M. Bruce Edmonson

A Population-Based Study of Acute Care Revisits following Tonsillectomy

OBJECTIVES To describe the clinical spectrum and frequency of acute care revisits after tonsillectomy in a population-based sample from a single state in the US. STUDY DESIGN We used California state discharge databases from 2009 to 2011 to retrospectively identify retrospectively routine tonsillectomy discharges in residents <25 years of age and to establish record linkage to revisits within 30 days at ambulatory surgery, inpatient, and emergency department facilities statewide. Percentages and descriptive statistics were sample-weighted, and revisit rates were adjusted for demographic factors, expected payer, chronic conditions, surgical indication, facility type, and clustering. RESULTS Records were available for 35 085 index tonsillectomies, most of which were performed at hospital-owned ambulatory and inpatient facilities. There were 4944 associated revisits: 3761 (75.9%) treat-and-release emergency room visits, 816 (17.1%) inpatient admissions, and 367 (7.0%) ambulatory surgery visits. Most revisits (3225 [67.7%]) were unrelated to bleeding; these typically occurred early (mode, day 2) and were commonly associated with diagnosis codes indicating pain, nausea/vomiting, or dehydration. Crude all-cause revisit and readmission rates were 10.5% and 2.1%, respectively. Adjusted all-cause revisit rates (range, 8.6%-24.5%) were lowest in young children, increased in adolescents, and peaked in young adults. Adjusted bleeding-related revisit rates increased abruptly in adolescents and reached 13.9% in males (6.8% in females, P < .001) ages 20-24 years. CONCLUSIONS Acute care revisits after tonsillectomy performed at predominantly hospital-owned facilities in California are common and strongly age-related. Most revisits are early treat-and-release outpatient encounters, and these are usually associated with potentially preventable problems such as pain, nausea and vomiting, and dehydration.

Treatment Trends and Outcomes in US Hospital Stays of Children With Empyema

Background: Recently published practice guidelines continue to reflect uncertainty about the comparative effectiveness of various treatments for empyema in children. We describe treatment trends and outcomes in pediatric empyema using the most current nationally representative data. Methods: Using survey methods and Kids’ Inpatient Databases from 1997 to 2009, we evaluated hospital stays in children 0–18 years of age. We used 2009 data to compare transfer-out rates and lengths of stay across various types of treatment, after adjusting for patient and hospital factors. Results: From 1997 to 2009, empyema discharges steadily increased from 3.1 to 6.0 per 100,000 children (P < 0.001 for trend) and also were increasingly likely (P < 0.01) to be coded for: (1) at least 1 pleural drainage procedure (76.4–83.2%), (2) multiple drainage procedures (36.0–41.6%) and (3) home health care (8.7–15.0%). By 2009, video-assisted thoracoscopic surgery was more commonly coded than chest tube drainage and was associated with a lower transfer-out rate (0.6% vs. 10.1%, adjusted P < 0.001) but no reduction in mean length of stay [11.2 vs. 13.4 days, adjusted incidence rate ratio 0.95 (95% confidence interval: 0.88–1.04)] for children neither admitted nor discharged by transfer. Conclusions: US hospital stays for empyema in children not only continued to increase through 2009 but were also characterized by more intense procedural management. Outcomes results in this population-based study are consistent with practice guidelines and recommendations that recently endorsed chest tube drainage as an acceptable first treatment option for most children with empyema.

Outer membrane protein subtypes and investigation of recurrent Haemophilus influenzae type b disease

Ten previously healthy patients, ages 3 to 26 months, developed recurrent episodes of deep-tissue Haemophilus influenzae type b infections from 4 to 191 days (median = 28 days) after the last day of antibiotic therapy given for the first episode. None of the patients had a persistent focus of infection and eight were considered to have had adequate therapy for the initial episode. Bacteremia, without evidence of relapse at the site of the original infection, was documented in eight of the ten recurrent episodes. The ampicillin susceptibilities of the HITB isolates changed between episodes in two of the patients. Blood or CSF isolates from both episodes in seven patients were examined for biotypes and outer membrane protein subtypes. Concordance of both biotype and OMP subtype was present for all seven paired isolates, including the two pairs in which the HITB ampicillin sensitivities had changed. These data imply that some patients become reinfected with their original HITB isolates and that OMP and capsular antigens do not always elicit protective immunity, even after natural infection.

Weight Gain and Obesity in Infants and Young Children Exposed to Prolonged Antibiotic Prophylaxis

Importance An association between antibiotic use and excessive weight gain or obesity in healthy infants and young children has been reported, but evidence is inconsistent and based on observational studies of growth in relation to incidental antibiotic exposures. Objective To evaluate whether prolonged antibiotic exposure is associated with weight gain in children participating in a clinical trial of antibiotic prophylaxis to prevent recurrent urinary tract infection. Design, Setting, and Participants Secondary analysis of data from the Randomized Intervention for Children With Vesicoureteral Reflux Study, a 2-year randomized clinical trial that enrolled participants from 2007 to 2011. All 607 children who were randomized to receive antibiotic (n = 302) or placebo (n = 305) were included. Children with urinary tract anomalies, premature birth, or major comorbidities were excluded from participation. Interventions Trimethoprim-sulfamethoxazole or placebo taken orally, once daily, for 2 years. Main Outcomes and Measures Weight gain as measured by change in weight-for-age z score from baseline to the end-of-study visit at 24 months. Secondary outcomes included weight gain at 6, 12, and 18 months and the prevalence of overweight or obesity at 24 months. Results Participants had a median age of 12 months (range, 2-71 months) and 558 of 607 (91.9%) were female. Anthropometric data were complete at the 24-month visit for 428 children (214 in the trimethoprim-sulfamethoxazole group and 214 in the placebo group). Weight gain in the trimethoprim-sulfamethoxazole group and the placebo group was similar (mean [SD] change in weight-for-age z score: +0.14 [0.83] and +0.18 [0.85], respectively; difference, −0.04 [95% CI, −0.19 to 0.12]; P = .65). There was no significant difference in weight gain at 6, 12, or 18 months or in the prevalence of overweight or obesity at 24 months (24.8% vs 25.7%; P = .82). Subgroup analyses showed no significant interaction between weight gain effect and age, sex, history of breastfeeding, prior antibiotic use, adherence to study medication, or development of urinary tract infection during the study. Conclusions and Relevance Based on a secondary analysis of data from a large clinical trial of trimethoprim-sulfamethoxazole prophylaxis, there was no evidence that prolonged exposure to this antibiotic has a concurrent effect on weight gain or the prevalence of overweight or obesity in healthy infants and young children.

Validation and Clinical Utility of a Bowel Habit Questionnaire (BHQ) in School-Aged Children

Objectives: The aim of the study was to validate a brief Bowel Habit Questionnaire (BHQ) with prospectively obtained data from a 14-day diary and to determine whether the BHQ predicts the development of medically significant constipation (MSC) during the following year. Materials and Methods: The BHQ was distributed to parents of children ages 5 to 8 years during health supervision visits. Both the BHQ and subsequent diary were scored to indicate constipation if at least 2 of the following were reported: infrequent bowel movements, stool accidents, straining, avoidance, discomfort with defecation, or passing large stools >25% of the time. One year later, the BHQ was repeated to assess for MSC, defined as medical encounters about constipation or use of enemas, suppositories, laxatives, or stool softeners. Results: MSC was reported for 57 (13.7%) of 416 children on the first BHQ. Paired BHQ and diary data were obtained for 269 children; 54 (20.1%) had diary scores indicating constipation. BHQ had a sensitivity of 59.6% (95% confidence interval [CI] 46.7%–71.4%) and a specificity of 82.6% (95% CI 77.0%–87.1%). One year later, 11 children (5.2%) had developed new-onset MSC; 7 (63.6%) of these children had initial BHQ scores of at least 2. Positive and negative predictive values for MSC were 19.4% (95% CI 9.8%–35.0%) and 97.7% (94.2%–99.1%), respectively. Conclusions: Parents often do not recognize constipation in young school-age children and most constipated children remain untreated. A brief screening questionnaire in this population proved to be valid but only moderately sensitive; efforts to improve sensitivity are needed before recommending it for routine use.

Trends in Hospital Treatment of Empyema in Children in the United States

Objective To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first‐line alternative to video‐assisted thoracoscopic surgery. Study design We used National Inpatient Samples to describe empyema‐related discharges of children ages 0‐17 years during 2008‐2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. Results Empyema‐related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008‐2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video‐assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema‐related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8‐4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. Conclusions The use of video‐assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.