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OBJECTIVE: To determine the clinical benefit of oral dexamethasone in children admitted to the hospital with bronchiolitis treated with nebulized salbutamol. METHODS: Randomized, double-blind, placebo-controlled trial in the inpatient wards of a pediatric tertiary care hospital. The participants, children aged 6 weeks to 15 months, admitted with first-time wheezing, were eligible if their oxygen saturation was less than 95% on admission to the hospital and their Respiratory Distress Assessment Instrument (RDAI) score was greater than 6. Patients were excluded if they had any one of the following: an underlying disease that might affect cardiopulmonary status, asthma, recent treatment with steroids (within 2 weeks), or any history of adverse reaction to steroids. Patients were randomly assigned to receive either orally administered dexamethasone with 0.5 mg/kg as the first dose and 0.3 mg/kg for the next 2 mornings, or an equal volume of an orally administered placebo with an identical appearance. All patients received nebulized salbutamol at 0.15 mg/kg every 4 hours for the first 24 hours. The primary outcome measure was the change from baseline in the RDAI score at 24 hours. Secondary outcome measures were oxygen saturation, respiratory rate, RDAI measurement twice daily for the first 4 days, and the length of hospitalization. RESULTS: At 24 hours the mean change (SD) from baseline in the RDAI score was 1.6 (2.3) in the placebo group (n = 28) and 1.4 (2.0) in the dexamethasone group (n = 33; p = 0.74). There were no significant differences between the two groups in change in oxygen saturation, respiratory rate, and RDAI score at any assessment period. The median length of stay (95% confidence interval) for the placebo group was 48 (42, 54) hours compared with 57 (38, 76) hours in the dexamethasone group (p = 0.19). CONCLUSIONS: Oral dexamethasone therapy does not affect the clinical course of children hospitalized with bronchiolitis and therefore cannot be recommended in this clinical situation.

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Assuntos

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This randomized, double-blind trial compared the efficacy of nebulized epinephrine with salbutamol in the treatment of infants with acute bronchiolitis. The mean percent oxygen saturation at 60 minutes was significantly higher in the epinephrine group. Thirty-three percent of the patients in epinephrine group were admitted to the hospital compared with 81% of the salbutamol group (p = 0.003). We conclude that nebulized epinephrine is more efficacious than salbutamol for infants with acute bronchiolitis seen in an emergency department.

Assuntos

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OBJECTIVE: To determine, from the societal perspective, the most cost efficient of the three methods commonly used to repair pediatric facial lacerations: nondissolving sutures, dissolving sutures, or a tissue adhesive (Histoacryl blue). DESIGN: Cost-minimization analysis and willingness-to-pay survey. SETTING: Tertiary-care pediatric emergency department. METHODS: All differential costs relevant to equipment utilization, pharmaceutical use, health care worker time, and parental loss of income for follow-up visits were calculated for each method. On the basis of previous research, our model assumes equal cosmetic outcome for the three methods. In addition, a convenience sample of 30 parents were surveyed in the emergency department to rank their preferences and willingness to pay for the three methods of wound closure. RESULTS: The reduction in cost (in Canadian dollars) per patient of switching from the standard nondissolving sutures was $49.60 for switching to tissue adhesive and $37.90 for dissolving sutures. Sensitivity analyses performed on key variables did not significantly alter our conclusions. Of those parents surveyed; 90% (95% confidence interval, 74% to 98%) chose tissue adhesive and 10% (95% confidence interval, 2% to 26%) chose dissolving sutures as their first choice for wound closure. Nondissolving sutures were ranked third by 29 of 30 parents. Parents were willing to pay a median (25th to 75th percentile) of $40 ($25 to $100) for tissue adhesive and $25 ($10 to $56) for dissolving sutures if only nondissolving sutures provided by the health care system (p = 0.1). CONCLUSIONS: Tissue adhesive is the preferred method of closure of pediatric facial lacerations because it results in the most efficient use of resources and is preferred by the majority of parents.

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OBJECTIVE: To determine the costs and clinical outcomes of three alternative treatments of the acute phase of Kawasaki syndrome: aspirin alone; low doses of intravenously administered immune globulin (IVIG-LD), 400 mg/kg per dose for 4 days; and high doses of intravenously administered immune globulin (IVIG-HD), 2.0 gm/kg for one dose. DESIGN: A model was developed that assumed the inclusion of 100 patients with acute Kawasaki syndrome in each treatment option. Costs were valued by using the Chedoke-McMaster Corporate Cost Model in 1992 Canadian dollars. Clinical outcome, based on the published literature, was measured by the prevalence of coronary artery dilation at 7 weeks from the diagnosis of Kawasaki syndrome. RESULTS: For every 100 patients with Kawasaki syndrome, the cost was reduced by $323,400 when aspirin therapy alone was changed to IVIG-HD therapy and 14 cases of coronary artery dilation were thereby prevented. When IVIG-HD therapy was compared with IVIG-LD therapy, the cost was reduced by $118,200 because two cases of coronary artery aneurysm were prevented. This latter result was sensitive to the duration of hospitalization, with IVIG-HD costing $8500 more for every 100 patients than IVIG-LD when it was assumed that both groups were hospitalized for 5 days, an unlikely occurrence. CONCLUSIONS: Treatment with IVIG-HD for Kawasaki syndrome is preferred because it results in both lower costs and lower rates of coronary artery dilation.

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PURPOSE: To select diagnostic tests that confidently identify febrile infants less than 3 months of age seen at an outpatient facility as being at low risk for serious bacterial infection (SBI). DATA IDENTIFICATION: An English-language literature search employing MEDLINE (1966 to 1991), Science Citation Index (1977 to 1991) using key citations, bibliographic reviews of primary research and review articles, and correspondence with authors of recent articles. STUDY SELECTION: After independent review by two observers, 10 of 333 originally identified titles were selected on the basis of prespecified selection criteria. DATA EXTRACTION: Two observers independently assessed studies by using explicit methodologic criteria for evaluating the quality of studies dealing with diagnostic tests. One reviewer extracted all the data from the articles; the second reviewer checked these data for accuracy. RESULTS OF DATA ANALYSIS: On the basis of prespecified criteria, results were pooled from two studies that used the Rochester criteria, had high methodologic validity, and did not have significant heterogeneity (p = 0.32, Breslow-Day test), to give an estimate of the best negative likelihood ratio (95% confidence interval) for SBI = 0.03; 0 to 0.23). CONCLUSION: The negative likelihood ratio of 0.03 allowed us to conclude that after the Rochester criteria for low risk of SBI have been satisfied, the probability of SBI in a febrile infant less than 3 months of age drops from a baseline rate of 7% (or 1 in 14 infants) to 0.2% (or 1 in 500). An expectant approach in these low-risk infants is therefore a reasonable choice.

Assuntos

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To test whether nebulized salbutamol (albuterol) is safe and efficacious for the treatment of young children with acute bronchiolitis, we enrolled 83 children (median age 6 months, range 1 to 21 months) in a randomized, double-blind clinical trial. Participants received two treatments at 30-minute intervals of either nebulized salbutamol (0.10 mg/kg in 2 ml 0.9% saline solution) or a similar volume of 0.9% saline solution placebo. Outcome measures were the respiratory rate, pulse oximetry, and a clinical score based on the degree of wheezing and retractions. Patients in the salbutamol arm had significantly greater improvement in clinical scores after the initial treatment (p = 0.04). There was no difference between the groups in oxygen saturation (p = 0.74); patients treated with salbutamol had a small increase in heart rate after two treatments (159 +/- 16 vs 151 +/- 16; p = 0.03). We conclude that salbutamol is safe and effective for the initial treatment of young children with acute bronchiolitis.

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