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Clinical characteristics of 2009 pandemic influenza A (H1N1) infection in children and the performance of rapid antigen test.

In autumn 2009, the swine-origin influenza A (H1N1) virus spread throughout South Korea. The aims of this study were to determine the clinical characteristics of children infected by the 2009 H1N1 influenza A virus, and to compare the rapid antigen and real-time polymerase chain reaction (PCR) tests.

METHODS: We conducted a retrospective review of patients ≥18 years of age who presented to Soonchunhyang University Hospital in Seoul with respiratory symptoms, including fever, between September 2009 and January 2010. A real-time PCR test was used to definitively diagnose 2009 H1N1 influenza A infection. Medical records of confirmed cases were reviewed for sex, age, and the time of infection. The decision to perform rapid antigen testing was not influenced by clinical conditions, but by individual factors such as economic conditions. Its sensitivity and specificity were evaluated compared to real-time PCR test results.

RESULTS: In total, 934 patients tested positive for H1N1 by real-time PCR. The highest number of patients (48.9%) was diagnosed in November. Most patients (48.2%) were aged between 6 and 10 years. Compared with the H1N1 real-time PCR test results, the rapid antigen test showed 22% sensitivity and 83% specificity. Seventy-eight patients were hospitalized for H1N1 influenza A virus infection, and fever was the most common symptom (97.4%).

CONCLUSION: For diagnosis of 2009 H1N1 influenza A virus infection, the rapid antigen test was inferior to the real-time PCR test in both sensitivity and specificity. This outcome suggests that the rapid antigen test is inappropriate for screening.

ALMA, a new tool for the management of asthma patients in clinical practice: development, validation and initial clinical findings.

Several instruments have been developed for measuring asthma control, but there is still a need to provide a structure for primary care asthma reviews. AIMS: The Active Life with Asthma (ALMA) tool was developed with the aim of structuring patient visits and assessing asthma treatment in primary care. The ability of ALMA to map out the care of asthma patients was evaluated and validated.

METHODS: ALMA was developed with patient and clinical expert input. Questions were generated in focus groups and the resulting tool was subsequently validated by factor analysis in 1779 patients (1116 females) of mean age 51 years (range 18-89) in primary care.

RESULTS: The ALMA tool includes 19 questions, 14 of which belong to a subset assessing asthma control. In this subset, factor analysis revealed three domains (factors): physical, psychological, and environmental triggers. Correlation with the Asthma Control Questionnaire was 0.72 and the Cronbach's alpha was 0.88. The test-retest reliability was 0.93. Of the 1779 patients tested with ALMA in primary care, 62% reported chest tightness, 30% nightly awakenings and 45% asthma breakthrough despite medication.

CONCLUSIONS: The ALMA tool is useful as a follow-up instrument in clinical practice to structure patient visits and assess asthma treatment in primary care. The breadth of the questions and the pragmatic use in clinical practice also make it useful as an outcome measure.

Impact of antisecretory treatment on respiratory symptoms of gastroesophageal reflux disease in children.

The effect of antisecretory treatment on extraesophageal symptoms of gastroesophageal reflux disease was evaluated.

Seventy-eight children presenting with typical and extraesophageal symptoms of gastroesophageal reflux disease underwent a multichannel intraluminal impedance and pH monitoring (MII/pH). Children with a positive MII/pH were randomly treated with proton pump inhibitors (PPIs) or histamine H(2) -receptor antagonists (H(2) RAs) during 3 months. At the end of the treatment period, all patients were recalled.

A second treatment period of 3 months was given to those patients who were not symptom-free after 3 months. Thirty-five of the forty-one (85.4%) children with a pathologic MII/pH presented with extraesophageal symptoms and were treated with PPIs (omeprazole; n:19) or H(2) RAs (ranitidine; n:16) for 12 weeks.

After 3 months, 11/19 (57.9%) PPI-treated patients had a complete resolution of symptoms; 6/8 nonresponders were treated with PPI for another 3 months and became all symptom-free. The other two underwent a Nissen fundoplication. Only 5/16 (31.2 %) patients treated with H(2) RAs had a complete resolution of symptoms after 3 months; 1/11 was treated again with H(2) RAs during 3 months, and 10/11 were changed to PPIs. In 3/10, a partial resolution of symptoms was achieved, while in 7/10, a complete remission was obtained (P < 0.05).

Antisecretory reflux treatment improves extraesophageal reflux symptoms. The efficacy of PPIs is superior to that of H(2) RAs in these children.

Clinical features of paediatric pulmonary hypertension: a registry study.

Paediatric pulmonary hypertension, is an important cause of morbidity and mortality, and is insufficiently characterised in children. The Tracking Outcomes and Practice in Pediatric Pulmonary Hypertension (TOPP) registry is a global, prospective study designed to provide information about demographics, treatment, and outcomes in paediatric pulmonary hypertension.

METHODS: Consecutive patients aged 18 years or younger at diagnosis with pulmonary hypertension and increased pulmonary vascular resistance were enrolled in TOPP at 31 centres in 19 countries from Jan 31, 2008, to Feb 15, 2010. Patient and disease characteristics, including age at diagnosis and at enrolment, sex, ethnicity, presenting symptoms, pulmonary hypertension classification, comorbid disorders, medical and family history, haemodynamic indices, and functional class were recorded. Follow-up was decided by the patients' physicians according to the individual's health-care needs.

FINDINGS: 362 of 456 consecutive patients had confirmed pulmonary hypertension (defined as mean pulmonary artery pressure ≥25 mm Hg, pulmonary capillary wedge pressure ≤12 mm Hg, and pulmonary vascular resistance index ≥3 WU/m(-2)). 317 (88%) patients had pulmonary arterial hypertension (PAH), which was idiopathic [IPAH] or familial [FPAH] in 182 (57%), and associated with other disorders in 135 (43%), of which 115 (85%) cases were associated with congenital heart disease. 42 patients (12%) had pulmonary hypertension associated with respiratory disease or hypoxaemia, with bronchopulmonary dysplasia most frequent. Finally, only three patients had either chronic thromboembolic pulmonary hypertension or miscellaneous causes of pulmonary hypertension. Chromosomal anomalies, mainly trisomy 21, were reported in 47 (13%) of patients with confirmed disease. Median age at diagnosis was 7 years (IQR 3-12); 59% (268 of 456) were female. Although dyspnoea and fatigue were the most frequent symptoms, syncope occurred in 31% (57 of 182) of patients with IPAH or FPAH and in 18% (eight of 45) of those with repaired congenital heart disease; no children with unrepaired congenital systemic-to-pulmonary shunts had syncope. Despite severe pulmonary hypertension, functional class was I or II in 230 of 362 (64%) patients, which is consistent with preserved right-heart function.

INTERPRETATION: TOPP identifies important clinical features specific to the care of paediatric pulmonary hypertension, which draw attention to the need for paediatric data rather than extrapolation from adult studies. FUNDING: Actelion Pharmaceuticals.

Frequency and relevance of ischemic electrocardiographic findings in patients with chronic obstructive pulmonary disease.

Cardiovascular disease is common in patients with chronic obstructive pulmonary disease (COPD) but often remains unrecognized. Ischemic electrocardiographic (ECG) changes are associated with a higher risk of dying from coronary heart disease but have never been systematically evaluated in COPD. Also, their relation to clinical outcome has not been studied.

We aimed to determine the frequency of ischemic ECG changes and its relevance in relation to clinical outcome and predictors of impaired survival in patients with COPD. Clinical characteristics, pulmonary function, and co-morbidities were assessed in 536 patients with COPD during baseline assessment of a comprehensive pulmonary rehabilitation program. Moreover, electrocardiograms at rest were obtained in all patients. All electrocardiograms were scored independently by 2 cardiologists using the Minnesota scoring system. Major or minor Q or QS pattern, ST junction and segment depression, T-wave items, or left bundle branch block were considered ischemic ECG changes.

One hundred thirteen patients (21%) had ischemic ECG changes. Moreover, 42 of 293 patients (14%) without self-reported cardiovascular co-morbidities had ischemic ECG changes. In addition, patients with ischemic ECG changes had higher dyspnea grades (Modified Medical Research Council (mMRC) 2.9 ± 1.1 vs 2.6 ± 1.1, p = 0.032), worse exercise performance (6-minute walking distance 387 ± 126 vs 425 ± 126 m, p = 0.004), more systemic inflammation (high-sensitivity C-reactive protein 11.2 ± 16.2 vs 7.9 ± 10.7 mmol/l, p = 0.01), higher scores on the Charlson Co-morbidity Index (1.8 ± 0.9 vs 1.5 ± 0.8 points), and higher scores BODE (5.3 ± 3.7 vs 4.5 ± 3.4 points, p = 0.033) and on ADO indexes (5.2 ± 1.7 vs 4.8 ± 1.7 points, p = 0.029) compared to patients without ischemic ECG changes, whereas forced expiratory volume in the first second was similar (40.8 ± 15.2% vs 42.6% ± 15.9%, p = 0.30).

In conclusion, ischemic ECG changes are common in patients with COPD and associated with poor clinical outcome irrespective of forced expiratory volume in the first second. These results suggest an important role for cardiovascular disease in impaired survival in these patients.

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