The potential impact of prophylaxis against bronchiolitis due to the respiratory syncytial virus in children with congenital cardiac malformations.

AIMS: To determine the number of infants in the Mersey and North West regions with congenital cardiac disease for whom palivizumab may be appropriate, and to examine the potential impact of introducing prophylaxis with palivizumab on these patients and their economic management. METHODS: We identified those infants deemed to be at high risk, matching the population recently studied by the Cardiac Synagis Group, from the database of the cardiology department of the hospital. The number of patients under the care of the paediatric cardiologists admitted to Alder Hey Hospital with respiratory syncytial viral bronchiolitis over the last three seasons was identified from hospital coding records, and the database of the cardiology department. RESULTS: There are 131 patients at high risk each year. Of these, over the last three "bronchiolitis seasons", 39 infants have been admitted to the hospital with bronchiolitis due to the respiratory syncytial virus. This represents a hospitalisation rate of 10 per cent, as was seen in the study of the Cardiac Synagis Group. Using a monthly dose of 15 milligrams per kilogram for five doses, the cost per patient is 2,650 pounds sterling for the season. To treat the 131 patients seen at Alder Hey, therefore, would cost 346,800 pounds each year. Applying the reductions in hospitalisation identified in the study by the Cardiac Synagis Group to our population would produce an expected reduction in patients hospitalised from 13 to 7 per year, reducing the total length of stay in our hospital wards from 169 to 76 days, and in the paediatric intensive care unit from 93 to 21 days. This amounts to a potential saving of 190,800 pounds per year. Reducing transfers to more distant paediatric intensive care units for referrals refused because of lack of beds could save an additional 50,000 pounds. DISCUSSION: We estimate the net cost of introducing palivizumab for this population to be 106,000 pounds per year. There would, of course, be additional costs involved in setting up this service, as well as additional savings and benefits. This cost is comparable with other new biologic therapies now routinely used in the United Kingdom, such as etanercept for juvenile arthritis. There are, currently, no other obvious therapies that have the potential to reduce admissions to hospital and intensive care during the winter months, when beds are at their most scarce.

Early severe neutropenia and thrombocytopenia identifies the highest risk cases of severe meningococcal disease.

OBJECTIVE: To determine the performance of established predictors of mortality in pediatric acute meningococcal disease (MD) in a contemporary population and to develop a simple predictive score that will not vary with observer. DESIGN: Prospective study for development set and mixed retrospective and prospective study for validation set. Setting and PATIENTS: A total of 227 patients with clinical meningococcal disease who were referred to three multidisciplinary pediatric intensive care units from 1993 to 1999. Early deaths before transfer to pediatric intensive care unit and deaths from cerebral herniation were included in the analysis. MEASUREMENTS AND MAIN RESULTS: The product of platelet and neutrophil counts at presentation (PN product) predicts mortality from meningococcal disease better than either count alone and at least as well as established severity scores. The Glasgow Meningococcal Septicaemia Prognostic Score and Malley scores performed poorly in these populations. The positive predictive value (PPV) for a Glasgow meningococcal septicemia prognostic score of >/=8/15 was 17.5% (16 of 91; 95% CI = 9%-25%), significantly lower than published estimates of 30%-74%, (p <.01). The PPV for death (or amputation) with a Malley score of 3/3 was 50% (12 of 24; 29%-71%), significantly lower than the published value of 100% (p <.001). The PN product appears to be a useful predictor. For a PN product of <40, PPV = 82% (9 of 11), specificity = 99% (195 of 197), and sensitivity = 73% (23 of 30). The performance of this score was greatest in younger children <5 yrs of age in whom clinical cerebral herniation was not seen as a cause of death (0 of 21 deaths at <5 yrs of age; 4 of 9 deaths at >/=5 yrs of age). CONCLUSION: Established scores significantly overestimate the occurrence of adverse outcomes in meningococcal disease. This may reflect improved resuscitation and outcome or variability in the application of these scores. The PN product achieves similar prediction to the scores currently in use and is independent of the observer. Factors that reflect the extent of the inflammatory response rather than the care before presentation are becoming increasingly important.