Archive for May 26, 2010

Novel Influenza A(H1N1) Virus Among Gravid Admissions

Archives of Internal Medicine May 24, 2010  V.170  N.10 p.868-873

Andrew C. Miller, MD; Farnaz Safi, MD; Sadia Hussain, BS; Ramanand A. Subramanian, PhD; Elamin M. Elamin, MD, MSc; Richard Sinert, DO

Departments of Internal Medicine (Dr Miller), Emergency Medicine (Drs Miller, Subramanian, and Sinert), and Obstetrics and Gynecology (Dr Safi), State University of New York Downstate Medical Center and Kings County Hospital Center, Brooklyn; State University of New York Downstate College of Medicine, Brooklyn (Ms Hussain); and Pulmonary, Critical Care, and Sleep Medicine Section, James A. Haley Veterans Hospital, Tampa, Florida (Dr Elamin).

Background

Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population.

Methods

We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957.

Results

Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17% (n = 3). Demographically, 2 patients were health care workers (11%); 15 were black (83%); 2, Hispanic (11%); and 1, white (6%). None reported recent travel. Half of the patients presented with gastrointestinal or abdominal complaints; 13 patients met sepsis criteria (72%). The most common comorbidities were asthma, sickle cell disease, and diabetes. Fourteen patients tested positive for H1N1 on DAT (initial or repeated) (78%); in the other 4 cases, H1N1 was identified by viral culture or rRT-PCR (22%). Seven patients delivered during hospitalization (39%), 6 prematurely and 4 via emergency cesarean delivery. There were 2 fetal deaths (11%). No maternal mortality was recorded.

Conclusions

Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death. A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes.

abstract

http://archinte.ama-assn.org/cgi/content/abstract/170/10/868?etoc

PDF

http://archinte.ama-assn.org/cgi/reprint/170/10/868

May 26, 2010 at 5:05 pm Leave a comment

Differing Symptom Patterns in Early Pandemic vs Seasonal Influenza Infections

Archives of Internal Medicine May 24, 2010  V.170  N.10 p.861-867

Julian Wei-Tze Tang, PhD, MRCP, MRCPath; Paul A. Tambyah, MBBS; Florence Yuk Lin Lai, MSc; Hong Kai Lee, BSc; Chun Kiat Lee, BSc; Tze Ping Loh, MD; Lily Chiu, MSc; Evelyn Siew-Chuan Koay, PhD, FRCPath

Molecular Diagnosis Centre, Department of Laboratory Medicine, National University Hospital (Drs Tang, Loh, and Koay, Messrs H. K. Lee and C. K. Lee, and Ms Chiu), Departments of Medicine (Dr Tambyah) and Pathology (Dr Koay), Yong Loo Lin School of Medicine, National University of Singapore, and Communicable Diseases Division, Ministry of Health (Ms Lai), Singapore.

Background

Singapore is a tropical country with a temperature range of 23°C to 35°C and relative humidity of 48% to 100% throughout the year. Influenza incidence peaks in June through July and November through January, though influenza cases can be detected throughout the year.

Methods

Between May 1 and July 28, 2009, a novel dual-gene diagnostic polymerase chain reaction assay targeting the hemagglutinin (HA) and nucleoprotein (NP) genes of the new influenza A(H1N1/2009) virus was specifically designed for enhanced influenza surveillance using nasopharyngeal swabs collected from symptomatic patients (including their close contacts) and returning travelers returning from influenza A(H1N1/2009)–affected areas, presenting to affiliated primary care clinics as well as the main hospital emergency department.

Results

From the week of June 16 to June 23, 2009, this pandemic influenza A(H1N1/2009) displaced and then replaced the seasonal influenzas (H3N2, H1N1, and B). Of 2683 samples tested during this 12-week surveillance period, 742 (27.6%) were positive for any influenza virus using this assay, with 547 cases of A(H1N1/2009) (20.4%), 167 cases of A(H3N2) (6.2%), 14 cases of A(H1N1) (0.5%), and 12 cases of influenza B (0.4%). Results of multivariate analysis showed that age (P < .001), fever (P < .001), cough (P < .001), sore throat (P = .002), rhinorrhea (P = .001), and dyspnea (P < .001) were significantly different among these groups.

Conclusions

From this large prospective study, there was a lower incidence of fever and dyspnea in patients with pandemic influenza A(H1N1/2009) infection. Similar to reports from elsewhere, it was also found that this pandemic virus tends to infect younger people, though with fewer symptoms, on average, than seasonal influenza. Early pandemic influenza A(H1N1/2009) infections appeared to be slightly milder than seasonal influenza as indicated by different symptom patterns in the presentation of more than 500 cases of influenza A(H1N1/2009) during April through July to a large teaching hospital in Singapore.

abstract

http://archinte.ama-assn.org/cgi/content/abstract/170/10/861?etoc

May 26, 2010 at 5:00 pm Leave a comment

Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

JAMA Table of Contents for May 26, 2010; Vol. 303, No. 20 p.2035-2042

Michael B. Rothberg, MD, MPH; Penelope S. Pekow, PhD; Maureen Lahti, MBBS, MPH; Oren Brody, MD; Daniel J. Skiest, MD; Peter K. Lindenauer, MD, MSc

Center for Quality of Care Research (Drs Rothberg, Pekow, and Lindenauer), Division of General Medicine and Geriatrics (Drs Rothberg and Brody), and Division of Infectious Diseases (Dr Skiest), Baystate Medical Center, Springfield; Tufts University School of Medicine, Boston (Drs Rothberg, Brody, and Lindenauer); and University of Massachusetts School of Public Health, Amherst (Drs Pekow and Lahti).

Context

Guidelines recommend antibiotic therapy for acute exacerbations of chronic obstructive pulmonary disease (COPD), but the evidence is based on small, heterogeneous trials, few of which include hospitalized patients.

Objective

To compare the outcomes of patients treated with antibiotics in the first 2 hospital days with those treated later or not at all.

Design, Setting, and Patients

Retrospective cohort of patients aged 40 years or older who were hospitalized from January 1, 2006, through December 31, 2007, for acute exacerbations of COPD at 413 acute care facilities throughout the United States.

Main Outcome Measures

A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbations of COPD within 30 days of discharge; length of stay, and hospital costs.

Results

Of 84 621 patients, 79% received at least 2 consecutive days of antibiotic treatment. Treated patients were less likely than nontreated patients to receive mechanical ventilation after the second hospital day (1.07%; 95% confidence interval [CI], 1.06%-1.08% vs 1.80%; 95% CI, 1.78%-1.82%), had lower rates of inpatient mortality (1.04%; 95% CI, 1.03%-1.05% vs 1.59%; 95% CI, 1.57%-1.61%), and had lower rates of readmission for acute exacerbations of COPD (7.91%; 95% CI, 7.89%-7.94% vs 8.79%; 95% CI, 8.74%-8.83%). Patients treated with antibiotic agents had a higher rate of readmissions for Clostridium difficile (0.19%; 95% CI, 0.187%-0.193%) than those who were not treated (0.09%; 95% CI, 0.086%-0.094%). After multivariable adjustment, including the propensity for antibiotic treatment, the risk of treatment failure was lower in antibiotic-treated patients (odds ratio, 0.87; 95% CI, 0.82-0.92). A grouped treatment approach and hierarchical modeling to account for potential confounding of hospital effects yielded similar results. Analysis stratified by risk of treatment failure found similar magnitudes of benefit across all subgroups.

Conclusion

Early antibiotic administration was associated with improved outcomes among patients hospitalized for acute exacerbations of COPD regardless of the risk of treatment failure.

abstract

http://jama.ama-assn.org/cgi/content/abstract/303/20/2035?etoc

May 26, 2010 at 4:58 pm Leave a comment


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