Risk Factors and Clinical Prognosis Associated With RSV-ALRI Intensive Care Unit Admission in Children <2 Years of Age: A Multicenter Study.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infections (ALRIs) in children aged <2 years. Currently, there are limited data on risk factors for very severe RSV-ALRI requiring intensive care unit (ICU) admission. METHODS: We conducted a case-control study of children aged <2 years admitted with RSV-ALRI to the Sydney Children's Hospital Network, comprising 2 large tertiary pediatric hospitals. Cases were children with laboratory-confirmed RSV-ALRI admitted to ICU, and controls were (1:2, matched on date of admission) children hospitalized with RSV-ALRI but not requiring ICU transfer. Data on risk factors were retrieved from the electronic medical record system. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) associated with risk factors for ICU admission and the association with clinical and treatment factors were determined from logistic regression models. RESULTS: A total of 44 (44%) of 100 cases and 90 (48.1%) of 187 controls were male. Age <6 months and preterm births were associated with a 2.10-fold (95% CI: 1.14-3.79) and 2.35-fold (95% CI: 1.26-4.41) increased risk in ICU admissions, respectively. The presence of any chronic health condition was a significant risk factor for ICU admission. The clinical presentations on admission more commonly seen in cases were apnea (aOR: 5.01, 95% CI: 1.50-17.13) and respiratory distress (aOR: 15.91, 95% CI: 4.52-55.97). Cases were more likely to be hospitalized for longer duration and require respiratory support. CONCLUSIONS: Our results can be translated into a clinical risk algorithm to identify children at risk of very severe RSV disease.

Risk Factors for Poor Outcomes in Children Hospitalized With Virus-associated Acute Lower Respiratory Infections: A Systematic Review and Meta-analysis.

BACKGROUND: Acute lower respiratory infection (ALRI) caused by respiratory viruses is among the most common causes of hospitalization and mortality in children. We aimed to identify risk factors for poor outcomes in children <5 years old hospitalized with ALRI caused by respiratory syncytial virus (RSV), influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We searched Embase, Medline and Global Health databases and included observational studies reporting risk factors for poor outcomes (defined as use of supplemental oxygen, mechanical ventilation, intensive care unit admission, prolonged hospital stay and mortality) published between January 2011 and January 2023. Two authors independently extracted data on study characteristics, outcomes and risk factors. Due to limited data, meta-analyses were only conducted for RSV-ALRI poor outcome risk factors using random effects model when there were at least 3 studies. RESULTS: We included 30 studies. For RSV-related ALRI, significant risk factors based on meta-analysis were: neurological disease [odds ratio (OR): 6.14; 95% confidence intervals (CIs): 2.39-15.77], Down's syndrome (5.43; 3.02-9.76), chronic lung disease (3.64; 1.31-10.09), immunocompromised status (3.41; 1.85-6.29), prematurity (2.98; 1.93-4.59), congenital heart disease (2.80; 1.84-4.24), underlying disease (2.45; 1.94-3.09), age <2 months (2.29; 1.78-2.94), age <6 months (2.08; 1.81-2.39), viral coinfection (2.01; 1.27-3.19), low birth weight (1.88; 1.19-2.95) and being underweight (1.80; 1.38-2.35). For influenza-related ALRI, chronic conditions and age 6-24 months were identified as risk factors for poor outcomes. Cardiovascular disease, immunosuppression, chronic kidney disease, diabetes and high blood pressure were reported as risk factors for mortality due to SARS-CoV-2 associated ALRI. CONCLUSIONS: These findings might contribute to the development of guidelines for prophylaxis and management of ALRI caused by RSV, influenza and SARS-CoV-2.

Asthma-community acquired pneumonia co-diagnosis in children: a scoping review.

OBJECTIVE: This scoping review investigated the existing literature and identified the evidence gaps related to diagnosis and management in children aged 2-18 years presenting to hospitals with a co-diagnosis of asthma and community-acquired pneumonia. DATA SOURCES: We designed a scoping review following Arksey and O'Malley's scoping review framework and PRISMA extension for a scoping review. We searched literature using five electronic databases: PubMed, CINAHL, Scopus, Web of Science, and Embase from 2003 to June 2023. RESULTS: A total of 1599 abstracts with titles were screened and 12 abstracts were selected for full review. Separate guidelines including Modified Global Initiative for Asthma (GINA) guidelines; modified Integrated Management of Childhood Illness (IMCI) guidelines; and a consensus guideline developed by the Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) were used for diagnosing asthma and CAP individually. Chest X-rays were used in 83.3% (10/12) of studies to establish the co-diagnosis of asthma-CAP in children. Variations were observed in using different laboratory investigations across the studies. Infectious etiologies were detected in five (41.7%) studies. In 75% (9/12) of studies, children with asthma-CAP co-diagnosis were treated with antimicrobials, however, bacterial etiology was not reported in 44.4% (4/9) of the studies. CONCLUSIONS: Our scoping review suggests that chest X-rays are commonly used to establish the co-diagnosis of asthma-CAP and antibiotics are often used without laboratory confirmation of a bacterial etiology. Clinical practice guidelines for the management of asthma and pneumonia in children who present with co-diagnosis may standardize clinical care and reduce variation.

Asthma and Susceptibility to COVID-19 in Australian Children During Alpha, Delta and Omicron Waves of the COVID-19 Pandemic.

Purpose: Earlier coronavirus-19 (COVID-19) pandemic reports did not implicate increased disease burden in asthmatics while subsequent findings have been inconsistent. To date, the impact of COVID-19 on childhood asthma remains undetermined and is further complicated with ongoing emergence of new variants. This study aimed to investigate association between asthma and COVID-19 for children in New South Wales (NSW), Australia and compare its differences across four major outbreaks from alpha, delta and omicron variants/subvariants. Methods: This is a retrospective cross-sectional study of all children aged ≤17 years old who sought care for COVID-19 at Sydney Children's Hospitals Network (SCHN) between 1 January 2020 and 31 May 2022. Results: Of the 18,932 children with polymerase chain reaction (PCR) confirmed COVID-19 who attended SCHN, 60% received their care during delta wave, and 5.41% (n = 913) had prior diagnosis of asthma. Among children with COVID-19, the odds of having asthma were lower during alpha (aOR = 0.43; 95% CI, 0.19-0.83) and delta wave (aOR = 0.84; 95% CI, 0.73-0.96), but were higher during omicron wave (aOR = 1.56; 95% CI, 1.23-1.95). Length of hospital stay (LOS) for asthmatic children were increased by 0.55 days and 1.17 days during delta and the second omicron wave, respectively. Intensive care and mechanical ventilation requirements were not significantly different between asthmatic and non-asthmatic children. Eleven deaths were reported but none had asthma. Conclusion: Although children with asthma were more susceptible to COVID-19 infections during omicron waves compared to that of alpha or delta waves, they were not at greater risk of COVID-19 severity at any stage of the outbreak regardless of the predominant SARS-CoV-2 variants/subvariants.

Automated detection of airflow obstructive diseases: A systematic review of the last decade (2013-2022).

BACKGROUND AND OBJECTIVE: Obstructive airway diseases, including asthma and Chronic Obstructive Pulmonary Disease (COPD), are two of the most common chronic respiratory health problems. Both of these conditions require health professional expertise in making a diagnosis. Hence, this process is time intensive for healthcare providers and the diagnostic quality is subject to intra- and inter- operator variability. In this study we investigate the role of automated detection of obstructive airway diseases to reduce cost and improve diagnostic quality. METHODS: We investigated the existing body of evidence and applied Preferred Reporting Items for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search records in IEEE, Google scholar, and PubMed databases. We identified 65 papers that were published from 2013 to 2022 and these papers cover 67 different studies. The review process was structured according to the medical data that was used for disease detection. We identified six main categories, namely air flow, genetic, imaging, signals, and miscellaneous. For each of these categories, we report both disease detection methods and their performance. RESULTS: We found that medical imaging was used in 14 of the reviewed studies as data for automated obstructive airway disease detection. Genetics and physiological signals were used in 13 studies. Medical records and air flow were used in 9 and 7 studies, respectively. Most papers were published in 2020 and we found three times more work on Machine Learning (ML) when compared to Deep Learning (DL). Statistical analysis shows that DL techniques achieve higher Accuracy (ACC) when compared to ML. Convolutional Neural Network (CNN) is the most common DL classifier and Support Vector Machine (SVM) is the most widely used ML classifier. During our review, we discovered only two publicly available asthma and COPD datasets. Most studies used private clinical datasets, so data size and data composition are inconsistent. CONCLUSIONS: Our review results indicate that Artificial Intelligence (AI) can improve both decision quality and efficiency of health professionals during COPD and asthma diagnosis. However, we found several limitations in this review, such as a lack of dataset consistency, a limited dataset and remote monitoring was not sufficiently explored. We appeal to society to accept and trust computer aided airflow obstructive diseases diagnosis and we encourage health professionals to work closely with AI scientists to promote automated detection in clinical practice and hospital settings.

Coverage and predictors of influenza and pertussis vaccination during pregnancy: a whole of population-based study.

BACKGROUND: Respiratory infections including influenza and pertussis are associated with significant morbidity and mortality in mothers and newborns. Vaccination during pregnancy against influenza and pertussis is recommended for all women but data on uptake in Australia is limited. METHODS: We conducted a retrospective population-based cohort study in Australia's largest state, New South Wales (NSW), using a Perinatal Data Collection (PDC). Data included demographic, pregnancy, and birth details including pertussis and influenza vaccination during pregnancy for all women giving birth between 01 January 2016 and 31 December 2020. We used descriptive statistics to assess uptake of influenza and pertussis vaccination during pregnancy and Poisson loglinear regression to estimate associations between maternal characteristics and vaccine receipt. RESULTS: During 2016-2020, there were 477,776 births (mean maternal age 32.25 years). In 176,255 (36.9%) births the mother received both vaccines; 202,922 (42.5%) influenza and 315,620 (66.1%) pertussis vaccine. From 2016 to 2020, reported coverage increased from 26.7% to 58.7% for influenza and 43.1% to 78.8% for pertussis, respectively. After adjustment, characteristics associated with lower likelihood of receiving influenza and pertussis vaccination included: younger age (<30 years), being born in Australia/New Zealand, from lower socio-economic strata, having previous pregnancies, being later to first antenatal care, utilising the public hospital care model, smoking, having chronic hypertension and BMI > 25 kg/m2. CONCLUSIONS: While reported coverage of both influenza and pertussis vaccine in birthing women in NSW has increased over time, disparities in coverage exist and they highlight areas where evidence-based interventions to improve maternal vaccination could be targeted.

Variation in clinical practice guidelines for use of palivizumab in preventing severe respiratory syncytial viral (RSV) disease in high-risk infants.

BACKGROUND: Uniformity and compliance with clinical practice guidelines (CPGs) for use of palivizumab in preventing severe respiratory syncytial viral infection in Australian high-risk infants remain unclear. METHODS: An online survey was conducted across the Australian and New Zealand Neonatal Network (ANZNN) to determine clinical practices around palivizumab. A literature search was also performed to identify and compare national and international guidelines. RESULTS: A total of 65 of 422 ANZNN members completed the survey. Respondents included 61 senior medical staff of consultants/staff specialists (78%) and four nursing staff (6%). According to the survey, infants most likely to be recommended palivizumab included preterm infants born <29 weeks gestational age (GA) (30%), children with chronic lung diseases (CLDs) born <32 weeks GA (40%), and with hemodynamically significant heart disease (35%). Many of the respondents (53%) stated that CPGs for palivizumab were developed locally. Literature search identified 20 guidelines (10 international and 10 domestic); 16 (80%) recommended palivizumab use in preterm infants, 16 (80%) recommended use in infants with CLD, 17 (85%) in congenital heart disease and 6 (30%) in bronchopulmonary dysplasia (BPD). Eight (40%) guidelines provided specific recommendations for immunocompromised infants. Canada, Western Australia, and American Academy of Paediatrics provided recommendations for Indigenous children. Frequency and dosage of palivizumab was universal across all CPGs. None of the international guidelines obtained were from low- or middle-income countries. CONCLUSIONS: Standardization of CPGs may improve clinical decision making around use of palivizumab in high-risk infants.

Advancing One human-animal-environment Health for global health security: what does the evidence say?

In this Series paper, we review the contributions of One Health approaches (ie, at the human-animal-environment interface) to improve global health security across a range of health hazards and we summarise contemporary evidence of incremental benefits of a One Health approach. We assessed how One Health approaches were reported to the Food and Agricultural Organization of the UN, the World Organisation for Animal Health (WOAH, formerly OIE), and WHO, within the monitoring and assessment frameworks, including WHO International Health Regulations (2005) and WOAH Performance of Veterinary Services. We reviewed One Health theoretical foundations, methods, and case studies. Examples from joint health services and infrastructure, surveillance-response systems, surveillance of antimicrobial resistance, food safety and security, environmental hazards, water and sanitation, and zoonoses control clearly show incremental benefits of One Health approaches. One Health approaches appear to be most effective and sustainable in the prevention, preparedness, and early detection and investigation of evolving risks and hazards; the evidence base for their application is strongest in the control of endemic and neglected tropical diseases. For benefits to be maximised and extended, improved One Health operationalisation is needed by strengthening multisectoral coordination mechanisms at national, regional, and global levels.

Real world impact of 13vPCV in preventing invasive pneumococcal pneumonia in Australian children: A national study.

BACKGROUND: We aimed to assess the direct protective effect of 13 valent pneumococcal conjugate vaccine (13vPCV) against invasive pneumococcal pneumonia (IPP; including pneumonia and empyema) in children using a nation-wide case-control study across 11 paediatric tertiary hospitals in Australia. METHODS: Children < 18 years old admitted with pneumonia were eligible for enrolment. IPP was defined as Streptococcus pneumoniae (SP) cultured or detected by polymerase chain reaction (PCR) from blood or pleural fluid. Causative SP serotype (ST) was determined from blood or pleural fluid SP isolates by molecular methods in PCR positive specimens or else inferred from nasopharyngeal isolates. For each IPP case, 20 population controls matched by age and socio-economic status were sampled from the Australian Immunisation Register. Conditional logistic regression was used to estimate the adjusted odds ratio (aOR) of being fully vaccinated with 13vPCV (≥3 doses versus < 3 doses) among IPP cases compared to controls, adjusted for sex and Indigenous status. RESULTS: From February 2015 to September 2018, we enrolled 1,168 children with pneumonia; 779 were 13vPCV-eligible and were individually matched to 15,580 controls. SP was confirmed in 195 IPP cases, 181 of whom had empyema. ST3 and ST19A were identified in 52% (102/195) and 11% (21/195) of IPP cases respectively. The aOR of being fully vaccinated with 13vPCV was 0.8 (95% CI 0.6-1.0) among IPP cases compared to matched controls. CONCLUSION: We failed to identify a strong direct protective effect of 13vPCV against IPP among Australian children, where disease was largely driven by ST3.

Identifying the research, advocacy, policy and implementation needs for the prevention and management of respiratory syncytial virus lower respiratory tract infection in low- and middle-income countries.

Introduction: The high burden of respiratory syncytial virus (RSV) infection in young children disproportionately occurs in low- and middle-income countries (LMICs). The PROUD (Preventing RespiratOry syncytial virUs in unDerdeveloped countries) Taskforce of 24 RSV worldwide experts assessed key needs for RSV prevention in LMICs, including vaccine and newer preventive measures. Methods: A global, survey-based study was undertaken in 2021. An online questionnaire was developed following three meetings of the Taskforce panellists wherein factors related to RSV infection, its prevention and management were identified using iterative questioning. Each factor was scored, by non-panellists interested in RSV, on a scale of zero (very-low-relevance) to 100 (very-high-relevance) within two scenarios: (1) Current and (2) Future expectations for RSV management. Results: Ninety questionnaires were completed: 70 by respondents (71.4% physicians; 27.1% researchers/scientists) from 16 LMICs and 20 from nine high-income (HI) countries (90.0% physicians; 5.0% researchers/scientists), as a reference group. Within LMICs, RSV awareness was perceived to be low, and management was not prioritised. Of the 100 factors scored, those related to improved diagnosis particularly access to affordable point-of-care diagnostics, disease burden data generation, clinical and general education, prompt access to new interventions, and engagement with policymakers/payers were identified of paramount importance. There was a strong need for clinical education and local data generation in the lowest economies, whereas upper-middle income countries were more closely aligned with HI countries in terms of current RSV service provision. Conclusion: Seven key actions for improving RSV prevention and management in LMICs are proposed.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh.

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Impact of integrated care coordination on pediatric asthma hospital presentations.

Introduction: Frequent asthma attacks in children result in unscheduled hospital presentations. Patient centered care coordination can reduce asthma hospital presentations. In 2016, The Sydney Children's Hospitals Network launched the Asthma Follow up Integrated Care Initiative with the aim to reduce pediatric asthma emergency department (ED) presentations by 50% through developing and testing an integrated model of care led by care coordinators (CCs). Methods: The integrated model of care was developed by a multidisciplinary team at Sydney Children's Hospital Randwick (SCH,R) and implemented in two phases: Phase I and Phase II. Children aged 2-16 years who presented ≥4 times to the ED of the SCH,R in the preceding 12 months were enrolled in Phase I and those who had ≥4 ED presentations and ≥1 hospital admissions with asthma attack were enrolled in Phase II. Phase I included a suite of interventions delivered by CCs including encouraging parents/carers to schedule follow-up visits with GP post-discharge, ensuring parents/carers are provided with standard asthma resource pack, offering referrals to asthma education sessions, sending a letter to the child's GP advising of the child's recent hospital presentation and coordinating asthma education webinar for GPs. In addition, in Phase II CCs sent text messages to parents/carers reminding them to follow-up with the child's GP. We compared the change in ED visits and hospital admissions at baseline (6 months pre-enrolment) and at 6-and 12-months post-enrolment in the program. Results: During December 2016-January 2021, 160 children (99 in Phase I and 61 in Phase II) were enrolled. Compared to baseline at 6- and 12-months post-enrolment, the proportion of children requiring ≥1 asthma ED presentations reduced by 43 and 61% in Phase I and 41 and 66% in Phase II. Similarly, the proportion of children requiring ≥1 asthma hospital admissions at 6- and 12-months post-enrolment reduced by 40 and 47% in Phase I and 62 and 69% in Phase II. Conclusion: Our results support that care coordinator led integrated model of asthma care which enables integration of acute and primary care services and provides families with asthma resources and education can reduce asthma hospital presentations in children.

The Impact of COVID-19 Pandemic on Inequity in Routine Childhood Vaccination Coverage: A Systematic Review.

BACKGROUND: Routine childhood vaccination coverage rates fell in many countries during the COVID-19 pandemic, but the impact of inequity on coverage is unknown. METHODS: We synthesised evidence on inequities in routine childhood vaccination coverage (PROSPERO, CRD 42021257431). Studies reporting empirical data on routine vaccination coverage in children 0-18 years old during the COVID-19 pandemic by equity stratifiers were systematically reviewed. Nine electronic databases were searched between 1 January 2020 and 18 January 2022. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Tool for Cohort Studies. Overall, 91 of 1453 studies were selected for full paper review, and thirteen met the inclusion criteria. RESULTS: The narrative synthesis found moderate evidence for inequity in reducing the vaccination coverage of children during COVID-19 lockdowns and moderately strong evidence for an increase in inequity compared with pre-pandemic months (before March 2020). Two studies reported higher rates of inequity among children aged less than one year, and one showed higher inequity rates in middle- compared with high-income countries. CONCLUSIONS: Evidence from a limited number of studies shows the effect of the pandemic on vaccine coverage inequity. Research from more countries is required to assess the global effect on inequity in coverage.

Reducing household air pollution exposure to improve early child growth and development; a randomized control trial protocol for the "Poriborton-Extension: The CHANge trial".

BACKGROUND: Globally, household air pollution (HAP) is a leading environmental cause of morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on child health outcomes, compared to usual cooking practices in Bangladesh. The primary aim is to evaluate if reduced exposure to HAP through the provision of LPG for cooking from early gestation through to age 2 improves child anthropometry, health, and neuro-cognitive developmental outcomes, compared to children exposed to emissions from usual practice. METHODS: Two-arm parallel cluster randomized controlled trial (cCRT). We will extend the intervention and follow-up of our existing "Poriborton" trial. In a subset of the original surviving participants, we will supply LPG cylinders and LPG stoves (intervention) compared to usual cooking practices and extend the follow-up to 24 months of age. The expected final sample size, for both (intervention and control) is 1854 children with follow-up to 2 years of age available for analysis. DISCUSSION: This trial will answer important research gaps related to HAP and child health and neuro-cognitive developmental outcomes. This evidence will help to understand the impact of a HAP intervention on child health to inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: The Poriborton: Change trial: Household Air Pollution and Perinatal and early Neonatal mortality is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001214224, original trial registered on 19th July 2018, extension approved on 23rd June 2021. www.anzctr.org.au .

Impact of lockdowns on paediatric asthma hospital presentations over three waves of COVID-19 pandemic.

Public health measures to mitigate the COVID-19 pandemic have altered health care for chronic conditions. The impact of the COVID-19 pandemic on paediatric asthma, the most common chronic respiratory cause of childhood hospitalisation, in Australia, remains unknown. In a multicentre study, we examined the impact of three waves of COVID-19 on paediatric asthma in New South Wales Australia. Time series analysis was performed to determine trends in asthma hospital presentations in children aged 2-17 years before (2015-2019) and during the COVID-19 pandemic (2020-2021) using emergency department and hospital admission datasets from two large tertiary paediatric hospitals.In this first report from Australia, we observed a significant decrease in asthma hospital presentations during lockdown periods including April (68.85%), May (69.46%), December (49.00%) of 2020 and August (66.59%) of 2021 compared to pre-pandemic predictions.The decrease in asthma hospital presentations coincided with the lockdown periods during first, second and third waves of the COVID-19 pandemic and was potentially due to reduced transmission of other common respiratory viruses from restricted movement.

Hospital service use for young people with chronic health conditions: A population-based matched retrospective cohort study.

AIM: This study aims to identify the hospitalised morbidity associated with three common chronic health conditions among young people using a population-based matched cohort. METHODS: A population-level matched case-comparison retrospective cohort study of young people aged ≤18 years hospitalised with asthma, type 1 diabetes (T1D) or epilepsy during 2005-2018 in New South Wales, Australia using linked birth, health and mortality records. The comparison cohort was matched on age, sex and residential postcode. Adjusted rate ratios (ARR) were calculated by sex and age group. RESULTS: There were 65 055 young people hospitalised with asthma, 6648 with epilepsy, and 2209 with T1D. Young people with epilepsy (ARR 10.95; 95% confidence interval (CI) 9.98-12.02), T1D (ARR 8.64; 95% CI 7.72-9.67) or asthma (ARR 4.39; 95% CI 4.26-4.53) all had a higher risk of hospitalisation than matched peers. Admission risk was highest for males (ARR 11.00; 95% CI 9.64-12.56) and females with epilepsy (ARR 10.83; 95% CI 9.54-12.29) compared to peers. The highest admission risk by age group was for young people aged 10-14 years (ARR 5.50; 95% CI 4.77-6.34) living with asthma, children aged ≤4 years (ARR 12.68; 95% CI 11.35-14.17) for those living with epilepsy, and children aged 5-9 years (ARR 9.12; 95% CI 7.69-10.81) for those living with T1D compared to peers. CONCLUSIONS: The results will guide health service planning and highlight opportunities for better management of chronic health conditions, such as further care integration between acute, primary and community health services for young people.

Assessment and diagnosis of chronic dyspnoea: a literature review.

Dyspnoea or breathlessness is a common presenting symptom among patients attending primary care services. This review aimed to determine whether there are clinical tools that can be incorporated into a clinical decision support system for primary care for efficient and accurate diagnosis of causes of chronic dyspnoea. We searched MEDLINE, EMBASE and Google Scholar for all literature published between 1946 and 2020. Studies that evaluated a clinical algorithm for assessment of chronic dyspnoea in patients of any age group presenting to physicians with chronic dyspnoea were included. We identified 326 abstracts, 55 papers were reviewed, and eight included. A total 2026 patients aged between 20-80 years were included, 60% were women. The duration of dyspnoea was three weeks to 25 years. All studies undertook a stepwise or algorithmic approach to the assessment of dyspnoea. The results indicate that following history taking and physical examination, the first stage should include simply performed tests such as pulse oximetry, spirometry, and electrocardiography. If the patient remains undiagnosed, the second stage includes investigations such as chest x-ray, thyroid function tests, full blood count and NT-proBNP. In the third stage patients are referred for more advanced tests such as echocardiogram and thoracic CT. If dyspnoea remains unexplained, the fourth stage of assessment will require secondary care referral for more advanced diagnostic testing such as exercise tests. Utilising this proposed stepwise approach is expected to ascertain a cause for dyspnoea for 35% of the patients in stage 1, 83% by stage 3 and >90% of patients by stage 4.