Severe asthma that was endotracheally intubated 16 times in 20 years

Introduction: Severe asthma is a complex airway disease characterised by multiple aggravating-factors, and frequent comorbidities. Poor asthma control does not always correspond to the severity of airflow obstruction. One cause of disproportionate breathlessness in asthma is dysfunctional breathing/hyperventilation syndrome which is increasingly recognized. Case study: This female individual arrived at our asthma centre for the first time, coming from a primary care site 20 years ago. During the past 20 years she was intubated 16 times. Airway obstruction was never assessed surrounding the acute asthma episodes. Asthma diagnosis was confirmed by spirometry many times during routine visits at the asthma centre, where she never came to our asthma centre during an acute asthma exacerbation. Despite warranting the availability of controller medication with high ICS dose plus LABA, she repeated the episodes of severe dyspnoea requiring endotracheal intubations. Results: At a routine outpatient visit to our asthma centre for claiming her asthma medication, she developed an extreme dyspnoea as it occurred so many times earlier, using accessory respiratory muscles. The modified Borg scale for dyspnoea was 9/10. Pulse oximetry showed 96% O2 saturation breathing at room air. Baseline FEV1 was 1.96 L. Dyspnoea did not improve after 30 minutes of treatment. However, the FEV1 increased 29% to 2.53 L (96% predicted). Relaxation respiratory techniques began and the extreme dyspnoea slowly disappeared. Conclusion: Hyperventilation syndrome was confirmed with a score 32 with the Nijmegen Questionnaire (normal <23). Hyperventilation syndrome could coexist with severe asthma in 47% of cases. Keywords: Asthma; Asthma primary care; Hyperventilation syndrome.

Automated identification of implausible values in growth data from pediatric electronic health records

Objective Large electronic health record (EHR) datasets are increasingly used to facilitate research on growth, but measurement and recording errors can lead to biased results. We developed and tested an automated method for identifying implausible values in pediatric EHR growth data. Materials and Methods Using deidentified data from 46 primary care sites, we developed an algorithm to identify weight and height values that should be excluded from analysis, including implausible values and values that were recorded repeatedly without remeasurement. The foundation of the algorithm is a comparison of each measurement, expressed as a standard deviation score, with a weighted moving average of a child’s other measurements. We evaluated the performance of the algorithm by (1) comparing its results with the judgment of physician reviewers for a stratified random selection of 400 measurements and (2) evaluating its accuracy in a dataset with simulated errors. Results Of 2 000 595 growth measurements from 280 610 patients 1 to 21 years old, 3.8% of weight and 4.5% of height values were identified as implausible or excluded for other reasons. The proportion excluded varied widely by primary care site. The automated method had a sensitivity of 97% (95% confidence interval [CI], 94–99%) and a specificity of 90% (95% CI, 85–94%) for identifying implausible values compared to physician judgment, and identified 95% (weight) and 98% (height) of simulated errors. Discussion and Conclusion This automated, flexible, and validated method for preparing large datasets will facilitate the use of pediatric EHR growth datasets for research.

The other side of teledermatology: patient preferences

We studied patient preferences for a real-time teledermatology consultation or a conventional dermatology consultation. Dermatology patients were given the option of being seen by a dermatologist at their outlying primary care site via telemedicine or of being examined face-to-face by the same dermatologist at the primary care site. The same dermatologist provided the teleconsultations and the conventional consultations. During a 16-month study period, 52 patients were evaluated via telemedicine and 46 patients were seen face-to-face. The demographics for both study groups were similar. Those patients who selected telemedicine were more likely to have seen a dermatologist fewer than twice during the previous year, more likely to self-describe themselves in excellent health and more likely to choose a face-to-face evaluation when presenting with a possible skin cancer or a mole. Patients aged 56 years or less tended to be more likely to be seen via telemedicine, although the association with age was not significant ( P = 0.06). This information may help providers to devise strategies to direct patients to telemedicine if and when it is appropriate.

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting

Purpose The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. Methods In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Conclusions Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Geriatric Psychiatry at the Interface of Consultation-Liaison Psychiatry and Primary Care

Objective: This article describes the evolution of a primary care geriatric psychiatry program which serves clinical, educational, and research functions. Methods: Program development proceeded through stages of liaison using research, focusing on primary care attendings, and developing the common interest of geriatrics. Results: Collaborative research with external funding has continued. A geriatric psychiatry primary care fellowship program was established. Clinical activity is based on consultation-liaison work in nursing homes, an outpatient dementia clinic, a general hospital medical service, and the outpatient clinic. Fellows are involved in training both psychiatry and primary care residents. Conclusions: Necessary components of a successful collaboration include: 1) primary care physicians with an interest in and aptitude for psychiatric issues; 2) delivery of service and training based on an assessment of the primary care site's needs; 3) a physical presence in the primary care site.

Is Continuity of Care Preserved in Children Who Utilize the Pediatric Emergency Department?

Objective. Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained? Methods. Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis. Results. During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period. Conclusion. Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.