Viral load in hospitalized infants with respiratory syncytial virus bronchiolitis: a three-way comparative analysis

Viral load measurement of Respiratory syncytial virus (RSV) in acute bronchiolitis depends on specimen collection, viral load quantification, and transport media. The aim of this study was to investigate viral load in three-way-comparative analyses; nasal swab versus nasal wash, quantitative real-time polymerase chain reaction (RT-PCR) versus cell tissue culture, and various transport media. A prospective cohort study of infants aged < 12 months, admitted to the Soroka Medical Center, due to acute bronchiolitis, was conducted. Two nasal swabs and two nasal wash samples (in UTM and VCM) were collected from each infant upon admission and after 48 h. Samples were immediately stored at -80 °C and tested at Viroclinics DDL (Rotterdam, Netherlands). Quantitative RT-PCR and quantitative virus culture were performed using tissue culture infective dose (TCID50). Spearman's correlation coefficient test assessed the correlation between the different methods, viral load, and clinical severity score. One hundred samples were collected from 13 infants (mean age 5.7 ± 3.8 months, 46% males). Twelve patients were RSV-A positive, and one was RSV-B positive. A high correlation was found between transport media- UTM and VCM (0.92, P < 0.001) and between nasal swabs and nasal wash samples (0.62, P = 0.02). RSV signals were higher in nasal wash than in swabs. PCR signals were lower in the second collection compared to the first. No correlation was found between viral load and clinical severity.    Conclusion: RSV viral load is comparable across nasal wash, nasal swabs, and various transport media. However, it did not correlate with clinical severity, probably due to the limited sample size. Broader analyses are warranted. What is Known: • Viral load measurement in Respiratory Syncytial Virus (RSV) bronchiolitis depends on specimen collection, viral load quantification, and transport media. • The COVID-19 pandemic underscored the paramount significance of proper specimen collection, notably through nasal swabs. What is New: • RSV viral load was investigated in three-way-comparative analyses. • RSV viral load correlated well across PCR and tissue culture, nasal wash and swabs, and various transport media. RSV viral load did not correlate with clinical severity.

Videofluoroscopy compared with clinical feeding evaluation in children with suspected aspiration

Aim

Videofluoroscopy swallow studies (VFSS) are gold standard to diagnose aspiration in children but require resources and radiation compared with clinical feeding evaluation (CFE). We evaluated their added value for diagnosis, feeding management and clinical status.

Methods

A retrospective single‐centre cross‐sectional study of children aged 0–18 years, with respiratory morbidity, referred for VFSS at a tertiary pediatric hospital.

Results

A total of 113 children, median age (range) 2.2 years (0.1–17.9), underwent VFSS. Diagnosis included chronic pulmonary aspiration (CPA), 87 (77%); neurological, 73 (64%); gastrointestinal, 73 (64%) and congenital heart disease, 42 (37%), not mutually exclusive. Forty‐six (41%) aspirated, 9 (8%) only overtly and 37 (33%) including silent aspirations. Those with CPA or cerebral palsy were more likely to have VFSS aspiration, OR 3.2 and 9.8 respectively.

Feeding recommendations after VFSS differed significantly from those based on prior CFE, p < 0.001: The rate of exclusively orally fed children rose from 65% to 79%, p = 0.006; exclusively enterally fed children from 10% to 14%; p = 0.005. During the year after VFSS, there were significantly less antibiotic courses, total and respiratory admissions.

Conclusion

In this population with high prevalence of clinically suspected CPA, VFSS altered feeding management compared with CFE and may have contributed to subsequent clinical improvement.

Modified Tal Score: Validated score for prediction of bronchiolitis severity

OBJECTIVE

To further validate the use of the Modified Tal Score (MTS), a clinical tool for assessing bronchiolitis severity, by physicians with varying experience and training levels, and to determine the ability of the MTS to predict bronchiolitis severity.

METHODS

This prospective cohort study included infants of <12 months of age who were diagnosed with bronchiolitis and assessed via MTS. We calculated the intra-class correlation coefficient (ICC) among four groups of raters: group 1, board-certified pediatric pulmonologists; group 2, board-certified pediatricians; group 3, senior pediatric residents; and group 4, junior pediatric residents. Clinical outcomes were determined as length of oxygen support and length of stay (LOS). We assessed MTS's prediction of these outcomes. Relative risk (RR) for clinical severity was calculated via a Generalized Linear Model.

RESULTS

Twenty-four physicians recorded a total of 600 scores for 50 infants (average age 5 ± 3 months; 56% male). The ICC values with group 1 as a reference were 0.92, 0.87, and 0.83, for groups 2, 3, and 4, respectively (P < 0.001). RR for oxygen support required was; 1.33 (CI 1.12-1.57), 1.26 (1.1-1.46), 1.26 (1.06-1.5), and 1.21 (0.93-1.58) for groups 1, 2, 3, and 4, respectively. RR for LOS was; 1.15 (CI 0.97-1.37), 1.19 (1.03-1.38), 1.18 (1.0-1.39), and 1.18 (0.93-1.51) for groups 1, 2, 3, and 4, respectively.

CONCLUSION

The MTS is a simple and valid scoring system for evaluating infants with acute bronchiolitis, among different physician groups. The first score upon admission is a fair predictor of oxygen requirement at 48 h, and LOS at 72 h.

Cystic duct remnant calculi after cholecystectomy

Unrecognized lithiasis of the cystic duct (CDL) may be responsible for post cholecystectomy. This retrospective study looked at the incidence of CDL during cholecystectomy, as well as the context of its occurrence; recommendations for a practical surgical approach are offered.

PATIENTS AND METHODS

Over a period of 30 months, 143 consecutive cholecystectomies (103 women, 40 men; mean age: 57 years) were performed by the same surgeon: 142 by laparoscopy, and one by laparotomy due to a history of previous gastrectomy. The cystic duct was always opened and milked upward in search of CDL before immediate clip occlusion or performance of cholangiography (106 times, 74.1%). In seven cases, cholangiography was impossible because the cystic duct was too narrow.

RESULTS

There was no mortality. CDL was found in 21 cases (14.7%) and removed. This had not been identified by preoperative imaging (ultrasound or CT). Pain in the month preceding cholecystectomy occurred more frequently in cases of CDL (19/21[90.4%] vs 36/122 [29.5%]; P<0.001). Similarly, liver function tests were more often abnormal with CDL (10/21 [47.6%] vs 30/122 [24.5%]; P<0.05). However, neither jaundice nor gallbladder inflammation was predictive of CDL in this study. Echoendoscopy (EUS) was performed more often for suspected common duct lithiasis migration (CBDL) in patients with CDL than for those without (9/21 [42.8%] vs 26/122 [21.3%]; P<0.05). CBDL was present in 12 of 143 patients (8.3%). This was treated by preoperative endoscopic sphincterotomy in 10 cases, and twice by trans-cystic stone extraction during the laparoscopic intervention. CBDL occurred more frequently in association with CDL (5/21 [23.8%] vs 7/122 [5.7%]; P<0.01). In addition, CDL was still present at cholecystectomy in the four patients who underwent preoperative endoscopic sphincterotomy.

CONCLUSION

Cystic duct lithiasis is found frequently during cholecystectomy; CDL is often associated with preoperative pain, abnormal liver function tests and choledocholithiasis. It can persist despite preoperative sphincterotomy. The search for and treatment of CDL should be routinely performed during cholecystectomy.