Underlying Medical Condition Research Articles

SARS-CoV-2-Associated Deaths Among Persons Aged

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED).† These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers.

Health service utilization by a semi-urban community in Kedah, Malaysia, 2019

Background: Socioeconomic development in Malaysia and the call for Universal health coverage has resulted in comprehensive health care being easily available and accessible at an exceptionally low cost to the people. The aim was to study the health utilization pattern of a semi-urban community to determine their health seeking preference, to understand the extent to which the medical facilities are being used by them and their level of satisfaction with the services received.Methods: We used a pre-tested structured questionnaire, with face-to-face interview of representatives of randomly selected households in 2 housing estates in Kedah. The questionnaire covered education level, income, and information relevant to health service utilization. Data, after verification was transcribed into excel and analysed using Epiinfo7.2.Results: Out of 112 households visited, 80.3% was in the B40 group. Of all, 96 (85.7%) individuals chose Government healthcare with no significant difference between the B40 and others (p=0.3). Currently 52.6% have children utilizing child health services and 47.1% utilizing the maternal health services. Most (70.5%), irrespective of education level do not go for general checkup. Those that do, have an underlying medical condition. Payments for hospitalization and medications were done by 38.4% and 30.3% respectively. Most frequent investigation was X-ray, ECG, and ultrasonography. Dental checkup accounted for 50.7% of type of service utilized. Overall, 63.4% of respondents were satisfied with the level of healthcare in the country.Conclusions: This community opts for Government health care and is generally satisfied with the level of care provided.

METHODOLOGICAL RECOMMENDATIONS ON THE CODING AND SELECTION OF THE UNDERLYING MEDICAL CONDITION IN THE STATISTICS OF MORBIDITY AND THE PRIMARY CAUSE OF DEATH IN THE STATISTICS OF MORTALITY IN RELATION TO COVID-19 (Approved by the Ministry of Health of the Russian Federation on 05.27.2020)

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COVID-19 in hospitalized children and adolescents

HintergrundDas klinische Wissen zu Verlauf, Komplikationen und Therapie von COVID-19 bei Kindern und Jugendlichen ist bisher begrenzt.ZielDer vorliegende systematische Review fasst die aktuelle wissenschaftliche Evidenz zum klinischen Verlauf von COVID-19 bei hospitalisierten Kindern zusammen. Zusätzlich werden die ersten Daten aus Deutschland aus einem Kinderklinik-Survey der Deutschen Gesellschaft für Pädiatrische Infektiologie e. V. (DGPI) vorgestellt.MethodikAusgewertet wurden insgesamt 12 Fallserien aus China mit 6 bis 2143 SARS-CoV-2-infizierten Kindern, die über eine PubMed-Literatursuche bis zum 31.03.2020 identifiziert wurden. Die Datenbank des deutschlandweiten COVID-19 Kinderklinik-Survey der DGPI wurde am 06.04.2020 abgefragt.ErgebnisseIn den Fallserien lag das mediane Alter zwischen 2 und 7 Jahren, mit einem Anteil von Säuglingen von 18 bis 45 %. Am häufigsten berichtete Symptome waren Fieber und Husten; bei 40–100 % lag eine radiologisch (zumeist CT) bestätigte Lungenbeteiligung vor. Schwere/kritische Verläufe – inklusive 2 Todesfälle – wurden bei bis zu 8 % der Kinder berichtet. Die Hospitalisierungsdauer lag bei 5 bis 20 Tagen. Der COVID-19-Survey der DGPI erfasste bis zum 06.04.2020 33 Kinder aus 21 Kliniken, mit überwiegenden Infektionen der oberen Atemwege. 45 % waren Säuglinge, 32 % hatten eine Vorerkrankung. Bislang benötigten 3 Kinder (9 %) eine intensivstationäre Behandlung.DiskussionCOVID-19 bei hospitalisierten Kindern und Jugendlichen verläuft überwiegend als unkomplizierte febrile Erkrankung der oberen oder der unteren Atemwege. Nur sehr selten kommt es bei Kindern zu schweren Komplikationen oder Todesfällen. Weitere Informationen zum Verlauf von COVID-19 bei Neugeborenen, Säuglingen und Patienten mit Vorerkrankungen sowie zu therapeutischen und präventiven Maßnahmen werden dringend benötigt.

IADVL Position Statement and Recommendations on Post Lockdown Dermatology Practice Amidst the Covid -19 Pandemic (IADVL Academy and IADVL Executive Committee).

IADVL Position Statement and Recommendations on Post Lockdown Dermatology Practice Amidst the Covid -19 Pandemic (IADVL Academy and IADVL Executive Committee).

Surveillance Data for Eight Consecutive Influenza Seasons in Sicily, Italy.

Influenza A and B outbreaks occur each year with different activity and molecular patterns. To date, knowledge of seasonal epidemiology remains a prerequisite not only to put in place the most effective immunization strategy against influenza but also to identify population groups at higher risk of developing serious complications. A retrospective analysis of influenza surveillance data from 2010 to 2018 aimed to explore the epidemiology of influenza in Sicily, at the primary care and hospital level. Overall, 6,740 patients with acute respiratory infection were tested, of which 3,032 (45.0%) were positive for influenza. The relative proportion of type A and B viruses markedly varied across seasons. Type A similarly spreads among children and adults, whereas type B was more commonly identified among pediatric population aged 5-9 years. The median age of confirmed influenza cases differed by health-care setting, increasing according to disease severity (range: 8-54 years). Among influenza-confirmed cases, more than 80% of hospitalized patients had an underlying medical condition. Cardiovascular disease, lung disease, diabetes, and obesity were some of the most frequent. Overall, patients admitted to an intensive care unit were more likely to have multiple comorbidities and being infected with influenza infection strongly increased the risk of severe clinical outcomes. Understanding of the epidemiology of influenza and the molecular features of circulating viruses is of paramount importance to optimize prevention and control strategies. Knowledge of predictors for the occurrence of severe forms of the disease may help to address adequate preventive measures to high-risk population groups.

Urine cytological examination: an appropriate method that can be used to detect a wide range of urinary abnormalities

Background:Urine cytology is a method that can be used for the primary detection of urothelial carcinoma, as well as other diseases related to the urinary system, including hematuria and infectious agents. In this study we aimed at investigating urine abnormalities among Sudanese patients attending Omdurman teaching hospital.Methods:A descriptive cross-sectional study was conducted from November 2016 to October 2017. A voided urine samples were collected and stained using Papanicolaou stain.Results:A total of 1238 urine samples were meticulously examined, 832 (67.2%) from males (mean age 41.7±12.67), and 406 (32.8%) from females (mean age 43.8±10.94). 147 (11.9%) patients had an underlying medical condition, either AIDs, diabetes mellitus type 2 or historical renal transplantation. Hematuria was more frequent amongst males than females, 100 (68.9%) and 45 (31.1%), respectively. Urine cytology diagnosis was 43 cases (3.5%) of candidiasis, 36 cases (2.9%) of reactive urothelial cells, 11 cases (0.9%) of cryptococcosis, 9 cases (0.7%) of urothelial carcinoma, 9 (0.7%) human papilloma virus (HPV) diagnoses, 8 (0.6%) polyomavirus (BKV) diagnoses, 6 (0.5%) schistosomiasis diagnoses and 3 cases (0.2%) of low grade urothelial cells.Conclusion:Urine cytology seems to be a non-invasive technique that is suitable for all patients with urinary tract infections; those with diabetes, renal transplants, and HIV; and patients with macroscopic or microscopic hematuria for the detection of infectious agents and malignancy.

2205. Clinical Burden of Pneumococcal Disease in US Adults Aged 65 Years and Above with Chronic or Immunocompromising Conditions

BackgroundThe presence of chronic and immunocompromising conditions is associated with a disproportionately high risk of developing pneumococcal disease at older ages. The objective of this study was to quantify the risk of all-cause pneumonia (ACP) and invasive pneumococcal disease (IPD) in older US adults aged 65 years and older with underlying medical conditions.MethodsA retrospective observational study was conducted using the Humana claims database. The study cohorts were identified at January 1 of each calendar year of observation from 2012 to 2017 and comprised adults aged 65 years and older with continuous enrollment for at least one year before and at least one year after January 1 of each year. For each yearly cohort, medical conditions were identified during the one year before each calendar year and episodes of ACP and IPD were identified during the corresponding 1-year follow-up period from January 1 to December 31. Individuals were stratified into 3 groups: those without any medical conditions of interests (healthy), those with chronic conditions (at-risk) and those with immunocompromising conditions (high-risk). Rate of ACP or IPD was expressed as the number of cases per 100,000 person-years and the rate ratio (RR) was expressed as the rate of pneumococcal disease of patients with medical conditions divided by the rate of pneumococcal disease in healthy adults.ResultsOf the 10,766,827 adults included in the study, 75% of adults had an underlying medical condition linked to an increased risk of pneumococcal disease. In adults with at-risk conditions, rates of ACP and IPD were 3.1 and 3.6 times the rate in healthy adults, respectively. In adults with high-risk conditions, rates of ACP and IPD were 4.1 and 5 times the rate in healthy adults, respectively. Rate of pneumococcal disease increased substantially with the addition of medical conditions: RR for ACP and IPD increased from 2.1 and 2.2, respectively, in adults with one at-risk conditions to 4.8 and 6.2, respectively, among adults with 2 or more at-risk conditions.ConclusionDespite recommendations of universal pneumococcal vaccination in older adults aged 65 years and above in the United States, the burden of pneumococcal disease remains high, particularly among those with chronic and immunocompromising conditions.Disclosures All authors: No reported disclosures.

Diagnosis and qualitative identification of hyperhidrosis

Hyperhidrosis is a dermatologic disease defined as excessive sweating that exceeds thermoregulatory needs, and is estimated to affect at least 4.8% of the population. The condition can be classified as either primary and idiopathic, or secondary due to an underlying medical condition or medication adverse event. Primary hyperhidrosis accounts for 93% of all cases. The diagnosis is partially determined and supported by objective quantitative tools, but is mainly identified by subjective accounts of patients regarding the extent of impact the excessive sweating has on their daily and general quality of life. This article will elaborate on the common and practical tools available for diagnosing hyperhidrosis.

High prevalence of Group B Streptococcus colonization among pregnant women in Amman, Jordan

BackgroundLittle is known of the burden of Group B Streptococcus (GBS) colonization among pregnant women in Jordan. We conducted a pilot study to determine the prevalence of GBS among pregnant women in Amman, Jordan, where GBS testing is not routine. We also explored GBS serotypes and the performance of a rapid GBS antigen diagnostic test.MethodsWe collected vaginal-rectal swabs from women who presented for labor and delivery at Al-Bashir Hospital. Three methods were used to identify GBS: Strep B Rapid Test (Creative Diagnostics), blood agar media (Remel) with confirmed with BBL Streptocard acid latex test (Becton Dickinson), and CHROMagar StrepB (Remel). Results were read by a senior microbiologist. We defined our gold standard for GBS-positive as a positive blood agar culture confirmed by latex agglutination and positive CHROMagar. PCR testing determined serotype information. Demographic and clinical data were also collected.ResultsIn April and May 2015, 200 women were enrolled with a median age of 27 years (IQR: 23–32); 89.0% were Jordanian nationals and 71.9% completed secondary school. Median gestational age was 38 weeks (IQR: 37–40); most women reported prenatal care (median 9 visits; IQR: 8–12). Median parity was 2 births (IQR: 1–3). Pre-pregnancy median BMI was 24.1 (IQR: 21.5–28.0) and 14.5% reported an underlying medical condition. Obstetric complications included gestational hypertension (9.5%), gestational diabetes (6.0%), and UTI (53.5%), of which 84.5% reported treatment. Overall, 39 (19.5%) of women were GBS-positive on blood agar media and CHROMagar, while 67 (33.5%) were positive by rapid test (36% sensitivity, 67% specificity). Serotype information was available for 25 (64%) isolates: III (48%), Ia (24%), II (20%), and V (8%). No demographic or clinical differences were noted between GBS+ and GBS-negative women.ConclusionsNearly one in five women presenting for labor in Jordan was colonized with GBS, with serotype group III as the most common. The rapid GBS antigen diagnostic had low sensitivity and specificity. These results support expanded research in the region, including defining GBS resistance patterns, serotyping information, and risk factors. It also emphasizes the need for routine GBS testing and improved rapid GBS diagnostics for developing world settings.

736. Incidence and Etiology of Community-Acquired Pneumonia Requiring Hospitalization Among American Indian/Alaskan Native Adults

BackgroundA leading infectious cause of hospitalization among adults in the United States is community-acquired pneumonia (CAP). The etiology and incidence of CAP in American Indians/Alaskan Natives (AI/AN) has not been described.MethodsWe conducted a retrospective study by reviewing the medical records of all AI/AN patients 18 years or older admitted to W.W. Hastings Hospital in Tahlequah, Oklahoma with a diagnosis of a respiratory infection from January 1, 2016 to December 31, 2016. Only patients with a radiographically confirmed CAP were included and those with a recent hospitalization or immunosuppressed were excluded. Patient demographics, comorbidities and results of molecular tests, antigen detection, high quality sputum culture and blood culture were reviewed. Population-based incidence rates of CAP requiring hospitalization were calculated according to age.ResultsFrom January 2016 through December 2016, 763 patients were admitted with a diagnosis of a respiratory infection, of which 193 (25%) met the inclusion criteria. Of this group, 103 (53%) had at least one pathogen detected: one or more viruses were detected in 47 (24%), one or more bacteria were detected in 63 (33%). The most common pathogens were Streptococcus pneumoniae (12% of patients), rhinovirus/enterovirus (11% of patients), respiratory syncytial virus (5% of patients), legionella pneumophila (4% of patients), and human metapneumovirus (4% of patients). The annual incidence of CAP was 13.6 cases (95% confidence interval, 11.9, 15.7) per 10,000 adults, with the highest incidence among adults ages 65–79 (43 cases per 10,000 adults) and those 80 years of age or older (102 cases per 10,000 adults). Seventy-five percent of patients had an underlying medical condition, 47% had diabetes mellitus (DM), followed by chronic obstructive lung disease (38%) and chronic heart disease (32%).ConclusionIn this AI/AN population, a respiratory pathogen was identified in 53% of the cases despite the use of cutting edge diagnostic tests in most patients. Bacteria were detected more often than viruses. Compared with recent publications of CAP affecting non-Hispanic whites, non-Hispanic blacks and Hispanics, the population described in this study was older and had higher prevalence of DM.Disclosures All authors: No reported disclosures.

741. Impact of Adenovirus Co-detections on Illness Severity

BackgroundHuman adenovirus (AdV) is a common pathogen among children with acute respiratory illnesses (ARI) and is often associated with co-detection with other respiratory viral pathogens. We sought to compare demographic and clinical characteristics in children with ARI who had single-AdV vs. AdV-co-detection with other viruses.MethodsChildren <18 years with fever and/or ARI were enrolled in Vanderbilt Children’s Hospital inpatient setting from 2015 to 2018 and emergency department from 2016 to 2018. Interviews were conducted using standardized case report forms. Nose and throat swab specimens were collected and tested by RT-qPCR for common respiratory pathogens (AdV, RSV, HRV, hMPV, PIV1–4 and Influenza).ResultsOf 2,740 ARI cases, 174 were positive for AdV [88 (51%) single detection], with 53% male, 47% White, 36% Black, 30% Hispanic and median age of 17.2 months. Co-detected pathogens in AdV-positive specimens were RSV(15%), HRV(14%), influenza(5%), PIV1(1%), PIV2(0.6%), PIV3(1.7%), and PIV4(0.6%), hMPV(3%), >1 co-pathogens(9%). Subjects with single-AdV detection were more likely to have an underlying medical condition (42% vs. 24%, P < 0.05). Table 1 compares clinical presentation and severity of single-AdV and AdV-co-detection cases.Table 1:AdV-Single n = 88 (%)AdV-co-Detection n = 86 (%) P-Value*Fever78(89)71(83)0.25Cough63(72)79(92)<0.01Dyspnea38(43)57(66)<0.01Wheezing36(41)50(58)<0.05Chest in-drawing8(9)29(34)<0.01Nasal congestion/runny nose71(81)79(92)<0.05Diarrhea13(15)27(31)<0.01Supplemental oxygen5/88(6)23/84(27)<0.01Admitted (2015–2016)6/6(100)20/20(100)—ICU Admission (2015–2016)1/69(16.7)4/20(20.0)0.86Admitted (2016–2018)15/82(18)20/66(30)0.09ICU admission (2016–2018)1/15(6.7)2/20(10.0)0.72ConclusionPatients with single-AdV detection were less likely to present with ARI symptoms and require oxygen, but were more likely to have underlying medical conditions compared with AdV-co-detection. Further studies to type AdV isolates will help elucidate the role of specific adenovirus types associated with co-detections and illness severity and inform epidemiological information for future vaccine initiatives.Disclosures J. V. Williams, Quidel: Board Member, Consulting fee. GlaxoSmithKline: Consultant, Consulting fee. N. B. Halasa, sanofi pasteur: Investigator, Research support. GSK: Consultant, Consulting fee. Moderna: Consultant, Consulting fee.

Odontogenic Maxillofacial Space Infections: A 5-Year Retrospective Review in Navi Mumbai.

The aim of this study is to comprehensively review and analyse pure odontogenic maxillofacial space infections in a tertiary care hospital in Navi Mumbai over a period of 5years. A retrospective analysis of 315 patients treated at Dr. D. Y. Patil Dental College and Hospital at Nerul, Navi Mumbai, from January 2007 to December 2011 was done. Multiple variables were analysed. Localised infections like dentoalveolar infections without space involvement and infection of non-odontogenic cause were excluded from the study. Analysis of the records was done. Majority of patients were from lower socioeconomic background and were daily wage workers who had either consulted a general physician or a general dental practitioner or had self-medicated themselves before presenting to us with acute symptoms. Early recognition and prompt treatment involving intravenous antibiotics with extraction of involved tooth/teeth and incision and drainage helped in resolution of infections in a span of 72h. Medically compromised patients had longer duration of hospital stay as compared to the patients who had no underlying medical condition. Majority of space infections involved multiple spaces and local anaesthesia with sedation was found to be the satisfactory mode of anaesthesia. Complications were very few. We concurred that any form of odontogenic maxillofacial space infection should be rendered prompt and aggressive treatment and hospitalisation should be recommended wherever required.

Clinical features of Clostridium difficile infection in an intensive care unit: from 2009 to 2017

Background: The incidence, severity and mortality of Clostridium difficile infection (CDI) has been on the rise over the last 20 year and its mortality has been estimated in 6-38%. Our aims are to determine clinical characteristics of CDI and factors related to mortality in an intensive care unit (ICU). Methods & Materials: Among 1122 patients living with HIV admitted to ICU between 2009 and 2016, 60 had CDI. Univariate analysis was performed to identify death related factors. Results are expressed as percentage (%), median (Me), mean (M) and range. A p value of < 0.05 was considered significant Results: Incidence was 0,02, it was found to be 61% higher between 2014-2017. 60% men. M/Me age were 47 years. M/Me time from admission to diarrhea onset was 46/33 days. Estimated length of IC stay before CDI acquisition was M/Me 14/10 days. 93% had an underlying medical condition, 62% HIV/Aids. Use of antibiotics 95%; M/Me prior exposure of 29/19 days. 100% were undergoing gastric acid suppression (GAS). Most common symptoms/signs were: 95% diarrhea, 52% abdominal pain and 48% arterial hypotension. 90% present hypoalbuminemia less than 3,5 g/L, Me 2,2 g/L. 95% were diagnosed with enzyme immunoassays for toxins A/B. Patients developed mild/moderated CDI 38%, severe 53%, complicated 37% and 8% recurred. M/Me APACHE II score (Score Acute Physiology and Chronic Health Evaluation II) on IC admission of 19 points and M/Me SOFA (Sequential Organ Failure Assessment score) of 5 points. 7% were not treated. Overall mortality was 61%; an increased mortality 108% was noted when 2 periods were compared (2009-2013 and 2014-2017). Hypoalbuminemia (≤2,4 g/L), APACHE II > 18 points, SOFA > 5 points, severe CDI present statistically significant in mortality (p < 0,05) Conclusion: More than a half occured in HIV seropositive individuals. Almost 100% had been exposed to antibiotics and 100% to GAS. More than half were severe, a factor that as well as hypoalbuminemia, and the severity scores used in the ICU, are associated with higher mortality. Mortality associated with CDI increased during the study period and was more likely to occur in younger patients and in hospitalizations lasting longer than 4 wk.

First Presentation with Psychotic Symptoms to the Emergency Department

BackgroundMental health conditions account for 52.8 million (4.9–6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. ObjectiveWe aimed to determine the underlying etiology and characteristics of patients presenting to the ED with a first episode of psychotic symptoms. MethodsMedical records of 159 African, Asian, white, and mixed-race patients were prospectively reviewed. Subjects were classified into one of three groups; psychosis due to an underlying medical condition (UMC), substance-induced psychotic disorders (SIPDs), and psychosis due to other primary psychiatric disorders (OPD). Demographic details and presenting features were described and compared. ResultsOverall mean (standard deviation [SD]) age of all study subjects was 34.3 (13.4) years. A UMC was responsible for a first presentation with psychotic features in more than half of the study subjects (n = 87 [54.7%]), while SIPD (n = 37 [23.3%]) and OPD (n = 35 [22.0%]) were responsible for the remainder of cases. The majority of subjects were male (n = 95 [59.7%]), unemployed (n = 105 [66.0%]), and had not completed secondary school (n = 109 [68.6%]). More than one-third of subjects tested positive for human immunodeficiency virus infection (n = 63 [39.6%]). Mean (SD) duration of psychotic symptoms before ED presentation was 16.6 (26.3) days. ConclusionsUMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.

HIV prevalence among first-presentation psychotic patients.

First-episode psychosis is a frequent emergency department (ED) presentation that may potentially be secondary to an underlying life-threatening HIV-related condition. The aim of this study was to determine the prevalence of HIV infection in patients presenting with a first episode of psychosis. Medical records of 159 consecutive African, Asian, White and mixed ethnicity patients presenting to a tertiary academic hospital ED with a first episode of psychotic features were prospectively reviewed. Of the 159 subjects, 63 (39.6%) were HIV positive. An underlying medical condition was the most common aetiology of psychosis in both HIV-positive (84.2%) and HIV-negative (35.4%) subjects, but was significantly more common in HIV-positive individuals (P<0.001). Substance-induced psychotic disorders and other primary psychiatric disorders were significantly more common in subjects without HIV infection (P<0.001 and P<0.001, respectively). While there were more men in the HIV-negative group (66.7%), gender distribution was almost equal in the HIV-infected group (49.2% male). Overall, as well as in both groups, most subjects were of African race, were unemployed and had not completed high school. Co-occurrence of HIV infection was a frequent finding in first-episode psychotic individuals residing in a high-prevalence HIV setting. These individuals are more likely to have an underlying medical condition precipitating the onset of psychosis, not to have been initiated on antiretroviral therapy and to present with a low CD4 cell count and high HIV viral load.

Impact of influenza in the post-pandemic phase: Clinical features in hospitalized patients with influenza A (H1N1) pdm09 and H3N2 viruses, during 2013 in Santa Fe, Argentina.

It is important to characterize the clinical and epidemiological pattern of the influenza A (H1N1) pdm09 virus and compare it with influenza A (H3N2) virus, as surveyed in just a few studies, in order to contribute to the implementation and strengthening of influenza control and prevention strategies. The aims in this study were to describe influenza clinical and epidemiological characteristics in hospitalized patients, caused by influenza A (H1N1)pdm09 and influenza A (H3N2) viruses during 2013, in Santa Fe, Argentina. A retrospective study was conducted over 2013 among hospitalized patients with laboratory-confirmed influenza diagnosis. In contrast to patients with influenza A (H3N2) (20.5%), a higher proportion of hospitalizations associated with influenza H1N1pdm were reported among adults aged 35-65 years (42.8%). Of all patients, 73.6% had an underlying medical condition. Hospitalized patients with H1N1pdm were subject to 2.6 (95%CI, 1.0-6.8) times higher risk of severity, than those hospitalized with influenza A (H3N2). This results demonstrate the impact in the post-pandemic era of H1N1pdm virus, with increased risk of severe disease, in relation to H3N2 virus, both viruses co-circulating during 2013.

Honing in on the Range: Using the Electronic Medical Record to Establish Normal Reference Ranges for Pediatric Coagulation Testing

Laboratories typically validate testing for prothrombin time (PT) and activated partial thromboplastin time (aPTT) by collecting samples from 21 to 50 healthy individuals and using the mean value, plus or minus two standard deviations, to establish a normal reference range. It is more difficult to establish pediatric reference intervals because parents are often unwilling to volunteer their children for unnecessary blood draws. At our institution, a large, tertiary care pediatric academic center, it has been our practice to establish normal coagulation test ranges by collecting extra blood from approximately 50 children getting blood drawn for other reasons. Since well children typically require blood draws at very limited times, such as the 9-12 month well visit screen, our ranges have been based on a disproportionately large percentage of very young children. We worried that this may have resulted in an inappropriately narrow reference range for the PT in our lab as we noted a large number of otherwise healthy children referred for evaluation of a mildly prolonged PT who were found to have normal factor levels, reassuring bleeding histories and unremarkable coagulation workups.We sought to address this issue by interrogating our current reference ranges for PT and aPTT by using our electronic medical record (EMR). On reviewing the literature, we have found no published reports of another institution using the EMR to validate normal laboratory reference intervals. We believe that this method has several advantages. It has permitted us to collect data from a larger and more diverse cohort of pediatric patients and allowed us to investigate appropriate reference ranges for age and gender specific groups of patients. To carry out this study, two pediatric hematologists reviewed de-identified laboratory data obtained during routine testing from 2012-2014, along with associated medical diagnoses, on pediatric outpatients, ages 2 to 23 years, at The Children's Hospital of Philadelphia. 265 patient samples were identified as appropriate for study inclusion. Patients were excluded if they had an underlying medical condition or were taking medications that might lead to alterations in coagulation testing.The previously established normal reference ranges for PT and aPTT were 11.6-13.8 and 22-36 seconds respectively. Using data obtained from the EMR, we found similar reference ranges for the aPTT at 25-38 seconds, and a narrowed ranged for the PT at 12.9 to 13.9 seconds. We were able to stratify by age and gender and while we found that there was no significant difference between the normal ranges of PT and aPTT for boys and girls, we did find that there was a significant difference in the ranges of the PT when patients were divided by age. The range for PT in children age of 2-11 years was 12.5-13.6 seconds while the range for children 12-23 years was 13.05 -13.9 seconds (p<0.01). The PT in the younger children was narrower and not normally distributed, while in the older children, it was normally distributed but significantly wider with a much higher upper limit. Interestingly, there was no significant difference in the range of aPTTs for children of different ages.We anticipate that in the future, it will be possible to use the increasingly vast quantity of data stored in EMRs to establish more accurate laboratory reference ranges for unique subgroups of patients. We hope that this information will eventually allow us to precisely identify abnormal lab results and minimize additional testing that is often medically unnecessary, expensive and anxiety provoking. Using the EMR may be a way to validate normal ranges in a laboratory performing routine testing on pediatric specimens. Further studies are needed to confirm these findings. DisclosuresLambert:GSK: Consultancy; NovoNordisk: Honoraria; Hardin Kundla McKeon & Poletto: Consultancy.

Risk Factors for Community-associated Clostridium difficile-associated Diarrhea in Children.

Clostridium difficile-associated diarrhea (CDAD) is increasingly diagnosed in children in community settings. This study aims to assess recent antibiotic use and other risk factors in children with community-associated (CA-) CDAD compared with children with other diarrheal illnesses in a tertiary care setting. Children with CA-CDAD evaluated at Texas Children's Hospital (Houston, TX) from January 1, 2012 to June 30, 2013 were identified. Two control subjects with community-associated diarrhea who tested negative for C. difficile were matched to case subjects. Data on demographics, medication exposure and outpatient healthcare encounters were collected from medical records. Multivariate logistic regression was performed to identify predictors of pediatric CA-CDAD. Of 69 CA-CDAD cases, most (62.3%) had an underlying chronic medical condition and 40.6% had antibiotic exposure within 30 days of illness. However, no traditional risk factor for CDAD was identified in 23.2% and 15.9% of CA-CDAD cases within 30 and 90 days of illness onset, respectively. Outpatient healthcare encounters within 30 days were more common among CA-CDAD cases than control subjects (66.7% vs. 48.6%; P = 0.01). In the final multivariate model, CA-CDAD was associated with cephalosporin use within 30 days [odds ratio: 3.32; 95% confidence interval: 1.10-10.01] and the presence of a gastrointestinal feeding device (odds ratio: 2.59; 95% confidence interval: 1.07-6.30). Recent use of cephalosporins and the presence of gastrointestinal feeding devices are important risk factors for community- associated CDAD in children. Reduction in the use of outpatient antibiotics may decrease the burden of CA-CDAD in children.

A comparison of H1N1 influenza among pediatric inpatients in the pandemic and post pandemic era

BackgroundThe novel influenza A H1N1 (A[H1N1]pdm09) strain emerged in 2009, contributing to significant morbidity and mortality. It is not known whether illness associated with A(H1N1) pdm09 in the post-pandemic era exhibits a similar disease profile. ObjectiveThe objectives of this study were to compare the burden of disease of A(H1N1) pdm09 influenza from the 2009 pandemic year to the post-pandemic years (2010–2014), and to explore potential reasons for any differences. Study designWe conducted a retrospective cohort study of inpatients admitted to Children’s Hospital Colorado with a positive respiratory specimen for influenza from May–December, 2009 and December, 2010–April, 2014. Univariate and multivariate analyses were conducted to compare the demographics and clinical characteristics of patients with H1N1 during the two periods. ResultsThere were 388 inpatients with influenza A(H1N1) pdm09 in 2009, and 117 during the post-pandemic years. Ninety-four percent of all H1N1 during the post-pandemic era was observed during the 2013–2014 influenza season. Patients with A(H1N1) pdm09 during the post-pandemic year were less likely to have an underlying medical condition (P<0.01). Patients admitted to the ICU during the post-pandemic year had a lower median age (5 vs 8 years, P=0.01) and a lower proportion of patients were intubated, had mental status changes, and ARDS compared with the pandemic years, (P<0.01 for all), with decreased mortality (P=0.02). ConclusionPatients with influenza A(H1N1) pdm09 during the post-pandemic years appeared to have less severe disease than patients with A(H1N1) pdm09 during the pandemic year. The reasons for this difference are likely multifactorial.