SARS-CoV-2 RNAaemia in children: An Iranian referral hospital-based study

Although severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) RNA is generally detected in nasopharyngeal swabs, viral RNA can be found in other samples including blood. Recently, associations between SARS‐CoV‐2 RNAaemia and disease severity and mortality have been reported in adults, while no reports are available in pediatric patients with coronavirus disease 2019 (COVID‐19). The aim of this study was to evaluate the mortality, severity, clinical, and laboratory findings of SARS‐CoV‐2 RNA detection in blood in 96 pediatric patients with confirmed COVID‐19. Among all patients, 6 (6%) had SARS‐CoV‐2 RNAaemia. Out of the six patients with SARS‐CoV‐2 RNAaemia, four (67%) had a severe form of the disease, and two out of the 6 patients with SARS‐CoV‐2 RNAaemia passed away (33%). Our results show that the symptoms more commonly found in the cases of COVID‐19 in the study (fever, cough, tachypnea, and vomiting), were found at a higher percentage in the patients with SARS‐CoV‐2 RNAaemia. Creatine phosphokinase and magnesium tests showed significant differences between the positive and negative SARS‐CoV‐2 RNAaemia groups. Among all laboratory tests, magnesium and creatine phosphokinase could better predict SARS‐CoV‐2 RNAemia with area under the curve  levels of 0.808 and 0.748, respectively. In conclusion, 67% of individuals with SARS‐CoV‐2 RNAaemia showed a severe COVID‐19 and one‐third of the patients with SARS‐CoV‐2 RNAaemia passed away. Our findings suggest that magnesium and creatine phosphokinase might be considered as markers to estimate the SARS‐CoV‐2 RNAaemia.

Transdermal opioid patch in treatment of paroxysmal autonomic instability with dystonia with multiple cerebral insults: A case report

RATIONALE

Paroxysmal autonomic instability with dystonia (PAID) is an underdiagnosed syndrome that describes a collection of symptoms following diverse cerebral insults, such as traumatic brain injury, hydrocephalus, hemorrhagic stroke, or brain anoxia. It is manifested by systemic high blood pressure, hyperthermia, tachycardia, tachypnea, diaphoresis, intermittent agitation, and certain forms of dystonia.

PATIENT CONCERNS

A semi-comatose 46-year-old man was transferred from the regional rehabilitation hospital with various complaints involving fluctuating vital signs, including uncontrolled hyperthermia, hypertension, tachycardia, and tachypnea, and dystonia in all extremities. The patient underwent brain surgery for astrocytoma in 1996. The patient also had a history of first ischemic stroke on the basal ganglia in 2008 and a second one in the same area in 2017.

DIAGNOSIS

The laboratory, electrocardiography, and radiologic findings were normal. Brain imaging indicated an old infarction on the basal ganglia with hydrocephalus. Tractography using diffusion tensor imaging showed discontinuity of multiple tracts, and electrophysiologic tests, such as evoked potentials, displayed an absent response. Based on the dysautonomic symptoms and brain evaluations, the physiatrist diagnosed the patient with PAID.

INTERVENTIONS

Bromocriptine, propranolol, and clonazepam were administered sequentially, but autonomic instability persisted. Then, intravenous opioid was administered, and fluctuations in body temperature, heart rate, and respiratory rate, as well as decerebrate-type dystonia were improved. However, simultaneously, drug-induced severe hypotension developed (systolic blood pressure, 57 mm Hg). Subsequently, a transdermal opioid (fentanyl) patch for PAID was applied once every 3 days.

OUTCOMES

Ultimately, all vital signs and dystonia were managed without further complications, and the patient was discharged.

LESSONS

A patient diagnosed with PAID following multiple cerebral insults was observed, whose condition was controlled by application of opioid patch rather than by intravenous or oral routes. A transdermal opioid patch, such as fentanyl patch, can thus be effective in the treatment of patients with PAID following multiple cerebral insults.

CD64 Expression on Polymorph Nuclear Cells as a Sensitive and Specific Diagnostic Biomarker for Neonate Pneumonia

BACKGROUND

Neonatal pneumonia (NP) is one of the major causes of neonatal death. Current NP diagnosis depends on a detailed history, physical examination, and radiographic and laboratory findings. There is no specific biomarker or diagnostic indicator of NP.

METHODS

In this study, we tried to find a reliable biomarker for quick NP diagnosis by collecting peripheral blood from neonates with NP and transient tachypnea of the newborn (TTN), and subsequently tested the expression of CD64 on white blood cells using flow cytometry. The cellularity of each blood cell population was also quantified. Furthermore, procalcitonin (PCT) and C-reactive protein (CRP) levels were evaluated in the blood sera.

RESULTS

We found that NP patients had moderately increased polymorphonuclear cells (PMNs), as well as elevated PCT and CRP levels in the blood sera. Importantly, the expression of CD64 on PMNs was profoundly increased in NP patients but not TTN patients. The receiver operating characteristic (ROC) curve of PMN CD64 index suggests that PMN CD64 index is sensitive and specific for NP diagnosis.

CONCLUSIONS

Our study reveals that PMN CD64 could be a fast and reliable biomarker for NP diagnosis.

Tachypnea and Other Danger Signs vs Pulse Oximetry for Prediction of Hypoxia in Severe Pneumonia/Very Severe Disease

OBJECTIVE

To compare the performance of respiratory rate and other clinical signs against pulse oximetry for predicting hypoxia in children with Severe pneumonia/Very severe disease as per Integrated Management of Neonatal and Childhood Illness (IMNCI) classification.

DESIGN

Cross-sectional study.

SETTING

Pediatric emergency department of a tertiary-care hospital in Delhi, India.

SUBJECTS

112 hospitalized children (2 mo - 5 y) with Severe pneumonia/Very severe disease as per IMNCI classification.

METHODS

Respiratory rate was recorded at enrolment, along with other clinical signs and symptoms. Oxygen saturation (SpO2) was measured by a pulse oximeter. Clinical predictors of hypoxia (SpO2 <90%) and their combinations (index test) were evaluated for their sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of hypoxia, against pulse oximetry (reference test).

RESULTS

Hypoxia was present in 57 (50.9%) children. Presence of tachypnea, head nodding, irritability, inability to drink/breastfeed, vomiting, and altered sensorium was significantly associated with hypoxia (P<0.05). Multiple logistic regression revealed that age-specific tachypnea (RR≥70/min for 2-12 mo, and RR ≥60/min for ≥12 mo), head nodding, and inability to drink/breastfeed were independent predictors for hypoxia with sensitivity of 70.2%, 50.9% and 75.4%, respectively; and specificity of 88.9%, 96.4%, and 90.9%, respectively. When all three predictors were used in conjunction, the sensitivity increased to 91.2% and specificity was 81.8%.

CONCLUSION

No single clinical sign can perform as well as pulse oximetry for predicting hypoxia in children with severe pneumonia. In settings where pulse oximetry is not available, combination of signs, age-specific tachypnea, head nodding, and inability to drink/breastfeeding has acceptable sensitivity and specificity.

Predicting neonatal respiratory morbidity by lamellar body count and gestational age

AIMS

To develop a predictive model for assessing the risk of developing neonatal respiratory morbidity using lamellar body counts (LBCs) and gestational age (GA) to provide a more patient-specific assessment.

METHODS

Retrospective cohort study of patients' ≥32 weeks' gestation who received amniocentesis with LBC analysis over a 9-year period. Respiratory morbidity was defined as respiratory distress syndrome, transient tachypnea of the newborn or oxygen requirement for >24 h. Logistic regression analyses were used to predict the absolute risk and odds of respiratory morbidity as a function of GA and lamellar body count.

RESULTS

Two hundred and sixty-seven mother-infant pairs included in the analysis with 32 cases (12.0%) of respiratory morbidity. When compared to those without respiratory morbidity, neonates with respiratory morbidity had amniocentesis performed at an earlier median GA, had lower mean birthweight and had lower median LBC (P<0.01). The GA specific absolute risks and odds ratios for the presence of respiratory morbidity were calculated. The predicted absolute risks of neonatal respiratory morbidity ranged from 38% at 32 weeks to 6% at 40 weeks when LBC were 35,000/μL.

CONCLUSION

GA specific predicted risk of neonatal respiratory morbidity using LBC provides a statistical model, which can aid clinicians in individually counseling patients regarding the absolute risk of their neonate developing respiratory morbidity.

Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

IMPORTANCE

The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown.

OBJECTIVE

To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis.

DESIGN, SETTINGS, AND POPULATION

Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706,399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013.

EXPOSURES

Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100 mm Hg], tachypnea [≥22/min], or altered mentation).

MAIN OUTCOMES AND MEASURES

For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC).

RESULTS

In the primary cohort, 148,907 encounters had suspected infection (n = 74,453 derivation; n = 74,454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome.

CONCLUSIONS AND RELEVANCE

Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.

Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

IMPORTANCE

The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown.

OBJECTIVE

To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis.

DESIGN, SETTINGS, AND POPULATION

Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706,399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013.

EXPOSURES

Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic Organ Dysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100 mm Hg], tachypnea [≥22/min], or altered mentation).

MAIN OUTCOMES AND MEASURES

For construct validity, pairwise agreement was assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay ≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC).

RESULTS

In the primary cohort, 148,907 encounters had suspected infection (n = 74,453 derivation; n = 74,454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortality was lower for SIRS (AUROC = 0.64; 95% CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95% CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95% CI, 0.73-0.76; P < .001 for both) or LODS (AUROC = 0.75; 95% CI, 0.73-0.76; P < .001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95% CI, 0.80-0.82) that was greater than SOFA (AUROC = 0.79; 95% CI, 0.78-0.80; P < .001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P < .001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome.

CONCLUSIONS AND RELEVANCE

Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.

Early warning scores generated in developed healthcare settings are not sufficient at predicting early mortality in Blantyre, Malawi: a prospective cohort study

AIM

Early warning scores (EWS) are widely used in well-resourced healthcare settings to identify patients at risk of mortality. The Modified Early Warning Score (MEWS) is a well-known EWS used comprehensively in the United Kingdom. The HOTEL score (Hypotension, Oxygen saturation, Temperature, ECG abnormality, Loss of independence) was developed and tested in a European cohort; however, its validity is unknown in resource limited settings. This study compared the performance of both scores and suggested modifications to enhance accuracy.

METHODS

A prospective cohort study of adults (≥18 yrs) admitted to medical wards at a Malawian hospital. Primary outcome was mortality within three days. Performance of MEWS and HOTEL were assessed using ROC analysis. Logistic regression analysis identified important predictors of mortality and from this a new score was defined.

RESULTS

Three-hundred-and-two patients were included. Fifty-one (16.9%) died within three days of admission. With a cut-point ≥2, the HOTEL score had sensitivity 70.6% (95% CI: 56.2 to 82.5) and specificity 59.4% (95% CI: 53.0 to 65.5), and was superior to MEWS (cut-point ≥5); sensitivity: 58.8% (95% CI: 44.2 to 72.4), specificity: 56.2% (95% CI: 49.8 to 62.4). The new score, dubbed TOTAL (Tachypnoea, Oxygen saturation, Temperature, Alert, Loss of independence), showed slight improvement with a cut-point ≥2; sensitivity 76.5% (95% CI: 62.5 to 87.2) and specificity 67.3% (95% CI: 61.1 to 73.1).

CONCLUSION

Using an EWS generated in developed healthcare systems in resource limited settings results in loss of sensitivity and specificity. A score based on predictors of mortality specific to the Malawian population showed enhanced accuracy but not enough to warrant clinical use. Despite an assumption of common physiological responses, disease and population differences seem to strongly determine the performance of EWS. Local validation and impact assessment of these scores should precede their adoption in resource limited settings.

[A newborn with tachypnea]

A neonate developed a tachypnea 2 hours after his birth. Blood measurements showed low infectious parameters and a respirator acidosis. The x-ray showed a pneumomediastinum. A spontaneous pneumomediastinum is rare in newborns, causes can be underlying lung diseases or mechanical ventilation. The treatment prognosis is good; spontaneous recovery without treatment is common.

Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study

OBJECTIVES

To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of lower respiratory tract infections (LRTI) in children with fever.

DESIGN

Prospective observational study.

PARTICIPANTS

Febrile children aged at least 1 month to just under 16 years (derivation population, n = 1555; validation population, n = 671) selected from patients attending paediatric emergency departments or assessment units in hospitals.

SETTING

One hospital in the Netherlands in 2006 and 2008 (derivation population); one hospital in the Netherlands in 2003-05 and one hospital in the United Kingdom in 2005-06 (validation population).

INTERVENTION

We used the derivation population to produce respiratory rate centile charts, and calculated 50th, 75th, 90th, and 97th centiles of respiratory rate at a specific body temperature. Multivariable regression analysis explored associations between respiratory rate, age, and temperature; results were validated in the validation population by calculating diagnostic performance measures, z scores, and corresponding centiles of children with diagnoses of pneumonic LRTI (as confirmed by chest radiograph), non-pneumonic LRTI, and non-LRTI.

MAIN OUTCOME MEASURE

Age, respiratory rate (breaths/min) and body temperature (°C), presence of LRTI.

RESULTS

Respiratory rate increased overall by 2.2 breaths/min per 1°C rise (standard error 0.2) after accounting for age and temperature in the model. We observed no interactions between age, temperature, and respiratory rates. Age and temperature dependent cut-off values at the 97th centile were more useful for ruling in LRTI (specificity 0.94 (95% confidence interval 0.92 to 0.96), positive likelihood ratio 3.66 (2.34 to 5.73)) than existing respiratory rate thresholds such as Advanced Pediatrics Life Support values (0.53 (0.48 to 0.57), 1.59 (1.41 to 1.80)). However, centile cut-offs could not discriminate between pneumonic LRTI and non-pneumonic LRTI.

CONCLUSIONS

Age specific and temperature dependent centile charts describe new reference values for respiratory rate in children with fever. Cut-off values at the 97th centile were more useful in detecting the presence of LRTI than existing respiratory rate thresholds.