Developing a short-term prediction model for asthma exacerbations from Swedish primary care patients' data using machine learning - Based on the ARCTIC study.

OBJECTIVE: The ability to predict impending asthma exacerbations may allow better utilization of healthcare resources, prevention of hospitalization and improve patient outcomes. We aimed to develop models using machine learning to predict risk of exacerbations. METHODS: Data from 29,396 asthma patients was collected from electronic medical records and national registers covering clinical and epidemiological factors (e.g. comorbidities, health care contacts), between 2000 and 2013. Machine-learning classifiers were used to create models to predict exacerbations within the next 15 days. Model selection was done using the mean cross validation score of area under precision-recall curve (AUPRC). RESULTS: The most important predictors of exacerbation were comorbidity burden and previous exacerbations. Model validation on test data yielded an AUPRC = 0.007 (95% CI: ± 0.0002), indicating that historic clinical information alone may not be sufficient to predict a near future risk of asthma exacerbation. CONCLUSIONS: Supplementation with additional data on environmental triggers, (e.g. weather, pollen count, air quality) and from wearables, might be necessary to improve performance of the short-term predictive model to develop a more clinically useful tool.

Do beta-adrenergic blocking agents increase asthma exacerbation? A network meta-analysis of randomized controlled trials.

Beta-adrenergic blocking agents (abbreviated as beta-blockers) have been used for treating various cardiovascular diseases. However, the potential for asthma exacerbation is one of the major adverse effects of beta-blockers. This study aimed to compare the level of risk for an asthma attack in patients receiving various beta-blockers. We searched for randomized controlled trials (RCTs) of either placebo-controlled or active-controlled design. The current network meta-analysis (NMA) was conducted under a frequentist model. The primary outcome was the incidence of asthmatic attack. A total of 24 RCTs were included. Overall NMA revealed that only oral timolol [risk ratio (RR) = 3.35 (95% confidence interval (CI) 1.04-10.85)] and infusion of propranolol [RR = 10.19 (95% CI 1.29-80.41)] were associated with significantly higher incidences of asthma attack than the placebo, whereas oral celiprolol [RR = 0.39 (95% CI 0.04-4.11)], oral celiprolol and propranolol [RR = 0.46 (95% CI 0.02-11.65)], oral bisoprolol [RR = 0.46 (95% CI 0.02-11.65)], oral atenolol [RR = 0.51 (95% CI 0.20-1.28)], infusion of practolol [RR = 0.80 (95% CI 0.03-25.14)], and infusion of sotalol [RR = 0.91 (95% CI 0.08-10.65)] were associated with relatively lower incidences of asthma attack than the placebo. In participants with a baseline asthma history, in addition to oral timolol and infusion of propranolol, oral labetalol, oxprenolol, propranolol, and metoprolol exhibited significantly higher incidences of asthma attack than did the placebo. In conclusion, oral timolol and infusion of propranolol were associated with a significantly higher risk of developing an asthma attack in patients, especially in those with a baseline asthma history, and should be avoided in patients who present a risk of asthma.Trial registration: PROSPERO CRD42020190540.

Hipovitaminosis D y malnutrición por exceso en niños asmáticos hospitalizados / Hypovitaminosis D and malnutrition by excess in hospitalized asthmatic children

La tasa de hospitalización por crisis de asma en niños chilenos se ha duplicado en los últimos años. Diversos estudios muestran una asociación entre hipovitaminosis D y crisis de asma. El objetivo principal del presente estudio fue describir la prevalencia de déficit e insuficiencia de vitamina D (vitD) en escolares asmáticos hospitalizados por crisis de asma y evaluar su estado nutricional. METODOLOGÍA: Estudio analítico, transversal, que incluyó a todos los pacientes de 5 años o más que se hospitalizaron por crisis de asma durante un año calendario en el Servicio de Pediatría del Hospital Clínico de la Universidad de Chile. Se aplicó una encuesta que incluyó datos sociodemográficos y clínicos, se evaluó el nivel de control del asma mediante el cuestionario Asthma Control Test (ACT), se determinó el estado nutricional y se midió la concentración de vitD. RESULTADOS: Se observó que 6 de cada 10 pacientes presentaba déficit o insuficiencia de vitD (22,8 ng/ml ± 10,5), encontrándose una asociación positiva entre concentración de vitD y ACT. La malnutrición por exceso estaba presente en casi la mitad de los pacientes. Aquellos pacientes que se hospitalizaron por más de 3 días tenían una concentración sérica de vitD significativamente menor. CONCLUSIONES: La hipovitaminosis D afectó a la mayoría de los niños hospitalizados por crisis de asma. Se encontró una asociación significativa entre concentración de vitD con días de hospitalización y control de la enfermedad medido por ACT.

Asthma hospitalization rates in Chilean children has doubled in recent years. Multiple studies show an association between hypovitaminosis D and asthma attacks. OBJECTIVES: To determine the prevalence of vitamin D (vitD) deficiency and insufficiency in asthmatic school age children hospitalized for asthma crisis and to evaluate their nutritional status. METHODS: Cross-sectional, analytical study that included patients 5 years of age or older hospitalized for asthma attacks during one calendar year, in the Pediatric Service of the University of Chile Clinical Hospital. A survey was conducted that included sociodemographic and clinical data, the level of asthma control was evaluated using the Asthma Control Test questionnaire (ACT), the nutritional status was determined and the concentration of vitD was measured. RESULTS: 6 out of 10 patients had either Vit D deficiency or insufficiency (22,8 ng/ml ± 10,5), showing a positive association between vitD concentration and ACT. Malnutrition due to excess was present in almost half of the patients. Children hospitalized for more than 3 days had a significantly lower vitD serum concentration. CONCLUSIONS: Most of the patients had hypovitaminosis D. An association was found between vitD concentration and hospital stay and between vitD concentration and asthma control, measured by ACT .

Noninvasive Ventilation Use in Critically Ill Patients with Acute Asthma Exacerbations.

Rationale: Noninvasive ventilation decreases the need for invasive mechanical ventilation and mortality among patients with chronic obstructive pulmonary disease but has not been well studied in asthma.Objectives: To assess the association between noninvasive ventilation and subsequent need for invasive mechanical ventilation and in-hospital mortality among patients admitted with asthma exacerbation to the ICU.Methods: We performed a retrospective cohort study using administrative data collected during 2010-2017 from 682 hospitals in the United States. Outcomes included receipt of invasive mechanical ventilation and in-hospital mortality. Generalized estimating equations, propensity-matched models, and marginal structural models were used to assess the association between noninvasive ventilation and outcomes.Measurements and Main Results: The study population included 53,654 participants with asthma exacerbation. During the study period, 13,540 patients received noninvasive ventilation (25.2%; 95% confidence interval [CI], 24.9-25.6%), 14,498 underwent invasive mechanical ventilation (27.0%; 95% CI, 26.7-27.4%), and 1,291 died (2.4%; 95% CI, 2.3-2.5%). Among those receiving noninvasive ventilation, 3,013 patients (22.3%; 95% CI, 21.6-23.0%) required invasive mechanical ventilation after first receiving noninvasive ventilation, 136 of whom died (4.5%; 95% CI, 3.8-5.3%). Across all models, the use of noninvasive ventilation was associated with a lower odds of receiving invasive mechanical ventilation (adjusted generalized estimating equation odds ratio, 0.36; 95% CI, 0.32-0.40) and in-hospital mortality (odds ratio, 0.48; 95% CI 0.40-0.58). Those who received noninvasive ventilation before invasive mechanical ventilation were more likely to have comorbid pneumonia and severe sepsis.Conclusions: Noninvasive ventilation use during asthma exacerbation was associated with improved outcomes but should be used cautiously with acute comorbid conditions.

Clinical Phenotypes of Atopy and Asthma in COPD: A Meta-analysis of SPIROMICS and COPDGene.

BACKGROUND: Little is known about the concordance of atopy with asthma COPD overlap. Among individuals with COPD, a better understanding of the phenotypes characterized by asthma overlap and atopy is needed to better target therapies. RESEARCH QUESTION: What is the overlap between atopy and asthma status among individuals with COPD, and how are categories defined by the presence of atopy and asthma status associated with clinical and radiologic phenotypes and outcomes in the Genetic Epidemiology of COPD Study (COPDGene) and Subpopulation and Intermediate Outcome Measures in COPD Study (SPIROMICS)? STUDY DESIGN AND METHODS: Four hundred three individuals with COPD from SPIROMICS and 696 individuals from COPDGene with data about specific IgEs to 10 common allergens and mixes (simultaneous assessment of combination of allergens in similar category) were included. Comparison groups were defined by atopic and asthma status (neither, atopy alone, atopic asthma, nonatopic asthma, with atopy defined as any positive specific IgE (≥0.35 KU/L) to any of the 10 allergens or mixes and asthma defined as self-report of doctor-diagnosed current asthma). Multivariable regression analyses (linear, logistic, and zero inflated negative binomial where appropriate) adjusted for age, sex, race, lung function, smoking status, pack-years smoked, and use of inhaled corticosteroids were used to determine characteristics of groups and relationship with outcomes (exacerbations, clinical outcomes, CT metrics) separately in COPDGene and SPIROMICS, and then adjusted results were combined using meta-analysis. RESULTS: The prevalence of atopy was 35% and 36% in COPD subjects from SPIROMICS and COPDGene, respectively, and less than 50% overlap was seen between atopic status with asthma in both cohorts. In meta-analysis, individuals with nonatopic asthma had the most impaired symptom scores (effect size for St. George's Respiratory Questionnaire total score, 4.2; 95% CI, 0.4-7.9; effect size for COPD Assessment Test score, 2.8; 95% CI, 0.089-5.4), highest risk for exacerbations (incidence rate ratio, 1.41; 95% CI, 1.05-1.88) compared with the group without atopy or asthma. Those with atopy and atopic asthma were not at increased risk for adverse outcomes. INTERPRETATION: Asthma and atopy had incomplete overlap among former and current smokers with COPD in COPDGene and SPIROMICS. Nonatopic asthma was associated with adverse outcomes and exacerbation risk in COPD, whereas groups having atopy alone and atopic asthma had less risk.

Procalcitonin Levels in Critically Ill Children With Status Asthmaticus.

BACKGROUND: Children with status asthmaticus (SA) often present with fever and are evaluated with chest radiographs (CXRs). In the absence of a confirmatory test for bacterial infection, antibiotics are started whenever there are radiological infiltrates or if there is a suspicion of pneumonia. We undertook this study to determine if serum procalcitonin (PCT) levels at admission are altered in critically ill children with SA. We also sought to determine if serum PCT levels are elevated in children with radiological infiltrates or in children who were treated with antibiotics. METHODS: This is a prospective single-center observational study evaluating serum PCT levels in critically ill children with SA. Study subjects included children 1 to 21 years old, admitted to a pediatric intensive care unit (PICU) with SA between March 2012 and April 2013. For the purposes of this study, patients whose CXRs were read by the radiologist as probable bacterial pneumonia was defined as having "radiological bacterial pneumonia," whereas patients who received antibiotics by the treating physician were defined as having "clinician-diagnosed pneumonia." RESULTS: Sixty-one patients with a median age of 7.3 years (interquartile range, 4-10 years) were included in the study. Fifty-one percent were male. Average Pediatric Risk of Mortality III score was 2.7 (SD, 2.9). Three patients (5%) were determined to have radiological bacterial pneumonia, whereas 52 (85%) did not. Six patients (10%) were indeterminate. The mean PCT level for all patients was 0.65 (SD, 1.54) ng/mL, whereas the median PCT level was 0.3 ng/mL. There was no significant difference in the mean PCT levels between the patients with and without clinician-diagnosed pneumonia (0.33 [SD, 0.36] vs 0.69 [SD, 1.67], P = 0.44). Using a PCT cutoff level of 0.5 ng/mL, a significant association was found with the presence of fever (P = 0.004), but no significant association was found with the presence of CXR infiltrates, radiological bacterial pneumonia, hospital length of stay, PICU length of stay, Pediatric Risk of Mortality III scores, or receipt of antibiotics. CONCLUSIONS: Serum PCT level was not elevated to greater than 0.5 ng/mL in 75% of this cohort of critically ill children with SA admitted to PICU. Presence of CXR infiltrates was not associated with higher PCT levels. Large clinical trials are needed to study the diagnostic and predictive role of PCT in this patient population.

Predictors of Hospital Reuse Among Publicly Insured Children Hospitalized for Status Asthmaticus.

BACKGROUND: Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma. METHODS: This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ2 tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse. RESULTS: Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis (P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01). CONCLUSIONS: For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse.

Characteristics and outcomes of treatment in status asthmaticus patients at emergency department.

INTRODUCTION: The characteristics and treatment outcomes of status asthmaticus patients in emergency department (ED) have not been described previously especially in Thailand. OBJECTIVE: To describe the characteristics, treatment outcomes and factors associated with status asthmaticus in Thai patients presenting to a single center ED. METHODS: A prospective observational study was performed at Thammasat University hospital, Thailand. The data collected included demographics, asthma history and control, previous ED attendances and hospital admissions, presenting clinical, laboratory and radiographic features, treatments given, and outcomes. Multivariable regression was used to determine independent factors associated with status asthmaticus. RESULTS: Over one year (2015-16), 209 patients were recruited, aged 6 - 54 years (median 33 y), of whom 145 (69.3%) had status asthmaticus. The factors associated with status asthmaticus were: (i) age > 60 y, (ii) presence of a comorbidity, (iii) having uncontrolled asthma, (iv) hospitalizations or visits to the ED in the last year, and (v) using > 1 metered dose inhaler canister per month. Status asthmaticus patients were significantly less likely to speak in sentences (p=0.001) and more likely to have poor air entry and chest wall retraction (p<0.0001), an abnormal chest X ray (p=0.011), receive magnesium sulphate and be admitted into hospital (p<0.0001). No patients died. CONCLUSIONS: Status asthmaticus was common in this cohort of patients in our setting. Our findings are consistent with previous studies and underscore the need for better patient management.

Non-invasive ventilation use in status asthmaticus: 16 years of experience in a tertiary intensive care.

OBJECTIVE: To describe the use of non-invasive ventilation (NIV) in adults presenting with status asthmaticus to Middlemore Hospital Critical Care Complex (CCC, South Auckland, New Zealand) from 2000 to 2015. METHOD: Retrospective review of all adult asthma admissions to the Hospital CCC between 2000 and 2015. Demographic, physiological, treatment data and blood gas results were recorded. RESULTS: There were 265 asthma admissions to Middlemore Hospital CCC during the study period. The median age was 34 years; 64% were female. NIV was used in 186 admissions, of which eight went on to require intubation and invasive mechanical ventilation (IMV). Twenty-three other admissions received IMV without a trial of NIV and a further 58 were managed with medical care only. The average pH for all admissions was 7.23 and the IMV group had an average pH of 6.99. Forty-five admissions presented with a Glasgow Coma Scale (GCS) score of ≤10. Twenty-five of these were managed with NIV with only one requiring subsequent intubation. The mean duration of NIV in this group was 5 h (range 1-17 h) with a mean ICU and hospital length of stay of 17 h and 3.5 days, respectively. All patients in this group effectively lowered the pCO2 over a 2 h period with NIV having an average drop of 5.9 kPa and IMV 3.4 kPa. CONCLUSION: The use of NIV appears to be safe and effective in patients with severe asthma, including selected patients with an altered level of consciousness. NIV was well tolerated with a low need for subsequent intubation.

Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients.

Objectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO2) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17-21) vs 49.5 (20-73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4-12) vs 7 (3-15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Asthma exacerbations among asthmatic children receiving live attenuated versus inactivated influenza vaccines.

OBJECTIVE: To investigate whether there is a difference in the risk of asthma exacerbations between children with pre-existing asthma who receive live attenuated influenza vaccine (LAIV) compared with inactivated influenza vaccine (IIV). MATERIAL AND METHODS: We identified IIV and LAIV immunizations occurring between July 1, 2007 and March 31, 2014 among Kaiser Permanente Northern California members aged 2 to <18years with a history of asthma, and subsequent asthma exacerbations seen in the inpatient or Emergency Department (ED) setting. We calculated the ratio of the odds (OR) of an exacerbation being in the risk interval (1-14days) versus the comparison interval (29-42days) following immunization, separately for LAIV and IIV, and then examined whether the OR differed between children receiving LAIV and those receiving IIV ("difference-in-differences"). RESULTS: Among 387,633 immunizations, 85% were IIV and 15% were LAIV. Children getting LAIV vs. IIV were less likely to have "current or recent, persistent" asthma (25% vs. 47%), and more likely to have "remote history" of asthma (47% vs. 25%). Among IIV-vaccinated asthmatic children, the OR of an inpatient/ED asthma exacerbation was 0.97 (95% CI: 0.82-1.15). Among LAIV-vaccinated asthmatic children the OR was 0.38 (95% CI: 0.17-0.90). In the difference-in-differences analysis, the odds of asthma exacerbation following LAIV were less than IIV (Ratio of ORs: 0.40, CI: 0.17-0.95, p value: 0.04). CONCLUSION: Among children ≥2years old with asthma, we found no increased risk of asthma exacerbation following LAIV or IIV, and a decreased risk following LAIV compared to IIV.

Severe maternal morbidity and comorbid risk in hospitals performing <1000 deliveries per year.

BACKGROUND: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide. OBJECTIVE: We sought to characterize maternal risk profiles and severe maternal morbidity at low-volume hospitals in the United States. STUDY DESIGN: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness. RESULTS: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low-volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35-0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period. CONCLUSION: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume.

Hospital delivery volume, severe obstetrical morbidity, and failure to rescue.

BACKGROUND: In the setting of persistently high risk for maternal death and severe obstetric morbidity, little is known about the relationship between hospital delivery volume and maternal outcomes. OBJECTIVE: The objectives of this analysis were (1) to determine maternal risk for severe morbidity during delivery hospitalizations by hospital delivery volume in the United States and (2) to characterize, by hospital volume, the risk for death in the setting of severe obstetric morbidity, a concept known as failure to rescue. STUDY DESIGN: This cohort study evaluated 50,433,539 delivery hospitalizations across the United States from 1998-2010. The main outcome measures were (1) severe morbidity that was defined as a composite of any 1 of 15 diagnoses that are representative of acute organ injury and critical illness and (2) failure to rescue that was defined as death in the setting of severe morbidity. RESULTS: The prevalence of severe morbidity rose from 471.2-751.5 cases per 100,000 deliveries from 1998-2010, which was an increase of 59.5%. Failure to rescue was highest in 1998 (1.5%), decreased to 0.6% in 2007, and rose to 0.9% in 2010. In models that were adjusted for comorbid risk and hospital factors, both low and high annualized delivery volume were associated with increased risk for failure to rescue and severe morbidity. However, the relative importance of hospital volume for both outcomes compared with other factors was relatively small. CONCLUSION: Although low-and high-delivery volume are associated with increased risk for both failure to rescue and severe maternal morbidity, other factors, in particular characteristics of individual centers, may be more important in the determination of outcomes.

Impact of Obesity on Clinical Outcomes in Urban Children Hospitalized for Status Asthmaticus.

BACKGROUND AND OBJECTIVE: The prevalence of both childhood asthma and obesity remain at historically high levels and disproportionately affect urban children. Asthma is a common and costly cause for pediatric hospitalization. Our objective was to determine the effect of obesity on outcomes among urban children hospitalized with status asthmaticus. METHODS: A retrospective cohort study was performed by using billing system data and chart review to evaluate urban children admitted for asthma. Demographics, asthma severity, reported comorbidities, and outcomes were assessed. Obesity was defined by BMI percentile (lean<85%, overweight 85%-95%, obese≥95%). Outcomes were length of stay, hospitalization charges, ICU stay, repeat admissions, and subsequent emergency department (ED) visits. Bivariate analysis assessed for differences between overweight/obese and lean children. Multivariable regression assessed the relationship between overweight status and primary outcomes while controlling for other variables. Post hoc age-stratified analysis was also performed. RESULTS: The study included 333 subjects; 38% were overweight/obese. Overweight/obese children admitted with asthma were more likely than lean children to have subsequent ED visits (odds ratio 1.6, 95% confidence interval 1.0-2.6). When stratified by age, overweight/obese preschool-age children (<5 years) were >2 times as likely to have repeat ED visits than lean preschool-age children (odds ratio 2.3, 95% confidence interval 1.0-5.6). There were no differences in the other outcomes between overweight/obese and lean individuals within the entire cohort or within other age groups.

[Retrospective analysis of omalizumab in patients with severe allergic asthma]. / Estudio observacional retrospectivo de la utilización de omalizumab en el tratamiento del asma grave persistente.

OBJECTIVE: To assess the efficacy and safety profile of omalizumab treatment. The conditions under which omalizumab was prescribed agreed with those in Xolair® drug information: age > 12 years old, severe uncontrolled asthma, FEV1 < 80%, IgE 30-700 UI/ml and positive test results for perennial allergens. METHODS: Asthmatic patients treated with omalizumab between January 2010 and July 2011 were evaluated retrospectively. Age, sex, weight, IgE level, concomitant asthma medications, change in FEV1, emergency department visits, hospitalizations, asthma exacerbations and corticosteroids bursts were recorded before and after omalizumab initiation. A 1.5- year period was chosen. RESULTS: A total of 22 patients were included. The mean weight of subjects was 73 Kg (range, 51-102). Mean IgE was 203 UI/ml (range, 30-992) and mean FEV1 60% (range, 30-93%) at baseline. Adverse events were observed in 4 patients. There were no significant changes in FEV1 values after omalizumab treatment but omalizumab was associated with a reduction in concomitant asthma medications use in 14 patients and improvements in global asthma control in 12. CONCLUSION: In these patients add-on therapy with omalizumab reduced asthma exacerbations and emergency visits or hospitalizations. Only 55% of patients significantly improved global asthma control and no significant changes in FEV1 were observed.

Objetivo: Evaluar la eficacia y seguridad del omalizumab. Las condiciones para la administración de dicho fármaco fueron las indicadas en ficha técnica: edad superior a 12 años, asma alérgica grave persistente, mal control de síntomas, FEV1<80%, IgE total entre 30 y 700 UI/mL y pruebas cutáneas y/o IgE específica positiva al alérgeno persistente. Método: Estudio retrospectivo observacional de pacientes que hubieran sido tratados con omalizumab en la indicación de asma grave durante el período enero 2010 a julio de 2011. Se registraron la edad, sexo, peso, IgE y reactividad in vitro a los alergenos perennes, FEV1, tratamiento de base, exacerbaciones asmáticas y necesidad de corticosteroides sistémicos o ingresos en urgencias, presencia de síntomas durante el día o que originen despertares durante la noche al inicio del tratamiento, a las 16 semanas, 32 semanas y a los 1,5 años tras al inicio del tratamiento. Se recogieron los efectos secundarios y los cambios en el tratamiento de base. Resultados: 22 pacientes con un peso medio de 73 kg (51-102). La concentración basal de IgE antes del inicio de omalizumab fue de 203 UI/ml (30-992). 21 pacientes presentaban una función pulmonar reducida, con un FEV1 al inicio del 60% (30-93%). El FEV1 a las 16 semanas fue del 60% (39-71%) y a las 32 semanas del 68% (29-102%). La dosis media de omalizumab administrada cada 30 días fue de 368 mg (150- 900 mg). Se observaron reacciones adversas en 4 pacientes, uno de los cuales requirió la retirada del tratamiento. Al final del periodo de seguimiento 14 pacientes habían disminuido el tratamiento control y doce presentaron mejoría global. Conclusión: Omalizumab se ha utilizado en pacientes con asma grave alérgica no respondedores a terapia convencional observándose una disminución en el número de exacerbaciones y visitas a urgencias e ingresos. Sólo un 55% experimentan una mejoría global según criterios clínicos y no se observaron cambios estadísticamente significativos en la FEV1.

Quality in triage: indicators in patients with respiratory disease.

OBJECTIVES: The objective was to apply quality indicators in respiratory disease triage during a set time period. METHODS: This was a retrospective, descriptive, and comparative study of all patients attending the emergency department of Acosta Ñu Children's Hospital with breathing difficulty, between January 1 and July 31, 2011. RESULTS: Two thousand five hundred eighty-two patients were included in the study. The delay in medical care according to severity of breathing difficulty was as follows: for critical patients, 1 minute (100% compliance); for emergencies, 6.4 minutes (93.4% compared with 95% standard); for urgencies, 15.8 minutes (90% compared with the standard 90%); and for semiurgencies, 35 minutes (92.4% vs. 85% standard). Regarding to the admission-triage time indicator: mean time was 6.1 minutes; 2220 patients (86%) were classified in less than 10 minutes from the time of hospital admission, and 2453 (95%) were evaluated before 15 minutes. Respiratory rate was recorded in 2368 patients (91.7%), and pulse oximetry in 2443 (94.6%). Both parameters were recorded in 2271 children (88%). Errors in classification were detected, mainly tendency to underestimate the risk or exacerbate the clinical situation; 441 patients underwent subtriage (20.5%), and 44 overtriage (1.7%). There were drawbacks to classify emergencies error rate 45.8% (P < 0.00001). Relationship between pathophysiologic diagnosis and triage level was significant (P < 0.00001). CONCLUSIONS: Indicators of triage quality were acceptably met in respiratory disease. Breathing difficulty was identified and classified as urgent, although problems arouse at differentiation between moderate and severe dyspnea.

Status asthmaticus in the medical intensive care unit: a 30-year experience.

OBJECTIVES: To investigate the characteristics, trends in management (permissive hypercapnia; mechanical ventilation (MV); neuromuscular blockade) and their impact on complications and outcomes in Status Asthmaticus (SA). METHODS: We performed a retrospective observational study of subjects admitted with SA to a single multidisciplinary MICU over a 30-year period. All laboratory, radiologic, respiratory care, physician notes and orders were extracted from an electronic medical record (EMR) maintained during the entire duration of the study. RESULTS: Two hundred and twenty-seven subjects were admitted with 280 episodes of SA. While subjects reflected our regional population (52% Hispanic), African Americans were over-represented (22%) and Caucasians under-represented (21%). Thirty-eight percent reported childhood asthma, 27% were steroid dependent (10% in the last 10 years), and 18% had a recent steroid taper. One hundred and thirty-nine (61.2%) required intubation. The duration of hospitalization was similar between mechanically ventilated and non-ventilated subjects (5.8±4.41 vs. 6.8±7.22 days; p=0.07). The overall complication rate remained low irrespective of the use of permissive hypercapnia or mode of mechanical ventilation (overall mortality 0.4%; pneumothorax 2.5%; pneumonia 2.9%). The frequency of SA declined significantly in the last 10 years of the study (12.4 vs. 3.2 cases/year). CONCLUSIONS: Despite the frequent use of mechanical ventilation, mortality/complication rates remained extremely low. MV did not significantly increase the duration of hospitalization. At our institution, the frequency of SA significantly decreased despite an increase in emergency room visits for asthma.

Impact of environmental tobacco smoke on children admitted with status asthmaticus in the pediatric intensive care unit.

INTRODUCTION: Environmental tobacco smoke (ETS) and allergens are risk factors in children with critical status asthmaticus. Genetic studies support that ETS-associated asthma is a special inflammatory entity, causing significant number of hospital admissions and relapses. Accordingly, the course and outcome of patients with ETS-induced status asthmaticus might also be different. HYPOTHESIS: We hypothesized that the progression, course, and outcome of patients with ETS-induced status asthmaticus would be worse than those of patients without ETS exposure. METHODS: Medical records of children who were admitted to the Pediatric Intensive Care Unit (PICU) with the diagnosis of asthma at the Children's Hospital of Winnipeg, Manitoba, over 10 years were audited after Institutional Review Board (IRB) approval. Two hundred thirty records were reviewed. We extracted data including demographics and analyzed the patient's deterioration defined as clinical asthma score (CAS) drift between the ED and PICU. We computed the treatment response, expressed as length of stay (LOS) in the PICU and in hospital. The risk factors were stratified as none, ETS exposure, allergies, and ETS with allergies. RESULTS: There were 55 (25%) patients with no risk factors, 66 (30%) with ETS exposure only, 46 (21%) with allergies only, and 53 (24%) with both. There was a 25% decrease in CAS deterioration when patients were exposed to ETS (P < 0.05). For patients with or without allergies but with exposure to ETS, both the PICU and overall hospital LOS were ∼15% longer (P < 0.05) than for those not exposed to ETS. Stratifying for gender and race in multivariate analysis did not alter the results. CONCLUSIONS: Patients with ETS-associated critical status asthmaticus deteriorate and recover slower than non-ETS-exposed patients.

Referral to the emergency department by a primary care provider predicts severity of illness.

OBJECTIVE: The purpose of this study was to assess whether referral to a pediatric emergency department (PED) by a primary care provider was associated with greater severity of illness, as determined on the basis of clinical measures and increased resource utilization. METHODS: A retrospective study of data for 121 088 children who presented to a PED with abdominal pain, fever, or respiratory complaints during a 5-year period was performed. Demographic data, referral status, and proxy markers of illness severity were collected from the medical records and analyzed. RESULTS: A total of 26.3% of all patients seen in the PED presented with these 3 complaint categories. With adjustment for age, gender, race, and insurance class, referred patients were significantly more likely to have high triage acuity designations, higher rates of very abnormal vital signs, and higher admission rates, compared with patients who were self-referred. Referred patients were more likely to undergo testing (laboratory or radiologic), to receive intravenous fluid therapy and pain medications, and to be assigned higher-severity discharge diagnoses, such as appendicitis, septic shock, or status asthmaticus. CONCLUSIONS: Referral by a primary care provider to a PED was significantly and independently associated with greater severity of illness and resource utilization. Referral status should be considered in algorithms used to triage cases for evaluation in the PED.