Unscheduled Medical Visits Research Articles

The Relationship Between Hyperalbuminemia and Unscheduled Medical Visits: A Retrospective Cohort Study.

Introduction Hyperalbuminemia, defined as elevated serum albumin levels, may influence healthcare utilization, particularly unscheduled medical visits. The sympathetic nervous system (SNS) regulates serum albumin, which is crucial for maintaining oncotic pressure and substance transport. SNS instability, linked to chronic diseases, can impact albumin levels. This study investigates the association between hyperalbuminemia and unscheduled medical visits in community hospital outpatient departments, aiming to establish its potential as a predictor of healthcare utilization. Methods This retrospective cohort study utilized electronic medical records from Unnan City Hospital, Japan, from September 2021 to August 2023. Participants were over 15 years old and had albumin data available, excluding those with acute albumin conditions. The case group consisted of 321 hyperalbuminemia patients (serum albumin ≥ 5 g/dL), matched monthly with 16 controls. Data on demographics, chronic diseases, and unscheduled medical visits were collected. Multivariate logistic regression analyzed the association between hyperalbuminemia and unscheduled medical visits. Results Among 716 participants, the hyperalbuminemia group (mean age 59.13 years) was younger than the non-hyperalbuminemia group (mean age 74.36 years). Hyperalbuminemia patients had a higher BMI, pulse rate, and prevalence of diabetes, dyslipidemia, and brain stroke. Significant associations were found between hyperalbuminemia and unscheduled medical visits (OR 2.35, 95% CI 1.56-3.53, p < 0.001), age, BMI, pulse rate, and brain stroke. Conclusion Hyperalbuminemia is significantly associated with increased unscheduled medical visits in rural outpatient settings. Routine serum albumin assessments can aid in risk stratification and personalized care, potentially reducing acute healthcare needs. Future research should explore underlying mechanisms and broader populations to enhance clinical applications.

Efficacy of bronchial thermoplasty in a patient panel with uncontrolled severe persistent asthma

Background Bronchial thermoplasty (BT) is an approved procedure to manage uncontrolled severe persistent asthma. Many insurance providers are reluctant to pay for BT without proven benefit among their specific patient panel. Objective Determine if BT is effective in a panel patient panel with uncontrolled severe persistent asthma. Study design and methods This was an unblinded prospective study of adult subjects with uncontrolled severe persistent asthma who underwent BT. Outcomes were assessed at baseline and then 3-, 6-, 12-, 18- and 24-months post-BT. The primary metric was an improved Asthma Quality of Life Questionnaire (AQLQ) score. Other metrics included improved Asthma Control Test (ACT), peak expiratory flow rates (PEFR), spirometry, fractional excretion of nitric oxide (FeNO), number of unscheduled medical visits, and lost days of work/activity. Respiratory adverse events were assessed during the BT treatment period and at each post-BT visit. Results Twenty-nine subjects completed the study; the median interquartile range (IQR) age was 47 (42-61), and the majority were female (69%), white (93%), and non-Hispanic (90%). After BT, mean (±std) AQLQ scores improved by 1.6(±1.1) at 3 months (p < 0.0001), 1.6(±1.2) at 6 months (p < 0.0001), 1.4(±1.0) at 12 months (p < 0.0001), 1.8(±1.1) at 18 months (p < 0.0001), and 1.6 (±1.5) at 24 months (p < 0.0001). There were significant improvements in ACT, PEFR, unscheduled medical visits and lost days of work and activity. Spirometry and FeNO metrics were unchanged. The average cost for subjects completing all 3 BT procedures was approximately $15,000. Conclusion BT is an effective adjunctive therapeutic modality in subjects with uncontrolled severe persistent asthma.

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

IntroductionAs health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare. ObjectivesTherefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations. Design and methodsThis study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses. ResultsEmployee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = −0.55, p < .001).Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings. DiscussionWhile results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination.

The Level of Self-Care among Patients with Chronic Heart Failure.

Introduction: In a long-term approach to the treatment of heart failure, importance is given to the process of self-care management and behaviors. The number of rehospitalizations and unscheduled medical visits can be reduced by actively engaging patients in the self-care process. Methods: The study included 403 patients with chronic heart failure (mean LVEF 40.53%), hospitalized in the Cardiology Department. Medical record analysis and a self-report questionnaire were used to obtain basic sociodemographic and clinical data. The European Heart Failure Self-care Behavior Scale, revised into a nine-item scale (EHFScBS-9), was used to evaluate self-care behavior. Results: Analysis of the EHFSc-9 self-care behavior scale showed that the mean score was 49.55 out of 100 possible points (SD = 22.07). Univariate analysis revealed that significant (p < 0.05) negative predictors of the EHFScB-9 self-care scale included: male sex (b = −5146), hospitalizations in the last year (b = −5488), NYHA class II (b = −11,797) and NYHA IV class (b = −15,196). The multivariate linear regression model showed that a significant (p ˂ 0.05) negative predictor of the EHFScB-9 self-care scale was male sex (b = −5.575). Conclusions: Patients with chronic HF achieve near optimal self-care behavior outcomes. A patient prepared to engage with self-care will have fewer rehospitalizations and a better quality of life.

Sublingual Bacterial Vaccination Reduces Recurrent Infections in Patients With Autoimmune Diseases Under Immunosuppressant Treatment.

IntroductionConventional or biologic disease-modifying anti-rheumatic drugs (DMARDs) are the mainstay of treatment for systemic autoimmune disease (SAD). Infectious complications are a major concern in their use.ObjectiveTo evaluate the clinical benefit of sublingual mucosal polybacterial vaccines (MV130 and MV140), used to prevent recurrent respiratory and urinary tract infections, in patients with SAD and secondary recurrent infections following conventional or biologic DMARDs.MethodsAn observational study in SAD patients with recurrent respiratory tract infections (RRTI) and/or recurrent urinary tract infections (RUTI) was carried out. All patients underwent mucosal (sublingual) vaccination with MV130 for RRTI or with MV140 for RUTI daily for 3 months. Clinical evaluation was assessed during 12 months of follow-up after the first dose, i.e., 3 months under treatment and 9 months once discontinued, and compared with the previous year.ResultsForty-one out of 55 patients completed 1-year follow-up. All patients were on either conventional or biologic DMARDs. A significant decrease in the frequency of RUTI (p<0.001), lower respiratory tract infections (LRTI) (p=0.009) and upper respiratory tract infections (URTI) (p=0.006) at 12-mo with respect to the previous year was observed. Antibiotic prescriptions and unscheduled medical visits decreased significantly (p<0.020) in all groups. Hospitalization rate also declined in patients with RRTI (p=0.019). The clinical benefit demonstrated was concomitant to a significant increase in both anti-S. pneumoniae IgA and IgG antibodies following MV130 vaccination.ConclusionsSublingual polybacterial vaccines prevent recurrent infections in patients with SAD under treatment with immunosuppressant therapies, supporting a broad non-specific anti-infectious effect in these patients.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration.

This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy. This study used a two-phase, qualitatively driven, mixed-methods descriptive design. 11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls. Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis. Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy. Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

Identification of clusters of asthma control: A preliminary analysis of the Inspirers studies

Aims: To identify distinct asthma control clusters based on Control of Allergic Rhinitis and Asthma Test (CARAT) and to compare patients’ characteristics among these clusters. Methods: Adults and adolescents (≥13 years) with persistent asthma were recruited at 29 Portuguese hospital outpatient clinics, in the context of two observational studies of the INSPIRERS project. Demographic and clinical characteristics, adherence to inhaled medication, beliefs about inhaled medication, anxiety and depression, quality of life, and asthma control (CARAT, &gt;24 good control) were collected. Hierarchical cluster analysis was performed using CARAT total score (CARAT -T). Results: 410 patients (68% adults), with a median (percentile 25–percentile 75) age of 28 (16­‑46) years, were analysed. Three clusters were identified [mean CARAT -T (min -max)]: cluster 1 [27(24 -30)], cluster 2 [19(14 -23)] and cluster 3 [10(2 -13)]. Patients in cluster 1 (34%) were characterised by better asthma control, better quality of life, higher inhaler adherence and use of a single inhaler. Patients in clusters 2 (50%) and 3 (16%) had uncontrolled asthma, lower inhaler adherence, more symptoms of anxiety and depression and more than half had at least one exacerbation in the previous year. Furthermore, patients in cluster 3 were predominantly female, had more unscheduled medical visits and more anxiety symptoms, perceived a higher necessity of their prescribed inhalers but also higher levels of concern about taking these inhalers. There were no differences in age, body mass index, lung function, smoking status, hospital admissions or specialist physician follow -up time among the three clusters. Conclusion: An unsupervised method based on CARAT- -T, identified 3 clusters of patients with distinct, clinically meaningful characteristics. The cluster with better asthma control had a cut -off similar to the established in the validation study of CARAT and an additional cut -off seems to distinguish more severe disease. Further research is necessary to validate the asthma control clusters identified.

Association Between Fungal Spore Exposure in Inner-City Schools and Asthma Morbidity

SN Baxi, WJ Sheehan, JE Sordillo. Ann Allergy Asthma Immunol . 2019;122(6):610–615.e1 To evaluate the association of school-based fungal spore exposures on asthma symptom days in children with asthma. Children 4–13 years of age with persistent asthma attending an elementary school in the Northeast US from 2008–2013, where environmental sampling was obtained. Children had to have physician diagnosed asthma with symptoms in the prior 12 months, daily controller medication usage, or unscheduled medical visits for asthma in the past year. Children were recruited from participating schools …

Reported Asthma Control Predicts Future Visits, Independent of Guideline-Based Control Measures

SR Kochis, T Grant, W Phipatanakul. J Allergy Clin Immunol Pract . 2019;7(5):1516–1521.e1 This study assessed how a caregiver’s perception of their child’s asthma control might impact the child’s risk for having future urgent visits for asthma care. Two cohorts of low income, ethnic minority children in Baltimore or Boston from the Mouse Allergen and Asthma Cohort Study (MAACS) and the Mouse Allergen and Asthma Intervention Trial (MAAIT) with persistent asthma, aged 5 to 17 years were included. The MAACS study correlated mouse exposure with asthma features, while the MAAIT study evaluated …

Comparative Effectiveness of Oral Steroids in Croup

Research Article| December 01 2019 Comparative Effectiveness of Oral Steroids in Croup AAP Grand Rounds (2019) 42 (6): 68. https://doi.org/10.1542/gr.42-6-68 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Comparative Effectiveness of Oral Steroids in Croup. AAP Grand Rounds December 2019; 42 (6): 68. https://doi.org/10.1542/gr.42-6-68 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: comparative effectiveness research, croup, steroids, prednisone Source: Parker CM, Cooper, MN. Prednisolone versus dexamethasone for croup: a randomized controlled trial. Pediatrics. 2019; 144(3): e20183772; doi: https://doi.org/10.1542/peds.2018-3772Google Scholar Investigators at multiple Australian institutions conducted a randomized controlled trial to assess the efficacy of 3 oral steroid regimens in the treatment of croup. Patients were eligible if they presented to 1 of 2 study EDs between 2009–2012, were clinically diagnosed with croup, and were >6 months old. Patients were excluded if they had a known steroid allergy or were already on oral steroids. Demographics of enrolled participants were collected at baseline. Participants were randomized to receive either 0.6 mg/kg dexamethasone (DEX), low-dose (0.15 mg/kg) dexamethasone (LD-DEX), or 1 mg/kg prednisolone (PRED). Staff and patients were blinded to treatment allocation. Each participant was assessed at baseline and 1-hour post-treatment using a validated measure of croup severity: the Westley croup score (WCS). The WCS is scored from 0–17, with higher scores indicating higher severity. Participant caregivers were contacted at 4 weeks to assess subsequent unscheduled medical visits within 7 days after treatment. The primary outcomes were WCS scores at 1 hour and unscheduled medical visits within 7 days. Secondary outcomes included the use of nebulized epinephrine and the need for additional steroid doses. Investigators performed a noninferiority analysis for the WCS score outcome, with noninferiority specified as the upper bound of the 95% CI not exceeding a WCS score of 0.5. There were 1,231 participants included in analyses, with 410 assigned to DEX, 410 to LD-DEX, and 411 to PRED. The baseline mean WCS scores were 1.4 in the DEX group, 1.5 in the LD-DEX group, and 1.5 in the PRED group. There were no significant differences in demographics between participants in each group. Mean WCS scores at 1 hour were 0.43, 0.48, and 0.49 in the DEX, LD-DEX, and PRED groups, respectively. Compared to DEX, these WCS scores in LD-DEX and PRED groups were not significantly different and had upper 95% CI bounds within the prespecified 0.5 margin. There was also no difference between groups in unscheduled medical visits (17.8%, 19.5%, and 21.7% for the DEX, LD-DEX, and PRED groups, respectively; P=.19) or the need for nebulized epinephrine. The proportion receiving additional steroid doses was different by treatment group (11.3% in the DEX group, 15.1% in the LD-DEX group, and 18.9% in the PRED group; P=.04). The investigators conclude that LD-DEX and PRED are as effective for the treatment of croup as dexamethasone, though more doses may be required. Dr Bechtel has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The current study is well-designed (prospective, double-blinded, randomized controlled) to evaluate if a single dose of either PRED (1 mg/kg/dose) or oral LD-DEX (0.15 mg/kg/dose) is “not inferior” or “not acceptably less efficacious”1 to a single dose of oral DEX (0.6 mg/kg/dose), the usual dosing for children with infectious croup.2... You do not currently have access to this content.

School–Supervised Use of a Once-Daily Inhaled Corticosteroid Regimen: A Cluster Randomized Trial

To evaluate the efficacy of school-supervised administration of once-daily inhaled corticosteroid to improve asthma control and reduce school absences in a primarily low-income Latino population.Students with asthma in 20 Tucson Unified School District elementary schools were selected to represent a large urban school population of low-income Latino students.The study was a 2-year, cluster-randomized, delayed-intervention trial comparing 9 months of supervised, unblinded, open-label mometasone furoate therapy with usual care. At entry, schools were randomized 1:1 to immediately initiate supervised therapy or delay implementation until year 2. Need for controller therapy was based on in-person evaluation the first year and by telemedicine during the second year. Medication was administered by school health personnel once daily on weekdays; parents were instructed to continue their own home medication during weekends and holidays. The primary outcome was change in Asthma Control Questionnaire (ACQ) score. Secondary outcomes included absences, unscheduled medical visits and hospitalizations, and oral steroid use.Nine hundred ninety-five (11%) of 8916 students reported asthma; 393 (39%) students enrolled, and 332 provided adequate data for analysis. Mean age was 8.1 years. At baseline, only one-fourth had well-controlled asthma. Thirty-nine percent reported controller medication use, and 80% were prescribed controller medication after clinical evaluation. During year 1, the mean ACQ score for students receiving immediate intervention did not significantly differ from those receiving delayed intervention. Medications were administered 98% of the time when students were at school; however, total calendar adherence was 53% due to absences, weekends, and holidays. Average school absences were noted to be 16 and 15 in immediate- and delayed-intervention groups, respectively, with only 4 to 5 of those due to asthma.School-supervised administration of once-daily inhaled corticosteroid did not result in improved asthma control as measured by ACQ, school absences, or health care use when compared with usual care in an urban, low-income, Latino elementary school population. Because of absences, weekends, and school holidays, the regimen achieved 53% calendar adherence despite excellent adherence to school-administered dosing. Further research is needed to clearly define the minimal adherence necessary to result in meaningful improvement in asthma control.There are numerous studies illustrating the benefits of school-supervised asthma therapy; this study provides a real-world application of school-based intervention with humbling but important results. Unique characteristics of the low-income Latino population and minimal research staff involvement may have played a role in outcomes and deserve further study. Of note is the high overall absenteeism rate and low calendar adherence rate. Hence, institution of school medication administration programs alone may not sufficiently impact asthma control without addressing home dosing and other societal determinants of school attendance and overall health.

Disentangling the heterogeneity of allergic respiratory diseases by latent class analysis reveals novel phenotypes.

Refined phenotyping of allergic diseases may unravel novel phenotypes. Conjunctivitis as an independent disorder has never been approached. To identify distinct classes of allergic respiratory diseases using latent class analysis (LCA) and distinguish each class using classification and regression tree (CART) analysis. Seven hundred and twenty-eight adults from the Portuguese general population study ICAR had a structured medical interview combined with blood collection, skin prick tests, spirometry with bronchodilation, and exhaled nitric oxide. LCA was applied to 19 variables. The CART algorithm selected the most likely variables distinguishing LCA-classes. A six-class model was obtained. Class 1 (25%): nonallergic participants without bronchial or ocular symptoms. Classes 2 (22%) and 3 (11%): nasal and ocular (low levels) symptoms without nasal impairment, monosensitized (Class 2) or polysensitized (Class 3). Class 4 (13%): polysensitized participants with high levels of nasal and ocular symptoms, and nasal impairment. Classes 5 (16%) and 6 (14%): high level of nasal, bronchial and ocular symptoms with nasal impairment (non-allergic or polysensitized, respectively). Participants in classes 5 and 6 had more bronchial exacerbations and unscheduled medical visits (P<0.001). Ocular symptoms were significantly higher in classes with nasal impairment, compared to those without impairment (P<0.001) or no nasal symptom (P<0.001). CART highlighted ocular symptoms as the most relevant variable in distinguishing LCA-classes. Novel severe phenotypes of participants with co-occurrence of ocular, nasal and bronchial symptoms, and exacerbation-prone were identified. The tree algorithm showed the importance of the ocular symptoms in the expression of allergic diseases phenotypes.

Gene-environment interaction between an IL4R variant and school endotoxin exposure contributes to asthma symptoms in inner-city children

Gene-environment interaction between an IL4R variant and school endotoxin exposure contributes to asthma symptoms in inner-city children

Efficacy and safety of omalizumab in children and adolescents with moderate-to-severe asthma: A systematic literature review.

There are limited pediatric data about the use of omalizumab, especially the effectiveness and safety of omalizumab in the real-world management of allergic asthma. The objective of this study was to summarize the safety and efficacy of omalizumab in both randomized clinical trials (RCT) used for U.S. Food and Drug Administration registration and real-world studies (RWS) based on clinical care of children with moderate-to-severe asthma. Studies that evaluated omalizumab use in patients <18 years old and with asthma, published between January 2003 and October 2016, were retrieved from medical literature data bases. Assessed outcomes included the following: exacerbation rates, spirometric indices, changes in asthma medication use, asthma control, patient-reported outcomes, and health care resource utilization. A total of five RWS were identified; outcomes reported were compared with three omalizumab RCTs. Overall, the mean rate of annual exacerbations was significantly lower after 6 months to 2 years of treatment with omalizumab in both RCTs and RWS. In two RCTs and three RWS, inhaled corticosteroid use was significantly reduced in patients who used omalizumab. Similar reductions in the use of rescue medication were also observed in the RCTs and RWS on omalizumab. Real-world evidence demonstrated improvement in forced expiratory volume in the first second of expiration (% predicted) in patients treated with omalizumab as well as significant improvement in the level of asthma control observed over 1 year. There also was evidence that omalizumab treatment reduced health care resource utilization, including fewer hospitalizations, emergency department visits, and unscheduled medical visits. Safety outcomes in all five RWS showed no new safety signals and demonstrated that omalizumab was well tolerated. Overall, RCT evidence strongly supported omalizumab efficacy and safety as add-on treatment in children 6 to 11 years old with moderate-to-severe persistent allergic asthma. RWS data confirmed these findings in an extended patient population of children and adolescents that is more generalizable to the actual day-to-day management of these patients.

The pregnancy “super-utilizer”: how does a high-risk depression screen affect medical utilization?

Objective: Our objective was to determine whether a score of >11 on the Edinburgh postnatal depression scale (EPDS) at the initial prenatal visit was associated with an increased use of acute medical visits when compared to pregnant women with an initial EPDS score of ≤11.Methods: This was a retrospective cohort study comparing the utilization of acute medical care during pregnancy and the first eight weeks after delivery amongst 200 women with an EPDS score >11 at their initial prenatal visit compared with 200 women with an EPDS score ≤11. “Super-utilization” was defined as ≥4 acute or unscheduled medical visits during pregnancy and the first eight weeks after delivery (90th percentile). Logistic regression was used to control for confounders.Results: Women with an initial EPDS score >11 were significantly more likely to engage in super-utilization of acute medical care compared with those women scoring ≤11 (adjusted odds ratio [aOR], 2.12; 95% confidence interval [CI], 1.53–3.90).Conclusions: Pregnant women scoring >11 on the EPDS at their initial prenatal visit are more likely to super-utilize acute medical care in the perinatal period. This subset of patients at-risk for increased utilization can be identified early during prenatal care. Interventions to better meet the medical and psychosocial needs of these women warrant future research.

Oxygen Saturation and Bronchiolitis Severity

Research Article| June 01 2016 Oxygen Saturation and Bronchiolitis Severity AAP Grand Rounds (2016) 35 (6): 64. https://doi.org/10.1542/gr.35-6-64 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Oxygen Saturation and Bronchiolitis Severity. AAP Grand Rounds June 2016; 35 (6): 64. https://doi.org/10.1542/gr.35-6-64 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bronchiolitis, oxygen saturation measurement, oxygen Principi T, Coates AL, Parkin PC, et al. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis [published online ahead of print February 29, 2016]. JAMA Pediatr. doi: https://doi.org/10.1001/jamapediatrics.2016.0114 Investigators from The Hospital for Sick Children in Toronto, Canada sought to determine if oxygen desaturations at home (unknown to parents) in previously healthy infants 6 weeks to 12 months of age who were discharged from the emergency department (ED) with bronchiolitis predict future unscheduled medical visits. Research nurses enrolled study participants who were diagnosed with bronchiolitis and deemed suitable for discharge from the ED. At enrollment, parents were given a pulse oximeter to take home with the child. Although the study pulse oximeters continuously recorded the oxygen saturation, they did not display saturation values and only alarmed for probe dislodgement. Prior to discharge from the ED, a pulse oximeter probe was applied to each study child and parents were taught how to reapply it. Parents were asked to record times of feeding, sleeping, and car seat use while the child was monitored. Parents were contacted 72 hours after discharge from the ED and asked about subsequent medical visits and hospitalizations. Following study completion, data from the pulse oximeters were analyzed using proprietary oximetry software which excluded artifacts and poor signal and generated the oximetry reports. A desaturation was defined as at least 1 oxygen saturation reading of <90% lasting at least 1 minute. Major desaturations were defined as 3 desaturations, or a reading of <90% for 3 minutes continuously or ≥10% of the total monitored time, including percentage of time with saturations 80%–89% and <80%. The primary outcome measure was an unscheduled visit for bronchiolitis within 72 hours of discharge; secondary outcomes included hospitalizations and all-cause medical visits. These outcomes were compared among infants with and without oxygen desaturations. Of the 118 participants, 64% (n = 75) had at least 1 desaturation during home monitoring. Of those with desaturations, 79% spent >1 minute with saturations ≤80%, 39% spent >1 minute with saturations ≤70%, and 53% experienced major desaturations. Most infants with desaturations (77%) experienced them during sleep or while feeding. There was no difference in unscheduled visits for bronchiolitis among infants with or without desaturations (24% vs 26%, respectively; P = .66). There was also no difference in rates of unscheduled visits between those with or without major desaturations. Rates of all-cause medical visits and hospitalizations also did not differ between infants with or without desaturations. The authors conclude that the majority of infants with mild bronchiolitis experienced desaturations at home, and that pulse oximetry does not predict return for care. Dr Garber has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. This is yet another study challenging the value of pulse oximetry in infants with bronchiolitis. Similar studies have been discussed in this journal (see AAP Grand Rounds, December... You do not currently have access to this content.

Asthma Status and Risk of Incident Myocardial Infarction: A Population-Based Case-Control Study

The role of asthma status and characteristics of asthma in the risk of myocardial infarction (MI) are poorly understood. We determined whether asthma and its characteristics are associated with risk of MI. The study was designed as a population-based retrospective case-control study, which included all eligible incident MI cases between November 1, 2002, and May 31, 2006, and their matched controls. Asthma was ascertained using predetermined criteria. Active (current) asthma was defined as the occurrence of asthma-related episodes (asthma symptoms, use of asthma medications, unscheduled medical or emergency department visit, or hospitalization for asthma) within 1 year before MI index date. There were 543 eligible incident MI cases during the study period. Of the 543 MI cases, 81 (15%) had a history of asthma before index date of MI, whereas 52 of 543 controls (10%) had such a history (adjusted odds ratio [OR]: 1.68; 95% CI: 1.06-2.66) adjusting for risk factors for MI and comorbid conditions (excluding chronic obstructive lung disease). Although inactive asthma did not increase the risk of MI, individuals with active asthma had a higher odds of MI, compared with those without asthma (adjusted OR: 3.18; 95% CI: 1.57-6.44) without controlling for chronic obstructive pulmonary disease (COPD). After adjusting for COPD, although asthma overall was no longer statistically significant (adjusted OR: 1.34, 95% CI: 0.84-2.15), active asthma still was associated (adjusted OR: 2.33, 95% CI: 1.12-4.82). Active asthma is an unrecognized risk factor for MI. Further studies are needed to assess the role of asthma control and medications in the risk of MI.

LO039: The effect of desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis

Introduction: Bronchiolitis is the most common lower respiratory tract infection among infants, characterized by wheeze and respiratory distress. Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay and escalation of care. The objectives were to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who desaturate to &lt;90% for at least one minute during home oximetry monitoring versus those without desaturations. Methods: This is a prospective cohort study from 2008 to 2013 enrolling 118 otherwise healthy infant aged 6 weeks to 12 months discharged home from a tertiary care pediatric emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, a visit to any health care provider due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge and the effect of activity on desaturations. Results: During a mean monitoring period of 19 hours, 75/118 (64%) infants had at least one desaturation event (median continuous duration 3.4 minutes). 59/118 infants (50%) had at least 3 desaturations, 12 (10%) desaturated for &gt;10% monitored time and 51(43%) had desaturations lasting ≥ 3 minutes continuously. 59/118 (50%) infants desaturated to ≤ 80% and 29 (24%) to ≤ 70% for ≥ 1 minute. A total 18/75 infants with desaturations (24.0%) had an unscheduled visit for bronchiolitis versus 11/43 of their non-desaturating counterparts (25.6%) [Difference - 1.6%; 95%CI -0.15 to ∞, p=0.66]. One of 75 desaturating infants (1.3%) and 2/43 (4.6%) of those without desaturations were hospitalized within 72 hours [Difference of -3.3%; 95% CI -0.04 to 0.10, p = 0.27]. Seventy seven percent of infants with desaturations experienced them during sleep or while feeding. Conclusion: The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.

Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay, and escalation of care. To examine whether there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who have oxygen desaturations to lower than 90% for at least 1 minute during home oximetry monitoring vs those without desaturations. Prospective cohort study conducted from February 6, 2008, to April 30, 2013, at a tertiary care pediatric emergency department in Toronto, Ontario, Canada, among 118 otherwise healthy infants aged 6 weeks to 12 months discharged home from the emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, including a visit to any health care professional due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge, and the effect of activity on desaturations. A total of 118 infants were included (mean [SD] age, 4.5 [2.1] months; 69 male [58%]). During a mean (SD) monitoring period of 19 hours 57 minutes (10 hours 37 minutes), 75 of 118 infants (64%) had at least 1 desaturation event (median continuous duration, 3 minutes 22 seconds; interquartile range, 1 minute 54 seconds to 8 minutes 50 seconds). Among the 118 infants, 59 (50%) had at least 3 desaturations, 12 (10%) had desaturation for more than 10% of the monitored time, and 51 (43%) had desaturations lasting 3 or more minutes continuously. Of the 75 infants who had desaturations, 59 (79%) had desaturation to 80% or less for at least 1 minute and 29 (39%) had desaturation to 70% or less for at least 1 minute. Of the 75 infants with desaturations, 18 (24%) had an unscheduled visit for bronchiolitis as compared with 11 of the 43 infants without desaturation (26%) (difference, -1.6%; 95% CI, -0.15 to ∞; P = .66). One of the 75 infants with desaturations (1%) and 2 of the 43 infants without desaturations (5%) were hospitalized within 72 hours (difference, -3.3%; 95% CI, -0.04 to 0.10; P = .27). Among the 62 infants with desaturations who had diary information, 48 (77%) experienced them during sleep or while feeding. The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

357 Effect of Ultrasound as an Initial Imaging Modality in Children With Appendicitis

The objective of this study was to evaluate whether use of ultrasound as an initial imaging modality increases complication rates in children with appendicitis. Retrospective review was performed for children ≤ 17 years old diagnosed with appendicitis in two urban pediatric emergency departments (EDs). Patients with known appendiceal perforation, transfers from an outside hospital, and patients not operated upon were excluded. Patients who had ultrasound as their initial imaging modality were compared to those who had computed tomography (CT) only. Complication rates and time from ED triage to surgical incision were measured. Complications were defined as one or more of the following: perforated or gangrenous appendix on surgical or pathology reports; pertinent unscheduled medical visits, radiology studies, and/or procedures performed within 6 months after appendectomy. Time to appendectomy was expressed using medians and interquartile range (IQR). Mann-Whitney tests were used to compare groups where appropriate. Of the 1411 charts reviewed, 661 patients were eligible for analysis. Those with ultrasound performed initially were not at increased odds of experiencing a complication compared to the CT only group (OR= 0.98 [95% CI 0.70-1.38]). Time (minutes) to appendectomy was not significantly different between the ultrasound group (553 [IQR 385, 846]) and the CT only group (594 [IQR 437, 797], p=0.24). Of patients in the U/S group, 103 (28.8%) underwent a subsequent CT scan. This subgroup, compared to the CT only group, had a greater time to appendectomy (867 [IQR 604.5, 1149.55], P < .01) but was not more likely to experience a complication (OR 1.02 [95% CI 0.62-1.68]). Performing ultrasound followed by CT does not increase complication rate compared with performing ultrasound or CT alone. Thus, ultrasound should be offered as the initial imaging modality due to its safety features.