Association Between Outpatient Follow-Up and Pediatric Emergency Department Asthma Visits

Background. The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. Objective. To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. Design. We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. Results: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. Conclusions. Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.     

Implementation of Evidence-Based Tobacco Use Cessation Guidelines in Managed Care Organizations

Background: Although managed care organizations (MCOs) may be optimal settings for implementing tobacco use cessation clinical guidelines, such guidelines remain poorly implemented in many MCO settings.Purpose: We examined issues related to the implementation of guidelines in MCOs, to provide examples of studies that have addressed issues related to guideline implementation and to suggest ways behavioral medicine researchers can play a role in examining issues of how guidelines can be better implemented.Methods: Surveys of clinical guideline implementation, studies from the Robert Wood Johnson Foundation addressing tobacco use cessation in a managed care database, selected to illustrate issues related to system-wide implementation.Results: Surveys show that effective tobacco use cessation interventions remain underutilized in MCOs. A few studies have evaluated and shown the benefit of insurance coverage for tobacco use and dependence treatments, clinician reimbursement and leadership incentives, practice feedback, and leveraging administrative data to create tobacco use tracking systems. The studies also point to the need for large-scale, multidisciplinary, methodologically rigorous studies that allow one to isolate the effects of promising strategies as well as to explore synergistic effects as different system changes are combined.Conclusions: Tobacco use cessation guidelines need to be better implemented in MCOs. Behavioral medicine research needs to move beyond treatment efficacy and effectiveness studies to focus on rigorous evaluations of these and other strategies to enhance guideline implementation and dissemination. This research was supported by grants from the Tobacco-Related Disease Research Program (Taylor) and from the Robert Wood Johnson Foundation (Taylor and Curry).     

The relation of dizziness to functional decline

OBJECTIVE: to assess the effect of dizziness on the probability that an older person will die or become functionally disabled within 2 years. Dizziness is a common symptom for which the prognosis is uncertain. This report compares the prognoses for dizzy and not-dizzy older people in order to assist clinicians who diagnose and treat these patients. DESIGN: a prospective study of a representative sample of elderly (70+) non-institutionalized Americans. Elderly subjects (n = 3,798) in the Longitudinal Study of Aging (LSOA) were asked questions about the presence of dizziness, medical conditions, and functional disability in 1984. The cohort was reinterviewed about functional disability in 1986. OUTCOME MEASURE: transition from functional ability to disability after 2 years. RESULTS: Bivariate analyses showed that dizziness predicts functional decline but not mortality. Multivariate models revealed that age, race, sensory impairment, vascular disease, and other morbidity are independent predictors of becoming disabled. Controlling for these potential confounders, dizziness does not predict an increased probability of becoming disabled. CONCLUSION: Elderly people who are dizzy should be evaluated for the presence of these related conditions.     

Psychosocial Factors and Prediction of Headaches in College Adults

The current study evaluated psychosocial variables that may contribute to the experience of headache in college adults. One hundred ninety-nine participants, 103 women and 96 men, completed head pain logs for 4 weeks after completing measures assessing psychosocial variables. Multiple regression analyses indicated that level of emotional functioning, perception of stress, and gender were predictive of future headache frequency, intensity, and duration. Family history and health habits did not predict headache activity. These findings are consistent with research investigating psychosocial variables and headache activity.     

Growth and invasion of human melanomas in human skin grafted to immunodeficient mice.

An orthotopic model of human melanoma was developed in which malignant cells were injected into human skin grafted to nude and SCID mice. Melanoma cells proliferated and invaded the human skin grafts with characteristic patterns. Three of six melanomas grew as multiple nodules and infiltered the grafts without major architectural changes in the dermis, whereas the others invaded the dermis along collagen fibers with prominent endothelial vessels. By contrast, melanoma cells inoculated into mouse skin grew as diffusely expanding nodules that did not invade the murine dermis. In human skin grafts, human melanoma cells were angiogenic for human blood vessels, and murine vessels were only found at the periphery of grafts. Tumor cells invaded the human vessels, and four out of seven cell lines metastasized to lungs, suggesting that this model is useful to determine in vivo the interactions between normal and malignant human cells.     

Quantitative Magnetic Resonance Imaging of Human Brain Development: Ages 4-18

Brain magnetic resonance images (MRI) of 104 healthy childrenand adolescents, aged 4–18, showed significant effectsof age and gender on brain morphometry. Males had larger cerebral(9%) and cerebellar (8%) volumes (P < 0.0001 and P = 0.008.respectively), which remained significant even after correctionfor height and weight After adjusting for cerebral size, theputamen and globus pallidus remained larger in males, whilerelative caudate size was larger in females. Neither cerebralnor cerebellar volume changed significantly across this agerange. Lateral ventricular volume increased significantly inmales (trend for females), with males showing an increase inslope after age 11. In males only, caudate and putamen decreasedwith age (P = 0.007 and 0.05, respectively). The left lateralventricles and putamen were significantly greater than the rightP = 0.01 and 0.0001, respectively). In contrast, the cerebralhemispheres and caudate showed a highly consistent right greater-than-leftasymmetry (P < 0.0001 for both). All volumes demonstrateda high degree of variability. These findings highlight gender-specificmaturational changes of the developing brain and the need forlarge gender-matched samples in pediatric neuropsychiatric studies.