This is the fi rst clinical practice guideline from the American Academy of Pediatrics that specifi cally applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defi ned as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper-or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this defi nition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient-and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefi t-harm relationship, and the strength of recommendation.

Aims: To determine the most likely diagnoses when infants first present with an apparent life threatening event (ALTE). Methods: Medline (1966Medline ( -2002, Embase (1980-2002), and Cinahl (1982-2002 were searched. Primary authors and content experts were contacted to identify further studies. Bibliographies from studies, reviews, and textbooks were searched. Foreign language studies were translated. Articles were included if the ALTE was clearly defined and if the evaluation recorded was from the initial contact. Case reports and studies focusing on single conditions or non-clinical data were excluded. Results: From an initial 2912 papers, eight studies involving 643 infants (aged 0-13 months) were included. All studies were non-randomised and methodological quality varied. All diagnoses were made after evaluation in hospital but investigation protocols varied widely. There were 728 diagnoses assigned overall. Some infants had multiple diagnoses. The most common diagnoses were gastro-oesophageal reflux (n = 227), seizure (n = 83), lower respiratory tract infection (n = 58), and ''unknown'' (n = 169). Five deaths were noted in total. Conclusions: There is a wide range of diagnoses reported after evaluation of an ALTE. Differing management protocols contributed to variations in the frequency of the diagnoses. The development and validation of an evidence based management plan may contribute to the care of this common condition.

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budesonide versus oral steroid in severe exacerbations of childhood asthma.

Background: Bronchiolitis describes a viral inflammation of the bronchioles in the lower respiratory tract that is typically caused by infection with respiratory syncytial virus (RSV). Bronchiolitis is characterized by high morbidity and affects approximately one in three infants. Children are currently treated with a variety of therapies that may be ineffective or even harmful; potential therapies include antibiotics, bronchodilators, chest physiotherapy, epinephrine, extrathoracic pressure, glucocorticoids, heliox, hypertonic saline, immunoglobulin, inhaled corticosteroids and oxygen therapy.Objectives: This updated overview of reviews aims to synthesize evidence from the Cochrane Database of Systematic Reviews (CDSR) on the effectiveness and safety of 11 pharmacologic and non-pharmacologic treatments to improve bronchiolitis symptoms in outpatient, inpatient and intensive care populations. Methods:The CDSR was searched using the term 'bronchiolitis' restricted to the title, abstract or keywords for all systematic reviews examining pharmacologic or non-pharmacologic interventions for the treatment of bronchiolitis in infants and children. Data were extracted, complied into tables, and synthesized using qualitative and quantitative methods.Main Results: For outpatients with bronchiolitis (defined as the first episode of wheezing in children under two), nebulized epinephrine decreased hospitalization rate on day one by 33% (RR: 0.67; 95% CI: 0.50, 0.89; 4 trials; 920 participants). With the addition of glucocorticoids, there was a reduction of similar magnitude for hospitalization rate within seven days (RR: 0.65; 95% CI: 0.44, 0.95; 1 trial; 400 participants). For inpatients, nebulized epinephrine versus bronchodilator and 3% hypertonic saline versus 0.9% saline each decreased length of stay: epinephrine decreased length of stay by seven hours (MD: −0.28; 95% CI: −0.46, −0.09; 4 trials; 261 participants), and 3% hypertonic saline decreased length of stay by 28 hours (MD: −1.16; 95% CI: −1.55, −0.77; 4 trials; 282 participants).Outpatients treated with epinephrine or epinephrine and glucocorticoid combined both had significantly lower clinical scores at 60 minutes (SMD: −0.45; 95% CI: −0.66, −0.23; 4 trials; 900 participants, and SMD: −0.34; 95% CI: −0.54, −0.14; 1 trial; 399 participants). For inpatients, epinephrine versus bronchodilator led to a significantly lower clinical score at both 60 minutes (SMD: −0.79; 95% CI: −1.45, −0.13; 4 trials; 248 participants; I 2 : 79%) and 120 minutes (SMD: −0.52; 95% CI: −0.86, −0.18; 1 trial; 140 participants). Inpatients treated with chest physiotherapy or 3% hypertonic saline both had significantly lower clinical scores at 1-3 days (SMD: −0.55; 95% CI: −0.98, −0.12; 1 trial; 87 participants, and SMD: −0.84; 95% CI: −1.39, −0.30; 3 trials; 183 participants). Authors' Conclusions:For outpatients with bronchiolitis, nebulized epinephrine can be effective in avoiding hospitalization. Systemic glucocorticoids such as dexamethasone cannot be recommended as a routine therapy gi...

Background: Patients with inflammatory bowel diseases (IBD) require repeated healthcare encounters, although the focus of care differs when patients are seen in ambulatory, emergency department (ED), or inpatient settings. We examined contemporary trends and disparities in IBDrelated healthcare visits. Methods:We used data from the National Ambulatory Medical Care Survey, Nationwide Emergency Department Sample, and National Inpatient Sample to estimate the total number of annual IBD-related visits from 2005 through 2016. We performed logistic regression analyses to test temporal linear trends. Slope and differences in distributions of patient demographics were compared across time and treatment settings.Results: From 2005 through 2016, approximately 2.2 million IBD-related ambulatory visits (95 CI, 1.9-2.5 million IBD-related ambulatory visits) occurred annually on average, increasing by 70.3% from the time period of 2005-2007 through the time period of 2008-2010, and decreasing by 19.8% from the time period of 2011-2013 through the time period of 2014-2016. An average of 115,934 IBD-related ED visits (95% CI, 113,758-118,111 IBD-related ED visits) and 89,111 IBD-related hospital discharges (95% CI, 87,416-90,807 IBD-related hospital discharges) occurred annually. Significant increases in the rate of IBD-related ED visits (3.2 visits/10,000 encounters, P<.0001) and hospital discharges (6.0 discharges/10,000 encounters, P<.0001) were observed from 2005 through 2016. The proportion of patients paying with private insurance decreased from 2005 through 2016, among all care settings. A greater proportion of young patients, patients with Crohn's disease, non-white patients, and patients with Medicare or Medicaid used hospital-based vs ambulatory services. Conclusions:In an analysis of data from 3 large databases, we found that although IBD-related ambulatory visits stabilized-to-decreased from 2005 through 2016, rates of ED use and admission Ma et al.

Objectives: The objectives of this study were to: 1) determine the association between vasopressor dosing intensity during the first 6 hours and first 24 hours after the onset of septic shock and 30-day in-hospital mortality; 2) determine whether the effect of vasopressor dosing intensity varies by fluid resuscitation volume; and 3) determine whether the effect of vasopressor dosing intensity varies by dosing titration pattern. Design: Multicenter prospective cohort study between September 2017 and February 2018. Vasopressor dosing intensity was defined as the total vasopressor dose infused across all vasopressors in norepinephrine equivalents. Setting: Thirty-three hospital sites in the United States (n = 32) and Jordan (n = 1). Patients: Consecutive adults requiring admission to the ICU with septic shock treated with greater than or equal to 1 vasopressor within 24 hours of shock onset. Interventions: None. Measurements and Main Results: Out of 1,639 patients screened, 616 were included. Norepinephrine (93%) was the most common vasopressor. Patients received a median of 3,400 mL (interquartile range, 1,851–5,338 mL) during the 24 hours after shock diagnosis. The median vasopressor dosing intensity during the first 24 hours of shock onset was 8.5 μg/min norepinephrine equivalents (3.4–18.1 μg/min norepinephrine equivalents). In the first 6 hours, increasing vasopressor dosing intensity was associated with increased odds ratio of 30-day in-hospital mortality, with the strength of association dependent on concomitant fluid administration. Over the entire 24 hour period, every 10 μg/min increase in vasopressor dosing intensity was associated with an increased risk of 30-day mortality (adjusted odds ratio, 1.33; 95% CI, 1.16–1.53), and this association did not vary with the amount of fluid administration. Compared to an early high/late low vasopressor dosing strategy, an early low/late high or sustained high vasopressor dosing strategy was associated with higher mortality. Conclusions: Increasing vasopressor dosing intensity during the first 24 hours after septic shock was associated with increased mortality. This association varied with the amount of early fluid administration and the timing of vasopressor titration.

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