Lung ultrasound findings in asymptomatic healthy children with asthma.

BACKGROUND: Lung ultrasound (LUS) has been shown to be an effective tool to rapidly diagnose certain causes of pediatric respiratory distress. However, very little is known about LUS findings in pediatric asthma. OBJECTIVES: The primary objective of this study was to characterize LUS findings in a cohort of pediatric patients with a definitive diagnosis of asthma, outside of an asthma exacerbation. METHODS: Eligible patients, aged 6-17 years old and diagnosed with asthma, underwent LUS during an outpatient visit. LUS was conducted using a six-zone scanning protocol. Presence of a LUS artifact was defined by one or more of the following: ≥3 B-lines per intercostal space, pulmonary consolidation, and/or pleural abnormality. Images were interpreted by an expert sonographer blinded to patient clinical characteristics. RESULTS: Fifty-two patients were included. 10/52 (19.2%) patients demonstrated the presence of LUS artifacts: 8 with ≥3 B-lines, 1 with consolidation >1 cm, and 7 with subpleural consolidations <1 cm, 1 with a pleural line abnormality. Artifacts were seen in the right anterior and lateral zones in 60% of participants and were limited to 1-2 intercostal space(s) within one lung zone in all participants. No association was found between presence of LUS artifacts and asthma control or severity. CONCLUSION: To our knowledge, this is the first report of LUS findings in outpatient pediatric asthma. LUS artifacts in asthmatic children can be seen outside of acute exacerbations. Such baseline findings need to be taken into consideration when using LUS for the acute evaluation of a pediatric patient with asthma.

Paediatric post-concussive symptoms: symptom clusters and clinical phenotypes.

OBJECTIVE: To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity. METHODS: We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings. RESULTS: 3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity. CONCLUSION: Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes.

Characterizing pediatric lung ultrasound findings during a chemically induced bronchospasm.

BACKGROUND: Lung ultrasound (LUS) has been shown to be a useful clinical tool in pediatrics, but very little is known about the LUS findings of asthma in children. OBJECTIVES: The primary objective was to characterize LUS findings of pediatric patients before and after a chemically induced bronchospasm. The secondary objective was to evaluate the effect of bronchodilators on LUS findings. METHODS: Eligible children 6-17 years old presenting for a methacholine challenge test (MCT) in a pediatric respiratory clinic were recruited. Patients with viral symptoms were excluded. A six-zone LUS protocol was performed before and after the MCT, and after bronchodilator administration; video recordings were analysed by an expert blinded to the patient characteristics and MCT results. RESULTS: Forty-four patients were included in the study. Five patients had positive LUS findings at baseline. Nine patients out of 29 (31%) had new-onset positive LUS following a reactive MCT. There was a significant association between having a chemically induced bronchospasm and a positive LUS post-MCT (odds ratio [95% confidence interval]: 5.3 [1.0-27.7]; p = 0.05). Among patients who developed positive LUS findings post-MCT, four out of nine returned to having a negative LUS postbronchodilator administration. CONCLUSIONS: This is the first known report of an association between LUS findings and bronchospasm in pediatric patients. It is also the first documentation of resolution of LUS findings postbronchodilator administration. Most LUS findings observed were small and limited to a few intercostal spaces. Further research is required to quantify these findings and evaluate the effect of salbutamol on LUS.

Symptom Burden, School Function, and Physical Activity One Year Following Pediatric Concussion.

OBJECTIVES: To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion. STUDY DESIGN: Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury. RESULTS: Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009). CONCLUSIONS: Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport.

Derivation and Initial Validation of Clinical Phenotypes of Children Presenting with Concussion Acutely in the Emergency Department: Latent Class Analysis of a Multi-Center, Prospective Cohort, Observational Study.

The identification of clinical phenotypes may help parse the substantial heterogeneity that characterizes children with concussion. This study used latent class analysis (LCA) to identify discernible phenotypes among children with acute concussion and examine the association between phenotypes and persistent post-concussive symptoms (PPCS) at 4 and 12 weeks post-injury. We conducted LCA of variables representing pre-injury history, clinical presentation, and parent symptom ratings, derived from a prospective cohort, observational study that recruited participants from August 2013 until June 2015 at nine pediatric emergency departments within the Pediatric Emergency Research Canada network. This substudy included 2323 children from the original cohort ages 8.00-17.99 years who had data for at least 80% of all variables included in each LCA. Concussion was defined according to Zurich consensus statement diagnostic criteria. The primary outcome was PPCS at 4 and 12 weeks after enrollment. Participants were 39.5% female and had a mean age of 12.8 years (standard deviation = 2.6). Follow-up was completed by 1980 (85%) at 4 weeks and 1744 (75%) at 12 weeks. LCA identified four groups with discrete pre-injury histories, four groups with discrete clinical presentations, and seven groups with discrete profiles of acute symptoms. Clinical phenotypes based on the profile of group membership across the three LCAs varied significantly in their predicted probability of PPCS at 4 and 12 weeks. The results indicate that children with concussion can be grouped into distinct clinical phenotypes, based on pre-injury history, clinical presentation, and acute symptoms, with markedly different risks of PPCS. With further validation, clinical phenotypes may provide a useful heuristic for clinical assessment and management.

Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric ED.

OBJECTIVES: Primary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED. METHODS: Eligible patients 2-17years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart. RESULTS: A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p=0.03), prolonged ED length of stay (30% vs. 9%, p=0.04) and admission rate (30% vs 0%, p=0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84-1.00). CONCLUSIONS: This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice.

Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze.

OBJECTIVE: Characterise lung ultrasound (LUS) findings, diagnostic accuracy and agreement between novice and expert interpretations in young children with respiratory tract infections and wheeze. METHODS: Prospective cross-sectional study in a paediatric ED. Patients ≤2 years with a respiratory tract infection and wheeze at triage were recruited unless in severe respiratory distress. Prior to clinical management, a novice sonologist performed the LUS using a six-zone scanning protocol. The treating physician remained blinded to ultrasound findings; final diagnoses were extracted from the medical record. An expert sonologist, blinded to all clinical information, assessed the ultrasound video clips at study completion. Positive LUS was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. RESULTS: Ninety-four patients were enrolled (median age 11.1 months). LUS was positive in 42% (39/94) of patients (multiple B-lines in 80%, consolidation in 64%, pleural abnormalities in 23%). The proportion of positive LUS, along with their diagnostic accuracy (sensitivity (95% CI), specificity (95% CI)), were as follows for children with bronchiolitis, asthma, pneumonia and asthma/pneumonia: 46% (45.8% (34.0% to 58.0%), 72.7% (49.8% to 89.3%)), 0% (0% (0.0% to 23.3%), 51.3% (39.8% to 62.6%)), 100% (100% (39.8% to 100.0%), 61.1% (50.3% to 71.2%)), 50% (50% (6.8% to 93.2%), 58.9% (48.0% to 69.2%)), respectively. There was good agreement between the novice and expert sonographers for a positive LUS (kappa 0.68 (95% CI 0.54 to 0.82)). CONCLUSIONS: Among children with respiratory tract infections and wheeze, a positive LUS seems to distinguish between clinical syndromes by ruling in pneumonia and ruling out asthma. If confirmed in future studies, LUS may emerge as a point-of-care tool to guide diagnosis and disposition in young children with wheeze.

Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.

IMPORTANCE: Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist. OBJECTIVE: To derive and validate a clinical risk score for PPCS among children presenting to the emergency department. DESIGN, SETTING, AND PARTICIPANTS: Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury. EXPOSURES: All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria. MAIN OUTCOMES AND MEASURES: The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury. RESULTS: In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort. CONCLUSIONS AND RELEVANCE: A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.

Performance of the Canadian Triage and Acuity Scale for children: a multicenter database study.

STUDY OBJECTIVE: We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). METHODS: This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. RESULTS: A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. CONCLUSION: The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.

Gaze-, eye-, and head-movement dynamics during closed- and open-loop gaze pursuit.

Horizontal step-ramp stimuli were used to examine gaze-, eye-, and head-movement dynamics during head-unrestrained pursuit in two rhesus monkeys. In a first series of experiments, we characterized and compared head-restrained (HR) and -unrestrained (HU) pursuit responses to unpredictable, nonperiodic, constant velocity (20-80 degrees/s) stimuli. When the head was free to move, both monkeys used a combination of eye and head motion to initially fixate and then pursue the target. The pursuit responses (i.e., gaze responses) were highly stereotyped and nearly identical among the HR and HU conditions for a given step-ramp stimulus. In the HU condition, initial eye and initial head acceleration tended to increase as a function of target velocity but did not vary systematically with initial target eccentricity. In a second series of experiments, step-ramp stimuli (40 degrees/s) were presented, and, approximately 125 ms after pursuit onset, a constant retinal velocity error (RVE) was imposed for a duration of 300 ms. In each monkey, HR and HU gaze velocity was similarly affected by stabilizing the target with respect to the monkey's fovea (i.e., RVE = 0 degrees/s) and by moving the target with constant retinal velocity errors (i.e., RVE = +/- 10 degrees/s). In the HU condition, changes in both eye and head velocity trajectories contributed to the observed gaze velocity responses to imposed RVEs. We conclude that eye and head movements are not independently controlled during HU pursuit but rather are controlled, at least in part, by a shared upstream controller within the pursuit pathways.