Development and validation of a risk score for predicting hospitalization in children with influenza virus infection

Comparisons in the Health and Economic Assessments of Using Quadrivalent Versus Trivalent Influenza Vaccines: A Systematic Literature Review

OBJECTIVES

Seasonal influenza vaccines protect against 3 (trivalent influenza vaccine [IIV3]) or 4 (quadrivalent influenza vaccine [IIV4]) viruses. IIV4 costs more than IIV3, and there is a trade-off between incremental cost and protection. This is especially the case in low- and middle-income countries (LMICs) with limited budgets; previous reviews have not identified studies of IIV4-IIV3 comparisons in LMICs. We summarized the literature that compared health and economic outcomes of IIV4 and IIV3, focused on LMICs.

METHODS

We systematically searched 5 databases for articles published before October 6, 2021, that modeled health or economic effects of IIV4 versus IIV3. We abstracted data and compared findings among countries and models.

RESULTS

Thirty-eight studies fit our selection criteria; 10 included LMICs. Most studies (N = 31) reported that IIV4 was cost-saving or cost-effective compared with IIV3; we observed no difference in health or economic outcomes between LMICs and other countries. Based on cost differences of influenza vaccines, only one study compared coverage of IIV3 with IIV4 and reported that the maximum IIV4 price that would still yield greater public health impact than IIV3 was 13% to 22% higher than IIV3.

CONCLUSIONS

When vaccination coverage with IIV4 and IIV3 is the same, IIV4 tends to be not only more effective but more cost-effective than IIV3, even with relatively high price differences between vaccine types. Alternatively, where funding is limited as in most LMICs, higher vaccine coverage can be achieved with IIV3 than IIV4, which could result in more favorable health and economic outcomes.

Prediction of Influenza Complications: Development and Validation of a Machine Learning Prediction Model to Improve and Expand the Identification of Vaccine-Hesitant Patients at Risk of Severe Influenza Complications

Influenza vaccinations are recommended for high-risk individuals, but few population-based strategies exist to identify individual risks. Patient-level data from unvaccinated individuals, stratified into retrospective cases (n = 111,022) and controls (n = 2,207,714), informed a machine learning model designed to create an influenza risk score; the model was called the Geisinger Flu-Complications Flag (GFlu-CxFlag). The flag was created and validated on a cohort of 604,389 unique individuals. Risk scores were generated for influenza cases; the complication rate for individuals without influenza was estimated to adjust for unrelated complications. Shapley values were used to examine the model’s correctness and demonstrate its dependence on different features. Bias was assessed for race and sex. Inverse propensity weighting was used in the derivation stage to correct for biases. The GFlu-CxFlag model was compared to the pre-existing Medial EarlySign Flu Algomarker and existing risk guidelines that describe high-risk patients who would benefit from influenza vaccination. The GFlu-CxFlag outperformed other traditional risk-based models; the area under curve (AUC) was 0.786 [0.783−0.789], compared with 0.694 [0.690−0.698] (p-value < 0.00001). The presence of acute and chronic respiratory diseases, age, and previous emergency department visits contributed most to the GFlu-CxFlag model’s prediction. When higher numerical scores were assigned to more severe complications, the GFlu-CxFlag AUC increased to 0.828 [0.823−0.833], with excellent discrimination in the final model used to perform the risk stratification of the population. The GFlu-CxFlag can better identify high-risk individuals than existing models based on vaccination guidelines, thus creating a population-based risk stratification for individual risk assessment and deployment in vaccine hesitancy reduction programs in our health system.

Clinical characteristics and outcomes of mixed virus or bacterial infection in children with laboratory-confirmed influenza infection

BACKGROUND/PURPOSE

This study investigated the demographic characteristics and influenza complications of paediatric patients and explored the association of different influenza virus types and viral and bacterial coinfections with disease severity.

METHODS

This retrospective cohort study used data collected in 2010-2016 from the Chang Gung Research Database (CGRD), the largest collection of multi-institutional electronic medical records in Taiwan. Data were retrieved for children aged 0-18 years with laboratory-confirmed influenza. We extracted and analysed the demographic characteristics and the data on clinical features, complications, microbiological information, and advanced therapies of each case.

RESULTS

We identified 6193 children with laboratory-confirmed influenza, of whom 1964 (31.7%) were hospitalised. The age of patients with influenza A infection was lower than that of patients with influenza B (4.48 vs. 6.68, p < 0.001). Patients with influenza B infection had a higher incidence of myositis or rhabdomyolysis (4.4%, p < 0.001) and a higher need for advanced therapies (OR, 1.96; 95% CI, 1.32-2.9, p < 0.001). In addition to bacterial (OR, 9.07; 95% CI, 5.29-15.54, p < 0.001) and viral coinfection (OR, 7.73; 95% CI, 5.4-11.07, p < 0.001), dual influenza A and B infection was also a risk factor for influenza complications (OR, 2.13; 95% CI, 1.47-3.09, p < 0.001).

CONCLUSION

Dual influenza A and B infection and bacterial coinfection can contribute to influenza complications. Early recognition of any influenza complication is critical for the timely initiation of organ-specific advanced therapies to improve influenza-associated outcomes.

Predicting poor outcomes in children aged 1-12 with respiratory tract infections: A systematic review

Background

Demand for NHS services is high and rising. In children respiratory tract infections (RTI) are the most common reason for consultation with primary care. Understanding which features are associated with good and poor prognosis with RTI will help develop interventions to support parents manage illness.

Aim

To identify symptoms, signs, and investigation results associated with good and poor prognosis, and clinical decision making in children aged 1–12 years with RTI symptoms, at home and presenting to ambulatory care.

Design and setting

Systematic literature review.

Methods

We searched MEDLINE, EMBASE, Cinahl, Web of Science and the Cochrane database of systematic reviews for studies of children aged 1 to 12 years with a RTI or related condition reporting symptoms, signs and investigation results associated with prognostic outcomes. Quality was assessed using the QUIPS tool.

Results

We included 27 studies which included 34802 children and measured 192 factors. Nine studies explored future outcomes and the remainder explored clinical management from the initial consultation with the health services. None were conducted in a home setting. Respiratory signs, vomiting, fever, dehydration and tachycardia at the initial contact were associated with future hospitalisation. Little evidence was available for other outcomes.

Conclusion

Some evidence is available to clinicians to stratify risk of, future hospitalisation, but not of other prognostic outcomes. There is little evidence available to parents to identify children at risk of poor prognosis. Research is needed into whether poor prognosis can be predicted by parents in the home.

Unreliable usage of a single influenza virus IgM antibody assay in influenza-like illness: A retrospective study of the 2016-2018 flu epidemic

We retrospectively analyzed serum IgM antibodies (Abs) to influenza viruses from two tertiary hospitals in Beijing from December 2016 to February 2018. Samples from 36,792 patients, aged 0–98 years, were collected and tested. Among the patients, 923 children from two winter flu seasons were assayed with both antigens and IgM Abs to Flu A and Flu B and assigned as paired groups. Another 2,340 adults and 1,978 children with only antigen tested in the 2016 and 2017 winter flu seasons were named as unpaired groups. IgM Abs-positivity rates in children were 0.80% and 36.57% for Flu A and Flu B, respectively, peaking at 4–5 years of age. For adults, the Flu A and Flu B IgM Abs-positivity rates were 10.34% and 21.49%, respectively, peaking at 18–35 years of age. The trend of temporal distribution between the children and the adults was significantly correlated for IgM Abs to Flu B, but not for Flu A. Compared with unpaired groups, the detection rate of Flu A antigen was significantly higher than IgM Abs in children, whereas frequencies of IgM Abs were higher than antigen in adults. Incidence of Flu B antigen was sharply increased in 2017 winter than in the 2016 winter in both children and adults, but no concomitant increase was observed in IgM Abs to Flu B. For paired children groups, incidence of Flu B antigen in the 2017 flu season was significantly higher than that in the 2016 flu season; in contrast, positive rates of IgM Abs in the 2017 flu season were even lower than those in 2016. Considering antigen detection may reflect the Flu A/Flu B epidemic, our results indicate single-assayed IgM Abs were less effective in the diagnosis of acute influenza virus infection, and the use of this assay for epidemiology evaluations was not supported by these findings.

Severe Obesity in Children May Not Pose Independent Risk for Influenza Complications

PURPOSE

Subsets of children are targeted for influenza vaccination due to known conditions that increase the risk of influenza complications. The purpose of this study was to determine if severe obesity in children suggests targeted vaccination.

DESIGN AND METHODS

A retrospective chart review of a large Midwestern pediatric hospital identified 188 cases of influenza complications (defined as requiring hospitalization or death) aged 2 to <20 years old from August 1, 2010 through June 30, 2013. Severe obesity was defined as body mass index (BMI) ≥99% for age and gender, with patients grouped by severe obesity status (yes vs. no). Cases were reviewed for previously identified risk conditions for influenza complications (e.g., asthma, pneumonia, diabetes), and were classified as having or not having a known high risk condition.

RESULTS

Of 188 cases, 174 (93%) had a high-risk condition, while only 14 (7%) had no known condition. All 14 (100%) with no known high-risk condition had a BMI <99%. All 15 (100%) with BMI ≥99% had a known high-risk condition. The association between severe obesity status and influenza complications was not statistically significant (p = 0.61).

CONCLUSIONS

This suggests that severe obesity in children is not an independent high-risk condition for influenza complications defined as requiring hospitalization or resulting in death, once other known influenza risk factors are considered.

IMPLICATIONS

Based on this data, clinicians should not target children for influenza vaccination based on weight status. We cannot comment about whether severe obesity represents increased risk for less severe cases of influenza.

Intracerebral Hematoma Due to Aneurysm Rupture: Are There Risk Factors Beyond Aneurysm Location?

BACKGROUND

Along with subarachnoid hemorrhage (SAH), a ruptured aneurysm may also cause an intracerebral hematoma (ICH), which negatively impacts the functional outcome of SAH.

OBJECTIVE

To identify independent risk factors of aneurysmal ICH.

METHODS

Six hundred thirty-two consecutive patients with aneurysmal SAH treated at our institution from January 2005 to December 2012 were eligible for this study. Demographic parameters and preexisting comorbidities of patients, as well as various clinical and radiographic characteristics of SAH were correlated with the incidence and volume of aneurysmal ICH.

RESULTS

One hundred fifty-five patients (25%) had ICH on initial computed tomography with a mean volume of 26.7 mL (±26.8 mL). Occurrence and volume of ICH were associated with the location (distal anterior or middle cerebral artery >proximal anterior cerebral or internal carotid artery >posterior circulation, P < .001/P < .001) and size (>12 mm, P = .026/P < .001) of the ruptured aneurysm. Vascular risk factors independently increased the risk of ICH as well (arterial hypertension: odds ratio [OR] = 1.62, P = .032; diabetes mellitus: OR = 3.06, P = .009), while the use of aspirin (P = .037) correlated with the volume of ICH. The predictors of ICH were included into a risk score (0-9 points) that strongly predicted the occurrence of ICH (P = .01). Poor functional outcome after SAH was independently associated with the occurrence of ICH (P = .003, OR = 2.77) and its volume (P = .001, OR = 1.07 per-mL-increase).

CONCLUSION

Aneurysmal ICH is strongly associated with poorer functional outcome and seems to be predictable even before the bleeding event. The proposed risk factors for aneurysmal ICH require further validation and may be considered for treatment decisions regarding unruptured intracranial aneurysms.

ABBREVIATIONS

ACA, anterior cerebral arteryDHC, decompressive hemicraniectomyEVD, external ventricular drainageICA, internal carotid arteryICH, intracerebral hematomaMCA, middle cerebral arterymRS, modified Rankin scalePC, posterior circulationSAH, subarachnoid hemorrhageSIRS, systemic inflammatory response syndromeTCD, transcranial Doppler sonography.

Usefulness of C-Reactive Protein as a Predictor of Contrast-Induced Nephropathy After Percutaneous Coronary Interventions in Patients With Acute Myocardial Infarction and Presentation of a New Risk Score (Athens CIN Score)

Contrast-induced nephropathy (CIN) after percutaneous coronary interventions (PCI) in patients with acute myocardial infarction (AMI) is associated with high morbidity and mortality, whereas there are no reliable predictive tools easy to use. We evaluated the association of pre-procedural high-sensitivity C-reactive protein (hsCRP) with the development of CIN and integrated this variable in a new risk CIN prediction model. Consecutive patients (348 AMI subjects) who underwent PCI were recruited. Creatinine levels were detected on admission, at 24, 48, and 72 hours after PCI. CIN was defined using the Kidney Disease: Improving Global Outcomes criteria. In our study population (348 subjects), CIN developed in 54 patients (15.5%). Patients with CIN were older and had higher hsCRP at admission, whereas their ejection fraction (EF) and glomerular filtration rate (GFR) were lower. In multivariate analysis after incorporating potential confounders, hsCRP at admission was an independent predictor of CIN (OR for logCRP 2.00, p = 0.01). In receiver-operating characteristic curve analysis, a model incorporating hsCRP, age, GFR, and EF showed good accuracy in predicting the development of CIN (c statistic 0.84, 95% confidence interval 0.793 to 0.879). A total risk score derived from the proposed model yielded significant positive and negative predictive values and classified 85.8% of our patients correctly for CIN. In conclusion, measuring hsCRP levels at admission in patients who underwent PCI for AMI may offer additional assistance in predicting the development of CIN. A model incorporating age and admission hsCRP, EF, and GFR emerged as an accurate tool for predicting CIN in this context.

Hospitalization for Influenza A Versus B

BACKGROUND

The extent to which influenza A and B infection differs remains uncertain.

METHODS

Using active surveillance data from the Canadian Immunization Monitoring Program Active at 12 pediatric hospitals, we compared clinical characteristics and outcomes of children ≤16 years admitted with laboratory-confirmed influenza B or seasonal influenza A. We also examined factors associated with ICU admission in children hospitalized with influenza B.

RESULTS

Over 8 nonpandemic influenza seasons (2004-2013), we identified 1510 influenza B and 2645 influenza A cases; median ages were 3.9 and 2.0 years, respectively (P < .0001). Compared with influenza A patients, influenza B patients were more likely to have a vaccine-indicated condition (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.14-1.47). Symptoms more often associated with influenza B were headache, abdominal pain, and myalgia (P < .0001 for all symptoms after adjustment for age and health status). The proportion of deaths attributable to influenza was significantly greater for influenza B (1.1%) than influenza A (0.4%); adjusted for age and health status, OR was 2.65 (95% CI = 1.18-5.94). A similar adjusted OR was obtained for all-cause mortality (OR = 2.95; 95% CI = 1.34-6.49). Among healthy children with influenza B, age ≥10 years (relative to <6 months) was associated with the greatest odds of ICU admission (OR = 5.79; 95% CI = 1.91-17.57).

CONCLUSIONS

Mortality associated with pediatric influenza B infection was greater than that of influenza A. Among healthy children hosptialized with influenza B, those 10 years and older had a significant risk of ICU admission.

A comprehensive review of the epidemiology and disease burden of Influenza B in 9 European countries

This review was undertaken to consolidate information on the epidemiology and burden of influenza B, as well as the circulation patterns of influenza B lineage in 9 European countries. Following a comprehensive search of peer-reviewed and gray literature sources, we found that published data on influenza B epidemiology and burden are scarce. Surveillance data show frequent co-circulation of both influenza B lineages during influenza seasons, but little is known about its impact, especially in adults and the clinical burden of influenza B remains unknown. Mismatch between the circulating influenza B lineage and vaccine recommendations has been seen in at least one influenza season in every country. Such observations could impact the effectiveness of seasonal influenza vaccination programs using trivalent vaccines, which contain only one influenza B lineage (B/Yamagata or B/Victoria) and highlight the need for local studies to better understand the epidemiology and burden of influenza B in these countries.

Pediatric Respiratory Emergencies

Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.

Clinical and epidemiological features of respiratory virus infections in preschool children over two consecutive influenza seasons in southern Brazil

This study reports the results of a systematic screening for respiratory viruses in pediatric outpatients from an emergency department (ED) in southern Brazil during two consecutive influenza seasons. Children eligible for enrollment in this study were aged 24–59 months and presented with acute respiratory symptoms and fever. Naso‐ and oropharyngeal swabs were collected and multiplex reverse transcription PCR (RT‐PCR) was performed to identify the respiratory viruses involved. In total, 492 children were included in this study: 248 in 2010 and 244 in 2011. In 2010, 136 samples (55%) were found to be positive for at least one virus and the most frequently detected viruses were human rhinovirus (HRV) (18%), adenovirus (AdV) (13%), and human coronavirus (CoV) (5%). In 2011, 158 samples (65%) were found to be positive for at least one virus, and the most frequently detected were HRV (29%), AdV (12%), and enterovirus (9%). Further, the presence of asthma (OR, 3.17; 95% CI, 1.86–5.46) was independently associated with HRV infection, whereas fever was associated with AdV (OR, 3.86; 95% CI, 1.31–16.52) and influenza infections (OR, 3.74; 95% CI, 1.26–16.06). Ten patients (2%) were diagnosed with pneumonia, and six of these tested positive for viral infection (4 HRV, 1 RSV, and 1 AdV). Thus, this study identified the most common respiratory viruses found in preschool children in the study region and demonstrated their high frequency, highlighting the need for improved data collection, and case management in order to stimulate preventive measures against these infections. J. Med. Virol. 88:1325–1333, 2016. © 2016 Wiley Periodicals, Inc.

Early identification of individuals at high risk for cerebral infarction after aneurysmal subarachnoid hemorrhage: the BEHAVIOR score

Cerebral infarction (CI) is a crucial complication of aneurysmal subarachnoid hemorrhage (SAH) associated with poor clinical outcome. We aimed at developing an early risk score for CI based on clinical characteristics available at the onset of SAH. Out of a database containing 632 consecutive patients with SAH admitted to our institution from January 2005 to December 2012, computed tomography (CT) scans up to day 42 after ictus were evaluated for CIs. Different parameters from admission up to aneurysm treatment were collected with subsequent construction of a risk score. Seven clinical characteristics were independently associated with CI and included in the Risk score (BEHAVIOR Score, 0 to 11 points): Blood on CT scan according to Fisher grade ⩾3 (1 point), Elderly patients (age ⩾55 years, 1 point), Hunt&Hess grade ⩾4 (1 point), Acute hydrocephalus requiring external liquor drainage (1 point), Vasospasm on initial angiogram (3 points), Intracranial pressure elevation >20 mm Hg (3 points), and treatment of multiple aneurysms ('Overtreatment', 1 point). The BEHAVIOR score showed high diagnostic accuracy with respect to the absolute risk for CI (area under curve=0.806, P<0.0001) and prediction of poor clinical outcome at discharge (P<0.0001) and after 6 months (P=0.0002). Further validation in other SAH cohorts is recommended.

Key issues and challenges in estimating the impact and cost-effectiveness of quadrivalent influenza vaccination

Evidence has shown that quadrivalent influenza vaccines containing all four subtypes are safe and immunogenic. However, to date there have been few published studies exploring the population-level clinical and economic impact of quadrivalent compared to trivalent influenza vaccines. Economic evaluation studies need to be conducted in order to inform country-level decision making about whether (and how to) introduce and replace the current trivalent influenza vaccines with quadrivalent influenza vaccination programs. Several key issues associated with estimating the clinical and economic impact of the trivalent versus quadrivalent vaccines are discussed in this article, particularly the complexities involved in estimating the incremental preventable disease and economic burden. Other factors, such as the indirect (herd) protection from quadrivalent influenza vaccination and the timing of the replacement of trivalent influenza vaccination programs are also discussed.

The substantial hospitalization burden of influenza in central China: surveillance for severe, acute respiratory infection, and influenza viruses, 2010-2012

BACKGROUND

Published data on influenza in severe acute respiratory infection (SARI) patients are limited. We conducted SARI surveillance in central China and estimated hospitalization rates of SARI attributable to influenza by viral type/subtype.

METHODS

Surveillance was conducted at four hospitals in Jingzhou, China from 2010 to 2012. We enrolled hospitalized patients who had temperature ≥37·3°C and at least one of: cough, sore throat, tachypnea, difficulty breathing, abnormal breath sounds on auscultation, sputum production, hemoptysis, chest pain, or chest radiograph consistent with pneumonia. A nasopharyngeal swab was collected from each case-patient within 24 hours of admission for influenza testing by real-time reverse transcription PCR.

RESULTS

Of 17 172 SARI patients enrolled, 90% were aged <15 years. The median duration of hospitalization was 5 days. Of 16 208 (94%) SARI cases tested, 2057 (13%) had confirmed influenza, including 1427 (69%) aged <5 years. Multiple peaks of influenza occurred during summer, winter, and spring months. Influenza was associated with an estimated 115 and 142 SARI hospitalizations per 100 000 during 2010-2011 and 2011-2012 [including A(H3N2): 55 and 44 SARI hospitalizations per 100 000; pandemic A(H1N1): 33 SARI hospitalizations per 100 000 during 2010-2011; influenza B: 26 and 98 hospitalizations per 100 000], with the highest rate among children aged 6-11 months (3603 and 3805 hospitalizations per 100 000 during 2010-2011 and 2011-2012, respectively).

CONCLUSIONS

In central China, influenza A and B caused a substantial number of hospitalizations during multiple periods each year. Our findings strongly suggest that young children should be the highest priority group for annual influenza vaccination in China.

Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis

OBJECTIVE

To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza.

DESIGN

Systematic review.

STUDY SELECTION

Observational studies reporting on risk factor-outcome combinations of interest in participants with influenza. Outcomes included death, ventilator support, admission to hospital, admission to an intensive care unit, pneumonia, and composite outcomes.

DATA SOURCES

Medline, Embase, CINAHL, Global Health, and the Cochrane Central Register of Controlled Trials to March 2011.

RISK OF BIAS ASSESSMENT

Newcastle-Ottawa scale to assess the risk of bias. GRADE framework to evaluate the quality of evidence.

RESULTS

63 537 articles were identified of which 234 with a total of 610 782 participants met the inclusion criteria. The evidence supporting risk factors for severe outcomes of influenza ranged from being limited to absent. This was particularly relevant for the relative lack of data for non-2009 H1N1 pandemics and for seasonal influenza studies. Limitations in the published literature included lack of power and lack of adjustment for confounders was widespread: adjusted risk estimates were provided for only 5% of risk factor-outcome comparisons in 39 of 260 (15%) studies. The level of evidence was low for "any risk factor" (odds ratio for mortality 2.77, 95% confidence interval 1.90 to 4.05 for pandemic influenza and 2.04, 1.74 to 2.39 for seasonal influenza), obesity (2.74, 1.56 to 4.80 and 30.1, 1.74 to 2.39), cardiovascular diseases (2.92, 1.76 to 4.86 and 1.97, 1.06 to 3.67), and neuromuscular disease (2.68, 1.91 to 3.75 and 3.21, 1.84 to 5.58). The level of evidence was very low for all other risk factors. Some well accepted risk factors such as pregnancy and belonging to an ethnic minority group could not be identified as risk factors. In contrast, women who were less than four weeks post partum had a significantly increased risk of death from pandemic influenza (4.43, 1.24 to 15.81).

CONCLUSION

The level of evidence to support risk factors for influenza related complications is low and some well accepted risk factors, including pregnancy and ethnicity, could not be confirmed as risks. Rigorous and adequately powered studies are needed.

The burden of influenza B: a structured literature review

We reviewed the epidemiology, clinical characteristics, disease severity, and economic burden of influenza B as reported in the peer-reviewed published literature. We used MEDLINE to perform a systematic literature review of peer-reviewed, English-language literature published between 1995 and 2010. Widely variable frequency data were reported. Clinical presentation of influenza B was similar to that of influenza A, although we observed conflicting reports. Influenza B-specific data on hospitalization rates, length of stay, and economic outcomes were limited but demonstrated that the burden of influenza B can be significant. The medical literature demonstrates that influenza B can pose a significant burden to the global population. The comprehensiveness and quality of reporting on influenza B, however, could be substantially improved. Few articles described complications. Additional data regarding the incidence, clinical burden, and economic impact of influenza B would augment our understanding of the disease and assist in vaccine development.

Secondhand tobacco smoke exposure and severity of influenza in hospitalized children

OBJECTIVE

To assess whether children with influenza who are exposed to secondhand tobacco smoke (SHS) would have more severe illness than those not exposed.

STUDY DESIGN

We abstracted charts from pediatric inpatients with confirmed influenza from 2002-2009 for demographics, medical history, and smoke exposure. Severity indicators included intensive care, intubation, and length of stay (LOS) in the hospital; potential confounding factors included demographics and the presence of asthma or chronic conditions. All χ(2), t tests, and regression analyses were run using SPSS v. 18.0.

RESULTS

Of 117 children, 40% were exposed to SHS, who had increased need for intensive care (30% vs 10%, P < .01) and intubation (13% vs 1%, P < .05), and had longer LOS (4.0 vs 2.4 days, P < .01). Children with chronic conditions and SHS exposure required more intensive care (53% vs 18%, P < .05) and had longer LOS (10.0 vs 3.5 days, P < .01) than children not exposed to SHS with chronic conditions. In multivariate analyses controlling for potential confounding factors, children with SHS exposure were 4.7 times more likely to be admitted to intensive care (95% CI 1.4-18.5) and had a 70% longer LOS (95% CI 12%-230%).

CONCLUSIONS

Children with SHS exposure who are hospitalized with influenza have more severe illness. Efforts are needed to immunize this population against influenza, and eliminate children's exposure to SHS.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Risk factors for hospitalized seasonal influenza in rural western Kenya

Background

Risk factors for influenza hospitalization in Africa are unknown, including the role of HIV.

Methods

We conducted a case-control study of risk factors for hospitalized seasonal influenza among persons in rural western Kenya, a high HIV prevalence area, from March 2006- August 2008. Eligible cases were ≥five years old, admitted to health facilities with respiratory symptoms, and had nasopharyngeal/oropharyngeal swab specimens that tested positive for influenza A or B by real-time reverse transcription-PCR. Three randomly selected age-, sex- and neighborhood-matched controls were enrolled per case. A structured questionnaire was administered and home-based HIV testing was performed. Risk factors were evaluated using conditional logistic regression.

Results

A total of 64 cases (38 with influenza A and 26 with influenza B) and 190 controls were enrolled. The median age was 16 years (range 5–69 years). Among cases, 24.5% were HIV-infected versus 12.5% of controls (p = 0.004). Among persons ≥18 years old, 13 (59%) of 22 tested cases were HIV-positive compared with 15 (24%) of 62 tested controls (p = 0.005). In multivariable analysis, HIV-infection was associated with hospitalization due to influenza [adjusted Odds Ratio (aOR) 3.56, 95% CI 1.25–10.1]. The mean CD4 count among HIV-infected cases and controls was similar (399 vs. 387, respectively, p = 0.89). Chronic lung disease (aOR 6.83, 95% CI 1.37–34.0) was also associated with influenza hospitalization in multivariable analysis. Active pulmonary tuberculosis was associated with influenza hospitalization in bivariate, but not multivariable, analysis.

Conclusions

People with HIV infection and chronic lung disease were at increased risk of hospitalized influenza in rural Kenya. HIV infection is common in many parts of sub-Saharan Africa. Influenza vaccine might prevent severe influenza in these risk groups.

Predicting need for hospitalization of patients with pandemic (H1N1) 2009, Chicago, Illinois, USA

In the absence of established guidelines for hospitalization of patients with pandemic (H1N1) 2009, we studied emergency department patients to identify clinical parameters that predict need for hospitalization. Independent predictors of hospitalization include multiple high-risk medical conditions, dyspnea, and hypoxia. These findings are easily applicable, with a 79% positive predictive value for hospitalization.

A systematic review of clinical decision rules for the diagnosis of influenza

PURPOSE

In this study, we assessed whether multivariate models and clinical decision rules can be used to reliably diagnose influenza.

METHODS

We conducted a systematic review of MEDLINE, bibliographies of relevant studies, and previous meta-analyses. We searched the literature (1962-2010) for articles evaluating the accuracy of multivariate models, clinical decision rules, or simple heuristics for the diagnosis of influenza. Each author independently reviewed and abstracted data from each article; discrepancies were resolved by consensus discussion. Where possible, we calculated sensitivity, specificity, predictive value, likelihood ratios, and areas under the receiver operating characteristic curve.

RESULTS

A total of 12 studies met our inclusion criteria. No study prospectively validated a multivariate model or clinical decision rule, and no study performed a split-sample or bootstrap validation of such a model. Simple heuristics such as the so-called fever and cough rule and the fever, cough, and acute onset rule were each evaluated by several studies in populations of adults and children. The areas under the receiver operating characteristic curves were 0.70 and 0.79, respectively. We could not calculate a single summary estimate, however, as the diagnostic threshold varied among studies.

CONCLUSIONS

The fever and cough, and the fever, cough, and acute onset heuristics have modest accuracy, but summary estimates could not be calculated. Further research is needed to develop and prospectively validate clinical decision rules to identify patients requiring testing, empiric treatment, or neither.

2009 pandemic influenza: a review

PURPOSE OF REVIEW

A review of influenza is particularly relevant this year due to the ongoing novel H1N1 influenza pandemic.

RECENT FINDINGS

Surveillance and clinical data including risk factors for infection and complications due to the current H1N1 pandemic are reviewed. New evidence on the safety of antiviral agents in children and studies on interventions to reduce community transmission of influenza are included. Influenza vaccine efficacy and improving immunization coverage have also been addressed by recent studies.

SUMMARY

These studies from the early phase of the pandemic identify the population that are at high risk for complications, and affirm that active surveillance and prevention are important aspects of a public health response. Appropriate use of antiviral agents and improving influenza immunization coverage for all ages continue to be a challenge. Further studies are underway to improve the public health response, and the pandemic H1N1 strain is being incorporated into the 2010 seasonal influenza vaccine.

Quality initiatives in the emergency department

PURPOSE OF REVIEW

To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate.

SUMMARY

There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.