151
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Bohmwald K, Gálvez NMS, Canedo-Marroquín G, Pizarro-Ortega MS, Andrade-Parra C, Gómez-Santander F, Kalergis AM. Contribution of Cytokines to Tissue Damage During Human Respiratory Syncytial Virus Infection. Front Immunol 2019; 10:452. [PMID: 30936869 PMCID: PMC6431622 DOI: 10.3389/fimmu.2019.00452] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/19/2019] [Indexed: 12/26/2022] Open
Abstract
The human respiratory syncytial virus (hRSV) remains one of the leading pathogens causing acute respiratory tract infections (ARTIs) in children younger than 2 years old, worldwide. Hospitalizations during the winter season due to hRSV-induced bronchiolitis and pneumonia increase every year. Despite this, there are no available vaccines to mitigate the health and economic burden caused by hRSV infection. The pathology caused by hRSV induces significant damage to the pulmonary epithelium, due to an excessive inflammatory response at the airways. Cytokines are considered essential players for the establishment and modulation of the immune and inflammatory responses, which can either be beneficial or harmful for the host. The deleterious effect observed upon hRSV infection is mainly due to tissue damage caused by immune cells recruited to the site of infection. This cellular recruitment takes place due to an altered profile of cytokines secreted by epithelial cells. As a result of inflammatory cell recruitment, the amounts of cytokines, such as IL-1, IL-6, IL-10, and CCL5 are further increased, while IL-10 and IFN-γ are decreased. However, additional studies are required to elicit the mediators directly associated with hRSV damage entirely. In addition to the detrimental induction of inflammatory mediators in the respiratory tract caused by hRSV, reports indicating alterations in the central nervous system (CNS) have been published. Indeed, elevated levels of IL-6, IL-8 (CXCL8), CCL2, and CCL4 have been reported in cerebrospinal fluid from patients with severe bronchiolitis and hRSV-associated encephalopathy. In this review article, we provide an in-depth analysis of the role of cytokines secreted upon hRSV infection and their potentially harmful contribution to tissue damage of the respiratory tract and the CNS.
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Affiliation(s)
- Karen Bohmwald
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás M. S. Gálvez
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gisela Canedo-Marroquín
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena S. Pizarro-Ortega
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Andrade-Parra
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Gómez-Santander
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexis M. Kalergis
- Millenium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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152
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Observational study of newborn infant parasympathetic evaluation as a comfort system in awake patients admitted to a pediatric intensive care unit. J Clin Monit Comput 2019; 33:749-755. [PMID: 30721390 PMCID: PMC7088066 DOI: 10.1007/s10877-019-00268-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/25/2019] [Indexed: 11/27/2022]
Abstract
To compare the newborn infant parasympathetic evaluation system (NIPE) scores with a validated clinical scale using two different nebulizers in children with bronchiolitis admitted to a PICU. Comfort was evaluated using the COMFORT-behavior scale (CBS) before (T1), during (T2) and after (T3) each nebulization. In order to compare NIPE and CBS values during the whole T1 to T3 period, the variable Dif-CBS was defined as the difference between maximal and minimal CBS scores, and Dif-NIPE as the difference between 75th and 25th percentile NIPE values. Analyses were carried out, firstly for the total of nebulizations and secondly comparing two different nebulization systems: a jet nebulizer (JN) and a nebulizer integrated in high flow nasal cannulas (NHF). 84 nebulizations were recorded on 14 patients with a median [25th–75th percentile] age of 6 months (3.1–9.5). A Dif-CBS of 4 points (2–7), as well as changes in CBS scores between T1 and T2, defined the nebulization as a discomfort stimulus. The NIPE system, represented as the Dif-NIPE, showed a median variation of 9 points (7–10), and was poorly correlated to Dif-CBS [rs 0.162 (P = 0.142)]. Discomfort during nebulization, assessed by CBS was greater with the JN system compared to NHF: 17 (13–22) vs 13 (9–15) (P = 0.001). NIPE monitoring detected no significant differences between both nebulization systems (P = 0.706). NIPE monitoring showed a variation in comfort during nebulization in the patient with bronchiolitis, though correlation with CBS was poor. Further research is required before NIPE can be suggested as a comfort monitoring system for the awake infant.
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153
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O'Connell P, Gaston B, Bonfield T, Grabski T, Fletcher D, Shein SL. Periostin levels in children without respiratory disease. Pediatr Pulmonol 2019; 54:200-204. [PMID: 30548226 DOI: 10.1002/ppul.24206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/13/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Periostin is a protein that serves as a downstream marker of the T-helper type 2 (Th2) cell response. It may serve to identify drug-responsive inflammatory phenotypes, particularly in children with asthma and possibly bronchiolitis. There are no published levels of periostin in healthy children <2 years of age, limiting interpretation of periostin levels in disease. We sought to explore the range of periostin levels of children <2 years without significant confounding illnesses. METHODS Children undergoing clinically indicated phlebotomy or having a peripheral intravenous catheter inserted prior to general anesthesia or procedural sedation were enrolled. A 0.5 mL sample of blood was collected and frozen at -70°C. After thawing, periostin was measured with a Luminex assay (R&D Systems, Minneapolis, MN). Medical record review and/or parental interview elicited potential variables associated with periostin. Association was evaluated using Mann-Whitney rank sum test, Kruskal-Wallis ANOVA, and Spearman correlation as appropriate. RESULTS Among 43 children (23 male, 20 female, age range 9-15.7 months), periostin levels were inversely correlated to age (r = -0.438, P = 0.003). Periostin levels also differed significantly between children <12mo (734.0 [576.6-906.5] ng/mL), 12-18mo (645.1 [363.8-538.2] ng/mL) and >18mo (416.4 [363.8-538.15] ng/mL) (P < 0.001). CONCLUSION In our sample of relatively healthy patients <2 years old, periostin levels were inversely correlated with age and not dependent on other studied variables. However, further work is needed to establish normal periostin values in young children.
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Affiliation(s)
- Patricia O'Connell
- Department of Emergency Medicine, Northwestern University, Chicago, Illinois.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Benjamin Gaston
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Tracey Bonfield
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - David Fletcher
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Steven L Shein
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Rainbow Babies and Children's Hospital, Cleveland, Ohio
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154
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Huang MZ, Rhee KE, Gist L, Fisher ES. Barriers to Minimizing Respiratory Viral Testing in Bronchiolitis: Physician Perceptions on Testing Practices. Hosp Pediatr 2019; 9:79-86. [PMID: 30647087 DOI: 10.1542/hpeds.2018-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess pediatric providers' perceptions on viral testing and to determine barriers to minimizing respiratory viral testing (RVT) in bronchiolitis. METHODS A single-center, cross-sectional study was conducted and included 6 focus group discussions with pediatric providers. Questions were focused on identifying factors associated with obtaining RVT. Focus group discussions were transcribed verbatim and coded for emergent themes. RESULTS Clinicians report that they themselves do not typically obtain RVT in otherwise healthy patients with bronchiolitis. The most commonly cited reasons for not obtaining RVT is that it does not aid medical decision-making and that it is used as an educational opportunity for trainees. However, clinicians tend to obtain RVT when they are directed by another clinician, when they desire reassurance, when RVT is perceived as "doing something," and when there are knowledge gaps on institutional cohorting policies. CONCLUSIONS Clinician medical decision-making is influenced by multiple internal and external factors. Intended behaviors do not always correlate with actual actions because of these influences. Developing interventions in which some of these factors are addressed may help reduce unnecessary RVT among healthy patients with bronchiolitis and could be considered for broader application beyond this patient population.
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Affiliation(s)
| | | | - Lauren Gist
- Developmental-Behavioral Pediatrics, Department of Pediatrics, School of Medicine, University of California, San Diego, San Diego, California
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155
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Gold J, Hametz P, Sen AI, Maykowski P, Leone N, Lee DS, Gagliardo C, Hymes S, Biller R, Saiman L. Provider Knowledge, Attitudes, and Practices Regarding Bronchiolitis and Pneumonia Guidelines. Hosp Pediatr 2019; 9:87-91. [PMID: 30610012 DOI: 10.1542/hpeds.2018-0211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Practice guidelines have been published for bronchiolitis and community-acquired pneumonia (CAP), but little is known about pediatricians' knowledge of and attitudes toward these guidelines since their publication. METHODS We surveyed pediatric providers at 6 children's hospitals in the New York City area. Two vignettes, an infant with bronchiolitis and a child with CAP, were provided, and respondents were asked about management. Associations between respondent characteristics and their reported practices were examined using χ2 and Fisher's exact tests. Associations between questions probing knowledge and attitude barriers relevant to guideline adherence and reported practices were examined using Cochran-Mantel-Haenszel relative risk estimates. RESULTS Of 283 respondents, 58% were trainees; 57% of attending physician respondents had finished training within 10 years. Overall, 76% and 45% of respondents reported they had read the bronchiolitis and CAP guidelines, respectively. For the bronchiolitis vignette, 40% reported ordering a chest radiograph (CXR), and 38% prescribed bronchodilators (neither recommended). For the CAP vignette, 38% prescribed ceftriaxone (not recommended). Study site, level of training, and practice locations were associated with nonrecommended practices. Site-adjusted knowledge and attitude barriers were used to identify that those who agreed CXRs were useful in managing bronchiolitis were more likely to order CXRs, and those who felt bronchodilators shortened length of stay were more likely to prescribe them. Concerns about ampicillin resistance and lack of confidence using local susceptibility patterns to guide prescribing were associated with ordering ceftriaxone. CONCLUSIONS Provider-level factors and knowledge gaps were associated with ordering nonrecommended treatments for bronchiolitis and CAP.
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Affiliation(s)
- Jessica Gold
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Patricia Hametz
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Anita I Sen
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Philip Maykowski
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Nicole Leone
- Cohen Children's Medical Center, Northwell Health, Queens, New York
| | - Diana S Lee
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Christina Gagliardo
- Goryeb Children's Hospital, Morristown Medical Center, Morristown, New Jersey
| | - Saul Hymes
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York; and
| | - Rachel Biller
- Department of Pediatrics, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York
| | - Lisa Saiman
- Morgan Stanley Children's Hospital, Columbia University Medical Center and.,Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York City, New York
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156
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Sprecher E, Chi G, Ozonoff A, Cox J, Patel N, Conroy K. Use of Social Psychology to Improve Adherence to National Bronchiolitis Guidelines. Pediatrics 2019; 143:peds.2017-4156. [PMID: 30518671 DOI: 10.1542/peds.2017-4156] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The American Academy of Pediatrics' bronchiolitis guidelines recommend against albuterol and corticosteroids for treating and chest radiographs (CRs) for diagnosing infants with bronchiolitis. However, high rates of nonadherence have been documented. Our objective was to improve guideline adherence in infants with bronchiolitis. METHODS This quality improvement study was conducted in 1 urban academic pediatric primary care clinic caring for predominately minority and publicly insured children. We tested provider guideline education, display of guidelines in patient care areas, and monthly e-mails to all providers documenting deviation rates, with individual e-mails to providers who deviated. P-charts and interrupted time series analysis were used to estimate the effect of the intervention. RESULTS There were 380 children <2 years of age with a diagnosis of bronchiolitis in the 16 nonsummer months preintervention and 417 in the 15 postintervention months. Rates of prescribed and administered albuterol declined from 45.7% in the baseline period to 13.7% in the intervention period and CR use dropped from a mean of 10.1% to 3.4%, both demonstrating special cause variation. Steroid use did not change significantly. In interrupted time series analyses, the intervention was associated with a significant decrease in albuterol use (P < .001) but not in CR or steroid use. Emergency department visits declined slightly but admissions for bronchiolitis were stable. CONCLUSIONS Traditional quality improvement efforts coupled with social psychology techniques resulted in improved guideline adherence in outpatient bronchiolitis management. Additional study will help identify which techniques are most effective for increasing guideline adherence in cases of low-value care.
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Affiliation(s)
- Eli Sprecher
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Harvard University Boston, Massachusetts
| | - Grace Chi
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University Boston, Massachusetts
| | - Al Ozonoff
- Department of Pediatrics, Harvard Medical School, Harvard University Boston, Massachusetts.,Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Joanne Cox
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University Boston, Massachusetts
| | - Nolan Patel
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Kathleen Conroy
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Harvard University Boston, Massachusetts
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157
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Riikonen R, Lauhkonen E, Törmänen S, Backman K, Koponen P, Helminen M, Nuolivirta K, Korppi M. Prospective study confirms that bronchiolitis in early infancy increases the risk of reduced lung function at 10-13 years of age. Acta Paediatr 2019; 108:124-130. [PMID: 29782663 DOI: 10.1111/apa.14412] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/09/2018] [Accepted: 05/16/2018] [Indexed: 02/02/2023]
Abstract
AIM This study evaluated children hospitalised for bronchiolitis at less than six months of age to see if they had reduced lung function in early adolescence. METHODS We have prospectively followed 166 children hospitalised for infant bronchiolitis in 2001-2004 at Tampere University Hospital, Finland. At 10-13 years of age, flow-volume spirometry was measured in 89 cases and 108 controls without infant bronchiolitis from the local population register. Parameters of flow-volume spirometry before and after bronchodilation were analysed. RESULTS Forced expiratory volume in one second/forced vital capacity (FEV1/FVC) after bronchodilation was lower in cases than controls. FEV1 was pathological - under the 5th percentile of the national references - in 25% of cases and 12% of controls (p = 0.020) before bronchodilation and in 18% of cases and 5% of controls (p = 0.003) after bronchodilation. FEV1/FVC was pathological in 25% of cases and 13% of controls (p = 0.034) before bronchodilation. Logistic regression, adjusted for current asthma and maternal smoking, showed that infant bronchiolitis was associated with pathological FEV1 before (odds ratio 2.4) and after (odds ratio 4.4) bronchodilation. The result was similar for positive respiratory syncytial virus cases. CONCLUSION Reduced FEV1 after bronchodilation was found in early adolescence after infant bronchiolitis, suggesting irreversible bronchial obstruction.
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Affiliation(s)
- Riikka Riikonen
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
| | - Eero Lauhkonen
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
| | - Sari Törmänen
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
| | - Katri Backman
- Department of Paediatrics Kuopio University Hospital Kuopio Finland
| | - Petri Koponen
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
| | - Merja Helminen
- Department of Paediatrics Tampere University Hospital Tampere Finland
| | - Kirsi Nuolivirta
- Department of Paediatrics Seinäjoki Central Hospital Seinäjoki Finland
| | - Matti Korppi
- Center for Child Health Research Tampere University and University Hospital Tampere Finland
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158
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O'Brien S, Borland ML, Cotterell E, Armstrong D, Babl F, Bauert P, Brabyn C, Garside L, Haskell L, Levitt D, McKay N, Neutze J, Schibler A, Sinn K, Spencer J, Stevens H, Thomas D, Zhang M, Oakley E, Dalziel SR. Australasian bronchiolitis guideline. J Paediatr Child Health 2019; 55:42-53. [PMID: 30009459 DOI: 10.1111/jpc.14104] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/01/2018] [Indexed: 11/29/2022]
Abstract
AIM Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population. METHODS The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies. RESULTS The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting. CONCLUSION This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.
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Affiliation(s)
- Sharon O'Brien
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Meredith L Borland
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Divisions of Paediatric and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Department of Paediatrics, School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - David Armstrong
- Department of Respiratory Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Franz Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Bauert
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Christine Brabyn
- Emergency Department, Waikato District Health Board, Hamilton, New Zealand
| | - Lydia Garside
- General Paediatrics, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - David Levitt
- University of Queensland, Brisbane, Queensland, Australia
| | - Nicola McKay
- Children's Healthcare Network Western Region, Sydney, New South Wales, Australia
| | | | - Andreas Schibler
- University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Paediatric Critical Care Research Group (PCCRG), Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Kam Sinn
- Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Janine Spencer
- Department of Paediatrics, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Helen Stevens
- Children's Healthcare Network, Sydney, New South Wales, Australia
| | - David Thomas
- General Paediatrics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Ed Oakley
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Paediatrics: Youth and Child Health, University of Auckland, Auckland, New Zealand
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159
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Maraña Pérez AI, Rius Peris JM, Rivas Juesas C, Torrecilla Cañas J, Hernández Muelas S, de la Osa Langreo A. Multimodal implementation of clinical practice guidelines on bronchiolitis: Ending the overuse of diagnostic resources. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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160
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Implementación multimodal de una guía de práctica clínica en bronquiolitis: acabando con el uso excesivo de recursos diagnósticos. An Pediatr (Barc) 2018; 89:352-360. [DOI: 10.1016/j.anpedi.2018.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 11/23/2022] Open
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161
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Holster A, Teräsjärvi J, Vuononvirta J, Koponen P, Peltola V, Helminen M, He Q, Korppi M, Nuolivirta K. Polymorphisms in the promoter region of IL10 gene are associated with virus etiology of infant bronchiolitis. World J Pediatr 2018; 14:594-600. [PMID: 29802545 DOI: 10.1007/s12519-018-0161-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 05/09/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bronchiolitis is the most common infection leading to hospitalization in infancy. Interleukin-10 (IL-10) is an anti-inflammatory cytokine, and in our previous study, IL10 gene rs1800896 (- 1082A/G) polymorphism was associated with viral etiology of infant bronchiolitis. The objective of this study was to evaluate the associations between IL10 single nucleotide polymorphisms (SNPs) at rs1800890 (- 3575A/T), rs1800871 (- 819C/T) or rs1800872 (- 592C/A) either alone or combined with the SNP at rs1800896 (- 1082G/A), and the etiology and severity of infant bronchiolitis. METHODS Data on four IL10 SNPs were available from 135 full-term infants, hospitalized for bronchiolitis at age less than 6 months, and from 378 to 400 controls. Viral etiology was studied, and oxygen support, feeding support and the length of stay in hospital were recorded during bronchiolitis hospitalization. RESULTS Infants with rhinovirus bronchiolitis had the IL10 rs1800890 variant AT or TT genotype less often (18.2%) than controls (63.3%, P = 0.03), and likewise, had the IL10 rs1800896 variant AG or GG genotype less often (27.3%) than controls (65.5%, P = 0.009). Twenty-eight infants with bronchiolitis had the variant-variant Grs1800896Trs1800890 haplotype, and none of them had rhinovirus infection. The IL10 rs1800871 or rs1800872 genotypes showed no associations with viruses. No association was found between any genotypes and bronchiolitis severity measures. CONCLUSION IL10 rs1800890 and rs1800896 polymorphisms differed between infants with rhinovirus bronchiolitis and controls, but not between infants with respiratory syncytial virus bronchiolitis and controls.
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Affiliation(s)
- Annukka Holster
- Seinäjoki Central Hospital, Hanneksenrinne 7, 60220, Seinäjoki, Finland
| | - Johanna Teräsjärvi
- Department of Medical Microbiology and Immunology, Turku University, Turku, Finland
| | - Juho Vuononvirta
- Department of Medical Microbiology and Immunology, Turku University, Turku, Finland
| | - Petri Koponen
- Tampere Center for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Ville Peltola
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and Child and Youth Research Institute, University of Turku, Turku, Finland
| | - Merja Helminen
- Tampere Center for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Qiushui He
- Department of Medical Microbiology and Immunology, Turku University, Turku, Finland.,Department of Medical Microbiology, Capital Medical University, Beijing, China
| | - Matti Korppi
- Tampere Center for Child Health Research, Tampere University and University Hospital, Tampere, Finland
| | - Kirsi Nuolivirta
- Seinäjoki Central Hospital, Hanneksenrinne 7, 60220, Seinäjoki, Finland.
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162
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Vo P, Koppel C, Espinola JA, Mansbach JM, Celedón JC, Hasegawa K, Bair-Merritt M, Camargo CA. Vitamin D Status at the Time of Hospitalization for Bronchiolitis and Its Association with Disease Severity. J Pediatr 2018; 203:416-422.e1. [PMID: 30243543 DOI: 10.1016/j.jpeds.2018.07.097] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/27/2018] [Accepted: 07/27/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the association between circulating 25-hydroxyvitamin D [25(OH)D] status at admission and disease severity among infants hospitalized for bronchiolitis and to determine whether the association differs by the form of 25(OH)D-total, bioavailable or free 25(OH)D. STUDY DESIGN We conducted a 17-center prospective cohort study of 1016 US infants <12 months old hospitalized with bronchiolitis. Vitamin D status was defined by total 25(OH)D levels, and by calculated levels of bioavailable and free 25(OH)D. Bronchiolitis severity was defined by requirement for intensive care and hospital length-of-stay (LOS). Logistic and Poisson regression were used for unadjusted and multivariable analyses. RESULTS The median age of hospitalized infants was 3.2 months (IQR 1.6-6.0). The median total 25(OH)D was 26.5 ng/mL (IQR 18.0-33.1); 298 (29%) infants had total 25(OH)D <20 ng/mL. In multivariable models, infants with total 25(OH)D <20 ng/mL had higher risk of requiring intensive care (aOR 1.72, 95% CI 1.12-2.64) and longer LOS (adjusted rate ratio 1.39, 95% CI 1.17-1.65) compared with infants with total 25(OH)D ≥30 ng/mL. Infants with the lowest tertile of bioavailable 25(OH)D, compared with those with the highest tertile, had longer LOS (adjusted rate ratio 1.32, 95% CI 1.07-1.62); admission to the intensive care unit was not statistically significant in the adjusted model (aOR 1.39, 95% CI 0.96-2.64). Free 25(OH)D level was not associated with severity of bronchiolitis in either unadjusted or adjusted models. CONCLUSION In a large, multicenter cohort of US infants hospitalized for bronchiolitis, infants with total 25(OH)D <20 ng/mL had increased risk of intensive care and longer hospital LOS.
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Affiliation(s)
- Phuong Vo
- Department of Pediatrics, Boston Medical Center, Boston, MA.
| | - Claire Koppel
- Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan M Mansbach
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Juan C Celedón
- Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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163
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Turi KN, Wu P, Escobar GJ, Gebretsadik T, Ding T, Walsh EM, Li SX, Carroll KN, Hartert TV. Prevalence of infant bronchiolitis-coded healthcare encounters attributable to RSV. Health Sci Rep 2018; 1:e91. [PMID: 30623050 PMCID: PMC6295609 DOI: 10.1002/hsr2.91] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/18/2018] [Accepted: 08/22/2018] [Indexed: 12/28/2022] Open
Abstract
AIM We sought to determine the proportion of bronchiolitis episodes attributable to respiratory syncytial virus (RSV) among ICD-9 coded infant bronchiolitis episodes which were tested for RSV. METHODS Bronchiolitis healthcare encounters were extracted from Kaiser Permanente Northern California databases for years 2006 to 2009. We used ICD-9 codes for bronchiolitis to capture bronchiolitis-related healthcare encounters including hospital admissions (Hospitalization), emergency department visits (EDV), and outpatient visits (OPV). We reported the monthly proportion of RSV-positive bronchiolitis episodes among tested bronchiolitis episodes. We used logistic regression to assess association between bronchiolitis episodes and patient demographic and health care characteristics. We also used logistic regression to assess association between decision to test and patient demographics and health care characteristics. RESULTS Among 10,411 ICD-9 coded infant bronchiolitis episodes, 29% were RSV tested. Fifty one percent of those tested were RSV positive. Between December and February, and in infants ≤6 months, the proportion of bronchiolitis episodes that were attributable to RSV was 77.2% among hospitalized episodes, 78.3% among EDV episodes, and 60.9% among OPV episodes, respectively. The proportion of RSV-positive bronchiolitis episodes varied based upon infant age at diagnosis, level of health care service used, and time of the year of the episode. CONCLUSION Estimation of the proportion of ICD-9 coded bronchiolitis episodes attributable to RSV is more specific when restricting to bronchiolitis episodes during peak months, younger infant age, and those requiring higher level of healthcare.
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Affiliation(s)
- Kedir N. Turi
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Pingsheng Wu
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Gabriel J. Escobar
- Kaiser Permanente Northern California, Systems Research Initiative, Perinatal Research Unit, Division of ResearchKaiser PermanenteOaklandCAUSA
- Department of Inpatient PediatricsKaiser Permanente Medical CenterWalnut CreekCAUSA
| | - Tebeb Gebretsadik
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Tan Ding
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Eileen M. Walsh
- Department of Inpatient PediatricsKaiser Permanente Medical CenterWalnut CreekCAUSA
| | - Sherian X. Li
- Department of Inpatient PediatricsKaiser Permanente Medical CenterWalnut CreekCAUSA
| | - Kecia N. Carroll
- Department of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Tina V. Hartert
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
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164
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Nayani K, Naeem R, Munir O, Naseer N, Feroze A, Brown N, Mian AI. The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department. BMC Pediatr 2018; 18:339. [PMID: 30376827 PMCID: PMC6208017 DOI: 10.1186/s12887-018-1317-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/22/2018] [Indexed: 01/03/2023] Open
Abstract
Background Respiratory distress is a common presenting complaint in children brought to the Emergency Department (ED). The Clinical Respiratory Score (CRS) has shown promise as a screen for severe illness in High Income Countries. We aimed to validate the admission CRS in children presenting to the ED of a Low-to Middle Income Country. Methods Children (1 month to 16 years) presenting with respiratory distress to the ED of the Aga Khan University Hospital, Karachi, Pakistan, between November 2015 to March 2016, were enrolled. The CRS was measured at initial presentation, prior to any management and 2 h after treatment was started. The predictive value for admission to the paediatric critical care units for a variety of cut offs for CRS at presentation were derived. Results A total of 112 children (70% male) of median age 12 months (IQR 2, 34.5 months) were enrolled. Patients with severe CRS (score 8–12) at presentation were more likely to be admitted to paediatric critical care (90% vs. 23% with mild-moderate CRS; OR: 5.7; 95% CI: 2.2–15.3, p < 0.001). The sensitivity and specificity of CRS > 3 in predicting outcome were 94% (95% CI 79.8–99.3) and 40% (95% CI 35–45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31–1.98) and negative predictive value of 94% (95% CI 81–98). Conclusion An admission CRS of > 3 in the ED of a Low-to Middle Income Country had excellent predictive value for disease severity, and it should be considered for incorporation into ED triage protocols.
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Affiliation(s)
- Kanwal Nayani
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan
| | - Rubaba Naeem
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Owais Munir
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Naureen Naseer
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Asher Feroze
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Nick Brown
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan.,International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Paediatrics, Länssjukhuset Gävle-Sandviken, 801 87, Gävle, Sweden
| | - Asad I Mian
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
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165
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Gerretsen HE, Capone S, Vitelli A, Reyes LS, Thompson A, Jones C, Green CA, Pollard AJ, Sande CJ. Antibodies in lymphocyte supernatants can distinguish between neutralising antibodies induced by RSV vaccination and pre-existing antibodies induced by natural infection. Vaccine 2018; 36:6988-6994. [PMID: 30318168 DOI: 10.1016/j.vaccine.2018.09.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/25/2018] [Accepted: 09/29/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Respiratory syncytial virus (RSV) is the single most important cause of severe respiratory illness in infants. There is no effective vaccine and the only effective treatment available is the monoclonal antibody palivizumab which reduces the risk of severe RSV disease in prematurely born infants. However, palivizumab is too costly to allow for wide implementation and thus treatment is restricted to supportive care. Despite extensive efforts to develop a vaccine, progress has been hindered by the difficulty in measuring and assessing immunological correlates of RSV vaccine efficacy in the presence of high levels of pre-existing RSV antibodies. METHODS Here we describe a new method for measuring the functional activity of antibodies induced by vaccination distinct from pre-existing antibodies. Antibodies in lymphocyte supernatants (ALS) from the cultured peripheral blood mononuclear cells (PBMCs) of young adults who had recently been vaccinated with a novel RSV candidate vaccine were directly assayed for virus neutralising activity. An ELISA method was used to measure antibodies in nasal and serum samples and then compared with the adapted ALS based method. RESULTS There was a wide background distribution of RSV-specific antibodies in serum and nasal samples that obscured vaccine-specific responses measured two weeks after vaccination. No RSV-specific antibodies were observed at baseline in ALS samples, but a clear vaccine-specific antibody response was observed in ALS seven days after the administration of each dose of vaccine. These vaccine-specific antibodies in ALS displayed functional activity in vitro, and quantification of this functional activity was unperturbed by pre-existing antibodies from natural exposure. The results demonstrate a promising new approach for assessing functional immune responses attributed to RSV vaccines.
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Affiliation(s)
- Hannah E Gerretsen
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | | | | | - Laura S Reyes
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | - Amber Thompson
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | - Christopher A Green
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK
| | - Charles J Sande
- Oxford Vaccine Group, Department of Paediatrics, and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 7LE,UK; KEMRI-Wellcome Trust Research Programme, Bofa Road, Kilifi, Kenya.
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166
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Mormile R. Respiratory syncytial virus infection in cardiac patients: outcomes preordained by IL-6 gene polymorphism? Minerva Pediatr 2018; 71:218-219. [PMID: 30299023 DOI: 10.23736/s0026-4946.18.05236-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Raffaella Mormile
- Division of Pediatrics and Neonatology, Moscati Hospital, Aversa, Caserta, Italy -
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167
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Egron C, Roszyk L, Rochette E, Jabaudon M, Sapin V, Mulliez A, Labbé A, Coste K. Serum soluble receptor for advanced glycation end-products during acute bronchiolitis in infant: Prospective study in 93 cases. Pediatr Pulmonol 2018; 53:1429-1435. [PMID: 30113140 PMCID: PMC7167909 DOI: 10.1002/ppul.24141] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/25/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Acute bronchiolitis is a major cause of acute respiratory distress in infants. The soluble receptor for advanced glycation end-products (sRAGE) is a biomarker of pulmonary damage processes, with a diagnostic and a prognostic value in acute respiratory distress syndrome (ARDS). The RAGE pathway is also implicated in the pathogenesis of other respiratory diseases like asthma, but the value of sRAGE levels in acute bronchiolitis remains under-investigated. MATERIAL AND METHODS A prospective, observational, and analytical study was conducted at Clermont-Ferrand University Hospital. The main objective was to evaluate the correlation between serum sRAGE and clinical severity of bronchiolitis in hospitalized infants aged <1 year. We analyzed correlations between serum sRAGE and Wainwright score, short-term morbidity attributable to bronchiolitis, causal viruses and risk for recurrent wheezing at 1 year. RESULTS The study included 93 infants. sRAGE levels were significantly lower in acute bronchiolitis patients (mean 1101 pg/mL) than in controls (2203 pg/mL, P < 0.001) but did not correlate with clinical severity. No correlation was found between serum sRAGE and severity score, respiratory viruses, and recurrent wheezing at 1 year. Serum sRAGE levels were negatively correlated with age (r = -0.45, P < 0.001). CONCLUSION Serum sRAGE levels are decreased in acute bronchiolitis but not correlated with disease severity. sRAGE levels should be age-adjusted in infants. Serum sRAGE levels measured in the setting of acute bronchiolitis were not predictive of recurrent wheezing.
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Affiliation(s)
- Carole Egron
- Department of Pediatrics, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurence Roszyk
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand and GReD, Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, Clermont-Ferrand, France
| | - Emmanuelle Rochette
- Department of Clinical Research for Children (CRECHE) at CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand and GReD, Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand and GReD, Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, Clermont-Ferrand, France
| | - Aurélien Mulliez
- Department of Clinical Research and Innovation at CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - André Labbé
- Department of Pediatrics, CHU Clermont-Ferrand, Clermont-Ferrand and Université Clermont Auvergne, Clermont-Ferrand, France
| | - Karen Coste
- Department of Pediatrics, CHU Clermont-Ferrand and GReD, Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, Clermont-Ferrand, France
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168
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Gökçe Ş, Kurugöl Z, Suner A. The role of mean platelet volume in the early detection of acute bronchiolitis: A prospective study. CLINICAL RESPIRATORY JOURNAL 2018; 12:2513-2518. [DOI: 10.1111/crj.12947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/24/2018] [Accepted: 07/11/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Şule Gökçe
- General Pediatrics Unit, Department of Pediatrics, Ege University Faculty of Medicine; Ege University; Bornova İzmir Turkey
| | - Zafer Kurugöl
- Division of Pediatric Infection, Department of Pediatrics, Ege University Faculty of Medicine; Ege University; Bornova İzmir Turkey
| | - Aslı Suner
- Department of Biostatistics and Medical Informatics, Ege University Faculty of Medicine; Ege University; Bornova İzmir Turkey
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Hoover J, Eades S, Lam WM. Pediatric Antiviral Stewardship: Defining the Potential Role of Ribavirin in Respiratory Syncytial Virus-Associated Lower Respiratory Illness. J Pediatr Pharmacol Ther 2018; 23:372-378. [PMID: 30429691 PMCID: PMC6213624 DOI: 10.5863/1551-6776-23.5.372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although no longer included in the American Academy of Pediatrics guideline, ribavirin was shown to be beneficial in a subset of adult patients with severe respiratory syncytial virus (RSV)-associated bronchiolitis. This study aimed to investigate risk factors for progression to severe acute respiratory tract infections in hospitalized pediatric patients with RSV-associated bronchiolitis to identify which patients may benefit from inhaled ribavirin therapy, despite its substantial cost, diffcult administration, and potential complications. METHODS Patients were identified by ICD-9 codes for RSV bronchiolitis and were only included if they had a confirmed positive result for RSV via polymerase chain reaction for detection and typing of respiratory viruses. Patient characteristics, including underlying conditions and comorbidities, were analyzed for the risk of severe acute respiratory tract infection. RESULTS A total of 299 patients were included in the study population. Ninety-six patients (32%) were admitted to the pediatric intensive care unit, and almost half of those patients (46%) required mechanical ventilation. Weight and presence of atrial septal defect were the only factors significantly associated with the need for mechanical ventilation, as identified by univariate analysis. Two patients required extracorporeal membrane oxygenation (ECMO), and a total of 5 patients, including one who received ECMO, died with RSV infection as the primary cause. Of these patients, all were less than 1 year of age. Two had a history of prematurity; however, no variables were associated with mortality. CONCLUSIONS Given the side effect profile and expense of ribavirin therapy, it is prudent to limit use to patients at risk for significant morbidity and mortality from RSV disease. Because we were unable to identify patients who would most likely benefit from ribavirin antiviral therapy, we cannot recommend the routine use of ribavirin to prevent mechanical ventilation, ECMO, or death from RSV bronchiolitis in our institution.
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170
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Domachowske JB, Khan AA, Esser MT, Jensen K, Takas T, Villafana T, Dubovsky F, Griffin MP. Safety, Tolerability and Pharmacokinetics of MEDI8897, an Extended Half-life Single-dose Respiratory Syncytial Virus Prefusion F-targeting Monoclonal Antibody Administered as a Single Dose to Healthy Preterm Infants. Pediatr Infect Dis J 2018; 37:886-892. [PMID: 29373476 PMCID: PMC6133204 DOI: 10.1097/inf.0000000000001916] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND MEDI8897 is a recombinant human monoclonal antibody being developed for prophylaxis of serious respiratory syncytial virus (RSV) disease in all infants. METHODS In this phase 1b/2a dose-escalation study, healthy preterm infants with a gestational age of 32-35 weeks were randomized to receive a single intramuscular injection of MEDI8897 (10, 25 or 50 mg) or placebo. Safety, pharmacokinetics, RSV-neutralizing antibody and antidrug antibody (ADA) assessments were performed during the 360-day follow-up period. Infants who experienced medically attended lower respiratory tract infections (LRTIs) were tested for RSV. RESULTS MEDI8897 serum half-life ranged from 62.5-72.9 days. On day 151, 87% of infants in the 50 mg group had serum concentrations above the 90% effective concentration target level of 6.8 µg/mL, and 90% showed a ≥4-fold rise from baseline in serum RSV-neutralizing antibody levels. Adverse events (AEs) were reported in 17 of 18 (94.4%) placebo and 66 of 71 (93.0%) MEDI8897 recipients. Three MEDI8897 recipients experienced 5 serious AEs (3 LRTIs, 2 febrile seizures). ADA was detected at any time postbaseline in 28.2% of MEDI8897 recipients and at day 361 only in 26.5% of subjects. ADA response was not associated with AEs. Five (7%) MEDI8897 recipients experienced medically attended LRTIs through day 150; 1 tested positive for RSV (10 mg group). CONCLUSIONS MEDI8897 had a favorable safety profile in healthy preterm infants. The extended half-life of MEDI8897 and demonstrated RSV-neutralizing activity support protection from RSV for the duration of a typical 5-month season after a single 50 mg intramuscular (IM) dose.
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MESH Headings
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/genetics
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Neutralizing/adverse effects
- Antibodies, Neutralizing/pharmacology
- Antibodies, Viral/adverse effects
- Antibodies, Viral/pharmacology
- Antiviral Agents/adverse effects
- Antiviral Agents/pharmacokinetics
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Gestational Age
- Half-Life
- Humans
- Infant
- Infant, Premature
- Injections, Intramuscular
- Male
- Respiratory Syncytial Virus Infections/prevention & control
- Respiratory Syncytial Virus, Human/drug effects
- Respiratory Syncytial Virus, Human/isolation & purification
- Viral Fusion Proteins/immunology
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Affiliation(s)
- Joseph B. Domachowske
- From the Division of Infectious Diseases, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
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171
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Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Atenafu EG, Stephens D, Steele DW, Fernandes RM, Florin TA, Kharbanda A, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. Predicting Escalated Care in Infants With Bronchiolitis. Pediatrics 2018; 142:peds.2017-4253. [PMID: 30126934 DOI: 10.1542/peds.2017-4253] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.
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Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Australia.,University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Departments of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - David Schnadower
- Department of Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles G Macias
- Department of Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, and .,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Rauf A, Singhi S, Nallasamy K, Walia M, Ray P. Non-Respiratory and Non-Diarrheal Causes of Acute Febrile Illnesses in Children Requiring Hospitalization in a Tertiary Care Hospital in North India: A Prospective Study. Am J Trop Med Hyg 2018; 99:783-788. [PMID: 29988003 PMCID: PMC6169172 DOI: 10.4269/ajtmh.18-0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/04/2018] [Indexed: 02/04/2023] Open
Abstract
Acute febrile illnesses (AFIs) in children from the developing world can have varying etiologies. Awareness of local epidemiology helps in prioritizing investigations and empiric treatment. This prospective study was carried out in a tertiary care center in North India, aiming to determine the burden, etiology, and outcome of AFI other than pneumonia and diarrhea in hospitalized children. A total of 613 consecutive children aged 3 months to 12 years with febrile illness of < 7 days during four selected months of 2014 representing different seasons were screened for eligibility. Those with acute respiratory diseases (N = 175, 28.5%) and diarrheal illness (N = 46, 7.5%) were excluded and 217 children were enrolled. Mean (standard deviation) age was 4.8 (3.4) years. Nearly half (N = 91, 41.9%) presented in post-monsoon season. Diagnosis could be established in 187 (86.2%) children. Acute central nervous system infections were the most common (N = 54, 24.8%). Among specific infections, scrub typhus was the most frequent (N = 23, 10.5%) followed by malaria (N = 14, 6.4%), typhoid (N = 14, 6.5%), and viral hepatitis (N = 13, 6.0%). Blood culture had a low (6.5%) yield; Salmonella typhi (N = 6) and Staphylococcus aureus (N = 5) were the common isolates. Serological tests were helpful in 50 (23%) cases. In multivariate analysis, hepatomegaly and/or splenomegaly independently predicted scrub typhus. Mortality rate was 10.1%. We conclude that AFI other than pneumonia and diarrhea are a significant burden and follow a seasonal trend. Scrub typhus has emerged as an important etiology of childhood AFIs in northern India. Periodic review of regional epidemiology will help in understanding the changing pattern of infectious diseases.
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Affiliation(s)
- Abdul Rauf
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunit Singhi
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karthi Nallasamy
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandeep Walia
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Pallab Ray
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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173
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Praznik A, Vinšek N, Prodan A, Erčulj V, Pokorn M, Mrvič T, Paro D, Krivec U, Strle F, Petrovec M, Žnidaršič Eržen M, Grosek Š. Risk factors for bronchiolitis severity: A retrospective review of patients admitted to the university hospital from central region of Slovenia. Influenza Other Respir Viruses 2018; 12:765-771. [PMID: 29944781 PMCID: PMC6185887 DOI: 10.1111/irv.12587] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/11/2018] [Indexed: 12/01/2022] Open
Abstract
Aim Study's objective was to identify risk factors associated with bronchiolitis severity. Methods A retrospective chart review of all children <2 years old diagnosed with bronchiolitis at the University Medical Centre Ljubljana between May 2014 and April 2015, who were treated as outpatients (paediatric emergency department, PED group) or as inpatients in the standard hospital setting (WARD group) or in the paediatric intensive care unit (PICU group). Detection of respiratory viruses in nasopharyngeal swab was accomplished by RT‐PCR. Severity was assessed by Wang Respiratory Score and hospitalization longer than 24 hours. Results The study included 761 children. The three most frequently detected viruses were respiratory syncytial virus (RSV), human rhinovirus (hRV) and human bocavirus (hBoV) (57.5%, 272/473; 25.6%, 121/473; 18.4%, 87/473). Patient groups differed in Wang Respiratory Score for the severity of bronchiolitis (P < 0.001). No differences regarding the causative viruses were found. There was a lower proportion of children with the presence of more than one virus in PICU group compared to other two groups (P = 0.017). The three groups significantly differed in age, birthweight, comorbidities, bronchodilator treatment and antibiotic usage. However, multiple regression analysis revealed that younger age and the use of antibiotics were associated with bronchiolitis severity defined as hospitalization for >24 hours. Conclusions Respiratory syncytial virus, hRV and hBoV were the most frequently detected viruses. The majority of patients admitted to the PICU had only one virus detected. Younger age and the use of antibiotics were associated with bronchiolitis severity.
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Affiliation(s)
- Ajda Praznik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Neža Vinšek
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ana Prodan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Chair of Infectious Diseases, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tatjana Mrvič
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Darja Paro
- Department of Neonatology, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia.,Chair of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Uroš Krivec
- Pulmonology Department, University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Miroslav Petrovec
- Chair of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marta Žnidaršič Eržen
- Pediatric Clinical Department, Community Health Centre Ljubljana, Ljubljana, Slovenia
| | - Štefan Grosek
- Chair of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Pediatric Surgery and Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
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174
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Abstract
RATIONAL Several studies have found higher risks for childhood respiratory illness, associated with exposure to particulate matter (PM) less than 10 μm in diameter (PM10) and PM2.5 and gaseous pollution. OBJECTIVES We analyzed the association between air pollution and hospitalizations due to bronchiolitis, an obstructive pulmonary disorder, commonly caused by respiratory syncytial virus infant infection. METHODS Data were obtained from a local tertiary medical center providing services for a population of 700,000 comprising two ethnic groups: predominantly urban Jews and rural Bedouin Arabs. The latter group includes 30% residing in unrecognized villages in a temporary dwelling. We included all infants (0-2 yr) hospitalized with bronchiolitis between 2003 and 2013. Daily PM estimates were obtained from a satellite-based model incorporating daily remote sensing data and assigned to the family residence locality. Other air pollutants and meteorological parameters were obtained from a local monitoring site. We used case-crossover models with adjustment for temperature. RESULTS We identified 4,069 bronchiolitis hospitalizations (3,889 children), with 55.3% being Bedouin Arabs, of whom 16.8% resided in temporary dwellings. An increase in interquartile range of average weekly air pollutants was associated with an increased odds of bronchiolitis (odds ratio [95% confidence interval]): PM10 (1.06 [1.02-1.09]), PM2.5 (1.04 [1.02-1.06]) and nitrogen dioxide (1.36 [1.12-1.65]). Higher effect-estimates for PM were observed among Bedouin Arabs residing in temporary dwellings (1.14 [1.01-1.30] and 1.07 [1.01-1.15]) compared with Jewish individuals (1.05 [0.99-1.11] and 1.03 [1.01-1.07]) and other Bedouin Arabs (1.05 [1.01-1.10] and 1.03 [1.01-1.07]), and among males (1.11 [1.06-1.16] and 1.06 [1.03-1.09]) compared with females (0.99 [0.94-1.05] and 1.01 [0.97-1.04]). CONCLUSIONS High PM levels were positively associated with bronchiolitis. The stronger associations among Bedouin Arabs may be related to higher pollution infiltration and exposure in residents of temporary dwellings.
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175
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Nicholson EG, Munoz FM. A Review of Therapeutics in Clinical Development for Respiratory Syncytial Virus and Influenza in Children. Clin Ther 2018; 40:1268-1281. [PMID: 30077340 DOI: 10.1016/j.clinthera.2018.06.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/15/2018] [Accepted: 06/21/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE Respiratory syncytial virus (RSV) and influenza are important viral pathogens worldwide. Children, in particular, bear considerable burdens of morbidity and mortality associated with these viruses. There are limited therapeutic options for children infected with RSV or influenza. This review focuses on therapeutics for RSV and influenza that are currently under clinical investigation. METHODS This study used a systematic approach to identify prospective therapeutics in clinical trials and briefly reviewed those that are currently available for use in adults and children. FINDINGS Overall, we found 14 investigational drugs currently in clinical trials for RSV and 20 investigation drugs currently in clinical trials for influenza. These candidates range in development from Phase I to Phase III clinical trials. IMPLICATIONS Both RSV and influenza are targets for active therapeutic research, and promising candidates for both viruses are currently in clinical development.
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Affiliation(s)
- Erin G Nicholson
- Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas.
| | - Flor M Munoz
- Departments of Pediatrics and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
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176
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Behrooz L, Balekian DS, Faridi MK, Espinola JA, Townley LP, Camargo CA. Prenatal and postnatal tobacco smoke exposure and risk of severe bronchiolitis during infancy. Respir Med 2018; 140:21-26. [PMID: 29957275 PMCID: PMC6056008 DOI: 10.1016/j.rmed.2018.05.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/01/2018] [Accepted: 05/13/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Maternal prenatal smoking has adverse effects on the growing fetus including those of respiratory nature. Although postnatal smoke exposure is a risk factor for respiratory infections, the effects of prenatal smoking independent of postnatal smoke exposure are less established. We hypothesized that both maternal prenatal smoking, and postnatal smoke exposure are risk factors for severe bronchiolitis during infancy. METHODS We performed a case-control study of 1353 children born between 1996 and 2011 at a single teaching hospital. Cases were admitted to the same hospital for bronchiolitis during infancy. Maternal prenatal smoking was collected from birth records. Postnatal smoke exposure was collected from review of electronic health records. Multivariable logistic regression was used to evaluate the independent associations of the two smoking variables with severe bronchiolitis. RESULTS 6% of cases were exposed to maternal prenatal smoking, compared with 4% of controls (P = 0.10). Postnatal smoke exposure was present in the households of 17% of cases compared with 3% of controls (P < 0.001). In a multivariable model with both smoking variables and adjustment for 10 covariates, maternal prenatal smoking was not a significant risk factor for severe bronchiolitis (adjusted OR = 1.02, 95%CI 0.56-1.84). By contrast, postnatal smoke exposure was associated with >300% increased odds (adjusted OR 4.19, 95%CI 2.51-6.98). CONCLUSIONS Although maternal prenatal smoking has many known adverse effects, it was not associated with increased odds of severe bronchiolitis in either unadjusted or multivariable analyses. Postnatal smoke exposure was a consistently strong risk factor. Our findings support ongoing efforts to decrease infant exposure to ambient smoke.
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Affiliation(s)
- Leili Behrooz
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Liam P Townley
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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177
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Mecklin M, Heikkilä P, Korppi M. The change in management of bronchiolitis in the intensive care unit between 2000 and 2015. Eur J Pediatr 2018; 177:1131-1137. [PMID: 29766326 DOI: 10.1007/s00431-018-3156-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.
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Affiliation(s)
- Minna Mecklin
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland.
| | - Paula Heikkilä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
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178
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Alharbi AS, Alqwaiee M, Al-Hindi MY, Mosalli R, Al-Shamrani A, Alharbi S, Yousef A, Al Aidaroos A, Alahmadi T, Alshammary A, Miqdad A, Said Y, Alnemri A. Bronchiolitis in children: The Saudi initiative of bronchiolitis diagnosis, management, and prevention (SIBRO). Ann Thorac Med 2018; 13:127-143. [PMID: 30123331 PMCID: PMC6073791 DOI: 10.4103/atm.atm_60_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022] Open
Abstract
Bronchiolitis is the leading cause of admissions in children less than two years of age. It has been recognized as highly debated for many decades. Despite the abundance of literature and the well-recognized importance of palivizumab in the high risk groups, and despite the existence of numerous, high-quality, recent guidelines on bronchiolitis, the number of admissions continues to increase. Only supportive therapy and few therapeutic interventions are evidence based and proved to be effective. Since Respiratory Syncytial Virus (RSV) is the major cause of bronchiolitis, we will focus on this virus mostly in high risk groups like the premature babies and children with chronic lung disease and cardiac abnormalities. Further, the prevention of RSV with palivizumab in the high risk groups is effective and well known since 1998; we will discuss the updated criteria for allocating infants to this treatment, as this medication is expensive and should be utilized in the best condition. Usually, diagnosis of bronchiolitis is not challenging, however there has been historically no universally accepted and validated scoring system to assess the severity of the condition. Severe RSV, especially in high risk children, is unique because it can cause serious respiratory sequelae. Currently there is no effective curative treatment for bronchiolitis. The utility of different therapeutic interventions is worth a discussion.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mansour Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mohammed Y Al-Hindi
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Department of Pediatric, Ministry of National Guard, Jeddah, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Saleh Alharbi
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Amal Al Aidaroos
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Turki Alahmadi
- King Abdulaziz University, College of Medicine, Department of Pediatrics, Jeddah, Saudi Arabia
| | | | - Abeer Miqdad
- Department of Pediatrics, Security forces hospital, Riyadh, Saudi Arabia
| | - Yazan Said
- King Fahad Specialist Hospital, Ministry of Health, Dammam, Saudi Arabia
| | - Abdulrahman Alnemri
- College of Medicine, Peadiatric Department, King Saud University, Riyadh, Saudi Arabia
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179
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Törmänen S, Teräsjärvi J, Lauhkonen E, Helminen M, Koponen P, Korppi M, Nuolivirta K, He Q. TLR5 rs5744174 gene polymorphism is associated with the virus etiology of infant bronchiolitis but not with post-bronchiolitis asthma. Health Sci Rep 2018; 1:e38. [PMID: 30623075 PMCID: PMC6266536 DOI: 10.1002/hsr2.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/09/2018] [Accepted: 03/13/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIM Bronchiolitis is a leading cause of hospitalization in infants and is associated with a risk of subsequent asthma. The innate immunity genes, such as those encoding toll-like receptors (TLRs), are likely to play a role in bronchiolitis and post-bronchiolitis outcome. Thus far, only one study has considered TLR5 genes in respiratory syncytial virus (RSV) bronchiolitis. The aim of this study was to investigate the association of TLR5 gene polymorphism with virus etiology and severity of bronchiolitis, and with post-bronchiolitis asthma. METHODS We recruited 164 infants (age < 6 months) hospitalized for bronchiolitis in this study and determined TLR5 rs5744174 (C > T) single nucleotide polymorphism, virus etiology and severity markers of bronchiolitis, and presence of post-bronchiolitis asthma until age 11 to 13 years. RESULTS RSV was detected in 113 (68.9%), rhinovirus in 19 (11.6%), and some other virus in 20 (12.2%) cases. Non-RSV etiology was more common among infants with the variant CT or TT genotype in the TLR5 rs5744174 gene than in those with the CC genotype (89.7% vs 71.7%, P = 0.03). TLR5 rs5744174 polymorphism was not associated with the need of supplementary oxygen or feeding support, with the length of hospital stay, or with post-bronchiolitis asthma at any age. CONCLUSION The TLR5 rs5744174 variant genotype may increase the susceptibility to bronchiolitis not caused by RSV.
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Affiliation(s)
- Sari Törmänen
- Center for Child Health ResearchTampere University and University HospitalTampereFinland
| | - Johanna Teräsjärvi
- Department of Medical Microbiology and ImmunologyTurku UniversityTurkuFinland
| | - Eero Lauhkonen
- Center for Child Health ResearchTampere University and University HospitalTampereFinland
| | - Merja Helminen
- Center for Child Health ResearchTampere University and University HospitalTampereFinland
| | - Petri Koponen
- Center for Child Health ResearchTampere University and University HospitalTampereFinland
| | - Matti Korppi
- Center for Child Health ResearchTampere University and University HospitalTampereFinland
| | - Kirsi Nuolivirta
- Department of PediatricsSeinäjoki Central HospitalSeinäjokiFinland
| | - Qiushui He
- Department of Medical Microbiology and ImmunologyTurku UniversityTurkuFinland
- Department of Medical MicrobiologyCapital Medical UniversityBeijingChina
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180
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Binding investigation between M2-1protein from hRSV and acetylated quercetin derivatives: 1H NMR, fluorescence spectroscopy, and molecular docking. Int J Biol Macromol 2018; 111:33-38. [DOI: 10.1016/j.ijbiomac.2017.12.141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/21/2017] [Accepted: 12/24/2017] [Indexed: 11/24/2022]
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181
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Condella A, Mansbach JM, Hasegawa K, Dayan PS, Sullivan AF, Espinola JA, Camargo CA. Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. West J Emerg Med 2018; 19:475-483. [PMID: 29760843 PMCID: PMC5942012 DOI: 10.5811/westjem.2018.3.35837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/14/2018] [Accepted: 03/05/2018] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Although bronchiolitis is a common reason for infant hospitalization, significant heterogeneity persists in its management. The American Academy of Pediatrics currently recommends that inhaled albuterol not be used in routine care of children with bronchiolitis. Our objective was to identify factors associated with pre-admission (e.g., emergency department or primary care) use of albuterol among infants hospitalized for bronchiolitis. METHODS We analyzed data from a 17-center observational study of 1,016 infants (age <1 year) hospitalized with bronchiolitis between 2011-2014. Pre-admission albuterol use was ascertained by chart review, and data were available for 1,008 (99%) infants. We used multivariable logistic regression to identify infant characteristics independently associated with pre-admission albuterol use. RESULTS Half of the infants (n=508) received at least one albuterol treatment before admission. Across the 17 hospitals, pre-admission albuterol use ranged from 23-84%. In adjusted analysis, independent predictors of albuterol use were the following: age ≥2 months (age 2.0-5.9 months [odds ratio (OR) 2.09, 95% confidence interval (CI) {1.45-3.01}] and age 6.0-11.9 months [OR 2.89, 95% CI {1.99-4.19}]); prior use of a bronchodilator (OR 1.89, 95% CI [1.24-2.90]); and presence of wheezing documented in pre-admission chart (OR 3.94, 95% CI [2.61-5.93]). By contrast, albuterol use was less likely among those with ≥7 days since the start of breathing problem (OR 0.66, 95% CI [0.44-1.00]) and parent-reported fever (OR 0.75, 95% CI [0.58-0.96]). CONCLUSION Variation in pre-admission albuterol use suggests that local practice had a strong influence on use, but that patient characteristics also influenced the decision. While we agree with current guidelines in recommending against albuterol for all infants with bronchiolitis, our understanding of possible subgroups of responders may improve through investigation of infants with the identified characteristics.
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Affiliation(s)
- Anna Condella
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Jonathan M. Mansbach
- Harvard Medical School, Boston Children’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Kohei Hasegawa
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Peter S. Dayan
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Ashley F. Sullivan
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Janice A. Espinola
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A. Camargo
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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182
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Hendaus MA, Alhammadi AH, Chandra P, Muneer E, Khalifa MS. Identifying agents triggering bronchiolitis in the State of Qatar. Int J Gen Med 2018; 11:143-149. [PMID: 29692622 PMCID: PMC5901157 DOI: 10.2147/ijgm.s154424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Bronchiolitis is considered as the most frequent lower respiratory tract infection in infants and young children. This disorder is marked by acute inflammation, edema, damage of epithelial cells lining small airways, and augmentation of mucus production. OBJECTIVE The goal of the study was to identify agents triggering bronchiolitis in the State of Qatar. MATERIALS AND METHODS A cross-sectional retrospective study was performed at Hamad Medical Corporation, the only tertiary and academic medical center in the State of Qatar. The study included infants and young children aged 0-24 months who were admitted to our pediatric ward with diagnosis of acute bronchiolitis (2010-2012). RESULTS Eight hundred thirty-five infants and young children met the study inclusion criteria with mean age at diagnosis of 3.61±3.56 months. Respiratory virus real-time polymerase chain reaction was performed on 769 (92.0%) of the participants. Respiratory syncytial virus (RSV) was positive in 352 (45.7%) children admitted with clinical bronchiolitis. In addition, no viruses were identified in 142 (18.4%) of those admitted, and respiratory viruses other RSV were found in 275 (35.7%) of the children. Our investigations and observations show that there has been a steady and periodic seasonal variation in the RSV rate over the study period. A seasonal trend for the RSV (detected by respiratory virus real-time polymerase chain reaction) rate was evident, showing annual peaks in the months of October, November, December, and January, with a significant test for seasonality (test statistics [T]=3.15, P=0.009). CONCLUSION In countries with desert hot weather, bronchiolitis might affect children throughout the year. Our results suggest that the combination of date regarding uninterrupted RSV seasonality can provide guidance for health care planning and application of RSV prevention scheme, such as extending the palivizumab immunoglobulin series.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad General Corporation, Doha, Qatar
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
| | - Ahmed H Alhammadi
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad General Corporation, Doha, Qatar
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
| | - Prem Chandra
- Department of Statistics, Medical Research Center, Hamad General Corporation, Doha, Qatar
| | - Eshan Muneer
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad General Corporation, Doha, Qatar
| | - Mohamed S Khalifa
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad General Corporation, Doha, Qatar
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183
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Törmänen S, Lauhkonen E, Riikonen R, Koponen P, Huhtala H, Helminen M, Korppi M, Nuolivirta K. Risk factors for asthma after infant bronchiolitis. Allergy 2018; 73:916-922. [PMID: 29105099 DOI: 10.1111/all.13347] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Five studies carried out after bronchiolitis at less than 24 months of age, with a follow-up of more than 10 years, reported that atopic dermatitis, family asthma, early-life exposure to tobacco smoke and rhinovirus aetiology were early-life risk factors for later asthma. This study evaluated the long-term outcome at 11-13 years of age of children who were hospitalized for bronchiolitis in early infancy. METHODS We previously prospectively followed 166 children hospitalized for bronchiolitis at less than 6 months of age until 5-7 years of age. The current study included a structured questionnaire, parental interviews, clinical examinations and bronchodilation test of 138 of those children at 11-13 years of age. RESULTS Respiratory syncytial virus caused 66% of the bronchiolitis cases, and nearly half of the patients were exposed to tobacco smoke in early life. Doctor-diagnosed asthma was present in 13% of the former bronchiolitis patients at 11-13 years of age. Maternal asthma was the only independently significant risk factor in early life (adjusted OR 3.45, 95% CI 1.07-11.74), as was allergic rhinitis at 5-7 years of age (adjusted OR 4.06, 95% CI 1.35-12.25). CONCLUSIONS After bronchiolitis at less than 6 months of age, the risk of doctor-diagnosed asthma at 11-13 years was about twice that of the general Finnish population. Maternal asthma was the only independently significant early-life risk factor for current asthma at 11-13 years of age.
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Affiliation(s)
- S. Törmänen
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - E. Lauhkonen
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - R. Riikonen
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - P. Koponen
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - H. Huhtala
- School of Health Sciences; Tampere University; Tampere Finland
| | - M. Helminen
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - M. Korppi
- Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - K. Nuolivirta
- Department of Pediatrics; Seinäjoki Central Hospital; Seinäjoki Finland
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184
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Oakley E, Brys T, Borland M, Neutze J, Phillips N, Krieser D, Dalziel SR, Davidson A, Donath S, Jachno K, South M, Williams A, Babl FE. Medication use in infants admitted with bronchiolitis. Emerg Med Australas 2018; 30:389-397. [PMID: 29573212 DOI: 10.1111/1742-6723.12968] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 02/14/2018] [Accepted: 02/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied. OBJECTIVES To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]). METHODS A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics. RESULTS There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay. CONCLUSIONS Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed.
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Affiliation(s)
- Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trusha Brys
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith Borland
- Department of Emergency Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health and School of Primary, Rural and Aboriginal Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jocelyn Neutze
- Department of Emergency Medicine, Kidz First Hospital Middlemore, Auckland, New Zealand
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, The University of Queensland, Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David Krieser
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Andrew Davidson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kim Jachno
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mike South
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amanda Williams
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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185
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Kyler KE, McCulloh RJ. Current Concepts in the Evaluation and Management of Bronchiolitis. Infect Dis Clin North Am 2018; 32:35-45. [DOI: 10.1016/j.idc.2017.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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186
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Oxygen in Acute Bronchiolitis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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187
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Chandelia S, Yadav AK, Kumar D, Chadha N. Magnesium sulphate for acute bronchiolitis in children under two years of age. Hippokratia 2018. [DOI: 10.1002/14651858.cd012965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sudha Chandelia
- PGIMER and Dr. RML Hospital; Pediatric Emergency and Critical Care; New Delhi India 110001
| | - Arun K Yadav
- AIIMS; Department of Neurology; Delhi India 110029
| | - Dinesh Kumar
- PGIMER; Division of Pediatric Cardiology, Department of Pediatrics; Delhi India 110001
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188
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Walpert AS, Thomas ID, Lowe MC, Seckeler MD. RSV prophylaxis guideline changes and outcomes in children with congenital heart disease. CONGENIT HEART DIS 2018; 13:428-431. [PMID: 29436781 DOI: 10.1111/chd.12590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/12/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to compare inpatient outcomes and costs for children with respiratory syncytial virus and congenital heart disease before and after the change in management guidelines for respiratory syncytial virus prophylaxis. DESIGN Hospital discharge data from the Vizient (formerly University HealthSystem Consortium) were queried from October 2012 to June 2014 (Era 1) and July 2014 to April 2016 (Era 2) for patients aged <24 months with an any International Classification of Disease (ICD)-9 or ICD-10 code for congenital heart disease (745-747.49, Q20.0-Q26.4) and a primary or secondary admitting diagnosis of respiratory syncytial virus infection (079.6, J20.5), acute bronchiolitis due to respiratory syncytial virus (466.11, J21.0) or respiratory syncytial virus pneumonia (480.1, J12.1). SETTING This study is a review of a national administrative discharge database. PATIENTS Respiratory syncytial virus admissions were identified in 1269 patients aged <24 months with congenital heart disease, with 644 patients in Era 1 and 625 in Era 2. Patients 0-12 months old represented 83% of admissions. INTERVENTIONS Prior to 2014, children aged 0-24 months with congenital heart disease were eligible to receive respiratory syncytial virus prophylaxis. Updated guidelines, published in 2014, restricted the recommendation to administer palivizumab respiratory syncytial virus prophylaxis to children with congenital heart disease only if they are ≤12 months old. OUTCOME MEASURES The outcome measures are hospital length of stay, ICU admission rate, mortality, and direct costs. RESULTS There was no change in length of stay, ICU admission rate, in-hospital mortality, or direct costs for children 13-24 months old with congenital heart disease after the change in guidelines. There were no deaths in 13-24 month olds, regardless of era. CONCLUSIONS Our findings provide additional support for the new guideline recommendations to provide respiratory syncytial virus prophylaxis only for children ≤12 months old with congenital heart disease.
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Affiliation(s)
- Adam S Walpert
- Division of Pediatric Hospital Medicine and Outreach, Department of Pediatrics, Banner Diamond Children's Medical Center, University of Arizona, Tucson, Arizona, USA
| | - Ian D Thomas
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Merlin C Lowe
- Division of Pediatric Hospital Medicine and Outreach, Department of Pediatrics, Banner Diamond Children's Medical Center, University of Arizona, Tucson, Arizona, USA
| | - Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, Arizona, USA
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189
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O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. BMC Med Res Methodol 2018; 18:22. [PMID: 29433429 PMCID: PMC5809867 DOI: 10.1186/s12874-018-0478-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 01/21/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Bronchiolitis is the commonest respiratory infection in children less than 12 months and cause of hospitalisation in infants under 6 months of age in Australasia. Unfortunately there is substantial variation in management, despite high levels of supporting evidence. This paper reports on the process, strengths and challenges of the hybrid approach used to develop the first Australasian management guideline relevant to the local population. METHOD An adaption of the nine steps recommended by the National Health and Medical Research Council (NHMRC) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology were utilised. Following establishment of the Guideline Development Committee (GDC), we identified the population, intervention, comparator, outcomes and time of interest (PICOt) questions, undertook a systematic literature search and graded the evidence and recommendations using the NHMRC and GRADE processes. Using Nominal Group Techniques (NGT), consensus was sought in formulating the clinical practice recommendations and practice points. Key health professional bodies were consulted to ensure relevance in the Australasian emergency and ward settings. RESULTS From 33 PICOT questions, clinical recommendations for practice that were deemed relevant to the Australasian population were identified. Specific considerations for the management of Australian and New Zealand indigenous infants in relation to the use of azithromycin and risk factors for more serious illness are included. Using NGT, consensus demonstrated by a median Likert score > 8 for all recommendations was achieved. The guideline presents clinical guidance, followed by the key recommendations and evidence review behind each recommendation. CONCLUSION Developing evidence-based clinical guidelines is a complex process with considerable challenges. Challenges included having committee members located over two countries and five time zones, large volume of literature and variation of member's knowledge of grading of evidence and recommendations. The GRADE and NHMRC processes provided a systematic and transparent approach ensuring a final structure including bedside interface, and a descriptive summary of the evidence base and tables for each key statement. Involvement of stakeholders who will ultimately be end-users as members of the GDC provided valuable knowledge. Lessons learnt during this guideline development process provide valuable insight for those planning development of evidence-based guidelines.
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Affiliation(s)
- Sharon O’Brien
- Child and Adolescent Health Service, Princess Margaret Hospital for Children, Roberts Road Subiaco, Perth, WA 6008 Australia
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA Australia
| | - Sally Wilson
- Child and Adolescent Health Service, Princess Margaret Hospital for Children, Roberts Road Subiaco, Perth, WA 6008 Australia
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA Australia
| | - Fenella J. Gill
- Child and Adolescent Health Service, Princess Margaret Hospital for Children, Roberts Road Subiaco, Perth, WA 6008 Australia
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA Australia
| | - Elizabeth Cotterell
- School of Rural Medicine, University of New England, Armidale, NSW 2351 Australia
| | - Meredith L Borland
- Child and Adolescent Health Service, Princess Margaret Hospital for Children, Roberts Road Subiaco, Perth, WA 6008 Australia
- School of Paediatric and Child Health, School of Primary, Aboriginal and Rural health Care, University of Western Australia, Perth, WA 6840 Australia
| | - Edward Oakley
- Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville, VIC 3052 Australia
- University of Melbourne, Cnr Grattan Street & Royal Parade, Melbourne, VIC 3010 Australia
- Paediatric Emergency Medicine Centre of Research Excellence, Melbourne, Australia
| | - Stuart R Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
| | - on behalf of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, Australasia
- Child and Adolescent Health Service, Princess Margaret Hospital for Children, Roberts Road Subiaco, Perth, WA 6008 Australia
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA Australia
- School of Rural Medicine, University of New England, Armidale, NSW 2351 Australia
- School of Paediatric and Child Health, School of Primary, Aboriginal and Rural health Care, University of Western Australia, Perth, WA 6840 Australia
- Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville, VIC 3052 Australia
- University of Melbourne, Cnr Grattan Street & Royal Parade, Melbourne, VIC 3010 Australia
- Paediatric Emergency Medicine Centre of Research Excellence, Melbourne, Australia
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
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190
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Xin Y, Weng W, Murray BP, Eisenberg EJ, Chien JW, Ling J, Silverman JA. The Drug-Drug Interaction Profile of Presatovir. J Clin Pharmacol 2018; 58:771-780. [PMID: 29412463 DOI: 10.1002/jcph.1073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/04/2017] [Indexed: 11/10/2022]
Abstract
Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections in young children. Presatovir (previously GS-5806) is a novel, orally administered RSV fusion inhibitor with a favorable safety profile and proven antiviral efficacy in preclinical and clinical studies. In vitro, presatovir is a substrate of the efflux transporters P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) and hepatic uptake transporters organic anion transporting polypeptide (OATP) 1B1 and OATP1B3 and is slowly metabolized by cytochrome P450 (CYP) 3A4 and CYP3A5. This study enrolled 64 healthy subjects to evaluate the effect of cyclosporine, a P-gp, BCRP, and OATP1B1/1B3 inhibitor; rifampin, a strong CYP3A4 and P-gp inducer; efavirenz, a moderate CYP3A4 inducer; and cobicistat, a potent CYP3A inhibitor, on presatovir pharmacokinetics. Presatovir plasma exposures (maximum observed plasma concentration [Cmax ] and area under the plasma concentration-time curve from time 0 extrapolated to infinity [AUCinf ]) were not affected by coadministration of cyclosporine, suggesting presatovir is not a sensitive substrate of P-gp, BCRP, or OATP1B1/1B3. As expected, based on the role of CYP3A in presatovir metabolism, presatovir exposure was increased by cobicistat (122% in AUCinf ), and decreased by rifampin (40.3% in Cmax and 82.5% in AUCinf ) and efavirenz (55.7% in AUCinf ). These data support coadministration of presatovir with inhibitors of P-gp, BCRP, OATP1B1/1B3, or CYP3A, but not with moderate or strong CYP3A4 inducers. Presatovir was well-tolerated with the most common drug-related adverse events of dizziness (n = 12) and somnolence (n = 4) reported during efavirenz treatment.
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Affiliation(s)
- Yan Xin
- Gilead Sciences, Inc., Foster City, CA, USA
| | | | | | | | | | - John Ling
- Gilead Sciences, Inc., Foster City, CA, USA
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191
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Mussman GM, Lossius M, Wasif F, Bennett J, Shadman KA, Walley SC, Destino L, Nichols E, Ralston SL. Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care. Pediatrics 2018; 141:peds.2017-0830. [PMID: 29321255 DOI: 10.1542/peds.2017-0830] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment. METHODS Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure. RESULTS Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated. CONCLUSIONS Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.
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Affiliation(s)
- Grant M Mussman
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio;
| | - Michele Lossius
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | - Faiza Wasif
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Jeffrey Bennett
- Department of General Pediatrics, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee
| | - Kristin A Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Susan C Walley
- Children's of Alabama and Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren Destino
- Lucile Packard Children's Hospital School of Medicine and Department of Pediatrics, Stanford University, Stanford, California
| | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Shawn L Ralston
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
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192
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Hendaus MA, Nassar S, Leghrouz BA, Alhammadi AH, Alamri M. Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis. Patient Prefer Adherence 2018; 12:483-487. [PMID: 29662305 PMCID: PMC5892958 DOI: 10.2147/ppa.s152880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE The purpose of the study was to investigate parental preference of continuous pulse oximetry in infants and children with bronchiolitis. MATERIALS AND METHODS A cross-sectional prospective study was conducted at Hamad Medical Corporation in Qatar. Parents of infants and children <24 months old and hospitalized with bronchiolitis were offered an interview survey. RESULTS A total of 132 questionnaires were completed (response rate 100%). Approximately 90% of participants were 20-40 years of age, and 85% were females. The mean age of children was 7.2±5.8 months. Approximately eight in ten parents supported the idea of continuous pulse oximetry in children with bronchiolitis. Almost 43% of parents believed that continuous pulse-oximetry monitoring would delay their children's hospital discharge. Interestingly, approximately 85% of caregivers agreed that continuous pulse oximetry had a good impact on their children's health. In addition, around one in two of the participants stated that good bedside examinations can obviate the need for continuous pulse oximetry. Furthermore, 80% of parents believed that continuous pulse-oximetry monitoring would give the health-care provider a good sense of security regarding the child's health. Finally, being a male parent was associated with significantly increased risk of reporting unnecessary fatigue, attributed to the sound of continuous pulse oximetry (P=0.031). CONCLUSION Continuous pulse-oximetry monitoring in children with bronchiolitis was perceived as reassuring for parents. Involving parents in decision-making is considered essential in the better management of children with bronchiolitis or any other disease. The first step to decrease continuous pulse oximetry will require provider education and change as well. Furthermore, we recommend proper counseling for parents, emphasizing that medical technology is not always essential, but is a complementary mode of managing a disease.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
- Correspondence: Mohamed A Hendaus, Department of Pediatrics, Sidra Medicine, Al Al Luqta Street, PO BOX 26999, Doha, Qatar, Tel +974 4003 6559, Fax +974 4443 9571, Email
| | - Suzan Nassar
- Department of Pediatrics, Hamad General Corporation, Doha, Qatar
| | | | - Ahmed H Alhammadi
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
| | - Mohammed Alamri
- Pediatric Emergency Center, Hamad General Corporation, Doha, Qatar
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193
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Piteau S. Update in Pediatric Hospital Medicine. UPDATE IN PEDIATRICS 2018. [PMCID: PMC7121028 DOI: 10.1007/978-3-319-58027-2_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Pediatric Hospital Medicine has significantly developed as a field over the past two decades. With the goal of improving care for hospitalized children, much of the research in this field has focused on reducing unnecessary interventions, optimizing necessary treatments, and reducing variability for common inpatient conditions. While this is far from an exhaustive chapter on the vast diversity and advances in this field, it focuses on the updates for some of the top diagnoses in hospital medicine and the major trends in the field. Updated management of acute viral bronchiolitis, urinary tract infections, neonatal infections, brief resolved unexplained events (formerly, apparent life-threatening events), and osteomyelitis are highlighted with emphasis on major management changes. In addition, and distinct to pediatric hospital medicine, the topics of overuse and high value care are discussed as they have gained momentum in influencing the way hospitalists think and practice.
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Affiliation(s)
- Shalea Piteau
- Chief/Medical Director of Pediatrics at Quinte Health Care, Assistant Professor at Queen’s University, Belleville, Ontario Canada
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194
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Rodriguez-Fernandez R, Tapia LI, Yang CF, Torres JP, Chavez-Bueno S, Garcia C, Jaramillo LM, Moore-Clingenpeel M, Jafri HS, Peeples ME, Piedra PA, Ramilo O, Mejias A. Respiratory Syncytial Virus Genotypes, Host Immune Profiles, and Disease Severity in Young Children Hospitalized With Bronchiolitis. J Infect Dis 2017; 217:24-34. [PMID: 29045741 PMCID: PMC5853407 DOI: 10.1093/infdis/jix543] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Data on how respiratory syncytial virus (RSV) genotypes influence disease severity and host immune responses is limited. Here, we characterized the genetic variability of RSV during 5 seasons, and evaluated the role of RSV subtypes, genotypes, and viral loads in disease severity and host transcriptional profiles. Methods A prospective, observational study was carried out, including a convenience sample of healthy infants hospitalized with RSV bronchiolitis. Nasopharyngeal samples for viral load quantitation, typing, and genotyping, and blood samples for transcriptome analyses were obtained within 24 hours of hospitalization. Multivariate models were constructed to identify virologic and clinical variables predictive of clinical outcomes. Results We enrolled 253 infants (median age 2.1 [25%-75% interquartile range] months). RSV A infections predominated over RSV B and showed greater genotype variability. RSV A/GA2, A/GA5, and RSV B/BA were the most common genotypes identified. Compared to GA2 or BA, infants with GA5 infections had higher viral loads. GA5 infections were associated with longer hospital stay, and with less activation of interferon and increased overexpression of neutrophil genes. Conclusions RSV A infections were more frequent than RSV B, and displayed greater variability. GA5 infections were associated with enhanced disease severity and distinct host immune responses.
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Affiliation(s)
- Rosa Rodriguez-Fernandez
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Lorena I Tapia
- Department of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics and Virology Program, Facultad de Medicina, Universidad de Chile, Santiago
| | - Chin-Fen Yang
- Department of Research, Medimmune LLC, Mountain View, California
- Enimmune Corporation, Taiwan
| | - Juan Pablo Torres
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
- Department of Pediatrics and Virology Program, Facultad de Medicina, Universidad de Chile, Santiago
| | - Susana Chavez-Bueno
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
- Children’s Mercy Hospital, Kansas City, Missouri
| | - Carla Garcia
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
- PID Associates, Carrollton, Texas
| | - Lisa M Jaramillo
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Hasan S Jafri
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
- Medimmune /AztraZeneca
| | - Mark E Peeples
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Pedro A Piedra
- Department of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Octavio Ramilo
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Infectious Diseases, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Asuncion Mejias
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Division of Pediatric Infectious Diseases, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
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195
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Reducing Antibiotic Use in Respiratory Syncytial Virus-A Quality Improvement Approach to Antimicrobial Stewardship. Pediatr Qual Saf 2017; 2:e046. [PMID: 30229182 PMCID: PMC6132889 DOI: 10.1097/pq9.0000000000000046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 10/15/2017] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objective: The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood. Methods: Baseline data from the 2011–2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards. Results: We included a total of 290 children in the final analysis. After full implementation of the ASP, there was a significant reduction of antibiotic exposure from 56.2% to 30.9% (P < 0.001), an absolute reduction of 25% and a relative reduction of 45%. There was also a significant decrease in DOT/1000PD from 432.7 to 268.1 days (P = 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation. Conclusion: Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.
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196
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Schuh S, Babl FE, Dalziel SR, Freedman SB, Macias CG, Stephens D, Steele DW, Fernandes RM, Zemek R, Plint AC, Florin TA, Lyttle MD, Johnson DW, Gouin S, Schnadower D, Klassen TP, Bajaj L, Benito J, Kharbanda A, Kuppermann N. Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study. Pediatrics 2017; 140:peds.2017-0842. [PMID: 29184035 DOI: 10.1542/peds.2017-0842] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). RESULTS Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). CONCLUSIONS More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.
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Affiliation(s)
- Suzanne Schuh
- Division of Paediatric Emergency Medicine and.,The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, and University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, and University of Auckland, Auckland, New Zealand
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Derek Stephens
- The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dale W Steele
- Section of Pediatric Emergency Medicine, Hasbro Children's Hospital and Section of Pediatric Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark D Lyttle
- Pediatric Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine.,Emergency Medicine, and.,Physiology and Pharmacology, Department of Pediatrics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Serge Gouin
- Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - David Schnadower
- Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Anupam Kharbanda
- Emergency Department, Children's Hospital of Minnesota, Minneapolis, Minnesota; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, Davis School of Medicine, University of California, Sacramento, California
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197
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SGEM Hot Off the Press: Management of bronchiolitis in community
hospitals. CAN J EMERG MED 2017; 19:475-479. [DOI: 10.1017/cem.2017.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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198
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Jartti T, Gern JE. Role of viral infections in the development and exacerbation of asthma in children. J Allergy Clin Immunol 2017; 140:895-906. [PMID: 28987219 PMCID: PMC7172811 DOI: 10.1016/j.jaci.2017.08.003] [Citation(s) in RCA: 277] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/03/2017] [Accepted: 08/22/2017] [Indexed: 12/31/2022]
Abstract
Viral infections are closely linked to wheezing illnesses in children of all ages. Respiratory syncytial virus (RSV) is the main causative agent of bronchiolitis, whereas rhinovirus (RV) is most commonly detected in wheezing children thereafter. Severe respiratory illness induced by either of these viruses is associated with subsequent development of asthma, and the risk is greatest for young children who wheeze with RV infections. Whether viral illnesses actually cause asthma is the subject of intense debate. RSV-induced wheezing illnesses during infancy influence respiratory health for years. There is definitive evidence that RSV-induced bronchiolitis can damage the airways to promote airway obstruction and recurrent wheezing. RV likely causes less structural damage and yet is a significant contributor to wheezing illnesses in young children and in the context of asthma. For both viruses, interactions between viral virulence factors, personal risk factors (eg, genetics), and environmental exposures (eg, airway microbiome) promote more severe wheezing illnesses and the risk for progression to asthma. In addition, allergy and asthma are major risk factors for more frequent and severe RV-related illnesses. Treatments that inhibit inflammation have efficacy for RV-induced wheezing, whereas the anti-RSV mAb palivizumab decreases the risk of severe RSV-induced illness and subsequent recurrent wheeze. Developing a greater understanding of personal and environmental factors that promote more severe viral illnesses might lead to new strategies for the prevention of viral wheezing illnesses and perhaps reduce the subsequent risk for asthma.
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Affiliation(s)
- Tuomas Jartti
- Department of Paediatrics, Turku University Hospital and University of Turku, Turku, Finland.
| | - James E Gern
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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199
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Hoeppner T, Borland M, Babl FE, Neutze J, Phillips N, Krieser D, Dalziel SR, Davidson A, Donath S, Jachno K, South M, Williams A, Zhang G, Oakley E. Influence of weather on incidence of bronchiolitis in Australia and New Zealand. J Paediatr Child Health 2017; 53:1000-1006. [PMID: 28727197 DOI: 10.1111/jpc.13614] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 01/19/2023]
Abstract
AIM We aimed to examine the impact of weather on hospital admissions with bronchiolitis in Australia and New Zealand. METHODS We collected data for inpatient admissions of infants aged 2-12 months to seven hospitals in four cities in Australia and New Zealand from 2009 until 2011. Correlation of hospital admissions with minimum daily temperature, wind speed, relative humidity and rainfall was examined using linear, Poisson and negative binomial regression analyses as well as general estimated equation models. To account for possible lag between exposure to weather and admission to hospital, analyses were conducted for time lags of 0-4 weeks. RESULTS During the study period, 3876 patients were admitted to the study hospitals. Hospital admissions showed strong seasonality with peaks in wintertime, onset in autumn and offset in spring. The onset of peak incidence was preceded by a drop in temperature. Minimum temperature was inversely correlated with hospital admissions, whereas wind speed was directly correlated. These correlations were sustained for time lags of up to 4 weeks. Standardised correlation coefficients ranged from -0.14 to -0.54 for minimum temperature and from 0.18 to 0.39 for wind speed. Relative humidity and rainfall showed no correlation with hospital admissions in our study. CONCLUSION A decrease in temperature and increasing wind speed are associated with increasing incidence of bronchiolitis hospital admissions in Australia and New Zealand.
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Affiliation(s)
- Tobias Hoeppner
- Department of Emergency Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Meredith Borland
- Department of Emergency Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health and School of Primary, Rural and Aboriginal Health, University of Western Australia, Perth, Western Australia, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Jocelyn Neutze
- Department of Emergency Medicine, Kidz First Children's Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, University of Queensland Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David Krieser
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Andrew Davidson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Kim Jachno
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mike South
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amanda Williams
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Guicheng Zhang
- School of Public Health, Curtin University, Perth, Western Australia, Australia.,Centre for Genetic Origins of Health and Disease, Curtin University and University of Western Australia, Perth, Western Australia, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Nazif JM, Taragin BH, Azzarone G, Rinke ML, Liewehr S, Choi J, Esteban-Cruciani N. Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis. Clin Pediatr (Phila) 2017; 56:1054-1059. [PMID: 28871880 DOI: 10.1177/0009922817698802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.
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Affiliation(s)
- Joanne M Nazif
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin H Taragin
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gabriella Azzarone
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael L Rinke
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sheila Liewehr
- 3 Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Jaeun Choi
- 2 Albert Einstein College of Medicine, Bronx, NY, USA
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