Do the residents in the emergency department appropriately manage patients with acute asthma attack? A study of self-criticism

The objective of this study was to investigate the management of patients with asthma attack admitted to the emergency department (ED) in terms of compliance with international guidelines. The records of patients with asthma who were admitted to a university-based ED between December 2001 and December 2002 were evaluated. A total of 72 cases with available data were evaluated retrospectively. Twenty-six patients (36.1%) were admitted more than once during the study period. The number of multiple admissions ranged from 2 (15 patients, 20.0%) to 11 (2 patients, 2.8%). Peak expiratory flow (PEF) measurements were recorded in 17 patients (23.6%) on presentation. Pulse and respiratory rates were recorded in 70 (97.0%) and 67 patients (93.0%), respectively. Thirty-four patients (47.2%) underwent chest x-ray; results were normal in most patients. Salbutamol was the most commonly used drug as first-line therapy. Ipratropium bromide (inhaled) and systemic corticosteroids were added to the salbutamol in 47 (65.2%), 42 (58.4%), and 32 patients (44%), respectively. Pulmonologists were consulted in only 7 cases (9.7%). Thirty patients (43.4%) were prescribed corticosteroids on discharge. The role of functional parameters in determining asthma severity and monitoring treatment effects should be emphasized in clinical practice. Finally, more prevalent use of management guidelines will help determine their usefulness.     

Pulque intake during pregnancy and lactation in rural Mexico: alcohol and child growth from 1 to 57 months

OBJECTIVE: To examine maternal intake of a mildly alcoholic beverage (pulque) during pregnancy and lactation, and its potential effect on postpartum child growth and attained size. DESIGN: A prospective cohort study that followed mothers (during pregnancy and lactation) and their offspring (from birth to approximately 57 months of age). SETTING: Six villages in rural, central Mexico. SUBJECTS: Subjects are 58 mother-child pairs. Pulque intake was measured as part of a dietary assessment that was conducted for 2days/month during pregnancy and early lactation. RESULTS: Most mothers consumed pulque during pregnancy (69.0%) and lactation (72.4%). Among pulque drinkers, the average ethanol intake was 125.1 g/week during pregnancy and 113.8 g/week during lactation. Greater pulque intake during lactation, independent of intake during pregnancy, was associated with slower weight and linear growth from 1 to 57 months, and smaller attained size at 57 months. Low-to-moderate pulque intake during pregnancy, in comparison to either nonconsumption or heavy intake, was also associated with greater stature at 57 months. CONCLUSIONS: Pulque intake during lactation may have adversely influenced postnatal growth in this population. Public health interventions are urgently needed in Mexico to reduce heavy intake of pulque by pregnant and lactating women, and to replace intake with foods that provide the vitamins and minerals present in the traditional alcoholic beverage.     

Empirical assessment of the economic behaviour of Dutch general hospitals

We study the cost structure and efficiency of Dutch general hospitals over the period 1985-1995. Several studies on the efficiency of hospitals now exist. Most of them start from the assumption that hospital management attempts to minimize cost. We went beyond this assumption by trying to collect empirical evidence on management behaviour with respect to patient selection. We did so by estimating both the direct cost function and the indirect cost function as proposed by F?re and Primont and compared the results. We found that acknowledging the possibility of output reallocation increases the validity of optimizing models in the hospital sector but a complete indirect optimizing model ignores that some output categories are less flexible especially in the short run. Endogenous shifts in the allocation of patients appear to be realized through time by increased specialization of hospitals. We suggest that a mixed direct-indirect cost model is probably preferable.     

Predictors of successful work role functioning after carpal tunnel release surgery

This study identified the clinical, individual, and workplace predictors of successful work role functioning (WRF) after carpal tunnel release surgery (CTRS). A community-based cohort (n = 197) was followed for 6 months post-CTRS. Predictors of successful WRF were analyzed prospectively using ordinal logistic regression. Baseline WRF predicted successful WRF at 2 months, whereas being depressed and a workers' compensation claimant predicted being out of work. Baseline WRF, improved self-efficacy, and a supportive organization predicted 6-month successful WRF. Supportive organizations have an impact on the effectiveness of medical interventions for CTS. The significance of improved self-efficacy at 6 months and depression at 2 months postsurgery highlights the importance of psychosocial management of musculoskeletal disorders.     

The impact of incontinence on health-related quality of life in a South Australian population sample

OBJECTIVE: To assess prevalence of incontinence in a South Australian representative population sample and compare the health-related quality-of-life impact of incontinence with other chronic conditions. METHOD: The 1998 South Australian Health Omnibus Survey interviewed 3,010 male and female respondents aged 15 to 97 years (response rate 70.2%). This representative population survey included questions to determine the prevalence of urinary (stress and urge), and anal (faecal and flatus) incontinence, and other chronic conditions. Respondents also completed the MOS SF-36 questionnaire. RESULTS: Self-reported prevalence of all types of incontinence was 26.0%. The prevalence of anal and urinary incontinence were 10.5% and 20.3% respectively, with 4.8% of respondents experiencing both. Univariate analysis found the prevalence of incontinence was statistically significantly higher among females, and those who were older, widowed, had no post-school education, and lower incomes. After adjusting for differences in age and sex, it was found that people with incontinence were significantly impaired across all dimensions of the SF-36, scoring in the lowest 42% of the population, compared with those people without incontinence. People with incontinence exhibited different SF-36 profiles to those with other chronic conditions. CONCLUSIONS: Incontinence is common in South Australia, affecting more than one-quarter of the population, particularly older women (56.2% for 60 years and over). The impact of incontinence on health-related quality of life is characteristically different to that demonstrated by other chronic conditions. IMPLICATIONS: In an ageing population, identification of the impact of incontinence is necessary to direct policy development and resource allocation to this area.     

Differential genetic effects of ESR1 gene polymorphisms on osteoporosis outcomes

Context  Both bone mineral density (BMD) and fracture risk have a strong genetic component. Estrogen receptor (ESR1) is a candidate gene for osteoporosis, but previous studies of ESR1 polymorphisms in this field were hampered by small sample size, lack of standardization, and inconclusive results. Objective  To generate large-scale evidence on whether 3 common ESR1 polymorphisms (intron 1 polymorphisms XbaI [dbSNP: rs9340799] and PvuII [dbSNP: rs2234693] and promoter TA repeats microsatellite) and haplotypes thereof are associated with BMD and fractures. Design and Setting  Meta-analysis of individual-level data involving standardized genotyping of 18 917 individuals in 8 European centers. Main Outcome Measures  BMD of femoral neck and lumbar spine; all fractures and vertebral fractures by genotype. Results  No between-center heterogeneity was observed for any outcome in any genetic contrast. None of the 3 polymorphisms or haplotypes had any statistically significant effect on BMD in adjusted or unadjusted analyses, and estimated differences between genetic contrasts were 0.01 g/cm² or less. Conversely, we found significant reductions in fracture risk. In women homozygous for the absence of an XbaI recognition site, the adjusted odds of all fractures were reduced by 19% (odds ratio, 0.81 [95% CI, 0.71-0.93]; P = .002) and vertebral fractures by 35% (odds ratio, 0.65 [95% CI, 0.49-0.87]; P = .003). Effects on fractures were independent of BMD and unaltered in adjusted analyses. No significant effects on fracture risk were seen for PvuII and TA repeats. Conclusions  ESR1 is a susceptibility gene for fractures, and XbaI determines fracture risk by mechanisms independent of BMD. Our study demonstrates the value of adequately powered studies with standardized genotyping and clinical outcomes in defining effects of common genetic variants on complex diseases.