Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10.

BACKGROUND: The international classification of diseases version 10 (ICD-10) uses alphanumeric expanded codes and external cause of injury codes (E-codes). OBJECTIVE: To examine the reliability and validity of emergency department (ED) coders in applying E-codes in ICD-9 and -10. METHODS: Bicycle and pedestrian injuries were identified from the ED information system from one period before and two periods after transition from ICD-9 to -10 coding. Overall, 180 randomly selected bicycle and pedestrian injury charts were reviewed as the reference standard (RS). Original E-codes assigned by ED coders (ICD-9 in 2001 and ICD-10 in 2004 and 2007) were compared with charts (validity) and also to ICD-9 and -10 codes assigned from RS chart review, to each case by an independent (IND) coder (reliability). Sensitivity, specificity, simple, and chance-corrected agreements (κ statistics) were calculated. RESULTS: Sensitivity of E-coding bicycle injuries by the IND coder in comparison with the RS ranged from 95.1% (95% CI 86.3 to 99.0) to 100% (95% CI 94.0 to 100.0) for both ICD-9 and -10. Sensitivity of ED coders in E-coding bicycle injuries ranged from 90.2% (95% CI 79.8 to 96.3) to 96.7% (95% CI 88.5 to 99.6). The sensitivity estimates for the IND coder ranged from 25.0% (95% CI 14.7 to 37.9) to 45.0% (95% CI 32.1 to 58.4) for pedestrian injuries for both ICD-9 and -10. CONCLUSION: Bicycle injuries are coded in a reliable and valid manner; however, pedestrian injuries are often miscoded as falls. These results have important implications for injury surveillance research.

Bicycle helmet use four years after the introduction of helmet legislation in Alberta, Canada.

BACKGROUND: Bicycle helmets reduce fatal and non-fatal head and face injuries. This study evaluated the effect of mandatory bicycle helmet legislation targeted at those less than 18 years old on helmet use for all ages in Alberta. METHODS: Two comparable studies were conducted two years before and four years after the introduction of helmet legislation in Alberta in 2002. Bicyclists were observed in randomly selected sites in Calgary and Edmonton and eight smaller communities from June to October. Helmet wearing and rider characteristics were recorded by trained observers. Poisson regression adjusting for clustering by site was used to obtain helmet prevalence (HP) and prevalence ratio (PR) (2006 vs. 2000) estimates. RESULTS: There were 4002 bicyclists observed in 2000 and 5365 in 2006. Overall, HP changed from 75% to 92% among children, 30% to 63% among adolescents and 52% to 55% among adults. Controlling for city, location, companionship, neighborhood age proportion <18, socioeconomic status, and weather conditions, helmet use increased 29% among children (PR = 1.29; 95% CI: 1.20-1.39), over 2-fold among adolescents (PR 2.12; 95% CI: 1.75-2.56), and 14% among adults: (PR = 1.14; CI: 1.02-1.27). CONCLUSIONS: Bicycle helmet legislation was associated with a greater increase in helmet use among the target age group (<18). Though HP increased over 2-fold among adolescents to an estimated 63% in 2006, this percentage was approximately 30% lower than among children <13.

Rates of initial virological suppression and subsequent virological failure after initiating highly active antiretroviral therapy: the impact of aboriginal ethnicity and injection drug use.

OBJECTIVES: To compare rates of initial virological suppression and subsequent virological failure by Aboriginal ethnicity after starting highly active antiretroviral therapy (HAART). METHODS: We conducted a retrospective cohort study of antiretroviral-naïve HIV-patients starting HAART in January 1999-June 2005 (baseline), followed until December 31, 2005 in Alberta, Canada. We compared the odds of achieving initial virological suppression (viral load <500 copies/mL) by Aboriginal ethnicity using logistic regression and, among those achieving suppression, rates of virological failure (the first of two consecutive viral loads >1000 copies/mL) by Aboriginal ethnicity using cumulative incidence curves and Cox proportional hazards models. Sex, injection drug use as an HIV exposure category (IDU), baseline age, CD4 cell count, viral load, calendar year, and HAART regimen were considered as potential confounders. RESULTS: Of 461 study patients, 37% were Aboriginal and 48% were IDUs; 71% achieved initial virological suppression and were followed for 730.4 person-years. After adjusting for confounding variables, compared to non-Aboriginals with other exposures, the odds of achieving initial virological suppression were lower for Aboriginal IDUs (odds ratio (OR)=0.33, 95% CI=0.19-0.60, p=0.0002), non-Aboriginal IDUs (OR=0.30, 95% CI=0.15-0.60, p=0.0006), and Aboriginals with other exposures (OR=0.38, 95% CI=0.21-0.67, p=0.0009). Among those achieving suppression, Aboriginals experienced higher virological failure rates ≥1 year after suppression (hazard ratio=3.35, 95% CI=1.68-6.65, p=0.0006). CONCLUSIONS: Future research should investigate adherence among Aboriginals and IDUs treated with HAART and explore their treatment experiences to assess ways to improve outcomes.

Risk factors for ciprofloxacin resistance in reported Campylobacter infections in southern Alberta.

We conducted a case-control study examining risk factors for ciprofloxacin resistance in Campylobacter infections that were reported in 2004 and 2005 in two health regions in southern Alberta. The study questionnaire included questions about recent travel and antibiotic use, food consumption frequency, use of household and personal hygiene products with antibacterial agents, contact with animals, and potential misuse of antibiotics. Of the 210 patients who participated, 31.0% had ciprofloxacin-resistant Campylobacter infections. Foreign travel was the strongest predictor of resistance. Surprisingly, possession of antibiotics for future use was identified as a risk factor for resistance. We also examined the potential for participation bias and resistance misclassification to affect the resulting multivariable models. Participation bias appears to have had a substantial effect on the model results, but the estimated misclassification effect due to the use of different ciprofloxacin susceptibility testing methods was only slight.

Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway.

BACKGROUND: Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization. METHODS: A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization. RESULTS: Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group. CONCLUSION: Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.

Utilization of health services following spinal cord injury: a 6-year follow-up study.

STUDY DESIGN: Cohort study with 6-years follow-up. OBJECTIVE: To describe the utilization of health services by persons with spinal cord injury (SCI) and compare it with that of the general population. SETTING: Alberta, Canada. METHODS: All persons who sustained an SCI in Alberta between April 1992 and March 1994 were followed from date of injury to 6 years postinjury. Cases were matched (1:5) with controls randomly selected from the general population and matched for age, gender, and region of residence. Administrative data from centralized health care databases were compiled to provide a complete picture of health care use, including hospitalizations, physician contacts, long-term care admissions, home care services, and the occurrence of secondary complications. RESULTS: In all, 233 individuals with SCI and 1165 matched controls were followed for 6 years. Compared with the control group, persons with SCI were rehospitalized 2.6 times more often, spent 3.3 more days in hospital, were 2.7 times more likely to have a physician contact, and required 30 times more hours of home care services. Of those with SCI, 47.6% were treated for a urinary tract infection, 33.8% for pneumonia, 27.5% for depression, and 19.7% for decubitus ulcer. CONCLUSION: SCI places a heavy burden on the health care system. Persons with SCI have greater rates of contact with the health system compared with the general population. Secondary complications continue to affect persons with SCI long after the acute trauma.

Gastric cancer: establishing predictors of biologic behavior with use of population-based data.

BACKGROUND: Tumor thickness and nodal status are important predictors of survival following curative resection for gastric cancer. Lymphovascular invasion (LVI) is a potential predictor of biological behavior. The relationship between LVI and tumor thickness (T status) has not been established in population-based studies. METHODS: Clinicopathological and survival data of 577 patients at nine centers, from between 1991 and 1997, was collected from patient records and a Provincial Cancer Registry. The primary endpoint of the study was death. A secondary analysis of a node-negative subgroup examined the significance of LVI with respect to T status. RESULTS: The population disease-specific survival was 28%. In a multivariate analysis, T, N, M, esophageal margin, tumor morphology, and residual tumor category were independent predictors of survival. LVI was documented in 58% of resected tumors. LVI correlated with advancing T and N status but was not significant in a multivariate population model. Subgroup analysis of node-negative gastric cancer found T status and LVI to be independent predictors of survival. LVI was associated with a 5-year survival of 8%, versus 43% among patients in whom it was absent (P <.001). CONCLUSIONS: T status and N status were the most important independent predictors of survival in a population-based study of gastric cancer. LVI correlated with advancing N and T status. Multivariate analysis of node-negative patients showed LVI and T status are independent predictors of survival.

Appendectomies in rural hospitals. Safe whether performed by specialist or GP surgeons.

OBJECTIVE: To compare outcomes of appendectomies performed in rural hospitals by specialist surgeons and GP surgeons. DESIGN: Retrospective analysis of the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database (DAD) 1996-1999. SETTING: Rural hospitals in Ontario, Saskatchewan, Alberta, and British Columbia. PARTICIPANTS: All surgeons who performed appendectomies in these hospitals during the study period. MAIN OUTCOME MEASURES: Mortality; diagnostic accuracy, perforation, and repeat laparotomy rates; length of stay; and need for transfer to another acute-care institution. RESULTS: Specialist surgeons performed 3624 appendectomies; GP surgeons performed 963. Rates of comorbidity, diagnostic accuracy, and transfer, and mean lengths of stay were similar for patients of GP and specialist surgeons. Patients operated on by specialists were older and more likely to have perforations and to require second intra-abdominal or pelvic procedures. Triage to a specialist, older age, and comorbidity all independently predicted perforation. Only perforation predicted a second intra-abdominal or pelvic procedure. CONCLUSION: Appendectomy is a safe procedure in rural hospitals, whether performed by specialist or GP surgeons. Some difficult cases are routinely referred to specialists.

Nedocromil sodium for preventing exercise-induced bronchoconstriction.

BACKGROUND: Exercise-induced bronchoconstriction (EIB) following strenuous physical exertion afflicts many people. It can be the cause of sub-optimal performance, symptoms such as cough, dyspnea, wheeze and chest tightness, and can lead people to avoid physical activity. Management of EIB focuses on prevention through pharmaco-therapy and alternate strategies. Single use, pre-exercise, beta-agonists and non-steroidal antiinflammatory agents are recommended. OBJECTIVES: Bronchodilator medications have been commonly used to prevent narrowing of airways after exercise, but anti-inflammatory drugs such as nedocromil sodium have also been used. The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise-induced bronchoconstriction. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. SELECTION CRITERIA: Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise-induced bronchoconstriction in patients with EIB over six years of age. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. MAIN RESULTS: The combined results from 20 randomised controlled trials involving 280 participants, show that 4 mg, of nedocromil sodium inhaled 15 to 60 minutes prior to exercise significantly reduce the severity and duration of EIB in both adults and children, when compared to placebo. The maximum percentage fall in FEV1 was improved significantly compared to placebo (weighted mean difference 15.5 %; 95% confidence interval:13.2 to 18.1). For the maximum percentage fall in peak expiratory flow rate (PEFR) the improvement was similar: WMD 15.0%, (95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. It had a greater effect on those patients with more severe exercise-induced bronchoconstriction (defined as an exercise-induced fall in lung function > 30% from baseline). There were no significant adverse effects reported with the short term use of nedocromil. A further search conducted in September 2001 did not yield any further studies. REVIEWER'S CONCLUSIONS: Nedocromil sodium used before exercise reduces the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise-induced bronchoconstriction.

Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes.

OBJECTIVES: To study prevalence, risk factors, and maternal and infant outcomes of women with gestational diabetes mellitus (GDM). METHODS: A retrospective cohort study was performed based on 111563 pregnancies delivered between 1991 through 1997 in 39 hospitals in northern and central Alberta, Canada. Multivariate logistic regression was used to estimate the odds ratios with 95% confidence intervals, and to control for confounding variables. RESULTS: The prevalence of GDM was 2.5%. Risk factors for GDM included age >35 years, obesity, history of prior neonatal death, and prior cesarean section. Teenage mothers and women who drank alcohol were less likely to have GDM. Mothers with GDM were at increased risk of presenting with pre-eclampsia, premature rupture of membranes, cesarean section, and preterm delivery. Infants born to mothers with GDM were at higher risk of being macrosomic or large-for-gestational-age. CONCLUSIONS: Specific conditions predispose to GDM which itself is associated with a significantly increased risk of maternal and fetal morbidity.

Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators.

BACKGROUND: Studies of survival of patients with multivessel coronary artery disease (MVD) in the prestent era suggested that outcomes after coronary artery bypass surgery (CABG) are similar to those after percutaneous coronary intervention (PCI) in subsets of coronary severity. The purpose of this study of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) was to examine the association between treatment and survival up to 5 years in patients with MVD enrolled from 1995 through 1998. METHODS AND RESULTS: Data on patient characteristics were obtained at the time of the initial coronary angiography. Survival was determined through data linkage to the provincial Bureau of Vital Statistics. Risk-adjusted hazard ratios were calculated to compare different treatments. In the 11,661 patients with MVD, CABG was the initial therapy in 3782, PCI in 3540, and medical therapy in 4339. Cumulative 5-year survival was 91.4% with CABG, 91.9% with PCI, and 82.9% with medical therapy (P <.001). Hazard ratios were CABG: medical 0.53 (95% confidence interval [CI] 0.46-0.71), PCI: medical 0.65 (95% CI 0.56-0.74), and CABG: PCI 0.81 (95% CI 0.68-0.96). Analysis across coronary severity groups revealed a benefit of CABG compared with PCI only in the group with severe left main CAD: 0.30 (95% CI 0.17-0.54). CONCLUSIONS: In a multicenter clinical setting, MVD patients treated with revascularization have significantly higher 5-year survival rate than do those treated medically. Risk-adjusted comparison reveals PCI treatment to be associated with long-term survival similar to treatment with CABG in all coronary severity subgroups except the group with severe left main coronary artery disease. Patient selection factors are likely to be contributing to these findings.

Preeclampsia and cerebral palsy in low-birth-weight and preterm infants: implications for the current "ischemic model" of preeclampsia.

OBJECTIVE: One of the prevailing hypotheses for the pathogenesis of preeclampsia is the "ischemic model." It assumes that reduced uteroplacental perfusion is the primary step and the point of convergence of diverse pathogenic processes in the development of preeclampsia. One might expect a fetus under such "ischemic conditions" to be at an increased risk of later development of cerebral palsy (CP). The objective of this study was to test the hypothesis that maternal preeclampsia increases the risk of CP in preterm and low-birth-weight infants. METHODS: A meta-analysis was performed based on published articles identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, Current Contents, Biological Abstracts, and Dissertation Abstracts) from 1966 through 1999. Ten observational studies on the association between preeclampsia and CP were identified based on prespecified inclusion criteria. Two independent reviewers extracted data and assessed the methodological quality of eligible articles. Odds ratios (OR) of CP for preeclampsia from individual studies were pooled. MAIN OUTCOME MEASURE: Cerebral palsy. RESULTS: In case-control studies, preeclampsia was associated with a statistically significant decreased risk of CP [pooled adjusted OR, 0.50; 95% confidence interval (CI), 0.33-0.81; p < 0.01). In cohort studies, preeclampsia was associated with a nonstatistically significant reduced risk of CP (pooled OR, 0.91; 95% CI, 0.35-2.41; p > 0.05). CONCLUSIONS: Preeclampsia may be associated with a decreased risk of CP in preterm and low-birth-weight infants. This challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiological process in preeclampsia.

Maternal smoking and preeclampsia.

OBJECTIVE: To study the relationship between maternal smoking and preeclampsia and whether this association differs between primiparous and multiparous women. STUDY DESIGN: We conducted a population-based, retrospective, cohort study of 58,216 singleton pregnancies from northern and central Alberta, Canada, between 1995 and 1997. Multivariate logistic regression was used to control for maternal alcohol consumption, drug dependence, maternal age, maternal weight, prior intrauterine growth restriction and other confounders. RESULTS: Maternal smoking was associated with a significantly reduced overall risk of preeclampsia (adjusted odds ratio [aOR]: .61; 95% confidence interval [CI]: .50-.75; P < .01). Stratified analyses showed that in primiparous pregnancies, maternal smoking was associated with a significantly decreased risk (aOR: .63; 95% CI: .50-.80; P < .01); in multiparous women, maternal smoking was not associated with a statistically significant decreased risk of preeclampsia (aOR: 0.72; 95% CI: .51-1.02; P > .05). CONCLUSION: Maternal smoking is protective against preeclampsia. Understanding the underlying biologic mechanisms of this protective effect may advance our knowledge of the pathogenesis of preeclampsia.

Association of preeclampsia with high birth weight for age.

OBJECTIVE: The purpose of this study was to examine the effect of gestational hypertension and preeclampsia on fetal growth. STUDY DESIGN: A retrospective cohort study was conducted on the basis of 97,270 pregnancies delivered between 1991 and 1996 in 35 hospitals in northern and central Alberta, Canada. Univariate and multivariate logistic analyses were performed to examine the impact of preeclampsia and gestational hypertension on high-birth-weight (> or =4200 g), large-for-gestational-age, low-birth-weight (<2500 g), and small-for-gestational-age babies. RESULTS: The rate of high-birth-weight fetuses in women with gestational hypertension (7. 3%) was higher than in those with normal blood pressure (5.6%). After we controlled for confounders, the adjusted odds ratio of high birth weight was 1.44 (95% confidence interval, 1.21-1.70) in women with gestational hypertension. Preeclampsia was also associated with a statistically nonsignificant (P =.054) increased risk of high birth weight (adjusted odds ratio, 1.40; 95% confidence interval 0. 99-1.98). The rate of large-for-gestational-age babies was significantly higher in women with gestational hypertension (4.5%) and preeclampsia (4.7%) than in those with normal blood pressure (2. 2%), with adjusted odds ratios of 1.50 (95% confidence interval, 1. 22-1.85) for gestational hypertension and 1.87 (95% confidence interval, 1.31-2.67) for preeclampsia. Concurrently, women who had gestational hypertension were also at higher risk of having low-birth-weight (adjusted odds ratio, 2.4; 95% confidence interval, 2.13-2.93) and small-for-gestational-age (adjusted odds ratio, 2.04; 95% confidence interval, 1.68-2.48) babies. Women with preeclampsia were also at markedly higher risk of having low-birth-weight (adjusted odds ratio, 4.14; 95% confidence interval, 3.32-5.15) and small-for-gestational-age (adjusted odds ratio, 2.56; 95% confidence interval, 1.92-3.41) babies. CONCLUSIONS: There is a significant association of preeclampsia and gestational hypertension with large-for-gestational-age infants, in addition to a significant association with low-birth-weight and small-for-gestational-age infants. This study challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiologic process in preeclampsia.

Nedocromil sodium in the treatment of exercise-induced asthma: a meta-analysis.

Exercise-induced asthma (or bronchoconstriction) afflicts millions of people worldwide. While generally self-limiting, it can hinder performance and reduce activity levels, thus it is an important condition to diagnose and treat. The objective of this review was to assess the prophylactic effect of a single dose of nedocromil sodium on exercise-induced asthma. The Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, reference lists of relevant articles, review articles and textbooks were searched for randomized trials comparing a single dose of nedocromil to placebo to prevent exercise-induced asthma in people >6 yrs of age. Authors and the drug manufacturer were contacted for additional trials. Trial quality assessments and data extraction were conducted independently by two reviewers. Authors were contacted when possible. Twenty trials were included. All were rated as having good methodological quality. Nedocromil inhibited bronchoconstriction in all age groups. The pooled weighted mean difference for the maximum percentage fall in forced expiratory volume in one second was 15.6%, (95% confidence interval (95% CI): 13.2-18.1) and for the peak expiratory flow was 15.0% (95% CI: 8.3-21.6). These differences are both statistically and clinically significant. After nedocromil the time to recover normal lung function was <10 min compared to >30 min with placebo. Nedocromil had a greater effect on people with a fall in lung function of >30% from baseline. There were no significant adverse effects reported with this short-term use. In conclusion, Nedocromil taken before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced as severity increases.

Inhaled steroids in acute asthma following emergency department discharge.

BACKGROUND: Patients with acute asthma treated in the emergency department are frequently treated with inhaled beta-agonists and corticosteroids (CS) after discharge. The use of inhaled CS (ICS) following discharge may also be beneficial in acute asthma. OBJECTIVES: To determine the effect of inhaled corticosteroids (ICS) on outcomes in the treatment of acute asthma following discharge from the emergency department (ED). SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register which consists of systematic searches of EMBASE, MEDLINE and CINAHL databases supplemented by hand searching of 20 respiratory journals. In addition, abstracts from conferences were searched; primary authors and pharmaceutical companies were contacted to identify eligible studies. Bibliographies from included studies, known reviews, and texts also were searched. SELECTION CRITERIA: Only RCTs or quasi RCTs were eligible for inclusion. Studies were included if patients were treated for acute asthma in the ED or its equivalent, and following ED discharge were treated with ICS therapy either in addition to, or as a substitute for, oral corticosteroids (CS). Two reviewers independently assessed articles for potential relevance, final inclusion, and methodological quality - to "expand" the search. We didn't include any in the end) DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers if the authors were unable to verify the validity of information. Several authors and pharmaceutical companies provided unpublished data. The data were analysed using the Cochrane Review Manager 4.0.4. MAIN RESULTS: Ten trials were selected for inclusion. Three of these trials, involving a total of 909 patients, compared ICS plus CS Vs CS therapy alone. There was no demonstrated benefit of ICS therapy when used in addition to CS therapy in the trials. Relapses were reduced, but not significantly, with the addition of ICS therapy (OR: 0.68; 95% CI: 0.46 to 1.02). As well, no differences were demonstrated between the two groups for relapses requiring admission, quality of life, symptom scores, or adverse effects. Seven trials, involving a total of 1204 patients, compared high-dose ICS therapy alone Vs CS therapy alone after ED discharge. There were no significant differences demonstrated between ICS therapy alone and CS therapy alone for relapse rates (OR: 1.00; 95% CI: 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to confidently exclude the possibility of either treatment being significantly inferior, and severe asthmatics were excluded from these trials. REVIEWER'S CONCLUSIONS: There is insufficient evidence that ICS therapy provides additional benefit when used in combination with standard CS therapy upon ED discharge for acute asthma. There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics upon ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion. Further research is needed to clarify whether ICS therapy should be employed in acute asthma treatment in the ED or following ED discharge.

Nedocromil sodium for preventing exercise-induced bronchoconstriction.

BACKGROUND: Exercise-induced asthma causes cough, dyspnea, wheeze and chest tightness. Management of focuses on prevention through pharmaco-therapy and alternate strategies. Single use, pre-exercise beta2-agonists and non-steroidal anti-inflammatory agents such as the cromones are the most common treatments. OBJECTIVES: The objective of this review was to assess the effects of a single dose of nedocromil sodium to prevent exercise-induced bronchoconstriction. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, the Cochrane Controlled Trials Register, Current Contents, review articles, textbooks and reference lists of articles. We also contacted the drug manufacturer and primary authors for additional citations. SELECTION CRITERIA: Randomised trials comparing a single dose of nedocromil sodium with placebo to prevent exercise-induced bronchoconstriction in people over six years of age. DATA COLLECTION AND ANALYSIS: Trial quality assessment and data extraction were conducted independently by two reviewers. Study authors were contacted for confirmation of data. MAIN RESULTS: Twenty randomised controlled trials involving 280 participants were identified. 15-60 min following inhalation of 4 mg nedocromil, the maximum fall in forced expiratory volume in one second due to exercise was improved by 15.6%, (95% CI:13.2 to 18.1) compared to the placebo response. The maximum percentage fall in peak expiratory flow rate was of the same magnitude (weighted mean difference 15.0%; 95% CI 8.3 to 21.6). Nedocromil shortened the time to recover lung normal function from more than 30 minutes with placebo to less than 10 minutes with the drug. The relative magnitude of its effect was greatest in patients with more severe exercise-induced bronchoconstriction (defined as an exercise-induced fall in lung function > 30% from baseline). There were no significant adverse effects reported. REVIEWER'S CONCLUSIONS: Nedocromil sodium used before exercise appears to reduce the severity and duration of exercise-induced bronchoconstriction. This effect appears to be more pronounced in people with severe exercise-induced bronchoconstriction.

Dealing with missing data in observational health care outcome analyses.

Observational outcome analyses appear frequently in the health research literature. For such analyses, clinical registries are preferred to administrative databases. Missing data are a common problem in any clinical registry, and pose a threat to the validity of observational outcomes analyses. Faced with missing data in a new clinical registry, we compared three possible responses: exclude cases with missing data; assume that the missing data indicated absence of risk; or merge the clinical database with an existing administrative database. The predictive model derived using the merged data showed a higher C statistic (C = 0.770), better model goodness-of-fit as measured in a decile-of-risk analysis, the largest gradient of risk across deciles (46.3), and the largest decrease in deviance (-2 log likelihood = 406.2). The superior performance of the enhanced data model supports the use of this "enhancement" methodology and bears consideration when researchers are faced with nonrandom missing data.

A cost-effectiveness analysis of the application of nitric oxide versus oxygen gas for near-term newborns with respiratory failure: results from a Canadian randomized clinical trial.

OBJECTIVE: To conduct a cost-effectiveness analysis of the use of inhaled nitric oxide (NO) vs. oxygen administered to near-term (gestational age > or =34 wks) newborns with severe respiratory illness that were referred for consideration of extracorporeal membrane oxygenation (ECMO). DESIGN: The cost-effectiveness analysis is based on outcome and utilization data from two multicentered randomized clinical trials conducted by the Canadian Inhaled Nitric Oxide Study group, one for patients with congenital diaphragmatic hernia (CDH) and one for patients without CDH. Data from the western Canadian ECMO center were used to establish costs. SETTING: Patients were cared for in Canadian regional neonatal intensive care units, including two ECMO centers. Air transport was used for transporting patients between centers. PATIENTS: Term and near-term newborns with severe respiratory illness who were receiving maximum conventional therapy and whose oxygenation index was >40. INTERVENTIONS: Patients randomly received NO or oxygen. If their conditions deteriorated, they qualified for ECMO. Not all that qualified for ECMO received it because of individual parent/ physician preferences. MEASUREMENTS AND MAIN RESULTS: The cost-effectiveness ratio was the ratio of net cost (including neonatal intensive care, ECMO, and transport) to net outcome (survival) for the two interventions. For non-CDH cases, the cost-effectiveness ratio was $36,613 (Canadian) per life saved; the confidence intervals were wide and the results were not statistically significant. For CDH patients, the death rate was lower for oxygen and the oxygen patients cost less; the results were not statistically significant. CONCLUSIONS: The small numbers of patients in the trials precluded significant results. Further, our results have a short-term time horizon (discharge to home or death). Thus, for non-CDH patients, the favorable ratio provides very qualified evidence in favor of NO.

The cost-effectiveness of magnetic resonance imaging for patients with internal derangement of the knee.

Magnetic resonance imaging (MRI) has excellent specificity and sensitivity for the diagnosis of internal derangement of the knee (IDK). The use of MRI to screen patients with suspected IDK could avoid unnecessary arthroscopies with a reduction in costs. The purpose of this study was to evaluate the use of arthroscopy among patients with IDK, and to estimate the potential cost-effectiveness of MRI in these patients to avoid unnecessary arthroscopies. The study was based on a retrospective cohort of all patients attending three orthopedic clinics between April and September 1993 with a new diagnosis of IDK. Charts were reviewed in 1994 to allow for a follow-up of more than 6 months. An economic evaluation was performed based on cost-effectiveness ratios (per averted arthroscopy), including direct and indirect costs. There were 241 patients with a new diagnosis of IDK (67% males, mean age 35 +/- 12 years), and 110 (46%) underwent arthroscopy. The remaining patients received conservative therapy and were not scheduled for arthroscopy within the period of observation. Using a priori established criteria, 10% of the arthroscopies could be considered diagnostic only (e.g., normal knee) and 27% were of doubtful efficacy from a therapeutic perspective (e.g., debridement alone). Many of these arthroscopies could have been avoided by performing a prior MRI. Using these findings, we conducted decision tree analyses of the use of MRI among patients requiring arthroscopy of the knee. A sensitivity analysis was performed to evaluate the various model assumptions. In general, MRI appeared to be a cost-effective diagnostic procedure for patients with IDK requiring arthroscopy of the knee, and there were cost savings associated with it in some of the models tested.