***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Rhinovirus-induced early wheezing has been suggested as a new important risk factor for recurrent wheezing . Objective We sought to investigate the risk factors for recurrent wheezing and to determine post hoc the efficacy of prednisolone in risk groups . Methods We followed for 1 year 118 children ( median age , 1.1 years ) who had had their first episode of wheezing and had participated in a trial comparing prednisolone with placebo in hospitalized children . Demographics and laboratory data were obtained at study entry . The follow-up outcome was recurrent wheezing ( 3 physician-confirmed episodes ) . Results Recurrent wheezing was diagnosed in 44 ( 37 % ) children . Independent risk factors were age < 1 year , atopy , and maternal asthma . The probability of recurrent wheezing was higher in rhinovirus than respiratory syncytial virus (RSV)–affected children among placebo recipients ( hazard ratio , 5.05 ; 95 % CI , 1.00 - 25.41 ) . Prednisolone decreased the probability of recurrent wheezing in children with eczema ( 0.15 ; 95 % CI , 0.04 - 0.63 ) but not in those without eczema ( 1.89 ; 95 % CI , 0.83 - 4.29 ; P = .007 for interaction ) . Prednisolone was associated with less recurrent wheezing in the rhinovirus group ( 0.19 ; 95 % CI , 0.05 - 0.71 ) , but not in the RSV ( 2.12 ; 95 % CI , 0.46 - 9.76 ) or in the RSV/rhinovirus-negative groups ( 2.03 ; 95 % CI , 0.83 - 5.00 ; P = .017 for interaction ) . Conclusion Rhinovirus-induced early wheezing is a major viral risk factor for recurrent wheezing . Prednisolone may prevent recurrent wheezing in rhinovirus-affected first-time wheezers . The presence of eczema may also influence the response to prednisolone . Clinical implication s A prospect i ve trial is needed to test the hypothesis that prednisolone reduces recurrent wheezing in rhinovirus-affected wheezing children OBJECTIVES . Although bronchiolitis is the leading cause of hospitalization for infants , there are limited data describing the epidemiology of bronchiolitis hospitalizations , and the associated cost is unknown . Our objective was to determine nationally representative estimates of the frequency of bronchiolitis hospitalizations and its associated costs . PATIENTS AND METHODS . We analyzed the 2002 Health Care Utilization Project-National Inpatient Sample , a federal , stratified r and om survey of hospital discharges . For admissions age < 2 years with a discharge diagnosis of bronchiolitis ( International Classification of Diseases , Ninth Revision , Clinical Modification , code 466.1 ) , we used nationally representative weighted estimates to determine frequency and total hospital charges . Costs were estimated from reported charges by applying hospital-specific cost/charge ratios based on all-payer inpatient cost . RESULTS . In 2002 , an estimated 149000 patients were hospitalized with bronchiolitis .  Frequency of hospitalizations was higher among children age < 1 year of age , male gender , and nonwhite race .  Mean length of stay was 3.3 days . Total annual costs for bronchiolitis-related hospitalizations were $ 543 million , with a mean cost of $ 3799 per hospitalization . Mean cost of bronchiolitis with a codiagnosis of pneumonia was $ 6191 . In a multivariate analysis controlling for 3 confounding factors ( including length of stay ) , cost per hospitalization was higher for children ≥1 year and lower for those in the South versus Northeast . CONCLUSIONS . Bronchiolitis admissions cost more than $ 500 million annually . A codiagnosis of bronchiolitis and pneumonia almost doubles the cost of the hospitalization . Inpatient health care costs of bronchiolitis are higher than estimated previously and highlight the need for initiatives to safely reduce bronchiolitis hospitalizations and thereby decrease health care costs Background The ideal evidence to answer a question about the effectiveness of treatment is a systematic review . However , for many clinical questions a systematic review will not be available , or may not be up to date . One option could be to use the evidence from an individual trial to answer the question ? Methods We assessed how often ( a ) the estimated effect and ( b ) the p-value in the most precise single trial in a meta- analysis agreed with the whole meta- analysis . For a r and om sample of 200 completed Cochrane Review s ( January , 2005 ) we identified a primary outcome and extracted : the number of trials , the statistical weight of the most precise trial , the estimate and confidence interval for both the highest weighted trial and the meta- analysis overall . We calculated the p-value for the most precise trial and meta- analysis . Results Of 200 review s , only 132 provided a meta- analysis of 2 or more trials , with a further 35 effect estimates based on single trials . The average number of trials was 7.3 , with the most precise trial contributing , on average , 51 % of the statistical weight to the summary estimate from the whole meta- analysis . The estimates of effect from the most precise trial and the overall meta-analyses were highly correlated ( rank correlation of 0.90).There was an 81 % agreement in statistical conclusions . Results from the most precise trial were statistically significant in 60 of the 167 evaluable review s , with 55 of the corresponding systematic review s also being statistically significant . The five discrepant results were not strikingly different with respect to their estimates of effect , but showed considerable statistical heterogeneity between trials in these meta-analyses . However , among the 101 cases in which the most precise trial was not statistically significant , the corresponding meta-analyses yielded 31 statistically significant results . Conclusions Single most precise trials provided similar estimates of effects to those of the meta-analyses to which they contributed , and statistically significant results are generally in agreement . However , " negative " results were less reliable , as may be expected from single underpowered trials . For systematic review ers we suggest that : ( 1 ) key trial(s ) in a review deserve greater attention ( 2 ) systematic review ers should check agreement of the most precise trial and the meta analysis . For clinicians using trials we suggest that when a meta- analysis is not available , a focus on the most precise trial is reasonable provided it is adequately powered BACKGROUND Although it is the most common lower respiratory infection of infancy , the optimal treatment for acute bronchiolitis is still controversial . The aim of this study was to compare the early and late effects of nebulized L-epinephrine ( EPI ) and intramuscular dexamethasone ( DEX ) combination therapy with nebulized salbutamol ( SAL ) and dexamethasone combination and bronchodilators alone in out patients with acute bronchiolitis . METHODS A total of 69 infants aged 2 - 21 months who were admitted to the Pediatrics Department of the Faculty of Medicine , Mersin University , with acute bronchiolitis were included in a r and omized , placebo-controlled , prospect i ve trial study . Patients were assigned to receive either nebulized L-epinephrine ( 3 mg ) or salbutamol ( 0.15 mg/kg ) and 15 min later , either dexamethasone 0.6 mg/kg or placebo ( PLA ) , intramuscularly , in a double-blind r and omized fashion . The study groups were : epinephrine + dexamethasone group ( group 1 , n=23 ) , salbutamol + dexamethasone group ( group 2 , n=23 ) , epinephrine + placebo group ( group 3 , n=11 ) , and salbutamol + placebo group ( group 4 , n=12 ) . The outcome measures were heart rate , respiratory rate and Respiratory Distress Assessment Instrument ( RDAI ) score determined at 30 , 60 , 90 and 120 min , 24 h , and 5 days after the first therapy . Patients were then followed-up during the subsequent 2 months for the prevalance of respiratory complaints regarding bronchial hyperreactivity . RESULTS There were no significant differences between the outcome variables of the four groups within the first 120 min and at 24 hours , or between the rates of requirement of a second dose of the same bronchodilator . However , fifth day RDAI score values of both DEX groups were significantly lower than that of SAL + PLA group ( P=0.000 and P=0.01 , respectively ) . The fifth day score value of group 1 was also significantly better than that value of EPI + PLA group but not different from group 2 . CONCLUSIONS A single dose of intramuscular dexamethasone added to nebulized L-epinephrine , or salbutamol therapies result ed in better outcome measures than bronchodilators alone in the late phase ( fifth day ) of mild to moderate degree bronchiolitis attack . However , effects of EPI + DEX combination was not different from SAL + DEX combination Background The evaluation of more than one intervention in the same r and omised controlled trial can be achieved using a parallel group design . However this requires increased sample size and can be inefficient , especially if there is also interest in considering combinations of the interventions . An alternative may be a factorial trial , where for two interventions participants are allocated to receive neither intervention , one or the other , or both . Factorial trials require special considerations , however , particularly at the design and analysis stages . Discussion Using a 2 × 2 factorial trial as an example , we present a number of issues that should be considered when planning a factorial trial . The main design issue is that of sample size . Factorial trials are most often powered to detect the main effects of interventions , since adequate power to detect plausible interactions requires greatly increased sample sizes . The main analytical issues relate to the investigation of main effects and the interaction between the interventions in appropriate regression models . Presentation of results should reflect the analytical strategy with an emphasis on the principal research questions . We also give an example of how baseline and follow-up data should be presented . Lastly , we discuss the implication s of the design , analytical and presentational issues covered . Summary Difficulties in interpreting the results of factorial trials if an influential interaction is observed is the cost of the potential for efficient , simultaneous consideration of two or more interventions . Factorial trials can in principle be design ed to have adequate power to detect realistic interactions , and in any case they are the only design that allows such effects to be investigated OBJECTIVE High incidence , rising admission rates , and relatively ineffective therapies make the management of bronchiolitis controversial . Since 1980 , the rate of hospitalization for children with bronchiolitis has increased by nearly 250 % , whereas mortality rates for the disease have remained constant . It has been speculated that the increasing use of pulse oximetry has lowered the threshold for admission and may have contributed to the rise in bronchiolitis-related admissions . The objective of this study was to describe pediatric emergency medicine physicians ' management preferences regarding infants with moderately severe bronchiolitis and to assess the influence of specific differences in oxygen saturation as measured by  pulse oximetry ( SpO2 ) and respiratory rate ( RR ) on the decision to admit . METHODS Physicians who are members of the American Academy of Pediatrics Section of Emergency Medicine and living in the United States were r and omized into 4 groups and mailed a survey that contained 1 of 4 vignettes . Vignettes were identical except for given SpO2 values ( 94 % or 92 % ) and RR ( 50/min or 65/min ) . Subjects were asked to answer questions regarding laboratory tests , treatment options , and the decision to admit for the patient in their vignette . RESULTS We received completed surveys from 519 ( 64 % ) of the 812 physicians contacted . Most respondents recommended use of bronchodilators ( 96 % ) , nasal suction ( 82 % ) , and supplemental oxygen ( 57 % ) . Few respondents recommended decongestants ( 9 % ) , steroids ( 8 % ) , or antibiotics ( 2 % ) . When asked to rank therapies , respondents gave nasal suction 182 number 1 votes ; bronchodilators received 164 . The decision to admit varied with SpO2 and RR . Forty-three percent of respondents who received a vignette featuring SpO2 of 94 % and a RR of 50/min recommended admission for the infant in their vignette . Fifty-eight percent recommended admission when the vignette SpO2 was 94 % and RR was 65/min ( chi2 = 5.021 ) . Respondents who received a vignette with SpO2 of 92 % were nearly twice as likely to recommend admission : 83 % recommended admission when vignette RR was 50/min , and 85 % recommended admission when vignette RR was 65/min ( chi2 = 0.126 ) . CONCLUSIONS When treating infants with moderately severe bronchiolitis , pediatricians who work in emergency departments frequently use bronchodilators and nasal suction , 2 practice s for which supporting data are either conflicting ( bronchodilators ) or nonexistent ( nasal suction ) . In addition , their decisions to admit differ markedly on the basis of only a 2 % difference in SpO2 . It is possible that increased reliance on pulse oximetry has contributed to the increase in bronchiolitis hospitalization rates seen during the past 2 decades A predictable event in the paediatrician ’s year is the advent of the bronchiolitis season somewhere around November or December , with large numbers of hospital admissions of infants , especially those under 6 months of age . This continues to occur despite recent developments including the availability of palivizumab for prophylaxis in high-risk infants . The Scottish Intercollegiate 
    Output:
    
Current evidence does not support a clinical ly relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization .