Diagnostic Accuracy of a Real-Time Host-Protein Test for Infection

OBJECTIVE

Determining infection etiology can be difficult because viral and bacterial diseases often manifest similarly. A host protein test that computationally integrates the circulating levels of TNF-related apoptosis-induced ligand, interferon γ-induced protein-10, and C-reactive protein to differentiate between bacterial and viral infection (called MMBV) demonstrated high performance in multiple prospective clinical validation studies. Here, MMBV's diagnostic accuracy is evaluated in febrile children for whom physicians were uncertain about etiology when applied at the physician's discretion.

METHODS

Patients aged 3 months to 18 years were retrospectively recruited (NCT03075111; SPIRIT study; 2014-2017). Emergency department physician's etiological suspicion and certainty level were recorded in a questionnaire at blood-draw. MMBV results are based on predefined score thresholds: viral/non-bacterial etiology (0 ≤ score <35), equivocal (35 ≤ score ≤65), and bacterial or coinfection (65 < score ≤100). Reference standard etiology (bacterial/viral/indeterminate) was adjudicated by 3 independent experts based on all available patient data. Experts were blinded to MMBV. MMBV and physician's etiological suspicion were assessed against the reference standard.

RESULTS

Of 3003 potentially eligible patients, the physicians were uncertain about infection etiology for 736 of the cases assigned a reference standard (128 bacterial, 608 viral). MMBV performed with sensitivity 89.7% (96/107; 95% confidence interval 82.4-94.3) and specificity 92.6% (498/538; 95% confidence interval 90.0-94.5), significantly outperforming physician's etiological suspicion (sensitivity 49/74 = 66.2%, specificity 265/368 = 72.0%; P < .0001). MMBV equivocal rate was 12.4% (91/736).

CONCLUSIONS

MMBV was more accurate in determining etiology compared with physician's suspicion and had high sensitivity and specificity according to the reference standard.

Paediatric hospital visit with laboratory-confirmed influenza improved family members' influenza vaccination

OBJECTIVES

Vaccination is the primary intervention to prevent influenza infection, yet vaccine uptake remains low among children and other at-risk patients. The aim of the study is to investigate the impact of a paediatric hospital visit with laboratory-confirmed influenza on the influenza vaccination behaviour of participants and their family members in the subsequent influenza season.

METHODS

This study compared the influenza vaccination coverage for participants < 18 years of age with a clinical suspicion of influenza in 2017-2018 during a hospital visit, in two subsequent influenza seasons. Data was retrieved from the hospital electronic medical record and a follow-up questionnaire (2018-2019) to ascertain the common reason(s) that families did not vaccinate their children the following year (2018-2019). The children were distributed into positive- (antigen and/or PCR) and negative-influenza groups.

RESULTS

A total of 133 children were enrolled in our study. Participants' mean age was 4.6 years and 74 (55.6%) were males. Overall, 47 (35.3%) had confirmed influenza virus. A significant increase in influenza immunization was found among both positive- and negative-influenza participants between 2017-2018 and 2018-2019 (6.4% vs. 27.7%, p < 0.001; 8.1% vs. 29.1%, p < 0.001, respectively), as well as among family members of positive-influenza participants - siblings and parents (6.4% vs. 19.6%, p = 0.003; 0% vs. 17%, p < 0.001, respectively). Common reasons for failure to vaccinate included doubt in vaccine effectiveness, unlikely to get "flu", busy, and side effects.

CONCLUSIONS

Our findings suggest that a paediatric hospital visit with laboratory-confirmed influenza increases vaccine uptake among families. Future studies should aim to evaluate evidence-based interventions to improve influenza vaccine uptake among children.

The diagnostic value of nasal microbiota and clinical parameters in a multi-parametric prediction model to differentiate bacterial versus viral infections in lower respiratory tract infections

Background

The ability to accurately distinguish bacterial from viral infection would help clinicians better target antimicrobial therapy during suspected lower respiratory tract infections (LRTI). Although technological developments make it feasible to rapidly generate patient-specific microbiota profiles, evidence is required to show the clinical value of using microbiota data for infection diagnosis. In this study, we investigated whether adding nasal cavity microbiota profiles to readily available clinical information could improve machine learning classifiers to distinguish bacterial from viral infection in patients with LRTI.

Results

Various multi-parametric Random Forests classifiers were evaluated on the clinical and microbiota data of 293 LRTI patients for their prediction accuracies to differentiate bacterial from viral infection. The most predictive variable was C-reactive protein (CRP). We observed a marginal prediction improvement when 7 most prevalent nasal microbiota genera were added to the CRP model. In contrast, adding three clinical variables, absolute neutrophil count, consolidation on X-ray, and age group to the CRP model significantly improved the prediction. The best model correctly predicted 85% of the ‘bacterial’ patients and 82% of the ‘viral’ patients using 13 clinical and 3 nasal cavity microbiota genera (Staphylococcus, Moraxella, and Streptococcus).

Conclusions

We developed high-accuracy multi-parametric machine learning classifiers to differentiate bacterial from viral infections in LRTI patients of various ages. We demonstrated the predictive value of four easy-to-collect clinical variables which facilitate personalized and accurate clinical decision-making. We observed that nasal cavity microbiota correlate with the clinical variables and thus may not add significant value to diagnostic algorithms that aim to differentiate bacterial from viral infections.

Multidomain Cognitive Impairment in Children With Pseudotumor Cerebri Syndrome

BACKGROUND

Although prompt and suitable treatment of pseudotumor cerebri syndrome (PTCS) leads to an excellent prognosis and can prevent optic nerve atrophy, adults show long-lasting neurocognitive deficits even with prompt treatment. The purpose of our study was to evaluate cognitive outcomes in pediatric patients with PTCS.

METHODS

We performed a prospective study on children diagnosed with PTCS and a healthy control group. Children with pre-existing neurological conditions or psychiatric drug use were excluded. Both groups underwent a neurocognitive evaluation, using the NeuroTrax computerized battery of tests. The PTCS group were tested 3 months after the initial diagnosis.

RESULTS

We evaluated 82 children (49 females [60%], 6.5-16 years old, mean age 13.3), including 26 diagnosed with idiopathic PTC and 56 controls. Global cognitive score (P < 0.001), verbal memory (P < 0.001), executive function (P < 0.001), attention (P< 0.003), and information processing speed (P < 0.004) were all significantly lower in the PTCS group. No differences were found between children currently being treated and those whose symptoms had resolved and treatment was stopped.

CONCLUSIONS

Children with PTCS experience comprehensive cognitive decline that persists after the resolution of the symptoms and treatment.

BV score differentiates viral from bacterial-viral co-infection in adenovirus PCR positive children

BACKGROUND AND OBJECTIVES

Adenovirus causes acute respiratory illness that can mimic bacterial infection, making it challenging to differentiate adenoviral infection from adenoviral-bacterial co-infection. A host-protein score (BV score) for differentiating bacterial from viral infection that combines the expression levels of TNF-related apoptosis-induced ligand, interferon gamma-induced protein-10, and C-reactive protein exhibited a negative predictive value (NPV) of 98% in prior studies. Here we evaluate BV score's diagnostic accuracy in pediatrics with adenovirus PCR detection.

METHODS

This is a sub-analysis of children aged 3 months to 20 years with adenovirus PCR-positive infection recruited prospectively in two previous cohort studies. Reference standard diagnosis (bacterial, viral or indeterminate) was based on expert adjudication. BV score ranges from 0 to 100 and provides three results based on predefined cutoffs: viral or other non-bacterial etiology (0 ≤ score < 35), equivocal (35 ≤ score ≤ 65), and bacterial or co-infection (65 < score ≤ 100). Experts were blinded to BV results.

RESULTS

Out of 1,779 children, 142 had an adenovirus PCR-positive nasopharyngeal swab. Median age was 1.2 years (interquartile range 0.6-1.8), 50.7% were male and 52.8% were hospitalized. 12 cases were reference standard bacterial, 115 reference standard viral and 15 were indeterminate. BV score attained sensitivity of 100.0% (no false negatives), specificity of 89.5% (95% confidence interval: 83.2-95.8), and NPV of 100.0% (92.6-100.0). Equivocal rate was 19.7%.

CONCLUSIONS

BV score accurately differentiated between adenoviral and bacterial-adenoviral co-infection in this cohort of children with PCR-positive adenovirus detection. This performance supports a potential to improve appropriate antibiotic use.

Evaluation of Israeli healthcare workers knowledge and attitudes toward the COVID-19 vaccine

Objectives

Healthcare workers (HCWs) are considered an important target group for the COVID‐19 vaccines. The current study assesses the knowledge and attitudes of Israeli HCWs regarding COVID‐19 immunization, and how various occupational and demographic factors may underlie COVID‐related knowledge and attitudes differences.

Methods

Following a pre‐test to validate measures, a cross‐sectional online anonymous survey was distributed to HCWs using a snowball sampling method.

Results

The survey was completed by 714 participants (mean age 39.9; range 18–74; 447 female), 52% doctors, 32% nurses, and the remainder by paramedical staff. Of the respondents, 553 (77.4%) answered the question are you in favor of getting the COVID‐19 vaccine, 105 (14.7%) were not sure, and 56 (7.8%) were not in favor. Doctors had higher odds of agreement as compared to both nurses (p < .025) and paramedical staff (p < .001). Multivariate logistic regression analysis revealed that increased age (OR: 1.075; 95% CI: 1.04–1.11, p < .001), profession (physician vs. nurse; OR: 2.73; 95% CI: 1.32–5.65; p < .007), and getting the current influenza vaccine (OR: 4.96; 95% CI: 2.47–9.95) were significant predictors of agreement.

Conclusions

A high level of HCWs knowledge and in favor attitudes were observed. Yet negative attitudes were also noted, particularly among nurses, paramedical staff, and young employees.

Outcomes of Migraine and Tension-Type Headache in Children and Adolescents

The aim of our study was to evaluate the long-term outcomes of pediatric migraine and TTH in a clinical setting. We conducted a cohort study. Pediatric patients who visited the pediatric neurology clinic due to diagnoses of migraine or TTH were contacted by phone 8–10 years after their initial diagnosis and interviewed about their outcomes. Of 147 children, we were able to reach 120 (81%) patients. Of these 120 patients, 59 were seen initially due to migraine and 61 due to TTH. For the migraine patients, headaches improved in 48 (81.4%) and worsened in four (6.8%). Regarding diagnosis at follow-up, 59% still had migraine, 17% had TTH, and 23% were headache-free. Aura and photophobia were significantly associated with persistence of a migraine diagnosis. For the TTH patients, headaches improved in 49 (81.7%) and worsened in nine (15.0%). Regarding diagnosis at follow-up, 36.7% still had TTH, 18.3% had migraine, and 45% were headache-free. Of the patients with TTH, 36.7% retained their initial diagnosis compared to 59.3% among the migraine patients. Most pediatric patients presenting with migraine or TTH will experience a favorable outcome over 10 years, with TTH patients having twice the chance of complete resolution.

Migraine and Tension-Type Headache Among Children and Adolescents: Application of International Headache Society Criteria in a Clinical Setting

INTRODUCTION

The International Headache Society criteria were written in order to help physicians establish a headache diagnosis. However, sometimes children with headache do not seem to fit any diagnosis. The purpose of our study was to assess the application of the criteria in a clinical setting.

METHODS

Medical records of children referred for primary headache to the pediatric neurology clinic at Bnai Zion Medical Center from 2008 to 2017 were assessed.

RESULTS

A total of 989 patients (range 6-18 years; 53% female) were assessed at our neurology clinic. Twenty-four percent (n = 241) were diagnosed with tension-type headache, 26% (n = 256) with migraine, and 4.5% (45) with mixed headache. In 41.5% (410), we were unable to reach a specific diagnosis. No differences in gender or age were found between the groups. Children in the migraine group used more analgesic treatments to stop the headache attacks compared with the tension-type headache group (50% vs 38%, P = .001). Patients diagnosed with tension-type headache reported having more emotional difficulties (P = .001). No significant differences were found in headache characteristics (ie, location, sidedness, character), frequency, or intensity between the younger children (ages 6-11) and the adolescents (ages 12-18) within either the tension-type headache or migraine groups.

CONCLUSIONS

Retrospective application of International Headache Society criteria in a large cohort of children with headaches failed to diagnose a specific type of headache in 41.5% of children. Migraine and tension-type headache were equally prevalent, and both constituted a major burden on our patients' everyday lives. We found no major differences in frequency, intensity, and characteristics of pain between younger children and adolescents.

Cat Scratch Disease Presenting as Fever of Unknown Origin Is a Unique Clinical Syndrome

BACKGROUND

Fever of unknown origin (FUO) is a rare manifestation of cat scratch disease (CSD). Data regarding CSD-associated FUO (CSD-FUO), particularly in adults, are limited. We aimed to study disease manifestations and long-term clinical outcome.

METHODS

A national CSD surveillance study has been conducted in Israel since 1991. Data are obtained using questionnaires, review of medical records, and telephone interviews. FUO was defined as fever of ≥14 days without an identifiable cause. CSD-FUO patients were identified in the 2004-2017 CSD national registry. Follow-up included outpatient clinic visits and telephone/e-mail surveys.

RESULTS

The study included 66 CSD-FUO patients. Median age was 35.5 years (range, 3-88). Median fever duration was 4 weeks (range, 2-9). Relapsing fever pattern was reported in 52% of patients, weight loss in 57%, and night sweats in 48%. Involvement of ≥1 organs occurred in 59% of patients; hepatosplenic space-occupying lesions (35%), abdominal/mediastinal lymphadenopathy (20%), ocular disease (18%), and multifocal osteomyelitis (6%) were the most common. Malignancy, particularly lymphoma, was the initial radiological interpretation in 21% of patients; 32% underwent invasive diagnostic procedures. Of the 59 patients available for follow-up (median duration, 31 weeks; range, 4-445), 95% had complete recovery; 3 patients remained with ocular sequelae.

CONCLUSION

This is the first attempt to characterize CSD-FUO as a unique syndrome that may be severe and debilitating and often mimics malignancy. Relapsing fever is a common clinical phenotype. Multiorgan involvement is common. Recovery was complete in all patients except in those with ocular disease.

Pooled saliva CMV DNA detection: A viable laboratory technique for universal CMV screening of healthy newborns

BACKGROUND

Most infants with congenital cytomegalovirus (cCMV) have no overt manifestations at birth, yet may later develop CMV-related sensorineural hearing loss (SNHL). With targeted screening, many asymptomatic neonates are missed and lose the opportunity for timely anti-viral treatment to ameliorate SNHL. Saliva is the preferred screening specimen given its ease of collection.

OBJECTIVES

Assess a pooled saliva CMV DNA detection technique for cCMV screening of healthy full-term neonates.

STUDY DESIGN

We conducted a prospective laboratory CMV PCR screening study in a secondary hospital from March-June 2019. Saliva specimens were obtained from 1000 newborns two-four hours after birth. Specimens were analyzed for CMV DNA with a real-time PCR platform (Altona) in pools of 10 and individually (40 μL and 400 μL, respectively). Neonates with positive saliva CMV DNA detection required urine CMV PCR testing to confirm cCMV diagnosis.

RESULTS

From the 1000 saliva samples, there were 6 urine-confirmed cCMV cases, yielding a prevalence rate of 0.6 %. The specificity was high for both pooled and individual saliva sampling (99.9 % and 98.1 %, respectively). The positive predictive value of the pooled sample was 85.7 %, compared to 24.0 % for a single saliva sample.

CONCLUSIONS

Pooling saliva of healthy newborns appears to be a reliable method to identify asymptomatic cCMV infection when positive results are confirmed by urine CMV DNA. Pooling in sizes appropriate to the cCMV prevalence rate may improve the laboratory workflow and decrease costs. Further studies should evaluate the clinical implications of this widespread cCMV pooled screening technique.

Sensory processing patterns affect headache severity among adolescents with migraine

Objective

To evaluate the relationship between pain catastrophizing level, sensory processing patterns, and headache severity among adolescents with episodic migraine.

Background

Catastrophizing about pain is a critical variable in how we understand adjustment to pain and has a unique contribution in predicting pain intensity. Recent reports found that migraine is also related to enhanced sensory sensitivity. However, the relationship between pain severity, pain catastrophizing level and sensory sensitivity requires greater study especially among adolescents.

Methods

Participants were 92 adolescents aged 13–18 years, 40 with episodic migraine and 52 healthy controls. The migraine patients were prospectively recruited from outpatient pediatric neurology clinics. All participants completed the Adolescent/Adult Sensory Profile (AASP), and the Pain Catastrophizing Scale for children (PCS-ch). The migraine groups also completed the PedMIDAS, which measures Headache related disability.

Results

Adolescents with migraine had significantly lower tendency to seek sensory input than healthy controls. Elevated rumination and helplessness correlated with higher migraine pain severity. Tendency to avoid sensory input predicted the migraine related disability level. They also significantly higher pain catastrophizing level than healthy controls, as seen in enhanced rumination (p ≤ 0.001) and helplessness (p ≤ 0.05).

Conclusions

Sensory processing difficulties are common among adolescents with episodic migraine. Sensory avoidance may be related to pain experience, and pain catastrophizing and disability level.

Trial registration

ISRCTN ISRCTN73824458. Registered 28 September 2014. retrospectively registered.

A Retrospective Study of the Impact of Pneumococcal Conjugate Vaccine-13 Immunization in a Northern Israel Hospital

BACKGROUND

The introduction of pneumococcal conjugate vaccine-13 (PCV-13) has reduced the burden of invasive pneumococcal disease.

OBJECTIVES

To characterize true positive blood cultures of children who presented to our hospital following implementation of the PCV-13 vaccine.

METHODS

A retrospective study was conducted on positive blood cultures of children presenting with fever from 2010-2017. Subjects were divided into two age groups: a younger group 3-36 months and an older group 3-18 years. Patients were classified as either having or not having a focus of infection at the time of their bacteremia. Pneumococcal isolates were typed at Israel's Streptococcal Reference Laboratory.

RESULTS

The samples included 94 true positive blood cultures. Focal infection with concomitant bacteremia was more common than bacteremia without a focus both overall: 67/94 (71%) vs. 27/94 (28.7%), P <0.001 as well as in the two groups: 32/48 (66%) vs. 16/48 (33%), P = 0.02 in the younger group and 35/46 (76%) vs. 11/46 (24%), P = 0.001 in the older group. Streptococcus pneumoniae was the most common pathogen overall, 27/94 (29%), and in the younger group, 21/48 (44%), but rare in the older group, 6/46 (13%). In the latter, Brucella species predominated, 12/46 (26%), along with Staphylococcus aureus 12/46 (26%).

CONCLUSIONS

Our findings are consistent with other studies reporting decreased pneumococcal bacteremia, bacteremia primarily accompanying focal infection, and changing etiological agents among PCV-13-vaccinated children. Brucella species was prominent in older children with osteoarticular infections. Ongoing surveillance is warranted to better understand the implications of PCV-13.

2624. Viral Pneumonia in Children: Facing the Challenge Using the Host Response

Background

Diagnosing viral pneumonia in children is challenging. Chest radiographic imaging and clinical findings cannot reliably distinguish viral from bacterial pneumonia. Furthermore, pathogen-based diagnosis is limited by inaccessible site of infection and high asymptomatic detection rates. The objectives of this analysis were twofold: first, to establish pneumonia etiology by applying a rigorous expert panel process, and second, to evaluate whether a novel host-immune signature that integrates viral induced proteins TRAIL and IP-10 together with bacterial CRP, can accurately differentiate viral from bacterial pneumonia.

Methods

This analysis included 1025 febrile children enrolled in two multi-center clinical studies that evaluated the host-immune signature performance: ‘Curiosity’ study (Oved et al., PLoS One 2015) and ‘Pathfinder’ study (Srugo et al., Pediatrics 2017). Pneumonia etiology – viral or bacterial – was determined by a panel of 3 independent experts, after reviewing patients’ clinical, laboratory, microbiological, and radiological data. Only cases with majority panel assignment were included. The host-signature generated one of the three results: viral, equivocal or bacterial, based on predetermined cut-offs.

Results

A total of 709 children were eligible for analysis and had an expert panel etiology determination. Of them, 114 were diagnosed with pneumonia: 51 assigned viral and 63 assigned bacterial (Figure 1). The signature separated viral from bacterial pneumonia with a sensitivity of 94% (95% CI: 85%–99%) and specificity of 95% (85%–99%) with 14% equivocal test results. Out of the 51 children diagnosed with viral pneumonia by the expert panel, 40 (78%) were given antibiotics, and 43 (83%) underwent chest x-ray evaluation. The signature correctly classified 42 of these 51 viral children, indicating its potential to reduce antibiotic overuse rates by 4.4-fold (from 78% to 18%; P < 0.001) and chest x-ray examination by 4.8-fold (from 83% to 18%; P < 0.001).

Conclusion

The TRAIL/IP-10/CRP signature exhibits high accuracy for diagnosing viral pneumonia in children. The signature’s potential to safely decrease unnecessary antibiotics and chest radiographic imaging should be examined in future utility studies.

Disclosures

All authors: No reported disclosures.

Sensory Processing Difficulties Correlate With Disease Severity and Quality of Life Among Children With Migraine

Introduction: Headaches are common among children and about 80% of children reporting them. Migraine and tension type headaches are the most common primary headaches in children and the prevalence of migraine is about 8%. Accompanying sensory symptoms are common before, during and after migraine attacks. They may be a part of a wider symptom constellation called sensory processing disorder or difficulties (SPD). This includes both hyper or hypo sensitivity to sensations. However, the literature regarding sensory processing symptoms of children and youth with headaches as well as its interaction with child's emotional aspects and quality of life is scarce. Materials and Methods: One hundred and thirty-four children between the ages of 8 and 12 participated in this study. Fifty-four children (22 boys and 32 girls) with episodic migraine were prospectively recruited from pediatric neurological clinics during the years 2014-2017. The control group included 80 healthy children. Both groups completed a health and demographic questionnaire, headache assessment including Ped-MIDAS, Short Sensory Profile, State-Trait Anxiety Inventory (STAI) for children, and the Pediatric Quality of Life Inventory. Results: Children with migraine showed significantly higher prevalence of sensory processing difficulties and lower quality of life compared to healthy controls. Among children with migraine, sensory processing difficulties significantly correlated with lower quality of life. Headache-related disability and sensory processing difficulties predicted quality of life. Conclusion: The possible relationship between migraine and sensory processing disorder or difficulties stresses the need to screen for sensory processing difficulties among children with migraine and when found-refer to their impacts on children's daily function and quality of life.

Antibiotic misuse in respiratory tract infections in children and adults-a prospective, multicentre study (TAILORED Treatment)

Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages.

873. Using the Host Immune Response to Identify Viral-Bacterial Coinfection in Children With Respiratory Syncytial Virus Infection

Background

A major challenge in the effective management of children with RSV infection is the clinical difficulty of distinguishing a simple viral from viral–bacterial coinfections. As a result, despite the low rates of viral–bacterial coinfection, RSV patients are often prescribed antibiotics with recent reports demonstrating more than 60% antibiotic overuse rates (Van Houten et al. 2018). Here, we examined whether a host-immune signature combining the viral-induced proteins TRAIL and IP-10 with the bacterial-induced protein CRP (ImmunoXpert; Oved et al. 2015) can distinguish simple viral from viral–bacterial coinfection in RSV patients.

Methods

We studied 402 febrile children enrolled as part of “Curiosity,” a prospective study designed to develop and validate the host-immune signature. Infection etiology—viral or viral-bacterial coinfection—was determined by a panel of experts following a review of patients’ clinical, laboratory, radiological, microbiological, and follow-up data. RSV strains were detected using a respiratory multiplex PCR applied to nasal swabs (Seeplex-RV15).

Results

Out of the 402 children with suspected acute infection 29 had a positive RSV detection (Figure 1); of them, 27 had a unanimous expert panel etiology determination: 24 viral and 3 viral–bacterial coinfections. Out of the 24 patients unanimously assigned viral by the expert panel, 13 were given antibiotics, indicating a 54% antibiotic overuse rate. The host-immune signature correctly identified all 3 viral-bacterial coinfection cases, as well as 22 out of the 24 (92%) simple viral patients. This finding supports that the signature has the potential to reduce antibiotic overuse by 6.5-fold (from an overuse of 13/24 = 54% to 2/24 = 8%, P < 0.001).

Conclusion

Our results demonstrate high antibiotic overuse rates for RSV patients, consistent with previous reports. The host-immune signature correctly distinguished simple viral from viral–bacterial coinfection and therefore may have the potential to aid physicians in the correct management of children with RSV infection. Implementation studies are required to evaluate its utility in safely decreasing unnecessary antibiotic use for RSV patients.

Disclosures

N. Mastboim, MeMed Diagnostics: Employee, Salary. K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. T. Gottlieb, MeMed Diagnostics: Employee, Salary. A. Cohen, MeMed Diagnostics: Employee, Salary. R. Navon, MeMed Diagnostics: Employee, Salary. M. Paz, MeMed Diagnostics: Employee, Salary. E. Bamberger, MeMed Diagnostics: Employee, Salary. T. Friedman, MeMed Diagnostics: Employee, Salary. L. Etshtein, MeMed Diagnostics: Employee, Salary. O. Boico, MeMed Diagnostics: Employee, Salary. I. Potasman, MeMed Diagnostics: Holding stock options, Stock options. E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. L. Shani, MeMed Diagnostics: Employee, Salary.

1948. A Host-Response Assay Distinguishes Between Simple Influenza Patients and Influenza Patients With Bacterial Coinfection

Background

Identifying bacterial coinfection in influenza patients can be difficult as the symptoms of simple influenza vs. mixed infections are often similar, leading to antibiotic overuse. A new host-response assay (ImmunoXpert™) that integrates the levels of three proteins (TRAIL, IP-10, and CRP) was shown to exhibit high performance in distinguishing between bacterial and viral disease in two double-blind validation studies. Here we sought to evaluate its ability to differentiate between simple influenza and influenza with bacterial coinfection.

Methods

The study population included 653 febrile pediatric and adult patients prospectively recruited in the “Curiosity” study. Patient etiology (simple viral vs. mixed infection) was determined by unanimous expert adjudication based on comprehensive clinical, laboratory and radiological assessment. Influenza strains (A or B) were detected using multiplex PCR applied to nasal swabs (Seeplex-RV15). We compared the expert panel diagnosis with the assay that gives three possible outcomes: viral, bacterial (including viral with bacterial coinfection) or equivocal. An equivocal outcome does not provide diagnostic information and is observed in ~10% of cases.

Results

Out of 653 patients, 51 had positive influenza detection and unanimous expert diagnosis: 44 simple viral infections and seven influenza with bacterial coinfections (Figure 1). Antibiotics were prescribed to all seven cases of influenza with bacterial coinfection and to 20/44 cases adjudicated as simple viral infections, indicating an overuse rate of 45%. The assay correctly classified 40 of the 44 simple viral cases (out of the remaining four, two were assigned viral with bacterial coinfection, and two received equivocal outcomes) as well as five of the seven viral with bacterial coinfection cases (the remaining two received equivocal outcomes) supporting the assay’s potential to reduce antibiotic overuse 5-fold (from 45% to 4/44 = 9%, P < 0.001).

Conclusion

The host–response assay can differentiate between simple influenza and influenza patients with bacterial coinfection, with potential to reduce antibiotic overuse. Utility studies are warranted to demonstrate that the assay can safely assist physicians in correct management of influenza patients.

Disclosures

M. Paz, MeMed Diagnostics: Employee, Salary. K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. T. Gottlieb, MeMed Diagnostics: Employee, Salary. A. Cohen, MeMed Diagnostics: Employee, Salary. R. Navon, MeMed Diagnostics: Employee, Salary. N. Mastboim, MeMed Diagnostics: Employee, Salary. E. Bamberger, MeMed Diagnostics: Employee, Salary. T. Friedman, MeMed Diagnostics: Employee, Salary. L. Etshtein, MeMed Diagnostics: Employee, Salary. O. Boico, MeMed Diagnostics: Employee, Salary. I. Potasman, MeMed Diagnostics: Holding stock options, Stock options. E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary. L. Shani, MeMed Diagnostics: Employee, Salary.

A host-protein signature is superior to other biomarkers for differentiating between bacterial and viral disease in patients with respiratory infection and fever without source: a prospective observational study

Bacterial and viral infections often present with similar symptoms. Etiologic misdiagnosis can alter the trajectory of patient care, including antibiotic overuse. A host-protein signature comprising tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein-10 (IP-10), and C-reactive protein (CRP) was validated recently for differentiating bacterial from viral disease. However, a focused head-to-head comparison of its diagnostic performance against other biomarker candidates for this indication was lacking in patients with respiratory infection and fever without source. We compared the signature to other biomarkers and prediction rules using specimens collected prospectively at two secondary medical centers from children and adults. Inclusion criteria included fever > 37.5 °C, symptom duration ≤ 12 days, and presentation with respiratory infection or fever without source. Comparator method was based on expert panel adjudication. Signature and biomarker cutoffs and prediction rules were predefined. Of 493 potentially eligible patients, 314 were assigned unanimous expert panel diagnosis and also had sufficient specimen volume. The resulting cohort comprised 175 (56%) viral and 139 (44%) bacterial infections. Signature sensitivity 93.5% (95% CI 89.1–97.9%), specificity 94.3% (95% CI 90.7–98.0%), or both were significantly higher (all p values < 0.01) than for CRP, procalcitonin, interleukin-6, human neutrophil lipocalin, white blood cell count, absolute neutrophil count, and prediction rules. Signature identified as viral 50/57 viral patients prescribed antibiotics, suggesting potential to reduce antibiotic overuse by 88%. The host-protein signature demonstrated superior diagnostic performance in differentiating viral from bacterial respiratory infections and fever without source. Future utility studies are warranted to validate potential to reduce antibiotic overuse.

A novel host-protein assay outperforms routine parameters for distinguishing between bacterial and viral lower respiratory tract infections

Bacterial and viral lower respiratory tract infections (LRTIs) are often clinically indistinguishable, leading to antibiotic overuse. We compared the diagnostic accuracy of a new assay that combines 3 host-biomarkers (TRAIL, IP-10, CRP) with parameters in routine use to distinguish bacterial from viral LRTIs. Study cohort included 184 potentially eligible pediatric and adult patients. Reference standard diagnosis was based on adjudication by an expert panel following comprehensive clinical and laboratory investigation (including respiratory PCRs). Experts were blinded to assay results and assay performers were blinded to reference standard outcomes. Evaluated cohort included 88 bacterial and 36 viral patients (23 did not fulfill inclusion criteria; 37 had indeterminate reference standard outcome). Assay distinguished bacterial from viral LRTI patients with sensitivity of 0.93±0.06 and specificity of 0.91±0.09, outperforming routine parameters, including WBC, CRP and chest x-ray signs. These findings support the assay's potential to help clinicians avoid missing bacterial LRTIs or overusing antibiotics.

A Novel Host-protein Assay Accurately Distinguishes Bacterial From Viral Upper Respiratory Tract Infections

Background

Bacterial and viral infections are often clinically indistinguishable, particularly in upper respiratory tract infections (URTI), which leads to antibiotic misuse. A novel assay (ImmunoXpert™) that integrates measurements of three host-response proteins (TRAIL, IP-10, CRP) was recently developed to assist in differentiation between bacterial and viral etiologies. We evaluated the assay performance in URTI patients and compared it with standard laboratory measures.

Methods

We performed a sub-analysis of 464 patients with clinical suspicion of URTI enrolled in three previously conducted multi-center clinical studies that evaluated the assay performance in patients with acute infections: ‘Curiosity’ study (NCT01917461), ‘Opportunity’ study (NCT01931254), and ‘Pathfinder’ study (NCT01911143). Comparator method was predetermined criteria combined with expert panel adjudication, which was blinded to the test results. Diagnostic performance was evaluated by comparing test and comparator method outcomes.

Results

A unanimous panel adjudication was attained for 61 bacterial (13%) and 241 viral (52%) patients (162 patients (35%) had an indeterminate diagnosis). The assay distinguished between bacterial and viral infected patients with a sensitivity of 92% (95% CI: 82%- 98%) and specificity of 93% (88%-96%) with 11% equivocal test results. Overall the assay outperformed other routine laboratory tests (FIG 1), including: white blood cell count (WBC; cutoff 15,000 cells/µL, sensitivity 48% (35%-60%), P < 10^-−6; specificity 85% (80%-90%), P < 0.05); CRP (cutoff 40 mg/L, sensitivity 82% (72%–92%), P = 0.16, specificity 79% (74%–84%), P < 10^-4); Procalcitonin (PCT; cutoff 0.5 ng/mL, sensitivity 22% (11%–32%), P < 10^–14, specificity 80% (74%–85%), P < 0.001); absolute neutrophil count (ANC; cutoff 10,000 cells/µL, sensitivity 58% (45%–71%), P < 10^-−4, specificity 94% (91%–97%), P = 0.7).

Conclusion

The novel assay demonstrated superior performance compared with routine laboratory tests (WBC, ANC) and biomarkers (CRP, PCT), in distinguishing bacterial from viral etiologies in patients with URTI. It has the potential to help clinicians avoid missing bacterial infections or prescribing unwarranted antibiotics for viral URTIs.

Disclosures

K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary T. Gottlieb, MeMed Diagnostics: Employee, Salary R. Navon, MeMed Diagnostics: Employee, Salary A. Cohen, MeMed Diagnostics: Employee, Salary O. Boico, MeMed Diagnostics: Employee, Salary M. Paz, MeMed Diagnostics: Employee, Salary L. Etshtein, MeMed Diagnostics: Employee, Salary G. Kronenfeld, MeMed Diagnostics: Employee, Salary T. Friedman, MeMed Diagnostics: Employee, Salary E. Bamberger, MeMed Diagnostics: Employee, Salary I. Chistyakov, MeMed Diagnostics: Consultant, Consulting fee I. Potasman, MeMed Diagnostics: Holding stock options, stock options

Validation of a Novel Assay to Distinguish Bacterial and Viral Infections

BACKGROUND

Reliably distinguishing bacterial from viral infections is often challenging, leading to antibiotic misuse. A novel assay that integrates measurements of blood-borne host-proteins (tumor necrosis factor-related apoptosis-inducing ligand, interferon γ-induced protein-10, and C-reactive protein [CRP]) was developed to assist in differentiation between bacterial and viral disease.

METHODS

We performed double-blind, multicenter assay evaluation using serum remnants collected at 5 pediatric emergency departments and 2 wards from children ≥3 months to ≤18 years without (n = 68) and with (n = 529) suspicion of acute infection. Infectious cohort inclusion criteria were fever ≥38°C and symptom duration ≤7 days. The reference standard diagnosis was based on predetermined criteria plus adjudication by experts blinded to assay results. Assay performers were blinded to the reference standard. Assay cutoffs were predefined.

RESULTS

Of 529 potentially eligible patients with suspected acute infection, 100 did not fulfill infectious inclusion criteria and 68 had insufficient serum. The resulting cohort included 361 patients, with 239 viral, 68 bacterial, and 54 indeterminate reference standard diagnoses. The assay distinguished between bacterial and viral patients with 93.8% sensitivity (95% confidence interval: 87.8%-99.8%) and 89.8% specificity (85.6%-94.0%); 11.7% had an equivocal assay outcome. The assay outperformed CRP (cutoff 40 mg/L; sensitivity 88.2% [80.4%-96.1%], specificity 73.2% [67.6%-78.9%]) and procalcitonin testing (cutoff 0.5 ng/mL; sensitivity 63.1% [51.0%-75.1%], specificity 82.3% [77.1%-87.5%]).

CONCLUSIONS

Double-blinded evaluation confirmed high assay performance in febrile children. Assay was significantly more accurate than CRP, procalcitonin, and routine laboratory parameters. Additional studies are warranted to support its potential to improve antimicrobial treatment decisions.

Occipital Headaches in Children: Are They a Red Flag?

Occipital headache is considered a risk factor for serious secondary headache pathology. The purpose of our study was to assess the etiology of occipital headaches among children visiting the emergency department. Subjects were children aged 5 to 18 years who were referred to the emergency department due to headaches during the years 2013 to 2014. A total of 314 patients with headaches were seen at our emergency department. Thirty-nine patients had occipital headaches. Viral infections were the most prevalent final diagnosis (97; 31%), followed by migraine (37; 11.8%). None of our patients had a brain tumor. There was no difference in final diagnosis between the occipital and nonoccipital groups. The most common causes of occipital headaches are viral infections and primary headaches. Serious intracranial disorders presenting solely as occipital headaches and not accompanied by other neurologic signs are uncommon. Thus, occipital headaches should be evaluated in the same manner as other headache locations.

Bronchiolitis in young infants: is it a risk factor for recurrent wheezing in childhood?

BACKGROUND

Acute bronchiolitis in infancy is considered a risk factor for recurrent wheezing episodes in childhood. The present study assessed prevalence, clinical manifestations and risk factors for recurrent wheezing events during the first 3 years of life and persistent wheezing events beyond this age in children hospitalized as young infants with acute bronchiolitis.

METHODS

Two groups of children aged 6 years were included. The study group comprised 150 children with a history of hospitalization for bronchiolitis, with the first event at <6 months of age. The control group comprised 66 age- and sex-matched children with no history of bronchiolitis before 6 months of age. Children in both groups had been followed until 6 years of age by their pediatricians; data were obtained retrospectively by reviewing ambulatory records during children's visits in pediatricians' clinics. The data included epidemiological parameters, prevalence, age at onset, number of and treatments given for episodes of wheezing events prior to 6 years of age, pathogens detected, and severity of acute bronchiolitis in the study group.

RESULTS

Overall, 58% and 27% of children in the study and control groups, respectively (P=0.001) had recurrent wheezing episodes prior to the age of 3 years. Children in the study group had earlier onset of recurrent wheezing, had more episodes of wheezing, and required more bronchodilator and systemic steroids treatments compared to the control group.

CONCLUSION

Hospitalization within the first six months of life for acute bronchiolitis is an independent risk factor for recurrent wheezing episodes during the first 3 years of life.

A pilot study of an emotional intelligence training intervention for a paediatric team

OBJECTIVE

Emotional intelligence (EI) is the individual's ability to perceive, understand and manage emotion and to understand and relate effectively to others. We examined the degree to which EI training may be associated with a change in EI among different medical personnel and patient satisfaction.

DESIGN, SETTING AND PARTICIPANTS

The EI of 17 physicians and 10 nurses in paediatric ward was prospectively evaluated with Bar-On's EI at baseline and after 18 months. 11 physicians who did not undergo the intervention served as controls.

INTERVENTIONS

The intervention consisted of a training programme comprising group discussions, simulations and case studies.

MAIN OUTCOMES AND MEASURES

Pre-emotional quotient inventory (EQ-i) and post-EQ-i scores and patient satisfaction surveys of nurse and physicians pre-intervention and post-intervention were analysed.

RESULTS

The mean overall EI score of the study sample rose from 99.0±9.6 (both plus and minus mathematical operations standing for SD) at baseline to 105.4±10 (p<0.000) after 18 months, with the most robust increase (nearly 6%; p<0.003) manifested among physicians. In contrast, the control group's EI scores did not change over this period. Within the intervention group, physicians displayed a statistically significant increase in three of the five EI dimensions, compared with only one of the five EI dimensions for nurses. Patient satisfaction scores relating to physician care rose from 4.4 pre-intervention to 4.7 post-intervention (p=0.03).

CONCLUSION

An EI intervention led to an overall increase in EI scores, with a significant improvement in patient satisfaction. These findings suggest important potential benefits for both staff and their patients.

The Effect of Elevated Intra-Abdominal Pressure on TLR4 Signaling in Intestinal Mucosa and on Intestinal Bacterial Translocation in a Rat

BACKGROUND

Recent evidence suggests that elevated intra-abdominal pressure (IAP) may adversely affect the intestinal barrier function. Toll-like receptor 4 (TLR-4) is responsible for the recognition of bacterial endotoxin or lipopolysaccharide and for initiation of the Gram-negative septic shock syndrome. The objective of the current study was to determine the effects of elevated IAP on intestinal bacterial translocation (BT) and TLR-4 signaling in intestinal mucosa in a rat model.

METHODS

Male Sprague-Dawley rats were randomly assigned to one of two experimental groups: sham animals (Sham) and IAP animals who were subjected to a 15 mmHg pressure pneumoperitoneum for 30 minutes. Rats were sacrificed 24 hours later. BT to mesenteric lymph nodes, liver, portal vein blood, and peripheral blood was determined at sacrifice. TLR4-related gene and protein expression (TLR-4; myeloid differentiation factor 88 [Myd88] and TNF-α receptor-associated factor 6 [TRAF6]) expression were determined using real-time PCR, western blotting, and immunohistochemistry.

RESULTS

Thirty percent of sham rats developed BT in the mesenteric lymph nodes (level I) and 20% of control rats developed BT in the liver and portal vein (level II). abdominal compartment syndrome (ACS) rats demonstrated an 80% BT in the lymph nodes (Level I) and 40% BT in the liver and portal vein (Level II). Elevated BT was accompanied by a significant increase in TLR-4 immunostaining in jejunum (51%) and ileum (35.9%), and in a number of TRAF6-positive cells in jejunum (2.1%) and ileum (24.01%) compared to control animals. ACS rats demonstrated a significant increase in TLR4 and MYD88 protein levels compared to control animals.

CONCLUSIONS

Twenty-four hours after the induction of elevated IAP in a rat model, increased BT rates were associated with increased TLR4 signaling in intestinal mucosa.

Adult Pertussis Is Hazardous for the Newborn

We report 4 cases involving the likely transmission of pertussis from parents to newborns in a hospital setting. The adoption of proper infection control measures and targeted screening of parents may reduce the potential for such transmission.

Pediatric mixed headache -The relationship between migraine, tension-type headache and learning disabilities - in a clinic-based sample

Background

Headache is a common complaint among children. The most common primary headache syndromes in childhood are migraine and TTH. However many times they seem to overlap. The purpose of our study was to assess the relationship between pediatric migraine, tension-type headache (TTH) and learning disabilities.

Methods

Children presenting with headache to three pediatric neurology clinics in the last 5 years were assessed. Two hundred sixty-two children, 5–18 years of age, who met the criteria for migraine were included.

Results

Of 262 children (54 % female) who had migraine, 26.2 % had migraine with aura. 59 children (22.5 % of the full sample) reported also having headaches that met the criteria for episodic TTH/mixed headaches. Females were more than 2.8 times more likely to experience mixed headaches than males (OR: 2.81, 95 % CI: 1.43–5.54; p <.003). Multiple logistic regression analysis revealed that older age (p <0.02), family history of aura (p <.02), and (lack of) TTH (p <.003) were significant predictors of aura, whereas gender was not significant (p >0.20). Children who had migraine with aura were less likely to have mixed headaches than children who did not have aura (OR: 0.26, 95 % CI: 0.11–0.63; p <.003). Children with mixed headaches were 2.7 times more likely to have a learning disability than children with migraine alone.

Conclusions

Episodic TTH and migraine without aura (mixed headaches) in children might be part of a continuum, which can explain the high incidence of their co-occurrence as opposed to migraine with aura. Children with mixed headaches have a higher incidence of learning disability compare to those with migraine alone.

Frequency of pediatric migraine with aura in a clinic-based sample

OBJECTIVE

To assess the prevalence and risk factors for pediatric migraine with aura (MWA) among patients presenting to pediatric neurology clinics.

BACKGROUND

Headache is a common complaint among children, and the prevalence of migraine is about 8%. Up to one third of adults with migraine report experiencing aura; however, the exact percentage in children is unknown.

METHODS

Medical records of children presenting with headache to three pediatric neurology clinics in Haifa in the last 5 years were retrospectively reviewed. Inclusion criteria were a diagnosis of migraine headache at 5-18 years of age.

RESULTS

Of 260 children (140 female) who had migraine, 26.2% experienced aura. MWA was more common among females compared to males (32.6% vs 18.9%, P < .01) and among older children (OR: 2.50, 95% CI: 1.20-5.20; P < .01). Among those who experienced aura, visual aura was more common in females than males (66.7% vs 33.3%, P < .04). Family history of migraine was strongly related to MWA (P < .02): the odds of MWA were 2.46 times greater in children who had a family history of migraine. (OR: 2.46, 95% CI: 1.08-5.62; P < .03).

CONCLUSIONS

MWA is as common in children as in adults. Aura is more common in older children. Children who have MWA are more likely to have a family history of migraine.

[PRIMARY HEADACHE IN CHILDREN AND ADOLESCENTS--DIAGNOSIS AND TREATMENT]

BACKGROUND

Primary headaches are one of the most common disorders of childhood, with migraine and tension type headaches (TTHs) being the most frequent ones. In spite of their prevalence, there is paucity of knowledge regarding the underlying pathophysiological mechanisms that cause headaches and regarding the unique aspects of headaches in children and adolescents.

AIM

To review the literature and summarize the knowledge regarding clinical features, diagnosis and management of primary headache in children and adolescents, mainly migraine and TTH.

RESULTS AND CONCLUSIONS

Most of our current knowledge regarding primary headaches in children and adolescents is driven from extrapolations from studies that were conducted with adult patients. Therefore, it needs to be validated for the different age groups. Migraines may be diagnosed effectively based on the 2nd edition of the International Classification of Headache Disorders (ICHD-II), however, TTH is diagnosed mainly by the absence of features found in other headache types. Treatment strategies for primary headaches vary according to patient's age, family structure, culture and beliefs, headache diagnosis, and based on the disability the headache imposes on the patient's daily living. It was shown that a multidisciplinary approach, that includes continuing counseling, education, and reassurance, in combination with pharmacological and non-pharmacological treatment, is an effective strategy for children and adolescents suffering from primary headaches. Further studies are needed to enrich our knowledge about the pathophysiological mechanisms that cause headaches in children and adolescents and to develop efficient strategies to alleviate their burden.

The Decline of Pertussis-Specific Antibodies After Tetanus, Diphtheria, and Acellular Pertussis Immunization in Late Pregnancy

We prospectively measured pertussis-specific antibodies 9-15 months after delivery in women immunized with tetanus, diphtheria, and acellular pertussis (Tdap) after the 20th week of their recent pregnancy. The Tdap-immunized women (n = 38) exhibited a decline in geometric mean concentrations between their peripartum and follow-up levels for immunoglobulin G to pertussis toxin (21.48 [95% confidence interval, 12.51-36.89] vs 11.72 [7.09-19.37] IU/mL];); filamentous hemagglutinin (185.95 [157.93-218.94] vs 140.33 IU/mL [113.46-173.57] IU/mL); and pertactin (171.52 [120.73-243.67] vs 83.74 [60.58-115.75] IU/mL) (all P < .001). For women immunized with Tdap during late pregnancy, pertussis-specific immunoglobulin G levels decreased significantly 9-15 months after delivery.

The prognostic value of cerebrospinal fluid characteristics in dogs without deep pain perception due to thoracolumbar disc herniation

Providing a pre-operative prognosis for dogs presented with absent deep pain perception (DPP) is extremely challenging, as the overall recovery rates widely vary. This study assesses the possible correlation between the severity of spinal cord injury and CSF cytology in 31 paraplegic dogs presented with absent DPP due to acute thoracolumbar intervertebral disc herniation (TL-IVDH). All dogs underwent surgical decompression immediately following diagnosis. CSF TNCC, macrophage percentage and macrophage to monocyte (MΦ:M) ratio were significantly higher in dogs that failed to regain DPP within 10 days post-operatively and in dogs that failed to regain ambulation at the end of the study period (P< 0.05). MΦ:M of 0.73 and higher corresponded to a sensitivity of 54% and specificity of 100% for prediction of a negative long-term outcome. CSF TNCC, macrophage percentage and MΦ:M ratio effectively predicted regaining DPP and the long-term outcome in dogs that lost DPP due to acute TL-IVDH.

Immunization of pregnant women against pertussis: the effect of timing on antibody avidity

BACKGROUND

The Centers for Disease Control and Prevention recommend tetanus-diphteria-acellular pertussis (Tdap) immunization during pregnancy, preferably at 27-36 weeks gestation.

AIMS

First, to assess the relative avidity index (RAI) of umbilical cord immunoglobulin G (IgG) to pertussis toxin (PT) for newborns of women immunized with Tdap during late pregnancy as compared to unimmunized women. Second, to assess whether there is a preferential period of gestational Tdap immunization that provides the highest RAI of umbilical cord IgG to PT.

METHODS

RAI of IgG to PT was assessed via an adapted ELISA using NH4SCN as a dissociating agent.

RESULTS

We found that newborns of women immunized with Tdap during late pregnancy (n=52) had higher mean RAI of umbilical cord IgG to PT than those of unimmunized women (n=8), 73.77%±12.08 (95% CI, 70.41-77.13) vs. 50.23%±21.32 (95% CI, 32.41-68.06), p<0.001. Further, the RAI of umbilical cord IgG to PT was significantly higher in newborns of women immunized at 27-30(+6) weeks gestation (n=20) when compared with newborns of women immunized at 31-36 weeks (n=22) and >36 weeks (n=7), 79.53%±5.61 (95% CI, 76.91-82.16) vs. 71.56%±12.58 (95% CI, 65.98-77.14) vs. 63.93%±17.98 (95% CI, 47.31-80.56), p<0.03.

CONCLUSION

Gestational Tdap immunization between 27 and 30(+6) weeks resulted in the highest avidity of IgG to PT conveyed at delivery as compared with immunization beyond 31 weeks gestation. Future studies should be conducted to confirm our findings to optimize pertussis-controlling strategies.

Use of Cellular Telephones and Transmission of Pathogens by Medical Staff in New York and Israel

Hands and instruments used by healthcare workers may serve as vectors for the nosocomial transmission of microorganisms. The use of cellular telephones by medical personnel and the associated nosocomial transmission of pathogens have not been thoroughly examined. Findings from our study show that cellular telephones are commonly used by hospital personnel, even during patient contact. One-fifth of the cellular telephones examined in this study were found to harbor pathogenic microorganisms, showing that these devices may serve as vectors for transmission to patients.

The effect of timing of maternal tetanus, diphtheria, and acellular pertussis (Tdap) immunization during pregnancy on newborn pertussis antibody levels - a prospective study

BACKGROUND

The Centers for Disease Control and Prevention recommend Tdap immunization during pregnancy, preferably at 27-36 weeks.

AIM

To ascertain whether there is a preferential period of maternal Tdap immunization during pregnancy that provides the highest concentration of pertussis-specific antibodies to the newborn.

METHODS

This prospective study measured pertussis-specific antibodies in paired maternal-cord sera of women immunized with Tdap after the 20th week of their pregnancy (n=61).

RESULTS

The geometric mean concentrations (GMCs) of Immunoglobulin G (IgG) to pertussis toxin (PT) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks (n=21) compared with 31-36 weeks (n=30) and >36 weeks (n=7), 46.04 international units/milliliter (IU/mL) (95% CI, 24.29-87.30) vs. 8.69IU/mL (95% CI, 3.66-20.63) and 21.12IU/mL (95% CI, 7.93-56.22), p<0.02, respectively. The umbilical cord GMCs of IgG to filamentous hemagglutinin (FHA) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks compared with 31-36 weeks and >36 weeks, 225.86IU/mL (95% CI, 182.34-279.76) vs. 178.31IU/mL (95% CI, 134.59-237.03) and 138.03IU/mL (95% CI, 97.61-195.16), p<0.02, respectively.

CONCLUSIONS

Immunization of pregnant women with Tdap between 27-30(+6) weeks was associated with the highest umbilical cord GMCs of IgG to PT and FHA compared with immunization beyond 31 weeks gestation. Further research should be conducted to reaffirm these finding in order to promote an optimal pertussis controlling policy.

The induction of breast milk pertussis specific antibodies following gestational tetanus-diphtheria-acellular pertussis vaccination

BACKGROUND

Center for Disease Control and Prevention recommends vaccination of pregnant women with tetanus-diphtheria-acellular pertussis (Tdap).

AIM

To measure pertussis specific antibodies, total protein and their ratio in breast milk following gestational Tdap vaccination.

METHODS

Women who received Tdap after the 20th week of pregnancy were recruited and unvaccinated women served as controls. Breast milk total protein, immunoglobulin A (IgA) to pertussis toxin (PT), filamentous hemagglutinin (FHA) and immunoglobulin G (IgG) to PT, FHA and pertactin (PRN) were measured. To overcome the dilution that occurs in the transition from colostrum to mature breast milk, we calculated pertussis specific antibody to total protein ratio.

RESULTS

Pertussis specific IgA was the predominant pertussis immunoglobulin in the colostrum of Tdap vaccinated women with the geometric mean concentrations (GMCs) of IgA to FHA higher than for IgA to PT, 24.12 ELISA units/milliliter (EU/mL) vs. 8.18EU/mL, respectively, p<0.004. There were differences between the vaccinated women and controls in the GMCs of IgA to FHA and IgG to PRN in the colostrum, 24.12EU/mL vs. 6.52EU/mL, p=0.01 and 2.46EU/mL vs. <0.6EU/mL, p=0.03, respectively. The GMCs of total protein showed significant decline over 8 weeks in the vaccinated women and controls, p<0.004. Among vaccinated women, there was significant decline in the GMCs of IgA to PT and FHA over 8 weeks, p<0.001. The geometric mean ratio of IgA to FHA to total protein also declined significantly over 8 weeks in the vaccinated women, p<0.01, demonstrating a true decrease, however, pertussis IgA was measurable at 8 weeks.

CONCLUSIONS

Select colostrum pertussis antibody levels were significantly higher among women vaccinated with Tdap during pregnancy compared with unvaccinated women. Among vaccinated women, maximal levels of pertussis specific IgA were in the colostrum but still detected at 8 weeks. Lactation may augment infant's protection against pertussis.

Headache and physical and sexual abuse among Jewish and Arab adolescents in Israel

The purpose of the present study was to evaluate the relationship between headaches and physical and sexual abuse. A self-administered, anonymous questionnaire was presented to 2088 tenth grade students in Northern Israel. Participants were Jews and Arabs between the ages of 15 to 16 years. Arab adolescents comprised 55% of the analyzed sample and adolescent Jews 45%. With regard to gender, 56% of participants were females. Of the Arab participants, 18.6% reported having frequent headaches, less than that reported in the Jewish group (27.9%). Jewish girls who were physically abused during childhood had a higher prevalence of frequent headaches (55% vs 33% P < .001). Jewish students who reported being sexually abused had higher headache prevalence as well (44.4% vs 27.3% P = .05). In conclusion, adolescents who reported to have been physically or sexually abused report a higher prevalence of headache compared to their peers.

Legionella pneumophila and Pneumocystis jirovecii coinfection in an infant treated with adrenocorticotropic hormone for infantile spasm: case report and literature review

We describe an 8-month-old infant with infantile spasms treated with adrenocorticotropic hormone (ACTH) who presented with fatal Legionella pneumophila and Pneumocystis jirovecii infection. Emphasis is placed on the ensuing immunosuppression and infectious sequelae of ACTH therapy. Given that ACTH therapy may increase the risk of fatal infection, patients undergoing such treatment should be closely monitored, with particular attention paid to the functioning of the immune system.

[Genital ulcers--what's new?]

The most common infectious causes of genital ulcers are herpes simplex virus and syphilis. However, mixed infections can occur and genital ulcer may increase the risk of acquiring human immunodeficiency virus. Although the history and physical examination can narrow the differential diagnosis, there is a need for initial routine laboratory testing for the most common pathogens that includes: for syphilis: serologic screening and dark field examination of the lesion; for herpes simplex virus: serology, vial culture and/or polymerase chain reaction. Human immunodeficiency testing is mandatory. Recently, some clinical laboratories adapted the reverse screening algorithm for syphilis (initial treponemal test, and, if positive, followed by non-treponemal test) that may potentially lead to overtreatment. Early and prompt therapy may decrease the risk of transmission of the infectious agent to others. This article reviews the infectious pathogens causing genital ulcers, their unique clinical manifestation, diagnosis and treatment.

Primary headaches, attention deficit disorder and learning disabilities in children and adolescents

Background

Primary headaches and Learning difficulties are both common in the pediatric population. The goal of our study was to assess the prevalence of learning disabilities and attention deficit disorder in children and adolescents with migraine and tension type headaches.

Methods

Retrospective review of medical records of children and adolescents who presented with headache to the outpatient pediatric neurology clinics of Bnai-Zion Medical Center and Meyer Children’s Hospital, Haifa, during the years 2009–2010. Demographics, Headache type, attention deficit disorder (ADHD), learning disabilities and academic achievements were assessed.

Results

243 patients met the inclusion criteria and were assessed: 135 (55.6%) females and 108 (44.4%) males. 44% were diagnosed with migraine (35.8% of the males, 64.2% of the females, p = 0.04), 47.7% were diagnosed with tension type headache (50.4% of the males, 49.6% of the females). Among patients presenting with headache for the first time, 24% were formerly diagnosed with learning disabilities and 28% were diagnosed with attention deficit disorder (ADHD). ADHD was more prevalent among patients with tension type headache when compared with patients with migraine (36.5% vs. 19.8%, p = 0.006). Poor to average school academic performance was more prevalent among children with tension type headache, whereas good to excellent academic performance was more prevalent among those with migraine.

Conclusions

Learning disabilities and ADHD are more common in children and adolescents who are referred for neurological assessment due to primary headaches than is described in the general pediatric population. There is an association between headache diagnosis and school achievements.

Is it justified to include urine cultures in early (< 72 hours) neonatal sepsis evaluations of term and late preterm infants?

OBJECTIVE

Evaluate the need for urine culture in early neonatal sepsis workup of term and late preterm infants.

STUDY DESIGN

Urine culture by suprapubic aspiration or catheter was included in early sepsis evaluations of 173 term and late preterm newborns (mean gestational age 38.6 ± 2.0 weeks) during a 6-month study period. A historic control group included 182 newborns (38.6 ± 2.9 weeks) who had sepsis evaluations without routine urine cultures a year earlier.

RESULTS

Urine cultures were sampled in 106 (61%) of the study group, No significant differences were found between study and control groups in the rate of bacteremia (1.73% versus 2.2%) or urinary tract infection (UTI; 0.94% versus 1.1%), which was low. Early UTIs were not accompanied by bacteremia or structural anomalies and were associated with exacerbation of neonatal jaundice in two of three infants.

CONCLUSIONS

There seems to be no justification for routine urine culture in early neonatal sepsis workup of term and late preterm infants, unless there are accompanying clinical symptoms, usually related to neonatal jaundice.

Beyond "safe sex"--can we fight adolescent pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is a common disorder affecting sexually active adolescents. The Centers for Disease Control and Prevention (CDC) and European CDC report Chlamydia trachomatis as the most common sexually transmitted infection and one of the main etiological agents causing PID. C. trachomatis' and PID's high prevalence may be attributed to multiple factors including high-risk sexual behaviors, sensitive laboratory diagnostics (polymerase chain reaction), and the introduction of chlamydia screening programs. The pathogenesis of C. trachomatis infection is complex with recent data highlighting the role of toll-like receptor 2 and four in the mediation of the inflammatory cascade. The authors review the etiology of the disease, explore its pathogenesis, and discuss a variety of strategies that may be implemented to reduce the prevalence of C. trachomatis including: (a) behavioral risk reduction, (b) effective screening of asymptomatic females, (c) targeted male screening, (d) implementation of a sensitive, rapid, self-administered point-of-care testing, and (e) development of an effective vaccine.

The cross- ethnic variations in the prevalence of headache and other somatic complaints among adolescents in Northern Israel

Background

Headache is the most common cause for chronic or recurrent pain in childhood and adolescence. Chronic pain may have a long-term effect on adolescents. It might contribute to functional limitations, such as poor school attendance, and it may adversely affect development of healthy social relationships. The aim of our study was to examine the cross- ethnic variation in the prevalence of headache in a non- clinical sample of adolescents in Northern Israel and to learn about its association to other somatic complaints.

Methods

A self-administered, anonymous questionnaire was presented to 2,088 tenth grade students attending 19 high-schools in Northern Israel (all the public high schools within two districts). Participants were Jews and Arabs, the latter including Muslim, Christians, and Druze, aged 15 to 16. Parental and student consent was obtained from all participants. The study was approved by the IRB of our institution.

Results

All 2088 questionnaires were returned although only 2019 were usable and analyzed. Arab adolescents comprised 55% (1117) of the analyzed sample and Jews 45% (902), 56% of participants were girls. Of the Arab participants, 18.6% reported having frequent headaches (girls 25.3%, boys 9.1%, P<0.0001) much less than their Jewish peers (P<0.0001) among whom 27.9% reported having frequent headaches (girls 35.6%, boys 19% P<0.0001). Other somatic complaints such as abdominal pain, palpitations, disordered sleep and fatigue were more frequent in adolescents (Jews and Arabs, girls and boys) who suffered from headaches than in their peers who did not report having headaches (P<0.0001), the same pattern observed in the Jewish and the Arab group.

Conclusions

Headache is a frequent complaint among adolescents in Northern Israel. Jewish adolescents reported having headaches more frequently than their Arab peers. Those who suffered from frequent headaches also reported having significantly more other somatic complaints than adolescents without headaches. Girls had more somatic complaints then boys in the two ethnic groups.