General data. 15 y/o boy with fever, cough and blood tinged sputum for 2 days. Present Illness

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Pediatric Emergency Morning Report 15 y/o boy with fever, cough and blood tinged sputum for

history: denied Occupational contact history : denied Operation history : denied Present

8C, productive cough with yellow sputum, headache and leg pain for 2 days.

Rhinorrhea, throat soreness and dizziness were accompanied with fever. Then fever up to 39.

1 Pediatric Emergency Morning Report 15 y/o boy with fever, cough and blood tinged sputum for 2 days 指導教授 : 夏紹軒主任吳昌騰主任 Speaker: 李浩遠 General data Age: 15-year-old Gender: male Traveling history: denied Occupational contact history : denied Operation history : denied Present Illness The 1.5 y/o boy suffered from fever up to 38.8C, productive cough with yellow sputum, headache and leg pain for 2 days. He went to LMD but in vain. Rhinorrhea, throat soreness and dizziness were accompanied with fever. Then fever up to 39.5C with chillness and cough with blood tinged sputum were onset this morning so he was brought to our ER. As to physical examination, we found mild right lung crackle. What are your impressions and treatments? 1

In the ward Tamiflu was given by self-pay in our ER.

Added azithromycin and augmentin then fever subsided.

Ag: Positive(0111) Infl-A PCR Negative(0113) Infl-B PCR

) 項目 : 項目 ( 檢體 ) 細菌及生長狀態 ( 日期 ) Aerobic Culture(SP) Haemo.

2 In the ward Tamiflu was given by self-pay in our ER. Unasyn (ampicillin/sulbactam) was given in our ER but stopped in the ward. Fever persisted and symptoms aggravated. Added azithromycin and augmentin then fever subsided. Results of Cultures 檢體 :TH Inf A Ag: Negative(0111) Inf B Ag: Positive(0111) Infl-A PCR Negative(0113) Infl-B PCR Positive(0113) 檢體 :U Strep.P.Ag(U) Negative(0112) 檢驗 ( 微生物 ) 項目 : 項目 ( 檢體 ) 細菌及生長狀態 ( 日期 ) Aerobic Culture(SP) Haemo.influenzae Moderate(0111) Discussion Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed

Primary influenza viral pneumonia begins with a typical onset of influenza, followed by a rapid progression of fever, cough, dyspnea,, and cyanosis.

Such patients do not respond to antibiotics, and mortality is high.

At the present time, severe primary influenza viral pneumonia is rare. Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed.

Not all influenza-related deaths are manifested as pneumonia. Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed.

3 Primary influenza viral pneumonia begins with a typical onset of influenza, followed by a rapid progression of fever, cough, dyspnea,, and cyanosis.. Physical examination and chest radiographic results reveal bilateral findings consistent with the respiratory disease syndrome but no consolidation. Such patients do not respond to antibiotics, and mortality is high.. At autopsy, findings consist of tracheitis,, bronchitis, diffuse hemorrhagic pneumonia, hyaline membranes lining alveolar ducts and alveoli, and a paucity of inflammatory cells within the alveoli. At the present time, severe primary influenza viral pneumonia is rare. Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed The level of excess mortality is highest in years when influenza A (H3N2) viruses predominate, but influenza B and to a lesser extent H1N1 viruses also can be associated with excess mortality. Not all influenza-related deaths are manifested as pneumonia. Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed Influenza B viruses are approximately 10-fold less sensitive to neuraminidase inhibitors than influenza A viruses, but they are still sensitive well within clinically achievable concentrations. Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed CLINICAL MANIFESTATIONS OF NONTYPEABLE HAEMOPHILUS INFLUENZAE Otitis Media Exacerbations of Chronic Obstructive Pulmonary Disease Community-Acquired Pneumonia The clinical features are indistinguishable from those of pneumonia caused by other bacteria and include fever, cough, and purulent sputum, usually of several days' duration. The chest film reveals infiltrates that may be patchy or show lobar distribution. A Gram-stained smear of the sputum shows a predominance of small gram-negative coccobacilli. Acute Respiratory Tract Infections in Children in Developing Countries Sinusitis Neonatal and Maternal Sepsis Bacteremia and Invasive Infections Conjunctivitis Mandell: Mandell,, Douglas, and Bennett's Principles and Practice of Infectious Diseases, D 7th ed Comparison of influenza A and influenza B virus infection in hospitalized children in Australia J. Paediatr. Child Health (2000) 36, Influenza B virus infection was more common in children with underlying medical problems (P = 0.01), such as asthma, cardiac disease, immunodeficiency disorders, diabetes and chronic renal failure. Neurological manifestations were present in eight (12.5%) of 64 children with influenza A and none with influenza B virus infection (P = 0.09). 3

4 Comparison of influenza A and influenza B virus infection in hospitalized children in Australia. J. Paediatr. Child Health (2000) 36, There was a significant difference in the age distribution of patients with 36 of 64 (56%) children with influenza A infection compared with seven of 27 (26%) children with influenza B being under 12 months of age (P = 0.02). Comparison of influenza A and influenza B virus infection in hospitalized children in Australia J. Paediatr. Child Health (2000) 36, Comparison of influenza A and influenza B virus infection in hospitalized children in Australia J. Paediatr. Child Health (2000) 36, Comparison of influenza A and influenza B virus infection in hospitalized children in Australia J. Paediatr. Child Health (2000) 36, A Mouse Model of Lethal Synergism Between Influenza Virus and Haemophilus influenzae Am J Pathol 2010, 176: ; DOI: /ajpath Secondary bacterial infections that follow infection with influenza virus result in considerable morbidity and mortality. We herein describe a mouse model for investigating the interaction between influenza virus and the bacterium Haemophilus influenzae. A Mouse Model of Lethal Synergism Between Influenza Virus and Haemophilus influenzae Am J Pathol 2010, 176: ; DOI: /ajpath Bacterial growth was prolonged in the lungs of dual-infected mice, although influenza virus titers were unaffected. Dual infection induced severe damage to the airway epithelium and confluent pneumonia, similar to that observed in victims of the 1918 global influenza pandemic. Increased bronchial epithelial cell death was observed as early as 1 day after bacterial inoculation in the dual-infected mice. 4

A Mouse Model of Lethal Synergism Between Influenza Virus and Haemophilus influenzae Am J Pathol 2010, 176:000 000; DOI: 10.2353/ajpath.2010.090596 Histology of lungs in 9 days after influenza infection (6 days after Hib infection).

001 Low power comparison of lung tissue Incidence, Seasonality and Mortality Associated with Influenza Pneumonia in Thailand: 2005 2008 LoS One. 2009 Nov 11;4(11):e7776.

g004 Multipathogen infections in hospitalized children with acute respiratory infections. Wuhan University, Wuhan, PR China. Virol J. 2009 Sep 29;6:155. Respiratory agents were detected in 164 (51.

5 A Mouse Model of Lethal Synergism Between Influenza Virus and Haemophilus influenzae Am J Pathol 2010, 176: ; DOI: /ajpath Histology of lungs in 9 days after influenza infection (6 days after Hib infection). A Mouse Model of Lethal Synergism Between Influenza Virus and Haemophilus influenzae Am J Pathol 2010, 176: ; DOI: /ajpath , normal; 1, mild; 2, moderate; 3, severe. P< Low power comparison of lung tissue Incidence, Seasonality and Mortality Associated with Influenza Pneumonia in Thailand: LoS One Nov 11;4(11):e7776. Seasonal distribution of influenza positive pneumonia (n = 1,346 influenza positive among 13,110 pneumonia cases). doi: /journal.pone g004 Multipathogen infections in hospitalized children with acute respiratory infections. Wuhan University, Wuhan, PR China. Virol J Sep 29;6:155. Respiratory agents were detected in 164 (51.9%) of 316 children with ARTI. A single agent was identified in 50 (15.8%) children, and multiple agents in 114 (36.1%). Flu A was the most frequently detected agent, followed by Flu B. Coinfection occurred predominantly in August and was more frequent in children between 3 and 6 years of age. A significantly higher proportion of Flu A, Flu B, and PIV 1 (parainfluenza virus) was detected in samples with two or more pathogens per sample than in samples with a single pathogen. Multipathogen infections in hospitalized children with acute respiratory infections. Wuhan University, Wuhan, PR China. Virol J Sep 29;6:155. Multipathogen infections in hospitalized children with acute respiratory infections. Wuhan University, Wuhan, PR China. Virol J Sep 29;6:155. 5

Severe Human Influenza Infections in Thailand: Oseltamivir Treatment and Risk Factors for Fatal Outcome PLoS One. 2009 Jun 25;4(6):e6051.

6 Severe Human Influenza Infections in Thailand: Oseltamivir Treatment and Risk Factors for Fatal Outcome PLoS One Jun 25;4(6):e6051. Twenty-two (1%) deaths occurred including seven deaths in children less than ten years of age. 35% of hospitalized human influenza infections had chest X-ray confirmed pneumonia. Treatment with Oseltamivir was statistically associated with survival with a crude OR of.11 (95% CI: ) and.13 (95% CI: ) after controlling for age. CONCLUSIONS: Treatment with Oseltamivir is associated with survival in hospitalized human influenza pneumonia patients. Severe Human Influenza Infections in Thailand: Oseltamivir Treatment and Risk Factors for Fatal Outcome PLoS One Jun 25;4(6):e6051. Human influenza cases and deaths reported by National Avian Influenza Surveillance. Severe Human Influenza Infections in Thailand: Oseltamivir Treatment and Risk Factors for Fatal Outcome. Factors associated with a fatal outcome. Journal Reading Demographics of patient visits during high daily census in a pediatric ED American Journal of Emergency Medicine (2010) 28, Nathan L. Timm MD, Richard M. Ruddy MD Division of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center,Cincinnati, OH 45229, USA Purpose and Introduction The aim of this study is to describe patient demographics in a pediatric emergency department (PED) during low, average, and high daily census days. CCHMC is a large, urban, tertiary care, pediatric teaching hospital, with an ED patient volume of approximately 95,000 visits per year (260 visits per day) Methods Daily PED census, between January 1, 2006, and December 31, 2006, was categorized into very low, low, average, high, and very high quintiles. Variables of interest included acuity, age, health care coverage, and disposition. χ2 analysis assessed the significance of differences in proportions of patient populations across the census quintiles. 6

Daily census was organized into quintiles: very low, low, average, high, and very high.

0001) with an increasing proportion of younger children (<2 years of age) seen in higher volume

nonurgent), for this particular study, we categorized patients into 2 groupings: urgent and

The proportion of nonurgent visits in patients greater than 2 years of age increased with higher

02) There was a statistically significant difference in distribution of health insurance coverage

7 Daily census was organized into quintiles: very low, low, average, high, and very high. There was a significant difference in the age proportion across census quintiles (P <.0001) with an increasing proportion of younger children (<2 years of age) seen in higher volume quintiles Although our hospital uses a 4-tier triage system (critical, immediate, urgent, and nonurgent), for this particular study, we categorized patients into 2 groupings: urgent and nonurgent. The urgent category included all patients in the critical, immediate, and urgent. The proportion of nonurgent visits in patients greater than 2 years of age increased with higher census (P =.02) There was a statistically significant difference in distribution of health insurance coverage across quintiles (P <.0001): the proportion of government assisted or self-pay patients increased across census quintiles, whereas proportions of commercially insured patients decreased. The differences (P <.0001) intuitively are clear. 7

There was no statistically significant difference between the various quintiles in terms of admission rates (P =.32) with an overall rate of 12.

During this particular year, March and December were our busiest months, with June, July, and August having a small number of high volume days.

Proportions of Medicaid and self-pay patient increased, whereas that of commercially insured patients decreased as daily census increased (P <.0001).

Conclusions Younger children with self-pay and government-assisted health care coverage make up a greater proportion of children seen in a PED during high census

8 There was no statistically significant difference between the various quintiles in terms of admission rates (P =.32) with an overall rate of 12.8% consistent throughout the calendar year. During this particular year, March and December were our busiest months, with June, July, and August having a small number of high volume days. Results An increasing proportion of younger children (<2 years of age) received care as daily volumes increased (P <.0001). Proportions of Medicaid and self-pay patient increased, whereas that of commercially insured patients decreased as daily census increased (P <.0001). The distributions of patient acuity level (63.1% nonurgent) and admission rate (12.8%) did not differ significantly cross census quintiles. Conclusions Younger children with self-pay and government-assisted health care coverage make up a greater proportion of children seen in a PED during high census days. Forecasting Daily Patient Volumes in the Emergency Department ACADEMIC EMERGENCY MEDICINE 2008; 15: ER in hospitals and clinics in Utah and southern Idaho, USA Forecasting Daily Patient Volumes in the Emergency Department ACADEMIC EMERGENCY MEDICINE 2008; 15: This study confirms the widely held belief that daily demand for ED services is characterized by seasonal and weekly patterns. 8

Supplementary Appendix

Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients