Assessment of weight and height of patients with primary immunodeficiency disorders and group of children with recurrent respiratory tract infections.

BACKGROUND: Primary immunodeficiences (PIDs) are a group of chronic, serious disorders in which the immune response is insufficient. In consequence, it leads to an increased susceptibility to infections. Up to date, there are about 350 different disorders classified in that group. There are also patients suffering from recurrent respiratory tract infections (RRTI), however that group doesn't present any abnormalities in terms of conducted immunological tests. Many factors, including medical, can have an impact on physical development of a child. Data such as birth weight and length, also weight, height, BMI during admission to the hospital were collected from 195 patients' medical histories from their hospitalization at Clinical Immunology and Paediatrics Ward of J. Gromkowski Hospital in Wroclaw. Investigated groups included patients with PIDs, RRTI and a control group of healthy children. Our purpose was to evaluate the physical growth of children with PID and children with RRTI by assessment of their height and weight. All of parameters were evaluated using centile charts, suitable best for the Polish population. RESULTS: The lowest mean birth weight and height was found among the PIDs patients group. Children with PIDs during hospitalization had statistically relevant lower mean weight than the control group and almost 18% of them had their height situated below 3rd percentile. The statistically relevant differences have been found between them and RRTI group in terms of weight, height and nutritional status. The statistically significant difference was detected between the nutritional status of PID and control group. CONCLUSIONS: There is a higher percentage of PID patients with physical growth abnormalities in comparison to healthy children. Our findings indicate a need for further investigation of immune system irregularities and their influence on physical growth of children.

Burden of disease in children with respiratory tract infections in primary care: diary-based cohort study.

BACKGROUND: Respiratory tract infections (RTIs) are a common reason for children to consult in general practice. Antibiotics are often prescribed, in part due to miscommunication between parents and GPs. The duration of specific respiratory symptoms has been widely studied. Less is known about illness-related symptoms and the impact of these symptoms on family life, including parental production loss. Better understanding of the natural course of illness-related symptoms in RTI in children and impact on family life may improve GP-parent communication during RTI consultations. OBJECTIVE: To describe the general impact of RTI on children and parents regarding illness-related symptoms, absenteeism from childcare, school and work, use of health care facilities, and the use of over-the-counter (OTC) medication. METHODS: Prospectively collected diary data from two randomized clinical trials in children with RTI in primary care (n = 149). Duration of symptoms was analysed using survival analysis. RESULTS: Disturbed sleep, decreased intake of food and/or fluid, feeling ill and/or disturbance at play or other daily activities are very common during RTI episodes, with disturbed sleep lasting longest. Fifty-two percent of the children were absent for one or more days from childcare or school, and 28% of mothers and 20% of fathers reported absence from work the first week after GP consultation. Re-consultation occurred in 48% of the children. OTC medication was given frequently, particularly paracetamol and nasal sprays. CONCLUSION: Appreciation of, and communication about the general burden of disease on children and their parents, may improve understanding between GPs and parents consulting with their child.

Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations.

OBJECTIVES: The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral. DESIGN: Cross-sectional design. SETTING: One urban primary care OOH facility located in the midwest of Ireland. PARTICIPANTS: 457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants. RESULTS: 435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic. CONCLUSIONS: Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.

Perioperative respiratory adverse event risk assessment in children with upper respiratory tract infection: Validation of the COLDS score.

BACKGROUND: The decision to proceed with anesthesia and surgery has been controversial in pediatric patients with an upper respiratory tract infection. The COLDS score was proposed by Lee and August as a potential risk stratification scheme, but no validation has been performed on this scale. AIMS: The aim of this study was to evaluate the utility of the COLDS score in predicting perioperative respiratory adverse events and optimize its predictive ability. METHODS: COLDS scores, incidence of perioperative respiratory adverse events, surgical procedure type, and age were prospectively collected for 536 patients who met inclusion criteria. Area under the receiver operating characteristic curves was computed for total COLDS score and individual COLDS score categories. Multivariable regression was used create an optimized score. To quantify the decrease in risk associated with case cancelation due to illness, the other risk factors in COLDS were assessed separately from upper respiratory infection status and a risk model was created. RESULTS: The area under the receiver operating characteristic curve for the total COLDS score was 0.69, suggesting that the COLDS score has a moderate predictive ability for perioperative respiratory adverse events. When split into individual component scores, the area under the receiver operating characteristic curve ranged from 0.55 to 0.63. We also found that the area under the receiver operating characteristic curve for the scoring system was higher in younger children than for children aged 4-6 (area under receiver operating characteristic curve of 0.70-0.71 vs 0.66). The area under the receiver operating characteristic curve for the optimized scoring system was 0.71. CONCLUSION: The COLDS score has the potential to be a valuable risk assessment tool for prediction of perioperative respiratory adverse events and appears to have a better predictive value in certain subpopulations.

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.

Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India.

BACKGROUND & OBJECTIVES: Hospital-acquired infections (HAIs) are a major challenge to patient safety and have serious public health implications by changing the quality of life of patients and sometimes causing disability or even death. The true burden of HAI remains unknown, particularly in developing countries. The objective of this study was to estimate point prevalence of HAI and study the associated risk factors in a tertiary care hospital in Pune, India. METHODS: A series of four cross-sectional point prevalence surveys were carried out between March and August 2014. Data of each patient admitted were collected using a structured data entry form. Centers for Disease Control and Prevention guidelines were used to identify and diagnose patients with HAI. RESULTS: Overall prevalence of HAI was 3.76 per cent. Surgical Intensive Care Unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have significant association with HAI. Prolonged hospital stay [odds ratio (OR=2.81), mechanical ventilation (OR=18.57), use of urinary catheter (OR=7.89) and exposure to central air-conditioning (OR=8.59) had higher odds of acquiring HAI (P<0.05). INTERPRETATION & CONCLUSIONS: HAI prevalence showed a progressive reduction over successive rounds of survey. Conscious effort needs to be taken by all concerned to reduce the duration of hospital stay. Use of medical devices should be minimized and used judiciously. Healthcare infection control should be a priority of every healthcare provider. Such surveys should be done in different healthcare settings to plan a response to reducing HAI.

Sleep Habits and Susceptibility to Upper Respiratory Illness: the Moderating Role of Subjective Socioeconomic Status.

BACKGROUND: Sleep is a predictor of infectious illness that may depend on one's socioeconomic status (SES). PURPOSE: This study aimed to investigate the moderating effects of objective and subjective SES on sleep-clinical cold risk link and test whether nasal inflammation serves as a plausible biological pathway. METHODS: This study combined data (n = 732) from three viral challenge studies. Measures of self-reported sleep and objective and subjective measures of SES were obtained. Participants were quarantined and administrated rhinovirus (RV) or influenza virus and monitored over 5 (RV) or 6 (influenza) days for the development of a cold. Symptom severity, including mucus production and nasal clearance time, and levels of nasal cytokines (interleukin (IL)-6 and IL-1ß) were measured prior to administration and each day during the quarantined period. RESULTS: Subjective SES, but not objective SES, moderated associations between shorter sleep duration and increased likelihood of a clinical cold. Compared to ≥8-hour sleepers, ≤6-hour sleepers with low subjective SES were at increased risk for developing a cold (OR = 2.57, 95% CI 1.10-6.02). There was no association between sleep duration and colds in high subjective SES participants. Among infected individuals who reported low subjective SES, shorter sleep duration was associated with greater mucus production. There was no evidence that markers of nasal inflammation mediated the link between sleep duration and cold susceptibility among those reporting low subjective SES. CONCLUSION: Subjective SES may reflect an important social factor for understanding vulnerability to and protection against infectious illness among short sleepers.

Probability of IV antibiotic retreatment within thirty days is associated with duration and location of IV antibiotic treatment for pulmonary exacerbation in cystic fibrosis.

BACKGROUND: There are few objective data to guide management of cystic fibrosis (CF) pulmonary exacerbations. We studied intravenous (IV) antibiotic treatment failure as defined by a need to retreat patients with IV antibiotics within 30days of completion of a prior IV antibiotic treatment for pulmonary exacerbation. METHODS: The first IV-treated exacerbation on or after Jan. 1, 2010 among US CF Foundation Patient Registry patients was studied, combining treatments separated by <7days into single treatments. IV treatment duration categories were: 1-4, 5-8, 9-12, 13-16, 17-22, and ≥23days (inclusive). Logistic regressions for IV retreatment in ≤30days were adjusted with 12 categorical covariates, including age, sex, lung function, prior-year exacerbations, CF complications, CF Care Program, and ever/never treated in hospital. RESULTS: 777 of 13,579 patients (5.7%) were retreated within 30days, with incidence varying by treatment duration: 1-4days, 8.7%; 5-8days; 6.6%; 9-12days, 3.2%; 13-16days, 4.5%; 17-22days, 6.2%; ≥23days, 10.3% and hospitalization: ever, 5.0%; never 8.5%. Adjusted odds ratios (OR) for retreatment (compared to 13-16days treatment) were: 1-4days, 1.94 [95%CI 1.49, 2.54] P<.001; 5-8days, 1.55 [1.18, 2.04] P=.002; 9-12days, 0.78 [0.58, 1.04] P=.09; 17-22days, 1.12 [0.88, 1.42] P=.37; ≥23days, 1.46 [1.12, 1.91] P=.005. Adjusted retreatment OR for never/ever hospitalized was 1.57 [1.29, 1.90] P<.001. Prior-year exacerbation number, oxygen therapy, non-invasive ventilation, and female sex were significantly associated with retreatment. Modeling hazard rate time-dependence showed that treatment duration and location-associated hazard rates attenuated within a few months after treatment. CONCLUSION: After adjustment for covariates known to be associated with increased risk of IV treatment for exacerbation, IV antibiotic treatments of <9 and ≥23days and those without hospitalization were significant risk factors for IV retreatment within 30days of completion of an exacerbation treatment.

Coronavirus and Other Respiratory Illnesses Comparing Older with Young Adults.

BACKGROUND: Study of human coronavirus and other virus-associated respiratory illnesses is needed to describe their clinical effects on chronically ill, older adults. METHODS: A prospective study during 2009 to 2013 clinically assessed acute respiratory illnesses soon after onset and 3 to 4 weeks later in patients aged ≥60 years with chronic lung and heart diseases (group 1, 100 subjects) and healthy adults aged 18 to 40 years (group 2, 101 subjects). Respiratory secretions were tested for nucleic acids of a panel of respiratory viruses. An increase in antibody titer was assessed for 4 coronavirus strains. RESULTS: Virus-associated illnesses (29 [39.1%] of 74 illnesses in group 1 and 59 [48.7%] of 121 illnesses in group 2) occurred in all calendar quarters, most commonly in the first and fourth quarters. Coronaviruses (group 1: 14 [18.9%] illnesses; group 2: 26 [21.5%] illnesses) and enteroviruses/rhinoviruses (group 1: 14 [18.9%] illnesses; group 2: 37 [30.6%] illnesses) were most common. Virus co-infections occurred in 10 illnesses. Illnesses with 9 to 11 symptoms were more common in group 1 (17 [23.0%]) than in group 2 (15 [12.4%]) (P < .05). Compared with group 2, more group 1 subjects reported dyspnea, more severe disease of longer duration, and treatment for acute illness with prednisone and antibiotics. Coronavirus-associated illnesses (percent of illnesses, group 1 vs group 2) were characterized by myalgias (21% vs 68%, P < .01), chills (50% vs 52%), dyspnea (71% vs 24%, P < .01), headache (64% vs 72%), malaise (64% vs 84%), cough (86% vs 68%), sputum production (86% vs 60%), sore throat (64% vs 80%), and nasal congestion (93% vs 96%). CONCLUSIONS: Respiratory illnesses were commonly associated with coronaviruses and enteroviruses/rhinoviruses affecting chronically ill, older patients more than healthy, young adults.

Relationship between the GOLD combined COPD assessment staging system and bacterial isolation.

BACKGROUND: Acute exacerbations, which are a significant cause of mortality and morbidity, adversely affect chronic obstructive pulmonary disease (COPD) prognosis by accelerating loss of lung function. It is important to know the microorganisms that commonly cause exacerbations in the patient groups classified according to clinical and functional characteristics for fast and accurate treatment of acute exacerbations. OBJECTIVES: The last Global Initiative for Chronic Obstructive Lung Disease (GOLD) publication recommended a new staging system containing obstruction degree, frequency of exacerbations, and quality of life questionnaires. This study is designed to analyze the relationship between the bacteria isolated in acute exacerbations and new GOLD stages. METHODS: Potentially pathogenic bacteria (PPB) isolation with culture and polymerase chain reaction methods were obtained from 114 acute exacerbation COPD patients, classified into A, B, C, and D groups by analyzing the forced expiratory volume in 1 second (FEV1) value, COPD Assessment Test (CAT) score, and exacerbation frequency according to the new GOLD staging system. RESULTS: There was a significant correlation between exacerbation frequency and PPB isolation (P=0.002). There was no relationship between GOLD stage, FEV1, and CAT score with PPB isolation. The isolated bacteria diversity and mixed infection frequency were higher in the GOLD stage D group. Pseudomonas aeruginosa, Escherichia coli, and Acinetobacter baumannii were isolated only from D group patients. CONCLUSION: Bacterial infection may cause an acute exacerbation equally in each stage for COPD. The difference in bacterial etiology is more related to exacerbation frequency than FEV1 and CAT scores for an acute exacerbation. Determining exacerbation frequency is significant for treatment success in empirical antibiotic selection.

Use of long-term macrolide therapy in chronic obstructive pulmonary disease.

PURPOSE OF REVIEW: Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with adverse outcomes and thus prevention of exacerbations is crucial. New data attest that long-term macrolide therapy decreases the risk of COPD exacerbations. We review the key studies that analyzed the effect of long-term use of macrolide antibiotics on the prevention of exacerbations, focusing on the higher quality evidence. Health-related quality of life, sputum bacteriology and development of resistance, inflammatory markers, lung function, cost-benefit analysis, and lung function in relation to long-term macrolide therapy are also discussed. RECENT FINDINGS: Two well designed, randomized, placebo-controlled trials report that select patients treated for 1 year with erythromycin or azithromycin, in addition to usual care, have prolonged time to and lower frequency of COPD exacerbations. There are more hearing decrements and higher prevalence of macrolide-resistant bacteria among the patients treated with macrolide therapy. SUMMARY: Prevention of COPD exacerbations is paramount given the adverse consequences on quality of life, lung function, and survival. Macrolide therapy for 1 year, in addition to usual therapy, decreases the risk of COPD exacerbations but carries the risk of hearing decrements and development of macrolide-resistant bacteria.

Lung-enriched organisms and aberrant bacterial and fungal respiratory microbiota after lung transplant.

RATIONALE: Long-term survival after lung transplantation is limited by infectious complications and by bronchiolitis obliterans syndrome (BOS), a form of chronic rejection linked in part to microbial triggers. OBJECTIVES: To define microbial populations in the respiratory tract of transplant patients comprehensively using unbiased high-density sequencing. METHODS: Lung was sampled by bronchoalveolar lavage (BAL) and upper respiratory tract by oropharyngeal wash (OW). Bacterial 16S rDNA and fungal internal transcribed spacer sequencing was used to profile organisms present. Outlier analysis plots defining taxa enriched in lung relative to OW were used to identify bacteria enriched in lung against a background of oropharyngeal carryover. MEASUREMENTS AND MAIN RESULTS: Lung transplant recipients had higher bacterial burden in BAL than control subjects, frequent appearance of dominant organisms, greater distance between communities in BAL and OW indicating more distinct populations, and decreased respiratory tract microbial richness and diversity. Fungal populations were typically dominated by Candida in both sites or by Aspergillus in BAL but not OW. 16S outlier analysis identified lung-enriched taxa indicating bacteria replicating in the lower respiratory tract. In some cases this confirmed respiratory cultures but in others revealed enrichment by anaerobic organisms or mixed outgrowth of upper respiratory flora and provided quantitative data on relative abundances of bacteria found by culture. CONCLUSIONS: Respiratory tract microbial communities in lung transplant recipients differ in structure and composition from healthy subjects. Outlier analysis can identify specific bacteria replicating in lung. These findings provide novel approaches to address the relationship between microbial communities and transplant outcome and aid in assessing lung infections.

Nutritional assessment in patients with pulmonary nontuberculous mycobacteriosis.

OBJECTIVE: To determine the nutritional factors that influence disease spread in patients with pulmonary Mycobacterium avium complex (MAC) infection. METHODS: A prospective observational study. PATIENTS: Patients with pulmonary MAC infection were enrolled in this study. Chest computed tomography (CT), abdominal CT, and physical, clinical, and nutritional laboratory data were collected after obtaining informed consent. RESULTS: Seventy-eight patients (16 males and 62 females) were consecutively enrolled. While the mean body mass index (BMI) was low (19.6 ± 2.7 kg/m(2)), the mean serum albumin concentration was within normal range (4.2 ± 0.2 g/dL). We evaluated the number of affected lung segments to define the degree of disease spread, and examined the relationships between various parameters and disease spread. Multivariate analysis identified the duration of the disease (+1.6 segment/100 months, p=0.03), BMI (-0.5 segment/BMI, p=0.003), and white blood cell count (+0.7 segment/1,000 WBC, p=0.03) as factors contributing to disease spread. CONCLUSION: BMI is an excellent marker for nutritional assessment and for predicting disease spread in patients with pulmonary MAC infection.

[Adult asthma exacerbations in questions]. / Les exacerbations de l'asthme de l'adulte en questions.

In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.

Early eradication therapy against Pseudomonas aeruginosa in cystic fibrosis patients.

In cystic fibrosis (CF) patients early antibiotic treatment of lung infection has been shown to lead to Pseudomonas aeruginosa eradication. The present study determined: 1) the time period from eradication to new P. aeruginosa acquisition; 2) P. aeruginosa re-growth and new acquisition; and 3) the impact of eradication therapy on lung function, antimicrobial resistance, emergence of other pathogens and treatment costs. Ciprofloxacin and colistin were used to eradicate P. aeruginosa in 47 CF patients. Bacterial pathogens, lung function decline, P. aeruginosa antimicrobial resistance and anti-pseudomonal serum antibodies were assessed quarterly and compared with an age-matched CF control group. Additionally, costs of antibiotic therapy in both groups were assessed. Early antibiotic therapy leads to a P. aeruginosa free-period of a median (range) of 18 (4-80) months. New acquisition with different P. aeruginosa genotypes occurs in 73% of episodes. It also delays the decline of lung function compared with chronically infected patients, prevents the occurrence of antibiotic resistant P. aeruginosa strains, does not lead to emergence of other pathogens, and significantly reduces treatment costs. The treatment substantially lowers P. aeruginosa prevalence in CF. In conclusion, early antibiotic therapy exerts beneficial effects on the patient's clinical status and is cost-effective compared with conventional antibiotic therapy for chronically infected cystic fibrosis patients.

A new paradigm for clinical investigation of infectious syndromes in older adults: assessment of functional status as a risk factor and outcome measure.

Adults aged >or=65 years comprise the fastest-growing segment of the United States population, and older adults experience greater morbidity and mortality due to infection than do young adults. Although age is well established as a risk factor for infection, most clinical investigations of infectious diseases in older adults focus on microbiology and on crude end points of clinical success, such as cure rates or death; however, they often fail to assess functional status, which is a critical variable in geriatric care. Functional status can be evaluated either as a risk factor for infectious disease or as an outcome of interest after specific interventions using well-validated instruments. This article outlines the currently available data that suggest an association between infection, immunity, and impaired functional status in elderly individuals, summarizes the instruments commonly used to determine specific aspects of functional status, and provides recommendations for a new paradigm in which clinical trials that involve older adults include assessment of functional status.

A children's acute respiratory illness scale (CARIFS) predicted functional severity and family burden.

OBJECTIVE: The Canadian Acute Respiratory Illness and Flu Scale (CARIFS) was developed to measure illness severity in children with acute respiratory infection. The objective of this study was to evaluate its performance in a European primary care setting. STUDY DESIGN AND SETTING: 178 children (median age 3 years) with cough and fever were recruited in UK general practice. Perceived severity of illness at recruitment was recorded by parents, doctors, and nurses. Parents also completed an illness diary, including the CARIF scale, until their child had recovered. In-depth interviews were conducted with 24 parents. RESULTS: Parents found CARIFS relatively easy and quick to complete (78% of parents returned a fully completed diary covering the duration of the illness), internal consistency was high (minimum item correlation with total score 0.22; overall Cronbach's alpha statistic 0.85), and responsiveness to improvement in health was good (observed effect size of 0.45 at 8 h). At presentation, however, neither the overall CARIFS score nor the clinical element of the score correlated with physician assessment of clinical severity. CONCLUSION: Of the three recognized domains of illness severity, CARIFS appears to be a good and valid measure of functional severity and burden of illness to the parent but it may not be a good measure of physiological severity.