Fewer Days Of Fever Research Articles

Association of Recent and Long-Term Supplement Intakes With Laboratory Indices in Patients With COVID-19 in Tehran, Iran, During 2020.

BackgroundAlthough previous studies observed the relationship between individual dietary supplements and enhancing body resistance against viruses, few studies have been conducted regarding the role of different supplements in treatment of COVID-19. This article aims to determine the association of recent and long-term supplement consumption on the biochemical indices and impatient duration among patients with COVID-19.MethodsIn this cross-sectional study on 300 adult men and women with COVID-19, recent and long-term supplement intakes were investigated by using a questionnaire. In addition, lifestyle was also assessed in aspects of fruits and vegetable consumption, physical activity, sleeping duration, fluid intake, and smoking status. Furthermore, the laboratory and paraclinical parameters were obtained from medical records. The relationship between supplement intake with the length of hospitalization and clinical laboratory tests was investigated by one-way analysis of variance (ANOVA).ResultsThose patients with supplement intake in the last 2 months had a significantly lower amount of blood urea nitrogen (BUN) (31.31 ± 13.87 vs. 37.57 ± 19.77 mg/dL, P: 0.002) and higher serum 25(OH)D (28.13 ± 14.09 vs. 23.81 ± 13.55 ng/mL, P: 0.03). Subjects with long-term supplement intake had a significantly lower invasive oxygen support (0.00 vs 5.10 %, P: 0.05), lactate dehydrogenase (LDH) (498.11 ± 221.43 vs. 576.21 ± 239.84 U/L, P: 0.02), fewer days of fever (0.49 ± 3.54 vs. 2.64 ± 9.21, P: 0.02), and higher serum 25(OH)D (31.03 ± 13.20 vs. 22.29± 13.42 ng/mL, P < 0.001). The length of hospital stay was practically the same between groups who received and did not receive supplementation during the 2 months prior to hospitalization (6.36 ± 3.32 vs. 6.71 ± 4.33 days, P: 0.004). Similarly, people who took supplements during the past year had practically similar hospitalization lengths (6.29 ± 4.13 vs. 6.74 ± 3.55 days, P: 0.004).ConclusionIn conclusion, although practically the length of hospital stay was the same in both groups of supplement consumers and others, immune-boosting supplements were associated with improved several laboratory indices. However, due to the cross-sectional nature of our study, further longitudinal studies seem to be essential.

Multiple Emergency Department Visits for a Diagnosis of Kawasaki Disease: An Examination of Risk Factors and Outcomes

To determine predictors of >1 emergency department (ED) visit for a Kawasaki disease diagnosis in a quaternary care pediatric hospital and compare outcomes between patients with 1 vs>1 visit for Kawasaki disease diagnosis. Medical records of patients evaluated for Kawasaki disease between January 2006 and August 2018 at Boston Children's Hospital were abstracted for demographic and clinical data. Predictors of >1 visit were explored using logistic regression and classification and regression tree analysis. Of 530 patients diagnosed with Kawasaki disease, 117 (22%) required multiple ED visits for Kawasaki disease diagnosis. Multivariable regression and classification and regression tree analysis identified ≤2 Kawasaki disease criteria (OR 33.9; 95% CI 18.1-63.6), <3days of fever at the first visit (OR 3.47; 95% CI 1.77-6.84), and non-White race (OR 2.15; 95% CI 1.18-3.95) as predictors of >1 visit. There were no significant differences in duration of hospitalization, day of illness at initial Kawasaki disease treatment, intravenous immunoglobulin resistance, need for adjunctive therapies, or coronary artery outcomes between patients diagnosed with Kawasaki disease at initial visit vs subsequent visits. Incomplete Kawasaki disease criteria, fewer days of fever, and non-White race were significant predictors of multiple ED visits for Kawasaki disease diagnosis in this single institution study. Our findings underscore the importance of maintaining a high index of suspicion for Kawasaki disease in patients with <4 Kawasaki disease criteria. Further research is needed to determine causes for increased healthcare use in non-White patients to receive a Kawasaki disease diagnosis.

Increasing Rates of Pediatric Empyema and Disease Severity With Predominance of Serotype 3 S. pneumonia: An Australian Single-center, Retrospective Cohort 2011 to 2018.

The impact of universal 13-valent pneumococcal conjugate vaccine immunization on pediatric empyema rates and pathogens in Australia is not known. We aimed to describe empyema epidemiology, clinical characteristics and treatment during an 8-year period. A retrospective study between 2011 and 2018 of empyema cases admitted to a large pediatric referral hospital, for management with either pleural drainage and fibrinolytics or surgical intervention. There were 195 cases in 8 years. Empyema incidence and ICU admission rates significantly increased during the study with a peak incidence of 7.1/1000 medical admissions in 2016 (χ for trend of incidence 37.8, P < 0.001 and for ICU admissions 15.3, P < 0.001). S. pneumoniae was the most common pathogen (75/195, 39%) with serotype 3 the most detected (27/75: 27%). S. pyogenes compared with S. pneumoniae had significantly fewer days of fever before admission (3.9 vs. 6.4, mean difference 2.4, 95% CI: 0.84-4.08, P = 0.003) and higher proportion requiring direct ICU admission (6/75; 8% vs. 7/15; 47%, P < 0.001). Compared with S. pneumoniae, cases with no pathogen detected by culture or PCR had fewer days of fever post intervention (4.4 vs. 7.4 days, mean difference 2.7 days, P = 0.002). S. aureus occurred more commonly in infants (10/25; 40% vs. 1/75; 1%, P < 0.001) and children of indigenous background (5/25; 20% vs. 1/75; 1%, P < 0.001) compared with S. pneumoniae. We report increasing rates of pediatric empyema with higher proportions requiring ICU treatment. The most common pathogens detected were S. pneumoniae, S. aureus and S. pyogenes. Despite high 13-valent pneumococcal conjugate vaccine coverage, serotype 3 was the most common S. pneumoniae serotype identified.

Feasibility of feeding Aedes aegypti mosquitoes on dengue virus-infected human volunteers for vector competence studies in Iquitos, Peru.

BackgroundTransmission of dengue virus (DENV) from humans to mosquitoes represents a critical component of dengue epidemiology. Examinations of this process have generally been hampered by a lack of methods that adequately represent natural acquisition of DENV by mosquitoes from humans. In this study, we assessed artificial and natural blood feeding methods based on rates of DENV infection and dissemination within mosquitoes for use in a field-based epidemiological cohort study in Iquitos, Peru.Methodology/Principal findingsOur study was implemented, stepwise, between 2011 and 2015. Participants who were 5 years and older with 5 or fewer days of fever were enrolled from ongoing clinic- and neighborhood-based studies on dengue in Iquitos. Wild type, laboratory-reared Aedes aegypti were fed directly on febrile individuals or on blood collected from participants that was either untreated or treated with EDTA. Mosquitoes were tested after approximately 14 days of extrinsic incubation for DENV infection and dissemination. A total of 58 participants, with viremias ranging from 1.3 × 102 to 2.9 × 106 focus-forming units per mL of serum, participated in one or more feeding methods. DENV infection and dissemination rates were not significantly different following direct and indirect-EDTA feeding; however, they were significantly lower for mosquitoes that fed indirectly on blood with no additive. Relative to direct feeding, infection rates showed greater variation following indirect-EDTA than indirect-no additive feeding. Dissemination rates were similar across all feeding methods. No differences were detected in DENV infection or dissemination rates in mosquitoes fed directly on participants with different dengue illness severity.Conclusions/SignificanceOur study demonstrates the feasibility of using direct and indirect feeding methods for field-based studies on vector competence. Direct mosquito feeding is preferable in terms of logistical ease, biosecurity, and reliability.

Symptomatic Zika Virus Infection in Infants, Children, and Adolescents Living in Puerto Rico

Little information is available regarding Zika virus (ZIKV) infection in children. To describe patients younger than 18 years who were infected with ZIKV and were enrolled in the Sentinel Enhanced Dengue and Acute Febrile Illness Surveillance System (SEDSS). Children infected with ZIKV with 7 or fewer days of fever or emancipated minors aged 14 to 17 years with a generalized maculopapular rash, arthritis or arthralgia, or nonpurulent conjunctivitis were eligible for enrollment on or before December 31, 2016, in Puerto Rico. Patients were evaluated using ZIKV polymerase chain reaction testing at 7 or fewer days after the onset of symptoms. Available ZIKV polymerase chain reaction-positive specimens were evaluated to determine viral loads. Confirmed polymerase chain reaction-positive ZIKV infection. Clinical characteristics and viral loads of symptomatic children with confirmed ZIKV infection. Of 7191 children enrolled in SEDSS on or before December 31, 2016, only those with confirmed ZIKV infection (351 participants) were included in this study. Participants who had confirmed ZIKV infection included 25 infants (7.1%), 69 children (19.7%) aged 1 to 4 years, 95 (27.1%) aged 5 to 9 years, and 162 (46.1%) aged 10 to 17 years. Among these, 260 patients (74.1%) presented for evaluation of ZIKV infection at fewer than 3 days after the onset of symptoms, 340 (96.9%) were discharged to home after evaluation, and 349 (99.4%) had fever, 280 (79.8%) had a rash, 243 (69.2%) had facial or neck erythema, 234 (66.7%) had fatigue, 223 (63.5%) had headache, 212 (60.4%) had chills, 206 (58.7%) had pruritus, and 204 (58.1%) had conjunctival hyperemia. Of 480 specimens collected (317 serum and 163 urine specimens) from 349 children, the median number of days after the onset of symptoms was lower for children who had serum specimens (1 day [interquartile range (IQR), 1-2 days]) than for children who had urine specimens (2 [1-3] days) (P < .001). Of 131 children who had both serum and urine specimens collected on the same day, the median viral load was higher in serum than in urine (median [IQR], 23 098 [8784-88 242] copies/mL for serum vs 9966 [2815-52 774] copies/mL for urine; P = .02). When a single serum sample from each of 317 patients was analyzed, there were no statistically significant differences in median viral loads according to age, sex, or disposition. However, the median serum viral load varied significantly according to the number of days after the onset of symptoms (0 days, 106 778 [IQR, 9772-1 571 718] copies/mL; 1 day, 46 299 [10 663-255 030] copies/mL; 2 days, 20 678 [8763-42 458] copies/mL; and ≥3 days, 15 901 [5135-49 248] copies/mL; P = .001). This study represents the largest study to date of ZIKV infection in the pediatric population. Most children infected with ZIKV had fever, rash, and conjunctival hyperemia. The children usually presented for evaluation at fewer than 3 days after the onset of symptoms. Viral loads for ZIKV were higher in serum vs urine specimens. Median viral loads in serum specimens differed significantly according to the number of days after the onset of symptoms.

Biological roles of milk osteopontin

Osteopontin (OPN) is an extensively phosphorylated acidic glycoprotein that is present at high concentration in human milk. Bovine milk OPN has recently become commercially available, and can thus be added to infant formula as well as other food products. Studies in experimental animals as well as a clinical trial in human infants reveal important biological roles for milk OPN. Newborn wild-type mice nursing knock-out dams lacking milk OPN showed impaired cognitive development, reduced brain OPN and myelin-related proteins as compared with pups nursing wild-type dams. Transcriptomic analysis of intestinal biopsies from infant rhesus monkeys fed formula with added bovine milk OPN showed that OPN positively regulated intestinal proliferation, cell migration, and cellular chemotaxis via binding to integrin receptors. A clinical trial on human infants fed formula with added bovine milk OPN showed significantly reduced levels of serum tumor necrosis factor a and fewer days of fever as compared with infants fed regular formula. Further, their immune cell profile was more similar to that of breast-fed infants. Milk OPN affects immune functions, and intestinal development in the newborn as well as brain development in a mouse model. Addition of bovine milk OPN to infant formula may improve the performance of formula-fed infants and make them more similar to breast-fed infants. Due to its multiple functions, milk OPN is also used for various adult applications.

NS1: An early Diagnostic Tool for Dengue Virus Fever

Dengue virus is a highly prevailing unremitting pathological menace in the developing countries like Pakistan. The variation in the type and frequency of dengue infection demands a continuous surveillance on its spread and diagnosis, in order to develop appropriate management and therapeutic strategies. Dengue Virus is highly complex disease with various manifestations. It is hard to characterize the dengue viral infection with ordinary laboratory tests. However, NS1 could serve a good diagnostic tool in the first few days of fever. In this research, 88 patients from Lahore regions of Punjab were analysed for the presence of dengue specific NS1 antigen from 1 to 30 days of dengue fever. ELISA based kit was employed. The obtained data was analysed expressed percentage frequency of NS1 positive and negative along with IgM positive and negative in all dengue fever patients. Importantly it was observed that 36.3 % were infected by dengue. NS1 antigen was efficiently quantified at earlier days of infection. IgM was negative in all the subjects who were positive for NS1 on the second day of fever. However, this association weakened with the progression of fever. It was analysed that thrombocytopenia and leuckocytopenia are not linked with the NS1 positivity and these states were random. It can be inferred that dengue diagnosis is very complicated and the antigenic profile dramatically changes with the progression of fever in terms of days. Clinicians should employ a diagnostic method based on a comprehensive analysis of subjects in order to minimize

Community-acquired lobar pneumonia encountered at autopsy

A 72-year-old woman 12 years status-post partial mastectomy, adjuvant radiation, and five years of anastrozole for stage I estrogen receptor/progesterone receptor positive breast adenocarcinoma presented with neck pain. MRI showed extensive metastatic disease involving the skull and the vertebral bodies of the cervical and thoracic spine. She was started on dexamethasone. Bone scan revealed multiple sites of disease, including the ribs, spine, and pelvis. Four weeks following initiation of radiation to the cervical spine for palliation of neurologic symptoms, the patient exhibited a few days of fever at home, without respiratory distress, and died in her sleep. The patient did not have any documented pneumococcal vaccination. At autopsy, dense lobar consolidation with red hepatization was found in the entire lower lobe of the left lung (Fig. 1). On microscopic examination, the alveolar spaces were completely filled with fibrin and scattered neutrophilic leukocytes (Fig. 2). Gram stain revealed multiple lancet-shaped Gram positive diplococci in pairs, consistent with Streptococcus pneumoniae (Fig. 3). Additionally, several bones contained metastatic ER positive adenocarcinoma (not shown). The cause of death was typical community-acquired lobar pneumonia with respiratory failure in the setting of widely metastatic breast cancer. In the era of modern antimicrobials and polyvalent vaccination, S. pneumoniae accounts for approximately 10–15% of cases of community-acquired pneumonia, and is attended by a 10–12% 30-day mortality rate.

Yogurt and health

The medical and lay literature is replete with studies of probiotics and their potential effects on health. Indeed, there are so many studies of this topic that journals such as ours need to be rather selective in choosing them. The current issue of The Journal contains a rather unique study of this topic, with intriguing results. Ringel-Kulka et al report a study of healthy children in a day care center who received a daily dose of a probiotic-containing yogurt product or an unsupplemented acidified milk placebo drink. The probiotic product also contained inulin as a “synbiotic.” During the four months of the trial, a variety of health and wellness measures were assessed. The children receiving the supplement had fewer days of fever and better school and social functioning, as assessed by a validated instrument. The supplemented children had a tendency toward looser stools, possibly a function of the inulin included in the product. Although the magnitude of these effects was quite modest, (if confirmed in a larger trial) they could be important because of the sheer numbers of children in day care. Thus, even though this study should not become the basis for a recommendation, it can certainly inform further investigations of the topic. Article page 1475▶ Randomized, Double-Blind, Placebo-Controlled Study of Synbiotic Yogurt Effect on the Health of ChildrenThe Journal of PediatricsVol. 166Issue 6PreviewTo assess the effects of daily consumption of a synbiotic yogurt drink on the health, growth, and quality of life of healthy children 12-48 months of age in out-of-home child care. Full-Text PDF

Management of Kawasaki disease in resource-limited settings.

Management of Kawasaki disease in resource-limited settings.

Utility of TNF-α as a Biomarker and the Possibility of anti-TNF-α Therapy for Kawasaki Diseases

Kawasaki disease (KD) is the most common systemic vasculitis syndrome, primarily affecting the coronary arteries. Timely treatment with high-dose intravenous immunoglobulin (IVIG) reduces the duration of fever and incidence of Coronary Artery Lesions (CAL). However, even after IVIG treatment ∼5%-7% of patients develop aneurysms. TNF-α is a cytokine with multiple biological effects produced primarily by monocytes and macrophages. In the last decade, TNF-α has been the focus of research aimed at uncovering its role during the acute phase of KD. Previous studies reported that TNF-α is responsible for the increase in its soluble receptors and is involved in the pathogenesis of the clinical features and CAL in KD. Anti-TNF-α therapies, such as infliximab or etanercept, seem to be effective in controlling inflammation in patients with KD who fail to respond to IVIG. Several trials of the usage of infliximab as the first, second, or third line therapy for KD since 2004 showed that infliximab was safe and well tolerated, and patients treated with infliximab had fewer days of fever. Etanercept was recently shown to be safe and well tolerated as adjunctive initial therapy with IVIG in a small study of children with KD.

Acute Disseminated Encephalomyelitis Following Pneumococcal Meningitis Infection

Introduction: Acute disseminated encephalomyelitis (ADEM) is an acute inflammatory and demyelinating disease of the central nervous system, resulting in various neurological symptoms. Usually, the disease appears following vaccination or systemic viral infections. In rare cases, the disease appears following pneumococcal infections. Case Presentation: The patient was a 27 year-old man who was referred to the clinic following a few days of fever and cold with consciousness deficit and right hemiplegia. Based on the analysis of cerebrospinal fluid (CSF) and diagnosis of pneumococcal meningitis, he received suitable antibiotic treatment. Despite complete return of consciousness, good general condition, and negative smear and culture of CSF, fever continued and no considerable improvement was observed in the hemiplegia. Therefore, brain magnetic resonance imaging (MRI) was performed and according to the findings, treatment was started with the diagnosis of acute disseminated encephalomyelitis. Treatment with prednisolone at first obviated the fever and after a month brought about a complete hemiplegia cure. Following the status of the patient after three months, his MRI clearly showed considerable reduction in lesions. Discussion: There is possible occurrence of ADEM following pneumococcal meningitis. Regarding the occurrence of neurological symptoms such as visual disturbance, hemiparesis or hemiplegia following bacterial meningitis, ADEM can be considered as one of the differential diagnoses to be accompanied by MRI. Acute disseminated encephalomyelitis should be treated using suitable dose of corticosteroids.

Commentary

Commentary

Impact of Home Environment Interventions on the Risk of Influenza-Associated ARI in Andean Children: Observations from a Prospective Household-Based Cohort Study

BackgroundThe Respiratory Infections in Andean Peruvian Children (RESPIRA-PERU) study enrolled children who participated in a community-cluster randomized trial of improved stoves, solar water disinfection, and kitchen sinks (IHIP trial) and children from additional Andean households. We quantified the burden of influenza-associated acute respiratory illness (ARI) in this household-based cohort.MethodsFrom May 2009 to September 2011, we conducted active weekly ARI surveillance in 892 children age <3 years, of whom 272 (30.5%) had participated in the IHIP trial. We collected nasal swabs during ARI, tested for influenza and other respiratory viruses by RT-PCR, and determined influenza incidence and risk factors using mixed-effects regression models.ResultsThe overall incidence of influenza-associated ARI was 36.6/100 child-years; incidence of influenza A, B, and C was 20.5, 8.7, and 5.2/100 child-years, respectively. Influenza C was associated with fewer days of subjective fever (median 1 vs. 2) and malaise (median 0 vs. 2) compared to influenza A. Non-influenza ARI also resulted in fewer days of fever and malaise, and fewer healthcare visits than influenza A-associated ARI. Influenza incidence varied by calendar year (80% occurred in the 2010 season) and IHIP trial participation. Among households that participated in the IHIP trial, influenza-associated ARI incidence was significantly lower in intervention than in control households (RR 0.40, 95% CI: 0.20–0.82).ConclusionsInfluenza burden is high among Andean children. ARI associated with influenza A and B had longer symptom duration and higher healthcare utilization than influenza C-associated ARI or non-influenza ARI. Environmental community interventions may reduce influenza morbidity.

Infliximab for intensification of primary therapy for Kawasaki disease: a phase 3 randomised, double-blind, placebo-controlled trial

Kawasaki disease, the most common cause of acquired heart disease in developed countries, is a self-limited vasculitis that is treated with high doses of intravenous immunoglobulin. Resistance to intravenous immunoglobulin in Kawasaki disease increases the risk of coronary artery aneurysms. We assessed whether the addition of infliximab to standard therapy (intravenous immunoglobulin and aspirin) in acute Kawasaki disease reduces the rate of treatment resistance. We undertook a phase 3, randomised, double-blind, placebo-controlled trial in two children's hospitals in the USA to assess the addition of infliximab (5 mg per kg) to standard therapy. Eligible participants were children aged 4 weeks-17 years who had a fever (temperature ≥38·0°C) for 3-10 days and met American Heart Association criteria for Kawasaki disease. Participants were randomly allocated in 1:1 ratio to two treatment groups: infliximab 5 mg/kg at 1 mg/mL intravenously over 2 h or placebo (normal saline 5 mL/kg, administered intravenously). Randomisation was based on a randomly permuted block design (block sizes 2 and 4), stratified by age, sex, and centre. Patients, treating physicians and staff, study team members, and echocardiographers were all masked to treament assignment. The primary outcome was the difference between the groups in treatment resistance defined as a temperature of 38·0°C or higher at 36 h to 7 days after completion of the infusion of intravenous immunoglobulin. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00760435. 196 patients were enrolled and randomised: 98 to the infliximab group and 98 to placebo. One patient in the placebo group was withdrawn from the study because of hypotension before receiving treatment. Treatment resistance rate did not differ significantly (11 [11·2%] for infliximab and 11 [11·3%] for placebo; p=0·81). Compared with the placebo group, participants given infliximab had fewer days of fever (median 1 day for infliximab vs 2 days for placebo; p<0·0001). At week 2, infliximab-treated patients had greater mean reductions in erythrocyte sedimentation rate (p=0·009) and a two-fold greater decrease in Z score of the left anterior descending artery (p=0·045) than did those in the placebo group, but this difference was not significant at week 5. Participants in the infliximab group had a greater mean reduction in C-reactive protein concentration (p=0·0003) and in absolute neutrophil count (p=0·024) at 24 h after treatment than did those given placebo, but by week 2 this difference was not significant. At week 5, none of the laboratory values differed significantly compared with baseline. No significant differences were recorded between the two groups at any timepoint in proximal right coronary artery Z scores, age-adjusted haemoglobin values, duration of hospital stay, or any other laboratory markers of inflammation measured. No reactions to intravenous immunoglobulin infusion occurred in patients treated with infliximab compared with 13 (13·4%) patients given placebo (p<0·0001). No serious adverse events were directly attributable to infliximab infusion. The addition of infliximab to primary treatment in acute Kawasaki disease did not reduce treatment resistance. However, it was safe and well tolerated and reduced fever duration, some markers of inflammation, left anterior descending coronary artery Z score, and intravenous immunoglobulin reaction rates. US Food and Drug Administration, Robert Wood Johnson Foundation, and Janssen Biotech.

An Unwelcome Synergy: Leishmaniasis and HIV

m PRESENTATION When patients with HIV/AIDS travel to the United States from other parts of the world, they can bring more exotic opportunistic infections with them. In November 2010, a 29-year-old man presented to the emergency department after a few days of fever, chills, diffuse abdominal pain, vomiting, and dysuria. For the previous 6 months, he also had experienced diarrhea and unintentional weight loss, totaling 40 lb (18 kg). Two weeks prior to his acute presentation, he had been treated for pyelonephritis at an outside institution, where he also had reported 2-3 weeks of worsening diarrhea. The patient had been diagnosed with HIV/AIDS in 2007. At the time of diagnosis, he was treated for cerebral toxoplasmosis with pyrimethamine, sulfadiazine, and leucovorin. In 2008, he was treated with intraocular ganciclovir for cytomegalovirus retinitis. Since his diagnosis, he had been intermittently adherent to antiretroviral therapy with Atripla, (Bristol-Myers Squibb, New York, NY), a combination of efavirenz, emtricitabine, and tenofovir disoproxil fumarate and to his maintenance therapy for the aforementioned opportunistic infections. He also had a history of pancytopenia, diagnosed in 2008; a bone marrow biopsy was hypocellular with poorly-formed noncaseating granulomas. His attendance at follow-up visits was erratic, preventing further workup. Born in Honduras, the patient worked on a farm, and moved to the United States in 2004, where has worked in construction. He had had a single male sexual contact and multiple female sexual partners. Condom use was inconsistent.

Presenting Signs and Symptoms of Rapidly Progressing Severe Pneumonia in the Pediatric Emergency Department

Background: Children with pneumonia are often diagnosed in the emergency department based on clinical and/or radiographic findings. Many of these patients can be treated as outpatients. However, patients with severe pneumonia often require Intensive Care Unit (ICU) admission and have significant morbidity. There is no published data to aide in rapid identification of children with severe pneumonia who require ICU admission. Objectives: To identify clinical variables, laboratory and radiographic data that may predict the need for ICU admission. Methods: Retrospective analysis of ED patients aged 0 to 18 years, admitted to a tertiary pediatric hospital with a diagnosis of severe pneumonia between 2002 and 2007 was performed. Severe pneumonia was defined as: empyema and/or pleural effusion. Patients were assigned into two cohorts: 1) admitted to the ICU and 2) admitted to general inpatient unit. Patients with significant past medical history were excluded. Demographic information, signs, symptoms, laboratory, and radiographic data were collected and compared. The Student t-test was used to compare the means for continuous variables and Chi Square for categorical variables. Results: Patients admitted to ICU (n=113) had similar symptoms compared with the non ICU admission group (n=180), however the ICU cohort presented with a more acute onset of illness with significantly fewer days of fever and cough prior to presentation. They were also significantly more tachypenic and tachycardic on presentation. Laboratory analysis found the ICU patients had significantly greater bandemia with mean band count of 20.4 (95% CI 17.0, 23.8) compared to 11.8, (95% CI 9.8, 13.7). The general inpatient pneumonia patients had significantly higher mean platelet counts at 389 (95% CI 364,414) versus the ICU patients at 304 (95% CI 276, 332) as well as ESR values at 79 (95% CI 73, 85) versus the ICU patients at 58 (95% CI 49, 67). Conclusions: This data suggest that children with severe pneumonia with rapid illness onset and bandemia are at higher risk for ICU admission. More insidious onset, elevated platelet counts and ESR may predict a more stable course of illness. Continued analysis of these variables may be helpful in constructing a diagnostic algorithm for pediatric pneumonia patients at presentation, facilitating earlier detection, treatment, and appropriate in-patient disposition.

Effects of challenge with a virulent genotype II strain of porcine reproductive and respiratory syndrome virus on piglets vaccinated with an attenuated genotype I strain vaccine

Porcine reproductive and respiratory syndrome virus (PRRSV) is endemic in most parts of Asia, where genotype I and II strains of diverse virulence may coexist. This study evaluated the outcome of infection with a highly virulent Asian genotype II PRRSV isolate in piglets vaccinated with a genotype I vaccine. Twenty-one 3-week-old piglets were divided in three groups: Pigs in group V (n=8) were vaccinated with an attenuated genotype I commercial PRRSV vaccine, while pigs in group U (n=8) and a control group (group C; n=5) were unvaccinated; 6 weeks later, pigs in groups V and U were challenged intranasally with a highly virulent strain of genotype II PRRSV (1×10(5) 50% tissue culture infectious doses/mL), while pigs in group C received a placebo. Over a period of 21 days after challenge, vaccinated pigs had significantly lower mortality (0/8 versus 2/8), fewer days of fever, a lower frequency of catarrhal bronchopneumonia, higher weight gains (13.4 versus 6.6 kg) and lower levels of viraemia compared to unvaccinated challenged pigs. Immunisation with a genotype I attenuated PRRSV vaccine provided partial protection against challenge with a highly virulent genotype II strain.

Infliximab for Intravenous Immunoglobulin Resistance in Kawasaki Disease: A Retrospective Study

To test the hypothesis that first re-treatment with infliximab, compared with intravenous immunoglobulin (IVIG), might improve outcomes in IVIG-resistant Kawasaki disease. In a two-center retrospective review from January 2000 to March 2008, we compared duration of fever and coronary artery dimensions in patients with IVIG-resistance whose first re-treatment was with IVIG compared with infliximab given for fever ≥38.0°C beyond 36 hours after first IVIG completion. Patients in the IVIG group (n = 86, 2 g/kg) and infliximab group (n = 20, 5 mg/kg) were similar in demographics, days of fever at diagnosis, and baseline coronary artery dimensions. Patients had similar coronary dimensions 6 weeks after diagnosis, both in univariate and multivariate analysis. The infliximab group had fewer days of fever (median 8 days versus10 days, P = .028), and in a multivariate analysis, the infliximab group had 1.2 fewer days of fever (P = .033). Patients who received infliximab had shorter lengths of hospitalization (median 5.5 days versus 6 days, P = .040). Treatment groups did not differ significantly in adverse events (0% versus 2.3%, P = 1.0). In our retrospective study, patients with IVIG-resistant Kawasaki disease whose first re-treatment was with infliximab, compared with IVIG, had faster resolution of fever and fewer days of hospitalization. Coronary artery outcomes and adverse events were similar; the power of the study was limited.

Pyogenic Liver Abscess in the Elderly

We analyzed the characteristics of elderly patients with pyogenic liver abscess, including clinical features, laboratory analyses and outcomes. A retrospective review of patient records from January 1, 2007 to June 30, 2008, identified 140 cases of liver abscess hospitalized in a medical center in northern Taiwan. Patients transferred from other hospitals, or those who had amoebic, fungal, traumatic or iatrogenic LA were excluded, and 122 cases were enrolled. We divided patients into two groups: an elderly group aged ≥ 65 years, and a non-elderly group. We collected information on clinical manifestations, laboratory data, imaging, blood and pus culture, and surgical findings for statistical analyses. We compared the elderly and the non-elderly with pyogenic liver abscess with respect to diabetes history ( p = 0.03), presence of fever ( p = 0.19), days of fever before hospital visit ( p = 0.001), abdominal pain ( p = 0.08), diarrhea ( p = 0.36), shock ( p = 0.25), white blood cell count ( p = 0.70), serum glucose ( p = 0.49), aspartate aminotransferase ( p = 0.95), length of hospital stay ( p = 0.10), and mortality ( p = 0.12). Most positive results in cultures were for Klebsiella pneumoniae , and the positive rates in culture of blood and pus were 43% and 60%, respectively. We found that there was no significant statistical difference between elderly and non-elderly pyogenic liver abscess patients in the presence of fever, abdominal pain, diarrhea, shock, white blood cell count, serum glucose, aspartate aminotransferase, hospital stay, and mortality. The elderly pyogenic liver abscess patients had fewer days of fever before hospital visit (2.2 ± 2.2 vs. 6.3 ± 6.9; p = 0.001). The elderly were taken to hospital earlier, because their families were more concerned about their constitutional symptoms. More cases of diabetes in the elderly pyogenic liver abscess group (44.7% vs. 39.3%) may arise because of more diabetes in the elderly population.