COVID-related dysphonia and persistent long-COVID voice sequelae: A systematic review and meta-analysis.

PURPOSE: Dysphonia is a common symptom due to the coronavirus disease of the 2019 (COVID-19) infection. Nonetheless, it is often underestimated for its impact on human's health. We conducted this first study to investigate the global prevalence of COVID-related dysphonia as well as related clinical factors during acute COVID-19 infection, and after a mid- to long-term follow-up following the recovery. METHODS: Five electronic databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and Web of Science were systematically searched for relevant articles until Dec, 2022, and the reference of the enrolled studies were also reviewed. Dysphonia prevalence during and after COVID-19 infection, and voice-related clinical factors were analyzed; the random-effects model was adopted for meta-analysis. The one-study-removal method was used for sensitivity analysis. Publication bias was determined with funnel plots and Egger's tests. RESULTS: Twenty-one articles comprising 13,948 patients were identified. The weighted prevalence of COVID-related dysphonia during infection was 25.1 % (95 % CI: 14.9 to 39.0 %), and male was significantly associated with lower dysphonia prevalence (coefficients: -0.116, 95 % CI: -0.196 to -0.036; P = .004) during this period. Besides, after recovery, the weighted prevalence of COVID-related dysphonia declined to 17.1 % (95 % CI: 11.0 to 25.8 %). 20.1 % (95 % CI: 8.6 to 40.2 %) of the total patients experienced long-COVID dysphonia. CONCLUSIONS: A quarter of the COVID-19 patients, especially female, suffered from voice impairment during infection, and approximately 70 % of these dysphonic patients kept experiencing long-lasting voice sequelae, which should be noticed by global physicians.

COVID-19 vaccine uptake and hesitancy in Chinese patients with asthma.

OBJECTIVE: Both patients and physicians may be hesitant toward vaccination in patients with asthma, which may result in lower vaccine uptake. The aim of this work was to investigate the vaccination rate, the adverse reactions, as well as the factors associated with vaccine acceptance and hesitancy toward COVID-19 vaccination among asthmatic patients in Beijing. METHODS: A multi-center, cross-sectional face-to-face survey was conducted in patients with asthma consecutively recruited from December 2021 to April 2022. The survey included asthma status, COVID-19 vaccine uptake and adverse reactions, and knowledge of and attitude toward COVID-19 vaccination. RESULTS: A total of 261 patients were enrolled. The rate of COVID-19 vaccination during the study period was 73.6%, as compared to 87.64% in the general population in China. Patients who were currently working, had received other vaccines in the past, and had had no adverse reactions to other vaccines, showed a higher rate of COVID-19 vaccination. Patients believing that the vaccination of family members and colleagues had a positive impact on their decision to get vaccinated, were more likely to get the COVID-19 vaccines. The COVID-19 vaccination rate was lower in those with poorly monitored asthma and those using biologic therapies. The adverse effects of COVID-19 vaccines in asthmatic patients were similar to those in the general population. CONCLUSION: The COVID-19 vaccination rate in asthmatic patients was lower than the general population in China. Active measures should be taken to control asthma and increase vaccination rates in these patients.

Biotransformation and brain distribution of the anti-COVID-19 drug molnupiravir and herb-drug pharmacokinetic interactions between the herbal extract Scutellaria formula-NRICM101.

The aim of this study was to explore the effects of herbal drug pharmacokinetic interactions on the biotransformation of molnupiravir and its metabolite ß-D-N4-hydroxycytidine (NHC) in the blood and brain. To investigate the biotransformation mechanism, a carboxylesterase inhibitor, bis(4-nitrophenyl)phosphate (BNPP), was administered. Not only molnupiravir but also the herbal medicine Scutellaria formula-NRICM101 is potentially affected by coadministration with molnupiravir. However, the herb-drug interaction between molnupiravir and the Scutellaria formula-NRICM101 has not yet been investigated. We hypothesized that the complex bioactive herbal ingredients in the extract of the Scutellaria formula-NRICM101, the biotransformation and penetration of the bloodbrain barrier of molnupiravir are altered by inhibition of carboxylesterase. To monitor the analytes, ultrahigh-performance liquid chromatography tandem mass spectrometry (UHPLCMS/MS) coupled with the microdialysis method was developed. Based on the dose transfer from humans to rats, a dose of molnupiravir (100 mg/kg, i.v.), molnupiravir (100 mg/kg, i.v.) + BNPP (50 mg/kg, i.v.), and molnupiravir (100 mg/kg, i.v.) + the Scutellaria formula-NRICM101 extract (1.27 g/kg, per day, for 5 consecutive days) were administered. The results showed that molnupiravir was rapidly metabolized to NHC and penetrated into the brain striatum. However, when concomitant with BNPP, NHC was suppressed, and molnupiravir was enhanced. The blood-to-brain penetration ratios were 2% and 6%, respectively. In summary, the extract of the Scutellaria formula-NRICM101 provides a pharmacological effect similar to that of the carboxylesterase inhibitor to suppress NHC in the blood, and the brain penetration ratio was increased, but the concentration is also higher than the effective concentration in the blood and brain.

Subunit vaccines with a saponin-based adjuvant boost humoral and cellular immunity to MERS coronavirus.

Middle East respiratory syndrome coronavirus (MERS-CoV) outbreaks have constituted a public health issue with drastic mortality higher than 34%, necessitating the development of an effective vaccine. During MERS-CoV infection, the trimeric spike protein on the viral envelope is primarily responsible for attachment to host cellular receptor, dipeptidyl peptidase 4 (DPP4). With the goal of generating a protein-based prophylactic, we designed a subunit vaccine comprising the recombinant S1 protein with a trimerization motif (S1-Fd) and examined its immunogenicity and protective immune responses in combination with various adjuvants. We found that sera from immunized wild-type and human DPP4 transgenic mice contained S1-specific antibodies that can neutralize MERS-CoV infection in susceptible cells. Vaccination with S1-Fd protein in combination with a saponin-based QS-21 adjuvant provided long-term humoral as well as cellular immunity in mice. Our findings highlight the significance of the trimeric S1 protein in the development of MERS-CoV vaccines and offer a suitable adjuvant, QS-21, to induce robust and prolonged memory T cell response.

What are the pandemic's shocks on carbon emission trading? The different management applications

Maintaining the stability of the carbon market is of great significance for China to meet its goal of "Double Carbon,” but at the beginning of 2020 the COVID-19 pandemic emerged and the economy was greatly affected. A natural question is whether it impacted domestic carbon markets. This paper thus presents the event research method on eight carbon emission trading markets in China, because it can timely exhibit the benefits investors gained during the COVID-19 pandemic and also can overcome the difficulty of separating those benefits from the overall performance of the carbon market via high-frequency data. The results herein confirm that China's carbon market has reacted negatively to the COVID-19 pandemic, which mainly relates to the mandatory blockade and isolation policy adopted by the central government. The production and operation activities of enterprises decreased along with the demand for carbon quotas. Because of the panic, investors also had a negative attitude towards the carbon market, influencing the supply and demand curve of carbon quotas and causing a decline in carbon prices. Under the effectiveness of government epidemic prevention and control policies, we further find that the negative impact was gradually eliminated. Overall, our findings offer some important information for the decision-making of governments, carbon market investors, and policymakers.

Is Postextubation Dysphagia Underestimated in the Era of COVID-19? A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate the incidence rate of postextubation dysphagia (PED) in patients with COVID-19, as well as relative factors potentially influencing the clinical course of dysphagia. DATA SOURCES: Six databases including PubMed, MEDLINE, Embase, ScienceDirect, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were searched with no restriction on the language. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Data were extracted and cross-examined among 3 of the authors. The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of the PED incidence rate. Subgroup analyses, sensitivity analyses, and metaregression were also performed to identify the heterogeneity among the studies. RESULTS: A total of 594 patients were enrolled and analyzed from the 10 eligible studies. The weighted incidence of PED in patients with COVID-19 was 66.5% (95% CI: 49.7%-79.9%). Age was the potential factor influencing the incidence rate after heterogeneity was adjusted by the metaregression analysis. CONCLUSION: Compared to the current evidence reporting only 41% of the non-COVID patients experienced PED, our study further disclosed that a higher 66.5% of COVID-19 patients suffered from PED, which deserves global physicians' attention. With the association between COVID-19 and dysphagia having been more clearly understood, future clinicians are suggested to identify intubated patients' risk factors earlier to strengthen PED care programs in the era of COVID-19.

A 30-Year-Old Woman with an 8-Week History of Anxiety, Depression, Insomnia, and Mild Cognitive Impairment Following COVID-19 Who Responded to Accelerated Bilateral Theta-Burst Transcranial Magnetic Stimulation Over the Prefrontal Cortex.

BACKGROUND This report is of a 30-year-old woman with an 8-week history of anxiety, depression, insomnia, and mild cognitive impairment following COVID-19 infection, who responded to accelerated bilateral theta-burst transcranial magnetic stimulation (TBS) over the prefrontal cortex. CASE REPORT A previously healthy 30-year-old woman visited our psychiatric clinic for symptoms including anxiety, depression, insomnia, and brain fog (mild cognitive impairment) for more than 8 weeks after being diagnosed with COVID-19 on May 9, 2022. Continuous TBS of the right dorsolateral prefrontal cortex (DLPFC), followed by intermittent TBS of the left DLPFC, was performed twice daily over 5 days for a total of 10 sessions. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAMD), Beck Anxiety Inventory (BAI), Pittsburgh Sleep Quality Index (PSQI), and subsets of the Wechsler Memory Scale (WMS)-Third Edition were administered at baseline and at the end of treatment. After 10 sessions of treatment, her BAI, BDI, HAMD, PSQI, WMS-Logical Memory, WMS-Faces, WMS-Verbal Paired Associates, and WMS-Family Pictures scores had improved from 4, 18, 10, 14, 8, 10, 12, and 8, respectively, to 0, 7, 1, 10, 15, 15, 15, and 10, respectively. CONCLUSIONS Accelerated TBS over the bilateral DLPFC may ameliorate long-COVID-associated neuropsychiatric symptoms. Additional trials are warranted to evaluate the effect of neuropsychiatric symptoms following COVID-19.

Rare, convergent antibodies targeting the stem helix broadly neutralize diverse betacoronaviruses.

Humanity has faced three recent outbreaks of novel betacoronaviruses, emphasizing the need to develop approaches that broadly target coronaviruses. Here, we identify 55 monoclonal antibodies from COVID-19 convalescent donors that bind diverse betacoronavirus spike proteins. Most antibodies targeted an S2 epitope that included the K814 residue and were non-neutralizing. However, 11 antibodies targeting the stem helix neutralized betacoronaviruses from different lineages. Eight antibodies in this group, including the six broadest and most potent neutralizers, were encoded by IGHV1-46 and IGKV3-20. Crystal structures of three antibodies of this class at 1.5-1.75-Å resolution revealed a conserved mode of binding. COV89-22 neutralized SARS-CoV-2 variants of concern including Omicron BA.4/5 and limited disease in Syrian hamsters. Collectively, these findings identify a class of IGHV1-46/IGKV3-20 antibodies that broadly neutralize betacoronaviruses by targeting the stem helix but indicate these antibodies constitute a small fraction of the broadly reactive antibody response to betacoronaviruses after SARS-CoV-2 infection.

The exploration of phytocompounds theoretically combats SARS-CoV-2 pandemic against virus entry, viral replication and immune evasion.

BACKGROUND: The novel coronavirus disease-2019 (COVID-19) that emerged in China, is an extremely contagious and pathogenic viral infection caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) that has sparked a global pandemic. The few and limited availability of approved therapeutic agents or vaccines is of great concern. Urgently, Remdesivir, Nirmatrelvir, Molnupiravir, and some phytochemicals including polyphenol, flavonoid, alkaloid, and triterpenoid are applied to develop as repurposing drugs against the SARS-CoV-2 invasion. METHODS: This study was conducted to perform molecular docking and absorption, distribution, metabolism, excretion and toxicity (ADMET) analysis of the potential phytocompounds and repurposing drugs against three targets of SARS-CoV-2 proteins (RNA dependent RNA polymerase, RdRp, Endoribonclease, S-protein of ACE2-RBD). RESULTS: The docking data illustrated Arachidonic acid, Rutin, Quercetin, and Curcumin were highly bound with coronavirus polyprotein replicase and Ebolavirus envelope protein. Furthermore, anti- Ebolavirus molecule Remedesivir, anti-HIV molecule Chloroquine, and Darunavir were repurposed with coronavirus polyprotein replicase as well as Ebolavirus envelope protein. The strongest binding interaction of each targets are Rutin with RdRp, Endoribonclease with Amentoflavone, and ACE2-RBD with Epigallocatechin gallate. CONCLUSIONS: Taken altogether, these results shed a light on that phytocompounds have a therapeutic potential for the treatment of anti-SARS-CoV-2 may base on multi-target effects or cocktail formulation for blocking viral infection through invasion/activation, transcription/reproduction, and posttranslational cleavage to battle COVID-19 pandemic.

Is N -acetylcysteine effective in treating patients with coronavirus disease 2019? A meta-analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). It has brought tremendous challenges to public health and medical systems around the world. The current strategy for drug repurposing has accumulated some evidence on the use of N -acetylcysteine (NAC) in treating patients with COVID-19. However, the evidence remains debated. METHODS: We performed the systematic review and meta-analysis that complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five databases and reference lists were searched from inception to May 14, 2022. Studies evaluating the efficacy of NAC in treating patients with COVID-19 were regarded as eligible. The review was registered prospectively on PROSPERO (CRD42022332791). RESULTS: Of 778 records identified from the preliminary search, four studies were enrolled in the final qualitative review and quantitative meta-analysis. A total of 355 patients were allocated into the NAC group and the control group. The evaluated outcomes included intubation rate, improvement, duration of intensive unit stay and hospital stay and mortality. The pooled results showed nonsignificant differences in intubation rate (OR, 0.55; 95% CI, 0.16-1.89; p = 0.34; I2 = 75%), improvement of oxygenation ([MD], 80.84; 95% CI, -38.16 to 199.84; p = 0.18; I2 = 98%), ICU stay (MD, -0.74; 95% CI, -3.19 to 1.71; p = 0.55; I2 = 95%), hospital stay (MD, -1.05; 95% CI, -3.02 to 0.92; p = 0.30; I2 = 90%), and mortality (OR, 0.58; 95% CI, 0.23-1.45; p = 0.24; I2 = 54%). Subsequent trial sequential analysis (TSA) showed conclusive nonsignificant results for mortality, while the TSA for the other outcomes suggested that a larger sample size is essential. CONCLUSIONS: The current evidence reveals NAC is not beneficial for treating patients with COVID- 19 with regard to respiratory outcome, mortality, duration of ICU stay and hospital stay.

Implementation of E-Learning in New Taipei City during COVID-19

During the COVID-19 pandemic, educational institutions around the world have closed, affecting more than 60% of students and causing massive disruption to the education system. Taiwan is no exception. For this sudden and dramatic change, teachers, students, and parents all confront significant challenges. In order to make specific suggestions for improvement, the study aims to explore the current state of e-learning in Taiwan and to understand the difficulties faced by teachers, parents, and students. The study conducted in-depth interviews with 20 teachers, 12 parents, and 24 students. The research results show that in New Taipei City, there are barely any online courses for grades 1 and 2, blended learning is mainly for grades 3 and 4, and synchronous e-learning is designed for grades 5 and 6. The main challenges in adopting e-learning in primary schools include, as follows: (i) Teachers, parents, and students are unfamiliar with the user interface of the e-learning platform, (ii) Insufficient hardware and software equipment at home, (iii) Teachers cannot take care of special students, (iv) Communication between teachers and parents is not smooth, (v) Difficulty in assessing learning progress online, and (vi) Students are easily distracted from their studies. Based on the above research results, the researchers put forward specific suggestions for future online teaching practices.

Obligation or getaway? A qualitative inquiry into medical professionalism under COVID-19 among medical students and new physicians in a Taiwan hospital.

OBJECTIVES: During the COVID-19 outbreak, medical educators' main concern has been how to prepare new physicians and medical students to meet their obligations as healthcare providers under novel circumstances. This study aims at exploring how trainees perceive their commitments as physicians under the threat of a pandemic. DESIGN: A qualitative method was employed. Researchers interviewed medical students under clerkship training (fifth and sixth-year medical students) and new physicians undergoing postgraduate year (PGY) and specialty training. SETTING: A university hospital in Taipei, Taiwan. PARTICIPANTS: The team conducted three focus groups for participants in three separate training stages: clerks, PGY students (PGYs), and residents. Researchers collected data from 31 March to 2 April 2020 and analysed the thematic analysis results. RESULTS: Seventeen medical students and new physicians took part in the focus groups, five of whom (31.25%) were female. Participants consisted of four residents, six PGYs, and seven medical students. Through their responses, the authors determined four major dimensions with corresponding subdimensions that significantly affected their sense of medical professionalism, including medical knowledge and clinical skills, sense of duty towards public health, teamwork and protection of patient rights. CONCLUSIONS: We therefore concluded that participants grew to accept their roles after acquiring the knowledge and skills needed to care for patients with COVID-19. Alternative teaching arrangements and their impact on trainees' clinical performance require further discussion.

Strategies for the sustainable development of China in the post‐epidemic era

Countries around the world are facing enormous challenges in their economic and social development as COVID-19 continues to spread, resulting in slower economic recovery in the post-pandemic era. Considering the impact of economic growth on future sustainable development in this new era, green economic recovery (GER) can achieve a win-win situation between economic recovery and environmental improvement and bring forth environmentally sustainable economic growth. This research first lists related COVID-19 literature surveys and GER policies in the post-pandemic era in China. Based on a comparative study of the international experience of GER policy practices, this paper then analyzes the opportunities and challenges China faces for GER and puts forward countermeasures and suggestions on how to promote its sustainable development in the post-epidemic era. We believe our research presents useful enlightenments for sustainable economic and social development in the post-epidemic era.

Broadly neutralizing antibodies target the coronavirus fusion peptide.

The potential for future coronavirus outbreaks highlights the need to broadly target this group of pathogens. We used an epitope-agnostic approach to identify six monoclonal antibodies that bind to spike proteins from all seven human-infecting coronaviruses. All six antibodies target the conserved fusion peptide region adjacent to the S2' cleavage site. COV44-62 and COV44-79 broadly neutralize alpha- and betacoronaviruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron subvariants BA.2 and BA.4/5, albeit with lower potency than receptor binding domain-specific antibodies. In crystal structures of COV44-62 and COV44-79 antigen-binding fragments with the SARS-CoV-2 fusion peptide, the fusion peptide epitope adopts a helical structure and includes the arginine residue at the S2' cleavage site. COV44-79 limited disease caused by SARS-CoV-2 in a Syrian hamster model. These findings highlight the fusion peptide as a candidate epitope for next-generation coronavirus vaccine development.

Computer-aided discovery, design, and investigation of COVID-19 therapeutics.

Coronavirus disease 2019 (COVID-19) pandemic is currently the most serious public health threat faced by mankind. Thus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, is being intensively investigated. Several vaccines are now available for clinical use. However, owing to the highly mutated nature of RNA viruses, the SARS-CoV-2 is changing at a rapid speed. Breakthrough infections by SARS-CoV-2 variants have been seen in vaccinated individuals. As a result, effective therapeutics for treating COVID-19 patients is urgently required. With the advance of computer technology, computational methods have become increasingly powerful in the biomedical research and pharmaceutical drug discovery. The applications of these techniques have largely reduced the costs and simplified processes of pharmaceutical drug developments. Intensive and extensive studies on SARS-CoV-2 proteins have been carried out and three-dimensional structures of the major SARS-CoV-2 proteins have been resolved and deposited in the Protein Data Bank. These structures provide the foundations for drug discovery and design using the structure-based computations, such as molecular docking and molecular dynamics simulations. In this review, introduction to the applications of computational methods in the discovery and design of novel drugs and repurposing of existing drugs for the treatments of COVID-19 is given. The examples of computer-aided investigations and screening of COVID-19 effective therapeutic compounds, functional peptides, as well as effective molecules from the herb medicines are discussed.

Neutralizing Antibody Response to Sarbecovirus Is Delayed in Sequential Heterologous Immunization.

Antigenic imprinting, which describes the bias of the antibody response due to previous immune history, can influence vaccine effectiveness. While this phenomenon has been reported for viruses such as influenza, there is little understanding of how prior immune history affects the antibody response to SARS-CoV-2. This study provides evidence for antigenic imprinting through immunization with two Sarbecoviruses, the subgenus that includes SARS-CoV-2. Mice were immunized subsequently with two antigenically distinct Sarbecovirus strains, namely SARS-CoV-1 and SARS-CoV-2. We found that sequential heterologous immunization induced cross-reactive binding antibodies for both viruses and delayed the emergence of neutralizing antibody responses against the booster strain. Our results provide fundamental knowledge about the immune response to Sarbecovirus and important insights into the development of pan-sarbecovirus vaccines and guiding therapeutic interventions.

A Survey of Mobile Apps for the Care Management of Patients with Dementia.

OBJECTIVE: Dementia is a progressive neurocognitive disorder that currently affects approximately 50 million people globally and causes a heavy burden for their families and societies. This study analyzed mobile apps for dementia care in different languages and during the COVID-19 pandemic. METHODS: We searched PubMed, Cochrane Collaboration Central Register of Con-trolled Clinical Trials, Cochrane Systematic Reviews, Google Play Store, Apple App Store, and Huawei App Store for mobile applications for dementia care. The Mobile Application Rating Scale (MARS) was used to assess the quality of applications. RESULTS: We included 99 apps for dementia care. No significant difference in MARS scores was noted between the two language apps (Overall MARS: English: 3.576 ± 0.580, Chinese: 3.569 ± 0.746, p = 0.962). In the subscale analysis, English apps had higher scores of perceived impact than Chinese apps but these were not significant (2.654 ± 1.372 vs. 2.000 ± 1.057, p = 0.061). (2) Applications during the COVID-19 pandemic had higher MARS scores than those before the COVID-19 pandemic but these were not significant (during the COVID-19 pandemic: 3.722 ± 0.416; before: 3.699 ± 0.615, p = 0.299). In the sub-scale analysis, apps during the COVID-19 pandemic had higher scores of engagement than apps before the COVID-19 pandemic but these were not significant (3.117 ± 0.594 vs. 2.698 ± 0.716, p = 0.068). CONCLUSIONS: Our results revealed that there is a minor but nonsignificant difference between different languages and during the COVID-19 pandemic. Further cooperation among dementia professionals, technology experts, and caregivers is warranted to provide evidence-based and user-friendly information to meet the needs of users.

Vaccine hesitancy and COVID-19 immunization among rural young adults.

Rural young adults may be more averse to receiving a COVID-19 immunization than urban young adults. We aimed to assess differences in COVID-19 vaccine hesitancy for rural, compared with urban, young adults and characterize modifiable factors. This cross-sectional online survey collected demographic data, vaccination attitudes, and COVID-19 impacts from 2937 young adults, ages 18-26 years, across the western U.S. from October 2020 to April 2021. Rurality was determined by participants' zip code and classified using the rural and urban continuum codes (RUCC). Multivariable logistic regression described adjusted (age, gender, race and ethnicity, being a current student, and month of survey) odds of self-reported intent to receive the COVID-19 vaccination by rurality. Mediation analysis was used to decompose total effects into average direct effects and average causal mediation (indirect) effects. Rural participants had 40% lower odds than urban participants of intending to receive the COVID-19 vaccine after adjustments (adjusted odds ratio, 0.62 [95% CI, 0.50-0.76]). The direct effect remained (P < 0.001), but was mediated by both education (8.3%, P < 0.001) and month in which the survey was taken (23.5%, P < 0.001). We observed a divergence after December 2020 in vaccination intent between rural and urban young adults that widened over time. Hesitancy to receive the COVID-19 vaccine was greater among rural, compared with urban young adults, and grew disproportionally after December 2020. Mediation by whether one was a current student or not suggests differences in sources of information for vaccination decision-making, and highlights areas for addressing vaccine hesitancy.

Smartphone-Enabled versus Conventional Otoscopy in Detecting Middle Ear Disease: A Meta-Analysis.

Traditional otoscopy has some limitations, including poor visualization and inadequate time for evaluation in suboptimal environments. Smartphone-enabled otoscopy may improve examination quality and serve as a potential diagnostic tool for middle ear diseases using a telemedicine approach. The main objectives are to compare the correctness of smartphone-enabled otoscopy and traditional otoscopy and to evaluate the diagnostic confidence of the examiner via meta-analysis. From inception through 20 January 2022, the Cochrane Library, PubMed, EMBASE, Web of Science, and Scopus databases were searched. Studies comparing smartphone-enabled otoscopy with traditional otoscopy regarding the outcome of interest were eligible. The relative risk (RR) for the rate of correctness in diagnosing ear conditions and the standardized mean difference (SMD) in diagnostic confidence were extracted. Sensitivity analysis and trial sequential analyses (TSAs) were conducted to further examine the pooled results. Study quality was evaluated by using the revised Cochrane risk of bias tool 2. Consequently, a total of 1840 examinees were divided into the smartphone-enabled otoscopy group and the traditional otoscopy group. Overall, the pooled result showed that smartphone-enabled otoscopy was associated with higher correctness than traditional otoscopy (RR, 1.26; 95% CI, 1.06 to 1.51; p = 0.01; I2 = 70.0%). Consistently significant associations were also observed in the analysis after excluding the simulation study (RR, 1.10; 95% CI, 1.00 to 1.21; p = 0.04; I2 = 0%) and normal ear conditions (RR, 1.18; 95% CI, 1.01 to 1.40; p = 0.04; I2 = 65.0%). For the confidence of examiners using both otoscopy methods, the pooled result was nonsignificant between the smartphone-enabled otoscopy and traditional otoscopy groups (SMD, 0.08; 95% CI, -0.24 to 0.40; p = 0.61; I2 = 16.3%). In conclusion, smartphone-enabled otoscopy was associated with a higher rate of correctness in the detection of middle ear diseases, and in patients with otologic complaints, the use of smartphone-enabled otoscopy may be considered. More large-scale studies should be performed to consolidate the results.