Michelle D. Stevenson

Prospective Multicenter Study of Children With Bronchiolitis Requiring Mechanical Ventilation

OBJECTIVE: To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis. METHODS: We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens. RESULTS: There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7–11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1–1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0–2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2–2.1), presence of apnea (OR 4.8; 95% CI 2.5–8.5), inadequate oral intake (OR 2.5; 95% CI 1.3–4.3), severe retractions (OR 11.1; 95% CI 2.4–33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0–4.8). The optimism-corrected c-statistic for the final model was 0.80. CONCLUSIONS: In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.

Performance of Ultrasound in the Diagnosis of Appendicitis in Children in a Multicenter Cohort

OBJECTIVES The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site-related variations based on the frequency of its use. Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized. METHODS This was a secondary analysis of a prospective, 10-center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician. RESULTS Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%). CONCLUSIONS Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.

Evaluation of a Web-based Asynchronous Pediatric Emergency Medicine Learning Tool for Residents and Medical Students

OBJECTIVES To examine the effectiveness of an asynchronous learning tool consisting of web-based lectures for trainees covering major topics pertinent to pediatric emergency medicine (PEM) and to assess resident and student evaluation of this mode of education. METHODS PEM faculty and fellows created a 21-lecture, web-based curriculum. These 20-minute online lectures used Microsoft PowerPoint with the voice-over feature. A 75-question test was created to assess the effectiveness of the web-based learning model, administered online before and after the rotation in the pediatric emergency department (PED). All fourth-year medical students and residents (across all specialties) rotating through the PED were required to complete 10 of the 21 lectures during their 1-month rotation. The main outcome variable was difference in score between pre- and post-rotation tests of participants who viewed no lectures and those who viewed at least one lecture. Evaluation of the program was assessed by anonymous survey using 5-point discrete visual analog scales. Responses of 4 or 5 were considered positive for analysis. RESULTS One hundred eleven residents and fourth-year medical students participated in the program. An initial 32 completed testing before implementation of the on-line lectures (March 2007-August 2007), and another five did not complete the on-line lectures after implementation (September 2007-February 2008). Seventy-one completed testing and on-line lectures, and all but three completed at least 10 on-line lectures during their rotation. Fourteen of 111 trainees did not complete the pre- or post-test (including two who viewed the lectures). The mean change in score was a 1% improvement from pre-test to post-test for trainees who viewed no lectures and a 6.2% improvement for those who viewed the lectures (mean difference = 5.2%, 95% confidence interval = 2.5% to 7.9%). In the linear regression model, the estimate of the coefficient was 0.43 (p < 0.001), meaning that, for each lecture viewed, post-test score rose by 0.43%. Sixty-nine of 75 test items (92%) had a point biserial correlation greater than 0.15. Thirty of the 72 trainees who completed the online lectures and testing (42%) returned surveys. All were comfortable using the Internet, and 87% (26/30) found the web-site easy to use. All felt that their educational goals were met, and 100% felt that the format would be useful in other areas of education. CONCLUSIONS Although not a replacement for traditional bedside teaching, the use of web-based lectures as an asynchronous learning tool has a positive effect on medical knowledge test scores. Trainees were able to view online lectures on their own schedules, in the location of their choice. This is helpful in a field with shift work, in which trainees rarely work together, making it difficult to synchronously provide lectures to all trainees.

Surfactant protein D alters allergic lung responses in mice and human subjects

BACKGROUND Surfactant protein (SP) D has been proposed to be protective in allergic airway responses. OBJECTIVE We aimed to determine the effect of SP-D deficiency on murine and human airway allergy. METHODS Immunologic responses of SP-D gene-deficient mice (Sftpd-/-) at baseline and after 4 intranasal Aspergillus fumigatus exposures were assessed. In addition, the significance of a single nucleotide polymorphism (Met(11)Thr) in the human SP-D gene (known to decrease SP-D function) was investigated. RESULTS Macrophage and neutrophil bronchoalveolar lavage fluid levels and large airway mucus production were increased in naive Sftpd-/- mice in association with increased lung CCL17 levels and CD4+ T cell numbers. T(H)2-associated antibody levels (IgG1 and IgE) were significantly lower in 4- to 5-week-old Sftpd-/- mice (P < .05). Accordingly, naive Sftpd-/- splenocytes released significantly less IL-4 and IL-13 on anti-CD3/CD28 stimulation (P < .01). After intranasal allergen exposures, a modest decrease in bronchoalveolar lavage fluid eosinophilia and IL-13 levels was observed in Sftpd-/- mice compared with values seen in wild-type mice in association with decreased airway resistance (P < .01). A single nucleotide polymorphism in the SFTPD gene, affecting SP-D levels and pathogen binding, was associated with decreased atopy in black subjects and potentially lower asthma susceptibility in white subjects. CONCLUSION Sftpd-/- mice have an impaired systemic T(H)2 response at baseline and reduced inflammation and airway responses after allergen exposure. Translational studies revealed that a polymorphism in the SFTPD gene was associated with lower atopy and possibly asthma susceptibility. Taken together, these results support the hypothesis that SP-D-dependent innate immunity influences atopy and asthma.

Apnea in Children Hospitalized With Bronchiolitis

OBJECTIVE: To identify risk factors for inpatient apnea among children hospitalized with bronchiolitis. METHODS: We enrolled 2207 children, aged <2 years, hospitalized with bronchiolitis at 16 sites during the winters of 2007 to 2010. Nasopharyngeal aspirates (NPAs) were obtained on all subjects, and real-time polymerase chain reaction was used to test NPA samples for 16 viruses. Inpatient apnea was ascertained by daily chart review, with outcome data in 2156 children (98%). Age was corrected for birth <37 weeks. Multivariable logistic regression was performed to identify independent risk factors for inpatient apnea. RESULTS: Inpatient apnea was identified in 108 children (5%, 95% confidence interval [CI] 4%–6%). Statistically significant, independent predictors of inpatient apnea included: corrected ages of <2 weeks (odds ratio [OR] 9.67) and 2 to 8 weeks (OR 4.72), compared with age ≥6 months; birth weight <2.3 kg (5 pounds; OR 2.15), compared with ≥3.2 kg (7 pounds); caretaker report of previous apnea during this bronchiolitis episode (OR 3.63); preadmission respiratory rates of <30 (OR 4.05), 30 to 39 (OR 2.35) and >70 (OR 2.26), compared with 40 to 49; and having a preadmission room air oxygen saturation <90% (OR 1.60). Apnea risk was similar across the major viral pathogens. CONCLUSIONS: In this prospective, multicenter study of children hospitalized with bronchiolitis, inpatient apnea was associated with younger corrected age, lower birth weight, history of apnea, and preadmission clinical factors including low or high respiratory rates and low room air oxygen saturation. Several bronchiolitis pathogens were associated with apnea, with similar apnea risk across the major viral pathogens.

The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.

STUDY OBJECTIVE Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. METHODS A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologists interpretation. RESULTS A total of 1,810 children were analyzed (49% boys, mean age 10.9 years [SD 3.8 years]); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 [13%] had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). CONCLUSION The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain.

Child life intervention during angiocatheter insertion in the pediatric emergency department.

Objective: Current literature is deficient regarding the scope of procedures for which certified child life specialist (CCLS) services are effective in the pediatric emergency department. The purpose of this study is to analyze the effect of CCLS intervention during routine peripheral venous angiocatheter insertion on child procedure-related distress. Methods: Eligible children were aged 2 to 16 years. Subjects were randomly assigned to CCLS intervention or standard care. The Observation Scale of Behavior Distress-revised (OSBD-r) [J Pediatr Psychol 12 (1987) 543] was recorded during the procedure. Secondary outcomes included child and parent State Trait Anxiety Inventories [Manual for the State-Trait Anxiety Inventory (1973) and Manual for the State-Trait Anxiety Inventory for Children (1973)] and an adapted parent customer satisfaction survey [Eval Program Plann 5 (1982) 233; Eval Program Plann 6 (1983) 299; and J Paediatr Child Health 31 (1995) 435]. Explanatory and intention-to-treat analyses were performed. Results: One hundred forty-nine children completed the study. Although there was no statistical difference in mean total OSBD-r in the intention-to-treat analysis, the mean difference of 0.61 OSBD units (95% confidence interval, 0.04-1.19) in the anticipation phase in the 4- to 7-year age group was statistically significant. When the patients with only 1 insertion attempt were analyzed (n = 121), the total OSBD-r, anticipation, and preparation phase differences were statistically significant in the intention-to-treat analysis. In the explanatory analysis (n = 138), a mean significant difference in total OSBD-r score of 1.80 (95% confidence interval, 0.19-3.42) was found. There were no significant differences in child or parent anxiety or customer satisfaction between groups. Conclusions: CCLS intervention may reduce the behavioral stress associated with angiocatheter insertion, especially in children aged 4 to 7 years. These data further support the role of the CCLS as a patient and family advocate during routine procedures.

Interrater Reliability of Clinical Findings in Children With Possible Appendicitis

OBJECTIVE: Our objective was to determine the interrater reliability of clinical history and physical examination findings in children undergoing evaluation for possible appendicitis in a large, multicenter cohort. METHODS: We conducted a prospective, multicenter, cross-sectional study of children aged 3–18 years with possible appendicitis. Two clinicians independently evaluated patients and completed structured case report forms within 60 minutes of each other and without knowing the results of diagnostic imaging. We calculated raw agreement and assessed reliability by using the unweighted Cohen κ statistic with 2-sided 95% confidence intervals. RESULTS: A total of 811 patients had 2 assessments completed, and 599 (74%) had 2 assessments completed within 60 minutes. Seventy-five percent of paired assessments were completed by pediatric emergency physicians. Raw agreement ranged from 64.9% to 92.3% for history variables and 4 of 6 variables had moderate interrater reliability (κ > .4). The highest κ values were noted for duration of pain (κ = .56 [95% confidence intervals .51–.61]) and history of emesis (.84 [.80–.89]). For physical examination variables, raw agreement ranged from 60.9% to 98.7%, with 4 of 8 variables exhibiting moderate reliability. Among physical examination variables, the highest κ values were noted for abdominal pain with walking, jumping, or coughing (.54 [.45–.63]) and presence of any abdominal tenderness on examination (.49 [.19–.80]). CONCLUSIONS: Interrater reliability of patient history and physical examination variables was generally fair to moderate. Those variables with higher interrater reliability are more appropriate for inclusion in clinical prediction rules in children with possible appendicitis.

Pediatric urolithiasis: clinical predictors in the emergency department.

OBJECTIVE: The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. METHODS: A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Childrens Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. RESULTS: A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. CONCLUSIONS: UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

The Fecal Microbiota Profile and Bronchiolitis in Infants.

BACKGROUND: Little is known about the association of gut microbiota, a potentially modifiable factor, with bronchiolitis in infants. We aimed to determine the association of fecal microbiota with bronchiolitis in infants. METHODS: We conducted a case–control study. As a part of multicenter prospective study, we collected stool samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 115 age-matched healthy controls. By applying 16S rRNA gene sequencing and an unbiased clustering approach to these 155 fecal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis. RESULTS: Overall, the median age was 3 months, 55% were male, and 54% were non-Hispanic white. Unbiased clustering of fecal microbiota identified 4 distinct profiles: Escherichia-dominant profile (30%), Bifidobacterium-dominant profile (21%), Enterobacter/Veillonella-dominant profile (22%), and Bacteroides-dominant profile (28%). The proportion of bronchiolitis was lowest in infants with the Enterobacter/Veillonella-dominant profile (15%) and highest in the Bacteroides-dominant profile (44%), corresponding to an odds ratio of 4.59 (95% confidence interval, 1.58–15.5; P = .008). In the multivariable model, the significant association between the Bacteroides-dominant profile and a greater likelihood of bronchiolitis persisted (odds ratio for comparison with the Enterobacter/Veillonella-dominant profile, 4.24; 95% confidence interval, 1.56–12.0; P = .005). In contrast, the likelihood of bronchiolitis in infants with the Escherichia-dominant or Bifidobacterium-dominant profile was not significantly different compared with those with the Enterobacter/Veillonella-dominant profile. CONCLUSIONS: In this case–control study, we identified 4 distinct fecal microbiota profiles in infants. The Bacteroides-dominant profile was associated with a higher likelihood of bronchiolitis.