***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: OBJECTIVE In previously well infants hospitalized with acute viral bronchiolitis , the effectiveness of repeated nebulized therapy with epinephrine ( EPI ) was compared with treatment with albuterol ( ALB ) or saline placebo ( PLAC ) . STUDY DESIGN In this r and omized , double-blind , parallel-group , controlled trial , infants received study nebulizations every 1 to 6 hours and were assessed twice daily by the research team . The primary outcome was length of hospital stay ( LOS ) . Secondary outcomes included the time from admission until the infant had normal hydration , oxygenation , and minimal respiratory distress . RESULTS A total of 149 infants were r and omized ; 50 were allocated to receive racemic EPI , 51 were given ALB , and 48 received PLAC . Baseline characteristics and pre-enrollment symptoms , signs , and therapy were similar between groups . There were no group differences in the primary outcome measure , mean LOS (hours)(+/- SD ) : EPI = 59.8 ( 62 ) , ALB = 61.4 ( 54 ) , and PLAC = 63.3 ( 47 ) ; P = .95 by intent-to-treat analysis . Group differences were not statistically significant in any of the secondary outcomes . CONCLUSIONS There were no group differences in the effectiveness of therapy for infants hospitalized with bronchiolitis . Based on these results , we do not recommend routine use of either nebulized EPI or ALB in this patient group OBJECTIVE To investigate whether nebulized racemic epinephrine or albuterol improves respiratory distress in infants with acute bronchiolitis . DESIGN A r and omized , placebo-controlled , double-blind study . SETTING A university hospital providing primary hospital care for all pediatric patients in a defined area . PATIENTS One hundred consecutive infants younger than 24 months treated in the hospital for acute bronchiolitis . INTERVENTION The patients received two inhalations at 30-minute intervals : racemic epinephrine followed by physiologic saline ( REP group ; n = 24 ) , albuterol followed by physiologic saline ( AP group ; n = 27 ) , physiologic saline followed by racemic epinephrine ( PRE group ; n = 24 ) , and physiologic saline followed by albuterol ( PA group ; n = 25 ) . All patients received intramuscular epinephrine 60 minutes after the beginning of the study . MAIN OUTCOME MEASURES Oxygen saturation , respiratory rate , and two clinical scores were used : one based on wheezing and retractions ( Respiratory Distress Assessment Instrument ) and the other based on changes in wheezing , retractions , and respiratory rate ( Respiratory Assessment Change Score ) . MAIN RESULTS During the study , there were no significant differences among the four groups in clinical scores , oxygen saturations , and respiratory rates . Mean Respiratory Distress Assessment Instrument scores improved significantly within the REP , PRE , and AP groups 15 minutes after the first inhalation . In only the REP group , which received racemic epinephrine , the confidence limits did not overlap . A comparison of paired data of each patient revealed that the difference in Respiratory Assessment Change Score was significant between racemic epinephrine and physiologic saline , but not between albuterol and physiologic saline . Intramuscular epinephrine significantly improved Respiratory Distress Assessment Index scores in those groups treated earlier with racemic epinephrine ( REP and PRE groups ) . No significant adverse effects were seen in any group or at any phase of the study . CONCLUSIONS Elimination of hypoxia by supplemental oxygen and moistening of inspired air relieve the symptoms of acute bronchiolitis . Nebulized racemic epinephrine and albuterol are safe and useful in the treatment of acute bronchiolitis . Improvements in symptom scores at 15 minutes favor the use of racemic epinephrine . As the action of epinephrine is short , the effect can be increased by repeated inhalations OBJECTIVES Bronchiolitis is the most common disease of the lower respiratory tract in the first year of life . Treatment is controversial , with studies giving conflicting views on the benefits of bronchodilators and steroids . The objectives of this study were 1 ) to characterize the management of bronchiolitis in pediatric emergency departments ( PEDs ) in Canada , 2 ) to determine patient outcomes following emergency department ( ED ) visits , and 3 ) to provide descriptive data regarding bronchiolitis symptoms and family/personal medical history of these patients . METHODS A prospect i ve consecutive cohort of children with bronchiolitis presenting to seven Canadian PEDs was enrolled during a seven-to-21-day period . St and ardized interviews with parents provided data regarding symptoms , previous treatment , and past history . Charts were review ed for treatment , investigations , and disposition . Telephone follow-up at two to three weeks collected information regarding duration of illness and return visits . RESULTS Two hundred thirty-seven ( 91 % ) of 260 eligible patients were enrolled . One hundred eighty-nine patients ( 80 % ) had both an interview and chart review , and 48 ( 20 % ) had only chart review s ; follow-up was completed for 163 ( 69 % ) patients . One hundred fifteen ( 63 % ) had seen their primary care provider during their illness prior to the ED visit . Seventy-three percent of patients ( range per site 59 - 100 % ) were treated in the ED with bronchodilators ( usually salbutamol or epinephrine ) and 5 % ( range per site 0 - 14 % ) with oral steroids . Twenty-four percent ( 58/237 ) were prescribed bronchodilators on discharge , 3 % ( 7/237 ) inhaled steroids , and 2 % ( 5/237 ) oral steroids . Chi-square tests indicated significant practice variation by site in ED bronchodilator use ( p < 0.001 ) and bronchodilator use at discharge ( p = 0.0003 ) . Admission rate was 31 % ( range by site 22 - 43 % ) , 17 % of patients had more than one ED visit , and 1 % were admitted more than once . Admission rates were increased in younger children , children with comorbidities , and children with lower oxygen saturation . Viral studies were obtained in 53 % , with 76 % of these positive for respiratory syncytial virus ( RSV ) . Median duration of cough was 12 days , poor sleeping and irritability eight days , and wheeze and poor feeding seven days . CONCLUSIONS This study prospect ively describes the treatment of bronchiolitis in the pediatric ED . The findings are consistent with the literature regarding the reported use of bronchodilators ; however , use of steroids was found to be much lower than reported in other studies .  Bronchodilator  use in the ED and at discharge varied significantly by site . The results capture variation in treatment practice s in Canadian PEDs , which may be the result of discordant r and omized controlled trial evidence . Further research is needed to establish best practice OBJECTIVE . Postnatal steroid use decreases lung inflammation but increases impairment . We hypothesized that increased dose is associated with increased neurodevelopmental impairment , lower postmenstrual age at exposure increases impairment , and risk of bronchopulmonary dysplasia modifies the effect of postnatal corticosteroid . METHODS . Steroid dose and timing of exposure beyond 7 days was assessed among 2358 extremely low birth weight infants nested in a prospect i ve trial , with 1667 ( 84 % ) survivors examined at 18 to 22 months ' postmenstrual age . Logistic regression tested the relationship between impairment ( Bayley Mental Developmental Index/Psychomotor Developmental Index of < 70 , disabling cerebral palsy , or sensory impairment ) , total dose ( tertiles : < 0.9 , 0.9–1.9 , and ≥1.9 mg/kg ) , and postmenstrual age at first dose . Separate logistic regression tested effect modification according to bronchopulmonary dysplasia severity ( Romagnoli risk > 0.5 as high risk , n = 2336 ( 99 % ) for days of life 4–7 ) . RESULTS . Three hundred sixty-six ( 16 % ) neonates were steroid-treated ( 94 % dexamethasone ) . Treated neonates were smaller and less mature ; 72 % of those treated were at high risk for bronchopulmonary dysplasia . Exposure was associated with neurodevelopmental impairment/death . Impairment increased with higher dose ; 71 % dead or impaired at highest dose tertile . Each 1 mg/kg dose was associated with a 2.0-point reduction on the Mental Developmental Index and a 40 % risk increase for disabling cerebral palsy . Older age did not mitigate the harm . Treatment after 33 weeks ' postmenstrual age was associated with greatest harm despite not receiving the highest dose . The relationship between steroid exposure and impairment was modified by the bronchopulmonary dysplasia risk , with those at highest risk experiencing less harm . CONCLUSIONS . Higher steroid dose was associated with increased neurodevelopmental impairment . There is no “ safe ” window for steroid use in extremely low birth weight infants . Neonates with low bronchopulmonary dysplasia risk should not be exposed . A r and omized trial of steroid use in infants at highest risk is warranted 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 This r and omized , double-blind trial compared the efficacy of nebulized epinephrine with salbutamol in the treatment of infants with acute bronchiolitis . The mean percent oxygen saturation at 60 minutes was significantly higher in the epinephrine group . Thirty-three percent of the patients in epinephrine group were admitted to the hospital compared with 81 % of the salbutamol group ( p = 0.003 ) . We conclude that nebulized epinephrine is more efficacious than salbutamol for infants with acute bronchiolitis seen in an emergency department 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 tri 
    Output:
    
There was no difference in LOS for in patients .
This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for out patients , particularly in the first 24 hours of care .
Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points .
There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among in patients