-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to evaluate the effectiveness of the probiotic Lactobacillus GG (LGG) in reducing the duration of acute infectious diarrhea in the pediatric emergency department.
We conducted a double-blind, randomized controlled trial of children 6 months to 6 years presenting to the pediatric emergency department with a complaint of diarrhea. Patients were randomized to receive either placebo or LGG powder twice daily for 5 days. With each dose, parents recorded the stool history in a home diary and were followed up daily by a blinded researcher. Groups were compared in terms of time to normal stool and number of diarrheal stools.
Of 155 patients enrolled, 129 completed the study: 63 in the LGG group and 66 in the placebo group. There was no significant difference in the median (interquartile range) time to normal stool (LGG: 60 hours [37-111] vs placebo: 74 hours [43-120]; P = 0.37) or the number of diarrheal stools (LGG: 5.0 [1-10] vs placebo: 6.5 [2-14]; P = 0.19). Among children who presented with more than 2 days of diarrhea, the LGG group returned to normal stool earlier (LGG: 51 hours [32-78] vs placebo: 74 hours [45-120]; P = 0.02), had fewer episodes of diarrheal stools (LGG: 3.5 [1.0-7.5] vs placebo: 7 [3.0-16.3]; P = 0.02), and were 2.2 times more likely to return to normal stool (95% confidence interval, 1.3-3.9; P = 0.01) compared with children in the placebo group.
Lactobacillus GG may reduce the duration of acute diarrheal illness among children presenting with more than 2 days of symptoms.
Pediatric emergency care 09/2012; 28(10):1048-51. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: To describe the beliefs and preferences of pediatric surgeons regarding the emergent nature of nonperforated appendicitis. METHODS: An electronic mailing was sent to all 1052 members of the American Pediatric Surgical Association (APSA) inviting participation in a 26-item survey, which was administered by Survey Monkey (www.surveymonkey.com). Chi-square and Mann-Whitney tests were used for bivariate analysis. Spearman's rho was used for nonparametric correlation. RESULTS: Four hundred eighty-four pediatric surgeons (46%) responded to the survey. Few respondents (4%) considered nonperforated appendicitis to be a surgical emergency. A minority (14%) would come in from home to perform an overnight appendectomy. Most (92%) believe that postponing overnight appendectomy until daytime does not result in a clinically significant increase in perforation. Respondents endorsed surgeon fatigue (56%) and limited operating room availability (56%) most often among factors that would make them more likely to postpone surgery. Sixty-eight percent reported no departmental guideline regarding delay of overnight appendectomy. CONCLUSIONS: Most pediatric surgeons in our study believe nonperforated appendicitis is not a surgical emergency and prefer to postpone overnight appendectomy.
Academic pediatrics 09/2012;
-
[show abstract]
[hide abstract]
ABSTRACT: The objective was to determine whether a 3-question version of the Edinburgh Postpartum Depression Scale (EPDS) performs as well as the full EPDS in screening for postpartum depression in a pediatric emergency department (PED).
Mothers of infants younger than 6 months presenting to an urban PED were enrolled. After the PED encounter, mothers were asked about demographics, health problems, insurance status, social support, food and housing security, and 3 questions from the EPDS. Mothers then completed the full EPDS. The primary outcome was the score on the full EPDS. Agreement between the 3 questions and the full EPDS for screening positive was measured. Test performance characteristics for screening positive with the 3 questions were calculated. Logistic regression determined the association between sociodemographic characteristics and screening positive. Provider impression of maternal depressive symptoms was recorded.
Of 195 mothers enrolled, 23% screened positive using the EPDS; 34% screened positive using the 3 questions (κ = 0.74). Compared with the EPDS, sensitivity of the 3 questions was 100%. Number of children younger than 5 years at home and having food and housing concerns were associated with screening positive. Of 44 mothers who screened positive on the full EPDS, providers identified 14 (32%) as having depressive symptoms or possibly being depressed.
Three questions from the EPDS performed similarly to the full EPDS in screening for postpartum depressive symptoms in a PED. Future studies are needed to confirm these findings and examine whether screening improves maternal and child health outcomes and quality-of-life concerns.
Pediatric emergency care 08/2011; 27(9):795-800. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture.
A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture).
Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01).
Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.
Pediatric emergency care 06/2011; 27(7):596-600. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To explore the utility of two measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a pediatric emergency department (PED) visit for acute asthma and to compare verbal and self-completion of these measures.
Prospective cohort study of children 3 to 11 years of age presenting to a PED with an acute asthma exacerbation. Caretakers were randomized to self-completion of a questionnaire assessing RN and AN or to verbally respond to the same questionnaire administered by a research assistant. Five asthma morbidity indicators were collected at 2, 4, and 8 weeks following discharge from the PED.
One hundred fifty-four patients were enrolled. There were no significant differences in asthma severity, RN, or AN, or the number of items missing on questionnaires between the self-completion and verbal administration groups. Patients with a RN score >4 had an adjusted odds of 3.67 (95% confidence interval [CI] 1.57-8.58) for waking >2 nights due to asthma symptoms. The adjusted odds of patients with any AN to report needing >4 days of rescue asthma medication was 3.16 (95% CI 1.37-7.26).
RN and AN were both associated with morbidity indices following an acute asthma exacerbation and can identify children at risk for increased short-term morbidity regardless of the method of questionnaire administration. Assessment of RN and AN by self-administered questionnaire during an ED visit for asthma maybe feasible.
Journal of Asthma 06/2010; 47(5):545-50. · 1.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To identify a population of children at low risk for bacterial conjunctivitis on the basis of history and physical examination findings.
Prospective observational cohort study.
Urban pediatric emergency department.
Children aged 6 months to 17 years with conjunctival erythema, eye discharge, or both. The exclusion criteria were eye trauma, exposure to a noxious chemical, contact lens use, and antibiotic drug use in the past 5 days.
Clinicians completed a checklist of signs and symptoms and collected a conjunctival swab for bacterial culture.
The chi(2) test, the Mann-Whitney test, and logistic regression were used to create a prediction model for a negative bacterial culture.
Of 368 patients enrolled, 194 (52.7%) were males. The median patient age was 3 years (interquartile range, 1-5 years). Conjunctival cultures were negative in 130 patients (35.3%). Age 6 years or older, presentation in April through November, no or watery discharge, and no glued eye in the morning were the clinical factors found to be independently associated with a negative conjunctival culture. If 3 factors were present, 76.4% (95% confidence interval, 63.6%-85.6%) of patients had a negative culture. If all 4 factors were present, 92.3% (95% confidence interval, 66.1%-98.2%) of patients had a negative culture.
The combination of 4 clinical factors may enable clinicians to identify children at low risk for bacterial conjunctivitis and may reduce routine antibiotic drug administration.
Archives of pediatrics & adolescent medicine 03/2010; 164(3):263-7. · 3.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine whether parents who deliver albuterol treatments in a pediatric emergency department with a metered dose inhaler with a spacer device (MDIS) report better adherence to MDIS use at home compared to parents whose children undergo standard nebulizer therapy. Children aged 1-5 years were randomized by day to usual treatment with nebulized albuterol (40 children) or to treatment by the parent with albuterol with an MDIS (46 children). All caregivers received standard discharge instructions, a spacer and an MDI. Two weeks following the visit, a trained research assistant blinded to the child's group status, administered a brief telephone questionnaire to each caretaker. At follow-up, children in the MDIS group were 7.5 times more likely to be using the MDIS for their albuterol treatments (95%CI 1.6-35.6). Involving parents in treatment of asthma exacerbations in the emergency department using an MDIS may improve adherence to MDIS use at home.
Journal of Asthma 10/2009; 46(8):792-5. · 1.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction.
Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined.
Thirty-three patients were enrolled, the mean age was 9.1 years (+/-3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction.The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0.96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively.
These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries.
Pediatric emergency care 05/2009; 25(4):221-25. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Osteopathic physicians believe that the birthing process causes cranial dysfunction that may be manifested in somatic symptoms, one of which is excessive crying of infancy. Cranial dysfunction can be determined by assessing the cranial rhythmic impulse (CRI).
The objective of this study is to examine whether an abnormal CRI is associated with excessive crying of infancy.
Full-term infants in the well-baby nursery of an urban public hospital in the Bronx, New York were enrolled. Two (2) osteopathic physicians independently measured the CRI in infants before discharge. One (1) osteopath repeated the CRI measurement at 2 weeks. At 6 weeks, an investigator blinded to the CRI and birth data assessed infant crying using the modified Ames Cry Score via telephone interview with the primary caretaker. The caretaker was also asked about maternal stress, use of home or cultural remedies, and the infant's diet. The main outcome measure was the presence of excessive crying.
One hundred and thirty-nine (139) patients were included in the final sample. The overall incidence of excessive crying was 41.7%. Excessive crying was associated with an abnormal CRI at 2 weeks (p < 0.001) but not with the CRI at birth (p = 0.23). Infants with an abnormal CRI at 2 weeks were 6.8 times (95% confidence intervals 2.2, 20.6) more likely to develop excessive crying than infants with a normal CRI. Infant diet was independently associated with excessive crying. Inter-rater agreement for CRI measurement was 0.70 using the kappa statistic.
These data suggest that an abnormal CRI at 2 weeks of age may be associated with excessive crying.
Journal of alternative and complementary medicine (New York, N.Y.) 04/2009; 15(4):341-5. · 1.69 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their child's allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments.
To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits.
A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patient's asthma clinic visit.
Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P < .05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1.
Parents who receive evidence in the PED of their child's allergic status and probable relationship to the child's asthma are more likely to adhere to scheduled continuity visits.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 02/2009; 102(1):35-40. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study compared parental adherence to delayed antibiotic therapy for acute otitis media with and without a written prescription in a pediatric emergency department.
Children aged 2 to 12 years who met criteria for delayed antibiotic treatment were randomly assigned to observation therapy with or without a prescription. Patients randomly assigned to observation therapy without prescription were instructed to seek follow-up care if symptoms persisted for 2 to 3 days. Patients assigned to observation therapy with a prescription were discharged with an antibiotic prescription, and instructed to fill it if their child's symptoms persisted 2 to 3 days. A research assistant who was blinded to group assignment called parents 7 to 10 days after the visit to assess adherence to observation therapy.
Of 117 children assigned to the observation therapy group, 100 completed follow-up; of 115 assigned to the observation therapy with a prescription group, 106 completed follow-up. In the observation therapy group, 87 parents reported no antibiotic use within the 3-day observation period compared with 66 parents in the prescription group. During the entire study period, 81% of the observation therapy group reported no use of antibiotics compared with 53% in the prescription group. These groups did not differ in satisfaction with the visit; 91% and 95% were very or extremely satisfied, respectively. No complications were reported.
Observation therapy with and without a prescription were both well accepted by parents of children diagnosed with acute otitis media in an urban pediatric emergency department. Adherence to delayed antibiotic therapy was better for those not offered a prescription. These data suggest that, in the pediatric emergency department setting, observation therapy reduces antibiotic use without compromising satisfaction with the visit.
PEDIATRICS 06/2008; 121(5):e1352-6. · 4.47 Impact Factor
-
George T O'Connor,
Lucas Neas,
Benjamin Vaughn,
Meyer Kattan,
Herman Mitchell, Ellen F Crain,
Richard Evans,
Rebecca Gruchalla,
Wayne Morgan,
James Stout,
G Kenneth Adams,
Morton Lippmann
[show abstract]
[hide abstract]
ABSTRACT: Children with asthma in inner-city communities may be particularly vulnerable to adverse effects of air pollution because of their airways disease and exposure to relatively high levels of motor vehicle emissions.
To investigate the association between fluctuations in outdoor air pollution and asthma morbidity among inner-city children with asthma.
We analyzed data from 861 children with persistent asthma in 7 US urban communities who performed 2-week periods of twice-daily pulmonary function testing every 6 months for 2 years. Asthma symptom data were collected every 2 months. Daily pollution measurements were obtained from the Aerometric Information Retrieval System. The relationship of lung function and symptoms to fluctuations in pollutant concentrations was examined by using mixed models.
Almost all pollutant concentrations measured were below the National Ambient Air Quality Standards. In single-pollutant models, higher 5-day average concentrations of NO2, sulfur dioxide, and particles smaller than 2.5 microm were associated with significantly lower pulmonary function. Higher pollutant levels were independently associated with reduced lung function in a 3-pollutant model. Higher concentrations of NO2 and particles smaller than 2.5 microm were associated with asthma-related missed school days, and higher NO2 concentrations were associated with asthma symptoms.
Among inner-city children with asthma, short-term increases in air pollutant concentrations below the National Ambient Air Quality Standards were associated with adverse respiratory health effects. The associations with NO2 suggest that motor vehicle emissions may be causing excess morbidity in this population.
The Journal of allergy and clinical immunology 06/2008; 121(5):1133-1139.e1. · 9.17 Impact Factor
-
Pediatric emergency care 02/2008; 24(1):50-6; quiz 57-8. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To examine attitudes toward the use of oral rehydration therapy (ORT) by pediatric emergency medicine physicians before and after being given recent data that might affect their practice and to see if there is a difference in responses based upon year of graduation from medical school.
A national survey of all members of the American Academy of Pediatrics' Section on Emergency Medicine was conducted. Respondents were asked about their use of ORT for mild, moderate, and severe dehydration, and then presented with data refuting the concern for longer emergency department length of stay with ORT. Participants were then asked about their knowledge of, agreement with, and reaction to these data. Demographic information, such as board eligibility and year of graduation from medical school, was also obtained. The graduates were plotted on a distribution curve by year of graduation, and the group was split into thirds.
The response rate was 59%. Before being presented with new data, earlier medical school graduates used ORT 86% for mild and 33% for moderate dehydration, whereas recent graduates used ORT 95% for mild dehydration and 55% for moderate dehydration. Overall, only 23% of physicians were familiar with the new data, but 80% agreed with the new data, and 83% would now incorporate ORT into their practice. Although the earliest graduates were as familiar with the new data as recent graduates (24% vs. 19%), they were less likely to agree with the new data (74% vs. 90%) and to incorporate ORT into practice (75% vs. 92%).
When pediatric emergency medicine physicians are presented with data refuting the perceived barrier of prolonged time for the use of ORT, more practitioners reported that they would use ORT for mild to moderate dehydration. However, a substantial number, especially those who graduated medical school earliest, would maintain their current practice. Additional barriers need to be explored.
Pediatric emergency care 10/2007; 23(9):624-6. · 0.92 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This pilot study examined the utility of a routinely performed digital rectal examination (DRE) in pediatric trauma patients. A prospective convenience sample of patients 0 to 18 years of age presenting to the pediatric emergency department of an urban level I trauma center with a history of trauma to the spine or trunk was enrolled. An abnormal DRE was defined by the presence of gross or occult blood, decreased sphincter tone, compromised integrity of the rectal vault, or a high riding prostate. We defined DRE-identifiable injuries as spinal injury, pelvic fracture, rectal or other lower intestinal injury, and urethral injury. One hundred thirty-five patients were studied; 8 patients had DRE-identifiable injuries. The sensitivity and negative predictive value of the physical examination with and without the DRE were equivalent. Routine performance of the digital rectal examination may not improve the identification of serious injury during the secondary survey in pediatric trauma patients.
Journal of Emergency Medicine 02/2007; 32(1):59-62. · 1.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To investigate the association between a child's preprocedural state anxiety and the success of sedation.
A consecutive sample of children aged 2 through 17 years requiring sedation for a procedure was enrolled. Pain, preprocedural anxiety (range, 0-9), and success of sedation (10=most successful) were measured.
Fifty-nine patients were enrolled. The median age was 7 years. The median anxiety score was 1.0 (interquartile ratio, 0-3). Pain and anxiety were weakly correlated (r=.21, P>.10). The mean sedation score was 7.8 (+/-2.2). Preprocedural anxiety and successful sedation were inversely correlated (r=-0.31, P=.002). Sedation was successful in 81% of children with anxiety scores below the median and 52% with anxiety scores above the median (P=.02). Children with low anxiety were 3.8 times more likely to be successfully sedated (95% confidence interval, 1.19-12.14).
Our data suggest that preprocedural state anxiety is associated with the success of sedation in children.
American Journal of Emergency Medicine 08/2006; 24(4):397-401. · 1.98 Impact Factor
-
Meyer Kattan, Ellen F Crain,
Suzanne Steinbach,
Cynthia M Visness,
Michelle Walter,
James W Stout,
Richard Evans,
Ernestine Smartt,
Rebecca S Gruchalla,
Wayne J Morgan,
George T O'Connor,
Herman E Mitchell
[show abstract]
[hide abstract]
ABSTRACT: Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest.
The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall).
In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year.
Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.
PEDIATRICS 07/2006; 117(6):e1095-103. · 4.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine if an emergency department-based asthma follow-up clinic could improve outcomes within a high-morbidity pediatric population.
Prospective, randomized clinical trial with 6 months of follow-up.
Emergency department of an urban pediatric medical center.
Convenience sample of 488 patients aged 12 months to 17 years, inclusive, with prior physician-diagnosed asthma and 1 or more other unscheduled visits in the previous 6 months and/or 1 or more hospitalizations in the prior 12 months.
Single follow-up clinic visit focusing on 3 domains: asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing care.
The primary outcome measure was unscheduled visits for acute asthma care. Secondary outcomes included compliance with a medical plan and asthma quality of life. Analysis was by intention to treat with adjustment for baseline differences.
Of those randomized to the clinic visit, 172 (70.5%) of 244 attended. The intervention group had significantly fewer mean unscheduled visits for asthma care during follow-up (1.39 vs 2.34; relative risk [RR] = 0.60 [95% confidence interval (CI), 0.46-0.77]). At 6 months, significantly more patients in the intervention group reported use of inhaled corticosteroids in the prior 2 days (49.3% vs 26.5%; RR = 2.03 [95% CI, 1.57-2.62]), no limitation in daytime quality of life (43.8% vs 34.4%; RR = 1.36 [95% CI, 1.06-1.73]), and no functional limitations in quality of life (49.8% vs 40.8%; RR = 1.33 [95% CI, 1.08-1.63]).
Attendance in the follow-up clinic was high. The intervention decreased subsequent unscheduled health care use while improving compliance and quality of life.
Archives of Pediatrics and Adolescent Medicine 06/2006; 160(5):535-41. · 4.14 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Current guidelines for asthma management emphasize the control of environmental irritants and allergens within the home. Understanding the prevalence of indoor home exposures within such a population may be important for any emergency department (ED) program that seeks to improve the quality of its asthma care and patient education.
We sought to determine the prevalence of indoor home exposures in a cohort of children with moderate to severe asthma who were treated in an urban pediatric ED and to correlate these exposures with household income, prior asthma morbidity, health care utilization, and quality of life (QoL).
We enrolled a cohort of children with chronic asthma who were 12 months through 17 years of age and who had at least one other unscheduled visit for asthma within the previous 6 months. Trained research assistants interviewed the children's parent or guardian regarding the prevalence of home exposures to environmental tobacco smoke (ETS) and common allergens. In addition, data were collected on each patient's prior asthma history, morbidity, health care utilization, medication use, and QoL.
Of the 488 eligible children enrolled, 60.0% were <6 years of age, 63.9% were male, 85.9% were black, 68.4% were publicly insured, and 51.8% had >3 ED visits in the previous 12 months. Home exposure to ETS and potential allergens was high. Exposure to cockroach allergen was significantly associated with household income. Coexistence of exposures was common: significantly more patients reporting ETS exposure also reported exposure to cockroach allergen and mold than those not reporting ETS exposure. Poorer QoL was significantly associated with cockroach exposure, although this effect was limited to those also exposed to ETS. Higher rates of unscheduled health care utilization and persistent asthma symptoms were not associated with exposures.
Additional investigation is necessary to clarify the role of exposure-avoidance measures as a component of ED-based interventions for asthma care.
PEDIATRICS 04/2006; 117(4 Pt 2):S152-8. · 4.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Disadvantaged urban children with asthma depend heavily on emergency departments (EDs) for episodic care. We hypothesized that among an urban population of children with asthma, higher spatial accessibility to primary care pediatric services would be associated with (1) more scheduled primary care visits for asthma, (2) better longitudinal asthma management, and (3) fewer unscheduled visits for asthma care.
We enrolled children aged 12 months to 17 years, inclusive, who sought acute asthma care in an urban pediatric ED. Eligibility criteria included a history of unscheduled visits for asthma in the previous year. We collected comprehensive data on each participant's asthma medical management and prior health care utilization. In addition, we calculated each participant's spatial accessibility to primary care pediatric services, reported as a provider-to-population ratio at their place of residence. Patients then were stratified by their spatial accessibility to care and compared with respect to measures of medical management and health care utilization.
Among the 411 eligible participants, the spatial accessibility of primary care ranged from 7.4 to 350.2 full-time pediatric providers per 100,000 children <18 years of age, with a mean of 57.7 +/- 40.0. Patients in the middle and highest tertiles of spatial accessibility made significantly more scheduled visits for asthma care than patients in the lowest tertile. There were no differences among tertiles of accessibility with respect to asthma management or with respect to unscheduled visits for asthma care.
Within this highly urban, largely disadvantaged and minority population of children with chronic asthma, patients with higher spatial accessibility to primary care services made significantly more scheduled visits for asthma care.
PEDIATRICS 04/2006; 117(4 Pt 2):S78-85. · 4.47 Impact Factor
