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.     

Association between ozone and asthma emergency department visits in Saint John, New Brunswick, Canada

This study examines the relationship of asthma emergency department (ED) visits to daily concentrations of ozone and other air pollutants in Saint John, New Brunswick, Canada. Data on ED visits with a presenting complaint of asthma (n = 1987) were abstracted for the period 1984-1992 (May-September). Air pollution variables included ozone, sulfur dioxide, nitrogen dioxide, sulfate, and total suspended particulate (TSP); weather variables included temperature, humidex, dewpoint, and relative humidity. Daily ED visit frequencies were filtered to remove day of the week and long wave trends, and filtered values were regressed on air pollution and weather variables for the same day and the 3 previous days. The mean daily 1-hr maximum ozone concentration during the study period was 41.6 ppb. A positive, statistically significant (p < 0.05) association was observed between ozone and asthma ED visits 2 days later, and the strength of the association was greater in nonlinear models. The frequency of asthma ED visits was 33% higher (95% CI, 10-56%) when the daily 1-hr maximum ozone concentration exceeded 75 ppb (the 95th percentile). The ozone effect was not significantly influenced by the addition of weather or other pollutant variables into the model or by the exclusion of repeat ED visits. However, given the limited number of sampling days for sulfate and TSP, a particulate effect could not be ruled out. We detected a significant association between ozone and asthma ED visits, despite the vast majority of sampling days being below current U.S. and Canadian standards.     

Demographic predictors of asthma treatment site: outpatient, inpatient, or emergency department

We evaluated physical activity changes resulting from a six-month public health model intervention that encouraged seniors (N = 89) 62-91 years of age (mean = 76) living in two low-income congregate housing facilities to increase their physical activity by participating in existing community-based physical activity classes and programs of their choice. The program was offered to everyone regardless of their health problems. Enrollees were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income, and transportation resources. Using a comparison-group design, the intervention group was more active for all comparison months of the intervention period (p values < .05). The intervention also was associated with improvements in self-esteem (p < .05), though not with an array of other measures of health-related quality-of-life. Those who adopted and maintained a new physical activity over the six-month intervention period experienced improvements in anxiety, depression, and overall psychological well-being relative to those who did not. The intervention was subsequently replicated through a senior center (N = 22). A much larger proportion of the senior center sample adopted and maintained a new activity for six months (68%) compared to the congregate facilities sample (35%), which may have been due to differences in recruitment methods and sample characteristics in the two settings. An intervention promoting increased physical activity through the use of existing community resources may help increase physical activity in older adults.     

Biofeedback treatment for pediatric migraine: Prediction of treatment outcome.

Despite a growing number of studies showing good effectiveness of nonpharmacological treatments such as thermal biofeedback (TBF) for pediatric migraine, little is known about psychosocial variables that might be predictive of treatment outcome. The identification of predictors appears especially important when children are treated in a home-based treatment format that tends to be somewhat less effective than a therapist-administered treatment. A total of 32 children between the ages 8 and 16 years completed a home-based TBF treatment program with treatment outcome being of similar magnitude as previously reported in the literature. Multiple regression analysis revealed externalizing behavior tendencies, initial level of psychosomatic complaints, and the child's age to be highly predictive of outcome, whereas dimensions of family functioning failed to exert a direct influence. The implications of these findings for the development and evaluation of future treatment programs are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute pain, analgesia and sedation in children (IV): analgesia and sedation in medical procedure and in emergency room

Clinicians are confronted with a complex challenge when a patient is admitted to a critical care unit (CCU) with a significant chest roentgenography (CXR) abnormality. The etiology of a new infiltrate seen on CXR in a patient already in the CCU is more difficult to establish, but is of equal concern.     

Parental criticism and treatment outcome in adolescents hospitalized for severe, chronic asthma

This pilot study investigated the relationship between parental criticism and medical treatment outcome across an inpatient hospitalization in 19 adolescents with severe, chronic asthma. Parental criticism toward their asthmatic adolescent was assessed using the Five Minute Speech Sample technique (FMSS) at the beginning of the adolescent's inpatient stay at a national asthma referral center. Those adolescents whose parents were rated as high in criticism on the FMSS were found to have greater improvement in their overall asthma severity, greater reduction in their steroid medication dose, and shorter lengths of stay in the hospital than those whose parents were rated as low in criticism. The adolescents whose parents were rated as high in criticism also showed lower compliance with their prescribed theophylline and oral steroid medication at admission than the low criticism group. These findings do not appear to be due to misdiagnosis secondary to the presence of vocal cord dysfunction or to the allergy status of the children. Clinical implications and possible causal mechanisms underlying these findings are discussed.     

Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients

OBJECTIVE: To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders. SUMMARY BACKGROUND DATA: The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce. METHODS: One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients. RESULTS: Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months. CONCLUSIONS: LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.     

Predictors of treatment adherence among asthma patients in the emergency department

N-Nitroso-N-(3-keto-1,2-butanediol)-3'-nitrotyramine (NO-NTA) is a product of model browning system generated in the presence of sodium nitrite. The chemical structure of this compound has been confirmed by UV, mass and nuclear magnetic resonance, and infrared spectroscopy in our previous study. A two-stage transformation protocol was used to chemically transform the mouse embryo fibroblasts C3H10T1/2 cells. To initiate transformation, the cells were treated with benzo[a]pyrene (BaP) (0.1 mg/ml), and NO-NTA (0.01, 0.1 and 1 mg/ml) was employed subsequently to complete the transformation process. Malignant transformed foci were formed in BaP-initiated and NO-NTA promoted C3H10T1/2 cells after 8 wk. Cells treated with NO-NTA alone failed to induce transformation. However, cells initiated with BaP and promoted by cells initiated with BaP and promoted by NO-NTA demonstrated oncogenic properties. Cell lines transformed with NO-NTA-transformed colonies exhibited enhanced growth rate, anchorage independence and tumorigenicity in animals relative to parent cells. These results indicate that NO-NTA is a new tumour promoter and may induce tumour promotion by two-stage oncogenesis. Further studies on the mechanism of action of NO-NTA are now in progress.     

The experience with berodual inhalation in emergency treatment of bronchial asthma

Of 56 patients with bronchial asthma demanding emergency care 27 had moderate exacerbation (group 1) and 29--a severe one (group 2). All the patients inhaled berodual (B) solution with a compressive pneumatic nebuliser Medic-Aide. The relief of the attack was achieved for 20 minutes of the inhalation in 22 and 19 patients of groups 1 and 2, respectively. Inhalation monotherapy with B solutions using a compressive nebuliser provides control of moderate and severe attacks of bronchial asthma.     

Young inner-city children visiting the emergency room (ER) for asthma: risk factors and chronic care behaviors

A longitudinal growth study with monthly measurements during the 1st year of life was conducted by nine paediatricians working in private practice in Zurich. Of 92 children, none was lost to the study and only 32 of 1104 planned visits were missed; the quality of the measurements was comparable to that of a specialised university clinic. Compared to the Zurich Longitudinal Growth Studies, children of this study were considerably heavier and taller. In 92% of the subjects, growth velocity was at least once outside the reference range (3rd 97th percentile). For weight increments, the corresponding proportion was 87%. CONCLUSIONS: The data indicate that current standards for the 1st year of life for the Zurich area might no longer be appropriate and need to be updated. The currently used velocity percentiles based on 3-monthly measurements are not suitable to assess individual height and weight increments calculated from monthly measurements.     

Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996

OBJECTIVE: This report describes ambulatory care visits in the United States across three ambulatory care settings--physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for all ambulatory care visits and separately for each setting. METHODS: The data presented in this report were collected by means of the 1996 National Ambulatory Medical Care Survey (NAMCS) and the 1996 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of providers. The NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1996 an estimated 892 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.4 visits per person. Visits to office-based physicians accounted for 82.3 percent of ambulatory care utilization, followed by visits to emergency departments (10.1 percent) and outpatient departments (7.5 percent). Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. About two-thirds of ambulatory care visits by black persons were to physician offices. There were an estimated 129.3 million injury-related ambulatory care visits during 1996 or 48.9 visits per 100 persons.     

Postviral gastroparesis: presentation, treatment, and outcome

We describe the clinical features and long-term outcome of 11 children who had persistent gastroparesis after an acute viral illness, eight of whom tested positive for rotavirus. Gastric emptying was delayed in the 10 children evaluated with scintigraphy. Antroduodenal manometry confirmed postprandial antral hypomotility in 10 subjects. All children recovered within 6 to 24 months.     

Delirium: prevention, treatment, and outcome studies

The purpose of this paper was to contribute to a new conceptual understanding of delirium by reviewing evidence related to its prevention, treatment, and outcome. The review process involved a systematic search of the literature on each topic, assessment of the validity of the studies retrieved, and examination of their results. The literature search identified 10 studies on prevention, 13 studies on treatment, and 15 studies on outcome. Most studies had methodological limitations. Abroad spectrum of interventions appeared to be modestly effective in preventing delirium in young and old surgical patients but not elderly medical patients; systematic detection and intervention programs and special nursing care appeared to add large benefits to traditional medical care in young and old surgical patients and modest benefits in elderly medical patients; haloperidol, chlorpromazine, and mianserin appeared to be useful in controlling the symptoms of delirium in both surgical and medical patients; and good levels of premorbid function seemed to be related to better outcomes. Although the above findings do not contribute to a new conceptual understanding of delirium, they do suggest directions for further research on the treatment of delirium.     

Systemic Candida infection in pediatric BM autotransplantation: clinical signs, outcome and prognosis

Of the 393 children who underwent BM autotransplantation in the pediatric oncology unit of the Institut Gustave Roussy between February 1979 and September 1991, 14 (3.56%) developed disseminated Candida infection within 3 months. This incidence was far lower than in other published series. Eleven of the 14 patients recovered from the infection, giving a far higher survival rate (78%) than among adult BM transplant recipients (usually < 30%). All 14 patients had four or more risk factors and persistent BM aplasia (median, 25 days); six had Candida tropicalis infection. Four cases of deep visceral involvement were documented, two of which were lethal. Clinical signs were relatively uniform and included secondary high-grade fever (> 40 degrees C) for 8 days; half the patients developed cardiovascular impairment, respiratory distress, neurological disturbances (altered consciousness or delirium) and severe diarrhoea, within as little as 10 days after transplantation. Blood cultures rapidly became positive after the onset of clinical signs and this permitted prompt treatment with a combination of amphotericin B and 5-fluorocytosine; in addition, central catheters were removed. Blood cultures became sterile within 4 days of treatment in 10 of the 14 cases. The generally favourable outcome in this series could be related to the young age of the patients, the absence of GVHD, the absence of total body irradiation in the conditioning regimen, and early antifungal treatment.     

Referral, admission, and discharge patterns in a pediatric emergency department in Israel

The pediatric emergency department (PED) is an important component of the medical services provided by a hospital. The purpose of the study was to describe the patterns of referrals, admissions, and discharges in a PED to determine to what extent the PED is used solely as an emergency unit, as opposed to being used as a part of a set of primary care facilities. Data were recorded from 1200 patient charts, out of 19,000 visits to a PED in Israel in 1988. Variables such as age, sex, ethnicity, and distance between residence and hospital were checked. About half of the patients arrived during the morning shift. There was an inverse relationship between the distance from the patient's home to the hospital and the rate of visits to the PED. Fifty-eight percent of the total were self-referred; this rate increased to 84% during the night shift. Only one quarter of all children had additional laboratory or x-ray tests. Most of the diagnoses did not require emergency services. Eighty-one percent of the patients were discharged from the PED to their community physician. The rate of admissions was low (11%). This study shows that a large part of the PED work is actually primary care. Some of the demographic, cultural, and ethnic reasons for these patterns are reviewed.     

Treatment of snake, insect, scorpion, and spider bites in the pediatric emergency department

Obtaining an adequate depth of anesthesia is a continuous challenge to the anesthetist. With the introduction of muscle-relaxing agents the traditional signs of awareness are often obscured, or difficult to interpret. These signs include blood pressure, heart rate, pupil size, etc. However, these factors do not describe the depth of anesthesia (DA) in a cerebral activity sense. Hence, a better measure of the DA is required. It has been suggested that Auditory-Evoked Potentials (AEP) can provide additional information about the DA. The general method of extracting AEP is by use of a Moving Time Average (MTA). However, the MTA is time consuming because a large number of repetitions is needed to produce an estimate of the AEP. Hence, changes occurring over a small number of sweeps will not be detected by the MTA average. We describe a system-identification method, an autoregressive model with exogeneous input (ARX) model, to produce a sweep-by-sweep estimate of the AEP. The method was clinically evaluated in 10 patients anesthetized with alfentanil and propofol. The time interval between propofol induction and the time when the Na-Pa amplitude was decreased to 25% of the initial amplitude was measured. These measurements showed that ARX-estimated compared to MTA-estimated AEP was significantly faster in tracing transition from consciousness to unconsciousness during propofol induction (p < 0.05).     

A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma

BACKGROUND: Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy. OBJECTIVE: To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care. METHODS: A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks. MAIN OUTCOME MEASURES: Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life. RESULTS: The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001). CONCLUSIONS: Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.