Showing posts with label pulmonology. Show all posts
Showing posts with label pulmonology. Show all posts

Thursday, August 28, 2014

Benchmarks to Strive for in Caring for Children with Asthma, Bronchiolitis & Pneumonia

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Hey Paul Studios via Flickr
Pediatrics, along with other journals, has published studies on the variability of tests ordered, treatments used, and length of stay for a number of common pediatric illnesses. In fact, hospitalists use variability studies to help them identify care pathways to improve quality and reduce costs of care. But is there an ideal set of benchmarks we should strive for in creating our care pathways?

Parikh et al. (doi: 10.1542/peds.2014-1052) believe there are, as a result of their performing a cross-sectional study of data obtained from the Pediatric Health Information System (PHIS) to identify common benchmarks used at the top 10 percent of performing hospitals to note how often images, lab and viral studies, types of antibiotics and frequency of usage could be or should be utilized for inpatient care of asthma, bronchiolitis, and pneumonia.

And speaking of benchmarks, Ralston et al. (doi: 10.1542/peds.2014-1036) add to the discussion with release of their systematic review article of quality improvement studies on ways to reduce unnecessary tests and treatments for children hospitalized with bronchiolitis and provide some additional benchmarks for you to consider.

After reading these studies, you will want to reflect on your own patients or those cared for by your local hospitalists to see whether the benchmarks recommended in these two studies are being adhered to or not when children present with asthma, bronchiolitis, or pneumonia. Benchmark this article for further reference – you’ll likely need it as we move away from volume-based to value-based quality care.

Wednesday, June 25, 2014

Readmissions for Pneumonia: Coughing Up Some Troublesome Data

By: Lewis First, MD, MS

While we recognize that children with pneumonia do find themselves on occasion as inpatients, how often do these same children require readmission and for what reasons?

Photo by the US CDC
Neuman et al. (doi: 10.1542/ peds. 2014-0331) addressed these questions using a retrospective cohort of children hospitalized at 43 hospitals between 2008 and 2011 to better understand patient and hospital characteristics and the costs associated with readmission. As it turns out, readmissions play more of a role in overall hospitalizations for pneumonia than you may have expected. Just why that is, and what might we do differently to reduce the readmission rate form the crux of a good discussion by the authors.

Take a deep breath and read this interesting study to become more aware of what you might do to reduce readmissions rates for pneumonia.

Related Reading:

Tuesday, April 22, 2014

Codeine Use Despite Two National Guidelines That Say No

Public Domain Photo via Wikimedia Commons
Since 2006, there have been two national guidelines recommending avoidance of codeine in children for cough or upper respiratory symptoms—so how effective have those guidelines been in curtailing use of this drug for this purpose?

Kaiser et al. (doi: 10.1542/peds. 2013-3171) did a cross-sectional ten year look at codeine prescriptions written in emergency facilities as part of the National Ambulatory Care Survey both before and after the guidelines were published. The results may surprise or more likely disappoint those of you who are not using codeine for common cough and cold symptoms. Many still are. Why?

Both the authors and an accompanying commentary by pediatric toxicologists Drs. Alan Woolf and Christine Greco (doi: 10.1542/peds.2013-4057) shed some light on this issue and are worth your consideration. Hopefully publishing this article and commentary will make more of a dent in curtailing codeine usage than efforts have to date—but read both and learn more.

Related Reading:

Wednesday, February 19, 2014

Recurrent Viral Wheezing and Beclomethasone: Should You or Your Patients Breathe a Sigh of Relief?

Photo by Amanda Mills, via the CDC
Many studies have been published looking at the role of steroids in the setting of a viral lower respiratory infection and this week we add to those with a well-done randomized double blind placebo-controlled trial of nebulized beclomethasone as a treatment for recurrent viral wheezing that was conducted by Clavenna et al. (doi: 10.1542/peds.2013-2404).

More than 500 children who had had prior viral wheezing and subsequently presented with upper respiratory symptoms were entered in a 10 day trial of the inhaled steroid with follow-up 10 days later to see if viral wheezing was still present in both the drug and placebo groups.

The results may delight some and irritate others, but are certainly worth your attention. Are you using inhaled steroids for viral wheezing in your young patients? Is it working? Do you agree with the results of this study—and if not, why not? Share your comments and concerns with us via eLetter, in the comment space below on this blog, Facebook or Twitter.

Related Reading:

Thursday, February 13, 2014

Tuberculosis in Young Children in the US: Is It Prevalent and Who's Getting It?

We may not see a lot of tuberculosis (TB) in this country nowadays, especially in our youngest patients, but it does exist—especially in children born to foreign-born parents or foreign-born children who come to this country. So how commonly seen is it?

Photo by Janice Carr , Centers for Disease Control & Prevention
Pang et al. (doi: 10.1542/peds.2013-2570) studied this topic by collecting cases of TB in children less than 5 years of age in 20 US jurisdictions and comparing them to data obtained from parental interviews and health department and TB surveillance records.

This descriptive study provides information about just who is getting TB in the country, how it’s spreading to children, and what can be done to reduce the rate of TB cases in children. Additionally, in an accompanying commentary, TB experts Drs. Jeffrey Starke and Andrea Cruz (doi: 10.1542/peds.2013-4139), explain the importance of this study’s findings.

Give this article and commentary some attention if you want to more accurately identify who in your practice is at risk for TB so you are better attuned to diagnosing and treating it sooner than later.

Related Reading:

Wednesday, January 15, 2014

Human Rhinovirus Infection in Children: Something to Sneeze At!

Photo by D. Sharon Pruitt via Flickr
We certainly think of human rhinovirus (HRV) as a common cause of upper respiratory infections in children—but
is it really something to worry about relative to other viruses that can
present with moderate to severe symptoms, such as respiratory
syncytial virus (RSV)?

In a study we are releasing this week, Costa et al. (doi: 10.1542/peds.2013-2216) examined 434 children with respiratory symptoms and classified them by severity. They then tested for HRV and 8 other respiratory viruses
to determine HRV’s prevalence and whether it operates alone or with other viruses as a co-infection—especially if symptoms are moderate to severe.

The co-morbidities associated with HRV disease severity are well-worth reading about, so wash your hands, grab a tissue, and learn more about what HRV is and is-snot.

Wednesday, December 18, 2013

Hypertonic Versus Normal Saline for Acute Bronchiolitis: Which Is More Effective and Which Is-Not?

Photo by anjanettew via Flickr
With bronchiolitis season here, it is time to bring out the hypertonic saline nebulized solution with the hope of loosening secretions and improving breathing as prior studies have suggested. Yet this week, we release a randomized controlled study by Jacobs et al. (doi: 10.1542/peds.2013-1646) that goes against the grain (of lots of salt) and proves earlier studies may not have been as valid as they implied and that normal saline may be just as effective as hypertonic salt solutions.

Using bronchiolitis severity scores as well as hospitalization rates, ED and inpatient length of stay, the authors have some findings that will make you take a deep breath before you use this therapy for infants to help them take a deeper breath. Dr. David Cornfield, an intensivist and member of our Editorial Board sheds additional light on the findings of this study in a provocative commentary (doi: 10.1542/peds.2013-3250) that accompanies this article.

Are you using hypertonic saline? Does it work for your bronchiolitic patients? Are you going to change as a result of this study? Share your thoughts and comments with us in the response area of this blog, or via social media, or even an eLetter to the journal. We look forward to your comments on this interesting study.

Friday, December 13, 2013

Some Quality Thoughts This Bronchiolitis Season

Photo by Hey Paul Studios via Flickr
Quality Reports Editor Dr. Alex Kemper offers a preview of a Quality Report being early released this week from our January issue:

There is no doubt that bronchiolitis is difficult for both babies and their families— the cough, the noisy and sometimes fast breathing, and the exhausted families. Even though there are a lot of data to show that interventions are rarely effective, we often prescribe therapy such as bronchodilators or antibiotics or get tests that rarely change management, such as rapid viral tests or chest X-rays.

What can we do to change our management behaviors? Would changing our patterns of care lead to unintended harm? Dr. Akenroye and colleagues (doi: 10.1542/peds.2013-1991) from Boston Children’s Hospital give some compelling and important answers to these questions.

Let me know what you think! Leave your comment below, share your thoughts through Twitter or on our Facebook page, or submit an eLetter to tell us what you think.

Wednesday, December 4, 2013

AAP Guidelines for Bronchiolitis: Are We Using Them? How Do We Know?

In 2006, the AAP published a set of evidence-based Clinical Practice Guidelines for diagnostic testing and treatment of bronchiolitis (doi: 10.1542/peds.2006-2223). Once published, did anyone use them, and if so, can that be reflected in less diagnostic testing and certain- types of treatments?

Parikh et al. (doi: 10.1542/peds.2013-2005) decided to examine this by looking at inpatients with bronchiolitis before and after the Guidelines were published using a large administrative billing database. In a representative cohort of 41 pediatric hospitals involving more than 130,000 patients over an 8 year period, it appears the guidelines are making a difference in reducing inappropriate non-evidence-based tests and some treatments.

To find out just how utilization is reduced and in what way, take a deep breath and read this article for yourself. If you haven’t been adhering to these Guidelines, you likely will after you read this interesting study.

Wednesday, October 16, 2013

RSV Prophylaxis and Recurrent Wheezing: A Statistical Difference May Not Be a Cost-Effective One

Photo by Taxiarchos228 via Wikimedia Commons
In 2009, the Red Book committee modified its recommendations for prophylactic use of palivizumab in at-risk infants after carefully reviewing existing studies and recognizing as well the cost-benefit of this particular drug.

Since then, studies have continued to look at the role of palivizumab in reducing short- and long-term respiratory symptoms in preterm infants, and we are early-releasing one this week by Yoshihara et al. (doi: 10.1542/peds.2013-0982). The authors conducted an observational prospective multicenter trial in infants between 33 to 35 weeks of age who were followed for three years for recurrent wheezing.  The good news is that there was a statistically lower incidence of recurrent wheezing in infants given palivizumab, and the details await your perusal of this study.

On the other hand, a statistical result may not mean a cost-effective one—and to illustrate that point, Dr. Cody Meissner, an ex-officio member of the Red Book committee, shares a commentary (doi: 10.1542/peds.2013-2449) that presents an important different view of what this study means (or doesn’t mean). I value your take on the palivizumab issue and hope you will share it via our blog comment space below, Facebook, or e-letter sites—but only after you have read both articles.

Friday, October 4, 2013

Eighteen Years of Data on Pediatric Interstitial Lung Disease: What Can We Learn?

Interstitial lung diseases are not the most common pulmonary problem we see in our pediatric patients with respiratory difficulties—but they can and do occur. Just how they present and what we should do about them once suspected form the nidus for a fascinating retrospective review of 93 cases seen at Vanderbilt Children’s Hospital between 1994 and 2011 that Soares et al. (doi: 10.1542/peds.2013-1780) share with us in an article we are releasing this week. The authors, knowing the natural history of these cases, suggest that a lung biopsy is not necessarily required for diagnosis, making this problem one that may be initially diagnosed and subsequently followed (likely  with guidance from a pediatric pulmonary specialist) by a child’s primary care pediatrician. If you need to brush up on your knowledge of pediatric interstitial lung diseases and how they present, you’ll find this article inspiring.

Wednesday, September 25, 2013

State of the Art Care for Late Preterm Infants

In the last few years, the pediatric community has developed a growing awareness about late preterm infants. These children were previously considered "near term", which meant that they could be managed, for the most part, like term infants.

It is now very clear that they are at risk for long-term neurodevelopment and pulmonary disabilities, perhaps due to interruption of development at a crucial period, as proposed by Kugelman and Colin (doi: 10.1542/peds.2013-1131) in the September State of the Art Review. Pediatric practitioners will encounter many of these infants in their practices as they constitute over 75% of all premature infants. Educators will also need to be aware of the subtle cognitive deficits for which these infants are at risk.

Monday, September 2, 2013

Pulmonary Embolus in Children: They Do Occur, But Who’s at Risk?

While pulmonary embolus (PE) sits prominently on the adult differential diagnosis of acute respiratory distress, we probably don’t think of it as often as we might in our younger patients. It is perhaps for that reason that Agha et al. (doi: 10.1542/peds.2013-0126) opted to review patients in their emergency department who were diagnosed with a pulmonary embolus from 2003 to 2011.  While only 105 PEs were identified from over one million patient visits, this is still a number we can learn from—and learn we do in this article in terms of demographic risk factors as well as whether these patients would have been identified using adult exclusionary criteria or missed in their diagnosis. The authors indicate that even children with PEs are not just little adults and instead require their own specific clinical decision rules if we are going to have a high pretest probability of diagnosing and not missing a pulmonary embolus in our pediatric patients. You’ll breathe easier if you read this study to learn more.