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Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (5)

Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (5)No written guidelines or protocols are used in our ER with respect either to treatment of acute asthma or the need for hospital admission. The latter decision is based on the clinical judgment of the attending physician. It is possible that some children in our series were hospitalized unnecessarily. It is not possible on the basis of our data to identify patients who were hospitalized and might have been safely treated at home. However, it should be pointed out that easy access to hospital and earlier admission has been shown to reduce mortality and morbidity in asthma, suggesting that physicians should admit patients to hospital if in doubt.
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Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (4)

Conflicting results have also been reported in the literature as to the value of lung function measurements in predicting outcome in both adults and children with acute asthma.’ In our study, patients who were hospitalized had significantly lower pulmonary function values as compared to those who were discharged home, but the variability of the results was very high. In addition, patients who were discharged home with low FEX^ values did not relapse. Thus, neither the initial nor the final pulmonary function measurements or the absolute change in their value with treatment were helpful in predicting outcome in our study.

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Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (3)

Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (3)Of interest are the variables which did not exert an appreciable effect in predicting outcome in our patient population. Studies in children have previously shown that the patient s age is not predictive of hospitalization, and our study confirms this finding. Likewise, the duration of the current asthmatic attack, and the number of previous admissions, were not predictive of the need for hospitalization. buy asthma inhalers

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Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (2)

When each individual component of the clinical score on presentation was analyzed as an independent variable, the dyspnea score came out to be the most predictive, with increased sensitivity but less specificity than the overall clinical score. In the present study, “dyspnea” was defined as the observers impression of the childs breathlessness, as most of our patients were too young to be questioned about their subjective feeling of respiratory distress. flovent inhaler

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Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (1)

Predicting the Need for Hospitalization in Children with Acute Asthma: Discussion (1)The objective of the present study was to determine the value of clinical measurements and common, noninvasive laboratory variables both alone and in various combinations in predicting physicians’ decisions to admit children with acute asthma to the hospital. Although the hospitalized and the discharged groups of patients had statistically significant differences in most of the variables measured, the clinical score, based on standard physical examination, was found to be the most effective in predicting outcome. Buy Asthma Inhalers Online

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Predicting the Need for Hospitalization in Children with Acute Asthma: Results (5)

Analysis 5 examines the importance of individual components of the clinical score, along with the other presentation variables. It should be noted that the value of pulsus paradoxus as a predictive variable is hampered by the fact that it was not measured in 79 patients (39.5 percent), particularly in the younger children. Dyspnea was the sole variable chosen from all presentation variables, as a prediction rule, with a sensitivity of 88 percent, but, specificity of only 71 percent. buy ampicillin

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Predicting the Need for Hospitalization in Children with Acute Asthma: Results (4)

Predicting the Need for Hospitalization in Children with Acute Asthma: Results (4)Once again, the resulting decision tree chose from the presentation variables only the clinical score as the prediction rule, but now with a lower cut point of 0.65. This results in a slightly higher sensitivity (80 percent) but a lower specificity (72 percent). A clinical score of >0.65 means that at least four of the variables had been assigned a score of 1 (regardless of whether pulsus paradoxus was measured). Further increasing the prespecified penalty of discharging a patient who should have been hospitalized led to little change in this rule.
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Predicting the Need for Hospitalization in Children with Acute Asthma: Results (3)

The overall misclassification rate (percentage of observations classified incorrectly) is 41/200 = 20.5 percent. Of the 41 misclassifi-cations, 14 were patients with a clinical score ^0.75 who should have been discharged but were admitted, and 27 were patients with clinical score >0.75 who should have been hospitalized but were discharged. Thus, if hospitalization is considered the “disease,” the rule has a sensitivity rate of 79 percent, and a specificity rate of 80 percent. These rates use the same data to estimate and assess the rule, and for this reason, tend to be somewhat optimistic. The crossvalidated cost gives a more realistic estimate, and was 23 percent (Table 4). The cross-validated sensitivity and specificity values will be given in terms of their cross validated values. birth control pills
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Predicting the Need for Hospitalization in Children with Acute Asthma: Results (2)

Predicting the Need for Hospitalization in Children with Acute Asthma: Results (2)All patients with initial Sa02 values above 96 percent were discharged home, and none of them subsequently returned to the ER. However, most of the patients had initial Sa02 values between 92 and 96 percent (Fig 1). Similarly, patients with high clinical scores on presentation tended to be hospitalized and patients with low clinical scores tended to be discharged. However, there were patients with high clinical scores who were discharged and patients with low clinical scores who were hospitalized (Fig 1). The clinical score on disposition, ie> after ER treatment, seems to differentiate the groups more clearly, but still there is an area of overlap. It is also not clear from these data which clinical score or Sa02 value, or combination of variables, would be most predictive of outcome. Further analysis was, therefore, required. buy diabetes drugs
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Predicting the Need for Hospitalization in Children with Acute Asthma: Results (1)

Of the 200 patients in the study, 66 (33 percent) were hospitalized, and 134 (67 percent) were discharged home. Five of the discharged patients returned to the ER within seven days, and one was subsequently hospitalized. All patients were treated with nebulized albuterol, and in addition, 8 percent received intravenous theophylline, and 8 percent received systemic corticosteroids. The mean age of all patients was 5.6 ±3.1 years (range 0.4 to 16 years). No statistically significant age difference was found in the hospitalized vs the discharged groups (Table 2).

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