Search

Monkeypox (mpox) cases in the 2022 outbreak have primarily occurred among adult gay, bisexual, and other men who have sex with men (MSM); however, other populations have also been affected (1). To date, data on mpox in cisgender women and pregnant persons have been limited. Understanding transmission in these populations is critical for mpox prevention. In addition, among pregnant persons, Monkeypox virus can be transmitted to the fetus during pregnancy or to the neonate through close contact during or after birth (2-5). Adverse pregnancy outcomes, including spontaneous abortion and stillbirth, have been reported in previous mpox outbreaks (3). During May 11-November 7, 2022, CDC and U.S. jurisdictional health departments identified mpox in 769 cisgender women aged ≥15 years, representing 2.7% of all reported mpox cases.

In July 2021, Public Health–Seattle & King County investigated a coronavirus disease 2019 (COVID-19) outbreak at an indoor event intended for fully vaccinated individuals, revealing unvaccinated staff, limited masking, poor ventilation, and overcrowding. Supporting businesses to develop and implement comprehensive COVID-19 prevention plans is essential for reducing spread in these settings.

Cholera is a severe acute, highly transmissible diarrheal disease which affects many low- and middle-income countries. Outbreaks of cholera are confirmed using microbiological culture, and additional cases during the outbreak are generally identified based on clinical case definitions, rather than laboratory confirmation. Many low-resource areas where cholera occurs lack the capacity to perform culture in an expeditious manner. A simple, reliable, and low-cost rapid diagnostic test (RDT) would improve identification of cases allowing rapid response to outbreaks. Several commercial RDTs are available for cholera testing with two lines to detect either serotypes O1 and O139; however, issues with sensitivity and specificity have not been optimal with these bivalent tests. Here, we report an evaluation of a new commercially available cholera dipstick test which detects only serotype O1. In both laboratory and field studies in Kenya, we demonstrate high sensitivity (97.5%), specificity (100%), and positive predictive value (100%) of this new RDT targeting only serogroup O1. This is the first field evaluation for the new Crystal VC-O1 RDT; however, with these high-performance metrics, this RDT could significantly improve cholera outbreak detection and improve surveillance for better understanding of cholera disease burden.

Background Declines in malaria burden in Uganda have slowed. Modelling predicts that indoor residual spraying (IRS) and mass drug administration (MDA), when co-timed, have synergistic impact. This study investigated additional protective impact of population-based MDA on malaria prevalence, if any, when added to IRS, as compared with IRS alone and with standard of care (SOC). Methods The 32-month quasi-experimental controlled before-and-after trial enrolled an open cohort of residents (46,765 individuals, 1st enumeration and 52,133, 4th enumeration) of Katakwi District in northeastern Uganda. Consented participants were assigned to three arms based on residential subcounty at study start: MDA+IRS, IRS, SOC. IRS with pirimiphos methyl and MDA with dihydroartemisinin- piperaquine were delivered in 4 co-timed campaign-style rounds 8 months apart. The primary endpoint was population prevalence of malaria, estimated by 6 cross-sectional surveys, starting at baseline and preceding each subsequent round. Results Comparing malaria prevalence in MDA+IRS and IRS only arms over all 6 surveys (intention-to-treat analysis), roughly every 6 months post-interventions, a geostatistical model found a significant additional 15.5% (95% confidence interval (CI): [13.7%, 17.5%], Z = 9.6, p = 5e−20) decrease in the adjusted odds ratio (aOR) due to MDA for all ages, a 13.3% reduction in under 5’s (95% CI: [10.5%, 16.8%], Z = 4.02, p = 5e−5), and a 10.1% reduction in children 5–15 (95% CI: [8.5%, 11.8%], Z = 4.7, p = 2e−5). All ages residents of the MDA + IRS arm enjoyed an overall 80.1% reduction (95% CI: [80.0%, 83.0%], p = 0.0001) in odds of qPCR confirmed malaria compared with SOC residents. Secondary difference-in-difference analyses comparing surveys at different timepoints to baseline showed aOR (MDA + IRS vs IRS) of qPCR positivity between 0.28 and 0.66 (p < 0.001). Of three serious adverse events, one (nonfatal) was considered related to study medications. Limitations include the initial non-random assignment of study arms, the single large cluster per arm, and the lack of an MDA-only arm, considered to violate equipoise. Conclusions Despite being assessed at long time points 5–7 months post-round, MDA plus IRS provided significant additional protection from malaria infection over IRS alone. Randomized trials of MDA in large areas undergoing IRS recommended as well as cohort studies of impact on incidence. Trial registration: This trial was retrospectively registered 11/07/2018 with the Pan African Clinical Trials Registry (PACTR201807166695568).

On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories

Background In mid-2016, a cholera outbreak occurred in Kathmandu Valley, Nepal. This retrospective study aims to determine if a reactive, ring vaccination strategy would have been useful in preventing cholera transmission during that outbreak. Methods Data on cholera cases were collected as part of hospital-based surveillance in the Kathmandu Valley in 2016. Global Positioning System (GPS) coordinates were obtained during household visits. Geographic clusters of cases were visually determined and tested statistically for clustering. Cluster size was determined based on the distribution of cases around the index case. Results GPS coordinates for 69 cases were analysed. Six geographic clusters were identified, all of which showed significant clustering of cases. Approximately 85% of cases within a cluster occurred more than 7 d after the index case. The median ring size was 1 km, with a population of 14 000 people. Conclusions Cholera cases were clustered in space and the majority of cases occurred over 1 week after the initial cases in the cluster, allowing for an opportunity to prevent transmission through the use of the vaccine soon after the initial case was identified. A ring vaccination strategy may be especially useful for large urban areas with recurrent seasonal outbreaks but where the specific locations for such outbreaks are not predictable.

Background:Declines in malaria burden in Uganda have slowed. Modelling predicts that indoor residual spraying (IRS) and mass drug administration (MDA), when co-timed, have synergistic impact. This study investigated additional protective impact of population-based MDA on malaria prevalence, if any, when added to IRS, as compared with IRS alone and with standard of care (SOC).Methods:The 32-month prospective controlled community trial enrolled an open cohort of residents (46,765 individuals, 1st enumeration and 52,133, 4th enumeration) in Katakwi District in northeastern Uganda. Consented participants were assigned to three arms based on residential subcounty: MDA+IRS, IRS, and SOC (insecticide treated bednets and case management). IRS with pirimiphos methyl and MDA with dihydroartemisinin- piperaquine were delivered in 4 co-timed campaign-style rounds 8 months apart. The primary endpoint was population prevalence of malaria, estimated by 6 cross-sectional surveys, starting at baseline and preceding each subsequent round.Results:Comparing malaria prevalence in MDA+IRS and IRS only arms over all 6 surveys (intention-to-treat analysis), roughly every 6 months, post-interventions, a geostatistical model found a significant additional 15.5% (95% confidence interval (CI): [13.7%, 17.5%], Z=9.6, p= 5e-20) decrease in the adjusted odds ratio (aOR) due to MDA for all ages, a 13.3% reduction in under 5's (95% CI: [10.5%, 16.8%], Z=4.02, p= 5e-5), and a 10.1% reduction in children 5-15 (95% CI: [8.5%, 11.8%], Z=4.7, p= 2e-5). All ages residents of the MDA + IRS arm enjoyed an overall 80.1% reduction (95% CI: [80.0%,83.0%, pConclusions:Despite being assessed at long timepoints 5-7 months post-round, MDA plus IRS provided significant additional protection from malaria infection over IRS alone. Future cohort studies of impact on incidence recommended. Trial registration: This trial was retrospectively registered July 7th, 2018 with the Pan African Clinical Trials Registry (PACTR 201807166695568).

ObjectivesTo evaluate the quality and coverage of the campaign to distribute oral cholera vaccine (OCV) during a cholera outbreak in Hoima, Uganda to guide future campaigns of cholera vaccine.DesignSurvey of communities targeted for vaccination to determine vaccine coverage rates and perceptions of the vaccination campaign, and a separate survey of vaccine staff who carried out the campaign.SettingHoima district, Uganda.ParticipantsRepresentative clusters of households residing in the communities targeted for vaccination and staff members who conducted the vaccine campaign.ResultsAmong 209 households (1274 individuals) included in the coverage survey, 1193 (94%; 95% CI 92% to 95%) reported receiving at least one OCV dose and 998 (78%; 95% CI 76% to 81%) reported receiving two doses. Among vaccinated individuals, minor complaints were reported by 71 persons (5.6%). Individuals with ‘some’ education (primary school or above) were more knowledgeable regarding the required OCV doses compared with non-educated (p=0.03). Factors negatively associated with campaign implementation included community sensitisation time, staff payment and problems with field transport. Although the campaign was carried out quickly, the outbreak was over before the campaign started. Most staff involved in the campaign (93%) were knowledgeable about cholera control; however, 29% did not clearly understand how to detect and manage adverse events following immunisation.ConclusionThe campaign achieved high OCV coverage, but the surveys provided insights for improvement. To achieve high vaccine coverage, more effort is needed for community sensitisation, and additional resources for staff transportation and timely payment for campaign staff is required. Pretest and post-test assessment of staff training can identify and address knowledge and skill gaps.

OBJECTIVES: Public health and clinical recommendations should be based on results from multiple studies, however trials often have outcomes that are not defined in the same way. This project aims to harmonize selected protocols, outcome definitions, and data analysis across five randomized trials of antenatal balanced energy-protein supplementation being conducted in Burkina Faso, Ethiopia, India, Nepal, and Pakistan. METHODS: Harmonization efforts include a range of activities from reviewing detailed protocols, biospecimen collection plans, data dictionaries, and data analysis plans to proposing best practices and acceptable practices based on field limitations. Most studies have not begun or are early in enrollment, an ideal time frame to make changes. A two-day workshop of lead investigators, content experts and advisors will be held in late February, and harmonization activities will continue thereafter. RESULTS: All studies are examining anthropometry at birth as a primary outcome, however the timing of birth measurements (hours since birth) and types of measurements taken differ across trials. All studies are estimating gestational age by ultrasound measurements, but the gestational age at ultrasound differs (in part due to differences in timing of antenatal care by country) as well as the number of fetal biometry measures. Finally, stillbirth is a key outcome across trials, but initial definitions had slight differences that will now be harmonized. We are also able to add new, important maternal and child health outcomes to each trial that will have the same protocols from inception (e.g., microbiome). CONCLUSIONS: Efforts thus far have resulted in communication between study investigators, consideration of improved protocols, and addition of new outcomes to collect across all sites. Further results are forthcoming after the February workshop, which will include documentation of how much definitions vary across studies and the challenges of standardization. We expect the harmonization process to improve overall reporting within each study and provide opportunities for better meta-analyses. FUNDING SOURCES: The Bill and Melinda Gates Foundation.

AimsThe aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).Patients and MethodsNIRS sensors were placed on 86 patients with, and 23 without (controls), severe leg injury. NIRS values were recorded for up to 48 hours. Longitudinal data were analyzed using summary and graphical methods, bivariate comparisons, and multivariable multilevel modelling.ResultsMean NIRS values in the anterior, lateral, superficial posterior, and deep posterior compartments were between 72% and 78% in injured legs, between 69% and 72% in uninjured legs, and between 71% and 73% in bilaterally uninjured legs. In patients without ACS, the values were typically > 3% higher in injured compartments. All seven limbs with ACS had at least one compartment where NIRS values were 3% or more below a reference uninjured control compartment. Missing data were encountered in many instances.ConclusionNIRS oximetry might be used to aid the assessment and management of patients with ACS. Sustained hyperaemia is consistent with the absence of ACS in injured legs. Loss of the hyperaemic differential warrants heightened surveillance. NIRS values in at least one injured compartment(s) were > 3% below the uninjured contralateral compartment(s) in all seven patients with ACS. Additional interventional studies are required to validate the use of NIRS for ACS monitoring. Cite this article: Bone Joint J 2018;100-B:787–97.

Purpose: Trapeziectomy with suture button suspensionplasty (SBS) to treat thumb carpometacarpal (CMC) arthritis has been proposed as an alternative to ligament reconstruction tendon interposition. There have been limited large-scale or long-term reports regarding SBS outcomes. Single-surgeon intermediate follow-up is reported. Methods: We conducted a retrospective review of patients undergoing SBS procedures by a single surgeon. Implant manufacturer and postoperative immobilization protocol were recorded. Surgical outcomes, complications, and revision procedures were identified. Postoperative Disabilities of the Arm, Shoulder, and Hand scores were collected. Results: A total of 242 SBS surgeries were included, involving 215 patients, average age 64.82 years (range, 42–86 years). Average follow-up was 35 ± 25 months. In all, 183 Arthrex and 59 Stryker systems were used, 42 of which were immobilized for 6 weeks after surgery and 200 of which were mobilized at 2 weeks afterward. Postoperative Disabilities of the Arm, Shoulder, and Hand surveys were completed by 122 patients (57%), with an average score of 12. No scaphometacarpal abutment was reported. Thirteen complications were reported (5%), 7 of which were implant-associated (3%) and 6 of which were not (2%). Implant-associated complications consisted of 3 suture button pull-outs, 2 thumb–index metacarpal abutments, one suture tail irritation, and one index metacarpal fracture. Operative revision was required in 4 of 7 implant-associated cases and 5 of 6 non–implant associated cases. No suture button pull-outs required revision surgery. Conclusions: Results for a large series of SBS for CMC arthroplasty with intermediate follow-up revealed excellent clinical outcomes and low complication rates. Clinical relevance: Suture button suspensionplasty as an alternative to ligament reconstruction tendon interposition may be a viable option for treating thumb CMC arthritis. In addition, a technique to manage thumb–index metacarpal abutment is described. Key words: Basilar thumb arthritis, Carpometacarpal arthritis, Carpometacarpal arthroplasty, Suture button suspensionplasty, Trapeziectomy

The purpose of this study was to determine the effects of skin pigmentation regarding Near Infrared Spectroscopy (NIRS) tissue oxygen saturation values (StO2). The study examined NIRS values in individuals with varying skin pigmentation on the anterior compartment of the lower leg and volar forearm to determine if correlation exists among three NIRS devices, the EQUANOX, Casmed, and INVOS. Skin pigmentation was measured on the anterior lower leg (AL) and volar forearm (VF) of participants using a noninvasive colorimeter that employed reflective spectroscopy to produce a quantitative value for erythema (skin “redness”) and melanin (skin pigment). Muscle oxygenation was measured using three oximetry devices with sensors placed in the same areas. The EQUANOX device showed no significant correlation with skin pigmentation, while the Casmed and INVOS devices showed moderate and significant correlation with skin pigmentation, respectively. Different devices have different abilities to remove confounding variables, such as skin pigmentation and erythema, which may affect clinical decision-making, and affect the use of NIRS technology.

Background: Pulse oximetry measures oxygen saturation in arterial blood non-invasively and is routinely practiced in many clinical settings. Technological advancements have expanded the performance capabilities of these devices to operate wirelessly, making pulse oximetry measures more convenient to obtain. Factors such as patient motion however can potentially complicate the ability to retrieve these measures. We examined the performance of two wireless pulse oximeters in patients who shiver postoperatively. Methods: Two additional pulse oximeter sensors (Masimo and Nonin) were added to 30 patients who shivered post-operatively and met eligibility criteria. Dropout rates were calculated by dividing the number of times that each instrument displayed no SpO2 or pulse rate value by the total time both sensors were in camera view for that subject. We used Wilcoxon matched pairs tests to compare the average time until the first reading displayed on the sensor for each device as well as dropout times. Dropout events were also compared using McNemar's test. Results: Drops in signal occurred in thirteen subjects. The Masimo sensor had more dropouts and a longer average drop duration, which was found to be statistically significant (p=0.02). Masimo's sensor required more s on average than Nonin's (8.86>8.78) to display the first reading, but this was not found to be statistically significant (p=0.90). Masimo also had a higher percentage of drops however this was not statistically significant (p=0.07). Conclusion: Overall incidence of shivering was low among patients in this setting (0.1%). More than 1/3 of subjects experienced drops during identical time intervals indicating that motion artifact may impact results regardless of technology. Additionally, Masimo's sensor is not meant for clinical use thereby raising questions regarding our statistically significant result in this particular setting. Combined with results from part I of this study, we cannot confidently detect a statistically significant difference between manufacturers.

Pulse oximetry is a noninvasive method of measuring the oxygen saturation (SpO2) of the arterial blood and is considered standard-of-care in post-operative settings. Patient motion or low perfusion can present challenges in obtaining accurate readings. Postoperative shivering occurs in anywhere from 5-65% of patients who have received general anesthesia and can manifest as continuous tremors and/or sporadic muscle movements. Objective: Compare the effect of post-operative shivering on functioning capabilities of two commercially available pulse oximeters. Methods: Two additional pulse oximeter sensors (Nonin 7500 Pulse Oximeter with 8000AA Sensor and Masimo Rad-8 with Rainbow DCI SC-200 Adult Reusable Sensor) were added to 40 shivering patients who met eligibility criteria. Shivering episodes were documented by recording the start and stop times for each episode as it occurred. Dropout rates for each device were calculated by dividing the amount of time that each instrument displayed no SpO2 or pulse rate value by the total time of the test. A 2-sample T-test was performed to compare dropout times of the devices and dropout rates were compared using a z-test for 2 proportions. Results: Drops in signal occurred in fourteen subjects. The Masimo sensor dropped 21 times, for an average of 40 seconds per drop and Nonin's dropped 16 times averaging 29 seconds per drop. Nonin's dropout rate of 0.108 was less than that of Masimo's at 0.149, however this difference was not found to be statistically significant (p=0.87). Conclusion: The incidence of shivering was very low among patients in this particular study setting (0.1%) For 5 different subjects, both sensors experienced drops during identical time intervals indicating that motion artifact may impact readings regardless of specific technology. Clinically significant shivering varied in duration among subjects therefore individual shiver rates varied as well. This preliminary analysis shows no significant difference between Nonin and Masimo sensors.

We conducted a study to highlight areas of risk with distal radius fixation to prevent occurrence of extensor tendon injury without compromising the security and stability of the fixation. Twelve cadaveric forearms were used. The volar locking plate was placed to best anatomical and radiologic fit on the distal radius of each arm. All 7 holes in the plate were drilled, and bicortical length was measured using a depth gauge under fluoroscopy to estimate screw lengths. Screws were secured into place, and dorsal prominence was measured. The central screw positions had the least dorsal screw prominence, mean (SD) of 0.50 (1.06) mm, and were considered low-risk. The radial and ulnar screw positions had more dorsal screw prominence, 3.38 (1.38) mm and 1.03 (1.30) mm, respectively. Although only radial prominence was statistically significant, both radial and ulnar screw positions were considered high-risk and in need of screw length adjustments. The data suggest that screw length for this plate should be decreased by about 3 mm for the radial positions and by 1 mm for the ulnar positions to decrease the risk for tendon rupture and irritation secondary to dorsal screw prominence.

Background Acute compartment syndrome is a rare but serious consequence of traumatic leg injury. Near-infrared spectroscopy (NIRS) is able to measure oxygenation to a depth of 2 cm to 3 cm below the skin, raising concerns over the ability of NIRS to accurately determine oxygenation of injured leg compartments in the presence of swelling and in the obese. The purpose of this study was to measure the thickness of the subcutaneous tissue overlying the posterior muscle compartment in subjects with tibia fractures to determine if it might compromise rSO₂ measurement in the muscle. Methods Data were analyzed on 50 patients with severe leg injuries. Distance from the skin to the fascia in the superficial posterior compartment of both legs was measured on each patient using a portable ultrasound device. Results Subject age ranged from 18 years to 65 years (mean, 39 years), with 43 male and 7 female patients. The mean (SD) subcutaneous adipose tissue thickness (ATT) was 6.98 (3.17) mm for the injured leg and 7.06 (3.37) mm for the uninjured leg, and the mean body mass index for the group was 27.08 kg/m. No significant correlation was found between the ATT of the injured or uninjured legs and body mass index. Mean comparison testing revealed no difference in ATT between the injured and uninjured legs (null hypothesis: equal means, p > 0.05). Of the 50 subjects analyzed, no subject had a subcutaneous depth of more than 2 cm on the injured or uninjured leg. Conclusion These data suggest that, within this traumatically injured population, symptoms associated with leg injury (such as swelling and edema) do not significantly affect the distance from the skin to the fascia. It is also notable that subcutaneous depth beyond the 2-cm mark (validated in previous studies) is a rare occurrence in this population. These results further support the use of continuous NIRS monitoring for diagnosis of acute compartment syndrome. Level of evidence Therapeutic study, level IV.

Near-Infrared Spectroscopy (NIRS) measures to a depth of 2 to 3 cm below the skin, raising concern over the utility of NIRS in the obese patient. The purpose of this prospective study is to investigate the effect of overlying adipose tissue thickness (ATT) on NIRS oxygenation measurements of skeletal muscle. ATT was measured by ultrasound. NIRS sensors were placed over the anterior and superficial posterior compartments of one leg during exercise and the change in regional oxygen saturation was calculated for each compartment. There was a decreasing trend in change of rSO2 from baseline with increasing ATT. Extremely obese patients (BMI >40) had significantly smaller changes in rSO2 from baseline as compared to otherwise similar patients in both the compartments (p

Similar to pulse-oximetry, near infrared spectroscopy (NIRS) uses the proportionate differential in reflection and absorption of different wavelengths of light to estimate the proportion of hemoglobin saturated with oxygen approximately 2-3 cm below the sensor. The depth of readings is based on the separation between the light source (s) and the receptor (s); the farther the receptor and source are separated, the deeper the arc of penetration. This technology is currently FDA approved for the noninvasive, continuous monitoring of cerebral and somatic tissue regional perfusion. This makes NIRS an ideal technology to consider when seeking a best means for diagnosing acute compartment syndrome (ACS), which is a condition that is physiologically defined as a regional hypoperfused/ ischemic states due to excessive pressure within a muscle compartment.

Background: Concerns have been raised about the ability of Near Infrared Spectroscopy (NIRS) to monitor skeletal tissue regional oxygen saturation (rSO2) in excessive light conditions, as are found under the overhead lights of the operating room. This study seeks to determine whether varying intensities of ambient light exert an influence on NIRS measurements of skeletal tissue rSO2. Methods: Thirty people were recruited from the staff of a local surgical center to participate in the study. Three separate NIRS devices (Covidien INVOS Cerebral Oximeter 510°C, Nonin EQUANOX Model 7600, and a CASMED MC-2030C Cerebral Oximeter) were used to obtain readings from the anterior compartment of the leg. Illuminance was recorded simultaneously with oximetry data in an operating room with (1) no lights on, (2) room lights, and (3) surgical lamps set to maximal intensity. Results: No differences were seen in rSO2 values under the different lighting conditions while using the Nonin device. There was a statistically significant difference between rSO2 for lights off versus room lights (-0.933, p=0.0045) as well as for lights off versus operating room (OR) lamps (level 5) (-0.50, p=0.0035) for the INVOS device, although the INVOS device was not always able to produce a reading in the presence of high-intensity OR light. While there was no difference found between lights off and room lights when using the CASMED device, it was unable to display a value in the presence of high-intensity OR lamp light. Conclusions: The results indicate that the presence of light has an effect on oximetry readings; however, the presence of such an effect is dependent upon the device being used. While other applications of the device, such as cerebral oximetry, may allow for drapes to cover the areas being monitored, monitoring for compartment syndrome of the leg would not be as forgiving. This application would be best served by a device capable of monitoring at all light levels.