Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis.

OBJECTIVE: Morphine is a long-standing therapy in acute decompensated heart failure (ADHF), despite few supporting data. A study was undertaken to compare the outcomes of patients who did and did not receive morphine for ADHF. METHODS: The study was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE) which enrols hospitalised patients with treatment for, or a primary discharge diagnosis of, ADHF. Patients were stratified into cohorts based on whether or not they received intravenous morphine. ANOVA, Wilcoxon and chi(2) tests were used in univariate analysis, followed by multivariate analysis controlling for parameters previously associated with mortality. Analyses were repeated for ejection fraction subgroups and in patients not on mechanical ventilation. RESULTS: There were 147 362 hospitalisations in ADHERE at December 2004, 20 782 of whom (14.1%) received morphine and 126 580 (85.9%) did not. There were no clinically relevant differences between the groups in the initial age, heart rate, blood pressure, blood urea nitrogen, creatinine, haemoglobin, ejection fraction or atrial fibrillation. A higher prevalence of rest dyspnoea, congestion on chest radiography, rales and raised troponin occurred in the morphine group. Patients on morphine received more inotropes and vasodilators, were more likely to require mechanical ventilation (15.4% vs 2.8%), had a longer median hospitalisation (5.6 vs 4.2 days), more ICU admissions (38.7% vs 14.4%), and had greater mortality (13.0% vs 2.4%) (all p<0.001). Even after risk adjustment and exclusion of ventilated patients, morphine was an independent predictor of mortality (OR 4.84 (95% CI 4.52 to 5.18), p<0.001). CONCLUSIONS: Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.

Observation unit treatment of heart failure with nesiritide: results from the proaction trial.

This was a multicenter, randomized, double-blind, placebo-controlled pilot study, evaluating the safety and efficacy of a standard care treatment regimen with the addition of either nesiritide or placebo (SCP) in 237 Emergency Department (ED)/Observation Unit (OU) patients with decompensated heart failure (HF). Efficacy measures included initial admission, length of hospital stay (LOS), and inpatient rehospitalization through 30 days. Compared to the standard care group, patients who also received nesiritide had 11% fewer inpatient hospital admissions at the index ED visit (55% SCP, 49% nesiritide, p = 0.436), and 57% fewer inpatient hospitalizations within 30 days after discharge from the index hospitalization (23% SCP, 10% nesiritide, p = 0.058). The duration of rehospitalization was shorter for nesiritide patients (median LOS 2.5 vs. 6.5 days, p = 0.032). The incidence of symptomatic hypotension was low and did not differ between the groups. This study showed that nesiritide is safe when used in the emergency department, observation units, or similar settings.

Differences between men and women in reporting of symptoms during an asthma exacerbation.

STUDY OBJECTIVE: Compared with men, women presenting to the emergency department with acute asthma are more likely to be admitted and to have a longer hospital stay. This study compares peak expiratory flow rate (PEFR) with reported symptom severity between men and women with acute asthma. The null hypothesis was that men and women report similar severity symptoms for similar levels of airway obstruction. METHODS: This study combined data from 4 prospective cohort studies performed from 1996 to 1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, investigators at 64 EDs in 21 US states and 4 Canadian provinces provided 24-hour per day coverage for a median of 2 weeks. RESULTS: Of the 1,291 patients with moderate to severe exacerbations (initial percentage of predicted PEFR <80%), 62% were women. Women were more likely than men to report "severe" complaints in terms of symptom frequency, symptom intensity, and resulting activity limitations (all P <.05). Women with moderate exacerbations were especially likely to describe their exacerbation as causing "severe" activity limitations (sex-PEFR interaction, P =.05). CONCLUSION: Men are less likely than women to report severe asthma symptoms and activity limitations in the presence of airway obstruction. This finding supports use of objective measures of airway obstruction when managing patients with asthma so that those whose symptoms do not reflect the severity of their obstruction can be recognized and properly treated. It also reconfirms the need for increased research on differences between men and women in acute asthma.

Normal CK, elevated MB predicts complications in acute coronary syndromes.

The implications of an elevated Creatine kinase (CK)-MB isoenzyme (MB) in suspected acute coronary syndromes, with a normal total CK, is not well established. Despite many guidelines on managing patients with acute coronary ischemia, none indicates strategies for patients with elevated MB and with a normal CK. The outcome consequence of this result is not firmly established. Our objective was to prospectively evaluate outcomes in patients with suspected acute coronary syndromes, normal initial total CK, and increased MB. All Emergency Department patients with suspected acute coronary syndromes and creatinine < 2.0 mg/dL were eligible for study entry. Serial CK and MB fractions were measured on arrival in the Emergency Department, then 8 and 16 h postpresentation. A composite outcome of death, Q-wave myocardial infarction, or revascularization was defined at the index visit and 6 months later. Outcomes were determined by blinded record review and by telephone contact. In the 698 patients entered, the acute composite outcome rate was 25% (175) and 6.3% (44) at 6 months. Acute and 6 month adverse outcome rates were statistically the same for all patients with an elevated MB fraction, regardless of the total CK level. An elevated MB conferred a higher event rate than did a normal MB. We conclude that the adverse event rate for patients with suspected acute coronary syndromes and an elevated MB is the same whether or not the total CK is elevated. These patients should be considered as having had an acute coronary syndrome.

Prospective multicenter study of relapse after treatment for acute asthma among children presenting to the emergency department.

OBJECTIVE: Single-center studies have reported varying relapse rates after treatment of patients with acute asthma. We determined the relapse rate after emergency department (ED) treatment in a cohort of children. DESIGN: This was a prospective inception cohort study performed during 1997-1998. SETTING: The study was performed in 44 EDs including both general and pediatric centers. PATIENTS: Children (n = 1184) aged 2 to 17 years who had been admitted to EDs, with acute asthma restricted to 881 patients discharged from the ED. MAIN RESULTS: Two weeks after discharge, families were telephoned to determine relapse. Follow-up data were available for 762 (86%) of the children with a 10% incidence of relapse. On univariate analysis several factors were associated with relapse including current medications and markers of asthma severity. On multivariate analysis the factors associated with relapse were age (OR 1.4 per 5-year increase), use of second-line asthma medications (OR 3.7), exposure to cigarette smoke (OR 0.5), and ED visits within the past year (OR 1.2 per 5 ED visits). CONCLUSIONS: The incidence of relapse among children is lower than that observed among adults and varies with age. Other risk factors such as frequent ED visits are likely markers of chronic asthma severity. Further research should focus on ways to decrease the relapse rate among patients at high risk.

Women in academic emergency medicine.

OBJECTIVE: To evaluate the achievement of women in academic emergency medicine (EM) relative to men. METHODS: This study was a cross-sectional mail survey of all emergency physicians who were employed at three-fourths full-time equivalent or greater at the 105 EM residency programs in the United States from August 1997 to December 1997. The following information was obtained: demographics, training and practice issues, roles and responsibilities in academic EM, percentage of time spent per week in clinical practice, teaching, administrative and research activities, academic productivity, and funding. RESULTS: Of the 1,575 self-administered questionnaires distributed by the office of the chairs, 1,197 (76%) were returned. Two hundred seventy-four (23%) of the respondents were women, and 923 (77%) were men. There was a significant difference noted between men and women in all demographic categories. The numbers of respondents who were nonwhite were extremely small in the sample and, therefore, the authors are hesitant to draw any conclusions based on race/ethnicity. There was no difference in training in EM between men and women (82% vs 82%, p = 0.288), but a significantly higher proportion of male respondents were board-certified in EM (84% vs 76%, p < 0.002). Women in academic EM were less likely to hold major leadership positions, spent a greater percentage of time in clinical and teaching activities, published less in peer-reviewed journals, and were less likely to achieve senior academic rank in their medical schools. CONCLUSIONS: These findings mirror those of most medical specialties: academic achievement of women in academic EM lags behind that of men. The paucity of minority physicians in academic EM didn't permit analysis of their academic achievements.

Prediction of short- and long-term outcomes by troponin T levels in low-risk patients evaluated for acute coronary syndromes.

STUDY OBJECTIVE: Recent reports suggest a short series of cardiac troponin (cTnT) testing effectively identifies patients at risk for cardiac events. However, there are few studies validating this strategy. The purpose of this study was to determine the ability of cTnT levels to predict short- and long-term outcomes in low-risk patients with suspected acute coronary syndromes. METHODS: This prospective longitudinal study was conducted in a 20-bed emergency department observation unit. Patients at low risk for acute coronary ischemia, with a normal creatine kinase-isoenzyme subunit MB (CKMB) index, were admitted to an observation unit for chest pain evaluation. Serum cTnT levels were measured at baseline and at 4, 8, and 16 hours after admission. The main outcome measures were adverse cardiac events (death, acute myocardial infarction, unstable angina, revascularization) during the index visit and within 6 months after discharge. Using manufacturer's recommendations, the cTnT level was considered abnormal if it exceeded 0.2 microg/L. RESULTS: Two hundred sixty-six patients were evaluated. Twenty-one (7.9%) had an adverse event during their index hospitalization. Troponin testing identified only 2 (9.5%) of these patients. Twenty (7.5%) had a cardiac event within 6 months; none were identified by cTnT testing. The sensitivity and specificity were 9.5% and 99.2%, respectively, at the index visit, and 0% and 98.4% at 6 months. The positive and negative predictive values were 50% and 93%, respectively, at the index visit; and 0% and 92% at 6 months. CONCLUSION: Determination of troponin T levels has a low sensitivity and high specificity for predicting outcomes in low-risk patients evaluated for suspected acute coronary syndromes. This study does not support a strategy of relying solely on troponin testing for disposition decisions.

Relapse following treatment of acute asthma in the emergency department.

Most patients presenting to the emergency department (ED) with acute asthma will have some, if not significant, relief of respiratory distress following treatment. The majority of patients are discharged to home; however, a significant portion of patients relapse and require urgent medical treatment. Many patients have continued respiratory symptoms and impairment in activities of daily living after ED treatment. In a large multicenter trial, we found that 17% of patients relapse within 2 weeks, requiring urgent medical treatment. The factors associated with asthma relapse were a history of numerous ED visits over the previous year, a history of urgent clinic visits over the previous year, use of a home nebulizer, multiple asthma triggers, and duration of symptoms between 1 and 7 days. In other studies, we found that many patients relapse before they can see their primary care physician, and that the lack of an identifiable primary care physician is associated with a higher incidence of relapse. Two interventions have been shown in studies to decrease the rate of relapse. The first, the administration of corticosteroids, has been adopted into general medical practice. Despite the routine use of corticosteroids following ED treatment, however, relapse remains a substantial problem. The second intervention involves focused long-term management by an asthma specialist. Several projects have demonstrated the efficacy of this approach in decreasing ED visits. Although it is time- and resource-intensive, this approach may be necessary for those patients who have frequent ED visits. Whether this approach is generalizable has yet to be demonstrated. In this article, we review the previous work on asthma relapse and suggest areas for further study.

Bioimpedance monitoring: better than chest x-ray for predicting abnormal pulmonary fluid?

Bioimpedance monitoring may aid in treating heart failure. Mean thoracic electrical impedance (Zo) is inversely proportional to thoracic fluid volume and may offer greater sensitivity for detecting thoracic fluid. OBJECTIVE. Compare bioimpedance monitoring thoracic fluid detection to that of chest x-ray. METHOD. Prospective convenience sample. SETTING. 1000 bed teaching hospital. PARTICIPANTS. Patients with suspected heart failure and shortness of breath. A single blinded radiologist interpreted chest x-rays as: normal, cardiomegaly, or abnormal pulmonary fluid. STATISTICS. General linear model with post hoc Bon Ferroni pairwise comparisons. RESULTS. 131 patients, mean age 66.8 years, 64.3% male, with an initial mean Zo=18 ohms. There was a significant difference (p<0.0002) between patients with cardiomegaly (Zo=17.5+/-5.5) or abnormal pulmonary fluid on chest x-ray (Zo=17.2+/-4.2) compared to normals (Zo=23.4+/-5.4). There was no difference between cardiomegaly and abnormal pulmonary fluid patients. CONCLUSION. Bioimpedance measurement may detect pulmonary fluid not apparent on chest radiograph. (c)2000 by CHF, Inc.

Utility of clinical characteristics in identifying depression in geriatric ED patients.

We will determine if clinical characteristics can be useful in identifying depression in geriatric Emergency Department (ED) patients. We have provided a cross-sectional observational study of geriatric patients presenting to an urban university-affiliated public hospital. A brief self-rated depression scale (SRDS) was used to identify depression. Clinical characteristics, examined retrospectively, included chief complaint, chronic illnesses, mode and time of arrival and discharge disposition. Relative prevalence of depression was calculated for these clinical characteristics. 70 (27%; 95% CI, 22% to 32%) of 259 patients were found to be depressed by the SRDS. Patients with nonspecific chief complaints were more commonly depressed than patients with system-specific chief complaints, but not significantly (relative prevalence 1.6; 95% CI, 1.0 to 2.4; p = 0.19). The relative prevalence of depression also did not vary significantly when analyzed by specific chronic illness (P = 0.42) except cardiac disease (1.6; 95% CI, 1.1 to 2.4), PM or night arrival (1.3; 95% CI, 0.8 to 2.3; p = 0.17), ambulance use (1.1; 95% CI, 0.7 to 1.7; p = 0.88), or need for medical admission (1.0; 95% CI, 0.7 to 1.5; p = 0.97). Depression is common in geriatric ED patients. Clinical characteristics fail to identify elderly ED patients who are likely to be depressed. Use of a brief SRDS can aid in recognition of depression in this group.

Changes in asthma claims in a Medicaid population from 1991-1994.

Previous reports have found an increase in asthma prevalence and severity during the 1980s. The purpose of this study was to evaluate changes in asthma claims in a cohort of Medicaid enrollees from 1991 through 1994. A historical study used Ohio Medicaid claims data for fiscal years 1989 through 1994. Adult and pediatric enrollees with at least one claim for asthma care during fiscal year 1989 who subsequently were continuously eligible through fiscal year 1994 were divided into 2 cohorts consisting of those with (Cohort 1) or without (Cohort 2) an asthma claim in 1990. Claims were then analyzed forward from 1991-1994. Patients consisted of 3,027 enrollees, including 2,206 children and 821 adults. Overall emergency department visits increased in both cohorts, primarily due to an increase in adult visits. Visits by children who were preschool-aged in 1989 decreased. Patients in the cohort with an asthma visit in both 1989 and 1990 continued to have an increased frequency of emergency department (ED) visits compared to cohort 2. Outpatient visits decreased in both cohorts but the decrease was greater in cohort 1 in spite of the assumption that these patients should have greater attendance at outpatient clinics. The percentage of patients with an outpatient clinic visit within 3 days of their ED visit also decreased. Admissions decreased in both cohorts indicating that there was not a marked increase in asthma severity. Patients in cohort 1 with ED visits in 2 successive years represent those under relatively poorer control. In spite of a continued higher frequency of ED use, these patients had decreased use of outpatient facilities. Severity to the extent reflected by admissions did not increase over this period. Further research may demonstrate that improved outpatient management and followup of higher frequency ED users may lead to greater asthma control.

Acute asthma among pregnant women presenting to the emergency department.

Asthma complicates up to 4% of pregnancies. Our objective was to compare emergency department (ED) visits for acute asthma among pregnant versus nonpregnant women. We performed a prospective cohort study, as part of the Multicenter Asthma Research Collaboration. ED patients who presented with acute asthma underwent a structured interview in the ED, and another by telephone 2 wk later. The study was performed at 36 EDs in 18 states. A total of 51 pregnant women and 500 nonpregnant women, age 18 to 39, were available for analysis. Pregnant women did not differ from nonpregnant women by duration of asthma symptoms (median: 0.75 versus 0.75 d, p = 0.57) or initial peak expiratory flow rate (PEFR) (51% versus 53% of predicted, p = 0.52). Despite this similarity, only 44% of pregnant women were treated with corticosteroids in the ED compared with 66% of nonpregnant women (p = 0.002). Pregnant women were equally likely to be admitted (24% versus 21%, p = 0.61) but less likely to be prescribed corticosteroids if sent home (38% versus 64%, p = 0.002). At 2-wk follow-up, pregnant women were 2.9 times more likely to report an ongoing exacerbation (95% CI, 1.2 to 6.8). Among women presenting to the ED with acute asthma, pregnant asthmatics are less likely to receive appropriate treatment with corticosteroids.

Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department.

STUDY OBJECTIVES: Bilevel pressure ventilation has had proven success in the treatment of acute respiratory failure (ARF). The purpose of this study was to identify patient characteristics early in the course of acute illness that can predict the successful use of bilevel pressure ventilation. METHODS: Ventilatory assistance using a ventilatory support system (BiPAP model ST-D; Respironics; Murrysville, PA) was considered a treatment option for stable patients with ARF. The system was titrated to patient comfort. Once stable settings had been achieved for 30 min, a posttrial arterial blood gas (ABG) measurement was obtained. Patient charts were reviewed for pretrial and posttrial ABG levels, along with demographics, APACHE (acute physiology and chronic health evaluation) II score, Glasgow Coma Scale (GCS), and length of stay (LOS) data. RESULTS: Bilevel pressure ventilation trials were performed on 58 patients. In 43 patients (74.1%), the trials were successful. Of the 15 patients (25.9%) in whom the trials were not successful, 13 patients required intubation. The pretrial ABG levels did not predict success, as there were no significant differences between the success and failure groups for pH and PaCO2, respectively: 7.26 vs 7.26 mm Hg and 75.3 vs 72.8 mm Hg. After 30 min, posttrial ABG levels for pH and PaCO2 predicted successful avoidance of intubation: 7.34 vs 7.27 mm Hg (p < 0.002) and 61.9 vs 73.0 mm Hg (p < 0.04), respectively. There were no significant differences between the success and failure groups in age, gender, GCS, or APACHE II. There were differences between the success and failure groups for LOS data (ventilator days, ICU days, and hospital days): 1.8 vs 10.4 days (p < 0.01), 4.2 vs 12.3 days (p < 0.02), and 7.5 vs 15.6 days (p < 0.02), respectively. CONCLUSION: Successful treatment with bilevel pressure ventilation could not be predicted by pretrial data (including pH and PaCO2) obtained in the emergency department; however, a successful outcome could be determined quickly with a 30-min trial. Successful treatment with bilevel pressure ventilation significantly reduced LOS data. CLINICAL IMPLICATIONS: Our inability to predict success based on initial data supports the use of bilevel pressure ventilation trials for all stable patients with ARF. If the patient's condition fails to improve within 30 min, intubation and mechanical ventilation is indicated.

Academic emergency medicine staffing nonacademic emergency department sites: a national survey.

UNLABELLED: Changing health care markets have threatened academic health centers and their traditional focus on teaching and research. OBJECTIVES: To determine the number of academic emergency medicine departments (AEMDs) that staff additional non-academic ED sites and to determine whether clinical reimbursement monies from those ED sites are used for academic purposes. METHODS: A two-part survey of all 119 academic EM programs listed in the 1997-1998 Graduate Medical Education Directory was conducted. Questionnaires were addressed to each AEMD chair. AEMDs and ED sites were characterized. Hiring difficulties, EM faculty academic productivity, and use of ED site reimbursement monies for academic activities were assessed. RESULTS: Ninety-nine of 119 (83%) AEMDs responded. Twenty-three (23%) AEMDs staffed 28 added ED sites. These sites tended to be urban (65%), with moderate volumes (25,000-35,000 patients/year), and had an equal or better reimbursement rate than the AEMD (89%). ED sites were commonly staffed by academic EM faculty (79%) and EM residents (29%). Ninety-six percent of the AEMDs had hired additional faculty; hiring new faculty was considered easy. Academic productivity at AEMDs with added ED sites was reported as unchanged. Reimbursement monies from these ED sites were commonly used for faculty salary support, faculty development, and EM research and residency activities. CONCLUSIONS: Academic EM departments are often affiliated with nonacademic ED sites. These additional sites are commonly staffed by academic EM faculty and EM residents. Academic productivity does not appear to decrease when additional ED sites are added. Reimbursement monies from these ED sites commonly supports academic activities.

Prospective multicenter study of relapse following treatment for acute asthma among adults presenting to the emergency department. MARC investigators. Multicenter Asthma Research Collaboration.

STUDY OBJECTIVE: To identify factors associated with relapse following treatment for acute asthma among adults presenting to the emergency department (ED). DESIGN: Prospective inception cohort study performed during October 1996 to December 1996 and April 1997 to June 1997, as part of the Multicenter Asthma Research Collaboration. SETTING: Thirty-six EDs in 18 states. PATIENTS: ED patients, aged 18 to 54 years, with physician diagnosis of acute asthma. For the present analysis, we restricted the cohort to patients sent home from the ED (n = 971), then further excluded patients with comorbid respiratory conditions (n = 32). This left 939 eligible subjects to have follow-up data. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Two weeks after being sent home from the ED, patients were contacted by telephone. A relapse was defined as an urgent or unscheduled visit to any physician for worsening asthma symptoms during the 14-day follow-up period. Complete follow-up data were available for 641 patients, of whom 17% reported relapse (95% confidence interval, 14 to 20). There was no significant difference in peak expiratory flow rate (PEFR) between patients who suffered relapse and those who did not. In a multivariate logistic regression analysis (controlling for age, gender, race, and primary care provider status), patients who suffered relapse were more likely to have a history of numerous ED (odds ratio [OD] 1.3 per 5 visits) and urgent clinic visits (OR 1.4 per 5 visits) for asthma in the past year, use a home nebulizer (OR 2.2), report multiple triggers of their asthma (OR 1.1 per trigger), and report a longer duration of symptoms (OR 2.5 for 1 to 7 days). CONCLUSION: Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome. By contrast, several historical features were associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinician may wish to consider these historical factors when making ED decisions.

Comparison of 2.5 vs 7.5 mg of inhaled albuterol in the treatment of acute asthma.

PURPOSE: The optimal dose of albuterol to use in the treatment of acute asthma has yet to be established. The National Asthma Education and Prevention Program (NAEPP) recommends a starting dose of 2.5 to 5 mg of aerosolized albuterol every 20 min, although European authorities recommend higher doses. The purpose of this study was to compare 2.5 vs 7.5 mg of nebulized albuterol for the treatment of acute asthma. SUBJECTS: We studied 160 patients presenting to the emergency department with acute asthma. METHODS: On enrollment, patients underwent baseline testing, including initial spirometry. All patients received prednisone, 60 mg, orally. Patients then received in a randomized, double-blinded fashion, nebulized albuterol either 2.5 or 7.5 mg every 20 min for a total of three doses. Spirometry was repeated after each of the first two treatments and again 40 min after completion of the three treatments. RESULTS: The pretreatment FEV1 was 36.9+/-16.6% of predicted normal in the low-dose group vs 41.5+/-15.4% of predicted normal in the high-dose group (not significant [NS]). The patients in the low-dose group had a 50.3+/-62.6% improvement in FEV1 pretreatment to post-treatment, whereas those in the high-dose group had a 44.6+/-48.2% improvement in FEV1 (NS). There was no difference in the admission rate in the low-dose group (43%) as compared with that of the high-dose group (39%; NS). CONCLUSION: We conclude that there is no advantage to the routine administration of doses of albuterol higher than 2.5 mg every 20 min. It is possible that there may be an advantage in the most severely obstructed patients, although this study did not enroll enough patients with very severe asthma to evaluate this. As has been previously demonstrated, patients who subsequently require admission have a diminished response to albuterol. This decreased responsiveness is seen with the first aerosol administration and is unaffected by increasing the dose.

Behavioral and environmental factors associated with acute exacerbation of asthma.

BACKGROUND: The relapse rate following treatment for acute asthma is high. While previous studies have evaluated the utility of pulmonary function measurements to identify patients likely to relapse, the results are conflicting. The purpose of this study was to evaluate other correctable, risk factors that may be associated with relapse. PARTICIPANTS: Two hundred twenty-three patients treated in the emergency department during 1994, including those either admitted or discharged. METHODS: Patient interviews to identify behavioral and environmental risk factors for asthma exacerbation. Telephone contact and medical record review to determine incidence of relapse. RESULTS: Two hundred twenty-three patients were enrolled of whom follow-up data were available for 152 (68%). Twenty-one percent of the patients relapsed within 14 days. Relapse was associated with the lack of an identifiable primary care physician and inability to obtain discharge medications. There was no relationship between relapse and the use of a spacer, hypoallergenic pillow or mattress cover, cigarette smoking, the presence of pets in the home, or weekly carpet cleaning. CONCLUSION: Even following hospitalization for acute asthma, there is a significant relapse rate. Improving patients' access to primary care physicians and to appropriate medications may decrease the relapse rate. Although a significant portion of patients have behavioral and environmental risk factors for asthma exacerbation including cigarette smoking and failure to maintain a hypoallergenic environment, these factors are not associated with short-term relapse.

Injured intoxicated drivers: citation, conviction, referral, and recidivism rates.

STUDY OBJECTIVES: Several studies have suggested that legally intoxicated drivers who are injured when involved in a motor vehicle crash are unlikely to be cited or prosecuted for driving under the influence (DUI). The purpose of this study was to determine (1) the rates of citation and prosecution of legally intoxicated drivers who are injured in a motor vehicle crash and hospitalized in a Level I trauma center, (2) the rates of previous and subsequent alcohol-related citation in this population, and (3) the rate of referral for treatment of alcohol-related problems made during the hospital stay. METHODS: In a retrospective review of trauma registry and Cleveland Municipal Court records from January 1993 through April 1995, we examined the records of all drivers injured in a motor vehicle crash who were transported to a Level I urban trauma center, admitted to the trauma service, and determined to have a blood alcohol content (BAC) of .10 gm% or higher at the time of admission to the emergency department. RESULTS: Seventy drivers admitted after a motor vehicle crash had a BAC of .10 gm% or higher. This represented 33% of the drivers older than 16 years of age who were admitted to the trauma service. Twenty-three drivers (32.8%) were cited for DUI, and 15 (21%) of the 70 were successfully prosecuted and convicted. Four of 23 cited drivers had previous citations; another 5 incurred subsequent citations during the study period. Eight of the 70 drivers who were admitted with a high BAC were referred for outpatient alcohol counseling after discharge. None were offered counseling as inpatients. CONCLUSION: Citation and prosecution rates of legally intoxicated drivers injured in motor vehicle crashes and hospitalized in our trauma center were low. Recognition of alcoholism and inpatient counseling were rare. Multiple alcohol-related citations were common among drivers cited for DUI.

Adrenal function and physiologic stress during acute asthma exacerbation.

OBJECTIVE: Adrenal function in stable asthmatics has been extensively studied. The purpose of this study was to determine the effect of asthma exacerbation on adrenal function. METHODS: We studied an observational cohort, convenience sample of patients at a university-affiliated county hospital. Adult patients with asthma who were not steroid-dependent and who presented to the emergency department because of their asthma comprised the study group. All patients were examined and pulmonary function tests were performed. Blood samples for determination of initial cortisol levels were obtained, followed by the administration of .25 mg cosyntropin intramuscularly. Standard therapy with aerosolized albuterol was then initiated. Plasma cortisol levels were measured 30 and 60 minutes later. Steroid therapy was withheld until completion of the rapid cosyntropin stimulation test. RESULTS: A total of 74 patients participated; 64% (47) were women. The range of pretreatment FEV1 was from 10% predicted to 74% predicted. The range of cortisol levels on presentation was from 1.6 micrograms/dL to 35.8 micrograms/dL. Twelve patients had initial cortisol levels greater than 20 micrograms/dL, a level indicative of physiologic stress. Four patients had initial cortisol levels greater than 30 micrograms/dL. Mean plasma cortisol levels at 0, 30, and 60 minutes were 13.7 micrograms/dL (+/- 7.2 micrograms/dL), 28.7 micrograms/dL (+/- 7.4 micrograms/dL), and 33.0 micrograms/dL (+/- 8.2 micrograms/dL). We found an association between evidence of physiologic stress and severe airflow obstruction (P < .03) but no linear correlation (r = -.15). CONCLUSION: Few patients with asthma have adrenal suppression on presentation. Asthma exacerbation does not provoke a physiologic stressor response in most asthmatic patients.