Assessment and comparison of the ILI case definition in clinical and school-based community settings: ORCHARDS/IISP

Context: Influenza-like illness (ILI) is commonly used in clinical and public health settings to identify influenza cases. CDC defines ILI as fever and either cough or sore throat, with symptom onset within 7 days. Objective: Assess performance of ILI criteria in two settings (clinical and community), comparing symptom profiles and laboratory detection of influenza in children. Study Design and Analysis: Retrospective analyses of data from medically attended influenza (MAI) surveillance and a communitybased study. Datasets were analyzed separately to assess predictors of influenza cases. Analyses were limited to specimens collected within 7 days of symptom onset. Relationships between influenza and each categorical variable were described by the confusion matrix, sensitivity, and specificity. Associations were tested using chi-square tests. Unadjusted and adjusted logistic regression models were used for all variables with RT-PCR result as the outcome. Setting or Dataset: The ORegon CHild Absenteeism due to Respiratory Disease Study (ORCHARDS) is a respiratory infection study based in the Oregon School District (Dane County, WI). The Wisconsin Influenza Incidence Surveillance Project (IISP) is a MAI surveillance system operating in five family medicine clinics in Dane County. Population Studied: Children aged 4-18 years with acute respiratory infections. Intervention/Instrument: Oropharyngeal specimens, collected by research staff (ORCHARDS) or clinicians (IISP), were tested for influenza via RT-PCR and for multiple respiratory viruses at the Wisconsin State Laboratory of Hygiene. Extensive demographic and symptoms data were collected from all participants. Outcome Measures: Influenza(+)PCR. Results: From 9/7/2010-3/12/2020, 1,338 and 2,359 specimens meeting inclusion criteria were collected for IISP and ORCHARDS, respectively. Cough, fever, and ILI classification were significantly associated with influenza (sensitivity ≥92.8%, ≥85.9%, and ≥84.5%, respectively). Receiver operator curve analysis confirmed ILI had high predictive ability in both settings, improved by the inclusion of seasonality and influenza vaccination status (IISP: 0.61 vs 0.76, ORCHARDS: 0.68 vs 0.78). Conclusions: ILI performed well in both clinical and community contexts. Factors most highly associated with increased odds of RT-PCR(+) results were cough, fever, and ILI. Inclusion of seasonality and influenza vaccination status improved the predictive value of ILI in both datasets.

Rapid Antigen Testing in School Health Offices for Surveillance of SARS-CoV-2 and Influenza A

Context: Evaluation of acute respiratory infections (ARIs) has been disrupted by the SARS-CoV-2 (SC2) pandemic, limiting comprehensive surveillance for respiratory pathogens in clinical settings. Alternatives to using medically attended ARI for public health surveillance are needed. A potential approach involves assessing children and school personnel in school health offices (SHOs) as pandemic-related responses enhanced innovative approaches for SC2 testing in novel settings. Objective: Evaluate the comparability of SC2 and influenza A (FLuA) detection based on rapid antigen testing in SHOs to traditional surveillance systems. Study Design: Prospective evaluation of results from rapid antigen testing for SC2 and FluA in SHOs of a suburban/rural school district compared to large-scale, countywide detection of SC2 and clinic-based surveillance of FluA using cross correlation analyses. Setting: Oregon School District (OSD) in Dane County (DC: southcentral Wisconsin) over two academic years (September 2021-April 2023). Population Studied: School-aged children (4-18 years) and school staff/teachers reporting to SHOs with ARI symptoms. Comparator data included all PCR-based testing for SC2 reported to Public Health Madison & Dane County and PCR-based testing for influenza at five family medicine clinics in DC. Intervention/Instrument: Quidel Sofia SARS/Influenza Fluorescent Immunoassay with wireless transmission of anonymous results to a cloud-based server with availability to the study team. Outcome Measures: Cross correlation and lag estimates for weekly counts of SC2 and FLuA cases comparing school-based and community-based results. Results: The SHOs at the 7 OSD schools performed 1,508 tests with few invalid tests (n=7; 0.46%). Participants had a wide age range [1-71 years] with a median age of 13 years, and included 1,145 (76%) students. SC2: 118 and 119,630 cases were identified in OSD and DC, respectively. The maximum cross correlation (r=0.82) occurred with no time lag. FluA: 61 and 75 cases were identified in OSD and DC, respectively. The maximum cross correlation (r=0.69) occurred with DC lagging OSD by 1 week. Conclusions: Surveillance for significant respiratory pathogens can be based on rapid antigen testing within SHOs, is highly comparable with larger scale surveillance programs, and demonstrates either advanced (FluA) or concurrent detections (SC2). Performance of similar programs are needed in other geographical areas and for other pathogens.

Health-related quality of life across disease stages in patients with amyotrophic lateral sclerosis: results from a real-world survey

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is characterized by a rapid disease course, with disease severity being associated with declining health-related quality of life (HRQoL) in persons living with ALS (pALS). The main objective of this study was to assess the impact of disease progression on HRQoL across King's, Milano-Torino Staging (MiToS), and physician-judgement clinical staging. Additionally, we evaluated the impact of the disease on the HRQoL of care partners (cALS).

METHODS

Data were sourced from the Adelphi ALS Disease Specific Programme (DSP)™, a cross-sectional survey of neurologists, pALS and cALS presenting in a real-world clinical setting between July 2020 and March 2021 in Europe and the United States.

RESULTS

Neurologists (n = 142) provided data for 880 pALS. There were significant negative correlations between all three clinical staging systems and EuroQol (European Quality of Life) Five Dimension Five Level Scale (EQ-5D-5L) utility scores and visual analogue scale (VAS) ratings. Although not all differences were significant, 5-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-5) scores showed a stepwise increase in HRQoL impairment at each stage of the disease regardless of the staging system. At later stages, high levels of fatigue and substantial activity impairment were reported. As pALS disease states progressed, cALS also experienced a decline in HRQoL and increased burden.

CONCLUSIONS

Across outcomes, pALS and cALS generally reported worse outcomes at later stages of the disease, highlighting an unmet need in this population for strategies to maximise QoL despite disease progression. Recognition and treatment of symptoms such as pain and fatigue may lead to improved outcomes for pALS and cALS.

Descriptive Epidemiology of Pathogens Associated with Acute Respiratory Infection in a Community-Based Study of K-12 School Children (2015-2023)

School-based outbreaks often precede increased incidence of acute respiratory infections in the greater community. We conducted acute respiratory infection surveillance among children to elucidate commonly detected pathogens in school settings and their unique characteristics and epidemiological patterns. The ORegon CHild Absenteeism due to Respiratory Disease Study (ORCHARDS) is a longitudinal, laboratory-supported, school-based, acute respiratory illness (ARI) surveillance study designed to evaluate the utility of cause-specific student absenteeism monitoring for early detection of increased activity of influenza and other respiratory viruses in schools from kindergarten through 12th grade. Eligible participants with ARIs provided demographic, epidemiologic, and symptom data, along with a nasal swab or oropharyngeal specimen. Multipathogen testing using reverse-transcription polymerase chain reaction (RT-PCR) was performed on all specimens for 18 respiratory viruses and 2 atypical bacterial pathogens (Chlamydia pneumoniae and Mycoplasma pneumoniae). Between 5 January 2015 and 9 June 2023, 3498 children participated. Pathogens were detected in 2455 of 3498 (70%) specimens. Rhinovirus/enteroviruses (36%) and influenza viruses A/B (35%) were most commonly identified in positive specimens. Rhinovirus/enteroviruses and parainfluenza viruses occurred early in the academic year, followed by seasonal coronaviruses, RSV, influenza viruses A/B, and human metapneumovirus. Since its emergence in 2020, SARS-CoV-2 was detected year-round and had a higher median age than the other pathogens. A better understanding of the etiologies, presentations, and patterns of pediatric acute respiratory infections can help inform medical and public health system responses.

Effect of planned school breaks on student absenteeism due to influenza-like illness in school aged children-Oregon School District, Wisconsin September 2014-June 2019

Background

School-aged children and school reopening dates have important roles in community influenza transmission. Although many studies evaluated the impact of reactive closures during seasonal and pandemic influenza outbreaks on medically attended influenza in surrounding communities, few assess the impact of planned breaks (i.e., school holidays) that coincide with influenza seasons, while accounting for differences in seasonal peak timing. Here, we analyze the effects of winter and spring breaks on influenza risk in school-aged children, measured by student absenteeism due to influenza-like illness (a-ILI).

Methods

We compared a-ILI counts in the 2-week periods before and after each winter and spring break over five consecutive years in a single school district. We introduced a "pseudo-break" of 9 days' duration between winter and spring break each year when school was still in session to serve as a control. The same analysis was applied to each pseudo-break to support any findings of true impact.

Results

We found strong associations between winter and spring breaks and a reduction in influenza risk, with a nearly 50% reduction in a-ILI counts post-break compared with the period before break, and the greatest impact when break coincided with increased local influenza activity while accounting for possible temporal and community risk confounders.

Conclusions

These findings suggest that brief breaks of in-person schooling, such as planned breaks lasting 9-16 calendar days, can effectively reduce influenza in schools and community spread. Additional analyses investigating the impact of well-timed shorter breaks on a-ILI may determine an optimal duration for brief school closures to effectively suppress community transmission of influenza.

Feasibility and Functionality of SARS-CoV-2 Rapid Testing in K-12 School Health Offices

INTRODUCTION

The COVID-19 pandemic created unprecedented opportunities to introduce rapid SARS-CoV-2 antigen testing (RSAT) into kindergarten through 12th grade (K-12) school settings. We evaluated the feasibility and functionality of Sofia Fluorescent Immunoassay Flu + SARS in 1 school district across the 2021-2022 academic year.

METHODS

Seven schools in the Oregon School District (Oregon, Wisconsin) were supplied with RSAT analyzers and test kits, along with minimal training of health office staff. We assessed RSAT utilization among schools, rate of invalid results, and comparability to 952 190 reverse transcription-polymerase chain reaction tests performed countywide during the same time period. A feedback survey was distributed to all 13 health office staff to assess respondents' perceptions regarding the feasibility and acceptability of RSAT in the Oregon School District.

RESULTS

Over the school year, 1226 RSATs were performed; SARS-CoV-2 was detected in 103 specimens. Percent positivity was similar to the county level (8.4 vs 9.2%; chi-square = 0.74; P = 0.39). Cross-correlation of weekly positive tests between the Oregon School District and Dane County was maximal with no lag (rs = 0.69; P < 0.001). Health office staff indicated Sofia2 RSAT was easy to perform, and 92.3% reported interest in continuing to utilize RSAT in the upcoming school year.

CONCLUSIONS

Implementing a RSAT protocol is feasible and acceptable for monitoring SARS-CoV-2 cases in K-12 school settings. High rates of compliance and confidence in results demonstrate program effectiveness. Continuing to use RSAT in school settings after the urgency of the pandemic subsides could help address future outbreaks of SARS-CoV-2 and other respiratory viruses within schools and in the larger community.

Rapid Detection of Influenza Outbreaks in Long-Term Care Facilities Reduces Emergency Room Visits and Hospitalization: A Randomized Trial

OBJECTIVES

To assess whether the use of rapid influenza diagnostic tests (RIDTs) for long-term care facility (LTCF) residents with acute respiratory infection is associated with increased antiviral use and decreased health care utilization.

DESIGN

Nonblinded, pragmatic, randomized controlled trial evaluating a 2-part intervention with modified case identification criteria and nursing staff-initiated collection of nasal swab specimen for on-site RIDT.

SETTING AND PARTICIPANTS

Residents of 20 LTCFs in Wisconsin matched by bed capacity and geographic location and then randomized.

METHODS

Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, antiviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalizations, hospitalizations for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over 3 influenza seasons.

RESULTS

Oseltamivir use for prophylaxis was higher at intervention LTCFs [2.6 vs 1.9 courses per 1000 person-weeks; rate ratio (RR) 1.38, 95% CI 1.24-1.54; P < .001]; rates of oseltamivir use for influenza treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR 0.78, 95% CI 0.64-0.92; P = .004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR 0.79, 95% CI 0.67-0.93; P = .004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR 0.64, 95% CI 0.0.59-0.69; P < .001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality.

CONCLUSIONS AND IMPLICATIONS

The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across 3 combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites.

Four Methods for Monitoring SARS-CoV-2 and Influenza A Virus Activity in Schools

This cross-sectional study describes 4 parallel approaches used simultaneously to monitor influenza A virus and SARS-CoV-2 activity within a Wisconsin school district during the Fall 2022 semester and briefly following winter break.

The Influence of Rapid Influenza Diagnostic Testing on Clinician Decision-Making for Patients With Acute Respiratory Infection in Urgent Care

BACKGROUND

The potential benefits of using rapid influenza diagnostic tests (RIDTs) in urgent care facilities for clinical care and prescribing practices are understudied. We compared antiviral and antibiotic prescribing, imaging, and laboratory ordering in clinical encounters with and without RIDT results.

METHODS

We compared patients with acute respiratory infection (ARI) symptoms who received an RIDT and patients who did not at 2 urgent care facilities. Primary analysis using 1-to-1 exact matching resulted in 1145 matched pairs to which McNemar 2 × 2 tests were used to assess the association between the likelihood of prescribing, imaging/laboratory ordering, and RIDT use. Secondary analysis compared the same outcomes using logistic regression among the RIDT-tested population between participants who tested negative (RIDT(-)) and positive (RIDT(+)).

RESULTS

Primary analysis revealed that compared to the non-RIDT-tested population, RIDT(+) patients were more likely to be prescribed antivirals (OR, 10.23; 95% CI, 5.78-19.72) and less likely to be prescribed antibiotics (OR, 0.15; 95% CI, .08-.27). Comparing RIDT-tested to non-RIDT-tested participants, RIDT use increased antiviral prescribing odds (OR, 3.07; 95% CI, 2.25-4.26) and reduced antibiotic prescribing odds (OR, 0.52; 95% CI, .43-.63). Secondary analysis identified increased odds of prescribing antivirals (OR, 28.21; 95% CI, 18.15-43.86) and decreased odds of prescribing antibiotics (OR, 0.20; 95% CI, .13-.30) for RIDT(+) participants compared with RIDT(-).

CONCLUSIONS

Use of RIDTs in patients presenting with ARI symptoms influences clinician diagnostic and treatment decision-making, which could lead to improved patient outcomes, population-level reductions in influenza burden, and a decreased threat of antibiotic resistance.

Changing pattern of respiratory virus detections among school-aged children in a small community - Dane County, Wisconsin, September to December 2022

Widespread school closures and other non-pharmaceutical interventions (NPIs), used to limit the spread of SARS-CoV-2, significantly disrupted transmission patterns of seasonal respiratory viruses. As NPIs were relaxed, populations were vulnerable to resurgence. This study within a small community assessed acute respiratory illness among kindergarten through grade 12 students as they returned to public schools from September through December 2022 without masking and distancing requirements. The 277 specimens collected demonstrated a shift from rhinovirus to influenza. With continued circulation of SARS-CoV-2 and return of seasonal respiratory viruses, understanding evolving transmission patterns will play an important role in reducing disease burden.

Adequacy of using a single nasal swab for rapid influenza diagnostic testing, PCR, and whole genome sequencing

Rapid influenza diagnostic tests (RIDT) demonstrate varying sensitivities, often necessitating reverse transcriptase polymerase chain reaction (RT-PCR) to confirm results. The two methods generally require separate specimens. Using the same anterior nasal swab for both RIDT and molecular confirmation would reduce cost and waste and increase patient comfort. The aim of this study was to determine if RIDT residual nasal swab (rNS) specimens are adequate for RT-PCR and whole genome sequencing (WGS). We performed RT-PCR and WGS on paired rNS and nasopharyngeal or oropharyngeal (NP/OP) swab specimens that were collected from primary care patients across all ages. We randomly selected 199 and 40 paired specimens for RT-PCR and WGS, respectively, from the 962 paired surveillance specimens collected during the 2014-2015 influenza season. Sensitivity and specificity for rNS specimens were 81.3% and 96.7%, respectively, as compared to NP/OP specimens. The mean cycle threshold (Ct) value for the NP/OP specimen was significantly lower when the paired specimens were both positive than when the NP/OP swab was positive and the nasal swab was negative (25.5 vs 29.5; p<0.001). Genomic information was extracted from all 40 rNS specimens and 37 of the 40 NP/OP specimens. Complete WGS reads were available for 67.5% (14 influenza A; 13 influenza B) of the rNS specimens and 59.5% (14 influenza A; 8 influenza B) of the NP/OP specimens. It is feasible to use a single anterior nasal swab for RIDT followed by RT-PCR and/or WGS. This approach may be appropriate in situations where training and supplies are limited. Additional studies are needed to determine if residual nasal swabs from other rapid diagnostic tests produce similar results.

Rapid Detection of Influenza Outbreaks in Long Term Care Facilities Reduces Emergency Room Visits and Hospitalization

Context: Influenza is a significant respiratory pathogen for residents of long-term care facilities (LTCFs). Rapid influenza detection tests (RIDT) may enable early outbreak detection allowing a timely response. Objective: We assessed whether RIDT for LTCF residents with acute respiratory infection is associated with increased antiviral use and decreased healthcare utilization. Study Design and Analysis: Non-blinded, pragmatic, randomized controlled trial (clinicaltrials.gov: NCT0296487). Setting: Wisconsin LTCFs. Population Studied: Residents of 20 LTCFs matched by bed capacity and geographic location. Intervention: (1) modified case identification criteria and (2) nursing-staff initiated collection of nasal swab specimen for on-site RIDT. Outcome Measures: Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, aniviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalization, hospitalization for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over three influenza seasons. Results: Oseltamivir use for prophylaxis was higher at intervention LTCFs (2.6 vs 1.9 courses per 1000 person-weeks; rate ratio: 1.38; 95%CI: 1.24-1.54; p<0.001); rates of oseltamivir use for treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR=0.78; 95%CI: 0.64-0.92; p=0.004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR=0.79; 95%CI: 0.67-0.93; p=0.004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR=0.64; 95%CI: 0.0.59-0.69; p<0.001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality. Conclusions: The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across three combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites. This feasible, and low-cost intervention may provide significant benefit and should be further tested in other settings.

Factors influencing sensitivity of a rapid influenza diagnostic test in a community-based population of kindergarten through 12th-grade students: Wisconsin 2015-2020

Rapid influenza diagnostic tests (RIDTs) have variable sensitivity. In a community-based population of kindergarten through 12th-grade (K-12) students, we assessed factors that may influence RIDT performance using 2368 paired results from Sofia® influenza A + B fluorescent immunoassay and reverse transcription polymerase chain reaction (RT-PCR). RIDT sensitivity and specificity were 76.1% (95% CI: 72.8-79.1) and 97.2% (96.2-97.9), respectively. Factors associated with sensitivity included runny nose (OR = 3.0, p < 0.001), nasal congestion (1.59, p = 0.045), days from symptom onset (per day; 0.75; p < 0.001), myalgia (0.61; p = 0.014), age (per 5 years; 0.55; p = 0.001), and detection of another virus (0.50; p = 0.043). Understanding these factors can aid in interpreting negative results.

Surveillance of SARS-CoV-2 in Asymptomatic Faculty and Staff at the University of Wisconsin-Madison

INTRODUCTION

Surveillance of SARS-CoV-2 among university employees is an important part of mitigation strategies to prevent asymptomatic transmission and ensure a safe learning and work environment. Here, we assess the feasibility and performance of a program that relies on monitored self-collected nasal swabs to detect SARS-CoV-2 among asymptomatic faculty and staff.

METHODS

We recruited 1,030 faculty and staff via rolling enrollment who completed the required University of Wisconsin-Madison employee COVID-19 training and reported working on campus. Asymptomatic participants visited a designated location during a specified timeframe each week where they self-collected nasal swabs supervised by study staff. Specimens were stored in a cooler between 2 °C and 8 °C, then transported to the Wisconsin Veterinary Diagnostic Laboratory for polymerase chain reaction testing. Symptomatic participants or participants with a known exposure were advised to test elsewhere and follow quarantine guidelines from the Centers for Disease Control and Prevention.

RESULTS

Over the course of 31 weeks, 1,030 participants self-collected 17,323 monitored nasal swabs resulting in high participation (90%). SARS-CoV-2 was detected in 16 specimens. Eight specimens were inconclusive but were treated as positive results because of the implied detection of 1 or more SARS-CoV-2 genes. There were no invalid tests. Weekly SARS-CoV-2 incidence among participants ranged from 0 to 1.54% (x̄ = 0.20%). The SARS-CoV-2 incidence among participants was similar to estimated incidence in the greater university employee population.

CONCLUSION

Weekly SARS-CoV-2 surveillance of asymptomatic faculty and staff on campus allowed for estimation of weekly SARS-CoV-2 incidence among on-campus employees. This surveillance protocol presents a low-cost, effective, and scalable option to identify asymptomatic cases of SARS-CoV-2 among university employees.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Codetection With Influenza A and Other Respiratory Viruses Among School-Aged Children and Their Household Members-12 March 2020 to 22 February 2022, Dane County, Wisconsin

BACKGROUND

Concurrent detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and another respiratory virus in individuals can document contemporaneous circulation. We used an ongoing, community-based study of school-aged children and their households to evaluate SARS-CoV-2 codetections with other respiratory viruses in a non-medically attended population over a 2-year period.

METHODS

Household enrollment was predicated on an acute respiratory illness in a child residing in that household who was also a kindergarten through 12th-grade student in the participating school district. Demographic, symptom, and household composition data and self-collected nasal specimens were obtained on the recruitment day, and 7 and 14 days later, from the index child and all other household members. All specimens were tested for SARS-CoV-2 and influenza A/B by reverse-transcription polymerase chain reaction. Day 0 specimens from the index children were simultaneously tested for 16 pathogens using a commercial respiratory pathogen panel (RPP). To assess viral codetections involving SARS-CoV-2, all household specimens were tested via RPP if the index child's day 0 specimen tested positive to any of the 16 pathogen targets in RPP and any household member tested positive for SARS-CoV-2.

RESULTS

Of 2109 participants (497 index children in 497 households with 1612 additional household members), 2 (0.1%) were positive for both SARS-CoV-2 and influenza A; an additional 11 (0.5%) were positive for SARS-CoV-2 and another RPP-covered respiratory virus. Codetections predominantly affected school-aged children (12 of 13 total) and were noted in 11 of 497 households.

CONCLUSIONS

SARS-CoV-2 codetections with other respiratory viruses were uncommon and predominated in school-aged children.

POS0743 CLINICAL CHARACTERISTICS AND BURDEN AMONG PATIENTS WITH SLE AND MUSCULOSKELETAL ORGAN INVOLVEMENT: RESULTS FROM A REAL-WORLD STUDY IN THE US

Background

Limited information exists concerning the clinical burden and unmet need of musculoskeletal (MSK) organ involvement among patients with SLE in clinical practice.

Objectives

To examine demographics, clinical status, treatment patterns, and patient-reported outcomes (PROs) among patients with SLE in clinical practices and assess the impact of MSK organ involvement.

Methods

Data were drawn from the Adelphi Real World Lupus IV (2021) Disease Specific Programme™, a point-in-time survey of 79 US physicians and their patients with SLE. Physicians completed questionnaires regarding patient demographics, clinical status, and treatment. The same patients were invited to complete questionnaires containing the EuroQoL 5-Dimensions (EQ-5D), Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-Fatigue) and Work Productivity & Activity Impairment questionnaire (WPAI) PRO tools.

Physicians stated their patients’ organ involvement at the time of data collection (current), in the categories of musculoskeletal, mucocutaneous, renal, cardiorespiratory, constitutional, haematologic, ophthalmologic, gastrointestinal, respiratory, or other.

Two mutually exclusive patient groups were analysed:

A.MSK – Current physician assessed musculoskeletal organ involvement (+/- other organ/tissue involvement).

B.Non-MSK – No current musculoskeletal organ involvement as assessed by the physician

Bivariate analysis was conducted for numeric variables using t-tests; binary categorical variables using a Fisher’s exact test; ordinal categorical variables using a Mann-Whitney test; and other categorical variables were compared using a chi-squared test.

Results

A total of 595 patients were included in this analysis: 64.7% MSK and 35.3% non-MSK. Mean[SD] patient age was 45.2[14.3] years, 83.2% were female, 53.3% were White/Caucasian, 27.9% were African American, and mean[SD] time diagnosed with any SLE was 5.3[6.2] years.

Point-in-time assessment of clinical status, treatment patterns and patient-reported outcomes, revealed that those with MSK organ involvement assessed by their rheumatologist had higher overall SLE disease severity, more flares in the last 12 months, and slightly worse quality of life scores and work impairment.

Table 1.

Point-in-time clinical status, treatment patterns and PROs among patients with SLE MSK organ involvement

TotalMSKNon-MSKp value(n=595)(n=385)(n=210)Physician-Reported Patient Clinical Status & Treatment HistoryCurrent SLE severity, n(%)Mild405 (68.1)243 (63.1)162 (77.1)<0.001Moderate169 (28.4)128 (33.3)41 (19.2)Severe21 (3.5)14 (3.6)7 (3.3)Current joint symptoms, n(%)Joint tenderness251 (42.2)210 (54.6)41 (19.5)<0.001Joint stiffness255 (42.9)212 (55.1)43 (20.5)<0.001Joint swelling135 (22.7)111 (28.8)24 (11.4)<0.001Mean [SD] Flares in the last 12 months1.6 [1.7]1.7 [1.8]1.2 [1.3]0.015Currently prescribed, n(%)Belimumab113 (19.0)79 (20.5)34 (16.2)0.198Immunosuppressant164 (27.6)105 (27.3)59 (28.1)0.830Corticosteroids333 (56.0)228 (59.2)105 (50.0)0.030Antimalarials429 (72.1)268 (69.6)161 (76.7))0.067Mean [SD] years on current treatment2.9 [3.6]2.5 [3.0]3.6 [4.4]<0.001Patient-Reported OutcomesMean [SD] EQ5D-5L Utility score (0= death to 1= full health)0.79 [0.20]0.76 [0.22]0.85 [0.16]0.002Mean [SD] FACIT-Fatigue score (0 worst fatigue to-52= no fatigue)32.4 [12.0]31.0 [11.5]35.4 [12.6]0.005Mean [SD] WPAI, overall work impairment score(0= no impact to 100= completely impacted)29.0 [21.0]30.5 [18.6]25.9 [25.2]0.223

Conclusion

In this large sample of patients with SLE followed in clinical practices in the U.S., compared to those with little or no rheumatologist assessed MSK involvement, those with MSK involvement, had lower quality of life, with higher impact on their work productivity. These results highlight the heterogeneity of SLE and the impact of major MSK manifestations on quality of life in SLE.

References

N/A

Disclosure of Interests

Aisha Vadhariya Employee of: Eli Lilly and Company, Julie Birt Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jianmin Wu Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Kirstin Griffing Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Fiona Bailey: None declared, James Hetherington: None declared, Elke Rottier: None declared, Sophie Barlow: None declared, Karen Costenbader Consultant of: Lilly, Astra Zeneca, Janssen, Amgen, Glaxo Smith Kline, Grant/research support from: Exagen, Gilead, Merck

AB0554 CLINICAL CHARACTERISTICS AND BURDEN AMONG PATIENTS WITH SLE STRATIFIED BY SLEDAI DERIVED SEVERITY: RESULTS FROM A REAL-WORLD STUDY IN THE US

Background

Data are limited concerning the distribution of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores among patients with SLE in clinical practice and the characteristics of patients with specific SLEDAI scores.

Objectives

To investigate SLE patient demographics, clinical status, treatment patterns, and patient reported outcomes (PROs), overall and stratified by SLEDAI score.

Methods

Data were drawn from the Adelphi Real World Lupus IV (2021) Disease Specific Programme™, a point-in-time survey of 79 US rheumatologists and patients with SLE. Rheumatologists completed questionnaires regarding patient demographics, clinical status, and treatment. The same patients were invited to complete questionnaires containing the EuroQoL 5-Dimensions (EQ-5D), Functional Assessment of Chronic Illness Therapy Fatigue Subscale (FACIT-Fatigue) and Work Productivity & Activity Impairment questionnaire (WPAI) Patient-Reported Outcomes (PRO) tools.

Physicians completed 24 questions based on the SLEDAI-2K questionnaire regarding their patients’ current clinical manifestations, from which a SLEDAI score was derived1. Patients were grouped based on their score: SLEDAI=0 (none), SLEDAI=1-6 (mild), SLEDAI=7-12 (moderate), and SLEDAI>12 (severe)2.

Data from patients without rheumatologist-perceived renal organ involvement and ≥ 1 year of SLE duration were included for analysis using bivariate tests.

Results

A total of 273 patients were included in this analysis. Mean [SD] patient age was 47.0[14.2] years, 83.9% were female, 57.1% were White/Caucasian, and 24.9% were African American.

Table 1.

Point-in-time clinical status, treatment patterns and PROs among patients with SLE stratified by SLEDAI score

Table 1.Total Sample (n=273)SLEDAI=0 (n=60, 22%)SLEDAI=1-6 (n=79, 28.9%)SLEDAI=7-12 (n=70, 25.6%)SLEDAI>12 (n=64, 23.4%)p valuePhysician-Reported Clinical Status and Treatment HistoryCurrent SLE severity, n(%)Mild221 (81.0)51 (85.0)70 (88.6)53 (75.7)47 (73.4)0.057Moderate49 (18.0)9 (15.0)9 (11.4)16 (22.9)15 (23.4)Severe3 (1.1)0 (0.0)0 (0.0)1 (1.4)2 (3.1)Current joint symptoms, n(%)Joint tenderness109 (39.9)24 (40.0)27 (34.2)28 (40.0)30 (46.9)0.498Joint stiffness121 (44.3)22 (36.7)33 (41.8)37 (52.9)29 (45.3)0.293Joint swelling60 (22.0)17 (28.3)13 (16.5)19 (27.1)11 (17.2)0.190Mean [SD] Flares in the last 12 months1.6 [1.5]1.3 [1.2]1.7 [1.7]1.5 [1.3]1.8 [1.5]0.550Currently prescribed, n(%)Belimumab58 (21.3)14 (23.3)18 (12.9)8 (10.1)15 (21.4)0.011Immunosuppressants48 (17.6)7 (11.7)26 (18.6)10 (12.7)13 (18.6)0.052Corticosteroids138 (50.6)35 (58.3)62 (44.3)29 (36.7)32 (45.7)0.003Antimalarials206 (75.5)28 (46.7)108 (77.1)64 (81.0)59 (84.3)<0.001Patient-Reported OutcomesMean [SD] EQ5D-5L Utility score (0=death to 1= full health)0.79 [0.19]0.83 [0.12]0.82 [0.21]0.79 [0.14]0.69 [0.25]0.024Mean [SD] FACIT-Fatigue score (0=worst fatigue to 52= no fatigue)32.7 [12.2]36.8 [8.7]36.1 [12.5]29.1 [9.8]26.4 [14.3]<0.001Mean [SD] WPAI overall (0= no impact to 100= completely impacted)26.8 [21.2]25.2 [15.8]19.5 [23.6]35.7 [20.2]31.9 [26.7]0.131

49% of SLE patients were categorized as SLEDAI 7-12 or >12 (moderate or severe).

Among the SLEDAI 7-12 (moderate) patients, 75.7% were subjectively categorized by their physician as having mild SLE. Of the SLEDAI >12 patients (severe), 73.4% were categorized as having mild SLE.

Joints symptoms and flaring in the last 12 months were not significantly different across SLEDAI groups.

Patients with greater SLEDAI reported lower EQ5D and greater FACIT-Fatigue scores. There was no statistical difference in WPAI between the SLEDAI groups.

Conclusion

A disconnect between point-in-time SLEDAI and physician-perceived severity exists. Patients with SLE, irrespective of SLEDAI, had high prevalence of joint symptoms, but higher SLEDAI impacted quality of life.

References

[1]Gladman D et al., Journal of Rheumatology, 2002.

[2]Fanouriakis A et al., Annals of the rheumatic diseases, 2019.

Disclosure of Interests

Aisha Vadhariya Employee of: Eli Lilly and Company, Julie Birt Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jianmin Wu Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Kirstin Griffing Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Fiona Bailey: None declared, James Hetherington: None declared, Elke Rottier: None declared, Sophie Barlow: None declared, Karen Costenbader Consultant of: Lilly, Astra Zeneca, Janssen, Amgen, Glaxo Smith Kline, Grant/research support from: Exagen, Gilead, Merck

Cause-specific student absenteeism monitoring in K-12 schools for detection of increased influenza activity in the surrounding community—Dane County, Wisconsin, 2014–2020

Background

Schools are primary venues of influenza amplification with secondary spread to communities. We assessed K-12 student absenteeism monitoring as a means for early detection of influenza activity in the community.

Materials and methods

Between September 2014 and March 2020, we conducted a prospective observational study of all-cause (a-TOT), illness-associated (a-I), and influenza-like illness–associated (a-ILI) absenteeism within the Oregon School District (OSD), Dane County, Wisconsin. Absenteeism was reported through the electronic student information system. Students were visited at home where pharyngeal specimens were collected for influenza RT-PCR testing. Surveillance of medically-attended laboratory-confirmed influenza (MAI) occurred in five primary care clinics in and adjoining the OSD. Poisson general additive log linear regression models of daily counts of absenteeism and MAI were compared using correlation analysis.

Findings

Influenza was detected in 723 of 2,378 visited students, and in 1,327 of 4,903 MAI patients. Over six influenza seasons, a-ILI was significantly correlated with MAI in the community (r = 0.57; 95% CI: 0.53–0.63) with a one-day lead time and a-I was significantly correlated with MAI in the community (r = 0.49; 0.44–0.54) with a 10-day lead time, while a-TOT performed poorly (r = 0.27; 0.21–0.33), following MAI by six days.

Discussion

Surveillance using cause-specific absenteeism was feasible and performed well over a study period marked by diverse presentations of seasonal influenza. Monitoring a-I and a-ILI can provide early warning of seasonal influenza in time for community mitigation efforts.

The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS): Rationale, objectives, and design

BACKGROUND

Influenza viruses pose significant disease burdens through seasonal outbreaks and unpredictable pandemics. Existing surveillance programs rely heavily on reporting of medically attended influenza (MAI). Continuously monitoring cause-specific school absenteeism may identify local acceleration of seasonal influenza activity. The Oregon Child Absenteeism Due to Respiratory Disease Study (ORCHARDS; Oregon, WI) implements daily school-based monitoring of influenza-like illness-specific student absenteeism (a-ILI) in kindergarten through Grade 12 schools and assesses this approach for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

METHODS

Starting in September 2014, ORCHARDS combines automated reporting of daily absenteeism within six schools and home visits to school children with acute respiratory infection (ARI). Demographic, epidemiological, and symptom data are collected along with respiratory specimens. Specimens are tested for influenza and other respiratory viruses. Household members can opt into a supplementary household transmission study. Community comparisons are possible using a pre-existing and highly effective influenza surveillance program, based on MAI at five family medicine clinics in the same geographical area.

RESULTS

Over the first 5 years, a-ILI occurred on 6634 (0.20%) of 3,260,461 student school days. Viral pathogens were detected in 64.5% of 1728 children with ARI who received a home visit. Influenza was the most commonly detected virus, noted in 23.3% of ill students.

CONCLUSION

ORCHARDS uses a community-based design to detect influenza trends over multiple seasons and to evaluate the utility of absenteeism for early detection of accelerated influenza and other respiratory pathogen transmission in schools and surrounding communities.

Evidence of Early Household Transmission of SARS-CoV-2 Involving a School-aged Child

INTRODUCTION

Little is known about the role of school-aged children and household transmission at the start of the SARS-CoV-2 pandemic. To evaluate for SARS-CoV-2 in school-aged children and assess household transmission, we performed reverse transcription polymerase chain reaction on 670 archived specimens that were collected between September 1, 2019 and June 30, 2020 as part of a community-based study.

CASE PRESENTATION

A single SARS-CoV-2 case was detected in an 11-year-old girl on March 18, 2020, resulting in very low prevalence (0.15% [95% CI, 0.03-0.84]) in this population. This case was associated with SARS-CoV-2 detection in all other household members. Symptoms were reported as mild to moderate. Whole genome sequencing supported household transmission of near-identical viruses within the 19B clade.

DISCUSSION

This case represents the earliest known household cluster of SARS-CoV2 in Wisconsin.

CONCLUSION

This case suggests that household transmission associated with school-aged children may have contributed to wide seeding across populations.

An assessment of parental knowledge, attitudes, and beliefs regarding influenza vaccination

INTRODUCTION

Seasonal influenza imposes a significant clinical and economic burden. Despite the availability of an annual vaccine to prevent influenza infection and reduce disease severity, influenza vaccination rates remain suboptimal. Research suggests personal experience, perceived effectiveness, and concerns regarding vaccine safety and side effects are the most influential factors in predicting a parent's decision to vaccinate. However, current literature is primarily focused on the vaccine decision-making of healthcare workers and those at high risk for influenza complications.

METHODS

To assess parental attitudes and beliefs regarding the influenza vaccine, a brief mixed-methods survey was developed and optimized for an electronic platform. The Health Belief Model informed survey design and data analysis. Questions were classified into five core concepts: knowledge, barriers, benefits, experience, and severity. Participants were solicited from a population of parents whose children had participated in a school-based influenza surveillance study (n = 244, 73% response rate). We tested associations between responses and children's influenza vaccination status the prior season. Categorical questions were tested using Pearson's chi-squared tests and numerical or ordered questions using Mann-Whitney tests. P-values were corrected using the Bonferroni method.

RESULTS

Doubting effectiveness, concerns about side effects, inconvenience, and believing the vaccine is unnecessary were barriers negatively associated with parents' decision to vaccinate their children during the 2017-18 flu season (p < 0.001). Knowledge that the vaccine is effective in lowering risk, duration, and severity of influenza; receiving the influenza vaccine as an adult; and recognizing the importance of vaccination to prevent influenza transmission in high-risk populations were positively associated with parents' decision to vaccinate (p < 0.001).

CONCLUSION

Understanding barriers and motivators behind parents' decision to vaccinate provides valuable insight that has the potential to shape vaccine messaging, recommendations, and policy. The motivation to vaccinate to prevent influenza transmission in high-risk populations is a novel finding that warrants further investigation.

Evaluation of Viruses Associated With Acute Respiratory Infections in Long-Term Care Facilities Using a Novel Method: Wisconsin, 2016‒2019

Residents of long-term care facilities (LCTFs) have high morbidity and mortality associated with acute respiratory infections (ARIs). Limited information exists on the virology of ARI in LTCFs, where virological testing is reactive. We report on findings of a surveillance feasibility substudy from a larger prospective trial of introducing rapid influenza diagnostic testing (RIDT) at 10 Wisconsin LTCFs. Any resident with symptoms consistent with ARI had a nasal swab specimen collected for RIDT by staff. Following RIDT, the residual swab was placed into viral transport medium and tested for influenza using Reverse transcription polymerase chain reaction, and for 20 pathogens using a multiplex polymerase chain reaction respiratory pathogen panel. Numbers of viruses in each of 7 categories (influenza A, influenza B, coronaviruses, human metapneumovirus, parainfluenza, respiratory syncytial virus, and rhinovirus/enterovirus) across the 3 years were compared using χ². Totals of 160, 215, and 122 specimens were collected during 2016‒2017, 2017‒2018, and 2018‒2019, respectively. Respiratory pathogen panel identified viruses in 54.8% of tested specimens. Influenza A (19.2%), influenza B (12.6%), respiratory syncytial virus (15.9%), and human metapneumovirus (20.9%) accounted for 69% of all detections, whereas coronaviruses (17.2%), rhinovirus/enterovirus (10.5%) and parainfluenza (3.8%) were less common. The distribution of viruses varied significantly across the 3 years (χ² = 71.663; df = 12; P < .001). Surveillance in LTCFs using nasal swabs collected for RIDT is highly feasible and yields high virus identification rates. Significant differences in virus composition occurred across the 3 study years. Simple approaches to surveillance may provide a more comprehensive assessment of respiratory viruses in LTCF settings.

Sequential, within-season infection with influenza A (H3N2) in a usually healthy vaccinated child

Cocirculation of varying influenza types, strains, and lineages allows coinfection and intra-season sequential infection, although a same-strain sequential infection has not been previously described. This case report describes the first known case of sequential laboratory-confirmed influenza A (H3N2) infections in a child within one season.

686. Use of an Influenza-Like Illness School Absenteeism Monitoring System to Identify Seasonal Influenza Outbreaks in the Community: ORCHARDS (Wisconsin, September 2014–June 2017)

Background

Schools are purported to be primary venues of influenza transmission and amplification with secondary spread to communities. We assessed K—12 student absenteeism monitoring as a means for early detection of influenza activity in the community. Methods. We conducted a 3-year, prospective observational study of all-cause (a-TOT), illness-associated (a-I), and influenza-like illness-associated (a-ILI) absenteeism within the Oregon School District, Oregon, WI (OSD: enrollment = 3,900 students). Absenteeism reporting was facilitated by automated processes within OSD’s electronic student information system. Students were screened for ILI, and, if eligible, visited at home, where pharyngeal specimens were collected for influenza RT-PCR (IVD CDC Human Influenza Virus RT-PCR Diagnostic Panel) and multipathogen testing (Luminex NxTAG RPP). The study definition of a-ILI was validated for 700 children with acute respiratory infections using binomial logistic regression. Surveillance of medically attended laboratory-confirmed influenza (MAI) occurred in five primary care clinics in and adjoining OSD as part of the Wisconsin Influenza Incidence Surveillance Project using the same laboratory testing. Poisson general additive log linear regression models of daily counts of absenteeism and MAI were compared using correlation analysis. Results. Influenza A and B were detected in 54 and 51 of the 700 visited students, respectively. Influenza was significantly associated with a-ILI status (OR = 4.74; 95% CI: 2.78—8.18; P &lt; 0.001). Of MAI patients, 371 had influenza A and 143 had influenza B. a-I was significantly correlated with MAI in the community (r = 0.472; P &lt; 0.001) with a 15-day lead time. a-ILI was significantly correlated with MAI in the community (r = 0.480; P &lt; 0.001) with a 1-day lead time. a-TOT performed poorly (r = 0.278; P &lt; 0.001), following MAI by 9 days (Figure 1). Conclusion. Surveillance using cause-specific absenteeism was feasible to implement in OSD and performed well over a 3-year period marked by diverse presentations of seasonal influenza. Monitoring a-I and a-ILI can detect influenza outbreaks in the community, providing early warning in time for community mitigation efforts for seasonal and pandemic influenza.

Disclosures

All authors: No reported disclosures.

Sensitivity and Specificity of the Quidel Sofia Influenza A+B FIA Rapid Influenza Detection Test in Long-Term Care Facilities

Background

Influenza is a significant pathogen for long-term care facility (LTCF) residents. As part of a randomized controlled trial to assess early detection of influenza in LTCFs, we deployed rapid influenza detection tests (RIDTs) at intervention LTCFs. Our primary objectives for this interim analysis were to evaluate the sensitivity and specificity of the Quidel Sofia® Influenza A+B Fluorescent Immunoassay RIDT in a high-risk, nontraditional population, and to describe the virology of acute respiratory infections (ARI) in LTCF residents.

Methods

Personnel at LCTFs identified cases of ARI, collected nasal specimens, and ran RIDTs from 10/21/2016 to 4/28/2017. The residual nasal swab and leftover lysis buffer were placed into a viral transport medium tube and sent to the Wisconsin State Laboratory of Hygiene for confirmatory influenza RT-PCR testing. In addition, all specimens were tested for other viruses using the Luminex NxTAG® Respiratory Pathogen Panel. Sensitivity and specificity of the Sofia RIDT were calculated using RT-PCR results as the reference standard.

Results

Specimens were collected from 228 residents (mean age = 71.3 ± 22.4 years). The mean time from symptom onset to specimen collection was 1.4 ± 1.6 days (range: 0-7 days). Respiratory viruses were identified in 134/228 cases (58.8%); influenza viruses (A: 7.5% and B: 14.5%) were the most commonly detected virus by PCR, followed by rhinovirus/enterovirus (13.2%), RSV (11.0%) and coronaviruses (10.1%). The sensitivities of Sofia RIDT for influenza A and influenza B were 77.8% (95% CI: 52.4–93.6%) and 80.0% (95% CI: 61.4–92.3%), respectively, with specificities of 98.4% (95.3–99.7%) and 97.1% (93.4–99.1%), respectively. Overall performance assessment for influenza A or B yielded a sensitivity of 79.2% (65.0–89.5%) and specificity of 96.1% (91.7–98.6%). The estimated likelihood of discovering one of the first two influenza cases at a LTCF using this RIDT is estimated to be ≥95.7%.

Conclusion

Although a wide constellation of respiratory viruses cause ARIs within LTCF populations, influenza is very common. Early ARI recognition in residents, with testing shortly after symptom onset, likely contributed to high performance of the Sofia RIDT. Use of RIDTs allows early identification of influenza with high sensitivity and specificity in elderly LTCF residents.

Disclosures

J. Temte, Quidel: Investigator, Research support

Volumetric MRI study of the intrauterine growth restriction fetal brain

OBJECTIVES

Intrauterine growth restriction (IUGR) is a pathologic fetal condition known to affect the fetal brain regionally and associated with future neurodevelopmental abnormalities. This study employed MRI to assess in utero regional brain volume changes in IUGR fetuses compared to controls.

METHODS

Retrospectively, using MRI images of fetuses at 30-34 weeks gestational age, a total of 8 brain regions-supratentorial brain and cavity, cerebral hemispheres, temporal lobes and cerebellum-were measured for volume in 13 fetuses with IUGR due to placental insufficiency and in 21 controls. Volumes and their ratios were assessed for difference using regression models. Reliability was assessed by intraclass correlation coefficients (ICC) between two observers.

RESULTS

In both groups, all structures increase in absolute volume during that gestation period, and the rate of cerebellar growth is higher compared to that of supratentorial structures. All structures' absolute volumes were significantly smaller for the IUGR group. Cerebellar to supratentorial ratios were found to be significantly smaller (P < 0.05) for IUGR compared to controls. No other significant ratio differences were found. ICC showed excellent agreement.

CONCLUSIONS

The cerebellar to supratentorial volume ratio is affected in IUGR fetuses. Additional research is needed to assess this as a radiologic marker in relation to long-term outcome.

KEY POINTS

• IUGR is a pathologic fetal condition affecting the brain • IUGR is associated with long-term neurodevelopmental abnormalities; fetal characterization is needed • This study aimed to evaluate regional brain volume differences in IUGR • Cerebellar to supratentorial volume ratios were smaller in IUGR fetuses • This finding may play a role in long-term development of IUGR fetuses.

Efficient light emission from inorganic and organic semiconductor hybrid structures by energy-level tuning

The fundamental limits of inorganic semiconductors for light emitting applications, such as holographic displays, biomedical imaging and ultrafast data processing and communication, might be overcome by hybridization with their organic counterparts, which feature enhanced frequency response and colour range. Innovative hybrid inorganic/organic structures exploit efficient electrical injection and high excitation density of inorganic semiconductors and subsequent energy transfer to the organic semiconductor, provided that the radiative emission yield is high. An inherent obstacle to that end is the unfavourable energy level offset at hybrid inorganic/organic structures, which rather facilitates charge transfer that quenches light emission. Here, we introduce a technologically relevant method to optimize the hybrid structure's energy levels, here comprising ZnO and a tailored ladder-type oligophenylene. The ZnO work function is substantially lowered with an organometallic donor monolayer, aligning the frontier levels of the inorganic and organic semiconductors. This increases the hybrid structure's radiative emission yield sevenfold, validating the relevance of our approach.

Detection of viral and bacterial pathogens in acute respiratory infections

OBJECTIVES

The role of bacteria in acute respiratory illnesses (ARI) of adults and interactions with viral infections is incompletely understood. This study tested the hypothesis that bacterial co-infection during ARI adds to airway inflammation and illness severity.

METHODS

Two groups of 97 specimens each were randomly selected from multiplex-PCR identified virus-positive and virus-negative nasal specimens obtained from adults with new onset ARI, and 40 control specimens were collected from healthy adults. All specimens were analyzed for Haemophilus influenzae(HI), Moraxella catarrhalis(MC) and Streptococcus pneumoniae(SP) by quantitative-PCR. General linear models tested for relationships between respiratory pathogens, biomarkers (nasal wash neutrophils and CXCL8), and ARI-severity.

RESULTS

Nasal specimens from adults with ARIs were more likely to contain bacteria (37% overall; HI = 28%, MC = 14%, SP = 7%) compared to specimens from healthy adults (5% overall; HI = 0%, MC = 2.5%, SP = 2.5%; p < 0.001). Among ARI specimens, bacteria were more likely to be detected among virus-negative specimens compared to virus-positive specimens (46% vs. 27%; p = 0.0046). The presence of bacteria was significantly associated with increased CXCL8 and neutrophils, but not increased symptoms.

CONCLUSION

Pathogenic bacteria were more often detected in virus-negative ARI, and also associated with increased inflammatory biomarkers. These findings suggest the possibility that bacteria may augment virus-induced ARI and contribute to airway inflammation.

Advantage of meditation over exercise in reducing cold and flu illness is related to improved function and quality of life

Please cite this paper as: Obasi et al. (2012) Advantage of meditation over exercise in reducing cold and flu illness is related to improved function and quality of life. Influenza and Other Respiratory Viruses 00(0), 00–00.

Purpose  To examine whether apparent advantages following training in meditation over exercise can be attributed to specific symptoms, functional impairments, or quality‐of‐life indicators assessed by the Wisconsin Upper Respiratory Symptom Survey (WURSS‐24).

Methods  Results from the randomized controlled trial “Meditation or Exercise for Preventing Acute Respiratory Illness” showed mean global severity and total days of illness were worse in control (358, 8·9) compared with exercise (248, 5·1) or meditation (144, 5·0). Global severity of illness was estimated using area under the curve from daily self‐reported severity scores on the WURSS‐24. For this project, we estimated within‐group WURSS item‐level severity and between‐group effect sizes (Cohen’s “d” statistic) relative to control. The item‐level effect sizes were grouped into (i) symptom and (ii) function and quality of life domains.

Results  Among the three groups, mediators showed the lowest severity estimates for 21 of 22 WURSS items. Item‐level Cohen’s “d” indicated most benefit was evident in WURSS items representing function and quality of life. Compared with exercise, meditation fostered larger reductions in illness severity, although due mostly to improved function and the quality of life domain (d = −0·33, P < 0·001) compared with symptom domain (d = −0·22, P < 0·001).

Conclusions  The apparent advantage of training in meditation over exercise for reducing cold and flu illness is explained more by improved function and quality of life than by a reduction in symptom severity.

Guidelines for the public health management of typhoid and paratyphoid in England: practice guidelines from the National Typhoid and Paratyphoid Reference Group

OBJECTIVES

The Typhoid and Paratyphoid Reference Group (TPRG) was convened by the Health Protection Agency (HPA) and the Chartered Institute of Environmental Health (CIEH) to revise guidelines for public health management of enteric fever. This paper presents the new guidelines for England and their rationale.

METHODS

Methods include literature reviews including grey literature such as audit data and case studies; analysis of enhanced surveillance data from England, Wales and Northern Ireland; review of clearance and screening schedules in use in other non-endemic areas; and expert consensus.

RESULTS

The evidence and principles underpinning the new guidance are summarised. Significant changes from previous guidance include: • Algorithms to guide risk assessment and management, based on risk group and travel history; • Outline of investigation of non-travel cases; • Simplified microbiological clearance schedules for cases and contacts; • Targeted co-traveller screening and a "warn and inform" approach for contacts; • Management of convalescent and chronic carriers.

CONCLUSIONS

The guidelines were launched in February 2012. Feedback has been positive: the guidelines are reported to be clear, systematic, practical and risk-based. An evaluation of the guidelines is outlined and will add to the evidence base. There is potential for simplification and consistency between international guidelines.

Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial

PURPOSE

This study was designed to evaluate potential preventive effects of meditation or exercise on incidence, duration, and severity of acute respiratory infection (ARI) illness.

METHODS

Community-recruited adults aged 50 years and older were randomized to 1 of 3 study groups: 8-week training in mindfulness meditation, matched 8-week training in moderate-intensity sustained exercise, or observational control. The primary outcome was area-under-the-curve global illness severity during a single cold and influenza season, using the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) to assess severity. Health care visits and days of missed work were counted. Nasal wash collected during ARI illness was assayed for neutrophils, interleukin-8, and viral nucleic acid.

RESULTS

Of 154 adults randomized into the study, 149 completed the trial (82% female, 94% white, mean age 59.3 ± 6.6 years). There were 27 ARI episodes and 257 days of ARI illness in the meditation group (n = 51), 26 episodes and 241 illness days in the exercise group (n = 47), and 40 episodes and 453 days in the control group (n = 51). Mean global severity was 144 for meditation, 248 for exercise, and 358 for control. Compared with control, global severity was significantly lower for meditation (P = .004). Both global severity and total days of illness (duration) trended toward being lower for the exercise group (P=.16 and P=.032, respectively), as did illness duration for the meditation group (P=.034). Adjusting for covariates using zero-inflated multivariate regression models gave similar results. There were 67 ARI-related days of-work missed in the control group, 32 in the exercise group (P = .041), and 16 in the meditation group (P <.001). Health care visits did not differ significantly. Viruses were identified in 54% of samples from meditation, 42% from exercise, and 54% from control groups. Neutrophil count and interleukin-8 levels were similar among intervention groups.

CONCLUSIONS

Training in meditation or exercise may be effective in reducing ARI illness burden.

Risedronate in adults with osteogenesis imperfecta type I: increased bone mineral density and decreased bone turnover, but high fracture rate persists

Bisphosphonates can increase bone mineral density (BMD) in children with osteogenesis imperfecta (OI). In this study of adults with OI type I, risedronate increased BMD at lumbar spine (but not total hip) and decreased bone turnover. However, the fracture rate in these patients remained high.

INTRODUCTION

Intravenous bisphosphonates given to children with OI can increase BMD and reduce fracture incidence. Oral and/or intravenous bisphosphonates may have similar effects in adults with OI. We completed an observational study of the effect of risedronate in adults with OI type I.

METHODS

Thirty-two adults (mean age, 39 years) with OI type I were treated with risedronate (total dose, 35 mg weekly) for 24 months. Primary outcome measures were BMD changes at lumbar spine (LS) and total hip (TH). Secondary outcome measures were fracture incidence, bone pain, and change in bone turnover markers (serum procollagen type I aminopropeptide (P1NP) and bone ALP). A meta-analysis of published studies of oral bisphosphonates in adults and children with OI was performed.

RESULTS

Twenty-seven participants (ten males and seventeen females) completed the study. BMD increased at LS by 3.9% (0.815 vs. 0.846 g/cm(2), p = 0.007; mean Z-score, -1.93 vs. -1.58, p = 0.002), with no significant change at TH. P1NP fell by 37% (p = 0.00041), with no significant change in bone ALP (p = 0.15). Bone pain did not change significantly (p = 0.6). Fracture incidence remained high, with 25 clinical fractures and 10 major fractures in fourteen participants (0.18 major fractures per person per year), with historical data of 0.12 fractures per person per year. The meta-analysis did not demonstrate a significant difference in fracture incidence in patients with OI treated with oral bisphosphonates.

CONCLUSIONS

Risedronate in adults with OI type I results in modest but significant increases in BMD at LS, and decreased bone turnover. However, this may be insufficient to make a clinically significant difference to fracture incidence.

Placebo effects and the common cold: a randomized controlled trial

PURPOSE

We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all.

METHODS

We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later.

RESULTS

Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were -0.16 days (95% CI, -0.90 to 0.58 days) for illness duration and -22 severity points (95% CI, -70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, -0.28 to 1.12 days) and 22 severity points (95% CI, -19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea's effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, -4.47 to -0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (-97.0, 95% CI, -249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group.

CONCLUSIONS

Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

Echinacea for treating the common cold: a randomized trial

BACKGROUND

Echinacea is widely used to treat the common cold.

OBJECTIVE

To assess the potential benefits of echinacea as a treatment of common cold.

DESIGN

Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00065715)

SETTING

Dane County, Wisconsin.

PATIENTS

719 patients, aged 12 to 80 years, with new-onset common cold.

INTERVENTION

Patients were assigned to 1 of 4 parallel groups: no pills, placebo pills (blinded), echinacea pills (blinded), or echinacea pills (unblinded, open-label). Echinacea groups received the equivalent of 10.2 g of dried echinacea root during the first 24 hours and 5.1 g during each of the next 4 days. Indistinguishable placebo tablets contained only inert ingredients.

MEASUREMENTS

The primary outcome was the area under the curve for global severity, with severity assessed twice daily by self-report using the Wisconsin Upper Respiratory Symptom Survey, short version. Secondary outcomes included interleukin-8 levels and neutrophil counts from nasal wash, assessed at intake and 2 days later.

RESULTS

Of the 719 patients enrolled, 713 completed the protocol. Mean age was 33.7 years, 64% were female, and 88% were white. Mean global severity was 236 and 258 for the blinded and unblinded echinacea groups, respectively; 264 for the blinded placebo group; and 286 for the no-pill group. A comparison of the 2 blinded groups showed a 28-point trend (95% CI, -69 to 13 points) toward benefit for echinacea (P = 0.089). Mean illness duration in the blinded and unblinded echinacea groups was 6.34 and 6.76 days, respectively, compared with 6.87 days in the blinded placebo group and 7.03 days in the no-pill group. A comparison of the blinded groups showed a nonsignificant 0.53-day (CI, -1.25 to 0.19 days) benefit (P = 0.075). Median change in interleukin-8 levels and neutrophil counts were also not statistically significant (30 ng/L and 1 cell/high-power field [hpf] in the no-pill group, 39 ng/L and 1 cell/hpf in the blinded placebo group, 58 ng/L and 2 cells/hpf in the blinded echinacea group, and 70 ng/L and 1 cell/hpf in the open-label echinacea group).

LIMITATION

Higher-than-expected variability limited power to detect small benefits.

CONCLUSION

Illness duration and severity were not statistically significant with echinacea compared with placebo. These results do not support the ability of this dose of the echinacea formulation to substantively change the course of the common cold.

PRIMARY FUNDING SOURCE

National Center for Complementary and Alternative Medicine, National Institutes of Health.

Rationale and methods for a trial assessing placebo, echinacea, and doctor-patient interaction in the common cold

BACKGROUND

Clinical medicine and healthcare policy are increasingly guided by randomized controlled trials, which in turn are dependent on the validity of placebo control. It is important to understand the effects of placebo control on outcome measurement, especially for assessment of symptoms and functional impairments where subjectivity, expectancy, and motivation may significantly impact outcome evaluation. This paper describes the rationale and methodology of a trial designed to evaluate placebo effects related to taking pills and to compare these with effects attributable to standard or enhanced (patient-oriented) doctor-patient interaction.

DESIGN

This trial uses two-way factorial allocation to randomize people with new onset common cold in two directions: pill related and doctor related. In one direction, participants are randomized to (1) no pills, (2) blinded placebo, (3) blinded echinacea, or (4) unblinded open-label echinacea. In the other direction, participants are randomized to: (1) no doctor-patient interaction, (2) standard doctor-patient interaction, and (3) enhanced doctor-patient interaction. Enhanced interaction includes education, empathy, empowerment, positive prognosis, and connectedness. Area under the time severity curve is the primary outcome, with the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) the measure of severity. A priori power studies called for a sample size of N = 720 trial finishers to detect 15% to 20% between-group differences in this outcome. Secondary outcomes include general health-related quality of life, perceived stress, interpersonal support, optimism, patient satisfaction, and positive and negative affectivity. Two biomarkers are also assessed: interleukin-8 (inflammatory cytokine) and neutrophil count from nasal wash.

IMPORTANCE

This paper describes the rationale and methodology of a trial assessing placebo effects related to pills and to doctor-patient interaction. This is one of very few similar studies and is the first in the common cold. Data collected will also provide an excellent opportunity to investigate relationships among demographic (age, sex, education, income) and psychosocial (perceived stress, interpersonal support, optimism, affectivity) indicators in relation to common cold outcomes.

Clinical significance of common cold treatment: professionals' opinions

BACKGROUND

Little is known about professionals' knowledge and attitudes regarding the clinical significance of treatments for common cold (upper respiratory infection, presumed viral).

METHODS

We surveyed university-associated family physicians and published common cold researchers ("experts") regarding evidence-of-benefit and magnitude-of-benefit for 8 treatments: antihistamine, oral decongestant, nasal decongestant, nasal steroid, zinc lozenge, zinc nasal spray, vitamin C, and the herbal echinacea.

RESULTS

Responding family physicians (N = 89) and experts (N = 45) agreed that cold remedies do not reduce illness duration. There was substantial disagreement, however, regarding the evidence for severity reduction. Decongestants were rated most favorably. Alternative therapies (zinc, vitamin C, and echinacea) were rated approximately as favorably as the other conventional treatments (antihistamine, decongestant, nasal steroid). Published experts and family physicians responded similarly, as did men (N = 84) and women (N = 49). Older respondents (age > or = 45; N = 67) were less likely to rate treatments as justifiable than were their younger counterparts (P-values ranged from 0.001 to 0.078).

CONCLUSIONS

Family physicians and common cold experts tend to agree that available cold remedies offer limited benefit, with conventional and alternative therapies rated similarly. Substantive disagreements exist, however, regarding strength-of-evidence, and over whether current evidence justifies treatment. Older professionals appear more skeptical.

Evaluation of certain food additives and contaminants

This report represents the conclusions of a Joint FAO/WHO Expert Committee convened to evaluate the safety of various food additives, including flavouring agents, with a view to recommending acceptable daily intakes (ADIs) and to preparing specifications for identity and purity. The Committee also evaluated the risk posed by two food contaminants, with the aim of advising on risk management options for the purpose of public health protection. The first part of the report contains a general discussion of the principles governing the toxicological evaluation and assessment of intake of food additives (in particular flavouring agents) and contaminants. A summary follows of the Committee's evaluations of technical, toxicological and intake data for certain food additives (acidified sodium chlorite, asparaginase from Aspergillus oryzae expressed in Aspergillus oryzae, carrageenan and processed Eucheuma seaweed, cyclotetraglucose and cyclotetraglucose syrup, isoamylase from Pseudomonas amyloderamosa, magnesium sulfate, phospholipase A1 from Fusarium venenatum expressed in Aspergillus oryzae, sodium iron(III) ethylenediaminetetraacetic acid (EDTA) and steviol glycosides); eight groups of related flavouring agents (linear and branched-chain aliphatic, unsaturated, unconjugated alcohols, aldehydes, acids and related esters; aliphatic acyclic and alicyclic terpenoid tertiary alcohols and structurally related substances; simple aliphatic and aromatic sulfides and thiols; aliphatic acyclic dials, trials and related substances; aliphatic acetals; sulfur-containing heterocyclic compounds; aliphatic and aromatic amines and amides; and aliphatic alicyclic linear alpha, beta -unsaturated di- and trienals and related alcohols, acids and esters); and two food contaminants (aflatoxin and ochratoxin A). Specifications for the following food additives were revised: maltol and ethyl maltol, nisin preparation, pectins, polyvinyl alcohol, and sucrose esters of fatty acids. Specifications for the following flavouring agents were revised: maltol and ethyl maltol, maltyl isobutyrate, 3-acetyl-2,5-dimethylfuran and 2,4,5-trimethyl-delta-oxazoline (Nos 1482, 1506 and 1559), and monomenthyl glutarate (No. 1414), as well as the method of assay for the sodium salts of certain flavouring agents. Annexed to the report are tables summarizing the Committee's recommendations for intakes and toxicological evaluations of the food additives and contaminants considered.

Risk assessment of substances that are both genotoxic and carcinogenic

The European Food Safety Authority (EFSA) and the World Health Organization (WHO), with the support of the International Life Sciences Institute, European Branch (ILSI Europe), organized an international conference on 16-18 November 2005 to discuss how regulatory and advisory bodies evaluate the potential risks of the presence in food of substances that are both genotoxic and carcinogenic. The objectives of the conference were to discuss the possible approaches for risk assessment of such substances, how the approaches may be interpreted and whether they meet the needs of risk managers. ALARA (as low as reasonably achievable) provides advice based solely on hazard identification and does not take into account either potency or human exposure. The use of quantitative low-dose extrapolation of dose-response data from an animal bioassay raises numerous scientific uncertainties related to the selection of mathematical models and extrapolation down to levels of human exposure. There was consensus that the margin of exposure (MOE) was the preferred approach because it is based on the available animal dose-response data, without extrapolation, and on human exposures. The MOE can be used for prioritisation of risk management actions but the conference recognised that it is difficult to interpret it in terms of health risk.

Quantum-chemical investigation of second-order nonlinear optical chromophores: Comparison of strong nitrile-based acceptor end groups and role of auxiliary donors and acceptors

We report a detailed quantum-chemical investigation of donor-acceptor substituted dipolar nonlinear optical chromophores incorporating the 4-(dimethylamino)phenyl donor end group and a variety of strong heterocyclic acceptor end groups, including tricyanofurans and tricyanopyrroles. In particular, we study the variation of the molecular second-order polarizability (beta) with the acceptor end group and when inserting auxiliary donors (thiophene) and acceptors (thiazole) into the pi bridge. Both finite-field calculations (in the context of local contributions) and sum-over-states calculations were carried out in order to probe the relationship between beta and the chemical structure of the various chromophores. The trends obtained with these two methods are fully consistent. The large beta values (up to 700 x 10(-30) esu) as well as the observed tunability of the optical absorption maximum (lambda(max)) make the chromophores investigated here interesting candidates for use in electro-optic applications at telecommunications wavelengths.