Antiviral Pharmacology: A Standardized Patient Case for Preclinical Medical Students.

Introduction: Pharmacology is an important learning topic in preclinical medical education. Simulated patient encounters allow students to apply basic science knowledge in a clinical setting and have been useful in previous studies of pharmacology education. We developed a standardized patient (SP) encounter to reinforce antiviral pharmacology content for first-year medical students. Methods: Students were instructed to recommend a medication for shingles during an SP encounter and to answer questions from the SP on mechanism of action and adverse effects. Students then attended a large-group debrief session. Following the activity, students evaluated the exercise through a voluntary survey. For knowledge assessment, students were randomized into two groups to complete three multiple-choice questions either before or after the learning activity. Results: In 2020 and 2021, 144 and 145 students, respectively, participated. In 2020, there was no significant difference in the proportion of correct answers between the pre- and postsimulation groups (p > .05). In 2021, the postsimulation group significantly outperformed the presimulation group in knowledge of mechanism of action (p < .01) and adverse effects (p < .01), but no difference was seen between the groups regarding medication selection (p = .27). Most learners assessed the instructional design as effective for the tasks assigned. Discussion: This SP activity provided an opportunity for early medical students to practice integrating antiviral pharmacology knowledge into a patient encounter and was well received by learners. The instructional method offers a clinically relevant approach for reinforcing pharmacology knowledge for preclinical medical students.

Early Pre-clerkship Clinical Skills Assessments Predict Clerkship Performance.

Introduction: Assessment of medical students' clinical skills (CS) remains a challenge. Little is known about early predictors of future CS performance. This study examines the relationship between students' pre-clerkship clinical skills (PCCS) performance and year 3 clerkship performance measures. Methods: The authors performed a retrospective analysis of four medical student cohorts who matriculated between 2014 and 2017 and participated in a longitudinal pre-clerkship CS curriculum. A total of 440 students were included in the analyses. Students' clinical skills were assessed through a series of PCCS exams, each consisting of a single standardized patient encounter. First-year PCCS exams assessed history taking, physical examination, professionalism, and communication skills; second-year PCCS exams also assessed clinical documentation and clinical reasoning skills. Evaluators assigned a grade of "satisfactory," "borderline," or "unsatisfactory" for each skill set. Regression analyses compared year 3 performance outcomes between students with one or more "unsatisfactory" or "borderline" PCCS skill set grades and students assessed as "satisfactory" for all PCCS skill set assessments. Results: Thirty-two percent (n = 140) of the 440 students had at least one borderline or unsatisfactory (US) PCCS skill set grade. These students performed significantly worse on year 3 National Board of Medical Examiner subject exams, workplace-based clinical performance evaluations, and overall year 3 performance compared to students who passed all PCCS exam components. In addition, a higher percentage of students with PCCS performance deficiencies failed the United States Medical Licensing Examination Step 2 CS exam on the first attempt versus students who passed all PCCS exam components. Conclusions: PCCS exam performance at our institution aligned with future student performance on multiple year 3 clerkship outcome measures. This pre-clerkship performance data can be used to identify at-risk students who would benefit from additional resources to achieve competency in the clerkship environment and future medical training. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01519-8.

Student, Faculty, and Coach Perspectives on Why Athletes Excel in Medical School: A Qualitative Analysis.

Phenomenon Medical schools are tasked with selecting applicants who will excel in a rigorous curriculum and successfully perform as future physicians. While many studies have assessed quantitative prematriculation data for predicting success in medical school, fewer studies have assessed for qualitative prematriculation factors influencing medical school performance. A recent study revealed that medical students with at least one year of varsity level college athletics participation outperformed their peers on United States Medical Licensing board exams and clinical clerkships. The current study sought to explore medical student, medical school faculty, and college coach perspectives about factors explaining why medical students with collegiate athletic experience succeed in medical school. Approach: In 2019, the authors conducted semi-structured interviews with medical students with collegiate athletic experience, medical school faculty with experience educating student athletes, and college coaches with experience training student athletes who matriculated into medical school. The interview transcripts were systematically coded and analyzed for themes using a grounded theory approach. Participants were recruited and interviewed until saturation of data was reached. Findings: Fifteen medical students with collegiate athletic experience, five medical school faculty, and three collegiate coaches participated in the study. Six themes were identified as important factors explaining the academic success of these students in medical school and each of these themes appeared in student, faculty, and coach interviews: goal setting, goal pursuit, and performance appraisal; development of time management, planning, and organizational skills; development of team values and teamwork skills; development of communication and interpersonal skills; acceptance of, coping strategies for, and resilient response to stress and adversity; and prioritization of personal wellness. Participants described meaningful connections between these attributes and skills, suggesting the students' development, transfer, and application of them is interrelated. Insights: In this study, academic success of medical students with collegiate athletic experience was attributed to specific skills and attributes developed during college. The grounded theory life skills transfer model can explain transfer of these attributes and skills from college to the medical school setting. Theoretical frameworks and empirical study findings from the sociology, educational psychology, sports psychology, and medical education literature provide helpful lenses for understanding why these skills and attributes confer success among student athletes in medical school. These findings offer important insights on skill development that may support the academic success of all medical students.

Simulation: an Innovative Approach to Engaging Preclinical Medical Students with Bioethics.

BACKGROUND: Integrating bioethical concepts into preclinical medical school curriculum and engaging early medical learners in bioethics are a challenge. ACTIVITY: A total of 140 medical students participated in a 2-h simulation activity consisting of a series of standardized patient (SP) encounters. RESULTS: A total of 41 of 140 students (29%) completed the learner evaluation survey. Ninety-one percent thought that the SP encounter was relevant to their role as a future physician. Ninety-three percent of students rated the exercise as highly effective. CONCLUSIONS: SP encounters enhance preclinical medical students' engagement with bioethics and provide learners practice applying these concepts to clinically relevant scenarios.

The Zombie Virus Pandemic: An Innovative Simulation Integrating Virology, Population Health, and Bioethics for Preclinical Medical Students.

Introduction: Understanding population health in the context of infectious disease outbreaks is an important physician competency. However, identifying effective ways to engage early medical students in this content remains a challenge. We designed an innovative pandemic simulation for first-year medical students utilizing the pop culture theme of zombies. Methods: This 2.5-hour simulation was conducted in 2018 and 2020 during students' virology course. Student teams collected and analyzed data to formulate hypotheses for the source pathogen. The teams completed reports explaining their diagnostic hypotheses, infection containment recommendations, and resource allocation recommendations. Learners completed an evaluation of the simulation through an online survey. Responses were analyzed using descriptive statistics; narrative responses were analyzed qualitatively for themes. A content analysis was performed on students' reports. Results: Two hundred eighty-four medical students participated in this activity. Nearly all respondents agreed that the small-group format (98%, 2018 and 2020) and pace and duration (92%, 2018; 94%, 2020) were appropriate and that the activity was intellectually stimulating (97%, 2018; 96%, 2020). Learner engagement measures were high (90%-97%, 2018; 83%-96%, 2020). Analysis of students' reports revealed evidence of cognitive integration of virology, population health, and bioethics concepts, including integration of new learning content. Discussion: Collaborative problem-solving during a simulated zombie-themed pandemic provided preclinical medical students with an engaging opportunity to integrate virology, population health, and bioethics concepts. Implementing this event required advanced planning, use of multiple spaces, learning materials preparation, and recruitment of several faculty, staff, and actors.

The Simulated Virology Clinic: A Standardized Patient Exercise for Preclinical Medical Students Supporting Basic and Clinical Science Integration.

Introduction: Virology is inherently challenging due to the sheer volume of information medical students are responsible for learning. Cognitive integration of this content is critical for early medical students to practice applying this knowledge to diagnostic problem-solving. Simulation offers learners engaging opportunities to practice cognitive integration. We developed a simulated clinic activity for first-year medical students consisting of standardized patient (SP) encounters representing viral infections. Methods: Student small groups rotated through eight SP encounters during which they collected patient histories, reviewed physical exam findings, and developed a differential diagnosis and diagnostic plan for each case. The instructor debriefed students on the cases afterward. We assessed students' evaluation of the activity through online surveys. Results: Two hundred seventy-eight students participated in the simulated clinic in 2018 and 2019. Students rated the activity as very effective for learning about the infections represented and for providing opportunities to integrate clinical skills. Students agreed that the event's instructional design was appropriate for its objectives and that the problem-solving aspect was intellectually stimulating. They indicated that the most effective aspects were solidifying illness scripts for the infections represented, integrating knowledge and skills to diagnose patients in a realistic clinical context, and working collaboratively to problem-solve. Discussion: The simulated virology clinic is an effective method for providing students opportunities to integrate microbiology and clinical skills and has been positively received by students. This instructional method offers learners an opportunity to solidify illness scripts for viral infections using an interactive, collaborative approach.

Medical Students' Clinical Reasoning During a Simulated Viral Pandemic: Evidence of Cognitive Integration and Insights on Novices' Approach to Diagnostic Reasoning.

INTRODUCTION: Cognitive integration from multiple disciplines is essential to clinical problem-solving. Because it is not directly observable, demonstrating evidence of learners' cognitive integration remains a challenge. In addition, little is known about preclinical medical students' approach to diagnostic reasoning despite widespread implementation of clinical reasoning curricula for these early learners. The objectives of this study were to characterize how first-year medical students integrated knowledge to problem-solve during a simulated viral pandemic and to characterize students' diagnostic reasoning approach to this clinical scenario. MATERIALS AND METHODS: Student teams analyzed clinical data to formulate hypotheses for the pandemic's source and submitted reports justifying their hypotheses and treatment recommendations. A content analysis on students' reports identified codes and themes characterizing the learning content integrated and students' approaches to diagnostic reasoning tasks. RESULTS: Sixteen problem-solving codes were identified, demonstrating integration of new and previously encountered content from multiple disciplines. A compare-contrast analytical approach was the most commonly employed diagnostic reasoning approach (100%), with a smaller subset of teams also using a causal approach (20%). DISCUSSION: Content analysis of preclinical students' diagnostic justification tasks provided insights into their approach to diagnostic reasoning, which was most consistent with the search-inference framework rather than a causal approach, likely due to limited pathophysiological knowledge at that point in training. CONCLUSIONS: Evidence of cognitive integration can be made explicit through learners' narrative justification of diagnostic reasoning tasks. Preclinical students' diagnostic reasoning development has implications for curricular design and implementation for this learner group.

Prematriculation Healthcare Employment Predicts Success in Clerkship Environment.

PURPOSE: The average age of the matriculating medical student is increasing as more students take time between college and medical school. Increasing numbers of students are employed in the healthcare field during these gap years. Studies have explored the relationship between matriculation age and medical school performance with conflicting findings. The impact of prior healthcare employment (PHE) on future clerkship performance has not been explored. We hypothesize that medical school performance metrics would be higher for students with PHE than their peers. METHODS: A retrospective review of four medical school classes at a single institution was conducted. Each student's admission application was examined to identify students with at least 6 months paid employment in a clinical healthcare position (i.e., pre-matriculation direct patient interaction, PHE cohort). Multiple medical school performance metrics were obtained for each student. RESULTS: Of the 434 included students, 49 were PHE (11.29%) and percent of students with PHE trended up over time. MCAT scores, USMLE Step 1, and Step 2 CK scores were not different for PHE and non-PHE medical students. PHE students had significantly higher NBME subject exams, clinical clerkship scores, and cumulative year 3 performance. CONCLUSIONS: Students who matriculate to medical school with prior healthcare employment outperform their peers in the clinical environment, possibly due to acquisition of knowledge or skills from their prior employment. These findings support students seeking paid healthcare experiences prior to medical school and have implications for pre-medicine advising, admissions, and medical school curricula.

Performing Under Pressure: Varsity Athletes Excel in Medical School.

PURPOSE: The admission process for medical school relies on objective and subjective measures of personal achievement, and selecting successful medical students is a daunting task for admission committees. While there is a significant body of literature examining MCAT scores and undergraduate grade point average (GPA) with medical school performance, there is a paucity of research on impact of specific student accomplishments on future performance. We hypothesize participation in a varsity collegiate sport will correlate with higher performance during medical school. METHODS: A retrospective review of four medical school classes at a single institution was completed. Each student's admission application was examined for at least 1 year of participation in a varsity-level sport at their respective undergraduate institution. A total of 62 athletes (16.36%) were identified out of 441 total students. Multiple medical school performance metrics were obtained for each student. RESULTS: There was no difference in MCAT scores between athletes and non-athlete medical students. There was a significant difference in step 1, step 2 CK, NBME shelf exams, cumulative year 3 performance, and AOA status with the athletes outperforming their peers. CONCLUSION: Students who participate in collegiate varsity athletics excel in medical school. One explanation for this finding may be participation in high-stakes athletic training and competition results in development of specific attributes beneficial in medical school. These attributes may include receptiveness to criticism, time management, resiliency, team participation, and performing under pressure. Additional research is needed to elucidate the attributes that determine improved medical school performance, such that medical educators can utilize this knowledge to better prepare all students for the rigors of medical school.

Is weight associated with severity of acute respiratory illness?

BACKGROUND/OBJECTIVES: Obesity was an independent risk factor for severe disease in hospitalized adults during the 2009 pandemic H1N1 influenza season. Few studies have investigated the association between weight and severity of acute respiratory illnesses in children or in adults seeking care in the emergency department (ED) during other winter respiratory seasons. SUBJECTS/METHODS: We prospectively and systematically enrolled patients ≥2 years of age who presented to the ED or inpatient setting in a single geographic region with fever/acute respiratory illness over four consecutive winter respiratory seasons (2010-2014). We collected demography, height and weight, and high risk co-morbid conditions. Multivariable logistic regression was used for prediction of hospital admission (primary outcome), length of stay and supplemental oxygen requirement among those hospitalized, and antibiotic prescription (secondary outcomes). RESULTS: We enrolled 3560 patients (N = 749 children, 2811 adults), 1405 (39%) with normal weight, 860 (24%) with overweight, and 1295 (36%) with obesity. Following multivariable logistic regression, very young or very old age (p < 0.001) and high-risk conditions (p < 0.001) predicted hospitalization. Risk of hospitalization was decreased for adults with overweight [aOR 0.8 (95% CI 0.6-1.0)], class 1 obesity [aOR 0.7 (95% CI 0.5-1.0)], and class 2 obesity [aOR 0.6 (95% CI 0.4-0.8)] compared to normal-weight. Class 3 obesity was associated with supplemental oxygen requirement in adults [aOR 1.6 (95% CI 1.1-2.5)]. No association was seen in children. CONCLUSION: Overweight and obesity were not associated with increased risk of hospitalization during winter respiratory seasons in children or adults.

Association of Prior Vaccination With Influenza Vaccine Effectiveness in Children Receiving Live Attenuated or Inactivated Vaccine.

Importance: Some studies have reported negative effects of prior-season influenza vaccination. Prior-season influenza vaccination effects on vaccine effectiveness (VE) in children are not well understood. Objective: To assess the association of prior-season influenza vaccination with subsequent VE in children aged 2 to 17 years. Design, Setting, and Participants: This multiseason, test-negative case-control study was conducted in outpatient clinics at 4 US sites among children aged 2 to 17 years with a medically attended febrile acute respiratory illness. Participants were recruited during the 2013-2014, 2014-2015, and 2015-2016 seasons when influenza circulated locally. Cases were children with influenza confirmed by reverse-transcription polymerase chain reaction. Test-negative control individuals were children with negative test results for influenza. Exposures: Vaccination history, including influenza vaccine type received in the enrollment season (live attenuated influenza vaccine [LAIV], inactivated influenza vaccine [IIV], or no vaccine) and season before enrollment (LAIV, IIV, or no vaccine), determined from medical records and immunization registries. Main Outcomes and Measures: LAIV and IIV effectiveness by influenza type and subtype (influenza A[H1N1]pdm09, influenza A[H3N2], or influenza B), estimated as 100 × (1 - odds ratio) in a logistic regression model with adjustment for potential confounders. Prior season vaccination associations were assessed with an interaction term. Results: Of 3369 children (1749 [52%] male; median age, 6.6 years [range, 2-17 years]) included in the analysis, 772 (23%) had a positive test result for influenza and 1674 (50%) were vaccinated in the enrollment season. Among LAIV recipients, VE against influenza A(H3N2) was higher among children vaccinated in both the enrollment and 1 prior season (50.3% [95% CI, 17.0% to 70.2%]) than among those without 1 prior season vaccination (-82.4% [95% CI, -267.5% to 9.5%], interaction P < .001). The effectiveness of LAIV against influenza A(H1N1)pdm09 was not associated with prior season vaccination among those with prior season vaccination (47.5% [95% CI, 11.4% to 68.9%]) and among those without prior season vaccination (7.8% [95% CI, -101.9% to 57.9%]) (interaction P = .37). Prior season vaccination was not associated with effectiveness of IIV against influenza A(H3N2) (38.7% [95% CI, 6.8% to 59.6%] among those with prior-season vaccination and 23.2% [95% CI, -38.3% to 57.4%] among those without prior-season vaccination, interaction P = .16) or with effectiveness of IIV against influenza A[H1N1]pdm09 (72.4% [95% CI, 56.0% to 82.7%] among those with prior season vaccination and 67.5% [95% CI, 32.1% to 84.4%] among those without prior season vaccination, interaction P = .93). Residual protection from prior season vaccination only (no vaccination in the enrollment season) was observed for influenza B (LAIV: 60.0% [95% CI, 36.8% to 74.7%]; IIV: 60.0% [36.9% to 74.6%]). Similar results were observed in analyses that included repeated vaccination in 2 and 3 prior seasons. Conclusions and Relevance: Influenza VE varied by influenza type and subtype and vaccine type, but prior-season vaccination was not associated with reduced VE. These findings support current recommendations for annual influenza vaccination of children.

2015-2016 Vaccine Effectiveness of Live Attenuated and Inactivated Influenza Vaccines in Children in the United States.

Background: In the 2015-2016 season, quadrivalent live attenuated influenza vaccine (LAIV) and both trivalent and quadrivalent inactivated influenza vaccine (IIV) were available in the United States. Methods: This study, conducted according to a test-negative case-control design, enrolled children aged 2-17 years presenting to outpatient settings with fever and respiratory symptoms for <5 days at 8 sites across the United States between 30 November 2015 and 15 April 2016. A nasal swab was obtained for reverse-transcriptase polymerase chain reaction (RT-PCR) testing for influenza, and influenza vaccination was verified in the medical record or vaccine registry. Influenza vaccine effectiveness (VE) was estimated using a logistic regression model. Results: Of 1012 children retained for analysis, most children (59%) were unvaccinated, 10% received LAIV, and 31% received IIV. Influenza A (predominantly antigenically similar to the A/California/7/2009 strain) was detected in 14% and influenza B (predominantly a B/Victoria lineage) in 10%. For all influenza, VE was 46% (95% confidence interval [CI], 7%-69%) for LAIV and 65% (48%-76%) for IIV. VE against influenza A(H1N1)pdm09 was 50% (95% CI, -2% to 75%) for LAIV and 71% (51%-82%) for IIV. The odds ratio for vaccine failure with RT-PCR-confirmed A(H1N1)pdm09 was 1.71 (95% CI, 0.78-3.73) in LAIV versus IIV recipients. Conclusions: LAIV and IIV demonstrated effectiveness against any influenza among children aged 2-17 years in 2015-2016. When compared to all unvaccinated children, VE against influenza A(H1N1)pdm09 was significant for IIV but not LAIV. Clinical Trials Registration: NCT01997450.

Effectiveness of live attenuated influenza vaccine and inactivated influenza vaccine in children during the 2014-2015 season.

BACKGROUND: A clinical study found that live attenuated influenza vaccine (LAIV) was superior to inactivated influenza vaccine (IIV) against drifted A(H3N2) viruses in children. During the 2014-2015 influenza season, widespread circulation of antigenically and genetically drifted A(H3N2) viruses provided an opportunity to evaluate subtype-specific vaccine effectiveness (VE) of quadrivalent LAIV (LAIV4) and IIV in children. METHODS: Children (2-17years) with febrile acute respiratory illness <5days' duration were enrolled at 4 outpatient sites in the United States during the 2014-2015 influenza season. Nasal swabs were tested for influenza by reverse transcription polymerase chain reaction; vaccination dates were obtained from medical records or immunization registries. VE was estimated using a test-negative design comparing odds of vaccination among influenza cases and test-negative controls with adjustment for potential confounders. RESULTS: Among 1696 children enrolled, 1511 (89%) were included in the analysis. Influenza was detected in 427 (28%) children; 317 had influenza A(H3N2) and 110 had influenza B. Most influenza isolates were characterized as a drifted strain of influenza A(H3N2) or a drifted strain of B/Yamagata. For LAIV4, adjusted VE was 50% (95% confidence interval [CI], 27-66%) against any influenza, 30% (95% CI, -6% to 54%) against influenza A(H3N2), and 87% (95% CI, 63-96%) against type B. For IIV, adjusted VE was 39% (95% CI, 18-54%) against any influenza, 40% (95% CI, 16-58%) against A(H3N2), and 29% (95% CI, -15% to 56%) against type B. Odds of influenza for LAIV4 versus IIV recipients were similar against influenza A(H3N2) (odds ratio [OR], 1.17; 95% CI, 0.73-1.86) and lower against influenza B (OR, 0.18; 95% CI, 0.06-0.55). CONCLUSIONS: LAIV4 and IIV provided similar protection against a new antigenic variant A(H3N2). LAIV4 provided significantly greater protection than IIV against a drifted influenza B strain. ClinicalTrials.gov identifier: NCT01997450.

Estimating the Burden of Pandemic Infectious Disease: The Case of the Second Wave of Pandemic Influenza H1N1 in Forsyth County, North Carolina.

BACKGROUND: Understanding the burden of influenza A(H1N1)pdm09 virus during the second wave of 2009-2010 is important for future pandemic planning. METHODS: Persons who presented to the emergency department (ED) or were hospitalized with fever and/or acute respiratory symptoms at the academic medical center in Forsyth County, North Carolina were prospectively enrolled and underwent nasal/throat swab testing for influenza A(H1N1)pdm09. Laboratory-confirmed cases of influenza A(H1N1)pdm09 virus identified through active surveillance were compared by capture-recapture analysis to those identified through independent, passive surveillance (physician-ordered influenza testing). This approach estimated the number of total cases, including those not captured by either surveillance method. A second analysis estimated the total number of influenza A(H1N1)pdm09 cases by multiplying weekly influenza percentages determined via active surveillance by weekly counts of influenza-associated discharge diagnoses from administrative data. Market share adjustments were used to estimate influenza A(H1N1)pdm09 virus ED visits or hospitalizations per 1,000 residents. RESULTS: Capture-recapture analysis estimated that 753 residents (95% confidence interval [CI], 424-2,735) with influenza A(H1N1)pdm09 virus were seen in the academic medical center from September 2009 through mid-April 2010; this result yielded an estimated 4.7 (95% CI, 2.6-16.9) influenza A(H1N1)pdm09 virus ED visits or hospitalizations per 1,000 residents. Similarly, 708 visits were estimated using weekly influenza percentages and influenza-associated discharge diagnoses, yielding an estimated 4.4 influenza A(H1N1)pdm09 virus ED visits or hospitalizations per 1,000 residents. CONCLUSION: This study demonstrates that the burden of influenza A(H1N1)pdm09 virus in ED and inpatient settings by capture-recapture analysis was 4-5 per 1,000 residents; this rate was approximately 8-fold higher than that detected by physician-ordered influenza testing.

Effectiveness of live attenuated influenza vaccine and inactivated influenza vaccine in children 2-17 years of age in 2013-2014 in the United States.

BACKGROUND: A postmarketing observational study was initiated to evaluate quadrivalent live attenuated influenza vaccine (LAIV) effectiveness in children aged 2-17 years in the United States. METHODS: Children and adolescents aged 2-17 years seeking outpatient care for febrile acute respiratory illness <5 days duration were enrolled at 4 geographically diverse sites during the 2013-2014 influenza season. Nasal swabs were tested for influenza using reverse transcription polymerase chain reaction. Vaccination status was documented from medical records or immunization registries. Children who received ≥1 dose of influenza vaccine ≥14 days before study visit were considered vaccinated. Vaccine effectiveness (VE) was estimated as 100×(1-adjusted odds ratio), where the odds of interest are the odds of vaccine exposure among influenza cases and test-negative controls. RESULTS: In total, 1033 children and adolescents were included in the analysis. Influenza was detected in 14% (145/1033) of all children, with 74% (108/145) of the influenza cases due to A/H1N1pdm09 strains, 21% (31) to influenza B, and 4% (6) to influenza H3N2. LAIV did not show significant effectiveness against A/H1N1pdm09 (VE 13% [95% CI: -55 to 51]) but was effective against B/Yamagata strains (82% [95% CI: 12-96]). Inactivated influenza vaccine was effective against A/H1N1pdm09 (74% [95% CI: 50-86]) and B/Yamagata (70% [95% CI: 18-89]). CONCLUSIONS: LAIV provided significant protection against B/Yamagata influenza but not against A/H1N1pdm09 in children aged 2-17 years in 2013-2014, resulting in a proposed change of the 2015-2016 formulation with a new and more heat-stable A/H1N1pdm09 LAIV strain.

Otopathogens Detected in Middle Ear Fluid Obtained during Tympanostomy Tube Insertion: Contrasting Purulent and Non-Purulent Effusions.

Otitis media is a prominent disease among children. Previous literature indicates that otitis media is a polymicrobial disease, with Haemophilus influenzae, Streptococcus pneumoniae, Alloiococcus otitidis and Moraxella catarrhalis being the most commonly associated bacterial pathogens. Recent literature suggests that introduction of pneumococcal conjugate vaccines has had an effect on the etiology of otitis media. Using a multiplex PCR procedure, we sought to investigate the presence of the aforementioned bacterial pathogens in middle ear fluid collected from children undergoing routine tympanostomy tube placement at Wake Forest Baptist Medical Center during the period between January 2011 and March 2014. In purulent effusions, one or more bacterial organisms were detected in ~90% of samples. Most often the presence of H. influenzae alone was detected in purulent effusions (32%; 10 of 31). In non-purulent effusions, the most prevalent organism detected was A. otitidis (26%; 63 of 245). Half of the non-purulent effusions had none of these otopathogens detected. In purulent and non-purulent effusions, the overall presence of S. pneumoniae was lower (19%; 6 of 31, and 4%; 9 of 245, respectively) than that of the other pathogens being identified. The ratio of the percentage of each otopathogen identified in purulent vs. non-purulent effusions was >1 for the classic otopathogens but not for A. otitidis.

Predictors of Influenza Diagnosis Among Patients With Laboratory-Confirmed Influenza.

OBJECTIVE: This study was performed to determine predictors of clinical influenza diagnosis among patients with laboratory-confirmed influenza. METHODS: Prospective, laboratory-confirmed surveillance for influenza was conducted among patients of all ages who were hospitalized or presented to the emergency department with fever and respiratory symptoms during 2009-2013. We evaluated all enrolled persons who had influenza confirmed by viral culture and/or polymerase chain reaction and received any discharge diagnosis. The primary outcome, clinical influenza diagnosis, was defined as (1) a discharge diagnosis of influenza, (2) a prescription of neuraminidase inhibitor, or (3) a rapid test positive for influenza virus. Bivariate analyses and multiple logistic regression modeling were performed. RESULTS: Influenza was diagnosed for 29% of 504 enrolled patients with laboratory-confirmed influenza and for 56% of 236 patients with high-risk conditions. Overall, clinical influenza diagnosis was predicted by race/ethnicity, insurance status, year, being hospitalized, having high-risk conditions, and receiving no diagnosis of bacterial infection. Being diagnosed with a bacterial infection reduced the odds of receiving an influenza diagnosis by >3-fold for all patients and for patients with high-risk conditions. CONCLUSIONS: Many influenza virus-positive patients, including those with high-risk conditions, do not receive a clinical diagnosis of influenza. The pattern of clinical diagnoses among influenza virus-positive patients suggests preferential consideration of bacterial diseases as a diagnosis.

Multi-scale modeling for the transmission of influenza and the evaluation of interventions toward it.

Mathematical modeling of influenza epidemic is important for analyzing the main cause of the epidemic and finding effective interventions towards it. The epidemic is a dynamic process. In this process, daily infections are caused by people's contacts, and the frequency of contacts can be mainly influenced by their cognition to the disease. The cognition is in turn influenced by daily illness attack rate, climate, and other environment factors. Few existing methods considered the dynamic process in their models. Therefore, their prediction results can hardly be explained by the mechanisms of epidemic spreading. In this paper, we developed a heterogeneous graph modeling approach (HGM) to describe the dynamic process of influenza virus transmission by taking advantage of our unique clinical data. We built social network of studied region and embedded an Agent-Based Model (ABM) in the HGM to describe the dynamic change of an epidemic. Our simulations have a good agreement with clinical data. Parameter sensitivity analysis showed that temperature influences the dynamic of epidemic significantly and system behavior analysis showed social network degree is a critical factor determining the size of an epidemic. Finally, multiple scenarios for vaccination and school closure strategies were simulated and their performance was analyzed.

Multicenter surveillance of Streptococcus pneumoniae isolates from middle ear and mastoid cultures in the 13-valent pneumococcal conjugate vaccine era.

BACKGROUND: Streptococcus pneumoniae is a common cause of otitis media (OM) in children; mastoiditis remains an important complication of OM. Limited data are available on the impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on pneumococcal otitis. METHODS: Investigators from 8 children's hospitals in the United States prospectively collected pneumococcal isolates from middle ear or mastoid cultures from children from 2011 to 2013. Serotype and antibiotic susceptibilities were determined and PCV13 doses for children documented. RESULTS: Over the 3-year period, the proportion of isolates included in PCV13 (plus a related serotype) decreased significantly (P = .0006) among the middle ear/mastoid isolates (2011, 50% [74/149]; 2012, 40.5% [47/116]; 2013, 29% [34/118]). The number of serotype 19A isolates in 2013 (n = 12, 10.2% of total) decreased 76% compared with the number of 19A isolates in 2011 (n = 50, 33.6% of total). Of the children from whom serotype 19A was isolated (n = 93), 55% had previously received <3 doses of PCV13. The most common non-PCV13 serotypes for the combined years were 35B (n = 37), 21 (n = 20), 23B (n = 20), 15B (n = 18), 11 (n = 17), 23A (n = 14), 15A (n = 14), and 15C (n = 14). The proportion of isolates with a penicillin minimal inhibitory concentration >2 µg/mL decreased significantly over the 3 years (2011, 22% [35/154]; 2012, 20% [24/118]; 2013, 10% [12/120]; P < .02). CONCLUSIONS: The number of pneumococcal isolates and the percentage of isolates with high-level penicillin resistance from cultures taken from children with OM or mastoiditis for clinical indications have decreased following PCV13 use, largely related to decreases in serotype 19A isolates.

Relative timing of influenza disease by age group.

A detailed understanding of influenza movement in communities during yearly epidemics is needed to inform improved influenza control programs. We sought to determine the relative timing of influenza presentation and symptom onset by age group and influenza strain. Prospective, laboratory-confirmed surveillance was performed over three moderate influenza seasons in emergency departments and inpatient settings of both medical centers in Winston-Salem, NC. Influenza disease presented first in school age children through community epidemics of influenza A(H1N1)pdm09 and influenza B, and first in persons 5-49 years old for influenza A(H3N2). This finding indicates that influenza prevention in persons 5-49 years of age may be particularly important in influenza epidemic control.