Acute respiratory infections (ARI) caused by influenza and other respiratory viruses affect millions of people annually. Although usually self-limiting a more complicated or severe course may occur in previously healthy people but are more likely in individuals with underlying illnesses. The most common viral agent is rhinovirus whereas influenza is less frequent but is well known to cause winter epidemics. In primary care, rapid diagnosis of influenza virus infections is essential in order to provide treatment. Clinical presentations vary among the different pathogens but may overlap and may also depend on host factors. Predictive models have been developed for influenza but study results may be biased because only individuals presenting with fever were included. Most of these models have not been adequately validated and their predictive power, therefore, is likely overestimated. The main objective of this thesis was to compare different mathematical models for the
derivation of clinical prediction rules in individuals presenting with symptoms of ARI to better distinguish between influenza, influenza A subtypes and entero-/rhinovirus-related illness in children and adults and to evaluate model performance by using data-splitting for internal validation.
Data from a completed prospective cluster-randomized trial for the indirect effect of influenza vaccination in children of Hutterite communities served as a basis of my thesis. There were a total of 3288 first episodes per season of ARI in 2202 individuals and 321 (9.8%) influenza positive events over three influenza seasons (2008-2011). The data set was divided into children under 18 years and adults. Both data sets were randomly split by subjects into a derivation (2/3 of the dataset) and a validation population (1/3 of the dataset). All predictive models were developed in the derivation sets. Demographic factors and the classical symptoms of ARI were evaluated with logistic regression and Cox proportional hazard models using forward stepwise selection applying robust estimators to account for non-independent data and by means of recursive partitioning. The beta coefficients of the independent predictors were used to develop different point scores. These scores were then tested in the validation groups and performance between validation and derivation set was compared using receiver operating characteristics (ROC) curves. We determined sensitivities and specificities, positive and negative predictive values, and likelihood ratios at different cut-points which could reflect test and treatment thresholds. Fever, chills, and cough were the most important predictors in children whereas chills and cough but not fever were most predictive of influenza virus infection in adults. Performance of the individual models was moderate with areas under the receiver operating characteristic curves between 0.75 and 0.80 for the main outcome influenza A or B virus infection. There was no statistically significant difference in performance between the derivation and validation sets for the main outcome. The results have shown, that various mathematical models have similar discriminative ability to
distinguish influenza from other respiratory viruses. The scores could assist clinicians in their decision-making. However, performance of the models was slightly overestimated due to potential clustering of data and the results would first needed to be validated in a different population before application in clinical practice. / Thesis / Master of Science (MSc) / Every year, millions of people are attacked by "the flu" or the common cold. Certain signs and symptoms apparently are more discriminative between the common cold and the flu. However, the decision between starting a simple symptom orientated treatment, treating empirically for influenza or ordering a rapid diagnostic test that has only moderate sensitivity and specificity can be challenging.
This thesis, therefore, aims to help physicians in their decision-making process by developing simple scores and decision trees for the diagnosis of influenza versus non-influenza respiratory infections.
Data from a completed trial for the indirect effect of influenza vaccination in children of Hutterite communities served as a basis of my thesis. There were a total of 3288 first seasonal episodes of ARI in 2202 individuals and 321 (9.8%) influenza positive events over three influenza seasons (2008-2011). The data set was divided into children under 18 years and adults. Both data sets were split into a derivation and a validation set (=holdout group). Different mathematical models were applied to the derivation set and demographic factors as well as the classical symptoms of ARI were evaluated. The scores generated from the most important factors that remained in the model were then tested in the validation group and performance between validation and derivation set was compared. Accuracy was determined at different cut-points which could reflect test and treatment thresholds. Fever, chills, and cough were the most important predictors in children whereas chills and cough but not fever were most predictive of influenza virus infection in adults. Performance of the individual models was moderate for the main outcome influenza A or B virus infection. There was no statistically significant difference in performance between the derivation and validation sets for the main outcome. The results have shown, that various mathematical models have similar discriminative ability to distinguish influenza from other respiratory viruses. The scores could assist clinicians in their decision-making. However, the results would first needed to be validated in a different population before application in clinical practice.
| Identifer | oai:union.ndltd.org:mcmaster.ca/oai:macsphere.mcmaster.ca:11375/20547 |
| Date | January 2016 |
| Creators | Vuichard Gysin, Danielle |
| Contributors | Loeb, Mark, Health Research Methodology |
| Source Sets | McMaster University |
| Language | English |
| Detected Language | English |
| Type | Thesis |
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