Quality of the discussion of asthma on twitter.

IntroductionPatients obtain a large amount of medical information online. Much of this information may not be reliable or of high quality. We investigated what influences the discussion of asthma on Twitter by evaluating the most popular tweets and the quality of the links shared.MethodsWe used Symplur Signals to extract data from Twitter examining characteristics of the top 100 most shared tweets and the 50 most shared links that included the hashtag #asthma. Information on each site was assessed using an Asthma Content score, and validated DISCERN scores and HONCode criteria.ResultsThe top 100 asthma-related tweets were shared 10,169 times and had 16,044 likes. Healthcare organizations posted 49 of the top 100 tweets, non-healthcare individuals posted 20, non-healthcare organizations posted 16 and clinicians posted 14. Of the top 100 tweets, 62 were educational, 11 research-related, 10 political and 15 promotional. The top 50 links were shared 6009 times (median number of shares 92 per link (range 60-710)). Links most commonly (42%) led to educational content while 24% of links led to research articles, 22% to promotional websites, and 12% to political websites. Educational links had higher Asthma Content scores than other links (p < 0.005). Overall, all three scores were low for all types of links. Only 34% of sites met HONCode criteria, and 14% were assessed as high quality by DISCERN score.ConclusionThe top tweets using the hashtag #asthma were commonly educational. The majority of top links on Twitter scored poorly on asthma content, quality, and reliability.

Assessing Frequency of Respiratory Complications in Children Undergoing Adenotonsillectomy.

OBJECTIVES: To determine the frequency of respiratory complications in children admitted to the ICU after adenotonsillectomy and to identify factors associated with the risk of respiratory complications in this cohort. DESIGN: Retrospective observational study. SETTING: PICU. PATIENT POPULATION: All children admitted to the ICU following adenotonsillectomy from September 30, 2009, to March 30, 2014. MEASUREMENTS AND MAIN RESULTS: Of the 165 children included in the study, 150 (91%) received no respiratory support other than oxygen in the first 2 hours postoperatively. Of the 15 who required support following 2 hours, 14 required nasopharyngeal airways, one required invasive mechanical ventilation, and seven required supplemental oxygen for more than 2 hours. None of the children who received respiratory support for less than 2 hours required subsequent ICU level care. When comparing those who received support for more than 2 hours to those who did not, there were no differences in clinical characteristics except that those who received support were more likely to have chronic neurologic disease including autism, seizures, or cerebral palsy (odds ratio, 3.7; 95% CI, 1.1-11.9; p = 0.04). Intraoperative events were not predictive of need for respiratory support. Most of the children (n = 117/165 or 71%) had sleep studies preoperatively. Abnormal sleep studies (apnea-hypopnea index > 20 [n = 68] or oxygen saturation nadir < 80% [n = 48]) were not associated with need for postoperative respiratory support. CONCLUSIONS: Most children admitted to the ICU following adenotonsillectomy in this population required no support after 2 hours. Preoperative factors such as obesity and abnormal sleep studies were not predictive of need for postoperative respiratory support. Need for respiratory support at 2 hours may be a useful criterion for need for ICU level care in this population.

Describing the Digital Footprints or "Sociomes" of Asthma for Stakeholder Groups on Twitter.

Background: Although there is a great deal of conversation on social media, there may not be good communication. Objective: We sought to investigate communicaton activity online by examining digital footprints (or "sociomes") of asthma stakeholders on Twitter. Methods: Tweets containing the word "asthma" and the hashtag #asthma were collected using Symplur Signals. Characteristics of usage and tweets were analyzed and compared first between the word "asthma" and the hashtag #asthma, and then among four different stakeholder groups: clinicians, patients, healthcare organizations, and industry. Results: The #asthma sociome was significantly smaller than the "asthma" sociome, with fewer users and tweets per month. However, the #asthma sociome correlated better to asthma seasons and was less susceptible to vulgarity and viral memes. For the #asthma sociome, there were 695,980 tweets by 308,370 users between April 2015 and November 2018. Clinicians were responsible for 16% of tweets, patients 9%, healthcare organizations 22%, and industry 0.3%. There were significant differences in the tweet characteristics, with healthcare organizations more likely to tweet with links, clinicians more likely to mention other users, and industry more likely to use visuals. Each April-May, there were significant spikes in the frequency of tweets by patients, healthcare organizations, and industry, whereas the usage patterns of clinicians were more random. There were also differences in the top terms and hashtags tweeted with #asthma in the stakeholder groups. Conclusion: Asthma stakeholder groups tweet differently, at different times, and use different associated terms. Further exploration may help improve health care-related communication and help guide education of patients and clinicians.

Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis.

OBJECTIVE: Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. Response to albuterol is determined by clinical assessment, but this subjective determination is potentially unreliable. In this study, we compared providers' clinical assessment of response to albuterol with the measurement of response by pulmonary mechanics in intubated, sedated, and ventilated infants. DESIGN: Before and 20 minutes following racemic albuterol therapy, a nurse, respiratory therapist, and physician performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times. SETTING: This study was conducted in a PICU of a children's hospital. PATIENTS: Seventy-five paired clinical assessments were made in 25 infants who were intubated and mechanically ventilated for severe bronchiolitis. INTERVENTIONS: Pulmonary function measurements and clinical assessments before and after administration of albuterol. MEASUREMENTS AND MAIN RESULTS: Response to albuterol was defined using a threshold of improvement in respiratory system resistance from baseline. Nine children (36%) had greater than 20% change and were deemed responders. Providers' discrimination of response was poor. The positive predictive values of nurses, respiratory therapists, and physicians were 38%, 25%, and 25%, respectively, and the negative predictive values were 67%, 54%, and 59%, respectively. Overall accuracy was 44% for nurses, 40% for respiratory therapists, and 48% for physicians. When comparing separate assessments of wheezing, aeration, and expiratory time, there was poor agreement between groups of providers in all variables (κ < 0.4 for each). CONCLUSIONS: A provider's clinical assessment was not a reliable method for determining response to albuterol in children with bronchiolitis. Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.

A regional cohort study of the treatment of critically ill children with bronchiolitis.

OBJECTIVE: To describe the treatment practices in critically ill children with RSV bronchiolitis across four regional PICUs in the northeastern United States, and to determine the factors associated with increased ICU length of stay in this population. METHODS: We conducted a retrospective cohort study of children who were admitted with RSV bronchiolitis between July 2009 and July 2011 to the PICUs of Connecticut Children's Medical Center, Yale-New Haven Children's Hospital, Maria Fareri Children's Hospital, and Baystate Children's Hospital. Data were collected regarding clinical characteristics and intensive care course among these hospitals. RESULTS: During the study period, 323 children were admitted to one of the four ICUs with RSV bronchiolitis. Despite similar mortality risk scores among ICUs, there was considerable variation in the use of therapies, particularly intubation and mechanical ventilation, in which there was greater than a 3.5-fold increased risk of intubation between sites with the highest and lowest frequency of intubation (odds ratio: 3.8; 95% confidence interval: 2.2-6.4). Albuterol was the most commonly used respiratory treatment, followed by chest physiotherapy, high-flow nasal cannula, and hypertonic saline. Longer stays in the ICU were associated with more frequent use of therapies, specifically invasive mechanical ventilation, inhaled corticosteroids, intrapulmonary percussive ventilation, and chest physiotherapy. CONCLUSIONS: Even within a close geographic region, there is significant variation in the treatment provided to critically ill children with RSV bronchiolitis. None of these treatments were associated with shorter durations of hospitalization in this population and some, such as mechanical ventilation, were associated with longer ICU lengths of stay.

Factors associated with disease severity in children with bronchiolitis.

OBJECTIVE: Bronchiolitis is one of the top causes of hospitalization of infants in the United States. Several clinical factors have been associated with hospitalization; however, few studies have examined factors related to severe disease. Our goal was to describe the clinical characteristics and hospital course of children admitted with bronchiolitis and to identify factors related to intensive care unit (ICU) admission in this population. METHODS: We conducted a retrospective review of all children less than 2 years of age admitted to a children's hospital with bronchiolitis between July 2008 and July 2011. Demographic and clinical data were collected including information regarding hospital course, treatments received and respiratory pathogens. RESULTS: During the study period, 734 children were admitted to the hospital with bronchiolitis, 22% of whom were admitted to the ICU and 10% of whom were intubated and mechanically ventilated. Admission to the ICU was associated with younger age [110 (45-210) days versus 69 (35-149) days, p < 0.001] and history of premature birth (OR 1.7, 95% CI 1.1-2.4, p = 0.01), but not with race or ethnicity. The use of respiratory treatments was common in the children admitted to the ICU but was not associated with shortened durations of hospitalization. In addition, neither prematurity nor young age were associated with either increased duration of hospitalization or with increased likelihood of mechanical ventilation. CONCLUSIONS: During acute bronchiolitis infections, younger children and those with a history of prematurity were more likely to be admitted to the ICU with severe disease.

Transient occult cardiotoxicity in children receiving continuous beta-agonist therapy.

BACKGROUND: Continuous beta-agonist therapy, typically in the form of inhaled albuterol, is the first line therapy for the treatment of acute and severe bronchospasm in children. Although this treatment is commonly used, concerns about cardiotoxicity have been raised. We aimed to investigate the cardiotoxic effects of continuous beta-agonist therapy in children. METHODS: We conducted a retrospective review of children admitted to the intensive care unit (ICU) between May 2008 and April 2009, who were treated with continuous beta-agonist therapy (intravenous and nebulized). RESULTS: Twenty of the 36 children treated with continuous albuterol had repeated serum troponin-T and lactate levels measured. Eleven patients (55%) were also treated with continuous intravenous terbutaline. Elevated levels of troponin-T levels were found in 25% of children, and elevated lactate levels were found in 60%. However, all returned to normal levels within 48 hours of ICU admission, despite continued beta-agonist therapy. No children experienced arrhythmias during therapy. There was no association between intravenous terbutaline use and elevated troponin-T [odds ratio (OR), 1.3; 95% CI, 0.2-10.3] or with elevated serum lactate (OR, 0.6; 95% CI, 0.1-3.7). There was also no association between elevated troponin-T or lactate and ICU or hospital length of stay. CONCLUSIONS: In this small study, a significant proportion of children had elevated serum troponin-T and lactate levels while receiving inhaled continuous beta-agonist therapy, irrespective of intravenous therapy. However, these abnormal values all returned to normal within 48 hours of ICU admission and were not associated with increased duration of hospitalization.

Pediatric code events: does in-house intensivist coverage improve outcomes?*.

OBJECTIVES: A change in our children's hospital coverage model to providing full-time in-house supervision by intensivists allowed us to evaluate the impact of this change on patient safety outcomes. Our aim was to determine whether in-house attending coverage influenced the prevalence and outcomes of pediatric code events. DESIGN: We conducted a retrospective review of all code events between October 2005 and October 2007 (before in-house intensivist supervision) and compared the prevalence, interventions, and outcomes of these codes with those occurring between April 2008 and April 2010 (after in-house intensivist supervision). A code event was defined as any activation of the code system. SETTING: One hundred eighty-seven bed children's hospital. SUBJECTS: All children with code events. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 99 codes during these two periods: 39 codes occurring prior to in-house intensivist coverage (of which eight on the ward and 31 in the ICU) and 60 occurring following in-house attending coverage (30 on the ward and 30 in the ICU). Survival was significantly improved following the implementation of in-house coverage (odds ratio, 4.3; 95% CI, 1.7-10.8; p = 0.003). There was no significant change in the overall rate of codes during these two periods (0.82 codes/1,000 patient-days before implementation vs 1.17 codes/1,000 patient-days after implementation). However, there were significantly more codes on the ward following in-house intensivist coverage (0.2 codes/1,000 patient-days before implementation vs 0.71 codes/1,000 patient-days after implementation; p = 0.013). An intensivist was significantly more likely to be present during these events (odds ratio, 28; 95% CI, 3-273; p = 0.001); however, the acuity of the children with codes on the ward was significantly lower during the in-house coverage period (p = 0.001). There were no changes in the rate or outcomes of codes occurring in the ICU with this change in coverage. CONCLUSIONS: In the period following implementation of in-house intensivist supervision, children with code events were more likely to survive to hospital discharge. Having an intensivist in-house 24 hr/d, 7 d/wk may be associated with improved outcomes in hospitalized children.

Pediatric status asthmaticus.

Status asthmaticus is a frequent cause of admission to a pediatric intensive care unit. Prompt assessment and aggressive treatment are critical. First-line or conventional treatment includes supplemental oxygen, aerosolized albuterol, and corticosteroids. There are several second-line treatments available; however, few comparative studies have been performed and in the absence of good evidence-based treatments, the use of these therapies is highly variable and dependent on local practice and provider preference. In this article the pathophysiology and treatment of status asthmaticus is discussed, and the literature regarding second-line treatments is critically assessed to apply an evidence basis to the treatment of this severe disease.

ß2-adrenergic receptor haplotype linked to intubation and mechanical ventilation in children with asthma.

BACKGROUND AND AIMS: Children with asthma and respiratory failure comprise a small but significant subset of children with acute asthma. In addition to clinical and historical factors that have been associated with respiratory failure, there may also be genetic factors that predispose some asthmatic children to intubation and mechanical ventilation. However, this has not previously been assessed in this population. We hypothesized that genetic polymorphisms of the ß(2)-adrenergic receptor (ADRß(2)) are associated with intubation and mechanical ventilation in children with asthma. MATERIALS AND METHODS: We performed genotyping of the ADRß(2) in a pooled cohort of 104 children admitted to the intensive care unit (ICU) with a severe asthma exacerbation between 2002 and 2008. Genotype of the ADRß(2) was compared with intubation for respiratory failure. RESULTS: At amino acid position 16, 33% (n = 34) of children were homozygous for the glycine allele (Gly16Gly), 15% (n = 16) were homozygous for the arginine allele (Arg16Arg), and 52% (n = 54) were heterozygous (Arg16Gly). At amino acid position 27, 54% (n = 56) of children were homozygous for the glutamine allele (Gln27Gln), 8% (n = 8) were homozygous for the glutamic acid allele (Glu27Glu), and 38% (n = 40) were heterozygous (Gln27Glu). The haplotypes at these positions were Arg16Gly-Gln27Gln (29%, n = 30), Arg16Gly-Gln27Glu (22%, n = 23), Gly16Gly-Gln27Glu (16%, n = 17), Arg16Arg-Gln27Gln (16%, n = 17), Gly16Gly-Gln27Gln (9%, n = 9), and Gly16Gly-Glu27Glu (8%, n = 8). Twelve children in this cohort were intubated for respiratory failure. Intubation was not associated with age, obesity, race/ethnicity, or NHBLI asthma classification. However, children with the Arg16Gly-Gln27Gln haplotype were significantly more likely to be intubated and mechanical ventilated (OR = 4.2; 95% CI = 1.2-14.5; p = .036) than children with other haplotypes of the ADRß(2). When examining the subset of intubated children, those with the Arg16Gly-Gln27Gln haplotype trended towards longer ICU length of stay (329 ± 270 vs. 124 ± 57 hours; p = .09), but this was not statistically significant. CONCLUSIONS: Children with the Arg16Gly-Gln27Gln haplotype of the ADRß(2) were four times more likely to be intubated and mechanically ventilated during severe asthma exacerbations. Genetic factors may influence the development of a more severe asthma phenotype during acute exacerbations.

Pulmonary mechanics following albuterol therapy in mechanically ventilated infants with bronchiolitis.

BACKGROUND AND AIMS: Bronchiolitis is a common cause of critical illness in infants. Inhaled ß(2)-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. MATERIALS AND METHODS: We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. RESULTS: Fifty-four infants were enrolled. The median age was 44 days (25-75%; interquartile range (IQR) 29-74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. CONCLUSIONS: In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.

Beta-adrenergic receptor polymorphisms associated with length of ICU stay in pediatric status asthmaticus.

BACKGROUND: During severe exacerbations, asthmatic children vary significantly in their response to high-dose continuous ß(2) -adrenergic receptor (ADRß(2) ) agonist therapy. Genetic polymorphisms have been identified within the ADRß(2) that may be functionally relevant, but few studies have been performed in this population. Our hypothesis was that genotypic differences are associated with magnitude of response to ADRß(2) agonist treatment during severe asthma exacerbations in children. METHODS: Children aged 2-18 years admitted to the ICU (intensive care unit) with a severe asthma exacerbation between 2006 and 2008 were eligible. Genotyping of the ADRß(2) was performed. RESULTS: Eighty-nine children consented and were enrolled. Despite similar clinical asthma scores on admission, children with the Gly(16) Gly genotype at amino acid position 16 had significantly shorter ICU length of stay (LOS) and hospital LOS, compared to children with Arg(16) Arg and Arg(16) Gly genotypes. Children with either the Gln(27) Glu or Glu(27) Glu genotype at amino acid position 27 also had significantly shorter ICU LOS and hospital LOS compared to children with the Gln(27) Gln genotype. The Arg(16) Gly-Gln(27) Gln haplotype was associated with the longest ICU LOS, but this was not statistically different from other haplotypes. CONCLUSIONS: In this cohort of children with severe asthma exacerbations, ADRß(2) polymorphisms were associated with responses to therapy. Knowledge of the genetic profile of children with asthma may allow for targeted therapy during acute exacerbations.

Factors associated with the development of severe asthma exacerbations in children.

BACKGROUND: Asthma exacerbations are one of the most common causes of hospitalization in children and account for approximately 10,000 intensive care unit (ICU) admissions per year in the United States. Despite the prevalence of this disease in children, the factors associated with the development of these severe exacerbations are largely unknown. METHODS: A retrospective case-control study was conducted involving all eligible children admitted to the hospital with asthma for a 1-year period. Potential associated factors and outcomes of children admitted to the ICU with a severe exacerbation (cases) were compared to those of children with acute asthma admitted to the ward (controls). RESULTS: A total of 188 children were hospitalized with asthma during the study period, 57 (30%) of whom required admission to the ICU. There were no differences in age, gender, or race between cases and controls. Children admitted to the ICU were significantly more likely to have an allergy or irritant-triggered exacerbation than children admitted to the ward (OR 3.9; 95% CI 1.9-8.2; p = .0003). Additionally, children in the ICU had a significantly shorter duration of illness before being admitted to the hospital compared to those admitted to the ward (1.7 ± 2.3 vs. 3.4 ± 4.8 days; p = .002). CONCLUSIONS: In this retrospective review, severe asthma exacerbations in children are associated with a more rapid onset of symptoms and are more likely to be associated with allergens or irritants, supporting the importance of atopy in this population.