Dawn O’Shea

Two studies published in Thorax have found that the use of continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO) to treat moderate to severe COVID-19 is not linked to a heightened risk of infection, as currently thought. Researchers say hospitals should use this information to re-examine aerosol procedures in regard to risk of transmission of SARS-CoV-2.

CPAP and HFNO have been thought to generate virus particles capable of contaminating the air and surfaces, necessitating additional infection control precautions such as segregating patients. However, this research demonstrates that both methods produced little measurable air or surface viral contamination. The amount of contamination was no more than with the use of supplemental oxygen and less than that produced when breathing, speaking, or coughing.

In one study, led by a team from the North Bristol NHS Trust, 25 healthy volunteers and eight hospitalized patients with COVID-19 were recruited and asked to breathe, speak, and cough in ultra-clean, laminar flow theaters followed by use of CPAP and HFNO. Aerosol emission was measured via two methodologies, simultaneously. Hospitalized patients with COVID-19 had cough recorded via the same methodology on the infectious diseases ward.

CPAP (with exhalation port filter) was found to produce less aerosol than breathing, speaking, and coughing, even with large > 50 L/min face mask leaks. Coughing was associated with the highest aerosol emissions of any recorded activity.

HFNO was associated with aerosol emission from the machine. Generated particles were small (< 1 mcm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, and, consequently, would be unlikely to carry viral particles.

More aerosol was generated in cough from patients with COVID-19 (n = 8) than from volunteers.

In the second study, 30 hospitalized patients with COVID-19 requiring supplemental oxygen were prospectively enrolled. In this observational environmental sampling study, participants received either supplemental oxygen, CPAP, or HFNO (n = 10 in each group). A nasopharyngeal swab, three air, and three surface samples were collected from each participant and the clinical environment.

Overall, 21 of the 30 participants tested positive for SARS-CoV-2 RNA in the nasopharynx. In contrast, 4 out of 90 air samples and 6 of 90 surface samples tested positive for viral RNA, although there were an additional 10 suspected-positive samples in both air and surfaces samples.

Neither the use of CPAP nor HFNO nor coughing were associated with significantly more environmental contamination than supplemental oxygen use. Of the total positive or suspected-positive samples by viral PCR detection, only one nasopharynx sample from an HFNO patient was biologically viable in cell culture assay.

“Our findings show that the noninvasive breathing support methods do not pose a higher risk of transmitting infection, which has significant implications for the management of the patients,” said coauthor Danny McAuley, MD.

“If there isn’t a higher risk of infection transmission, current practices may be overcautious measures for certain settings, for example preventing relatives visiting the sickest patients, whilst underestimating the risk in other settings, such as coughing patients with early infection on general wards.”

Although both studies are small, the results do suggest that there is a need for an evidence-based reassessment of infection prevention and control measures for noninvasive respiratory support treatments that are currently considered aerosol generating procedures.
 

A version of this article first appeared on Univadis.com.

Two studies published in Thorax have found that the use of continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO) to treat moderate to severe COVID-19 is not linked to a heightened risk of infection, as currently thought. Researchers say hospitals should use this information to re-examine aerosol procedures in regard to risk of transmission of SARS-CoV-2.

CPAP and HFNO have been thought to generate virus particles capable of contaminating the air and surfaces, necessitating additional infection control precautions such as segregating patients. However, this research demonstrates that both methods produced little measurable air or surface viral contamination. The amount of contamination was no more than with the use of supplemental oxygen and less than that produced when breathing, speaking, or coughing.

In one study, led by a team from the North Bristol NHS Trust, 25 healthy volunteers and eight hospitalized patients with COVID-19 were recruited and asked to breathe, speak, and cough in ultra-clean, laminar flow theaters followed by use of CPAP and HFNO. Aerosol emission was measured via two methodologies, simultaneously. Hospitalized patients with COVID-19 had cough recorded via the same methodology on the infectious diseases ward.

CPAP (with exhalation port filter) was found to produce less aerosol than breathing, speaking, and coughing, even with large > 50 L/min face mask leaks. Coughing was associated with the highest aerosol emissions of any recorded activity.

HFNO was associated with aerosol emission from the machine. Generated particles were small (< 1 mcm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, and, consequently, would be unlikely to carry viral particles.

More aerosol was generated in cough from patients with COVID-19 (n = 8) than from volunteers.

In the second study, 30 hospitalized patients with COVID-19 requiring supplemental oxygen were prospectively enrolled. In this observational environmental sampling study, participants received either supplemental oxygen, CPAP, or HFNO (n = 10 in each group). A nasopharyngeal swab, three air, and three surface samples were collected from each participant and the clinical environment.

Overall, 21 of the 30 participants tested positive for SARS-CoV-2 RNA in the nasopharynx. In contrast, 4 out of 90 air samples and 6 of 90 surface samples tested positive for viral RNA, although there were an additional 10 suspected-positive samples in both air and surfaces samples.

Neither the use of CPAP nor HFNO nor coughing were associated with significantly more environmental contamination than supplemental oxygen use. Of the total positive or suspected-positive samples by viral PCR detection, only one nasopharynx sample from an HFNO patient was biologically viable in cell culture assay.

“Our findings show that the noninvasive breathing support methods do not pose a higher risk of transmitting infection, which has significant implications for the management of the patients,” said coauthor Danny McAuley, MD.

“If there isn’t a higher risk of infection transmission, current practices may be overcautious measures for certain settings, for example preventing relatives visiting the sickest patients, whilst underestimating the risk in other settings, such as coughing patients with early infection on general wards.”

Although both studies are small, the results do suggest that there is a need for an evidence-based reassessment of infection prevention and control measures for noninvasive respiratory support treatments that are currently considered aerosol generating procedures.
 

A version of this article first appeared on Univadis.com.

Two studies published in Thorax have found that the use of continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO) to treat moderate to severe COVID-19 is not linked to a heightened risk of infection, as currently thought. Researchers say hospitals should use this information to re-examine aerosol procedures in regard to risk of transmission of SARS-CoV-2.

CPAP and HFNO have been thought to generate virus particles capable of contaminating the air and surfaces, necessitating additional infection control precautions such as segregating patients. However, this research demonstrates that both methods produced little measurable air or surface viral contamination. The amount of contamination was no more than with the use of supplemental oxygen and less than that produced when breathing, speaking, or coughing.

In one study, led by a team from the North Bristol NHS Trust, 25 healthy volunteers and eight hospitalized patients with COVID-19 were recruited and asked to breathe, speak, and cough in ultra-clean, laminar flow theaters followed by use of CPAP and HFNO. Aerosol emission was measured via two methodologies, simultaneously. Hospitalized patients with COVID-19 had cough recorded via the same methodology on the infectious diseases ward.

CPAP (with exhalation port filter) was found to produce less aerosol than breathing, speaking, and coughing, even with large > 50 L/min face mask leaks. Coughing was associated with the highest aerosol emissions of any recorded activity.

HFNO was associated with aerosol emission from the machine. Generated particles were small (< 1 mcm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, and, consequently, would be unlikely to carry viral particles.

More aerosol was generated in cough from patients with COVID-19 (n = 8) than from volunteers.

In the second study, 30 hospitalized patients with COVID-19 requiring supplemental oxygen were prospectively enrolled. In this observational environmental sampling study, participants received either supplemental oxygen, CPAP, or HFNO (n = 10 in each group). A nasopharyngeal swab, three air, and three surface samples were collected from each participant and the clinical environment.

Overall, 21 of the 30 participants tested positive for SARS-CoV-2 RNA in the nasopharynx. In contrast, 4 out of 90 air samples and 6 of 90 surface samples tested positive for viral RNA, although there were an additional 10 suspected-positive samples in both air and surfaces samples.

Neither the use of CPAP nor HFNO nor coughing were associated with significantly more environmental contamination than supplemental oxygen use. Of the total positive or suspected-positive samples by viral PCR detection, only one nasopharynx sample from an HFNO patient was biologically viable in cell culture assay.

“Our findings show that the noninvasive breathing support methods do not pose a higher risk of transmitting infection, which has significant implications for the management of the patients,” said coauthor Danny McAuley, MD.

“If there isn’t a higher risk of infection transmission, current practices may be overcautious measures for certain settings, for example preventing relatives visiting the sickest patients, whilst underestimating the risk in other settings, such as coughing patients with early infection on general wards.”

Although both studies are small, the results do suggest that there is a need for an evidence-based reassessment of infection prevention and control measures for noninvasive respiratory support treatments that are currently considered aerosol generating procedures.
 

A version of this article first appeared on Univadis.com.

People whose treatment for cancer is delayed by even 1 month have a 6%-13% higher risk of dying, suggests research published online in the BMJ.

In light of the treatment delays resulting from the pandemic, Canadian and U.K. researchers carried out a review and analysis of relevant studies published between January 2000 and April 2020.

Included studies examined data on surgical interventions, systemic therapy, or radiotherapy for seven forms of cancer – bladder, breast, colon, rectum, lung, cervix, and head and neck. Delays were measured from diagnosis to the first treatment or from the completion of one treatment to the start of the next.

The search identified 34 suitable studies for 17 indications, with data from more than 1.2 million patients. The analysis identified a significant association between delay and increased mortality for 13 of the 17 indications (P < .05).

For surgery, there was a 6%-8% increase in the risk of death for every 4-week treatment delay. Estimates for systemic treatment varied (hazard ratio range, 1.01-1.28). Four-week delays in radiotherapy were for radical radiotherapy for head and neck cancer (HR, 1.09; 95% confidence interval, 1.05-1.14), adjuvant radiotherapy after breast-conserving surgery (HR, 0.98; 95% CI, 0.88-1.09), and cervical cancer adjuvant radiotherapy (HR, 1.23; 95% CI, 1.00-1.50).

Delays of up to 8 and 12 weeks further increased mortality. An 8-week delay in breast cancer surgery was linked to a 17% increased mortality, and a 12-week delay would increase mortality by 26%.

A surgical delay of 12 weeks for patients with breast cancer continuing for 1 year – which is likely to be the case as the pandemic continues – would lead to 1,400 excess deaths in the United Kingdom.

The authors said the results of this study could be used to guide policy making on the organization of cancer services, particularly as the pandemic continues and further delays are expected.

This article originally appeared on Univadis, part of the Medscape Professional Network.

People whose treatment for cancer is delayed by even 1 month have a 6%-13% higher risk of dying, suggests research published online in the BMJ.

In light of the treatment delays resulting from the pandemic, Canadian and U.K. researchers carried out a review and analysis of relevant studies published between January 2000 and April 2020.

Included studies examined data on surgical interventions, systemic therapy, or radiotherapy for seven forms of cancer – bladder, breast, colon, rectum, lung, cervix, and head and neck. Delays were measured from diagnosis to the first treatment or from the completion of one treatment to the start of the next.

The search identified 34 suitable studies for 17 indications, with data from more than 1.2 million patients. The analysis identified a significant association between delay and increased mortality for 13 of the 17 indications (P < .05).

For surgery, there was a 6%-8% increase in the risk of death for every 4-week treatment delay. Estimates for systemic treatment varied (hazard ratio range, 1.01-1.28). Four-week delays in radiotherapy were for radical radiotherapy for head and neck cancer (HR, 1.09; 95% confidence interval, 1.05-1.14), adjuvant radiotherapy after breast-conserving surgery (HR, 0.98; 95% CI, 0.88-1.09), and cervical cancer adjuvant radiotherapy (HR, 1.23; 95% CI, 1.00-1.50).

Delays of up to 8 and 12 weeks further increased mortality. An 8-week delay in breast cancer surgery was linked to a 17% increased mortality, and a 12-week delay would increase mortality by 26%.

A surgical delay of 12 weeks for patients with breast cancer continuing for 1 year – which is likely to be the case as the pandemic continues – would lead to 1,400 excess deaths in the United Kingdom.

The authors said the results of this study could be used to guide policy making on the organization of cancer services, particularly as the pandemic continues and further delays are expected.

This article originally appeared on Univadis, part of the Medscape Professional Network.

People whose treatment for cancer is delayed by even 1 month have a 6%-13% higher risk of dying, suggests research published online in the BMJ.

In light of the treatment delays resulting from the pandemic, Canadian and U.K. researchers carried out a review and analysis of relevant studies published between January 2000 and April 2020.

Included studies examined data on surgical interventions, systemic therapy, or radiotherapy for seven forms of cancer – bladder, breast, colon, rectum, lung, cervix, and head and neck. Delays were measured from diagnosis to the first treatment or from the completion of one treatment to the start of the next.

The search identified 34 suitable studies for 17 indications, with data from more than 1.2 million patients. The analysis identified a significant association between delay and increased mortality for 13 of the 17 indications (P < .05).

For surgery, there was a 6%-8% increase in the risk of death for every 4-week treatment delay. Estimates for systemic treatment varied (hazard ratio range, 1.01-1.28). Four-week delays in radiotherapy were for radical radiotherapy for head and neck cancer (HR, 1.09; 95% confidence interval, 1.05-1.14), adjuvant radiotherapy after breast-conserving surgery (HR, 0.98; 95% CI, 0.88-1.09), and cervical cancer adjuvant radiotherapy (HR, 1.23; 95% CI, 1.00-1.50).

Delays of up to 8 and 12 weeks further increased mortality. An 8-week delay in breast cancer surgery was linked to a 17% increased mortality, and a 12-week delay would increase mortality by 26%.

A surgical delay of 12 weeks for patients with breast cancer continuing for 1 year – which is likely to be the case as the pandemic continues – would lead to 1,400 excess deaths in the United Kingdom.

The authors said the results of this study could be used to guide policy making on the organization of cancer services, particularly as the pandemic continues and further delays are expected.

This article originally appeared on Univadis, part of the Medscape Professional Network.

Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.

In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).

Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).

Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.

There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).

In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.

There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).

The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.

There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.

This article originally appeared on Univadis, part of the Medscape Professional Network.

Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.

In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).

Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).

Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.

There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).

In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.

There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).

The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.

There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.

This article originally appeared on Univadis, part of the Medscape Professional Network.

Researchers from the Royal Wolverhampton (England) Hospitals National Health Service Trust say shielding – or taking extra steps to protect oneself against COVID-19 if at high risk – has had little effect on the incidence of COVID-19 in rheumatology patients.

In Annals of the Rheumatic Diseases, the team present data from a large rheumatology cohort in the United Kingdom between Feb. 1, 2020, and May 1, 2020. Patients’ health-related quality of life (HRQoL) was assessed on April 24, 2020, using the Short Form–12 to assess Physical Component Score (PCS) and Mental Component Score (MCS) on a 0-100 scale (0 being the lowest score).

Of 1,693 participants, at the time, there were 61 (3.6%) reported COVID-19 infections (eight had confirmatory swab results; three had clinical diagnoses with “false-negative” swab; 50 had clinical diagnosis but were not swabbed in line with U.K. policy at that time).

Seven of the 61 (11.5%) patients were hospitalized, two requiring intensive care. Of this group, 24 were shielding, a similar proportion to the non-COVID cohort (24/61 vs. 768/1,632; P = .24). There was no significant effect of treatment on self-reported COVID-19 incidence.

There were significantly lower MCSs in the infected group, compared with control participants (38.9 vs. 42.2; mean difference: −3.3; 95% CI, −5.2 to 1.4; P < .001). There was no difference in PCS (−0.4; 95% CI, −2.1 to 1.3).

In patients without COVID-19, the ‘shielding’ group had significantly lower MCS (−2.1; 95% CI, −2.9 to 1.4; P < .001) and PCS (−2.2; 95% CI, −3.8 to 2.5; P < .001) than those not shielding.

There were no differences in MCSs between patients on non–biologic disease-modifying antirheumatic drugs and biologic DMARDs (0.6; 95% CI, 0.1-2.4).

The findings suggest that overall strict social isolation had little effect on the incidence of COVID-19 infection. Patients who had suffered from the virus had reduced mental but not physical HRQoL scores.

There was an adverse effect on both MCS and PCS reported by patients undergoing shielding,n compared with those not. This has also been shown in previous work from India.

This article originally appeared on Univadis, part of the Medscape Professional Network.

It is time to broaden the definition of osteoporosis used in clinical guidelines, states an article published in Age and Ageing, the official journal of the British Geriatrics Society.

The authors recommend that the World Health Organization and the International Society for Clinical Densitometry consider a broader definition of osteoporosis, which encompasses clinical diagnosis, providing clear guidance on communicating bone mineral density (BMD) results to patients.

The WHO definition of osteoporosis, which is endorsed as a diagnostic threshold in current U.K. and European guidance, still relies purely on BMD testing (T score of −2.5 SD or more). The authors say this definition no longer relates to the population for whom osteoporosis drugs are recommended.

In the past 15 years, they write, there has been a change in the field of osteoporosis, namely to base osteoporosis management not just on absolute values of BMD but also on broader consideration of future fracture risk. This change has been underpinned by observations that the majority of patients with a fragility fracture do not have osteoporotic BMD.

Coauthor Zoe Paskins, MBChB, a senior lecturer at Keele (England) University and clinical lead for the osteoporosis service in North Staffordshire, argues that many people with osteoporosis do not receive the treatment they need because of inconsistencies in how the condition is diagnosed around the world, resulting in confusion for both clinicians and patients.

“We think it is time for the WHO to reconsider the definition of osteoporosis, which is now more than 25 years old. A new definition is needed to acknowledge that it is possible, in some circumstances, to give a clinical diagnosis of osteoporosis in those who have osteoporotic fractures. In our view, this would help address current confusion and improve uptake of treatments,” she said.

This article first appeared on Univadis.

It is time to broaden the definition of osteoporosis used in clinical guidelines, states an article published in Age and Ageing, the official journal of the British Geriatrics Society.

The authors recommend that the World Health Organization and the International Society for Clinical Densitometry consider a broader definition of osteoporosis, which encompasses clinical diagnosis, providing clear guidance on communicating bone mineral density (BMD) results to patients.

The WHO definition of osteoporosis, which is endorsed as a diagnostic threshold in current U.K. and European guidance, still relies purely on BMD testing (T score of −2.5 SD or more). The authors say this definition no longer relates to the population for whom osteoporosis drugs are recommended.

In the past 15 years, they write, there has been a change in the field of osteoporosis, namely to base osteoporosis management not just on absolute values of BMD but also on broader consideration of future fracture risk. This change has been underpinned by observations that the majority of patients with a fragility fracture do not have osteoporotic BMD.

Coauthor Zoe Paskins, MBChB, a senior lecturer at Keele (England) University and clinical lead for the osteoporosis service in North Staffordshire, argues that many people with osteoporosis do not receive the treatment they need because of inconsistencies in how the condition is diagnosed around the world, resulting in confusion for both clinicians and patients.

“We think it is time for the WHO to reconsider the definition of osteoporosis, which is now more than 25 years old. A new definition is needed to acknowledge that it is possible, in some circumstances, to give a clinical diagnosis of osteoporosis in those who have osteoporotic fractures. In our view, this would help address current confusion and improve uptake of treatments,” she said.

This article first appeared on Univadis.

It is time to broaden the definition of osteoporosis used in clinical guidelines, states an article published in Age and Ageing, the official journal of the British Geriatrics Society.

The authors recommend that the World Health Organization and the International Society for Clinical Densitometry consider a broader definition of osteoporosis, which encompasses clinical diagnosis, providing clear guidance on communicating bone mineral density (BMD) results to patients.

The WHO definition of osteoporosis, which is endorsed as a diagnostic threshold in current U.K. and European guidance, still relies purely on BMD testing (T score of −2.5 SD or more). The authors say this definition no longer relates to the population for whom osteoporosis drugs are recommended.

In the past 15 years, they write, there has been a change in the field of osteoporosis, namely to base osteoporosis management not just on absolute values of BMD but also on broader consideration of future fracture risk. This change has been underpinned by observations that the majority of patients with a fragility fracture do not have osteoporotic BMD.

Coauthor Zoe Paskins, MBChB, a senior lecturer at Keele (England) University and clinical lead for the osteoporosis service in North Staffordshire, argues that many people with osteoporosis do not receive the treatment they need because of inconsistencies in how the condition is diagnosed around the world, resulting in confusion for both clinicians and patients.

“We think it is time for the WHO to reconsider the definition of osteoporosis, which is now more than 25 years old. A new definition is needed to acknowledge that it is possible, in some circumstances, to give a clinical diagnosis of osteoporosis in those who have osteoporotic fractures. In our view, this would help address current confusion and improve uptake of treatments,” she said.

This article first appeared on Univadis.