Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations.

OBJECTIVE: To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED). STUDY DESIGN: Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge. RESULTS: 564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes. CONCLUSIONS: Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Emergency management and asthma risk in young Medicaid-enrolled children with recurrent wheeze.

OBJECTIVES: To describe clinical characteristics of young children presenting to the emergency department (ED) for early recurrent wheeze, and determine factors associated with subsequent persistent wheeze and risk for early childhood asthma. METHODS: Retrospective cohort study of Medicaid-enrolled children 0-3 years old with an index ED visit for wheeze (e.g. bronchiolitis, reactive airway disease) from 2009 to 2013, and at least one prior documented episode of wheeze at an ED or primary care visit. The primary outcome was persistent wheeze between 4 and 6 years of age. Demographics and clinical characteristics were collected from the index ED visit. Logistic regression was used to estimate the association between potential risk factors and subsequent persistent wheeze. RESULTS: During the study period, 41,710 children presented to the ED for recurrent wheeze. Mean age was 1.3 years; 59% were male, 42% Black, and 6% Hispanic. At index ED visits, the most common diagnosis was acute bronchiolitis (40%); 77% of children received an oral corticosteroid prescription. Between 4 and 6 years of age, 11,708 (28%) children had persistent wheeze. A greater number of wheezing episodes was associated with an increased odds of ED treatment with asthma medications. Subsequent persistent wheeze was associated with male sex, Black race, atopy, prescription for bronchodilators or corticosteroids, and greater number of visits for wheeze. CONCLUSIONS: Young children with persistent wheeze are at risk for childhood asthma. Thus, identification of risk factors associated with persistent wheeze in young children with recurrent wheeze might aid in early detection of asthma and initiation of preventative therapies.

Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting.

OBJECTIVE: To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting. METHODS: Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome. RESULTS: There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8). CONCLUSIONS: There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.

Anaphylaxis in Children.

ABSTRACT: Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.

Late-Onset Vitamin K Deficiency Presenting as Scrotal Bruising and Mediastinal Mass.

Although there are several reports of intracranial hemorrhage associated with vitamin K deficient bleeding, there are few reported cases of extracranial manifestations, specifically involving the thymus. Here, we discuss the unique case of a 4-week-old infant presenting with scrotal discoloration, respiratory distress, and widened mediastinum, found to have thymic hemorrhage related to confirmed coagulopathy secondary to late-onset vitamin K deficiency bleeding of the newborn.

A Qualitative Study of Pediatric Residents' Experiences at Morning Report.

Objectives: Morning Report is a prevalent classroom learning activity in residency programs. Yet, its contribution to resident education remains unclear. Our objective was to explore pediatric residents' perceptions of the purpose of Morning Report as well as their experiences at Morning Report both as learners and resident presenters. Methods: We performed a qualitative study with a grounded theory approach using semi-structured focus groups of pediatric residents (November 2016-July 2017) from a large academic health center. We analyzed data with the constant comparative method, generating codes using an iterative approach and collecting data until reaching saturation. We identified major themes and resolved disagreements by consensus. Results: Twenty-six residents participated in five focus groups. Data analysis yielded four themes: Morning Report is Multipurpose, Socialization and Engagement Influence the Learning Environment, Potential for Emotional Discomfort, and Barriers to Prioritizing Morning Report Attendance. Residents felt the primary purpose of Morning Report was acquiring medical knowledge, but also acknowledged Morning Report's added benefits of providing an opportunity for socialization and a mental reprieve before work rounds. Residents felt Morning Report was educational when engaged in interactive discussion; however, it was challenging to meet the differing needs in this mixed learner level format. Some resident learners were hesitant to participate due to fears of being judged, and some resident presenters perceived a need to be topic experts. Clinical responsibilities and exhaustion following busy service rotations often precluded Morning Report attendance. Conclusion: Pediatric residents described numerous purposes of Morning Report, including opportunities for valuable learning. Self-perceived learning was positively influenced by engagement and a sense of connection and challenged by emotional discomfort at times. Future work can explore how to best promote engagement and foster a safe learning environment.

Bacteremia in Pediatric Liver Transplant Recipients.

BACKGROUND: We aimed to determine the frequency of bacteremia, septic shock and bacterial meningitis in pediatric liver transplant recipients (pLTRs) in the outpatient setting and to identify clinical factors associated with bacteremia. METHODS: Multicenter retrospective study of pLTRs evaluated in the emergency department or outpatient clinic between 2010 and 2018 for suspected infection, defined as fever ≥38 °C or a blood culture obtained. We excluded patients with nontransplant immunodeficiency, multiorgan transplants or intestinal failure. The primary outcome was bacteremia; secondary outcomes included fluid-refractory septic shock, bacterial meningitis and antibiotic resistance. The unit of analysis was the encounter. RESULTS: A total of 151 children had 336 encounters for infection evaluation within 2 years of transplant. Of 307 (91.4%) encounters with blood cultures, 17 (5.5%) had bacteremia, with 10 (58.8%) occurring within 3 months of transplant. Fluid-refractory septic shock and bacterial meningitis occurred in 7 of 307 (2.8%) and 0 of 307 encounters, respectively. Factors associated with bacteremia included closer proximity to transplant (<3 months) [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3-9.8; P = 0 .01], shorter duration of illness (OR: 4.3; 95% CI: 1.5-12.0; P < 0.01) and the presence of a central venous catheter (CVC) (OR: 12.7; 95% CI: 4.4-36.6; P < 0.01). However, 5 (29.4%) encounters with bacteremia had none of these factors. Among Gram-positive pathogens, 1 of 7 (14.2%) isolates were resistant to vancomycin. Among Gram-negative pathogens, 3 of 13 (23.1%) isolates were resistant to 3rd generation cephalosporins. CONCLUSIONS: Bacteremia was an important cause of infection within 2 years of pLTR. Clinical factors increased the risk of bacteremia. Further, large sample studies should derive multivariable models to identify those at high and low risk of bacteremia to optimize antibiotic use.

A Wireless Wearable Patch for Remote Monitoring of Respiratory and Cardiac Rhythm in Children.

Remote patient monitoring (RPM) is an innovative strategy to promote health and improve patient management and care. Recent advances in healthcare technologies have seen the emergence of wearable sensors allowing longitudinal physiological measurements in any environment. This paper introduces a wireless wearable patch 'Leo' for continuous remote monitoring of physiological data at home and healthcare settings. This includes single lead ECG, chest impedance, heart rate (HR), respiration rate (RR) and body posture. To test Leo's ability to capture longitudinal physiological data at home, 15 children experiencing acute severe asthma exacerbations were recruited during their emergency department (ED) visits. Participants wore the Leo device for 7 (+/-2) days post-hospital discharge. Nocturnal RR and HR and variability were higher during the first half of the night on Day1 compared to Day7 (p<0.005). Participants also completed a usability questionnaire and reported the patch wear to be comfortable (average score of 3.3 out of 5) and easy to wear during the night (average score of 3.5 out of 5) with 5/15 (33%) reported very slight barely perceptible skin irritation/redness and 2 (13%) reported well defined skin irritation and redness.Clinical Relevance- These results highlight the potential use of the Leo device in clinical practice for continuous un-obstructive monitoring of diseased populations, such as asthma.

Frequency of Bacteremia and Urinary Tract Infection in Pediatric Renal Transplant Recipients.

BACKGROUND: Our primary goal was to determine the frequency of bacteremia and urinary tract infections (UTI) in pediatric renal transplant recipients presenting with suspected infection within 2 years of transplant and to identify clinical and laboratory factors associated with bacteremia. METHODS: We conducted a retrospective cross-sectional study for all pediatric ( < 18 years old) renal transplant recipients seen at 3 large children's hospitals from 2011 to 2018 for suspected infection within 2 years of transplant date, defined as pyrexia ( > 38°C) or a blood culture being ordered. Patients with primary immunodeficiencies, nontransplant immunosuppression, intestinal failure, and patients who had moved out of the local area were excluded. The primary outcome was bacteremia or UTI; secondary outcomes included pneumonia, bacterial or fungal meningitis, respiratory viral infections, and antibiotic resistance. The unit of analysis was the visit. RESULTS: One hundred fifteen children had 267 visits for infection evaluation within 2 years of transplant. Bacteremia (with or without UTI) was diagnosed in 9/213 (4.2%) and UTIs in 63/189 (33.3%). Tachycardia and hypotension were present in 66.7% and 0% of visits with documented bacteremia, respectively. White blood cell (12,700 cells/mm 3 vs. 10,900 cells/mm 3 ; P = 0.43) and absolute neutrophil count (10,700 vs. 8200 cells/mm 3 ; P = 0.24) were no different in bacteremic and nonbacteremic patients. The absolute band count was higher in children with bacteremia (1900 vs. 600 cells/mm 3 ; P = 0.02). Among Gram-negative pathogens, antibiotic resistance was seen to 3rd (14.5%) and 4th (3.6%) generation cephalosporins, 12.7% to semisynthetic penicillins, and 3.6% to carbapenems. CONCLUSIONS: Bacteremia or UTIs were diagnosed in one-quarter of all pediatric renal transplant recipients presenting with suspected infection within 2 years of transplant. Evaluations were highly variable, with one-third of visits not having urine cultures obtained. No single demographic, clinical or laboratory variable accurately identified patients with bacteremia, although combinations of findings may identify a high-risk population.

Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians' Perspectives of Clinical Pathways.

INTRODUCTION: Healthcare costs are rising, and clinical pathways (CPW) are one means to promote high-value care by standardizing care and improving outcomes without compromising cost or quality. However, providers do not always follow CPW, and our understanding of their perceptions is limited. Our objective was to examine pediatric hospital medicine (PHM) and pediatric emergency medicine (PEM) physician perspectives of CPW. METHODS: We conducted semistructured, in-depth, one-on-one qualitative interviews with PHM and PEM physicians between February 2017 and August 2017. Interviews were audio-recorded, professionally transcribed, and accuracy verified. Using an inductive analytic strategy, we systematically coded the data to identify themes. RESULTS: We interviewed 15 PHM and 15 PEM physicians. These providers identified many benefits and limitations of CPW, which positively or negatively impact resource utilization, communication, education of personnel, patients, and families, as well as practice behaviors and attitudes. Perceived benefits included (1) reduction of unnecessary utilization, (2) standardization of care, (3) improved communication, (4) education of oneself and others, and (5) confidence and validation when actions align with CPW. Limitations of CPW were (1) resource utilization for revisions, updates, and dissemination; (2) "tunnel vision" and cognitive biases; (3) loss of autonomy; (4) prescriptive medicine; (5) information overload; (6) pressure to adhere; and (7) guilt if actions do not align with CPW. CONCLUSIONS: CPW are tools with advantages and disadvantages that are used and viewed differently by providers. Such insight into how physicians perceive CPW may help to optimize hospital improvement work and enhance high-value care.