JUST WHEN YOU THOUGHT IT WAS OVER
Okay, so the 2013–2014 bronchiolitis season may be a distant memory by time of publication, but I’m writing this in late March and currently have 4 infants with bronchiolitis on my service. So here’s 1 last bronchiolitis paper…until next season, that is.
This prospective, cross-sectional study conducted in Brazil sought to determine the impact of specific viruses on the severity of lower respiratory tract infection in children <3 years of age admitted to observation or inpatient units. Viral polymerase chain reaction testing on nasopharyngeal secretions was performed for a variety of common respiratory viruses. The primary outcome metric of interest was length of stay.
The key findings.
At least 1 virus was detected in 222 (85%) patients and 146 patients tested positive for multiple viruses. Respiratory syncytial virus (RSV) was the most commonly identified virus and was found in 54% of cases. Infants <6 months of age remained in the hospital 3.8 days (95% confidence interval [CI]: 2.7–5.0 days) longer than other children. A family history of asthma was linked to an extra 2.4 inpatient days (95% CI: 1.2–3.6 days). Infants with rhinovirus and RSV coinfection had longer length of stay than other infants (5.5 days longer, P <.001).
Why do we care?
Although the authors present a plethora of data regarding epidemiology of lower respiratory tract infection in infants and young children, the information I find specifically pertinent to us as pediatric hospitalists is the data regarding coinfection, particularly with regard to RSV and rhinovirus. This year alone, I’ve had several dozen infants with RSV and rhinoviral coinfection. These data will help not only in providing anticipatory guidance to families about the expected clinical course but also in clinical decision-making regarding those infants in whom recovery is delayed.
Straight from the author’s mouth…
“As one would expect, RSV was the most common pathogen detected by [polymerase chain reaction], but interestingly, the rate of co-detection was quite high (65%). Also, infants below the age of 6 months with double RSV plus human RV infections needed supplemental oxygen and days in hospital for significantly longer periods than did those with RSV-only. These data have been confirmed in yet another recent study from our group and already published online in PIDJ [the Pediatric Infectious Disease Journal], where co-infection was a significant risk factor for increased disease burden in the first year of life among children born prematurely. This information on the role of co-infection on bronchiolitis severity adds another important variable in an explanatory model and sure does shed some light on lifestyle issues that may be behind this new information.”
– Dr. Stein (senior author)
Citation: da Silva ER, Pitrez MC, Arruda ER, et al. Severe lower respiratory tract infection in infants and toddlers from a non-affluent population: viral etiology and co-detection as risk factors. BMC Infect Dis. 2013;13:41
MY LEAST FAVORITE PORTMANTEAU
Given the ridiculously cold 2013–2014 winter for most of the country, maybe you forgot all about global warming. Well, it turns out that pollution, specifically smog (a combination of the words smoke and fog), is still around, and over the past 15 years or so, we have started to see research examining the relationship between pollution and health. Although, to quote The Office’s Michael Scott, “I don’t need fresh air, because I’ve got the freshest air around. A.C.”
This retrospective, case-crossover study used Canada’s Discharge Abstract Database to collect data on patients hospitalized with appendicitis from 2004 through 2008 in 12 Canadian cities. Associations between ambient ozone concentrations and appendicitis were examined using daily maximum ozone concentrations collected by Canada’s National Air Pollution Surveillance network.
The key findings.
The study included 35 811 patients. The median age of the study population was 30 years, and 31% of patients had a perforated appendix. An increase in the 7-day average daily maximum ozone concentration of 16 parts-per-billion was positively associated with overall appendicitis (odds ratio = 1.07; 95% CI: 1.02–1.13) and with perforated appendicitis (odds ratio = 1.22; 95% CI: 1.09–1.36).
Why do we care?
Photochemical smog, the kind of smog commonly seen in places like Los Angeles, is produced when nitrogen dioxide from motor vehicle exhaust or industrial emissions is converted by sunlight into nitrogen oxide and an oxygen atom. This oxygen atom then combines with an oxygen molecule to produce ozone. Nitrogen oxide in the air typically acts as a buffer by converting ozone back into nitrogen dioxide and an oxygen molecule; however, volatile organic compounds (from chemicals, fabrics, paint, and the like) oxidize nitrogen oxide back into nitrogen dioxide without utilizing ozone, thereby causing the buildup of ozone that we see and smell as “smog.” This study suggests that an increase in ozone of 16 parts-per-billion can result in increased risk of perforated appendix. For reference, in 2013 Los Angeles recorded a daily average ozone concentration of 122 parts-per-billion.
Straight from the author’s mouth…
“Our findings indicate that the air we breathe may increase the risk of being hospitalized for acute perforated appendicitis. This is an important finding because perforated appendicitis is a potentially life threatening disease and air pollution exposure can be modified to protect health. These findings add to a growing body of literature that shows that acute elevation in air pollutants can harm human health. Pediatric hospitalists should be aware that they may see a rise in hospital admissions during periods when air pollution is elevated in their communities.”
– Dr. Gil Kaplan (lead author)
Citation: Kaplan G, Tanyingoh D, Dixon E, et al. Ambient ozone concentrations and the risk of perforated and nonperforated appendicitis: a multicity case-crossover study. Environ Health Perspect. 2013;121(8):939–943
SCANDALOUS MEDICAL RESEARCH
Here’s something a little different. This isn’t original research, nor is it even a journal article, but it’s a fascinating opinion piece on medical research titled “Medical Research—Still a Scandal” written by Dr. Richard Smith, former editor of the British Medical Journal, that probably warrants our attention. I won’t provide a huge synopsis here because the entire essay is only a page or 2 long, but if you’ve got a few spare minutes, it’s worth a read. He outlines an argument, using previously published essays and data, that the quality of medical research is often poor because “researchers are publishing studies that are too small, conducted over too short a time, and too full of bias in order to get promoted and secure future funding.”
Citation: Smith, R. “Medical research—still a scandal.” BMJ Group Blogs. Jan 31, 2014. Available at: http://blogs.bmj.com/bmj/2014/01/31/richard-smith-medical-research-still-a-scandal. Accessed April 10, 2014
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
- 95% confidence interval
- respiratory syncytial virus
- Copyright © 2014 by the American Academy of Pediatrics