Practice Patterns for Acute Asthma Exacerbation in Adult Patients Admitted to US Intensive Care Units.

RATIONALE: Guidelines recommend systemic corticosteroids and inhaled beta-agonists for patients with severe asthma exacerbation admitted to intensive care units (ICUs). The benefits and utilization of adjunct treatments after guideline recommended first-line treatments have been initiated are unclear. METHODS: Using the Premier Inc. PINC AI multicenter database (2016-2022), we sought to explore the use of adjunct interventions (medications [e.g., magnesium, leukotriene inhibitors, terbutaline, heliox]; and procedures [e.g., invasive and non-invasive mechanical ventilation]) for adult patients admitted to United States (US) ICUs with acute asthma exacerbations. We used hierarchical generalized linear models to calculate risk-adjusted rates of adjunct interventions and quantified between-hospital variation in adjunct interventions using the intraclass correlation coefficient (ICC - higher values correspond to higher between hospital variation). We then used K-means clustering to identify groups of hospitals with similar risk-adjusted practice profiles of all adjunct treatments and examined associations between identified hospital clusters and patient outcomes. RESULTS: We identified 62,392 patients from 961 hospitals for inclusion. Adjunct interventions with the highest between hospital variation after risk-adjustment were heliox (ICC 91%), inhaled steroids (ICC 23%), invasive mechanical ventilation (ICC 21%), terbutaline (ICC 22%), paralytics (ICC 16%), and non-invasive ventilation (ICC 15%). K-means clustering identified two distinct hospital clusters: patients admitted to cluster 1 hospitals (399 hospitals) had higher risk-adjusted rates of non-invasive ventilation (51% vs 33%) compared to patients admitted to cluster 2 hospitals (234 hospitals) which had higher risk-adjusted rates of invasive mechanical ventilation (63% vs 30%). Cluster 2 was associated with fewer hospital free days (beta -0.75 days, CI -0.95, -0.55 days) and increased in-hospital mortality (aOR 1.28, CI 1.17, 1.40). CONCLUSIONS: The use of adjunct interventions for patients with severe asthma exacerbations vary widely across US hospitals; however, hospitals generally fall into two clusters differentiated primarily by the use of invasive or non-invasive mechanical ventilation. Our results help to inform usual care arms of future comparative effectiveness studies and efforts to standardize asthma practice.

Lifestyle changes of a family caring for a 25-year-old quadriplegic man after delayed spinal cord infarction.

Worldwide, 110-190 million people over the age of 15 years are estimated to live with severe disability-a physical state of being defined by the WHO as "the equivalent of disability inferred for conditions such as quadriplegia, severe depression, or blindness." Modes and qualities of disability care undoubtedly vary globally, dependent on income, health infrastructure and culture. Quadriplegia has a unique set of emotional and physical challenges that demand a great deal from care regimens and health systems. This case study examines a specific-and successful-configuration of quadriplegic care in a Druze village in the Golan and looks to the economic, geographic and sociocultural aspects of care.