Genie Roosevelt

Dexamethasone in bronchiolitis: a randomised controlled trial

BACKGROUNDnAlthough corticosteroids are commonly prescribed in the treatment of bronchiolitis, there is no evidence on the efficacy of these drugs in this disorder. We designed a randomised, double-blind, prospective study to assess the efficacy of dexamethasone in infants with bronchiolitis who require hospital management.nnnMETHODSnInfants younger than 12 months who had been admitted to hospital for an initial episode of wheezing, were randomly allocated intramuscular dexamethasone (1 mg/kg daily) or placebo, every 24 h for three doses. We excluded infants who were younger than 4 weeks, who required admission to the intensive care unit, or who had a history of congenital heart disease, mechanical ventilation, or supplemental oxygen use. We assessed infants on admission and every 12 h thereafter--vital signs were taken, severity of accessory muscle use and wheezing were measured by a clinical severity score, and pulse oximetry in room air was done. Our primary endpoints were the time to resolution of symptoms--defined as the number of assessments needed to reach oxygen saturation of more than 95% while receiving no supplemental oxygen, an accessory muscle score of 0, a wheeze score of 0 or 1, and resumption of normal feeding--and duration of oxygen therapy. Follow-up assessments were made 10-14 days after discharge by telephone. We used a proportional-hazards model for our survival analysis.nnnFINDINGSn197 infants presented with bronchiolitis that required inpatient management. 75 were not enrolled (31 no consent, 28 no approach made, 16 transferred elsewhere). Of the 122 enrolled, four were excluded (clinical deterioration, diagnosis of cystic fibrosis, previous intubation, did not receive all study treatment). There were no differences between the dexamethasone (n = 65) and placebo-treated infants in demographic factors, exposure to tobacco smoke, duration of illness, presence of respiratory syncytial virus (RSV) antigen, respiratory rate, or severity score. More dexamethasone-treated patients had an initial oxygen saturation of 95% or less (51 [79%] dexamethasone vs 31 [59%] placebo, p = 0.02). There were no differences in duration of oxygen therapy (p = 0.74) or time to resolution of symptoms (p = 0.22). Stratification for presence of RSV antigen or family history of atopy did not affect the results.nnnINTERPRETATIONnOur findings do not support the use of dexamethasone in the treatment of bronchiolitis in infants.

Interpreters: telephonic, in-person interpretation and bilingual providers.

CONTEXT: Language barriers affect health care interactions. Large, randomized studies of the relative efficacy of interpreter modalities have not been conducted. OBJECTIVE: To compare the efficacy of telephonic and in-person medical interpretation to visits with verified bilingual physicians. METHODS: This was a prospective, randomized trial. The setting was an urban pediatric emergency department at which ∼20% of visits are by families with limited English proficiency. The participants were families who responded affirmatively when asked at triage if they would prefer to communicate in Spanish. Randomization of each visit was to (1) remote telephonic interpretation via a double handset in the examination room, (2) an in-person emergency department–dedicated medical interpreter, or (3) a verified bilingual physician. Interviews were conducted after each visit. The primary outcome was a blinded determination of concordance between the caregivers description of their childs diagnosis with the physicians stated discharge diagnosis. Secondary outcomes were qualitative measures of effectiveness of communication and satisfaction. Verified bilingual providers were the gold standard for noninferiority comparisons. RESULTS: A total of 1201 families were enrolled: 407 were randomly assigned to telephonic interpretation and 377 to in-person interpretation, and 417 were interviewed by a bilingual physician. Concordance between the diagnosis in the medical record and diagnosis reported by the family was not different between the 3 groups (telephonic: 95.1%; in-person: 95.5%; bilingual: 95.4%). The in-person–interpreter cohort scored the quality and satisfaction with their visit worse than both the bilingual and telephonic cohorts (P < .001). Those in the bilingual-provider cohort were less satisfied with their language service than those in the in-person and telephonic cohorts (P < .001). Using the bilingual provider as a gold standard, noninferiority was demonstrated for both interpreter modalities (telephonic and in-person) for quality and satisfaction of the visit. CONCLUSIONS: Both telephonic and in-person interpretation resulted in similar concordance in understanding of discharge diagnosis compared with bilingual providers. In general, noninferiority was also seen on qualitative measures, although there was a trend favoring telephonic over in-person interpretation.

Discharged on Supplemental Oxygen From an Emergency Department in Patients With Bronchiolitis

BACKGROUND AND OBJECTIVE: Bronchiolitis is the most common reason for hospital admission in patients aged <1 year. Admissions have been increasing with hypoxia frequently cited as the determinant. Home oxygen (O2) has been shown to be feasible, although safety data are lacking. The objective of this study was to evaluate the impact of a home O2 clinical care protocol on admission rates in patients with bronchiolitis from the pediatric emergency department. METHODS: We performed a retrospective chart review of patients with bronchiolitis who presented to a children’s hospital pediatric emergency department (altitude 1600 m) between 2005 and 2009. Patients between the ages of 1 and 18 months were included in the analysis. Patients requiring baseline O2 were excluded. We calculated the percentage of patients discharged on O2 and their readmission rates. We reviewed charts of patients who were admitted after home O2 for adverse outcomes. We also compared rates of admission before and after initiation of the protocol. RESULTS: In this study, 4194 illnesses were analyzed; 2383 (57%) were discharged on room air, 649 (15%) were discharged on O2, and 1162 (28%) were admitted. Of those discharged on room air, 4% were subsequently admitted, and 6% of those discharged on O2 were admitted. There were no ICU admissions or need for advanced airway management in those patients discharged on O2. Our overall admission rates for bronchiolitis dropped from a rate of 40% to 31%. CONCLUSIONS: Home O2 is an effective way to decrease hospital admissions in a select group of patients with bronchiolitis.

Utility of anaerobic blood cultures in a pediatric emergency department.

Objectives: To determine the frequency with which clinically significant bacterial pathogens are isolated only from the anaerobic blood culture medium in children evaluated for bacteremia and to describe the clinical features associated with these positive cultures. Methods: Retrospective review of all blood cultures received from the emergency department in the microbiology laboratory. Clinically significant pathogens were defined as microorganisms that rarely are considered to be contaminants or microorganisms that are recovered from multiple blood cultures or sites from the same individual. Charts of all patients with positive anaerobic cultures for clinically significant pathogens in the presence of negative aerobic cultures were reviewed. The setting was an urban tertiary care pediatric emergency department. Results: 2675 paired blood cultures were performed between January 1, 1998 and December 31, 2000. Growth of a bacterial organism occurred in 595 of the paired samples. Two hundred seventy-eight were clinically significant pathogens. One hundred sixty-two (58.3%) were present in both the aerobic and anaerobic mediums, 85 (30.6%) were only in the aerobic medium, and 31 (11.2%) were only in the anaerobic medium. Most patients with growth only in the anaerobic medium had underlying conditions (ie, central venous line, immunocompromised, congenital heart disease, liver disease, age < 3 months). No obligate anaerobic organisms were detected. Conclusions: In a pediatric emergency department setting, almost all pathogenic bacteria were isolated from aerobic culture mediums in otherwise healthy children. The yield of routinely performed anaerobic blood cultures is low. In previously healthy children, it may be optimal to inoculate the entire blood volume obtained into the aerobic medium.

Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUNDnThe co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication.nnnOBJECTIVEnOur objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED).nnnMETHODSnThis was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21xa0years of age. The attending physician administered either ketamine 1xa0mg/kg i.v. or ketamine 0.5xa0mg/kg and propofol 0.5xa0mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5xa0mg/kg/dose) or ketamine/propofol (0.25xa0mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores.nnnRESULTSnNinety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores byxa0providers, including nurses, were higher for KM, althoughxa0parents were equally satisfied with both sedation regimens.nnnCONCLUSIONSnWe found no significant differences in adverse events between the KM and CoKP groups. Whilexa0CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Evaluation of drug use and medication compliance in adolescents admitted to a psychiatric facility from the pediatric emergency department

OBJECTIVESnKnowledge of drug use and medication compliance during mental health evaluation can help guide evaluation and treatment. The objective was to evaluate drug use and medication compliance in a pediatric emergency department (PED) psychiatric population by comparing medical history, standard urine drug screen (EIA), and expanded urine drug screen (HPLC-MS/MS).nnnMETHODSnA prospective cohort study of admitted psychiatric patients ≥13years and ≤18years in a tertiary-care childrens hospital psychiatric ED from January 31, 2013 through April 16, 2014.nnnRESULTSn100 patients in our PED were enrolled. Marijuana was the most commonly admitted and detected substance; 43% had co-ingestions. HPLC-MS/MS revealed 36 additional substance exposures than identified by history. All substances detected by EIA were also detected by HPLC-MS/MS. Combination of history and HPLC-MS/MS revealed the most substances used. HPLC-MS/MS identified antidepressants in 76% of patients prescribed a detectable antidepressant.nnnCONCLUSIONnMarijuana use was greater than nicotine use and was associated with concomitant polysubstance abuse. A combination of history and HPLC-MS/MS was the most thorough in obtaining history of drug use. Almost a quarter of patients did not have their prescribed antidepressant detected by HPLC-MS/MS. A rapid, affordable expanded drug screen should replace the more standard limited drug screen particularly for patients who are refractory to treatment.

The 2012 PEMpix photograph competition award winner: making a case for pringles-flavored carrots.

This is a case report of a 14-year-old boy with autism who presented with photophobia. Physical examination was significant for bilateral corneal ulcers. Differential diagnosis of this chief complaint and the management of the suspected condition are discussed. This case was presented at the Section of Emergency Medicine Meeting at the National Conference and Exhibition of the American Academy of Pediatrics in 2012 and was awarded first place in the PEMpix photograph competition.