[Treatment of exacerbation of asthma: what are today's issues?]

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

Another look at emergency room overcrowding: accessibility of the health services and quality of care

PURPOSE

To describe both the social characteristics and the health needs of the medical users of a pediatric hospital Emergency Room with special emphasis on frequent use.

STUDY SELECTION

Observational study on health services utilization and health care needs of young children consulting at a teaching hospital's Emergency Room.

DATA SOURCES

Mother interview and medical record review.

RESULTS OF DATA SYNTHESIS

Children from underprivileged strata are more often high Emergency Room users. Their preventive needs are satisfied but adequate follow-up of their medical problems is more often lacking.

CONCLUSION

To understand why some achievable benefits are not achieved it is necessary to evaluate the varying performance of health services according to the social origin of the users.

[Analysis of emergency recruitment in a pediatric hospital. Effect on the organization of available care]

BACKGROUND

The increasing demand on the emergency wards of pediatric hospitals raise the question of whether the services delivered are adequate for the explicit and implicit needs of outpatients.

POPULATION AND METHODS

The files of all the 334 children consulting at the medical emergency ward of Robert-Debré hospital in Paris between April 19 and April 26, 1989 were analyzed. Socio-demographic data, reasons for visit and final diagnosis were collected. Each outpatient was assigned to one of 3 categories: 1) severe emergency; 2) simple emergency; 3) consultation. Further data on the events leading to the visit were obtained by a second survey covering 213 children seen between May 11 and May 14, 1991 from 8 hrs to 20 hrs.

RESULTS

The mean age of the 334 children in the first survey was 3.2 years. Half of the mothers were unemployed. Half of the families was of foreign extraction. 3.4% of the children had no social insurance. Ten percent of the patients were frequent users of the emergency ward. Infectious diseases were the most prevalent reason for visit. Severe emergencies were 28%, simple emergencies 44% and consultations 28%. Among the 213 children of the second survey, half of the families had seen (43%) or attempted to see (7%) a physician outside the hospital before coming to the emergency ward.

CONCLUSION

The needs of the children could best be met by performing a true medico-social examination at the medical emergency ward, enhancing access for children and revitalizing a partnership with the community to provide continuous care for those children in need of it.

Effectiveness of the daily record review at the medical emergency room department in a French teaching children's hospital

We evaluate the effectiveness of the daily record review (DRR) of 4393 ambulatory medical patients seen at the emergency room department of a teaching pediatric hospital in Paris between 8th January and 11 March 1991. For these patients, 137 potential quality problems were found, 117 of them remaining after discussion with the junior. For 80 of the 117 confirmed problems (68.4%), the reviewing senior estimated that sufficient advice had been given to the child's usual caretaker or health care provider and (or) the children returned to seek medical advice when indicated. Experts proved the procedure to be reliable: they detected a problem for 36% of the cases with potential quality problems and for only 2% of a sample of control records considered without potential quality problems after the DRR.

[Kawasaki syndrome]

Recent studies support the hypothesis that Kawasaki disease is due to a hyperimmune vasculitis, probably of infectious origin. In addition, current data highlight the frequency of atypical (oligosymptomatic) aspects of the disease which may not be recognized, thereby worsening its cardiovascular prognosis. The types of cardiac lesions encountered, notably those of the coronary arteries, have now been well established by sequential echocardiographic studies. Several therapeutic trials have confirmed the effectiveness of gammaglobulins (400 mg/kg.day) and acetylsalicylic acid in preventing the formation of coronary aneurysms. These recent advances in the understanding and treatment of Kawasaki disease may lead to a reappraisal of its diagnostic and prognostic criteria and open the way to multiple lines of research.