Paediatric asthma hospital utilization varies by demographic factors and area socio-economic status

OBJECTIVES

Associations of emergency department (ED) visits and hospital admissions for asthma in children with demographics and area socio-economic status (SES) were examined to evaluate long-term trends and identify vulnerable populations.

STUDY DESIGN

Retrospective population-based trend and cross-sectional analyses.

METHODS

Asthma hospital admissions (2000-2007) and ED visits (2005-2007) for children aged 0-14 years living in Orange County, California were linked with zip-code-level SES data (2000 US Census). Annual population estimates were obtained to calculate age-specific admissions and ED visit rates. Average annual percentage changes (AAPC) were calculated with joinpoint analyses. The risks of ED visits and hospital admissions were estimated from SES indicators with negative binomial regression.

RESULTS

Rates of asthma hospital admissions and ED visits were highest among children aged 0-4 years, males and African Americans, and lowest among Asian/Pacific Islanders. African Americans and Hispanics/Latinos were more likely to be uninsured. Asthma admissions decreased significantly for all age groups over the study period. The greatest declines per 100,000 were among children aged 0-4 years (AAPC: -15.3%, 95% confidence interval -17.0% to -13.4%). Rates of hospital admissions and ED visits were significantly higher in low-SES groups. Hospital admission rates were 30-60% higher and ED visits were 80-90% higher in zip codes in the lowest tertile of median household income compared with the highest tertile of median household income.

CONCLUSIONS

Paediatric asthma hospitalizations and ED visit rates are declining in Orange County. However, certain groups are disproportionately affected, including those living in areas with low SES. This information will help in targeting intervention strategies to children at highest risk for severe asthma episodes.

Repeated respiratory hospital encounters among children with asthma and residential proximity to traffic

OBJECTIVE

The prevalence of adverse respiratory outcomes among children has been frequently associated with measurements of traffic-related exposures, and other data suggest asthma severity is worsened with residence near heavy traffic. We examined the association between neighbourhood traffic burden and repeated acute respiratory illnesses that required emergency department visits and/or hospitalisation for children with a primary or secondary diagnosis of asthma (89% acute bronchitis or pneumonia).

METHODS

This is a hospital-based longitudinal study of a southern California urban catchment area around two adjacent children's hospitals. Subjects' home addresses were geocoded and linked to nearby traffic data. Recurrent event proportional hazard analysis was used to estimate the hazard of repeated hospital encounters.

RESULTS

We found living within 300 metres of arterial roads or freeways increased risk of repeated hospital encounters in 3297 children age 18 years or less. At highest risk were children in the top quintile of traffic density (HR = 1.21; 95% CL 0.99 to 1.49) and those who had 750 metres or more of arterial road and freeway length within 300 metres of their residence (HR = 1.18; 95% CL 0.99 to 1.41). Associations between repeated hospital encounters and residence near heavy traffic were stronger in females than males and in children without insurance or who required government sponsored insurance than children with private insurance. The gender disparity was most notable among infants (age 0) and children ages 6-18 years.

CONCLUSIONS

Results suggest exposure to traffic-related air pollution increases asthma severity as indicated by hospital utilisation. The finding in infants suggests this is an especially vulnerable population, although the validity of asthma diagnosis at this age is unknown. Females and children who do not have private insurance may also be more vulnerable to air pollution from traffic.

Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group

BACKGROUND

The acute chest syndrome is the leading cause of death among patients with sickle cell disease. Since its cause is largely unknown, therapy is supportive. Pilot studies with improved diagnostic techniques suggest that infection and fat embolism are underdiagnosed in patients with the syndrome.

METHODS

In a 30-center study, we analyzed 671 episodes of the acute chest syndrome in 538 patients with sickle cell disease to determine the cause, outcome, and response to therapy. We evaluated a treatment protocol that included matched transfusions, bronchodilators, and bronchoscopy. Samples of blood and respiratory tract secretions were sent to central laboratories for antibody testing, culture, DNA testing, and histopathological analyses.

RESULTS

Nearly half the patients were initially admitted for another reason, mainly pain. When the acute chest syndrome was diagnosed, patients had hypoxia, decreasing hemoglobin values, and progressive multilobar pneumonia. The mean length of hospitalization was 10.5 days. Thirteen percent of patients required mechanical ventilation, and 3 percent died. Patients who were 20 or more years of age had a more severe course than those who were younger. Neurologic events occurred in 11 percent of patients, among whom 46 percent had respiratory failure. Treatment with phenotypically matched transfusions improved oxygenation, with a 1 percent rate of alloimmunization. One fifth of the patients who were treated with bronchodilators had clinical improvement. Eighty-one percent of patients who required mechanical ventilation recovered. A specific cause of the acute chest syndrome was identified in 38 percent of all episodes and 70 percent of episodes with complete data. Among the specific causes were pulmonary fat embolism and 27 different infectious pathogens. Eighteen patients died, and the most common causes of death were pulmonary emboli and infectious bronchopneumonia. Infection was a contributing factor in 56 percent of the deaths.

CONCLUSIONS

Among patients with sickle cell disease, the acute chest syndrome is commonly precipitated by fat embolism and infection, especially community-acquired pneumonia. Among older patients and those with neurologic symptoms, the syndrome often progresses to respiratory failure. Treatment with transfusions and bronchodilators improves oxygenation, and with aggressive treatment, most patients who have respiratory failure recover.

The determination of a degradation product in clidinium bromide drug substance by capillary electrophoresis with indirect UV detection

A capillary electrophoresis (CE) method utilizing indirect ultraviolet (UV) detection was developed for the determination of a non-UV absorbing degradation product, Ro 5-5172, in clidinium bromide drug substance. The electrophoresis buffer consisted of sodium phosphate and benzyltrimethylammonium bromide. Rinsing the capillary with sodium hydroxide followed by water then fresh capillary electrophoresis buffer was found to significantly improve the reproducibility of the migration times of the analytes. To further improve run-to-run reproducibility, an internal marker was used to account for differences in injection volumes and migration times between runs. The precision of the method was found to be less than 1% relative standard deviation for the migration time ratio and peak area ratio of Ro 5-5172 to the internal standard. The method was found to be linear for 0.05-1% Ro 5-5172 with respect to a 10 mg ml-1 sample preparation. The limit of detection was found to be less than 0.01% Ro 5-5172. Results obtained for the analysis of a clidinium bromide drug substance lot using this CE method and a thin layer chromatography method were compared and found to be in agreement.

Acute chest syndrome in sickle cell disease: clinical presentation and course. Cooperative Study of Sickle Cell Disease

Acute chest syndrome (ACS) is an important cause of morbidity and mortality in sickle cell disease (SCD). Previous studies reported conflicting pictures of ACS making therapeutic interventions difficult. The Cooperative Study of Sickle Cell Disease prospectively followed 3,751 patients enrolled from birth to 66 years of age for ACS. Data on presenting signs and symptoms, laboratory findings, and hospital course were collected. There were 1,722 ACS episodes in 939 patients. Young children (age 2 to 4 years) presented with fever and cough, a negative physical exam, and rarely had pain. Adults were often afebrile and complained of shortness of breath, chills, and severe pain. Upper lobe disease was more common in children; multilobe and lower lobe disease affected adults more often. Severe hypoxia occurred in 18% of adults tested and could not be predicted by examination or laboratory findings. Bacteremia was documented in 3.5% of episodes, but was strongly influenced by age (14% of infants and 1.8% of patients > 10 years). ACS was most common in winter with children having the most striking increase. Transfusion was used less frequently, but earlier in children. Young children were hospitalized for 5.4 days versus 9 days for adults. Fifty percent of adults had a pain event in the 2 weeks preceding ACS and children were more likely to have febrile events. The death rate was four times higher in adults than in children. Fatal cases generally developed rapid pulmonary failure and one third were associated with bacteremia. Age has a striking effect on the clinical picture of ACS. In children, ACS was milder and more likely due to infection, whereas in adults ACS was severe, associated with pain and had a higher mortality rate.

The use of capillary electrophoresis to monitor the stability of a dual-action cephalosporin in solution

Ro 23-9424 is a broad-spectrum antibacterial agent consisting of a cephalosporin and a quinolone moiety which are held together by an ester linkage. This compound has limited solubility in water but is more soluble at alkaline pH. Such high pH values, however, lead to stability problems due to the lability of the ester linkage, and result in the formation of the free quinolone and cephalosporin moieties. The balance between solubility and stability presents a challenge in formulation development for this compound. Thus, it is important to effectively monitor the stability of Ro 23-9424 after it has been reconstituted in different solvent systems. In this manner, a diluent which does not lead to degradation of the drug can be identified. A capillary electrophoresis method was developed and validated to monitor the stability of Ro 23-9424. The method was found to meet acceptable criteria for method precision, system precision, linearity and limits of detection and quantitation. The method was used to monitor the stability and measure the half-life of Ro 23-9424 in water and in an L-arginine-sodium benzoate-saline diluent designed to mimic the drug delivery system. This work shows that capillary electrophoresis can be used to compare the stability of a drug in different solutions as an aid in formulation development.

Zygomatic fractures: comparison of methods of internal fixation

We have analyzed different methods of internal fixation of simple displaced fractures of the zygoma in an attempt to define the simplest method(s) of achieving postreduction stability. Twenty-five combinations of interfragmentary wiring and miniplate and screw fixation of fractured zygomas on human skulls were compared for postreduction rotational stability against stresses simulating the muscular forces that act to displace the zygoma once it has been reduced. Analysis of the data suggests that while three-point fixation using either miniplates or interosseous wires allows for virtually no displacement, two-point fixation and in some cases one-point fixation provide acceptable stability. In general, stable fixation is achieved by methods that involve the use of at least one miniplate and incorporate the frontozygomatic suture line as one of the points of fixation.

Characterization of a post-column reaction-laser-induced fluorescence detector for capillary zone electrophoresis

Several modifications have been made to a post-column labeling system for use with capillary zone electrophoresis. Fluorescence excitation is now performed with a helium-cadmium laser rather than an arc lamp. The focusability of the laser beam allows the use of larger diameter capillaries in the post-column reactor without the excessive band broadening observed previously. These larger capillaries can be assembled in the reactor much more easily. Another improvement is that the flow-rate of the labeling reagent can now be accurately controlled and determined. Incorporating these changes, the performances of two reactors with capillaries of the same dimensions are compared.

Microcolumn separations and the analysis of single cells

Capillary zone electrophoresis and open tubular liquid chromatography are two examples of an emerging area of analytical instrumentation known as microcolumn separations. The high resolution and small sample requirements of these methods make them suitable for the quantitative, multicomponent chemical analysis of single cells. Appropriate instrumentation for the analysis of nanoliter and subnanoliter samples is discussed. Data from the analysis of individual neurons are presented, including amino acid and neurotransmitter content.

Inadequate erythroid response to hypoxia in cystic fibrosis

An increase in hemoglobin concentration characterizes the normal compensatory response to chronic tissue hypoxia. We observed no such increase in 42 chronically hypoxic patients with cystic fibrosis, in whom the mean concentration was 12.6 gm/dl; one third of the patients were anemic. Compared with patients with cyanotic heart disease, patients with cystic fibrosis did not have a compensatory increase in P50 or 2,3-diphosphoglycerate. Despite anemia, erythropoietin levels in patients with cystic fibrosis were not significantly different from normal control values. The growth of colony-forming units-erythroid in patients with cystic fibrosis was similar to that in control subjects, and there was no inhibition of growth with the addition of autologous serum. Erythropoietin sensitivity, determined by measuring the CFUe dose response curve, was normal in both patients and controls. Results of iron studies were consistent with iron deficiency in the majority of patients. Impaired absorption of iron was observed in six of 13 iron-deficient patients with cystic fibrosis. An inverse correlation between erythrocyte sedimentation rate and peak serum iron was obtained during the iron absorption study. Eight patients who underwent a therapeutic trial of iron demonstrated a 1.8 gm/dl rise in hemoglobin concentration. Two patients with previously documented iron malabsorption responded to parenteral iron therapy after failure to respond to oral supplementation. These studies demonstrate that patients with cystic fibrosis not only have an impaired erythroid response to hypoxia, but are frequently anemic. Their inadequate erythroid response to hypoxia results in part from disturbances in erythropoietin regulation and iron availability.

Kartagener's syndrome with absence of inner dynein arms of respiratory cilia

Morphologic abnormalities of spermatozoa and respiratory cilia at the electron microscopic level have been described in the immotile-cilia syndrome and chronic respiratory diseases. Most often there has been a total absence of the dynein arms. The current report describes absence of only the inner dynein arm in respiratory cilia from a patient with Kartagener's Syndrome, thus recording another variation in the abnormality of ciliary morphologic features believed to be recessive inherited.