Serial antigen testing may be an effective strategy for controlling infection during a nursing home

Below please find summaries of new articles that will be published in the next issue of

Annals of Internal Medicine

. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. Serial antigen testing may be an effective strategy for controlling infection during a nursing home SARS-CoV-2 outbreak

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A prospective study found that serial antigen testing could be an effective strategy to support infection control in nursing homes having a SARS-CoV-2 outbreak. While less sensitive than real-time reverse transcription-polymerase chain reaction (RT-PCR) diagnostic tests, the authors say that antigen tests perform well when it counts–when someone is infectious and at risk for spreading the virus. The findings are published in

Annals of Internal Medicine

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Serial, facility-wide testing for SARS-CoV-2 can help identify cases in outbreak settings, allowing for rapid implementation of transmission-based precautions and infection prevention and control strategies. RT-PCR testing performed in a laboratory has the highest sensitivity, but its prolonged turnaround time can delay quarantine and isolation implementation. Antigen tests are easy to do and produce results in minutes, facilitating rapid action. However, performance data are lacking, especially in asymptomatic people.

Researchers from the Centers for Disease Control and Prevention (CDC) studied 532 specimens from 234 available residents and staff at a nursing home with a SARS-CoV-2 outbreak to evaluate the performance of antigen testing when used during an emerging outbreak. Two specimens were collected from all residents and staff 3 times over a 13-day period. Trained laboratory scientists tested one swab onsite using a rapid antigen test and the other was sent to the CDC for RT-PCR and virus culture reference testing. The researchers found that overall, the antigen test was less sensitive than RT-PCR, but it performed well in identifying early infections and specimens with replication-competent virus (that is, culture-positive). Further, consensus test analysis of individuals with a positive result and more than one test suggested that repeated testing produced similar positive agreement for antigen testing compared with RT-PCR, even in asymptomatic patients. According to the authors, these data suggest that early and frequent antigen testing during a SARS-CoV-2 outbreak may be an effective strategy for identifying infectious people with the greatest potential to transmit the virus.

Media contacts: For an embargoed PDF, please contact Angela Collom at

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. The corresponding author, Susannah L. McKay, PhD, MPH, can be reached through Martha Sharan at

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or Curtis Gill at

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2. ACP calls for improving privacy protections to increase trust in digital health technology

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A new policy paper from the American College of Physicians (ACP) seeks to improve the existing health information privacy framework and expand similar privacy guardrails in which physicians have practiced for decades to entities that are not currently governed by privacy laws and regulations. Published in

Annals of Internal Medicine

, the new policy paper offers principles and evidence-based recommendations for health information privacy, protection, and use.

Technological advancements and ongoing efforts to improve access to and exchange of valuable health information will undoubtedly help improve the US health care system. However, these advancements have led to other challenges around privacy protections for personal health information that is generated and collected, both within and outside of traditional health care. To maintain trust within the patient-physician relationship, these challenges must be addressed through establishing comprehensive health information privacy and security protections that are transparent, understandable, adaptable, and enforceable.

The policy principles were drafted to build upon ACP health information privacy policy for the evolving digital health landscape. The policy paper details the following six principles:

Principle 1: ACP believes that protecting the privacy and security of personal health information collected both within and outside the health care system–while providing individual rights to that information–is essential for fostering trust in the evolving digital health care system, maintaining ethical standards, and respect for persons, and promoting the safe delivery of health care.

Principle 2: ACP supports increased transparency and public understanding and improved models of consent about the collection, exchange, and use of personal health information within existing HIPAA rules as well as for entities collecting, exchanging, and using personal health information outside the health care system.

Principle 3: ACP believes that the confidentiality of personal health information is a fundamental aspect of medical care, and physicians and other clinicians have an obligation to adhere to appropriate privacy and security protocols to protect individual privacy.

Principle 4: ACP believes that health IT and other digital technologies, including personalized digital health products, should incorporate privacy and security principles within their design as well as consistent data standards that support privacy and security policies and promote safety.

Principle 5: ACP supports oversight and enforcement to ensure that all entities not currently subject to HIPAA rules and regulations and that interact with personal health information are held accountable for maintaining confidentiality, privacy, and security of that information.

Principle 6: ACP believes that new approaches to privacy and security measures should be tested before implementation and regularly reevaluated to assess the effect of these measures in real-world health care settings.

Media contacts: For an embargoed PDF, please contact Angela Collom at

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. To speak with someone from ACP, please contact Taneishia Bundy at

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3. ACP Clinical Guideline recommends appropriate use of point-of-care ultrasound for patients in ER and in-patient settings

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A new Clinical Guideline from the American College of Physicians (ACP) focuses on the appropriate use of point-of-care ultrasound (POCUS) for patients with acute dyspnea in emergency departments or in-patient settings. Acute dyspnea is a common symptom that contributes to more than 1 million emergency room visits each year and is defined as a subjective and distressing experience of breathing discomfort. Published in

Annals of Internal Medicine

, the guideline provides recommendations to improve the diagnostic, treatment, and health outcomes of patients with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax.

ACP suggests that clinicians may use POCUS in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings. The standard diagnostic approach to identify the underlying causes of acute dyspnea involves taking a patient history, conducting a physical examination, and ordering diagnostic testing such as blood laboratory, chest or cardiac imaging, and electrocardiogram. Evidence was inconclusive to make a recommendation for or against using POCUS as a replacement for the standard diagnostic approach in patients with acute dyspnea

In recent years, the use of POCUS as a potential diagnostic tool has increased due to its increased availability. Physicians trained to use POCUS can perform it in real-time at the patient bedside to possibly improve diagnostic performance when used in addition to standard clinical examinations.

The rationale to add POCUS to the standard diagnostic pathway is largely based on diagnostic accuracy studies and encompasses several considerations. POCUS increased the proportion of correct diagnoses by 32% when used in addition to the standard diagnostic pathway and the test accuracy of standard diagnostic testing with the addition of POCUS is better than with the standard diagnostic alone. Additionally, it is unlikely that POCUS is directly associated with serious harms and it is not a high-cost test. However, the test accuracy varied according to the likelihood of underlying diseases

Media contacts: For an embargoed PDF, please contact Angela Collom at

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. To speak with someone from ACP, please contact Andrew Hachadorian at

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4. ACP releases new recommendations for appropriate use of high-flow nasal oxygen in hospitalized patients with acute respiratory failure

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A new Clinical Guideline from the American College of Physicians (ACP) provides recommendations for the appropriate use of high-flow nasal oxygen in hospitalized patients for initial or post-extubation management of acute respiratory failure. The new, evidence-based clinical guideline is published in

Annals of Internal Medicine

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ACP’s guideline is based on the best available evidence on the benefits and harms of high-flow nasal oxygen, taken in the context of costs and patient values and preferences. The target patient population is adult patients with acute respiratory failure treated in a hospital setting (including emergency departments, hospital wards, intermediate/step-down units, and intensive care units). The guideline also includes input from 2 CGC public members and a 7-member CGC Public Panel, who provide layperson perspectives on values and preferences.

High-flow nasal oxygen (HFNO) therapy is a relatively new type of noninvasive respiratory support that has been gaining widespread use for hospitalized patients in recent years. It involves the delivery of warm and humidified oxygen at a flow higher than the patient’s inspiratory flow via a small nasal cannula. The purported benefits of HFNO compared to conventional oxygen therapy (COT) and high-flow systems and noninvasive ventilation (NIV) include improved patient comfort, compliance, and physiological advantages, and can be used as respiratory support in critically ill patients for a number of indications including respiratory failure or support post-extubation.

For the management of acute hypoxemic respiratory failure in hospitalized adults, ACP suggests clinicians use high-flow nasal oxygen rather than noninvasive ventilation (NIV). The evidence showed demonstrable improvement in clinically meaningful outcomes, including a large reduction in mortality, modest reduction in intubations and in hospital-acquired pneumonia as well as an improvement in patient comfort. Additionally, the CGC considered that most patients can use HFNO and there are usually no contraindications unless related to issues with fitting the nasal cannula.

In hospitalized adults with post-extubation acute hypoxemic respiratory failure, ACP suggests clinicians use high-flow nasal oxygen rather than conventional oxygen therapy (COT). In this population, evidence showed HFNO may reduce re-intubation slightly and may improve patient comfort compared to COT, and that HFNO may not perform worse than COT with regard to all-cause mortality, hospital-acquired pneumonia, and length of ICU stay

The guideline notes that more research is needed to identify which patients are most likely to benefit from HFNO, particularly by type of acute respiratory failure as evidence was insufficient on patients with hypercapnia.

None of the included studies compared the use of HFNO with NIV or COT for acute respiratory failure in the setting of post lung transplantation, pulmonary embolism, pulmonary arterial hypertension, or asthma. COVID-19 and related treatments were not part of this guideline.

Media contacts: For an embargoed PDF, please contact Angela Collom at

[email protected]

. To speak with someone from ACP, please contact Andrew Hachadorian at

[email protected]

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