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Background Practitioners of epidemiology require efficient real-time communication and shared access to numerous documents in order to effectively manage a study. Much of this communication involves study logistics and does not require the use of Protected Health Information. Slack is a team collaboration app; it archives all direct messages and group conversations, hosts documents internally and integrates with the Google Docs application. Slack has both desktop and mobile applications, allowing users to communicate in real time without the need to find email addresses or phone numbers or create contact lists. Methods We piloted the integration of Slack into our research team of one faculty member, one research coordinator and approximately 20 research assistants. Statistics describing the app’s usage were calculated 12 months after its implementation. Results The results indicating heavy usage by both research professionals and assistants are presented. Our Slack group cumulatively included 51 users. Between October 2015 and November 2016, approximately 10,600 messages were sent through Slack; 53% were sent by research assistants (RAs) and 47% were sent by us. Of the 106 files stored on Slack, 82% were uploaded by research staff. In a survey from January 2016, 100% of RAs agreed or strongly agreed that Slack improved communication within the team. Conclusion We demonstrate a model for integration of communication technology into academic activities by research teams. Slack is easily integrated into the workflow at an urban, academic medical centre and is adopted by users as a highly effective tool for meeting research teams’ communication and document management needs.

This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996–1998 (n 64 EDs). In each study, consecutive adult patients, aged 18–54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27–32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26–31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8–14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p 0.05). Among patients who ran out of medications, 49% (95% CI, 43–55%) ran out of inhaled beta-agonists and 72% (95% CI, 58–84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted. (Allergy Asthma Proc 35:e42–e50, 2014; doi: 10.2500/aap.2014.35.3747)

Compared with men, women presenting to the emergency department with acute asthma are more likely to be admitted and to have a longer hospital stay. This study compares peak expiratory flow rate (PEFR) with reported symptom severity between men and women with acute asthma. The null hypothesis was that men and women report similar severity symptoms for similar levels of airway obstruction.This study combined data from 4 prospective cohort studies performed from 1996 to 1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, investigators at 64 EDs in 21 US states and 4 Canadian provinces provided 24-hour per day coverage for a median of 2 weeks.Of the 1,291 patients with moderate to severe exacerbations (initial percentage of predicted PEFR80%), 62% were women. Women were more likely than men to report "severe" complaints in terms of symptom frequency, symptom intensity, and resulting activity limitations (all P.05). Women with moderate exacerbations were especially likely to describe their exacerbation as causing "severe" activity limitations (sex-PEFR interaction, P =.05).Men are less likely than women to report severe asthma symptoms and activity limitations in the presence of airway obstruction. This finding supports use of objective measures of airway obstruction when managing patients with asthma so that those whose symptoms do not reflect the severity of their obstruction can be recognized and properly treated. It also reconfirms the need for increased research on differences between men and women in acute asthma.

The bactericidal activity and mechanisms of action of the new fluoroquinolone gemifloxacin were investigated against the laboratory strains Escherichia coli KL16, Staphylococcus aureus E3T and Streptococcus pneumoniae C3LN4. Gemifloxacin was found to be highly bactericidal against these bacteria, producing a biphasic dose- response curve typical of the fluoroquinolones. This novel fluoroquinolone was more bactericidal than all other fluoroquinolones so far tested (ciprofloxacin, ofloxacin, enoxacin, lomefloxacin, levofloxacin, clinafloxacin, trovafloxacin, DV-7751 and sitafloxacin) against S. aureus and was more bactericidal than most other fluoroquinolones against E. coli or Str. pneumoniae. These data show gemifloxacin to be an improved member of the fluoroquinolone class of antibacterial agents.

Study Objective: This study explored how a variety of demographic and illness-related factors were associated with telephone follow-up among patients visiting the emergency department for acute asthma. Methods: We performed a prospective cohort study as part of the Multicenter Airway Research Collaboration (MARC). The study was performed at 77 EDs in 22 US states and 4 Canadian provinces. ED patients, ages 2 to 54 years, who presented with acute asthma underwent a structured interview during their visit. Two weeks later, research personnel attempted to contact participants by telephone, using numbers obtained during the ED interview. Results: A total of 1,847 adult and 1,184 pediatric patients were interviewed in the ED. Of these, 1,308 (71%) adult patients and 1,026 (87%) pediatric patients were successfully reached for 2-week telephone follow-up. Multivariate analyses revealed the factor most strongly related to contact was age, with pediatric patients being 2.5 times more likely to be reached than adults (95% confidence interval 2.0 to 3.2). Also, participants who were black, low in socioeconomic status, lacking a primary care provider, and exposed to tobacco smoke were significantly less likely to have been reached (all P Conclusion: In contrast to some reports in the literature, telephone contact rates were high. However, successful contact was not equally likely among all patient groups. Although the high contact rates support the feasibility of telephone follow-up of asthmatic patients visiting the ED, the results also act as a reminder of the potential biases that may arise when using telephone contact for clinical, quality assurance, and research reasons. [Boudreaux ED, Clark S, Camargo CA Jr, on behalf of the MARC Investigators. Telephone follow-up after the emergency department visit: experience with acute asthma. Ann Emerg Med. June 2000;35:555-563.]

Introduction Geriatric patients are more likely than younger patients to be admitted to the hospital when they present to the emergency department (ED). Identifying trends in geriatric short-stay admission may inform the development of interventions designed to improve acute care for the elderly. Objective To evaluate trends in US geriatric short-stay hospitalizations from 1990 to 2010. Methods Retrospective study using the National Hospital Discharge Survey (NHDS). Trends in short-stay hospitalizations were analyzed from 1990 to 2010 for age groups 22 to 64, 65 to 74, 75 to 84, and at least 85 years using linear regression. Results A total of 4.5 million survey visits representing 580 million adult hospitalizations were available for analysis; 250 million (43%) were among patients 65 years or older. Of these, 12%, 25%, and 40% were ≤ 1, ≤ 2 and ≤ 3 days' short-stay admissions, respectively. Between 1990 and 2010, short-stay admissions increased as a percentage of total hospitalizations for each geriatric age group but remained relatively constant for younger adults. Admissions from NHDS were similar to admissions from the ED for years where ED-specific data were available. The older a patient was (age > 65 years), the more likely their admission was to have started in the ED. Discussion For all elderly patients, short-stay admissions represented a growing proportion of total admissions, regardless of the definition of short stay. These trends were identified despite the NHDS exclusion of observation status hospitalizations. The increase in short-stay admissions was the most pronounced in the extreme elderly (age ≥ 85 years). Future research is needed to optimize treatment for geriatric patients presenting to the ED, some of whom, with brief observation and appropriate follow-up, may be better cared for without hospitalization.

Summary Objective: Based on US. Centers for Disease Control and Prevention recommendations, New York State enacted legislation in 2010 requiring healthcare providers to offer non-targeted human immunodeficiency virus (HIV) testing to all patients aged 13–64. Three New York City adult emergency departments implemented an electronic alert that required clinicians to document whether an HIV test was offered before discharging a patient. The purpose of this study was to assess the impact of the electronic alert on HIV testing rates and diagnosis of HIV positive individuals. Methods: During the pre-intervention period (2.5–4 months), an electronic “HIV Testing” order set was available for clinicians to order a test or document a reason for not offering the test (e.g., patient is not conscious). An electronic alert was then added to enforce completion of the order set, effectively preventing ED discharge until an HIV test was offered to the patient. We analyzed data from 79,786 visits, measuring HIV testing and detection rates during the pre-intervention period and during the six months following the implementation of the alert. Results: The percentage of visits where an HIV test was performed increased from 5.4% in the pre-intervention period to 8.7% (p Conclusions: An electronic alert which enforced non-targeted screening was effective at increasing HIV testing rates but did not significantly increase the detection of persons living with HIV. The impact of this electronic alert on healthcare costs and quality of care merits further examination. Citation: Schnall R, Liu N, Sperling J, Green R, Clark S, Vawdrey D. An electronic alert for HIV screening in the emergency department increases screening but not the diagnosis of HIV. Appl Clin Inf 2014; 5: 299–312 http://dx.doi.org/10.4338/ACI-2013-09-RA-0075

Keeping patients with complex medical illnesses up to date with their preventive care and chronic disease management services, such as lipid testing and retinal exam in patients with diabetes, is challenging. Within a commercially available electronic health record (EHR) with a secure personal health record (PHR), we developed a system that sends up to three weekly reminders to patients who will soon be due for preventive care services. The reminder messages reside within the secure PHR, which is linked to the EHR, and are displayed on a screen where patients can also send to the physician's office an electronic message to request appointments for the needed services. The reminder messages stop when the patient logs on to review the reminders. The system, designed with patient input, groups together all services that will be due in the next 3 months to avoid repeatedly messaging the patient. After 2 months, the cycle of reminders begins again. This system, which is feasible and economical to build, has the potential to improve care and compliance with quality measures.

Introduction: Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students’ knowledge acquisition, comfort, and perceived competence with regards to the AMS patient. Methods: AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS. Results: A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not ( p

Children with bronchiolitis often are considered a homogeneous group. However, in a multicenter, prospective study of 2,207 young children hospitalized for bronchiolitis, we found that children with respiratory syncytial virus detected differ from those with rhinovirus detected; the latter patients resemble older children with asthma, including more frequent treatment with corticosteroids.

Background The epidemiology of allergic drug reactions is poorly understood due, in large part, to difficulty in identifying true cases in population data sets. Use of International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) codes is a potentially valuable approach that requires formal evaluation. Objective To better understand the utility of ICD-9-CM codes for identification of allergic drug reactions, including the validation of specific codes by chart review. Methods We reviewed randomly sampled medical records of patients treated in the emergency department (ED) between January 1, 2001, and December 31, 2006, with ICD-9-CM codes for drug allergy and E codes (E930-949) for adverse drug reactions. Results During the 6-year period, 11,130 charts were identified by ICD-9-CM and E codes and 1,634 were reviewed. Allergic drug reactions were found in 444 (27%) of the reviewed ED visits. The codes that identified the highest percentage of true allergic drug reactions were dermatitis due to drug (693.0; 87%), adverse reaction to drug (995.2; 52%), and anaphylaxis (995.0; 38%). Patients with both an ICD-9-CM code and an E code had a high likelihood of having an allergic drug reaction (76%). Most allergic drug reactions were attributed to antibiotics (42%), intravenous contrast (7%), and nonsteroidal anti-inflammatory drugs (6%). The estimated frequency of allergic drug reactions increased from 0.49% of ED visits in 2001 to 0.94% in 2012. Conclusions Specific ICD-9-CM and E codes can be used in combination to identify allergic drug reactions. Further study of these codes in the inpatient and outpatient settings is necessary to better understand the utility of diagnosis codes for improving epidemiologic research on drug allergy.

Background Food-induced anaphylaxis is a potentially life-threatening condition that frequently results in emergency department (ED) visits and/or hospitalization. Little information is available on patient compliance with recommended postdischarge anaphylaxis care. Objective To describe patient characteristics, concordance with recommended postdischarge care, and risk of repeated events among adults with an initial ED visit and/or hospitalization for food-induced anaphylaxis. Methods In this retrospective study of health care claims, adults with an ED visit and/or hospitalization for food-induced anaphylaxis were identified from the 2002-2008 Truven Health MarketScan Databases by using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. The first identified ED visit and/or hospitalization was the index event. Data from patients with continuous medical and prescription coverage for ≥1 year before and after the index event were retained for analysis. Analyses included baseline demographic and clinical characteristics, postdischarge epinephrine autoinjector (EAI) prescription fills and allergist/immunologist visits, and repeated events in the 1-year postindex period. Results Patients (n = 1370) had a mean (SD) age of 44 ± 15 years, 58% were women. Most (86%) were seen in the ED and/ discharged from the ED. Within 1 year after discharge, 54% of adults had filled ≥1 EAI prescription (71% within 1 week) and 22% had ≥1 allergist/immunologist visit (53% within 4 weeks). Overall, 73 patients (5%) had evidence of a subsequent anaphylaxis-related ED visit and/or hospitalization 1 year after discharge. Conclusion Concordance with recommended postdischarge anaphylaxis care was low among adults with food-induced anaphylaxis. Within 1 year after discharge, 54% of patients filled an EAI prescription and 22% consulted an allergist/immunologist.

Bronchiolitis, a respiratory illness, is the leading cause of hospitalization for infants. The authors examined whether environmental factors contributed to the severity of the bronchiolitis illness. They compiled environmental data (temperature, dew point, wind speed, precipitation, altitude, and barometric pressure) to augment clinical data from a 30-center prospective cohort study of emergency department patients with bronchiolitis. They analyzed these data using multivariable logistic regression. Higher altitude was modestly associated with increased retractions (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.1-2.1; p.001) and decreased air entry (OR = 2.0; 95% CI = 1.6-2.6; p.001). Increasing wind speed had a minor association with more severe retractions (OR = 1.3; 95% CI = 1.1-1.7; p = .02). Higher dew points had a minor association with lower admission rates (OR = 0.9; 95% CI = 0.8-0.996; p = .04). Altitude and environmental climate variables appear to have modest associations with the severity of bronchiolitis in the emergency department. Further studies need to be conducted, however, on limiting exposure to these environmental variables or increasing humidity before making broad recommendations.

OBJECTIVE: To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis. METHODS: We performed a 16-center, prospective cohort study of hospitalized children aged RESULTS: There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age CONCLUSIONS: In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support

We reexamined the finding of an inverse relationship between values of nasopharyngeal lactate dehydrogenase, a marker of the innate immune response, and bronchiolitis severity. In a prospective, multicenter study of 258 children, we found in a multivariable model that higher nasopharyngeal lactate dehydrogenase values in young children with bronchiolitis were independently associated with a decreased risk of hospitalization.

Communication between physicians caring for hospitalized patients and those patients' primary care providers (PCPs) is often suboptimal, which can lead to diminished health care quality and safety. It is unclear what hospital information PCPs would find most valuable in their patients' continuing care, as is how and when they would prefer to receive such information.Using the modified Delphi survey methodology, we developed a consensus list of information items PCPs want to receive about their hospitalized patients, using general internists and family physicians considered experts in primary care. Panelists rated items on a 5-point Likert scale signifying their level of agreement with the information's importance and with the information communication mode. Consensus agreement or disagreement was determined using 95% confidence intervals.Twelve physicians (five family physicians, seven general internists), averaging 19.6 years of primary care experience, participated in Delphi round 1; 41.6% (37 of 89) of the items were accepted by consensus, one item was rejected (receiving daily progress notes), and the remaining 51 items were equivocal. In round 2, nine physician panelists participated (four family physicians, five general internists), and six additional items were accepted. They generally preferred notification at the patient's first hospital interaction and at discharge. No consensus was found regarding communication mode; e-mail was most favored.We found broad areas of consensus regarding information PCPs wish to receive about their hospitalized patients that are generally consistent with previous surveys. Our findings also suggest that physicians are becoming more comfortable with patient-related electronic communications.

Objectives: Emergency department (ED) length of stay (LOS) is a quality of care measure and, when prolonged, contributes to ED crowding. Bronchiolitis, a common seasonal illness of infants, provides an opportunity to examine factors affecting ED LOS. Methods: We analyzed data from a 30-center prospective cohort study of ED patients younger than 2 years with an attending physician diagnosis of bronchiolitis to determine what factors affect LOS. Researchers conducted a structured interview and chart review. Results: Among 1459 children enrolled, ED LOS was available for 1416 children (97%). The median ED LOS was 3.3 hours (interquartile range, 2.3-4.8 hours). Multivariate analysis demonstrated that factors significantly (P < 0.05) associated with ED LOS were larger annual ED visit volume (reference, lowest tertile [

Recent studies suggest a possible role for low ultraviolet radiation exposure and low vitamin D status as a risk factor for food allergy. We hypothesized that children born in autumn/winter months (less sun exposure) might have higher food allergy rates than those born in spring/summer.We compared IgE-mediated food allergy rates by season of birth in 835 children aged 0-4 yr assessed 1995-2009 in a specialist referral clinic, using population births as controls. To address potential concerns about generalizability, we also examined national prescriptions for adrenaline autoinjectors (2007) and infant hypoallergenic formula (2006-2007).Although live births in the general ACT population showed no seasonal pattern (50% autumn/winter vs. 50% spring/summer), autumn/winter births were more common than spring/summer births among food allergy patients (57% vs. 43%; p0.001). The same seasonal pattern was observed with peanut (60% vs. 40%; p0.001) and egg (58% vs. 42%; p = 0.003). Regional UVR intensity was correlated with relative rate of overall food allergy (β, -1.83; p = 0.05) and peanut allergy (β, -3.27; p = 0.01). National data showed that autumn/winter births also were more common among children prescribed EpiPens (54% vs. 46%; p0.001) and infant hypoallergenic formula (54% vs. 46%; p0.001).The significantly higher rates of food allergy in children born autumn/winter (compared to spring/summer), the relationship between relative food allergy rates and monthly UVR, combined with national adrenaline autoinjector and infant hypoallergenic formula prescription data, suggest that ultraviolet light exposure/vitamin D status may be one of many potential factors contributing to childhood food allergy pathogenesis.

Food-induced anaphylaxis may be more difficult to recognize in younger children. We describe age-related patterns in the clinical presentation of children with anaphylaxis, which may facilitate the early recognition and treatment of this potentially life-threatening condition.

Background Guidelines do not provide specific hospitalization criteria for patients presenting to the emergency department (ED) with food-related allergic reactions. Objective To determine predictors of hospital admission for ED patients with food-related allergic reactions. Methods We performed a medical record review at 3 academic centers of patients presenting to the ED for food-related allergic reactions ( International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.0, 995.1, 995.3, 995.7, 995.60–995.69, 558.3, 692.5, and 708.X) between January 1, 2001, and December 31, 2006. We focused on patient demographics, medical history, food triggers, clinical presentation, pre-ED and ED management with a specific focus on epinephrine treatment, and disposition. Predictors of hospital admission were determined using multivariable logistic regression. Results Through random sampling and appropriate weighting, the 1,112 cases reviewed represented a study cohort of 2,583 patients. Most patients (80%) were discharged from the ED. The age and sex of patients admitted to the hospital and those discharged were similar. Multivariable analysis identified 3 factors associated with a higher likelihood of hospital admission: meeting the criteria for food-related anaphylaxis (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.23–4.33), pre-ED epinephrine treatment (OR, 6.65; 95% CI, 3.04–14.57), and epinephrine treatment within 1 hour of ED triage (OR, 3.78; 95% CI, 1.68–8.50). Patients with food-related allergic reactions triggered by shellfish were less likely to be admitted to the hospital (OR, 0.23; 95% CI, 0.08–0.68). Conclusions Most patients presenting to the ED with food-related allergic reactions are discharged. Several patient factors were independently associated with hospital admission in ED patients with food-related allergic reactions.

Data are sparse on epinephrine treatment for stinging insect hypersensitivity (SIH) reactions.To establish the frequency of receiving more than 1 dose of epinephrine in patients presenting to the emergency department (ED) with SIH reactions.We performed a medical record review of all 153 patients with SIH reactions presenting to 3 EDs in Boston, Massachusetts, between January 1, 2001, and December 31, 2006. Patients were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (989.5, 995.0, and 995.3). We focused on clinical presentations and treatments, including epinephrine treatments given before and during the ED visit.The cohort was 54% male, with a median age of 33 years. Bees were the most frequently reported triggering insect (74%). A total of 59% of patients experienced large local reactions, whereas 36% had systemic reactions (10% cutaneous systemic and 26% anaphylaxis). The remaining 5% presented with normal local reactions to insect stings. Among patients with systemic reactions, 82% were stung within 3 hours of arrival at the ED. Most (60%) received treatments before arrival at the ED, including 26% who received epinephrine. While in the ED, these patients received antihistamines (76%), systemic corticosteroids (55%), and epinephrine (9%). Overall, 35% of patients with systemic reactions received epinephrine, and among this subset, 16% received more than 1 dose. Most patients with systemic reactions (67%) were discharged to home. At ED discharge, 68% received a prescription for self-injectable epinephrine, but only 11% had documentation of referral to an allergist.Among patients with systemic SIH reactions who received epinephrine, 16% received a second dose. Physicians should consider prescribing 2 doses of self-injectable epinephrine for patients at risk for systemic SIH reactions.

Background The safety of inhaled long-acting β 2 -agonists (LABAs) in the treatment of chronic asthma remains controversial and has not been evaluated in emergency department (ED) patients with acute asthma. Objective To determine whether ED patients undergoing long-term LABA therapy would have increased risk of asthma-related hospitalization compared with those not undergoing LABA therapy and whether concurrent long-term inhaled corticosteroid (ICS) therapy would mitigate this risk. Methods Prospective cohort study of patients aged 12 to 54 years with acute asthma in 115 EDs. Four patient groups were created based on their asthma regimen: no ICS or salmeterol (group A), salmeterol monotherapy (group B), ICS monotherapy (group C), and combination ICS and salmeterol (group D). Results Of the 2,236 included patients, group A had 1,221 patients (55%), group B had 48 patients (2%), group C had 787 patients (35%), and group D had 180 patients (8%); 489 patients (22%) required hospitalization. In a multivariable model controlling for 20 factors and using group A as the reference, group B had an increased risk of hospitalization (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.0–4.9), whereas groups C (OR, 1.1; 95% CI, 0.8–1.5) and D (OR, 1.2; 95% CI, 0.8–1.9) did not. Conclusion Among ED patients with acute asthma, those undergoing salmeterol monotherapy had an increased risk of hospitalization; however, this risk was not seen among patients undergoing combination ICS-salmeterol therapy. Our findings provide data from a unique ED population on clinical response to acute asthma treatment among patients undergoing long-term LABA therapy.

There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post-ED unscheduled visits.The authors conducted a prospective cohort study of patients discharged from 2004 to 2006 at 30 EDs in 15 U.S. states. Inclusion criteria were diagnosis of bronchiolitis, age2 years, and discharge home; the exclusion criterion was previous enrollment. Unscheduled visits were defined as urgent visits to an ED/clinic for worsened bronchiolitis within 2 weeks.Of 722 patients eligible for the current analysis, 717 (99%) had unscheduled visit data, of whom 121 (17%; 95% confidence interval [CI] = 14% to 20%) had unscheduled visits. Unscheduled visits were more likely for children age2 months (11% vs. 6%; p = 0.04), males (70% vs. 57%; p = 0.007), and those with history of hospitalization (27% vs. 18%; p = 0.01). The two groups were similar in other demographic and clinical factors (all p0.10). Using multivariable logistic regression, independent predictors of unscheduled visits were age2 months, male, and history of hospitalization.In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization.

OBJECTIVE: We sought to establish the frequency of receiving >1 dose of epinephrine in children who present to the emergency department (ED) with food-related anaphylaxis. PATIENTS AND METHODS: We performed a medical chart review at Boston hospitals of all children presenting to the ED for food-related acute allergic reactions between January 1, 2001, and December 31, 2006. We focused on causative foods, clinical presentations, and emergency treatments. RESULTS: Through random sampling and appropriate weighting, the 605 reviewed cases represented a study cohort of 1255 patients. These patients had a median age of 5.8 years (95% confidence interval [CI]: 5.3–6.3), and the cohort was 62% male. A variety of foods provoked the allergic reactions, including peanuts (23%), tree nuts (18%), and milk (15%). Approximately half (52% [95% CI: 48–57]) of the children met diagnostic criteria for food-related anaphylaxis. Among those with anaphylaxis, 31% received 1 dose and 3% received >1 dose of epinephrine before their arrival to the ED. In the ED, patients with anaphylaxis received antihistamines (59%), corticosteroids (57%), epinephrine (20%). Over the course of their reaction, 44% of patients with food-related anaphylaxis received epinephrine, and among this subset of patients, 12% (95% CI: 9–14) received >1 dose. Risk factors for repeat epinephrine use included older age and transfer from an outside hospital. Most patients (88%) were discharged from the hospital. On ED discharge, 43% were prescribed self-injectable epinephrine, and only 22% were referred to an allergist. CONCLUSIONS: Among children with food-related anaphylaxis who received epinephrine, 12% received a second dose. Results of this study support the recommendation that children at risk for food-related anaphylaxis carry 2 doses of epinephrine.

There is little information on the regional distribution of anaphylaxis in Australia.To examine the influence of latitude (a marker of sunlight/vitamin D status) as a contributor to anaphylaxis in Australia, with a focus on children from birth to the age of 4 years.Epinephrine autoinjector (EpiPen) prescriptions (2006-2007) in 59 statistical divisions and anaphylaxis hospital admission rates (2002-2007) in 10 regions were used as surrogate markers of anaphylaxis.EpiPen prescription rates (per 100,000 population per year) were higher in children from birth to the age of 4 years (mean, 951) than in the overall population (mean, 324). In an unadjusted model of children from birth to the age of 4 years, decreasing absolute latitude was associated with a decrease in EpiPen prescription rates, such that rates were higher in southern compared with northern regions of Australia (beta, -44.4; 95% confidence interval, -57.0 to -31.8; P.001). Adjusting for age, sex, ethnicity, indexes of affluence, education, or access to medical care (general, specialist allergy, or pediatric) did not attenuate the finding (beta, -51.9; 95% confidence interval, -71.0 to -32.9; P.001). Although statistical power was limited, anaphylaxis admission rates (most prominent in children aged 0-4 years) showed a similar south-north gradient, such that admission rates were higher in southern compared with northern regions of Australia.EpiPen prescription rates and anaphylaxis admissions are more common in southern regions of Australia. These data provide additional support for a possible role of vitamin D in the pathogenesis of anaphylaxis.

Background Epinephrine auto-injectors provide life-saving prehospital treatment for individuals experiencing anaphylaxis in community settings. Objective To determine the number, demographics, and associated circumstances and outcomes of unintentional injections from epinephrine auto-injectors. Methods We searched the databases of the American Association of Poison Control Centers and the Food and Drug Administration's Safety Information and Adverse Event Report System for these incidents as reported by members of the public and by health care professionals. Results From 1994 to 2007, a total of 15,190 unintentional injections from epinephrine auto-injectors were reported to US Poison Control Centers, 60% of them from 2003 to 2007. Those unintentionally injected had a median age of 14 years (interquartile range, 8-35), 55% were female, and 85% were injected in a home or other residence. Management was documented in only 4101 cases (27%), of whom 53% were observed without intervention, 29% were treated, 13% were neither held for observation nor treated, and 4% refused treatment. In contrast, from 1969 to 2007, only 105 unintentional injections from epinephrine auto-injectors were reported to MedWatch. Forty percent of these occurred during attempts to treat allergic reactions. Injuries resulting in permanent sequelae were rarely reported to either US Poison Control Centers or to MedWatch. Conclusion The number of reported unintentional injections from epinephrine auto-injectors increased annually from 1994 to 2007. To prevent these unintentional injections, improved epinephrine auto-injector design is needed, along with increased vigilance in training the trainers and in training and coaching the users, as well as efforts to increase public awareness of the role of epinephrine auto-injectors in the first-aid treatment of anaphylaxis in the community.

To determine the prevalence of obesity among children presenting to the emergency department (ED) with acute asthma, and to examine the relationship between body mass index (BMI) and acute asthma severity in the ED setting. We analyzed data from a multicenter prospective cohort study during 1997-1998; 44 ED in 17 US states and two Canadian provinces enrolled 672 patients, age 5-17, with acute asthma. BMI and Pulmonary Index were collected in the ED. We defined overweight and obesity using age, sex, and race-specific BMI values from national and international databases. The prevalence of obesity was significantly higher among ED patients with acute asthma as compared with children from the general population (23% vs. 9-15%; p0.001). Obese children with acute asthma did not differ from their non-obese counterparts, by demographic factors or chronic asthma severity (all p0.2). Initial Pulmonary Index was the same across underweight, intermediate, and obese groups (3.7 +/- 2.4, 3.8 +/- 2.2, 3.7 +/- 2.3; p = 0.70). Admission status also did not vary across groups (22%, 22% and 23%; p = 0.98). Stratifying the analysis by age group and sex did not change these results. The prevalence of obesity among children presenting to the ED with acute asthma was significantly higher compared with children from the general population. BMI was not associated with markers of chronic and acute asthma severity. The results of this study support a positive association between obesity and asthma, and suggest that asthma exacerbations among obese children are very similar to those experienced by other children.

Chronic wounds such as diabetic foot ulcers, venous ulcers, and pressure ulcers are a major source of morbidity and mortality. To describe wound characteristics associated with a wound emergency, the Wound Electronic Medical Records (WEMR) of 200 consecutive admissions (139 patients, average number of admissions 1.4) to a dedicated inpatient wound healing unit over a period of 5 months were retrospectively reviewed. Patient mean age was 62 +/- 16 years, 59% were men, 27% had a foot ulcer and diabetes mellitus, and 29% had venous ulcers. Presenting signs and symptoms included wound pain, cellulitis, nonpurulent drainage, and undermining, but few presented with classic local clinical signs of infection. Treatment consisted of sharp debridement with deep tissue culture and pathology from the wound base and/or systemic antibiotics. Twenty-percent (20%) of patients had pathology-confirmed and 38% had pathology- or radiology-confirmed osteomyelitis on admission, supporting that new or increasing wound pain, cellulitis, and/or nonpurulent drainage or presence of significant undermining may be indicative of an invasive infection and that patients presenting with these signs and symptoms require an immediate treatment plan and consideration of hospital admission. Use of an objective documentation system such as the WEMR may help alert clinicians to subtle wound changes that require aggressive treatment; thereby, avoiding emergency room visits and hospital admissions. Future research is needed utilizing the WEMR across multiple medical centers to further define criteria for a chronic wound emergency.

Most studies of anaphylaxis in the community focus on persons at risk who might, or might not, have experienced anaphylaxis.We sought to focus on survivors of anaphylaxis in the community and their experiences in using, or not using, an epinephrine autoinjector for first-aid treatment.An e-mail survey was conducted. Responses were anonymous and could not be traced to any person or location. Anaphylaxis was defined as the most severe sudden-onset allergic reaction ever experienced by the participants or a person for whom they were responsible (eg, a child). There were 17 core multiple-choice questions for all participants, with 16 additional questions for users who injected epinephrine either into themselves or someone else, and 1 additional question for nonusers.Of the 1885 participants, 500 (27%) were epinephrine users, and 1385 (73%) were nonusers. The groups were similar with regard to multisystem organ involvement (82% vs 78%, P = .07) and many other aspects of anaphylaxis; however, epinephrine users were more likely (all P.05) to report respiratory or shock symptoms; to report peanut, fish, or insect sting triggers; to be asthmatic; and to have taken or been given asthma medication on the day of the episode. Epinephrine users reported problems in deciding whether to give the injection, repeat the dose, and/or go to an emergency department. Nonusers reported not injecting epinephrine for various reasons, including use of an H(1)-antihistamine (38%), no prescription for epinephrine (28%), and/or a mild anaphylaxis episode (13%).In a unique population composed of 1885 survivors of anaphylaxis in the community, users of epinephrine autoinjectors for first-aid treatment were outnumbered by nonusers. The insights reported by epinephrine users and the reasons why nonusers did not inject epinephrine are documented.

Background Since 2001, Massachusetts state law dictates that emergency department (ED) patients with limited English proficiency have the right to a professional interpreter. Methods one year later, for two 24-h periods, we interviewed adult patients presenting to four Boston EDs. We assessed language barriers and compared this need with the observed use and type of interpreter during the ED visit. Results We interviewed 530 patients (70% of eligible) and estimated that an interpreter was needed for 60 (11%; 95% confidence interval, 7–12%) patients. The primary interpreter for these clinical encounters was a physician (30%), friend or family member age ≥18 years (22%), hospital interpreter services (15%), younger family member (11%), or other hospital staff (17%). Conclusions We found that 11% of ED patients had significant language barriers, but use of professional medical interpreters remained low. One year after passage of legislation mandating access, use of professional medical interpreters remained inadequate.

INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.OBJECTIVES: To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.METHODS: A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.RESULTS: Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; PCONCLUSIONS: Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

The objective of this study is to determine the prevalence of respiratory syncytial virus (RSV) and other viral respiratory pathogens in emergency department (ED) patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). COPD patients presenting to the ED with

OBJECTIVE. Bronchiolitis is the leading cause of hospitalization for infants. Our objective was to identify factors associated with safe discharge to home from the emergency department. METHODS. We conducted a prospective cohort study during 2 consecutive bronchiolitis seasons, from 2004 to 2006. Thirty US emergency departments contributed data. All patients were RESULTS. Of 1456 enrolled patients, 837 (57%) were discharged home from the emergency department. The following factors predicted safe discharge to home: age of ≥2 months, no history of intubation, a history of eczema, age-specific respiratory rates ( CONCLUSIONS. This large multicenter study of children presenting to the emergency department with bronchiolitis identified several factors associated with safe discharge, including cut points for respiratory rate and oxygen saturation. Although the low-risk model requires further study, we believe that it will assist clinicians evaluating children with bronchiolitis and may help reduce some unnecessary hospitalizations.

Objective To estimate the prevalence and demographic disparities in limited numeracy among emergency department (ED) patients. Methods We performed two cross-sectional studies of ED patients with sub-critical illness in 2000–2001 and 2006. We enrolled 959 adult patients from 28 EDs in 17 US states and measured numeracy based on four validated questions. Results Rates of correct responses for individual numeracy questions ranged from 15% to 68%; only 11% of participants answered all questions correctly. Several demographic characteristics were independently associated with frequency of correct answers, including age (OR 0.92 [95% confidence interval (CI), 0.87–0.97] per ↑5 years), race/ethnicity (compared to whites: OR 0.35 for blacks [95%CI, 0.20–0.63]; and OR 0.36 for Hispanics [95%CI, 0.19–0.69]), education (OR 4.74 [95%CI, 2.01–11.14] for high school graduates vs. not), health insurance (OR 1.70 [95%CI, 1.06–2.71] for those with private insurance vs. not), and income (OR 1.13 [95%CI, 1.05–1.22] per ↑$10,000). Conclusion We found a higher prevalence of limited numeracy among ED patients compared to the general population. Significant demographic disparities are consistent with previous observations for general health literacy. Practice implications Greater understanding of the high prevalence of limited numeracy may guide healthcare providers to simplify messages and communicate health information more effectively.

Background Research on the use of more than 1 dose of epinephrine in the treatment of food-induced anaphylaxis is limited. Objective To perform a medical record review to examine the frequency of repeated epinephrine treatments in patients presenting with food-induced anaphylaxis to the emergency department (ED). Methods We reviewed 39 medical records of patients who presented with food-induced allergic reactions to the Massachusetts General Hospital ED during a 1-year period. The analysis focused on the timing of the onset of symptoms and on the number of epinephrine treatments given before and during the ED visit. Results Of the 39 patients, 34 had an acute food-induced allergic reaction. Nineteen had anaphylaxis. Twelve patients with anaphylaxis (63%; 95% confidence interval, 38%-84%) received at least 1 dose of epinephrine, and 3 (16%; 95% confidence interval, 3%-40%) were given 2 doses. Although statistical analysis was not possible, repeated epinephrine treatment occurred in patients with anaphylaxis to peanut or tree nut and hypotension. There was no apparent association between time from ingestion of the causative agent to epinephrine treatment(s). Conclusions Of patients presenting to the ED with food-induced anaphylaxis, approximately 16% were treated with 2 doses of epinephrine. This study supports the recommendation that patients at risk for food-induced anaphylaxis carry 2 doses of epinephrine. Further study is needed to confirm these results and to expand them to patients who do not present to the ED because that group may have a lower frequency of epinephrine use.

Planning for emergency department (ED)-initiated interventions for mood disorders requires confirmation of prevalence data, identification of predictors, and an assessment of patient interest in such interventions.For two 24-h periods, consecutive patients aged 18+ years presenting to four Boston EDs were enrolled. We collected data on demographics, medical history, psychiatric history, healthcare utilization, depressive symptoms, manic symptoms and interest in hypothetical ED-initiated interventions. Patients with severe illness, altered mental status or severe emotional disturbance were excluded.Of 476 screened patients, 152 (32%; 95% CI, 28-36%) screened positive for depression and 17 (4%; 95% CI, 2-6%) for mania. Depressed patients were more likely than nondepressed patients (all P.01) to have income20,000/year (43% vs. 25%), a substance abuse history (19% vs. 5%), a chronic medical condition (67% vs. 53%), use tobacco (42% vs. 22%), have at least one ED visit in the past 6 months (76% vs. 56%) and have at least one hospitalization for substance abuse in the past 6 months (5% vs. 1%). About 50% of patients who screened positive for any mood disorder were interested in at least one ED-based intervention.ED patients screening positive for mood disorder symptoms are likely to have complex psychiatric, medical and social histories, which will be necessary to take into account when designing ED-initiated interventions.

Objective Monthly palivizumab injections from November to March decrease risk of respiratory syncytial virus (RSV)-related hospitalization during RSV season in high-risk infants born less than 35 weeks of gestation. Our objective was to investigate compliance with the American Academy of Pediatrics (AAP) recommendations for palivizumab prophylaxis among children who present to the emergency department (ED) with bronchiolitis. Methods Seventeen centers, from 9 US states, performed a prospective, observational study of ED patients less than 2 years with an attending physician diagnosis of bronchiolitis. Researchers conducted a structured interview, followed by a chart review, and a 2-week follow-up phone call. Results Of 825 eligible children, 624 (73%) were enrolled. According to AAP recommendations, 35 children (6%) should have received palivizumab, but only 17 (49%; 95% confidence interval, 31%-66%) did. Prophylaxis with palivizumab did not differ by US region (P > 0.50). The ED clinical presentations were similar when comparing those children that did and did not receive prophylaxis (all P > 0.27). Those receiving palivizumab were more likely to come to the ED using systemic corticosteroids (22% vs 7%; P = 0.003) and to be treated with corticosteroids in the ED (31% vs 15%; P = 0.02). The 2 groups were at similar risk of hospitalization (52% vs 39%; P = 0.11). Conclusions According to parental report, only half of children presenting to the ED with bronchiolitis who met AAP criteria for palivizumab prophylaxis received this monoclonal antibody. Emergency department visits provide an untapped opportunity for staff to educate families and communicate with PCPs about RSV prophylaxis.

Background The clinical epidemiology of acute allergic reactions in the emergency department (ED) is uncertain. Objectives To characterize ED visits for acute allergic reactions and to evaluate national trends in ED management. Methods The National Hospital Ambulatory Medical Care Survey was used to identify a nationally representative sample of ED visits between 1993 and 2004. Cases with a diagnosis of acute allergic reaction were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (9950, 9951, 9952, 9953, 9956). Results A total of 12.4 million allergy-related ED visits occurred from 1993 to 2004, representing 1.0% (95% confidence interval, 0.93%-1.10%) of all ED visits or 1.03 million ED visits per year. The number of allergy-related ED visits remained relatively stable, averaging 3.8 per 1,000 US population per year (95% confidence interval, 3.4–4.1; P for trend=.39). Although 63% of all visits were coded as urgent, only 4% required hospitalization. Anaphylaxis coding was rare (1%). ED staff prescribed medications in 87% of visits, especially histamine 1 blockers (62%; P for trend=.29). Increases were noted from 1993 to 2004 for corticosteroids (22% to 50%; P 2 blockers (7% to 18%; P P = .008). Epinephrine use was infrequent and declining (19% to 7%; P = .04). Conclusion Between 1993 and 2004, significant variability has occurred in ED management of acute allergic reactions.

BackgroundIt remains unclear whether the quality of acute asthma care in US emergency departments (EDs) has improved over time.ObjectivesWe investigated changes in concordance of ED asthma care with 2007 National Institutes of Health guidelines, identified ED characteristics predictive of concordance, and tested whether higher concordance was associated with lower risk of hospitalization.MethodsWe performed chart reviews in ED patients aged 18 to 54 years with asthma exacerbations in 48 EDs during 2 time periods: 1997-2001 (2 prior studies) and 2011-2012 (new study). Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores at the patient and ED levels; these scores ranged from 0 to 100.ResultsThe analytic cohort comprised 4039 patients (2119 from 1997-2001 vs 1920 from 2011-2012). Over these 16 years, emergency asthma care became more concordant with level A recommendations at both the patient and ED levels (both P < .001). By contrast, concordance with non-level A recommendations (peak expiratory flow measurement and timeliness) decreased at both the patient (median score, 75 [interquartile range, 50-100] to 50 [interquartile range, 33-75], P < .001) and ED (mean score, 67 [SD, 7] to 50 [SD, 16], P < .001) levels. Multivariable analysis demonstrated ED concordance was lower in Southern and Western EDs compared with Midwestern EDs. After adjusting for severity, guideline-concordant care was associated with lower risk of hospitalization (odds ratio, 0.37; 95% CI, 0.26-0.53).ConclusionsBetween 1997 and 2012, we observed changes in the quality of emergency asthma care that differed by level of guideline recommendation and substantial interhospital and geographic variations. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations.

Background The epidemiology of anaphylaxis is uncertain, especially its geographic distribution. Objective To address this deficit, we examined regional rates of EpiPen prescriptions in the United States. Methods EpiPen prescriptions in 2004 were obtained for all 50 states and Washington, DC, from NDCHealth, Pharmaceutical Audit Suite (Alpharetta, Ga). Data included the number of total filled prescriptions, including refills, and the actual number of EpiPens prescribed. Several data sets were used to obtain state-specific populations, as well as multiple demographic, health, and weather characteristics. State population was used to calculate the average number of prescriptions written per person. Results Overall, there were 1,511,534 EpiPen prescriptions filled during 2004. These prescriptions accounted for 2,495,188 EpiPens. On average, there were 5.71 EpiPens prescribed per 1000 persons. Massachusetts had the highest number of prescriptions per 1000 persons (11.8), whereas Hawaii had the lowest (2.7). In addition to state-to-state variation, there was an obvious regional difference: New England (Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine) had the highest values, with 8 to 12 EpiPen prescriptions per 1000 persons, whereas the southern states (between and including California and Mississippi) had only 3 prescriptions per 1000 persons. The New England finding persisted even when controlling for all available factors (eg, population demographic characteristics, number of health care providers, prescriptions for other medications). Conclusion A strong north-south gradient was observed for the prescription of EpiPens in the United States, with the highest rates found in New England. Clinical implications The regional differences in EpiPen prescribing may provide important etiologic clues (vitamin D status) and merit further investigation.

Study objective Emergency departments (EDs) provide round-the-clock emergency care but also serve as a health care "safety net." We seek to determine the number, distribution, and characteristics of US EDs, with a long-term goal of improving access to emergency care. Methods We created an inventory of nonfederal nonspecialty US hospitals using 2001 data from 2 independent sources. Hospitals that did not report ED visit data, or with large changes in visit volume by 2003, were contacted to obtain or verify visit volume (n=437; 9% of all hospitals). EDs were divided into 2 groups: those with at least 1 patient per hour, 24 hours per day, 7 days per week (≥ 8,760 visits/year) and those with fewer visits. Results Of 4,917 hospitals, 4,862 (99%) reported an ED. These EDs collectively received 101.6 million visits. One in 3 EDs (n=1,535) received less than 8,760 visits per year; the national median was 15,711 visits per year. Excluding the low-volume EDs, the remaining 3,327 reported 95.2 million annual visits. The typical higher-volume ED received approximately 28,000 visits per year; 28% (n=922) were in a nonurban setting. Among all EDs, per-capita visits varied by state, with the highest ED visit rates in Washington, DC; West Virginia; and Mississippi. Conclusion Significant variation exists in the distribution and use of US EDs. One third of EDs have an annual visit volume less than 8,760 and, together, they account for 6% of all visits. The United States should consider classifying EDs, as it does trauma centers, to clarify the type of care available in this heterogeneous clinical setting and the distribution of different types of EDs.

Objective Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations. Methods We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later. Results Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit. Conclusion An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.

Objective: We sought to derive preliminary estimates of the prevalence of bipolar disorder among a sample of emergency department (ED) patients. Method: For 1 week in November 2003, consecutive patients aged ≥ 18 years presenting to an urban ED between 8:00 a.m. and midnight were screened for bipolar disorder. We used the National Depression Screening Day protocol, which includes the Mood Disorder Questionnaire. Patients who were severely ill or who had altered mental status were excluded. Demographic factors, past mental health history, and medical history also were assessed. Results: Of the 212 patients that were approached and eligible, 182 (86%) were enrolled. Our sample's point prevalence for positive screen for bipolar disorder was 6.6% (95% CI = 3.5% to 11.2%). Conclusion: Nearly 7% of ED patients screened positive for bipolar disorder, which is considerably higher than community estimates of 1.3%. Further prospective research on bipolar disorders among ED patients is needed to further define the scope of the problem and to inform the development of appropriate screening, assessment, and intervention programs.

Purpose Approximately 4500 Americans die from asthma each year. Our objective was to determine the feasibility of creating a national fatal asthma registry to better understand this problem. Methods Using a standard questionnaire, 18 state vital statistics departments and 22 medical examiner offices were contacted in 2001 to assess availability of fatal asthma data. Funding was obtained in 2002 to implement a fatal asthma registry. During 2003, the project was put on hold due to uncertainty about the impact of HIPAA. The project was revived in 2004 when a standard protocol was submitted to IRBs in four different states. Results All vital statistics departments reported that they were able to identify the decedent's name and demographic characteristics. Contact information for a relative or doctor was available in all states. Demographic characteristics and autopsy findings were available from 100% of the Medical Examiner's offices. In late 2003, investigators in Massachusetts met with their IRB Chair and made two detailed revisions of the protocol, which resulted in local IRB approval of a protocol with methods that complied with HIPAA guidelines, as interpreted by the IRB at their institution. This version was then shared with investigators in three other states. Even after extensive review and approval in Massachusetts, and close contact between investigators at each site and their local IRB, there was an average of two revisions required at the other three participating sites before approval was obtained. Based on different interpretations of HIPAA, each IRB required major protocol modifications, including language and approach for contacting next of kin. Conclusion Availability of demographic and clinical data across states is consistent. The creation of a national fatal asthma registry appears feasible, but different IRB interpretations of what is permissible preclude a standard approach across states.

To describe acute asthma in younger versus older adults presenting to the emergency department (ED).Prospective cohort study. Asthmatic adults were divided into three age groups: 18 to 34, 35 to 54, and 55 and older. The analysis was restricted to never smokers and smokers with fewer than 10 pack-years.ED.Two thousand sixty-four patients aged 18 and older with a physician diagnosis of asthma.Medications and peak expiratory flow.There were 1,158 (56%) subjects aged 18 to 34; 777 (37%) aged 35 to 54; and 129 (6%) aged 55 and older. Older patients were most likely to have a primary care provider (65%, 74%, and 91%, respectively; P.001); most were not taking inhaled corticosteroids (39%, 55%, and 48%, respectively; P.001). Older patients reported fewer ED visits for asthma (2, 2, and 1, respectively; P=.001) but were more likely to report asthma hospitalization (24%, 31%, and 37%, respectively; P.001). All groups had severe exacerbations (initial percentage predicted peak flow: 47, 47, and 47, respectively; P=.50), but older patients were least likely to report severe symptoms (72%, 79%, and 67%, respectively; P=.001). Older patients did not respond as well to bronchodilators, even after controlling for other demographic factors, markers of asthma severity, and ED management (change between initial and final peak expiratory flow, using subjects aged 18 to 34 as reference: aged 35-54, beta=-0.7 (95% CI=-9.4-8.0); agedor = 55, beta=-18.4 (-31.9 to -4.9)). The smaller change in peak expiratory flow contributed most to older patients' greater likelihood of hospitalization.Older asthma patients were less responsive to emergency bronchodilation. This may reflect chronic undertreatment with inhaled corticosteroids.