Predictive value of capnography for severity of acute gastroenteritis in the emergency department.

OBJECTIVE: This study first aims to assess the utility of ETCO2 levels in evaluating the severity of dehydration in adult patients that present to the ED with acute gastroenteritis. AGE. Second, it intends to evaluate the correlation between ETCO2 and several metabolic parameters: creatinine, pH, bicarbonate (HCO3), and bases excessive (BE). METHOD: This prospective study was conducted with AGE patients in the ED of a training and research hospital between June 2018 and April 2019 after approval of the local ethical-committee. The two groups were defined according to the severity of AGE: mild and non-mild groups. For both groups, ETCO2 levels were measured and recorded on admission of the patients. RESULTS: 87 patients were included in the analyses. The median of ETCO2 values was found as lower in non-mild group than mild group; 30 (25-35) & 39 (33-34), respectively (p < 0.001). In ROC analysis for distinguishing between the both groups, the AUC value was found to be 0.988 and the best cut-off level was found as 33.5 with 95% sensitivity and 93% specificity. In addition, strong negative correlation between ETCO2 and creatinine (p < 0.001, r: -0.771) were found. CONCLUSION: ETCO2 levels decreased in the non-mild group of AGE patients; it could be useful to distinguish the mild group from the non-mild group. ETCO2 could be a reliable marker in predicting AKI in the management of AGE patients.

Impact of self-financed rotavirus vaccines on hospital stays and costs in Spain after a 3-year introductory period.

Vaccination has reduced rotavirus hospitalizations by 25% in European regions with low-moderate vaccine availability. We aimed to quantify the reduction in hospital costs after the longest period in which Rotarix® and Rotateq® were simultaneously commercially available in Spain. Cases, length of stay (LOS), and diagnosis-related groups (DRGs) were retrieved from the Minimum Basic Data Set. Healthcare expenditure was estimated through the cost accounting system Gescot®. DRGs were clustered: I, non-bacterial gastroenteritis with complications; II, without complications; III, requiring surgical/other procedures or neonatal cases (highest DRG weights). Comparisons between pre (2003-2005)- and post-vaccine (2007-2009) hospital stays and costs by DRG group were made. Rotaviruses were the most common agents of specific-coded gastroenteritis (N = 1657/5012). LOS and extended LOS of rotaviruses fell significantly in 2007-2009 (ß-coefficient = -0·43, 95% confidence intervals (95% CI) -0·68 to -0·17; and odds ratio 0·62, 95% CI 0·50-0·76, respectively). Overall, costs attributable to rotavirus hospitalizations fell approximately €244 per patient (95% CI -365 to -123); the decrease in DRG group III was €2269 per patient (95% CI -4098 to -380). We concluded modest savings in hospital costs, largely attributable to cases with higher DRG weights, and a faster recovery. A universal rotavirus vaccination program deserves being re-evaluated, regarding its potential high impact on both at-risk children and societal costs.

Comparison of Vesikari and Clark scales regarding the definition of severe rotavirus gastroenteritis in children.

BACKGROUND: Two clinical severity scales, the Vesikari scale and the Clark scale, are commonly used to assess the efficacy of rotavirus vaccines. The results obtained using the two severity scales differ significantly and hamper comparisons. The aim of this study was to compare the Clark and Vesikari scales and to determine whether modified classifications would provide a better correlation between the two scales. METHODS: The severity of rotavirus gastroenteritis was assessed for each child using both the Vesikari and Clark scales. To make a statistical comparison between the two scales, the classifications were modified. RESULTS: In total, 200 children with rotavirus gastroenteritis were evaluated. Of these, 57% were classified as severe by the Vesikari scale, and only 1.5% by the Clark scale (p < 0.001). When the Clark three-category scale was transformed into a two-category scale by merging mild and moderate categories as non-severe, a good correlation with the Vesikari scale still could not be found. Using the median of the severity scores as the severity threshold did not provide a better correlation between the two scales. Transforming the Vesikari two-category scale into a three-category scale by further subdividing the severe category into two parts, as moderate and severe (≥ 16), provided a better correlation between the two severity scales, but still did not achieve a good level of agreement. CONCLUSIONS: The Clark and Vesikari scales differ significantly in the definition of severe gastroenteritis. Even the attempts at reclassifying the scales did not achieve a good correlation.

Trends in gastroenteritis-associated mortality in the United States, 1985-2005: variations by ICD-9 and ICD-10 codes.

BACKGROUND: Trends in gastroenteritis-associated mortality are changing over time with development of antibiotic resistant strains of certain pathogens, improved diagnostic methods, and changing healthcare. In 1999, ICD-10 coding was introduced for mortality records which can also affect trends. We assess trends in gastroenteritis-associated mortality and changes associated with coding. METHODS: Trends in gastroenteritis-associated mortality rates in the United States were examined using the National Center for Health Statistics Multiple Cause-of-Death Mortality databases for 1985-2005. All deaths with the underlying cause or any contributing cause included gastroenteritis were included. Cases were selected based on ICD9 (pre-1999) and ICD10 (1999-2005) codes and all analyses were stratified by ICD usage. Annual trends in age adjusted mortality rates were assessed using linear regression spline analysis. Relative risks and 95% confidence intervals (CIs) were calculated using Poisson regression adjusted for age group, sex, race, and region. RESULTS: There were a total of 190,674 deaths related to gastroenteritis in the U.S. from 1985-2005 with an average of 9,080 per year. During this time the percent of deaths related to gastroenteritis more than tripled, increasing from 0.25% to 0.80% of all deaths. Though the time periods varied in length, we demonstrate a significant increase in slope from a 0.0054% annual increase during the period 1985-1998, when ICD-9 coding was used, to a 0.0550% annual increase during 1999-2005, when ICD-10 coding was used. For both time periods, the oldest age group (75+ years) demonstrated the highest risk of death due to gastroenteritis. Additionally, males demonstrated higher risk than females and blacks were at higher risk than whites for death due to gastroenteritis. CONCLUSIONS: This analysis demonstrates the public health burden of gastroenteritis-associated mortality in the United States and changes in trends due to change from ICD-9 to ICD-10 coding. The overall rate of gastroenteritis-associated mortality has more than tripled over the 21-year period from 1985 to 2005 and the primary burden of deaths due to gastroenteritis is in the elderly population.

Design of a simplified histopathologic model for gastrointestinal inflammation in dogs.

Significant interobserver variability in the diagnostic interpretation of endoscopic gastrointestinal (GI) specimens exists even with the use of World Small Animal Veterinary Association (WSAVA) standardization criteria. Chi-square analyses compared the extent of pathologists' agreement for microarchitectural features of inflammation in endoscopic specimens obtained from 253 animals of the original WSAVA study. Patterns of agreement between pathologists were classified as broad (3/4 pathologists agreed), dichotomous (2/4 pathologists agreed), or divergent (no agreement between pathologists). The simplified model for GI inflammation was based on those parameters for which the pathologists had either broad or minimally divergent opinions of histopathologic significance. In this model, the parameters chosen were as follows: gastric parameters (intraepithelial lymphocytes [IELs], lamina propria [LP] infiltrates, and mucosal fibrosis), duodenal parameters (villus atrophy, epithelial injury, IELs, crypt changes, and LP infiltrates), and colonic parameters (epithelial injury, crypt dilation, fibrosis, LP infiltrates, and goblet cell depletion). Preliminary data using this simplified model showed excellent correlation between pathologists in defining the presence and extent of GI inflammation in dogs.

Emergence of GII.4 Sydney norovirus in South Korea during the winter of 2012-2013.

Norovirus is the major cause of acute gastroenteritis worldwide. Between November 2012 and June 2013, 1718 stool samples were requested for norovirus antigen testing in the metropolitan areas of South Korea, and 91 samples were genotyped. The norovirus antigen-positive rate peaked at 52.8% in December 2012. [corrected]. A novel norovirus GII.4 variant, GII.4 Sydney 2012, was the most frequently found genotype (60.4%) during this period. This study demonstrates that norovirus activity increased during the winter of 2012-2013 in South Korea and that norovirus GII.4 Sydney 2012 was the cause of the norovirus epidemic during this period.

Mucosal-type eosinophilic gastroenteritis in Thailand: 12-year retrospective study.

OBJECTIVE: To evaluate the clinical features and natural course of disease among patients with mucosal-type eosinophilic gastroenteritis in Thailand. MATERIAL AND METHOD: The present study was conducted by retrospectively searching for the ICD-10 code for eosinophilic gastroenteritis (EGE) among medical records for the period 2001-2012. Clinical and pathological specimens were reviewed using the same diagnostic criteria. Appropriate tests were conducted to exclude other secondary causes of EGE. All patients had to have either received empirical treatment for parasitic infections or were tested for parasites in the stool. After the diagnosis had been established, each patient received 30-40 mg/day of oral prednisoloneforfour weeks, which was tapered down as clinical status improved. All patients were followed up by monitoring clinical symptoms and relevant laboratory findings. Patients who did not maintain follow-up appointments were contacted by telephone and asked about their clinical symptoms. RESULTS: Seventeen patients with a diagnosis of mucosal-type E (6 male, 11 female, M:F ratio 1:1.83) were found. Mean age at the time of presentation was 52.5 +/- 13.04 years. Four patients (23.5%) had either allergic or atopic conditions. Chronic diarrhea and weight loss were the most common initial presentation in 16 patients (94.1%). Microscopically and macroscopically, bloody diarrhea was observed in 13 cases (76.5%). Four patients were found to have protein-losing enteropathy. Peripheral eosinophilia was found in 10 patients (58.8%) with absolute eosinophil counts between 744 and 23,550 cells/mm3. Eight of these had an absolute eosinophil count in the hypereosinophilic range (> 1,500 cells/mm3). All patients treated with prednisolone treatment showed symptomatic improvement within four weeks. One patient's symptom resolved spontaneously, without treatment. Thirteen patients relapsed during the tapering-off of prednisolone. Seven patients showed complete remission. Three patients subsequently developed cancer (lung, breast, and bladder) after EGE was diagnosed. CONCLUSION: EGE, although uncommon, is present in Thailand, where parasitic infections continue to be a significant public-health problem.

[Clinical analysis of eosinophilic gastroenteritis in six children].

OBJECTIVE: To analyze the clinical characteristics and treatment of eosinophilic gastroenteritis (EG) in children. METHOD: A retrospective analysis of the clinical manifestation, laboratory test, endoscopy, biopsy, bone marrow examination and treatment of 6 children diagnosed with EG in Beijing Children's Hospital seen from Jun. 2005 to May 2009 was performed. RESULT: Five of the cases were boys and 1 was girl, the range of age was from 2 to 13 years; food allergy test was positive in 4 cases. Clinical manifestations included:abdominal pain, diarrhea, vomiting, digestive tract hemorrhage, and ascites was found in 4 children. The eosinophilic cell count in blood increased in 5 cases [(160 - 13,560) × 10(6)/L]. The percentage of eosinophilic cell in bone marrow increased in 6 cases (0.18 - 0.41). Beside stomach and duodenum, anatomical foci were found in mesentery (5 cases), small intestine (4 cases), colon (3 cases), and esophagus (2 cases). Endoscopy and imaging showed edema, congestion, erosion, ulcer, bile reflux and gastric juice retention. Stomach and duodenum pathological changes included epithelial erosion, large quantities of eosinophilic cell infiltration in lamina propria and scattered lymphoid cells, which were more obvious in duodenum. In the group received glucocorticoid therapy, clinical symptoms disappeared 3 days later, the eosinophilic cell count in blood returned to normal one-week later;in the group of non-glucocorticoid therapy, most of the clinical symptoms disappeared after two weeks. The eosinophilic cell count in blood was still high 5 weeks later. CONCLUSION: Compared to the common gastroenteritis, gastrointestinal symptoms in EG cases were nonspecific, the increase of blood eosinophilic cells can suggest the possibility of EG, but biopsy is the key to the diagnosis of EG. The therapeutic effect of glucocorticoid seemed to be better than non-glucocorticoid therapies in the improvement of clinical symptoms and the decrease of blood eosinophilic cell.

The collagenous gastroenteritides: similarities and differences.

Collagenous gastritis, collagenous sprue, and collagenous colitis share striking histologic similarities and occur together in some patients. They also share some drug and disease associations. Pediatric cases of collagenous gastritis, however, lack most of these associations. The etiologies of the collagenous gastroenteritides are not known, so it is not clear whether they are similar because they share pathogeneses, or because they indicate a common histologic response to varying injuries. The features, disease and drug associations, and the inquiries into the pathogenesis of these disorders are reviewed.

Norovirus and Rotavirus--two major causative agents of sporadic viral gastroenteritis in hospitalized Polish children.

PURPOSE: The aim of the study was to establish the main etiologic agents of acute viral gastroenteritis and to asses the severity of illness associated with the different viral agents of gastroenteritis in children hospitalized during spring/summer season 2008. MATERIAL AND METHODS: 181 stool specimens were collected from children under 5 years of age, hospitalized with acute viral diarrhea from April to September 2008. Commercial enzyme immunoassay kits were used to detect noroviruses. The immunochromatographic tests for combined detection of rotaviruses and adenoviruses were performed routinely in our department in all in-patients suspected for viral gastroenteritis. RESULTS: A viral etiologic agents were detected in 108 of 181 (59.7%) samples tested. Dual viral pathogens (rotavirus and norovirus) were found in 3 of 181 (1.7%) samples. Rotavirus was the most common viral pathogen found in the study group (86/181; 47.5%), followed by NV (19/181; 10.5%) and adenoviruses (3/181; 1.7%). Approximately, 60% of acute gastroenteritis episodes occurring in children less than 5 years of age were accounted for by infection due to rotavirus and/or norovirus. Norovirus cases were clinically indistinguishable from those of rotavirus origin in children aged less than 2 years whereas they were slightly milder in older group of patients. CONCLUSIONS: Rotavirus infections are leading cause of children's hospitalization in spring months whereas Norovirus infections during spring/summer time. There is a great need to apply molecular diagnostic tools to determine the actual and monitoring the changing etiology of acute enteritis in Polish population.

[Prospective epidemiological study of rotavirus gastroenteritis in Europe (REVEAL study). Results in the French area of the study]. / Etude épidémiologique prospective de la gastroentérite à rotavirus en Europe (étude REVEAL). Résultats de la zone d'étude française.

PRIMARY OBJECTIVE: To estimate the incidence of acute gastroenteritis (AGE) and rotavirus acute gastroenteritis (RVAGE) in children less than 5 years of age seeking medical care in primary care, emergency department, and hospital settings. SECONDARY OBJECTIVES: To compare the clinical profile of RVAGE and non-RVAGE and to describe the distribution of RV serotypes among RVAGE cases. METHODS: A prospective primary care, emergency ward and hospital-based observational study was conducted during 1 year in a selected city of France with 250,000 inhabitants. Children less than 5 years of age presenting with symptoms of AGE were included. Rotavirus was identified using an Elisa test in stools. RESULTS: The estimated annual incidence of RVAGE was 1.56% for AGE and 0.87% for RVAGE in hospital, 5.87% for AGE and 2.65% for RVAGE in emergency-wards, 7.39% for AGE and 1.45% for RVAGE in primary care. Total incidence was 14.82% for AGE and 4.96% for RVAGE among children less than 5 years of age. RVAGE were more clinically severe than the AGE: dehydration (26.8% vs. 14.7%, p<0.0001), vomiting 84.9% vs. 60.9%, p<0.0001), fever (74.3% vs. 44.4%, p<0.0001), lethargy (84.9% vs. 70.2%, p<0.0001). G9 serotype was the most frequent serotype encountered (54.7%) during the study period followed by G3 serotype (33.6%) and G2 serotype (7.9%). CONCLUSION: In this study, RVAGE, caused by serotypes G9 and G3, represented about 1/3 of AGE and were more severe than non-RV AGE with twice as high dehydration rate. These results underline the need for continued promotion on the use of oral rehydration fluids and provide some arguments on the benefits of vaccination against rotavirus and also permanent virological monitoring of circulating serotypes.

Norovirus and sapovirus infections among children with acute gastroenteritis in Ho Chi Minh City during 2005-2006.

A molecular epidemiological study on common diarrheal viruses was conducted in a children's hospital in Ho Chi Minh City between December 2005 and November 2006. Fecal samples were collected from 502 pediatric patients with acute gastroenteritis, and were screened for the presence of norovirus (NoV) and sapovirus (SaV). NoVs GII and SaVs were detected in 6.4% and 1.2% specimens, respectively, while there was no NoV GI found among studied samples. NoVs could be identified through the year, except in April and July, with the peak of detection rate (62.5%) during the rainy season. Conversely, four out of six (66.7%) of the SaV strains were identified during the dry season. Patients aged between 6 and 23 months were found to be more infected by NoVs. The overall mean severity score of norovirus-positive patients was 9.8 +/- 3.6, and no significant difference of severity scores among patients belonged to different age groups, gender and place of living. The results of phylogenetic analysis showed the diversity of caliciviruses circulating in the area, and various types of recombination were identified among NoVs and SaVs detected. These results provide important information on calicivirus infections among Vietnamese children.

Efficacy of human rotavirus vaccine against rotavirus gastroenteritis during the first 2 years of life in European infants: randomised, double-blind controlled study.

BACKGROUND: We aimed to assess the efficacy of the oral live attenuated human rotavirus vaccine Rotarix (RIX4414) for prevention of rotavirus gastroenteritis in European infants during their first 2 years of life. METHODS: 3994 study participants were enrolled from six countries and were randomly assigned two oral doses of either RIX4414 (n=2646) or placebo (n=1348), which were coadministered with the first two doses of specific childhood vaccinations. Follow-up for gastroenteritis episodes was undertaken from 2 weeks post-dose two through the two consecutive rotavirus seasons following vaccinations (combined efficacy follow-up period; mean duration 17 months [SD 1.6]). Our primary endpoint was vaccine efficacy against rotavirus gastroenteritis of any severity during the first efficacy follow-up period (2 weeks post-dose two to the end of the first rotavirus season). Stool specimens obtained during gastroenteritis episodes were tested for rotavirus by ELISA and typed by RT-PCR. Episodes scoring 11 or greater on the 20-point Vesikari scale were classified as severe. Analysis was according to protocol. This study is registered with ClinicalTrials.gov, number NCT00140686 (eTrack102247). FINDINGS: 120 infants were excluded from the according-to-protocol analysis. During the first efficacy follow-up period (mean duration 5.7 months [SD 1.2]), 24 of 2572 infants allocated RIX4414 versus 94 of 1302 given placebo had rotavirus gastroenteritis episodes of any severity, resulting in a vaccine efficacy of 87.1% (95% CI 79.6-92.1; p<0.0001). For the combined efficacy follow-up period, vaccine efficacy against severe rotavirus gastroenteritis was 90.4% (85.1-94.1; p<0.0001), for admission owing to rotavirus gastroenteritis 96.0% (83.8-99.5; p<0.0001), and for rotavirus-related medical attention 83.8% (76.8-88.9; p<0.0001), and significant protection against severe rotavirus gastroenteritis by circulating G1, G2, G3, G4, and G9 rotavirus types was shown. INTERPRETATION: In a European setting, two doses of RIX4414 coadministered with childhood vaccines provided high protection against any and severe rotavirus gastroenteritis, with an overall reduction of admissions for gastroenteritis over two consecutive rotavirus epidemic seasons.

Evaluation of immunochromatography tests for detection of rotavirus and norovirus among Vietnamese children with acute gastroenteritis and the emergence of a novel norovirus GII.4 variant.

A prospective study was conducted to evaluate two immunochromatography (ICG) tests for detection of group A rotavirus and norovirus GII, the commercial Dipstick 'Eiken' Rota kit (SA Scientific, USA) and the NV IC-1 stick (Immuno-Probe, Japan). Polymerase chain reaction (PCR) with specific primer pairs (Beg9 and VP7-1', for group A rotavirus; COG2F and G2SKR, for norovirus GII) was used as the reference method. The results of ICG tests were compared with those of reference method. The sensitivity, specificity and agreement between ICG tests and PCR were 87.8%, 93.3% and 89.4%, respectively, for rotavirus ICG test; and 73.7%, 100% and 95.2%, respectively, for norovirus ICG test. The immunochromatography assay for norovirus used in this study could detect not only common noroviruses, but also a novel norovirus GII.4 variant, which emerged in Ho Chi Minh City in 2006. Immunochromatography tests are easy, rapid and useful assays for detection of rotavirus and norovirus among pediatric patients with acute gastroenteritis in Vietnam.

Rotavirus and not age determines gastroenteritis severity in children: a hospital-based study.

BACKGROUND: The severity of childhood gastroenteritis is generally believed to be age-related rather than aetiology-related. Rotavirus-induced gastroenteritis is more severe than gastroenteritis caused by other enteric pathogens and is also age-related. We thus addressed the question of whether the increased severity of rotavirus-induced gastroenteritis is related to age or to features intrinsic to the agent. STUDY DESIGN: In this multicentre, hospital-based, prospective survey, we evaluated the severity of diarrhoea in rotavirus-positive and rotavirus-negative children up to 4 years of age. Severity was assessed with a score in four groups of age-matched children. RESULTS: Rotavirus was detected in 381 of 911 children. Disease severity was evaluated in 589 cases for which clinical data were complete. The rotavirus-positive and rotavirus-negative groups differed with regards to diarrhoea duration, hospital stay, degree of dehydration and the number of episodes of vomiting. Gastroenteritis was more severe in rotavirus-positive than in rotavirus-negative children. In contrast, none of the main severity parameters differed in the four age groups, irrespective of the presence of rotavirus. CONCLUSIONS: These data provide the evidence that aetiology and not age determines diarrhoeal severity. The demonstration that diarrhoea was more severe in rotavirus-positive children supports the need for a rotavirus vaccine and for studies that address the duration of vaccine protection.

Use of active surveillance to validate international classification of diseases code estimates of rotavirus hospitalizations in children.

OBJECTIVE: National estimates of hospitalizations for rotavirus, the leading cause of acute gastroenteritis (AGE) in children, have been used to establish the need for rotavirus vaccines. A previous method directly estimated discharges by using the rotavirus-specific International Classification of Diseases (ICD) code, but this method has not been validated. Our study evaluated the sensitivity of the rotavirus ICD code among children hospitalized for AGE by using active surveillance for rotavirus at a tertiary children's hospital. DESIGN: We compared data for rotavirus-coded hospital discharges in 2000-2001 at Cincinnati Children's Hospital Medical Center with data on laboratory-confirmed cases of rotavirus obtained from active surveillance. We estimated additional rotavirus hospitalizations by extrapolating the proportion of rotavirus-positive results from active-surveillance cases to those with an unknown rotavirus status. RESULTS: Of 767 cases of AGE-related discharge codes, 103 (13%) were coded as rotavirus, 91% (94 of 103) of which were laboratory-confirmed diagnoses. Among all children discharged with an AGE-related illness, 260 (34%) were enrolled in active surveillance, of whom 155 (60%) tested positive for rotavirus. An additional 47 laboratory-confirmed rotavirus-case patients not enrolled in active surveillance yielded a total of 202 rotavirus cases and a maximum sensitivity of the rotavirus code of 47%. Extrapolation indicated that an additional 170 untested children might be rotavirus-positive, yielding a total of 372 rotavirus hospitalizations and a minimum sensitivity of the rotavirus code of 25%. CONCLUSIONS: Measurement of rotavirus-coded hospital discharges alone seems to greatly underestimate the true burden of rotavirus-associated hospitalizations. The numbers of national rotavirus hospitalization discharges may be substantially greater than previously estimated.

Food safety: emerging trends in foodborne illness surveillance and prevention.

Between 250 and 350 million Americans are estimated to suffer acute gastroenteritis annually, with 25% to 30% thought to be caused by foodborne illnesses. Most vulnerable to foodborne diseases are elderly people, pregnant women, immune-compromised people, and children. While bacterial causes such as Salmonella are widely recognized and monitored as foodborne infections, other important bacterial causes such as Clostridium perfringens , Bacillus cereus , and Staphylococcus aureus are less well known. While the majority of cases of foodborne diseases are of unknown cause, bacteria and viruses are the most likely causative agents. Caliciviridae (Norwalk-like) virus cases are more difficult to identify, but represent the most common cause of known and probably unknown cases. Fresh produce has to be added to the traditional list of foods requiring careful selection and handling to prevent foodborne disease. To assess the disease burden in the United States, morbidity and mortality surveillance activities are done by several networks and systems with collaboration among federal agencies and health departments. Not all important causes are being equally monitored. Critical behaviors by food processors, food retailers, foodservice personnel, and consumers can reduce the risk of foodborne illness episodes. Dietetics professionals can more readily monitor new developments and update knowledge and practice through online resources.