Lower respiratory tract infection in the community: associations between viral aetiology and illness course.

OBJECTIVES: This study determined associations between respiratory viruses and subsequent illness course in primary care adult patients presenting with acute cough and/or suspected lower respiratory tract infection. METHODS: A prospective European primary care study recruited adults with symptoms of lower respiratory tract infection between November 2007 and April 2010. Real-time in-house polymerase chain reaction (PCR) was performed to test for six common respiratory viruses. In this secondary analysis, symptom severity (scored 1 = no problem, 2 = mild, 3 = moderate, 4 = severe) and symptom duration were compared between groups with different viral aetiologies using regression and Cox proportional hazard models, respectively. Additionally, associations between baseline viral load (cycle threshold (Ct) value) and illness course were assessed. RESULTS: The PCR tested positive for a common respiratory virus in 1354 of the 2957 (45.8%) included patients. The overall mean symptom score at presentation was 2.09 (95% confidence interval (CI) 2.07-2.11) and the median duration until resolution of moderately bad or severe symptoms was 8.70 days (interquartile range 4.50-11.00). Patients with influenza virus, human metapneumovirus (hMPV), respiratory syncytial virus (RSV), coronavirus (CoV) or rhinovirus had a significantly higher symptom score than patients with no virus isolated (0.07-0.25 points or 2.3-8.3% higher symptom score). Time to symptom resolution was longer in RSV infections (adjusted hazard ratio (AHR) 0.80, 95% CI 0.65-0.96) and hMPV infections (AHR 0.77, 95% CI 0.62-0.94) than in infections with no virus isolated. Overall, baseline viral load was associated with symptom severity (difference 0.11, 95% CI 0.06-0.16 per 10 cycles decrease in Ct value), but not with symptom duration. CONCLUSIONS: In healthy, working adults from the general community presenting at the general practitioner with acute cough and/or suspected lower respiratory tract infection other than influenza impose an illness burden comparable to influenza. Hence, the public health focus for viral respiratory tract infections should be broadened.

The ReSVinet Score for Bronchiolitis: A Scale for All Seasons.

The ReSVinet Scale is a clinical score for the assessment of respiratory difficulty in infancy. Our aim was to provide an update on the characteristics that make this tool different to any other. We descriptively compared the characteristics of the ReSVinet Scale with other options that can be found in the current literature or mobile apps stores. The ReSVinet Scale has been devised for its use regardless of the age of the child, entity causing respiratory symptoms, and setting. To this date, it is the only pediatric respiratory scale for acute respiratory distress that provides a parental version, and it is also the first one to have undergone validation in primary care. The tool can be found either in paper format or can be downloaded via App stores for devices running on Android or iOS systems. It has also been adopted recently as the assessment instrument for several clinical trials and for an IMI2 initiative (RESCEU project). All the aforementioned characteristics of the ReSVinet Scale should help toward its dissemination, as currently no other clinical tool for the assessment of respiratory difficulty can offer those advantages.

Treatment stratification of respiratory syncytial virus infection in allogeneic stem cell transplantation.

BACKGROUND: Due to paucity of evidence to guide management of allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients with respiratory syncytial virus (RSV) infections national and international guidelines make disparate recommendations. METHODS: The outcomes of allo-HSCT recipients with RSV infection between 2015 and 2017 were assessed using the following treatment stratification; upper respiratory tract infections (URTI) being actively monitored and lower respiratory tract infections (LRTI) treated with short courses of oral ribavirin combined with intravenous immunoglobulin (IVIG, 2 g/kg). RESULTS: During the study period 49 RSV episodes were diagnosed (47% URTI and 53% LRTI). All patients with URTI recovered without pharmacological intervention. Progression from URTI to LRTI occurred in 15%. Treatment with oral ribavirin given until significant symptomatic improvement (median 7 days [3-12]) and IVIG for LRTI was generally well tolerated. RSV-attributable mortality was low (2%). CONCLUSIONS: In this cohort study, we demonstrate that active monitoring of allo-HSCT patients with RSV in the absence of LRTI was only associated with progression to LRTI in 15% of our patients and therefore appears to be a safe approach. Short course oral ribavirin in combination with IVIG was effective and well-tolerated for LRTI making it a practical alternative to aerosolised ribavirin. This approach was beneficial in reducing hospitalisation, saving nursing times and by using oral as opposed to nebulised ribavirin.

Utility of predictive tools for risk stratification of elderly individuals with all-cause acute respiratory infection.

PURPOSE: A number of scoring tools have been developed to predict illness severity and patient outcome for proven pneumonia, however, less is known about the utility of clinical prediction scores for all-cause acute respiratory infection (ARI), especially in elderly subjects who are at increased risk of poor outcomes. METHODS: We retrospectively analyzed risk factors and outcomes of individuals ≥ 60 years of age presenting to the emergency department with a clinical diagnosis of ARI. RESULTS: Of 276 individuals in the study, 40 had proven viral infection and 52 proven bacterial infection, but 184 patients with clinically adjudicated ARI (67%) remained without a proven microbial etiology despite extensive clinical (and expanded research) workup. Patients who were older, had multiple comorbidities, or who had proven bacterial infection were more likely to require hospital and ICU admission. We identified a novel model based on 11 demographic and clinical variables that were significant risk factors for ICU admission or mortality in elderly subjects with all-cause ARI. As comparators, a modified PORT score was found to correlate more closely with all-cause ARI severity than a modified CURB-65 score (r, 0.54, 0.39). Interestingly, modified Jackson symptom scores were found to inversely correlate with severity (r, - 0.34) but show potential for differentiating viral and bacterial etiologies. CONCLUSIONS: Modified PORT, CURB-65, Jackson symptom scores, and a novel ARI scoring tool presented herein all offer predictive ability for all-cause ARI in elderly subjects. Such broadly applicable scoring metrics have the potential to assist in treatment and triage decisions at the point of care.

Are we missing respiratory viral infections in infants and children? Comparison of a hospital-based quality management system with standard of care.

OBJECTIVES: Hospital-based surveillance of influenza and acute respiratory infections relies on International Classification of Diseases (ICD) codes and hospital laboratory reports (Standard-of-Care). It is unclear how many cases are missed with either method, i.e. remain undiagnosed/coded as influenza and other respiratory virus infections. Various influenza-like illness (ILI) definitions co-exist with little guidance on how to use them. We compared the diagnostic accuracy of standard surveillance methods with a prospective quality management (QM) programme at a Berlin children's hospital with the Robert Koch Institute. METHODS: Independent from routine care, all patients fulfilling pre-defined ILI-criteria (QM-ILI) participated in the QM programme. A separate QM team conducted standardized clinical assessments and collected nasopharyngeal specimens for blinded real-time quantitative PCR for influenza A/B viruses, respiratory syncytial virus, adenovirus, rhinovirus and human metapneumovirus. RESULTS: Among 6073 individuals with ILI qualifying for the QM programme, only 8.7% (528/6073) would have undergone virus diagnostics during Standard-of-Care. Surveillance based on ICD codes would have missed 61% (359/587) of influenza diagnoses. Of baseline ICD codes, 53.2% (2811/5282) were non-specific, most commonly J06 ('acute upper respiratory infection'). Comparison of stakeholder case definitions revealed that QM-ILI and the WHO ILI case definition showed the highest overall sensitivities (84%-97% and 45%-68%, respectively) and the CDC ILI definition had the highest sensitivity for influenza infections (36%, 95% CI 31.4-40.8 for influenza A and 48%, 95% CI 40.5-54.7 for influenza B). CONCLUSIONS: Disease-burden estimates and surveillance should account for the underreporting of cases in routine care. Future studies should explore the effect of ILI screening and surveillance in various age groups and settings. Diagnostic algorithms should be based on the WHO ILI case definition combined with targeted testing.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections.

OBJECTIVES: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

Seeking out SARI: an automated search of electronic health records.

The definition of severe acute respiratory infection (SARI) - a respiratory illness with fever and cough, occurring within the past 10 days and requiring hospital admission - has not been evaluated for critically ill patients. Using integrated electronic health records data, we developed an automated search algorithm to identify SARI cases in a large cohort of critical care patients and evaluate patient outcomes. We conducted a retrospective cohort study of all admissions to a medical intensive care unit from August 2009 through March 2016. Subsets were randomly selected for deriving and validating a search algorithm, which was compared with temporal trends in laboratory-confirmed influenza to ensure that SARI was correlated with influenza. The algorithm was applied to the cohort to identify clinical differences for patients with and without SARI. For identifying SARI, the algorithm (sensitivity, 86.9%; specificity, 95.6%) outperformed billing-based searching (sensitivity, 73.8%; specificity, 78.8%). Automated searching correlated with peaks in laboratory-confirmed influenza. Adjusted for severity of illness, SARI was associated with more hospital, intensive care unit and ventilator days but not with death or dismissal to home. The search algorithm accurately identified SARI for epidemiologic study and surveillance.

Assessment of 12 influenza-like illness case definitions using Department of Defense Global, Laboratory-based Influenza Surveillance Program data, 2011-2014.

Despite the growth in influenza surveillance programs, standardization of a globally accepted influenza-like illness (ILI) case definition remains difficult. With 2011-2014 Department of Defense Global, Laboratory-based Influenza Surveillance Program (DISP) data, 12 case definitions were evaluated using a combination of ILI case definitions from the Centers for Disease Control and Prevention, World Health Organization, and the DISP. The sensitivity, specificity, positive and negative predictive values, and odds ratios for each case definition were calculated. Additionally, area under the curve (AUC) was calculated for a receiver operating characteristic (ROC) curve to compare the case definitions. Between 2 October 2011 and 27 September 2014, 52.3% (5,575 of 10,662) of respiratory specimens submitted met the inclusion criteria. The case definition for the DISP had a sensitivity of 54.6% and specificity of 63.7%. Case definitions should be selected according to the objectives of the surveillance system and resources available. Sensitive case definitions capture a larger proportion of cases but at the cost of testing more specimens. Definitions with higher specificity result in fewer false positives but may miss more cases.

Viral etiology, seasonality and severity of hospitalized patients with severe acute respiratory infections in the Eastern Mediterranean Region, 2007-2014.

INTRODUCTION: Little is known about the role of viral respiratory pathogens in the etiology, seasonality or severity of severe acute respiratory infections (SARI) in the Eastern Mediterranean Region. METHODS: Sentinel surveillance for SARI was conducted from December 2007 through February 2014 at 20 hospitals in Egypt, Jordan, Oman, Qatar and Yemen. Nasopharyngeal and oropharyngeal swabs were collected from hospitalized patients meeting SARI case definitions and were analyzed for infection with influenza, respiratory syncytial virus (RSV), adenovirus (AdV), human metapneumovirus (hMPV) and human parainfluenza virus types 1-3 (hPIV1-3). We analyzed surveillance data to calculate positivity rates for viral respiratory pathogens, describe the seasonality of those pathogens and determine which pathogens were responsible for more severe outcomes requiring ventilation and/or intensive care and/or resulting in death. RESULTS: At least one viral respiratory pathogen was detected in 8,753/28,508 (30.7%) samples tested for at least one pathogen and 3,497/9,315 (37.5%) of samples tested for all pathogens-influenza in 3,345/28,438 (11.8%), RSV in 3,942/24,503 (16.1%), AdV in 923/9,402 (9.8%), hMPV in 617/9,384 (6.6%), hPIV1 in 159/9,402 (1.7%), hPIV2 in 85/9,402 (0.9%) and hPIV3 in 365/9,402 (3.9%). Multiple pathogens were identified in 501/9,316 (5.4%) participants tested for all pathogens. Monthly variation, indicating seasonal differences in levels of infection, was observed for all pathogens. Participants with hMPV infections and participants less than five years of age were significantly less likely than participants not infected with hMPV and those older than five years of age, respectively, to experience a severe outcome, while participants with a pre-existing chronic disease were at increased risk of a severe outcome, compared to those with no reported pre-existing chronic disease. CONCLUSIONS: Viral respiratory pathogens are common among SARI patients in the Eastern Mediterranean Region. Ongoing surveillance is important to monitor changes in the etiology, seasonality and severity of pathogens of interest.

Antibiotics for acute respiratory infections in general practice: comparison of prescribing rates with guideline recommendations.

OBJECTIVE: To compare the current rate of antibiotic prescribing for acute respiratory infections (ARIs) in Australian general practice with the recommendations in the most widely consulted therapeutic guidelines in Australia (Therapeutic Guidelines). DESIGN AND SETTING: Comparison of general practice activity data for April 2010 - March 2015 (derived from Bettering the Evaluation and Care of Health [BEACH] study) with estimated rates of prescribing recommended by Therapeutic Guidelines. MAIN OUTCOME MEASURES: Antibiotic prescribing rates and estimated guideline-recommended rates per 100 encounters and per full-time equivalent (FTE) GP per year for eight ARIs; number of prescriptions nationally per year. RESULTS: An estimated mean 5.97 million (95% CI, 5.69-6.24 million) ARI cases per year were managed in Australian general practice with at least one antibiotic, equivalent to an estimated 230 cases per FTE GP/year (95% CI, 219-240 cases/FTE/year). Antibiotics are not recommended by the guidelines for acute bronchitis/bronchiolitis (current prescribing rate, 85%) or influenza (11%); they are always recommended for community-acquired pneumonia (current prescribing rate, 72%) and pertussis (71%); and they are recommended for 0.5-8% of cases of acute rhinosinusitis (current prescribing rate, 41%), 20-31% of cases of acute otitis media (89%), and 19-40% cases of acute pharyngitis or tonsillitis (94%). Had GPs adhered to the guidelines, they would have prescribed antibiotics for 0.65-1.36 million ARIs per year nationally, or at 11-23% of the current prescribing rate. Antibiotics were prescribed more frequently than recommended for acute rhinosinusitis, acute bronchitis/bronchiolitis, acute otitis media, and acute pharyngitis/tonsillitis. CONCLUSIONS: Antibiotics are prescribed for ARIs at rates 4-9 times as high as those recommended by Therapeutic Guidelines. Our data provide the basis for setting absolute targets for reducing antibiotic prescribing in Australian general practice.

Common Cold - an Umbrella Term for Acute Infections of Nose, Throat, Larynx and Bronchi.

Acute respiratory tract infections, i. e. rhinitis, sinusitis, pharyngitis, laryngitis, bronchitis, belong to the most common medical conditions with a high economic burden. Nonetheless, there is little agreement concerning their differential diagnosis.This paper will discuss to what extent different anatomical sites of acute respiratory tract infections can be uniquely identified or whether the overlap and consecutive development in signs and symptoms renders these distinctions meaningless.Acute respiratory tract infections are variable but definition of diagnostic categories based on the anatomical sites of the dominant complaints shows that signs and symptoms both overlap to a great extent and/or emerge successively. Thus, in common cold distinguishing between acute symptom-based diagnoses arising from different anatomical sites of the aerodigestive system remains elusive. Therefore, preferred symptomatic treatments should foster a resolution of all possible symptoms as opposed to an isolated treatment of a single symptom (e. g. mucus hypersecretion) according to the presumed anatomical site (i. e. acute bronchitis).

[Evaluation of an ICD-10-based electronic surveillance of acute respiratory infections (SEEDARI) in Germany]. / Evaluation einer ICD-10-basierten elektronischen Surveillance akuter respiratorischer Erkrankungen (SEEDARE) in Deutschland.

BACKGROUND: Every year epidemic waves of influenza and other acute respiratory infections (ARIs) cause a highly variable burden of disease in the population. Thus, assessment of the situation and adaptation of prevention strategies have to rely on real time syndromic surveillance. OBJECTIVE: We have established an ICD-10-based electronic system allowing rapid capture and transmission of information on ARI (SEEDARI), in Germany. Here we report the evaluation of this new system based on results of the syndromic and virologic surveillance carried out by the working group on influenza in Germany (AGI). METHODS: Consultations and ICD10-codes (J00-J22, J44.0 and B34.9) between week 16 in 2009, and week 15 in 2013, were used for comparison with AGI data. The time course and the correlation of weekly estimates of the incidence of medically attended ARI (MAARI) and ARI/100 consultations were analyzed for the different surveillance systems. RESULTS: The number of participating medical practices in SEEDARI almost doubled from 2009 (n = 65) to 2013 (n = 111). A total of almost 6.8 million consultations and 465,006 diagnosed ARIs were transmitted. The comparison of weekly estimated incidence of MAARI per 100,000 capita derived from SEEDARI and the results of the AGI showed high statistical correlation (Spearman correlation coefficient rs = 0,924; n = 209; p < 0,001). The proportion of diagnosed influenza (J09-J11) and the weekly positivity rate from virological surveillance during epidemic waves also showed high correlations. DISCUSSION: We conclude that SEEDARI represents a valid system for syndromic influenza surveillance. The case-based ICD-10 approach allows a detailed analysis of the actual situation and also seems suitable for population-based studies.

Necessity of office visits for acute respiratory infections in primary care.

BACKGROUND: Acute respiratory infections (ARIs) are the most common symptomatic reason to seek ambulatory care, but many ARI visits may not be necessary. OBJECTIVE: To measure the proportion of primary care ARI visits that may not require an office visit. METHODS: We identified 58398 ARI visits to 14 primary care practices between May 2011 and May 2012 and randomly selected 500 visits, 439 of which were new ARI visits. We separated non-visit-required information [e.g. history of present illness (HPI), past medical history, etc.] from information that required an office visit (e.g. physical exam, testing, etc.). Reviewing non-visit-required information, we identified the diagnosis (HPI diagnosis) and whether office visit appeared necessary. Independently, we reviewed the visit-required information and determined if the visit changed antibiotic management. RESULTS: Based on non-visit-required information, 72% (316/439) of visits did not appear to require an office visit. The most common diagnoses were non-specific upper respiratory infection (39%), sinusitis (24%) and acute bronchitis (22%). The HPI diagnosis was an exact match for clinicians' diagnosis in 67% (213/316) of visits. After reviewing the visit-required information, antibiotic management did not change for 87% (276/316) of visits. For the remaining 13% (40/316) for which the visit changed management, the clinician prescribed an antibiotic for an antibiotic-appropriate diagnosis (65%; 26/40); prescribed an antibiotic for a non-antibiotic-appropriate diagnosis (25%; 10/40); or avoided an antibiotic prescription for patients with an HPI diagnosis of sinusitis (10%; 4/40). CONCLUSION: About two-thirds of primary care ARI visits may not be necessary for appropriate antibiotic management.

Acute respiratory infection case definitions for young children: a systematic review of community-based epidemiologic studies in South Asia.

OBJECTIVE: To explore the variability in childhood acute respiratory infection case definitions for research in low-income settings where there is limited access to laboratory or radiologic investigations. METHODS: We conducted a systematic review of community-based, longitudinal studies in South Asia published from January 1990 to August 2013, in which childhood acute respiratory infection outcomes were reported. Case definitions were classified by their label (e.g. pneumonia, acute lower respiratory infection) and clinical content 'signatures' (array of clinical features that would be always present, conditionally present or always absent among cases). Case definition heterogeneity was primarily assessed by the number of unique case definitions overall and by label. We also compared case definition-specific acute respiratory infection incidence rates for studies reporting incidence rates for multiple case definitions. RESULTS: In 56 eligible studies, we found 124 acute respiratory infection case definitions. Of 90 case definitions for which clinical content was explicitly defined, 66 (73%) were unique. There was a high degree of content heterogeneity among case definitions with the same label, and some content signatures were assigned multiple labels. Within studies for which incidence rates were reported for multiple case definitions, variation in content was always associated with a change in incidence rate, even when the content differed by a single clinical feature. CONCLUSION: There has been a wide variability in case definition label and content combinations to define acute upper and lower respiratory infections in children in community-based studies in South Asia over the past two decades. These inconsistencies have important implications for the synthesis and translation of knowledge regarding the prevention and treatment of childhood acute respiratory infection.

New Epidemiological and Clinical Signatures of 18 Pathogens from Respiratory Tract Infections Based on a 5-Year Study.

BACKGROUND: Respiratory tract infections (RTIs) are a heavy burden on society. However, due to the complex etiology of RTIs, the clinical diagnosis, treatment, and prevention of these infections remain challenging, especially in developing countries. METHODS: To determine the epidemiological and clinical characteristics of 18 respiratory pathogens, we analyzed 12,502 patients with acute respiratory infections (ARIs) by performing polymerase chain reaction (PCR) on patient pharyngeal swabs. RESULTS: Samples positive for at least 1 pathogen were obtained from 48.42% of the total patients. Of these pathogen-positive patients, 17.99% were infected with more than 1 pathogen. Of the 18 pathogens analyzed, four were detected with a positive detection rate (PDR) > 5%: influenza A virus (IAV) > respiratory syncytial virus (RSV) >Mycoplasma pneumoniae (MP) > human coronavirus (HCoV). The pathogens with the 4 highest co-infection rates (CIRs) were as follows: HCoV > human bocavirus (HBoV) > enterovirus (EV) > parainfluenza virus (PIV). The overall positive detection rate (PDR) varied significantly according to patient age, the season and year of detection, and the disease subgroup, but not according to patient sex. The individual PDRs of the pathogens followed 3 types of distributions for patient sex, 4 types of distributions for patient age, 4 types of seasonal distributions, 2 types of seasonal epidemic trends, 4 types of yearly epidemic trends, and different susceptibility distributions in the disease subgroups. Additionally, the overall CIR showed significantly different distributions according to patient sex, patient age, and the disease subgroup, whereas the CIRs of individual pathogens suggested significant preference characteristics. CONCLUSION: IAV remains the most common pathogen among the pathogens analyzed. More effort should be directed toward the prevention and control of pathogens that show a trend of increasing incidence such as HCoV, human adenovirus (ADV), and RSV. Although clinically distinguishing specific pathogens responsible for RTIs is difficult, the epidemiological and clinical characteristics of the various RTI-causing agents could provide clues for clinicians, thereby informing decisions regarding prevention and medication and guiding appropriate public health strategies.

Differences between the spectra of respiratory illnesses in children living in urban and rural environments.

A longitudinal study launched in 1994 within the framework of the Teplice Programme aimed at comparing the respiratory morbidity in children born (1994-1998) and living in the districts of Teplice (TE) and Prachatice (PRA) in the Czech Republic. Lists of all illnesses of 960 children from birth to 10 years of age were obtained from paediatric medical records. From 26,471 diagnoses (in ICD-10 codes), 34.7% were diagnoses of upper respiratory infections (URI, J00-02, J06), 11.3% of tonsillitis, 10.2% of influenza, 9.4% of bronchitis, 8.9% of laryngitis/tracheitis (J04), 2.7% of otitis media, and 0.5% of pneumonia. The more polluted district of Teplice was divided into two parts: the town itself (TE-town) and the rest of the district (TE-district). The cumulative incidence rates of the above respiratory illnesses per 100 children per 10 years were 2,212 in TE-town, 2,192 in PRA and 1,985 in TE-district. In the first two years of life, the children from TE-town had a significantly higher incidence of laryngitis/tracheitis, influenza, otitis media, and pneumonia and significantly lower incidence of bronchitis and tonsillitis than children living in PRA. The incidence rates of laryngitis/tracheitis and influenza in TE-town persisted as the highest among the three regions till the age of 10 years. The incidence rates of bronchitis (from the 1st to 5th year) and URI (from 4th to 10th year) were highest in children living in PRA. When compared to TE-town, children in TE-district had a higher incidence of upper respiratory infections (1-8 years) and lower incidence of bronchitis (6-8 years). Children in the district of Prachatice had a significantly higher prevalence of allergic rhinitis and a lower prevalence of wheezing than children in the district of Teplice. Thus, the three regions differed by the spectra of respiratory illnesses rather than by overall morbidity and, hypothetically, the effects of air pollution were obscurred by differences in the degree of urbanization.

Parainfluenza virus lower respiratory tract disease after hematopoietic cell transplant: viral detection in the lung predicts outcome.

BACKGROUND: Parainfluenza virus (PIV) commonly infects patients following hematopoietic cell transplantation (HCT), frequently causing lower respiratory tract disease (LRTD). The definition of LRTD significantly differs among studies evaluating the impact of PIV after HCT. METHODS: We retrospectively evaluated 544 HCT recipients with laboratory-confirmed PIV and classified LRTD into 3 groups: possible (PIV detection in upper respiratory tract with new pulmonary infiltrates with/without LRTD symptoms), probable (PIV detection in lung with LRTD symptoms without new pulmonary infiltrates), and proven (PIV detection in lung with new pulmonary infiltrates with/without LRTD symptoms). RESULTS: Probabilities of 90-day survival after LRTD were 87%, 58%, and 45% in possible, probable, and proven cases, respectively. Patients with probable and proven LRTD had significantly worse survival than those with upper respiratory tract infection (probable: hazard ratio [HR], 5.87 [P < .001]; proven: HR, 9.23 [P < .001]), whereas possible LRTD did not (HR, 1.49 [P = .27]). Among proven/probable cases, oxygen requirement at diagnosis, low monocyte counts, and high-dose steroid use (>2 mg/kg/day) were associated with high mortality in multivariable analysis. CONCLUSIONS: PIV LRTD with viral detection in lungs (proven/probable LRTD) was associated with worse outcomes than was PIV LRTD with viral detection in upper respiratory samples alone (possible LRTD). This new classification should impact clinical trial design and permit comparability of results among centers.

Diagnostic value of the soluble triggering receptor expressed on myeloid cells-1 in lower respiratory tract infections: a meta-analysis.

The soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is a promising diagnostic marker for many types of infections. A bivariate meta-analysis was performed to evaluate its diagnostic value for lower respiratory tract infections (LRTI). We searched PubMed, Cochrane Library and Web of Science (from January 1966 to August 2013) for all trials assessing diagnostic value of sTREM-1 for LRTI. The pooled sensitivity, specificity, positive likelihood ratio(PLR), negative likelihood ratio(NLR), diagnostic odds ratio (DOR), the area under summary receiver operator characteristic (SROC) curve and the Q* were calculated. Thirteen studies with 1138 patients were included in our meta-analysis. The pooled sensitivity and specificity of sTREM-1 for diagnosis of LRTI was 0.84 and 0.77. The PLR, NLR and DOR were 3.6, 0.21 and 17. The area under SROC curve was 0.88 and the Q* was 0.82. The univariate meta-regression analysis demonstrated that the assay method for sTREM-1 significantly affected sensitivity for LRTI. The Q* of sTREM-1 for diagnosis of community-acquired LRTI was 0.82, and the area under SROC curve was 0.88. The Q* of sTREM-1 in diagnosis of hospital-acquired LRTI was 0.83, and the area under SROC curve was 0.90. The Q* of sTREM-1 for distinguishing culture-positive LRTI from culture-negative diseases was 0.79, and the area under SROC curve was 0.86. Current evidence suggests that sTREM-1 is an accurate marker of LRTI. The overall diagnostic value of sTREM-1 for LRTI, community-acquired LRTI and hospital-acquired LRTI is similar.

[Juvenile onset respiratory papillomatosis: risk factors for severity].

OBJECTIVE: This study was designed to explore the risk factors associated with severity of juvenile onset recurrent respiratory papillomatosis. METHOD: A retrospective study was conducted to study determinants of severe forms of juvenile recurrent onset respiratory papillomatosis. The patients were separated into different groups based on the onset age, the first recurrence of age, the first recurrence of period, gender and incision of tracheal respectively. The relationship among the lesion severity score,the involvement of the subregion, operation period and the next operation period were also explored. RESULT: It was observed that some children who recurred before 4 years old required more surgery, shorter operation period(the average, longest or shortest operation period) than those elder children, the differences were statistically (P=0. 029, 0. 003, 0. 010, 0. 039, respectively). The severity score of lesion was correlated positively with the involvement of the subregion and negatively with operation period (r=0. 914, -0. 451, respectively). Some children who diagnosed before 4 years old had to endure more severity score and shorter operation period than those older children, the differences were statistically (P= 0. 036, 0. 000, respectively). 8 cases accepted incision of tracheal, they accepted more surgery too. But the differences in the onset age, the first recurrence of age, and the operation period were not statistically. CONCLUSION: The results showed that the clinical course of juvenile onset recurrent respiratory papillomatosis was closely related to the first recurrence age and period, while the severity of disease was associated to the onset age and the involvement of the subregion.