Stephen J. Rothenberg

A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis.

Objective: To develop and validate a logistic regression model to predict need for admission and length of hospital stay in children presenting to the Emergency Department with bronchiolitis. Setting: Two childrens hospitals in Dublin, Ireland. Methods: We reviewed 118 episodes of bronchiolitis in 99 children admitted from the Emergency Department. Those discharged within 24 h by a consultant/attending paediatrician were retrospectively categorized as suitable for discharge. We then validated the model using a cohort of 182 affected infants from another paediatric Emergency Department in a bronchiolitis season 2 years later. In the validation phase actual admission, failed discharge, and age less than 2 months defined the need for admission. Results: The model predicted admission with 91% sensitivity and 83% specificity in the validation cohort. Age [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.76–0.97], dehydration (OR 2.54, 95% CI 1.34–4.82), increased work of breathing (OR 3.39, 95% CI 1.29–8.92) and initial heart rate above the 97th centile (OR 3.78, 95% CI 1.05–13.57) predicted the need for admission and a longer hospital stay. Conclusion: We derived and validated a severity of illness model for bronchiolitis. This can be used for outcome prediction in decision support tools or severity of illness stratification in research/audit.

An artificial neural network ensemble to predict disposition and length of stay in children presenting with bronchiolitis.

Background: Artificial neural networks apply complex non-linear functions to pattern recognition problems. An ensemble is a ‘committee’ of neural networks that usually outperforms single neural networks. Bronchiolitis is a common manifestation of viral lower respiratory tract infection in infants and toddlers. Objective: To train artificial neural network ensembles to predict the disposition and length of stay in children presenting to the Emergency Department with bronchiolitis. Methods: A specifically constructed database of 119 episodes of bronchiolitis was used to train, validate, and test a neural network ensemble. We used EasyNN 7.0 on a 200 Mhz pentium PC with a maths co-processor. The ensemble of neural networks constructed was subjected to fivefold validation. Comparison with actual and predicted dispositions was measured using the kappa statistic for disposition and the Kaplan–Meier estimations and log rank test for predictions of length of stay. Results: The neural network ensembles correctly predicted disposition in 81% (range 75–90%) of test cases. When compared with actual disposition the neural network performed similarly to a logistic regression model and significantly better than various ‘dumb machine’ strategies with which we compared it. The prediction of length of stay was poorer, 65% (range 60–80%), but the difference between observed and predicted lengths of stay were not significantly different. Conclusion: Artificial neural network ensembles can predict disposition for infants and toddlers with bronchiolitis; however, the prediction of length of hospital stay is not as good.

Use of V4R in patients who sustain blunt chest trauma

OBJECTIVE In blunt chest trauma, the right ventricle is more vulnerable than the left. The purpose of this study was to determine whether recording V4R in patients with blunt chest trauma would provide additional useful information to that already obtained from the standard 12-lead electrocardiogram (ECG). METHODS Forty-five patients with blunt chest trauma and 40 unmatched control subjects without blunt chest trauma had standard 12-lead ECG and right precordial leads recorded. The ECGs were read blindly by three physicians. RESULTS Patients with chest trauma were distinguishable from controls on the basis of the left-sided ECGs (odds ratio, 2.9; 95% confidence interval, 1.71-4.90). This was not the case using V4R (odds ratio, 1.23; 95% confidence interval, 0.59-2.0). CONCLUSION Patients with a significant mechanism and physical findings of blunt chest trauma were more likely than controls to have an abnormal ECG. They were not more likely to have abnormalities in V4R. We recommend that a 12-lead ECG, but not V4R, be routinely obtained on these patients.

American Academy of Pediatrics 2014 Bronchiolitis Guidelines: Bonfire of the Evidence

N/A Supporting material: Figure Copyright Information: Copyright 2015 by the article author(s). This work is made available under the terms of the Creative Commons Attribution4.0 none 4.0 4.0 license, http://creativecommons.org/licenses/by/4.0 none 4.0 4.0/

Flawed meta-analysis creates doubt when answers are known

We were disappointed to see a Cochrane review recommend adrenaline and steroids in the outpatient management of bronchiolitis.1 The results of the meta-analysis reflect selection criteria excluding randomised controlled trials which do not support the author’s beliefs rather than the available data. The stated rationale for excluding studies in which infants have had previous wheezing was to minimise including infants who might later develop asthma …

Safety of ibuprofen in infants younger than six months: A retrospective cohort study

Objective We hypothesized (1) that gastrointestinal (GI) and renal adverse events (AE) would occur more often in infants first prescribed ibuprofen before rather than after six months of age and (2) that ibuprofen would be associated with more adverse effects than acetaminophen in infants younger than six months. Methods We created two partly overlapping retrospective cohorts of infants aged less than six months when California Medicaid first paid for ibuprofen or acetaminophen between 2004 and 2010. In the first cohort we compared the incidence rate ratio (RR) of GI and renal AE between those infants first prescribed ibuprofen before six months of age with those first prescribed ibuprofen after six months of age. In the second cohort we compared the RR of GI and renal AE between infants younger than six months prescribed ibuprofen (+/-acetaminophen) with those prescribed only acetaminophen. Results We identified 41,669 prescriptions for ibuprofen and 176,991 prescriptions for acetaminophen in 180,333 eligible infants (median age 2.1 months). We did not observe higher RR of any AE in infants first prescribed ibuprofen before rather than after six months of age. Most infants prescribed ibuprofen were also prescribed acetaminophen. Any GI (adjusted (a)RR 1.25, 95% CI 1.13–1.38) and moderate or severe GI AE (aRR 1.24, 95% CI 1.09–1.40) were more common in infants younger than six months who were prescribed ibuprofen versus acetaminophen alone. Severe GI (aRR 0.63, 95% CI 0.27–1.45) and renal AE (aRR 1.84 95% CI 0.66–5.19) were not different between the ibuprofen (+/-acetaminophen) and acetaminophen-only groups. Conclusions GI and renal AEs were not higher in infants younger than six months who were prescribed ibuprofen compared with those aged six to 12 months. AEs were increased in infants younger than six months who were prescribed ibuprofen compared with infants who were prescribed acetaminophen alone.

Wheezing after the use of acetaminophen and or ibuprofen for first episode of bronchiolitis or respiratory tract infection

Background Bronchiolitis sometimes triggers the development of subsequent recurrent wheezing. Treatment with either acetaminophen or ibuprofen during the initial episode may affect the occurrence of subsequent wheezing. Materials and methods We did a retrospective study comparing the effect of prescribing acetaminophen, ibuprofen, or neither for a first episode of bronchiolitis on medical attendances for subsequent wheezing in infants younger than 12 months. We created our cohorts using California Medicaid data from 2003 to 2010. We used propensity score derived inverse probability weights to adjust for non-random drug assignment. We used robust negative binomial regression to model incident rate ratios (IRR) for medical attendances at 365, 30, and 14-day follow-up. We did similar analyses for the effect of antipyretics for a first medically attended upper respiratory tract infection (URI) on subsequent wheezing. Results Compared with no antipyretic, treatment with acetaminophen or ibuprofen for a first episode of bronchiolitis was associated with decreased wheezing at 365-day follow-up (IRR 0.18, 95% CI 0.15–0.22), and ibuprofen plus acetaminophen over ibuprofen (IRR at 0.12, 95% CI 0.05–0.32). The results were similar at 30 and 14-day follow-up. Ibuprofen alone and ibuprofen plus acetaminophen were associated with decreased visits for subsequent wheezing at 365-day (IRR 0.79, 95% CI 0.68–0.92), but not earlier timepoints, when compared with acetaminophen. A smaller effect was seen for ibuprofen at one year if prescribed for a URI (IRR 0.87, 95% CI 0.76–1.00) but not at earlier follow-up. Conclusion Children who are prescribed antipyretics for a first episode of bronchiolitis may have less subsequent wheezing than those who are not. We found fewer visits for subsequent wheezing for those prescribed ibuprofen, and ibuprofen combined with acetaminophen, compared with acetaminophen alone.

Derivation of candidate clinical decision rules to identify infants at risk for central apnea

BACKGROUND AND OBJECTIVES: Central apnea complicates, and may be the presenting complaint in, bronchiolitis. Our objective was to prospectively derive candidate clinical decision rules (CDRs) to identify infants in the emergency department (ED) who are at risk for central apnea. METHODS: We conducted a prospective observational study over 8 years. The primary outcome was central apnea subsequent to the initial ED visit. Infants were enrolled if they presented with central apnea or bronchiolitis. We excluded infants with obstructive apnea, neonatal jaundice, trauma, or suspected sepsis. We developed 3 candidate CDRs by using 3 techniques: (1) Poisson regression clustered on the individual, (2) classification and regression tree analysis (CART), and (3) a random forest (RF). RESULTS: We analyzed 990 ED visits for 892 infants. Central apnea subsequently occurred in the hospital in 41 (5%) patients. Parental report of apnea, previous history of apnea, congenital heart disease, birth weight ≤2.5 kg, lower weight, and age ≤6 weeks all identified a group at high risk for subsequent central apnea. All CDRs and RFs were 100% sensitive (95% confidence interval [CI] 91%–100%) and had a negative predictive value of 100% (95% CI 99%–100%) for the subsequent apnea. Specificity ranged from 61% to 65% (95% CI 58%–68%) for CDRs based on Poisson models; 65% to 77% (95% CI 62%–90%) for CART; and 81% to 91% (95% CI 78%–92%) for RF models. CONCLUSIONS: All candidate CDRs had a negative predictive value of 100% for subsequent central apnea.