Severe Lower Respiratory Tract Research Articles

Validation of a Classification Model Using Complete Blood Count to Predict Severe Human Adenovirus Lower Respiratory Tract Infections in Pediatric Cases.

BackgroundHuman adenovirus (HAdV) lower respiratory tract infections (LRTIs) are prone to severe cases and even cause death in children. Here, we aimed to develop a classification model to predict severity in pediatric patients with HAdV LRTIs using complete blood count (CBC).MethodsThe CBC parameters from pediatric patients with a diagnosis of HAdV LRTIs from 2013 to 2019 were collected during the disease’s course. The data were analyzed as potential predictors for severe cases and were selected using a random forest model.ResultsWe enrolled 1,652 CBC specimens from 1,069 pediatric patients with HAdV LRTIs in the present study. Four hundred and seventy-four patients from 2017 to 2019 were used as the discovery cohort, and 470 patients from 2013 to 2016 were used as the validation cohort. The monocyte ratio (MONO%) was the most obvious difference between the mild and severe groups at onset, and could be used as a marker for the early accurate prediction of the severity [area under the subject operating characteristic curve (AUROC): 0.843]. Four risk factors [MONO%, hematocrit (HCT), red blood cell count (RBC), and platelet count (PLT)] were derived to construct a classification model of severe and mild cases using a random forest model (AUROC: 0.931 vs. 0.903).ConclusionMonocyte ratio can be used as an individual predictor of severe cases in the early stages of HAdV LRTIs. The four risk factors model is a simple and accurate risk assessment tool that can predict severe cases in the early stages of HAdV LRTIs.

Healthcare Resource Utilization and Healthcare Costs of COVID-19 Patients in A Tertiary Care Public Hospital: A Retrospective Cohort Study in Thailand

Objective: Health care costs (HCCs) are a significant concern in developing countries. The authors investigated the healthcare resource utilization (HCRU) and HCCs for patients with COVID-19 based on disease severity and infection site. Materials and Methods: The authors reviewed data from the electronic medical records of COVID-19 patients admitted to the present study hospital between January 2020 and April 2020. The authors used comorbidities and patient characteristics as covariates. Analyses were conducted using simple linear regression and generalized linear regression models with a log-link and gamma distribution. Results: Two hundred two patients had confirmed SARS-CoV-2 infection. Total costs per patient were 6,626 USD (756 to 45,586). Personal protection equipment costs were the most significant cost for COVID-19 patients with a mean of 3,778 USD. The mean treatment cost per patient was 326 USD. Patients with severe symptoms and lower respiratory tract infection (LRI) had a higher cost and resource utilization value before and after adjusting for covariates. Conclusion: COVID-19 patients with severe symptoms and LRI had higher HCRU. Length of stay, severity of symptoms, and LRI were associated with higher cost of treatment. Keywords: SARS-CoV-2; COVID-19; Healthcare resource utilization; Healthcare costs; Thailand

The Importance of Vaccinating Children and Pregnant Women against Influenza Virus Infection.

Influenza virus infection is responsible for significant morbidity and mortality in the pediatric and pregnant women populations, with deaths frequently caused by severe influenza-associated lower respiratory tract infection and acute respiratory distress syndrome (ARDS). An appropriate immune response requires controlling the viral infection through activation of antiviral defenses, which involves cells of the lung and immune system. High levels of viral infection or high levels of inflammation in the lower airways can contribute to ARDS. Pregnant women and young children, especially those born prematurely, may develop serious complications if infected with influenza virus. Vaccination against influenza virus will lead to lower infection rates and fewer complications, even if the vaccine is poorly matched to circulating viral strains. Maternal vaccination offers infants protection via antibody transmission through the placenta and breast milk. Despite the health benefits of the influenza vaccine, vaccination rates around the world remain well below targets. Trust in the use of vaccines among the public must be restored in order to increase vaccination rates and decrease the public health burden of influenza.

Approach for Optimizing Meropenem Therapy in Intubated and Mechanically-Ventilated, Adult Patients With Severe Gram-Negative Lower Respiratory Tract Infection

Approach for Optimizing Meropenem Therapy in Intubated and Mechanically-Ventilated, Adult Patients With Severe Gram-Negative Lower Respiratory Tract Infection

OLIGOGENIC HETEROZYGOUS MUTATIONS MANIFESTING AS COMBINED PRIMARY IMMUNODEFICIENCY

Introduction Combined immunodeficiencies involving T and B lymphocytes have historically thought to be results of monogenic homozygous mutations. Our case illustrates a pediatric patient with oligogenic heterozygous mutations with phenotypical manifestations of combined humoral immunodeficiency. Case Description The patient is a 12-year-old Amish male who had severe recurrent lower respiratory tract infections during his first three years of life. During this time he was admitted to the hospital for respiratory infections on four occasions due to viral and bacterial etiologies, three of which required intubation for respiratory failure. The immunological evaluation revealed a persistent CD3+ T cell lymphopenia as well as a non-responsiveness to polysaccharide and conjugate pneumococcal vaccination. Over the subsequent years, he developed CD19+ B cell lymphopenia. Intravenous immunoglobulin replacement and trimethoprim/sulfamethoxazole prophylaxis were initiated which resolved all severe respiratory infections. Recently genetic testing was performed revealing heterozygous variants of three genes involved in immunodeficiency including purine nucleoside phosphorylase (PNP), IL17RA, and CARD9. Discussion Previously, combined immunodeficiency was thought to be monogenic in origin. This case represents the identification of suspected oligogenic heterozygous gene mutation variants believed to be the source of his combined immunodeficiency. With the advancement and affordable genetic evaluation, previously underestimated gene variants and mutations may play a significant role in the understanding of the etiologies of immunodeficiencies as illustrated by this case.

Offering general pediatric care during the hard times of the 2014 Ebola outbreak: looking back at how many came and how well they fared at a M\xe9decins Sans Fronti\xe8res referral hospital in rural Sierra Leone

BackgroundIn Bo district, rural Sierra Leone, we assessed the burden of the 2014 Ebola outbreak on under-five consultations at a primary health center and the quality of care for under-15 children at a Médecins Sans Frontières (MSF) referral hospital.MethodsRetrospective cohort study, comparing a period before (May-October 2013) and during the same period of the Ebola outbreak (2014). Health worker infections occurred at the outbreak peak (October 2014), resulting in hospital closure due to fear of occupational-risk of contracting Ebola. Standardized hospital exit outcomes and case fatality were used to assess quality of care until closure.ResultsA total of 13,658 children under-five, were seen at the primary health center during 2013 compared to 8761 in 2014; a consultation decline of 36%. Of 6497 children seen in the hospital emergency room, during the outbreak, patients coming from within hospital catchment area declined with 38% and there were significantly more self-referrals (80% vs. 61%, P < 0.001). During Ebola, 23 children were dead on arrival and the proportion of children in severe clinical status (requiring urgent attention) was higher (74% during Ebola vs. 65% before, P < 0.001). Of 5,223 children with available hospital outcomes, unfavorable outcomes (combination of deaths and abandoned) were less than 15% during both periods, which is within the maximum acceptable in-house threshold set by MSF. Case fatality for severe malaria and lower respiratory tract infections (n = 3752) were similar (≤15%).ConclusionsValuable and good quality pediatric care was being provided in the pediatric hospital during the 2014 Ebola outbreak, but could not be sustained because of hospital closure. Health facility and health worker safety should be tackled as a universal requirement to try to avoid a déjà-vu.

Relation between pulse oximetry and clinical score in infants with acute bronchiolitis

Background: Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs. It is the most common severe viral lower respiratory tract infection of infancy. Clinical diagnosis remains the most important tool for diagnosis. Clinical diagnosis would be supplemented by pulse oximetry but pulse oximetry may not be always available. Aims & Objective: To study Relation between SPO2 (oxygen saturation) and clinical score in children with acute bronchiolitis patients less than 12 months of age. Materials and Methods: This was the cross sectional observational study done in paediatric department of Jhalawar medical college, Jhalawar. One hundred and forty two infants were evaluated by the single paediatrician. Modified Tal’s clinical score and SPO2 of the patient were recorded. Bonferroni analysis was used using Graph pad 5 prism software for statistical analysis. Results: The mean (± SD) SpO2 value was 98.2 ± 1.3% for children with clinical scores of 2–5 (n = 32); 95.2 ± 0.9% for those with scores of 6–7 (n = 84), and 92.3 ± 0.87% for children with scores of 8–10 (n = 26), (P < 0.001 by Bonferroni’s multiple comparison, when all two-way comparisons were done for each pair of results). The clinical score showed a good correlation with SpO2 [ r =−0.734(P < 0.0001)]. Conclusion: We conclude that Modified Tal’s clinical score can be used as a primary tool to confirm severity of hypoxemia in infants with acute bronchiolitis even if pulse oximetry is not available.

Should respiratory care in preterm infants include prophylaxis against respiratory syncytial virus infection? The case in favour

Respiratory syncytial virus (RSV) is the most significant cause of acute respiratory tract infections (RTI) in infants and young children throughout the world. Preterm infants are at increased risk for severe RSV lower respiratory tract infection due to small lung volumes, a reduced lung surface area, small airways and an increased air space wall thickness. Additionally, the airways of preterm infants have been ventilated mechanically and suctioned and potentially damaged by many microtraumas with disruption of endothelial surfaces enabling pathogens to invade more easily. The immune system of preterm infants is immature resulting in low antibody titers (incomplete transplacental transfer of maternal antibodies) and a reduced cellular immunity with reduced viral clearance. Rehospitalization rates of preterm compared to term infants due to RSV infection are increased as are total morbidity and mortality associated with RSV disease. Palivizumab effectively reduces RSV related rehospitalisation in this high-risk population.

Differential Effects of Zinc in Severe Pneumonia in Children

We read with great interest the article by Bansal et al. [1]. The authors had conducted a clinical trial and found that, zinc supplementation did not reduce recovery time and duration of hospital stay in children with severe acute lower respiratory tract infection (ALRTI). The study is well described, but there are few points that need comment. The authors describe that; zincmay bemore effective in the treatment of serious bacterial pneumonias, and not in viral pneumonias or bronchiolitis, which are predominantly viral illnesses. In their study, the percentage of children with wheezing was quite high (68.5%), and though they analyzed the outcome measures for wheezy and non-wheezy children separately, they did not find any significant difference in outcome. Actually, there is no published study examining the role of zinc in severe bacterial versus viral pneumonia. So, these are all speculations that zinc does not help children with pneumonia due to viral etiology (based on proportion of children with wheezing). If we look at the mechanism, how zinc might be beneficial in pneumonia, the following points need mention. Zinc deficiency enhances airway inflammation and cellular damage, whereas zinc supplementation might protect the lung from inflammatory states. Mechanisms for anti-inflammatory action of zinc in the respiratory tract include: blocking the binding of leucocytes to the endothelial cells via interaction between intercellular adhesion molecule (ICAM) -1 and leucocyte associated antigen-1 [2], inhibiting the release of preformed mediators from inflammatory cells, etc. So, the beneficial effects of zinc in severe pneumonia might depend upon the extent of inflammation and its resolution rate, as well as on the acute phase response mediated by the cytokines. Zinc also has potent antiviral action that includes: prevents the formation of viral capsid proteins (inhibiting in vitro replication of viruses) [3], prevents the virus from combining with the ICAM-1 (inhibiting viral entry into the cell), may induce the production of interferon (having non-specific antiviral actions) [4], inhibit human prostaglandin metabolism (thus decreasing inflammation). So, there is no reason for the differential effects of zinc in severe pneumonia according to the etiology. If this is proved, zinc may find its place in management of severe pneumonia as in acute diarrhea. We hope that, future trials should focus on this issue and try to compare the differential effects of zinc in severe bacterial and viral pneumonia. This might be difficult, but some suggestions include: use of chest radiograph in addition to clinical definition of pneumonia, designing the studies in a way to detect the difference in the subgroup of children without wheezing or totally excluding wheezing children, microbiological criteria (culture, PCR, antigen and/or antibody detection, etc), use of inflammatory markers (C reactive protein, procalcitonin), etc.

Severe Early Lower Respiratory Tract Infection is Associated with Subsequent Respiratory Morbidity in Preschool Inuit Children in Nunavut, Canada

Background. Inuit children in Nunavut, Canada, have high rates of lower respiratory tract infection (LRTI) early in life. Whether this commonly results in chronic respiratory symptoms later in life is unknown. Methods. A cross-sectional survey of 3- to 5-years-old Inuit children was conducted in all three regions of Nunavut, as part of the “Qanuippitali, what about us, how are we?” survey. Results. Reported chronic cough and wheezing were common in preschool Inuit children, although reported asthma diagnosed by a healthcare professional was uncommon. The presence of smokers in the home tended to be associated with severe LRTI in the first 2 years of life. Reported wheezing as well as reported bronchitis or pneumonia in the previous 12 months was significantly associated with severe LRTI in the first 2 years of life. Reported wheezing was also strongly associated with reported bronchitis or pneumonia in the past 12 months. The prevalence of chronic moist cough could not be clearly assessed, due to limitations in the questionnaire. Interpretation. Severe LRTI in the first 2 years of life was associated with ongoing respiratory morbidity in preschool Inuit children, although symptoms appeared to lessen in severity over time.

H5N1 Virus Attachment to Lower Respiratory Tract

Highly pathogenic avian influenza virus (H5N1) may cause severe lower respiratory tract (LRT) disease in humans. However, the LRT cells to which the virus attaches are unknown for both humans and other mammals. We show here that H5N1 virus attached predominantly to type II pneumocytes, alveolar macrophages, and nonciliated bronchiolar cells in the human LRT, and this pattern was most closely mirrored in cat and ferret tissues. These findings may explain, at least in part, the localization and severity of H5N1 viral pneumonia in humans. They also identify the cat and the ferret as suitable experimental animals based on this criterion.