Cost utility of fractional exhaled nitric oxide monitoring for the management of children asthma

Introduction Fractional exhaled nitric oxide is a simple, non-invasive measurement of airway inflammation with minimal discomfort to the patient and with results available within a few minutes. This study aimed to evaluate the cost-effectiveness of asthma management using fractional exhaled nitric oxide monitoring in patients between 4 and 18 years of age. Methods A Markov model was used to estimate the cost-utility of asthma management using fractional exhaled nitric oxide monitoring versus asthma management without using fractional exhaled nitric oxide monitoring (standard therapy) in patients between 4 and 18 years of age. Cost data were obtained from a retrospective study on asthma from a tertiary center, in Medellin, Colombia, while probabilities of the Markov model and utilities were obtained from the systematic review of published randomized clinical trials. The analysis was carried out from a societal perspective. Results The model showed that fractional exhaled nitric oxide monitoring was associated with a lower total cost than standard therapy (US $1333 vs. US$1452 average cost per patient) and higher QALYs (0.93 vs. 0.92 average per patient). The probability that fractional exhaled nitric oxide monitoring provides a more cost-effective use of resources compared with standard therapy exceeds 99% for all willingness-to-pay thresholds. Conclusion Asthma management using fractional exhaled nitric oxide monitoring was cost-effective for treating patients between 4 and 18 years of age with mild to moderate allergic asthma. Our study suggests evidence that could be used by decision-makers to improve clinical practice guidelines, but this should be replicated in different clinical settings

Oximetry signal processing identifies REM sleep-related vulnerability trait in asthmatic children

Rationale. The sleep-related factors that modulate the nocturnal worsening of asthma in children are poorly understood. This study addressed the hypothesis that asthmatic children have a REM sleep-related vulnerability trait that is independent of OSA. Methods. We conducted a retrospective cross-sectional analysis of pulse-oximetry signals obtained during REM and NREM sleep in control and asthmatic children (n=134). Asthma classification was based on preestablished clinical criteria. Multivariate linear regression model was built to control for potential confounders (significance level p ≤ 0.05). Results. Our data demonstrated that (1) baseline nocturnal respiratory parameters were not significantly different in asthmatic versus control children, (2) the maximal % of SaO2 desaturation during REM, but not during NREM, was significantly higher in asthmatic children, and (3) multivariate analysis revealed that the association between asthma and REM-related maximal % SaO2 desaturation was independent of demographic variables. Conclusion. These results demonstrate that children with asthma have a REM-related vulnerability trait that impacts oxygenation independently of OSA. Further research is needed to delineate the REM sleep neurobiological mechanisms that modulate the phenotypical expression of nocturnal asthma in children

Characterization of cytomegalovirus lung infection in non-HIV infected children

Cytomegalovirus (CMV) is a prevalent pathogen in the immunocompromised host and invasive pneumonia is a feared complication of the virus in this population. In this pediatric case series we characterized CMV lung infection in 15 non-HIV infected children (median age 3 years; IQR 0.2–4.9 years), using current molecular and imaging diagnostic modalities, in combination with respiratory signs and symptoms. The most prominent clinical and laboratory findings included cough (100%), hypoxemia (100%), diffuse adventitious breath sounds (100%) and increased respiratory effort (93%). All patients had abnormal lung images characterized by ground glass opacity/consolidation in 80% of cases. CMV was detected in the lung either by CMV PCR in bronchoalveolar lavage (82% detection rate) or histology/immunohistochemistry in lung biopsy (100% detection rate). CMV caused respiratory failure in 47% of children infected and the overall mortality rate was 13.3%. Conclusion: CMV pneumonia is a potential lethal disease in non-HIV infected children that requires a high-index of suspicion. Common clinical and radiological patterns such as hypoxemia, diffuse adventitious lung sounds and ground-glass pulmonary opacities may allow early identification of CMV lung infection in the pediatric population, which may lead to prompt initiation of antiviral therapy and better clinical outcomes

Human Metapneumovirus Infection is Associated with Severe Respiratory Disease in Preschool Children with History of Prematurity.

Background Human metapneumovirus (HMPV) is a recently discovered respiratory pathogen of the family Paramyxoviridae, the same family as that of respiratory syncytial virus (RSV). Premature children are at high risk of severe RSV infections, however, it is unclear whether HMPV infection is more severe in hospitalized children with a history of severe prematurity. Methods We conducted a retrospective analysis of the clinical respiratory presentation of all polymerase chain reaction-confirmed HMPV infections in preschool-age children (≤5 years) with and without history of severe prematurity (\u3c32 weeks gestation). Respiratory distress scores were developed to examine the clinical severity of HMPV infections. Demographic and clinical variables were obtained from reviewing electronic medical records. Results A total of 571 preschool children were identified using polymerase chain reaction-confirmed viral respiratory tract infection during the study period. HMPV was identified as a causative organism in 63 cases (11%). Fifty–eight (n = 58) preschool-age children with HMPV infection were included in this study after excluding those with significant comorbidities. Our data demonstrated that 32.7% of children admitted with HMPV had a history of severe prematurity. Preschool children with a history of prematurity had more severe HMPV disease as illustrated by longer hospitalizations, new or increased need for supplemental O2, and higher severity scores independently of age, ethnicity, and history of asthma. Conclusion Our study suggests that HMPV infection causes significant disease burden among preschool children with a history of prematurity leading to severe respiratory infections and increasing health care resource utilization due to prolonged hospitalizations

Phenotypical Characterization of Human Rhinovirus Infections in Severely Premature Children

Background: Human Rhinovirus (HRV) has been identified as the most common cause of acute respiratory infections and hospitalizations in premature children. It is unclear if premature children are more susceptible to HRV due to their decreased pulmonary reserve or because they have enhanced lower airway reactivity to HRV. Methods: We conducted a retrospective analysis of the clinical respiratory presentation of all PCR-confirmed HRV infections in full-term and premature children aged ≤ 3 years in our institution. Standardized respiratory distress scores were developed to examine lower airway obstruction (i.e., wheezing, hyperinflation, and sub-costal retractions) along with markers of decreased pulmonary reserve (hypoxemia and tachypnea) in young children with HRV infections. Demographic and clinical variables were obtained from reviewing electronic medical records (EMR). Results: This study included a total of 205 children; 71% of these children were born full-term (\u3e 37 weeks gestation), 10% preterm (32–37 weeks) and 19% severely premature (\u3c 32 weeks). Our results demonstrated that: 1) HRV infections in the first 3 years of life were associated with higher overall respiratory distress scores in severely premature children relative to children born preterm or full-term; 2) HRV-infected severely premature children ≤ 3 years old were more likely to have lower airway obstruction than HRV-infected children born preterm or full-term; and 3) other clinical signs of respiratory distress such as tachypnea and hypoxemia were not more common in severely premature than in preterm and full-term children during an HRV infection Conclusions: Our results indicate that HRV infections in severely premature children are associated with lower airway obstruction rather than hypoxemia or tachypnea. The latter suggests that enhanced airway reactivity is the underlying mechanism for the increased susceptibility to HRV in severely premature children. Longitudinal studies are needed to understand why premature babies develop airway hyper-reactivity to HRV and the long-term effects of early HRV infection in this population

In Vitro Fermentative Capacity of Equine Fecal Inocula of 9 fibrous Forages in the Presence of Different Doses of Saccharomyces cerevisiae

There is increasing interest in feeding fiber-based feeds as an alternative to high-starch cereal grains to horses as a means of meeting the energy demands and reduce various pathologies, such as gastric ulceration, hind-gut acidosis, laminitis, and colic [2,3], associated with feeding high levels of cereal grains. Depending on the forage type and time of harvest, forages of moderate to high nutritive value may meet the energy and crude protein (CP) requirements of horses [4]. Horses naturally use forage as a primary component of their diet, and forage is a basic necessity for normal function of the equine digestive system. High forage rations are desirable because they contain low levels of starch and sugar. Feeding a minimum 1% of body weight as fiber is very important to minimize the incidence of hindgut acidosis [5], colic [6], gastric ulcers [7], and stereotypical behaviors [8]. In tropical areas such as Mexico, forages used as feeds are generally low in digestibility and low in true protein [9]. Therefore, there is a need to develop feeding strategies which meet the requirements of performance horses while maintaining gut health and integrity.This experimentwas conducted to evaluate in vitro effects of equine fecal inocula fermentative capacity on 9 fibrous forages in the presence of Saccharomyces cerevisiae. The fibrous feeds were corn stover (Zeamays), oat straw(Avena sativa), sugarcane bagasseandleaves (Saccharum officinarum), llanero grass leaves (Andropogon gayanus), Taiwan grass leaves (Pennisetum purpureum), sorghum straw (Sorghum vulgare), and steria grass leaves (Cynodon plectostachyus). Fibrous feed samples were incubated with several doses of S. cerevisiae; 0 (control), 1.25 (low), 2.5 (medium) and 5 (high) mg/g dry matter (DM) of a commercial yeast product containing 1 1010/g. Fecal inoculumwas collected from4 adult horseswere fed onanamount of commercial concentrate and oat hay ad libitum. Gas production (GP)was recorded at 2, 4, 6, 8, 10, 12, 24, and 48 hours post inoculation. An interaction occurred between feeds and yeast dose for fecalpH(P<.01), asymptoticGP (b, ml/gDM); rate ofGP (c, /hr); initial delay beforeGP began (L, hours),GPat 4 hours and48 hours (P<.01), andGPat 8 hours (P<.01) andat 24 hours (P<.01). Differences in fecal fermentation capacity between the tropical and template grass (P < .05) occurred for fecal pH, c, and GP during first 12 hours, whereas differences occurred (P< .05) between the agriculture byproducts and the grasses for fecal pH, b, and GP from 8 to 48 hours. Fermentation capacity between straws versus not straws (P <.05) differed for fecal pH, b, and GP after 12 hours between straws versus not straws. Addition of S. cerevisiae to Z. mays stover reduced (P <.01) fecal pH and the c fraction with a higher (P <.01) b fraction versus the other feeds. From4 to 24 hours, S. officinarumbagasse improvedGP tothe highest values versus S. officinarum leaves. After 24 hours, Z. mays stover had the highest GP, whereas C. plectostachyus leaves had the lowest. There were no differences among the yeast doses for all measured parameters with the exception of L values (linear effect; P <.01). The Z. mays stover hadthe highestnutritive comparedtothe otherfibrous feeds.However, additionof S. cerevisiae at 2.5 to 5.0 g/kg DM improved fecal fermentation capacity of low-quality forage

Age-Related Effect of Viral-Induced Wheezing in Severe Prematurity

Abstract: Premature children are prone to severe viral respiratory infections in early life, but the age at which susceptibility peaks and disappears for each pathogen is unclear. Methods: A retrospective analysis was performed of the age distribution and clinical features of acute viral respiratory infections in full-term and premature children, aged zero to seven years. Results: The study comprised of a total of 630 hospitalizations (n = 580 children). Sixty-seven percent of these hospitalizations occurred in children born full-term (\u3e 37 weeks), 12% in preterm (32–37 weeks) and 21% in severely premature children (\u3c 32 weeks). The most common viruses identified were rhinovirus (RV; 60%) and respiratory syncytial virus (RSV; 17%). Age-distribution analysis of each virus identified that severely premature children had a higher relative frequency of RV and RSV in their first three years, relative to preterm or full-term children. Additionally, the probability of RV- or RSV-induced wheezing was higher overall in severely premature children less than three years old. Conclusions: Our results indicate that the vulnerability to viral infections in children born severely premature is more specific for RV and RSV and persists during the first three years of age. Further studies are needed to elucidate the age-dependent molecular mechanisms that underlie why premature infants develop RV- and RSV-induced wheezing in early life

Integrating the STOP-BANG Score and Clinical Data to Predict Cardiovascular Events After Infarction A Machine Learning Study

BACKGROUND: OSA conveys worse clinical outcomes in patients with coronary artery disease. The STOP-BANG score is a simple tool that evaluates the risk of OSA and can be added to the large number of clinical variables and scores that are obtained during the management of patients with myocardial infarction (MI). Currently, machine learning (ML) is able to select and integrate numerous variables to optimize prediction tasks. RESEARCH QUESTION: Can the integration of STOP-BANG score with clinical data and scores through ML better identify patients who experienced an in-hospital cardiovascular event after acute MI? STUDY DESIGN AND METHOD: This is a prospective observational cohort study of 124 patients with acute MI of whom the STOP-BANG score classified 34 as low (27.4%), 30 as intermediate (24.2%), and 60 as high (48.4%) OSA-risk patients who were followed during hospitalization. ML implemented feature selection and integration across 47 variables (including STOP-BANG score, Killip class, GRACE score, and left ventricular ejection fraction) to identify those patients who experienced an in-hospital cardiovascular event (ie, death, ventricular arrhythmias, atrial fibrillation, recurrent angina, reinfarction, stroke, worsening heart failure, or cardiogenic shock) after definitive MI treatment. Receiver operating characteristic curves were used to compare ML performance against STOP-BANG score, Killip class, GRACE score, and left ventricular ejection fraction, independently. RESULTS: There were an increasing proportion of cardiovascular events across the low, intermediate, and high OSA risk groups (P = .005). ML selected 7 accessible variables (ie, Killip class, leukocytes, GRACE score, c reactive protein, oxygen saturation, STOP-BANG score, and N-terminal prohormone of B-type natriuretic peptide); their integration outperformed all comparators (area under the curve, 0.83 [95% CI, 0.74-0.90]; P <.01). INTERPRETATION: The integration of the STOP-BANG score into clinical evaluation (considering Killip class, GRACE score, and simple laboratory values) of subjects who were admitted for an acute MI because of ML can significantly optimize the identification of patients who will experience an in-hospital cardiovascular event

Use of colonoscopy as a primary screening test for colorectal cancer in average risk people

The use of colonoscopy as a primary screening test for colorectal cancer (CRC) in average risk adults is a subject of controversy. Our primary objective was to build a predictive model based on a few simple variables that could be used as a guide for identifying average risk adults more suitable for examination with colonoscopy as a primary screening test. METHODS: The prevalence of advanced adenomas was assessed by primary screening colonoscopy in 2210 consecutive adults at least 40 yr old, without known risk factors for CRC. Age, gender, and clinical and biochemical data were compared among people without adenomas, those with non-advanced adenomas, and those with any advanced neoplasm. A combined score to assess the risk of advanced adenomas was built with the variables selected by multiple logistic regression analysis. RESULTS: Neoplastic lesions were found in 617 subjects (27.9%), including 259 with at least one neoplasm that was 10 mm or larger, villous, or with moderate-to-severe dysplasia, and 11 with invasive cancers. Advanced lesions were more frequent among men, older people, and those with a higher body mass index (BMI). These three variables were independent predictors of advanced adenomas in multivariate analysis. A score combining age, sex, and BMI was developed as a guide for identifying individuals more suitable for screening colonoscopy. CONCLUSIONS: Age, gender, and BMI can be used to build a simple score to select those average risk adults who might be candidates for primary screening colonoscop