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OBJECTIVE: To explore the relationship between tobacco smoke exposure (reported versus biomarker) and rates of readmission for children hospitalized for asthma.

METHODS: We enrolled a prospective cohort of 774 children aged 1 to 16 years admitted for asthma or bronchodilator-responsive wheezing. The primary outcome was at least 1 asthma- or wheeze-related readmission within 1 year. Caregivers reported any tobacco exposure at home, in a secondary residence, or in the car. We measured serum and saliva cotinine levels with mass spectrometry. We used logistic regression to evaluate associations between tobacco exposure and readmissions.

RESULTS: A total of 619 children had complete tobacco exposure data; 57% were African American and 76% had Medicaid. Seventeen percent of children were readmitted within 1 year. Tobacco exposure rates were 35.1%, 56.1%, and 79.6% by report, serum, and saliva measures, respectively. Caregiver report of any tobacco exposure was not associated with readmission (adjusted odds ratio: 1.18; 95% confidence interval: 0.79-1.89), but having detectable serum or salivary cotinine was associated with increased odds of readmission (adjusted odds ratio [95% confidence interval]: 1.59 [1.02-2.48] and 2.35 [1.22-4.55], respectively). Among children whose caregivers reported no tobacco exposure, 39.1% had detectable serum cotinine and 69.9% had detectable salivary cotinine. Of the children with reported exposure, 87.6% had detectable serum cotinine and 97.7% had detectable salivary cotinine.

CONCLUSIONS: Detectable serum and salivary cotinine levels were common among children admitted for asthma and were associated with readmission, whereas caregiver report of tobacco exposure was not.

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Multiple studies have evaluated capnography for the diagnosis of pulmonary embolism; accordingly, we conduct a meta-analysis of these trials. METHODS: We performed a systematic search from 1990 to 2011, using MEDLINE, EMBASE, and the Cochrane Library, including studies evaluating capnography as a diagnostic tool alone or in conjunction with other tests. After study quality evaluation, we calculated the pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. RESULTS: We included 14 trials with 2,291 total subjects, with a 20% overall prevalence of pulmonary embolism. The pooled diagnostic accuracy for capnography was sensitivity 0.80 (95% confidence interval [CI] 0.76 to 0.83), specificity 0.49 (95% CI 0.47 to 0.51), negative likelihood ratio 0.32 (95% CI 0.23 to 0.45), positive likelihood ratio 2.43 (95% CI 1.70 to 3.46), and diagnostic odds ratio 10.4 (95% CI 6.33 to 17.1). The area under the summary receiver operating characteristic curve was 0.84. To reach pulmonary embolism posttest probabilities less than 1%, 2%, or 5%, pulmonary embolism prevalence or pretest probability had to be less than 3%, 5%, or 10% respectively. Because of interstudy differences in dead space measurements methodologies, the best cutoff in alveolar dead space or end tidal CO2 conferring the best negative likelihood ratio could not be evaluated. CONCLUSION: Pooled data suggest a potential diagnostic role for capnography when the pulmonary embolism pretest probability is 10% or less, perhaps after a positive D-dimer test result.

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There is limited evidence to recommend use of noninvasive positive-pressure ventilation in patients with respiratory failure from severe asthma exacerbations.

Methods

Data Sources

The Cochrane Airways Group searched their specialized register of trials, composed of Central Register of Trials, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, The Allied and Complementary Medicine Database, and PsychINFO, and hand searched respiratory journals and meeting abstracts. Clinical trial registries for ongoing and recently completed studies were included. Manufacturing companies for ventilators were contacted to identify further research studies. The last search was July 2012.

Study Selection

Randomized controlled trials comparing use of usual medical care plus noninvasive positive-pressure ventilation to usual care only in adult patients (aged ≥18 years) with respiratory failure caused by severe asthma exacerbations were analyzed. Studies involving patients with Chronic Obstructive Pulmonary Disease or asthma were included if there were separate data for the patients with asthma. Trials of patients with pneumonia or acute respiratory distress syndrome were not included.

Data Extraction, Measurement, and Synthesis

Three review authors independently reviewed literature to search for studies meeting inclusion criteria. Two review authors extracted data onto standardized forms. Assessment of bias was conducted by grading of allocation sequence generation, allocation concealment, blinding of participants and outcome assessors, incomplete data, and selective outcome reporting and other threats to validity. Continuous outcomes are presented as mean difference with 95% confidence interval (CI). Dichotomous outcomes are presented as relative risk (RR) with 95% CIs. Heterogeneity was assessed with the I2 statistic.

Results : From 746 abstracts, only 5 randomized controlled trials with total of 203 patients were chosen; all patients had acute severe asthma as primary diagnosis. Four of the 5 studies used biphasic positive airway pressure and 1 used continuous positive airway pressure. Two of the studies adjusted respiratory pressure settings according to the patients' clinical parameters, whereas 3 used standardized respiratory pressures. There was no evidence to suggest improved primary outcomes and poor evidence to suggest improved secondary outcomes with noninvasive positive-pressure ventilation ...

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Despite some limitations in current evidence, antibiotics appear to be beneficial for patients with acute exacerbations of chronic obstructive pulmonary disease, particularly those of higher severity. Methods

Data Sources

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, PsycINFO, and ClinicalTrials.gov were searched from inception to April 2012. Abstracts and references were reviewed, and trialists and pharmaceutical companies were contacted for unpublished data.

Study Selection

The authors included randomized controlled trials comparing any antibiotic with placebo for the treatment of acute exacerbations of chronic obstructive pulmonary disease. Studies of patients with asthma, acute bronchitis, pneumonia, or bronchiectasis were excluded.

Data Extraction and Synthesis

Two authors independently screened references and abstracted data. Quality of evidence was determined with domain-based and Grading of Recommendations Assessment, Development and Evaluation approaches. Heterogeneity was expressed with the I2 statistic. Pooled risk ratios, Peto odds ratios, and weighted mean differences were calculated with fixed-effect models. ...