Psychological distress predicts quality of life in the first months of cancer diagnosis in cancer caregivers.

In cancer caregivers, anxiety and depression may negatively impact quality of life. Information regarding correlations and the predictive capacity of anxiety and depression with regard to the domains of quality of life of caregivers 6 months after a patient's cancer diagnosis is sparse. Sixty-seven caregivers of cancer patients were recruited and completed the Hospital Anxiety and Depression Scale (HADS) and the Short-Form Health Survey (SF-36) 30-45 days (T1) and 180-200 days (T2) after diagnosis. Depression and anxiety (T1) correlated with quality of life in terms of general health, vitality, social functioning, as well as role limitations due to emotional problems, and mental health (T2). Depression scores at T1 predicted general health, vitality, social functioning, role limitations due to emotional problems and mental health. Although these results are interesting, it must be noted that the sample size was somewhat limited and that the patients' cancer types may have influenced the results obtained. Psychological distress, particularly depression, correlated with and acted as a predictor for changes in the different domains of quality of life, highlighting the relevance of the evaluation of psychological distress in cancer caregivers shortly after cancer diagnosis. These results underscore the importance of differentiating between the different domains in the evaluation of impairments of quality of life in cancer caregivers.

A novel fast-vegetative propagation technique of the pioneer shrub Baccharis linearis on mine tailings by adding compost.

Interest in Baccharis linearis has increased as an alternative for assisted phytostabilization due to its spontaneous colonization of tailings dumps. The search for a novel fast-vegetative propagation technique to accelerate its coverage on mine tailings is a promising research area for sustainable mine closure plans. In this study, we determined the optimal proportion of compost and tailings as growing media to promote fast B. linearis propagation through a compound layering technique. The assessed growing substrates were: 100% tailings, 70% tailings + 30% compost, and 50% tailings + 50% compost. After 84 days of growth, the change in number and height of layering branches, root and shoot dry mass, percentage of ground coverage, and substrate chemical properties were assessed. The main results showed that compound layering of B. linearis is possible with compost addition. The growth of new roots and layering branches was significantly improved by either 30% or 50% compost addition into tailings, due to chemical improvements of substrate (higher nutrients and pH and decreased copper bioavailability). The study confirms that the compound layering of B. linearis may be an effective and novel technique for speeding the reclamation of post-operative mine tailings, which is improved by the incorporation of compost.

Acute Appendicitis in Children During the COVID-19 Pandemic: Neither Delayed Diagnosis Nor Worse Outcomes.

AIM: The aim of this study was to describe the incidence of complicated appendicitis during the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic lockdown. METHODS: This was a retrospective study of pediatric patients diagnosed with acute appendicitis in a single pediatric institution that assumed care responsibility for most of the pediatric emergencies during the lockdown period in Madrid (Spain). A control group was made up of the same number of patients diagnosed the previous year. RESULTS: One hundred fifty-one patients diagnosed with acute appendicitis were included (77 during self-quarantine and 74 during the previous year). The incidence of complicated appendicitis was 38.9% versus 28.3%, showing no significant differences. The 2 groups were homogeneous, with no differences in time elapsed between symptom onset and first emergency department visit, laboratory test results, median length of stay, intensive care admissions, or patients correctly diagnosed on their first visit. CONCLUSIONS: COVID-19 (coronavirus disease 2019) self-quarantine has not increased the incidence of complicated appendicitis, and children who developed complicated appendicitis did not have worse clinical outcomes. Parents did not delay presenting for medical attention, and emergency department pediatricians did not fail to diagnose this condition. Reorganization of hospital resources, fast-track treatment protocols for noncomplicated appendicitis, and extended use of home-stay hospitalization for complicated appendicitis could have contributed to these favorable outcomes.

Gastric plexiform fibromyxoma, an uncommon mesenchymal tumor.

Plexiform fibromyxoma (PF) is an uncommon primary tumor of the gastrointestinal tract, with a mesenchymal origin and a benign behavior. Herein, we report a case and provide a literature review. A 41-year-old male patient underwent surgery in our unit for a PF at the gastric antrum, after being admitted due to vomiting and weight loss. As illustrated by our case, the mean age at presentation is around 40 years, the antrum is the most common location and abdominal pain the most widely reported manifestation. None of the reviewed cases involved regional or distant spread.

Social support as predictor of anxiety and depression in cancer caregivers six months after cancer diagnosis: A longitudinal study.

AIMS AND OBJECTIVES: To establish the predictive utility of specific social support domains for emotional well-being in cancer caregivers, six months after their partner's cancer diagnosis. BACKGROUND: In cancer caregivers, social support has been consistently related to anxiety and depression. There is little information, however, about the predictive utility of specific social support domains for psychological well-being in the first six months after a partner's cancer diagnosis. DESIGN: Longitudinal research study. METHODS: Sixty-seven caregivers of recently diagnosed cancer patients were recruited from the Reina Sofia University Hospital in Cordoba (Spain). Participants completed a set of questionnaires including the Berlin Social Support Scale (BSSS), the Hospital Anxiety and Depression Scale (HADS) and a socio-demographic questionnaire. Data were collected at two time points: T1 (30-45 days after diagnosis) and T2 (180-200 days after). TRIPOD checklist was used. RESULTS: Most of the caregivers were female (65%) and the partner of the patient (58%), with an average age of 51.63 years (SD = 13.25). Statistical differences were observed between the two assessment points for the social support domains of perceived emotional support, satisfaction with support and protective buffering. Logistic regression analysis showed that less physical and sports activity, more support seeking and less informational support received at T1 predicted anxiety at T2, while less perceived available support predicted depression. CONCLUSIONS: Accurate information and support from other members of the community and the promotion of physical and sports routines for cancer caregivers may help to alleviate symptoms of anxiety and depression in the first months after a partner's cancer diagnosis. RELEVANCE TO CLINICAL PRACTICE: Clinicians must pay attention to the social support needs and physical activity of caregivers in the first days after diagnosis, in order to prevent anxiety and depression.

Interaction between cardiovascular risk factors and body mass index and 10-year incidence of cardiovascular disease, cancer death, and overall mortality.

The effect of above-normal body mass index (BMI) on health outcomes is controversial because it is difficult to distinguish from the effect due to BMI-associated cardiovascular risk factors. The objective was to analyze the impact on 10-year incidence of cardiovascular disease, cancer deaths and overall mortality of the interaction between cardiovascular risk factors and BMI. We conducted a pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79years old at basal examination. Body mass index was measured at baseline being the outcome measures ten-year cardiovascular disease, cancer and overall mortality. Multivariable analyses were adjusted for potential confounders, considering the significant interactions with cardiovascular risk factors. We included 54,446 individuals (46.5% with overweight and 27.8% with obesity). After considering the significant interactions, the 10-year risk of cardiovascular disease was significantly increased in women with overweight and obesity [Hazard Ratio=2.34 (95% confidence interval: 1.19-4.61) and 5.65 (1.54-20.73), respectively]. Overweight and obesity significantly increased the risk of cancer death in women [3.98 (1.53-10.37) and 11.61 (1.93-69.72)]. Finally, obese men had an increased risk of cancer death and overall mortality [1.62 (1.03-2.54) and 1.34 (1.01-1.76), respectively]. In conclusion, overweight and obesity significantly increased the risk of cancer death and of fatal and non-fatal cardiovascular disease in women; whereas obese men had a significantly higher risk of death for all causes and for cancer. Cardiovascular risk factors may act as effect modifiers in these associations.

Religiousness and spirituality in patients with bipolar disorder.

BACKGROUND: Religiousness and spirituality (R/S) are often neglected features among psychiatric patients but important both for quality of life and coping strategies for mental disorders. In patients affected by bipolar disorder (BD), R/S can sometimes be confused with symptoms related to the psychiatric disorder. This study aimed to perform a clinical review of the relationship between R/S and BD. METHODS: Data sources included Medline (OvidSP), CINAHL (Ebsco), EMBASE (Ovid), PsychINFO (Ebsco), Angeline, Cochrane Database of Systematic Reviews and Database of Abstract of Reviews of Effects, searching for pertinent Keywords: 'religiousness', 'spirituality' and 'bipolar disorder'. RESULTS: Nine works were found but only five used homogeneous samples with BD patients. R/S were important when facing symptoms and relapses in the lifeworld. These beliefs influenced the relationship with psychiatrists and spiritual figures of reference. CONCLUSIONS: R/S play a role as a psychosocial variable in the course of BD. However, the hypothesis that the R/S factor can be relevant both in terms of providing a protective effect as well as a provocative element in depressive or hypomanic phases was not fully supported at the moment.

Adiposity, mediating biomarkers and risk of colon cancer in the European prospective investigation into cancer and nutrition study.

Adiposity is a risk factor for colon cancer, but underlying mechanisms are not well understood. We evaluated the extent to which 11 biomarkers with inflammatory and metabolic actions mediate the association of adiposity measures, waist circumference (WC) and body mass index (BMI), with colon cancer in men and women. We analyzed data from a prospective nested case-control study among 662 incident colon cancer cases matched within risk sets to 662 controls. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression. The percent effect change and corresponding CIs were estimated after adjusting for biomarkers shown to be associated with colon cancer risk. After multivariable adjustment, WC was associated with colon cancer risk in men (top vs. bottom tertile RR 1.68, 95% CI 1.06-2.65; ptrend = 0.02) and in women (RR 1.67, 95% CI 1.09-2.56; ptrend = 0.03). BMI was associated with risk only in men. The association of WC with colon cancer was accounted mostly for by three biomarkers, high-density lipoprotein cholesterol, non-high-molecular-weight adiponectin and soluble leptin receptor, which in combination explained 46% (95% CI 37-57%) of the association in men and 50% (95% CI 40-65%) of the association in women. Similar results were observed for the associations with BMI in men. These data suggest that alterations in levels of these metabolic biomarkers may represent a primary mechanism of action in the relation of adiposity with colon cancer. Further studies are warranted to determine whether altering their concentrations may reduce colon cancer risk.

Derivation and validation of a set of 10-year cardiovascular risk predictive functions in Spain: the FRESCO Study.

OBJECTIVE: To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. METHOD: Pooled analysis of 11 population-based Spanish cohorts (1992-2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. RESULTS: The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. CONCLUSIONS: The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Development of a Vaping Cessation Text Messaging Intervention for Latino Young Adults: A Participatory Research Approach.

OBJECTIVE: Describe the participatory research procedures of developing Kick Vaping, a vaping cessation text messaging intervention for Latino young adults, available in English and Spanish. METHODS: Using community-based recruitment strategies, we convened a Community Advisory Board (CAB) of eight Latino young adults (ages 18-25) with different vaping experiences (never users, ex-users, and current users of e-cigarettes). Members held a series of working meetings to adapt Decídetexto, a smoking cessation text messaging intervention, for vaping cessation. Members provided iterative feedback on the text messages until reaching a consensus on content. Messages were translated from English to Spanish following a committee approach. Readability assessments were used to evaluate the legibility of the text messages. RESULTS: At baseline, members' mean age was 22.6 years old (SD 3.1), 75% were female, and 50% used both English and Spanish equally. Three members (37.5%) were ex-users and one member (12.5%) was a current user of e-cigarettes. 18 meetings provided sufficient opportunities for iterative feedback on the text messages for developing the intervention. The Kick Vaping intervention consists of 208 text messages. Readability scores of the text messages in English were equivalent to fourth and fifth grade, and in Spanish were equivalent to easy and somewhat easy. CONCLUSION: It is feasible and practical to build participatory research among Latino young adults focused on vaping cessation. Members of the CAB added innovation and creativity to the development of the vaping cessation text messaging intervention. Future research is needed to evaluate the impact of the intervention on vaping cessation.

Limited predatory effects on infaunal macrobenthos community patterns in intertidal soft-bottom of Arctic coasts.

Predation shapes marine benthic communities and affects prey species population dynamics in tropic and temperate coastal systems. However, information on its magnitude in systematically understudied Arctic coastal habitats is scarce. To test predation effects on the diversity and structure of Arctic benthic communities, we conducted caging experiments in which consumers were excluded from plots at two intertidal sedimentary sites in Svalbard (Longyearbyen and Thiisbukta) for 2.5 months. Unmanipulated areas served as controls and partial (open) cages were used to estimate potential cage effects. At the end of the experiment, we took one sediment core from each plot and quantified total biomass and the number of each encountered taxon. At both sites, the experimental exclusion of predators slightly changed the species composition of communities and had negligible effects on biomass, total abundance, species richness, evenness, and Shannon Index. In addition, we found evidence for cage effects, and spatial variability in the intensity of the predation effects was identified. Our study suggests that predators have limited effects on the structure of the studied intertidal macrobenthic Arctic communities, which is different from coastal soft-bottom ecosystems at lower latitudes.

A risk assessment on Zostera chilensis, the last relict of marine angiosperms in the South-East Pacific Ocean, due to the development of the desalination industry in Chile.

Seagrasses, which are considered among the most ecologically valuable and endangered coastal ecosystems, have a narrowly limited distribution in the south-east Pacific, where Zostera chilensis is the only remaining relict. Due to water scarcity, desalination industry has grown in the last decades in the central-north coasts of Chile, which may be relevant to address in terms of potential impacts on benthic communities due to their associated high-salinity brine discharges to subtidal ecosystems. In this work, we assessed ecophysiological and cellular responses to desalination-extrapolable hypersalinity conditions on Z. chilensis. Mesocosms experiments were performed for 10 days, where plants were exposed to 3 different salinity treatments: 34 psu (control), 37 psu and 40 psu. Photosynthetic performance, H2O2 accumulation, and ascorbate content (reduced and oxidized) were measured, as well as relative gene expression of enzymes related to osmotic regulation and oxidative stress; these, at 1, 3, 6 and 10 days. Z. chilensis showed a decrease in photosynthetic parameters such as electron transport rate (ETRmax) and saturation irradiance (EkETR) under hypersalinity treatments, while non-photochemical quenching (NPQmax) presented an initial increment and a subsequent decline at 40 psu. H2O2 levels increased with hypersalinity, while ascorbate and dehydroascorbate only increased under 37 psu, although decreased along the experimental period. Increased salinities also triggered the expression of genes related to ion transport and osmolyte syntheses, but salinity-dependent up-regulated genes were mostly those related to the reactive oxygen species metabolism. The relict seagrass Z. chilensis has shown to withstand increased salinities that may be extrapolable to desalination effects in the short-term. As the latter is not fully clear in the long-term, and considering the restricted distribution and ecological importance, direct brine discharges to Z. chilensis meadows may not be recommended.

Laser Therapy for Vulvar Lichen Sclerosus, a Systematic Review.

Lichen sclerosus (LS) is a chronic inflammatory disease that mainly affects the anogenital area, with a higher incidence in post-menopausal women. In the long term, it can lead to loss of vulvar architecture or progress to squamous cell carcinoma. The evidence-based treatment involves high-potency topical corticosteroids in long regimens. However, second-line treatments are not well-established, including laser therapy. This current study aims to assess the level of evidence supporting this therapy. We conducted a search for primary-level studies published before April 2023 through MEDLINE/PubMed, Embase, Web of Science, Scopus, and CENTRAL, with no restrictions on the publication language or date. The methodological quality and risk of bias of the included studies were evaluated using the updated Cochrane Collaboration's tool for assessing risk of bias (RoB-2). Six studies (177 patients) met our eligibility criteria. Laser therapy was compared to topical corticosteroid treatment in five out of six studies. No significant histological differences were found, except for an increase in collagen production in the laser group. A greater reduction in itching, pain, and dyspareunia at 1 and 3 months of treatment in the laser group, as well as in the Skindex-29 at 6 months, was reported. Patient satisfaction was significantly higher among those who received laser therapy. Tolerability was excellent. No significant differences were observed in any of the previous aspects in the study compared to the placebo. In conclusion, there is not enough evidence to recommend laser therapy as a standalone treatment.

Susceptibility Evaluation to Fire Blight and Genome-Wide Associations within a Collection of Asturian Apple Accessions.

Fire blight, caused by Erwinia amylovora, is one of the most devastating apple diseases. The selection of cultivars of low susceptibility and the study of the genetic mechanisms of the disease play important roles in fire blight management. The susceptibility level to fire blight was evaluated in 102 accessions originating from Asturias, a cider-producing region located in the north of Spain with a wide apple germplasm. Evaluations took place under quarantine conditions using artificial inoculations of grafted plants. The results revealed wide variation in susceptibility responses and low-susceptible cultivars were identified. In addition, 91 cultivars were genotyped using the Affymetrix Axiom® Apple 480 K SNP array to conduct genome-wide association studies (GWAS). A statistically significant signal was detected on chromosome 10 using the multi-locus mixed model (MLMM). Two genes were identified as major putative candidate genes: a TIR-NBS-LRR class disease protein and a protein containing a development and cell death (DCD) domain. The outcomes of this study provide a promising source of information, particularly in the context of cider apples, and set a starting point for future genetic and breeding approaches.

Validity of a short questionnaire to assess physical activity in 10 European countries.

To accurately examine associations of physical activity (PA) with disease outcomes, a valid method of assessing free-living activity is required. We examined the validity of a brief PA questionnaire (PAQ) used in the European Prospective Investigation into Cancer and Nutrition (EPIC). PA energy expenditure (PAEE) and time spent in moderate and vigorous physical activity (MVPA) was measured in 1,941 healthy individuals from 10 European countries using individually-calibrated combined heart-rate and movement sensing. Participants also completed the short EPIC-PAQ, which refers to past year's activity. Pearson (r) and Spearman (σ) correlation coefficients were calculated for each country, and random effects meta-analysis was used to calculate the combined correlation across countries to estimate the validity of two previously- and one newly-derived ordered, categorical PA indices ("Cambridge index", "total PA index", and "recreational index") that categorized individuals as inactive, moderately inactive, moderately active, or active. The strongest associations with PAEE and MVPA were observed for the Cambridge index (r = 0.33 and r = 0.25, respectively). No significant heterogeneity by country was observed for this index (I(2) = 36.3%, P = 0.12; I(2) = 0.0%, P = 0.85), whereas heterogeneity was suggested for other indices (I(2) > 48%, P < 0.05, I(2) > 47%, P < 0.05). PAEE increased linearly across self-reported PA categories (P for trend <0.001), with an average difference of approximately 460 kJ/d for men and 365 kJ/d for women, between categories of the Cambridge index. The EPIC-PAQ is suitable for categorizing European men and women into four distinct categories of overall physical activity. The difference in PAEE between categories may be useful when estimating effect sizes from observational research.

Involvement of citizens in hazardous waste management and use of recycling centres in the city of Madrid (Spain).

In Spain, hazardous household waste management by citizens occurs via fixed recycling centres (FRC) and mobile recycling centres (MRC) which usually depend on local governments. This paper addresses a request by the Madrid City Council, in an attempt to improve the service it provides to the city of Madrid. The aim of the study involved analysing the information people possess in relation to hazardous waste and to the use of available equipment, and conducting a post-evaluation of the effectiveness of an environmental communication campaign conducted by the Madrid City Council and aimed at providing awareness of the existence of new FRCs and MRCs. To this end, a questionnaire was conducted with 5644 inhabitants of the city of Madrid. Qualitative data was categorized using content analysis followed by chi-squared tests, considering some socio-demographic characteristics of the sample, such as age or place of residence (district). Communication campaigns influenced citizen awareness of what constituted hazardous waste, of how to properly separate waste and of the existence of FRCs and MRCs. However, few citizens actually used FRCs or MRC (18% across four districts), a fact that might be related to a lack of knowledge of downstream waste treatment issues, or to self-limiting hindrances to householders, such as distance to recycling centres. It is recommended that future communication campaigns investigate householder needs and pre-conceptions in relation to recycling, as well as tailored education aimed at addressing the barriers, perceived or otherwise, facing citizens.

Laser Therapy for the Treatment of Actinic Cheilitis: A Systematic Review.

Actinic cheilitis (AC) is a chronic inflammation of the lip considered an oral, potentially malignant disorder associated with an increased risk of lip squamous cell carcinoma (SCC) development. Controversies surrounding current therapeutic modalities of AC are under debate, and the implications of laser treatment have not been specifically investigated through a systematic review design. The present study aims to evaluate the degree of evidence of laser for the treatment of AC in terms of efficacy and safety. We searched for primary-level studies published before January 2022 through MEDLINE/PubMed, Embase, Web of Science, Scopus and CENTRAL, with no limitation in publication language or date. We evaluated the methodological quality and risk of bias of the studies included using the updated Cochrane Collaboration's tool for assessing risk of bias (RoB-2). Twenty studies (512 patients) met our eligibility criteria. Laser therapy showed a complete clearance of AC in 92.5% patients, with a maximum recurrence rate of 21.43%, and a very low frequency of malignant transformation to SCC (detected in only 3/20 studies analyzed). In addition, cosmetic outcomes and patient satisfaction were described as excellent. In conclusion, our findings indicate that laser therapy is a high efficacy approach to AC.

Improvements in climate and satisfaction after implementing a quality management system in education.

The overall aim of this study is to evaluate the impact of applying ISO:9001 on the school climate and satisfaction in schools. This was done by using a Likert-type evaluation instrument consisting of 21 items with an excellent reliability score for the general scale (Cronbach α = 0.955) and specifically for the school climate dimension (α = 0.969) and school satisfaction (α = 0.927). The instrument was applied to a sample of 2189 subjects (1881 teachers and 308 members of the school management team) at 85 schools in Spain where ISO:9001 has been implemented for at least 3 years. The results show that implementation of this QMS has generally had a medium level impact on school climate and on satisfaction among the teachers, students, and families at the schools in the sample. Moreover, descriptive and differential analyses have been carried out to identify any significant differences in the impact of implementing the QMS on improvements in the two dimensions as a function of the position, gender, seniority at the school, ownership, and size of the school, and length of time with the QMS implemented there. In addition, other analyses were carried out using single-variant general linear models that revealed an effect of interaction between the variables of position and age. Furthermore, cluster analyses were also performed to identify three teacher and management profiles attending to the levels of improvement brought about from implanting the QMS on the dimensions under study.

Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives.

INTRODUCTION: In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS: A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS: 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P < .001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P < .001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72 h. CONCLUSIONS: The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.