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1.
Eur Heart J Acute Cardiovasc Care ; 4(3): 241-53, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25228048

RESUMO

AIMS: To examine the association between cumulative missed opportunities for care (CMOC) and mortality in patients with ST-elevation myocardial infarction (STEMI). METHODS: A cohort study of 112,286 STEMI patients discharged from hospital alive between January 2007 and December 2010, using data from the Myocardial Ischaemia National Audit Project (MINAP). A CMOC score was calculated for each patient and included: pre-hospital ECG, acute use of aspirin, timely reperfusion, prescription at hospital discharge of aspirin, thienopyridine inhibitor, ACE-inhibitor (or equivalent), HMG-CoA reductase inhibitor and ß-blocker, and referral for cardiac rehabilitation. Mixed-effects logistic regression models evaluated the effect of CMOC on risk-adjusted 30-day and 1-year mortality (RAMR). RESULTS: 44.5% of patients were ineligible for ≥1 care component. Of patients eligible for all nine components, 50.6% missed ≥1 opportunity. Pre-hospital ECG and timely reperfusion were most frequently missed, predicting further missed care at discharge (pre-hospital ECG incident rate ratio [95% CI]: 1.64 [1.58-1.70]; timely reperfusion 9.94 [9.51-10.40]). Patients ineligible for care had higher RAMR than those eligible for care (30-days: 1.7% vs. 1.1%; 1-year: 8.6% vs. 5.2%), whilst those with no missed care had lower mortality than patients with ≥4 CMOC (30-days: 0.5% vs. 5.4%, adjusted OR (aOR) per CMOC group 1.22, 95% CI: 1.05-1.42; 1-year: 3.2% vs. 22.8%, aOR 1.23, 1.13-1.34). CONCLUSIONS: Opportunities for care in STEMI are commonly missed and significantly associated with early and later mortality. Thus, outcomes after STEMI may be improved by greater attention to missed opportunities to eligible care.


Assuntos
Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/terapia , Síndrome Coronariana Aguda/terapia , Antagonistas Adrenérgicos beta/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Aspirina/administração & dosagem , Estudos de Coortes , Inglaterra/epidemiologia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Sistema de Registros , Resultado do Tratamento , País de Gales/epidemiologia
2.
Int J Cardiol ; 170(1): 81-7, 2013 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-24182669

RESUMO

BACKGROUND: Hospital acute myocardial infarction (AMI) care is increasingly evaluated using composite quality scores. We investigated the influence of three aggregation methods for an AMI indicator on mortality and hospital rank. METHODS AND RESULTS: We studied 136,392 patients discharged alive from 199 hospitals with AMI recorded in the Myocardial Ischaemia National Audit Project, between 01/01/2008 and 31/12/2009. A composite of prescription of aspirin, thienopyridine inhibitor, ß-blocker, angiotensin converting enzyme inhibitor, HMG CoA reductase enzyme inhibitor and enrolment in cardiac rehabilitation at discharge was aggregated as opportunity based (OBCS), weighted opportunity-based (WOBCS) and all-or-nothing (ANCS) scores. We quantified adjusted 30-day, 6-month and 1-year mortality rates and hospital performance rank. Median (IQR) scores were OBCS: 95.0% (3.5), WOBCS: 94.7% (0.8) and ANCS: 80.9% (11.8). The three methods affected the proportion of hospitals outside 99.8% credible limits of the national median (OBCS: 52.2%, WOBCS: 64.3% and ANCS: 37.7%) and hospital rank. Each 1% increase in composite score was significantly associated with a 1 to 3% and a 4% reduction in 6-month and 1-year mortality, respectively. However, the ANCS had fewer cases and no significant association with 30-day mortality. CONCLUSIONS: A hospital composite score, incorporating 6 aspects of AMI care, was significantly inversely associated with mortality. However, composite aggregation method influenced hospital rank, number of cases available for analysis and size of the association with all-cause mortality, with the ANCS performing least well. The use and choice of composite scores in hospital AMI quality improvement requires careful evaluation.


Assuntos
Hospitalização , Auditoria Médica/normas , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/terapia , Indicadores de Qualidade em Assistência à Saúde/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais/normas , Inglaterra/epidemiologia , Feminino , Hospitalização/tendências , Humanos , Masculino , Auditoria Médica/tendências , Pessoa de Meia-Idade , Isquemia Miocárdica/epidemiologia , Indicadores de Qualidade em Assistência à Saúde/tendências , País de Gales/epidemiologia , Adulto Jovem
3.
Heart ; 95(19): 1593-9, 2009 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-19508971

RESUMO

OBJECTIVE: To investigate determinants of, and outcomes from, coronary angiography and intervention in patients with non-ST-segment elevation myocardial infarction (NSTEMI). DESIGN: Observational study. SETTING: 44 British hospitals with interventional facilities. PATIENTS: 13,489 admissions with NSTEMI; July 2005 to December 2006. MAIN OUTCOME MEASURES: Rate of angiography during index admission; death and readmission to hospital within 180 days. RESULTS: Significantly lower rates of angiography were seen for women, the elderly, the most deprived and those having cardiac, and most non-cardiac, comorbidities. Performance of angiography, compared with no angiography, was not associated with lower rate of readmission (multiple adjusted hazard ratio (HR) = 0.96, 95% CI 0.74 to 1.24) unless accompanied by coronary intervention (HR = 0.73, 95% CI 0.56 to 0.95). Angiography was associated with reduction in 180-day mortality for survivors of hospitalisation (HR = 0.59, 95% CI 0.49 to 0.72); with greater reduction when followed by an intervention (HR = 0.34, 95% CI 0.28 to 0.42). This mortality benefit after intervention was seen both in women (HR = 0.42, 95% CI 0.29 to 0.60) and men (HR = 0.31, 95% CI 0.24 to 0.41), and across age groups: <65 years (HR = 0.25, 95% CI 0.14 to 0.44), 65-79 years (HR = 0.29, 95% CI 0.22 to 0.39) and > or =80 years (HR = 0.52, 95% CI 0.37 to 0.74). Mortality benefit was not significantly attenuated by the presence of comorbidities. CONCLUSION: Performance of angiography and coronary intervention after NSTEMI was associated with mortality benefit that persisted in the presence of both cardiac and non-cardiac comorbidities. Mortality benefit was seen across age groups and was similar for both sexes.


Assuntos
Angiografia Coronária/estatística & dados numéricos , Infarto do Miocárdio/diagnóstico por imagem , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária/mortalidade , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Auditoria Médica , Infarto do Miocárdio/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Seleção de Pacientes , Recidiva , Medição de Risco
4.
Heart ; 95(9): 697-703, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-18697807

RESUMO

Patients with acute coronary syndrome (ACS) often have raised blood glucose concentrations when admitted to hospital; a marker for poorer prognosis. Interventions to rapidly normalise blood glucose inconsistently are applied and with uncertain utility. Here we review the association of hyperglycaemia with outcome, present evidence that this hyperglycaemia reflects more than a pre-existing diabetic state and discuss mechanisms by which glucose may adversely affect the course of acute myocardial infarction (AMI). Finally, we seek evidence that intensive insulin treatment improves outcome.


Assuntos
Síndrome Coronariana Aguda/complicações , Glicemia/metabolismo , Hiperglicemia/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/mortalidade , Biomarcadores/metabolismo , Feminino , Mortalidade Hospitalar , Humanos , Hiperglicemia/tratamento farmacológico , Hiperglicemia/mortalidade , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Prognóstico , Fatores de Risco , Resultado do Tratamento
5.
Heart ; 95(3): 221-7, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-18467355

RESUMO

OBJECTIVE: To compare the discriminative performance of the PURSUIT, GUSTO-1, GRACE, SRI and EMMACE risk models, assess their performance among risk supergroups and evaluate the EMMACE risk model over the wider spectrum of acute coronary syndrome (ACS). DESIGN: Observational study of a national registry. SETTING: All acute hospitals in England and Wales. PATIENTS: 100 686 cases of ACS between 2003 and 2005. MAIN OUTCOME MEASURES: Model performance (C-index) in predicting the likelihood of death over the time period for which they were designed. The C-index, or area under the receiver-operating curve, range 0-1, is a measure of the discriminative performance of a model. RESULTS: The C-indexes were: PURSUIT C-index 0.79 (95% confidence interval 0.78 to 0.80); GUSTO-1 0.80 (0.79 to 0.81); GRACE in-hospital 0.80 (0.80 to 0.81); GRACE 6-month 0.80 (0.79 to 0.80); SRI 0.79 (0.78 to 0.80); and EMMACE 0.78 (0.77 to 0.78). EMMACE maintained its ability to discriminate 30-day mortality throughout different ACS diagnoses. Recalibration of the model offered no notable improvement in performance over the original risk equation. For all models the discriminative performance was reduced in patients with diabetes, chronic renal failure or angina. CONCLUSION: The five ACS risk models maintained their discriminative performance in a large unselected English and Welsh ACS population, but performed less well in higher-risk supergroups. Simpler risk models had comparable performance to more complex risk models. The EMMACE risk score performed well across the wider spectrum of ACS diagnoses.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Infarto do Miocárdio/mortalidade , Idoso , Inglaterra/epidemiologia , Feminino , Humanos , Expectativa de Vida/tendências , Masculino , Modelos Estatísticos , Prognóstico , Curva ROC , Medição de Risco/métodos , Índice de Gravidade de Doença , País de Gales/epidemiologia
6.
Heart ; 94(11): 1407-12, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18070941

RESUMO

OBJECTIVE: Although early thrombolysis reduces the risk of death in STEMI patients, mortality remains high. We evaluated factors predicting inpatient mortality for patients with STEMI in a "real-world" population. DESIGN: Analysis of the Myocardial Infarction National Audit Project (MINAP) database using multivariate logistic regression and area under the receiver operating curve analysis. SETTING: All acute hospitals in England and Wales. PATIENTS: 34 722 patients with STEMI from 1 January 2003 to 31 March 2005. RESULTS: Inpatient mortality was 10.6%. The highest odds ratios for inpatient survival were aspirin therapy given acutely and out-of-hospital thrombolysis, independently associated with a mortality risk reduction of over half. A 10-year increase in age doubled inpatient mortality risk, whereas cerebrovascular disease increased it by 1.7. The risk model comprised 14 predictors of mortality, C index = 0.82 (95% CI 0.82 to 0.83, p<0.001). A simple model comprising age, systolic blood pressure (SBP) and heart rate (HR) offered a C index of 0.80 (0.79 to 0.80, p<0.001). CONCLUSION: The strongest predictors of in-hospital survival for STEMI were aspirin therapy given acutely and out-of-hospital thrombolysis, Previous STEMI models have focused on age, SBP and HR We have confirmed the importance of these predictors in the discrimination of death after STEMI, but also demonstrated that other potentially modifiable variables impact upon the prediction of short-term mortality.


Assuntos
Arritmias Cardíacas/mortalidade , Pressão Sanguínea/fisiologia , Mortalidade Hospitalar , Infarto do Miocárdio/mortalidade , Terapia Trombolítica/métodos , Fatores Etários , Idoso , Arritmias Cardíacas/fisiopatologia , Aspirina/uso terapêutico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/tratamento farmacológico , Prognóstico , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores Sexuais , Análise de Sobrevida , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento
9.
Coron Artery Dis ; 9(11): 753-8, 1998.
Artigo em Inglês | MEDLINE | ID: mdl-9919423

RESUMO

AIMS: To investigate the current use of thrombolytic therapy in the management of patients with acute myocardial infarction and to determine the potential for an increased use of thrombolysis or percutaneous transluminal coronary angioplasty (PTCA). METHODS AND RESULTS: All hospitalised cases of acute myocardial infarction were identified in three health districts in the UK (population of 960,000) in patients under the age of 76 years during a 2-year period; 2439 patients had acute myocardial infarction, of whom 1264 (52%) received thrombolytic therapy. Failure to administer thrombolytic therapy was a result of the absence of diagnostic electrocardiograms in 712 (29.2%) patients, late presentation in 127 (5.2%), therapeutic error in 112 (4.6%), presence of a bleeding risk in 139 (5.7%) and other miscellaneous reasons in 80 (3.3%) patients. Thirty-eight of the 139 patients in whom bleeding risk was reported as a contra-indication could, in retrospect, have received thrombolytic therapy and a further 76 would have been suitable for primary PTCA. CONCLUSIONS: The potential for increasing the use of thrombolytic therapy seems to be limited and is unlikely to make a major impact on the in-hospital mortality from acute myocardial infarction. However, primary PTCA should be considered in those who are ineligible for thrombolysis because of bleeding risk as a contra-indication.


Assuntos
Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Reperfusão Miocárdica , Terapia Trombolítica , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Análise de Sobrevida
11.
Resuscitation ; 34(3): 227-33, 1997 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-9178383

RESUMO

During 138 weeks an emergency medical service (EMS) of mixed skill-level attempted to resuscitate 954 patients from prehospital cardiac arrest (883 attempts per million population per year); 75% of the arrests were of cardiac cause. This paper is one of the first analyses from europe to use the 'Utstein template' to report outcomes of such arrests. In cases where an arrest rhythm could be recorded, 38.4% were ventricular fibrillation (VF), 45.5% were asystolic, and the remainder were either electromechanical dissociation or respiratory arrests. Using univariate analysis factors associated with a greater likelihood of survival include the presence of a witness, bystander-initiated cardiopulmonary resuscitation (CPR), early CPR and VF as the arrest rhythm. Twenty of 155 cases (13%) survived where VF arrest was witnessed by non-EMS personnel.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca/terapia , Idoso , Serviços Médicos de Emergência , Feminino , Hospitalização , Humanos , Masculino , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/terapia
12.
Ir Med J ; 90(4): 139-40, 1997.
Artigo em Inglês | MEDLINE | ID: mdl-9267090

RESUMO

A descriptive follow-up study of a hospital based chest pain clinic set up for the identification of the patients with unstable angina and acute myocardial infarction. The clinic is staffed by a cardiologist-in-training seeing patients on the day of referral by general practitioners because of acute chest pain of unclear origin. Over 6 months, 174 patients were assessed. 34 (19.5%) had a diagnosis of unstable angina or acute myocardial infarction (acute coronary syndrome), 52 (30%) had non-acute cardia pain and 88 (50.5%) had non-cardiac pain. Of those with a clinical diagnosis of acute coronary syndrome, 5 were subsequently shown to have non-cardiac, 8 had acute myocardial infarction and 21 had unstable angina. One month follow-up information was available on 136 of 139 (98%) patients not admitted to hospital via the chest pain clinic. 3 were admitted to hospital within the following 4 weeks because of myocardial infarction in 1 and unstable angina in 2. One year follow-up was available on 118 patients. One patient was admitted with unstable angina 6 months later and one patient sustained sudden cardiac death 3 months later. In the absence of the clinic, general practitioners would have arranged hospital admission for 66 (48%) or assessment in the emergency department for 13 (9%) of those discharged. Almost all general practitioners found the service helpful. The chest pain clinic was well received and provided an efficient method of identifying patients with acute coronary syndrome and minimised unnecessary admissions.


Assuntos
Angina Instável/diagnóstico , Dor no Peito/etiologia , Acessibilidade aos Serviços de Saúde , Infarto do Miocárdio/diagnóstico , Angina Instável/complicações , Dor no Peito/diagnóstico , Doença das Coronárias/complicações , Doença das Coronárias/diagnóstico , Emergências , Feminino , Hospitalização , Humanos , Irlanda , Masculino , Infarto do Miocárdio/complicações
13.
Resuscitation ; 34(1): 27-34, 1997 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-9051821

RESUMO

From 954 attempts to resuscitate patients from out-of-hospital cardiac arrest two datasets were derived, namely 861 cases of cardiac arrest and 906 cases of either cardiac or primary respiratory arrest. For each dataset, multivariate analysis was performed by fitting a number of explanatory variables with respect to the outcomes of admission to hospital and discharge home in logistic regression models. There were numerous interactions between these variables. Being conscious at the time of the arrival of the ambulance crew and subsequently having cardiac arrest strongly predicted survival, as did both the presence of a witness to the arrest and the initiation of cardiopulmonary resuscitation (CPR) by a bystander; this latter effect was a marker for early CPR. The strongest predictor of a poor outcome was delay to CPR or delay to advanced cardiac life support.


Assuntos
Reanimação Cardiopulmonar/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Distribuição por Idade , Idoso , Serviços Médicos de Emergência/normas , Feminino , Parada Cardíaca/epidemiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Fatores de Risco , Distribuição por Sexo , Taxa de Sobrevida , Fatores de Tempo , País de Gales/epidemiologia
15.
Int J Cardiol ; 54(3): 277-82, 1996 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-8818753

RESUMO

Two patients with haemodynamically significant aortic regurgitation and angiographically normal coronary arteries developed giant T wave inversion. The T wave abnormality partially resolved in both, following valve replacement in one and medical treatment in the other. This unusual electrocardiographic appearance may be related to myocardial ischaemia caused by increased left ventricular wall stress and changes in phasic coronary blood flow, abnormalities in cerebral perfusion associated with severe aortic regurgitation, or to coincidental neurological disease.


Assuntos
Insuficiência da Valva Aórtica/fisiopatologia , Vasos Coronários/fisiologia , Eletrocardiografia , Idoso , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/cirurgia , Angiografia Coronária , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Valores de Referência , Fluxo Sanguíneo Regional
18.
Resuscitation ; 29(2): 107-11, 1995 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-7659861

RESUMO

Of 954 attempted resuscitations outside hospital performed by ambulance personnel, 48 patients (5%) had primary respiratory arrest. Comparing this group with those manifesting cardiorespiratory arrest, patients with primary respiratory arrest were significantly more likely to be female (25 of 48 vs 269 of 906-P < 0.005), were more likely to have a non-cardiac cause (67% vs. 22%-P < 0.00001) and more likely to have witnessed arrest. Of all arrests witnessed by ambulance crew, 35% were respiratory arrests. Basic and advanced life-support was delivered sooner. Outcome was significantly better, with 19 patients (40%) being discharged compared to only 49 patients (5.1%) discharged in cases of cardiorespiratory arrest (p < 0.00001). Considering that many respiratory arrests were witnessed by ambulance crew, the type of crew (EMT or paramedic) made no difference to outcome. Our findings suggest that patients manifesting respiratory arrest outside hospital are a heterogeneous group who have a relatively good prognosis regardless of the type of ambulance crew that attends.


Assuntos
Serviços Médicos de Emergência , Parada Cardíaca/epidemiologia , Insuficiência Respiratória/epidemiologia , Ressuscitação , Distribuição por Idade , Idoso , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/terapia , Distribuição por Sexo , Taxa de Sobrevida , Reino Unido , População Urbana
19.
Resuscitation ; 29(1): 41-6, 1995 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-7784722

RESUMO

The Utstein style of reporting out-of-hospital cardiac arrests requires that all confirmed cardiac arrests considered for resuscitation are analysed and that a record is made of the number of cases where no resuscitation is attempted. We report a series of 942 confirmed cardiac arrests considered for resuscitation by South Glamorgan Emergency Medical Service (EMS). There were 370 (39.3%) cases where no resuscitation was attempted by the EMS. The ages, male/female ratio and EMS response times were similar in both the group that received ambulance resuscitation and those that did not. Those not receiving resuscitation were less likely to have had an arrest of cardiac aetiology (51.3% vs. 75%, P < 0.00001). Rigor mortis or decomposition of the body was present in 50.8% of cases and in 20% a doctor had already confirmed the patient dead. In the remainder the ambulance crew failed to start resuscitation for a variety of reasons.


Assuntos
Pessoal Técnico de Saúde , Reanimação Cardiopulmonar , Parada Cardíaca/terapia , Idoso , Ambulâncias , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
20.
Thorax ; 50(1): 79-80, 1995 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-7886655

RESUMO

BACKGROUND: The merits of the use of beta 2 agonists by ambulance crew and best methods of delivery have not been fully explored. METHODS: A prospective comparison has been made of treatments applied in three districts in South Wales (200 micrograms salbutamol by pressurised inhaler, 5 mg salbutamol via nebuliser, and 5 mg terbutaline via Nebuhaler) by emergency ambulance personnel to acutely wheezy patients en route to hospital. Pulse rate, respiratory rate, peak expiratory flow rate (PEFR), and breathlessness scored on a visual analogue scale were compared before and after treatment. Data were collected on diagnosis, artificial ventilation, cardiorespiratory arrest, and death. RESULTS: Thirty eight patients received salbutamol inhaler, 51 salbutamol via nebuliser, and 41 terbutaline via Nebuhaler. There were greater reductions in respiratory rate and breathlessness score and more improvement in PEFR in the group receiving nebulised salbutamol than in the other two groups. No patient was ventilated and of the five deaths none was caused by asthma. CONCLUSIONS: For wheezy, breathless patients treated en route to hospital by emergency ambulance personnel, 5 mg salbutamol given by an oxygen-driven nebuliser was more effective than either 5 mg terbutaline via a Nebuhaler or 200 micrograms salbutamol via a pressurised inhaler.


Assuntos
Albuterol/administração & dosagem , Serviços Médicos de Emergência , Sons Respiratórios/efeitos dos fármacos , Terbutalina/administração & dosagem , Doença Aguda , Administração por Inalação , Adolescente , Adulto , Idoso , Análise de Variância , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nebulizadores e Vaporizadores , Estudos Prospectivos , País de Gales
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