New developments related to lung complications in pediatric rheumatic disease.

PURPOSE OF REVIEW: While substantial progress has been made understanding lung disease in adult patients with rheumatic disease, pediatric lung disease has not been well addressed. Several recent studies provide new insights into diagnosis, management and treatment of lung disease in children with rheumatic disease. RECENT FINDINGS: Building on previous research, newly diagnosed patients may have abnormalities in pulmonary function tests and chest computed tomography imaging even when asymptomatic. New guidelines for screening for rheumatic-associated lung disease provide important recommendations for clinicians. New theories have been proposed about immunologic shifts leading to the development of lung disease in children with systemic juvenile idiopathic arthritis. Additionally, there are new antifibrotic agents that are being explored as treatments in pediatric patients with fibrotic lung diseases. SUMMARY: Patients appear to have frequent lung function abnormalities while being clinically asymptomatic, emphasizing importance for rheumatologists to refer for pulmonary function tests and imaging at diagnosis. New advances are helping define optimal approaches to treatment of lung disease, including use of biologic agents and antifibrotic medicines for pediatric patients with rheumatologic diseases.

Knowledge, Attitudes, and Practices of Allergists/Immunologists Regarding Transition of Care for Primary Immunodeficiency Patients.

PURPOSE: Only some allergists/immunologists provide care throughout the lifespan despite their training. Although transition of care (TOC) guidelines exist, research on provider perspectives on TOC for pediatric primary immunodeficiency (PID) patients is lacking. We aimed to characterize knowledge, attitudes, and practices and establish clinician needs using a needs assessment survey. METHODS: The 15-min online survey was adapted from an existing rheumatology TOC survey and was emailed to the American Academy of Allergy Asthma and Immunology (AAAAI) and Clinical Immunology Society (CIS) members. Our primary hypothesis was that both AAAAI and CIS providers report being underprepared for TOC and would express interest in TOC resources and consensus. RESULTS: Forty-nine of 1250 eligible AAAAI and 67 of 698 eligible CIS participants completed the survey (4.8% vs 11.3% participation rate). Many (53.1% vs 59.7%) respondents transition their own patients but also retain adult patients (59.2% vs 52.2%). Many accepted transition patients (85.7% vs 92.5%). In total, 24.1% of respondents did not have a TOC policy while 18.9% have an informal policy. Only 25.0% were satisfied with their current practices while 43.9% agreed that a consensus statement would be useful. CONCLUSION: Despite a small sample size and high rate of unanswered questions, our findings show that TOC remains overlooked in our specialty and that providers want and need additional training and resources. There is a clear need to develop and evaluate the effectiveness of evidence-based TOC guidelines, resources, and best practices for PID patients.

Diagnosis of EVALI in Adolescents During the COVID-19 Pandemic: A Case Series.

OBJECTIVE: Electronic-cigarette or vaping use-associated lung injury (EVALI) is an illness that requires further awareness for appropriate diagnosis and management. This series is a retrospective chart review of EVALI cases admitted from June to December 2020 at a large academic children's hospital in New York. METHODS: Notably during this time, the coronavirus disease 2019 (COVID-19) global pandemic rendered the world under strict quarantine mandates. We discuss 7 patients, all of whom were seen in a clinic, urgent care, or emergency department before presentation to our hospital. RESULTS: Patients presented with respiratory, gastroenterology, and constitutional complaints typically seen with EVALI and COVID-19. However, given their complex presentations in the setting of the COVID-19 pandemic, EVALI was not considered as pertinent history was not elicited. CONCLUSIONS: With the COVID-19 pandemic as a setting for these cases, we emphasize the importance of eliciting a complete psychosocial history for all adolescents because without vaping disclosure, EVALI will go undiagnosed. It is also imperative to ensure consistent outpatient follow-up, although difficult because of limited access or hesitation and fear of acquiring COVID-19 in health care settings during the pandemic, and to stress vaping cessation, both of which are crucial in preventing further complications.

An Analysis of Demographics and Inhaled Corticosteroid Use on COVID-19 Outcomes Among Hospitalized Adult Asthmatics: An Early Experience at a NY Hospital System.

PURPOSE: It is unclear whether asthma is a risk factor for the development of COVID-19; however, severe asthma is a risk factor for morbidity and mortality. While systemic corticosteroids are beneficial during the inflammatory phase of COVID-19, the impact of inhaled corticosteroids (ICS) is unclear. We sought to characterize asthmatics admitted with COVID-19 early in the pandemic, determine if baseline factors are associated with more severe COVID-19 disease, and if the use of ICS may mitigate the severity of COVID-19. PATIENTS AND METHODS: A retrospective chart review of hospitalized asthma patients >18 years testing positive for SARS-CoV2 from March to June 2020 was performed. Baseline demographic and asthma variables were collected. COVID-19 outcomes and laboratory values were extracted and compared between sex, race, ethnicity, and ICS use. RESULTS: Of the 906 patient charts reviewed, 787 asthmatics were confirmed to be admitted for symptomatic COVID-19. Sex differences were found in hospitalization and intubation. Non-Hispanic patients had a significantly greater number of days on ventilator. Patients on ICS were 1.6 times more likely to be discharged on supplemental oxygen compared to patients not on ICS (p = 0.01). CONCLUSION: While our findings confirm trends observed by others with respect to risk factors among asthmatics with COVID-19, differences based on sex, ethnicity and ICS use in asthmatics were observed. Our finding that ICS use was associated with discharge with oxygen is novel. Future research is needed to study the trajectory of asthmatics from diagnosis to outcomes.

A tale of caution: prolonged Bacillus clausii bacteraemia after probiotic use in an immunocompetent child.

INTRODUCTION: Bacillus clausii as a probiotic supplement is increasingly used in both adult and paediatric patient populations. There is limited awareness about potential adverse effects. CASE PRESENTATION: We report a case of prolonged (111 days) B. clausii bacteraemia after brief probiotic use in a 17-month-old immunocompetent child, without a definite focus of infection and in the absence of predisposing risk factors or underlying co-morbidities. We identified seven probiotic use-associated cases of prolonged B. clausii bacteraemia (mean duration [range] 64 days [14-93 days] where data were available) in the literature, all with underlying co-morbidities. CONCLUSION: B. clausii probiotic preparations may cause prolonged bacteraemia, rendering patients with underlying co-morbidities as well as those with unrecognized risk factors vulnerable for significant infectious complications.

Asthma and COVID-19: An early inpatient and outpatient experience at a US children's hospital.

BACKGROUND: Initially, persistent asthma was deemed a risk factor for severe COVID-19 disease. However, data suggests that asthmatics do not have an increased risk of COVID-19 infection or disease. There is a paucity of data describing pediatric asthmatics with COVID-19. OBJECTIVE: The objectives of this study were to determine the prevalence of asthma among hospitalized children with acute symptomatic COVID-19, compare demographic and clinical outcomes between asthmatics and nonasthmatics, and characterize behaviors of our outpatient pediatric population. METHODS: We conducted a single-center retrospective study of pediatric patients admitted to the Cohen Children's Medical Center at Northwell Health with symptomatic COVID-19 within 4 months of the surge beginning in March 2020 and a retrospective analysis of pediatric asthma outpatients seen in the previous 6 months. Baseline demographic variables and clinical outcomes for inpatients, and medication compliance, health behaviors, and asthma control for outpatients were collected. RESULTS: Thirty-eight inpatients and 95 outpatients were included. The inpatient prevalence of asthma was 34.2%. Asthmatics were less likely to have abnormal chest x-rays (CXRs), require oxygen support, and be treated with remdesivir. Among outpatients, 41% reported improved asthma control and decreased rescue medication use, with no COVID-19 hospitalizations, despite six suspected infections. CONCLUSIONS: Among children hospitalized for acute symptomatic COVID-19 at our institution, 34.2% had a diagnosis of asthma. Asthmatics did not have a more severe course and required a lower level of care. Outpatients had improved medication compliance and control and a low risk of hospitalization. Biological and behavioral factors may have mitigated against severe disease.

Comparison of Clinical and Epidemiologic Characteristics of Young Febrile Infants with and without Severe Acute Respiratory Syndrome Coronavirus-2 Infection.

OBJECTIVE: To determine features that distinguish febrile young infants with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. STUDY DESIGN: Retrospective single-center study included febrile infants <57 days of age evaluated in the emergency department of Cohen Children's Medical Center of Northwell Health, New Hyde Park, New York, from March 1 to April 30 of 2018, 2019, and 2020. Sociodemographic and clinical features were compared between those seen during the 2020 coronavirus disease-2019 pandemic and previous years, as well as between infants with SARS-CoV-2 infection and infants without SARS-CoV-2 infection (SARS-CoV-2 negative or evaluated during 2018 and 2019). RESULTS: In all, 124 febrile infants <57 days of age were identified; 38 during the 2-month study period in 2018, 33 in 2019, and 53 in 2020. During 2020, fewer febrile infants had a serious bacterial infection or a positive respiratory viral panel than in prior years (6% vs 21% [P = .02]; 15% vs 53% [P < .001], respectively). SARS-CoV-2 was the most frequent pathogen detected in 2020; of 30 infants tested, 20 tested positive. Infants with SARS-CoV-2 were more likely to identify as Hispanic (P = .004), have public insurance or be uninsured (P = .01), exhibited lethargy (P = .02), had feeding difficulties (P = .002), and had lower white blood cell (P = .001), neutrophil (P < .001), and lymphocyte counts (P = .005) than the 81 infants without SARS-CoV-2 infection. None of the infants with SARS-CoV-2 had concurrent serious bacterial infection or detection of another virus. Overall, disease in infants with SARS-CoV-2 was mild. CONCLUSIONS: During the peak of the pandemic, SARS-CoV-2 was the predominant pathogen among febrile infants. Socioeconomic, historical, and laboratory features differed significantly between infants infected or not infected with SARS-CoV-2. None of the 20 infants with SARS-CoV-2 infection had an identified coviral or serious bacterial infection.

A Case Series of the 2019 Novel Coronavirus (SARS-CoV-2) in 3 Febrile Infants in New York.

We describe 3 febrile infants <2 months of age admitted to a large tertiary care children's hospital in New York and subsequently found to be infected with severe acute respiratory syndrome coronavirus 2. All 3 patients presented with fever, feeding difficulty, lymphopenia, and thrombocytosis on laboratory evaluation. Two of the 3 patients were found to have neutropenia, and 2 had known exposures to sick contacts. In this case series, we describe 3 of the youngest patients to be reported with severe acute respiratory syndrome coronavirus 2 in the United States.

Is methicillin-resistant Staphylococcus Aureus infection associated with higher mortality and morbidity in hospitalized patients? A cohort study of 551 patients from South Western India.

PURPOSE: To determine morbidity and mortality of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) infections in a tertiary health care facility. METHODS: A cohort study among hospitalized adult patients with culture proven MRSA or MSSA monoinfection were recruited in a tertiary referral center in South India from November 2011 to December 2012. RESULTS: Of total 551 subjects, 284 (52%) had MRSA and 267 (48%) MSSA infection. A total of 184 (65%) subjects had health care-associated MRSA (HA-MRSA) and 100 (35%) community-associated MRSA (CA-MRSA). Chronic kidney disease and recent antibiotic use had significant association with MRSA. MRSA patients had significant respiratory infection (OR 2.24 [1.04, 5.16]) and bacteremia (OR 2.24 [10.40, 5.16]), relative to MSSA. MSSA group had better survival function compared to MRSA group (P=0.028). Median duration of ICU stays were 5 days (IQR 4, 8) and 2 days (IQR 2, 2) in MRSA and MSSA, respectively. Complications such as acute kidney injury, sepsis, multiorgan dysfunction, need for supportive measures were more in the MRSA group. CONCLUSION: MRSA imposes a huge burden in Indian scenario and HA-MRSA remains the main culprit. Patients with history of chronic kidney disease and recent use of antibiotics were found to be at a higher risk. Patients with MRSA infections tend to have poorer outcomes in terms of longer hospital stay, greater complications, and mortality.

Clinical - microbiological characterization and risk factors of mortality in infective endocarditis from a tertiary care academic hospital in Southern India.

AIMS: To dissect the clinical-microbiological profile of Infective endocarditis (IE) population and to determine the risk factors for IE related mortality. METHODS: A cohort study was conducted using relevant data from clinical records of patients (≥12years) with definite/possible IE from December 2007 to December 2013 and was analyzed using appropriate statistical tests. RESULTS: In the cohort of 139 IE patients, mean age was 47.9±15.8years, with male preponderance (68.3%). Rheumatic heart disease was the commonest (30.9%) underlying cardiac lesion followed by mitral valve prolapse with mitral regurgitation (23.7%), degenerative valvular disease (23%), congenital heart disease (15.8%) and prosthetic valves (3.6%). Vegetations were detected in 94.2% cases. Blood cultures were positive in 69.8% cases, commonest organism isolated was α - hemolytic streptococci (30.9%) followed by Enterococcus (12.9%) and methicillin sensitive Staphylococcus aureus (10.8%). Complications observed were congestive cardiac failure (31.2%), acute kidney injury (25.9%), stroke (21.6%), septic shock (16.5%), embolic phenomenon non-stroke (8.6%), atrial fibrillation (5%) and ring abscess (2.9%). Mortality rate was 17.3%. Congestive cardiac failure, increase in the peak leucocyte count and stroke were the independent predictors of mortality. CONCLUSIONS: This study reiterates the persistent dominance of rheumatic heart disease in the population studied and α - hemolytic Streptococci as the commonest responsible microorganism.

Evaluating clinicians' user experience and acceptability of LearnTB, a smartphone application for tuberculosis in India.

BACKGROUND: Tuberculosis (TB) is the leading infectious killer, and India accounts for 2.8 of the 10.4 million TB cases that occur each year, making it the highest TB burden country worldwide. Poor quality of TB care is a major driver of the epidemic in India. India's large private, unregulated sector manages over 50% of the TB patients, with studies showing suboptimal diagnosis and treatment in the private sector. Better education of doctors using mobile applications (apps) is a possible solution. While India has seen an explosion of mobile phone services, and while the use of mobile health interventions has been gaining interest, little is known about mHealth around tuberculosis in India. METHODS: Our study aimed to understand the user experience and acceptability of a smartphone application, LearnTB, amongst private sector academic clinicians in India. This study was conducted amongst 101 clinicians at Kasturba Hospital, Manipal, India. The user experience of participants (part 1) and acceptability (part 2) were evaluated with the use of two valid, English, paper-based questionnaires. The first questionnaire was based on the System Usability Scale (SUS); the second questionnaire was based on the Technology Acceptance Model (TAM). Data were collected during February and March 2017 and were analyzed using descriptive statistics, multiple linear regression as well as logistic regression analysis. RESULTS: A response rate of 99% was achieved; 100 participants responded to the second questionnaire and 100% of the participants responded to the first questionnaire. User experience was very high [mean SUS score =94.4 (92.07-96.76)]. Perceived usefulness (PU) was significantly correlated to intention to use (IU) (r=0.707, P<0.0001), and perceived ease of use (PEU) was significantly correlated to PU (r=0.466, P<0.0001). Path analysis confirmed the direct relationship between PU and IU (0.936, P<0.0001), and the indirect relationship between PEU and IU (0.5102, P<0.0001). Logistic regression analysis helped target items strongly influencing IU, such as "The use of the LearnTB application is compatible with my work habits" [OR =3.20 (1.04-9.84), P=0.004] and "The use of the LearnTB application could promote good clinical practice" [OR =5.23 (1.35-20.29); P=0.016]. CONCLUSION: The first part of the study indicated high user experience of the LearnTB application. The TAM questionnaire (second part) explained a significant portion of the variance in clinicians' IU the LearnTB application. The PU of the application has the highest impact on the clinicians' IU the Learn TB application. This study provides a preliminary analysis of mobile health interventions for tuberculosis in India, and emphasizes the need for future research in this domain.