Patient-perceived understanding of home-going medication with transitions of care services at a pediatric institution.

BACKGROUND: Transitions of care (TOC) is the coordination and continuity of health care as a patient transfers between different settings. This can include a wide range of services, such as medication reconciliation, patient counseling, bedside delivery of medications, and others that meet individual patient needs. In the pediatric population, patients are at increased risk of potential medication errors and subsequent harm owing to reduced patient and caregiver health literacy, limited dosage form availability, and errors in medication administration. The use of TOC services at the time of hospital discharge in this population has the potential to make a positive impact on patient safety and the treatment of medical conditions. OBJECTIVES: The primary objective of this study was to determine whether patient-perceived understanding of home-going medications was greater in patients and/or caregivers who received medication bedside delivery and education from a pharmacy-led TOC service at a large pediatric academic medical center. The secondary objective was to determine whether the primary practice area of the pharmacist providing medication education led to changes in understanding of home-going medication(s). METHODS: Using institution-wide, patient satisfaction surveys from January 1, 2021, to December 31, 2021, patient and caregiver responses were queried for 2 questions about home-going medications, relating to the understanding of administration and the potential adverse effects. Patients were divided into 2 groups depending on TOC services received, as documented in the electronic medical record (EMR). Survey responses for each of the 2 questions were categorized as top-box percentage by study group. Hypothesis testing between study groups for the primary and secondary outcomes were conducted using chi-squared tests at an alpha of 0.05. Statistical analyses were conducted using SAS version 9.4. RESULTS: Of the 1159 patients included in the study, 441 received TOC services, deemed the intervention group, and 718 did not receive TOC services, deemed the control group. When the intervention and control group were asked about understanding of medication administration, 96.37% versus 93.18% of patients (P = 0.007) gave the most favorable response of "yes, definitely," respectively. Furthermore, 78.51% versus 77.44% of patients (P = 0.053) gave the most favorable response when asked about understanding potential medication adverse effects, respectively. CONCLUSION: Patients receiving TOC services by a member of the pharmacy team had a greater score for understanding of both medication administration and adverse effects. Furthermore, this greater score was consistent among the education provided by the inpatient and outpatient pharmacist.

Predisposing factors to acquisition of acute respiratory tract infections in the community: a systematic review and meta-analysis.

BACKGROUND: Preventing respiratory tract infections (RTIs) could have profound effects on quality of life, primary care workload, antibiotic prescribing and stewardship. We aimed to identify factors that increase and decrease RTI acquisition within Organisation for Economic Cooperation and Development (OECD) member countries. METHODS: Systematic search of Medline, Embase, Cochrane and ISI Web of Knowledge for studies conducted up to July 2020 reporting predisposing factors for community RTI acquisition. Pooled odds ratios were calculated using a random-effects model. RESULTS: 23 studies investigated risk factors associated with community-acquired pneumonia (n = 15); any RTI (n = 4); influenza like illness (n = 2); and lower RTI (n = 2). Demographic, lifestyle and social factors were: underweight BMI (pooled odds ratio (ORp 2.14, 95% CI 1.58 to 2.70, p = 0.97); male sex (ORp 1.30, 95% CI 1.27 to 1.33, p = 0.66); contact with pets (ORp 1.35, 95% CI 1.16 to 1.54, p = 0.72); contact with children (ORp 1.35, 95% CI 1.15 to 1.56, p = 0.05); and ex-smoking status (ORp 1.57, 95% CI 1.26 to 1.88, p = 0.76). Health-related factors were: chronic liver condition (ORp 1.30, 95% CI 1.09 to 1.50, p = 0.34); chronic renal condition (ORp 1.47, 95% CI 1.09 to 1.85, p = 0.14); and any hospitalisation in previous five years (ORp 1.64, 95% CI 1.46 to 1.82, p = 0.66). CONCLUSIONS: We identified several modifiable risk factors associated with increased likelihood of acquiring RTIs in the community, including low BMI, contact with children and pets. Modification of risk factors and increased awareness of vulnerable groups could reduce morbidity, mortality and antibiotic use associated with RTIs. PROSPERO REGISTRATION: CRD42019134176.

Novel multi-virus rapid respiratory microbiological point-of-care testing in primary care: a mixed-methods feasibility evaluation.

BACKGROUND AND OBJECTIVES: Rapid multi-viral respiratory microbiological point-of-care tests (POCTs) have not been evaluated in UK primary care. The aim of this study was to evaluate the use of a multi-viral microbiological POCT for suspected respiratory tract infections (RTIs). METHODS: In this observational, mixed-methods feasibility study practices were provided with a POCT machine for any patient aged ≥3 months with suspected RTI. Dual throat/nose swabs tested for 17 respiratory viruses and three atypical bacteria, 65 minutes per sample. RESULTS: Twenty clinicians recruited 93 patients (estimated 1:3 of all RTI cases). Patient's median age was 29, 57% female, and 44% with co-morbidities. Pre-test diagnoses: upper RTI (48%); lower RTI (30%); viral/influenza-like illness (18%); other (4%). Median set-up time was 2.72 minutes, with 72% swabs processed <4 hours, 90% <24 hours. Tests detected ≥1 virus in 58%, no pathogen 37% and atypical bacteria 2% (3% inconclusive). Antibiotics were prescribed pre-test to 35% of patients with no pathogen detected and 25% with a virus. Post-test diagnoses changed in 20%, and diagnostic certainty increased (P = 0.02), more so when the test was positive rather than negative (P < 0.001). Clinicians predicted decreased antibiotic benefit post-test (P = 0.02). Interviews revealed the POCT has clear potential, was easy to use and well-liked, but limited by time-to-result and the absence of testing for typical respiratory bacteria. CONCLUSIONS: This POCT was acceptable and appeared to influence clinical reasoning. Clinicians wanted faster time-to-results and more information about bacteria. Randomized trials are needed to understand the safety, efficacy and patient perceptions of these POCTs.

The UK government has called for the introduction of rapid diagnostics to curb overuse of antibiotics for common infections. Multi-viral respiratory 'point-of-care' tests (POCTs) are available but have not been used in UK primary care before. These POCTs use samples from the nose or back of the throat and give results quickly, to see if viruses or bacteria are there. In this study, four GP practices were given POCT machines for 6 weeks to see how they were used. Of the 93 patient samples tested, 3% were inconclusive, 37% tested negative, 58% had at least one virus and only 2% had a bacterial infection. Clinicians were more certain of patient diagnoses after testing especially when a virus or bacterium was detected and they were also less likely to predict the patient would benefit from antibiotics. Clinical diagnoses changed in 20% of patients after testing but less than 10% were contacted to change their treatment plan. During interviews, clinicians revealed they liked the test finding it easy-to-use but wanted faster time-to-results and testing for more bacteria. Clinical trials are needed to see if these POCTs can safely and cost-effectively reduce antibiotic prescribing in primary care.

Relationship between microbiology of throat swab and clinical course among primary care patients with acute cough: a prospective cohort study.

BACKGROUND: Acute lower respiratory tract infections (ALRTIs) account for most antibiotics prescribed in primary care despite lack of efficacy, partly due to clinician uncertainty about aetiology and patient concerns about illness course. Nucleic acid amplification tests could assist antibiotic targeting. METHODS: In this prospective cohort study, 645 patients presenting to primary care with acute cough and suspected ALRTI, provided throat swabs at baseline. These were tested for respiratory pathogens by real-time polymerase chain reaction and classified as having a respiratory virus, bacteria, both or neither. Three hundred fifty-four participants scored the symptoms severity daily for 1 week in a diary (0 = absent to 4 = severe problem). RESULTS: Organisms were identified in 346/645 (53.6%) participants. There were differences in the prevalence of seven symptoms between the organism groups at baseline. Those with a virus alone, and those with both virus and bacteria, had higher average severity scores of all symptoms combined during the week of follow-up than those in whom no organisms were detected [adjusted mean differences 0.204 (95% confidence interval 0.010 to 0.398) and 0.348 (0.098 to 0.598), respectively]. There were no differences in the duration of symptoms rated as moderate or severe between organism groups. CONCLUSIONS: Differences in presenting symptoms and symptoms severity can be identified between patients with viruses and bacteria identified on throat swabs. The magnitude of these differences is unlikely to influence management. Most patients had mild symptoms at 7 days regardless of aetiology, which could inform patients about likely symptom duration.

Post-consultation illness trajectories in children with acute cough and respiratory tract infection: prospective cohort study.

Background: Little is known about respiratory tract infection (RTI) severity in children following consultation. Objectives: To investigate post-consultation symptom trajectories in children with acute cough and RTI and whether baseline characteristics predict trajectory group. Methods: Prospective cohort study of 2296 children (3 months-16 years) whose parents were invited to report cough severity and duration using a 7-point Likert scale. Longitudinal latent class analysis (LLCA) was used to identify post-consultation symptom trajectories in the first 15 days, and multinomial models to predict class membership. Results: Complete data were available for 1408 children (61%). The best LLCA model identified five post-consultation symptom trajectory groups: 'very rapid recovery' (28.5%), 'rapid recovery' (37.7%), 'intermediate recovery' (18.2%), 'persistent symptoms' (9.5%) and 'initial deterioration with persistent symptoms' (6.0%). Compared with very rapid recovery, parent-reported severe cough in the 24 hours prior to consultation increased the likelihood of rapid recovery (OR 1.79 [95% CI 1.23, 2.60]), intermediate recovery (OR 2.13 [1.38, 3.30] and initial deterioration with persistent symptoms (OR 2.29 [1.26, 4.16]). Initial deterioration was also associated with 'severe barking cough' (OR 3.64 [1.50, 8.82]), 'severely reduced energy in the 24 hours prior to consultation' (OR 3.80 [1.62, 8.87] and higher parent-assessed illness severity at consultation (OR 2.21 [1.17, 4.18]). Conclusion: We identified five distinct symptom trajectory groups showing the majority of children improved post-consultation, with only one group experiencing illness deterioration. The few characteristics associated with group membership did not fall into a pattern that seemed clinically useful.

What gives rise to clinician gut feeling, its influence on management decisions and its prognostic value for children with RTI in primary care: a prospective cohort study.

BACKGROUND: The objectives were to identify 1) the clinician and child characteristics associated with; 2) clinical management decisions following from, and; 3) the prognostic value of; a clinician's 'gut feeling something is wrong' for children presenting to primary care with acute cough and respiratory tract infection (RTI). METHODS: Multicentre prospective cohort study where 518 primary care clinicians across 244 general practices in England assessed 8394 children aged ≥3 months and < 16 years for acute cough and RTI. The main outcome measures were: Self-reported clinician 'gut feeling'; clinician management decisions (antibiotic prescribing, referral for acute admission); and child's prognosis (reconsultation with evidence of illness deterioration, hospital admission in the 30 days following recruitment). RESULTS: Clinician years since qualification, parent reported symptoms (illness severity score ≥ 7/10, severe fever < 24 h, low energy, shortness of breath) and clinical examination findings (crackles/ crepitations on chest auscultation, recession, pallor, bronchial breathing, wheeze, temperature ≥ 37.8 °C, tachypnoea and inflamed pharynx) independently contributed towards a clinician 'gut feeling that something was wrong'. 'Gut feeling' was independently associated with increased antibiotic prescribing and referral for secondary care assessment. After adjustment for other associated factors, gut feeling was not associated with reconsultations or hospital admissions. CONCLUSIONS: Clinicians were more likely to report a gut feeling something is wrong, when they were more experienced or when children were more unwell. Gut feeling is independently and strongly associated with antibiotic prescribing and referral to secondary care, but not with two indicators of poor child health.

Throat swabs in children with respiratory tract infection: associations with clinical presentation and potential targets for point-of-care testing.

Background and objectives: Diagnostic uncertainty over respiratory tract infections (RTIs) in primary care contributes to over-prescribing of antibiotics and drives antibiotic resistance. If symptoms and signs predict respiratory tract microbiology, they could help clinicians target antibiotics to bacterial infection. This study aimed to determine relationships between symptoms and signs in children presenting to primary care and microbes from throat swabs. Methods: Cross-sectional study of children ≥3 months to <16 years presenting with acute cough and RTI, with subset follow-up. Associations and area under receiver operating curve (AUROC) statistics sought between clinical presentation and baseline microbe detection. Microbe prevalence compared between baseline (symptomatic) and follow-up (asymptomatic) visits. Results: At baseline, ≥1 bacteria was detected in 1257/2113 (59.5%) children and ≥1 virus in 894/2127 (42%) children. Clinical presentation was not associated with detection of ≥1 bacteria [AUROC 0.54 (95% CI 0.52-0.56)] or ≥1 virus [0.64 (95% CI 0.61-0.66)]. Individually, only respiratory syncytial virus (RSV) was associated with clinical presentation [AUROC 0.80 (0.77-0.84)]. Prevalence fell between baseline and follow-up; more so in viruses (68% versus 26%, P < 0.001) than bacteria (56% versus 40%, P = 0.01); greatest reductions seen in RSV, influenza B and Haemophilus influenzae. Conclusion: Findings demonstrate that clinical presentation cannot distinguish the presence of bacteria or viruses in the upper respiratory tract. However, individual and overall microbe prevalence was greater when children were unwell than when well, providing some evidence that upper respiratory tract microbes may be the cause or consequence of the illness. If causal, selective microbial point-of-care testing could be beneficial.

Defective immunoregulation in RSV vaccine-augmented viral lung disease restored by selective chemoattraction of regulatory T cells.

Human trials of formaldehyde-inactivated respiratory syncytial virus (FI-RSV) vaccine in 1966-1967 caused disastrous worsening of disease and death in infants during subsequent natural respiratory syncytial virus (RSV) infection. The reasons behind vaccine-induced augmentation are only partially understood, and fear of augmentation continues to hold back vaccine development. We now show that mice vaccinated with FI-RSV show enhanced local recruitment of conventional CD4(+) T cells accompanied by a profound loss of regulatory T cells (Tregs) in the airways. This loss of Tregs was so complete that additional depletion of Tregs (in transgenic depletion of regulatory T-cell mice) produced no additional disease enhancement. Transfer of conventional CD4(+) T cells from FI-RSV-vaccinated mice into naive RSV-infected recipients also caused a reduction in airway Treg responses; boosting Tregs with IL-2 immune complexes failed to restore normal levels of Tregs or to ameliorate disease. However, delivery of chemokine ligands (CCL) 17/22 via the airway selectively recruited airway Tregs and attenuated vaccine-augmented disease, reducing weight loss and inhibiting local recruitment of pathogenic CD4(+) T cells. These findings reveal an unexpected mechanism of vaccine-induced disease augmentation and indicate that selective chemoattraction of Tregs into diseased sites may offer a novel approach to the modulation of tissue-specific inflammation.

Emergency Admissions for COPD in an Urban Population: The Role of Population and Primary Care Factors.

COPD is a major cause of emergency admissions worldwide. In many countries the majority of COPD care is provided by primary care teams. This study examined variation between primary care teams in rates of COPD admission and assessed the role of prevalence, deprivation, practice performance, and general practitioner (GP) and nurse supply on risk of COPD admission. Retrospective observational study of National Health Service admissions for COPD of patients registered with London general practices over four years (2006-2009). We sought associations using negative binomial regression between COPD admissions and population factors, practice organization and practice performance. Trends in rates of COPD admissions across London were stable between 2006 and 2009. COPD admission rates varied substantially between practices (2006/7: median 13.68/10,000 population (IQR 7.83-22.70)), with almost a 3-fold difference across the interquartile range each year. Practice characteristics varied to a similar extent. Variation in practice COPD admission rates was associated with diagnosed prevalence of COPD (Rate Ratio 2.06, 95% CI 1.84-2.3) and increasing levels of deprivation (RR 1.01, 1.006-1.01). Other practice characteristics, including GP and nurse supply, and practice performance scores were not predictive of practice level COPD admission rates, when controlling for COPD prevalence and socio-economic status. Main predictors of variation in rates of COPD admissions were prevalence of diagnosed COPD and socioeconomic status. The absence of evidence that variation in primary care services for COPD was associated with rates of COPD admission emphasizes the importance of primary prevention of COPD if COPD admission rates are to fall.

Pharmacologic management of adolescent catatonia: A dual-case series.

Introduction: Catatonia is a syndrome characterized by psychomotor and behavioral disturbances and is associated with a substantially increased mortality risk in adolescent patients. There is a dearth of published literature describing treatment strategies for pediatric patients with catatonia. This dual-case series will describe the treatment course of 2 adolescent patients with catatonia at our pediatric inpatient psychiatric facility. Case Series: This case series presents 2 adolescent patients (a 17-year-old male and a 16-year-old female) who initially presented with worsening agitation and paranoia, later developing catatonia. Both patients required long durations of hospitalization and were treated with high-dose lorazepam before requiring the addition of electroconvulsive therapy (ECT). Discussion: Treatment of pediatric patients with catatonia creates a significant burden on patients, families, and the healthcare system. Treatment with high-dose benzodiazepines is high risk, while ECT is both difficult to access and comes with its own risks. Both patients discussed are transitional age, meaning they will soon be young adults who will continue to require high-level psychiatric care. Psychiatric pharmacists have a large role to play in ensuring safe medication management for these complex patients. Conclusions: This case series of 2 adolescent patients with catatonia demonstrates marginal reduction in symptoms with high-dose lorazepam in conjunction with ECT, with minimal side effects. This case series adds to the limited available literature regarding treatment of catatonia in pediatric patients and highlights the need for further study into effective treatment alternatives.

The TARGET cohort study protocol: a prospective primary care cohort study to derive and validate a clinical prediction rule to improve the targeting of antibiotics in children with respiratory tract illnesses.

BACKGROUND: Children with respiratory tract infections are the single most frequent patient group to make use of primary care health care resources. The use of antibiotics remains highly prevalent in young children, but can lead to antimicrobial resistance as well as reinforcing the idea that parents should re-consult for similar symptoms. One of the main drivers of indiscriminate antimicrobial use is the lack of evidence for, and therefore uncertainty regarding, which children are at risk of poor outcome. This paper describes the protocol for the TARGET cohort study, which aims to derive and validate a clinical prediction rule to identify children presenting to primary care with respiratory tract infections who are at risk of hospitalisation. METHODS/DESIGN: The TARGET cohort study is a large, multicentre prospective observational study aiming to recruit 8,300 children aged ≥3 months and <16 years presenting to primary care with a cough and respiratory tract infection symptoms from 4 study centres (Bristol, London, Oxford and Southampton). Following informed consent, symptoms, signs and demographics will be measured. In around a quarter of children from the Bristol centre, a single sweep, dual bacterial-viral throat swab will be taken and parents asked to complete a symptom diary until the child is completely well or for 28 days, whichever is sooner. A review of medical notes including clinical history, re-consultation and hospitalisations will be undertaken. Multivariable logistic regression will be used to identify the independent clinical predictors of hospitalisation as well as the prognostic significance of upper respiratory tract microbes. The clinical prediction rule will be internally validated using various methods including bootstrapping. DISCUSSION: The clinical prediction rule for hospitalisation has the potential to help identify a small group of children for hospitalisation and a much larger group where hospitalisation is very unlikely and antibiotic prescribing would be less warranted. This study will also be the largest natural history study to date of children presenting to primary care with acute cough and respiratory tract infections, and will provide important information on symptom duration, re-consultations and the microbiology of the upper respiratory tract.

Non-linear associations of maternal pre-pregnancy body mass index with risk of stillbirth, infant, and neonatal mortality in over 28 million births in the USA: a retrospective cohort study.

Background: Higher maternal pre-pregnancy body mass index (BMI) has been associated with higher risk of stillbirth, infant and neonatal mortality. Studies exploring underweight have varied in their conclusions. Our aim was to examine the risk of stillbirth, infant and neonatal mortality across the BMI distribution and establish a likely healthy BMI range. Methods: In this retrospective cohort study, we used publicly available datasets (covering 1st January 2014 to 31st December 2021) from the US National Center for Health Statistics National Vital Statistics System. All births were eligible; analyses included those with non-missing data. Fractional polynomial multivariable logistic regression was used to examine the associations of maternal pre-pregnant BMI with stillbirth (birth with no signs of life at ≥24 weeks), infant mortality (death of a live born baby aged <365 days) and neonatal mortality (death of a live born baby aged <28 days). Findings: There were 77,896/28,310,154 (2.8 per 1000 births) stillbirths, 143,620/28,231,807 (5.1 per 1000 live births) infant deaths and 94,246/28,231,807 (3.3 per 1000 live births) neonatal deaths among complete cases. Mean (SD) BMI was 27.1 kg/m2 (6.7 kg/m2). We found non-linear associations between BMI and all three outcomes; risk was elevated at both low and high BMIs although, for stillbirth, the increased risk at low BMI was less marked than for infant/neonatal mortality. The lowest risk was at a BMI of 21 kg/m2 for infant and neonatal mortality and 19 kg/m2 for stillbirth. Interpretation: Public health messaging for preconception and postnatal care should focus on healthy weight to maximise maternal and child health, and not focus solely on maternal overweight or obesity. Funding: European Research Council, US National Institute of Health, UK Medical Research Council and National Institute for Health and Care Research.

Effectiveness, attendance, and completion of an integrated, system-wide pulmonary rehabilitation service for COPD: prospective observational study.

Pulmonary rehabilitation (PR) is one of the most effective treatments for COPD but not widely available. Uptake is poor and completion rates are low. In this integrated PR service we report on effectiveness, attendance, and completion of twice weekly rolling recruitment and once weekly cohort recruitment programmes in two hospital and five community PR sites. The hospital and two of the community programmes were 'rolling' recruitment twice weekly for 8 weeks. Three community programmes ran in once weekly cohorts for 8 weeks. Predictors of attendance, completion and effectiveness were sought. 1114 eligible COPD patients were referred. 812 (73%) attended assessment, 656 (59%) started and 441 (40%) completed. Significant improvements were seen in incremental shuttle walk test (ISWT) (mean 68.3 m; 95%CI 59.3-77.4), Chronic Respiratory Questionnaire self-report dyspnoea scale (CRQ-SR) (0.94; 0.80-1.07), Hospital Anxiety and Depression Scale anxiety (0.9; 0.5-1.2) and depression (1.1; 0.8-1.4) components, exceeding the minimum clinically important difference for ISWT and CRQ-SR. Twice weekly compared with once weekly programmes showed similar improvement. Patients were less likely to complete if they were deprived (4(th) quintile of deprivation 0.56; 0.33-0.94, 5(th) quintile 0.57; 0.34-0.85), reported MRC dyspnoea scale 4 (0.61; 0.37-0.97) or 5 (0.39; 0.16-0.93), or had been referred by their general practitioner (0.42; 0.24-0.74) (pseudo R(2) 0.103). PR is effective for COPD in real-world practice achieving results comparable to trials. Low rates of attendance and completion of PR were not explained by demographic characteristics, disease severity, psychological morbidity and source of referral despite the large number of participants.

Evolving Beyond the World Foods Course: Creating Racially and Ethnically Inclusive Educational Spaces for Dietetics Students.

Only 13.1% of US registered dietitian nutritionists and 27.8% of students enrolled in US dietetics education programs identify as racially/ethnically diverse individuals. National demographic trends show increasing percentages of racially/ethnically diverse individuals within the broader US and college student populations; however, these changes have not been mirrored within dietetics. Dietetics educators have an ethical and professional mandate to address diversity, equity, and inclusion within their programs. This paper reviews key terminology related to diversity, equity, and inclusion in the context of dietetics education, and describes a new framework to transform dietetics education based on the principles of cultural humility and culturally sustaining teaching. Strategies are presented to facilitate recruitment, admissions, retention, and mentorship for racially/ethnically diverse students and faculty, and to improve diversity, equity, and inclusion within curricula and classrooms. Lastly, this paper provides clear practice applications, including recommendations for program policy change and training/skill building activities for dietetics students, educators, and preceptors.

Implementation and Patient Outcomes of a Pediatric COVID-19 Monoclonal Antibody Program.

BACKGROUND: The severity and reach of the COVID-19 pandemic drove the development of various therapeutic approaches to combat SARS-CoV-2, including several neutralizing monoclonal antibody (mAb) therapies. A January 2021 pediatric consensus statement opposed routine use and recommended individualized risk assessments when considering COVID-19 mAb therapies in children and adolescents due to limited data. This report describes the implementation of a mAb referral process and the clinical outcomes of patients who received a mAb infusion in a pediatric hospital. METHODS: We developed a tiered allocation system based on underlying medical conditions and incorporated it into a standardized COVID-19 mAb referral and approval process. Demographics and clinical data were collected on all patients who received mAb therapy for treatment or post-exposure prophylaxis. Data recorded included sociodemographics, qualifying underlying medical conditions, clinical manifestations of infection, and overall course of treatment and disease. RESULTS: A total of 182 patients ≤21 years old received a COVID-19 mAb infusion between November 27, 2020 and January 26, 2022. Patient age ranged from 10 months to 21 years, with a median age of 15 years. In total, 7 patients (4%) had suspected adverse reactions during the infusion, and 15 (8%) patients required a COVID-19-related visit within 30 days of the mAb infusion. CONCLUSIONS: A tiered allocation process may provide the framework for the stratification and efficient distribution of mAb therapies. Future research must focus on the efficacy of these therapies in the pediatric population, standardized therapeutic prioritization, and the optimal timeframe for mAb delivery to prevent progression to severe disease.

Prognostic value of upper respiratory tract microbes in children presenting to primary care with respiratory infections: A prospective cohort study.

BACKGROUND: The association between upper respiratory tract microbial positivity and illness prognosis in children is unclear. This impedes clinical decision-making and means the utility of upper respiratory tract microbial point-of-care tests remains unknown. We investigated for relationships between pharyngeal microbes and symptom severity in children with suspected respiratory tract infection (RTI). METHODS: Baseline characteristics and pharyngeal swabs were collected from 2,296 children presenting to 58 general practices in Bristol, UK with acute cough and suspected RTI between 2011-2013. Post-consultation, parents recorded the severity of six RTI symptoms on a 0-6 scale daily for ≤28 days. We used multivariable hurdle regression, adjusting for clinical characteristics, antibiotics and other microbes, to investigate associations between respiratory microbes and mean symptom severity on days 2-4 post-presentation. RESULTS: Overall, 1,317 (57%) children with complete baseline, microbiological and symptom data were included. Baseline characteristics were similar in included participants and those lacking microbiological data. At least one virus was detected in 869 (66%) children, and at least one bacterium in 783 (60%). Compared to children with no virus detected (mean symptom severity score 1.52), adjusted mean symptom severity was 0.26 points higher in those testing positive for at least one virus (95% CI 0.15 to 0.38, p<0.001); and was also higher in those with detected Influenza B (0.44, 0.15 to 0.72, p = 0.003); RSV (0.41, 0.20 to 0.60, p<0.001); and Influenza A (0.25, -0.01 to 0.51, p = 0.059). Children positive for Enterovirus had a lower adjusted mean symptom severity (-0.24, -0.43 to -0.05, p = 0.013). Children with detected Bordetella pertussis (0.40, 0.00 to 0.79, p = 0.049) and those with detected Moraxella catarrhalis (-0.76, -1.06 to -0.45, p<0.001) respectively had higher and lower mean symptom severity compared to children without these bacteria. CONCLUSIONS: There is a potential role for upper respiratory tract microbiological point-of-care tests in determining the prognosis of childhood RTIs.

The HOME Study: Understanding How College Students at a Hispanic Serving Institution Coped with Food Insecurity in a Pandemic.

College students represent a unique population of adults, who may be more likely to experience food insecurity due to their transient circumstances, limited access to resources, and increased educational expenses. But little is known about how college students and their households mitigate food insecurity, particularly during a crisis like the COVID-19 pandemic. The Household Observations of Meals and Environments (HOME) Study described how college students in the US utilized multilevel resources, including an on-campus food pantry, to maintain food security during the pandemic. A convenience sample of college students (n = 18) were recruited from an on-campus food pantry and provided quantitative and qualitative data through online surveys and in-depth Zoom interviews. Survey data were analyzed to describe sociodemographic characteristics. In-depth interviews were recorded, transcribed, coded, and analyzed thematically to identify emergent themes. Social support and the use of an on-campus food pantry were primary factors in maintaining a food security safety net. Students faced barriers when trying to access federal and state food assistance programs and identified multilevel resources, their food security, and the role of social support as facilitators in their perceptions of food insecurity status and experiences. Findings highlight practical implications for research related to on-campus food insecurity interventions and policies to support food security among college students.

Should homes and workplaces purchase portable air filters to reduce the transmission of SARS-CoV-2 and other respiratory infections? A systematic review.

Respiratory infections, including SARS-CoV-2, are spread via inhalation or ingestion of airborne pathogens. Airborne transmission is difficult to control, particularly indoors. Manufacturers of high efficiency particulate air (HEPA) filters claim they remove almost all small particles including airborne bacteria and viruses. This study investigates whether modern portable, commercially available air filters reduce the incidence of respiratory infections and/or remove bacteria and viruses from indoor air. We systematically searched Medline, Embase and Cochrane for studies published between January 2000 and September 2020. Studies were eligible for inclusion if they included a portable, commercially available air filter in any indoor setting including care homes, schools or healthcare settings, investigating either associations with incidence of respiratory infections or removal and/or capture of aerosolised bacteria and viruses from the air within the filters. Dual data screening and extraction with narrative synthesis. No studies were found investigating the effects of air filters on the incidence of respiratory infections. Two studies investigated bacterial capture within filters and bacterial load in indoor air. One reported higher numbers of viable bacteria in the HEPA filter than in floor dust samples. The other reported HEPA filtration combined with ultraviolet light reduced bacterial load in the air by 41% (sampling time not reported). Neither paper investigated effects on viruses. There is an important absence of evidence regarding the effectiveness of a potentially cost-efficient intervention for indoor transmission of respiratory infections, including SARS-CoV-2. Two studies provide 'proof of principle' that air filters can capture airborne bacteria in an indoor setting. Randomised controlled trials are urgently needed to investigate effects of portable HEPA filters on incidence of respiratory infections.

Prospective Study of the Performance of Parent-Collected Nasal and Saliva Swab Samples, Compared with Nurse-Collected Swab Samples, for the Molecular Detection of Respiratory Microorganisms.

Respiratory tract infections (RTIs) are ubiquitous among children in the community. A prospective observational study was performed to evaluate the diagnostic performance and quality of at-home parent-collected (PC) nasal and saliva swab samples, compared to nurse-collected (NC) swab samples, from children with RTI symptoms. Children with RTI symptoms were swabbed at home on the same day by a parent and a nurse. We compared the performance of PC swab samples as the test with NC swab samples as the reference for the detection of respiratory pathogen gene targets by reverse transcriptase PCR, with quality assessment using a human gene. PC and NC paired nasal and saliva swab samples were collected from 91 and 92 children, respectively. Performance and interrater agreement (Cohen's κ) of PC versus NC nasal swab samples for viruses combined showed sensitivity of 91.6% (95% confidence interval [CI], 85.47 to 95.73%) and κ of 0.84 (95% CI, 0.79 to 0.88), respectively; the respective values for bacteria combined were 91.4% (95% CI, 86.85 to 94.87%) and κ of 0.85 (95% CI, 0.80 to 0.89). In saliva samples, viral and bacterial sensitivities were lower at 69.0% (95% CI, 57.47 to 79.76%) and 78.1% (95% CI, 71.60 to 83.76%), as were κ values at 0.64 (95% CI, 0.53 to 0.72) and 0.70 (95% CI, 0.65 to 0.76), respectively. Quality assessment for human biological material (18S rRNA) indicated perfect interrater agreement. At-home PC nasal swab samples performed comparably to NC swab samples, whereas PC saliva swab samples lacked sensitivity for the detection of respiratory microbes. IMPORTANCE RTIs are ubiquitous among children. Diagnosis involves a swab sample being taken by a health professional, which places a considerable burden on community health care systems, given the number of cases involved. The coronavirus disease 2019 (COVID-19) pandemic has seen an increase in the at-home self-collection of upper respiratory tract swab samples without the involvement of health professionals. It is advised that parents conduct or supervise swabbing of children. Surprisingly, few studies have addressed the quality of PC swab samples for subsequent identification of respiratory pathogens. We compared NC and PC nasal and saliva swab samples taken from the same child with RTI symptoms, for detection of respiratory pathogens. The PC nasal swab samples performed comparably to NC samples, whereas saliva swab samples lacked sensitivity for the detection of respiratory microbes. Collection of swab samples by parents would greatly reduce the burden on community nurses without reducing the effectiveness of diagnoses.

Parental and clinician agreement of illness severity in children with RTIs: secondary analysis of data from a prospective cohort study.

BACKGROUND: Severity assessments of respiratory tract infection (RTI) in children are known to differ between parents and clinicians, but determinants of perceived severity are unknown. AIM: To investigate the (dis)agreement between, and compare the determinants of, parent and clinician severity scores. DESIGN AND SETTING: Secondary analysis of data from a prospective cohort study of 8394 children presenting to primary care with acute (≤28 days) cough and RTI. METHOD: Data on sociodemographic factors, parent-reported symptoms, clinician-reported findings, and severity assessments were used. Kappa (κ)-statistics were used to investigate (dis) agreement, whereas multivariable logistic regression was used to identify the factors associated with illness severity. RESULTS: Parents reported higher illness severity (mean 5.2 [standard deviation (SD) 1.8], median 5 [interquartile range (IQR) 4-7]), than clinicians (mean 3.1 [SD 1.7], median 3 [IQR 2-4], P<0.0001). There was low positive correlation between these scores (+0.43) and poor inter-rater agreement between parents and clinicians (κ 0.049). The number of clinical signs was highly correlated with clinician scores (+0.71). Parent-reported symptoms (in the previous 24 hours) that were independently associated with higher illness severity scores, in order of importance, were: severe fever, severe cough, rapid breathing, severe reduced eating, moderate-to-severe reduced fluid intake, severe disturbed sleep, and change in cry. Three of these symptoms (severe fever, rapid breathing, and change in cry) along with inter/subcostal recession, crackles/crepitations, nasal flaring, wheeze, and drowsiness/irritability were associated with higher clinician scores. CONCLUSION: Clinicians and parents use different factors and make different judgements about the severity of children's RTI. Improved understanding of the factors that concern parents could improve parent-clinician communication and consultation outcomes.