What are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? Results from western Kenya, January 2007-July 2010.

Influenza causes severe illness and deaths, and global surveillance systems use different clinical case definitions to identify patients for diagnostic testing. We used data collected during January 2007-July 2010 at hospital-based influenza surveillance sites in western Kenya to calculate sensitivity, specificity, positive predictive value, and negative predictive value for eight clinical sign/symptom combinations in hospitalized patients with acute respiratory illnesses, including severe acute respiratory illness (SARI) (persons aged 2-59 months: cough or difficulty breathing with an elevated respiratory rate or a danger sign; persons aged ≥5 years: temperature ≥38 °C, difficulty breathing, and cough or sore throat) and influenza-like illness (ILI) (all ages: temperature ≥38 °C and cough or sore throat). Overall, 4800 persons aged ≥2 months were tested for influenza; 416 (9%) had laboratory-confirmed influenza infections. The symptom combination of cough with fever (subjective or measured ≥38 °C) had high sensitivity [87·0%, 95% confidence interval (CI) 83·3-88·9], and ILI had high specificity (70·0%, 95% CI 68·6-71·3). The case definition combining cough and any fever is a simple, sensitive case definition for influenza in hospitalized persons of all age groups, whereas the ILI case definition is the most specific. The SARI case definition did not maximize sensitivity or specificity.

Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study.

UNLABELLED: Acute lower respiratory illnesses (ALRI) are the leading cause of death among children <5 years. Studies have found that biomass cooking fuels are an important risk factor for ALRI. However, few studies have evaluated the influence of natural household ventilation indicators on ALRI. The purpose of this study was to assess the association between cooking fuel, natural household ventilation, and ALRI. During October 17, 2004-September 30, 2005, children <5 years living in a low-income neighborhood of Dhaka, Bangladesh, were assessed weekly for ALRI and surveyed quarterly about biomass fuel use, electric fan ownership, and natural household ventilation (windows, ventilation grates, and presence of a gap between the wall and ceiling). Bivariate and multivariate analyses were performed using generalized estimating equations. Six thousand and seventy-nine children <5 years enrolled during the study period (99% participation) experienced 1291 ALRI. In the multivariate model, ≥2 windows [OR = 0.75, 95% CI = (0.58, 0.96)], ventilation grates [OR = 0.80, 95% CI = (0.65, 0.98)], and not owning an electric fan [OR = 1.50, 95% CI = (1.21, 1.88)] were associated with ALRI; gap presence and using biomass fuels were not associated with ALRI. Structural factors that might improve household air circulation and exchange were associated with decreased ALRI risk. Improved natural ventilation might reduce ALRI among children in low-income families. PRACTICAL IMPLICATIONS: The World Health Organization has stated that controlling pneumonia is a priority for achieving the fourth Millennium Development Goal, which calls for a two-third reduction in mortality of children <5 years old compared to the 1990 baseline. Our study represents an important finding of a modifiable risk factor that might decrease the burden of respiratory illness among children living in Bangladesh and other low-income settings similar to our study site. We found that the existence of at least two windows in the child's sleeping room was associated with a 25% decreased ALRI risk. Increasing available natural ventilation within the household in similar settings has the potential to reduce childhood mortality because of acute lower respiratory illnesses.

Rainfall, household crowding, and acute respiratory infections in the tropics.

SUMMARYAcute respiratory infections (ARI) are the leading cause of death worldwide in children aged <5 years, and understanding contributing factors to their seasonality is important for targeting and implementing prevention strategies. In tropical climates, ARI typically peak during the pre-rainy and rainy seasons. One hypothesis is that rainfall leads to more time spent indoors, thus increasing exposure to other people and in turn increasing the risk of ARI. A case-crossover study design in 718 Bangladeshi children aged <5 years was used to evaluate this hypothesis. During a 3-month period with variable rainfall, rainfall was associated with ARI [odds ratio (OR) 2·97, 95% confidence interval (CI) 1·87-4·70]; some evidence of an increased strength of association as household crowding increased was found (≥3 people/room, OR 3·31, 95% CI 2·03-5·38), but there was a lack of association in some of the most crowded households (≥5 to <6 people/room, OR 1·55, 95% CI 0·54-4·47). These findings suggest that rainfall may be increasing exposure to crowded conditions, thus leading to an increased risk of ARI, but that additional factors not captured by this analysis may also play a role.

Clinical importance of measuring coronary graft flows in the revascularized heart. Ultrasonic or electromagnetic?

BACKGROUND: In the past, routine coronary graft flow measurement at the end of coronary artery bypass grafting (CABG) was not universally adopted by cardiac surgeons due to the lack of reliable flow measurement techniques. The purpose of this study was to investigate the efficacy of ultrasonic and electromagnetic techniques in coronary graft flow measurements and to determine the relationship, if any, between intraoperative ultrasonic or electromagnetic coronary graft flows and postoperative early clinical outcome. METHODS: We studied 66 consecutive patients who underwent elective CABG using internal thoracic artery (ITA) and reversed saphenous vein graft (SVG) conduits. All patients were males with the mean age of 65 +/- 1 yrs (range = 45 to 80 yrs). Coronary bypass graft flows (both ITA and SVG) were determined by the use of both ultrasonic and electromagnetic flowmeters. In addition, the flow waveform pattern was continuously recorded and analyzed with the ultrasonic technique. In this prospective non-randomized study, the following variables were considered in the forward stepwise multivariate regression analysis of the data: age, weight, body surface area, ejection fraction, perfusion and ischemia times, number of grafts, amount of allogenic banked blood, platelets, fresh frozen plasma transfusions, cardiac output/index, ultrasonic (USF) and electromagnetic flows (EMF), length of intensive care unit (ICU) and hospital stays, and early (30-day) mortality. RESULTS: Based on their location, 226 grafts were divided into four groups: (I) ITA to left anterior descending (LAD) (n = 66) 34 +/- 2.5 ml/min USF and 45 +/- 4.4 ml/min EMF; (II) SVG to circumflex (CX) (n = 62) 33 +/- 2.4 m/min USF and 58 +/- 4.9 ml/min EMF; (III) SVG to diagonal (DIAG) (n = 37); 30 +/- 3.5 ml/min USF and 50 +/- 6.0 ml/min EMF; (IV) SVG to right coronary artery (RCA) (n = 61); 36 +/- 3.1 ml/min USF and 56 +/- 5.3 ml/min EMF. Electromagnetic flow measurements were higher than USF values in all locations (p < 0.05). Difficulties in obtaining proper contact with the vessel wall and finding suitable size probes were major drawbacks in measurement of ITA graft flow by the use of electromagnetic technique. All flow measurements were done within 10 minutes or less. There was no demonstrable correlation between the length of stay (ICU and hospital), and coronary graft flows at the ITA to LAD, SVG to DIAG, or SVG to CX locations. However, ultrasonic coronary graft flows at the SVG to RCA location had a significant inverse correlation with the length of ICU and hospital stays (r = -0.45, p < 0.0005 for both). Early mortality was unaffected by the intraoperative coronary graft flow values (p = NS). CONCLUSIONS: The ultrasonic flowmeter is well-suited for intraoperative assessment of arterial and venous coronary graft flows at the completion of CABG. There is a real potential for using intraoperative graft flow values to predict early outcome after coronary bypass.

Influence of increasing age on long-term survival after coronary artery bypass grafting.

BACKGROUND: Despite the steady increase in the number of elderly patients undergoing coronary artery bypass grafting (CABG), skepticism still exists as to whether this operation is justified in older people with a reduced life expectancy. The purpose of this study was to examine the effects of increasing age on outcome after CABG. METHODS: A retrospective chart review was performed on 1,689 consecutive veterans of the United States Armed Forces undergoing isolated primary CABG from January 1972 through December 1994. For better comparison, they were arbitrarily divided by age into three groups: group I, 50 years of age or less (n = 213), group II, between 51 and 70 years of age (n = 1,258), and group III, more than 70 years of age (n = 218). Long-term survival for each group was compared to that of their age-matched population derived from Wisconsin life tables. RESULTS: The preoperative ejection fraction was comparable in all three groups (p = 0.114). The patients older than 70 years of age had received more grafts per operation than the patients 50 years of age and younger (3.7 versus 3.3) (p = 0.0001). Although the aortic cross-clamp time was prolonged with advanced age (p = 0.0002), the cardiopulmonary perfusion time was shortest in elderly patients (p = 0.0001). The early (30-day) mortality for the entire study population was 1.3%. There was a linear correlation between increasing age and early (30-day) mortality: group I, 0.5% (1/213); group II, 1.0% (13/1,258); and group III, 3.2% (7/218). The overall 10-year actuarial survival for all patients was 67%. The 10-year survival was diminished with increasing age (p = 0.0001): 74% for group I, 68% for group II, and 47% for group III. Comparative analysis of the three groups with their age-matched counterparts demonstrated an age-related survival after CABG. In group I, reduced survival was evident 4 years after the CABG: the 10-year survival in group I was 74.2%, and the survival of their age-matched population was 93.4% (confidence interval, 67% to 81.9%). In group II a survival difference was obvious 8 years after CABG: 10-year survival of 67.5% versus 75.1% in their age-matched population (confidence interval, 64.8% to 71.6%). In the elderly group of patients, no survival difference was noted: 10-year survival of 42.7% versus 45.9% of the age-matched population (confidence interval, 29.8% to 64.6%). CONCLUSIONS: An acceptable early mortality and long-term survival equal to those seen for an age-matched elderly population are sound outcome measures that support the justification of CABG in older patients irrespective of age.

The effects of intraoperative autologous whole blood sequestration on the need for transfusion of allogenic blood and blood products in coronary bypass operations.

We investigated the effect of intraoperative autologous blood sequestration (IABS), an old blood conservation method, on transfusion requirements for homologous packed red blood cells (PRBC), platelets, and fresh frozen plasma (FFP) for patients undergoing coronary bypass surgery. This non-randomized retrospective study involved 204 patients who underwent isolated primary coronary artery bypass grafting (CABG). In 140 patients (IABS Group), autologous heparinized whole blood was removed intraoperatively via aortic cannula before bypass and retransfused at the conclusion of extracorporeal circulation. In 64 control patients, no IABS was performed. Demographic characteristics and operative and perioperative variables for both groups were similar (p > 0.05). In 140 patients, the mean sequestered blood volume was 1430 ml (range = 700-2100 ml). The banked PRBC requirement during hospitalization was 1.91 units in the No IABS Group and 2.25 units for the IABS Group (p = 0.2957). The need for platelet transfusion was 3.06 units in the No IABS Group and 1.09 units in the IABS Group (p = 0.0003). In the No IABS Group, 1.31 units of FFP was transfused and in the IABS Group, 0.49 units was transfused (p = 0.0004). To identify possible confounding factors, we performed a multivariate Poisson regression analysis for the 22 patient variables by a forward stepwise procedure. Regression analysis indicated that IABS did not alter the need for PRBC transfusion (p = 0.6194) but adjusted differences did confirm that IABS was associated with decreased need for transfusion of platelets and FFP (p = 0.0001 and p = 0.0002, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Residual cervical intraepithelial neoplasia after laser ablation.

Some patients with histologically proven residual cervical intraepithelial neoplasia after laser ablation have false negative cytology. The explanation for this is not known, but there was no evidence of buried lesions. Follow-up of all patients treated by selective ablation is necessary. Cytology alone is inadequate and careful, accurate pre- and posttherapy colposcopy is essential.

Healing of cervical epithelium after laser ablation of cervical intraepithelial neoplasia.

Healing of cervical epithelium was studied in 30 patients after destruction of cervical intraepithelial neoplasia using a carbon dioxide laser. Repeated examinations, using photography and colposcopically directed punch biopsies, were made from the eighth to the 32nd day after treatment. The biopsy specimens were submitted to examination by light and transmission electron microscopy. There was complete epithelial cover of the laser induced craters in all patients by 28 days. The base of the crater and endocervical edge became covered by columnar epithelial cells originating in endocervical crypts, while the vaginal edge re- epithelialised by an ingrowth of the surrounding squamous epithelium. Squamous metaplasia of the new columnar epithelium was a common observation as early as eight days after treatment. There was no evidence for a stromal contribution to epithelial cover.