Hickman, Joel

Objective Respiratory syncytial virus (RSV) is an important viral pathogen in children, older adults and adults with certain high-risk conditions. In our prospective community-based cohort study of adults 50 years and older before the COVID-19 pandemic, the incidence of RSV acute respiratory infection (ARI) was 48.6 cases/1000 person-years (PY), which decreased to near zero during the COVID-19 pandemic. Our objective was to determine the incidence of RSV-ARI during the 2 years following the initial phase of the pandemic (2021–2022 and 2022–2023). Design This is a community-based prospective cohort study. Setting Adults living in southeast Minnesota from October 2021 to September 2022 (year 3) and October 2022 to September 2023 (year 4). Participants Adults≥50 years (n=2500). Primary and secondary outcomes We calculated incidence and attack rates for RSV-ARI as primary outcome and reported hospitalisations, pneumonia and death following ARI as secondary outcome. Results There were 2500 participants in the study with a mean age of 68.2 years (SD 9.3) at the start of year 3. Participants were predominantly female (60%), non-Hispanic white (96%) and residing in urban areas (76%). The incidence rate of RSV-ARI was 6.12/1000 PY (95% CI 3.42 to 10.09) in 2021–2022 and 16.40/1000 PY (95% CI 11.66 to 22.42) in 2022–2023. We noted higher attack rates of RSV-ARI during the winter months. There were no hospitalisations, pneumonia or deaths within 30 days of RSV-ARI. Conclusions Compared with the period before the COVID-19 pandemic, RSV-ARI incidence was lower in both 2021–2022 and 2022–2023 periods. In 2022–2023, the incidence increased 2.7-fold compared with the 2021–2022 period. The observed incidence rates, particularly the significant increase in the most recent season, underscore the continued public health relevance of RSV-ARI and support the rationale for ongoing RSV vaccination efforts to mitigate its overall burden in the population.

Context Adolescence is a critical period for bone development. Due to an elevated risk for low body mass index (BMI) and/or low energy availability, certain adolescent athletes are at increased risk of bone stress injury (BSI) and eating disorders (EDs). Despite this risk, the incidence of EDs in patients with BSI is unclear. Objective To compare the incidence of a premorbid drop in BMI percentile in a sample of adolescent athletes diagnosed with a BSI between 2005 and 2016. We also evaluated the relative risk of developing an ED for this sample, compared with a sex-matched, age-matched (±6 months), and time-matched (±2 years) sample of active adolescents with knee pain. Design Retrospective cohort study. Setting Data collected through the Rochester Epidemiology Project. Patients or Other Participants One hundred eighty-seven adolescent (aged 13–18) athletes with BSI and 187 active adolescents with knee pain. Main Outcome Measure(s) Conditional logistic regression was used to assess whether premorbid weight loss was a risk factor for BSI. A stratified log-rank test was used to evaluate the association between ED diagnosis and case-control status up to 5 years postinjury. Results Patients with a BSI had 1.53 times the odds of premorbid BMI percentile drop compared with controls (95% CI = 0.83, 2.12; P = .17). A total of 14 patients with a BSI had ED diagnoses after injury compared with 8 controls ( P = .13). Patients from weight-based or aesthetic sports had 1.93 times the odds of a BSI compared with controls (95% CI = 1.23, 3.02; P = .0040). The Kaplan-Meier estimates indicate that the case group had a greater risk of ED diagnosis. Conclusions Results suggest a trend toward a greater drop in BMI percentile and increased frequency of ED diagnoses in the BSI group compared with controls. The documented co-occurrence of weight loss, stress fractures, and EDs in adolescent athletes should inform guidelines for screening and treatment of adolescent athletes with BSIs.

Abstract Background Uncertainty exists regarding the effectiveness of COVID-19 vaccine to prevent postacute sequelae of COVID-19 (PASC) following a breakthrough infection. While most studies based on symptom surveys found an association between preinfection vaccination status and PASC symptoms, studies of medically attended PASC are less common and have reported conflicting findings. Methods In this retrospective cohort of patients with an initial SARS-CoV-2 infection who were continually empaneled for primary care in a large US health system, the electronic health record was queried for preinfection vaccination status, demographics, comorbidity index, and diagnosed conditions. Multivariable logistic regression was used to model the outcome of a medically attended PASC diagnosis within 6 months of SARS-CoV-2 infection. Likelihood ratio tests were used to assess the interaction between vaccination status and prevalent variant at the time of infection and between vaccination status and hospitalization for SARS-CoV-2 infection. Results During the observation period, 6.9% of patients experienced medically attended and diagnosed PASC. A diagnosis of PASC was associated with older age, female sex, hospitalization for the initial infection, and an increased severity-weighted comorbidity index and was inversely associated with infection during the Omicron period. No difference in the development of diagnosed PASC was observed between unvaccinated patients and those vaccinated with either 2 doses of an mRNA vaccine or >2 doses. Conclusions We found no association between vaccination status at the time of infection and development of medically diagnosed PASC. Vaccine remains an important measure to prevent SARS-CoV-2 infection and severity. Further research is needed to identify effective measures to prevent and treat PASC.

Importance Little is known about the burden and outcomes of respiratory syncytial virus (RSV)–positive acute respiratory infection (ARI) in community-dwelling older adults. Objective To assess the incidence of RSV-positive ARI before and during the COVID-19 pandemic, and to assess outcomes for RSV-positive ARI in older adults. Design, Setting, and Participants This was a community-based cohort study of adults residing in southeast Minnesota that followed up with 2325 adults aged 50 years or older for 2 RSV seasons (2019-2021) to assess the incidence of RSV-positive ARI. The study assessed outcomes at 2 to 4 weeks, 6 to 7 months, and 12 to 13 months after RSV-positive ARI. Exposure RSV-positive and -negative ARI. Main Outcomes and Measures RSV status was the main study outcome. Incidence and attack rates of RSV-positive ARI were calculated during each RSV season, including before (October 2019 to April 2020) and during (October 2020 to April 2021) COVID-19 pandemic, and further calculated during non-RSV season (May to September 2021) for assessing impact of COVID-19. The self-reported quality of life (QOL) by Short-Form Health Survey-36 (SF-36) and physical functional measures (eg, 6-minute walk and spirometry) at each time point was assessed. Results In this study of 2325 participants, the median (range) age of study participants was 67 (50-98) years, 1380 (59%) were female, and 2240 (96%) were non-Hispanic White individuals. The prepandemic incidence rate of RSV-positive ARI was 48.6 (95% CI, 36.9-62.9) per 1000 person-years with a 2.50% (95% CI, 1.90%-3.21%) attack rate. No RSV-positive ARI case was identified during the COVID-19 pandemic RSV season. Incidence of 10.2 (95% CI, 4.1-21.1) per 1000 person-years and attack rate of 0.42%; (95% CI, 0.17%-0.86%) were observed during the summer of 2021. Based on prepandemic RSV season results, participants with RSV-positive ARI (vs matched RSV-negative ARI) reported significantly lower QOL adjusted mean difference (limitations due to physical health, −16.7 [95% CI, −31.8 to −1.8]; fatigue, −8.4 [95% CI, −14.3 to −2.4]; and difficulty in social functioning, −11.9 [95% CI, −19.8 to −4.0] within 2 to 4 weeks after RSV-positive ARI [ie, short-term outcome]). Compared with participants with RSV-negative ARI, those with RSV-positive ARI also had lower QOL (fatigue: −4.0 [95% CI, −8.5 to −1.3]; difficulty in social functioning, −5.8 [95% CI, −10.3 to −1.3]; and limitation due to emotional problem, −7.0 [95% CI, −12.7 to −1.3] at 6 to 7 months after RSV-positive ARI [intermediate-term outcome]; fatigue, −4.4 [95% CI, −7.3 to −1.5]; difficulty in social functioning, −5.2 [95% CI, −8.7 to −1.7] and limitation due to emotional problem, −5.7 [95% CI, −10.7 to −0.6] at 12-13 months after RSV-positive ARI [ie, long-term outcomes]) independent of age, sex, race and/or ethnicity, socioeconomic status, and high-risk comorbidities. Conclusions and Relevance In this cohort study, the burden of RSV-positive ARI in older adults during the pre-COVID-19 period was substantial. After a reduction of RSV-positive ARI incidence from October 2020 to April 2021, RSV-positive ARI re-emerged during the summer of 2021. RSV-positive ARI was associated with significant long-term lower QOL beyond the short-term lower QOL in older adults.

AbstractBackground and AimsInfluenza is a challenging infectious illness for older adults. It is not completely clear whether influenza is associated with frailty or functional decline. We sought to determine the association between incident influenza infection and frailty and prefrailty in community patients over 50 years of age. We also investigated the association between influenza vaccination and frailty and prefrailty as a secondary aim.MethodsThis was a prospective community cohort study from October 2019 to November 2020 in participants over 50 years. The primary outcome was the development of frailty as defined by three of five frailty criteria (slow gait speed, low grip strength, 5% weight loss, low energy, and low physical functioning). The primary predictor was a positive polymerase chain reaction (PCR) for influenza infection. Influenza vaccination was based on electronic health record reviewing 1 year before enrollment. We reported the relationship between influenza and frailty by calculating odds ratios (OR) with 95% confidence intervals (CI) after adjustment for age, sex, socioeconomic status, Charlson Comorbidity Index (CCI), influenza vaccine, and previous self‐rated frailty from multinomial logistic regression model comparing frail and prefrail to nonfrail subjects.ResultsIn 1135 participants, the median age was 67 years (interquartile range 60−74), with 41% men. Eighty‐one participants had PCR‐confirmed influenza (7.1%). Frailty was not associated with influenza, with an OR of 0.50 (95% CI 0.17−1.43) for frail participants compared to nonfrail participants. Influenza vaccination is associated with frailty, with an OR of 1.69 (95% CI 1.09−2.63) for frail compared to nonfrail. Frailty was associated with a higher CCI with an OR of 1.52 (95% CI 1.31−1.76).ConclusionWe did not find a relationship between influenza infection and frailty. We found higher vaccination rates in participants with frailty compared to nonfrail participants While influenza was not associated with frailty, future work may involve longer follow‐up.

Abstract Objective We aimed to develop a model for accurate prediction of general care inpatient deterioration. Materials and Methods Training and internal validation datasets were built using 2-year data from a quaternary hospital in the Midwest. Model training used gradient boosting and feature engineering (clinically relevant interactions, time-series information) to predict general care inpatient deterioration (resuscitation call, intensive care unit transfer, or rapid response team call) in 24 hours. Data from a tertiary care hospital in the Southwest were used for external validation. C-statistic, sensitivity, positive predictive value, and alert rate were calculated for different cutoffs and compared with the National Early Warning Score. Sensitivity analysis evaluated prediction of intensive care unit transfer or resuscitation call. Results Training, internal validation, and external validation datasets included 24 500, 25 784 and 53 956 hospitalizations, respectively. The Mayo Clinic Early Warning Score (MC-EWS) demonstrated excellent discrimination in both the internal and external validation datasets (C-statistic = 0.913, 0.937, respectively), and results were consistent in the sensitivity analysis (C-statistic = 0.932 in external validation). At a sensitivity of 73%, MC-EWS would generate 0.7 alerts per day per 10 patients, 45% less than the National Early Warning Score. Discussion Low alert rates are important for implementation of an alert system. Other early warning scores developed for the general care ward have achieved lower discrimination overall compared with MC-EWS, likely because MC-EWS includes both nursing assessments and extensive feature engineering. Conclusions MC-EWS achieved superior prediction of general care inpatient deterioration using sophisticated feature engineering and a machine learning approach, reducing alert rate.

Abstract Introduction Identification of hospitalized patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses. Methods We recorded nurses’ perception of patient potential for deterioration in 2 medical and 2 surgical adult hospital units using a 5-point score at the start of the shift (the Worry Factor [WF]), and any time a change or an increase was noted by the nurse. Cases were evaluated by three reviewers. Intensive care unit (ICU) transfers were also tracked. Results 31 159 patient-shifts were recorded for 3185 unique patients during 3551 hospitalizations, with 169 total outcome events. Out of 492 potential deterioration events identified, 380 (77%) were confirmed by reviewers as true deterioration events. Likelihood ratios for ICU transfer were 17.8 (15.2–20.9) in the 24 hours following a WF > 2, and 40.4 (27.1–60.1) following a WF > 3. Accuracy rates were significantly higher in nurses with over a year of experience (68% vs 79%, P = 0.04). The area under the receiver operator characteristic curve (AUROC) was 0.92 for the prediction of ICU transfer within 24 hours. Discussion This is a higher accuracy than most published early warning scores. Conclusion Nurses’ pattern recognition and sense of worry can provide important information for the detection of acute physiological deterioration and should be included in the electronic medical record.

BACKGROUNDThe use of rapid response systems (RRS), which were designed to bring clinicians with critical care expertise to the bedside to prevent unnecessary deaths, has increased. RRS rely on accurate detection of acute deterioration events. Early warning scores (EWS) have been used for this purpose but were developed using heterogeneous populations. Predictive performance may differ in medical vs surgical patients.OBJECTIVETo evaluate the performance of published EWS in medical vs surgical patient populations.DESIGNRetrospective cohort study.SETTINGTwo tertiary care academic medical center hospitals in the Midwest totaling more than 1500 beds.PATIENTSAll patients discharged from January to December 2011.INTERVENTIONNone.MEASUREMENTSTime‐stamped longitudinal database of patient variables and outcomes, categorized as surgical or medical. Outcomes included unscheduled transfers to the intensive care unit, activation of the RRS, and calls for cardiorespiratory resuscitation (“resuscitation call”). The EWS were calculated and updated with every new patient variable entry over time. Scores were considered accurate if they predicted an outcome in the following 24 hours.RESULTSAll EWS demonstrated higher performance within the medical population as compared to surgical: higher positive predictive value (P < .0001 for all scores) and sensitivity (P < .0001 for all scores). All EWS had positive predictive values below 25%.CONCLUSIONSThe overall poor performance of the evaluated EWS was marginally better in medical patients when compared to surgical patients.