Prospective Multicenter Study of Bronchiolitis: Predictors of an Unscheduled Visit After Discharge From the Emergency Department

Objectives: There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post‐ED unscheduled visits. Methods: The authors conducted a prospective cohort study of patients discharged from 2004 to 2006 at 30 EDs in 15 U.S. states. Inclusion criteria were diagnosis of bronchiolitis, age <2 years, and discharge home; the exclusion criterion was previous enrollment. Unscheduled visits were defined as urgent visits to an ED/clinic for worsened bronchiolitis within 2 weeks. Results: Of 722 patients eligible for the current analysis, 717 (99%) had unscheduled visit data, of whom 121 (17%; 95% confidence interval [CI] = 14% to 20%) had unscheduled visits. Unscheduled visits were more likely for children age <2 months (11% vs. 6%; p = 0.04), males (70% vs. 57%; p = 0.007), and those with history of hospitalization (27% vs. 18%; p = 0.01). The two groups were similar in other demographic and clinical factors (all p > 0.10). Using multivariable logistic regression, independent predictors of unscheduled visits were age <2 months, male, and history of hospitalization. Conclusions: In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization. ACADEMIC EMERGENCY MEDICINE 2010; 17:376–382 © 2010 by the Society for Academic Emergency Medicine     

Pegvisomant for the treatment of gsp-mediated growth hormone excess in patients with McCune-Albright syndrome

CONTEXT: GH excess affects approximately 20% of the patients with McCune-Albright syndrome (MAS). MAS is caused by sporadic, postzygotic, activating mutations in the GNAS gene, which codes for the cAMP-regulating protein, G(s)alpha (gsp oncogene). These same mutations are found in approximately one third of the sporadic cases of acromegaly. OBJECTIVE: We examined efficacy of the GH receptor antagonist, pegvisomant, in controlling gsp oncogene-mediated GH excess and skeletal disease (fibrous dysplasia of bone) associated with MAS. SETTING AND PATIENTS: Five MAS patients with GH excess were treated with 20 mg/d sc injection of pegvisomant for 12 wk in a randomized, double-blind, placebo-controlled crossover study at the National Institutes of Health. MAIN OUTCOME MEASURES: The primary measure of efficacy was normalization of IGF-I. Secondary outcome measures were reduction in serum IGF binding protein-3 (IGFBP-3), improvement of fatigue and sweating, and reduction in markers of bone metabolism and bone pain. RESULTS: Combined mean changes in serum IGF-I at 6 and 12 wk were -236.4 ng/ml (53%, P < 0.005) and -329.8 ng/ml (62%, P < 0.001), respectively. IGFBP-3 decreased by 0.8 mg/liter (24%, P < 0.01) and 2.9 mg/liter (37%, P < 0.005), respectively. There were no significant changes in signs and symptoms of acromegaly or markers of bone metabolism and bone pain, nor was there a significant change in pituitary size. Retrospective comparison of the degree of control achieved with pegvisomant vs. other medications (long-acting octreotide +/- dopamine agonist) in the same group showed that the two regimens were similarly effective. CONCLUSIONS: Pegvisomant effectively reduced IGF-I and IGFBP-3 levels in gsp-mediated GH excess but had no effect on fibrous dysplasia.     

Factors Associated with Frequency of Emergency Department Visits for Chronic Obstructive Pulmonary Disease Exacerbation

Background Little is known about the factors associated with frequency of emergency department visits (FEDV) in chronic obstructive pulmonary disease (COPD) patients with recurrent exacerbations. Objective To characterize the use of emergency department (ED) services in patients with COPD exacerbation and identify factors associated with FEDV. Design A prospective, multicenter cohort study. Patients Three hundred eighty-eight patients were included. Fifty-two percent were women and the median age was 69 years (interquartile range 62–76). Measurements Using a standard questionnaire, consecutive ED patients with COPD exacerbation were interviewed. The number of ED visits in the previous year was retrospectively collected. Results Over the past year, this cohort reported a total of 1,090 ED visits because of COPD exacerbation. Thirteen percent of COPD patients had 6 or more ED visits, accounting for 57% of the total ED visits in the past year. Multivariate analysis showed that patients with an increased FEDV were more likely to be Hispanic (incidence rate ratio [IRR] 1.97, 95% confidence interval [CI] 1.16–3.33), to have more severe COPD as determined by previous hospitalizations (IRR 2.06, 95% CI 1.51–2.82), prior intubations (IRR 1.49, 95% CI 1.02–2.18), prior use of systemic corticosteroids (IRR 1.57, 95% CI 1.16–2.13) and methylxanthine (IRR 1.48, 95% CI 1.04–2.12), and less likely to have a primary care provider (IRR 0.51, 95% CI 0.31–0.82). Conclusions Our results suggest that both disease and health care-related factors were associated with FEDV in COPD exacerbation. Multidisciplinary efforts through primary care provider follow-up should be assessed to test the effects on reducing the high morbidity and cost of recurrent COPD exacerbations.     

Electronic Medical Records and Same Day Patient Tracing Improves Clinic Efficiency and Adherence to Appointments in a Community Based HIV/AIDS Care Program,in Uganda

Patients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre-EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to follow-up (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency.     

Change over time (2007–2009) in HIV preventive behaviours,evidence from two serial population‐based surveys in rural Zimbabwe

Objective T o assess reported HIV knowledge and attitudes, sexual behaviours and HIV testing in Zimbabwe. Methods Representative household surveys of all 18–24 year olds and a proportion of 25–44 year olds were conducted in six purposefully selected rural districts in two provinces in 2007 and 2009. Both surveys used the same methods and questionnaires. We compared differences in reported HIV knowledge, sexual behaviours and HIV testing, controlling for differences in socio‐demographics at baseline, using cross‐tabulations and multivariate regression analyses. Results Analysis was restricted to districts included in both baseline (n = 1891) and mid‐term (n = 2746) surveys. Comparisons indicate increased reports of HIV knowledge (35%vs. 22% had high knowledge) and more favourable individual attitudes towards HIV. There was an increase in reported HIV testing (men: 41%vs. 31%, women: 55%vs. 36%) and condom use (men: adjusted odds ratio (AOR) = 1.35, women: AOR = 1.22) and a decrease in number of sexual partners (men: 67%vs. 49% reported 1 partner/previous 6 months, women: 77%vs. 68%). Conclusions As Zimbabwe continues to document declines in HIV prevalence, this analysis offers insight into recent and continuing positive changes in knowledge, attitudes and behaviours among the rural population.