Enhanced electrooxidation/electrocoagulation-ultrafiltration membrane process with S2O42- for saline algae-containing surface water treatment: Purification and membrane performance.

The surface water in coastal areas involving algae, is often affected by saline and emerging contaminants caused by saltwater intrusion, and expanding aquaculture industry. Therefore, it is necessary to conduct studies to address the issues that affect ecological safety and health of aquatic environments. This study presents the development of an enhanced electrooxidation/electrocoagulation-ultrafiltration (EO/EC-UF) membrane process using S2O42- (DTN@EO/EC-UF) for the treatment of saline water containing algae. Our results have shown that significant removal of NH3-N (95.1 %), UV254 (89.4 %) and algae (75.7 %) was achieved with the addition of S2O42- (DTN). Additionally, an optimal DTN dosage of 40 mg/L was used in the DTN@EO/EC process to enhance water purification, utilizing reactive species such as SO4·- and ·OH. After coupling with the ultrafiltration (UF) process, optimal operating conditions (DTN: 40 mg/L, current density: 4.65 mA/cm2, electrolysis: 60 s) were applied to treat the saline algae-containing surface water. The generated free chlorine, including NHCl2, accounted for approximately 22 % (0.14 mg/L). In addition, DTN significantly improved the ceramic membrane's permeability and anti-fouling characteristics, with a maximum increasing specific flux from 0.76 to 0.93, mainly attributing to the reduced the irreversible fouling resistance. Furthermore, we discovered that common membrane cleaning using acid or base enhanced the DTN@EO/EC-UF process. In conclusion, this study established an innovative DTN@EO/EC-UF process with excellent performance in terms of water purification and membrane self-cleaning. The results provided a promising alternative for treating saline algae-containing surface water.

Core-shell structured lignin-stabilized silver nanoprisms for colorimetric detection of sulfur ions.

Widespread occurrence of sulfides in domestic and industrial wastewater contributes to environmental pollution and poses risks to human health. Therefore, the development of highly selective, sensitive, and rapid sulfur ion (S2-) detection probes in aquatic ecosystems is of paramount importance. In this study, lignin-stabilized silver nanoprisms (EHL@AgNPRs) were prepared using the seed growth and self-assembly methods. Based on this, a novel, high-performance, and environmentally friendly S2- colorimetric detection method was proposed. Lignin is believed to coat the surface of AgNPRs through cation-π and electrostatic interactions, acting as an excellent dispersant and stabilizer to prevent aggregation and shape deformation. This allows AgNPRs to maintain localized surface plasmon resonance (LSPR) characteristics and superior colorimetric sensing sensitivity towards S2- even after 30 d. The EHL@AgNPRs exhibited remarkable selectivity towards S2- with a minimum detection limit of 41.3 nM. The conjugation of lignin with AgNPRs offers a highly promising approach for the rapid detection of S2- in natural aquatic environments and for the valorization of lignin.

Selenium and nitrogen co-doped carbon dots with highly efficient electrochemiluminescence for ultrasensitive detection of microRNA.

In this work, selenium and nitrogen co-doped carbon dots (SeN-CDs) possessing highly efficient electrochemiluminescence (ECL) and excellent biocompatibility were synthesized as a new emitter with S2O82- as a coreactant for constructing a biosensor to detect microRNA-221 (miRNA-221) sensitively. Notably, the SeN-CDs exhibited superior ECL performance compared with the N-doped CDs, in which selenium with excellent redox activity served as a coreaction accelerator for facilitating the electroreduction of S2O82- to significantly improve ECL efficiency. Furthermore, target-induced T7 exonuclease (T7 Exo)-assisted double cycle amplification strategy could convert traces of target miRNA-221 into large amounts of output DNA to capture three-dimensional (3D) nanostructures (DTN-Au NPs-DOX-Fc) loaded with large amounts of ECL signal quencher. The constructed biosensor could realize ultrasensitive detection of miRNA-221 and has a low detection limit reaching 2.3 aM, with a successful application to detect miRNA-221 in lysate of Hela and MHCC97-L cancer cell. This work explored a novel method to strengthen the ECL performance of CDs to construct an ECL biosensing platform with sensitive detecting of biomarkers and disease diagnosis.

Mineralization of a Fully Halogenated Organic Compound by Persulfate under Conditions Relevant to in Situ Reduction and Oxidation: Reduction of Hexachloroethane by Ethanol Addition Followed by Oxidation.

Fully halogenated compounds are difficult to remediate by in situ chemical oxidation (ISCO) because carbon-halogen bonds react very slowly with the species that typically initiate contaminant transformation: sulfate radical (SO4•-) and hydroxyl radical (•OH). To enable the remediation of this class of contaminants by persulfate (S2O82-)-based ISCO, we employed a two-phase process to dehalogenate and oxidize a representative halogenated compound (i.e., hexachloroethane). In the first phase, a relatively high concentration of ethanol (1.8 M) was added, along with concentrations of S2O82- that are typically used for ISCO (i.e., 450 mM). Hexachloroethane underwent rapid dehalogenation when carbon-centered radicals produced by the reaction of ethanol and radicals formed during S2O82- decomposition reacted with carbon-halogen bonds. Unlike conventional ISCO treatment, hexachloroethane transformation and S2O82- decomposition took place on the time scale of days without external heating or base addition. The presence of O2, Cl-, and NO3- delayed the onset of hexachloroethane transformation when low concentrations of S2O82- (10 mM) were used, but these solutes had negligible effects when S2O82- was present at concentrations typical of in situ remediation (450 mM). The second phase of the reaction was initiated after most of the ethanol had been depleted when thermolytic S2O82- decomposition resulted in production of SO4•- that oxidized the partially dehalogenated transformation products. With proper precautions, S2O82--based ISCO with ethanol could be a useful remediation technology for sites contaminated with fully halogenated compounds.

Impact of Clinical Guidelines on Hospital Utilization in Children With Croup.

OBJECTIVES: To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. METHODS: Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. RESULTS: Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. CONCLUSIONS: Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

Variation in Organizational Clinical Practice Guidelines for Croup.

BACKGROUND: Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition. OBJECTIVES: To describe variation in CPGs across US children's hospitals. METHODS: We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement. RESULTS: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores. CONCLUSIONS: Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.

Performance, comparison and utilization of reduced sulfur (-2) compounds (S2-, FeS and SCN-) in autotrophic denitrification process by thiosulfate-driven autotrophic denitrifier.

The coexistence of reduced sulfur (-2) compounds (S2-, FeS and SCN-) are found in some industrial wastewaters due to pre-treatment of Fe(II) salts. These compounds as electron donors have attracted increasing interest in autotrophic denitrification process. However, the difference of their functions still remain unknown, which limit efficient utilization in autotrophic denitrification process. The study aimed to investigate and compare utilization behavior of these reduced sulfur (-2) compounds in autotrophic denitrification process activated by thiosulfate-driven autotrophic denitrifiers (TAD). Results showed that the best denitrification performance was observed in SCN-; while the reduction of nitrate was significantly inhibited in S2- system and the efficient accumulation of nitrite was observed in FeS system with cycle experiments continuing. Additionally, intermediates containing sulfur were produced rarely in SCN- system. However, the utilization of SCN- was limited obviously in comparison with S2- in coexistence systems. Moreover, the presence of S2- increased the accumulation peak of nitrite in coexistence systems. The biological results indicated that the TAD utilized rapidly these sulfur (-2) compounds, in which genus of Thiobacillus, Magnetospirillum and Azoarcus might play main roles. Moreover, Cupriavidus might also participate in sulfur oxidation in SCN- system. In conclusion, these might be attributed to the characteristics of sulfur (-2) compounds including the toxicity, solubility and reaction process. These findings provide theoretical basis for regulation and utilization of these reduced sulfur (-2) compounds in autotrophic denitrification process.

Predictors of Inpatient Racemic Epinephrine Use in Patients Admitted With Croup.

OBJECTIVE: Many patients hospitalized for croup receive no additional racemic epinephrine (RE) postadmission. We analyzed the association between inpatient racemic epinephrine (RE) use and demographic and emergency department (ED) parameters including timing between RE doses with a goal of identifying patients who may be low risk for ED discharge. METHODS: We completed a retrospective cohort study of previously healthy patients ages 2 months to <7 years old who were admitted with a diagnosis of croup from 2016 to 2019 at a freestanding tertiary-care children's hospital. Patients were eligible for this study if they received at least 1 RE treatment before admission. RESULTS: The cohort included 238 patients; 59 (24.7%) patients received additional RE during admission. The number of RE doses in the ED (P = .99) and the median time between RE doses (P = .71) were not different between inpatient RE and no inpatient RE groups. Younger patients (P = .045) and patients with tachypnea for age (odds ratio [OR] 2.33; 95% confidence interval = 1.2-4.4) were more likely to require RE during admission. Median length of hospitalization for patients receiving inpatient RE was significantly longer (38 hours vs 16.7 hours, P < .001), whereas readmit rates were similar between groups (5.1% vs 3.9%, P = .71). CONCLUSIONS: Fewer than 25% of admitted patients received inpatient RE. Age and tachypnea for age were associated with inpatient RE use. Reassessment of admission thresholds for multidose RE use may be warranted to prevent unnecessary hospitalizations.

Variation in Emergency Department Use of Racemic Epinephrine and Associated Outcomes for Croup.

OBJECTIVES: Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. METHODS: We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. RESULTS: We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%-27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39-95%; confidence interval [CI], 1.01-1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99-1.97) or ED revisit (OR, 1.00; 95% CI, 0.92-1.09). CONCLUSIONS: In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.

Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup.

BACKGROUND: Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS: At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS: There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS: Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.

Prediction Model for Croup Admission Need.

OBJECTIVES: This study aims to generate a predictive model stratifying the probability of requiring hospitalization and inpatient respiratory intervention for croup patients presenting to the emergency department (ED), and secondarily to compare the model's performance with that of ED providers. METHODS: Retrospective data was collected on croup patients presenting to the EDs of 2 pediatric and 1 community hospital from 2019 to 2020, including demographics, preexisting conditions, and history of croup. The ED length of stay, previous dexamethasone administration, time to ED dexamethasone, number of ED racemic epinephrine doses, viral testing, and ED revisits were also recorded. Westley croup scores were derived at ED presentation and final disposition. For admitted patients, any respiratory interventions were recorded. Admission need was defined as either admitted and required an inpatient intervention or not admitted with ED revisit. A prediction model for admission need was fit using L1-penalized logistic regression. RESULTS: We included 2951 patients in the study, 68 (2.3%) of which needed admission. The model's predictors were disposition Westley croup scores, number of ED racemic epinephrine doses, previous dexamethasone administration, and history of intubation. The model's sensitivity was 66%, specificity was 91%, positive predictive value was 15%, and negative predictive value was 99%. ED providers' performance had a sensitivity of 72%, a specificity of 94%, a positive predictive value of 23%, and a negative predictive value of 99%. CONCLUSIONS: The croup admission need predictive model appears to support clinical decision making in the ED, with the potential to improve decision making when pediatric expertise is limited.

Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients.

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

Retrospective Evaluation of Return Rates in Pediatric Patients Treated With Inhaled Racemic Epinephrine for Croup.

OBJECTIVES: To determine if the length of observation (< 2 hours vs ≥ 2 hours) following treatment of croup with inhaled racemic epinephrine in the emergency department (ED) is associated with return rates (within 48 hours after treatment) in pediatric patients. METHODS: We conducted a retrospective review of patients' medical records from February 2010 through June 2018 for pediatric patients (male and female, ≤ 12 years of age) diagnosed with croup in the ED, treated with racemic epinephrine, and discharged from the ED. RESULTS: We evaluated patients observed for less than 1 hour, 1 to 2 hours, and greater than 2 hours to determine difference in return rates within 48 hours. For patients with mild croup symptoms, 2% observed for less than 1 hour returned; 5% observed for 1 to 2 hours returned, and 3% observed for greater than 2 hours returned. Of the patients with moderate croup symptoms, 29% observed for less than 1 hour returned, 20% observed for 1 to 2 hours returned, and 20% observed for greater than 2 hours returned. A majority who returned for follow-up were not retreated with racemic epinephrine. CONCLUSION: Based on our study results, we can conclude that observing patients following treatment of croup with inhaled racemic epinephrine in the ED for less than 2 hours did not increase their risk of deterioration or need to return. Our data did not show that a longer observation time resulted in lower return rates within 48 hours.

Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway.

Background: Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017. Methods: We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy. Results: We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014. Conclusions: Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.

Croup Admissions: Can We Shrink the Elephant in the Room?

OBJECTIVE: This pilot study aims to identify potential predictors of postadmission interventions of hospitalized croup patients and derive a risk model aimed at reducing hospitalizations for croup. METHODS: Data were collected on all croup hospitalizations for patients aged 1 month to 17 years admitted through a community hospital's emergency department (ED) between 2012 and 2017. Potential predictors were obtained from the electronic medical records including demographics, vital signs, ED length of stay, preintervention and postintervention Westley Croup Score (WCS), number of racemic epinephrine nebulizations administered, time to dexamethasone administration, preexisting conditions, and additional interventions during hospitalization. Statistical analysis used the outcome "patient received racemic epinephrine after hospital admission (yes/no)" to identify characteristics of the child or ED visit associated with that outcome. Preliminary analyses using stepwise logistic regression, tree models, and random forests suggested predictors, interactions among predictors, and the form of their association with the outcome. A final analysis used logistic regression. RESULTS: A total of 116 croup admissions were included, of which 19 (16%) received racemic epinephrine posthospitalization. These characteristics were identified as having some predictive power: sex, preexisting conditions, and preintervention and postintervention WCS, along with the interaction between sex and postintervention WCS. Logistic regression estimated an equation describing the probability of postadmission intervention, permitting the choice among admission thresholds giving different sensitivities and specificities. CONCLUSIONS: There appear to be promising predictors in croup patients presenting to the ED, which might help stratify risk for interventions after the ED encounter and thus reduce the number of potentially avoidable admissions.

Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016.

BACKGROUND: Croup admission decision making is challenging because the rate of further interventions after stabilization is unclear. OBJECTIVE: We sought to describe rates of inpatient racemic epinephrine (IRE) and additional inpatient airway interventions (IAI) (oxygen or heliox therapy, intubation, or transfer to an intensive care unit) among patients presenting to a tertiary children's hospital with croup. METHODS: This was a retrospective descriptive study including patients (3 months to 8 years of age) with an emergency department (ED)/inpatient encounter for croup from January 1, 2015 to December 31, 2016 at a tertiary children's hospital. We excluded intensive care unit direct admissions and patients with bronchiolitis/asthma/pneumonia. We compared 3 groups (a weighted random 5% sample of patients evaluated in ED only, and those admitted with or without IRE/IAI) using Kruskal-Wallis, Pearson χ2, or the Fischer exact test, where appropriate. We used multivariate analysis to compare demographics and preadmission racemic epinephrine (RE) with rates of IRE/IAI in admitted patients. RESULTS: We included 588 patients (194 discharged from the ED, 394 admitted). In admitted patients, 20.8% (82/394) had IRE/IAI, most commonly IRE (20.0%, 79/394). Three admitted patients (0.76%) had IAI. Overall, patients with 2 outside hospital/ED doses of RE had a 12.1% rate of IRE/IAI (23.5% if ≥3 RE doses). Patients with ≥3 preadmission RE doses were more likely to have IRE/IAI compared with 2 RE (adjusted odds ratio = 2.08 [95% confidence interval 1.15-3.76]; p = 0.02); there were no other significant associations. CONCLUSIONS: We found a low rate of IRE/IAI after ED management in patients with croup and no significant associations aside from preadmission RE doses. These findings may be considered in admission decisions.

Inpatient use of racemic epinephrine for children admitted with croup.

BACKGROUND: Pediatric patients with croup are frequently admitted if they require two doses of racemic epinephrine (RE) in the emergency department (ED). We aimed to identify factors associated with the need for additional therapy (> 2 RE doses) among pediatric patients with croup. METHODS: We performed a single-center retrospective study of consecutive patients admitted from the ED with a diagnosis of croup between January 1, 2011 and December 31, 2015. Primary outcome was need for > 2 doses of RE. Secondary outcomes included time to third RE and 72-hour return visits. We performed logistic regression to identify factors associated with use of > 2 RE doses during hospitalization, and survival analysis to identify time to dosing of 3rd RE from 2nd RE. RESULTS: Of 353 included admissions [250 (70.8%) males, median age 1.48, interquartile range 0.97-2.51 years], 106/353 (30.0%) required > 2 RE. In univariate logistic regression, only recent use of steroids within 1 day prior to presentation (4.18, 1.48-11.83; P = 0.007) was associated with need for > 2 RE. Survival from third RE was 0.74 (95% CI 0.69-0.78), which was similar to the survival at 12 hours (0.70, 95% CI 0.65-0.75). Return visits occurred in 19 (5.4%) patients, of whom 12/19 (63.2%) were given RE. CONCLUSIONS: Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for > 2 RE during hospitalization. The majority who require inpatient RE will do so within 8-12 hours. These data provide information for risk stratification and duration of monitoring for patients hospitalized with croup.

Hospital Course of Croup After Emergency Department Management.

OBJECTIVES: To describe inpatient management of patients with croup admitted from the emergency department (ED). METHODS: In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. RESULTS: We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. CONCLUSIONS: Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.

Decreasing Racemic Epinephrine for Bronchiolitis in an Academic Children's Hospital.

BACKGROUND AND OBJECTIVES: Bronchiolitis is a leading cause of pediatric hospitalizations in the United States. Although the American Academy of Pediatrics recommends against routine use of bronchodilators in bronchiolitis management, racemic epinephrine was persistently used for this purpose at Le Bonheur Children's Hospital. Our aim was to decrease racemic epinephrine use for bronchiolitis by 50% within 8 months. METHODS: Our multidisciplinary team used the Institute for Healthcare Improvement's Model for Improvement to develop an aim statement, choose metrics, and perform plan-do-study-act cycles to reduce racemic epinephrine use. We used focused education through in-person and online methods and provided direct feedback to residents, respiratory therapists, and nurses primarily caring for these children. The percentage of all patients admitted for bronchiolitis receiving at least 1 dose of racemic epinephrine was collected from the medical record and recorded on statistical process control charts for distribution to their work areas. Albuterol use and length of stay were collected as balancing measures. We used statistical process control charts to establish special cause variation and identify statistically significant differences in our measures. RESULTS: During our intervention period, the percentage of bronchiolitis patients receiving at least 1 dose of racemic epinephrine to treat bronchiolitis decreased from an average of 26% to 5%, and similarly, albuterol use decreased from an average of 48% to 34%. There was no clinically significant difference in length of stay. CONCLUSIONS: Using a multidisciplinary approach and focused education techniques may be an effective way to reduce racemic epinephrine use for children with bronchiolitis.

Uncommon presentation of a common disease: influenza A presenting as adult croup .

An 88-year-old woman presented to our emergency room with complaints of fever, coryza, barking cough and generalised fatigue for 2 days. Physical examination showed stridor, tachypnoea with use of accessory muscles of respiration on admission. Laboratory tests were unremarkable except for monocytosis with a normal total white cell count. Rapid influenza diagnostic test was positive for influenza A. Chest X-ray showed subglottic narrowing of the trachea suggestive of steeple sign. A diagnosis of influenza A-induced croup was made. She was given humidified oxygen, nebulised racemic epinephrine, intravenous dexamethasone and oseltamivir. Stridor resolved within minutes of giving nebulised epinephrine. Work of breathing improved within 4-6 hours. She was discharged 2 days later on a tapering dose of steroids.