Third-level hospital emergency department visits by patients with acute asthma. 1990

BACKGROUND: In the natural history of an asthmatic patient's disease, emergency room visits can be significant, incidental, or accidental occurrences from the therapeutic, preventive, clinical, or epidemiological perspective. METHODS: In order to find out the characteristics of the severely asthmatic patients who visit the third-level emergency room of the hospital asking for medical attention, we studied their visits, as opposed to those of other patients, for a one-year period. RESULTS: We registered 477 emergency care patients for asthma (1.30/day) which implies visits to the hospital watch of 0.71%. It is maintained 24 hours a day, predominantly in the first three days of the week (52.41%), the last ten days of the month (36.68%), the second trimester of the year (34.48%), and the month of May (20%). Compared to the rest of the population who also went for emergency room care, the asthmatic patient had lower average age (44 vs. 50), a majority of women (67.29% vs. 48%) and more frequent visits (36.74% vs. 18.59%). In comparison with studies in other countries, we register a higher number of admission but a lower of relapses (4.06%). CONCLUSIONS: Emergency room visits by severely asthmatic patients is an epidemiological index of the public health significance of the disease as it is a reflection of the degree of control and type of asthma. It is an important factor in determining demand of emergency care given the frequency of visits and the rates of admission and relapse.     

Recent changes in emergency room visits and hospitalization for asthma in childhood

OBJECTIVE: The purpose of this study was to investigate recent changes in the emergency room visits and hospital admission rates between 1993 and 1997 in our hospital. PATIENTS AND METHODS: From January 1, 1993 until December 31, 1997, the 12,848 patients between 0 and 14 years of age whose discharge diagnosis was coded as asthma (ICD9) and who were managed in the emergency room of our hospital were included in the study. RESULTS: During the study period, the number of emergency room visits for asthma (EA) remained unchanged. However, in children between 0 and 5 years of age the number of EA showed a significant increase from 1305 in 1993 (53.5% of all EA) to 1849 in 1997 (68.9% of EA), with an increase of the repeat visits in this age group from 46 (35.8% of all EA in this age group) in 1993 to 791 (42.8%) in 1997 (p < 0.01). In the same period of time, the admission rates for asthma decrease from 7.2% to 2.9% (p < 0.01). There was a trend towards more intense treatment of asthma in the emergency observation unit. CONCLUSIONS: There has been an upward trend in the number of acute asthma episodes between 1993 and 1997 in children between 0 and 5 years of age. It was associated with an increase in the number of repeat visits per patient. The use of a more intense treatment in the emergency observation unit was associated with a reduction in the hospitalization rate for asthma.     

Dose distribution in conventional CT and spiral CT and on the topic of dose reduction with spiral CT

We retrospectively analyzed patterns of emergency room visits by patients with exacerbations of asthma from December 1995 through November 1996. A total of 591 episodes in 198 patients were reviewed. The average age was 35.8 years, ranging from 15 to 71. The largest number of visits occurred in September. The number of visits per year ranged from 1 to 22; the mean was 2.9 per year. In patients who were followed on a regular basis at our institution, serve attacks accounted for 7.1% of the total, compared with 21.6 percent at other hospitals or outpatient clinics. We suspect that this difference was related to differences in the use of inhaled steroids. At our institution, 89% of patients were taking inhaled steroids; at other hospitals or clinics, only 21% were taking inhaled steroids. Of the 198 patients, 33 fulfilled one of the following criteria: (1) endotracheal intubation for respiratory failure or respiratory arrest, (2) respiratory acidosis (pH < 7.35) without endotracheal intubation; 27% of those patients had been given a diagnosis of mild asthma before the acute exacerbation. We conclude that patient education and standard guidelines for treatment of asthma, are very important for appropriate management of asthma, to prevent exacerbations and asthma-related deaths.     

Intravascular ultrasound elastography

Asthma, a chronic disease of the respiratory tract, affects approximately five percent of the U.S. population, including almost five million children. Childhood asthma has been identified as the leading cause of school absences. This study was to examined efficacy of a school-based program to prevent exacerbation of asthma symptoms and manage asthma in school children using measured doses of an inhaled anti-inflammatory medication. The sample consisted of 22 African-American children in one inner-city elementary school in Dallas, Texas, ages 5-12 years with confirmed diagnoses of asthma. For three months, each child came to the school clinic two times per day for medication administration and measurement of respiratory peak flow rates. Data were collected for a number of variables including bronchodilator use, school absences, self-report of asthma symptoms, and number of visits to the physician. During the study, mean peak flow rates improved approximately 15%, and bronchodilator use decreased 66%. Improvement also was evident in several other areas.     

Management of fulminant hepatic failure

There has been considerable public concern that emissions from intensive livestock farming may have hazardous effects on human health, particularly on the respiratory system. From October 1991 to September 1992, data on consultations of asthmatic children (up to 8 years) were obtained by a network of 25 GP and paediatric practices in South Oldenburg, a region with one of the highest livestock densities in Germany. Comparable data from a similar network of 75 practices in 3 adjacent regions (Brunswick, Hanover, Verden) with average livestock density served as a reference. In South Oldenberg, 2084 consultations of 542 asthmatic children were observed, with asthma being the reason for visit in 734 of the contacts (36%). The boy-girl ratio was 2.1:1 among index patients and 1.9:1 among consultations. Consultation rate was 25.2 contacts by asthmatic children per 1,000 total consultations of children up to 8 years in South Oldenburg, compared to 17.8 per 1,000 in Hanover, 15.7 per 1,000 in Brunswick and 13.6 per 1,000 in Verden. Consultations due to asthma scored 11.2/1,000 in South Oldenburg, 10.8/1,000 in Hanover, 7.2/1,000 in Brunswick and 6.5/1,000 in Verden. Asthmatic patients in South Oldenburg were younger (mean age 38 vs. 42 months) than those observed in the reference regions. There were no regional patterns in sex ratio, severity of asthma, respiratory allergies or atopic dermatitis. As this is an ecological study design, inferences concerning the cause of the observed regional differences can only be weak. We therefore propose a case-control study in order to obtain exposure and health data on an individual level.     

Effects of depressive disorders on coronary artery disease: a review

In 1992, 112 pregnancies occurred per 1,000 U.S. women aged 15-19; of these, 61 ended in births, 36 in abortions and 15 in miscarriages. Black teenagers' rates of pregnancies, births and abortions were 2-3 times those of whites; Hispanic teenagers had rates of births and abortions between those of blacks and whites. While similar proportions of pregnant black and non-Hispanic white teenagers had abortions (40% and 38%, respectively), the proportion was lower among Hispanics (29%). Among all women 15-19, the birthrate rose 12 points between 1987 and 1991; one-third of the rise (four points) may be attributable to a fall in the abortion rate. Between 1991 and 1995, the birth rate of black teenagers fell from 116 to 96 per 1,000, a level well below that of Hispanics (106 per 1,000). Among the states, pregnancy rates per 1,000 teenagers in 1992 ranged from 159 (in California) to 59 (in North Dakota), birth rates per 1,000 varied from 84 (Mississippi) to 31 (New Hampshire) and abortion rates per 1,000 ranged from 67 (Hawaii) to nine (Utah). The pregnancy rates of white and black teenagers are negatively correlated.     

End-stage renal failure from renal amyloidosis of the AA type associated with giant lymph node hyperplasia (Castleman''s disease)

In a one year population based study of major trauma (Injury Severity Score greater than 15) reaching hospitals in Northern Ireland in 1990/91 the incidence was 23.2 per 100,000 of the population or 20.5 per 100,000 excluding terrorist activities. The expected number of patients with major trauma for the province, (population 1.54 million) is 359 patients per annum. Road accidents and falls accounted for 71% of all trauma. Ninetynine patients per annum are expected to require immediate surgery, a laparotomy in 59 instances and neurosurgical procedures in 26. These data facilitate resource allocation and help predict the effects of future changes in the trauma system.     

Urban air pollution and emergency admissions for asthma in four European cities: the APHEA Project

BACKGROUND: A study was undertaken to assess the combined association between urban air pollution and emergency admissions for asthma during the years 1986-92 in Barcelona, Helsinki, Paris and London. METHODS: Daily counts were made of asthma admissions and visits to the emergency room in adults (age range 15-64 years) and children (< 15 years). Covariates were short term fluctuations in temperature and humidity, viral epidemics, day of the week effects, and seasonal and secular trends. Estimates from all the cities were obtained for the entire period and separately by warm or cold seasons using Poisson time-series regression models. Combined associations were estimated using meta-analysis techniques. RESULTS: Daily admissions for asthma in adults increased significantly with increasing ambient levels of nitrogen dioxide (NO2) (relative risk (RR) per 50 micrograms/m3 increase 1.029, 95% CI 1.003 to 1.055) and non-significantly with particles measured as black smoke (RR 1.021, 95% CI 0.985 to 1.059). The association between asthma admissions and ozone (O3) was heterogeneous among cities. In children, daily admissions increased significantly with sulphur dioxide (SO2) (RR 1.075, 95% CI 1.026 to 1.126) and non-significantly with black smoke (RR 1.030, 95% CI 0.979 to 1.084) and NO2, though the latter only in cold seasons (RR 1.080, 95% CI 1.025 to 1.140). No association was observed for O3. The associations between asthma admissions and NO2 in adults and SO2 in children were independent of black smoke. CONCLUSIONS: The evidence of an association between air pollution at current urban levels and emergency room visits for asthma has been extended to Europe. In addition to particles, NO2 and SO2--by themselves or as a constituent of a pollution mixture--may be important in asthma exacerbations in European cities.     

Ambulatory health care visits by children: principal diagnosis and place of visit

OBJECTIVES: This report presents national estimates of ambulatory health care use by children under 15 years of age according to principal diagnosis, place of visit (physician office, hospital outpatient department, and hospital emergency department), and patient characteristics (age, sex, and race). METHODS: Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Data were from 1993-95. RESULTS: In 1993-95 children under 15 years of age made 165.3 million visits per year (289 visits per 100 children). Visit rates were highest among infants and varied inversely with age. Visit rates were 43 percent higher among white children than black children. Three-quarters of ambulatory visits occurred in physician offices, 8 percent in hospital outpatient departments, and 14 percent in hospital emergency departments. Visits by white children were more likely to occur in physician offices than visits by black children (81 percent and 54 percent). Conversely, visits by black children were more likely to occur in hospital outpatient departments (19 percent and 7 percent) and hospital emergency departments (28 percent and 12 percent) than visits by white children. The following principal diagnoses accounted for almost 40 percent of visits: well-child visit, 15 percent; middle ear infection, 12 percent; and injury, 10 percent. Rates for well-child visits were almost 80 percent higher among white infants than black infants. Continued monitoring of these differences in use of ambulatory care among children are needed, particularly in view of the possible impact of changes in the health care system on these differences.     

Criteria for the evaluation of neonatal pain

A study to investigate the socioeconomic impact of lymphatic filariasis was conducted in a rural community in northern Ghana. The incidence, severity, and duration of acute adenolymphangitis (ADL), as identified by local terminologies and confirmed using World Health Organization diagnostic criteria, were investigated. Local terminologies were found to be highly specific and sensitive for diagnosing ADL (sensitivity = 0.978, specificity = 0.980). The incidence of ADL was 95.9 per 1,000 per annum among adults more than 10 years of age, being much higher in females than in males. Among those with elephantiasis and other chronic filarial symptoms, there was no clear relationship between the stage of chronic lymphedema and the incidence of ADL. The incidence of ADL was found to be closely related to the rainfall pattern. The design of the study, its findings, and the public health implications of the findings are discussed in this paper.     

Interpreting indirect replies

PROBLEM/CONDITION: Asthma is one of the most common chronic diseases in the United States, and it has increased in importance during the preceding 20 years. Despite its importance, no comprehensive surveillance system has been established that measures asthma trends at the state or local level. REPORTING PERIOD: This report summarizes and reviews national data for specific end-points: self-reported asthma prevalence (1980-1994), asthma office visits (1975-1995), asthma emergency room visits (1992-1995), asthma hospitalizations (1979-1994), and asthma deaths (1960-1995). DESCRIPTION OF SYSTEM: The National Center for Health Statistics (NCHS) annually conducts the National Health Interview Survey, which asks about self-reported asthma in a subset of the sample. NCHS collects physician office visit data with the National Ambulatory Medical Care Survey, emergency room visit data with the National Hospital Ambulatory Medical Care Survey, and hospitalization data with the National Hospital Discharge Survey. NCHS also collects mortality data annually from each state and produces computerized files from these data. We used these datasets to determine self-reported asthma prevalence, asthma office visits, asthma emergency room visits, asthma hospitalizations, and asthma deaths nationwide and in four geographic regions of the United States (i.e., Northeast, Midwest, South, and West). RESULTS: We found an increase in self-reported asthma prevalence rates and asthma death rates in recent years both nationally and regionally. Asthma hospitalization rates have increased in some regions and decreased in others. At the state level, only death data are available for asthma; death rates varied substantially among states within the same region. INTERPRETATION: Both asthma prevalence rates and asthma death rates are increasing nationally. Available surveillance information are inadequate for fully assessing asthma trends at the state or local level. Implementation of better state and local surveillance can increase understanding of this disease and contribute to more effective treatment and prevention strategies.     

Anti beta 2glycoprotein I antibodies and lupus anticoagulant in patients with recurrent pregnancy loss: prevalence and clinical significance

Over 2000 electrocution deaths were identified among U.S. construction workers from 1980 to 1991, with the highest mean annual crude mortality rate (2.5 per 100,000 people), and second highest mean age-adjusted rate (2.7 per 100,000 people) of all industries. Although the crude fatality rates showed a downward trend, construction workers are still about four times more likely to be electrocuted at work than are workers in all industries combined. Nearly 40% of the 5083 fatal electrocutions in all industries combined occurred in construction, and 80% were associated with industrial wiring, appliances, and transmission lines. Electrocutions ranked as the second leading cause of death among construction workers, accounting for an average of 15% of traumatic deaths in the industry from 1980 to 1991. The study indicates that the workers most at risk of electrical injury are male, young, nonwhite, and electricians, structural metal workers, and laborers. The most likely time of injury is 11 a.m. to 3 p.m. from June to August. Focusing prevention on these populations and characteristics through better methods of worker and supervisor electrical safety training, use of adequate protective clothing, and compliance with established procedures could minimize the average annual loss of 168 U.S. construction workers.     

Tumor type and vascularity: important variables in infusional brachytherapy with colloidal 32P

PURPOSE: We determined the occurrence of and risk factors for acute urinary retention in the community setting. MATERIALS AND METHODS: A cohort of 2,115 men 40 to 79 years old was randomly selected from an enumeration of the Olmsted County, Minnesota population (55% response rate). Participants completed a previously validated baseline questionnaire that assessed symptom severity, and voided into a portable urometer to measure peak urinary flow rates. A 25% random subsample underwent transrectal sonographic imaging of the prostate to determine prostate volume. Followup was performed through a retrospective review of community medical records to determine the occurrence of acute urinary retention in the subsequent 4 years. RESULTS: During the 8,344 person-years of followup 57 men had a first episode of acute urinary retention (incidence 6.8/1,000 person-years, 95% confidence interval [CI] 5.2, 8.9). Among men with no to mild symptoms (American Urological Association symptom index score 7 or less) the incidence of acute urinary retention increased from 2.6/1,000 person-years among men 40 to 49 years old to 9.3/1,000 person-years among men 70 to 79 years old. By contrast, rates increased from 3.0/1,000 person-years for men 40 to 49 years old to 34.7/1,000 person-years among men 70 to 79 years old among men with moderate to severe symptoms (American Urological Association symptom index score greater than 7). Men with depressed peak urinary flow rate (less than 12 ml. per second) were at 4 times the risk of acute urinary retention compared with men with urinary flow rates greater than 12 ml. per second (95% CI 2.3, 6.6). Men with an enlarged prostate (greater than 30 ml.) experienced a 3-fold increase in risk (95% CI 1.0, 9.0, p = 0.04). CONCLUSIONS: Lower urinary tract symptoms, depressed peak urinary flow rates, enlarged prostates and older age are associated with an increased risk of acute urinary retention in community dwelling men. These findings may help to identify men at increased risk of acute urinary retention in whom closer evaluation may be warranted.     

Meta-analysis of DRD3 gene and schizophrenia: ethnic heterogeneity and significant association in Caucasians

BACKGROUND: Children with asthma may be at increased risk for low immunization rates given that they have recurrent illnesses that often result in acute care visits to their pediatrician, visits to the emergency room, admissions to the hospital, and visits to subspecialists, where immunizations are not routinely administered. OBJECTIVES: To assess immunization rates for routine and influenza vaccines in children with asthma and assess factors that may contribute to delay. METHODS: We conducted a cross-sectional survey of 117 children aged 6 to 48 months with onset of asthma within the first 15 months of life. Subjects were recruited from an allergy and immunology clinic at an urban, tertiary care center. Those judged to have immunization delay did not have the required 4 DTP, 3 OPV, and 1 MMR vaccine by age 24 months (4:3:1 series). Receipt of influenza vaccine was determined for eligible children with moderate to severe asthma. RESULTS: Seventy-four (80%) children had up-to-date immunizations at age 24 months. Those with delay had fewer visits to a subspecialist than those who were up-to-date (1 versus 2 visits P = .010). Twenty-two (25%) of 87 eligible subjects received influenza vaccine. Recipients were more likely to have been hospitalized than nonrecipients (77% versus 49%, P = .022). CONCLUSIONS: Though the majority of young children with asthma were up-to-date for routine immunizations, only 25% of children with moderate to severe asthma received influenza vaccine. Greater efforts must be made by pediatricians and asthma subspecialists to ensure that children with moderate to severe asthma are immunized against influenza virus.     

Medical care delivery at the 1996 Olympic Games. Centers for Disease Control and Prevention Olympics Surveillance Unit

CONTEXT: Mass gatherings like the 1996 Olympic Games require medical services for large populations assembled under unusual circumstances. OBJECTIVE: To examine delivery of medical services and to provide data for planning future events. DESIGN: Observational cohort study, with review of medical records at Olympics medical facilities. SETTING: One large multipurpose clinic and 128 medical aid stations operating at Olympics-sponsored sites in the vicinity of Atlanta, Ga. PARTICIPANTS: A total of 10715 patients, including 1804 athletes, 890 officials, 480 Olympic dignitaries, 3280 volunteers, 3482 spectators, and 779 others who received medical care from a physician at an Olympic medical station. MAIN OUTCOME MEASURES: Number of injuries and cases of heat-related illness among participant categories, medical use rates among participants with official Games credentials, and use rates per 10000 persons attending athletic competitions. RESULTS: Injuries, accounting for 35% of all medical visits, were more common among athletes (51.9% of their visits, P < .001) than among other groups. Injuries accounted for 31.4% of all other groups combined. Spectators and volunteers accounted for most (88.9%, P < .001) of the 1059 visits for heat-related illness. The rates for number of medical encounters treated by a physician were highest for athletes (16.2 per 100 persons, P < .001) and lowest for volunteers (2.0 per 100). Overall physician treatment rate was 4.2 per 10000 in attendance (range, 1.6-30.1 per 10000). A total of 432 patients were transferred to hospitals. CONCLUSIONS: Organizers used these data during the Games to monitor the health of participants and to redirect medical and other resources to areas of increased need. These data should be useful for planning medical services for future mass gatherings.     

National dermatology manpower requirements: the experience of prepaid group practices

Ten prepaid group health plans across the country were surveyed as part of an effort to estimate the need for dermatologists in the United States. Although generalizing the experiences of prepaid group practices to the general population is at best an imprecise approach, the dramatic shortage suggested by the data cannot be completely ascribed to the method used. Whereas the average ratio in the surveyed plans was 2.8 dermatologists per 100,00 subscribers, there are only about 1.9 dermatologists providing patient care per 100,000 persons in the general population. The difference between prepaid plan subscribers and the general population in annual visits to dermatologists is even more dramatic: 193 per 1,000 subscribers compared to 84 per 1,000 population.     

Temporal trends in hospital-based episodes of asthma care in a health maintenance organization

Studies reporting increased asthma hospitalizations and mortality in the United States and abroad have heightened concern about the changing epidemiology of asthma. We studied 20-yr patterns of acute asthma care occurring at two large community hospitals among members of a large health maintenance organization. The presentation focuses on the conceptualization and operationalization of an "episode" of asthma care, defined as a collection of encounters (emergency room visits, urgency care visits, and hospital admissions) that cluster in time, as well as on changes in episode rates over time. We found a statistically significant increase in asthma episodes among boys younger than 5 yr of age that continued unabated from 1967 to 1987 despite a drop in asthma hospitalization rates starting in 1985. We hypothesize that this difference may reflect a change in emergency room management practices and not a true change in the underlying epidemiology of asthma. The concept of an episode of acute asthma care has not been studied in the literature and represents a potentially useful methodologic innovation. Particularly in the context of managed health care systems, studies of such episodes may be less sensitive than studies of hospital admissions to changes in the organization and delivery of acute asthma care, and thus may be better suited for studying changes in the epidemiology of asthma.     

Racial differences in Helicobacter pylori seroprevalence in Singapore: correlation with differences in peptic ulcer frequency

The aim of this study was to determine, first, whether racial differences exist in the seroprevalence of Helicobacter pylori infection in Singapore, and second, whether these differences correlate with racial differences in peptic ulcer frequency. A commercial serological test for immunoglobulin (Ig)G antibody to H. pylori which was 90% sensitive and 83% specific in our population was used to screen 403 adult blood donors of Chinese, Malay and Indian origin, aged between 15-60 years. Serum specimens from 84 paediatric patients admitted to the Paediatrics Department, National University of Singapore, with non-gastroenterological illnesses were also tested. In all three races, seroprevalence of H. pylori increased with age. Indians have the highest prevalence of infection followed by Chinese and Malays. Peptic ulcer prevalences are known to be highest in Chinese, followed by Indians and Malays. The Malays have the lowest prevalence of H. pylori and peptic ulcer among the three races in Singapore. Indians have a higher prevalence of H. pylori antibodies but a lower frequency of peptic ulcer than the Chinese. Racial differences in peptic ulcer frequency between Chinese and Indians are not explained by the prevalence of H. pylori infection; other environmental or genetic factors may be involved.