National Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease, 1993–2005

Objectives: Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline‐recommended care. Methods: Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes. Concordance with guideline recommendations was evaluated using process measures. Results: Over the 13‐year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; P_trend = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all P_trend > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993–1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all P_trend < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9). Conclusions: The high burden of ED visits for AECOPD persisted. Overall concordance with guideline‐recommended care for AECOPD was moderate, and some emergency treatments had improved over time.     

Learning to Observe Relationships and Coping

Milieu relationships provide the critical background presence to staff's attempts to motivate, regulate, and teach patients how to cope with stress. Forging a connection with hospitalized children and adolescents demands attention to how they respond to adults and engage with staff around milieu expectations. Assessment guides that deal with these issues are presented. Important aspects of children's relatedness are presented in the context of their working models of adults and the influence of these representations on their response to staff. Coping skills are explained with particular emphasis on behavioral coping strategies. Tied to the assessment process are interventions that emphasize staff's role in helping patients manage strong affects and avoid the use of nonproductive behavior regulation strategies.     

Integrating Nursing Care into Systems of Care for Children with Emotional and Behavioral Disorders

PROBLEM: Recent developments in providing care to children with emotional and behavioral disorders, especially those with serious emotional disturbance, have included the establishment of systems of care. Guided by a set of principles and values, these systems of care have organized and delivered services to children and families with complex needs. To date, nurses have not had a salient role in systems of care. RESULTS: It is estimated that 20% of American children and adolescents have an emotional or mental disorder. As many as two thirds of these children are not receiving services. Systems of care have been funded to provide services for these children, particularly for the most severely affected. To date, nursing has not had a prominent role in these systems of care. CONCLUSIONS: Based on their knowledge, skills, and holistic approach to care, nurses could better integrate nursing care into systems of care. Possible roles as case managers, primary therapists, in-home interventionists, and in educational programs are suggested.     

Why culture and language matter: the clinical consequences of providing culturally and linguistically appropriate services to children in the emergency department

As the proportion of racial, ethnic, and cultural minorities in the United States continues to expand, pediatric emergency medicine providers are increasingly likely to encounter cultural and language barriers in practice. This paper reviews a conceptual framework encompassing the decision to seek emergency care, the process of providing such care, and the adherence to treatment plans and follow-up. The ways in which cultural and language barriers can negatively impact each element of this model are discussed in detail. Specific examples include provider ignorance of dangerous folk beliefs, communication barriers secondary to inappropriate interpreter use, and discriminatory assumptions regarding child abuse, pain management, and sexual activity. The practitioner is then provided with concrete recommendations to reduce these negative effects.     

Stromal progenitor cell therapy corrects the wound-healing defect in the ischemic rabbit ear model of chronic wound repair

Chronic wounds create a formidable clinical problem resulting in considerable morbidity and healthcare expenditure. The etiology for wound healing impairment appears to be multifactorial; however, ischemia is a common factor in most types of chronic wounds. Ideal therapy for such wounds would be to correct deficiencies in growth factors and matrix components and provide cellular precursors required for timely wound closure. We hypothesized that stromal progenitor cell (SPC) therapy could correct the ischemic wound-healing defect through both direct and indirect mechanisms. To test this hypothesis, we used the ischemic rabbit ear model of chronic wound healing. We found that treatment of the wounds with SPCs was able to reverse the ischemic wound-healing impairment, with improved granulation tissue formation and reepithelialization compared with vehicle or bone marrow mononuclear cell controls. In vitro, SPCs were found to produce factors involved in angiogenesis and reepithelialization, and extracellular matrix components, providing evidence for both direct and indirect mechanisms for the observed correction of the healing impairment in these wounds. Treatment of ischemic wounds with SPCs can dramatically improve wound healing and provides a rationale for further studies focused on SPCs as a potential cellular therapy in impaired wound healing.