International Recommendations on Postoperative Management for Potentially Resectable Locally Recurrent Nasopharyngeal Carcinoma.

PURPOSE: Locally recurrent nasopharyngeal carcinoma (NPC) presents substantial challenges in clinical management. While postoperative re-irradiation (re-RT) has been acknowledged as a potential treatment option, standardized guidelines and consensus regarding the use of re-RT in this context are lacking. This article provides a comprehensive review and summary of international recommendations on postoperative management for potentially resectable locally recurrent NPC, with a special focus on postoperative re-RT. METHODS AND MATERIALS: A thorough search was conducted to identify relevant studies on postoperative re-RT for locally recurrent NPC. Controversial issues, including resectability criteria, margin assessment, indications for postoperative re-RT, and the optimal dose and method of re-RT, were addressed through a Delphi consensus process. RESULTS: The consensus recommendations emphasize the need for a clearer and broader definition of resectability, highlighting the importance of achieving clear surgical margins, preferably through an en bloc approach with frozen section margin assessment. Furthermore, these guidelines suggest considering re-RT for patients with positive or close margins. Optimal postoperative re-RT doses typically range around 60Gy, and hyperfractionation has shown promise in reducing toxicity. CONCLUSION: These guidelines aim to assist clinicians in making evidence-based decisions and improving patient outcomes in the management of potentially resectable locally recurrent NPC. By addressing key areas of controversy and providing recommendations on resectability, margin assessment, and re-RT parameters, these guidelines serve as a valuable resource for the clinical experts involved in the treatment of locally recurrent NPC. SUMMARY: This article provides international recommendations on postoperative management for potentially resectable locally recurrent nasopharyngeal carcinoma (NPC), with a special focus on postoperative re-irradiation (re-RT). The consensus guidelines highlight the importance of achieving clear surgical margins, suggest considering re-RT for patients with positive or close margins, recommend an optimal re-RT dose of around 60Gy, and propose the use of hyperfractionation to reduce toxicity. The aim is to improve patient outcomes in the management of resectable locally recurrent NPC.

Prevalence of Haemophilus influenzae in the nasopharynx of children from regions with varying incidence of invasive H. influenzae serotype a disease: Canadian Immunization Research Network (CIRN) study.

Haemophilus influenzae serotype a (Hia) has recently emerged as an important cause of invasive disease in the North American Arctic and Sub-Arctic regions, mainly affecting young Indigenous children. In this study, we addressed the question of whether the prevalence of Hia and all H. influenzae in the nasopharynx differed between paediatric populations from regions with high versus low incidence of invasive Hia disease. Nasopharyngeal specimens from children with acute respiratory tract infections (ARTI) collected for routine diagnostic detection of respiratory viruses were analysed with molecular-genetic methods to identify and serotype H. influenzae. In Nunavut, a region with a high incidence of invasive Hia disease, all H. influenzae and particularly Hia were found in the nasopharynx of 60.6% and 3.0% children. In Southern Ontario (Hamilton region), where Hia invasive disease is rare, the frequencies of all H. influenzae and Hia detection were 38.5% and 0.6%, respectively. In both cohorts, non-typeable H. influenzae was prevalent (57.0% and 37.9%, respectively). Considering that Hia is an important cause of severe invasive disease in Nunavut children, 3% prevalence of Hia among children with ARTI can reflect continuing circulation of the pathogen in the Northern communities that may result in invasive disease outbreaks.

A case for implementing an HSV1/2, VZV, and syphilis lesion panel in Manitoba, Canada.

Syphilis, caused by Treponema pallidum subsp. pallidum (TPA), is becoming a significant public health concern, with rising incidence in Manitoba exceeding the national average. The province has also seen a demographic shift leading to women representing 51.9% of cases in 2021, leading to the re-emergence of congenital syphilis. Given the similarities in lesion appearance between TPA and other pathogens such as herpesviruses, accurate diagnosis is crucial for effective management and prevention. In order to address the potential for missed TPA cases, we conducted a quality assurance study from June 2021 to March 2023, screening over 5,000 mucocutaneous lesion swabs for TPA, initially submitted for herpes simplex virus (HSV) and varicella zoster virus (VZV) testing. Positivity rates were 13% for HSV1, 13% for HSV2, 6.7% for VZV, and 6.6% for TPA. Turnaround times (TAT) for TPA testing, as a send-out to the reference laboratory, averaged 17.8 days. Of the TPA-positive specimens, 36% did not have a corresponding TPA PCR test ordered, and 19% did not have accompanying syphilis serology within 30 days of collection. Creation of a multiplex lesion panel identified high sensitivity and specificity for HSV1, HSV2, VZV, and TPA, with robust reproducibility across multiple runs. Incorporation of TPA into a lesion panel improved the TAT to 4 days. Our findings emphasize the need for improved testing strategies to combat the syphilis epidemic and enhance public health outcomes.IMPORTANCESyphilis resurgence has become a significant global public health concern. In particular, the Canadian Prairies have been struggling with high incidence since 2016, exceeding the national Canadian average. We undertook a quality assurance study that highlighted significant gaps in diagnosis of acute syphilis, which led to the development of a highly sensitive and specific multiplex lesion assay for the dual detection of herpes simplex virus type 1 (HSV-1), herpes simplex virus type 2 (HSV-2), varicella zoster virus (VZV), and syphilis.

Management of chronic rhinosinusitis with nasal polyps in the Asia-Pacific region and Russia: Recommendations from an expert working group.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition of the nasal and paranasal tissues, characterized by the presence of bilateral nasal polyps. An expert panel of specialists from the Asian-Pacific region and Russia was convened to develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the chief observations and recommendations from this panel to provide guidance for clinicians in these areas. Etiology and pathogenetic mechanisms in CRSwNP are heterogeneous and complex. In many patients, CRSwNP is primarily driven by type 2 inflammation, although this may be less important in Asian populations. Frequent comorbidities include asthma and other inflammatory diseases such as non-steroidal anti-inflammatory drug (NSAID)/aspirin-exacerbated respiratory disease or atopic dermatitis. Clinical management of CRSwNP is challenging, and a multidisciplinary approach to evaluation and treatment is recommended. While many patients respond to medical treatment (topical irrigation and intranasal corticosteroids, and adjunctive short-term use of systemic corticosteroids), those with more severe/uncontrolled disease usually require endoscopic sinus surgery (ESS), although outcomes can be unsatisfactory, requiring revision surgery. Biological therapies targeting underlying type 2 inflammation offer additional, effective treatment options in uncontrolled disease, either as an alternative to ESS or for those patients with persistent symptoms despite ESS.

Carriage of Haemophilus influenzae serotype A in children: Canadian Immunization Research Network (CIRN) study.

Background: Haemophilus influenzae serotype a (Hia) has recently emerged as an important cause of invasive disease, mainly affecting young Indigenous children. Carriage of H. influenzae is a pre-requisite for invasive disease and reservoir for transmission. To better understand the epidemiology of invasive Hia disease, we initiated a multicentre study of H. influenzae nasopharyngeal carriage among Canadian children. Methods: With prior parental consent, we collected nasotracheal tubes used during general anaesthesia in healthy children following routine dental surgery in a regional hospital of northwestern Ontario and a dental clinic in central Saskatchewan. In northwestern Ontario, all children were Indigenous (median age 48.0 months, 45.8% female); in Saskatchewan, children were from various ethnic groups (62% Indigenous, median age 56.3 months, 43.4% female). Detection of H. influenzae and serotyping were performed using molecular-genetic methods. Results: A total of 438 nasopharyngeal specimens, 286 in northwestern Ontario and 152 in Saskatchewan were analyzed. Hia was identified in 26 (9.1%) and 8 (5.3%) specimens, respectively. In Saskatchewan, seven out of eight children with Hia carriage were Indigenous. Conclusions: The carriage rates of Hia in healthy children in northwestern Ontario and Saskatchewan are comparable to H. influenzae serotype b (Hib) carriage among Alaska Indigenous children in the pre-Hib-vaccine era. To prevent invasive Hia disease, paediatric conjugate Hia vaccines under development have the potential to reduce carriage of Hia, and thus decrease the risk of transmission and disease among susceptible populations. Addressing the social determinants of health may further eliminate conditions favouring Hia transmission in Indigenous communities.

Historique: L'Haemophilus influenzae de sérotype a (Hia) a récemment émergé comme une cause importante de maladie invasive, particulièrement chez les jeunes enfants autochtones. Il faut être porteur de l'H. influenzae pour contracter une maladie invasive et devenir un réservoir de transmission. Pour mieux comprendre l'épidémiologie de l'infection invasive à Hia, les chercheurs ont lancé une étude multicentrique sur le portage nasopharyngé de l'H. influenzae chez les enfants canadiens. Méthodologie: Après avoir obtenu le consentement des parents, les chercheurs ont recueilli les sondes nasotrachéales utilisées pendant l'anesthésie générale chez des enfants en santé après une chirurgie dentaire courante dans un hôpital régional du nord-ouest de l'Ontario et une clinique dentaire du centre de la Saskatchewan. Dans le nord-ouest de l'Ontario, tous les enfants étaient autochtones (âge médian de 48,0 mois, 45,8 % de filles); en Saskatchewan, les enfants provenaient de divers groupes ethniques (62 % d'Autochtones, âge médian de 56,3 mois, 43,4 % de femmes). La détection de l'H. influenzae et le sérotypage ont été effectués au moyen de méthodes de génétique moléculaire. Résultats: Au total, les chercheurs ont analysé 438 échantillons nasopharyngés, soit 286 du nord-ouest de l'Ontario et 152 de la Saskatchewan. L'Hia a été décelé dans 26 (9,1 %) et huit (5,3 %) échantillons, respectivement. En Saskatchewan, sept des huit enfants porteurs de l'Hia étaient autochtones. Conclusions: Le taux de portage de l'Hia chez les enfants en santé du nord-ouest de l'Ontario et de la Saskatchewan était comparable à celui du portage de l'H. influenzae du sérotype b (Hib) chez les enfants autochtones de l'Alaska avant le déploiement des vaccins contre le Hib. Pour éviter l'infection invasive à Hia, les vaccins pédiatriques conjugués contre l'Hia en cours de développement peuvent réduire le portage de l'Hia, et donc le risque de transmission et de maladie dans les populations susceptibles. Le fait d'aborder les déterminants sociaux de la santé pourrait contribuer à éliminer les conditions favorables à la transmission à Hia dans les communautés autochtones.

Temporal variations in the serogroup distribution of invasive meningococcal disease in Quebec, Canada, due to emerging unique clade of serogroup Y strain belonging to the Sequence Type-23 clonal complex.

OBJECTIVE: To identify recent trends in invasive meningococcal diseases (IMD) in Quebec, Canada, with a focus on MenY cases and MenY strains. METHODS: IMD cases and MenY strains from January 1, 2015 to August 11, 2023 were analyzed for clonal analysis and prediction of susceptibility to MenB vaccines. MenY strains of ST-23 CC from Quebec were analyzed with global MenY strains by core-genomic multi-locus sequence typing (cg-MLST). RESULTS: Since 2015 the serogroup distribution of IMD in Quebec has shifted from predominantly MenB to mainly MenY, with most (80.9 %) of the latter belonging to ST-23 CC. The median age of MenY cases due to ST-23 CC were statistically younger than MenY cases due to non-ST-23 CC. MenY of ST-23 CC showed genetic diversity and the major genetic cluster were similar to the Swedish Y1 strain. The increase in invasive MenY disease in Quebec was due to a sub-clade of Lineage 23.1 which caused an elevated proportion of severe disease in young adults. CONCLUSION: The increase in invasive MenY disease in Quebec, Canada was driven by the expansion of a sub-clade of Lineage 23.1 in young adults. Currently available quadrivalent A,C,W,Y-conjugate meningococcal vaccines were predicted to provide protection against these strains.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists.

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Vestibular rehabilitation therapy on balance and gait in patients after stroke: a systematic review and meta-analysis.

BACKGROUND: There is limited evidence to support the use of vestibular rehabilitation therapy (VRT) on improving balance and gait in patients after stroke. This systematic review aimed to evaluate the effects of VRT in addition to usual rehabilitation compared with usual rehabilitation on improving balance and gait for patients after stroke. METHODS: This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement guidelines. Ten electronic databases were searched up to 1 June 2023 without restrictions in language and publication status. The PEDro scale and the Grading of Recommendations Assessment Development, and Evaluation were used to evaluate the risk of bias and the certainty of evidence. The meta-analysis was conducted with Review Manager 5.3. RESULTS: Fifteen randomised controlled trials with 769 participants were included. PEDro scale was used to assess the risk of bias with a mean score of 5.9 (0.7). VRT was effective in improving balance for patients after stroke (SMD = 0.59, 95% CI (0.40, 0.78), p < 0.00001), particularly for patients after stroke that occurred within 6 months (SMD = 0.56, 95% CI (0.33, 0.79), p < 0.00001) with moderate certainty of evidence. Subgroup analysis showed that VRT provided as gaze stability exercises combined with swivel chair training (SMD = 0.85, 95% CI (0.48, 1.22), p < 0.00001) and head movements (SMD = 0.75, 95% CI (0.43, 1.07), p < 0.00001) could significantly improve balance. Four-week VRT had better effect on balance improvement (SMD = 0.64, 95% CI (0.40, 0.89), p < 0.00001) than the less than 4-week VRT. The pooled mean difference of values of Timed Up-and-Go test showed that VRT could significantly improve gait function for patients after stroke (MD = -4.32, 95% CI (-6.65, -1.99), p = 0.0003), particularly for patients after stroke that occurred within 6 months (MD = -3.92, 95% CI (-6.83, -1.00), p = 0.008) with moderate certainty of evidence. CONCLUSIONS: There is moderate certainty of evidence supporting the positive effect of VRT in improving balance and gait of patients after stroke. TRIAL REGISTRATION: PROSPERO CRD42023434304.

Diagnostic accuracy of the upper limb neurodynamic test with median bias (ULNT1) for cervical radiculopathy: a systematic review and meta-analysis.

BACKGROUND: The upper limb neurodynamic test for median nerve (ULNT1) is commonly applied for assessment of cervical radiculopathy (CR). However, the diagnostic accuracy of ULNT1 in diagnosing CR remains unclear. OBJECTIVE: This study aimed to examine the diagnostic accuracy of the ULNT1 for the CR. DATA SOURCES: Four databases were searched for relevant studies published up to April 30, 2023. STUDY SELECTION: Cross-sectional or cohort studies that assessed the diagnostic accuracy of ULNT1 for CR were included. DATA SYNTHESIS: The methodological quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. A bivariate random-effects regression model was used for the data synthesis. The overall quality of evidence was evaluated using the GRADE approach. RESULTS: A total of 592 references were identified, and five studies with 465 patients met the inclusion criteria. The overall quality of the body of evidence was very low across studies. Heterogeneity of studies was high. The pooled sensitivity and specificity of the ULNT1 were 0.69 (95% CI 0.50-0.83) and 0.54 (95% CI 0.36-0.71), respectively. The summary receiver operating characteristic curve area was 0.65 (95% CI 0.61-0.69). CONCLUSION: There is low certainty of evidence that the ULNT1 has only fair accuracy in diagnosing CR. The ULNT1 was recommended as an add-on test after the existing diagnostic pathway to enhance diagnostic accuracy further. High-quality studies which follow the Standards for Reporting of Diagnostic Accuracy and the QUADAS-2; a revised tool for the quality assessment of diagnostic accuracy, are needed. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO: CRD42021255686 CONTRIBUTION OF THE PAPER.

Combining Transoral Nasopharyngeal Brush and Plasma Epstein-Barr Virus DNA in Detecting Locally Recurrent Nasopharyngeal Carcinoma.

OBJECTIVE: To evaluate the sensitivities and specificities of Epstein-Barr virus (EBV) DNA in the detection of locally recurrent or persistent nasopharyngeal carcinoma (NPC) through nasopharyngeal (NP) brush biopsy and plasma, respectively, and whether a combination of both would be superior to the individual tests. STUDY DESIGN: A case-control study was conducted from September 2016 to June 2022. SETTING: A multicentre study at 3 tertiary referral centers in Hong Kong was conducted by the Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong. METHODS: Twenty-seven patients with biopsy-confirmed locally recurrent NPC were recruited as study subjects. Magnetic resonance imaging was performed to rule out regional recurrence. The control group consisted of 58 patients with a prior history of NPC who were now disease-free based on endoscopic and imaging findings. Patients underwent both the transoral NP brush (NP Screen®) and blood for plasma Epstein-Barr DNA levels. RESULTS: The sensitivity and specificity of the combined modalities were 84.62% and 85.19%, respectively. The positive predictive value was 73.33% and the negative predictive value was 92.0%. CONCLUSION: The combination of NP brush biopsy and plasma EBV DNA is potentially an additional surveillance modality in detecting the local recurrence of NPC. Further study with a larger sample size would be required to validate the cutoff values.

Intraoperative Imaging Techniques to Improve Surgical Resection Margins of Oropharyngeal Squamous Cell Cancer: A Comprehensive Review of Current Literature.

Inadequate resection margins in head and neck squamous cell carcinoma surgery necessitate adjuvant therapies such as re-resection and radiotherapy with or without chemotherapy and imply increasing morbidity and worse prognosis. On the other hand, taking larger margins by extending the resection also leads to avoidable increased morbidity. Oropharyngeal squamous cell carcinomas (OPSCCs) are often difficult to access; resections are limited by anatomy and functionality and thus carry an increased risk for close or positive margins. Therefore, there is a need to improve intraoperative assessment of resection margins. Several intraoperative techniques are available, but these often lead to prolonged operative time and are only suitable for a subgroup of patients. In recent years, new diagnostic tools have been the subject of investigation. This study reviews the available literature on intraoperative techniques to improve resection margins for OPSCCs. A literature search was performed in Embase, PubMed, and Cochrane. Narrow band imaging (NBI), high-resolution microendoscopic imaging, confocal laser endomicroscopy, frozen section analysis (FSA), ultrasound (US), computed tomography scan (CT), (auto) fluorescence imaging (FI), and augmented reality (AR) have all been used for OPSCC. NBI, FSA, and US are most commonly used and increase the rate of negative margins. Other techniques will become available in the future, of which fluorescence imaging has high potential for use with OPSCC.

Recommendations for Epstein-Barr virus-based screening for nasopharyngeal cancer in high- and intermediate-risk regions.

A meeting of experts was held in November 2021 to review and discuss available data on performance of Epstein-Barr virus (EBV)-based approaches to screen for early stage nasopharyngeal carcinoma (NPC) and methods for the investigation and management of screen-positive individuals. Serum EBV antibody and plasma EBV DNA testing methods were considered. Both approaches were found to have favorable performance characteristics and to be cost-effective in high-risk populations. In addition to endoscopy, use of magnetic resonance imaging (MRI) to investigate screen-positive individuals was found to increase the sensitivity of NPC detection with minimal impact on cost-effectiveness of the screening program.

Pediatric Rehabilitation Therapy and Physiotherapy Education in China.

AIMS: To explore the pediatric rehabilitation curriculum, clinical placement, faculty characteristics, facilitators and barriers to curriculum implementation, and satisfaction of graduates of entry-level programs of rehabilitation therapy and physiotherapy in China. METHODS: Two online cross-sectional surveys were conducted. With stratified random sampling, faculty were contacted to provide information on pediatric rehabilitation education in Survey A. In Survey B, the satisfaction of 2019 graduates was collected. Fifty-three faculty members (response rate 96.4%) completed Survey A and 154 graduates (response rate 85.6%) completed Survey B. RESULTS: There were variations in pediatric rehabilitation curriculum setting, clinical placement, and faculty characteristics. The key facilitator to implementation was a stand-alone pediatric course. The insufficient number of teachers was identified as the major barrier. The median satisfaction level of all 2019 graduates for curricular setting, faculty and placement was 4 (satisfied). The satisfaction level of 2019 graduates of programs accredited by the World Physiotherapy was statistically higher than that of graduates of non-accredited programs in curricular setting and faculty. CONCLUSIONS: The results support the need for faculty development and guidelines on minimum standards for entry-level pediatric rehabilitation education in China.

Effects of online exercise intervention on physical and mental conditions in young adults with chronic neck pain.

This study aimed to compare the efficacy of online exercise therapy with conventional exercise therapy for young adults with chronic neck pain. A randomized clinical trial recruiting 35 university students with self-reported chronic neck pain was conducted. The experimental group receiving 6-week online exercise therapy and active control group receiving the same face-to-face conventional exercise therapy. Visual analogue scale (VAS) for pain, Neck Disability Index (NDI), Work Limitations Questionnaire (WLQ), Hospital Anxiety and Depression Scale (HADS) and its subscales were evaluated. Both groups had improvements in VAS, NDI, HADS and WLQ scores from baseline to 6 weeks. All comparisons of changes in outcome variables between groups were not statistically significant. For young adults with chronic neck pain, both the online and conventional exercise interventions could improve their pain level, neck disability, anxiety state, and work efficiency. The online exercise intervention appeared feasible as an alternative treatment option for them.

Epidemiology of invasive Haemophilus influenzae serotype a disease in the North American Arctic, 2006-2017.

Invasive Haemophilus influenzae type a (iHia) disease was detected in Alaska and Northern Canada in 2002 and 2000, respectively. From 2006 to 2017, 164 iHia cases (Alaska=53, Northern Canada=111) were reported. Rates of iHia disease per 100,000 persons were higher in Northern Canada compared to Alaska and were significantly higher in Indigenous (Alaska 2.8, Northern Canada 9.5) compared to non-Indigenous populations (Alaska 0.1, Northern Canada=0.4). Disease rates were highest in Indigenous children <2 years of age (Alaska 56.2, Northern Canada=144.1) and significantly higher than in non-Indigenous children <2 (Alaska 0.1, Northern Canada 0.4). The most common clinical presentation in children <5 years was meningitis of age and pneumonia in persons ≥5 years old. Most patients were hospitalised (Alaska=87%, Northern Canada=89%) and fatality was similar (Alaska=11%, Northern Canada=10%). MLST testing showed sequence types ST23 and ST576 in Northern Canada and ST576, ST23 and ST56 in Alaska. Alaska and Northern Canada have high rates of iHia disease. A vaccine is needed in these regions to protect young children.

International recommendations for plasma Epstein-Barr virus DNA measurement in nasopharyngeal carcinoma in resource-constrained settings: lessons from the COVID-19 pandemic.

The effects of the COVID-19 pandemic continue to constrain health-care staff and resources worldwide, despite the availability of effective vaccines. Aerosol-generating procedures such as endoscopy, a common investigation tool for nasopharyngeal carcinoma, are recognised as a likely cause of SARS-CoV-2 spread in hospitals. Plasma Epstein-Barr virus (EBV) DNA is considered the most accurate biomarker for the routine management of nasopharyngeal carcinoma. A consensus statement on whether plasma EBV DNA can minimise the need for or replace aerosol-generating procedures, imaging methods, and face-to-face consultations in managing nasopharyngeal carcinoma is urgently needed amid the current pandemic and potentially for future highly contagious airborne diseases or natural disasters. We completed a modified Delphi consensus process of three rounds with 33 international experts in otorhinolaryngology or head and neck surgery, radiation oncology, medical oncology, and clinical oncology with vast experience in managing nasopharyngeal carcinoma, representing 51 international professional societies and national clinical trial groups. These consensus recommendations aim to enhance consistency in clinical practice, reduce ambiguity in delivering care, and offer advice for clinicians worldwide who work in endemic and non-endemic regions of nasopharyngeal carcinoma, in the context of COVID-19 and other airborne pandemics, and in future unexpected settings of severe resource constraints and insufficiency of personal protective equipment.

Canadian Public Health Laboratory Network guidelines for the use of point-of-care tests for Treponema pallidum in Canada.

Over the past few years, the increase in infectious syphilis outbreaks in major urban centres and remote or rural locations in Canada, often affecting hard-to-reach patient populations, has renewed an interest and urgency in studying the use of point-of-care tests (POCTs) that can provide test results at the time and place of primary health care delivery, obviating the repeat visit necessary with traditional syphilis serology or molecular diagnostic tests. In 2015, the Canadian Public Health Laboratory Network released its first laboratory guideline for the use of POCTs in the diagnosis of syphilis in Canada. Although Canada has no licensed POCT, two POCTs (Syphilis Health Check and the DPP® HIV Syphilis System) have received US Food and Drug Administration (FDA) approval under premarket approval applications. Most syphilis POCTs detect antibodies to treponemal antigens, so their results cannot be used to differentiate between active and past infection. The only POCT that detects antibodies to both treponemal and non-treponemal antigens does not yet have Health Canada or FDA approval. In this updated guideline, the current landscape of POCTs for syphilis, with an emphasis on data from low-prevalence countries, is described. Individual operators should consider the questions of where, when, how, and why a POCT is used before its actual implementation. Training in the operation and interpretation, quality control, proficiency program, safety, and careful documentation of the process and results are especially important for the successful implementation of POCTs.

Depuis quelques années, la recrudescence des éclosions de syphilis infectieuses dans les grands centres urbains et dans les régions éloignées ou rurales du Canada, qui touchent souvent des populations de patients difficiles à atteindre, a renouvelé l'intérêt pour l'étude des tests au point de service (TPDS) et l'urgence de les réaliser, afin d'obtenir des résultats au moment et au lieu de prestation des soins de santé primaires et d'ainsi éviter le deuxième rendez-vous après le test diagnostique sérologique ou moléculaire habituel de la syphilis. En 2015, le Réseau des laboratoires de santé publique du Canada a publié son premier guide de laboratoire pour l'utilisation des TPDS afin de diagnostiquer la syphilis au Canada. Même si le Canada ne possède pas de TPDS homologué, deux TPDS (Syphilis Health Check et HIV Syphilis System de DPPMD) ont été homologués par la Food and Drug Administration (FDA) des États-Unis en vertu des demandes d'autorisation précommercialisation. La plupart des TPDS de la syphilis décèlent les anticorps contre les antigènes tréponémiques, si bien que les résultats ne peuvent pas servir à distinguer une infection active d'une infection passée. Le seul TPDS qui détecte des anticorps contre les antigènes tréponémiques et non tréponémiques n'est pas encore homologué par Santé Canada ni par la FDA. Dans la présente mise à jour des directives, les chercheurs décrivent le paysage actuel des TPDS de la syphilis et s'attardent sur les données des pays où la prévalence est faible. Chaque opérateur devrait se demander où, quand, pourquoi et comment le TPDS est utilisé avant d'en amorcer la mise en œuvre. La formation sur l'utilisation, l'interprétation, le contrôle de la qualité, le programme de vérification de la compétence, l'innocuité et la consignation attentive du processus et des résultats revêt une importance particulière pour assurer la mise en œuvre réussie des TPDS.

Characteristics of polymerase chain reaction-positive syphilis cases in Manitoba, Canada, 2017 to 2020: Demographic analysis, specimen types, and Treponema pallidum gene targets.

BACKGROUND: A resurgence of syphilis infections has been described in a number of countries including Canada in the last decade. METHODS: This study identified polymerase chain reaction (PCR) positive syphilis cases based on detection of Treponema pallidum genes (polA, tpp47, and bmp) in 3,350 clinical specimens obtained from patients in the province of Manitoba, Canada between 2017 and 2020. Patient demographics were obtained from specimen requisition forms. RESULTS: PCR identified 740 syphilis cases: 718 were adolescents and adults, while 22 were congenital syphilis cases. For non-congenital syphilis investigation, the clinical specimens with the highest yield of positive PCR results were genital (632), oral (73), and anal (55), while for congenital syphilis, they were nasal or nasopharyngeal secretions (20), followed by blood (5) and umbilical cord (4). Female syphilis cases appeared younger (61.7% between 14 and 29 years), while male syphilis cases appeared older (58.4% between 30 and 65 years). Although, overall more syphilis cases (62.7%) occurred in the urban cities; the proportion of urban cases showed a significant decline from 87.0% in 2017 to 55.6% in 2020, while in rural regions it increased from 13.0% in 2017 to 44.4% in 2020. Most (98.8%) PCR- positive specimens were found to contain all three T. pallidum genes and 99.8% also displayed the macrolide resistance genotype. CONCLUSIONS: This study identified the clinical specimen types and T. pallidum genes most suitable for PCR diagnosis of syphilis. Changing demographics of cases were noted over time.

HISTORIQUE: Depuis dix ans, les infections par la syphilis sont en recrudescence dans plusieurs pays, y compris le Canada. MÉTHODOLOGIE: La présente étude relève les cas positifs à l'amplification en chaîne par polymérase (PCR) d'après la détection des gènes du Treponema pallidum (polA, tpp47 et bmp) dans 3 350 échantillons cliniques prélevés auprès de patients de la province du Manitoba, au Canada, entre 2017 et 2020. Les caractéristiques démographiques des patients sont tirées des formulaires de réquisition des prélèvements. RÉSULTATS: Le test PCR a permis de détecter 740 cas de syphilis, soit 718 chez des adolescents et des adultes et 22 cas de syphilis congénitale. Pour ce qui est des examens de la syphilis non congénitale, les échantillons cliniques donnant le plus fort taux de résultats positifs au test PCR ont été prélevés dans la région génitale (632), orale (73) et anale (55), tandis qu'à l'égard des cas de syphilis congénitale, ils provenaient des sécrétions nasales ou nasopharyngées (20), suivis du sang (5) et du cordon ombilical (4). La syphilis se manifestait chez des femmes plus jeunes (61,7 % entre 14 et 29 ans) et plus tard chez les hommes (58,4 % entre 30 et 65 ans). Même si, dans l'ensemble, plus de cas de syphilis (62,7 %) se déclaraient en région urbaine, cette proportion a connu un recul important, passant de 87,0 % en 2017 à 55,6 % en 2020, tandis que la proportion des cas en région rurale a progressé de 13,0 % en 2017 à 44,4 % en 2020. La plupart des échantillons ayant obtenu un résultat positif au test PCR (98,8 %) contenaient les trois gènes du T. pallidum, et 99,8 % possédaient également le génotype de résistance aux macrolides. CONCLUSIONS: La présente étude a relevé les types d'échantillons cliniques et les gènes de T. pallidum les plus appropriés pour le diagnostic de syphilis par test PCR. On constate une évolution de la démographie des cas au fil du temps.