A simple asthma prediction tool for preschool children with wheeze or cough.

BACKGROUND: Many preschool children have wheeze or cough, but only some have asthma later. Existing prediction tools are difficult to apply in clinical practice or exhibit methodological weaknesses. OBJECTIVE: We sought to develop a simple and robust tool for predicting asthma at school age in preschool children with wheeze or cough. METHODS: From a population-based cohort in Leicestershire, United Kingdom, we included 1- to 3-year-old subjects seeing a doctor for wheeze or cough and assessed the prevalence of asthma 5 years later. We considered only noninvasive predictors that are easy to assess in primary care: demographic and perinatal data, eczema, upper and lower respiratory tract symptoms, and family history of atopy. We developed a model using logistic regression, avoided overfitting with the least absolute shrinkage and selection operator penalty, and then simplified it to a practical tool. We performed internal validation and assessed its predictive performance using the scaled Brier score and the area under the receiver operating characteristic curve. RESULTS: Of 1226 symptomatic children with follow-up information, 345 (28%) had asthma 5 years later. The tool consists of 10 predictors yielding a total score between 0 and 15: sex, age, wheeze without colds, wheeze frequency, activity disturbance, shortness of breath, exercise-related and aeroallergen-related wheeze/cough, eczema, and parental history of asthma/bronchitis. The scaled Brier scores for the internally validated model and tool were 0.20 and 0.16, and the areas under the receiver operating characteristic curves were 0.76 and 0.74, respectively. CONCLUSION: This tool represents a simple, low-cost, and noninvasive method to predict the risk of later asthma in symptomatic preschool children, which is ready to be tested in other populations.

Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions.

BACKGROUND: Patients often establish initial contact with healthcare institutions by telephone. During this process they are frequently medically triaged. PURPOSE: To investigate the safety of computer-assisted telephone triage for walk-in patients with non-life-threatening medical conditions at an emergency unit of a Swiss university hospital. METHODS: This prospective surveillance study compared the urgency assessments of three different types of personnel (call centre nurses, hospital physicians, primary care physicians) who were involved in the patients' care process. Based on the urgency recommendations of the hospital and primary care physicians, cases which could potentially have resulted in an avoidable hazardous situation (AHS) were identified. Subsequently, the records of patients with a potential AHS were assessed for risk to health or life by an expert panel. RESULTS: 208 patients were enrolled in the study, of whom 153 were assessed by all three types of personnel. Congruence between the three assessments was low. The weighted κ values were 0.115 (95% CI 0.038 to 0.192) (hospital physicians vs call centre), 0.159 (95% CI 0.073 to 0.242) (primary care physicians vs call centre) and 0.377 (95% CI 0.279 to 0.480) (hospital vs primary care physicians). Seven of 153 cases (4.57%; 95% CI 1.85% to 9.20%) were classified as a potentially AHS. A risk to health or life was adjudged in one case (0.65%; 95% CI 0.02% to 3.58%). CONCLUSION: Medical telephone counselling is a demanding task requiring competent specialists with dedicated training in communication supported by suitable computer technology. Provided these conditions are in place, computer-assisted telephone triage can be considered to be a safe method of assessing the potential clinical risks of patients' medical conditions.

Hemoximetry as the "gold standard"? Error assessment based on differences among identical blood gas analyzer devices of five manufacturers.

BACKGROUND: The calibration and testing procedures of a pulse oximeter with arterial blood samples from healthy subjects are based on reference values from the hemoximeter. There are no tests to identify the accuracy of the reference devices. Because of this limitation and since the true values of oxygen saturation (sO2 in %) in blood samples were not known, we used the differences between two identical devices, A and B, for error assessment. METHODS: Two identical devices, A and B, from five leading manufacturers were investigated. Seventy-two arterial blood samples from 12 healthy volunteers at three different levels of saturation between 100% and 70% sO2 were randomly evaluated by the test systems. RESULTS: The observed differences (Delta) between Devices A and B, as a measure for the error of the hemoximeters, increased significantly with all manufacturers from level 97 (Deltamin, -0.9%; Deltamax, 2.6%) to 85 (Deltamin, -2.4%; Deltamax, 4.3), this effect was even stronger between levels 97 and 75 (Deltamin, -4.6%; Deltamax, 4.3%). A variance proportion analysis revealed the concentration of the reduced hemoglobin as the main error source for sO2 measurements. Independent from the sO2 levels there were also significant differences for the carboxy hemoglobin concentration in the range of 0%-4% and for the methemoglobin concentration in the range of 0%-1%. CONCLUSIONS: The variance of sO2 measurements between identical devices increased significantly when saturation decreased from the normal level of 97% to the hypoxemic levels of 85% and 75%.

Increased densities of monocarboxylate transporter MCT1 after chronic hyperglycemia in rat brain.

The brain is capable of taking up monocarboxylates as energy substrates. Under physiological conditions, plasma levels of monocarboxylates are very low and glucose is the primary energy substrate in brain metabolism. However, given conditions such as hyperglycemia and ketosis, levels of circulating monocarboxylates such as lactate and pyruvate are elevated. Previous studies reported an increased expression of monocarboxylate transporter MCT1 in brain following ketotic diet. The major aim of the present study was to answer the question whether chronic hyperglycemia is likewise sufficient to change local densities of MCT1 in the brain. Moreover, chronic hyperglycemia increases local cerebral glucose utilization (LCGU) in particular brain areas. Glucose hereby enters the brain parenchyma via glucose transporters and is partially metabolised by astrocytes, which then release lactate to meet the energetic demands of surrounding neurons. Streptozotocin was given intravenously to induce chronic hyperglycemia and local densities of MCT1 were measured by immunoautoradiographic methods in cryosections of rat brains. The density of monocarboxylate transporter MCT1 was significantly increased in 10 of 24 brain structures investigated (median increase 11.7+/-3.4 %). Immunocytochemical stainings of these substructures revealed an expression of MCT1 within endothelial cells and astrocytes. A comparison of MCT1 densities with LCGU measured in a previous study under normo- and hyperglycemic conditions revealed a partial correlation between both parameters and under both conditions. Four out of 10 brain areas, which showed a significant increase in MCT1 density due to hyperglycemia, also showed a significant increase in LCGU. In summary, our data show that chronic hyperglycemia induces a moderate increase of local and global density of MCT1 in several brain structures. However, in terms of brain topologies and substructures this phenomenon did only partially match with increased LCGU. It is concluded that MCT1 transporters were up-regulated during chronic hyperglycemia at the level of brain substructures and independently of LCGU.

Increased densities of monocarboxylate transport protein MCT1 after chronic administration of nicotine in rat brain.

Chronic administration of nicotine is followed by a general stimulation of brain metabolism that results in a distinct increase of glucose transport protein densities for Glut1 and Glu3, and local cerebral glucose utilization (LCGU). This increase of LCGU might be paralleled by an enhanced production of lactate. Therefore, the question arose as to whether chronic nicotine infusion is accompanied by increased local densities of monocarboxylate transporter MCT1 in the brain. Secondly, we inquired whether LCGU might be correlated with local densities of MCT1 during normal conditions and after chronic nicotine infusion. Nicotine was given subcutaneously for 1 week by osmotic mini-pumps and local densities of MCT1 were measured by immunoautoradiographic methods in cryosections of rat brains. MCT1 density was significantly increased in 21 of 32 brain structures investigated (median increase 15.0+/-3.6%). Immunohistochemical stainings of these substructures revealed an over-expression of MCT1 within endothelial cells and astrocytes of treated animals. A comparison of 23 MCT1 densities with LCGU measured in the same structures in a previous study revealed a partial correlation between both parameters under control conditions and after chronic nicotine infusion. 10 out of 23 brain areas, which showed a significant increase of MCT1 density due to chronic nicotine infusion, also showed a significant increase of LCGU. In summary, our data show that chronic nicotine infusion induces a moderate increase of local and global density of MCT1 in defined brain structures. However, in terms of brain topologies and substructures this phenomenon did partially match with increased LCGU. It is concluded that MCT1 transporters were upregulated during chronic nicotine infusion at the level of brain substructures and, at least partially, independently of LCGU.