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Ma Y, Gao Q. Clinical characteristics and assessment of risk factors in patients with influenza A-induced severe pneumonia after the prevalence of SARS-CoV-2. Open Med (Wars) 2024; 19:20240953. [PMID: 38633219 PMCID: PMC11022039 DOI: 10.1515/med-2024-0953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Purpose The aim of this study is to describe the novel epidemiological and clinical characteristics of influenza A-induced severe pneumonia occurring after the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and to further assess its potential risk factors for mortality. Methods We retrospectively studied the consecutive case series of 30 patients with confirmed influenza A-induced severe pneumonia treated in the intensive care unit at Dazhou Central Hospital in Sichuan, China, from March 1 to April 30, 2023. Logistic regression was used to analyze the independent risk factors, and receiver operating characteristic (ROC) curves were applied to evaluate the predictive efficacy of associated risk factors for mortality. Results The mortality rate was 33.3% in this study. Independent risk factors for mortality of patients were acute respiratory distress syndrome (ARDS) (p = 0.044) and septic shock (p = 0.012). ROC statistics for ARDS and septic shock to predict mortality in patients with influenza A-induced severe pneumonia demonstrated an area under the curve of 0.800 (sensitivity 80.0%, specificity 80.0%) and 0.825 (sensitivity 70.0%, specificity 95.0%), respectively. Conclusion ARDS and septic shock were the independent risk factors for mortality in patients with influenza A-induced severe pneumonia following the end of the SARS-CoV-2 pandemic. But high level of next generation sequencing reads Aspergillus coinfection, and comorbidities did not increase death risk of the study population.
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Affiliation(s)
- Yujie Ma
- Department of Cardiovascular Medicine, Dazhou Dachuan District People’s Hospital (Dazhou Third People’s Hospital), Dazhou, China
| | - Qiang Gao
- Department of Critical Care Medicine, Dazhou Central Hospital, No. 56 Nanyuemiao Street, Tongchuan District, Dazhou, 635000, Sichuan, China
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2
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Verdier V, Lilienthal F, Desvergez A, Gazaille V, Winer A, Paganin F. Severe forms of influenza infections admitted in intensive care units: Analysis of mortality factors. Influenza Other Respir Viruses 2023; 17:e13168. [PMID: 37483265 PMCID: PMC10359970 DOI: 10.1111/irv.13168] [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: 01/14/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Background The severe forms of influenza infection requiring intensive care unit (ICU) admission remain a medical challenge due to its high mortality. New H1N1 strains were hypothesized to increase mortality. The studies below represent a large series focusing on ICU-admitted influenza patients over the last decade with an emphasis on factors related to death. Methods A retrospective study of patients admitted in ICU for influenza infection over the 2010-2019 period in Réunion Island (a French overseas territory) was conducted. Demographic data, underlying conditions, and therapeutic management were recorded. A univariate analysis was performed to assess factors related to ICU mortality. Results Three hundred and fifty adult patients were analyzed. Overall mortality was 25.1%. Factors related to higher mortality were found to be patient age >65, cancer history, need for intubation, early intubation within 48 h after admission, invasive mechanical ventilation (MV), acute respiratory distress syndrome (ARDS), vaso-support drugs, extracorporal oxygenation by membrane (ECMO), dialysis, bacterial coinfection, leucopenia, anemia, and thrombopenia. History of asthma and oseltamivir therapy were correlated with a lower mortality. H1N1 did not impact mortality. Conclusion Patient's underlying conditions influence hospital admission and secondary ICU admission but were not found to impact ICU mortality except in patients age >65, history of cancer, and bacterial coinfections. Pulmonary involvement was often present, required MV, and often evolved toward ARDS. ICU mortality was strongly related to ARDS severity. We recommend rapid ICU admission of patients with influenza-related pneumonia, management of bacterial coinfection, and early administration of oseltamivir.
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Affiliation(s)
| | | | | | | | - Arnaud Winer
- Service de RéanimationCHU RéunionSaint‐DenisFrance
| | - Fabrice Paganin
- Cabinet de PneumologieLe PortFrance
- Service de PneumologieCHU RéunionSaint‐DenisFrance
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3
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Dicembrini I, Silverii GA, Clerico A, Fornengo R, Gabutti G, Sordi V, Tafuri S, Peruzzi O, Mannucci E. Influenza: Diabetes as a risk factor for severe related-outcomes and the effectiveness of vaccination in diabetic population. A meta-analysis of observational studies. Nutr Metab Cardiovasc Dis 2023; 33:1099-1110. [PMID: 37032254 DOI: 10.1016/j.numecd.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 04/11/2023]
Abstract
AIMS In order to better define the need for influenza vaccination in people with diabetes (DM), we collected all available evidence on the effect of DM as a risk factor for complications of both seasonal and pandemic influenza, and on the specific effectiveness of vaccines in patients with DM. DATA SYNTHESIS Two distinct systematic searches on MEDLINE, Cochrane, ClinicalTrials.gov and Embase databases were performed, one for each metanalysis, collecting all observational studies and randomized clinical trials performed on humans up to May 31st, 2022. We retrieved 34 observational studies comparing risk for influenza complications in people with or without diabetes, and 13 observational studies assessing vaccine effectiveness on preventing such complications. Mortality for influenza and hospitalization for influenza and pneumonia resulted significantly higher in individuals with versus without DM, both when unadjusted and adjusted data are analyzed. In diabetic individuals vaccinated for influenza overall hospitalization, hospitalization for influenza or pneumonia and overall mortality are significantly lower in comparison with not vaccinated DM subjects, both when unadjusted and adjusted data were analyzed. CONCLUSION This systematic review and meta-analysis shows that: 1) influenza is associated with more severe complications in diabetic versus not diabetic individuals and 2) influenza vaccination is effective in preventing clinically relevant outcomes in adults with DM with a NNT (number needed to treat) of 60, 319, and 250 for all-cause hospitalization, specific hospitalization, and all-cause mortality, respectively. The identification of diabetic patients as the target of vaccination campaigns for influenza appears to be justified by available clinical evidence.
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Affiliation(s)
- Ilaria Dicembrini
- Experimental and Clinical Biomedical Sciences Mario Serio Department, University of Florence, Italy.
| | | | | | | | - Giovanni Gabutti
- Coordinator Working Group Vaccines and Immunization Policies, Italian Scientific Society of Hygiene, Preventive Medicine and Public Health (SItI), Italy
| | - Valeria Sordi
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Silvio Tafuri
- Interdisciplinary Department of Medicine, Aldo Moro, University of Bari, Italy
| | - Ottavia Peruzzi
- Experimental and Clinical Biomedical Sciences Mario Serio Department, University of Florence, Italy
| | - Edoardo Mannucci
- Experimental and Clinical Biomedical Sciences Mario Serio Department, University of Florence, Italy
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Peng Y, Wang X, Yin S, Wang M. A new indicator: The diagnostic value of CD8+T/B lymphocyte ratio in sepsis progression. Int J Immunopathol Pharmacol 2022; 36:3946320221123164. [PMID: 36036157 PMCID: PMC9421217 DOI: 10.1177/03946320221123164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To reveal the value of single lymphocyte subpopulation and their ratios in
the progression of sepsis. Methods From January 2019 to March 2021, 39 sepsis patients, 16 septic shock
patients, and 50 healthy volunteers were recruited in the Second Xiangya
Hospital for this cross-sectional study. The absolute quantitation of CD4+T,
CD8+T, B lymphocytes, and NK cells in peripheral blood were determined by
flow cytometry. SPSS Software was used to analyze the results. Results On the whole, the numbers of lymphocytes in the sepsis group and in the
septic shock group were lower than that in the healthy control group.
Surprisingly, the percentage of CD8+T lymphocytes in the septic shock group
was slightly higher than that in the sepsis group. The percentage of B
lymphocytes in the sepsis group was higher than that in the healthy control
group. The AUC of CD8+T/B was 0.724, with the sensitivity and specificity
being 75.00% and 71.79%, respectively. Conclusion The immune expression pattern of patients with sepsis was not a simple
decrease in the number of lymphocytes. The change in the ratios of
lymphocyte subpopulation might be more meaningful along the development and
progression of sepsis. The ratio of CD8+T/B could be used to diagnose the
progression of sepsis and reduce the misdiagnosis rate to a certain
extent.
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Affiliation(s)
- Yizhi Peng
- Department of Laboratory Medicine, 70566The Second Xiangya Hospitalof Central South University, Changsha, Hunan, China
| | - Xiaofan Wang
- Department of Laboratory Medicine, 70566The Second Xiangya Hospitalof Central South University, Changsha, Hunan, China
| | - Sheng Yin
- Department of Laboratory Medicine, 70566The Second Xiangya Hospitalof Central South University, Changsha, Hunan, China
| | - Min Wang
- Department of Laboratory Medicine, 70566The Second Xiangya Hospitalof Central South University, Changsha, Hunan, China
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Soni B, Singh S. COVID-19 co-infection mathematical model as guided through signaling structural framework. Comput Struct Biotechnol J 2021; 19:1672-1683. [PMID: 33815692 PMCID: PMC7997053 DOI: 10.1016/j.csbj.2021.03.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 12/23/2022] Open
Abstract
SARS-CoV-2 and Influenza co-infection turned out to be a huge threat in recent times. The clinical presentation and disease severity is common in both the infection condition. The present paper deals with studying co-infection model system through systems biology approaches. Understanding signaling regulation in COVID-19 and co-infection model systems aid in the development of network-based models thereby suggesting intervention points for therapeutics. This paper highlights the aim of revealing such perturbations to decipher opportune mediating cross talks characterizing the deadly viral disease. The comparative analysis of both the models reveals major signaling protein NFκB and STAT1 playing a crucial role in establishing co-infection. By targeting these proteins at cellular level, it might help modulating the release of potent pro-inflammatory cytokines thereby taming the severity of the disease symptoms. Mathematical models developed here are precisely tailored and serves as a first step towards co-infection model offering flexibility and pitching towards therapeutic investigation.
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Affiliation(s)
- Bhavnita Soni
- National Centre for Cell Science, NCCS Complex, Ganeshkhind, SPPU Campus, Pune 411007, India
| | - Shailza Singh
- National Centre for Cell Science, NCCS Complex, Ganeshkhind, SPPU Campus, Pune 411007, India
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Khan MS, Shahid I, Anker SD, Solomon SD, Vardeny O, Michos ED, Fonarow GC, Butler J. Cardiovascular implications of COVID-19 versus influenza infection: a review. BMC Med 2020; 18:403. [PMID: 33334360 PMCID: PMC7746485 DOI: 10.1186/s12916-020-01816-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Due to the overlapping clinical features of coronavirus disease 2019 (COVID-19) and influenza, parallels are often drawn between the two diseases. Patients with pre-existing cardiovascular diseases (CVD) are at a higher risk for severe manifestations of both illnesses. Considering the high transmission rate of COVID-19 and with the seasonal influenza approaching in late 2020, the dual epidemics of COVID-19 and influenza pose serious cardiovascular implications. This review highlights the similarities and differences between influenza and COVID-19 and the potential risks associated with coincident pandemics. MAIN BODY COVID-19 has a higher mortality compared to influenza with case fatality rate almost 15 times more than that of influenza. Additionally, a significantly increased risk of adverse outcomes has been noted in patients with CVD, with ~ 15 to 70% of COVID-19 related deaths having an underlying CVD. The critical care need have ranged from 5 to 79% of patients hospitalized due to COVID-19, a proportion substantially higher than with influenza. Similarly, the frequency of vascular thrombosis including deep venous thrombosis and pulmonary embolism is markedly higher in COVID-19 patients compared with influenza in which vascular complications are rarely seen. Unexpectedly, while peak influenza season is associated with increased cardiovascular hospitalizations, a decrease of ~ 50% in cardiovascular hospitalizations has been observed since the first diagnosed case of COVID-19, owing in part to deferred care. CONCLUSION In the coming months, increasing efforts towards evaluating new interventions will be vital to curb COVID-19, especially as peak influenza season approaches. Currently, not enough data exist regarding co-infection of COVID-19 with influenza or how it would progress clinically, though it may cause a significant burden on an already struggling health care system. Until an effective COVID-19 vaccination is available, high coverage of influenza vaccination should be of utmost priority.
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Affiliation(s)
| | - Izza Shahid
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Scott D Solomon
- Brigham and Women's Hospital, Heart & Vascular Center, Boston, MA, USA
| | | | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS, 39216, USA.
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Estimating the Risk of Death from COVID-19 in Adult Cancer Patients. Clin Oncol (R Coll Radiol) 2020; 33:e172-e179. [PMID: 33218850 PMCID: PMC7671644 DOI: 10.1016/j.clon.2020.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 12/30/2022]
Abstract
AIMS During the coronavirus disease 2019 (COVID-19) pandemic, organisations have produced management guidance for cancer patients and the delivery of cytotoxic chemotherapy, but none has offered estimates of risk or the potential impact across populations. MATERIALS AND METHODS We combined data from four countries to produce pooled age-banded case fatality rates, calculated the sex difference in survival and used data from four recent studies to convert case fatality rates into age/sex-stratified infection fatality rates (IFRs). We estimated the additional risk of death in cancer patients and in those receiving chemotherapy. We illustrate the impact of these by considering the impact on a national incident cancer cohort and analyse the risk-benefit in some clinical scenarios. RESULTS We obtained data based on 412 985 cases and 41 854 deaths. The pooled estimate for IFR was 0.92%. IFRs for patients with cancer ranged from 0 to 29% and were higher in patients receiving chemotherapy (0.01-46%). The risk was significantly higher with age and in men compared with women. 37.5% of patients with a new diagnosis of cancer in 2018 had an IFR ≥5%. Survival benefits from adjuvant chemotherapy ranged from 5 to 10% in some common cancers, compared with the increased risk of death from COVID-19 of 0-3%. CONCLUSIONS Older male patients are at a higher risk of death with COVID-19. Patients with cancer are also at a higher risk, as are those who have recently received chemotherapy. We provide well-founded estimates to allow patients and clinicians to better balance these risks and illustrate the wider impact in a national incident cohort.
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Zou Q, Zheng S, Wang X, Liu S, Bao J, Yu F, Wu W, Wang X, Shen B, Zhou T, Zhao Z, Wang Y, Chen R, Wang W, Ma J, Li Y, Wu X, Shen W, Xie F, Vijaykrishna D, Chen Y. Influenza A-associated severe pneumonia in hospitalized patients: Risk factors and NAI treatments. Int J Infect Dis 2020; 92:208-213. [PMID: 31978583 DOI: 10.1016/j.ijid.2020.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/08/2020] [Accepted: 01/16/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The risk factors and the impact of NAI treatments in patients with severe influenza A-associated pneumonia remain unclear. METHODS A multicenter, retrospective, observational study was conducted in Zhejiang, China during a severe influenza epidemic in August 2017-May 2018. Clinical records of patients (>14 y) hospitalized with laboratory-confirmed influenza A virus infection and who developed severe pneumonia were compared to those with mild-to-moderate pneumonia. Risk factors related to pneumonia severity and effects of NAI treatments (monotherapy and combination of peramivir and oseltamivir) were analyzed. RESULTS 202 patients with influenza A-associated severe pneumonia were enrolled, of whom 84 (41.6%) had died. Male gender (OR = 1.782; 95% CI: 1.089-2.917; P = 0.022), chronic pulmonary disease (OR = 2.581; 95% CI: 1.447-4.603; P = 0.001) and diabetes mellitus (OR = 2.042; 95% CI: 1.135-3.673; P = 0.017) were risk factors related to influenza A pneumonia severity. In cox proportional hazards model, severe pneumonia patients treated with double dose oseltamivir (300mg/d) had a better survival rate compared to those receiving a single dose (150 mg/d) (HR = 0.475; 95%CI: 0.254-0.887; P = 0.019). However, different doses of peramivir (300 mg/d vs. 600 mg/d) and combination therapy (oseltamivir-peramivir vs. monotherapy) showed no differences in 60-day mortality (P = 0.392 and P = 0.658, respectively). CONCLUSIONS Patients with male gender, chronic pulmonary disease, or diabetes mellitus were at high risk of developing severe pneumonia after influenza A infection. Double dose oseltamivir might be considered in treating influenza A-associated severe pneumonia.
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Affiliation(s)
- Qianda Zou
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Shufa Zheng
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Xiaochen Wang
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Sijia Liu
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, PR China
| | - Jiaqi Bao
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Fei Yu
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Wei Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Xianjun Wang
- Department of Laboratory, Affiliated Hangzhou First People's Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China
| | - Bo Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province, Taizhou Enze Medical Center (Group), Linhai, PR China
| | - Tieli Zhou
- Department of Clinical Laboratory, First Affiliated Hospital, Wenzhou Medical University, Wenzhou, PR China
| | - Zhigang Zhao
- Department of Clinical Laboratory, Lishui Municipal Central Hospital, Lishui, PR China
| | - Yiping Wang
- Department of Clinical Laboratory, Yinzhou People's Hospital, Ningbo, PR China
| | - Ruchang Chen
- Medical Examination and Diagnosis Center, Yiwu Center Hospital, Yiwu, PR China
| | - Wei Wang
- Department of Clinical Laboratory, Lishui People's Hospital, the Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, PR China
| | - Jianbo Ma
- Department of Laboratory Medicine, the Affiliated Ningbo No.2 Hospital, College of Medicine, Ningbo University, Ningbo, PR China
| | - Yongcheng Li
- Department of Respiratory Diseases, the First People's Hospital of Xiaoshan, Hangzhou, PR China
| | - Xiaoyan Wu
- Department of Laboratory, Second Hospital of Jiaxing, Jiaxing, PR China
| | - Weifeng Shen
- Department of Laboratory, First Hospital of Jiaxing, Jiaxing, PR China
| | - Fuyi Xie
- Clinical Laboratory, Li Huili Hospital, Ningbo Medical Center, Ningbo, PR China
| | - Dhanasekaran Vijaykrishna
- Department of Microbiology, Biomedicine Discovery Institute, Monash University, Victoria, Australia; World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Yu Chen
- Key Laboratory of Clinical in Vitro Diagnostic Techniques of Zhejiang Province, Hangzhou, PR China; Center of Clinical Laboratory, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China; State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, PR China.
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Feldman C, Shaddock E. Epidemiology of lower respiratory tract infections in adults. Expert Rev Respir Med 2018; 13:63-77. [DOI: 10.1080/17476348.2019.1555040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Erica Shaddock
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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