Chu-Lin Tsai

Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies

Background  Breastfeeding is undisputedly preferable to formula feeding for infant nutrition because of its nutritional, immunological and psychological benefits. However, studies on the association between breastfeeding and development of atopic dermatitis (AD) have shown inconsistent results.

Quality of care for acute asthma in 63 US emergency departments

BACKGROUND Little is known about the quality of acute asthma care in the emergency department (ED). OBJECTIVES We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission. METHODS We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance. RESULTS The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (beta-coefficient, -8.2; 95% CI, -13.8 to -2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others. CONCLUSIONS Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

Inappropriate Use of Antibiotics for Acute Asthma in United States Emergency Departments

OBJECTIVES The aim was to examine the use of antibiotics to treat asthma patients in U.S. emergency departments (EDs). The authors sought to investigate inappropriate antibiotic prescriptions by identifying the frequency and predictors of antibiotics prescribed for asthma exacerbations using data from two sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Emergency Department Safety Study (NEDSS). METHODS The authors used data from NHAMCS and NEDSS to identify the proportion of ED visits for asthma exacerbations that resulted in the prescription of an antibiotic. NHAMCS provided national data from 1993 through 2004, while NEDSS provided data from 63 primarily academic EDs from 2003 through 2006. Univariate analysis and multivariate logistic regression modeling were used to identify variables associated with antibiotic administration. RESULTS Analysis of NHAMCS data revealed that 22% (95% confidence interval [CI] = 20% to 24%) of acute asthma visits resulted in an antibiotic prescription from 1993 through 2004, with no significant change in prescribing frequency over the 12-year period. NEDSS data from 2003 through 2006 showed that 18% (95% CI = 17% to 19%) of acute asthma cases in academic EDs received an antibiotic. Multivariate modeling of NHAMCS data revealed that African American patients (odds ratio [OR] = 0.8; 95% CI = 0.6 to 0.97) and patients in urban EDs (OR = 0.5; 95% CI = 0.4 to 0.7) were less likely to receive antibiotics for asthma exacerbations than white patients and patients in nonurban EDs, respectively. NHAMCS analysis also found that patients in the South were more likely to receive antibiotics than those in the Northeast (OR = 1.4; 95% CI = 1.1 to 1.9). A NEDSS multivariate model found a similar difference, with African Americans (OR = 0.6; 95% CI = 0.4 to 0.8) and Hispanics (OR = 0.6; 95% CI = 0.4 to 0.8) being less likely than whites to receive an antibiotic. CONCLUSIONS ED treatment of acute asthma with unnecessary antibiotics is likely to contribute to bacterial antibiotic resistance. Interventions are needed to reduce inappropriate antibiotic prescriptions and to address disparities in asthma care.

The Short-Form Chronic Respiratory Disease Questionnaire was a Valid, Reliable, and Responsive Quality-of-Life Instrument in Acute Exacerbations of Chronic Obstructive Pulmonary Disease

OBJECTIVE To assess the psychometric properties of the short-form chronic respiratory disease questionnaire (SF-CRQ) as a quality-of-life (QOL) instrument in chronic obstructive pulmonary disease (COPD) exacerbations. STUDY DESIGN AND SETTING In a prospective multicenter cohort study, consecutive emergency department (ED) patients with COPD exacerbation were interviewed using the SF-CRQ and other instruments. Baseline information was collected in the ED and from follow-up data 2 weeks later. The results of the SF-CRQ were compared with the results of the other instruments and clinical variables by correlation and factor analyses. RESULTS Of the 301 enrolled patients, 80% reported improvements across each of the domains of the SF-CRQ over the 2-week post-ED period. Overall median changes for the dyspnea, fatigue, emotional function, and mastery domains were 2, 1, 1, and 1.5, respectively (P<0.001 for each domain). Correlation and factor analyses support their convergent/divergent validity and construct validity. The reliability for the change score of the SF-CRQ was high (Cronbachs alpha coefficient, 0.82). Overall minimal clinically important difference for improvement in the SF-CRQ was 1.01 (95% confidence interval, 0.72-1.31). CONCLUSION SF-CRQ is a valid, reliable, and responsive instrument for the assessment of short-term QOL change in patients with COPD exacerbations.

Adjunctive traditional Chinese medicine therapy improves survival in patients with advanced breast cancer: A population-based study

Traditional Chinese medicine (TCM) is one of the most common complementary and alternative medicines used in the treatment of patients with breast cancer. However, the clinical effect of TCM on survival, which is a major concern in these individuals, lacks evidence from large‐scale clinical studies.

Airway surface mycosis in chronic TH2-associated airway disease

BACKGROUND Environmental fungi have been linked to TH2 cell-related airway inflammation and the TH2-associated chronic airway diseases asthma, chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), and allergic fungal rhinosinusitis (AFRS), but whether these organisms participate directly or indirectly in disease pathology remains unknown. OBJECTIVE To determine the frequency of fungus isolation and fungus-specific immunity in patients with TH2-associated and non-TH2-associated airway disease. METHODS Sinus lavage fluid and blood were collected from sinus surgery patients (n = 118) including patients with CRSwNP, patients with CRS without nasal polyps, patients with AFRS, and non-CRS/nonasthmatic control patients. Asthma status was determined from medical history. Sinus lavage fluids were cultured and directly examined for evidence of viable fungi. PBMCs were restimulated with fungal antigens in an enzyme-linked immunocell spot assay to determine total memory fungus-specific IL-4-secreting cells. These data were compared with fungus-specific IgE levels measured from plasma by ELISA. RESULTS Filamentous fungi were significantly more commonly cultured in patients with TH2-associated airway disease (asthma, CRSwNP, or AFRS: n = 68) than in control patients with non-TH2-associated disease (n = 31): 74% vs 16%, respectively (P < .001). Both fungus-specific IL-4 enzyme-linked immunocell spot (n = 48) and specific IgE (n = 70) data correlated with TH2-associated diseases (sensitivity 73% and specificity 100% vs 50% and 77%, respectively). CONCLUSIONS The frequent isolation of fungi growing directly within the airways accompanied by specific immunity to these organisms only in patients with TH2-associated chronic airway diseases suggests that fungi participate directly in the pathogenesis of these conditions. Efforts to eradicate airway fungi from the airways should be considered in selected patients.

Age-related differences in asthma outcomes in the United States, 1988-2006.

BACKGROUND Relatively little is known about the effect of age on asthma outcomes in adults, particularly at a national level. OBJECTIVE To investigate age-related differences in asthma outcomes in a nationally representative, longitudinal study. METHODS We analyzed data from the Third National Health and Nutrition Examination Survey (1988-1994) with linked mortality files through 2006. Adults with physician-diagnosed asthma were identified and were divided into 2 age groups: younger adults (17-54 years of age) and older adults (55 years or older). The outcome measures were both cross-sectional (health care use, comorbidity, and lung function) and longitudinal (all-cause mortality). RESULTS There were an estimated 9,566,000 adults with current asthma. Of these, 73% were younger adults and 27% older adults. Compared with younger adults, older adults had more hospitalizations in the past year, more comorbidities, and poorer lung function (eg, lower forced expiratory volume in 1 second) (P < .05 for all). During a median follow-up of 15 years, significant baseline predictors of higher all-cause mortality included older age (≥55 vs <55 years old: adjusted hazard ratio [HR], 6.77; 95% confidence interval [CI], 3.15-14.54), poor health status (fair and poor vs excellent health status: adjusted HR, 10.07; 95% CI, 3.75-27.01), and vitamin D deficiency (vitamin D level <30 vs ≥50 nmol/L: adjusted HR, 2.19; 95% CI, 1.05-4.58), whereas Mexican American ethnicity (adjusted HR, 0.31; 95% CI, 0.14-0.65) was associated with lower mortality. Controlling for age, asthma was not associated with increased all-cause mortality (adjusted HR, 1.28; 95% CI, 0.99-1.65). CONCLUSION Older adults with asthma have a substantial burden of morbidity and increased mortality. The ethnic differences in asthma mortality and the vitamin D-mortality link merit further investigation.

Safety Climate and Medical Errors in 62 US Emergency Departments

STUDY OBJECTIVE We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs. METHODS We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED. RESULTS We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines. CONCLUSION Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.

Impact of liver cirrhosis on mortality in patients with community-acquired bacteremia

Few studies have analyzed the impact of liver cirrhosis, a clinically significant comorbid medical condition, on the mortality of patients with community-acquired bacteremia. We conducted an observational study of 839 consecutive community-acquired bacteremia patients who were hospitalized through the emergency department (ED). We compared the 30-day mortality of bacteremia patients with and without liver cirrhosis using Cox proportional hazards regression. The probability of survival at day 30 was significantly different for the cirrhotic and noncirrhotic groups (53% versus 82%, respectively; P < 0.001 by the log-rank test). Multivariate analysis indicated that liver cirrhosis was associated with an increased risk of short-term mortality (hazard ratio, 2.0; 95% confidence interval, 1.1-3.5), as well as age, higher comorbidity index, and markers obtained from clinical presentation at ED. In conclusion, in addition to the effects from other prognostic factors, liver cirrhosis has a significant impact on the mortality of patients with community-acquired bacteremia.

Positive Predictive Value of ICD-9-CM Codes to Detect Acute Exacerbation of COPD in the Emergency Department

BACKGROUND Accurate identification of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) visits by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes will help organizations monitor quality of care for this common condition. A study was undertaken to validate ICD-9-CM coding for accurate identification of AECOPD visits. METHODS In a retrospective cohort study at two academic emergency departments (EDs) from July 2005 to June 2006, ICD-9-CM codes 491.2x (obstructive chronic bronchitis), 492.8 (other emphysema), and 496 (chronic airway obstruction, not elsewhere classified) in the principal diagnosis field were used to identify AECOPD visits. A random sample of 100 visits by patients age > or = 55 years of age was selected at each institution, and cases were confirmed by chart review consensus by two emergency physicians. The case definition for AECOPD was current respiratory infection, change in cough, or change in sputum in a patient with physician-diagnosed COPD. RESULTS On the basis of the selection criteria, 644 eligible visits were identified during the study period, and detailed chart review was performed for 200 randomly selected visits. Patients had a median age of 71 years, 50% were female, and 79% were white. Some 193 (97%) of the visits were confirmed to meet the case definition for AECOPD. Most cases were identified with the code 491.2x. All but one of the false positives were coded as 496, presumably because of lack of another billable diagnosis for these visits. DISCUSSION In the first known chart validation of ICD-9-CM codes for identification of AECOPD visits, the proposed ICD-9-CM codes accurately identified cases of AECOPD in the ED. The study contributed to the use of these codes in the National Committee for Quality Assurances new quality indicator for management of AECOPD.