVID-19 Latest from research publications
compiled by the SALHN (SA Health) library staff - updated 4 December 2023

For older articles please click here and you will be directed to the archival page on the SA health Library website

Key information sources - coronavirus resource pages have been created by various medical publications in order to disseminate clinical information as soon as it is available

COVID‐19 vaccination of children with refugee backgrounds in Western Australia: a retrospective observational study
These findings underscore the value of a specialist refugee health service for providing culturally and linguistically nuanced catch‐up vaccination and bridging gaps in hospital and community vaccination delivery. MJA 4 December 2023

Age disparities in prevalence of anxiety and depression among US adults during the COVID-19 pandemic
In this cross-sectional study of anxiety and depression during the COVID-19 pandemic, economic precarity was associated with high anxiety and depression among younger adults in the US compared with older adults in the US. These findings suggest a need for greater mental health care and economic policies targeted toward younger adults. JAMA 30 November 2023

Gray matter thickness and subcortical nuclear volume in men after SARS-CoV-2 Omicron infection
These findings may provide new insights into the emotional and cognitive mechanisms affected by an Omicron infection, demonstrate its association with nervous system symptoms, and provide an imaging basis for early detection and intervention for neurological sequelae. JAMA 30 November 2023

Pre–Covid-19, SARS-CoV-2–negative multisystem inflammatory syndrome in children
The clinical, biologic, and immunologic features that we observed in these prepandemic and SARS-CoV-2–negative patients are indistinguishable from those seen in patients with MIS-C. Rarely seen before the Covid-19 pandemic, this syndrome was not individualized and was reported as atypical Kawasaki’s disease, a syndrome resembling toxic shock syndrome, or Kawasaki’s disease shock syndrome. Therefore, MIS-C characterized by Vβ21.3+ T-cell expansion would appear to represent a severe pediatric condition that may be triggered by other pathogens, including seasonal HCoV. The presence of a SARS-CoV-2 spike is dispensable for Vβ21.3+ T-cell expansion and MIS-C. Although the management of MIS-C has improved,5 further research is needed to elucidate the underlying mechanisms of T-cell activation and to develop targeted interventions for this critical pediatric condition. NEJM 30 November 2023

Epitope mapping of SARS-CoV-2 Spike Antibodies in vaccinated kidney transplant recipients reveals poor spike coverage compared to healthy controls
Kidney transplant recipients (KTRs) develop decreased antibody titers to SARS-CoV-2 vaccination compared to healthy controls (HCs), but whether KTRs generate antibodies against key epitopes associated with neutralization is unknown. Plasma from 78 KTRs from a clinical trial of third doses of SARS-CoV-2 vaccines and 12 HCs underwent phage display immunoprecipitation and sequencing (PhIP-Seq) to map antibody responses against SARS-CoV-2. KTRs had lower antibody reactivity to SARS-CoV-2 than HCs, but KTRs and HCs recognized similar epitopes associated with neutralization. Thus, epitope gaps in antibody breadth of KTRs are unlikely responsible for decreased efficacy of SARS-CoV-2 vaccines in this immunosuppressed population. Journal of infectious diseases 29 November 2023

Associations between changes in habitual sleep duration and lower self-rated health among COVID-19 survivors: findings from a survey across 16 countries/regions
Changes in habitual sleep duration following SARS-CoV-2 infection were associated with lower Self-rated health (SRH). Decreased or increased habitual sleep duration might have a bidirectional relation with post-COVID-19 symptoms. Further research is needed to better understand the mechanisms underlying these relationships for in order to improve SRH in individuals with COVID-19. BMC public health 28 November 2023

Durability of cross-neutralizing antibodies 5.5 months after bivalent COVID-19 booster
The authors analyzed neutralizing antibodies in samples from ancestral+BA.1 and ancestral+BA.4/5 boosted individuals, collected around 5.5 months after booster. Titers of neutralizing antibodies generally decreased compared to a time point early after the bivalent booster immunization. This was more pronounced for individuals without infection history and for recently emerged omicron variants. Journal of infectious diseases 28 November 2023

Neutrophil virucidal activity against SARS-CoV-2 is mediated by NETs
The inflammation in the lungs and other vital organs in COVID-19 are characterized by the presence of neutrophils and high concentration of neutrophil extracellular traps (NETs), which also seems to mediate host tissue damage. However, it is not known whether NETs could have virucidal activity against SARS-CoV-2. The results pf this study provide evidence of the role of NETosis as a mechanism of SARS-CoV-2 viral capture and inhibition. Journal of infectious diseases 28 November 2023

Physical and mental health of informal caregivers before and during the COVID-19 pandemic in the United States
This study contends that the physical and mental health burden associated with informal caregiving in a period of great uncertainty may be heightened among certain populations. Policymakers should consider expanding access to resources through institutional mechanisms for informal caregivers, who may be likely to incur a higher physical and mental health burden during public health emergencies, especially those identified as higher risk. BMC public health 27 November 2023

All eyes on our future vaccination strategy as COVID-19 spikes
Two recent recommendations from the World Health Organization (WHO) will have an important influence on Australia’s evolving response to the coronavirus disease 2019 (COVID-19) pandemic. The way Australia authorities react to these decisions will affect the lives of thousands of Australians. MJA insight 27 November 2023

Variant-specific IgA protects against Omicron infection
The authors conclude that IgA may have a potential contributory role in protection against Omicron infection. Journal of infectious diseases 23 November 2023

Spike protein genetic evolution in patients at high-risk of severe COVID-19 treated by monoclonal antibodies
the probability of emerging mutations arising in response to Monoclonal antibodies (mAbs)  is significant, emphasizing the crucial need to investigate these mutations thoroughly and assess their impact on patients and the evolutionary trajectory of the SARS-CoV-2. Journal of infectious diseases 23 November 2023

Cellular mechanisms associated with sub-optimal immune responses to SARS-CoV-2 bivalent booster vaccination in patients with Multiple Myeloma
This study highlights varying immune responses observed in MM patients after receiving bivalent COVID-19 vaccination. Specifically, a subgroup of MM patients undergoing anti-CD38 and anti-BCMA therapy experience impairment in immune cells such DCs, B cells, NK cells and TFH cells, leading to an inability to generate adequate humoral and cellular responses to vaccination. eBioMedicine 22 November 2023

Determine the factors that affected COVID-19 prevention behaviors based on constructs of social cognition theory
Rendering to the result of this study constructs of Social Cognition Theory (SCT) is the key predictor of participants’ COVID-19 prevention behaviors (CPB). Hence, based on these predictors, effective interventions and healthy messages could be designed based on this predictor—outcomes expectations, self-regulation, social support, and self-efficacy which can be beneficial to improve healthy behavior. BMC public health 22 November 2023

Covid-19 vaccine effectiveness against post-covid-19 condition among 589 722 individuals in Sweden: population based cohort study
The results of this study suggest a strong association between covid-19 vaccination before infection and reduced risk of receiving a diagnosis of post-covid-19 condition (PCC). The findings highlight the importance of primary vaccination against covid-19 to reduce the population burden of PCC. BMJ 22 November 2023

Mortality and hospitalization risks in patients with cancer and the SARS-CoV-2 Omicron variant
This study showed that during the Omicron-dominant period, patients with solid cancer and COVID-19 had higher mortality and hospitalization risks following COVID-19 infection vs patients without solid cancer with COVID-19, and that COVID-19 vaccination in the patients with cancer mitigated this risk. JAMA 22 November 2023

The Novavax Heterologous COVID Booster demonstrates lower reactogenicity than mRNA: A targeted review
COVID-19 continues to be a global health concern and booster doses are necessary for maintaining vaccine-mediated protection, limiting the spread of SARS-CoV-2. Despite multiple COVID vaccine options, global booster uptake remains low. Reactogenicity, the occurrence of adverse local/systemic side effects, plays a crucial role in vaccine uptake and acceptance, particularly for booster doses. We conducted a targeted review of the reactogenicity of authorized/approved mRNA and protein-based vaccines demonstrated by clinical trials and real-world evidence. It was found that mRNA-based boosters show a higher incidence and an increased severity of reactogenicity compared with the Novavax protein-based COVID vaccine, NVX-CoV2373. In a recent NIAID study, the incidence of pain/tenderness, swelling, erythema, fatigue/malaise, headache, muscle pain, or fever was higher in individuals boosted with BNT162b2 (0.4 to 41.6% absolute increase) or mRNA-1273 (5.5 to 55.0% absolute increase) compared with NVX-CoV2373. Evidence suggests that NVX-CoV2373, when utilized as a heterologous booster, demonstrates less reactogenicity compared with mRNA vaccines, which, if communicated to hesitant individuals, may strengthen booster uptake rates worldwide. The journal of infectious disease 22 November 2023

3-year outcomes of discharged survivors of COVID-19 following the SARS-CoV-2 omicron (B.1.1.529) wave in 2022 in China: a longitudinal cohort study
Most long COVID symptoms at 3 years were mild to moderate, with lung function recovering to levels of matched controls. Survivors with long COVID had a higher proportion of participants with re-infection and newly occurring or worse symptoms 3 months after omicron infection than those without long COVID. Re-infection had increased symptom occurrence but not increased reduced daily activity. Although the organ function of survivors of COVID-19 recovered over time, those with severe long COVID symptoms, abnormal organ function, or limited mobility require urgent attention in future clinical practice and research. The Lancet respiratory medicine 21 November 2023

Risk profiles for smoke behavior in COVID-19: a classification and regression tree analysis approach
The main influencing factor is acceptance degree of passive smoking. More knowledge about the harm of secondhand smoke should be promoted. For high-risk population who smoke, the “mask protection” effect during the COVID-19 pandemic should be fully utilized to encourage smoking cessation. BMC public health 21 November 2023

Humoral and cellular immune responses following BNT162b2 XBB.1.5 vaccination
This data suggest that XBB.1.5-containing mRNA vaccines most likely increase protection against COVID-19 caused by currently circulating XBB subvariants and the emerging BA.2.86 variant. The Lancet infectious diseases 20 November 2023

Higher-dose Fluvoxamine and time to sustained recovery in outpatients with COVID-19: The ACTIV-6 randomized clinical trial
Among outpatients with mild to moderate COVID-19, treatment with fluvoxamine does not reduce duration of COVID-19 symptoms. JAMA 17 November 2023

Cognitive and emotional well-being of preschool children before and during the COVID-19 pandemic
This cross-sectional study found both positive and negative associations between pandemic exposure and preschool children’s cognitive and emotional well-being within a relatively socioeconomically advantaged sample. JAMA 16 November 2023

Prospective assessment of humoral and cellular immune responses to a 3rd COVID-19 mRNA vaccine dose among immunocompromised individuals
Dose 3 (D3)significantly improves serological but not T-cell responses among immunocompromised individuals. Solid organ transplant (SOT) and hematologic malignancy (HM) patients have suboptimal responses to D3. Journal of infectious diseases 16 November 2023

Immunogenicity and safety of heterologous Omicron BA.1 and bivalent SARS-CoV-2 recombinant spike protein booster vaccines: a phase 3, randomized, clinical trial
NVX-CoV2515 elicited a superior neutralizing antibody response against the Omicron BA.1 subvariant compared with NVX-CoV2373 when administered as a fourth dose. Safety data were consistent with the established safety profile of NVX-CoV2373. Journal of infectious diseases 16 November 2023

Safety and efficacy of the intranasal spray SARS-CoV-2 vaccine dNS1-RBD: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial
Although this trial did not meet the predefined efficacy criteria for success, dNS1-RBD was well tolerated and protective against omicron variants, both as a primary immunisation and as a heterologous booster. The Lancet rheumatology 15 November 2023

Effectiveness of a fourth dose of COVID-19 mRNA vaccine in patients with systemic autoimmune rheumatic diseases using disease-modifying antirheumatic drugs: an emulated target trial
In this emulated target trial, a fourth dose of COVID-19 mRNA vaccine reduced the risk of SARS-CoV-2 infection and severe COVID-19 among patients with systemic autoimmune rheumatic diseases using DMARDs during the Omicron era. Patients with systemic autoimmune rheumatic diseases should be encouraged to remain up-to-date with COVID-19 vaccinations. The Lancet rheumatology 15 November 2023

Efficacy and safety of baricitinib or ravulizumab in adult patients with severe COVID-19 (TACTIC-R): a randomised, parallel-arm, open-label, phase 4 trial
Neither baricitinib nor ravulizumab, as administered in this study, was effective in reducing disease severity in patients selected for severe COVID-19. Safety was similar between treatments and standard of care. The short period of dosing with baricitinib might explain the discrepancy between our findings and those of other trials. The therapeutic potential of targeting complement C5 activation product C5a, rather than the cleavage of C5, warrants further evaluation. The Lancet respiratory medicine 14 November 2023

Prevalence of insomnia and its association with quality of life in caregivers of psychiatric inpatients during the COVID-19 pandemic: a network analysis
The insomnia prevalence was high among caregivers of psychiatric inpatients during the COVID-19 pandemic, particularly in those with depression, anxiety and fatigue. Considering the negative impact of insomnia on QoL, effective interventions that address insomnia and alteration of sleep dissatisfaction should be developed. BMC psychiatry 14 November 2023

Intravenous Vitamin C for patients hospitalized with COVID-19: Two harmonized randomized clinical trials
In hospitalized patients with COVID-19, vitamin C had low probability of improving the primary composite outcome of organ support–free days and hospital survival. JAMA 14 November 2023

Severe respiratory disease among children with and without medical complexity during the COVID-19 pandemic
This cross-sectional study found a substantial decrease in severe respiratory disease resulting in hospitalizations, ICU admissions, and mortality during the first 2 years of the pandemic compared with the 3 prepandemic years. These findings suggest that future evaluations of the effect of public health interventions aimed at reducing circulating respiratory pathogens during nonpandemic periods of increased respiratory illness may be warranted. JAMA 14 November 2023

The SARS-CoV-2 infection in the pediatric oncology population: the definitive comprehensive report of Infectious Diseases Working Group (IDWG) of AIEOP
SARS-CoV-2 infection presented a self-limiting, benign course in the Italian pediatric onco-hematology population during the pandemic and its main consequence has been the discontinuation of cancer-directed therapies. The rate of asymptomatic patients who stopped chemotherapy reduced over the years, suggesting that the continuation of chemotherapy is a feasible option. Journal of infectious diseases 14 November 2023

mRNA SARS-CoV-2 vaccination before vs during pregnancy and Omicron infection among infants
In this population-based cohort study, maternal mRNA vaccination was associated with a lower risk of Omicron SARS-CoV-2 infection among infants up to 6 months of age only if the vaccine was given during the antenatal period. These findings suggest that mRNA vaccination during pregnancy may be needed for lower risk of SARS-CoV-2 infection among newborns. JAMA 10 November 2023

Nosocomial SARS-CoV-2 infections and mortality during unique COVID-19 epidemic waves
In this matched cohort study, nosocomial SARS-CoV-2 infections were associated with higher 30-day mortality during the early phases of the pandemic and lower mortality during the Omicron variant wave and after the introduction of vaccinations. Mitigation of excess mortality risk from nosocomial transmission should be a strong focus when population immunity is low through implementation of adequate infection prevention and control measures. JAMA 10 November 2023

Self-reported Neuropsychiatric Post–COVID-19 condition and CSF markers of Neuroinflammation
When comparing individuals with neuro-PCC with control participants who had never had COVID-19, the authors found no evidence of overt neuroinflammation (normal CSF cell count, inflammatory cytokines) or blood-brain barrier dysfunction (normal albumin ratio), suggesting that persistent central nervous system immune activation is not a primary driver of neurological long COVID-19. JAMA 10 November 2023

School closures and ED visits for suicidality in youths before and during the COVID-19 pandemic
This cohort study found an association between longer school closures in the public health response to the COVID-19 pandemic and increases in youth suicidality. Limitations of the study include comparing only 2 states without considering other factors that may be associated with suicidality, which is outside the scope of this article. These data revealed an association between school closures and youth mental health, calling for further investigation such that in future pandemics and other disasters, policy regarding school closures may better align with the mental health needs of youths. JAMA 10 November 2023

Update to living WHO guideline on drugs for covid-19
The latest version of this WHO living guidance has the following changes: Recommendations are now ordered by severity of covid-19, and patients stratified into those at low, moderate, or high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation against ivermectin was updated with additional trial evidence. A new recommendation was made against the antiviral agent VV116. BMJ 9 November 2023

Olfactory and gustatory function 3 years after Mild COVID-19—A cohort psychophysical study
The prevalence of olfactory dysfunction (OD)at enrollment was consistent with what has been documented, for both the cases and controls. The authors observed a favorable evolution in olfactory and gustatory function throughout the observation period with GD showing lower frequency and faster recovery compared with OD. Recovery from OD continued over the 3-year study period. At the 3-year study end point, OD was comparable between both groups. Patients with post–COVID-19 condition (PCC) exhibiting chemosensory alterations should be reassured that a recovery of olfaction appears to continue over 3 years after initial infection. These results can be generalized to individuals of White race who experienced mild symptoms during the early waves of the COVID-19 pandemic. JAMA 9 November 2023

Effect of Neutralizing Monoclonal antibody treatment on early trajectories of Virologic and Immunologic Biomarkers in patients hospitalized with COVID-19
This study suggests that nmAb has an antiviral effect assessed by plasma N-Ag among hospitalized patients with COVID-19, with no blunting of the endogenous anti-nucleocapsid antibody response. No effect on systemic inflammation or day 5 clinical status was observed. Journal. of infectious diseases 9 November 2023

Is convalescent plasma still useful as a covid treatment?
Enthusiasm for one of the earliest promising treatments for covid-19 has waned. Katharine Lang finds that convalescent plasma for covid may still have a place, particularly in immunocompromised people. BMJ 8 November 2023

Estimated effectiveness of coadministration of the BNT162b2 BA.4/5 COVID-19 vaccine with influenza vaccine
In this study, coadministration of BNT162b2-biv and seasonal influenza vaccine (SIV)  was associated with generally similar effectiveness in the community setting against COVID-19–related and SIV-related outcomes compared with giving each vaccine alone and may help improve uptake of both vaccines. JAMA 8 October 2023

Virus isolation and neutralisation of SARS-CoV-2 variants BA.2.86 and EG.5.1
This study addresses the paucity of BA.2.86 and EG.5.1 virus characterisation data on clinical isolates, which represent the pathogens circulating among individuals. Together with pseudovirus investigations, these live virus data suggest that, despite the highly different spike mutation constellation of BA.2.86 that alters monoclonal antibody specificities, the overall ability of polyclonal serum antibodies after an XBB.1.5 or BA.4 or BA.5 breakthrough infection to neutralise BA.2.86 is similar to that of circulating XBB recombinant strains. The Lancet infectious diseases 7 November 2023

The effect of smartphone addiction on the relationship between psychological stress reaction and bedtime procrastination in young adults during the COVID-19 pandemic
This study revealed the effect of smartphone addiction on the relationship between psychological stress reaction and bedtime procrastination during the COVID-19 pandemic, and these findings could provide novel evidence that family cohesion may serve as a protective factor against the negative consequences of smartphone addiction on bad bedtime procrastination. BMC psychiatry 7 November 2023

COVID-19 hospitalization in solid organ transplant recipients on immunosuppressive therapy
This study suggests that mycophenolic acid, sirolimus, and steroids are associated with an increased risk of COVID-19–related hospitalization in solid organ transplant recipients. These results should be considered by clinicians treating transplant recipients and may help inform epidemic-related decisions for this population in the future. JAMA 7 November 2023

Gestational diabetes mellitus screening and diagnosis criteria before and during the COVID‐19 pandemic: a retrospective pre–post study
Identifying women at low absolute risk of gestational diabetes‐related pregnancy complications on the basis of  fasting venous plasma glucose (FVPG) assessment as an initial step in gestational diabetes mellitus (GDM) screening could reduce the burden for pregnant women and save the health system substantial costs. MJA 6 November 2023

The complex impact of COVID‐19 on cancer outcomes in Australia
Although health services were disrupted and there is evidence that the pandemic affected cancer screening, diagnosis and treatment services in Australia, there is no indication yet of increased cancer mortality at a whole‐of‐population level. Ongoing review and analysis of cancer data are expected to yield valuable insights about longer term impacts and, in turn, help inform how Australia can best protect its evidence‐based, effective and sometimes hard‐won cancer control strategies by preparing for any future major disruptors. MJA 6 November 2023

COVID-19-related global health governance and population health priorities for health equity in G20 countries: a scoping review
This scoping review synthesised and identified knowledge gaps on how the COVID-19-related GHG is affecting population health priorities for policy, programme, and research in G20 countries. International Journal for equity in health 3 November 2023

Teleworking, parenting stress, and the health of mothers and fathers
This cross-sectional study examines the associations of telework during the COVID-19 pandemic with parents’ general health, changes to mental health, and parenting stress. JAMA 3 November 2023

Probing long COVID through a proteomic lens: a comprehensive two-year longitudinal cohort study of hospitalised survivors
The study findings provided molecular insights into potential mechanism of long COVID, and put forward biomarkers for more precise intervention to reduce burden of long COVID. eBioMedicine 2 November 2023

Cognitive decline in older adults in the UK during and after the COVID-19 pandemic: a longitudinal analysis of PROTECT study data
The COVID-19 pandemic resulted in a significant worsening of cognition in older adults, associated with changes in known dementia risk factors. The sustained decline in cognition highlights the need for public health interventions to mitigate the risk of dementia—particularly in people with mild cognitive impairment, in whom conversion to dementia within 5 years is a substantial risk. Long-term intervention for people with a history of COVID-19 should be considered to support cognitive health. The Lancet health longevity 2 November 2023

Determinants of passive antibody efficacy in SARS-CoV-2 infection: a systematic review and meta-analysis
Early administration before hospitalisation and sufficient doses of passive antibody therapy are crucial to achieving high efficacy in preventing clinical progression. The relationship between dose and efficacy provides a framework for the rational assessment of future passive antibody prophylaxis and treatment strategies for COVID-19. The Lancet microbe 2 November 2023

Core outcome measurement instruments for use in clinical and research settings for adults with post-COVID-19 condition: an international Delphi consensus study
Post-COVID-19 condition (also known as long COVID) is a new, complex, and poorly understood disorder. A core outcome set (COS) for post-COVID-19 condition in adults has been developed and agreement is now required on the most appropriate measurement instruments for these core outcomes. The authors conducted an international consensus study involving multidisciplinary experts and people with lived experience of long COVID. The study comprised a literature review to identify measurement instruments for the core outcomes, a three-round online modified Delphi process, and an online consensus meeting to generate a core outcome measurement set (COMS). 594 individuals from 58 countries participated. The Lancet respiratory medicine 2 November 2023

An early warning precision public health approach for assessing COVID-19 vulnerability in the UK: the Moore-Hill Vulnerability Index (MHVI)
The MHVI identifies regions with known high rates of poor health outcomes prior to the pandemic that case rates or mortality rates alone fail to identify. Pre-hospital early warning measures could be utilised to prevent mortality during a novel pandemic. BMC public health 2 November 2023

The impact of geo-political socio-economic factors on vaccine dissemination trends: a case-study on COVID-19 vaccination strategies
The analysis revealed strong indicators that the nations which spend more on healthcare were the ones that had the best SARS-Cov-2 vaccination rollout. To further support decision-making in the future, countries should address the trust and sentiment of their citizens towards vaccination. For this, expenses nBMC public health 2 November 2023eed to be made to develop and promote vaccines and project them as positive health tools. BMC public health 2 November 2023

COVID-19: A management update
Key points:

  • All patients with COVID-19, no matter how mild or severe it is, should self-isolate or be placed in isolation to avoid spreading the disease.
  • Nirmatrelvir-ritonavir is recommended for outpatients with mild or moderate COVID-19 who are at risk of progressing to serious disease.
  • Remdesivir can be considered in patients with mild to moderate disease who are at high risk for progression to severe COVID-19, and in hospitalized patients with oxygen saturation less than 94% breathing room air, but not in those who already need mechanical ventilation or extracorporeal membrane oxygenation.
  • Dexamethasone 6 mg is the standard of care for hospitalized patients with severe or critical COVID-19.

Cleveland Clinic journal of medicine 1 November 2023


Updated 1 December 2023 

Department of Health and Aged Care – health alert – Monkeypox (MPX) resources 

SA Health – health alert – Monkeypox

UpToDate – Monkeypox  if accessing outside of SA Health computer network use your library login

Monkeypox Resources for Health Professionals (Wolters Kluwer)

Monkeypox Resource Centre (JAMA)

World Health Organization Health alert

Journal articles

Preparing for mpox resurgence: Surveillance lessons from outbreaks in Toronto, Canada
This investigation demonstrates the importance of ongoing surveillance and preparedness for mpox outbreaks. Undetected local transmission was not a likely source of the 2022-2023 resurgence. Ongoing pre-exposure vaccine promotion remains important to mitigate disease burden. Journal of infectious diseases 30 November 2023

Prolonged mpox disease in people with advanced HIV: characterization of mpox skin lesions
The authorsreport three complicated and prolonged cases of mpox in people with advanced HIV not on antiretroviral therapy (ART) at mpox diagnosis. Multiple medical countermeasures were used, including prolonged tecovirimat treatment and immune optimization with ART initiation. Immunofluorescence of skin biopsies demonstrated a dense immune infiltrate of predominantly myeloid and CD8+ T-cells, with a strong type-I interferon local response. RNAscope detected abundant replication of monkeypox virus (MPXV) in epithelial cells and dendritic cells. These data suggest that prolonged mpox in people with advanced HIV may be due to ongoing MPXV replication, warranting aggressive medical countermeasures and immune optimization. Journal of infectious diseases 29 November 2023

Healthcare personnel exposure risk assessment and management during a Mpox outbreak in Chicago, Illinois, May 17-July 8, 2022
This report summarizes risk assessment interviews and follow up with healthcare personnel (HCP) after exposure to patients with mpox disease during May 17-July 8, 2022. HCP-case interactions were assessed using a standard questionnaire to categorize the risk associated with patient encounters. We assessed 150 interactions among 142 HCP and 30 cases. Four(2.7%) interactions were defined as high risk, 5(3.3%) intermediate, 107(71.3%) low, and 31(20.7%) no risk. High and intermediate exposures were offered post-exposure prophylaxis; four accepted. No documented mpox transmission after exposure was identified. These findings suggest transmission risk in healthcare settings during routine patient care is low. Journal of infectious diseases 29 November 2023

Associations between HIV and Severe Mpox in an Atlanta Cohort
People with HIV (PWH) with non-suppressed HIV viral loads had more mpox complications, hospitalizations, and protracted disease courses than people without HIV or PWH with suppressed viral loads. PWH with non-suppressed HIV viral loads who are diagnosed with mpox warrant particularly aggressive monitoring and treatment. Journal of infectious diseases 24 November 2023

Mpox knowledge, behaviours and barriers to public health measures among gay, bisexual and other men who have sex with men in the UK: a qualitative study to inform public health guidance and messaging
There are differential needs, preferences, and experiences of gay, bisexual, or other men who have sex with men (GBMSM) that limit the acceptability of some mitigation and prevention measures. Future public health interventions and campaigns should be co-designed in consultation with key groups and communities to ensure greater acceptability and credibility in different contexts and communities. BMC public health 17 November 2023

Mpox viral lineage analysis and technique development using next generation sequencing approach
The authors developed next generation sequencing (NGS) workflows to precisely detect and analyze Mpox viral clade and lineages and aid in genomic surveillance. Journal of infectious diseases 16 November 2023

Development and pilot of an Mpox severity scoring system (MPOX-SSS)
Clinical severity scores facilitate comparisons to understand risk factors for severe illness. For the 2022 multinational monkeypox Clade IIb virus outbreak, we developed a 7-item mpox severity scoring system (MPOX-SSS) with initial variables refined based on data availability and parameter correlation. Application of MPOX-SSS to the first 200 patients diagnosed with mpox revealed higher scores in those treated with tecovirimat, presenting >3 days after symptom onset and with CD4 counts <200 cells/mm3 . For individuals evaluated repeatedly, serial scores were concordant with clinical observations. The pilot MPOX-SSS demonstrated good discrimination, distinguished change over time, and identified higher scores in expected groups. Journal of infectious diseases 13 November 2023

Prior sexually transmitted infections and HIV in mpox patients, Chicago, Illinois—(June 2022–March 2023
HIV is associated with severe mpox. Sexually transmitted infections (STIs) could facilitate mpox transmission. The authors estimated HIV and STI frequency among patients with mpox, and compared characteristics associated with mpox severity. Mpox cases during June 1, 2022–March 31, 2023, were matched to Illinois HIV/AIDS surveillance data. Among 1,124 mpox patients, 489 (44%) had HIV and 786 (70%) had prior or concurrent STI; 307 (39%) had ≥3 STI episodes. More mpox patients living with HIV were hospitalized than without HIV (10.3% vs 4.1%, P <0.001). STI screening visits are opportunities to vaccinate against mpox and provide HIV prophylaxis or treatment. Journal of infectious diseases 8 November 2023

APOBEC3 deaminase editing in mpox virus as evidence for sustained human transmission since at least 2016
In March 2022, an international epidemic of human Mpox was detected, showing that it was not solely a zoonotic infection. A hallmark of the approximately 88,000 cases that have been reported were TC>TT and GA>AA mutations in Mpox viruses, which were acquired at a surprisingly high evolutionary rate for a pox virus. Knowing that these types of mutation are a sign of activity by a host antiviral enzyme called APOBEC3, O’Toole et al. investigated whether the mutations reflected human-to-human transmission rather than repeated zoonotic spillover. Bayesian evolutionary analysis showed that Mpox virus recently diversified into several lineages in humans that display elevated numbers of mutations, signaling APOBEC exposure and sustained human-to-human transmission rather than zoonosis as the source of new cases. Science 2 November 2023

Tzanck smear of Ulcerated Plaques
Tzanck smear is a useful technique that can be used to differentiate mpox from other infections at the bedside or in remote settings where PCR or additional culture techniques are not easily accessible. Infection prevention and control precautions are important to help prevent additional spread of this virus with sharp injuries, and caution with unroofing of the lesions is critical to avoid additional spread.7 Knowledge of the cytologic differences of mpox compared with other viral infections is important in the early recognition, diagnosis, and treatment of these patients. JAMA 25 October 2023

Detection of Mpox Virus using Microbial Cell-free DNA: the potential of Pathogen-Agnostic Sequencing for rapid identification of emerging pathogens
The authors demonstrate the potential of plasma mcfDNA sequencing to detect, quantify, and, for acute infections with high sequencing coverage, subtype MPXV using a single non-invasive test. Sequencing plasma mcfDNA may augment existing mpox testing in vulnerable patient populations or in patients with atypical symptoms or unrecognized mpox. Strain type information may supplement disease surveillance and facilitate tracking emerging pathogens. Journal of infectious diseases 12 October 2023

Effectiveness of Smallpox vaccination to prevent Mpox in military personnel
The authors conducted a retrospective, test-negative case–control study among current and former U.S. military personnel to determine the effectiveness of smallpox vaccines against mpox. Previous vaccination at a median of 13 years earlier with either a first- or second-generation smallpox vaccine reduced the likelihood of testing positive for orthopoxvirus among current or former military personnel for whom vaccination data were available. NEJM 21 September 2023

Mpox: Keep it on the differential
Key points:

  • In its worldwide outbreak in 2022, mpox was remarkably different from its historic profile, a viral zoonotic disease that inefficiently spread from person to person.
  • Mpox is currently primarily affecting men who have sex with men and is mainly transmitted through direct contact with an infectious lesion.
  • Clinicians should keep mpox in the differential diagnosis for single, multiple, or diffuse genital, anal, or skin lesions, as well as pharyngitis and proctitis.
  • Patients with suspected mpox should also be tested for sexually transmitted infections including human immunodeficiency virus (HIV), and should be offered HIV postexposure or preexposure prophylaxis and mpox vaccine if appropriate.

Cleveland journal of medicine 13 September 2023

Mpox (formerly monkeypox) emerged as a global pandemic in 2022 with more than 80,000 cases diagnosed to date worldwide. This Interactive Perspective is designed to aid clinicians in understanding the disease transmission, recognizing clinical signs, and treating mpox effectively. NEJM 7 September 2023

Breakthrough mpox despite two‐dose vaccination
Lessons from practice

  • Since May 2022, there has been a global outbreak of mpox, predominantly in gay, bisexual and other men who have sex with men.
  • Limited data exist for clinical vaccine effectiveness, but it has been estimated at about 85% after a full vaccination course.
  • Clinicians should be aware of the possibility of breakthrough infection, possibly of less severity and without typical constitutional symptoms, in patients with epidemiological risk factors and a characteristic vesiculopustular rash, irrespective of a history of previous vaccination.
  • Individuals at high risk should be offered vaccination, if not yet already received. These groups include gay, bisexual and other men who have sex with men; sex workers; and sexual partners of these groups.

MJA 4 September 2023

Sexual health doctors urge vigilance on mpox
Sexual health clinicians are urging GPs to keep an eye out for breakthrough mpox infection, even in vaccinated patients. MJA insight 4 September 2023

Mpox: China’s health authorities fight surge in cases of unknown origin
Chinese health authorities are facing an escalating outbreak of mpox where most cases are of unknown origin. A World Health Organization mpox situation report published on 14 August singled out “sustained community transmission in China” as driving the rise in cases in the region, which has bucked a broad global decline. BMJ 22 August 2023

Mpox and primary syphilis co‐infection in a newly arrived traveller from South America
Lessons from practice

  • Mpox, syphilis and genital herpes should be considered in at‐risk patients presenting with genital ulcers, as co‐infection may be present.
  • A detailed sexual and travel history is important to narrow down the differential diagnosis.
  • Careful examination and appropriate sampling for testing and consideration of presumptive treatment for syphilis and herpes simplex virus are crucial before isolation of the patient if mpox is suspected.
  • Information provision in the patients’ language and liaison with the public health unit is essential in contact tracing and provision of patient‐centred care for mpox.

MJA 7 August 2023

Tecovirimat resistance in an immunocompromised patient with Mpox and prolonged viral shedding
The objective of this paper is to describe the rapid selection of a tecovirimat-resistant MPXV variant during treatment of a severely immunocompromised patient with prolonged MPXV infection. Annals of internal medicine 25 July 2023

Vaccine effectiveness of JYNNEOS against Mpox disease in the United States
In this study using nationwide EHR data, patients with mpox were less likely to have received one or two doses of JYNNEOS vaccine than control patients. The findings suggest that JYNNEOS vaccine was effective in preventing mpox disease, and a two-dose series appeared to provide better protection. NEJM 29 June 2023

Monkeypox detection using deep neural networks
The DenseNet201 model outperforms the other models in terms of the confusion metrics, regardless of the scenario. One significant accomplishment of this study is the utilization of LIME and Grad-Cam to identify the affected areas and assess their significance in diagnosing diseases based on skin images. By incorporating these techniques, we enhance our understanding of the infected regions and their relevance in distinguishing Monkeypox from other similar diseases. Our proposed model can serve as a valuable auxiliary tool for diagnosing Monkeypox and distinguishing it from other related conditions. BMC infectious diseases 27 June 2023

WHO ends public health emergency designation for mpox
On 11 May 2023 the World Health Organization declared that the 2022-23 mpox epidemic was no longer a public health emergency of international concern (PHEIC). The decision, which followed the same announcement for covid-19 by only six days, is perhaps unsurprising; in most places new cases have tapered off, thanks to rapid vaccination and information campaigns. BMJ 5 June 2023

APOBEC3F is a mutational driver of the human Monkeypox virus identified in the 2022 outbreak
Stochastic or transient overexpression of APOBEC3F gene exposes the MPXV genome to a broad spectrum of mutations that may be modeling the mutational landscape after multiple cycles of viral replication. Journal of infectious diseases 24 May 2023

Vaccine effectiveness of JYNNEOS against Mpox disease in the United States
In this study using nationwide Epic electronic health record (EHR) data, patients with mpox were less likely to have received one or two doses of JYNNEOS vaccine than control patients. The findings suggest that JYNNEOS vaccine was effective in preventing mpox disease, and a two-dose series appeared to provide better protection. NEJM 18 May 2023

Short-term adverse events following immunization with modified Vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine for Mpox
This post marketing study of adverse events following MVA-BN vaccination found that local adverse event rates were highest following intradermal administration. However, absolute event rates were lower than in previous studies, which reported more than 30% systemic adverse events following both routes and local adverse event rates of more than 50% following subcutaneous administration and nearly 100% following intradermal vaccination. This study also found a low percentage of people reporting medical review or missing daily activities, suggesting that the vaccine is generally well-tolerated. JAMA 5 May 2023

Stability and inactivation of monkeypox virus on inanimate surfaces
The spread of non-zoonotic monkeypox virus (MPXV) infections necessitates the re-evaluation of hygiene measures. To date, only limited data is available on MPXV surface stability. Here, the authors evaluate the stability of infectious MPXV on stainless steel stored at different temperatures, while using different interfering substances to mimic environmental contamination. MPXV persistence increased with decreasing temperature. Additionally, they were able to show that MPXV could efficiently be inactivated by alcohol- and aldehyde-based surface disinfectants. These findings underline the stability of MPXV on inanimate surfaces and supports the recommendations to use alcohol-based disinfectants as prevention measure or in outbreak situations. Journal of infectious diseases 2 May 2023

Tecovirimat treatment of people with HIV during the 2022 Mpox outbreak
In this cohort of patients treated with tecovirimat for severe mpox, HIV status did not seem to affect treatment outcomes. Annuals of internal medicine 2 May 2023

Severe mpox in persons with advanced HIV (UptoDate)
In patients with mpox, severe disease can occur in the context of advanced HIV infection. In a multisite study that included 382 patients with HIV and a CD4 count <350 cells/microL, 107 (28 percent) were hospitalized [16]. All 27 deaths occurred in people with CD4 counts of <200 cells/microL. Some developed widespread, large, necrotizing skin lesions and unusual nodular lung lesions. One-quarter of the 85 people who started or restarted antiretroviral therapy (ART) had suspected immune reconstitution inflammatory syndrome (IRIS). Clinicians should be aware of these clinical features so that appropriate treatment can be initiated. We do not delay ART, despite the potential for IRIS, given the importance of immune recovery. (See "Epidemiology, clinical manifestations, and diagnosis of mpox (monkeypox)", section on 'Complications in people with advanced HIV'.)

Impact of mpox virus infection on immune parameters of a female person with HIV receiving clinically effective antiretroviral therapy
The authors describe the immunologic and virologic impact of mpox infection in a female person with HIV whose plasma viremia was suppressed by clinically effective antiretroviral therapy. Extensive phenotypic analyses of B and T cells in peripheral blood and biomarkers in plasma showed significant immunologic perturbations despite the presence of mild mpox disease. Dramatic shifts were noted in the frequencies of total B cells, plasmablasts (PB), and PB immunoglobulin isotypes. Flow cytometric analyses showed a dramatic increase in the frequency of CD38+HLA-DR+ CD8+ cells following mpox. This data offer guidance for future studies involving mpox infection in affected populations. Journal of infectious diseases 6 April 2023

Time scales of human mpox transmission in the Netherlands
Mpox has spread rapidly to many countries in non-endemic regions. After reviewing detailed exposure histories of 109 pairs of mpox cases in the Netherlands, the authors identified 34 pairs where transmission was likely and the infectee reported a single potential infector with a mean serial interval of 10.1 days (95% CI: 6.6–14.7 days). Further investigation into pairs from one regional public health service revealed that pre-symptomatic transmission may have occurred in five out of eighteen pairs. These findings emphasize that precaution remains key, regardless of the presence of recognizable symptoms of mpox. Journal of infectious diseases 4 April 2023

Erythema and Induration after Mpox (JYNNEOS) vaccination revisited
In a trial of Mpox vaccine, intradermal administration led to more erythema and induration than the subcutaneous route but resulted in a similar level of immune response with 20 % of the dose NEJM 22 March 2023

Monkeypox epidemiology, clinical presentation, and transmission: a systematic review
Monkeypox human-to-human and human-to-animal transmission are rising. Thus, it is essential to do research on the prevention, clinicodemographic trends, and treatment of monkeypox. Understanding this will enable us to treat monkeypox patients with a targeted and focused approach International journal of emergency medicine 17 March 2023

Monkeypox (Mpox) and occupational exposure
The highest work-related risk for mpox transmission has been noted among healthcare professionals, people working with animals, and sex workers. There is general agreement that a paramount issue to avoid transmission of infection in occupational settings is an appropriate decontamination of often-touched surfaces and usage of appropriate personal protective equipment by the workers at high risk of infection. The group that should especially protect themselves and be educated in the field of early symptoms of the disease and prevention are dentists, who are often the first to detect the symptoms of the disease on the oral mucosa. International journal of environmental research and public health 14 March 2023

Therapeutics for treating mpox in humans
This review found no evidence from randomized trials from which to draw certain conclusions concerning the efficacy of therapeutics in humans with mpox. Cochrane Database of Systematic Reviews – Intervention 14 March 2023

Potential anti-mpox virus activity of atovaquone, mefloquine, and molnupiravir, and their potential use as treatments
These data suggest that atovaquone would be potential candidates for treating mpox. Journal of infectious diseases 9 March 2023

Severe corneal involvement associated with Mpox infection
Mpox keratitis is rare but potentially severe. Infection of the eyelids should be monitored because it can spread to the cornea afterwards. Corneal infection is very painful and evolves from the limbus centripetally with a pathognomonic arcuate serpiginous epithelial pattern. The role of antivirals remains to be determined. JAMA 9 March 2023

An Mpox-related death in the United States
In hospitalized patients with severe mpox, it is important to consider treatment with intravenous tecovirimat. Second-line therapies including cidofovir, brincidofovir, and vaccinia immune globulin may also be considered. If progressive or persistent lesions are present after 14 days of treatment with tecovirimat, pharmacokinetic testing of tecovirimat and testing of lesion specimens for antiviral resistance are warranted. Patients with low CD4+ T-cell counts who become infected with MPXV should be monitored closely, given the potential risk of more severe illness. NEJM 8 March 2023

Brief report: Monkeypox virus cross-neutralizing antibodies in clinical trial subjects vaccinated with Modified Vaccinia Virus Ankara Encoding MERS-Coronavirus Spike Protein
Modified vaccinia virus Ankara (MVA) is used as a vaccine against monkeypox virus (MPXV) and as a viral vaccine vector. MVA-MERS-S is a vaccine candidate against Middle East respiratory syndrome- associated coronavirus (MERS-CoV). Here, we report that cross-reactive MPXV nAbs were detectable in only a single subject after the first dose, 3 out of 10 after the 2nd dose, and in 10 out of 10 after the 3rd dose of MVA-MERS-S vaccine. Journal of infectious diseases 1 March 2023

Possibility of mpox viral transmission and control from high-risk to the general population: a modeling study
Mpox has high transmissibility in men who have sex with men (MSM), which required minimize the risk of infection and exposure to high-risk populations. Community prevention and control is the top priority of interventions to contain the spread of mpox. BMC infectious diseases 24 February 2023

Mpox in people with advanced HIV infection: a global case series
A severe necrotising form of mpox in the context of advanced immunosuppression appears to behave like an AIDS-defining condition, with a high prevalence of fulminant dermatological and systemic manifestations and death. The Lancet 21 February 2023

Mpox—A rapidly evolving disease
This Special Communication provides an overview of the evolution of mpox skin findings from its initial description in humans in 1970 to the present-day multinational outbreak. JAMA 9 February 2023

Human monkeypox: diagnosis and management
What you need to know

  • Consider coinfections with monkeypox and other sexually transmitted infections among patients presenting with an acute rash or skin lesions and systemic symptoms
  • While it is safe to manage monkeypox patients virtually, they may need advice to maintain infection control measures and interventions to manage complications
  • A specialist infectious disease unit with access to novel antivirals such as tecovirimat and cidofovir should manage high risk patients
  • Healthcare workers should be aware of the stigma surrounding monkeypox, which may result in reduced health-seeking behaviours; healthcare staff should screen patients sensitively, using inclusive language to avoid alienating patients

BMJ 6 February 2023

Mpox vaccination encouraged ahead of World Pride
With upcoming World Pride events in Sydney, now is the perfect time to raise awareness and encourage vaccination against mpox. MJA InSight 30 January 2023

Use of wastewater for Mpox outbreak surveillance in California
Real-time results informed the state and local public health response, allowing for escalation of the state response level when detection in multiple watersheds suggested that MPXV was widespread or unexpected, alerting clinicians, and guiding the allocation of resources (e.g., testing, vaccines, and therapeutics) and personnel in affected areas. This experience in adapting routine wastewater-surveillance infrastructure to monitor for a nonenteric, nonrespiratory virus such as MPXV shows promise for the future use of this method as an adjunct public health tool. NEJM 18 January 2023

Real-time forecasting the trajectory of monkeypox outbreaks at the national and global levels, July–October 2022
The top-ranked model consistently predicted a decreasing trend in monkeypox cases on the global and country-specific scale during the last ten sequential forecasting periods. The findings reflect the potential impact of increased immunity, and behavioral modification among high-risk populations. BMC medicine 16 January 2023

MPXV transmission at a tattoo parlor
The authors describe cases of MPXV transmission that were likely to have occurred by means of direct inoculation from piercing and tattooing; such transmission has been observed with other poxviruses, such as Molluscum contagiosum. To date, sexual transmission of MPXV has been the most common mode of transmission, with men who have sex with men being disproportionately affected. In contrast, the cases in this report mostly involved female patients. MPXV may develop new networks of transmission, with epidemiologic changes of the disease. NEJM 5 January 2022

Tecovirimat treatment for Monkeypox Virus Keratouveitis
Currently, there is no specific medication to treat human monkeypox, and antiviral agents approved to treat smallpox have been used for its management. Compassionate use of tecovirimat has been reported in this setting, with minimal adverse effects. A case of MPXV keratouveitis confirmed by PCR and treated with tecovirimat was presented. Patients should be advised not to rub the eyes, since self-inoculation of the ocular surface from contaminated hands may occur. Although possible, we do not know whether MPXV is transmissible through tears. Resources are more than needed to put in place new action plans and strategies. JAMA 22 December 2022

Audio interview: Applying new studies of Mpox and Ebola to Covid-19
In this audio interview conducted on December 9, 2022, the editors discuss new data on mpox and Ebola and how what we’ve learned can be applied to the Covid-19 pandemic. NEJM 15 December 2022

Breakthrough infections after postexposure vaccination against Mpox
During the current outbreak of monkeypox (recently renamed mpox), smallpox vaccination has been recommended to prevent mpox infection in persons who have had mpox exposure, but evidence to support this practice is limited.1,2 We conducted a study to evaluate potential breakthrough infections in participants who had received smallpox vaccine after high-risk exposure to mpox. In this study population, 4% of the participants who had received postexposure vaccination with a third-generation smallpox vaccine had a subsequent mpox infection during the first month after receipt of the first vaccination. NEJM 7 December 2022

Monkeypox – review article
The gradual decline in immunity to smallpox may partly explain an increase in the incidence of monkeypox in some regions where the disease is endemic. However, the current epidemic reminds us that viral emergence is a permanent phenomenon without boundaries and is often unpredictable in its nature, target, and magnitude. This outbreak illustrates how a disease affecting one region of the world can have a strong effect on areas where it is not endemic, with different target populations and new clinical presentations. NEJM 10 November 2022

Contact tracing and exposure investigation in response to the first case of Monkeypox Virus infection in the United States during the 2022 Global Monkeypox Outbreak
In a contact tracing investigation involving 166 community and health care contacts of a patient with monkeypox, no secondary cases were identified. Annals of infectious diseases 8 November 2022

Immunological signature in human cases of monkeypox infection in 2022 outbreak: an observational study
Our data showed the immunological signature of monkeypox virus infection, characterised by an early expansion of activated effector CD4+ and CD8+ T cells that persisted over time. Almost all patients, even regardless of HIV infection, developed a poxvirus-specific Th1 cell response. These results might have implications on the expected immunogenicity of monkeypox vaccination, suggesting that it might not be necessary to vaccinate people who have already been infected. The Lancet infectious diseases 7 November 2022

Monkeypox virus and ophthalmology—A primer on the 2022 Monkeypox outbreak and Monkeypox-related ophthalmic disease
The ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical. JAMA 3 November 2022

Ocular pox lesions in a male patient with Monkeypox treated with Tecovirimat
Monkeypox can be transmitted via bodily fluids, blood, infected lesions, or respiratory droplets. The infection is usually self-limited, lasting 2 to 4 weeks. Along with cutaneous and systemic findings, ocular manifestations include conjunctivitis, eyelid edema, keratitis, corneal scarring, and conjunctival lesions. Herein, the authors describe a case of ocular pox lesions in a male individual successfully treated with tecovirimat, an expanded-access investigational therapy, and conservative ocular management. JAMA 3 November 2022

Transmission dynamics of monkeypox in the United Kingdom: contact tracing study
Analysis of the instantaneous growth rate of monkeypox incidence indicates that the epidemic peaked in the UK as of 9 July and then started to decline. Short serial intervals were more common than short incubation periods suggesting considerable pre-symptomatic transmission, which was validated through linked patient level records. For patients who could be linked through personally identifiable data, four days was the maximum time that transmission was detected before symptoms manifested. An isolation period of 16 to 23 days would be required to detect 95% of people with a potential infection. The 95th centile of the serial interval was between 23 and 41 days, suggesting long infectious periods. BMJ 2 November 2022

Monkeypox : review article
The gradual decline in immunity to smallpox may partly explain an increase in the incidence of monkeypox in some regions where the disease is endemic. However, the current epidemic reminds us that viral emergence is a permanent phenomenon without boundaries and is often unpredictable in its nature, target, and magnitude. This outbreak illustrates how a disease affecting one region of the world can have a strong effect on areas where it is not endemic, with different target populations and new clinical presentations. NEJM 26 October 2022

Monkeypox: Challenging clinical questions
This article summarizes the ACP/Annals virtual forum held on 11 October 2022. Annals of internal medicine 14 October 2022

Neonatal Monkeypox virus infection
Reports of neonatal monkeypox virus infection are rare. This was a case of neonatal monkeypox virus infection after peripartum transmission within a family cluster; transplacental transmission could not be ruled out. Because this was a single case, it is not possible to attribute the clinical illness to either pathogen (monkeypox virus or adenovirus) directly, nor is it possible to attribute the improvement in the infant’s clinical condition to the use of tecovirimat or cidofovir. Monkeypox virus infection should be considered in the differential diagnosis of a neonatal vesicular rash. NEJM 12 October 2022

Development of an accessible and scalable qPCR assay for Monkeypox virus detection
During the 2022 monkeypox (MPX) outbreak, testing has been limited and results delayed, allowing ongoing transmission. Gold-standard qPCR diagnostics are difficult to obtain. This research adapted the June 2022 CDC MPX qPCR assay for broad implementation. Validated using MPX stocks in a matrix with multiple sample types, MPX was detected with Cq values of 17.46 to 35.59 and titer equivalents 8.01 × 106 to 2.45 × 100 PFU/mL. The detection limit was 3.59 PFU/mL. Sensitivity and specificity were both 100%. This qPCR assay can be quickly and broadly implemented in research and public health labs to increase diagnostic capacity amid the growing MPX outbreak. Journal of infectious diseases 12 October 2022

Air and surface sampling for monkeypox virus in a UK hospital: an observational study
These data show contamination in isolation facilities and potential for suspension of monkeypox virus into the air during specific activities. PPE contamination was observed after clinical contact and changing of bedding. Contamination of hard surfaces in doffing areas supports the importance of cleaning protocols, PPE use, and doffing procedures. The Lancet microbe 7 October 2022

Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study
Clinical manifestations of monkeypox infection differed by HIV status. Recommendations should be expanded to include pre-exposure monkeypox vaccination of groups at high risk of infection who plan to engage in sexual or close intimate contact. The Lancet infectious diseases 7 October 2022

Asymptomatic monkeypox infection: a call for greater control of infection and transmission
National surveillance programmes should be conducted, particularly among populations at high risk of infection, to detect asymptomatic cases. Such surveillance will require rapid diagnostic or home-based tests that could identify undiagnosed infections. Surveillance at a country's entry points (eg, airports) might be effective, particularly in non-endemic countries with little evidence of local transmission, similar to approaches previously suggested for asymptomatic COVID-19 transmission.9,  10 Health-care providers should also establish a proper differential diagnosis before excluding monkeypox, especially considering the increasing non-specific presentations of the disease. Finally, cases could be decreased and the processes of case identification and contact tracing could be facilitated by individuals limiting their numbers of sexual partners and by limitations on areas and gatherings where people commonly engage in anonymous sexual activities. The Lancet microbe 6 October 2022

Recognizing minimal cutaneous involvement or systemic symptoms in Monkeypox
In patients with umbilicated or ulcerated lesions, particularly localized to the anogenital region, clinicians should perform a thorough social history and maintain a high index of suspicion for monkeypox, even in those with mild constitutional symptoms, who report a new sexual partner in the preceding 2 weeks. Increased public awareness of risk factors, the ability to recognize subtle skin findings, as well the increased availability/dissemination of vaccines will be important in containing and preventing further outbreaks. JAMA 6 October 2022

Human Monkeypox virus infection in the immediate period after receiving modified Vaccinia Ankara vaccine
In this small study, the majority of postvaccination monkeypox infections occurred within 2 weeks of receiving the first dose of MVA-BN, before full effectiveness was likely to have been achieved, in line with published immunogenicity data. Because the incubation period for monkeypox is 3 to 17 days, some of the cases occurring between 1 and 14 days after vaccination may not represent true vaccine failure because patients may have sought vaccination after realizing they were exposed. Of concern is that at least 2 breakthrough infections were observed in individuals at least 3 weeks after a second dose. JAMA 30 September 2022

Intradermal vaccination for Monkeypox — Benefits for individual and public health
Despite limited clinical evidence, all available data suggest that intradermal administration of JYNNEOS will be as immunogenic as subcutaneous dosing for preventing monkeypox infection and illness, which leads the authors to favor intradermal use from both the individual and public health perspectives. The Centers for Disease Control and Prevention and the FDA are committed to performing the studies needed to assure that these expectations are borne out. In the meantime, they urge people who are at the highest risk for infection to receive both doses of the two-dose vaccine, and we encourage manufacturers to consider routinely testing intradermal dose administration in future clinical vaccine trials, in order to expand our understanding of this operationally attractive option. The currently available evidence suggests that shifting to intradermal dosing that requires less vaccine is not a lesser option. Rather, it is a rational, evidence-informed means of advancing access, equity, and our chances of controlling the monkeypox outbreak. NEJM 29 September 2022

Neurologic complications of Smallpox and Monkeypox: A review
Monkeypox should be considered in high-risk populations who present with neurologic syndromes. Diagnosis may require serology and polymerase chain reaction testing of blood and spinal fluid. Antiviral therapy should be initiated early in the course of the illness. JAMA 20 September 2022

Monkeypox prevention and treatment while nursing
Although no specific guidelines have appeared for monkeypox, individuals with smallpox are recommended not to breastfeed their infant because of the risk of passing variola virus to the infant through direct contact. Presumably, the same precautions apply with monkeypox. Providing pumped milk to the infant may be possible if no lesions are near the breast and adequate precautions are taken with respect to cleaning hands, breasts, breast pumps, and any other apparatuses used to provide milk to the infant. As the current monkeypox situation evolves, recommendations may change, so refer to the CDC website for the most up-to-date information Breastfeeding medicine 15 September 2022

Annals on call - Diagnosis and treatment of Monkeypox Proctitis
In this episode of Annals On Call, Dr. Centor discusses the diagnosis and treatment of monkeypox proctitis with Drs. Jose Lucar and Tara Palmore. Annals of internal medicine 13 September 2022

Vaccinia-virus-based vaccines are expected to elicit highly cross-reactive immunity to the 2022 Monkeypox Virus
Beginning in May 2022, a novel cluster of monkeypox virus infections was detected in humans. This virus has spread rapidly to non-endemic countries, sparking global concern. Specific vaccines based on the vaccinia virus (VACV) have demonstrated high efficacy against monkeypox viruses in the past and are considered an important outbreak control measure. Viruses observed in the current outbreak carry distinct genetic variations that have the potential to affect vaccine-induced immune recognition. Here, by investigating genetic variation with respect to orthologous immunogenic vaccinia-virus proteins, we report data that anticipates immune responses induced by VACV-based vaccines, including the currently available MVA-BN and ACAM2000 vaccines, to remain highly cross-reactive against the newly observed monkeypox viruses. Viruses 3 September 2022

Reports of asymptomatic Monkeypox suggest that, at the very least, some infections go unnoticed
Two recent case reports from Europe have raised the possibility that some monkeypox virus infections may be asymptomatic. Whether or not these infections were truly symptom free, the studies suggest that clinicians and individuals at high risk should be aware that monkeypox can go unnoticed—possibly even when it’s transmissible. JAMA 31 August 2022

Monkeypox Virus infection in humans across 16 Countries — April–June 2022
In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread. NEJM 25 August 2022

Compassionate use of Tecovirimat for the treatment of Monkeypox infection
The authors assessed adverse events and clinical resolution of systemic symptoms and lesions in an uncontrolled cohort study of patients with monkeypox who were treated with tecovirimat on a compassionate use basis. In this preliminary study, oral tecovirimat was well tolerated by all patients with monkeypox infection, with minimal adverse effects. However, adverse effects could not always be differentiated from symptoms related to the infection. No control group was included, limiting conclusions of antiviral efficacy pertaining to duration of symptoms or severity. Time from symptom onset to presentation was variable among patients, and conclusions related to antiviral use vs natural evolution of disease should be made with caution. Limited clinical data exist on the use of tecovirimat for monkeypox infection. In one case report, no new lesions followed 24 hours of therapy and no adverse effects occurred by treatment completion at 14 days. JAMA 22 August 2022

How does monkeypox spread? An epidemiologist explains why it isn’t an STI and what counts as close contact
The monkeypox virus typically spreads through direct contact with respiratory secretions, such as mucus or saliva, or skin lesions. Skin lesions traditionally appear soon after infection as a rash – small pimples or round papules on the face, hands or genitalia. These lesions may also appear inside the mouth, eyes and other parts of the body that produce mucus. They can last for several weeks and be a source of virus before they are fully healed. Other symptoms usually include fever, swollen lymph nodes, fatigue and headache. MJA Insight 22 August 2022

Audio interview: Responding to Monkeypox
In this audio interview conducted on August 16, 2022, the editors are joined by White House National Monkeypox Response Deputy Coordinator Demetre Daskalakis to discuss the new public health emergency and what HIV and Covid-19 have taught us. NEJM 18 August 2022

Update on the Monkeypox Outbreak
The current monkeypox outbreak illustrates why global health cannot be ignored. Despite monkeypox being endemic in Africa for decades, clinical trials on treatments and vaccines were not done. Now more than 3 months into the global monkeypox outbreak, there is much to learn. While test capacity has been increased, more is needed. Contact tracing is not happening, and data systems are not informing the response in rapid fashion. Many individuals at risk for monkeypox may not be engaged with the health care system, making diagnosis, containment, and prevention challenging. The demand for vaccines far exceeds availability. Although the supply of tecovirimat has increased, this drug must still be used under an IND protocol, which limits access. In addition, a decentralized and wholly underresourced public health infrastructure is even more strained as officials must now respond to both COVID-19 and monkeypox. JAMA 11 August 2022

The changing face of monkeypox
What should patients and clinicians look out for? BMJ 10 August 2022

Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study
In this cohort, monkeypox caused genital, perianal, and oral lesions and complications including proctitis and tonsillitis. Because of the variability of presentations, clinicians should have a low threshold for suspicion of monkeypox. Lesion swabs showed the highest viral loads, which, combined with the history of sexual exposure and the distribution of lesions, suggests close contact is probably the dominant transmission route in the current outbreak. The Lancet 8 August 2022

Ophthalmic manifestation of monkeypox infection
Despite mucosal localisation of vesicles being not uncommon in monkeypox, the diagnosis might be overlooked. During the ongoing monkeypox outbreak, monkeypox should be included in the differential diagnosis of patients with vesicular and pustular eye lesions, especially in the presence of epidemiological links or risk factors. The Lancet infectious diseases 29 July 2022

Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series
These findings confirm the ongoing unprecedented community transmission of monkeypox virus among gay, bisexual, and other men who have sex with men seen in the UK and many other non-endemic countries. A variable temporal association was observed between mucocutaneous and systemic features, suggesting a new clinical course to the disease. New clinical presentations of monkeypox infection were identified, including rectal pain and penile oedema. These presentations should be included in public health messaging to aid early diagnosis and reduce onward transmission. BMJ 28 July 2022

Monkeypox virus infection in humans across 16 countries — April–June 2022
In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread. NEJM 21 July 2022

Is Australia ready for monkeypox?
Disease control efforts can draw on lessons from the past and prevent the epidemic from becoming established in Australia MJA 18 July 2022

Monkeypox emerges on a global scale: a historical review and dermatological primer
The current monkeypox outbreak reawakens the concern that poxviridae have high potential of zoonotic spillover and for causing pandemic.1 Much fieldwork and research has been done by healthcare and public health workers in Africa during previous human outbreaks, and their knowledge should inform our global response to the current outbreak. However, unusual clinical presentations now have potential implications in recognizing disease. Infections from poxviridae such as monkeypox have common cutaneous signs that occur early, may be related to periods of transmissibility, and can leave scarring. Therefore, dermatologists will play a key role in recognizing and diagnosing infections, and in educating and preparing front-line healthcare workers for early detection of new cases and clusters of monkeypox. Journal of the American Academy of Dermatology 8 July 2022

Efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses
As orthopoxviruses may stay infectious on inanimate surfaces under laboratory conditions for up to 42 days, disinfection may be relevant in the surroundings of confirmed cases. The aim of this review was to evaluate published data on the antiviral efficacy of biocidal agents and disinfectants against the monkeypox virus and other orthopoxviruses. Journal of hospital infection 28 June 2022

The outbreak of monkeypox 2022: An overview
On May 6, 2022 an outbreak of monkeypox (MPX) was confirmed in the United Kingdom, originating from a British resident who had travelled to Nigeria. As of May 21, 2022, 92 cases have been confirmed worldwide, from 13 countries where monkeypox virus (MPXV) is not endemic. Reported cases thus far have mainly but not exclusively been identified among gay and bisexual men aged 20–50. MPXV is a viral zoonosis transmitted to humans via contacting or eating an infected animal, and direct connect with natural host’s blood and body fluids. In addition to contacting with a patient’s respiratory droplets, lesions, body fluids and polluted personal objects. Symptoms including shivers, headaches, fainting, backaches, and myodynia do not have any specific characteristics making it difficult to establish a proper diagnosis. Nevertheless, lymphatic hyperplasia, one of the most common symptoms of monkeypox, can be useful for diagnosing the disease. Clinical symptoms help establish the suspicion of monkeypox. However, in the absence of confirmed diagnostic tests it is very difficult to verify the disease and determine its cause based on clinical symptoms alone. There are numerous methods for detecting MPX, involving genetic, phenotypic, immunological methods, and electron microscopy. These tests require modern equipment and expert hands, which may not be available in developing countries where this disease is prevalent. Currently, there is no definite treatment for MPX. CDC recommends administering the smallpox vaccine within 4 days of exposure which may prevent the disease from happening, and within 2 weeks to reduce symptoms severity. To promptly identify patients and prevent further spreading, physicians should be aware of the travel or contact history of the patient with compatible symptoms. Annals of medicine and surgery 24 June 2022

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