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Fishe JN, Garvan G, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby DW, Ostermeyer D, Riney L, Semenova O, Abo B, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Blake KV. Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT). Acad Emerg Med 2024; 31:49-60. [PMID: 37786991 PMCID: PMC10842452 DOI: 10.1111/acem.14813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes. METHODS Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS. RESULTS A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission. CONCLUSIONS In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Andrew Bertrand
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Shannon Burcham
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Manish Shah
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Daniel Ostermeyer
- McGovern Medical School, University of Texas Health, Houston, Texas, USA
| | - Lauren Riney
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Olga Semenova
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin Abo
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
- Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Benjamin Abes
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
| | - Nichole Shimko
- Golisano Children's Hospital of Southwest Florida, Fort Myers, Florida, USA
| | - Emily Myers
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Marshall Frank
- Florida State University College of Medicine, Tallahassee, Florida, USA
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Tim Turner
- Walton County Fire Rescue, Defuniak Springs, Florida, USA
| | - Mac Kemp
- Leon County EMS, Tallahassee, Florida, USA
| | - Kim Landry
- Leon County EMS, Tallahassee, Florida, USA
| | - Greg Roland
- Nassau County Fire Rescue Department, Yulee, Florida, USA
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby D, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe J. EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval. PREHOSP EMERG CARE 2023; 27:900-907. [PMID: 37428954 PMCID: PMC10592383 DOI: 10.1080/10903127.2023.2234996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | | | | | | | | | - Phyllis Hendry
- University of Florida College of Medicine – Jacksonville
| | - Manish Shah
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - David Ashby
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - Olga Semenova
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | - Benjamin N. Abo
- Lee County Emergency Medical Services, Florida
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Marshall Frank
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Greg Roland
- Nassau County Fire Rescue Department, Florida
| | - Jennifer Fishe
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
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Navanandan N, Florin TA, Leonard J, Ramgopal S, Cotter JM, Shah SS, Ruddy RM, Ambroggio L. Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia. Pediatr Emerg Care 2023; 39:482-487. [PMID: 37306694 PMCID: PMC10351650 DOI: 10.1097/pec.0000000000002984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Leonard
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Division of Hospital Medicine and Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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Navanandan N, Thompson T, Pyle L, Florin TA. Defining Treatment Response for Clinical Trials of Pediatric Acute Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1450-1458.e1. [PMID: 36621607 PMCID: PMC10164688 DOI: 10.1016/j.jaip.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND An agreed-upon definition of treatment response for clinical trials of pediatric acute asthma does not exist, limiting meaningful comparisons among therapeutic interventions and advances in asthma management. OBJECTIVE To develop a consensus definition of treatment response for clinical trials of pediatric acute asthma. METHODS A multidisciplinary panel of 22 experts participated in a Web-based modified Delphi process to achieve consensus on a definition of treatment response. Round 1 consisted of closed- and open-ended questions in which panelists ranked measures of treatment response developed by literature review, suggested additional measures, and explained their responses. In rounds 2 and 3, panelists reviewed summary statistics of the panel's rating from prior rounds and reconsidered their rankings. In round 3, pairwise ranking was performed to determine the ranked importance of components. Consensus was defined as 70% or greater agreement among panelists choosing Likert-scale values of 1 to 6 (extremely unimportant to extremely important) and an interquartile range less than 2. RESULTS Drawing on results from the expert panel, we developed a definition of treatment response that includes Clinical Severity Score, need for additional therapies, and hospitalization. Clinical Severity Score encompassed most ranked criteria (eg, respiratory distress, wheeze) for a treatment response definition. Panelists recommended that a valid and pragmatic severity score be used consistently across institutions. Panelists also achieved consensus on the top 10 criteria that appropriately classify need for hospitalization. CONCLUSIONS This consensus definition of treatment response can be used in clinical trials of children with acute asthma to standardize outcome measurement and report meaningful outcomes.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
| | - Talia Thompson
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Laura Pyle
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colo
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Au PCM, Tan KCB, Lam DCL, Cheung BMY, Wong ICK, Kwok WC, Sing CW, Cheung CL. Association of Sodium-Glucose Cotransporter 2 Inhibitor vs Dipeptidyl Peptidase-4 Inhibitor Use With Risk of Incident Obstructive Airway Disease and Exacerbation Events Among Patients With Type 2 Diabetes in Hong Kong. JAMA Netw Open 2023; 6:e2251177. [PMID: 36648944 PMCID: PMC9857182 DOI: 10.1001/jamanetworkopen.2022.51177] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
IMPORTANCE Patients with diabetes are at higher risk for obstructive airway disease (OAD). In recent meta-analyses of post hoc analyses of cardiorenal trials, sodium-glucose cotransporter 2 inhibitors (SGLT2Is) were suggested to reduce the risk of OAD adverse events. However, a clinical investigation of this association is warranted. OBJECTIVE This study aimed to investigate the association of SGLT2I use vs dipeptidyl peptidase-4 inhibitor (DPP4I) use with OAD incidence and exacerbation events in patients with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study used electronic health data from a territory-wide electronic medical database in Hong Kong. Data were collected for patients with type 2 diabetes who were prescribed SGLT2Is or DPP4Is between January 1, 2015, and December 31, 2018. Patients were followed for a median of 2.2 years between January 1, 2015, and December 31, 2020. A prevalent new-user design was adopted to match patients based on previous exposure to the study drugs. Propensity score matching was used to balance baseline characteristics. EXPOSURES Patients with type 2 diabetes using SGLT2Is (exposure of interest) or DPP4Is (active comparator). MAIN OUTCOMES AND MEASURES The main outcomes were the first incidence of OAD and the count of OAD exacerbations. The risk of incident OAD was estimated using a Cox proportional hazards regression model. The rate of exacerbations was estimated using zero-inflated Poisson regression. Statistical analysis was performed on November 13, 2022. RESULTS This study included 30 385 patients. The propensity score-matched non-OAD cohort (incidence analysis) consisted of 5696 SGLT2I users and 22 784 DPP4I users, while the matched OAD cohort (exacerbations analysis) comprised 381 SGLT2I users and 1524 DPP4I users. At baseline, 56% of patients in the non-OAD cohort were men and the mean (SD) age was 61.2 (9.9) years; 51% of patients in the OAD cohort were men and the mean age was 62.2 (10.8) years. Compared with DPP4I use, SGLT2I use was associated with a lower risk of incident OAD (hazard ratio, 0.65 [95% CI, 0.54-0.79]; P < .001) and a lower rate of exacerbations (rate ratio, 0.54 [95% CI, 0.36-0.83]; P = .01). The associations were consistent in sex subgroup analysis. CONCLUSIONS AND RELEVANCE The findings of this retrospective cohort study of patients with type 2 diabetes in Hong Kong suggest that SGLT2I use was associated with a reduced risk of incident OAD and a lower rate of exacerbations in a clinical setting compared with DPP4I use. These findings further suggest that SGLT2Is may provide additional protective effects against OAD for patients with type 2 diabetes and that further investigation is warranted.
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Affiliation(s)
- Philip C. M. Au
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kathryn C. B. Tan
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - David C. L. Lam
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Bernard M. Y. Cheung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Ian C. K. Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
| | - Wang Chun Kwok
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Chor-Wing Sing
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
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Fishe JN, Palmer E, Finlay E, Smotherman C, Gautam S, Hendry P, Hendeles L. A Statewide Study of the Epidemiology of Emergency Medical Services' Management of Pediatric Asthma. Pediatr Emerg Care 2021; 37:560-569. [PMID: 30829849 PMCID: PMC6693989 DOI: 10.1097/pec.0000000000001743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Little is known about emergency medical services' (EMS') management of pediatric asthma. This study's objective was to describe the demographic, clinical, and geographic characteristics of current EMS' management of pediatric asthma in the state with the fourth-largest pediatric population. METHODS This was a retrospective observational study of EMS patients ages 2 to 18 years with an asthma exacerbation from 2011 to 2016. Patients from Florida's EMS Tracking and Reporting System were included if their EMS chief complaint indicated respiratory distress, if they received at least 1 albuterol treatment, and if they were transported to a hospital. RESULTS A total of 11,226 patients met the inclusion criteria. The median age was 9 years, and 49% were African-American. Geospatial analysis revealed 4 rural counties with disproportionate numbers of African-American patients. In addition to albuterol, 37% of patients received ipratropium bromide and 9% received systemic corticosteroids. Adjusted logistic regression revealed that the strongest predictors of receiving systemic corticosteroids from EMS were intravenous access (odds ratio, 33.4; 95% confidence interval, 24.4-45.6) and intravenous magnesium sulfate administration (odds ratio, 5.0; 95% confidence interval, 3.4-7.3), indicating a more severe presentation. CONCLUSIONS This statewide study demonstrated low rates of EMS administration of ipratropium bromide and systemic corticosteroids, both evidence-based treatments for asthma exacerbations. Targeted EMS education should attempt to increase utilization of both those medications. In addition, the feasibility and efficacy of EMS administration of oral systemic corticosteroids for children should be explored.
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Affiliation(s)
- Jennifer N. Fishe
- University of Florida – Jacksonville, Department of Emergency Medicine
| | - Eugene Palmer
- University of Florida, College of Design, Construction, and Planning
- GeoPlan Center, University of Florida
| | - Erik Finlay
- University of Florida, College of Design, Construction, and Planning
- GeoPlan Center, University of Florida
| | | | - Shiva Gautam
- University of Florida – Jacksonville, College of Medicine
| | - Phyllis Hendry
- University of Florida – Jacksonville, Department of Emergency Medicine
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Nieto A, Mazón A, Nieto M, Calderón R, Calaforra S, Selva B, Uixera S, Palao MJ, Brandi P, Conejero L, Saz-Leal P, Fernández-Pérez C, Sancho D, Subiza JL, Casanovas M. Bacterial Mucosal Immunotherapy with MV130 Prevents Recurrent Wheezing in Children: A Randomized, Double-Blind, Placebo-controlled Clinical Trial. Am J Respir Crit Care Med 2021; 204:462-472. [PMID: 33705665 PMCID: PMC8480240 DOI: 10.1164/rccm.202003-0520oc] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/11/2021] [Indexed: 12/20/2022] Open
Abstract
Rationale: Recurrent wheezing in children represents a severe public health concern. Wheezing attacks (WA), mainly associated with viral infections, lack effective preventive therapies. Objectives: To evaluate the efficacy and safety of mucosal sublingual immunotherapy based on whole inactivated bacteria (MV130) in preventing WA in children. Methods: A Phase 3 randomized, double-blind, placebo-controlled, parallel-group trial including a cohort of 120 children <3 years old with ⩾3 WA during the previous year was conducted. Children with a positive skin test to common aeroallergens in the area where the clinical trial was performed were excluded from the trial. Subjects received MV130 or placebo daily for 6 months. The primary endpoint was the number of WA within 1 year after the first dose comparing MV130 and placebo. Measurements and Main Results: There was a significant lower number of WA in MV130 versus the placebo group, 3.0 (interquartile range [IQR], 2.0-4.0) versus 5.0 (IQR, 3.0-7.0) (P < 0.001). As secondary outcomes, a decrease in the duration of WA and a reduction in symptoms and medication scores in the MV130 versus placebo group were found. No adverse events were reported related to the active treatment. Conclusions: Mucosal bacterial immunotherapy with MV130 shows safety and clinical efficacy against recurrent WA in children.Clinical trial registered with www.clinicaltrials.gov (NCT01734811).
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Affiliation(s)
- Antonio Nieto
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | - Angel Mazón
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | - María Nieto
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | | | - Susana Calaforra
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | - Blanca Selva
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | - Sonia Uixera
- Unidad de Neumología y Alergia Pediátrica, Instituto de Investigaciones Sanitarias, Hospital Universitario La Fe, Valencia, Spain
| | | | - Paola Brandi
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | | | | | - Cristina Fernández-Pérez
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - David Sancho
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
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Navanandan N, Moss A, Tanverdi M, Ambroggio L, Brittan M. Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting. J Asthma 2020; 59:333-341. [PMID: 33106059 DOI: 10.1080/02770903.2020.1843176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting. METHODS Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome. RESULTS There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8). CONCLUSIONS There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Melisa Tanverdi
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lilliam Ambroggio
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
| | - Mark Brittan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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9
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Hikino K, Kobayashi S, Ota E, Mushiroda T, Urayama KY, Kobayashi T. A meta-analysis of the influence of ADRB2 genetic polymorphisms on albuterol (salbutamol) therapy in patients with asthma. Br J Clin Pharmacol 2020; 87:1708-1716. [PMID: 32986886 DOI: 10.1111/bcp.14570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS The associations of 2 nonsynonymous single nucleotide polymorphisms (Arg16Gly and Gln27Glu) in the adrenoceptor β2 (ADRB2) gene with response after albuterol use are conflicting. We conducted a meta-analysis to examine the cumulative evidence of the effects of these 2 variants on percent forced expiratory volume in 1 second (FEV1.0%) after albuterol use in asthma patients. METHODS We conducted a comprehensive literature search using MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to identify studies examining the association between ADRB2 Arg16Gly and Gln27Glu and FEV1.0% shortly after albuterol administration. The individual study results were combined with weights based on the inverse variance method. This systematic review was registered in the PROSPERO (registration number: CRD42019074554). RESULTS Among 273 initial studies identified, 7 studies met the inclusion criteria for quantitative evaluation. Results of the overall meta-analysis indicated no statistically significant mean difference of FEV1.0% between genotypes of Arg16Gly and Gln27Glu. In subgroup analyses, significant associations were found for Arg16Gly GG (vs AA) among studies where no methacholine bronchoconstriction was conducted (mean difference, -3.92; 95% confidence interval, -7.29 to -0.54; I2 = 0%), and for Arg16Gly GG (vs GA) among studies that included patients with no comorbidities (mean difference, -1.93; 95% confidence interval, -3.77 to -0.10; I2 = 0%). CONCLUSION Synthesis of the studies to date shows weak evidence for an association between ADRB2 Arg16Gly and Gln27Glu and FEV1.0% after albuterol use, results of which underscore significant heterogeneity across studies and the need for careful design and sample size considerations.
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Affiliation(s)
- Keiko Hikino
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Tsurumi-ku, Yokohama, Japan
| | - Shinobu Kobayashi
- Department of Social Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Erika Ota
- Graduate School of Nursing Sciences, Global Health Nursing, St. Luke's International University, Chuo-ku, Tokyo, Japan
| | - Taisei Mushiroda
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Tsurumi-ku, Yokohama, Japan
| | - Kevin Y Urayama
- Department of Social Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan.,Graduate School of Public Health, St. Luke's International University, Chuo-ku, Tokyo, Japan
| | - Tohru Kobayashi
- Department of Management and Strategy, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
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Schroter S, Thomas D, Nimmer M, Visotcky A, Fraser R, Colella MR, Browne LR. Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress. PREHOSP EMERG CARE 2020; 25:664-674. [PMID: 32870748 DOI: 10.1080/10903127.2020.1817211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. OBJECTIVE We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. METHODS This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children. RESULTS Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance. CONCLUSION Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.
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Affiliation(s)
- Stephanie Schroter
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Danny Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Mark Nimmer
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Alexis Visotcky
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Raphael Fraser
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - M Riccardo Colella
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Lorin R Browne
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
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11
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Cheng T, Farah J, Aldridge N, Tamir S, Donofrio‐Odmann JJ. Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations. J Am Coll Emerg Physicians Open 2020; 1:955-964. [PMID: 33145546 PMCID: PMC7593477 DOI: 10.1002/emp2.12103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies. METHODS Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma). RESULTS Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33). CONCLUSION Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Tabitha Cheng
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Jennifer Farah
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Nicholas Aldridge
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Sharon Tamir
- Department of PediatricsUCSDSan DiegoCaliforniaUSA
- Rady Children's Hospital of San DiegoSan DiegoCaliforniaUSA
| | - J. Joelle Donofrio‐Odmann
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
- Department of PediatricsUCSDSan DiegoCaliforniaUSA
- Rady Children's Hospital of San DiegoSan DiegoCaliforniaUSA
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12
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Oscillometry for acute asthma in the pediatric emergency department: A feasibility study. Ann Allergy Asthma Immunol 2020; 125:607-609. [PMID: 32652127 DOI: 10.1016/j.anai.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/27/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
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13
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Navanandan N, Moran E, Smith H, Hoch H, Mistry RD. Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children. J Asthma 2020; 58:547-553. [PMID: 31877252 DOI: 10.1080/02770903.2019.1709869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. METHODS PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. RESULTS A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. CONCLUSION There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth Moran
- Baylor College of Medicine, Section of Emergency Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Hana Smith
- General Academic Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Heather Hoch
- Children's Hospital Colorado, University of Colorado School of Medicine, Breathing Institute, Aurora, Colorado, USA
| | - Rakesh D Mistry
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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14
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Kocher KE, Arora R, Bassin BS, Benjamin LS, Bolton M, Dennis BJ, Ham JJ, Krupp SS, Levasseur KA, Macy ML, O'Neil BJ, Pribble JM, Sherwin RL, Sroufe NS, Uren BJ, Nypaver MM. Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC). Ann Emerg Med 2019; 75:192-205. [PMID: 31256906 DOI: 10.1016/j.annemergmed.2019.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/11/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.
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Affiliation(s)
- Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Rajan Arora
- Department of Emergency Medicine and Pediatrics, Wayne State University, Detroit, MI; Children's Hospital of Michigan, Detroit, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michaelina Bolton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Hurley Medical Center, Flint, MI
| | - Blaine J Dennis
- Beaumont Health System, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Hospital, Royal Oak and Troy, MI
| | - Jason J Ham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Seth S Krupp
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Henry Ford Health System, Detroit, MI
| | - Kelly A Levasseur
- Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Health System, Royal Oak, MI; Beaumont Hospital, Royal Oak and Troy, MI; Beaumont Children's Hospital, Royal Oak, MI
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Center, University of Michigan Medical School, Ann Arbor, MI; Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - James M Pribble
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Nicole S Sroufe
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Bradley J Uren
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Michele M Nypaver
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
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15
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Al-Shamrani A, Al-Harbi AS, Bagais K, Alenazi A, Alqwaiee M. Management of asthma exacerbation in the emergency departments. Int J Pediatr Adolesc Med 2019; 6:61-67. [PMID: 31388549 PMCID: PMC6676463 DOI: 10.1016/j.ijpam.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Fishe JN, Gautam S, Hendry P, Blake KV, Hendeles L. Emergency Medical Services Administration of Systemic Corticosteroids for Pediatric Asthma: A Statewide Study of Emergency Department Outcomes. Acad Emerg Med 2019; 26:549-551. [PMID: 30414344 DOI: 10.1111/acem.13660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer N. Fishe
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Shiva Gautam
- Department of Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Phyllis Hendry
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Kathryn V. Blake
- College of Pharmacy University of Florida Gainesville FL
- Nemours Center for Pharmacogenomics and Translational Research Jacksonville FL
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Kirkland SW, Vandermeer B, Campbell S, Villa-Roel C, Newton A, Ducharme FM, Rowe BH. Evaluating the effectiveness of systemic corticosteroids to mitigate relapse in children assessed and treated for acute asthma: A network meta-analysis. J Asthma 2018; 56:522-533. [PMID: 29693459 DOI: 10.1080/02770903.2018.1467444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this systematic review was to explore the effectiveness of various systemic corticosteroid (SCS) regimens to mitigate relapse in children with asthma discharged from an acute care setting. DATA SOURCES Medline, EMBASE, Global Health, International Pharmaceutical Abstracts, EMB ALL, CINAHL, SCOPUS, Proquest Dissertations and Theses Global, and LILACS were searched using controlled vocabulary and key words. Additional citations were searched via clinical trial registries, Google Scholar, bibliographies, a SCOPUS forward search of a sentinel paper, and hand searching conference abstracts. STUDY SELECTION No limitations based on language, publication status, or year of publication were applied. Two independent reviewers searched to identify randomized controlled trials comparing the effectiveness of SCS regimens to prevent relapse in children following treatment for acute asthma. RESULTS Fifteen studies were included. In 3 studies comparing SCS to placebo, asthma relapse was significantly reduced (RR = 0.10; 95% CI: 0.01, 0.77; I2 = 0%). A network analysis identified a significant reduction in relapse in children treated with intramuscular corticosteroids (OR = 0.038; 95% CrI: 0.001, 0.397), short-course oral prednisone (OR = 0.054; 95% CrI: 0.002, 0.451), and oral dexamethasone (OR = 0.071; 95% CrI: 0.002, 0.733) compared to placebo. CONCLUSION This review found evidence that SCS reduces relapse in children following treatment for acute asthma, albeit based on a limited number of studies. Additional studies are required to assess the differential effect of SCS doses and treatment duration to prevent relapse in children following discharge for acute asthma.
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Affiliation(s)
- Scott W Kirkland
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Ben Vandermeer
- b Department of Pediatrics, Alberta Research Centre for Health Evidence , University of Alberta, Edmonton Clinic Health Academy , Edmonton , AB , Canada
| | - Sandy Campbell
- c J.W. Scott Health Sciences Library , University of Alberta , Walter C. Mackenzie Health Sciences Centre, Edmonton , AB , Canada
| | - Cristina Villa-Roel
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada
| | - Amanda Newton
- d Department of Pediatrics , University of Alberta , Edmonton , AB , Canada
| | - Francine M Ducharme
- e Departments of Pediatrics and of Social and Preventive Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Brian H Rowe
- a Department of Emergency Medicine , University of Alberta , Edmonton , AB , Canada.,f School of Public Health, University of Alberta , Edmonton Clinic Health Academy , Edmonton , AB , Canada
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Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Mosquera-Restrepo SF, Caro AC, García LF, Peláez-Jaramillo CA, Rojas M. Fatty acid derivative, chemokine, and cytokine profiles in exhaled breath condensates can differentiate adult and children paucibacillary tuberculosis patients. J Breath Res 2017; 11:016003. [DOI: 10.1088/1752-7163/11/1/016003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Athanazio R, Carvalho-Pinto R, Fernandes FLA, Rached S, Rabe K, Cukier A, Stelmach R. Can severe asthmatic patients achieve asthma control? A systematic approach in patients with difficult to control asthma followed in a specialized clinic. BMC Pulm Med 2016; 16:153. [PMID: 27852260 PMCID: PMC5112706 DOI: 10.1186/s12890-016-0314-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/07/2016] [Indexed: 12/22/2022] Open
Abstract
Background Despite advances in asthma treatment, severe asthma (SA) still results in high morbidity and use of health resources. Our hypothesis was that SA patients would achieve adequate control with a systematic protocol, including oral corticosteroids, budesonide/formoterol maintenance and reliever therapy and a multidisciplinary approach to improve adherence. Methods Non-controlled (NC) SA patients were enrolled to receive 2 weeks of oral corticosteroids and 12 weeks of formoterol + budesonide. Assessments included asthma control questionnaire (ACQ), asthma control test (ACT), daily symptom diary, lung function and health-related quality of life (HRQoL) questionnaires. Results Of 51 patients, 13 (25.5%) achieved control. NC patients had higher utilization of health resources and higher exacerbation rates. Both controlled (C) and NC patients had significantly reduced ACQ scores after oral corticosteroid treatment. After 12 weeks, C patients continued improving. NC patients did not have significant changes. A similar pattern was found regarding lung function, use of rescue medication, and days free of symptoms. After 2 weeks of oral corticosteroids, an increase occurred in those who achieved the ACQ cut off; however, 53.8% of C patients had an ACQ < 1.57 versus 21.1% of NC patients (p = 0.03). Both groups had low HRQoL at baseline with improvement after intervention. Conclusions Despite rigorous, optimized follow-up treatment, 75% of SA patients did not achieve adequate symptom control and presented with impaired quality of life. Conversely, application of a low-cost, easy to implement systematic protocol can prevent up to 25% of SA patients from up-titrating to new and complex therapies, thus reducing costs and morbidity. Trial registration Retrospectively registered at ClinicalTrial.gov on 22 February 2010 (NCT01089322).
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Affiliation(s)
- Rodrigo Athanazio
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil.
| | - Regina Carvalho-Pinto
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil
| | - Frederico Leon Arrabal Fernandes
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil
| | - Samia Rached
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil
| | - Klaus Rabe
- Lungen Clinic Grosshansdorf and Department of Medicine, Christian Albrechts University Kiel, Airway Research Center North (ARCN) in the German Center for Lung Research (DZL), Kiel, Germany
| | - Alberto Cukier
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil
| | - Rafael Stelmach
- Pulmonary Division - Heart Institute (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/BR, Av Dr Eneas de Carvalho Aguiar, 44 - 5° andar (Pneumologia), São Paulo, 05403-900, SP, Brazil
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Muchão FP, Souza JME, Torres HCC, De Lalibera IB, de Souza AV, Rodrigues JC, Schvartsman C, da Silva Filho LVRF. Albuterol via metered-dose inhaler in children: Lower doses are effective, and higher doses are safe. Pediatr Pulmonol 2016; 51:1122-1130. [PMID: 27171324 DOI: 10.1002/ppul.23469] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/20/2016] [Accepted: 04/25/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND The ideal dosing of albuterol via metered-dose inhalers for acute childhood asthma is not well established. We hypothesized that greater doses of albuterol would result in less time in the hospital and lower admission rates. METHODS This was a randomized controlled double-blind multicenter study, conducted in emergency rooms (ER). We included patients with 2-17 years old with moderate to severe acute asthma (Pediatric Respiratory Assessment Measure, PRAM, score ≥5). Dosages administered during the first hour included: 6 (up to 25 kg) or 12 puffs (>25 kg) in the control group and 9 (up to 15 kg), 12 (>15-20 kg), 15 (>20-25 kg), or 18 puffs (>25 kg) in the study group. Several efficacy (changes in PRAM score, pulse oximetry, and FEV1 , length of stay, and admission rates) and safety (albuterol plasma levels, heart rate, serum potassium, glucose and bicarbonate levels, EKG, and tremor rates) outcome measures were assessed. RESULTS We included 119 patients with similar baseline conditions, and no significant differences were observed between groups in the length of stay (P = 0.48) or admission rate (P = 0.55). No significant differences were observed in FEV1 , PRAM score, and pulse oximetry changes after 1 hr and at discharge or admission. No significant differences were observed in safety outcomes between groups. CONCLUSIONS Higher albuterol dosage regimens did not result in lower admission rate or shorter length of stay in the ER, but showed similar safety profile for children with moderate to severe acute asthma. Pediatr Pulmonol. 2016;51:1122-1130. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabio Pereira Muchão
- Instituto da Criança, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil.,Centro de Pesquisa Experimental-Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Juliana Miguita E Souza
- Instituto da Criança, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | | | - Andréa Vieira de Souza
- Centro de Pesquisa Experimental-Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Joaquim Carlos Rodrigues
- Instituto da Criança, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Claudio Schvartsman
- Instituto da Criança, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luiz Vicente Ribeiro Ferreira da Silva Filho
- Instituto da Criança, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil. .,Centro de Pesquisa Experimental-Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil. .,Laboratório de Virologia-Instituto de Medicina Tropical, University of São Paulo, São Paulo, Brazil.
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Arabkhazaeli A, Vijverberg SJH, van der Ent CK, Raaijmakers JAM, Maitland-van der Zee AH. High incidence of oral corticosteroids prescriptions in children with asthma in early childhood. J Asthma 2016; 53:1012-7. [PMID: 27187595 DOI: 10.1080/02770903.2016.1185439] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Severe asthma exacerbations are often treated with short courses of oral corticosteroids (OCS). This study assessed the incidence of OCS being prescribed in asthmatic children of various age groups and calculated their chances of receiving subsequent OCS prescriptions. METHODS Longitudinal Dutch community pharmacy data of 2272 children who were regular users of asthma medication was analyzed retrospectively. Incidence rates for first, second and third prescriptions of OCS were calculated, stratified by age and sex. Probabilities of receiving first, second or third OCS prescriptions were assessed with Kaplan-Meier analysis. RESULTS Incidence rates for first OCS prescriptions were 4.5 for the 1(st) year of life per 100 person-years (100PY); 3.9 for the 2(nd); 4.6 for the 3(rd); 4.2 for the 4(th), and 4.7 for the 5(th) year of life per 100PY. This was relatively high compared to incidence rates for children between the ages of 6 and 11 (ranging between 2.2 per 100PY (age 9) and 3.7(age 11)). Incidence rates for second and third OCS prescriptions were very high: 78.2(95%CI: 45.0-123.7) and 241.2(95%CI: 81.2-583.4) per 100PY for infants, respectively. The chances of receiving a first OCS prescription was higher in males (P value < 0.01). CONCLUSIONS In the Netherlands, the incidence of OCS being prescribed to children being treated with asthma medication in early childhood is relatively high for first OCS prescriptions and extremely high for second and third OCS prescriptions compared to other ages. Furthermore, there is a high probability of receiving a further OCS prescription shortly after an OCS prescription.
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Affiliation(s)
- Ali Arabkhazaeli
- a Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University , Utrecht , the Netherland
| | - Susanne J H Vijverberg
- a Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University , Utrecht , the Netherland
| | - Cornelis K van der Ent
- b Departments of Pediatric Respiratory Medicine , Wilhelmina Children's Hospital, University Medical Centre Utrecht , Utrecht , the Netherlands
| | - Jan A M Raaijmakers
- a Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University , Utrecht , the Netherland
| | - Anke H Maitland-van der Zee
- a Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht University , Utrecht , the Netherland
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Hypoxaemia as a Mortality Risk Factor in Acute Lower Respiratory Infections in Children in Low and Middle-Income Countries: Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0136166. [PMID: 26372640 PMCID: PMC4570717 DOI: 10.1371/journal.pone.0136166] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/31/2015] [Indexed: 02/03/2023] Open
Abstract
Objective To evaluate the association between hypoxaemia and mortality from acute lower respiratory infections (ALRI) in children in low- and middle-income countries (LMIC). Design Systematic review and meta-analysis. Study Selection Observational studies reporting on the association between hypoxaemia and death from ALRI in children below five years in LMIC. Data Sources Medline, Embase, Global Health Library, Lilacs, and Web of Science to February 2015. Risk of Bias Assessment Quality In Prognosis Studies tool with minor adaptations to assess the risk of bias; funnel plots and Egger’s test to evaluate publication bias. Results Out of 11,627 papers retrieved, 18 studies from 13 countries on 20,224 children met the inclusion criteria. Twelve (66.6%) studies had either low or moderate risk of bias. Hypoxaemia defined as oxygen saturation rate (SpO2) <90% associated with significantly increased odds of death from ALRI (OR 5.47, 95% CI 3.93 to 7.63) in 12 studies on 13,936 children. An Sp02 <92% associated with a similar increased risk of mortality (OR 3.66, 95% CI 1.42 to 9.47) in 3 studies on 673 children. Sensitivity analyses (excluding studies with high risk of bias and using adjusted OR) and subgroup analyses (by: altitude, definition of ALRI, country income, HIV prevalence) did not affect results. Only one study was performed on children living at high altitude. Conclusions The results of this review support the routine evaluation of SpO2 for identifying children with ALRI at increased risk of death. Both a Sp02 value of 92% and 90% equally identify children at increased risk of mortality. More research is needed on children living at high altitude. Policy makers in LMIC should aim at improving the regular use of pulse oximetry and the availability of oxygen in order to decrease mortality from ALRI.
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Asthma essentials. Afr J Emerg Med 2013. [DOI: 10.1016/j.afjem.2012.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
The goal of this article is to inform readers of the common and uncommon signs and symptoms of asthma. After completion of this article, readers should have a firm understanding of the symptoms and presentation leading to a diagnosis of asthma.
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Affiliation(s)
- Monica Oberoi Patadia
- Department of Otolaryngology - Head and Neck Surgery, Loyola University Medical Center, 2160 South First Avenue, Building 105, Room 1870, Maywood, IL 60153, USA
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Knapp JF, Simon SD, Sharma V. Variation and trends in ED use of radiographs for asthma, bronchiolitis, and croup in children. Pediatrics 2013; 132:245-52. [PMID: 23878045 DOI: 10.1542/peds.2012-2830] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use. METHODS A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. RESULTS The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status. CONCLUSIONS The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.
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Affiliation(s)
- Jane F Knapp
- Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri–Kansas City, School of Medicine, Kansas City, Missouri 64108, USA.
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Kharbanda AB, Hall M, Shah SS, Freedman SB, Mistry RD, Macias CG, Bonsu B, Dayan PS, Alessandrini EA, Neuman MI. Variation in resource utilization across a national sample of pediatric emergency departments. J Pediatr 2013; 163:230-6. [PMID: 23332463 DOI: 10.1016/j.jpeds.2012.12.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 11/01/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe variations in emergency department (ED) quality measures and determine the association between ED costs and outcomes for 3 pediatric conditions: asthma, gastroenteritis, and simple febrile seizure. STUDY DESIGN This cross-sectional analysis of ED visits used the Pediatric Health Information System database. Children aged ≤ 18 years who were evaluated in an ED between July 2009 and June 2011 and had a discharge diagnosis of asthma, gastroenteritis, or simple febrile seizure were included. Two quality of care metrics were evaluated for each target condition, and Spearman correlation was applied to evaluate the relationship between ED costs (reflecting overall resource utilization) and admission and revisit rates among institutions. RESULTS More than 250,000 ED visits at 21 member hospitals were analyzed. Among children with asthma, the median rate of chest radiography utilization was 35.1% (IQR, 31.3%-41.7%), and that of corticosteroid administration was 82.6% (IQR, 78.5%-86.5%). For children with gastroenteritis, the median rate of ondansetron administration was 52% (IQR, 43.2%-57.0%), and that of intravenous fluid administration was 18.1% (IQR, 15.3%-21.3%). Among children with febrile seizures, the median rate of computed tomography utilization was 3.1% (IQR, 2.7%-4.3%), and that of lumbar puncture was 4.0% (IQR, 2.3%-5.6%). Increased costs were not associated with lower admission rate or 3-day ED revisit rate for the 3 conditions. CONCLUSION We observed variation in quality measures for patients presenting to pediatric EDs with common conditions. Higher costs were not associated with lower hospitalization or ED revisit rates.
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Affiliation(s)
- Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.
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Schuh S, Zemek R, Plint A, Black KJL, Freedman S, Porter R, Gouin S, Johnson DW. Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency research Canada study. Acad Emerg Med 2012; 19:E1019-26. [PMID: 22978728 DOI: 10.1111/j.1553-2712.2012.01433.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. METHODS This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. RESULTS The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4). CONCLUSIONS The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.
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Affiliation(s)
- Suzanne Schuh
- Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Song YH, Nam SY, Choi YJ, Kim JH, Kim YS, Jeong HJ. Socioeconomic impact of traditional Korean medicine, Pyeongwee-San (KMP6) as an anti-allergic inflammatory drug. ACTA ACUST UNITED AC 2012. [DOI: 10.5667/tang.2012.0027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shirakabe A, Hata N, Kobayashi N, Shinada T, Tomita K, Tsurumi M, Matsushita M, Okazaki H, Yamamoto Y, Yokoyama S, Asai K, Mizuno K. Clinical significance of acid-base balance in an emergency setting in patients with acute heart failure. J Cardiol 2012; 60:288-94. [PMID: 22819039 DOI: 10.1016/j.jjcc.2012.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 05/16/2012] [Accepted: 06/06/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE The role of an arterial blood gas analysis in acute heart failure (AHF) remains unclear. The acid-base balance could help to treat AHF, and it might help to distinguish different types of AHF, while it might be associated with the AHF prognosis. The present study was conducted to determine the relationship between the arterial blood gas sample at the time of hospital admission and clinical findings on admission, outcomes. METHODS AND RESULTS Six hundred twenty-one patients with AHF admitted to the intensive care unit were analyzed. Patients were assigned to an alkalosis group (n=99, pH>7.45), normal group (n=178, 7.35≤ pH≤ 7.45), and acidosis group (n=344, pH<7.35). The clinical findings on admission and outcomes (in-hospital mortality and any-cause death within 2 years) were compared between the three groups. The white blood cell counts (WBC), serum levels of total protein, albumin, and glucose were significantly lower, and the serum levels of C-reactive protein (CRP) and total bilirubin were significantly higher in the alkalosis group. Patients with orthopnea were significantly fewer, and the systolic blood pressure (SBP) and heart rate (HR) were significantly lower in the alkalosis group. The results of a multivariate logistic regression model for in-hospital mortality found that alkalosis was an independent risk factor (p=0.017, odds ratio: 2.589; 95% confidence interval: 1.186-5.648). The Kaplan-Meier curves showed the prognosis for any-cause death to be significantly poorer in the alkalosis group than in the normal group (p=0.026). CONCLUSIONS The factors associated with alkalosis AHF were high CRP, bilirubin, and low WBC, glucose, total protein, and albumin. The patients with alkalosis AHF were less likely to have orthopnea with low SBP and HR. They suggested that the patients with alkalosis AHF might have experienced AHF for a few days and were associated with high mortality.
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Affiliation(s)
- Akihiro Shirakabe
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan.
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Church MK, Casale TB. Principles of pharmacotherapy. Allergy 2012. [DOI: 10.1016/b978-0-7234-3658-4.00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Miñana G, Núñez J, Bañuls P, Sanchis J, Núñez E, Robles R, Mascarell B, Palau P, Chorro FJ, Llàcer A. Prognostic implications of arterial blood gases in acute decompensated heart failure. Eur J Intern Med 2011; 22:489-94. [PMID: 21925058 DOI: 10.1016/j.ejim.2011.01.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 01/18/2011] [Accepted: 01/21/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prognostic value of arterial blood gases (ABG) in patients with acute decompensated heart failure (ADHF) is not well-established. We therefore conducted the present study to determine the relationship between ABG on admission and long-term mortality in patients with ADHF. METHODS We studied 588 patients consecutively admitted to our department with ADHF. ABG and classical prognostic variables were determined at patients' arrival to the emergency department. The independent association among the main variables of ABG (pO2, pCO2 and pH) and mortality was assessed with Cox regression analysis. RESULTS At a median follow-up of 23months, 221 deaths (37.6%) were registered. 308 (52.4%), 54 (9.2%) and 50 (8.5%) patients showed hypoxemia (pO2<60mmHg), hypercapnia (pCO2>50mmHg) and acidosis (pH<7.35), respectively. Patients with hypoxemia, hypercapnia and acidosis did not show higher mortality rates (38% vs. 37.1%, 42.6% vs. 37.1%, and 48% vs. 36.6%, respectively; p-value=ns for all comparisons). In multivariate analysis, after adjusting for well-known prognostic covariates, pO2, pCO2 and pH did not show a significant association with mortality. Hazard ratios (HR) for these variables were: pO2, per increase in 10mmHg: 0.99 (95% CI: 0.90-1.09), p=0.861; pCO2, per increase in 10mmHg: 1.12 (95% CI: 0.91-1.39), p=0.262; pH per increase in 0.1: 1.01 (95% CI: 0.99-1.04), p=0.309. When dichotomizing these variables according to established cut-points, the HR were: hypoxemia (pO2<60mmHg):1.07 (95% CI: 0.81-1.40), p=0.637; hypercapnia (pCO2>50mmHg): 0.98 (95% CI: 0.62-1.57), p=0.952; acidosis (pH<7.35): 1.38 (95% CI: 0.87-2.19), p=0.173. CONCLUSION In patients admitted with ADHF, admission arterial pO2, pCO2 and pH were not associated with all-cause long-term mortality.
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Affiliation(s)
- Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain.
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Schneider WV, Bulloch B, Wilkinson M, Garcia-Filion P, Keahey L, Hostetler M. Utility of portable spirometry in a pediatric emergency department in children with acute exacerbation of asthma. J Asthma 2011; 48:248-52. [PMID: 21332428 DOI: 10.3109/02770903.2011.555036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The primary purpose of this study was to determine if portable spirometers can be successfully used in an emergency department (ED) in children with an acute exacerbation of asthma. The secondary purpose of this study was to determine if a validated clinical asthma score (CAS) correlates with the spirometry results in children with an acute exacerbation of asthma. METHODS Children between the ages of 6 and 17 years who presented to an urban free-standing children's hospital ED with an acute exacerbation of asthma were enrolled in our study. On arrival, the CAS was recorded and then portable spirometry was performed. Attempts were continued until acceptable and reproducible flow loop measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with the CAS. RESULTS A total of 101 patients were enrolled in this study. Of those patients, only 35 (35%) were able to successfully perform portable spirometry. Successful spirometry attempts were associated with older age (10.4 vs. 8.9, p = .01), lower respiratory rates (24.8 vs. 30.2, p = .001), lower heart rates (110 vs. 124, p = .004), and lower CASs (8.4 vs. 9.7, p = .001). Increasing asthma severity correlated with a decreased likelihood of successfully obtaining a useful forced expiratory volume in 1 second (FEV(1)) measurement (p = .013). Compared with cases of mild asthma, a patient with moderate asthma is 33% less likely to be able to perform spirometry, and a patient with severe asthma 93% less likely to perform spirometry. The CAS correlated poorly with the more objective measure of FEV(1)% predicted in those with mild asthma. CONCLUSION Many children are incapable of using portable spirometry for the evaluation of acute exacerbations of asthma in the ED. The clinical asthma scoring system demonstrated poor correlation with portable spirometry measurements in terms of severity classification.
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The exacerbation component of impairment and risk in pediatric asthma. Curr Opin Allergy Clin Immunol 2010; 10:155-60. [PMID: 20010093 DOI: 10.1097/aci.0b013e328335ce60] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The new guidelines for assessment of asthma control emphasize two domains: impairment and risk. Exacerbations of asthma are an important component of risk but have not received as much attention as the day-to-day symptoms that make up impairment. The purpose of this review is to report what has recently been learned about exacerbations. RECENT FINDINGS Exacerbations occur in the context of both controlled and uncontrolled asthma. Exacerbations are a strong independent risk factor of further exacerbations. This suggests that unrecognized factors may be involved in susceptibility to exacerbations in addition to more commonly recognized triggers such as viruses, allergens, and poorly controlled asthma. Such factors may be the result of genetic variation. Recent evidence now shows a residual effect on lung function from an exacerbation event. There are no current specific intervention measures to prevent exacerbations but attention to management practices continues to look at the role of the emergency department in improving care. SUMMARY The presence of exacerbations is considered a risk factor of the likelihood of further exacerbations and requires assessment of the triggers identified with history of exacerbations, host factors, atopic disposition, exposure to allergens, adherence to prescribed medications, and preventive measures to reduce future risk of such an event.
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