Judy Maselli

Characterization of Viral Agents Causing Acute Respiratory Infection in a San Francisco University Medical Center Clinic during the Influenza Season

Abstract Background. With use of polymerase chain reaction (PCR) and a centrifugation-enhanced viral culture method, we characterized the viruses causing acute respiratory infection in adults during an influenza season. Methods. During January-March 2002, nasopharyngeal wash specimens from previously healthy adults presenting with respiratory symptoms were evaluated for viral pathogens with centrifugation-enhanced viral culture and PCR. Results The diagnoses in 266 cases included unspecified upper respiratory infection (in 142 [54%] of the cases), acute bronchitis (42 [16%]), sinusitis (23 [9%]), pharyngitis (22 [8%]), and pneumonia (17 [6%]). The use of a shell vial assay and PCR identified a pathogen in 103 (39%) of the patients, including influenza A or B in 54, picornavirus in 28 (including rhinovirus in 24), respiratory syncytial virus (RSV) in 12, human metapneumovirus in 4, human coronavirus OC43 in 2, adenovirus in 2, parainfluenza virus type 1 in 1, and coinfection with influenza and parainfluenza virus type 1 in 2. Conclusion. Our findings demonstrate that, even during the influenza season, rhinovirus and RSV are prevalent and must be considered in the differential diagnosis of adult acute respiratory infection before prescribing antiviral medication. Human coronavirus and human metapneumovirus did not play a substantial role. PCR was an especially useful tool in the identification of influenza and other viral pathogens not easily detected by traditional testing methods.

Obstructive sleep apnea surgery practice patterns in the United States: 2000 to 2006.

OBJECTIVE: To determine obstructive sleep apnea (OSA) surgical volume, types, costs, and trends. To explore whether specific patient and hospital characteristics are associated with the performance of isolated palate versus hypopharyngeal surgery and with costs. STUDY DESIGN: Cross-sectional study. SETTING: Inpatient and outpatient medical facilities in the United States. SUBJECTS AND METHODS: OSA procedures were identified in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for 2000, 2004, and 2006 and from State Ambulatory Surgery Databases and State Inpatient Databases for 2006 from four representative states (California, New York, North Carolina, and Wisconsin). National combined inpatient and outpatient surgery estimates for 2006 were generated using a combination of databases. Chi-square and regression analysis examined procedure volume and type and inpatient procedure costs. RESULTS: In 2006, an estimated 35,263 surgeries were performed in inpatient and outpatient settings, including 33,087 palate, 6561 hypopharyngeal, and 1378 maxillomandibular advancement procedures. The odds of undergoing isolated palate surgery were higher for younger (18–39 yrs) and black patients. Outpatient procedures were more common than inpatient procedures. Inpatient surgical volume declined from 2000 to 2006, but it was not possible to evaluate trends in total volumes. In 2006, mean costs were approximately

Antimicrobial drug prescribing for pneumonia in ambulatory care.

6000 per admission. For inpatient procedures in 2004 and 2006, costs were higher for hypopharyngeal (vs isolated palate) surgery, in rural hospitals, and for patients who were younger, with greater medical comorbidity, and with primary Medicaid coverage. CONCLUSION: Surgical treatment is performed in 0.2 percent of all adults with OSA annually. Validation of the exploratory findings concerning procedure type and cost requires additional studies, ideally including adjustment for clinical factors.

A national depiction of children with return visits to the emergency department within 72 hours, 2001-2007.

Higher levels of fluoroquinolone use were associated with increasing age and later study year.

Health Care as a “Market Good”? Appendicitis as a Case Study

Objectives The objectives of this study were to estimate the frequency of pediatric 72-hour return visits (RVs) to the emergency department (ED) between 2001 and 2007 and to determine demographic and clinical characteristics associated with these RVs. Methods Data from the National Hospital Ambulatory Medical Care Survey between 2001 and 2007 were analyzed to estimate the frequency of RVs to EDs by children. Patient demographics and clinical variables were compared for RVs and non-RVs using the &khgr;2 test; RVs were further characterized using multivariable logistic regression. Results Between 2001 and 2007, there was an annual average of 698,000 RVs by children (2.7% of all ED visits). The RV rate significantly increased from 2001 to 2007. Factors associated with an RV included age younger than 1 year or 13 to 18 years, arrival to the ED between 7 A.M. and 3 P.M., recent discharge from the hospital, and western region of the United States. During ED RVs, a complete blood count was more likely to be obtained, and the patient was more likely to be admitted. Insurance was not associated with an RV to the ED. On RV, patients were less likely to have a diagnosis related to trauma or injury. Conclusions Analysis of the National Hospital Ambulatory Medical Care Survey database offers a national perspective into ED RVs in children. In this era of increasing utilization, these results can help physicians and policy makers address the unique needs of this population and create interventions that will optimize patient service while attempting to control potentially unnecessary RVs.

Complementary and Alternative Medicine Use and Adherence With Pediatric Asthma Treatment

Consumer-driven health care has emerged as a new paradigm in allowing patients to have a stronger say in how their health care dollars are spent.1 Patients are encouraged to consider medical care a commodity that can be bought and sold. Yet health care is a unique industry in which many traditional market principles fail. Consumers of health care do not always have good information about their condition and rely on the advice of professionals. Moreover, studies have shown that total costs and charges at different health care facilities vary substantially for what should be similar services.2 In this study, we analyzed charges for an unpredictable and emergent condition: acute appendicitis. We anticipated that charges would vary significantly in an unpredictable and nonobvious way.

CORRELATION OF PLASMA ANGIOTENSIN II CONCENTRATION AND PLASMA RENIN ACTIVITY DURING ACUTE HYPOXIA IN DOGS

BACKGROUND AND OBJECTIVE: Complementary and alternative medicine (CAM) use for pediatric asthma is increasing. The authors of previous studies linked CAM use with decreased adherence to conventional asthma medicines; however, these studies were limited by cross-sectional design. Our objective was to assess the effect of starting CAM on pediatric adherence with daily asthma medications. METHODS: We used a retrospective cohort study design. Telephone surveys were administered to caregivers of patients with asthma annually from 2004 to 2007. Dependent variables were percent missed doses per week and a previously validated “Medication Adherence Scale score.” Independent variables included demographic factors, caregiver perception of asthma control, and initiation of CAM for asthma. We used multivariate linear regression to assess the relationship between medication adherence and previous initiation of CAM. RESULTS: From our longitudinal data set of 1322 patients, we focused on 187 children prescribed daily medications for all 3 years of our study. Patients had high rates of adherence. The mean percent missed asthma daily controller medication doses per week was 7.7% (SD = 14.2%). Medication Adherence Scale scores (range: 4–20, with lower scores reflecting higher adherence) had an overall mean of 7.5 (SD = 2.9). In multivariate analyses, controlling for demographic factors and asthma severity, initiation of CAM use was not associated with subsequent adherence (P > .05). CONCLUSIONS: The data from this study suggest that CAM use is not necessarily “competitive” with conventional asthma therapies; families may incorporate different health belief systems simultaneously in their asthma management. As CAM use becomes more prevalent, it is important for physicians to ask about CAM use in a nonjudgmental fashion.

Physician Practice Patterns: Chest X-Ray Ordering for the Evaluation of Acute Cough Illness in Adults

1. The effects of isocapnic hypoxia on plasma renin activity (PRA) and angiotensin II (AH) concentration were studied in anaesthetized, artificially ventilated dogs. Regression analysis of plasma All concentration vs PRA, both measured by radio‐immunoassay (RIA), was used as an index of converting enzyme activity in vivo.

Interactions Between Vasopressin and the Renin–Angiotensin System

Objectives. The authors examine which clinical factors contribute to the clinician suspicion of pneumonia, as well as the relationship between clinical factors, clinician suspicion of pneumonia, and ordering chest X-rays (CXR). Methods. Three hundred consecutive adults presenting to the clinic with acute cough in the winter of 2003 were studied. Using standardized encounter forms, data were collected on sociodemographics, illness impact, symptoms, tobacco use, past medical history, vital signs, physical examination findings, chest X-ray result, and clinician diagnoses. Clinicians rated their suspicion of pneumonia on a 5-point Likert scale. Multivariable logistic regression analysis was used to determine independent predictors of clinician suspicion of pneumonia and of ordering of CXRs. Results. Clinician suspicion of pneumonia was low in the majority of patients presenting for evaluation of cough (63%). Higher clinician suspicion of pneumonia was predicted by advanced patient age (odds ratio [OR]: 4.6; 95% confidence interval [CI] [1.2–18.1]), shortness of breath (2.4; [1.0–6.0]), fever (5.5; [1.8–17.5]), tachycardia (3.8; [1.1–13.1]), rales (23.8; [5.7–98.7]), and rhonchi (14.6; [5.2–40.5]). CXRs were ordered in 19% of patients presenting with acute cough. Intermediate clinician suspicion of pneumonia (OR: 7.9; 95% CI: [2.8, 22.5]) (v. low suspicion), advanced patient age ([.greaterequal] 65 years) (9.2; [2.7, 31.6]) (v. ages 18–44 years), and decreased breath sounds on examination (5.1; [1.8, 14.3]) are independent predictors of ordering a CXR. Among patients with a clinical diagnosis of pneumonia (n = 31), CXRs were ordered in only 61%. Conclusions. Advanced patient age and physical findings on chest examination influence clinician practice in obtaining CXRs, beyond their contribution to clinician suspicion of pneumonia. Physicians do not appear to endorse recommendations that the diagnosis of community-acquired pneumonia be based on or confirmed by CXR.

Is emergency department closure resulting in increased distance to the nearest emergency department associated with increased inpatient mortality

Publisher Summary Vasopressin and the renin-angiotensin system interact in two major ways; angiotensin II, the physiologically active component of the renin-angiotensin system, acts centrally to stimulate the release of vasopressin, and vasopressin, in turn, acts on the kidney to inhibit the secretion of renin. This chapter provides an overview of the interactions between vasopressin and the renin-angiotensin system. The chapter also describes the current concepts concerning the site and mechanism of these actions, as well as their physiological significance. The available evidence indicates that vasopressin can suppress renin secretion by a variety of mechanisms. During long-term administration, the suppression appears to be secondary to retention of water and expansion of body fluids. With short-term administration, the suppression of renin secretion may be partly secondary to vasoconstriction; however, other mechanisms almost certainly play a role, because analogs of vasopressin, which lack vasoconstrictor activity, also suppress renin secretion. There is some evidence that vasopressin can inhibit renin secretion by direct action on the juxtaglomerular apparatus; however, the relative importance of these different mechanisms is not clear.