Use of Endocrine Consultation for HbA1c ≥ 9.0% as a Standardized Practice in an Emergency Department Observation Unit

OBJECTIVE

Severely uncontrolled Diabetes Mellitus (DM) is associated with poor long-term outcomes, and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute care setting, including the Emergency Department Observation Unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for Hemoglobin A1c (HbA1c) ≥ 9%.

MATERIALS AND METHODS

Standard practice in our EDOU includes universal HbA1c screening and endocrine consultation for HbA1c ≥ 9.0%. As part of a quality improvement program, EDOU patients with HbA1c ≥ 9.0% had an endocrinology consult. One month follow up phone calls assessed effects of consultation after discharge.

RESULTS

3,688 (95.7%) of 3,853 EDOU patients received an HbA1c test. 7.0% (n=258) were found to have HbA1c ≥ 9% (Mean HbA1c 11.7 ±1.8%; range 9 - 16.6%). Endocrine consults were completed for 190/258 (73.6%) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n=175) had discharge DM medication adjustments. Known DM patients (n=142) injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) on discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) on discharge. A total of 72.6% (n=138) were contacted at one-month and 94.9% (n=131) reported taking DM medications compared to 68.2% (n=94) prior to consult.

CONCLUSIONS

HbA1c screening coupled with endocrine consultation for HbA1c ≥ 9.0% was assessed as a performance improvement study and shown to have valuable results. Further study is recommended to determine long-term clinical impact and cost analysis of this novel approach.

Therapeutic responses to Roseomonas mucosa in atopic dermatitis may involve lipid-mediated TNF-related epithelial repair

Dysbiosis of the skin microbiota is increasingly implicated as a contributor to the pathogenesis of atopic dermatitis (AD). We previously reported first-in-human safety and clinical activity results from topical application of the commensal skin bacterium Roseomonas mucosa for the treatment of AD in 10 adults and 5 children older than 9 years of age. Here, we examined the potential mechanism of action of R. mucosa treatment and its impact on children with AD less than 7 years of age, the most common age group for children with AD. In 15 children with AD, R. mucosa treatment was associated with amelioration of disease severity, improvement in epithelial barrier function, reduced Staphylococcus aureus burden on the skin, and a reduction in topical steroid requirements without severe adverse events. Our observed response rates to R. mucosa treatment were greater than those seen in historical placebo control groups in prior AD studies. Skin improvements and colonization by R. mucosa persisted for up to 8 months after cessation of treatment. Analyses of cellular scratch assays and the MC903 mouse model of AD suggested that production of sphingolipids by R. mucosa, cholinergic signaling, and flagellin expression may have contributed to therapeutic impact through induction of a TNFR2-mediated epithelial-to-mesenchymal transition. These results suggest that a randomized, placebo-controlled trial of R. mucosa treatment in individuals with AD is warranted and implicate commensals in the maintenance of the skin epithelial barrier.

Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial

IMPORTANCE

Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting.

OBJECTIVE

To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration.

DESIGN, SETTING, AND PARTICIPANTS

This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017.

INTERVENTION

Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron.

MAIN OUTCOMES AND MEASURES

Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration.

RESULTS

Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02246439.

Treatment of benign cephalic histiocytosis with topical 1% rapamycin ointment

We report a pediatric case of extensive, progressive benign cephalic histiocytosis (BCH) involving the face, trunk, and extremities with response of facial lesions to treatment with topical 1% rapamycin. A split-face model was used to demonstrate improvement on the treated side versus the untreated side. After physician and parental perception of effectiveness, based in part on photodocumentation, subsequently both cheeks were treated with continued improvement.

Exogenous Cushing syndrome from an unexpected source of systemic steroids

A 12-year-old Hispanic boy with chronic atopic dermatitis and cushingoid features presented to our institution. He was being treated with an unknown quantity of oral prednisolone 15 mg/5 mL, equivalent to 70 mg/m² /d of oral prednisone, purchased over the counter in El Salvador. Systemic corticosteroids are not recommended for chronic therapy of atopic dermatitis because of their significant adverse effects. Foreign-sourced pharmaceuticals account for almost half of the drugs consumed in the United States, which means that, to protect our patients, medical providers must inquire about and report unsafe medications deemed legal outside the United States to the Food and Drug Administration.

Multicenter study of cigarette smoking among adults with asthma exacerbations in the emergency department, 2011-2012

INTRODUCTION

Previous studies demonstrated a high prevalence of cigarette smoking in patients presenting to the emergency department (ED) with acute asthma. Despite the clinical and public health importance, there have been no recent multicenter efforts to characterize this patient population. We aimed to update the prevalence of cigarette smoking among ED patients with asthma exacerbations.

METHODS

Multicenter chart review study of 48 EDs across 23 US states. We identified ED patients aged 18-54 years with asthma exacerbations during 2011-2012. We classified patients into three groups based on smoking status: never smoker, former smoker, and current smoker. We fit multivariable logistic regression models to examine independent predictors of being a current smoker.

RESULTS

Of 1801 enrolled patients, never smokers accounted for 51% (95%CI, 49%-54%), former smokers 13% (95%CI, 11%-14%), and current smokers 36% (95%CI, 34%-38%). The multivariable model demonstrated several independent predictors for current smoking: older age (age 30-39 and 40-54 years), non-Hispanic white or black, having public or no insurance, and not having an asthma specialist (all P < 0.05).

CONCLUSION

This large multicenter study of ED patients with asthma exacerbations demonstrated that one in three patients were current smokers. This burden of current smokers has not changed from multicenter findings in the late 1990s. The persistently high burden suggests the inadequacy of current measures to manage tobacco use in these high-risk patients.

Smoking status and smoking cessation intervention among U.S. adults hospitalized for asthma exacerbation

BACKGROUND

In a previous multicenter study during 1999-2000, we found a high prevalence of smoking among patients hospitalized for asthma exacerbations (35%) and suboptimal smoking cessation efforts. There have been no recent multicenter efforts to examine the smoking status and implementation of smoking cessation efforts among patients hospitalized for asthma exacerbation.

OBJECTIVE

To investigate the prevalence of cigarette smoking and the proportion and characteristics of patients who received an inpatient smoking cessation intervention.

METHODS

We conducted a secondary analysis of a 25-center observational study, which included 597 U.S. adults hospitalized for asthma exacerbation during 2012-2013.

RESULTS

Among the analytic cohort, 215 (36%) were current smokers. In the multivariable model, compared with patients with private health insurance, those with public health insurance (odds ratio [OR] 1.71 [95% confidence interval {CI}, 1.06-2.77]) or no health insurance (OR 1.75 [95% CI, 1.02-2.99]) were more likely to be current smokers. By contrast, patients with a previous evaluation by an asthma specialist in the past 12 months (OR 0.49 [95% CI, 0.28-0.86]) and use of inhaled corticosteroids (OR 0.63 [95% CI, 0.43-0.93]) were less likely to be current smokers. Among current smokers, only 55% received smoking cessation interventions during their hospitalization. In the multivariable model, current smokers who had public health insurance (OR 0.25 [95% CI, 0.07-0.82]) or no health insurance (OR 0.26 [95% CI, 0.07-0.94]) were less likely to receive inpatient smoking cessation interventions compared with those with private health insurance.

CONCLUSION

Our findings showed a persistently high prevalence of smokers among U.S. patients hospitalized for asthma exacerbations and an underutilized opportunity to provide this at-risk population with smoking cessation interventions.

Social Impact of Facial Infantile Hemangiomas in Preteen Children

IMPORTANCE

Involuted infantile facial hemangiomas (IHs) may adversely affect the social skills of children.

OBJECTIVE

To assess the social impact of involuted facial IHs, with or without prior treatment, in preteen children.

DESIGN, SETTING, AND PARTICIPANTS

An observational, cross-sectional study of social anxiety and skills in preteen children with facial IHs diagnosed during infancy. The study took place in an academic institution and a community dermatology practice between January 1, 2013, and July 30, 2014. Records on 236 children with IHs located in a cosmetically sensitive area were identified; of those, 144 potential participants (parents) were reached by telephone and mailed study packets. Thirty completed questionnaires were returned. Data analysis was performed from August 1, 2014, to September 7, 2015.

INTERVENTIONS

The questionnaires included the following psychiatric scales: (1) Social Anxiety Scale for Children-Revised (SASC-R), completed by parents and children, including the domains of Fear of Negative Evaluation and Social Avoidance/Distress in New Situations (SAD-New) (higher scores indicate greater social anxiety), and (2) Social Competency Inventory (SCI), completed by parents, including the domains of Prosocial Behavior and Social Initiative (lower scores indicate poorer social competency).

MAIN OUTCOMES AND MEASURES

Demographics, clinical details, and survey responses were collected. Analysis was conducted using t tests to compare scores for each survey domain with established normative data and between sex as well as between treatment vs nontreatment groups.

RESULTS

Of the 144 potential participants, 30 (21%) responded. The mean age of the preteen subjects was 10.0 years (range, 5.4-12.9 years) with a 2:1 female to male ratio. Twenty-five children (83%) had a single IH, and the remaining 5 participants (17%) had multiple IHs, with at least 1 IH in a cosmetically sensitive area. The periocular region was the most common site of the IH (10 [33%]), followed by the nose (6 [20%]), cheek (5 [17%]), forehead (4 [13%]), lip or perioral region (4 [13%]), and ear (1 [3%]). Eighteen children (60%) had received treatment for their IH. With results reported as mean (SD), the SASC-R test showed that social anxiety of the children was not increased over normative data; however, those who did not receive IH treatment had significantly greater anxiety for new situations compared with those who received treatment (SAD-New: 15.5 [5.1] vs 11.5 [3.8]; P = .02). Results of the SCI scale indicated that the Prosocial Orientation domain score for the children was similar to normative data (3.96 [0.48] vs 3.89 [0.55], P = .50). Social Initiative domain scores were significantly poorer in children who did not receive treatment vs those who received treatment (3.45 [0.43] vs 4.03 [0.55]; P = .006).

CONCLUSIONS AND RELEVANCE

Preteen children with involuted, untreated facial IHs have higher Social Anxiety domain scores in new situations and decreased Social Initiative domain scores compared with children who receive treatment for facial IH. Although this study is limited by a small sample size, it raises important considerations for whether early treatment of facial IHs in cosmetically sensitive areas has a beneficial effect on social skills in preteens.

Prevalence of undiagnosed dysglycemia in an emergency department observation unit

BACKGROUND

The proposed 2015 US Preventive Services Task Force guidelines recommend diabetes screening for individuals ≥45 years or demonstrating other risk factors for dysglycemia. Still, many patients with dysglycemia remain undiagnosed, and opportunities for early intervention are lost.

METHODS

To test novel approaches for diagnosis using the haemoglobin A1c (HbA1c ) test, we screened adult patients who were admitted to an observation unit from the emergency department with no known history of pre-diabetes or diabetes.

RESULTS

Of 256 subjects, 9% were newly diagnosed with diabetes and 52% were newly diagnosed with pre-diabetes. Of those aged 18-29 years, 33% were newly diagnosed with dysglycemia, while 55% of those aged 30-44 years and 70% of those aged ≥45 years were newly diagnosed with dysglycemia.

CONCLUSIONS

Our results suggest that regardless of age, a large proportion of patients in the emergency department observation unit have undiagnosed dysglycemia, an important finding given the large number of observation admissions. Copyright © 2015 John Wiley & Sons, Ltd.

Not for industry only: medical students and office-based academic detailing the PIVOT (Pregnant women Influenza Vaccine Optimization Team) initiative

Academic detailing is a method of educational outreach that utilizes individualized encounters with physicians to broach specific medical issues in an evidence-based and quality-driven manner. Medical students utilized the matter of influenza vaccination during pregnancy as a lens through which to explore the methods of academic detailing in a community setting. Structured and customized dialogues between North Shore-LIJ affiliated obstetricians and Hofstra North Shore-LIJ medical students were conducted regarding the disparity between the proportion of providers that recommend the vaccine and the percentage of pregnant women being vaccinated annually. Ultimately the project aimed to increase vaccine-carrying rates throughout office based practices in the community, while establishing a viable method for up-to-date information exchange between practicing physicians and academic medicine. While the extent of affected change is currently being quantified, the project proved successful insofar as academic detailing allowed the students to gain access to physicians, and engage in compelling and educational conversations. Both the physicians and students felt these interactions were valuable and well worth continuing. The goal for the future is to expand these practices to other pressing public health issues while continuing to refine the technique.

A randomized trial of benralizumab, an antiinterleukin 5 receptor α monoclonal antibody, after acute asthma

BACKGROUND

Patients with frequent asthma exacerbations resulting in emergency department (ED) visits are at increased risk for future exacerbations. We examined the ability of 1 dose of benralizumab, an investigational antiinterleukin 5 receptor α monoclonal antibody, to reduce recurrence after acute asthma exacerbations.

METHODS

In this randomized, double-blind, placebo-controlled study, eligible subjects presented to the ED with an asthma exacerbation, had partial response to treatment, and greater than or equal to 1 additional exacerbation within the previous year. Subjects received 1 intravenous infusion of placebo (n = 38) or benralizumab (0.3 mg/kg, n = 36 or 1.0 mg/kg, n = 36) added to outpatient management. The primary outcome was the proportion of subjects with greater than or equal to 1 exacerbation at 12 weeks in placebo vs the combined benralizumab groups. Other outcomes included the time-weighted rate of exacerbations at week 12, adverse events, blood eosinophil counts, asthma symptom changes, and health care resource utilization.

RESULTS

The proportion of subjects with greater than or equal to 1 asthma exacerbation at 12 weeks was not different between placebo and the combined benralizumab groups (38.9% vs 33.3%; P = .67). However, compared with placebo, benralizumab reduced asthma exacerbation rates by 49% (3.59 vs 1.82; P = .01) and exacerbations resulting in hospitalization by 60% (1.62 vs 0.65; P = .02) in the combined groups. Benralizumab reduced blood eosinophil counts but did not affect other outcomes, while demonstrating an acceptable safety profile.

CONCLUSIONS

When added to usual care, 1 dose of benralizumab reduced the rate and severity of exacerbations experienced over 12 weeks by subjects who presented to the ED with acute asthma.

Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents

Atopic dermatitis is a chronic, pruritic inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in atopic dermatitis management and care, providing recommendations based on the available evidence. In this third of 4 sections, treatment of atopic dermatitis with phototherapy and systemic immunomodulators, antimicrobials, and antihistamines is reviewed, including indications for use and the risk-benefit profile of each treatment option.

Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in the management and care of AD, providing updated and expanded recommendations based on the available evidence. In this first of 4 sections, methods for the diagnosis and monitoring of disease, outcomes measures for assessment, and common clinical associations that affect patients with AD are discussed. Known risk factors for the development of disease are also reviewed.

Seropositivity for influenza A(H1N1)pdm09 virus among frontline health care personnel

Seroprevalence of antibodies to influenza A(H1N1)pdm09 virus among 193 emergency department health care personnel was similar among 147 non–health care personnel (odds ratio 1.4, 95% CI 0.8–2.4). Working in an acute care setting did not substantially increase risk for virus infection above risk conferred by community-based exposures.

Variable response to propranolol treatment of kaposiform hemangioendothelioma, tufted angioma, and Kasabach-Merritt phenomenon

Propranolol is a non-selective beta-adrenergic antagonist successfully used in a case of kaposiform hemangioendothelioma (KHE) associated with Kasabach-Merritt phenomenon (KMP). We report 11 patients treated with propranolol for KHE and the related variant tufted angioma (TA), six of whom also had KMP. The varied responses to treatment, with only 36% responding in our series, demonstrate the need for further study of this medication before routine use for these indications.

The impact of acute illness on HbA(1c) determination of undiagnosed diabetes

OBJECTIVE

To improve diabetes screening efforts, the American Diabetes Association now recommends haemoglobin A(1c) (HbA(1c)) as a diagnostic test, increasing access to patients found in acute care environments. However, the influence of acute illness and care on HbA(1c) levels has not been well studied. To address this, we evaluated for intra-patient differences in HbA(1c) assessed in the emergency department (ED) and after recovery from the acute illness.

METHODS

Adult patients with no known history of diabetes were tested for HbA(1c) during an ED and scheduled follow-up visit. HbA(1c) differences between the two visits were compared using limits of agreement with 95% confidence intervals. The frequency of individuals who changed diagnostic categories (using ≥6.5% to classify newly diagnosed diabetes) from ED to follow-up was determined.

RESULTS

A total of 589 patients were included with a mean age of 50 years, and 57/589 (9.7%) had an ED HbA(1c)  ≥ 6.5% with the average follow-up visit 45 days after the ED visit. The mean ED HbA(1c) was 5.67% (±0.86), and the follow-up HbA(1c) was 5.65% (±0.89), (difference -0.0129%, 95% limits of agreement -0.740, 0.714). The ED and follow-up HbA(1c) was highly correlated (r² = 0.829). Although on follow-up almost all patients were classified in the same diagnostic category as in the ED, 17 patients had an HbA(1c)  ≥ 6.5% in the ED and an HbA(1c)  < 6.5%. On follow-up most patients (14/17) still fell in an abnormal range (6.0-6.5%).

CONCLUSION

The HbA(1c) value is not substantially affected by acute illness and is feasible as a screening assay for diabetes in the acute care setting such as an ED.

Impact of Citywide Blackout on an Urban Emergency Medical Services System

Introduction:

On 14 August 2003, New York City and a large portion of the northeastern United States experienced the largest blackout in the history of the country. An analysis of such a widespread disaster on emergency medical service (EMS) operations may assist in planning for and managing such disasters in the future.

Methods:

A retrospective review of all EMS activity within New York City's 9-1-1 emergency telephone system during the 29 hours during which all or parts of the city were without power (16:11 hours (h) on 14 August 2003 until 21:03 h on 15 August 2003) was performed. Control periods were established utilizing identical time periods during the five weeks preceding the blackout.

Results:

Significant increases were identified in the overall EMS demand (7,844 incidents vs. 3,860 incidents; p<0.001) as well as in 20 of the 62 calltypes of the system, including ca rd i ac arrests (119 vs.76, p= 0.043).Significant decreases were found only among calls related to psychological emergencies (114 vs. 221; p= 0.006) and drugor alcohol-related emergencies (78 vs. 146; p = 0.009). Though median response times increased by only 60 seconds, median call-processing times within the 9-1-1 emergency telephone system EMS dispatch center of the city increased from 1.1 to 5.5 minutes.

Conclusions:

The citywide blackout resulted in dramatic changes in the demands upon the EMS system of New York City, the types of patients for whom EMS providers were assigned to provide care, and the dispositions for those assignments. During this time of increased, system-wide demand, the use of cross-trained firefighter and first-responder engine companies resulted in improved response times to cardiac arrest patients. Finally, the ability of the EMS dispatch center to process the increased requests for EMS assistance proved to be the rate-limiting step in responding to these emergencies.These findings will prove useful in planning for future blackouts or any disaster that may broadly impact the infrastructure of a city.

Abatacept and sodium thiosulfate for treatment of recalcitrant juvenile dermatomyositis complicated by ulceration and calcinosis

We report the successful use of abatacept and sodium thiosulfate in a patient with severe recalcitrant juvenile dermatomyositis complicated by ulcerative skin disease and progressive calcinosis. This combination therapy resulted in significant reductions in muscle and skin inflammation, decreased corticosteroid dependence, and halted the progression of calcinosis.

Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma

BACKGROUND

Health care costs increase in patients with more severe asthma, but the effect of asthma exacerbations on costs among patients with more severe asthma has not been quantified.

OBJECTIVE

This study compared direct health care costs between patients with moderate/severe persistent asthma with and without exacerbations.

METHODS

Patients who had an asthma diagnosis (International Classification of Diseases-ninth revision-Clinical Modification code 493.x), were 12 to 64 years old, and were receiving controller therapy were identified from a large administrative claims database. Patients were categorized as having moderate/severe persistent asthma and were further evaluated for exacerbations during a 12-month exacerbation identification period. Patients with 1 or more exacerbations (asthma-related inpatient or emergency department visit or corticosteroid prescription) were matched to patients without exacerbations on demographic characteristics and asthma severity. Total and asthma-related health care costs during the 1-year study period after the exacerbation index date were calculated.

RESULTS

Patients with exacerbations had significantly higher total health care costs ($9223 vs $5011, P < .0001) and asthma-related costs ($1740 vs $847, P < .0001). The cost differences remained significant after controlling for patient differences by using multivariate models. Patients with exacerbations (n = 3830) had higher rates of sinusitis, allergy-related diagnoses or medications, pneumonia, and mental disorders and higher average Charlson Comorbidity Index scores at baseline. Patients with exacerbations filled their prescriptions for controllers more often and had higher asthma-related drug costs.

CONCLUSIONS

Patients with moderate/severe persistent asthma who had exacerbations had higher total and asthma-related health care costs than those without exacerbations. Moreover, controller medication use was higher in patients with exacerbations.

Prevalence of dysglycemia among coronary artery bypass surgery patients with no previous diabetic history

BACKGROUND

Dysglycemia is a major risk factor for atherosclerosis. In many patient populations dysglycemia is under-diagnosed. Patients with severe coronary artery disease commonly have dysglycemia and there is growing evidence that dysglycemia, irrespective of underlying history of diabetes, is associated with adverse outcome in coronary artery bypass graft (CABG) surgery patients, including longer hospital stay, wound infections, and higher mortality. As HbA1c is an easy and reliable way of checking for dysglycemia we routinely screen all patients undergoing CABG for elevations in HbA1c. Our hypothesis was that a substantial number of patients with dysglycemia that could be identified at the time of cardiothoracic surgery despite having no apparent history of diabetes.

METHODS

1045 consecutive patients undergoing CABG between 2007 and 2009 had HbA1c measured pre-operatively. The 2010 American Diabetes Association (ADA) diagnostic guidelines were used to categorize patients with no known history of diabetes as having diabetes (HbA1c ≥ 6.5%) or increased risk for diabetes (HbA1c 5.7-6.4%).

RESULTS

Of the 1045 patients with pre-operative HbA1c measurements, 40% (n = 415) had a known history of diabetes and 60% (n = 630) had no known history of diabetes. For the 630 patients with no known diabetic history: 207 (32.9%) had a normal HbA1c (< 5.7%); 356 (56.5%) had an HbA1c falling in the increased risk for diabetes range (5.7-6.4%); and 67 (10.6%) had an HbA1c in the diabetes range (6.5% or higher). In this study the only conventional risk factor that was predictive of high HbA1c was BMI. We also found a high HbA1c irrespective of history of DM was associated with severe coronary artery disease as indicated by the number of vessels revascularized.

CONCLUSION

Among individuals undergoing CABG with no known history of diabetes, there is a substantial amount of undiagnosed dysglycemia. Even though labeling these patients as "diabetic" or "increased risk for diabetes" remains controversial in terms of perioperative management, pre-operative screening could lead to appropriate post-operative follow up to mitigate short-term adverse outcome and provide high priority medical referrals of this at risk population.

Hemoglobin A1c as a screen for previously undiagnosed prediabetes and diabetes in an acute-care setting

OBJECTIVE

Hemoglobin A(1c) (HbA(1c)) is recommended for identifying diabetes and prediabetes. Because HbA(1c) does not fluctuate with recent eating or acute illness, it can be measured in a variety of clinical settings. Although outpatient studies identified HbA(1c)-screening cutoff values for diabetes and prediabetes, HbA(1c)-screening thresholds have not been determined for acute-care settings. Using follow-up fasting blood glucose (FBG) and the 2-h oral glucose tolerance test (OGTT) as the criterion gold standard, we determined optimal HbA(1c)-screening cutoffs for undiagnosed dysglycemia in the emergency department setting.

RESEARCH DESIGN AND METHODS

This was a prospective observational study of adults aged ≥18 years with no known history of hyperglycemia presenting to an emergency department with acute illness. Outpatient FBS and 2-h OGTT were performed after recovery from the acute illness, resulting in diagnostic categorizations of prediabetes, diabetes, and dysglycemia (prediabetes or diabetes). Optimal cutoffs were determined and performance data identified for cut points.

RESULTS

A total of 618 patients were included, with a mean age of 49.7 (±14.9) years and mean HbA(1c) of 5.68% (±0.86). On the basis of an OGTT, the prevalence of previously undiagnosed prediabetes and diabetes was 31.9 and 10.5%, respectively. The optimal HbA(1c)-screening cutoff for prediabetes was 5.7% (area under the curve [AUC] = 0.659, sensitivity = 55%, and specificity = 71%), for dysglycemia 5.8% (AUC = 0.717, sensitivity = 57%, and specificity = 79%), and for diabetes 6.0% (AUC = 0.868, sensitivity = 77%, and specificity = 87%).

CONCLUSIONS

We identified HbA(1c) cut points to screen for prediabetes and diabetes in an emergency department adult population. The values coincide with published outpatient study findings and suggest that an emergency department visit provides an opportunity for HbA(1c)-based dysglycemia screening.

Utilization of emergency medical services in a large urban area: description of call types and temporal trends

BACKGROUND

Emergency medical services (EMS) systems are used by the public for a range of medically related problems.

OBJECTIVE

To understand and analyze the patterns of EMS utilization and trends over time in a large urban EMS system so that we may better direct efforts toward improving those services.

METHODS

The 63 call type designations from all New York City (NYC) 9-1-1 EMS calls between 1999 and 2007 were obtained and grouped into 10 broad and 30 specific medical categories. Aggregated numbers of total EMS calls and individual categories were divided by NYC resident population estimates to determine utilization rates. Temporal trends were evaluated for statistical significance with Spearman's rho (ρ).

RESULTS

There were 9,916,904 EMS calls between 1999 and 2007, with an average of 1,101,878 calls/year. Utilization rates increased from 129.5 to 141.9 calls/1,000 residents/year over the study period (average annual rise of 1.16%). Among all medical/surgical call types (excluding trauma), there was an average annual increase of 1.8%/year. The most substantial increases were among "psychiatric/drug related" (+5.6%/year), "generalized illness" (+3.2%/year), and "environmental related" calls (+2.9%/year). The largest decrease was among "respiratory" calls (-1.2%/year), specifically for "asthma" (-5.0%/year). For trauma call types, there was an annual average decrease of 0.4%/year, with the category of "violence related" calls having the greatest decline (-3.3%/year).

CONCLUSION

There was an increase in overall EMS utilization rates, though not all call types rose uniformly. Rather, a number of significant trends were identified reflecting either changing medical needs or changing patterns of EMS utilization in NYC's population.

Increased A1C among adult emergency department patients with type 2 diabetes

STUDY OBJECTIVE

Long-term glycemic control can prevent or delay complications of diabetes. Although diabetes is a common comorbidity in emergency department (ED) patients, the adequacy of long-term control is not known. Our objectives are to determine the frequency of poorly controlled type 2 diabetes among adults presenting to an ED and to identify characteristics associated with poor control.

METHODS

An A1C level was obtained for diabetic patients 18 years and older who presented to the ED for acute medical problems and had blood tests performed for usual medical care. Consecutive patients were screened for a total of 58 24-hour periods during a 10-week period. A1C values were stratified, with less than 7% defined as good control and greater than or equal to 7% poor long-term control. Logistic regression analysis was used to identify factors associated with poor control.

RESULTS

Of the 500 patients with type 2 diabetes, 53.4% had inadequate long-term control. An increased ED glucose level was independently associated with an increased A1C level. If the ED glucose level was 126 to 149 mg/dL, the odds ratio (OR) for an increased A1C level relative to a glucose level less than 100 mg/dL was 2.3 (95% confidence interval [CI] 0.95, 5.68); the OR was 6.4 (95% CI 2.9, 14.1) for glucose levels 150 to 199 mg/dL, and for glucose level of 200 mg/dL or above, the OR for an increased A1C level was 21.2 (9.1, 49.3). Other factors independently associated with increased A1C level were black race, aged 40 to 59 years, and Medicaid insurance.

CONCLUSION

The high frequency of A1C levels more than 7% points to the ED as a potential source for identifying patients with poorly controlled type 2 diabetes.

Migrating hair: a case confused with cutaneous larva migrans

Pili migrans is an unusual skin condition in which a hair shaft migrates under the surface of the skin and mimics the parasitic infection, cutaneous larva migrans. If the migrating hair is located on the sole of the foot, it represents a foreign body from an exogenous source. We present a 3-year-old boy with bilateral pili migrans on the soles of his feet, acquired after running around in his socks while at his mother's beauty salon. This case highlights a distinctive presentation of a foreign body penetration of the skin that can easily be confused for and should be differentiated from the parasitic disease, cutaneous larva migrans.

Association of ambient fine particles with out-of-hospital cardiac arrests in New York City

Cardiovascular morbidity has been associated with particulate matter (PM) air pollution, although the relation between pollutants and sudden death from cardiac arrest has not been established. This study examined associations between out-of-hospital cardiac arrests and fine PM (of aerodynamic diameter ≤2.5 μm, or PM(2.5)), ozone, nitrogen dioxide, sulfur dioxide, and carbon monoxide in New York City. The authors analyzed 8,216 out-of-hospital cardiac arrests of primary cardiac etiology during the years 2002-2006. Time-series and case-crossover analyses were conducted, controlling for season, day-of-week, same-day, and delayed/apparent temperature. An increased risk of cardiac arrest in time-series (relative risk (RR) = 1.06, 95% confidence interval (CI): 1.02, 1.10) and case-crossover (RR = 1.04, 95% CI: 0.99, 1.08) analysis for a PM(2.5) increase of 10 μg/m³ in the average of 0- and 1-day lags was found. The association was significant in the warm season (RR = 1.09, 95% CI: 1.03, 1.15) but not the cold season (RR = 1.01, 95% CI: 0.95, 1.07). Associations of cardiac arrest with other pollutants were weaker. These findings, consistent with studies implicating acute cardiovascular effects of PM, support a link between PM(2.5) and out-of-hospital cardiac arrests. Since few individuals survive an arrest, air pollution control may help prevent future cardiovascular mortality.

Age-related association of fine particles and ozone with severe acute asthma in New York City

BACKGROUND

Ambient fine particles (particular matter <2.5 microm diameter [PM(2.5)]) and ozone exacerbate respiratory conditions including asthma. There is little documentation determining whether children are more vulnerable to the effects of ambient pollution than adults, or whether pollution causes life-threatening episodes requiring intensive care unit (ICU) admission.

OBJECTIVE

We investigate the relationship between severe asthma morbidity and PM(2.5) and ozone in the warm season, and determine whether there is an age-related susceptibility to pollution.

METHODS

Daily time-series analysis of 6008 asthma ICU admissions and 69,375 general (non-ICU) asthma admissions in 4 age groups (<6, 6-18, 19-49, and 50+ years) in 74 New York City hospitals for the months April to August from 1999 to 2006. The regression model adjusted for temporal trends, weather, and day of the week. Risks were estimated for interquartile range increases in the a priori exposure time window of the average of 0-day and 1-day lagged pollutants.

RESULTS

Age was a significant effect modifier for hospitalizations, and children age 6 to 18 years consistently had the highest risk. Among children age 6 to 18 years, there was a 26% (95% CI, 10% to 44%) increased rate of ICU admissions and a 19% increased rate of general hospitalizations (95% CI, 12% to 27%) for each 12-microg/m(3) increase in PM(2.5). For each 22-ppb increase in ozone, there was a 19% (95% CI, 1% to 40%) increased risk for ICU admissions and a 20% (95% CI, 11% to 29%) increased risk for general hospitalizations.

CONCLUSION

Warm weather patterns of ozone and PM(2.5) disproportionately affect children with asthma and appear responsible for severe attacks that could have been avoided.

Neonatal onychomadesis with candidiasis limited to affected nails

A case of onychomadesis in one of twins with onset in the neonatal period is reported. We hypothesize that the nail deformities were induced by the stress of a breech presentation during preterm labor and that candidiasis limited to the bands of onychomadesis exaggerated the appearance of the nail deformity.

Tetanus antibody protection among HIV-infected US-born patients and immigrants

INTRODUCTION

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients.

METHODS

A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml.

RESULTS

Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001).

CONCLUSION

The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.

Characterization of PM2.5, gaseous pollutants, and meteorological interactions in the context of time-series health effects models

Associations of particulate matter (PM) and ozone with morbidity and mortality have been reported in many recent observational epidemiology studies. These studies often considered other gaseous co-pollutants also as potential confounders, including nitrogen dioxide (NO2), sulfur dioxide (SO2), and carbon monoxide (CO). However, because each of these air pollutants can have different seasonal patterns and chemical interactions, the estimation and interpretation of each pollutant's individual risk estimates may not be straightforward. Multi-collinearity among the air pollution and weather variables also leaves the possibility of confounding and over- or under-fitting of meteorological variables, thereby potentially influencing the health effect estimates for the various pollutants in differing ways. To investigate these issues, we examined the temporal relationships among air pollution and weather variables in the context of air pollution health effects models. We compiled daily data for PM less than 2.5 mum (PM2.5), ozone, NO2, SO2, CO, temperature, dew point, relative humidity, wind speed, and barometric pressure for New York City for the years 1999-2002. We conducted several sets of analyses to characterize air pollution and weather data interactions, to assess different aspects of these data issues: (1) spatial/temporal variation of PM2.5 and gaseous pollutants measured at multiple monitors; (2) temporal relationships among air pollution and weather variables; and (3) extent and nature of multi-collinearity of air pollution and weather variables in the context of health effects models. The air pollution variables showed a varying extent of intercorrelations with each other and with weather variables, and these correlations also varied across seasons. For example, NO2 exhibited the strongest negative correlation with wind speed among the pollutants considered, while ozone's correlation with PM2.5 changed signs across the seasons (positive in summer and negative in winter). The extent of multi-collinearity problems also varied across pollutants and choice of health effects models commonly used in the literature. These results indicate that the health effects regression need to be run by season for some pollutants to provide the most meaningful results. We also find that model choice and interpretation needs to take into consideration the varying pollutant concurvities with the model co-variables in each pollutant's health effects model specification. Finally, we provide an example for analysis of associations between these air pollutants and asthma emergency department visits in New York City, which evaluate the relationship between the various pollutants' risk estimates and their respective concurvities, and discuss the limitations that these results imply about the interpretability of multi-pollutant health effects models.

FEV1 performance among patients with acute asthma: results from a multicenter clinical trial

OBJECTIVE

To determine the ability of patients seen for acute asthma exacerbations in the emergency department (ED) to perform good-quality FEV(1) measurements.

METHODS

Investigators from 20 EDs were trained to perform spirometry testing as part of a clinical trial that included standardized equipment with special software-directed prompts. Spirometry was done on ED arrival and 30 min, 1 h, 2 h, and 4 h later, and during follow-up outpatient visits.

MEASUREMENTS

Study performance criteria differed from American Thoracic Society (ATS) guidelines because of the population acuity and severity of illness as follows: ability to obtain acceptable FEV(1) measures (defined as two or more efforts with forced expiratory times >/= 2 s and time to peak flow < 120 ms or back-extrapolated volume < 5% of the FVC) and reproducibility criteria (two highest acceptable FEV(1) values within 10% of each other).

RESULTS

Of the 620 patients (age range, 12 to 65 years), > 90% met study acceptability criteria on ED arrival and 74% met study reproducibility criteria. Mean initial FEV(1) was 38% of predicted. Spirometry quality improved over time; by 1 h, 90% of patients met study acceptability and reproducibility criteria. Patients with severe airway obstruction (FEV(1) < 25% of predicted) were initially less likely to meet quality goals, but this improved with time. The site was also an independent predictor of quality.

CONCLUSION

When staff are well trained and prompt feedback regarding adequacy of efforts is given, modified ATS performance goals for FEV(1) tests can be met from most acutely ill adolescent and adult asthmatics, even within the first hour of evaluation and treatment for an asthma exacerbation.

The "vertical response time": barriers to ambulance response in an urban area

BACKGROUND

Ambulance response time is typically reported as the time interval from call dispatch to arrival on-scene. However, the often unmeasured "vertical response time" from arrival on-scene to arrival at the patient's side may be substantial, particularly in urban areas with high-rise buildings or other barriers to access.

OBJECTIVES

To measure the time interval from arrival on-scene to the patient in a large metropolitan area and to identify barriers to emergency medical services arrival.

METHODS

This was a prospective observational study of response times for high-priority call types in the New York City 9-1-1 emergency medical services system. Research assistants riding with paramedics enrolled a convenience sample of calls between 2001 and 2003.

RESULTS

A total of 449 paramedic calls were included, with a median time from call dispatch to arrival on-scene of 5.2 minutes. The median on-scene to patient arrival interval was 2.1 minutes, leading to an actual response interval (dispatch to patient) of 7.6 minutes. The median on-scene to patient interval was 2.8 minutes for residential buildings, 2.7 minutes for office complexes, 1.3 minutes for private homes (less than four stories), and 0.5 minutes for outdoor calls. Overall, for all calls, the on-scene to patient interval accounted for 28% of the actual response interval. When an on-scene escort provided assistance in locating and reaching the patient, the on-scene to patient interval decreased from 2.3 to 1.9 minutes. The total dispatch to patient arrival interval was less than 4 minutes in 8.7%, less than 6 minutes in 28.5%, and less than 8 minutes in 55.7% of calls.

CONCLUSIONS

The time from arrival on-scene to the patient's side is an important component of overall response time in large urban areas, particularly in multistory buildings.

The relationship of plasma glucose and HbA1c Levels among emergency department patients with no prior history of diabetes mellitus

OBJECTIVES

Patients without a history of diabetes mellitus may be incidentally found to be hyperglycemic in the emergency department (ED). If the hyperglycemia is due to undiagnosed diabetes, then an opportunity for detection exists. Hemoglobin A1c (HbA1c) provides a weighted average of blood glucose levels over the past several months; high HbA1c levels could indicate diabetes. The objective of this study was to determine whether hyperglycemia in ED patients without a history of diabetes was associated with higher HbA1c levels.

METHODS

This was a prospective nonconsecutive case series of adults aged 18 years or older presenting to the ED with acute illness for whom a plasma glucose sample was drawn for clinical management. A history of diabetes/hyperglycemia or current symptoms of diabetes excluded patients. HbA1c levels were analyzed for a glucose cutoff of 110 mg/dL; the data were further analyzed using additional glucose cutoffs. Based on the Third National Health and Nutrition Examination Survey outpatient screening data, an HbA1c level > or =6.2% was considered elevated (sensitivity of 63% and specificity of 97% for identifying diabetes).

RESULTS

There were 541 patients enrolled; the glucose level correlated with the HbA1c level (r = 0.60, p < 0.001). Among the 331 patients with a glucose level > or =110 mg/dL, 22.4% had an elevated HbA(1c) level; among the 210 patients with a glucose level < 110 mg/dL, 7.6% had an elevated HbA1c level. There were few patients (n = 13) with a glucose level > or =200 mg/dL, but most (85%) had an elevated HbA1c level. Among the 140 patients with a mildly elevated glucose level (110-125 mg/dL), 16.4% had an elevated HbA(1c) level.

CONCLUSIONS

Elevated HbA1c levels are found in ED patients with elevated random plasma glucose values. ED patients with hyperglycemia may warrant referral for diabetes testing.

Tissue plasminogen activator for acute ischemic stroke: A New York city emergency medicine perspective

Nationally, only 2-3% of patients with acute ischemic stroke (AIS) currently receive tissue plasminogen activator (TPA). To better understand the reasons, we investigated the practice patterns, level of familiarity and acceptance of TPA for AIS among emergency physicians in New York City (NYC). Fifty-seven 911-receiving hospital emergency department directors were surveyed regarding TPA use. Of those responding, 37% had never used TPA to treat AIS. Lack of neurological support was reported by 33%. Departments with formal protocols were more likely to use TPA for AIS. In conclusion, there is considerable variation in the practice, knowledge, and attitudes regarding the use of TPA for AIS in NYC emergency departments. Improved educational efforts and institutional support may be necessary to ensure the appropriate use of TPA by emergency physicians.

The relationship of fall school opening and emergency department asthma visits in a large metropolitan area

BACKGROUND

Asthma morbidity is seasonal, with the fewest exacerbations occurring in summer and the most exacerbations in early fall.

OBJECTIVE

To determine if the fall increase in pediatric asthma emergency department (ED) visits is related to the school year start.

DESIGN

Time-series study of daily asthma ED visits taken from an administrative claims database for the years 1991 to 2002.

SETTING

Eleven municipal hospitals in New York City, NY. Patients Emergency department visits with asthma as the primary diagnosis among children aged 2 to 4, 5 to 11, and 12 to 17 years and adults with asthma aged 22 to 45 years as comparative group. Main Outcome Measure Rate of asthma ED visits after the September school opening compared with before the opening, during a 60-day window of each year. The delayed effect of school opening was examined by the lagged school-opening indicator for lag 0 through 9 days. The model adjusted for factors that may influence morbidity. There were 86 731 ED visits within the study period.

RESULTS

Asthma ED visits for children aged 5 to 11 years were significantly associated with school opening day, with the highest lagged rate ratio being 1.46 (95% confidence interval [CI], 1.29-1.65). For children aged 2 to 4 years, the highest rate ratio was 1.19 (95% CI, 1.06-1.35), and for children aged 12 to 17 years, the highest lagged rate ratio was 1.13 (95% CI, 0.98-1.31). The rise in adult ED visits following school opening was less substantial, with the highest lagged rate ratio being 1.07 (95% CI, 1.00-1.14).

CONCLUSION

The start of the September school year was associated with increases in pediatric asthma ED visits, particularly among grade school children.

Zafirlukast treatment for acute asthma: evaluation in a randomized, double-blind, multicenter trial

CONTEXT

Acute asthma causes nearly 2 million hospital emergency department (ED) visits in the United States annually, and hospitalization after an ED visit and relapse after ED discharge are common.

OBJECTIVE

To evaluate the adding of therapy with zafirlukast to standardized care for patients with acute asthma in the ED and a 28-day follow-up period.

DESIGN AND PATIENTS

A total of 641 patients presenting to the ED with acute asthma were randomized to receive either single-dose zafirlukast, 160 mg (Z160) [162 patients], zafirlukast, 20 mg (Z20) [158 patients]), or placebo (321 patients) as adjunct treatment to standard care in this double-blind, multicenter trial. Assessments, including spirometry and symptom scores, were obtained before each albuterol treatment and at 4 h. Patients who were discharged from the ED after 4 h continued outpatient therapy over a 28-day period and received either Z20 bid (276 patients) or placebo (270 patients) in addition to prednisone, albuterol, and their previous asthma medications. FEV(1) was measured at clinic visits on days 10 and 28. Patients recorded outpatient clinical data twice daily on a home diary card.

MAIN OUTCOME MEASURES

the effect of zafirlukast on relapse after ED discharge. Other assessments were the rate of extended care (ie, ED stay for > 4 h or hospitalization), FEV(1), and symptoms.

RESULTS

At the end of the outpatient period, 65 of 276 patients (23.6%) treated with zafirlukast and 78 of 270 patients (28.9%) treated with placebo relapsed (p = 0.047; absolute reduction, 5.3%; relative reduction, 18.3%). At the end of the ED period, 16 of 162 patients (9.9%) treated with Z160, 26 of 158 patients (16.5%) treated with Z20, and 48 of 321 patients (15.0%) treated with placebo required extended care (p = 0.052; absolute reduction with Z160 compared to placebo, 5.1%; relative reduction, 34%). These findings were supported by a significant improvement in FEV(1) and dyspnea in the ED with the use of Z160 therapy, and by greater improvement in FEV(1) and symptoms during the outpatient period for patients treated with Z20.

CONCLUSIONS

When added to standardized care, therapy with Z20 bid reduced the risk of relapse compared with placebo over a 28-day treatment period. One dose of Z160 in the ED also reduced the rate of extended care.

Age-related seasonal patterns of emergency department visits for acute asthma in an urban environment

STUDY OBJECTIVE

Asthma morbidity is greater in younger patients. The reasons are not fully understood, although identifying demographic patterns of seasonality may help determine causes and potential prevention. The objective of this study is to determine the relationship between age and seasonal asthma periodicity in patients presenting to the emergency department (ED).

METHODS

We conducted a retrospective study of ED visits from 1991 to 2000 in 11 municipal hospitals in New York City, with 911 receiving facilities. There were 673,141 patients who presented to the ED during the study period and had a primary diagnosis of acute asthma.

RESULTS

Distinct seasonal patterns were observed, with the highest number of visits occurring in the fall and the fewest in the summer. Seasonal fluctuations of ED visits were highest in children aged 13 years or younger (coefficient of variation [CV] 37.8%; 95% confidence interval [CI] 37.5% to 38.1%), with a peak in CV occurring at approximately age 7 years (CV 43.3%; 95% CI 43.0% to 43.6%). Less variability was noted with increasing age, and the population aged 30 years and older appeared to be the least susceptible to seasonal influences (CV 11.7%; 95% CI 11.3% to 12.1%). Although the total number of asthma visits decreased by more than 30% from 1991 to 2000, the CVs for each year remained within a relatively narrow range of 24.2% to 30.5%.

CONCLUSION

In an urban population, seasonal variability of asthma episodes requiring ED visits are closely linked to age, which may be important in understanding the causes of asthma and developing disease-management strategies for the prevention of asthma episodes.

Cigarette smoking among asthmatic adults presenting to 64 emergency departments

STUDY OBJECTIVES

The emergency department (ED) is an important focal point for asthmatic individuals with uncontrolled illness. Anecdotally, many adults presenting to the ED with acute asthma are active cigarette smokers. The present study determined the prevalence of cigarette smoking among adults presenting to the ED with acute asthma and identified the factors associated with current smoking status.

DESIGN

A prospective cohort study conducted as part of the Multicenter Airway Research Collaboration.

PATIENTS

A structured interview was performed in 1,847 patients, ages 18 to 54 years, who presented to the ED with acute asthma.

SETTING

Sixty-four EDs in 21 US states and 4 Canadian provinces.

RESULTS

Thirty-five percent of the enrolled asthmatic patients were current smokers with a median of 10 pack-years (interquartile range, 4 to 20 pack-years), while 23% were former smokers, and 42% were never-smokers. Current smokers comprised 33% of asthmatic patients aged 18 to 29 years, 40% for ages 30 to 39 years, and 33% for ages 40 to 54 (p < 0.001). In a multivariate analysis, the factors independently associated with current smoking status (p < 0.05) were as follows: age 30 to 39 years; white race/ethnicity; non-high school graduate; lower household income; lack of private insurance; no recent inhaled steroid usage; and no history of systemic steroid usage. Although 50% of current smokers admitted that smoking worsens their asthma symptoms, only 4% stated that smoking was responsible for their current exacerbation.

CONCLUSIONS

Although cigarette smoke is generally recognized as a respiratory irritant, cigarette smoking is common among adults presenting to the ED with acute asthma. The ED visit may provide an opportunity for patients to be targeted for smoking cessation efforts.

Ken and Katie caterpillar: helpful props for treatment of molluscum contagiosum

A hand-made prop that aids in the efficient treatment of molluscum contagiosum with curettage or cantharidin is described. Small bandages or pieces of tape are affixed to a tongue depressor prior to the procedure so that they may be placed quickly over the treated molluscum. This improves time management and helps to reduce patient anxiety.

A prospective multicenter study of factors associated with hospital admission among adults with acute asthma

PURPOSE

We sought to determine patient characteristics associated with hospital admission after emergency treatment for asthma, and whether disposition guidelines are followed.

SUBJECTS AND METHODS

We performed a prospective multicenter cohort study involving 64 emergency departments in the United States and Canada. Consecutive adult patients with asthma exacerbations were interviewed, and their charts were reviewed using standardized protocols. Telephone follow-up at 2 weeks determined relapse.

RESULTS

Of 1805 patients, 363 (20%; 95% confidence interval [CI]: 18% to 22%) were hospitalized. Among patients with severe exacerbations (final peak flow <50% of predicted), 122 (49%; 95% CI: 43% to 55%) were hospitalized. Admission was associated with final peak flow, female sex, nonwhite race, severity of chronic illness, and severity of exacerbation. Admission predictors were similar regardless of hospital funding, region, or size. Among patients with mild or moderate exacerbations of asthma (peak flow >or=50% predicted), the likelihood of admission was associated significantly with the number of predefined risk factors for death from asthma. Of patients who were discharged from the emergency department, 62 (5%; 95% CI: 4% to 6%) relapsed within 72 hours. Relapse was not associated with final peak flow (P = 0.39).

CONCLUSION

Associations between patient characteristics and disposition were similar across sites. Despite guidelines to the contrary, half of patients with final peak flow <50% were discharged. After emergency department treatment and discharge, short-term relapse was uncommon among patients with asthma, suggesting that strict peak flow cutoffs may be unnecessary if risk factors in patients with mild or moderate exacerbations are considered.

IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial

BACKGROUND

Studies of IV magnesium sulfate as a treatment for acute asthma have had mixed results, with some data suggesting a benefit for acute severe asthma, but not for mild-to-moderate asthma. In a multicenter cohort, this study tests the hypothesis that administration of magnesium sulfate improves pulmonary function in patients with acute severe asthma.

DESIGN

Placebo-controlled, double-blind, randomized clinical trial.

SETTING

Emergency departments (EDs) of eight hospitals.

PATIENTS

Patients aged 18 to 60 years presenting with acute asthma and FEV1 < or = 30% predicted on arrival to the ED.

INTERVENTION

All patients received nebulized albuterol at regular intervals and IV methylprednisolone. Two grams of IV magnesium sulfate or placebo were administered 30 min after ED arrival. The primary efficacy end point was FEV1 at 240 min, and the data analysis was intent to treat.

RESULTS

Two hundred forty-eight patients were included, and the mean FEV1 on ED arrival was 22.9% predicted. At 240 min, patients receiving magnesium had a mean FEV1 of 48.2% predicted, compared to 43.5% predicted in the placebo-treated group (mean difference, 4.7%; 95% confidence interval [CI], 0.29 to 9.3%; p = 0.045). A regression model confirmed the effect of magnesium compared to placebo was greater in patients with a lower initial FEV1 (p < 0.05). If the initial FEV1 was < 25% predicted, the final FEV1 was 45.3% predicted in the magnesium-treated group and 35.6% predicted in the placebo-treated group (mean difference, 9.7%; 95% CI, 4.0 to 15.3%; p = 0.001). If the initial FEV was > or = 25% predicted, magnesium administration was not beneficial; the final FEV1 was 51.1% predicted in the magnesium-treated group and 53.9% predicted in the placebo-treated group (mean difference, - 2.9%, 95% CI, - 9.4 to 3.7; p = not significant). Overall, the use of magnesium sulfate did not improve hospital admission rates.

CONCLUSION

Administration of 2 g of IV magnesium sulfate improves pulmonary function when used as an adjunct to standard therapy in patients with very severe, acute asthma.