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TOP 10 PEM Studies

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Title: TOP 10 PEM Studies


1
TOP 10 PEM Studies
  • Antonia Stang MD, MBA
  • Division of Emergency Medicine
  • Alberta Childrens Hospital

2
Disclosure
  • I do not have an affiliation (financial or
    otherwise) with any commercial organization that
    may have a direct or indirect connection to the
    content of my presentation.

3
Objectives
  • After this session participants will be able to
  • Briefly outline an approach to translating
    evidence based medicine into clinical practice
  • Categorize the quality of medical evidence
  • Discuss some of the latest evidence on the
    diagnosis and treatment of pediatric patients
    relevant for Emergency Physicians

4
Search Strategy
  • Relevance to emergency physicians treating
    pediatric patients
  • Methodological quality
  • Potential to impact practice

5
The Quality of Medical Evidence
AAP Clinical Practice Guideline Diagnosis and
Management of Bronchiolitis. Pediatrics 2006
118( 4) 1774-1793.
6
Journals
  • Pediatrics
  • Pediatrics
  • J Pediatr
  • Arch Pediat Adol Med
  • Pediatr Infect Dis J
  • Arch Dis Child
  • Surgery
  • Ann Surg
  • Surgery
  • Medicine
  • New Engl J Med
  • Lancet
  • JAMA
  • Can Med Assoc J
  • Emergency Medicine
  • Ann Emerg Med
  • Resuscitation
  • Acad Emerg Med
  • Injury
  • Am J Emerg Med
  • Emerg Med J
  • Emerg Med Clin N Am
  • Pediatr Emerg Care
  • CJEM

7
Framework
  • Ask a pertinent and answerable clinical question
  • Track down articles
  • Three basic questions
  • Are the results of the study valid?
  • What are the results?
  • Will the results help me in caring for my
    patients?
  • Oxman AD, Sackett DL, Guyatt GH. How to Get
    Started. JAMA. 1993270(17)2093-2095.

8
Clinical Question 1
  • Would nebulized epinephrine and/or oral
    corticosteroids prevent hospital admission in a
    10 month old infant with bronchiolitis?

9
Epinephrine and Dexamethasone in Children with
Bronchiolitis
  • Plint A et al. N Engl J Med 2009360(20)
    2079-2089.

10
Objective and Methods
  • Objective To determine whether treatment with
    nebulized epinephrine, a short course of oral
    dexamethasone, or both resulted in a clinically
    important decrease in hospital admissions among
    infants with bronchiolitis who were seen in the
    ED
  • Methods Multi-center, randomized, double-blind,
    placebo-controlled, clinical trial with a
    factorial design
  • Primary outcome hospital admission up to 7 days
    after enrollment

Plint A et al. N Engl J Med 2009360 2079-2089
11
Results
  • 800 patients enrolled

Plint A et al. N Engl J Med 2009360 2079-2089
12
Frequency and Relative Risk of Hospital Admission
Frequency and Relative Risk of Hospital Admission
on the Day of the Initial Emergency Department
Visit, by Day 7, and by Day 22
Plint A et al. N Engl J Med 20093602079-2089
Plint A et al. N Engl J Med 2009360 2079-2089
13
Cumulative Admissions during the First 7 Days
after the Initial Emergency Department Visit
Plint A et al. N Engl J Med 2009360 2079-2089
14
Conclusions
  • Among infants with bronchiolitis treated in the
    emergency department, combined therapy with
    dexamethasone and epinephrine may significantly
    reduce hospital admissions
  • Confirmation by a study powered specifically to
    compare combined epinephrine and dexamethasone
    therapy with placebo is needed

Plint A et al. N Engl J Med 2009360 2079-2089
15
Clinical Question 2
  • Would oral corticosteroids shorten the duration
    of hospitalization in a 2 year old child with
    acute viral induced wheezing?

16
Oral Prednisolone for Preschool Children with
Acute Virus-Induced Wheezing
  • Panickar, J et al. N Engl J Med
    2009360(4)329-338.

17
Objective and Methods
  • Objective to assess the efficacy of a short
    course of therapy with oral prednisolone in
    children presenting to a hospital with virus
    induced wheezing
  • Methods Multi-centre, randomized, double-blind,
    placebo controlled trial
  • Primary outcome duration of hospitalization

Panickar J et al. N Engl J Med 2009360329-338
18
Results
  • 700 patients randomized (343 prednisolone, 344
    placebo)
  • Duration of hospitalization (median)
  • Prednisolone 13.9 hours
  • Placebo 11.0 hours
  • Difference -1.9 (95 CI -8.7 to 2.4)
  • No difference for secondary outcomes or number of
    adverse events

Panickar J et al. N Engl J Med 2009360329-338
19
Conclusions
  • In preschool children with mild-to-moderate
    wheezing associated with a viral infection, oral
    prednisolone was not superior to placebo
  • Results suggest that oral prednisolone should not
    be given to pre-school children presenting to the
    hospital with acute, mild-to-moderate
    virus-induced wheezing

Panickar J et al. N Engl J Med 2009360329-338
20
Conflicting Results?
  • Differences in study population
  • Age
  • Infants 6 weeks -12 months vs. children 10 to 60
    months of age
  • Etiologic heterogeneity
  • Bronchiolitis first episode of wheezing
  • Episodic (viral) wheeze
  • Multiple trigger wheeze
  • Severity of disease
  • Mild disease (PRAM 4)
  • Moderate disease (RDAI 8)
  • Synergism between corticosteroids and
    beta-agonists
  • Dose
  • 1mg/kg then .6mg/kg dexamethasone
  • Prednisolone 10mg 10 -24 months, 20 mg for older
    children

21
Clinical Question 3
  • In an 8 year old child with functional
    constipation what dose of polyethylene glycol
    (PEG) 3350 (Miralax) should be started to
    increase the frequency of BMs?

22
PEG 3350 in the Treatment of Childhood
Constipation A Multicenter, Double-Blinded,
Placebo-Controlled Trial
  • Nurko, S. J Pediatr 2008153254-261.

23
Objective and Methods
  • Objective
  • to establish the efficacy and best starting dose
    of polyethylene glycol (PEG) 3350 in the short
    term treatment of children with functional
    constipation
  • Methods
  • Prospective, randomized, multi-center,
    double-blinded, placebo controlled dose ranging
    study
  • Placebo, 0.2 g/kg per day, 0.4 g/kg, 0.8 g/kg
  • 1 week run in, 2 weeks of treatment
  • Primary outcome Proportion of patients who
    responded to treatment ( 3 BM during second week
    of treatment)
  • All received behavior modification

Nurko, S. J Pediatr 2008153254-261
24
Results
Bowl movement frequency before and after
administration of PEG 3350
Nurko, S. J Pediatr 2008153254-261
25
Conclusions
  • This study confirms the efficacy and safety of
    PEG 3350 for the short term treatment of children
    with functional constipation
  • Recommend a starting dose of 0.4 g/kg/day
  • The effect of behavior modification is significant

Nurko, S. J Pediatr 2008153254-261
26
Clinical Question 4
  • Would Lansoprazole (PPI) decrease the number of
    crying episodes in a 4 month old infant with
    symptoms of Gastroesophageal Reflux Disease?

27
Multicenter, Double-Blind, Randomized,
Placebo-Controlled Trial Assessing the Efficacy
and Safety of Proton Pump Inhibitor Lansoprazole
in Infants with Symptoms of Gastroesophageal
Reflux Disease
  • Orenstein SR et al. J Pediatr 2009154514-520.

28
Objective
  • Objective
  • To assess the efficacy and safety of lansoprazole
    in treating infants with symptoms attributed to
    GERD that have persisted despite a 1 week
    course of nonpharmacologic management

Orenstein SR et al. J Pediatr 2009154514-520
29
Methods
  • Phase 3, multicenter, randomized, double-blind,
    placebo-controlled study
  • 3 periods pretreatment (1-2 weeks before
    randomization), treatment (max 4 weeks), post
    treatment
  • 0.2 to 0.3 mg/kg/day for infants 10 weeks, 1.0
    to 1.5 mg/kg/day gt 10 weeks vs. placebo
  • Primary outcome daily diary documented number
    and duration of crying episodes during or 1
    hour after feeding

Orenstein SR et al. J Pediatr 2009154514-520
30
Results
  • Responder rate (N )
  • Lansoprazole 44 (54)
  • Placebo 44 (54)
  • No difference in individual symptoms or global
    severity assessment
  • Serious adverse events (N )
  • Lansoprazole 10 (12)
  • Placebo 2 (2)
  • P-value .032

Orenstein SR et al. J Pediatr 2009154514-520
31
Conclusion
  • This study found no difference in efficacy
    between lansoprazole and placebo in treating
    infants with symptomatic GERD
  • SAEs, particularly lower respiratory tract
    infections, occurred more frequently with
    double-blind lansoprazole than with placebo

Orenstein SR et al. J Pediatr 2009154514-520
32
Clinical Question 5
  • Would IV ondansetron reduce vomiting associated
    with IV Ketamine in an 8 year old male undergoing
    sedation in the ED?

33
Effect of Ondansetron on the Incidence of
Vomiting Associated With Ketamine Sedation in
Children A Double-Blind, Randomized,
Placebo-Controlled Trial
  • Lanston W et al. Ann Emerg Med 200852(1)30-34.

34
Objective
  • To determine whether vomiting associated with
    intravenous (IV) ketamine may be reduced or
    eliminated by the addition of prophylactic
    ondansetron
  • Study design randomized, double blind, placebo
    controlled trial
  • Primary outcomes vomiting in the ED and after
    discharge
  • Secondary outcomes length of ED stay, parent or
    guardian satisfaction with the sedation

Lanston W et al. Ann Emerg Med 200852(1)30-34
35
Results
  • No significant difference in ED length of stay or
    parental or guardian satisfaction with sedation

Lanston W et al. Ann Emerg Med 200852(1)30-34
36
Conclusion
  • IV ondansetron significantly reduces the
    incidence of vomiting associated with IV ketamine
    procedural sedation in children
  • Sites that experience a higher rate of vomiting
    may consider pretreatment with ondansetron,
    especially for children aged 5 years and older

Lanston W et al. Ann Emerg Med 200852(1)30-34
37
Clinical Question 6
  • Would procalcitonin help in identifying serious
    bacterial infection in a 2 month old infant with
    fever without a source?

38
Procalcitonin in Young Febrile Infants for the
Detection of Serious Bacterial Infections
  • Maniaci V et al. Pediatrics 2008122701-710.

39
Objectives
  • To study the test performance of procalcitonin
    for indentifying serious bacterial infections in
    febrile infants 90 days of age without an
    identifiable bacterial source
  • To determine an optimal cutoff value to identify
    infants at low risk for serious bacterial
    infection

Maniaci V et al. Pediatrics 2008122701-710
40
Methods
  • Prospective cohort study
  • Eligible infants age 90 days and measured
    temperature 38 seen in an urban, academic,
    pediatric hospital
  • Outcome
  • Definite SBI
  • Possible SBI
  • No SBI

Maniaci V et al. Pediatrics 2008122701-710
41
Results
  • Definite SBI (N 30)
  • 4 bacteremia, 2 bacteremia/UTI, 24 UTI
  • Procalcitonin level 2.21 /- 3.89
  • Definite and Possible SBI (N42)
  • 7 UTI, 5 bacterial pneumonia
  • Procalcitonin level 2.48 /- 4.59
  • No SBI (N192)
  • Procalcitonin level 0.38 /- 1.04

Maniaci V et al. Pediatrics 2008122701-710
42
Results
  • A cutoff value of 0.12 ng/ml
  • sensitivity of 95.2
  • specificity of 25.5
  • negative predictive value of 96.1
  • negative likelihood ratio of 0.19

Maniaci V et al. Pediatrics 2008122701-710
43
Post-test probability
44
Conclusion
  • Procalcitonin has favorable test characteristics
    for detecting serious bacterial infections in
    young febrile infants
  • Procalcitonin measurements performed well in
    detecting the most serious occult infections
  • The future utility of procalcitonin likely
    depends on its combination with other clinical
    data

Maniaci V et al. Pediatrics 2008122701-710
45
Clinical Question 7
  • Will Acetaminophen use for fever in a 6 month old
    infant increase the risk of asthma symptoms when
    aged 6-7 years old?

46
Association Between Paracetamol Use in Infancy
and Childhood, and risk of asthma,
rhinoconjunctivitis, and eczema in children aged
6-7 years analysis from Phase Three of the ISAAC
Programme
  • Beasley R et al. Lancet 20083721039-1048.

47
Objective
  • To analyze the association between acetaminophen
    use and parent-reported symptoms of asthma in 6-7
    year-old children
  • To explore the consistency of the association
    between acetaminophen use and asthma by examining
    the associations with symptoms of
    rhinoconjunctivitis

Beasley R et al. Lancet 20083721039-1048
48
Methods
  • ISAAC (International Study of Asthma and
    Allergies in Childhood) Phase 3
  • Multicentre, cross-sectional study of school
    children from a random sample of schools
  • Two standardized questionnaires completed by
    parent or guardian of the child
  • Primary Outcome association between
    acetaminophen use for fever in the first year of
    life and asthma symptoms at 6-7 years of age

Beasley R et al. Lancet 20083721039-1048
49
Results
  • 205,487 children aged 6-7 years from 73 centres
    in 31 countries
  • Association between Acetaminophen use for fever
    in the first year of life and symptoms at age 6-7
    years

Beasley R et al. Lancet 20083721039-1048
50
Results
  • Association between acetaminophen use in the past
    12 months and symptoms in children age 6-7 years
  • Population attributable risk (PAR) for asthma
    symptoms due to acetaminophen use for fever in
    the first year of life was 21
  • PAR(risk in exposed-risk in unexposed)
    prevalence of exposure to risk factor in the
    population
  • The reduction of risk in the total population if
    the exposure were removed

Beasley R et al. Lancet 20083721039-1048
51
Conclusion
  • This study provides further worldwide evidence
    that the use of acetaminophen in childhood can
    increase the risk of developing asthma and
    related allergic disorders
  • Evidence in insufficient to advise parents and
    health care workers of the risk-benefit of taking
    acetaminophen in childhood

Beasley R et al. Lancet 20083721039-1048
52
Clinical Question 8
  • Would ondansetron decrease the risk of hospital
    admission in a 6 year male with vomiting and
    moderate dehydration?

53
Use of Antiemetic Agents in Acute Gastroenteritis
  • DeCamp LR et al. Arch Pediatr Adolesc Med
    2008162(9)858-865.

54
Objective
  • To perform a systematic review and meta-analysis
    to determine whether taking antiemetic drugs
    reduces vomiting and decreases the need for
    further intervention in children with
    gastroenteritis without causing significant
    adverse effects

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
55
Methods
  • Search strategy prospective English language
    controlled trials
  • Quality assessment
  • Statistical analysis 2 X 2 tables were created
    for dichotomous outcomes (contacted authors when
    necessary)
  • Main outcomes
  • Hospital admission, IVF administration, Cessation
    of Vomiting in the ED, Return to Care, Adverse
    effects

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
56
Hospital Admission
  • NNT 14 (95 CI, 9-44)

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
57
IV Fluids
  • NNT 5 (95 CI, 4-8)

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
58
Persistent Emesis in the ED
  • NNT 5 (95 CI, 4-7)
  • Return to care RR 1.34 (CI 0.77-2.35)
  • Increased diarrhea in treatment group

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
59
Conclusion
  • Ondansetron therapy decreases the risk of
    persistent vomiting, the use of intravenous
    fluid, and hospital admissions in children with
    vomiting due to gastroenteritis
  • Other antiemetic drugs have not demonstrated
    consistent effectiveness and, therefore, should
    not be used
  • No available evidence exists demonstrating the
    efficacy of ondansetron in individuals with mild
    disease or in standard office settings

DeCamp LR et al. Arch Pediatr Adolesc Med
2008162(9)858-865
60
Clinical Question 9
  • Is a blood culture looking for occult bacteremia
    necessary in a 4 month old infant presenting to
    the ED with fever and no other source?

61
Prevalence of Occult Bacteremia in Children Aged
3 to 36 Months Presenting to the Emergency
Department with Fever in the Postpneumoccal
Conjugate Vaccine Era
  • Wilkinson M et al. Acad Emerg Med 200916220-225.

62
Objective and Methods
  • Objective to identify the prevalence of occult
    bacteremia in well-appearing previously healthy
    children aged 3 to 36 months who present to the
    ED with fever in the post-PCV era
  • Study Design Retrospective cohort study
  • Inclusion criteria age 3-36 months, febrile,
    previously healthy, no source of infection on
    exam, had blood culture drawn, discharged from ED
  • Outcome rates of occult bacteremia and
    contaminant rates

Wilkinson M et al. Acad Emerg Med 200916220-225
63
Results
  • Between July 1 2004 and June 30, 2007, 10,043
    children met inclusion criteria

64
Results and Discussion
  • With S. Pneumonia prevalence of 0.17 would need
    to test 588 children to detect one case

Wilkinson M et al. Acad Emerg Med 200916220-225
65
Canadian Pneumococcal Infection Rate
66
Conclusion
  • Given the current rate of occult bacteremia in
    the post-PCV era, it may no longer be cost
    effective to send blood cultures on
    well-appearing, previously healthy children aged
    3 to 36 months who have fever without source
  • If a child is known to be unimmunized it may
    still be wise to screen for OB as per pre-PCV
    recommendations

Wilkinson M et al. Acad Emerg Med 200916220-225
67
Clinical Question 10
  • How accurate is my ability to detect the absence
    of a pulse and the need to start chest
    compressions for cardiac arrest in a collapsed 1
    month old infant?

68
Reliability of Pulse Palpation by Healthcare
Personnel to Diagnose Paediatric Cardiac Arrest
  • Tibbals J and Russel P. Resuscitation
    20088061-64.

69
Objective and Methods
  • Objective to determine the reliability of pulse
    check to diagnose paediatric cardiac arrest
  • Methods
  • Doctors and nurses were asked to attempt pulse
    detection (within 10s) on an infant or child
    provided with non-pulsatile circulation with
    veno-arterial extracorporeal membrane oxygenation
    or left ventricular assistance for cardiac arrest
    or failure
  • Rescuer decision pulse present or pulse
    absent compared with concurred decision of
    investigators and bedside nurse

Tibbals J and Russel P. Resuscitation
20088061-64
70
Results
  • 209 doctors and nurses
  • Pulse palpation was conducted on 16 infants and
    children (average age 1.8 years, range 1 week to
    13 years)
  • 179 (86) were able to decide if a pulse was
    present or absent within 10 s

Tibbals J and Russel P. Resuscitation
20088061-64
71
Results
Tibbals J and Russel P. Resuscitation
20088061-64
72
Conclusion
  • This study suggests that pulse palpation is an
    unreliable method by healthcare personnel to
    determine the presence or absence of circulation
    when cardiac arrest is suspected in children

Tibbals J and Russel P. Resuscitation
20088061-64
73
Take Home Points
  • Using a structured framework, the results of
    medical research can be translated into clinical
    practice
  • The treatment of wheezing in infants and children
    is likely to differ based on age, severity and
    etiology
  • PEG 3350 (combined with behavior modification)
    appears to be safe and efficacious for the
    treatment of functional constipation in children
  • We overprescribe antireflux medications for
    infants with GERD
  • Consider pretreatment with ondansetron for
    ketamine sedation

74
Take Home Points
  • Be on the look out for the incorporation of
    procalcitonin in the work up of fever without a
    source
  • Be aware of the potential risks of the casual use
    of acetaminophen (and all drugs) in otherwise
    healthy children
  • Consider ondansetron in the ED setting in
    children with vomiting and moderate dehydration
  • Blood cultures may not be necessary in immunized,
    well appearing, previously healthy children age 3
    to 36 months with fever without a source
  • When in doubt regarding the presence or absence
    of a pulse in a pediatric cardiac arrest, start
    compressions

75
References
  • Users Guide to the Medical Literature
  • Oxman AD, Sackett DL, Guyatt GH. How to Get
    Started. JAMA. 1993270(17)2093-2095.
  • Guyatt G. H. et al. EBM Principles of Applying
    Users Guides to Patient Care.JAMA.
    2000284(10)1290-1296.
  • Guyatt GH, Sackett, D, Cook, DJ. How to Use an
    Article About Therapy or Prevention.
    JAMA1993270(21)2598-2601 and
    1994271(1)59-63.
  • Jaeschke,R et al. How to Use an Article About a
    Diagnostic Test. JAMA 1994271(5)389-391 and
    1994271(9)703-707.
  • Levine et al. How to Use an Article about Harm.
    JAMA271(20)1615-1619.
  • Oxman AD, Cook, DJ, Guyatt, GH. How to Use and
    Overview. JAMA1994272(17)1367-71.
  • Available online http//www.cche.net/usersguides/m
    ain.asp (accessed May 25, 2009).

76
References
  • Assessing the Quality of Evidence
  • Downs SH and Black N. The feasibility of creating
    a checklist for the assessment of the
    methodological quality both of randomized and
    non-randomised studies of health care
    interventions. J Epidemiol Community Health
    199852377-384.
  • Verhagen AP et al. The Delphi list a criteria
    list for quality assessment of randomized
    clinical trials for conducting systematic reviews
    developed by Delphi consensus. J Clin Epidemiol.
    199851(12) 1235-41.
  • West, S. et al. Systems to Rate the Strength of
    Scientific Evidence, Evidence Report/Technology
    Assessment No. 47. AHRQ Publication No. 02-E016.
    Rockville, MD Agency for Healthcare Research and
    Quality. April 2002. http//www.ncbi.nlm.nih.gov/b
    ooks/bv.fcgi?ridhstat1.chapter.70996 (accessed
    05/09)
  • AAP Clinical Practice Guideline. Diagnosis and
    Management of Bronchiolitis. Pediatrics
    2006118(4)1774-1793.

77
Hierarchy of Evidence
  • Strength of Evidence for Treatment Decisions
  • N of 1 randomized trial
  • Systematic reviews of randomized trials
  • Single randomized trial
  • Systematic review of observational studies
    addressing patient-important outcomes
  • Single observational study addressing
    patient-important outcomes
  • Physiological studies
  • Unsystematic clinical observations

78
Users' Guides for an Article About Therapy
  • Are the results of the study valid?
  • Was the assignment of patients to treatments
    randomized?
  • Were all patients who entered the trial properly
    accounted for and attributed at its conclusion?
  • Was follow-up complete?
  • Were patients analyzed in the groups to which
    they were randomized?
  • Were patients, health workers, and study
    personnel "blind" to treatment?
  • Were the groups similar at the start of the
    trial?
  • Aside from the experimental intervention, were
    the groups treated equally?
  • What were the results?
  • How large was the treatment effect?
  • How precise was the estimate of the treatment
    effect?
  • Will the results help me in caring for my
    patients?
  • Can the results be applied to my patient care?
  • Were all clinically important outcomes
    considered?
  • Are the likely treatment benefits worth the
    potential harms and costs?


79
Guides for Selecting Articles
  • Primary Studies
  • Therapy
  • Was the assignment of patients to treatments
    randomized
  • Were all of the patients who entered the trial
    properly accounted for and attributed at its
    conclusion?
  • Diagnosis
  • Was there an independent, blind comparison with a
    reference standard?
  • Did the patients sampled include an appropriate
    spectrum of the sort of patients to whom the
    diagnostic test will be applied in clinical
    practice?

80
Guides for Selecting Articles
  • Primary Studies
  • Harm
  • Were there clearly identified comparison groups
    that were similar with respect to important
    determinants of outcome (other than the one of
    interest)?
  • Were outcomes and exposures measured in the same
    way in the groups being compared
  • Integrative Studies
  • Overview
  • Did the review address a clearly focused
    question?
  • Were the criteria used to select articles for
    inclusion appropriate
  • Oxman AD, Sackett DL, Guyatt GH. How to Get
    Started. JAMA. 1993270(17)2093-2095.

81
Changes in Clinical Characteristics of Patients
and Time to Discharge
Plint AC et al. N Engl J Med 20093602079-2089
82
Median Days to Symptom Resolution, with Ratio to
Placebo Value
Plint AC et al. N Engl J Med 20093602079-2089
83
Enrollment and Outcomes
Enrollment and Outcomes
Panickar J et al. N Engl J Med 2009360329-338
Panickar J et al. N Engl J Med 2009360329-338
84
Baseline Characteristics of the Patients
Panickar J et al. N Engl J Med 2009360329-338
85
Secondary Outcomes during Hospitalization
Panickar J et al. N Engl J Med 2009360329-338
86
Duration of Hospitalization
Duration of Hospitalization (Primary Outcome)
Panickar J et al. N Engl J Med 2009360329-338
Panickar J et al. N Engl J Med 2009360329-338
87
Secondary Outcomes after Discharge
Panickar J et al. N Engl J Med 2009360329-338
88
Kaplan-Meier Estimates of the Proportion of
Children Remaining in the Hospital
Panickar J et al. N Engl J Med 2009360329-338
89
Temporal Patterns of Wheeze
  • Episodic (viral wheeze) wheezing during discrete
    time periods, often in association with clinical
    evidence of a viral cold, with absence of wheeze
    between episodes.
  • Multiple-trigger wheeze Wheezing that shows
    discrete exacerbations, but also symptoms between
    episodes

Brand PLP et al. Definition, assessment and
treatment of wheezing disorders in preschool
children an evidence based approach. Eur Resp J
2008321096-110.
90
Results
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