Sunil Kumar Dhuper

Utility of the modified ATP III defined metabolic syndrome and severe obesity as predictors of insulin resistance in overweight children and adolescents: a cross-sectional study

BackgroundThe rising prevalence of obesity and metabolic syndrome (MetS) has received increased attention since both place individuals at risk for Type II diabetes and cardiovascular disease. Insulin resistance (IR) has been implicated in the pathogenesis of obesity and MetS in both children and adults and is a known independent cardiovascular risk factor. However measures of IR are not routinely performed in children while MetS or severe obesity when present, are considered as clinical markers for IR.ObjectiveThe study was undertaken to assess the utility of ATPIII defined metabolic syndrome (MetS) and severe obesity as predictors of insulin resistance (IR) in a group of 576 overweight children and adolescents attending a pediatric obesity clinic in Brooklyn.MethodsInclusion criteria were children ages 3–19, and body mass index > 95th percentile for age. MetS was defined using ATP III criteria, modified for age. IR was defined as upper tertile of homeostasis model assessment (HOMA) within 3 age groups (3–8, n = 122; 9–11, n = 164; 12–19, n = 290). Sensitivity, specificity, positive predictive values and odds ratios (OR) with 95% confidence intervals (CI) were calculated within age groups for predicting IR using MetS and severe obesity respectively.ResultsMetS was present in 45%, 48% and 42% of the respective age groups and significantly predicted IR only in the oldest group (OR = 2.0, 95% CI 1.2, 3.4; p = .006). Sensitivities were <55%; specificities <63% and positive predictive values ≤ 42% in all groups. Severe obesity was significantly associated with IR in both the 9–11 (p = .002) and 12–18 (p = .01) groups but positive predictive values were nonetheless ≤ 51% for all groups.ConclusionThe expression of IR in overweight children and adolescents is heterogeneous and MetS or severe obesity may not be sufficiently sensitive and specific indicators of insulin resistance. In addition to screening for MetS in overweight children markers for IR should be routinely performed. Further research is needed to establish threshold values of insulin measures in overweight children who may be at greater associated risk of adverse outcomes whether or not MetS is present.

Replacing an Academic Internal Medicine Residency Program With a Physician Assistant—Hospitalist Model: A Comparative Analysis Study

This study describes a comparative analysis of replacing medical residents with physician assistants and hospitalists on patient outcomes in a community hospital. Prospective data during the physician assistants—hospitalists service for 2 years was compared with 2 years of retrospective data of the medical residents model. Outcome measures included mortality, adverse events, readmissions, and patient satisfaction. For physician assistants— hospitalists versus medical residents models, all-cause and case mix index—adjusted mortality was 107/5508 (1.94%) and 0.019 versus 156/5458 (2.85%) and 0.029, respectively (P ≤ .001). The adverse event cases were 9 versus 5 ( P = .29), and the readmission rate within 30 days was 64 versus 69 (P = .34). Patient satisfaction was 95% versus 96% (P = .33). Quality of care provided by the physician assistants—hospitalists model was equivalent. All-cause and case mix index— adjusted mortality was significantly lower during the physician assistants—hospitalists period.Although the application of these findings to other institutions requires further study, the authors found no intrinsic barriers that would impede implementation elsewhere. (Am J Med Qual 2009;24:132-139)

Efficacy and Cost Comparisons of Bronchodilatator Administration Between Metered Dose Inhalers with Disposable Spacers and Nebulizers for Acute Asthma Treatment

BACKGROUND Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice. OBJECTIVES We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population. METHODS This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test. RESULTS Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was

Emergency Department as the Main Source of Asthma Care

10.11 (

Profile of near-fatal Asthma in an inner-city hospital

10.03-

Interface accessory for use with an aerosol inhalation system

10.28) vs.

Aerosol delivery apparatus III

18.26 (

Endotracheal tube with aerosol delivery feature

9.88-

Adapter for use in an aerosol delivery system

22.45) in the spacer and nebulizer groups, respectively (p < 0.001). CONCLUSION There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.

Endotracheal tube with aerosol delivery apparatus II

Many asthma patients use the emergency department (ED) as the sole source of asthma care. This is considered inadequate and poor practice. This prospective study revealed that young age, lack of evening clinic, forgetting to keep the appointment, conflicting priorities of daily life, and easy access to the ED on an as-needed basis for urgent care, medications, and prescriptions, and failure to use inhaled corticosteroids were significant while lack of insurance or access to asthma clinic were not significant factors in exclusive use of the ED. Establishing ED asthma education programs or an after hours asthma clinic may alleviate the practice.