Susan A. Skull

ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged >, 65 years

This study examines the validity of using ICD-10 codes to identify hospitalized pneumonia cases. Using a case-cohort design, subjects were randomly selected from monthly cohorts of patients aged > or = 65 years discharged from April 2000 to March 2002 from two large tertiary Australian hospitals. Cases had ICD-10-AM codes J10-J18 (pneumonia); the cohort sample was randomly selected from all discharges, frequency matched to cases by month. Codes were validated against three comparators: medical record notation of pneumonia, chest radiograph (CXR) report and both. Notation of pneumonia was determined for 5098/5101 eligible patients, and CXR reports reviewed for 3349/3464 (97%) patients with a CXR. Coding performed best against notation of pneumonia: kappa 0.95, sensitivity 97.8% (95% CI 97.1-98.3), specificity 96.9% (95% CI 96.2-97.5), positive predictive value (PPV) 96.2% (95% CI 95.4-97.0) and negative predictive value (NPV) 98.2% (95% CI 97.6-98.6). When medical record notation of pneumonia is used as the standard, ICD-10 codes are a valid method for retrospective ascertainment of hospitalized pneumonia cases and appear superior to use of complexes of symptoms and signs, or radiology reports.

High prevalence of asymptomatic vitamin D and iron deficiency in East African immigrant children and adolescents living in a temperate climate

Objectives: Vitamin D deficiency (VDD) is common in immigrant children with increased skin pigmentation living in higher latitudes. We assessed the pattern of and risk factors for VDD in immigrant East African children living in Melbourne (latitude 37°49′ South). Study design: A prospective survey of 232 East African children attending a clinic in Melbourne. Data were collected by questionnaire, medical assessment and laboratory tests. Results: Low 25-hydroxyvitamin D (25-OHD) levels (<50 nmol/l) occurred in 87% of children, and VDD (25-OHD <25 nmol/l) in 44%. Risk factors included age <5 years, female gender, increased time in Australia, decreased daylight exposure and winter/spring season. Anaemia (20%), vitamin A deficiency (20%) and iron deficiency (19%) were also identified. Conclusions: Asymptomatic VDD is common in East African immigrant children residing at a temperate latitude. Risk factors for VDD limit endogenous vitamin D production. Screening of immigrant children with increased skin pigmentation for VDD, anaemia, iron and vitamin A deficiency is appropriate. VDD in adolescent females identifies an increased risk of future infants with VDD.

Survey of complementary and alternative medicine use at a tertiary children's hospital

Objective: The use of complementary and alternative medicine (CAM) within the Australian community is common. The objective of this study was to determine the prevalence and pattern of CAM usage in children attending a tertiary childrens hospital.

Screening for intestinal parasites in recently arrived children from East Africa

Background:  Intestinal parasitic carriage is common in East African populations with a wide spectrum of clinical severity. There are scant data on the rates of carriage in East African immigrants to Australia. This study describes the prevalence of and risk factors for intestinal parasite carriage among children recently arrived from East African countries.

Hospitalized community-acquired pneumonia in the elderly: an Australian case-cohort study

This study describes the epidemiology of community-acquired pneumonia (CAP) in elderly Australians for the first time. Using a case-cohort design, cases with CAP were in-patients aged > or = 65 years with ICD-10-AM codes J10-J18 admitted over 2 years to two tertiary hospitals. The cohort sample was randomly selected from all hospital discharges, frequency-matched to cases by month. Logistic regression was used to estimate risk ratios for factors predicting CAP or associated mortality. A total of 4772 in-patients were studied. There were 1952 cases with CAP that represented 4% of all elderly admissions: mean length of stay was 9.0 days and 30-day mortality was 18%. Excluding chest radiograph, 520/1864 (28%) cases had no investigations performed. The strongest predictors of CAP were previous pneumonia, history of other respiratory disease, and aspiration. Intensive-care-unit admission, renal disease and increasing age were the strongest predictors of mortality, while influenza vaccination conferred protection. Hospitalization with CAP in the elderly is common, frequently fatal and a considerable burden to the Australian community. Investigation is ad hoc and management empirical. Influenza vaccination is associated with reduced mortality. Patient characteristics can predict risk of CAP and subsequent mortality.

The clinical course of acute otitis media in high-risk Australian Aboriginal children: a longitudinal study

BackgroundIt is unclear why some children with acute otitis media (AOM) have poor outcomes. Our aim was to describe the clinical course of AOM and the associated bacterial nasopharyngeal colonisation in a high-risk population of Australian Aboriginal children.MethodsWe examined Aboriginal children younger than eight years who had a clinical diagnosis of AOM. Pneumatic otoscopy and video-otoscopy of the tympanic membrane (TM) and tympanometry was done every weekday if possible. We followed children for either two weeks (AOM without perforation), or three weeks (AOM with perforation), or for longer periods if the infection persisted. Nasopharyngeal swabs were taken at study entry and then weekly.ResultsWe enrolled 31 children and conducted a total of 219 assessments. Most children had bulging of the TM or recent middle ear discharge at diagnosis. Persistent signs of suppurative OM (without ear pain) were present in most children 7 days (23/30, 77%), and 14 days (20/26, 77%) later. Episodes of AOM did not usually have a sudden onset or short duration. Six of the 14 children with fresh discharge in their ear canal had an intact or functionally intact TM. Perforation size generally remained very small (<2% of the TM). Healing followed by re-perforation was common. Ninety-three nasophyngeal swabs were taken. Most swabs cultured Streptococcus pneumoniae (82%), Haemophilus influenzae (71%), and Moraxella catarrhalis (95%); 63% of swabs cultured all three pathogens.ConclusionIn this high-risk population, AOM was generally painless and persistent. These infections were associated with persistent bacterial colonisation of the nasopharynx and any benefits of antibiotics were modest at best. Systematic follow up with careful examination and review of treatment are required and clinical resolution cannot be assumed.

East African immigrant children in Australia have poor immunisation coverage

Aim:  To provide data on the immunisation status of recently arrived East African children and adolescents in Australia.

Pneumococcal polysaccharide vaccine may not prevent hospitalization for pneumonia in elderly individuals.

To the Editor—The recently published cohort study by Vila-Córcoles et al. [1] adds valuable data that inform the ongoing controversy regarding the effectiveness of 23-valent pneumococcal polysaccharide vaccine (23vPPV) against hospitalization for pneumonia among the elderly population. However, confounding may have biased the estimate of effect in favor of protection from vaccination. This study presents unadjusted estimates for vaccine effectiveness that indicate no benefit against hospitalization for pneumonia (vaccine effectiveness, 12%; 95% CI, 39% to 19%). With adjustment for age and sex, the estimate increased (vaccine effectiveness, 4%; 95% CI, 19% to 22%). When additionally adjusted for factors suggesting sickness (i.e., outpatient visits, hospitalization for pneumonia, chronic lung disease, chronic cardiomyopathy, and immunoincompetence), the point estimate became much larger, statistically significant, and in favor of vaccination (vaccine effectiveness, 26%; 95% CI, 8%–41%). This model instability suggests possible confounding by indication associated with a “healthy vaccinee” effect, in which healthier subjects were more likely to have received vaccination. Residual confounding is possible, given that only a small number of factors were adjusted for in the model. It would be useful to know the stability of coefficients for other variables in the model when each factor was added or removed. In addition, the authors discuss influenza vaccination as a confounder in some models. Yet this is not adjusted for in the model for hospitalization with pneumonia. Persons who were vaccinated with 23vPPV were more likely to be vaccinated with influenza vaccine. In the discussion section, the authors refer to supplementary analyses restricted to the influenza season. These did not adjust for influenza vaccination status and revealed an even greater effect for 23vPPV, with 95% CIs that almost included no effect (vaccine effectiveness, 31%; 95% CI, 2%–80%). Vila-Córcoles et al. [1] describe considerable uncertainty around their point estimates for vaccine effectiveness. Given the potential for confounding, their conclusions that “23-valent PPV should be recommended for all subjects aged 65 years” [1, p. 867] on the basis of its ability to prevent pneumonia may be overstated.

Missed opportunities for a diagnosis of acute otitis media in Aboriginal children

Objective:  Severe otitis media and its sequelae are common in rural and remote Aboriginal children. Identification of acute otitis media (AOM) is likely to reduce the number of children who go on to develop chronic suppurative otitis media and associated complications. The aim of this study was to compare the diagnoses made by researchers with that documented in the medical records of children admitted to the paediatric isolation ward of the Royal Darwin Hospital, Darwin, Northern Territory.