Category: Corona Virus

Introduction

Benign paroxysmal positional vertigo (BPPV) is characterized by sudden onset of vertigo elicited by change of head position. BPPV is the most common cause of vertigo, with an idiopathic etiology in the majority of cases. Idiopathic BPPV can be defined when the etiology of BPPV is unrecognizable, and common conditions, which can be associated with secondary BPPV, include head trauma, vestibular neuritis, Menieres disease, sudden sensorineural hearing loss and postsurgical. BPPV most commonly involves the posterior semicircular canal (PSCC), followed by the lateral semicircular canal (LSCC); however, several recent studies have shown that LSCC BPPV might be more common than reported previously.14 Because spontaneous remission often occurs in BPPV,57 the time interval from onset of vertigo to initial evaluation should be considered when estimating the true incidence of BPPV subtypes. Additionally, patient-perceived subjective vertigo may vary among individuals with BPPV, which can thus affect hospital use behavior. Furthermore, patient referral systems may keep patients with BPPV waiting pending the results of initial evaluations at the OPD clinics of tertiary hospitals. We have recently reported that the incidence of BPPV subtypes differs according to the type of hospital visit, ie, whether the patient is evaluated at the outpatient department (OPD) vs emergency room (ER).8

The coronavirus disease 2019 (COVID-19) pandemic has markedly impacted patient and provider lifestyles, including patterns of healthcare system use. During the severe crisis period, only emergency and oncology services were active in the tertiary referral medical center, as was the case in many other hospitals. Because dizzy patients may be concerned that hospitals are high-risk environments for COVID-19 infection, the pattern of hospital visit behavior in these patients may be different from that prior to the pandemic. We hypothesized that COVID-19 pandemic affected the medical healthcare use behavior in patients with BPPV, eliciting the change in the diagnosis of BPPV. This study aimed to investigate the impact of COVID-19 on the incidence of BPPV subtypes by hospital visit type (OPD vs ER) in a single tertiary university hospital. We also compared the duration between symptom onset and the initial professional evaluation in different subtypes of BPPV.

The medical records of patients who presented with BPPV to the hospitals OPD and ER during and before the COVID-19 pandemic were retrospectively reviewed. A total of 517 patients diagnosed with idiopathic BPPV between March 2018 and December 2019 (before the COVID-19 pandemic) and a total of 435 patients diagnosed with idiopathic BPPV between March 2020 and December 2021 (during the COVID-19 pandemic) were included in this study. Neurological examinations were performed in each patient, and brain magnetic resonance imaging (MRI) was performed in patients with additional neurological abnormalities, and in those with severe imbalance, ataxia, and isolated vertigo with ocular movements suggesting central disorders such as gaze-evoked nystagmus, vertical or pure torsional spontaneous nystagmus, skew deviation or perverted head-shaking nystagmus. Nystagmus was examined using a video-oculography system in all BPPV patients at OPD and ER.

This study included only typical BPPV, including canalolithiasis-type PSCC BPPV, geotropic LSCC BPPV, and apogeotropic LSCC BPPV, and BPPV was diagnosed according to the clinical practice guidelines of the American Academy of Otorhinolaryngology-Head and Neck Surgery and Barany Society.9,10 PSCC BPPV was diagnosed when upbeat-torsional nystagmus was provoked by the DixHallpike test. Geotropic LSCC BPPV was diagnosed when positional geotropic nystagmus lasting less than 1 min was induced by a head-roll test. Geotropic nystagmus was defined when the right-beating nystagmus was observed upon right head-rolling and the left-beating nystagmus was observed upon left head-rolling. Apogeotropic LSCC BPPV was diagnosed when positional apogeotropic nystagmus lasting longer than 1 min was provoked by the head-roll test. Apogeotropic nystagmus was defined when the left-beating nystagmus was observed upon right head-rolling and the right-beating nystagmus was observed upon left head-rolling.

Patients with superior semicircular canal (SSCC) BPPV, multicanal BPPV, recurrent BPPV, or central positional nystagmus were excluded from this study. To include cases of idiopathic BPPV, patients with suspected secondary BPPV, such as those with a current or recent history of inner ear disease, were excluded. Patients with post-traumatic BPPV or post-surgery conditions were excluded. Patients diagnosed with BPPV during severe medical illnesses, such as those undergoing chemotherapy or hemodialysis, were also excluded. Ninety-eight patients with apogeotropic LSCC BPPV underwent diffusion-weighted brain MRIs in the ER, all of which revealed no acute brain lesions. Routine contrast-enhanced brain MRIs, which were conducted on only two OPD patients with apogeotropic LSCC BPPV, demonstrated no abnormal findings.

SPSS version 24.0 (IBM SPSS, Armonk, NY, USA) was used for statistical analyses. The chi-square test or Fishers exact test was used for categorical variables, and Students t-test or MannWhitney U-test was used for continuous variables. We conducted ShapiroWilk test to examine if the samples are from a normally distributed population before performing Students t-test, and MannWhitney U-test was used in cases that the data tested are not assumed to be normally distributed. To assess the homogeneity of variances, Levenes test of Equality of Variances was used in Students t-test. For categorical variables, Fishers exact test was used instead of chi-square test when more than 20% of cells have expected frequencies <5. A p value <0.05 was considered significant. This study was approved by the local institutional review board of Konkuk University Medical Center (No. 2022-04-042). Informed consents were exempted from all participants; this study is a retrospective study using only medical records. The study was conducted according to the guidelines of the Declaration of Helsinki for studies on human subjects.

A total of 517 and 435 patients were diagnosed with idiopathic BPPV before (March 2018 and December 2019) and during (March 2020 and December 2021) the COVID-19 pandemic period, respectively. The patients mean age was 54.6 12.9 years (range, 2083 years) before the COVID-19 pandemic and 55.2 17.2 years (range, 1484 years) during the pandemic; however, these findings were not significantly different (p = 0.156, Students t-test). The male-to-female ratios were 141 (27%): 376 (73%) before the COVID-19 pandemic, and 129 (30%): 306 (70%) during the pandemic; these findings were also not significantly different (p = 0.417, chi-square test). The right-to-left ratio of the involved side was 253:264 before the COVID-19 pandemic and 216:219 during the pandemic, which was not significantly different (p = 0.825, chi-square test). Thirty-eight percent of BPPV patients (199/517) was diagnosed at the OPD before the COVID-19 pandemic, and 39.3% of BPPV patients (171/435) were diagnosed at the OPD during the pandemic; the proportion of patients with BPPV evaluated at the OPD was not significantly different between the two periods (p = 0.741, chi-square test).

Of the 517 BPPV patients before the COVID-19 pandemic, 198 (38%) were diagnosed with PSCC BPPV, 102 (20%) with geotropic LSCC BPPV, and 217 (42%) with apogeotropic LSCC BPPV (Table 1). Among the 198 patients with PSCC BPPV, more patients were diagnosed at the OPD (106/198 [54%]) than at the ER (92/198 [46%]) (Table 1). However, more patients were diagnosed at the ER than OPD in geotropic LSCC BPPV (76/102 [75%] at ER vs 26/102 [25%] at OPD) and apogeotropic LSCC BPPV (150/217 [69%] at ER vs 67/217 [31%] at OPD) (Table 1). Compared with PSCC BPPV, significantly higher proportions of patients were diagnosed at the ER in geotropic LSCC BPPV and apogeotropic LSCC BPPV (Figure 1). The mean time interval from vertigo onset to diagnosis was significantly longer in patients with PSCC BPPV (7.58 16.13 days; range, 0120 days) than in those with geotropic LSCC BPPV (2.05 6.17 days; range, 052 days) or apogeotropic LSCC BPPV (3.32 11.31 days; range, 0120 days) (Table 1, Figure 2). Irrespective of BPPV subtype, the mean time interval between vertigo onset and diagnosis was remarkably longer in BPPV patients diagnosed at the OPD than those who were diagnosed at the ER (Table 1, Figure 3).

Table 1 Number of Patients and Mean Duration Between Symptom Onset and Evaluation According to BPPV Subtype During the Period Before COVID-19 Pandemic (Mar. 2018 ~ Dec. 2019)

Figure 1 Proportion of patients (%) with PSCC BPPV, geotropic LSCC BPPV, and apogeotropic LSCC BPPV by hospital visit type before and during the COVID-19 pandemic. Significantly higher proportions of geotropic LSCC BPPV (p < 0.001, chi-square test) and ageotropic LSCC BPPV (p < 0.001, chi-square test) patients were diagnosed in the ER compared with those with PSCC BPPV in both before and during the COVID-19 pandemic. The proportion of patients who were diagnosed at the ER was not significantly different from those diagnosed at the OPD in PSCC BPPV (p = 0.084, chi-square test).

Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; ER, emergency room; Geo, geotropic; LSCC, lateral semicircular canal; OPD, outpatient department; PSCC, posterior semicircular canal.

Figure 2 Mean time interval between symptom onset and clinical evaluation by BPPV subtype before and during the COVID-19 pandemic. Before COVID-19 pandemic, the mean time interval was significantly longer in patients with PSCC BPPV (7.58 16.13 days) than in those with geotropic LSCC BPPV (2.05 6.17 days, p = 0.001, MannWhitney U-test) or apogeotropic LSCC BPPV (3.32 11.31 days, p = 0.002, MannWhitney U-test). During COVID-19 pandemic, the mean time interval was significantly longer in patients with PSCC BPPV (14.22 39.00 days) than in those with geotropic LSCC BPPV (1.48 2.33 days, p = 0.001, MannWhitney U-test) or apogeotropic LSCC BPPV (2.94 8.05 days, p < 0.001, MannWhitney U-test). The mean time interval was remarkably longer during the COVID-19 pandemic than before the COVID-19 pandemic in PSCC BPPV (p < 0.001, MannWhitney U-test).

Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; Geo, geotropic; LSCC, lateral semicircular canal; PSCC, posterior semicircular canal.

Figure 3 Differences in mean time intervals between symptom onset and clinical evaluation according to BPPV subtype by hospital visit type before and during the COVID-19 pandemic. Before the COVID-19 pandemic, the mean time interval for patients who were assessed at the OPD vs the ER was 12.92 20.43 days vs 1.41 3.14 days for PSCC BPPV (p < 0.001, MannWhitney U-test), 6.62 10.98 days vs 0.49 1.13 days for geotropic-LSCC BPPV (p < 0.001, MannWhitney U-test), and 9.70 18.76 days vs 0.47 1.69 days for apogeotropic-LSCC BPPV (p < 0.001, MannWhitney U-test), respectively. During the COVID-19 pandemic, the mean time interval for the patients who were diagnosed at the OPD vs ER was 22.26 47.68 days vs 0.90 1.46 days for PSCC BPPV (p = 0.001, MannWhitney U-test), 4.10 2.98 days vs 0.70 1.37 days for geotropic LSCC BPPV (p < 0.001, MannWhitney U-test), and 10.07 13.39 days vs 0.39 0.66 days for apogeotropic LSCC BPPV (p < 0.001, MannWhitney U-test), respectively.

Abbreviations: Apo, apogeotropic; BPPV, benign paroxysmal positional vertigo; COVID-19, coronavirus disease 2019; ER, emergency room; Geo, geotropic; LSCC, lateral semicircular canal; OPD, outpatient department; PSCC, posterior semicircular canal.

Of the 435 BPPV patients during the COVID-19 pandemic, 163 (37%) were diagnosed with PSCC BPPV, 116 (27%) with geotropic LSCC BPPV, and 156 (36%) with apogeotropic LSCC BPPV (Table 2). The BPPV subtype distribution according to hospital visit type was similar before and during the COVID-19 pandemic. Among the 163 patients with PSCC BPPV, more patients were diagnosed at the OPD (102/163 [63%]) than at the ER (61/163 [37%]) (Table 2). However, more patients were diagnosed at the ER than at the OPD in geotropic LSCC BPPV (88/116 [76%] vs 28/116 [24%]) and apogeotropic LSCC BPPV (115/156 [74%] vs 41/156 [26%]) (Table 2). Significantly higher proportions of patients were diagnosed at the ER in geotropic LSCC BPPV and apogeotropic LSCC BPPV compared with PSCC BPPV (Figure 1). The mean time interval was significantly longer for PSCC BPPV (14.22 39.00 days; range, 0365 days) than for geotropic LSCC BPPV (1.48 2.33 days; range, 030 days) or apogeotropic LSCC BPPV (2.94 8.05 days; range, 060 days) (Table 2, Figure 2). Irrespective of BPPV subtype, the mean time interval was significantly longer in patients diagnosed at the OPD than the ER (Table 2, Figure 3).

Table 2 Number of Patients and Mean Duration Between Symptom Onset and Evaluation According to BPPV Subtype During the Period of COVID-19 Pandemic (Mar. 2020 ~ Dec. 2021)

We then compared the incidence of BPPV subtypes and symptom duration prior to hospital visits between the periods before and during the COVID-19 pandemic. Irrespective of BPPV subtype, the proportion of patients who were evaluated at the ER was not significantly different from those evaluated at the OPD in geotropic LSCC BPPV (p = 0.370, chi-square test), apogeotropic LSCC BPPV (p = 0.335, chi-square test), and PSCC BPPV (p = 0.084, chi-square test, Figure 1). However, while the mean time interval from vertigo onset to diagnosis was also not significantly different before and during the COVID-19 pandemic in geotropic LSCC BPPV (p = 0.309, MannWhitney U-test) and apogeotropic LSCC BPPV (p = 0.367, MannWhitney U-test), in the case of PSCC BPPV, the mean time interval was remarkably longer during the COVID-19 pandemic than before the COVID-19 pandemic (p < 0.001, MannWhitney U-test, Figure 2). We then investigated the actual change in the proportion of BPPV patients during the COVID-19 pandemic. The numbers of patients who visited our ENT OPD or those who were evaluated by ENT specialists at the ER during COVID-19 pandemic (16,835 OPD patients, 1980 ER patients) and before the pandemic (22,149 OPD patients, 3059 ER patients) was calculated. The proportion of BPPV patients at the OPD was 0.90% (199 of 22,149) before the COVID-19 pandemic and 1.02% (171/16,835), which was not significantly different (p = 0.237, chi-square test). However, the proportion of BPPV patients at the ER was 10.40% (318 of 3059) before the COVID-19 pandemic and 13.3% (264/1980), which show significant difference (p < 0.001, chi-square test) (Table 3).

Table 3 Change in the Proportion of BPPV Patients Before and During COVID-19 Pandemic

In the present study, we compared the incidence of BPPV subtypes and the mean time interval from vertigo onset to initial evaluation in patients with BPPV before and during the COVID-19 pandemic. The results demonstrated that although the incidence of BPPV subtypes according to hospital visit type was not significantly different before and during the COVID-19 pandemic, the mean time interval between vertigo onset and initial evaluation in patients with PSCC BPPV became significantly longer during the COVID-19 pandemic.

Several previous studies have investigated the impact of the COVID-19 pandemic on the hospital visit behavior of patients with dizziness, with controversial results. Ueda et al investigated the impact of the COVID-19 pandemic on OPD follow-up cancellations by dizziness/vertigo patients in a university hospital and found that while most of the patients who cancelled during the COVID-19 pandemic had BPPV, patients with Menieres disease had the least number of cancellations during the COVID-19 pandemic.11 Li et al compared the demographic characteristics and etiological distribution of dizziness/vertigo patients in the OPD during and before the COVID-19 pandemic and demonstrated that although the absolute number of dizziness/vertigo patients decreased 40.4% during the COVID-19 pandemic, the proportion of BPPV diagnoses in dizziness/vertigo patients increased from 30.7% to 35%.12 Waissbluth et al reported that a high proportion of consultations for vertigo were observed, although overall number of medical consultations dropped significantly due to preventive lockdown during COVID-19 pandemic; furthermore, the number of consultations for BPPV increased 183% during COVID-19 pandemic compared with pre-pandemic levels.13 Parrino et al reported that there were no differences in the absolute number of acute audio-vestibular disorders during the COVID-19 pandemic compared with previous periods, and sudden hearing loss during the pandemic seemed worse in terms of hearing threshold, and with a higher incidence of associated vestibular involvement.14 Di Mauro et al evaluated 33 patients with acute vertigo after COVID-19 vaccination, and BPPV was diagnosed in 9 (27%) of 33 patients.15 Other studies have suggested the COVID-19 infection as a cause of BPPV.16,17 Due to the limited access to medical care provider during the COVID-19 pandemic, telemedicine for diagnosis and treatment of BPPV was proposed as a good alternative.1820

To our knowledge, this study is the first to examine the impact of COVID-19 on the incidence of BPPV subtypes by hospital visit (OPD vs ER), and the mean time interval between vertigo onset and primary evaluation. Our data demonstrated that the total number of BPPV patients who were diagnosed in the ER and OPD decreased by 15.9% (517 to 435) during the COVID-19 pandemic compared with pre-pandemic levels. Age and sex distributions were not significantly different between the two time periods. Remarkably, the proportion of BPPV patients diagnosed at the OPD was significantly higher for PSCC BPPV than for LSCC BPPV during both periods (Figure 1). So why are patients with LSCC BPPV being diagnosed more commonly in the ER than in the PSCC BPPV? It has been reported that patient-perceived severity of vertigo is more intense with LSCC BPPV than with PSCC BPPV, leading to increased treatment urgency among patients with LSCC BPPV.21,22 In addition, spontaneous resolution of LSCC BPPV occurs more quickly and easily in than with PSCC BPPV;57 as a result, PSCC BPPV patients with longer symptom durations may be more likely to seek treatment at the OPD. Finally, under Koreas healthcare delivery system, before being evaluated at the OPD of a tertiary referral center, patients with BPPV must usually wait for several days after undergoing an initial evaluation by a primary care physician.

Another interesting finding of our research was that LSCC BPPV was a more common subtype than PSCC BPPV prior to and during the pandemic (Tables 1 and 2), which was inconsistent with most previous studies that reported a higher incidence of PSCC BPPV.9,10,23 However, if we estimate the incidence of BPPV subtypes in patients who were diagnosed at the OPD, PSCC BPPV was the most common subtype, which is consistent with previous study findings. Furthermore, considering that many patients with PSCC BPPV might have been diagnosed at a primary health care clinic without being referred to a tertiary referral center, the actual incidence of PSCC BPPV is probably higher than that estimated in the present study. On the other hand, we suspect that the incidence of LSCC BPPV might also have been underestimated because spontaneous remission of this subtype is more likely, and, consequently, the natural course of LSCC BPPV is shorter.57 In the present study, we demonstrated that PSCC BPPV is more commonly diagnosed in the OPD setting than LSCC BPPV, and that LSCC BPPV is more common than PSCC BPPV in the ER setting. Indeed, although it is known that PSCC is the most common subtype of BPPV,9,24 the diagnosis appeared to have been made at the OPD in most studies that reported higher incidences of PSCC BPPV.2529 Further studies are needed to clarify the true incidence of BPPV subtypes.

It is noteworthy that the mean time interval from onset of PSCC BPPV symptoms to hospital evaluation was significantly longer during the COVID-19 pandemic than it was before the pandemic, whereas the interval was not significantly in cases of geotropic and apogeotropic LSCC BPPV. This finding may be explained by the fact that LSCC BPPV patients had more severe symptoms and thus visited the hospital earlier despite treatment limitations during the COVID-19 pandemic, whereas the pandemic delayed hospital visits for patients with PSCC BPPV whose symptoms were less severe and more tolerable. Another interesting finding was that although the proportion of BPPV patients was not changed significantly between during and before the COVID-19 at the OPD, the proportion of BPPV patients significantly increased during COVID-19 pandemic at the ER.

This study has two primary limitations intrinsic to an incidence study. First, because this study was conducted at a single tertiary referral center, it is difficult to generalize our results to other facilities and populations. Second, because patients with atypical BPPV including SSCC BPPV, posttraumatic BPPV, multiple canal BPPV, and secondary BPPV were excluded from the study, the incidence in the present study may not represent all BPPV populations.

The present study demonstrated that no differences were observed in the incidence of BPPV subtypes by hospital visit type (OPD vs ER) during the COVID-19 pandemic when compared with pre-pandemic levels. In patients with PSCC BPPV, the mean interval between vertigo onset and the first evaluation was remarkably longer during the pandemic period. Telemedicine or e-medicine may be considered to improve hospital accessibility in similar circumstances, in order to minimize delays in clinical evaluation and treatment.

COVID-19, coronavirus disease 2019; ER, Emergency room; OPD, outpatient department; BPPV, benign paroxysmal positional vertigo; PSCC, posterior semicircular canal; LSCC, lateral semicircular canal; SSCC, superior semicircular canal.

This paper was supported by Konkuk University in 2022.

The authors declare no conflicts of interest in this work.

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Investigation into the impact of COVID-19 on BPPV | IJGM - Dove Medical Press

President Biden responded to a heckler while delivering remarks in Milwaukee on Monday, saying, Everybodys entitled to be an idiot.

Biden traveled to Wisconsin on Labor Day to deliver a speech at Milwaukee Laborfest, where he spoke about his support for unions and lauded Democratic legislative victories such as last years coronavirus relief package and a bill to invest in domestic semiconductor manufacturing that he signed into law last month.

At one point, someone in the audience could be heard trying to disrupt the speech.

No, no, no, dont let him go. Hes, look, everybodys entitled to be an idiot, Biden said.It was not immediately clear what prompted the heckling or what the person was saying.

Biden also responded to protesters while delivering a prime-time speech at Independence Hall in Philadelphia on Thursday. Hecklers shouted F Joe Biden and the anti-Biden phrase Lets go, Brandon.

Theyre entitled to be outrageous. This is a democracy, Biden said during that speech, also saying, Good manners is nothing theyve ever suffered from.

Bidens stop in Wisconsin comes two months ahead of the November midterms. Wisconsin Gov. Tony Evers (D) and Democratic Senate nominee Mandela Barnes are gearing up for high-profile contests against Republican gubernatorial candidate Tim Michels and Sen. Ron Johnson (R-Wis.), respectively.

Read the original post:

Biden responds to heckler at speech: Everybodys entitled to be an idiot - The Hill

Avian Influenza Virus Activity Continues in California

Photo credit: CDFW Senior Environmental Scientist Krysta Rogers

As the Eurasian strain of Highly Pathogenic Avian Influenza (HPAI) H5N1 continues to impact wild and domestic birds across the state, California Department of Fish and Wildlife (CDFW) wildlife disease specialists are reminding the public of steps they can take to help reduce the spread of infection. To date HPAI H5N1 has been detected in 34 wild birds from 13 counties including Butte, Colusa, Glenn, Mendocino, Placer, Plumas, Sacramento, Santa Clara, Siskiyou, Solano, Sonoma, Stanislaus and Yolo. The California Department of Food and Agriculture (CDFA) has also reported detections of HPAI H5N1 in domestic birds in Butte, Contra Costa, Sacramento, Fresno and Tuolumne counties.

Highly pathogenic avian influenza is contagious among birds, and domestic birds such as chickens are especially vulnerable. The strain of Eurasian HPAI H5N1 currently in circulation in the U.S. and Canada has been causing illness and death in a higher diversity of wild bird species than during previous avian influenza outbreaks. In particular, waterfowl, other waterbirds, raptor predators and avian scavengers such as vultures and gulls have been affected. Unfortunately, infection in these species is nearly always fatal, and no vaccines or treatments are available.

Help reduce the spread of HPAI:

The Centers for Disease Control considers the transmission risk of avian influenza to people to be low, but as a general precaution recommends limiting contact with wild birds and sick or dead poultry. If there is a need to dispose of a dead bird, wear impermeable gloves or a plastic bag turned inside-out to collect the remains into a plastic garbage bag, which may then be placed in the regular trash collection. Afterwards, wash hands with soap and water and change clothing before having contact with domestic poultry or pet birds. If assistance or guidance is needed with the disposal of dead birds on private property, contact your county environmental health department or animal services for options available in your area.

For more information on HPAI H5N1, check out CDFWs informational flyer addressing frequently asked questions and links to additional resources. The U.S. Department of Agriculture (USDA) maintains the official list of HPAI H5N1 detections on its website. For guidance on keeping domestic birds healthy, please visit the CDFA and USDA websites.

For guidance on orphaned or injured live wild birds, please contact your nearest wildlife rehabilitation center prior to collecting the animal. Be advised that some wildlife rehabilitation centers may have restrictions on the wildlife species they will admit.

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Media Contacts:Ken Paglia, CDFW Communications, (916) 825-7120

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CDFW News | Avian Influenza Virus Activity Continues in California - California Department of Fish and Wildlife

This is an official CDC HEALTH ADVISORY

***Missouri healthcare providers in the City of St. Louis please contact the City of St. Louis Department of Health or the Missouri Department of Health and Senior Services (DHSS) Bureau of Communicable Disease Control and Prevention at 573-751-6113 or 800-392-0272 (24/7) with questions regarding this CDC Health Advisory, to report a case of influenza in a patient with recent exposure to swine, or to request additional subtype-specific real-time polymerase chain reaction (RT-PCR) testing of influenza isolates at the Missouri State Public Health Laboratory.***

SummaryThe Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to provide updates on recent variantinfluenza virus infections and summarize CDCs recommendations for identification, treatment, and prevention of variant influenza virus infection for the summer and fall of 2022.

BackgroundFive cases of human infection with influenza viruses that usually spread only in pigs, also known as variant influenza virus infections, were reported to CDC in August 2022. These cases include three infections with influenza A(H3N2) variant (A(H3N2)v) virus and two infections with influenza A(H1N2)v virus. These cases were identified in West Virginia (3), Oregon (1), and Ohio (1). Four of the five cases reported exposure to pigs or attendance at an agricultural fair prior to illness, and one reported no contact with pigs or attendance at an agricultural fair prior to illness. Clinical characteristics of these cases have been similar to those of seasonal influenza infections and have included fever, cough, pharyngitis, myalgia, and headache. No hospitalizations or deaths have occurred among these five cases, and all patients are recovering or have recovered from their illnesses. To date, no person-to person spread associated with the five recent variant influenza virus infections has been identified.

Early identification and investigation of variant influenza virus infections are important to determine whether the virus is spreading efficiently among people. Rapid detection and characterization of novel influenza A viruses and efforts to reduce transmission to other people remain important components of national efforts to prevent the emergence of new viruses that could have pandemic potential. To accomplish this, testing for influenza viruses and monitoring for novel influenza A virus infections, including variant influenza virus infection, should continue year-round.

Individuals, especially those at increased risk of influenza complications, can take public health measures to limit their risk of infection (e.g., limiting exposure to infected animals). Clinicians are encouraged to consider variant influenza virus infection as a possible diagnosis when evaluating patients with acute respiratory illnesses and exposure to pigs or agricultural fairs prior to illness.

Since 2005, 504 variant influenza virus infections (of different influenza A virus subtypes) have been identified in the United States; most of these infections have been associated with exposure to pigs or attendance at an agricultural fair prior to illness onset. Agricultural fairs occur across the United States each year, primarily during the summer and early fall. Many fairs have swine barns, where pigs from different geographic locations come in close contact with each other and with people. These venues may allow influenza viruses to spread among pigs and between pigs and people. Infected pigs may spread influenza viruses even if they are not symptomatic (e.g., coughing or sneezing).

CDC anticipates that state health departments may identify more cases of infection with variant influenza viruses in 2022 as the agricultural fair season continues. Testing for variant influenza viruses should focus primarily on persons with exposures known to be associated with variant influenza virus infection (e.g., agricultural fair attendance or workers in the swine industry). Novel influenza A virus infections, which include those caused by variant influenza viruses, are notifiable conditions in the United States, and all confirmed cases should be reported to CDC within 24 hours.

Recommendations for Clinicians

Recommendations for Public Health Departments and Laboratorians

Recommendations for the Public

For More Information

Influenza viruses that circulate in swine are called swine influenza viruses when isolated from swine but are called variant viruses when isolated from humans.

This includes persons with certain underlying chronic medical conditions such as asthma, diabetes, heart disease, or neurological conditions, pregnant people, and persons 5 years and younger and 65 years and older, or who have weakened immune systems.

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Health Advisory: Variant Influenza Virus Infections: Summer and Fall 2022 Recommendations - City of St. Louis

It has been suggested the flu season may be worse than the previous two years, when people were still largely adopting preventative measures to avoid Covid-19 and social distancing and mask wearing may have kept many flu cases at bay.

The European arm of the World Health Organisation (WHO) said it is too early to predict whether the UK could face a bad flu season but said health systems need to be ready.

It also predicted a surge in Covid-19 cases as it urged at-risk groups to ensure they have had a second booster shot.

With autumn and winter approaching, we anticipate a surge in (Covid-19) cases with or without a resurgence of seasonal influenza in Europe, said WHOs regional director for Europe, Dr Hans Kluge.

He added: People stabilised their lives without actually stabilising the pandemic.

Asked whether the southern hemispheres flu season could predict the UK and Europes impending flu season, Dr Catherine Smallwood, WHO Europes senior emergency officer, told a press briefing: We cant speak with any certainty because each region and each country has its own specificities, but we have looked quite closely at the flu season in the southern hemisphere.

Looking at countries such as Australia, where they saw quite early and a sharp increase in influenza in the season that did contribute some pressures, also in Latin America, we saw some pressures on health systems.

She added: But we dont know whats going to come.

What we do know is that its likely that the preventive measures that have really kept seasonal flu at bay wont be in place in the same way that they were in 2020 and 2021.

So there will likely be an interplay between the different viruses.

Link:

WHO: Systems need to be ready for flu season - Belfast News Letter

Patient deaths: 1,044,332

Total vaccine doses distributed: 806,829,135

Patients whove received the first dose: 262,643,277

Patients whove received the second dose: 223,914,723

% of population fully vaccinated (both doses, not including boosters): 67.4%

% tied to Omicron variant: 100%

% tied to Other: 0%

Continued here:

Coronavirus Omicron variant, vaccine, and case numbers in the United States: Aug. 30, 2022 - Medical Economics

The Johns Hopkins University Center for Systems Science and Engineering COVID-19 Dashboard: data collection process, challenges faced, and lessons learned  The Lancet

Originally posted here:

The Johns Hopkins University Center for Systems Science and Engineering COVID-19 Dashboard: data collection process, challenges faced, and lessons...

The adverse events and complications of coronavirus disease 19 (COVID-19) continue to challenge the medical profession despite the worldwide vaccination against the severe acute respiratory coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. Other than typical respiratory manifestations, COVID-19 also presents with neurological manifestations [1,2]. SARS-CoV-2 seems to have been transmitted from infected bats to humans and can spread through human-to-human transmission [3]. Patients with COVID-19 typically present with respiratory manifestations ranging from a mild cough to lung infection and respiratory failure in severe cases and can involve other body systems, including gastrointestinal, renal, and cardiovascular systems [4-9]. Many clinical trials for potential therapy and vaccines have combated this pandemic [10-14].

There is also growing evidence that COVID-19 can affect the nervous system, leading to several neurological manifestations and adverse events. Due to its neurotropic and neuroinvasive potential, the data on neurological involvement in COVID-19 has mounted rapidly with an exponential increase in publications [15,16]. Neurological manifestations of COVID-19 include headache, encephalopathy, myalgias, and dizziness, with more severe symptoms including anosmia, peripheral neuropathy, ataxia, seizure, acute cerebrovascular disease, and myopathies [17,18].

Patients with neurological involvement in the setting of COVID-19 infection are at risk of developing seizures due to hypoxia, metabolic derangements, intoxication, and organ failure. Seizures precipitated by COVID-19 may affect the functional outcomes in critically ill patients. This article summarizes the evidence of seizure occurrences in COVID-19 patients and the prevalence of seizures in patients with epilepsy diagnosed with COVID-19.

We performed this systematic review and meta-analysis by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (https://prisma-statement.org//) (Figure 1).

Study Selection and Eligibility Criteria

An extensive bibliographical search was conducted on PubMed and Google Scholar. The initial screening identified 1,375 articles using mesh terms and keywords for COVID-19, seizure, and epilepsy. The two authors screened the articles using predetermined screening criteria,retrieved the relevant articles in full text, and further screened them based on eligibility criteria. Case reports, articles published before 2020, and articles not addressing COVID-19-associated neurological aspects, particularly seizures, were excluded. Case-control studies, case series, and retrospective and prospective cohorts highlighting data on COVID-19 and seizures related to incidence and prevalence were included. Two authors assessed the relevant articles and resolved the disagreements through systemic discussion.

Data Extraction and Statistical Analysis

Two authors extracted the relevant and appropriate data using a Microsoft Excel standard extraction sheet. The relevant data included a proportion of infected patients with seizures, with control data for preexisting epilepsy and alternate provoking causes. Additional retrieved data included author(s), study design, gender, median age, comorbidities, and seizure as an initial manifestation of COVID-19. The quality of included studies was assessed through the Newcastle-Ottawa Quality Assessment Scale (NOS). Any conflicts were resolved through consensus. The publication bias was evaluated using a random-effect funnel plot model.

We performed a random effect analysis to determine the pooled incidence of COVID-19-induced seizures and 95% confidence intervals (CI) using the R programming language (v 4.0.2) [19]. We also estimated the seizure incidence in patients with epilepsy diagnosed with COVID-19. The study heterogeneity was assessed by theI2test, which estimates the proportion of total variation among included literature. In case of high heterogeneity, a subgroup analysis was performed based on the location of the studies.

Our study included 21 studies involving nine case series and 12 retrospective cohorts. Included studies had reported seizures as an initial manifestation of COVID-19. COVID-19 confirmation testing was performed through nasopharyngeal or oropharyngeal swabs using real-time polymerase chain reaction (PCR) in all studies.Data on author(s), publication year, number of infected SARS-CoV-2 patients, number of patients presenting with seizure as an initial COVID-19 presentation, and number of patients with epilepsy are highlighted in Table 1 [4,5,17-35].

A total of 11,526 patients from different countries were identified, with a median age of 61.9 years; 51.5% of the patients were male. In total, 255 patients presented with seizure as the first manifestation of COVID-19 with a prevalence of 2.2% (95% CI = 0.05-0.24, p< 0.01) (I2 = 97%) (Figure2). Fourteen studies reported epilepsy as neurological comorbidity, and 71 patients were diagnosed with epilepsy before COVID-19 infection with a proportion of 0.98% (0.03-0.018,p< 0.01). Among patients with epilepsy, 49 had seizures as an initial presentation of SARS-CoV-2 with an incidence of 69% (0.54-0.85, p = 0.1) (I2 = 34) (Figure3). The random-effect funnel model shows an association between COVID-19 and seizure occurrence with publication bias.

Due to high heterogeneity, we performed a subgroup analysis based on the location of the studies. We performed a pooled analysis of American and European studies. In total, 12 studies were from the United States and included 3,520 patients diagnosed with COVID-19.A total of 167 patients had COVID-19-induced seizure with a pooled prevalence of 4.7% (95% CI = 0.10-0.59,p< 0.01) (I2 = 67%) (Figure 4). Eight studies were from Europe and included 1,898 patients diagnosed with SARS-CoV-2. A total of 36 patients had COVID-19-induced seizure with an incidence of 1.89% (95% CI = 0.02-0.17, p< 0.01) (I2 = 78%) (Figure 5). Publication bias in included studies is shown in Figure 6.

The adverse events and complications of COVID-19 continue to challenge the medical profession despite the worldwide vaccination against COVID-19. There are reports of cerebrovascular adverse events associated with COVID-19 infection. Acute symptomatic seizure is one of the least reported neurological presentations in COVID-19patients. Once the pandemic had gained momentum, the number of reports of seizure occurrence in COVID-19 patients increased. Our study highlighted the proportion of patients with preexisting epilepsy who experienced seizure exacerbation as a manifestation of COVID-19 andthe proportion of patients who experienced provoked seizures due to COVID, which has significant implications for further management. Although the incidence of COVID-19-provoked seizures is not high, the incidenceof seizures in COVID-19 among epileptic patients is high.

Recently, there has been an increase in the number of cases of seizures in patients with COVID-19 infection [15]. The growing literature has documented the neurotropic properties of COVID-19 due to angiotensin-converting enzyme-2 (ACE2) receptors in the nervous system [24]. Seizures were also highlighted in the preceding epidemics of coronavirus infections during the SARS coronavirus infections in 2002 and the Middle East Respiratory Syndrome (MERS) coronavirus infections in 2012, with proportions of 1.9% and 8%, respectively [37,38]. The current pandemic has dramatically affected the population, and several patients have presented with seizuresas an initial or the earliest manifestation of COVID-19 [31].The pathophysiology behind the occurrence of seizures is not yet understood; however, some hypotheses can be postulated. ACE2 receptors for viral entry into the nervous system are predominantly present in the brainstem [3]. After the invasion, SARS-CoV-2 triggers a cascade of reactions leading to the production of inflammatory and proinflammatory cytokines, which result in neuronal hyperexcitability and seizures. Proinflammatory cytokines induce glutamate release and inhibit the release of inhibitory neurotransmitters in the hippocampus and cerebral cortex, leading to seizures and epilepsy [27]. COVID-19 can disrupt the respiratory and cardiovascular systems leading to hypoxia, and hypoxia-induced cerebral damage induces a higher neural activity[39]. Other mechanisms included disruption of the blood-brain barrier, multiorgan failure, severe metabolic derangements, electrolyte abnormalities, and coagulation cascade activation through the production and excessive release of proinflammatory cytokines [40].

Priorsmaller studies have highlighted the incidence and prevalence of seizures in patients diagnosed with COVID-19. A retrospective study from the United States reported that the prevalence of COVID-19-induced seizures was 2.1% among 3,218 patients[25]. Another study reported that 26% of patients with seizures were admitted to the hospital as a COVID-19 presentation among 50 infected patients[15].

Favas et al. performed a pooled analysis of seizure incidence in COVID-19 patients. This study included 2,043 patients from five studies and reported a prevalence of COVID-19-induced seizures of 1.1% (CI = 0.7-1.7%) [41]. Another analysis on COVID-19-induced seizures included 314 infected patients and reported a 0.5% incidence (95% CI = 0.02-6.04, p = 0.08), and a 0.3% incidence of status epilepticus (95% CI = 0.00-3.69) [40].COVID-19 incidence in patients with epilepsy is not widely described in the literature, and limited data are available on the prevalence of COVID-19 infection in epilepsy. Garcia et al. reported that COVID-19 incidence in epileptic patients was 1.2% compared to the normal population (0.6%)[42]. An increase in seizure exacerbation in patients diagnosed with epilepsy has also been reported during the pandemic[40,42]. Similar results were observed in our analysis. An interesting observation from our data is that the prevalence of seizures in COVID-19 patients with epilepsy is high.

Seizure exacerbation in patients with epilepsy is linked with prior history of COVID-19 during a pandemic. Multiple stress factors during the pandemic, undesirable outcomes of the infection on seizure-associated health conditions, or noncompliance/change in antiepileptic drugs had also led to seizure exacerbation in epileptic patients. A recent article highlighted that 30.3% of epileptic patients with a history of COVID-19 infection experienced increased seizure exacerbations, and only 7% of patients with epilepsy without exposure to COVID-19 underwent increased seizure exacerbation [43].

Our study has many limitations. Our research has high heterogeneity because many studies in our analysis have a small sample size and moderate quality. We also included case series in our research. We may have a remarkable publication bias in both pooled prevalence likely due to small case series and a less likely chance of negative study publication. Observational studies may have residual confounding. We could not find individual data in afew studies; therefore, we could not make our adjustments, leading to potentially incomplete data. In some publications, the number of patients with epilepsy was not reported. Finally, increasing published data makes retrieving relevant data on the topic difficult.

Our study also highlighted an increased prevalence of COVID-19-induced seizures raising many queries. It can be due to different virus strains, more studies reported from Europe, potentially biased studies with small sample sizes, or different physiological/emotional responses to the pandemic, which are needed to explain in future studies from the rapidly growing data.

Although seizure prevalence in COVID-19-infected patients is not high compared with other neurological manifestations, new-onset seizures in any patient can raise suspicion of a presentation or complication of COVID-19 infection in the absence of other causative factors during this pandemic. People with epilepsy diagnosed with COVID-19 infection reported increased seizures during the pandemic. Therefore, a comprehensive clinical picture and neurological investigations, including imaging modalities, are mandated while examining and managing such patients. Data from large cohorts are required to better understand this apparent association between seizures and COVID-19 infection, its etiology, increase in seizures in epileptic patients, prognosis, and follow-up protocols for these patients.

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COVID-19-Induced Seizures: A Meta-Analysis of Case Series and Retrospective Cohorts - Cureus

A recent study shows US adults with hearing and visual impairments have lower rates of vaccination for the coronavirus.

A recent cross-sectional study1 shows that COVID-19 vaccination rates are lower among individuals with hearing and visual impairments, compared to those without.

Reported by Kea Turner, PhD, MPH, MA, from the Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, and colleagues, the studyincluded adults who participated in the US Census Bureau Household Pulse Survey from April 2021 through March 2022.

The survey collected data on acquisition of the COVID-19 vaccine and determinants of health care access, including demographic and clinical characteristics, as well as social determinants of health, Turner described.

The primary outcome measure was the first COVID-19 vaccine.

The participating patients had difficulty seeing or hearing despite corrective measures or they were blind or deaf.

The study included 916,085 adults (mean age, 54.0 years; 52.0% women), most of whom (82.7%) started the COVID-19 vaccine series.

Compared with adults who were not visually impaired, those with serious visual impairment (mean difference, 6.3%, p<0.001) and blindness (mean difference, 20.1%, p< 0.001) had lower COVID-19 vaccination rates.

Compared with adults who were not hearing impaired or deaf, adults with serious hearing impairment (mean difference, 2.1%; p=0.003) and deafness (mean difference, 17.7%, p<0.001) were less likely to start the COVID-19 vaccine process.

The adults who were the most seriously affected, i.e., those who were blind (p=0.009) or deaf (p=0.003), were less likely to start the series of vaccinations compared with those who were less visually or hearing impaired, respectively.

The findings of this study suggest that COVID-19 vaccine initiation is lower among adults with vision or hearing disabilities compared with adults without disabilities; this information may inform initiatives to promote equitable and accessible vaccination. Additional research may be needed to monitor COVID-19 vaccination disparities among adults with vision or hearing disabilities and to address disparities, the investigators concluded.

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Study: Hearing, visually impaired adults less likely to be vaccinated for COVID-19 - Optometry Times

CABO DE GATA, Spain (VN) With temperatures soaring into the high 90Fs and rivals dropping to COVID-19 infections, the easiest part of defending his red jersey at the Vuelta a Espaa for Remco Evenepoel seems to be racing the bike.

Blazing summer heat and a rash of COVID infections is putting a chill on the Vuelta peloton, with GC challengers Simon Yates and Pavel Sivakov both leaving Wednesday with infections.

Behind the scenes, Quick-Step Alpha Vinyl has put into place several strategies and protocols to keep Evenepoel in the Vuelta and out of harms way.

We wear a mask, wash our hands, maintain our bubble every day, Evenepoel said of the ongoing risk of the coronavirus. The only moment we dont wear masks is when we get the official whistle from the start and at the table to eat our food.

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The team is also putting Evenepoel and the other riders in individual rooms, and assigning specific staff members to each rider to minimize the risk of infection.

Normally on a grand tour we have the families on the rest day, but we banned that, he said. Its really our team bubble. We are wearing masks in the bus, out of the bus, on the massage table.

Already racing in its third season with the coronavirus, the team is doing everything it can in terms of health protocols to keep Evenepoel safe.

Despite losing Julian Alaphilippe to a crash Wednesday, the safest place for Evenepoel seems to be in the race.

He safely made it through Wednesdays long transition stage without incident and there were no major shakeups in the overall standings.

Though he hails from Belgium, Evenepoel said hes not expecting the blazing Iberian sun to be a major issue for him in the second half of the Vuelta.

The first half of the race was contested in The Netherlands before racing across northern Spain, where the Cantabrian mountains were cloaked in fog and mist with cool racing temperatures when Evenepoel attacked into the red jersey.

Thats changed dramatically in the south, with temperatures nearing 100F and humidity also pushing high.

Evenepoel revealed that he did not race after smashing to victory at the Clsica San Sebastin in late July because he wanted to get used to the Spanish summer heat on his terms.

He retreated to a pre-Vuelta training camp in Calpe along Spains Mediterranean coast, where August temperatures were even hotter than they are now.

Thats why I didnt want to race ahead of the Vuelta and go into a long training camp around Calpe, Evenepoel said. I never had a day under 40 degrees, so every day it was super hot and super humid.

With Pea Blancas looming Thursday, Evenepoel said he expected the slightly easier and longer climbs in southern Spain in the second half of the Vuelta to be easier to manage in the extreme temperatures.

The steep climbs are the hardest to deal with in the heat, so what can be advantage from now on is that the climbs are not really super steep, he said. For sure, its going to be special with the heat.

We do the normal things, ice, cold drinks, our [ventilated] helmets to lose as much heat off the body as possible.

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How Remco Evenepoel is keeping cool and avoiding COVID-19 at the Vuelta a Espaa - VeloNews