Measuring the impact of steroid therapy on health-related quality of life in patients with rheumatic diseases: international development of a glucocorticoid treatment-specific patient-reported outcome measure.

OBJECTIVES: Glucocorticoids (GCs) ('steroids') are used to treat rheumatic diseases but adverse effects are common. We aimed to explore the impact of GC therapy on health-related quality of life (HRQoL), to inform the development of a treatment-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. METHODS: Semi-structured qualitative interviews were conducted with patients from the UK, USA and Australia, treated for a rheumatic condition with GCs in the last 2 years. Purposive sampling was used to select participants with a range of demographic and disease features. An initial conceptual framework informed interview prompts and cues. Interviews elicited GC-related physical and psychological symptoms and salient aspects of HRQoL in relation to GC therapy. Interview data were analysed inductively to develop initial individual themes and domains. Candidate questionnaire items were developed and refined. RESULTS: Sixty semi-structured qualitative interviews were conducted (UK n = 34, USA n = 10, Australia n = 16). The mean age was 58 years; 39/60 were female; and 18 rheumatic diseases were represented. Some 126 individual themes were identified and organized into six domains: physical symptoms; psychological symptoms; psychological impact of steroids; impact of steroids on participation; impact of steroids on relationships; and benefits of steroids. Candidate questionnaire items were tested and refined by piloting with patient research partners, iterative rounds of cognitive interviews and linguistic translatability assessment, informing a draft questionnaire. CONCLUSION: We describe an international qualitative study to develop candidate items for a treatment-specific PROM for patients with rheumatic diseases. A future survey will enable the validation of a final version of the PROM.

Study of dog control strategies.

OBJECTIVES: (1) To explore the relationship between regionally implemented dog control strategies and dog bite injuries (DBIs) and (2) to evaluate current implementation of dog control strategies. METHODS: Observational study using a nationwide online survey of territorial authorities (TAs). Domains of interest included complaints for attacks on people, dog population, primary and secondary prevention strategies, resourcing and perspectives of current strategies. Quantitative variables were compared with DBI Accident Compensation Corporation (ACC) claims by region from 2014 to 2018. RESULTS: Two-thirds of TAs (70%; n=47/67) responded to the survey. No clear relationship was observed between DBIs and: registered dog population, proportion sterilisations or microchipping, classifications due to dog behaviour, or existing limited resourcing. Legislated breeds and infringements for failure to control a dog or non-registration were higher in areas with greater DBIs. Educational messages varied widely and were predominantly victim directed (67%; n=71/106). Complaints for dog attacks on people were lower than DBIs in most areas, with no formal cross-agency notification policies. Few prosecutions or dog destruction orders were made. CONCLUSIONS: Regional inequity in DBIs could not be explained by differences in the registered dog population or dog control strategies. Minimal and inequitable resourcing exists to implement current dog control strategies and provide owner-directed education. Gaps in legislation include environmental barrier requirements for all dogs (leash/muzzle use, adequate fencing), notification of incidents and child protection. Partnership with the Indigenous community (Maori) and other community groups will be required to implement these measures successfully.

The effect of big-city news on rural America during the COVID-19 pandemic.

Can "urban-centric" local television news coverage of the COVID-19 pandemic affect the behavior of rural residents with lived experiences so different from their "local" news coverage? Leveraging quasi-random geographic variation in media markets for 771 matched rural counties, we show that rural residents are more likely to practice social distancing if they live in a media market that is more impacted by COVID-19. Individual-level survey responses from residents of these counties confirm county-level behavioral differences and help attribute the differences we identify to differences in local television news coverage-self-reported differences only exist among respondents who prefer watching local news, and there are no differences in media usage or consumption across media markets. Although important for showing the ability of local television news to affect behavior despite urban-rural differences, the media-related effects we identify are at most half the size of the differences related to partisan differences.

Systematic review of dog bite prevention strategies.

BACKGROUND: The prevention of dog bites is an increasingly important public health topic, as the incidence of serious injury continues to rise. OBJECTIVES: To evaluate the effectiveness of interventions to prevent dog bites and aggression. METHODS: Online databases were searched (PubMed, Cochrane Library, Embase and Google Scholar), using the search terms: dog/s, canine, canis, kuri, bite/s, bitten, aggression, attack, death, fatal, mortality, injury/ies, prevention, intervention, for studies between 1960 and 2021. All study designs were considered. Outcomes of interest were the incidence of dog bites or dog aggression. Non-English studies, and those without full-text access were excluded. RESULTS: Forty-three studies met the review criteria, including 15 observational and 27 interventional studies. Fifteen studies investigating dog-control legislation, including leash laws, stray dog control and infringements indicated this can reduce dog bite rates. Breed-specific legislation had less of an effect. Six studies investigating sterilisation, showed while this may reduce dog bites through a reduction in the dog population, the effect on dog aggression was unclear. An alcohol reduction programme showed a significant reduction in dog bite rates in one study. Seven studies assessing educational approaches found that intensive adult-directed education may be effective, with one study showing child-directed education was not effective. Eight studies on dog training (two police-dog related), and six evaluating dog medication or diet were generally low quality and inconclusive. CONCLUSIONS: Multiple strategies including effective engagement with indigenous communities and organisations will be required to reduce dog-bites and other incidents involving dog aggression. This review provides some evidence that legislated dog control strategies reduce dog bite rates. Available evidence suggests greater restrictions should be made for all dogs, rather than based on breed alone. Due to a burden of child injury, protection of children should be a focus of legislation and further investigations. Prevention strategies in children require redirection away from a focus on child-directed education and future research should investigate the effectiveness of engineering barriers and reporting strategies.

Tracheal Intubation Practice and Safety Across International PICUs: A Report From National Emergency Airway Registry for Children.

OBJECTIVES: It is unknown if variation in tracheal intubation practice and outcomes exist across PICUs in different geographical regions. We hypothesized there would be differences in the process of care and adverse outcomes for tracheal intubation across PICUs in six different geographical regions (New Zealand, Japan, Singapore, Germany, India, and North America). DESIGN: Prospective multicenter pediatric tracheal intubation database (National Emergency Airway Registry for Children) SETTING:: Six non-North American (International) and 36 North American PICUs. EVENTS: All PICU tracheal intubation encounters from July 2014 to June 2017 MEASUREMENTS AND MAIN RESULTS:: Adverse tracheal intubation-associated events and desaturation occurrence (oxygen saturation < 80%) were evaluated. A total of 1,134 and 9,376 TIs from International and North American PICUs were reported, respectively: primary tracheal intubation 9,060, endotracheal tube change 1,450. The proportion of tracheal intubations for endotracheal tube change was greater in International PICUs (37% vs 11%; p < 0.001). Median age for International tracheal intubations was younger compared with North America (0 yr [interquartile range, 0-2 yr] vs 1 yr (0-7 yr); p < 0.001). Among primary tracheal intubations, the most common indication was respiratory (International 67%, North American 63%; p = 0.049). Direct laryngoscopy was the most common device in both International (86%) and North American (74%) tracheal intubations. Occurrence of any adverse tracheal intubation-associated event was New Zealand 8%, Japan 17%, Singapore 9%, Germany 17%, and India 6%; International 11% versus North American 14%; p value equals to 0.003. Desaturation was reported less commonly in International PICUs: 13% versus North American 17%; p equals to 0.001. International PICUs used cuffed endotracheal tube less often (52% vs 95%; p < 0.001). Proportion of cuffed endotracheal tube use per PICU was inversely correlated with the rate of tube change (r = -0.67; p < 0.001). CONCLUSIONS: There were both similarities and differences in tracheal intubation practice and outcomes across international PICUs. Fewer adverse tracheal intubation-associated events were reported from International versus North American PICUs. International PICUs used cuffed endotracheal tube less often and had higher proportion of endotracheal tube change.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry.

OBJECTIVE: Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events. DESIGN: A multicenter retrospective cohort study. SETTING: Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative. PATIENTS: Primary tracheal intubation in children younger than 18 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics. CONCLUSIONS: Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs.

OBJECTIVES: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events. DESIGN: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014. SETTING: International PICUs. PATIENTS: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. INTERVENTIONS: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. MEASUREMENTS AND MAIN RESULTS: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001). CONCLUSIONS: In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

An International Interprofessional Study of Mental Models and Factors Delaying Neuroimaging of Critically Head-Injured Children Presenting to Emergency Departments.

OBJECTIVES: Thousands of head-injured children are cared for by interprofessional teams in emergency departments every day. Teams must balance performing time-consuming interventions with safe transport for neuroimaging. This study aims to describe and compare providers' perspectives on the transfer of head-injured children to neuroimaging and factors contributing to delays. METHODS: Participants were interprofessional health care providers involved in the care of head-injured children at sites in the United Kingdom, the United States, and New Zealand. They first viewed a 3-minute video of a child with a severe head injury presenting to their resuscitation bay. Next, they were presented with 5 physiologically different simulated scenarios and asked to report whether interventions were required before transporting each patient to neuroimaging. Then, they reported team and system factors contributing to delays in neuroimaging. RESULTS: Two hundred forty of 296 providers completed the intervention. The percentage of providers reporting that they would directly transport to neuroimaging without intervention was 89% for "stable," 49% for "Cushing's triad," 26% for "hypoxic," 25% for "tachycardic," and 5% for "extremis." There were differences noted in responses by profession for the hypoxia and tachycardia cases. No differences were noted between trainees and attending physicians for any cases. The most frequent factors reported as delaying neuroimaging were team decision making and waiting for equipment, medications, and scanner availability. CONCLUSIONS: There is variability in providers' perspectives on the interventions required before transporting severely head-injured patients for imaging. Diverse team and system factors contribute to delays in imaging.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand.

AIM: Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI. METHODS: We retrospectively reviewed a random sample of charts of children <15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009. RESULTS: Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006). CONCLUSION: Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.

Severe Acute Subdural Hematoma in a Child following a Minor Head Trauma in the Context of a Recent Antecedent Head Injury: A Case Report.

Knowledge of the force required to generate a subdural hematoma is important when considering the veracity of histories given by family members of young children. Traditional wisdom is that a substantial impact is required to cause an acute subdural hematoma. We present a case of acute subdural hematoma following a low-level fall in a 3-year-old patient. An antecedent head injury associated with normal CT scan might have had some bearing on this outcome.

Route less travelled? Ambulance use for children with high-acuity acute illness.

AIM: Ambulance transportation offers important supportive care and treatment en route to definitive treatment. However, children may be at risk of under-utilising ambulance transportation, where private vehicle is possible. This study aims to determine how many of the sickest children present to hospitals in Auckland via ambulance and whether certain population groups are lower users of ambulance services. METHODS: Transportation, demographic and outcome data were collected and analysed for children presenting to Starship Children's Health (Starship) from 1 January to 31 December 2011), who were 'self referrals' to hospital, less than 15 years of age, and assigned triage category 1 and 2 on presentation. RESULTS: There were 1047 presentations to Starship identified that met inclusion criteria. Of these, 256 of the 341 triage one presentations (75.1%) and 217 of the 706 triage two presentations (30.7%) were transported by ambulance.Ambulance use was higher among older children (P < 0.001). Severity of illness or injury, as estimated by admission rates (56.7% vs. 43.3%, P = 0.21) and length of hospital stay (median = 1 day, P = 0.92), did not differ significantly by mode of transportation. There was no observed relationship with gender, ethnicity or area deprivation index score. CONCLUSION: A significant proportion of acutely unwell children presenting to hospital were not transported by ambulance, particularly those aged less than 1 year. This has the potential to result in worse health outcomes. There were no identified associations with patient demographics, and further research is required to better understand this problem and develop solutions.

Outbreak of variant hand-foot-and-mouth disease caused by coxsackievirus A6 in Auckland, New Zealand.

Hand-foot-and-mouth disease is a common, usually mild childhood illness caused by enteroviruses. Over the last five years, coxsackievirus A6 has been identified as a causative agent in outbreaks in Europe, South-East Asia and America. It has an atypical presentation compared with other enteroviruses, with more widespread rash, larger blisters and subsequent skin peeling and/or nail shedding. We give the first description of an outbreak of coxsackievirus A6 in New Zealand and how health-care communication networks enabled detection of and dissemination of information about this emergent strain.

Health impact assessment in the UK planning system: the possibilities and limits of community engagement.

This paper explores the use of health impact assessment (HIA) as a means of facilitating community engagement in spatial planning. The paper discusses the background to the development of HIA as a tool for assessing the likely impact of policies and wider changes on health with a view to building those into planning and decision-making, and describes the evolution of HIA into more participatory forms. It then goes on to describe a case-study of plans for a waste incinerator in an inner-city area in the UK, where HIA was used in response to community concerns about the development as a means of building in the views of local people to the decision-making around the plan. We describe in detail how the HIA was conducted and additional research undertaken within a timescale set by the planning processes. We discuss the difficulties involved in conducting any kind of research-based HIA so rapidly and in a situation of multiple, competing stakeholder interests. We argue that although the HIA failed to influence the final decisions in this particular instance it does, nonetheless, provide a model for how to create 'knowledge spaces' in which different perspectives and information can be brought around the table to create more democratic approaches to planning for waste.

Mild traumatic brain injury: improving quality of care in the paediatric emergency department setting.

AIM: Traumatic brain injury (TBI) in childhood can impose a significant threat to life and longer-term disability. This study investigated the extent to which the documentation of key indicators of healthcare quality in the emergency department (ED) setting was consistent with clinical guidelines for the management of children with mild TBI (MTBI). METHODS: The clinical records of a random sample of 60 children (stratified by ethnicity and age group), who were seen and discharged from a large metropolitan paediatric hospital ED following a head injury, were systematically reviewed to examine the processes of care and follow-up. RESULTS: Based on the documentation in clinical records, processes designed to identify and manage potentially life-threatening acute complications (e.g. computed tomography scanning to identify intracranial haemorrhage) were consistent with best practice standards. However gaps existed between current and best practice for some aspects of care that could minimise risks of longer-term disability from MTBI. For example, relevant clinical criteria were well documented, but this information did not appear to be applied systematically to identify and to follow up children with definite or possible MTBI. CONCLUSION: The apparent absence of a systematic approach to the diagnosis and follow-up of MTBI in children presenting to ED suggests a missed opportunity to minimise the risk of disability following these injuries. Greater attention to an integrated care pathway that improves the identification, documentation, and follow-up of children with MTBI presenting to ED is required.

Factors Affecting Implementation of Simulation-Based Education After Faculty Training in a Low-Resource Setting.

INTRODUCTION: Simulation instructor training is a recognized key component of health care simulation implementation, including in low-resource settings. PediSTARS India (Pediatric Simulation Training and Research Society) has developed and delivered several instructor training courses and more recently a 3-level faculty development program. However, there is variability in adoption of simulation at workplaces. The goal of this study was to identify factors that influence translation of instructor training into workplace simulation. METHODS: At the conclusion of their faculty development program, participants of the 2018 PediSTARS simulation instructor workshop were invited to participate in a qualitative study with an online questionnaire followed by a semistructured interview. The 3 key questions explored the "enablers," "barriers," and "changes needed" at workplaces for simulation-based training. The responses were analyzed and classified into broad themes. RESULTS: Of the 76 participants of the workshop, 11 were interviewed. The enablers were classified under 3 themes; "management support," "trained team" and "smart sourcing." Barriers were "lack of infrastructure," "lack of time," and "lack of simulation culture." The proposed changes were to "raise awareness," "strengthen systems," and "curricular integration." CONCLUSIONS: This study demonstrates the importance of institutional leadership support for simulation-based training and also that new instructors should focus on training teams in the workplace and mapping simulation activities to existing curricula. These results have wide applicability to a variety of health care settings and instructor training programs. Collaboration between organizations for further research about the impact of simulation-based training on patient safety and outcomes is also required.

Evolution of a Simulation Faculty Development Program in a Low-Resource Setting.

SUMMARY STATEMENT: The PediSTARS Faculty Development Program is a novel approach for simulation faculty training with an aim to increase the pool of trained simulation faculty in India and neighboring countries that could then facilitate simulation-based training, both at their own workplaces and in the PediSTARS simulation-based workshops that provide training in pediatric and neonatal emergencies. This commentary describes the evolution of the faculty development program, the initial process, the feedback obtained, the changes undertaken, the progress made to date, and the challenges ahead. There is also an emphasis on the key generalizable principles that can be applicable to other low-resource settings.

Breaking barriers in establishing simulation in India-A collaborative approach by pediatric simulation training and research society (PediSTARS).

Simulation based training (SBT) plays a pivotal role in quality improvement and patient safety. Simulation is not only for training health care professionals but also an excellent tool for systems and facility changes which will potentially improve patient safety and ultimately outcomes. SBT is already established both as a training modality, and as a quality improvement tool in high income countries. It's use in low and middle-income countries (LMIC), including India, however, is sporadic and variable because of multiple barriers. The barriers for establishment of simulation are lack of knowledge about benefits of simulation, psychological resistance, cost, and lack of trained faculty. PediSTARS (Pediatric Simulation Training and Research Society), a simulation society was founded in August 2013 to spread the simulation across India and thus improve the quality and safety of health care using SBT. In this article we discuss various barriers for healthcare simulation in India and also our attempts to overcome some of these barriers by collaborative practice.

Evaluation of a simulation faculty training workshop in a low-resource setting: a qualitative study.

Introduction: Simulation instructor training courses are infrequent in low-resource countries. PediSTARS India organisation has been conducting a Training of Trainers (TOT) workshop annually since 2014 and has trained 380 instructors in the last 6 years. The objective of this study is to evaluate this workshop using the basic Kirkpatrick model with a blended evaluation approach. Methods: A qualitative study design was used with purposive sampling from the 2018 workshop cohort. An initial online questionnaire gathered demographic and professional profile of participants. Semistructured interviews with those who consented explored their perceptions about the workshop and their experiences using simulation for training at their workplaces. The analysis was done based on a deductive research approach around the framework of the first three levels of the Kirkpatrick model. Results: A total of 11 in-depth interviews were conducted. Participants reported long-term retention, translation and positive impact of the knowledge and skills gained at the TOT workshop. The results achieved saturation and underwent respondent validation. Conclusion: This study provides evidence to support simulation faculty training workshops as an effective educational intervention in promoting simulation-related workplace-based education and training among health practitioners and that follow-up activity may be useful in some cases. This is the first study of its kind in a low-resource setting, and supports similar simulation instructor training in these settings and provides a blueprint for such training. Follow-up studies are required to evaluate the longer term impact of this simulation instructor training.

The societal cost of unintentional childhood injuries in Aotearoa.

AIMS: To estimate the burden and inequity of unintentional childhood injury for children in Aotearoa. METHODS: We used administrative data from the Accident Compensation Corporation (ACC) and the Ministry of Health to estimate the direct, indirect and intangible costs of unintentional injuries in children aged under 15 and the inequity of the impact of childhood injury on discretionary household income. We used an incidence approach and attributed all costs arising from injuries to the year in which those injuries were sustained. RESULTS: 257,000 children experienced unintentional injury in 2014, resulting in direct and indirect costs of almost $400 million. The burden of lost health and premature death was the equivalent of almost 200 full lives at perfect health. Pacific children had the highest incidence rates. Maori had the lowest rates of ACC claims but the highest rate of emergency department attendance. Children living with the highest levels of socioeconomic deprivation had the highest rate of hospital admission following injury. The proportional loss in discretionary income arising from an injury was higher for Maori and Pacific compared to non-Maori, non-Pacific households. CONCLUSION: The burden of unintentional childhood injury is greater than previously reported and has a substantial and iniquitous societal impact. There should be a focus on addressing inequities in incidence and access to care in order to reduce inequities in health and financial impact.

Impact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trial.

OBJECTIVE: To determine if administration of oral prednisolone to preschool children with acute wheeze alters respiratory outcomes. DESIGN: Double-blind, randomised, placebo-controlled equivalence trial. SETTING: Three hospitals in New Zealand. PATIENTS: 477 children aged 24-59 months with acute wheeze associated with respiratory illness. INTERVENTIONS: 2 mg/kg (maximum 40 mg) oral prednisolone or similar placebo, once daily for 3 days. MAIN OUTCOME MEASURES: Primary outcome was change in Preschool Respiratory Assessment Measure (PRAM) score 24 hours after intervention. Secondary outcomes included PRAM score at 4 hours, length of emergency department and inpatient stays, admission and representation rates, time to return to normal activities and use of additional oral prednisolone or intravenous medications. Analysis was by intention-to-treat. RESULTS: There was no difference between groups for change in PRAM score at 24 hours (difference between means -0.39, 95% CI -0.84 to 0.06, p=0.09). Absolute PRAM score was lower in the prednisolone group at 4 hours (median (IQR) 1 (0-2) vs 2 (0-3), p=0.01) and 24 hours (0 (0-1) vs 0 (0-1), p=0.01), when symptoms had resolved for most children regardless of initial treatment. Admission rate, requirement for additional oral prednisolone and use of intravenous medication were lower in the prednisolone group, although there were no differences between groups for time taken to return to normal activities or rates of representation within 7 days. CONCLUSION: Oral prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool children presenting with acute wheeze.