Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.(SFRH/BPD/115169/2016) funded by Fundação para a Ciência e Tecnologia (FCT); ERDF (European Regional Development Fund) through the operations: POCI-01-0145-FEDER-029130 ('mINSPIRERS—mHealth to measure and improve adherence to medication in chronic obstructive respiratory diseases—generalisation and evaluation of gamification, peer support and advanced image processing technologies') cofunded by the COMPETE2020 (Programa Operacional Competitividade e Internacionalização), Portugal 2020 and by Portuguese Funds through FCT (Fundação para a Ciência e a Tecnologia).info:eu-repo/semantics/publishedVersio

Clinical phenotypes associated with impaired response to treatment in children with acute asthma

Asthma comprises inflammation of the airways, characterised by reversible airways obstruction, airway hyper-responsiveness (AHR) and bronchial spasm (Dougherty & Fahy, 2009). Asthma, particularly childhood asthma, is a National Health Priority costing Australia >$606 million annually. First symptoms of asthma usually occur during the first few years of childhood. Of those, a large proportion of children become symptom free by the time they reach school age and the rest continue to develop persistent asthma throughout childhood (Martinez & Vercelli, 2013). This project aims to predict the treatment response by identifying a specific group of children with acute wheezing and asthma who do not respond the treatment well and are likely to relapse and re-present to hospital. The recurrence of hospital presentations was further examined to see whether it is associated with specific asthma phenotypes and potential risk factors

A NICE combination for predicting hospitalisation at the Emergency Department : a European multicentre observational study of febrile children

Funding Information: DB, UB, EC, JD, ME, MF, NH, BK, FMT, HM, EL, ML, MP, IRC, FS, MT, CV, SY, DZ and WZ report grants from the European Union. Horizon 2020 research and innovation programme during the study conduct. FS reports a grant from the Slovenian Research Agency outside the submitted work. Funding Information: MP reports a grant from Pfizer and financial support from Pfizer and Sanofi outside the submitted work. MF reports a grant from CSL Behring outside the submitted work. RN reports a grant from the National Institute for Health Research during the study conduct. ME reports financial support from the National Institute for Health Research Biomedical Research Centre based at Newcastle Hospitals NHS Foundation Trust and Newcastle University ng the study conduct. MT is a member of the Advisory Board of MSD and Pfizer, a member of the National Committee on Immunization Practices and a member of the national Scientific Advisory Group for the management of the pandemic. Publisher Copyright: © 2021 The Author(s)Background: Prolonged Emergency Department (ED) stay causes crowding and negatively impacts quality of care. We developed and validated a prediction model for early identification of febrile children with a high risk of hospitalisation in order to improve ED flow. Methods: The MOFICHE study prospectively collected data on febrile children (0–18 years) presenting to 12 European EDs. A prediction models was constructed using multivariable logistic regression and included patient characteristics available at triage. We determined the discriminative values of the model by calculating the area under the receiver operating curve (AUC). Findings: Of 38,424 paediatric encounters, 9,735 children were admitted to the ward and 157 to the PICU. The prediction model, combining patient characteristics and NICE alarming, yielded an AUC of 0.84 (95%CI 0.83-0.84). The model performed well for a rule-in threshold of 75% (specificity 99.0% (95%CI 98.9-99.1%, positive likelihood ratio 15.1 (95%CI 13.4-17.1), positive predictive value 0.84 (95%CI 0.82-0.86)) and a rule-out threshold of 7.5% (sensitivity 95.4% (95%CI 95.0-95.8), negative likelihood ratio 0.15 (95%CI 0.14-0.16), negative predictive value 0.95 (95%CI 0.95-9.96)). Validation in a separate dataset showed an excellent AUC of 0.91 (95%CI 0.90- 0.93). The model performed well for identifying children needing PICU admission (AUC 0.95, 95%CI 0.93-0.97). A digital calculator was developed to facilitate clinical use. Interpretation: Patient characteristics and NICE alarming signs available at triage can be used to identify febrile children at high risk for hospitalisation and can be used to improve ED flow. Funding: European Union, NIHR, NHS.publishersversionPeer reviewe

Risk factors associated with paediatric unplanned hospital readmissions: A systematic review

Objective To synthesise evidence on risk factors associated with paediatric unplanned hospital readmissions (UHRs). Design Systematic review. Data source CINAHL, EMBASE (Ovid) and MEDLINE from 2000 to 2017. Eligibility criteria Studies published in English with full-text access and focused on paediatric All-cause, Surgical procedure and General medical condition related UHRs were included. Data extraction and synthesis Characteristics of the included studies, examined variables and the statistically significant risk factors were extracted. Two reviewers independently assessed study quality based on six domains of potential bias. Pooling of extracted risk factors was not permitted due to heterogeneity of the included studies. Data were synthesised using content analysis and presented in narrative form. Results Thirty-six significant risk factors were extracted from the 44 included studies and presented under three health condition groupings. For All-cause UHRs, ethnicity, comorbidity and type of health insurance were the most frequently cited factors. For Surgical procedure related UHRs, specific surgical procedures, comorbidity, length of stay (LOS), age, the American Society of Anaesthesiologists class, postoperative complications, duration of procedure, type of health insurance and illness severity were cited more frequently. The four most cited risk factors associated with General medical condition related UHRs were comorbidity, age, health service usage prior to the index admission and LOS. Conclusions This systematic review acknowledges the complexity of readmission risk prediction in paediatric populations. This review identified four risk factors across all three health condition groupings, namely comorbidity; public health insurance; longer LOS and patients<12 months or between 13-18 years. The identification of risk factors, however, depended on the variables examined by each of the included studies. Consideration should be taken into account when generalising reported risk factors to other institutions. This review highlights the need to develop a standardised set of measures to capture key hospital discharge variables that predict unplanned readmission among paediatric patients

Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya

Introduction: Patients’ unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya. Methods: We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya. Results: During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients’ median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=\u3c0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0–5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=\u3c0.001) and ambulatory status (p=0.041). Conclusion: The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment

Reducing attendances and waits in emergency departments : a systematic review of present innovations

Reducing the waits in emergency departments is important for patients and is a government priority. In order to reduce waits the whole system must be considered. The flow of patients before arrival at the emergency department determines the workload of the department. The staffing, resources and systems within the emergency department are key to providing high quality timely care. The flow of patients after leaving the emergency department until their return home will determine whether they can be discharged from the department in a timely manner. Despite the present focus on emergency care in the NHS there have been no reviews of the literature to inform the present changes to reduce waits

Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults

BackgroundThe measurement of severity and control of asthma in both children and adults can be based on subjective or objective measures. It has been advocated that fractional exhaled nitric oxide (FeNO) can be used to monitor airway inflammation as it correlates with some markers of asthma. Interventions for asthma therapies have been traditionally based on symptoms and/or spirometry.ObjectivesTo evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide in comparison to clinical symptoms (with or without spirometry/peak flow) for asthma related outcomes in children and adults.Search strategyWe searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and reference lists of articles. The last search was completed in February 2009.Selection criteriaAll randomised controlled comparisons of adjustment of asthma therapy based on exhaled nitric oxide compared to traditional methods (primarily clinical symptoms and spirometry/peak flow).Data collection and analysisResults of searches were reviewed against pre-determined criteria for inclusion. Relevant studies were independently selected in duplicate. Two authors independently assessed trial quality and extracted data. Authors were contacted for further information with response from one.Main resultsTwo studies have been added for this update, which now includes six (2 adults and 4 children/adolescent) studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cut off levels, the way in which FeNO was used to adjust therapy and duration of study. Of 1053 participants randomised, 1010 completed the trials. In the meta-analysis, there was no significant difference between groups for the primary outcome of asthma exacerbations or for other outcomes (clinical symptoms, FeNO level and spirometry). In post-hoc analysis, a significant reduction in mean final daily dose inhaled corticosteroid per adult was found in the group where treatment was based on FeNO in comparison to clinical symptoms, (mean difference -450 mcg; 95% CI -677 to 223 mcg budesonide equivalent/day). However, the total amount of inhaled corticosteroid used in one of the adult studies was 11% greater in the FeNO arm. In contrast, in the paediatric studies, there was a significant increase in inhaled corticosteroid dose in the FeNO strategy arm (mean difference of 140 mcg; 95% CI 29 to 251, mcg budesonide equivalent/day).Authors' conclusionsTailoring the dose of inhaled corticosteroids based on exhaled nitric oxide in comparison to clinical symptoms was carried out in different ways in the six studies and found only modest benefit at best and potentially higher doses of inhaled corticosteroids in children. The role of utilising exhaled nitric oxide to tailor the dose of inhaled corticosteroids cannot be routinely recommended for clinical practice at this stage and remains uncertain

A matter of life and breath:Children with severe acute asthma admitted to the pediatric intensive care unit

Risk factors, treatment and psychosocial outcomes of children with severe acute asthma admitted to the pediatric intensive care unit