Effect of Pneumococcal Conjugate Vaccines on Viral Respiratory Infections: A Systematic Literature Review.

BACKGROUND: In addition to preventing pneumococcal disease, emerging evidence indicates that pneumococcal conjugate vaccines (PCVs) might indirectly reduce viral respiratory tract infections (RTIs) by affecting pneumococcal-viral interactions. METHODS: We performed a systematic review of interventional and observational studies published during 2000-2022 on vaccine efficacy/adjusted effectiveness (VE) and overall effect of PCV7, PCV9, PCV10, or PCV13 against viral RTIs. RESULTS: Sixteen of 1671 records identified were included. Thirteen publications described effects of PCVs against viral RTIs in children. VE against influenza ranged between 41% and 86% (n = 4), except for the 2010-2011 influenza season. In a randomized controlled trial, PCV9 displayed efficacy against any viral RTI, human seasonal coronavirus, parainfluenza, and human metapneumovirus. Data in adults were limited (n = 3). PCV13 VE was 4%-25% against viral lower RTI, 32%-35% against coronavirus disease 2019 outcomes, 24%-51% against human seasonal coronavirus, and 13%-36% against influenza A lower RTI, with some 95% confidence intervals spanning zero. No protection was found against adenovirus or rhinovirus in children or adults. CONCLUSIONS: PCVs were associated with protection against some viral RTI, with the strongest evidence for influenza in children. Limited evidence for adults was generally consistent with pediatric data. Restricting public health evaluations to confirmed pneumococcal outcomes may underestimate the full impact of PCVs.

Breath Markers of Oxidative Stress in Children with Severe Viral Lower Respiratory Tract Infection.

Severe viral lower respiratory tract infection (LRTI), resulting in both acute and long-term pulmonary disease, constitutes a substantial burden among young children. Viral LRTI triggers local oxidative stress pathways by infection and inflammation, and supportive care in the pediatric intensive care unit may further aggravate oxidative injury. The main goal of this exploratory study was to identify and monitor breath markers linked to oxidative stress in children over the disease course of severe viral LRTI. Exhaled breath was sampled during invasive ventilation, and volatile organic compounds (VOCs) were analyzed using gas chromatography and mass spectrometry. VOCs were selected in an untargeted principal component analysis and assessed for change over time. In addition, identified VOCs were correlated with clinical parameters. Seventy breath samples from 21 patients were analyzed. A total of 15 VOCs were identified that contributed the most to the explained variance of breath markers. Of these 15 VOCs, 10 were previously linked to pathways of oxidative stress. Eight VOCs, including seven alkanes and methyl alkanes, significantly decreased from the initial phase of ventilation to the day of extubation. No correlation was observed with the administered oxygen dose, whereas six VOCs showed a poor to strong positive correlation with driving pressure. In this prospective study of children with severe viral LRTI, the majority of VOCs that were most important for the explained variance mirrored clinical improvement. These breath markers could potentially help monitor the pulmonary oxidative status in these patients, but further research with other objective measures of pulmonary injury is required.

Comparing the diagnostic value of targeted with metagenomic next-generation sequencing in immunocompromised patients with lower respiratory tract infection.

BACKGROUND: Accurate identification of the etiology of lower respiratory tract infections (LRTI) is crucial, particularly for immunocompromised patients with more complex etiologies. The advent of next-generation sequencing (NGS) has enhanced the effectiveness of pathogen detection. However, assessments of the clinical diagnostic value of targeted NGS (tNGS) in immunocompromised patients with LRTI are limited. METHODS: To evaluate the diagnostic value of tNGS in immunocompromised patients with LRTI, a total of 88 patients, of whom 54 were immunocompromised, were enrolled. These patients underwent tNGS testing of bronchoalveolar lavage fluid (BALF). Results from both metagenomic next-generation sequencing (mNGS) and conventional microbiological tests (CMT) were also available for all participants. The performance of tNGS was assessed by comparing its findings against mNGS, CMT, and the clinical composite diagnosis. RESULTS: In the cohort of 88 patients, tNGS showed comparable diagnostic value to mNGS and was significantly superior to CMT. Compared to CMT and composite reference standard, tNGS showed sensitivity of 94.55% and 90.48%, respectively. In immunocompromised patients, despite a more diverse pathogen variety, tNGS maintained similar sensitivity to mNGS and outperformed CMT. tNGS positively influenced etiologic diagnosis and antibiotic decision-making in 72.72% of cases, leading to a change in antibiotic regimen in 17.05% of cases. We also compared the detection of microbial nucleic acids by tNGS with mNGS and found that tNGS could identify 87.99% of the microbial nucleic acids identified by mNGS. CONCLUSION: In summary, our study demonstrated that tNGS offers promising clinical diagnostic accuracy in immunocompromised patients, as evidenced by its favorable comparison with CMT, the composite reference standard, and mNGS.

Risk factors for ventilator-associated lower respiratory tract infection in COVID-19, a retrospective multicenter cohort study in Sweden.

BACKGROUND: Ventilator-associated lower respiratory tract infections (VA-LRTI) increase morbidity and mortality in intensive care unit (ICU) patients. Higher incidences of VA-LRTI have been reported among COVID-19 patients requiring invasive mechanical ventilation (IMV). The primary objectives of this study were to describe clinical characteristics, incidence, and risk factors comparing patients who developed VA-LRTI to patients who did not, in a cohort of Swedish ICU patients with acute hypoxemic respiratory failure due to COVID-19. Secondary objectives were to decipher changes over the three initial pandemic waves, common microbiology and the effect of VA-LTRI on morbidity and mortality. METHODS: We conducted a multicenter, retrospective cohort study of all patients admitted to 10 ICUs in southeast Sweden between March 1, 2020 and May 31, 2021 because of acute hypoxemic respiratory failure due to COVID-19 and were mechanically ventilated for at least 48 h. The primary outcome was culture verified VA-LRTI. Patient characteristics, ICU management, clinical course, treatments, microbiological findings, and mortality were registered. Logistic regression analysis was conducted to determine risk factors for first VA-LRTI. RESULTS: Of a total of 536 included patients, 153 (28.5%) developed VA-LRTI. Incidence rate of first VA-LRTI was 20.8 per 1000 days of IMV. Comparing patients with VA-LRTI to those without, no differences in mortality, age, sex, or number of comorbidities were found. Patients with VA-LRTI had fewer ventilator-free days, longer ICU stay, were more frequently ventilated in prone position, received corticosteroids more often and were more frequently on antibiotics at intubation. Regression analysis revealed increased adjusted odds-ratio (aOR) for first VA-LRTI in patients treated with corticosteroids (aOR 2.64 [95% confidence interval [CI]] [1.31-5.74]), antibiotics at intubation (aOR 2.01 95% CI [1.14-3.66]), and days of IMV (aOR 1.05 per day of IMV, 95% CI [1.03-1.07]). Few multidrug-resistant pathogens were identified. Incidence of VA-LRTI increased from 14.5 per 1000 days of IMV during the first wave to 24.8 per 1000 days of IMV during the subsequent waves. CONCLUSION: We report a high incidence of culture-verified VA-LRTI in a cohort of critically ill COVID-19 patients from the first three pandemic waves. VA-LRTI was associated with increased morbidity but not 30-, 60-, or 90-day mortality. Corticosteroid treatment, antibiotics at intubation and time on IMV were associated with increased aOR of first VA-LRTI.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition.

PURPOSE: Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied. METHODS: Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained. RESULTS: A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT). CONCLUSIONS: Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Mortality Among US Infants and Children Under 5 Years of Age with Respiratory Syncytial Virus and Bronchiolitis: A Systematic Literature Review.

BACKGROUND: A systematic literature review was conducted to summarize the mortality (overall and by disease severity factors) of US infants and children aged <5 years with respiratory syncytial virus (RSV) or all-cause bronchiolitis (ACB). METHODS: Comprehensive, systematic literature searches were conducted; articles were screened using prespecified eligibility criteria. A standard risk of bias tool was used to evaluate studies. Mortality was extracted as the rate per 100 000 or the case fatality ratio (CFR; proportion of deaths among RSV/ACB cases). RESULTS: Among 42 included studies, 36 evaluated inpatient deaths; 10 used nationally representative populations updated through 2013, and only 2 included late-preterm/full-term otherwise healthy infants and children. The RSV/ACB definition varied across studies (multiple International Classification of Diseases [ICD] codes; laboratory confirmation); no study reported systematic testing for RSV. No studies reported RSV mortality rates, while 3 studies provided ACB mortality rates (0.57-9.4 per 100 000). CFRs ranged from 0% to 1.7% for RSV (n = 15) and from 0% to 0.17% for ACB (n = 6); higher CFRs were reported among premature, intensive care unit-admitted, and publicly insured infants and children. CONCLUSIONS: RSV mortality reported among US infants and children is variable. Current, nationally representative estimates are needed for otherwise healthy, late-preterm to full-term infants and children.

Differences between simple trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition for the treatment of trapeziometacarpal osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: The optimal management of trapeziometacarpal osteoarthritis remains controversial. This systematic review and meta-analysis assessed the subjective and objective outcomes and complications of simple trapeziectomy (T) versus trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI). METHODS: The PubMed, Embase, Web of science, and Cochrane electronic databases were searched from inception to Aug 31, 2020. Key words included "osteoarthrosis", "carpometacarpal joint", and "trapeziectomy". Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) including patients treated for trapeziometacarpal osteoarthritis were included. The subjective outcomes (visual analog scale [VAS] and disabilities of the arm, shoulder, and hand questionnaire scores), objective outcomes (grip strength, tip, and key pinch strength) and complications were extracted. The methodological quality of each was assessed independently. Meta-analysis was performed for comparative trials. The protocol for this meta-analysis is available in PROSPERO (CRD42020195752). RESULTS: From the 8 included studies (7 RCTs, 1 CCT), 656 cases were divided into T (n = 325) and T + LRTI (n = 331) groups. Compared with the T group, grip and tip pinch strength was better in the T + LRTI group (SMD = - 2.74, 95% confidence interval (CI) (- 3.46 to - 2.02), P < 0.00001) and (SMD = - 0.21, 95% CI (- 0.34 to - 0.08), P = 0.002), respectively, but there were significantly more complications 3 months after operation in the T + LRTI group (RR = 0.50, 95% CI (0.31 to 0.80), P = 0.004). The VAS score (SMD = 0.33, 95% CI (- 0.39 to 1.04), P = 0.37), DASH (SMD = - 1.86, 95% CI (- 7.59 to 3.87), P = 0.52), key pinch strength (SMD = - 0.13, 95% CI (- 0.28 to 0.01), P = 0.07), and incidence of complications 1 year after operation (RR = 0.83, 95% CI (0.53-1.29), P = 0.41) were not significantly different between the two groups. CONCLUSION: While the T + LRTI group demonstrated a better effect in grip and tip pinch strength at the one-year follow-up, there was no statistical difference in key pinch strength, pain relief, and DASH. Furthermore, T + LRTI has more latrogenic injury, more short-term postoperative complications, and higher surgical costs. Considered comprehensively, if there is no special strength requirement, we recommend simple trapeziectomy.

Paediatric pneumonia in high-income countries: Defining and recognising cases at increased risk of severe disease.

World Health Organisation definitions of pneumonia severity are routinely used in research. In high income health care settings with high rates of pneumococcal vaccination and low rates of mortality, malnutrition and HIV infection, these definitions are less applicable. National guidelines from leading thoracic and infectious disease societies describe 'severe pneumonia' according to criteria derived from expert consensus rather than a robust evidence base. Contemporary cohort studies have used clinical outcomes such as intensive care therapy or invasive procedures for complicated pneumonia, to define severe disease. Describing severe pneumonia in such clinically relevant terms facilitates the identification of risk factors associated with worsened disease and the subsequently increased morbidity, and need for tertiary level care. The early recognition of children at higher risk of severe pneumonia informs site of care decisions, antibiotic treatment decisions as well as guiding appropriate investigations. Younger age, malnutrition, comorbidities, tachypnoea, and hypoxia have been identified as important associations with 'severe pneumonia' by WHO definition. Most studies have been performed in low-middle income countries and whilst they provide some insight into those at risk of mortality or treatment failure, their generalisability to the high-income setting is limited. There is a need to determine more precise definitions and criteria for severe disease in well-resourced settings and to validate factors associated with intensive care admission or invasive procedures to enhance the early recognition of those at risk.

Deep Neural Network-Based Respiratory Pathology Classification Using Cough Sounds.

Intelligent systems are transforming the world, as well as our healthcare system. We propose a deep learning-based cough sound classification model that can distinguish between children with healthy versus pathological coughs such as asthma, upper respiratory tract infection (URTI), and lower respiratory tract infection (LRTI). To train a deep neural network model, we collected a new dataset of cough sounds, labelled with a clinician's diagnosis. The chosen model is a bidirectional long-short-term memory network (BiLSTM) based on Mel-Frequency Cepstral Coefficients (MFCCs) features. The resulting trained model when trained for classifying two classes of coughs-healthy or pathology (in general or belonging to a specific respiratory pathology)-reaches accuracy exceeding 84% when classifying the cough to the label provided by the physicians' diagnosis. To classify the subject's respiratory pathology condition, results of multiple cough epochs per subject were combined. The resulting prediction accuracy exceeds 91% for all three respiratory pathologies. However, when the model is trained to classify and discriminate among four classes of coughs, overall accuracy dropped: one class of pathological coughs is often misclassified as the other. However, if one considers the healthy cough classified as healthy and pathological cough classified to have some kind of pathology, then the overall accuracy of the four-class model is above 84%. A longitudinal study of MFCC feature space when comparing pathological and recovered coughs collected from the same subjects revealed the fact that pathological coughs, irrespective of the underlying conditions, occupy the same feature space making it harder to differentiate only using MFCC features.

Biomarkers for Disease Severity in Children Infected With Respiratory Syncytial Virus: A Systematic Literature Review.

BACKGROUND: Clinical manifestations of respiratory syncytial virus (RSV) infection vary widely from mild, self-limiting illness to severe life-threatening disease. There are gaps in knowledge of biomarkers to objectively define severe disease and predict clinical outcomes. METHODS: A systematic search was performed, 1945-March 2019 in databases Ovid Medline, Embase, Global health, Scopus, and Web of Science. Risk of bias was assessed using the Cochrane tool. RESULTS: A total of 25 132 abstracts were screened and studies were assessed for quality, risk of bias, and extracted data; 111 studies met the inclusion criteria. RSV severity was correlated with antibody titers, reduced T and B cells, dysregulated innate immunity, neutrophil mobilization to the lungs and blood, decreased Th1 response, and Th2 weighted shift. Microbial exposures in respiratory tract may contribute to neutrophil mobilization to the lungs of the infants with severe RSV compared with mild RSV disease. CONCLUSIONS: Although a wide range of biomarkers have been associated with RSV disease severity, robust validated biomarkers are lacking. This review illustrates the broad heterogeneity of study designs and high variability in the definition of severe RSV disease. Prospective studies are required to validate biomarkers. Additional research investigating epigenetics, metabolomics, and microbiome holds promise for novel biomarkers.

Evaluation of a Pharmacist-Driven Procalcitonin Protocol for Lower Respiratory Tract Infections Using a Clinical Decision Support System.

Purpose: Procalcitonin (PCT) may be an effective biomarker in the management of lower respiratory tract infections (LRTI) when combined with antimicrobial stewardship support. We assessed the impact of a PCT protocol with clinical pharmacy support for LRTI using a clinical decision support system (CDSS) for monitoring. Methods: This was a single-center retrospective cohort study conducted at a large, nonteaching hospital in Nashville, TN. All patients who met eligibility requirements and were initiated on the PCT protocol for a suspected LRTI between February and March 2018 were included and matched to historical control patients from 2016 to 2017 on a 1:1 basis based on antibiotics, indication, and time of year. Results: During this 2-month period, a total of 126 patients met eligibility requirements for inclusion in the PCT group and were matched to historical control patients. Patients in the PCT group received decreased median antibiotic days of therapy (DOT) compared to controls (11 vs 14, P = .004). There was no change in median length of stay (LOS) between groups. The acceptance rate for patient-specific antibiotic de-escalation recommendations from the clinical pharmacist was 62.5%. Conclusion: PCT protocols that utilize clinical pharmacist interpretation and a CDSS may be an effective intervention of the antimicrobial stewardship program (ASP) for decreasing antibiotic DOT for LRTI.

Clinical burden of severe respiratory syncytial virus infection during the first 2 years of life in children born between 2000 and 2011 in Scotland.

National data from Scotland (all births from 2000 to 2011) were used to estimate the burden associated with respiratory syncytial virus hospitalisation (RSVH) during the first 2 years of life. RSVHs were identified using the International Classification of Diseases 10th Revision codes. Of 623,770 children, 13,362 (2.1%) had ≥ 1 RSVH by 2 years, with the overall rate being 27.2/1000 (16,946 total RSVHs). Median age at first RSVH was 137 days (interquartile range [IQR] 62-264), with 84.3% of admissions occurring by 1 year. Median length of stay was 2 (IQR 1-4) days and intensive care unit (ICU) admission was required by 4.3% (727) for a median 5 (IQR 2-8) days. RSVHs accounted for 6.9% (5089/73,525) of ICU bed days and 6.2% (64,395/1,033,121) of overall bed days (5370/year). RSVHs represented 8.5% (14,243/168,205) of all admissions between October and March and 14.2% (8470/59,535) between December and January. RSVH incidence ranged from 1.7 to 2.5%/year over the study period. Preterms (RSVH incidence 5.2%), and those with congenital heart disease (10.5%), congenital lung disease (11.2%), Down syndrome (14.8%), cerebral palsy (15.5%), cystic fibrosis (12.6%), and neuromuscular disorders (17.0%) were at increased risk of RSVH.Conclusions: RSV causes a substantial burden on Scottish paediatric services during the winter months.What is known:• Respiratory syncytial virus (RSV) is a leading cause of childhood hospitalisation.What is new:• This 12-year study is the first to estimate the burden of RSV hospitalisation (RSVH) in Scotland and included all live births from 2000 to 2011 and followed > 600,000 children until 2 years old.• The overall RSVH rate was 27.2/1000 children, with 2.1% being hospitalised ≥ 1 times.• RSVHs accounted for 6.2% of all inpatient bed days, which rose to 14.2% during the peak months of the RSV season (December-January), equating to over 1400 hospitalisations and nearly 5500 bed days each year.

Mycoplasma pneumoniae detection in children with respiratory tract infections and influence on management - a retrospective cohort study in Switzerland.

AIM: To evaluate the frequency of Mycoplasma pneumoniae in nasopharyngeal specimens from children with respiratory tract infections (RTIs) and to detail clinical characteristics and management. METHODS: The study was designed as a retrospective cohort study. All children with RTI and nucleic acid amplification testing from nasopharyngeal specimens were analysed. Clinical data were extracted from electronic health records for all M. pneumoniae-positive cases. Stored samples of cases and a random selection of matched controls were retested using a M. pneumoniae-specific nucleic acid amplification test. RESULTS: Of 4460 children, 70 (1.6%) were positive for M. pneumoniae with a median age of 6.4 (IQR: 2.7-9.7). M. pneumoniae was the only organism identified in 50/64 (78%) cases. Macrolide treatment was prescribed in 52/65 (80%); prescription was empirical in 29/52 (56%) and targeted in 23/52 (44%) with no difference regarding patient age, oxygen requirement or duration of hospitalisation. CONCLUSION: The prevalence of M. pneumoniae in nasopharyngeal specimens of children with RTI was low. The detection of M. pneumoniae influenced antibiotic prescriptions, but the benefit of early empirical versus targeted treatment remains unclear.

The Effect of Surgical Treatments for Trapeziometacarpal Osteoarthritis on Wrist Biomechanics: A Cadaver Study.

PURPOSE: Studies have shown the effects of surgical treatments for trapeziometacarpal osteoarthritis on thumb biomechanics; however, the biomechanical effects on the wrist have not been reported. This study aimed to quantify alterations in wrist muscle forces following trapeziectomy with or without ligament reconstruction and replacement. METHODS: A validated physiological wrist simulator replicated cyclic wrist motions in cadaveric specimens by applying tensile loads to 6 muscles. Muscle forces required to move the intact wrist were compared with those required after performing trapeziectomy, suture suspension arthroplasty, prosthetic replacement, and ligament reconstruction with tendon interposition (LRTI). RESULTS: Trapeziectomy required higher abductor pollicis longus forces in flexion and higher flexor carpi radialis forces coupled with lower extensor carpi ulnaris forces in radial deviation. Of the 3 surgical reconstructions tested post-trapeziectomy, wrist muscle forces following LRTI were closest to those observed in the intact case throughout the range of all simulated motions. CONCLUSIONS: This study shows that wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. CLINICAL RELEVANCE: Trapeziectomy, as a standalone procedure in the treatment of trapeziometacarpal osteoarthritis, may result in the formation of a potentially unfilled trapezial gap, leading to higher wrist muscle forces. This biomechanical alteration could be associated with clinically important outcomes, such as pain and/or joint instability.

The Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Treatment of Thumb Carpometacarpal Osteoarthritis.

PURPOSE: Biopsychosocial factors are associated with patient-reported upper extremity disability; however, their impact on postoperative outcomes remains less clear. Our purpose was to test the hypothesis that high levels of preoperative patient-reported upper extremity and psychological disability are associated with lower magnitudes of improvement following trapeziectomy with ligament reconstruction tendon interposition (LRTI). METHODS: Adult patients undergoing LRTI by fellowship-trained hand surgeons between February 2014 and March 2017 were considered for inclusion. Patient-reported outcomes were collected by tablet computer, including the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Computer Adaptive Test (CAT), PROMIS Depression CAT, and PROMIS Anxiety CAT. Univariate and multivariable linear regression analyses were performed to identify factors associated with QuickDASH improvement. RESULTS: Of 119 included patients, the mean age was 62.7 ± 7.2 years and 74% were women. At a mean of 14 weeks after surgery, the QuickDASH improved by a mean of -10 ± 20 points. The QuickDASH improvement was significantly greater for patients with preoperative QuickDASH scores greater than the median (score change, -19 ± 20) versus those at or below the median (-2 ± 16), and for patients with preoperative PI CAT scores greater than the median (-17 ± 21) versus at or below the median (-4 ± 17). No differences were observed between groups when Anxiety or Depression CAT baseline scores were similarly dichotomized. Multivariable modelling revealed that higher preoperative QuickDASH scores were associated with greater improvement on the QuickDASH; however, no association was observed for preoperative PI CAT, Depression CAT, and Anxiety CAT scores. CONCLUSIONS: Patients with higher levels of preoperative upper extremity disability experienced more improvement in the early postoperative period following LRTI. Baseline pain interference, depression, and anxiety were not associated with early outcomes. These findings may be useful when identifying patients who may experience the most functional improvement in the immediate postoperative period following LRTI. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Phenotypic and molecular characterization of Acinetobacter baumannii isolates causing lower respiratory infections among ICU patients.

BACKGROUND: Multi-drug resistant Acinetobacter baumannii has emerged as important nosocomial pathogen associated with various infections including lower respiratory tract. Limited therapeutic options contribute to increased morbidity and mortality. Acinetobacter baumannii has the ability to persist in the environment for prolonged periods. Breach in infection control practices increases the chances of cross transmission between patients and inter/intraspecies transmission of resistance elements. The present prospective work was conducted among patients with lower respiratory tract infections (LRTI) in the intensive care unit (ICU) to study the etiology with special reference to Acinetobacter baumannii and the role of immediate patient environment in the ICU as possible source of infection. Acinetobacter baumannii were characterized for antimicrobial susceptibility, mechanism of carbapenem resistance and virulence determinants. Molecular typing of the clinical and environmental isolates was undertaken to study the probable modes of transmission. MATERIALS AND METHODS: Appropriate respiratory samples from 107 patients with LRTI admitted to ICU during September 2016 to March 2017 were studied for likely bacterial pathogens. Environmental samples (n = 71) were also screened. All the samples were processed using conventional microbiological methods. Consecutive Acinetobacter spp. isolated from clinical and environmental (health care workers and environment from ICU) samples were included in the study. Antimicrobial susceptibility was performed as per CLSI guidelines. Carbapenem resistance, mediated by carbapenemase genes (blaOXA-23-like,blaOXA-24-like,blaOXA-58-like and blaNDM-1) were studied by PCR. Biofilm forming ability was tested phenotypically using microtitre plate method. Pulse Field Gel Electrophoresis (PFGE) was used to study clonality of the clinical and environmental isolates. RESULTS: The prevalence of Acinetobacter baumannii was 26.2% (28/107) and 11.26% (8/71) among patients with LRTI and environmental samples respectively. The carbapenem resistance was high, 96.42% (27/28) and 87.5% (7/8) in clinical and environmental isolates respectively. The most common carbapenemase associated with resistance was blaOXA-23-like gene followed by blaNDM-1 among both the clinical and environmental isolates. All isolates were sensitive to colistin (MIC ≤ 1 µg/ml). Biofilm production was observed among all clinical (n = 28) and 87.5% (7/8) of the environmental isolates. Line listing of the cases suggests the occurrence of infections throughout the study period with no significant clustering. On PFGE, 12 clusters were observed and 16/36 isolates were present in one single cluster that included both clinical and environmental isolates which were either carbapenem resistant or sensitive. DISCUSSION: Carbapenem resistant Acinetobacter baumannii (CRAB) is an important cause of LRTI in the ICU. PFGE suggests spread of carbapenem resistant isolates via cross transmission among patients and the environment. The detection of blaNDM-1 gene among Acinetobacter baumannii and existence of carbapenem resistant and sensitive isolates within the same clones suggests horizontal transmission of resistant genes among various bacterial species. The ability of Acinetobacter baumannii to form biofilms may contribute to its persistence in the environment. This along with breach in infection control practices are the likely factors contributing to this transmission. This information can be used to strengthen and monitor infection control (IC) and the hospital cleaning and disinfection practices to prevent spread of resistant organisms within the ICU. Colistin remains drug of choice for management of CRAB.

Comparing the yield of oropharyngeal swabs and sputum for detection of 11 common pathogens in hospitalized children with lower respiratory tract infection.

BACKGROUND: Advances in molecular laboratory techniques are changing the prospects for the diagnosis of viral infectious diseases. Multiplex polymerase chain reaction assay (multiplex-PCR) can detect dozens of pathogens simultaneously, greatly reducing turnaround time (TAT) and improving detection sensitivity. But as a double-edged sword, due to the high sensitivity of PCR, the type of respiratory specimens is critical to diagnosis. In this work, we performed a head-to-head comparison to evaluate the multiplex-PCR yields between two samples, sputum and flocked oropharyngeal swabs (OPS). METHODS: Eleven common respiratory pathogens were tested in hospitalized children< 13 years of age who met the criteria for lower respiratory tract infection by GeXP-based multiplex-PCR of paired OPS and sputum. RESULTS: From January to June 2018, 440 children with paired OPS and sputum were tested. The positive rate was 84% (369/440) for OPS and 88% (386/440) for sputum (p = .007). The frequency of detection of HRV, RSV, Influenza A virus, HMPV, parainfluenza virus, adenovirus, M. pneumoniae, coronavirus, bocavirus and C. pneumoniae in sputa was higher than that of OPSs (all p < .001). Both types of specimens had similarly very good kappa values for most of pathogens, except for Mycoplasma pneumonia (κ = 0.61) and Chlamydia pneumoniae (κ = 0.24). Additionally, 79.3% (349/440) of cases showed consistent results between the two types of samples, and they were significantly younger than patients with inconsistent results (p = .002). CONCLUSIONS: Flocked oropharyngeal swabs and sputum performed similarly for the detection of common respiratory pathogens in hospitalized children by multiplex-PCR, except for Mycoplasma pneumoniae and Chlamydia pneumoniae. Young patients are likely to have consistent results between the two specimens.

Lung Function in African Infants in the Drakenstein Child Health Study. Impact of Lower Respiratory Tract Illness.

RATIONALE: Lower respiratory tract illness is a major cause of childhood morbidity and mortality. It is unknown whether infants are predisposed to illness because of impaired lung function or whether respiratory illness reduces lung function. OBJECTIVES: To investigate the impact of early life exposures, including lower respiratory tract illness, on lung function during infancy. METHODS: Infants enrolled in the Drakenstein child health study had lung function at 6 weeks and 1 year. Testing during quiet natural sleep included tidal breathing, exhaled nitric oxide, and multiple breath washout measures. Risk factors for impaired lung health were collected longitudinally. Lower respiratory tract illness surveillance was performed and any episode investigated. MEASUREMENTS AND MAIN RESULTS: Lung function was tested in 648 children at 1 year. One hundred and fifty (29%) infants had a lower respiratory tract illness during the first year of life. Lower respiratory tract illness was independently associated with increased respiratory rate (4%; 95% confidence interval [CI], 1.01-1.08; P = 0.02). Repeat episodes further increased respiratory rate (3%; 95% CI, 1.01-1.05; P = 0.004), decreased tidal volume (-1.7 ml; 95% CI, -3.3 to -0.2; P = 0.03), and increased the lung clearance index (0.13 turnovers; 95% CI, 0.04-0.22; P = 0.006) compared with infants without illness. Tobacco smoke exposure, lung function at 6 weeks, infant growth, and prematurity were other independent predictors of lung function at 1 year. CONCLUSIONS: Early life lower respiratory tract illness impairs lung function at 1 year, independent of baseline lung function. Preventing early life lower respiratory tract illness is important to optimize lung function and promote respiratory health in childhood.

Functional Outcomes of Thumb Trapeziometacarpal Arthrodesis With a Locked Plate Versus Ligament Reconstruction and Tendon Interposition.

PURPOSE: To compare standardized functional and patient-reported early outcomes following trapeziometacarpal arthrodesis (TMA) using a locking cage plate construct with trapezial excision, ligament reconstruction, and tendon interposition (LRTI). METHODS: This prospective cohort enrolled 50 consecutive patients with trapeziometacarpal osteoarthritis undergoing TMA or LRTI. Demographic data, objective measurements, Sollerman function testing, and patient-reported outcomes were collected before surgery and at various time intervals up to 12 months after surgery. The study was powered to detect a minimally clinically important difference on the Michigan Hand Questionnaire between groups at 12 months. To account for selection bias, we performed between-group statistical analysis of the magnitude of change from preoperative to postoperative data. All complications were recorded. RESULTS: There were no significant differences in the amount of change in grip or pinch strength, patient-reported outcomes, or functional hand testing between TMA and LRTI. The TMA group had significantly increased thumb tip opposition distance. The TMA group was complicated by a 26% overall nonunion rate of which 8% were symptomatic. The LRTI group (Wagner incision) had a significantly increased incidence of superficial branch of the radial nerve paresthesia. The incidence of complications was similar between operative groups, but revision surgery was more common after TMA. CONCLUSIONS: Compared with LRTI, TMA failed to demonstrate superior improvement in strength, standardized functional performance, or patient-reported function and is associated with an increased likelihood of revision surgery in the first 12 months. Trapeziometacarpal arthrodesis with a locking plate and screw construct does not ensure union, although most radiographic nonunions were asymptomatic. Wagner incisions are associated with a significantly increased incidence of superficial branch of the radial nerve paresthesia compared with dorsal trapeziometacarpal exposure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.