To validate the non-inferiority of QDTI to Luminex in terms of the accuracy of IL-6 measurement, two clinical parameters—the need for intensive care unit admission and the need for mechanical intubation—were chosen. IL-6 concentrations measured by the two assays were compared with respect to these clinical outcomes. Results demonstrated a comparative predictive performance between the two assays with a significant correlation coefficient. Conclusion: In short, the QDTI assay holds promise for implementation as a potential tool for rapid clinical decision in patients with IL-6-mediated diseases. It could also reduce healthcare costs and enable the development of future various biomolecule point-of-care tests for different clinical scenarios.Interleukin-6 (IL-6) has been linked to several life-threatening disease processes. Developing a point-of-care testing platform for the immediate and accurate detection of IL-6 concentrations could present a valuable tool for improving clinical management in patients with IL-6-mediated diseases. Drawing on an available biobank of samples from 35 patients hospitalized with COVID-19, a novel quantum-magnetic sensing platform is used to determine plasma IL-6 concentrations. A strong correlation was observed between IL-6 levels measured by QDTI10x and the Luminex assay (r = 0.70,  Rapid diagnostic modalities aimed at detecting host-derived biomarkers are better able to inform clinicians on disease management . A varieBiomarkers are biological molecules found in the body, and their expression levels can potentially differentiate and identify normal body conditions from abnormal life-threatening conditions . Many siInterleukin-6 (IL-6), an endogenous cytokine known to elicit pro-inflammatory responses, has been linked to several disease processes . IL-6-drThis correlation presented the rationale for using IL-6-blockade therapy to improve survival for COVID-19 patients in the intensive care unit (ICU) ,21,22,23The BACC Bay trial (NCT #04356937) used tocilizumab versus placebo early in COVID-19 infection to determine if IL-6 receptor blockade, prior to the need for ICU-level care and escalating supplemental oxygen, prevented disease progression. The data demonstrated that the early use of IL-6 blockade did not have a beneficial outcome . We sougThe QDTI platform utilizes quantum magnetic sensors to enable simple and rapid biomarker detection. Such biomarkers include proteins, cells, and nucleic acids using the same platform. In this study, we investigate the use of the novel QDTI platform for measuring plasma IL-6 using an existing biobank of COVID-19 plasma samples and compare its diagnostic accuracy to a traditional Luminex assay. We find that the QDTI assay demonstrates precise results when compared to the Luminex assay at a rate that can allow us to declare non-inferiority in terms of the accuracy of IL-6 measurements.Our enrolled study population was distributed among five Boston hospitals. The subjects were distributed as follows: 13 patients (37%) at Massachusetts General Hospital, 9 patients (26%) at North Shore Medical Center, 6 patients (17%) at Boston Medical Center, 5 patients (14%) at Brigham and Women’s Hospital, and 2 patients (6%) at Newton-Wellesley Hospital .The study was conducted according to the guidelines of the Declaration of Helsinki, and approval was obtained from the MGH institutional review boards (IRB) . Informed consent was obtained from all subjects involved in the study. We collected samples from control patients (N = 35) enrolled in the double-blinded randomized controlled trial—the BACC Bay trial (NCT #04356937). These control patients have SARS-CoV-2 infection but did not receive tocilizumab treatment. The sample size was not determined statistically prior to experimentation. The blood samples of all subjects were collected on hospital admission. Serum and plasma were separated, aliquoted, and stored at −80 °C in cryovials ready for IL-6 determination. The time from venipuncture to storage was approximately 2–4 h.The aim of this study is to compare the diagnostic performance of Luminex used to measure plasma IL-6 levels to a novel platform for analyte measurement—the Quantum Diamond Technologies Inc (QDTI) system. The primary outcomes of this study are to evaluate the correlation between IL-6 concentrations measured by both platforms and to compare the diagnostic performance of the two assays for patients who were admitted to the ICU during their hospital stay, and patients who received mechanical ventilation during their hospital stay, both of which were assumed to be correlated to worsened patient clinical outcomes .p-values are two-sided, and a p value of less than 0.05 was considered significant. Statistical analyses were performed using the R package version 4.0.3 and SAS software version 9.4 .Statistical graphs and descriptive measures such as frequency, percent, interquartile range (IQR), and median were used to summarize data. Spearman rank correlations were used to examine bivariate associations between QDTI and Luminex assay. The Lehmann family of Receiver Operating Characteristic (ROC) curves were used to assess the diagnostic performance of QDTI and Luminex assays for worsened patient outcomes, i.e., ICU admission and use of mechanical ventilation . The areA quantum diamond microscope provides the core functionality of the QDTI instrument ,28. The The QDTI magnetic assay counts immunocomplexes formed from pairs of magnetically distinct beads, with each bead bound to a specific epitope on the target analyte molecule a. The twThe QDTI instrument is a benchtop device for the magnetic imaging readout of samples supported in a 96-well cartridge format. The instrument processes cartridge wells sequentially, positioning each sample between the diamond chip and a microscope objective that collects NV center fluorescence. To maximize imaging resolution, samples are supported on thin polymer membranes that lie flat against the diamond surface during imaging. The membranes also provide a barrier between the chip and the samples to prevent inter-sample contamination. The acquisition time for one image is approximately one minute, including stage and pneumatic motions to position the cartridge and deflect the membrane against the diamond chip .The assay was performed in the Division of Infectious Diseases at Massachusetts General Hospital in Boston, MA. Beads were prepared according to the manufacturer’s instructions . Calibrator samples and clinical plasma samples were plated in quadruplicate on a 96-well plate and incubated for 30 min with shaking with capture beads (bead A). The 96-well plate was placed on a bar magnet, and all liquid was aspirated before addition of detector beads (bead B). Wells were washed using wash buffer provided by QDTI and incubated on a plate shaker and bar magnet. Wash buffer was aspirated from each well, and a second wash step occurred using imaging buffer. Fresh imaging buffer was placed into each well and transferred to the QDTI provided cartridge. The total sample manipulation time after incubation required less than 30 min. The cartridge was then transferred to a dry box with desiccant for 1 h and UV-inactivated prior to loading into the instrument. Cartridges were transported in secure biosafety containers to QDTI for readout.2 weighting. The lower limit of detection (LLOD) was calculated as three standard deviations from the mean background signal (zero standard) read back on each calibration curve, averaged over seven runs. The lower limit of quantification (LLOQ) is the lowest concentration at which the median CV of calculated concentration is <25%.  with a minor deviation immediately prior to acquisition. In brief, serum samples were thawed and centrifuged at 16,000× Plasma samples from 35 patients from the BACC Bay Trial were tested. The baseline characteristics of the patients are shown in 9/L (interquartile range: 4.14–7.6 × 109)A total of 24 patients (68%) were receiving supplemental oxygen at ≤6 L per minute, delivered by nasal cannula, to maintain an oxygen saturation > 92%; 2 patients (6%) were receiving supplemental ventilation at >6 L per minute, delivered by nasal cannula; 1 patient (3%) was receiving high-flow oxygen; and 7 patients (20%) were not receiving supplemental oxygen at baseline. One patient (3%) required invasive mechanical ventilation. The median concentration of ferritin was 686 ng/mL (interquartile range: 378–1346), D-dimer, 670 ng/mL (interquartile range: 399–1739), erythrocyte sedimentation rate (ESR), 68 mm/h. (interquartile range: 43–87), and white blood cell (WBC) count, 5.6 × 10p-value < 0.001) . As expected, strong correlation coefficient analyses were found between QDTI10x and QDTI80x.  , and further diluted 8-fold (QDTI80x) for the accurate measurement of IL-6 in samples that read above the calibration range at 10-fold dilution. All replicate IL-6 concentrations using single-well measurements were then determined . The QDT< 0.001) . Likewis< 0.001)  (Supplem< 0.001) .Receiver operating characteristic (ROC) curves were used to assess the diagnostic performance of QDTI and Luminex assays for worsened patient outcomes. Two clinical parameters, specifically ICU admission and use of mechanical ventilation, were used as measures of poor clinical outcomes. Twelve patients (34%) were admitted to the ICU during their hospital stay . LikewisIn this study, a strong correlation coefficient regarding diagnostic performance has been demonstrated between the QDTI assay and the Luminex assay, indicating that the novel QDTI platform provides firm evidence of statistical equivalence as compared to Luminex. It is noteworthy to mention that IL-6 levels measured using plasma are known to be higher than those using serum . The sigSuch rapid, high-sensitivity measurements might have the potential to result in the avoidance of unnecessary hospital stays and their associated costs and impacts for patients. Based on a recent study assessing inpatient hospital costs for COVID-19 patients in the United States, the overall median cost of a hospital stay per day is $1772, while the overall median cost of an ICU admission per day reaches $2902 . The utiAdditionally, from an economic perspective, we also find that the QDTI assay has a major advantage for application in terms of lower cost. One other advantage for the QDTI assay over the Luminex assay is that the cost of Luminex is only manageable if performed in large batches, implying that it is not feasible for the generation of clinically actionable results when compared to QDTI. The complexity of Luminex execution also requires more expertise to run the assay as compared to QDTI.It is also noteworthy that quantum magnetic sensors can be configured for the detection of additional biomolecules. The clinical scenarios in which rapid, accurate point-of-care detection of specific biomolecules could result in improved patient management are numerous. For example, developing an assay that rapidly detects and quantifies procalcitonin, a biomarker of infectious diseases, in the emergency department (ED) setting can aid in the identification and management of patients with invasive bacterial infections versus viral lower respiratory tract infections ,36. AnotFinally, the simplicity of execution and rapid turnaround time of modalities such as quantum sensing would facilitate their adoption as point-of-care tests in healthcare settings with limited or no access to clinical laboratories and other resources ,44,45.In short, the early diagnosis of disease remains crucial for optimal patient management and outcomes as well as reducing healthcare costs. Rapid diagnosis ultimately results in precise clinical decisions, directed treatment plans, and improved prognosticating capacity . From anAs with any study focusing on novel assays, the results presented in this manuscript have shortcomings. An important limitation in our study is the lack of an adequate sample size. Due to the limited sample size, we did not have the power to perform multivariate analyses. Multivariate analyses are required to adjust for the effect of confounding variables while comparing the three assays. Larger cohorts in prospective studies are required for the validation of the results presented in this manuscript. Moreover, the data presented in this manuscript are based on a single study center. A larger multi-center study might be adequate to achieve a larger sample size.Another limitation to the study is the focus on one type of infection, which is SARS-CoV-2, and the absence of a diversity of IL-6-mediated diseases. Future studies and clinical trials will be required to evaluate this novel assay’s performance with respect to multiple disease states.Finally, IL-6 concentrations for all subjects participating in this study were measured using blood collected at hospital admission. Serial measurements would be useful to evaluate the assay’s performance with respect to modifications of IL-6 levels over time and clinical outcomes.In conclusion, from a technical and analytical perspective, the results of this study show that the QDTI assay proves to be non-inferior to the Luminex assay in terms of accurate IL-6 measurement for patients hospitalized with COVID-19. This novel platform also shows more rapid generation of IL-6 concentrations when compared to the Luminex assay. Future validation studies would ultimately be needed before presenting any clinical implications of the presented findings.


Data on awareness of HIV status among people living with HIV (PLHIV) are critical to estimating progress toward epidemic control. To ascertain the accuracy of self-reported HIV status and antiretroviral drug (ARV) use in the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), we compared self-reported HIV status with HIV rapid diagnostic test (RDT) results and self-reported ARV use with detectable blood ARV levels.On the basis of responses and test results, participants were categorized by HIV status and ARV use. Self-reported HIV status and ARV use performance characteristics were determined by estimating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Proportions and other analyses were weighted to account for complex survey design.During NAIIS, 186,405 participants consented for interview out of which 58,646 reported knowing their HIV status. Of the 959  who self-reported being HIV-positive, 849 (92.1%) tested HIV positive and 64 (7.9%) tested HIV negative via RDT and polymerase chain reaction test for discordant positive results. Of the 849 who tested HIV positive, 743 (89.8%) reported using ARV and 72 (10.2%) reported not using ARV. Of 57,687 who self-reported being HIV negative, 686 (1.2%) tested HIV positive via RDT, with ARV biomarkers detected among 195 (25.1%). ARV was detected among 94.5% of those who self-reported using ARV and among 42.0% of those who self-reported not using ARV. Overall, self-reported HIV status had sensitivity of 52.7%  with specificity of 99.9% (95% CI: 99.8%–99.9%). Self-reported ARV use had sensitivity of 95.2% (95% CI: 93.6%–96.7%) and specificity of 54.5% (95% CI: 48.8%–70.7%).Self-reported HIV status and ARV use screening tests were found to be low-validity measures during NAIIS. Laboratory tests to confirm self-reported information may be necessary to determine accurate HIV and clinical status for HIV studies in Nigeria. To monitor these targets, data on self-awareness of HIV status among PLHIV are critical; population-based HIV surveys collect these data systematically . The objective of the Population-based HIV Impact Assessments (PHIAs) is to estimate progress toward the 90-90-90 targets and program impacts per UNAIDS guidance .In 2014, to spur the global community toward ending HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the 90-90-90 targets to achieve by the year 2020: 90% of all people living with HIV (PLHIV) know their HIV status; of these, 90% are receiving sustained antiretroviral therapy; and of these, 90% have viral suppression , 5 and is a simple, efficient, and cost-effective method for assessing the prevalence of antiretroviral therapy (ART) use, though the validity of self-reported ARV status has not been well characterized . Survey respondents might not reliably provide information about their HIV or ART status or might provide information based on tests conducted in the past which might not always be accurate, and inaccurate data based on self-reported HIV status or treatment would affect the accuracy of the 90-90-90 coverage estimates, thereby misleading interventions . To supplement self-reported ARV use, PHIA surveys have incorporated detection of ARV levels in blood specimens from all respondents who screened HIV positive. In 2018, Nigeria adapted the PHIA survey approach and conducted the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), one of the largest population-based HIV surveys  .Self-reported antiretroviral drug (ARV) status is now a common question in HIV population-based surveys . Self-reported HIV status (as a screening test) during NAIIS was compared with HIV biomarker screening using rapid diagnostic tests (RDT) based on the Nigeria testing algorithm ; PCR tests to detect HIV DNA/RNA are the gold-standard diagnostic test for HIV . To ascertain the accuracy and performance of self-reported HIV status and ART use in NAIIS, we compared self-reported HIV status with HIV rapid diagnostic tests and self-reported ARV use with detectable blood ARV levels using liquid chromatography-tandem mass spectrometry (LC/MS/MS). The accuracy of the difference between the self-reported HIV status and the RDT might be an underestimation when compared against imperfect gold-standard RDT, known as imperfect gold-standard bias . In the case of self-reported ARV use, LC/MS/MS was used as the gold standard to test the validity of the self-reported ARV use. LC/MS/MS is an efficient and sensitive method for evaluating ARV levels in biological samples .Screening tests are measured against gold-standard diagnostic tests that ideally should have a score of almost 100% for all performance measurements . Such gold-standard tests are also expected to be the best performing tests available; however, sometimes programs must use the best available tests under reasonable conditions, known as imperfect or alloyed gold-standard tests Our findings provide additional insights to the usefulness of including self-reported HIV and/or ARV questions in routinely conducted population-based HIV surveys for periodic monitoring of 90-90-90 coverage.This evaluation was supported by an approved protocol–the Nigeria AIDS Indicator and Impact Survey (NAIIS). Informed consent was obtained from all participants, and the protocol was approved by CDC IRB, University of Maryland Baltimore IRB, and Nigeria Health Research Ethics Committee.. Adult participants (18 years and above) and emancipated minors (15–17 years) provided written informed consent to the interview and biomarker tests. Children aged 15–17 years were asked for assent to the interview and biomarker components after permission was granted by their parents or guardians. During the survey, participants were asked if they had ever been tested for HIV. If so, participants were asked about when and where the test was done and the result of the test. Participants were asked a series of questions about their HIV care-seeking behaviors in addition to whether they had ever received ART, the months and year when ART was initiated, and whether they are currently receiving ART. Positive responses to ever been on ART or currently on ART were both compared to the outcome of blood ARV detection.NAIIS methods have been described elsewhere. The NAIIS sample design was a stratified multistage probability sample design, with strata defined by the 37 states of the country. The population of inference for NAIIS was comprised of the de facto household population. The de facto population was comprised of individuals who were present in households, i.e., slept in the household, on the night prior to the household interview . Participants with a non-reactive result on the HIV-screening test were reported as HIV negative. Individuals with a reactive screening test result had an RDT test repeated and confirmed with Geenius HIV 1/2 confirmatory assay. Those with a reactive result on both screening and confirmatory tests were classified as HIV positive. Participants who self-reported being HIV-positive but tested HIV-negative during the survey had their specimens further tested using DNA PCR to confirm HIV status.HIV rapid tests were conducted based on the Nigerian serial testing algorithm . The following drugs used in the Nigeria HIV treatment guidelines were tested: efavirenz and nevirapine (first-line regimen) and atazanavir and lopinavir (second-line regimen). These four drugs provide 100% coverage among all PLHIV receiving ARV in Nigeria. Detectable ARV biomarkers are defined as the presence of any of these four drugs in the participant’s specimen.Specimens were collected during survey period (July–December 2018) in the field, transported to laboratory and processed into plasma aliquots and dry blood spot (DBS) cards and stored at -80°C. ARV levels were detected in blood specimens using DBS cards by LC/MS/MS method with a limit of detection of 0.02 μg/mL for each drug and a signal-to-noise ratio of at least 5:1 for all drugs In this analysis, only individuals who agreed to be tested for HIV were included. Performance of self-reported HIV status and self-reported ARV use as measures were assessed by comparing self-reported HIV status and the confirmed final HIV test result and self-reported ARV use and the detectable ARV in blood specimens respectively and calculating sensitivity, specificity, positive and negative predictive values as described in svyset and anweight command in Stata version 15 was used to set the data for sampling weights, clustering, and stratification. The anweight corrects for differential selection probabilities within each sample location as specified by sample design, for nonresponse, for noncoverage, and for sampling error related to the four post-stratification variables and takes into account differences in population size across study location.Data were analyzed using Stata 15 at 0.05 alpha level of significance. All results were adjusted and weighted to account for the complex survey design. The .UNAIDS 90-90-90 targets were estimated based on self-reported HIV-positive status and verified by ARV biomarker data. Using only self-reported status, we categorized participants as aware of their HIV-positive status if they self-reported knowing they were HIV positive before NAIIS HIV testing and as receiving ART if they self-reported ARV use. Using both self-reported and biomarker data, we adjusted self-reported HIV positive awareness and ARV use to include participants with ARV biomarkers detected in their blood specimen, even if these participants did not self-report HIV positive status or ARV use. In both sets of results, individuals who had viral load suppression but were not aware of their HIV-positive status or were not receiving ART, either by self-report or ARV biomarker data, were excluded from the numerator for the third 90 Characteristics of HIV-positive study population and self-reported HIV status and self-reported antiretroviral drug (ARV) use among individuals who consented for interview during the study can be found in In NAIIS, self-reported HIV status had a low sensitivity : 49.4%–56.0%]) with high specificity (99.9% ) and low specificity (54.5% [95% CI: 48.8%–70.7%]) in determining ARV use . IndividEstimated progress toward the UNAIDS 90-90-90 targets of weighted population based on self-reported HIV and ARV status were 30-90-83 versus 47-96-81 after adjusting estimates with ARV biomarker detection of all confirmed HIV-positive cases.. Ethically, misdiagnosis of an individual as HIV-positive may have serious moral and psychological consequences which may lead to medico-legal complications  while, in monitoring progress toward UNAIDS 90-90-90 targets, it may lead to overestimation of 1st 90 (and 2nd 90 if initiated on ARV). HIV-negative participants were more likely to report their HIV status correctly than HIV-positive participants as confirmed by a high specificity of 99.9% and low sensitivity of 52.7% of self-reported HIV status.Self-reported HIV status and ARV use were found to be low-validity measures during NAIIS. A high proportion of participants who reported being tested for HIV and reported the results were confirmed by biomarker RDT test, with 7.0% false-positive and 1.3% false-negative results. The high false-positive rate is not surprising due to that self-reported HIV status was compared with the “imperfect” gold standard RDT  having a relatively low specificity. All the 64 (7.0%) individuals who self-reported as HIV-positive tested HIV-negative using RDT were further confirmed to be HIV negative on HIV DNA PCR. Results from 11 PHIA surveys in Sub-Saharan Africa have reported similar variance and it was extrapolated that about 73,000 individuals might have been misdiagnosed as PLHIV, with about 39.7% of them likely to have been erroneously initiated on ART in the 11 countries –20. Additionally, studies have shown HIV-positive individuals may decide to conceal their status, especially in healthcare-related activities such as surveys, due to concerns about breach of confidentiality, fear of denial of quality healthcare, and judgement from healthcare providers , 22. False-negative results lead to the underestimation of progress toward the first UNAIDS 90 target and HIV prevalence ; for example, in this study, unweighted prevalence among participants who self-reported their HIV status was 1.6% and was adjusted to 2.6% with biomarker RDT results. Factors such as stigma or seroconversion after their last HIV-negative test could explain the low sensitivity of 52.7% in our study. A similar study in rural Malawi also reported low sensitivity (38.7%) for self-reported HIV status .Following ARV testing of blood samples from all participants who tested HIV positive, a high proportion (28.4%) of individuals who self-reported being HIV negative had detectable ARV biomarkers, indicating possible intentional concealment of their HIV-positive status. This is not surprising due to pervasive HIV stigma and discrimination in Nigeria , perhaps because they were not informed about their status by caregivers  or because they fear stigma and isolation by their peers , 28; this may explain the low sensitivity of the screening question among adolescents and young adults in our analysis. Additionally, younger people may also have more likelihood of infections since their last test, since infection rates are higher in these age groups, leading to lower sensitivity in this age group.Studies have shown that adolescents and children have low disclosure rates . With 54.5% specificity, self-reported ARV use may not correctly identify individuals who are not using ARV because up to 45.5% may be misclassified as not receiving ART. It is difficult to ascertain why PLHIV may decide to conceal ARV use in survey settings after disclosing HIV-positive status. Some studies reported similar cases of disclosure of HIV status but non-disclosure of ARV use , 29–31 and suggested fear of exclusion from the survey or fear of breach of confidentiality if they had not disclosed their HIV-positive status to their partners  as possible explanations. We found that age influenced self-reported ARV use and, as with self-reported HIV status, the sensitivity of self-reported ARV use was lower among adolescents and young adults than adults. Therefore, self-reported HIV status or ARV use may need to be confirmed by RDT or ARV biomarker testing (LC/MS/MS) even though detecting blood ARV levels is expensive and requires expertise not readily available in most sub-Saharan African countries –35 including Nigeria. Inaccurate self-reported ARV use data could lead to underestimation of progress toward the second UNAIDS 90 target, as found in several studies and other PHIAs , 36–38 including NAIIS . Underreporting progress toward the second 90 target also could affect the first and third 90 coverage estimates.In contrast to self-reported HIV status, HIV-positive participants receiving ART were more likely to self-report ARV use, probably because ARV use is considered good practice and is encouraged. This is supported by the high PPV; additionally, among participants who reported receiving ART only 5.5% had no detectable ARV biomarkers in their blood in our study, which may be due to recent poor adherence, as reported in other studies , 36. The inclusion of biomarkers added to reliability of 90-90-90 estimates, which support planning and implementation of effective strategies for HIV epidemic control. In our study, the 17% gap in the first UNAIDS 90 target coverage between self-reported ARV status (30%) and adjusted ARV (47%) shows that self-reported HIV status may impact the accuracy of the underlying data used to estimate progress toward the first 90 target and also reiterated the importance of ARV biomarker results in adjusting not only progress toward the second 90 target but also the entire 90-90-90 cascade. In our study, ARV biomarker results were more likely to change estimated progress toward the first 90 target than the second or third 90 targets because individuals who have already disclosed their HIV-positive status are more likely to report receiving ART. In Kenya, a similar study showed that the progress toward the first 90 target changed from 46.9% based on self-reported HIV status to 52.7% after adjustment using ARV biomarker results, to 57.5% when adjusted by undetected viral load data, and to 59.8% when adjusted by either ARV biomarker or undetected viral load data . Unlike the Kenya study, in NAIIS, we did not adjust progress toward the first 90 target by undetected viral load data because few of the respondents had undetectable viral load. Despite the complexity, cost, and lack of ready availability, ARV biomarker tests’ impact on adjustment of progress toward the first 90 target outweigh these constraints. However, use of undetectable viral load data may serve as an alternative in populations with high undetectable viral load rates because viral load testing is a major component of comprehensive ART programs and is readily available in most resource-limited settings.Previous studies have shown ARV biomarker data can be used to adjust self-reported HIV status by recategorizing respondents with detectable ARV blood levels as having a previous HIV diagnosis and receiving ART Our findings are subject to at least four limitations. First, since only participants who agreed to be tested for HIV were analyzed, there is likelihood of some participants among those who didn’t accept testing to be aware of their HIV status and this might have affected the overall findings discussed. Similarly, ARV drug testing was not performed for participants with unknown or negative self-reported HIV status who had a single negative rapid test. While it may not have been feasible to test these persons for ARV drugs because of the large size of this group, some of these persons could have been on ART and it is well known that ART can down-regulate antibody production and can cause false negative HIV rapid tests , 40. SecS1 Data(CSV)Click here for additional data file.


Although recommendations exist for patients to be offered a post-operative helpline or telephone follow-up appointment at discharge after cholecystectomy, implementation of these is resource-intensive. Whilst the benefits of telephone follow-up are well documented, the use of digital modalities is less so. We aimed to identify if digital follow-up (DFU) was equivalent to routine care with telephone follow-up (TFU), for patients undergoing elective laparoscopic cholecystectomy.All patients listed for elective laparoscopic cholecystectomy between August 2016 and March 2018 were offered routine post-operative care (TFU or no follow-up) or DFU at a tertiary referral centre in Nottingham.p < 0.0001. Over 5 times as many patients who chose TFU missed their appointment compared to DFU . At 30-days post-operatively, patients undergoing TFU had significantly more post-operative wound infections identified then those undergoing DFU . However, this did not impact the incidence of 30-day readmissions between groups (7.2% TFU vs. 7.1% DFU). No complications were missed by either the DFU or TFU modalities. DFU was completed significantly earlier than TFU  with high patient acceptability, identifying complications and alerting clinicians to those patients requiring an early review.Of 597 patients undergoing laparoscopic cholecystectomy, 199 (33.3%) opted for TFU, and 98 (16.4%) for DFU. DFU was completed for 85 (86.7%) participants and TFU for 125 (62.8%), This feasibility study has demonstrated that digital follow-up is an acceptable alternative to telephone follow-up after elective laparoscopic cholecystectomy.The online version contains supplementary material available at 10.1007/s00268-022-06684-w. Over 60,000 cholecystectomies are performed in the UK each year , with laTelemedicine and TFU, although less resource-intensive than physical follow-up appointments, still requires the use of trained health care professionals when compared with no follow-up, resources which are already stretched in the current National Health Service (NHS) and could be better used , 11.Prior to Covid-19, the NHS aimed to deliver more health care remotely through the introduction of new technologies such as the NHS App . This enThe aim of this study was to identify if digital follow-up (DFU) using an online platform, was equivalent to routine care with telephone follow-up (TFU), for patients undergoing elective laparoscopic cholecystectomy. Primary objectives were to identify the incidence of 30-day post-operative complications identified by DFU compared with TFU. Secondary objectives were to identify the incidence of 30-day readmissions, reoperations, and the incidence of missed complications, in addition to follow-up compliance between groups.This prospective cohort study was conducted in a large NHS trust with tertiary centre capabilities. All patients listed for elective laparoscopic cholecystectomy between August 2016 and March 2018 were given free choice on whether they opted to use post-operative DFU or routine post-operative care. Routine care included TFU at the Nottingham City Hospital site, and no follow-up at the Queen’s Medical Centre and Circle Treatment Centre sites. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines .Participants were recruited to participate in this study on referral to hospital for management of symptomatic gallstones. On receiving study information either postally or in person, each participant indicated their consent to participate digitally.Access to the DFU survey was automated once participants had confirmation of an operation date and were discharged from hospital. Internally coded information technology links with the Nottingham University Hospitals NHS Trust (NUH) Patient Administration System (PAS) and the online platform meant that admission and discharge dates for surgery were inputted automatically. The entire process was overseen by a researcher to ensure no system glitches throughout.Study participants registering for DFU received a system-automated email to complete a digital survey at 7 days post-operatively, and one further reminder for non-responders at day 10.The 7-day follow-up survey Table  consisteVideo 1: Reassured and discharged:Participants were provided with a downloadable patient recovery information sheet and contact details for a specialist nurse should they need.Video 2: Telephone call-back within 24 h:Participants were informed they would receive a telephone consultation within 24 h. They were also provided with a downloadable patient recovery information sheet and contact details for a specialist nurse.Participant scores following completed DFU surveys were forwarded to the trial researcher who was then able to track responses and conduct TFU where appropriate.Participants who opted for TFU were called between post-operative day 10 and 14 by one of three surgical care practitioners (SCPs). These were pre-booked appointment slots arranged with the patient on discharge from hospital. SCPs are trained health care professionals with prior registration as either an operating department practitioner or registered nurse with more than 5 years of post-registration experience.Prospective audit was conducted for all patients. Data on complications, readmissions, reoperations, and mortality were taken from patient clinical notes, the PAS record of hospital attendances, and participant interview. Information on attendances to primary care, walk-in centres and other hospitals was, therefore, limited.The outcome measures monitored included 30-day post-operative complications, 30-day readmissions, re-operations, and missed post-operative complications, and follow-up compliance.Data on patient and hospital characteristics were collected, including patient age, sex, Charlson comorbidity index (CCI) , body map < 0.05.Data were analysed using GraphPad Prism® version 8.3.0 . Differences between groups were evaluated using either Fisher’s exact test or chi-squared tests for categorical variables and Mann–Whitney tests for continuous variables. Differences were considered significant at This study was a part of PhD project sponsored by NUH, through a collaboration with EIDO Healthcare Limited and The Royal College of Surgeons of England. The study proposal was appraised by the confidentiality advisory group: 16/CAG/0045, with public and patient involvement, and research ethics committee application: 16/SW/0088. It was registered with ClinicalTrials.gov: NCT02810860, and NUH research and innovation: 15GS002.A total of 898 eligible patients were invited to participate in the study and use the digital platform across the three NUH sites. Some 607 (67.6%) patients went on to undergo cholecystectomy, with the remainder having non-operative management  of all patients undergoing laparoscopic cholecystectomy were offered post-operative follow-up. One third (33%) were offered DFU and two-thirds (67%) were offered TFU.n = 56], vs. 5.6% [n = 5], p < 0.001).Of the patients who opted for follow-up, significantly more patients missed their TFU than DFU appointments  of all 63 complications in the follow-up group required attendance , and 2 (0.9%) a return to theatre. Only 3 1.4%) of the readmissions were identified at follow-up  in the DFU group required readmission, and 1 a return to theatre. Only 3 of the readmissions were identified at follow-up Table . ConversNo complications were missed by either the DFU or TFU modalities. Complications not identified were those which occurred either before follow-up was offered or after follow-up was completed. Early complications  occurred before follow-up, late complications  occurred after follow-up. Complications identified after follow-up were either not present at the time of follow-up  or identified at the time of follow-up with patients given appropriate advice should the complication evolve with time  (Table p = 0.001).Post-operative follow-up was completed significantly earlier with DFU then TFU .This feasibility study has demonstrated that utilizing a DFU system is a viable alternative to TFU in participants undergoing elective laparoscopic cholecystectomy.There were no statistically significant differences in participant variables between no follow-up and follow-up groups. Differences in total length of hospital stay after surgery could be explained due to differences in case complexity as the QMC site mainly has inpatient cholecystectomies performed by hepatobiliary surgeons. These participants with more technically difficult operations may experience a longer length of hospital stay, and in-hospital reviews; therefore, not warranting follow-up, or resulting in alternative follow-up arrangements not captured by this study. Unfortunately, operative difficulty was not collected as part of this study which would be a useful correlation , especiaAs expected, follow-up groups had significantly more complications identified at 30-days post-operatively than no follow-up groups. This would coincide with the fact that in this observational study participants who received follow-up were not only actively tracked but also reviewed either by telephone consultation or in person. Thus, even the smallest of complications, such as surgical site infections and the development of constipation were logged and monitored. Conversely obtaining data on no follow-up participants was a little less transparent involving prospective audit whilst in hospital, and then monitoring of PAS and health care records for recorded planned and unplanned admissions and treatments. Resultantly more subtle complications may have been managed in the community and therefore missed for the purposes of this study.Participants who received TFU had greater recorded surgical site infections than those who underwent DFU. Although DFU participants were closely monitored throughout the study, not all DFU participants received a telephone interview and, therefore, the more subtle features of a wound infection may have been missed on our automated survey. However, many of the wound infections identified by TFU received only verbal advice on wound care as opposed to the necessity for hospital or general practitioner attendance or a course of antibiotics, and therefore the extra complications identified at TFU were potentially insignificant.Overall numbers for readmission and reoperation at 30-days were small, and therefore although there were no significant differences between follow-up and no follow-up groups, the study was likely underpowered to comment. On review of national data however, 30-day readmission rates are quoted at 5.4–8.2%, and reoperation rates of 0.6–0.8% [As expected, there were no deaths in any group. This is in keeping with mortality being a poor outcome measure for cholecystectomy research given its low incidence , 17, 18.No complications were missed nor were complications falsely identified in either DFU or TFU groups. This suggests that the automated DFU survey and associated scoring system is a safe alternative to conventional TFU.The additional benefit of DFU is that the speed and ease of completion of follow-up surveys means that they could be offered at multiple post-operative time points to fully capture any possible early or late complications, such as those not captured in this study. Additionally, the digital process could be amended to facilitate a patient-triggered follow-up to aid earlier identification of those patients who may be developing a complication or need earlier clinician input. Such patient-triggered follow-up questionnaires could inform and give patients access to acute surgical triage units to ensure the timely admission and assessment of patients.p < 0.001) of participants missed their TFU compared with DFU appointments.Participants who were offered DFU were significantly more likely to complete their follow-up than those offered TFU. This was even though participants in both groups had opted in for their chosen follow-up modality. Additionally, TFU participants had a pre-arranged date and time for their follow-up appointment which was not only confirmed on discharge but also posted to participants. Despite this, 30.9% versus 5.6% Below is the link to the electronic supplementary material.


Although asthma does not appear to be a risk factor for severe coronavirus disease 2019 (COVID-19), outcomes could vary for patients with different asthma subtypes. The objective of this analysis was to compare COVID-19 outcomes in real-world cohorts in the United States among patients with asthma, with or without evidence of allergy.In a retrospective analysis of the COVID-19 Optum electronic health record dataset , patients diagnosed with COVID-19 with a history of moderate-to-severe asthma were divided into 2 cohorts: those with evidence of allergic asthma and those without . After 1:1 propensity score matching, in which covariates were balanced and potential bias was removed, COVID-19 outcomes were compared between cohorts.n = 1578 per cohort), risk of death from any cause after COVID-19 diagnosis was significantly lower for patients with allergic vs nonallergic asthma , and a smaller proportion of patients with allergic vs nonallergic asthma was hospitalized within − 7 to + 30 days of COVID-19 diagnosis . Among hospitalized patients, there were no significant differences between patients with allergic or nonallergic asthma in need for intensive care unit admission, respiratory support, or COVID-19 treatment.From a COVID-19 population of 591,198 patients, 1595 patients with allergic asthma and 8204 patients with nonallergic asthma were identified. After propensity score matching (Asthma subtype may influence outcomes after COVID-19; patients with allergic asthma are at lower risk for hospitalization/death than those with nonallergic asthma. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can result in life-threatening respiratory symptoms –6, have Interestingly, studies have reported that COVID-19 outcomes may be better for patients with allergic asthma than for patients with nonallergic asthma. For example, analysis of UK Biobank data found that nonallergic asthma was significantly associated with severe COVID-19, whereas allergic asthma had no association with severe COVID-19 . In addiBecause outcomes associated with COVID-19 may differ by data source , and by country , we conducted a real-world retrospective electronic health record (EHR) database analysis in the United States. To assess potential differences between asthma subtypes, COVID-19 outcomes, including deaths, hospitalizations, and interventions and treatments, were evaluated and compared in patients with and without evidence of allergic asthma.This was a retrospective analysis of data from the COVID-19 Optum EHR database , which includes medical records sourced from high proportions of ambulatory, hospital, and integrated delivery networks throughout the United States, regardless of insurance provider. Data for patients of any age (capped at birth year of 1930 and earlier) with confirmed COVID-19 between February 20, 2020 and January 28, 2021, were used.International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code of U07.1  or U07.2  ) had a diagnosis of allergic asthma than nonallergic asthma  and more likely to have severe asthma (26.5% [n = 422/1595] vs 6.5% [n = 533/8204]).A total of 591,198 records were identified for patients who had been diagnosed with COVID-19 during the study period. Among patients with an asthma diagnosis, considerably fewer patients , although the overall Charlson Comorbidity Index scores were similar for the matched cohorts.Propensity score matching yielded study cohorts for allergic and nonallergic asthma that both included 1578 patients . Among patients who visited the ED or who were hospitalized between 7 days before and 30 days after the index date, a higher proportion of patients with nonallergic asthma than allergic asthma died (from any cause).More patients with nonallergic asthma than allergic asthma died (from any cause) after a diagnosis of COVID-19 (2.4%  vs allergic asthma, 45.9% [n = 724]; P = 0.2253) The number of outpatient visits for asthma was also similar between patients with nonallergic asthma (36.1% [n = 569]) or allergic asthma . In addition, COVID-19–related outcomes that did not require hospitalization, including loss or distortion of sense of smell, change in sense of taste, or disturbances of senses of both taste and smell, were reported for less than 2.5% of patients (data not shown), and there were no significant differences between patients with allergic or nonallergic asthma.The number of outpatient visits for any reason was similar between the cohorts , a lower rate of outpatient visits for any reason or for asthma, and higher outpatient visits for COVID-19, compared with patients with allergic asthma Table . The oveOur real-world analysis used a large database  to evaluate COVID-19 outcomes in patients with different asthma subtypes. We found that patients with evidence of allergic asthma had a lower risk of hospitalization or death from any cause after diagnosis, compared with patients with nonallergic asthma. However, once hospitalized, the rates of ICU admissions, need for respiratory support, and treatment were similar in both cohorts. In addition, we found that only around 11% of patients with COVID-19 and asthma had allergic asthma, which was a lower proportion than might be expected from epidemiological studies of asthma . AltOur findings are in line with previous studies and support that allergic asthma is associated with lower risk of severe COVID-19 outcomes than nonallergic asthma , 11, 14.ACE2). ACE2 expression is upregulated in individuals who are at higher risk of severe COVID-19, such as people with diabetes and obesity, and in those who smoke [ACE2 in the airways of in adults and children with asthma and found that ACE2 expression was lower in the airway of patients with allergic sensitization and asthma compared with patients with nonallergic asthma [ACE2 expression combined with expression of immunomodulators could contribute to lower COVID-19 susceptibility for patients with nonallergic asthma, and this hypothesis is supported by a growing body of preclinical and clinical evidence [The potentially lower risk of SARS-CoV-2 infection in patients with allergic asthma compared with nonallergic asthma could theoretically be explained by differences in expression of the key SARS-CoV-2 cellular receptor, angiotensin-converting enzyme 2 (ho smoke –31. Jackc asthma . Reducedevidence , 32–37.This study had a number of strengths, including a large sample size of patients from across the United States. The data also allowed tracking of patients with COVID-19 from diagnosis through to treatment, and distinguishing of patient symptomology between patients with a positive COVID-19 test and those with a negative COVID-19 test. However, there are a number of limitations that could hinder the applicability and generalizability of the findings, which are mostly related to the database. The major limitation is that ICD-CM-10 codes do not exist for allergic asthma; as a result, the case definitions used for the 2 cohorts were based on current literature, clinical opinion, and available data in the database, which included a positive IgE test, omalizumab use, or a skin prick test ordered by a specialist. Therefore, it is possible some patients may have been misclassified as not having allergic asthma if these data were not available. However, a positive skin prick test is thought to be likely if it has been ordered by a specialist, and omalizumab is indicated for use in allergic asthma and not in nonallergic asthma. Although it is possible that omalizumab could be prescribed for chronic spontaneous urticaria in patients with nonallergic asthma, and these patients could have been misclassified as having allergic asthma, the presence of asthma as a comorbid condition in patients with chronic spontaneous urticaria is low . In addiIn summary, this real-world retrospective analysis of a large EHR database from the United States found that allergic asthma was associated with a lower risk of poor outcomes, including a lower risk of death, from COVID-19 compared with nonallergic asthma. Among patients with asthma and SARS-CoV-2 infection, a lower-than-expected proportion had allergic asthma, which may suggest a lower infection rate. These findings contribute to the growing body of evidence on SARS-CoV-2 infections in patients with asthma, including differences in outcomes for asthma subtypes.


To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat.A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention . Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years  or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years.PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture.Bone Joint J 2022;104-B(11):1256–1265.Cite this article:  Achilles tendon ruptures result in immediate and sustained limitations in weightbearing activities, leading to work incapacity and a prolonged period of inability to participate in sport.The most commonly ruptured tendon is the Achilles, and the incidence is rising as people maintain sporting participation into later life. and has received substantial public attention due to its promise as a regenerative therapy. PRP is an autologous blood product that provides a supraphysiological concentration of platelets, leucocytes, growth factors, and other bioactive proteins such as cytokines and chemokines for delivery to an injury site. PRP basic science studies have shown positive cellular and physiological effects on tendon healing under laboratory conditions, and although there are over 30 published clinical trials on PRP applications in musculoskeletal injuries, its efficacy remains uncertain.Platelet-rich plasma (PRP) is a popular intervention in sports medicine and orthopaedic practice for musculoskeletal soft-tissue injuries, The rationale for PRP in Achilles ruptures is to improve the speed of healing, final quality of recovery, or ideally both. If a difference in speed of healing is evident, it would be observed when the tendon was in the initial recovery stages. The PATH-2 trial primary outcome measure at 24 weeks post-injury was timed to capture speed of recovery, and found no evidence of a difference in objective muscle function (heel-rise endurance test (HRET)) and patient-reported outcomes. However, Achilles tendon rupture prevents full return to function, sport, and work over a longer period, with an overall recovery time of greater than two years post-injury. Therefore, if PRP affects the quality of the recovering tendon, we could expect to see this in longer-term outcomes. In this study we conducted extended follow-up at two years post-randomization, to assess whether there is any beneficial effect of PRP on the quality of the recovering Achilles tendon in terms of level of long-term recovery of function.In the PATH-2 study, we aimed to determine the clinical efficacy of a standardized PRP preparation for acute non-surgically managed Achilles tendon ruptures in a randomized controlled trial. The study was approved by the National Research Ethics Service Oxfordshire Committee A (reference 14/SC/1333) and overseen by an independent trial steering committee and data monitoring and ethics committee. Participants were recruited between 28 July 2015 and 18 September 2017, with two-year follow-up completed on 21 October 2019.PATH-2 was a placebo-controlled, multicentre, superiority, randomized controlled two-arm parallel-group trial with blinded participants and outcome assessments. The trial was conducted at 19 hospitals in England and Wales, UK. The trial protocol and analysis plan have been published and are summarized below.Participants were adults aged 18 years and over with a clinical diagnosis, with or without diagnostic imaging, of complete acute mid-substance Achilles tendon rupture. To be eligible, patients had to be within 12 days of injury, able to walk unaided pre-injury, and non-surgically managed with a cast or boot. Patients were not eligible if they had a tendon rupture at the insertion or musculotendinous junction, previous major leg injury or deformity, diabetes mellitus, platelet or haematological disorder, current systemic corticosteroids, treatment doses of anticoagulation therapy, or other contraindicating conditions . Development and amendments to the protocol have been described elsewhere. These amendments were approved by the trial oversight and ethics committees.Participants were recruited in the trauma clinic and after providing written informed consent, baseline data were collected. Participants were then individually randomized 1:1 to an injection of PRP or placebo via the Oxford Clinical Trials Research Unit central 24-hour web-based randomization allocation system. Initial randomization was variable permuted blocks stratified by study site and age group (< 55/≥ 55 years). Monitoring identified that a technical issue resulted in the age group strata not being implemented. To ensure balance at the end of the study over stratification factors the system was switched to minimization using the existing randomized participants, including a probabilistic element (0.8). Minimization factors were study site and age group as originally intended.In the outpatient trauma clinic and within 12 days of injury, participants had blood withdrawn and received an injection in the gap in the ruptured tendon. Participants in the placebo group had 5 ml of venous blood withdrawn that was used for whole blood analysis. Participants assigned to PRP injection had 55 ml of venous blood withdrawn. A total of 5 ml was used for whole blood analysis, and 50 ml was used to produce 8 ml of leucocyte- and platelet-rich plasma using a specialized automated centrifuge  and a sterile disposable kit . All participants waited approximately 17 minutes after blood withdrawal before having the injection.Participants lay face down on a treatment table and then the treating surgeon or specialist physiotherapist palpated the tendon to identify the tendon gap for injection. Ultrasound guidance was not mandated or recorded as this facility was not routinely available in the trauma clinic setting. After the injection site was cleaned, local anaesthetic (1 to 2 ml lidocaine) was injected into the skin, then the allocated injection (placebo or PRP) was performed in the centre of the tendon gap. For the PRP group, 4 ml of PRP was injected, and the remaining 4 ml was processed for laboratory analysis. The placebo injection used the same sized needle attached to an empty syringe inserted into the tendon gap, held in place for the duration of a PRP injection, and was withdrawn without injecting anything. All treating clinicians undertook study-specific training, used a step-by-step manual, and had access to a training video. Further details on PRP preparation and analysis are available elsewhere.Participants had the routine local non-surgical management for acute Achilles tendon rupture, apart from the standardized rehabilitation protocol. The rehabilitation requirements for the trial were that the ankle needed to be initially immobilized in an equinus position for at least three weeks post-injection, and avoidance of full-time ankle immobilization or non-weightbearing for longer than six weeks. All participants were referred to a physiotherapist for supervised rehabilitation. Platelet quality within fixed resting and activated samples  was analyzed by measuring the expression of the platelet-specific activation marker P-Selectin (CD62p) by flow cytometry . Growth factor concentrations (platelet-derived growth factor AB (PDGF-AB), insulin-like growth factor 1 (IGF-1), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGFb), and transforming growth factor beta 1 (TGF-β1)) within the PRP were measured by enzyme-linked immunosorbent assay.Whole blood and PRP samples were analyzed in a central laboratory at the Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK. Cell counts were assessed using a Sysmex XN-1000 Haematology analyser , providing three different platelet counts: impedance (PLT-I); optical (PLT-O); and fluorescent (PLT-F). Where possible, the PLT-F count was the preferred choice. Instrument performance was checked internally daily  and externally monthly .All participants were informed that up to 55 ml of venous blood would be taken. It was deemed unacceptable to take more venous blood than required for study participation, so the volume was different between the groups (55 ml for the PRP group and 5 ml for the placebo group). Injections were prepared away from participants and a dummy spin cycle was used for the placebo group if the centrifuge was nearby. Participants received the injection lying face down with instructions not to turn. Clinicians preparing or delivering the intervention could not be blinded.The two-year follow-up study was conducted by postal questionnaires. The study team telephoned participants to improve response rates if there was no response by post. The patient-reported outcomes at earlier stages were by questionnaires completed face-to-face or by telephone at four, seven, 13, and 24 weeks post-randomization by a researcher at the recruiting centre. Functional limitations due to pain were assessed using the score from the pain-related ATRS . Functional goal attainment was measured using the Patient-Specific Functional Scale (PSFS) . Health-related quality of life was assessed using the 12-Item Short-Form Health Survey questionnaire (SF-12) v2 Health Survey . Participants were also asked about re-ruptures since the 24-week follow-up.Patient-reported symptoms and function were assessed using the Achilles Tendon Rupture Score (ATRS)  (primary outcome for follow-up study).The primary outcome for the PATH-2 trial was the HRET, but the sample size also provided 90% power and 5% (two-sided) significance to detect an effect size of 0.5 in the principal secondary outcome, the ATRS, between the two treatment arms, based on a mean difference of 11 and a standard deviation (SD) of 21.4. A 58% response rate to the two-year follow-up (n = 124) would have provided 80% power at a 5% significance level to detect an effect size of 0.5 in the ATRS. With a more optimistic response rate of 79% (n = 168), the study would have had 90% power to detect a similar effect size (0.5) at the same significance level (5%). The actual response rate at two years was much higher at 84% (n = 182). Analysis was undertaken on the modified intention-to-treat (ITT) population, that is: all randomized participants with available outcome data were analyzed in the groups to which they were allocated. All participants with baseline and at least one post-treatment questionnaire were included in the analysis. ATRS, PSFS, and SF-12 physical and mental components were analyzed using repeated measures linear mixed effects regression models incorporating all timepoints (as time-elapsed from randomization) as a random effect and adjusting for baseline values, stratification factors (study site and age group), and important prognostic factors . Where the outcome measure was not normally distributed, non-parametric methods were used with no adjustment. As pain-related ATRS had hit the ceiling of ten points for many of the participants at 24 months, Spearman’s rank correlation coeficient was used to assess for differences between groups with no adjustment, and medians are presented. Compliance average causal effects (CACE) analyses were carried out for ATRS adjusting for treatment compliance and also for treatment compliance with high PRP. Consistency of effects across subgroups of age, BMI, smoking, and sex were assessed using Forest plots. Correlation between ATRS at two years and key blood parameters and bioactive factors for the participants who received the PRP intervention were explored using Pearson’s correlation. Statistical significance was set at a p-value < 0.05.The trial is reported following the Consolidated Standards of Reporting Trials (CONSORT) Statement and its related extensions.Overall, 1,166 patients were screened for eligibility, and 230 consented to randomization .Baseline characteristics were well balanced between the randomized groups and between responders and non-responders at two years’ follow-up . ParticiTwo-year questionnaires were sent to the 216 participants  who had completed a 24-week questionnaire and had not died or withdrawn consent. Of these, 182 returned their questionnaires , a response rate of 84%. Overall, 182/230 (79%) randomized participants provided two-year responses. Of the responding participants, 7.1% (13/182) were contacted by telephone rather than by questionnaire. in summary, the PRP prepared had 4.1-fold  3.6 to 4.5) greater platelet concentrations and 2.2-fold (95% CI 2.0 to 2.5) greater leucocyte concentrations than whole blood. Platelet quality measurements showed that PRP was not activated during preparation.An attending surgeon delivered the injections for 86/113 (76%) of the PRP group and 87/116 (75%) of the placebo group. Surgical residents/fellows or specialist physiotherapists delivered the remaining injections. Injections were delivered a mean 5.3 days (SD 3.0) post-injury. Further detail on PRP analysis is available elsewhere;Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of differences between the PRP and placebo groups in the patient-reported outcomes of the ATRS, ATRS pain score, PSFS, or SF-12 at two years . OverallConsistency of treatment effect for ATRS was explored for subgroups of age, BMI, smoking, sex, and sports participation . There wA total of 78 participants who received the allocated PRP injection and were not lost to follow-up at two years also completed their final ATRS assessment. Seven participants who received a placebo injection, in place of the PRP they were allocated to, completed their two-year follow-up ATRS. This resulted in a 92% (78/85) compliance to treatment allocation among PRP patients within the trial. In the subsequent CACE analyses for treatment compliance and for treatment compliance with high-quality PRP, there was no evidence of a difference between the PRP and placebo groups, consistent with the ITT analysis .Neither PRP cellular or growth factor  concentrations or quality measurements (activated CD62p and mean fluorescence intensity (MFI)) correlated with the two-year ATRS . Of the The PATH-2 trial two-year follow-up found no evidence that PRP improved Achilles tendon symptoms and function, pain, goal attainment, and quality of life in patients with Achilles tendon ruptures. These findings question the hypothesis that PRP affects the quality of the recovering tendon, in terms of resulting in improvements in longer-term recovery outcomes. This finding is supported by the good follow-up rate, robust trial methods and conduct, comparability between the characteristics of responders and non-responders, and consistency across outcome domains. Along with the 24-week follow-up reported previously, this study provides robust evidence to question the clinical efficacy and value of PRP for acute Achilles ruptures in both shorter-term and longer-term recovery.Previous under-powered trials of PRP in Achilles rupture were hampered by a lack of standardization in the PRP preparation methods and quality control procedures, small sample sizes, potential confounding effects of use with surgery, and short-term follow-up.The trajectory of recovery over two years showed improvements in patient-reported outcomes over time. There was evidence from pre-injury physical and mental quality of life (SF-12) scores, completed by recall during the acute trauma clinic visit within 12 days of injury, that participants were close to being fully recovered. However, this contrasts with the Achilles-specific symptoms and function assessed by the ATRS, which indicates deficits at two years. There were no pre-injury ATRS scores, which limits interpretation, but it could be anticipated that further recovery is possible after two years given the recovery at seven years reported by Brorsson et al. in line with modern guidelines. These quality control analyses revealed that the treated patients received a single injection of good-quality leucocyte-rich PRP (L-PRP), all prepared by the same methodology and device (MAG 200 MAGELLAN) across all trial centres. The platelet, leucocyte, and erythrocyte concentrations observed within the L-PRP preparations were not only in the same order of magnitude as previously reported studies, but they were in line with manufacturer specifications using the Magellan device. As expected, there were also significant associations between the concentrations of growth factors within the L-PRP with both platelet and leucocyte counts. Furthermore, the growth factor concentrations obtained were also comparable and within the same order of magnitude of previously reported levels using the same device. Remarkably, variations in L-PRP content  were not associated with the level of recovery of Achilles tendon-muscle function at 24 weeks or with patient-reported recovery at two years. Interestingly, a small number of participants also received very low concentrations of platelets and growth factors within their PRP due to a few unforeseen problems with the Magellan device, but this had no notable impact on recovery. A few patients also received very high concentrations of platelets, but this also had no positive or negative impact upon outcomes at 24 weeks or two years. Despite this, the biological effects of the leucocytes and red cells in L-PRP for tendon healing remain uncertain, with in vitro investigations potentially identifying both a range of positive or negative effects. Currently, leucocyte-rich preparations are widely used in clinical practice as buffy coat derived PRP results in leucocyte and red cell inclusion within L-PRP preparations. Future studies comparing different formulations including L-PRP and PRP both with and without red blood cells are therefore required.One important feature of the PATH-2 trial was the quality control measurements of all the PRP preparations that were injected into all participants,The PATH-2 trial limitations included that the volumes of whole blood taken from the two randomization groups were different (55 ml PRP vs 5 ml placebo). However, we would have anticipated any resentful demoralization from the placebo group participants upon realizing that they were not having the experimental intervention, to have only increased the likelihood of showing a difference in favour of PRP. We did not use the HRET for the two-year follow-up, the primary endpoint for the 24-week follow-up, as it required a hospital visit and specialist equipment and training over the 19 hospitals, which was beyond the resources available for this longer-term follow-up study. Deficits in performance in the HRET can be present at two years or more after Achilles rupture, so this measure could have provided greater sensitivity as an outcome measure.In conclusion, PRP injections did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo, indicating that PRP offers no patient benefit in the long term.Take home message- Autologous platelet-rich plasma (PRP) containing supraphysiological platelet concentrations from whole blood are used to treat acute Achilles ruptures with the aim of improving tendon healing, which may result in improvement in longer-term outcomes.- The PATH-2 trial found no evidence of efficacy at 24 weeks after treatment, but there is uncertainty about clinical efficacy in the longer term.- Our study found no evidence that PRP injection improved patient-reported function or quality of life two years after acute Achilles tendon rupture compared to placebo, and therefore offers no patient benefit in the longer term.


SARS-CoV-2 infection is associated with a wide range of clinical manifestations and severity. Pediatric cases represent <10% of total cases, with a mortality rate below 1%. Data of correlation between SARS-CoV-2 viral load in respiratory samples and severity of disease in pediatric patients is scarce. The cycle threshold (CT) value for the detection of SARS-CoV-2 could be used as an indirect indicator of viral load in analyzed respiratory samples.The aim of this study was to describe CT values and their correlation with clinical manifestations, epidemiology and laboratory parameters in pediatric patients with confirmed COVID-19.In this observational, retrospective, analytic and single-center study we included patients under 15 years with confirmed COVID-19 by RT-PCR SARS-CoV-2 admitted to the Isidoro Iriarte Hospital (Argentina) between March 1st 2020 and April 30th 2021.485 patients were included, the distribution according to disease severity was: 84% (408 patients) presented mild disease, 12% (59 patients) moderate disease and 4% (18 patients) severe disease. Patients with moderate and severe illness had an increased hospitalization rate, prolonged hospitalization, higher frequency of comorbidities and oxygen and antibiotics use. CT values, that could be used as an indirect measure of viral load, was associated with severity of clinical manifestations and age under 12 months. No patient required admission to PICU nor mechanical ventilation. No deaths were registered.In this study, the viral load of SARS-CoV-2 in respiratory samples, determined by the cycle threshold, was significantly correlated with moderate to severe cases and with age. Cases of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were first reported in late-December 2019. In March 2020 the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic. By August 12th 2021, 200 million cases and more than 4 million deaths were reported worldwide and 5 million cases and more than 100 thousand deaths in Argentina  values in a RT-PCR  assay is defined as the number of cycles required for the fluorescent signal to cross a certain threshold. CT levels are inversely proportional to the amount of target nucleic acid in the sample and can be an indirect measure of viral load of the samples. Although there is no direct viral load quantification, it can be extrapolated that each 3.3 increase in CT value correlates with ~1 log  less target in the nasopharyngeal sample undergoing the PCR. In line with this idea, it is possible to determine CT ranges of the different samples as indicators of high (CT below <25), moderate (CT between 25 and 35) and low (CT over 35) viral loads.Since COVID-19 outbreak, several reports have tried to address whether viral load and illness severity are correlated in adult and pediatric patients. The aim of this study is to contribute with this topic focusing on the correlation of SARS-CoV-2 viral load in respiratory samples with clinical severity. Additionally, epidemiological, clinical characteristics and laboratory parameters of COVID-19 positive patients are analyzed.An observational, retrospective and analytic study was conducted including patients aged <15 years with a RT-PCR SARS-CoV-2 test positive who attended to the Hospital Zonal General de Agudos “Dr. Isidoro G Iriarte” from Quilmes, Buenos Aires, Argentina between March 1st, 2021 and April 30th, 2021.Patients with confirmed SARS-CoV-2 infection by RT-PCR in samples from the upper respiratory tract.Clinical or epidemiological COVID-19 diagnosis, diagnosis by immunochromatographic methods or patients with incomplete clinical data.Severity of COVID-19 was defined by clinical and complementary evaluation according to Dong et al. .(1) Asymptomatic infection: no symptoms nor clinical signs, normal chest X-ray, positive SARS-CoV-2 RT-PCR; (2) mild: acute infection symptoms in the upper respiratory tract, including fever, fatigue, myalgia, cough, odynophagia, rhinorrhea, normal auscultation. Some cases presented no fever or had only digestive symptoms such as abdominal pain, diarrhea, nausea, and vomiting; (3) moderate: Pneumonia, persistent fever and cough-mainly dry cough followed by productive cough-, wheezing without dyspnea nor hypoxemia. Asymptomatic cases with subclinical pulmonary lesions determined by chest CT scan; (4) severe: early respiratory symptoms, fever and cough, presented with gastrointestinal symptoms such as diarrhea. Disease progression observed within 1 week reaching dyspnea with central cyanosis. Oxygen saturation of ≤92% with other hypoxia manifestations; (5) or critical: rapid progression to acute respiratory distress syndrome or respiratory insufficiency, shock, encephalopathy, myocardial lesion or cardiac insufficiency, coagulation disorders and acute renal lesions.Detection of SARS-CoV-2 RNA from samples from the upper respiratory tract was performed by RT-PCR. Nasopharyngeal swabs (combined swab) or nasopharyngeal aspirates (patients under 1 year) were collected following institutional and national recommendations. Samples were analyzed in the COVID-19 Unit of the Universidad Nacional de Quilmes (UNQ). Different commercial kits were used: GeneFinder™ COVID-19 Plus RealAmp kit  and Quantabio Script One-Step RT-PCR (Genbiotech SRL) for RNasa P detection; Real-Time Fluorescent RT-PCR Kit for Detecting SARS-CoV-2 ; DisCoVery SARS-CoV-2 RT-PCR detection kit Rox o Cy5 ; COVID-19 One-Step RT-PCR Kit FAPON . Viral load on respiratory samples was estimated using cycle threshold (CT): high viral load (CT < 25), intermediate viral load (CT 25–35) and low viral load (CT > 35). The samples were analyzed according recommendations of manufacturer.Different kits were used to detect SARS-CoV-2 RNA due availability of resources in the laboratory and the province of Buenos Aires. All of these commercially available tests were approved by the Ministry of Health of the Province of Buenos Aires and the Administración Nacional de Medicamentos, Alimentos y Tecnología Sanitaria (ANMAT). All of these kits are proven to have high efficiency. Given the differences found in cut-off values among the different commercial kits, in this work we analyzed ranges of CT values to circumvent this issue. Three different CT ranges were used <25, 25–35, and >35, to address high, moderate or low viral loads.t-test or the Wilcoxon test for those with parametric normally distributed or non-parametric distributed data, and were expressed as a mean and standard deviation or median and interquartile range, respectively. For categorical variables Chi-square test with Yates or Fisher correction was used and these were expressed as percentages. Univariate analysis was performed to identify potential predictors of severity and a multiple logistic regression model was performed to identify predictive variables for severe infection and COVID-19 fatality in the pediatric population analyzed. Variables with significant association in the initial analysis (p < 0.2) and/or those considered to be clinically relevant were analyzed using Wald test. To this realized model, we sequentially added age and comorbidities and other clinical or analytical parameters that were significant in the univariate analysis. All the variables were analyzed individually to find an independent relation with outcomes. A value of p < 0.05 was considered significant.Continuous variables were analyzed using the This study was approved for the Research Committee Board of the Hospital Isidoro Iriarte Number 65/2020. The information was processed following the guidelines of the Helsinki Declaration, the CIOMS guidelines and the national laws that determine the handling of people's data. The signing of an informed consent was not required as it was considered a low-risk investigation, with no interventions outside of standard care.p < 0.01), while gastrointestinal symptoms were more frequent in mild cases (p < 0.001). Interestingly, 21% (103 p) of patients had underlying comorbidities and these patients presented moderate and severe cases (p < 0.001).The study population included 485 patients (p), 53% (257 p) were male infants with a median age of 36 months. The distribution according to age is shown in p < 0.05). No significant differences were observed in hospital admission rates for all age groups. From hospitalized patients, 10% (49 p) required oxygen therapy and 6% (28 p) received antimicrobial therapy, being more frequent in severe cases (p < 0.05).Of the 485 analyzed patients, 20% (97 p) required hospital admission and patients with moderate and severe illness had more frequent and prolonged hospitalization (p < 0.001). In this regard, the viral load was higher in those under 12 months of age.Interestingly, patients with moderate and severe illness showed a higher viral load (No patients required to be transferred to the pediatric intensive care unit (PICU) and no patient died. The variables associated with clinical and age stratification are shown in In this study, 96% of patients had mild and moderate symptoms. These results are in line with most pediatric reports, showing mainly asymptomatic cases or mild to moderate disease. Regarding the classification of clinical severity, although we follow the one suggested by Dong et al., we consider that it would be necessary to reevaluate its application in clinical practice, as suggested by Buonsenso et al. –8.There were no differences in the proportion of male and female patients  and the clinical outcomes were not associated with sex. This differs from other reports in adults that showed that clinical infection is more likely to be more severe with higher mortality rates in men . It is iSeveral studies have shown that the median age of COVID-19 in pediatrics was between 7 and 11 years. In particular, a study in Argentina showed a median age of 7 years and infants under 12 months of age accounted for around 15% of the cases. Interestingly, our study shows a median age of 3 years and 62% of our cohort is under 5 years of age. It is according to data of a multinational experience from Latin America, where the median age of children with COVID-19 was 3 years (IQR 0.6–9 years) .Common symptoms at onset of illness were fever and respiratory manifestations, associated with moderate and severe cases; followed by gastrointestinal manifestations (such as vomiting or diarrhea) present mainly in mild disease. It is worth noting that several reports show 45–65% of pediatric cases present fever –17. On tDifferent studies show that comorbidities may be risk factors for poor outcomes with severe infection and hospitalization. Our results align with these observations, showing that 21% of cases had underlying comorbidities and these cases were associated with moderate and severe cases. These comorbidities mainly included chronic pulmonary diseases such as asthma, bronchopulmonary dysplasia and recurrent wheezing. Interestingly, obesity and diabetes mellitus explain the predominant comorbidities in a multicentric study in the United States and onco-hematological diseases were predominant in another study from Argentina , 12, 13.Our results show that 20% of patients required hospital admission and patients with moderate or severe disease had a more prolonged length of stay (LOS). No association between age and hospitalization requirement was found in our study. Similar results were found in previous studies, where hospitalization frequency varied between 6 and 25% reaching 75% depending on the facility setting –19.It is interesting to note that 6% of patients received antimicrobial treatment, mainly in moderate to severe cases due to possible bacterial co-infection. Another study in Latin America showed that 25% of patients received antimicrobial treatment and this was associated with severe cases of COVID-19 and MIS-C .Regarding SARS-CoV-2 viral load, our study showed that higher amounts of viral RNA were found in samples of moderate to severe patients and in patients under 12 months. Several studies carried out in pediatric patients show a significant association between viral load and age, sex, comorbidities, severity of disease and hospitalization requirement. Differences were found in different studies addressing viral load and age. In particular, one study in Chile showed higher viral load in children under 10 years, in another study in New York this was associated with patients under 1 year, and finally in Chicago it was reported for children under 5 years –31.Importantly, in our study no patient received a specific treatment, required admission to PICU nor required mechanical ventilation. No deaths were reported. These results are in line with reports from other healthcare settings, where critical cases and mortality are rarely observed. In Argentina, according to published data from the National Ministry of Health, two age groups of pediatric patients required PICU admission more frequently and showed higher mortality rates, children under 12 months and children between 10 and 14 years. It is important to note, that mortality in Argentina represents 0.5% of pediatric cases and was strongly associated with comorbidities  value as an indicator of viral load. In this regard, several variables might affect CT values such as collection technique, specimen type, sampling time, transport and storage conditions as well as nucleic acid extraction, viral RNA load, real time PCR efficiency and CT value determination method. Some of these limitations are thoroughly discussed by several authors and some modifications are proposed to reduce evaluation errors, such as normalization of CT values , 33. In Our study shows that the viral load of SARS-CoV-2 in respiratory samples, determined indirectly and inversely by the cycle threshold, was significantly correlated with moderate to severe cases and with age, since infants younger than 12 months showed higher amounts of RNA. Disease severity was associated with more frequent and longer hospitalization.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Hospital Zonal General de Agudos Dr. Isidoro G. Iriarte. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.MB designed the study. MB, SG, GC, MZ, LS, AC, and HF carried out and analyzed the data statistically and revised the manuscript. MB, SG, AC, and GC collected the information. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


As part of the intensified efforts, different interventions targeted at sSA’s under-five population are being considered or have been introduced in recent years. One of those is the mass distribution of azithromycin (MDA-azithromycin) to under-five children, which has shown to reduce U5M in sSA. It is postulated that since infectious disease is a leading cause of U5M in sSA, with malaria, diarrhoea, and pneumonia jointly accounting for about 40% of U5M in the region and azithromycin being effective against these diseases,3 perhaps MDA-azithromycin could be a cost-effective public health intervention to mitigate the overwhelming U5MR burden in sSA. Community-randomized trial in Ethiopia and MORDOR clinical trials across 3 sSA countries, namely Malawi, Tanzania, and Niger, on MDA-azithromycin showed reduction in U5MR by 50% and 14% respectively compared to placebo.1 As a result, in 2018, the WHO developed a guideline to guide the population-level implementation of MDA-azithromycin in countries with high U5M and a heavy burden of morbidities due to diarrhoea, pneumonia and malaria. Some sub-Saharan African countries have put plans in motion to roll-out the intervention. However, a pertinent question that keeps lingering is the potential negative attendant effects of MDA-azithromycin on anti-microbial resistance. Sub-Saharan Africa (sSA) accounts for the highest burden of under-five mortality (U5M) globally, with an estimated under-five mortality rate (U5MR) of 76 deaths per 1000 live births in 2018, leading to approximately 2.7 million deaths.4 The review on antimicrobial resistance (AMR) predicted that AMR could kill 10 million people per year by 2050, and sSA would contribute significantly to this number. With this, it is essential to critically analyze all possible interventions and practices that could contribute to the AMR burden in this region. Hence, a relevant question worth asking is “Will the population-level implementation of MDA-azithromycin exacerbate AMR-related issues in sSA?” While there is no clear-cut answer yet, evidence has shown that there is a possibility of a perpetual increase in macrolide and other antibiotic resistance in gut and respiratory bacteria after repeated MDA-azithromycin. The new Global Research on Antimicrobial Resistance (GRAM) reported that over 4.95 million deaths were attributable to AMR in 2019, with the highest case seen in western sSA at 27 deaths per 100 000 compared to Australasia, which had the least at 6.5 deaths per 100 000.E. coli strains by 400% in young children.5 Similarly, 24 months after the commencement of the MORDOR clinical trial, Doan et al showed higher proportion of macrolide-resistant nasopharyngeal S. pneumonia in azithromycin-treated communities  than in the placebo-treated communities .6 In the same vein, azithromycin-treated communities also had more macrolide-resistant determinants in the guts . Other studies also demonstrated marked rises in azithromycin-resistant pneumococcal isolates with a baseline macrolide-resistant rate of < 5% rising to 80% subsequent to multiple mass azithromycin treatments.1 Although the resistance rates decreased after cessations of MDA-azithromycin across the different studies, they did not return to the baseline levels again. Further, there are inconsistent reports on the effects of MDA-azithromycin on other classes of antibiotics. For instance, Doan et al described a significant increase in pneumococcal clindamycin resistance after MDA, whereas Skalet et al7 showed a non-consequential pattern of increasing clindamycin resistance after multiple rounds of MDA-azithromycin. Similar inconsistent trends were seen in pneumococcal resistance to sulfamethoxazole or chloramphenicol after MDA azithromycin. Thus, there is a need to conduct more elaborate studies to fully understand the effects of MDA-azithromycin on AMR before scaling up the intervention across sSA. Following MDA-azithromycin for trachoma control in rural Tanzania, Seidman et al demonstrated a significant increase in carriage of macrolide-resistant 8 Also, while significant reduction in mortality was recorded in the infant age group, about 25%, the intervention was of little benefits in children aged 1-5 years. The overall 14% reduction in all-cause mortality is significantly lower than that seen in the community-randomized trial in Ethiopia, which recorded approximately 50% overall reduction. Another trial conducted in Mali and Burkina Faso, alongside seasonal malaria chemoprevention, showed no reduction in mortality or rate of hospitalization in children aged 3-59 months.1 Based on this evidence, the need for more research on MDA-azithromycin before scale-up is critical. While MDA-azithromycin has been effective in addressing trachoma, contributing to the elimination of the disease in 14 countries as of March 2022, the impact of the intervention on U5M reduction is inconsistent. Although the MORDOR clinical trials, where children aged 1-59 months received bi-annual dosage of azithromycin over four years through mass campaigns in 3 sSA countries, showed an overall reduction in mortality by 14%, the outcomes varied across different age groups and countries. Majority of the under-five deaths averted were seen in Niger with about 18% reduction—the only site with a statistically significant U5M reduction—whereas Malawi and Tanzania had barely 5.7% and 3.5% reductions respectively. Admittedly, MDA-azithromycin is a possible tool in accelerating SDG-3 attainment by preventing U5M in sSA, but certain measures need to be put in place before rolling out the interventions at a large scale to achieve the desired outcome. For one, it is quite critical to conduct more studies on the extent of MDA azithromycin’s effect on AMR. While many studies have confirmed macrolide resistance as an undesired effect of the intervention, data is still quite limited on the effects of MDA-azithromycin on other classes of antibiotics. Likewise, it is also crucial to increase the AMR surveillance capacity of the eligible countries to track and speedily detect emerging resistance. This is particularly important as most of the countries eligible for this intervention have weak disease surveillance systems. To further reduce the likelihood of AMR, it might be prudent to conduct more studies to ascertain whether the intervention should be targeted at infants or the whole under-five age group. Considering that MDA-azithromycin showed more impact in the infant aged group with insignificant effect on children aged 1-5 years, limiting the intervention to under-one children might be a major mitigating factor in reducing AMR risk. Another relevant tool would be utilizing mathematical modelling to forecast the effectiveness of introducing MDA-azithromycin on U5M reduction against the negative attendant effects of AMR on U5M and the general population. Conclusively, evidence suggests that MDA-azithromycin holds the potential of averting several thousands of child mortalities, a menace that has longed plagued Africa; however, policymakers must as a matter of necessity conduct policy-relevant studies to determine the extent of MDA azithromycin’s effect on AMR while judiciously establishing the guiding precepts and scope of the intervention to ensure it achieves the desired impact. SIY: Conceptualizing the topic; conducting literature review; and writing the manuscript. IOO: Conceptualizing the topic, reviewing the article, and finding the right journal. OTP: Drafting the recommendation and reviewing the manuscript. BOV: Conducting literature review, writing some sections of the article and revising the manuscript. This article does not require ethical approval as all the data gathered are from literature review. There are no relevant financial or non-financial competing interests to report