Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department.
- 作者列表："Zamor R","Byczkowski T","Zhang Y","Vaughn L","Mahabee-Gittens EM
OBJECTIVES:Language barriers may influence the management of pediatric emergency department (PED) patients that may not align with evidence-based guidelines from the American Academy of Pediatrics (AAP). Our objective was to determine if a family's preferred language of Spanish versus English was associated with differences in management of bronchiolitis in the PED. STUDY DESIGN:We conducted a retrospective study of children ≤ 2 years old diagnosed with bronchiolitis in a PED over a seven-year period. Rates of PED testing, interventions and disposition among children whose families' preferred language was Spanish were compared to children whose families' preferred language was English. Primary outcomes were frequencies of chest x-ray and bronchodilator orders. Secondary outcomes were diagnostic testing, medication orders and disposition. Logistic regression was used to calculate adjusted odds ratios after controlling for age, emergency severity index, prior visit and nesting within attending physicians. RESULTS:A total of 13,612 encounters were included. Spanish-speaking families were more likely to have chest x-rays (35.8% vs. 26.7%, p<0.0001; adjusted odds ratio [aOR]:1.5; 95% confidence interval [CI]:1.2-1.9), CBCs (8.2% vs. 4.9%, p<0.005; aOR:1.7; 95%CI 1.2-2.5) and blood cultures ordered (8.1% vs. 5.0%, p<0.05; aOR:1.7; 95%CI 1.2-2.4). No other differences in bronchodilators, medication orders or disposition were found between the two groups. Conclusions: Among children diagnosed with bronchiolitis, Spanish-speaking families were more likely to have chest x-rays, CBCs and blood cultures ordered compared to English-speaking families.
目的: 语言障碍可能影响儿科急诊科 (PED) 患者的管理，可能不符合美国儿科学会 (AAP) 的循证指南。我们的目的是确定一个家庭的西班牙语与英语的首选语言是否与 PED 中毛细支气管炎管理的差异相关。 研究设计: 我们对在 PED 中诊断为毛细支气管炎的 ≤ 2 岁儿童进行了为期 7 年的回顾性研究。将家庭首选语言为西班牙语的儿童与家庭首选语言为英语的儿童的 PED 测试、干预和处置率进行比较。主要结局是胸部 x线和支气管扩张剂顺序的频率。次要结局为诊断测试、用药顺序和处置。在控制了年龄、急诊严重度指数、既往访视和主治医师嵌套后，使用 Logistic 回归计算调整后的优势比。 结果: 共纳入 13,612 次接触。讲西班牙语的家庭更有可能进行胸部 x光检查 (35.8% vs. 26.7%，p<0.0001; 校正比值比 [aOR]:1.5; 95% 置信区间 [CI]:1.2-1.9)，CBCs (8.2% vs. 4.9%，p<0.005; aOR:1.7; 95% CI 1.2-2.5) 和血培养有序 (8.1% vs. 5.0%，p<0.05; aOR:1.7; 95% CI 1.2-2.4)。两组之间未发现支气管扩张剂、用药顺序或处置的其他差异。 结论: 在诊断为毛细支气管炎的儿童中，与讲英语的家庭相比，讲西班牙语的家庭更有可能进行胸部 x光检查、 CBCs 和血培养。
METHODS:Background Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery. Methods Between April 2015 and March 2019, a total of 231 patients with small pulmonary lesions who received preoperative dye localization via AFB or percutaneous CT-guided technique were enrolled in the study. A propensity-matched analysis, incorporating preoperative variables, was used to compare localization and surgical outcomes between the two groups. Results After matching, a total of 90 patients in the AFB group ( N = 30) and CT-guided group ( N = 60) were selected for analysis. No significant difference was noted in the demographic data between both the groups. Dye localization was successfully performed in 29 patients (96.7%) and 57 patients (95%) with AFB and CT-guided method, respectively. The localization duration (24.1 ± 8.3 vs. 21.4 ± 12.5 min, p = 0.297) and equivalent dose of radiation exposure (3.1 ± 1.5 vs. 2.5 ± 2.0 mSv, p = 0.130) were comparable in both the groups. No major procedure-related complications occurred in either group; however, a higher rate of pneumothorax (0 vs. 16.7%, p = 0.029) and focal intrapulmonary hemorrhage (3.3 vs. 26.7%, p = 0.008) was noted in the CT-guided group. Conclusion AFB dye marking is an effective alternative for the preoperative localization of small pulmonary lesions, with a lower risk of procedure-related complications than the conventional CT-guided method.
METHODS:Background The use of artificial intelligence, including machine learning, is increasing in medicine. Use of machine learning is rising in the prediction of patient outcomes. Machine learning may also be able to enhance and augment anesthesia clinical procedures such as airway management. In this study, we sought to develop a machine learning algorithm that could classify vocal cords and tracheal airway anatomy real-time during video laryngoscopy or bronchoscopy as well as compare the performance of three novel convolutional networks for detecting vocal cords and tracheal rings. Methods Following institutional approval, a clinical dataset of 775 video laryngoscopy and bronchoscopy videos was used. The dataset was divided into two categories for use for training and testing. We used three convolutional neural networks (CNNs): ResNet, Inception and MobileNet. Backpropagation and a mean squared error loss function were used to assess accuracy as well as minimize bias and variance. Following training, we assessed transferability using the generalization error of the CNN, sensitivity and specificity, average confidence error, outliers, overall confidence percentage, and frames per second for live video feeds. After the training was complete, 22 models using 0 to 25,000 steps were generated and compared. Results The overall confidence of classification for the vocal cords and tracheal rings for ResNet, Inception and MobileNet CNNs were as follows: 0.84, 0.78, and 0.64 for vocal cords, respectively, and 0.69, 0.72, 0.54 for tracheal rings, respectively. Transfer learning following additional training resulted in improved accuracy of ResNet and Inception for identifying the vocal cords (with a confidence of 0.96 and 0.93 respectively). The two best performing CNNs, ResNet and Inception, achieved a specificity of 0.985 and 0.971, respectively, and a sensitivity of 0.865 and 0.892, respectively. Inception was able to process the live video feeds at 10 FPS while ResNet processed at 5 FPS. Both were able to pass a feasibility test of identifying vocal cords and tracheal rings in a video feed. Conclusions We report the development and evaluation of a CNN that can identify and classify airway anatomy in real time. This neural network demonstrates high performance. The availability of artificial intelligence may improve airway management and bronchoscopy by helping to identify key anatomy real time. Thus, potentially improving performance and outcomes during these procedures. Further, this technology may theoretically be extended to the settings of airway pathology or airway management in the hands of experienced providers. The researchers in this study are exploring the performance of this neural network in clinical trials.
METHODS:BACKGROUND:The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. This article compares the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination. METHODS:Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C). The primary outcome was the subject-rated severity of cough according to a visual analog scale. The secondary outcomes included bronchoscopist-rated severity of cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose, subject's willingness to undergo a repeat procedure, adverse reactions to lignocaine, and others. RESULTS:A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The median (interquartile range) score for subject-rated cough severity was significantly lower in group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30], respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P < .001), and the overall satisfaction was highest in group B (P < .001). The cumulative lignocaine dose administered was the least in group B (P < .001). A significantly higher proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events were observed. CONCLUSIONS:Ten actuations of 10% lignocaine oropharyngeal spray were superior to nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible bronchoscopy. TRIAL REGISTRY:ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.