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Obaid K, Basrak MT, Sawaf B, Habib H, Alkhatib M, Ashour AA, Habib MB. Rhinovirus infection presenting with symptomatic hyponatremia-Atypical presentation of a common infection. Clin Case Rep 2024; 12:e8773. [PMID: 38654937 PMCID: PMC11035375 DOI: 10.1002/ccr3.8773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024] Open
Abstract
Key Clinical Message Rhinovirus infection has the potential to exhibit unconventional symptoms like symptomatic hyponatremia. Health care professionals should remain vigilant about this potential complication, especially in cases with uncommon presentations. Timely identification and effective management of hyponatremia can mitigate potential complications and enhance patient prognosis. Abstract The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a prominent contributor to low sodium levels. Various factors can contribute to hyponatremia, affecting the diagnosis and treatment of the condition. Of note, some infections have been identified as potential causes of SIADH. Although rhinovirus infection has been linked to SIADH, it is usually associated with severe respiratory infections. Herein, we present a distinctive case where rhinovirus caused significant hyponatremia symptoms, even in the absence of typical respiratory symptoms or fever.
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Affiliation(s)
- Koutaibah Obaid
- Internal Medicine DepartmentHamad Medical CorporationDohaQatar
| | | | - Bisher Sawaf
- Internal Medicine DepartmentHamad Medical CorporationDohaQatar
| | - Hiba Habib
- Internal Medicine DepartmentAl‐Mowasat HospitalDamascusSyria
| | | | - Anas A. Ashour
- Internal Medicine DepartmentHamad Medical CorporationDohaQatar
| | - Mhd Baraa Habib
- Internal Medicine DepartmentHamad Medical CorporationDohaQatar
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Osei-Yeboah R, Johannesen CK, Egeskov-Cavling AM, Chen J, Lehtonen T, Fornes AU, Paget J, Fischer TK, Wang X, Nair H, Campbell H. Respiratory Syncytial Virus-Associated Hospitalization in Adults With Comorbidities in 2 European Countries: A Modeling Study. J Infect Dis 2024; 229:S70-S77. [PMID: 37970679 DOI: 10.1093/infdis/jiad510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/07/2023] [Accepted: 11/11/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Individuals with comorbidities are at increased risk of severe respiratory syncytial virus (RSV) infection. We estimated RSV-associated respiratory hospitalization among adults aged ≥45 years with comorbidities in Denmark and Scotland. METHODS By analyzing national hospital and virologic data, we estimated annual RSV-associated hospitalizations by 7 selected comorbidities and ages between 2010 and 2018. We estimated rate ratios of RSV-associated hospitalization for adults with comorbidity than the overall population. RESULTS In Denmark, annual RSV-associated hospitalization rates per 1000 adults ranged from 3.1 for asthma to 19.4 for chronic kidney disease (CKD). In Scotland, rates ranged from 2.4 for chronic liver disease to 9.0 for chronic obstructive pulmonary disease (COPD). In both countries, we found a 2- to 4-fold increased risk of RSV hospitalization for adults with COPD, ischemic heart disease, stroke, and diabetes; a 1.5- to 3-fold increased risk for asthma; and a 3- to 7-fold increased risk for CKD. RSV hospitalization rates among adults aged 45 to 64 years with COPD, asthma, ischemic heart disease, or CKD were higher than the overall population. CONCLUSIONS This study provides important evidence for identifying risk groups and assisting health authorities in RSV vaccination policy making.
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Affiliation(s)
- Richard Osei-Yeboah
- Centre for Global Health, Usher Institute, University of Edinburgh, United Kingdom
| | - Caroline Klint Johannesen
- Department of Virology and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - Amanda Marie Egeskov-Cavling
- Department of Clinical Research, Nordsjaellands Hospital Hilleroed, and Department of Public Health, University of Copenhagen, Denmark
| | - Junru Chen
- School of Public Health, Nanjing Medical University, China
| | - Toni Lehtonen
- Department of Health Security, Finnish Institute for Health and Welfare, Helsinki
| | - Arantxa Urchueguía Fornes
- Vaccine Research Department, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, Valencia, Spain
| | - John Paget
- Department of Primary Care, Netherlands Institute for Health Services Research, Utrecht
| | - Thea K Fischer
- Department of Virology and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - Xin Wang
- Centre for Global Health, Usher Institute, University of Edinburgh, United Kingdom
- School of Public Health, Nanjing Medical University, China
| | - Harish Nair
- Centre for Global Health, Usher Institute, University of Edinburgh, United Kingdom
| | - Harry Campbell
- Centre for Global Health, Usher Institute, University of Edinburgh, United Kingdom
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El Zakhem A, Mahmoud O, Bou Fakhreddine H, Mahfouz R, Bouakl I. Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon. Mol Biol Rep 2024; 51:346. [PMID: 38401017 DOI: 10.1007/s11033-023-09133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/08/2023] [Indexed: 02/26/2024]
Abstract
BACKGROUND Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI. METHODS AND RESULTS We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR. CONCLUSION Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.
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Affiliation(s)
- Aline El Zakhem
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, 110236, Lebanon
| | - Omar Mahmoud
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, 110236, Lebanon
| | - Hisham Bou Fakhreddine
- Division of Pulmonary and Critical Care, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Imad Bouakl
- Division of Pulmonary and Critical Care, American University of Beirut Medical Center, Beirut, Lebanon.
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Characteristics, Management, and Outcomes of Community-Acquired Pneumonia due to Respiratory Syncytial Virus: A Retrospective Study. Pulm Med 2023; 2023:4310418. [PMID: 36923702 PMCID: PMC10010887 DOI: 10.1155/2023/4310418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/08/2023] Open
Abstract
Background Respiratory syncytial virus (RSV), a well-known cause of bronchiolitis in children, can cause community-acquired pneumonia (CAP) in adults, but this condition is not well studied. Hence, we described the characteristics and outcomes of patients hospitalized for CAP due to RSV. Methods This was a retrospective study of patients admitted to a tertiary-care hospital between 2016 and 2019 with CAP due to RSV diagnosed by a respiratory multiplex PCR within 48 hours of admission. We compared patients who required ICU admission to those who did not. Results Eighty adult patients were hospitalized with CAP due to RSV (median age 69.0 years, hypertension 65.0%, diabetes 58.8%, chronic respiratory disease 52.5%, and immunosuppression 17.5%); 19 (23.8%) patients required ICU admission. The median pneumonia severity index score was 120.5 (140.0 for ICU and 102.0 for non-ICU patients; p = 0.09). Bacterial coinfection was rare (10.0%). Patients who required ICU admission had more hypotension (systolic blood pressure < 90 mmHg) and a higher prevalence of bilateral infiltrates on chest X-ray (CXR) (89.5% versus 32.7%; p < 0.001). Systemic corticosteroids were used in 57.3% of patients (median initial dose was 40 mg of prednisone equivalent) with ICU patients receiving a higher dose compared to non-ICU patients (p = 0.02). Most (68.4%) ICU patients received mechanical ventilation (median duration of 4 days). The overall hospital mortality was 8.8% (higher for ICU patients: 31.6% versus 1.6%, p < 0.001). Conclusions Most patients with CAP due to RSV were elderly and had significant comorbidities. ICU admission was required in almost one in four patients and was associated with higher mortality.
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Bahabri I, Abdulaal A, Alanazi T, Alenazy S, Alrumih Y, Alqahtani R, Bosaeed M, Al-Dorzi HM. Characteristics, Management, and Outcomes of Community-Acquired Pneumonia Due to Human Rhinovirus-A Retrospective Study. Can Respir J 2022; 2022:1349994. [PMID: 36531535 PMCID: PMC9757939 DOI: 10.1155/2022/1349994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Human rhinovirus (HRV) can lead to a variety of respiratory illnesses; it is also an uncommon cause of community-acquired pneumonia (CAP). We described the characteristics and outcomes of patients hospitalized for CAP due to HRV. METHODS We retrospectively studied consecutive adult patients admitted to King Abdulaziz Medical City-Riyadh with CAP due to HRV between 2016 and 2019. The diagnosis was made by respiratory multiplex PCR within 48 hours of hospitalization. We compared patients requiring ICU admission to those who did not. RESULTS One-hundred-and-six patients were studied (peak hospitalization between November and January, median age 71.5 years, hypertension 59%, diabetes 50%, and chronic respiratory disease 44.3%); 16 (15.1%) patients required ICU admission. The median pneumonia severity index score (PSI) was 107, with no significant difference between ICU and nonICU patients. ICU patients had a higher prevalence of tachypnea (62.5% vs. 26.7%, p=0.005), hemoptysis (12.5% vs 0%, p=0.001), and lymphopenia (71.4% vs 26.3%, p=0.01). Chest X-ray on presentation showed bilateral infiltrates in 47/101 (46.5%) patients and unilateral infiltrates in 26/101 (25.7%) patients. Systemic corticosteroids were used in 54.7% of patients (the median initial dose was 120 mg of prednisone equivalent and was higher in nonICU patients). Most (69.2%) ICU patients received mechanical ventilation (median duration of 8 days). Bacterial coinfection (6.6%) and superinfection (3.8%) were rare. The overall hospital mortality was 9.4% (higher for ICU patients: 37.5% vs. 4.4%, p < 0.001). CONCLUSIONS Most patients with CAP due to HRV were elderly and had significant comorbidities. ICU admission was required in almost one in six patients and was associated with higher mortality.
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Affiliation(s)
- Ibrahim Bahabri
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz Abdulaal
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Thamer Alanazi
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Sultan Alenazy
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Yasser Alrumih
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rakan Alqahtani
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammad Bosaeed
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hasan M. Al-Dorzi
- College of Medicine-Riyadh, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Galindo-Fraga A, Guerra de Blas PDC, Ortega-Villa AM, Mateja A, Ruiz Quiñones JA, Cervantes PR, Barrientos FL, Ortiz-Hernández AA, Llamosas-Gallardo B, Ramírez-Venegas A, Vázquez RV, Chepitel DN, Moreno-Espinosa S, Powers JH, Lourdes Guerrero M, Ruiz-Palacios GM, Beigel J. DIFFERENT CLINICAL PRESENTATIONS OF HUMAN RHINOVIRUS (HRV) SPECIES INFECTION IN CHILDREN AND ADULTS IN MEXICO. Open Forum Infect Dis 2022; 9:ofac303. [PMID: 35891697 PMCID: PMC9308452 DOI: 10.1093/ofid/ofac303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022] Open
Abstract
Background Human rhinoviruses (HRVs) are a common cause of influenza-like illness, with the ability to infect the upper and lower respiratory tracts. In this study we aim to describe the clinical and molecular features of HRV infection in Mexican children and adults. Methods We performed a hospital-based, 4-year multicenter prospective observational cohort study of patients with influenza-like illness. Participants who tested positive for HRV were included. We described demographic, clinical, and laboratory characteristics and the association between HRV types, illness severity, and clinical outcomes. Results Of the 5662 subjects recruited, 1473 (26%) had HRV; of those, 988 (67.1%) were adults (≥18 years) and 485 (32.9%) were children. One hundred sixty-seven (11.33%) samples were sequenced; 101 (60.5%) were rhinovirus species A (HRV-A), 22 (13.2%) were rhinovirus species B (HRV-B), and 44 (26.3%) were rhinovirus species C (HRV-C). Among children and adults, 30.5% and 23.5%, respectively, were hospitalized (non–intensive care unit [ICU]). The odds of HRV-C are higher than HRV-A for participants in the ICU (compared to outpatient) and when platelets, lymphocytes, white blood cells, and lactate dehydrogenase are increased. The odds of HRV-C are higher than HRV-A and HRV-B with shortness of breath. The odds of HRV-A are higher than HRV-B, and the odds of HRV-B are higher than HRV-C, when mild symptoms like muscle ache and headache occur. Conclusions Rhinoviruses are a common cause of influenza-like illness. It is necessary to improve the surveillance, testing, and species identification for these viruses to understand different clinical presentations and risk factors associated with worse outcomes. Clinical Trials Registration. NCT01418287.
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Affiliation(s)
- Arturo Galindo-Fraga
- Departamento de Epidemiología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | | | - Ana M Ortega-Villa
- National Institute of Allergy and Infectious Diseases , Bethesda, MD , USA
| | - Allyson Mateja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research , Frederick, Maryland , United States of America
| | - Jesus Arturo Ruiz Quiñones
- Departamento de Epidemiología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Pilar Ramos Cervantes
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Fernando Ledesma Barrientos
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Ana A Ortiz-Hernández
- División de Desarrollo y Enlace Interinstitucional, Instituto Nacional de Pediatría Mexico City , Mexico
| | - Beatriz Llamosas-Gallardo
- División de Desarrollo y Enlace Interinstitucional, Instituto Nacional de Pediatría Mexico City , Mexico
| | - Alejandra Ramírez-Venegas
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas” , Mexico City , Mexico
| | - Rafael Valdéz Vázquez
- Departamento de Infectología, Hospital General “Dr. Manuel Gea González” , Mexico City , Mexico
| | - Daniel Noyola Chepitel
- Microbiology Department, Facultad de Medicina, Universidad Autónoma de San Luís Potosí , San Luis Potosí , Mexico
| | - Sarbelio Moreno-Espinosa
- Departamento de Infectología, Hospital Infantil de México Federico Gómez, Instituto Nacional de Salud , Mexico City , Mexico
| | - John H Powers
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick , Maryland , United States of America
| | - M Lourdes Guerrero
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Guillermo M Ruiz-Palacios
- Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - John Beigel
- National Institute of Allergy and Infectious Diseases , Bethesda, MD , USA
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Spencer JA, Shutt DP, Moser SK, Clegg H, Wearing HJ, Mukundan H, Manore CA. Distinguishing viruses responsible for influenza-like illness. J Theor Biol 2022; 545:111145. [PMID: 35490763 DOI: 10.1016/j.jtbi.2022.111145] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
The many respiratory viruses that cause influenza-like illness (ILI) are reported and tracked as one entity, defined by the CDC as a group of symptoms that include a fever of 100 degrees Fahrenheit, a cough, and/or a sore throat. In the United States alone, ILI impacts 9-49 million people every year. While tracking ILI as a single clinical syndrome is informative in many respects, the underlying viruses differ in parameters and outbreak properties. Most existing models treat either a single respiratory virus or ILI as a whole. However, there is a need for models capable of comparing several individual viruses that cause respiratory illness, including ILI. To address this need, here we present a flexible model and simulations of epidemics for influenza, RSV, rhinovirus, seasonal coronavirus, adenovirus, and SARS/MERS, parameterized by a systematic literature review and accompanied by a global sensitivity analysis. We find that for these biological causes of ILI, their parameter values, timing, prevalence, and proportional contributions differ substantially. These results demonstrate that distinguishing the viruses that cause ILI will be an important aspect of future work on diagnostics, mitigation, modeling, and preparation for future pandemics.
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Affiliation(s)
- Julie A Spencer
- A-1 Information Systems and Modeling, Los Alamos National Laboratory, NM87545, USA.
| | - Deborah P Shutt
- A-1 Information Systems and Modeling, Los Alamos National Laboratory, NM87545, USA
| | - S Kane Moser
- B-10 Biosecurity and Public Health, Los Alamos National Laboratory, NM87545, USA
| | - Hannah Clegg
- A-1 Information Systems and Modeling, Los Alamos National Laboratory, NM87545, USA
| | - Helen J Wearing
- Department of Biology, University of New Mexico, NM87131, USA; Department of Mathematics and Statistics, University of New Mexico, NM87102, USA
| | - Harshini Mukundan
- C-PCS Physical Chemistry and Applied Spectroscopy, Los Alamos National Laboratory, NM87545, USA
| | - Carrie A Manore
- T-6 Theoretical Biology and Biophysics, Los Alamos National Laboratory, NM87545, USA
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8
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Nambafu J, Achakolong M, Mwendwa F, Bwika J, Riunga F, Gitau S, Patel H, Adam RD. A prospective observational study of community acquired pneumonia in Kenya: the role of viral pathogens. BMC Infect Dis 2021; 21:703. [PMID: 34301184 PMCID: PMC8300991 DOI: 10.1186/s12879-021-06388-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/02/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Lower respiratory tract infections continue to contribute significantly to morbidity and mortality across all age groups globally. In sub-Saharan Africa, many studies of community acquired pneumonia in adults have focused on HIV-infected patients and little attention has been given to risk factors and etiologic agents in an urban area with a more moderate HIV prevalence. METHODS We prospectively enrolled 77 patients admitted to a 280 bed teaching hospital in Kenya with radiographically confirmed community acquired pneumonia from May 2019 to March 2020. The patients were followed for etiology and clinical outcomes. Viral PCR testing was performed using the FTD respiratory pathogen-21 multiplex kit on nasopharyngeal or lower respiratory samples. Additional microbiologic workup was performed as determined by the treating physicians. RESULTS A potential etiologic agent(s) was identified in 57% including 43% viral, 5% combined viral and bacterial, 5% bacterial and 4% Pneumocystis. The most common etiologic agent was Influenza A which was associated with severe clinical disease. The most common underlying conditions were cardiovascular disease, diabetes and lung disease, while HIV infection was identified in only 13% of patients. Critical care admission was required for 24, and 31% had acute kidney injury, sometimes in combination with acute respiratory distress or sepsis. CONCLUSION Viruses, especially influenza, were commonly found in patients with CAP. In contrast to other studies from sub-Saharan Africa, the underlying conditions were similar to those reported in high resource areas and point to the growing concern of the double burden of infectious and noncommunicable diseases.
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Affiliation(s)
- Jamila Nambafu
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Mary Achakolong
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Fridah Mwendwa
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Jumaa Bwika
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Felix Riunga
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Samuel Gitau
- Department of Radiology, Aga Khan University, Nairobi, Kenya
| | - Hanika Patel
- Department of Radiology, Aga Khan University, Nairobi, Kenya
| | - Rodney D. Adam
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
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Comte A, Bour JB, Darniot M, Pitoiset C, Aho-Glélé LS, Manoha C. Epidemiological characteristics and clinical outcomes of human rhinovirus infections in a hospitalized population. Severity is independently linked to RSV coinfection and comorbidities. J Clin Virol 2020; 125:104290. [PMID: 32135487 DOI: 10.1016/j.jcv.2020.104290] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/21/2019] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
Human rhinovirus (hRV) is a predominant respiratory viral pathogen. The determinants that lead to adverse clinical outcomes in hospitalized patients are unclear. Our objective was to analyze the epidemiological and clinical characteristics of hRV infections in a hospitalized population and to compare non-severe and severe infections. The study was based on data from all patients with a respiratory episode admitted to Hospital from October 2015 to September 2016. During the study period, out of 2465 respiratory episodes, 434 were detected positive for hRV. Most of the coinfections involved the respiratory syncytial virus (RSV) and very few influenza viruses. A possible interference between rhinovirus and influenza virus is suggested. Airway involvement was present in a large part of hRV infections with 28.4 % (n = 48/169) of bronchiolitis and 3.6 % (n = 6/169) of bronchitis. One third of patients had at least one of the following severity criteria: need for oxygen therapy, hospitalization ≥ 5 days, and admission to the ICU. On multivariate analysis, a respiratory co-infection with RSV and the presence of a chronic respiratory disease (including a history of asthma) were shown to be independent risk factors for the onset of a severe infection in patients ≤ 2 years old. In a case control study based on 70 patients, hRV-A was the predominant lineage, followed closely by hRV-C. High viral load or viral genotypes were not associated with severe infection.
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Affiliation(s)
- Anthony Comte
- Virology Laboratory, University Hospital, Dijon, France
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10
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Pecego AC, Amâncio RT, Costa DM, Bozza FA, Siqueira MM, Oliveira ML, Cerbino-Neto J, Japiassu A. Etiology, clinical, and epidemiological characteristics of severe respiratory infection in people living with HIV. Int J STD AIDS 2020; 31:100-108. [PMID: 31969059 PMCID: PMC7206327 DOI: 10.1177/0956462419882587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
People living with HIV (PLWH) are more prone to severe respiratory infections. We used the severe acute respiratory infection (SARI) definition to describe the etiology, clinical, and epidemiological characteristics in this population. This was a prospective observational study including PLWH hospitalized with fever and cough. Those with symptom onset up to 10 days were classified as severe acute respiratory infection and 11–30 days as non-severe acute respiratory infection. Blood, urine samples and nasopharyngeal swabs were collected. Data were extracted from patient charts during their hospital stay. Forty-nine patients were included, median CD4 cell count: 80 cells/mm3, median time since HIV diagnosis and hospital admission: 84 months and 80% were antiretroviral therapy exposed. Twenty-seven patients were classified as SARI. Etiology was identified in 69%, 47% were polymicrobial. Respiratory virus (9 SARI vs. 13 non-SARI), bacteria (5 SARI vs. 4 non-SARI), Mycobacterium tuberculosis (6 SARI group vs. 7 non-SARI group), Pneumocystis jirovecii (4 SARI vs. 1 non-SARI), Cryptococcus neoformans (1 SARI vs. 3 non-SARI), and influenza A (1 SARI vs. 2 non-SARI). Dyspnea was statistically more prevalent in SARI (78% vs. 36%, p = 0.011) but the risk of death was higher in the non-SARI (4% vs. 36%, p = 0.0067). In the severely immunocompromised PLWH, severe acute respiratory infection can be caused by multiple pathogens and codetection is a common feature.
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Affiliation(s)
- AC Pecego
- Instituto Nacional de Infectologia – Fundação Oswaldo Cruz (Fiocruz) – Laboratório de Medicina Intensiva, Rio de Janeiro, Brazil
- AC Pecego, Instituto Nacional de Infectologia (INI), FIOCRUZ, Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, Brazil.
| | - RT Amâncio
- Instituto Nacional de Infectologia – Fundação Oswaldo Cruz (Fiocruz) – Laboratório de Medicina Intensiva, Rio de Janeiro, Brazil
| | - DM Costa
- Instituto Nacional de Infectologia – Fundação Oswaldo Cruz (Fiocruz) – Laboratório de Medicina Intensiva, Rio de Janeiro, Brazil
| | - FA Bozza
- Instituto Nacional de Infectologia – Fundação Oswaldo Cruz (Fiocruz) – Laboratório de Medicina Intensiva, Rio de Janeiro, Brazil
- Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - MM Siqueira
- Instituto Oswaldo Cruz – Fiocruz – Laboratório de Vírus Respiratório, do IOC/FIOCRUZ, Rio de Janeiro, Brazil
| | - ML Oliveira
- Instituto Oswaldo Cruz – Fiocruz – Laboratório de Vírus Respiratório, do IOC/FIOCRUZ, Rio de Janeiro, Brazil
| | - J Cerbino-Neto
- Laboratório de Pesquisa em Imunização e Vigilância em Saúde, Rio de Janeiro, Brazil
| | - A Japiassu
- Instituto Nacional de Infectologia – Fundação Oswaldo Cruz (Fiocruz) – Laboratório de Medicina Intensiva, Rio de Janeiro, Brazil
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11
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Panda S, Mohakud NK, Panda S, Kumar S. Epidemiology and phylogenetic analysis of human rhinovirus/ Enterovirus in Odisha, Eastern India. Indian J Med Microbiol 2019; 37:569-573. [PMID: 32436882 DOI: 10.4103/ijmm.ijmm_20_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Human rhinovirus (HRV) and Enterovirus (ENV) are the major causes of childhood acute respiratory tract infections (ARTIs). This study sought to understand the distribution pattern of HRV subgroups, their seasonality and association with respiratory complications in patients at a tertiary care hospital. Results Of the total 332 ARTI samples, 82 (24.7%) were positive for ENV/HRV. Twenty positive samples were processed further for phylogenetic analysis. Ten of the 20 samples were identified to be HRVs (70% HRV A and 30% HRV C) and nine were enteroviruses. HRV A clustered near three distinct HRV types (A12, A78 and A82). Four of the HRV strains (represented as SEQ 137 rhino, SEQ 282 rhino, SEQ 120 rhino and SEQ 82 rhino) had high sequence similarity. HRV C showed seasonality and was associated with disease severity. Conclusion The genotyping and phylogenetic analysis of the HRVs in the current study shows its circulatory pattern, association with risk factors and evolutionary dynamics.
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Affiliation(s)
- Swagatika Panda
- Infection Biology Lab, School of Biotechnology, KIIT University, Campus-XI, Bhubaneswar, Odisha, India
| | - Nirmal Kumar Mohakud
- Department of Pediatrics, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India
| | - Soumya Panda
- School of Biotechnology, Amity Institute of Biotechnology, Amity University, Noida, Uttar Pradesh, India
| | - Subrat Kumar
- Infection Biology Lab, School of Biotechnology, KIIT University, Campus-XI, Bhubaneswar, Odisha, India
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12
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Fica A, Sotomayor V, Fasce R, Dabanch J, Soto A, Charpentier P, Guerrero G, Olivares F, Triantafilo V, Omeiri NE, Gaínza-Lein M. Severe acute respiratory infections (SARI) from influenza in adult patients in Chile: the experience of a sentinel hospital. Rev Panam Salud Publica 2019; 43:e1. [PMID: 31093225 PMCID: PMC6393720 DOI: 10.26633/rpsp.2019.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 06/16/2018] [Indexed: 12/16/2022] Open
Abstract
Objective To 1) describe clinical characteristics of adult patients in Chile with severe acute respiratory infections (SARI) associated with influenza viruses, and 2) analyze virus subtypes identified in specimens collected from those patients, hospital resources used in clinical management, clinical evolution, and risk factors associated with a fatal outcome, using observational data from the SARI surveillance network (SARInet). Methods Adults hospitalized from 1 July 2011 to 31 December 2015 with influenza-associated SARI at a SARI sentinel surveillance hospital in Santiago were identified and the presence of influenza in all cases confirmed by reverse transcription polymerase chain reaction (RT-PCR), using respiratory samples. Results A total of 221 patients (mean age: 74.1 years) were hospitalized with influenza-associated SARI during the study period. Of this study cohort, 91.4% had risk factors for complications and 34.3% had been vaccinated during the most recent campaign. Pneumonia was the most frequent clinical manifestation, occurring in 57.0% of the cohort; other manifestations included influenza-like illness, exacerbated chronic bronchitis, decompensated heart failure, and asthmatic crisis. Cases occurred year-round, with an epidemic peak during autumn–winter. Both influenza A (H1N1pdm09 and H3N2) and B virus co-circulated. Critical care beds were required for 26.7% of the cohort, and 19.5% needed ventilatory assistance. Multivariate analysis identified four significant factors associated with in-hospital mortality: 1) being bedridden (adjusted odds ratio (aOR): 22.3; 95% confidence interval (CI): 3.0–164); 2) admission to critical care unit (aOR: 8.9; CI: 1.44–55); 3) Pa02/Fi02 ratio < 250 (aOR: 5.8; CI: 1.02–33); and 4) increased serum creatinine concentration (> 1 mg/dL) (aOR: 5.47; CI: 1.20–24). Seasonal influenza vaccine was identified as a significant protective factor (aOR: 0.14; CI: 0.021–0.90). Conclusions Influenza-associated SARI affected mainly elderly patients with underlying conditions. Most patients evolved to respiratory failure and more than one-quarter required critical care beds. Clinical presentation was variable. Death was associated with host characteristics and disease-associated conditions, and vaccine was protective. Virus type did not influence outcome.
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Affiliation(s)
- Alberto Fica
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | | | - Rodrigo Fasce
- Viral Hepatitis and Emerging Diseases Section, Viral Diseases Subdepartment, Instituto de Salud Pública de Chile, Santiago, Chile
| | - Jeannette Dabanch
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | - Andrés Soto
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | - Paulo Charpentier
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | - Gonzalo Guerrero
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | - Felipe Olivares
- Infectious Disease Service, Hospital Militar de Santiago, Santiago, Chile
| | | | - Nathalie El Omeiri
- Comprehensive Family Immunization Unit, Pan American Health Organization, Washington, D.C., United States of America
| | - Marina Gaínza-Lein
- School of Medicine, Universidad Austral de Chile-Campus Isla Teja, Valdivia, Chile
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13
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Leotte J, Trombetta H, Faggion HZ, Almeida BM, Nogueira MB, Vidal LR, Raboni SM. Impact and seasonality of human rhinovirus infection in hospitalized patients for two consecutive years. J Pediatr (Rio J) 2017; 93:294-300. [PMID: 27916571 PMCID: PMC7094701 DOI: 10.1016/j.jped.2016.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To report epidemiological features, clinical characteristics, and outcomes of human rhinovirus (HRV) infections in comparison with other community acquired respiratory virus (CRV) infections in patients hospitalized for two consecutive years. METHODS This was a cross-sectional study. Clinical, epidemiological, and laboratory data of patients hospitalized with acute respiratory syndrome in a tertiary care hospital from 2012 to 2013 were reviewed. RESULTS HRV was the most common CRV observed (36%, 162/444) and was present in the majority of viral co-detections (69%, 88/128), mainly in association with human enterovirus (45%). Most HRV-infected patients were younger than 2 years (57%). Overall, patients infected with HRV had a lower frequency of severe acute respiratory infection than those infected with other CRVs (60% and 84%, respectively, p=0.006), but had more comorbidities (40% and 27%, respectively; p=0.043). However, in the adjusted analysis this association was not significant. The mortality rate within the HRV group was 3%. Detection of HRV was more prevalent during autumn and winter, with a moderately negative correlation between viral infection frequency and temperature (r=-0.636, p<0.001) but no correlation with rainfall (r=-0.036, p=0.866). CONCLUSION HRV is usually detected in hospitalized children with respiratory infections and is often present in viral co-detections. Comorbidities are closely associated with HRV infections. These infections show seasonal variation, with predominance during colder seasons.
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Affiliation(s)
- Jaqueline Leotte
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brazil
| | - Hygor Trombetta
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brazil
| | - Heloisa Z Faggion
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brazil
| | - Bernardo M Almeida
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Epidemiologia Hospitalar, Curitiba, PR, Brazil
| | - Meri B Nogueira
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brazil
| | - Luine R Vidal
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brazil
| | - Sonia M Raboni
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brazil; Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brazil.
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14
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Leotte J, Trombetta H, Faggion HZ, Almeida BM, Nogueira MB, Vidal LR, Raboni SM. Impact and seasonality of human rhinovirus infection in hospitalized patients for two consecutive years. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [PMCID: PMC7153728 DOI: 10.1016/j.jpedp.2016.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objetivos Relatar as características epidemiológicas, as características clínicas e os resultados das infecções por rinovírus humano (RVH) em comparação a outras infecções por vírus respiratórios adquiridos na comunidade (VRCs) em pacientes internados por dois anos consecutivos. Métodos Este foi um estudo transversal. Foram revisados os dados clínicos, epidemiológicos e laboratoriais de pacientes internados com síndrome respiratória aguda em um hospital terciário de 2012 a 2013. Resultados O RVH foi o VRC mais comum observado (36%, 162/444) e esteve presente na maior parte das codetecções virais (69%, 88/128), principalmente em associação ao enterovírus humano (45%). A maioria dos pacientes infectados por RVH possuía menos de 2 anos (57%). De modo geral, os pacientes com RVH apresentaram uma menor frequência de infecção respiratória aguda grave que os pacientes infectados por outros VRCs (60% e 84%, respectivamente, p = 0,006), porém mais comorbidades (40% e 27%, respectivamente; p = 0,043). Contudo, em uma análise ajustada, essa associação não foi significativa. A taxa de mortalidade no grupo RVH foi 3%. A detecção de RVH foi mais prevalente durante o outono e inverno, com uma correlação negativa moderada entre a frequência de infecção viral e a temperatura (r = ‐0,636, p < 0,001), porém nenhuma correlação com a precipitação (r = −0,036, p = 0,866). Conclusão O RVH é normalmente detectado em crianças internadas com infecções respiratórias e normalmente está presente em codetecções virais. As comorbidades estão estreitamente associadas a infecções por RVH. Essas infecçõesmostram variação sazonal, com predominância durante as estações mais frias.
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Affiliation(s)
- Jaqueline Leotte
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brasil
| | - Hygor Trombetta
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brasil
| | - Heloisa Z. Faggion
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brasil
| | - Bernardo M. Almeida
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Epidemiologia Hospitalar, Curitiba, PR, Brasil
| | - Meri B. Nogueira
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brasil
| | - Luine R. Vidal
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brasil
| | - Sonia M. Raboni
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Divisão de Doenças Infecciosas, Curitiba, PR, Brasil
- Universidade Federal do Paraná (UFPR), Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brasil
- Autor para correspondência.
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15
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Abstract
Human rhinovirus (HRV) and coronavirus (HCoV) infections are associated with both upper respiratory tract illness (“the common cold”) and lower respiratory tract illness (pneumonia). New species of HRVs and HCoVs have been diagnosed in the past decade. More sensitive diagnostic tests such as reverse transcription-polymerase chain reaction have expanded our understanding of the role these viruses play in both immunocompetent and immunosuppressed hosts. Recent identification of severe acute respiratory syndrome and Middle East respiratory syndrome viruses causing serious respiratory illnesses has led to renewed efforts for vaccine development. The role these viruses play in patients with chronic lung disease such as asthma makes the search for antiviral agents of increased importance.
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Affiliation(s)
- Stephen B Greenberg
- Department of Medicine, Ben Taub Hospital, Baylor College of Medicine, Houston, Texas
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16
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Miller EK, Linder J, Kraft D, Johnson M, Lu P, Saville BR, Williams JV, Griffin MR, Talbot HK. Hospitalizations and outpatient visits for rhinovirus-associated acute respiratory illness in adults. J Allergy Clin Immunol 2015; 137:734-43.e1. [PMID: 26255695 DOI: 10.1016/j.jaci.2015.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/15/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rhinovirus is linked to asthma exacerbations and chronic obstructive pulmonary disease exacerbations in adults. The severity and rates of rhinovirus acute respiratory illnesses (ARIs) in adults are uncertain. OBJECTIVES We sought to determine rhinovirus-associated ARI rates in adults presenting for care in multiple settings and identify factors associated with rhinovirus detection. METHODS This prospective, population-based cohort enrolled Tennessee residents 18 years or older in the emergency department (ED), outpatient clinics, or hospitalized for ARI from December 2008 to May 2010. Nasal/throat swabs were collected and tested for rhinovirus and other viruses by using RT-PCR. Rates of ED visits and hospitalizations were calculated and rhinovirus-positive and rhinovirus-negative patients were compared. RESULTS Among 2351 enrollees, rhinovirus was detected in 247 (11%). There were 7 rhinovirus-associated ED visits and 3 hospitalizations per 1000 adults annually. Patients with rhinovirus, compared with virus-negative ARI, were more likely to present with wheezing (odds ratio [OR], 1.7; 95% CI, 1.23-2.35; P < .001), to be a current smoker (OR, 2.31; 95% CI, 1.68-3.19) or live with a smoker (OR, 1.72; 95% CI, 1.10-2.67), have a history of chronic respiratory disease (OR, 1.61; 95% CI, 1.17-2.22), and were less likely to be hospitalized versus seen in the outpatient setting (OR, 0.58; 95% CI, 0.41-0.83). CONCLUSIONS Rhinovirus is associated with a substantial number of ED visits and hospitalizations for ARIs in adults. There may be modifiable factors that can reduce the likelihood of presenting with rhinovirus-associated ARIs.
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Affiliation(s)
- E Kathryn Miller
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn.
| | - Jodell Linder
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn
| | - David Kraft
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Monika Johnson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Pengcheng Lu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Benjamin R Saville
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn
| | - John V Williams
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Marie R Griffin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Healthy Policy, Vanderbilt University Medical Center, Nashville, Tenn; Mid-South Geriatric Research Education and Clinical Center and Clinical Research Center of Excellence, VA TN Valley Health Care System, Nashville, Tenn
| | - H Keipp Talbot
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
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