An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations.

OBJECTIVES: A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization. METHODS: Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group. RESULTS: From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02). CONCLUSIONS: A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing.

BACKGROUND: Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies. METHODS: An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations. RESULTS: The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing. CONCLUSIONS: Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Official American Thoracic Society Clinical Practice Guidelines: diagnostic evaluation of infants with recurrent orPersistent wheezing

Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies. An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations. The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing. Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Response to sorafenib in a pediatric patient with papillary thyroid carcinoma with diffuse nodular pulmonary disease requiring mechanical ventilation.

BACKGROUND: Papillary thyroid cancer (PTC) presents with local and distant metastases more frequently in children than in adults. However, hypoxemia secondary to pulmonary metastases has not been reported in the literature. Sorafenib is a small-molecule multikinase inhibitor used in radioactive iodine ((131)I)-refractive papillary thyroid carcinoma. PATIENT FINDINGS: An eight-year-old boy presented with fever and hypoxemia and was found to have H1N1 viral pneumonia requiring mechanical ventilation and antiviral and glucocorticoid treatment. After initial improvement, he was readmitted one month later because of persistent hypoxemia. A high-resolution computed tomography of the chest and neck revealed multiple 1-4 mm nodules and necrotic lymph nodes on the right side of the neck. Left lung wedge resection and right deep cervical node biopsies were consistent with PTC. He underwent a total thyroidectomy with a central neck node dissection and postoperatively required prolonged mechanical ventilation. Due to the inability to be weaned from mechanical ventilation, treatment with sorafenib 200 mg daily (10 mg/kg/day, 250 mg/m(2)) was initiated. Eight days thereafter, ventilation support was discontinued and the child was extubated. However, he failed extubation secondary to supraglottic edema, and seven days later tracheostomy was performed. The dosage of sorafenib was increased to 200 mg twice daily (20 mg/kg/day, 500 mg/m(2)). After 52 days of therapy, a repeat computed tomography scan showed reduction in the lung nodule size to 1-2 mm. He underwent (131)I therapy 87 days after sorafenib was started. A post-treatment scan showed extensive uptake throughout the lungs and thyroid bed, supraclavicular nodes, and cervical nodes. CONCLUSIONS: This is the first reported case of a pediatric patient with respiratory failure possibly secondary to diffuse micronodular PTC requiring mechanical ventilation and subsequent delay in definitive therapy. Sorafenib could be considered for gap therapy when (131)I therapy cannot be administered in a timely manner. Treatment with this multikinase inhibitor does not seem to adversely affect the uptake of (131)I in radiation-naïve patients.