Annual Emergency Research Articles

Factors Affecting Emergency Medical Utilization After Self-harm and Effectiveness of Community-Based Suicide Prevention Provisions in Preventing Self-harm: A Nationwide Registry-Based Study in Korea.

In order to formulate and implement a community-based suicide prevention program, as well as evaluate the effectiveness of these programs, it is necessary to understand the epidemiological characteristics of self-harm. Clinical data were collected from the National Emergency Department Information System (NEDIS) data panel in Korea for patients seen after self-harm episodes. Socioeconomic factors were collected from Statistics Korea. Variables representing SP provisions (SPPs) were collected from the Korea Foundation for Suicide Prevention. Increasing the number of mental health providers resulted in lower annual emergency department visit rate after self-harm (VRSH) in the entire population, as well as in both the young and elderly populations. An increase in the mental health budget led to a significant reduction in VRSHs. However, the number of suicide prevention centers did not have any significant association with the VRSH. This study also provides substantial evidence that community-based SPPs are effective in preventing self-harm.

Trends in Reproductive Indicators of Green and Hawksbill Sea Turtles over a 30-Year Monitoring Period in the Southern Gulf of Mexico and Their Conservation Implications

Long-term monitoring programs of species at risk are efficacious tools to assess population changes, evaluate conservation strategies, and improve management practices to ensure populations reach levels at which they can fulfill their ecological roles. For sea turtles, annual nesting beach surveys are the most accessible method to estimating the population abundance and reproductive output, especially when these are done in primary nesting sites. However, little data exist on the long-term assessment of these parameters. Here, we present the trends of the nest abundance, female size, hatching, and emergence success of hawksbill (Eretmochelys imbricata) and green (Chelonia mydas) turtles at key nesting beaches in the southern Gulf of Mexico over 31 years (from 1990 to 2021). The nest abundance showed an increasing trend in both species as a result of the sustained protection and conservation effort, but there was no significant temporal trend in the annual female size, clutch size, hatching, and emergence success. However, these indicators showed decreasing mean values over the last decade and should be closely monitored. We suggest these decreases link to the combined effects of ocean warming and anthropogenic pressures affecting the sea turtle foraging grounds. Aside from protecting key nesting sites, protecting and restoring crucial foraging habitats should be an immediate priority requiring international cooperation.

Host condition and pathogen identity influence bacterial infection survival in the common eastern firefly,Photinus pyralis

AbstractThe degree to which host, pathogen, and environmental characteristics determine fitness outcomes in response to infection across the tree of life is a key question in ecoimmunology. Because infection experiments require large sample sizes and careful controls, studies have generally been limited to lab‐adapted organisms.Photinus pyralisis a charismatic firefly that is abundant during its annual summer emergence in the Eastern United States. Here, we assess the importance of host condition, pathogen identity and dose, and pre‐infection environment on survival outcomes in response to bacterial infection in wild‐caught adult maleP. pyralis.Although survival after sterile saline injection was not statistically different from survival of uninjected controls, survival kinetics support sterile saline injection as the most appropriate control.Serratia marcescensandProvidencia rettgeriinfections increased mortality, especially at high doses. In contrast to fruit fly studies,Providencia sneebia, Pseudomonas aeruginosa,andEnterococcus faecalisinfections did not. Infection with higher doses ofP. rettgerihad an increased risk of death for fireflies caught later in the season than those captured earlier, but seasonality did not significantly interact with dose to impact mortality with any of the other bacterial species.These results highlight the importance of considering host, pathogen, and environmental factors when investigating infection outcomes in wild‐caught, non‐model systems. The differences in survival between fireflies and fruit flies emphasise that further studies in a broad array of organisms are needed to explore the diversity of infection responses across the tree of life.

71 Barriers to providing optimal care to children with medical complexity in the emergency department: A physicians' perspective

Abstract Background Children with medical complexity (CMC) are a subset of the pediatric population with chronic medical conditions requiring specialized care and high health resource utilization. Due to the nature of their underlying diseases, along with the medical devices that they are reliant on, they account for a large proportion of annual pediatric emergency department (ED) visits in tertiary centres and about one third of the children admitted. ED physicians are often the first to interact with CMC patients and thus the quality of care they provide influences the hospital course of those patients. Objectives To determine and explore the barriers that ED physicians face when providing care to CMC in the ED and identify potential areas of improvement in care provided in the ED. Design/Methods Semi-structured personal interviews were conducted virtually with 20 pediatric emergency medicine physicians and fellows. Each participant was asked the same set of questions and given extra time to elaborate. Interviews were transcribed verbatim and manual coding was conducted to identify commonalities across the interviews. Results We identified four major themes and 12 sub-themes as barriers to optimal care of CMC in the ED. Major themes included time, training, medico-legal concerns, and care plans. The two most commonly identified barriers were time required to care for CMC patients, identified by 90% (n=18) of the participants, and limited exposure during fellowship training, identified by 80% (n=16) of the participants. Only 20% (n=4) identified medico-legal challenges as a unique barrier when managing CMC. All the participants (n=20) emphasized the importance of a care plan, a detailed document given to caregivers of CMC by the primary care team with details about their medical condition, and if not available, 85% (n=17) indicated that it will affect the efficiency and quality of care provided. Even if a care plan is available, 50% (n=10) of the participants would still contact the complex care team for further management recommendations. Conclusion Care plan accessibility and time restraint in the ED are major barriers faced by PEM physicians in the ED when caring for CMC. Additional training during fellowship in complex care medicine and providing patients with an updated care plan are two interventions suggested to optimize care of CMC in the ED.

A Multi-year Adult Emergence Study of the Cicada Neotibicen canicularis (Harris) (Hemiptera: Cicadidae) in Wisconsin

Based on daily collections of final instar exuviae, the widespread annual cicada adult emergence of Neotibicen canicularis (Harris) (Hemiptera: Cicadidae) was studied in southeastern Wisconsin in a combined plot containing 15 mature trees and suburban lawns for seven successive years and in a separate plot of two trees for four years. The daily numbers of males and females were recorded. Over the entire seven years of the 15-tree plot, total female and male exuviae were equal, a summative 50:50 ratio. However, there was considerable deviation from this ratio three of the seven years. More females than males eclosed in the first two years and more males eclosed in the final year, yet the overall trend was for females to eclose later than males for the entire seven-year study of the 15-tree plot, with many more females emerging in the last twenty plus days. Although ambient temperatures varied over the study (cooler in the first two years and warmer later), they did not have any discernible effect on the timing of female and male eclosions. The overall annual emergence period was 56.7 (se 4.48) d for a seven-year total of 2967 exuviae, with the annual average emergence being 437.6 (se 34.6) per year. The average density of exuviae, an estimate of the emerging adult population, was 1.3 ± 0.09 (se) per m2. In the separate two-tree plot, a greater number of males emerged than females for all four years. ARISTOTLE ADVISES: “Male cicadas are tastier when young, but the females are preferable later when they are full of eggs.”

Trends in hospitalizations due to endometriosis in Spain, 1999-2019

ABSTRACT Objective Although there have been variations in the management of the patients with endometriosis, an important population of these women still require hospitalization . This study aimed to analyze the trends in hospital admissions associated with endometriosis from 1999 to 2019 in Spain. Methods An observational study of temporal trends was performed including women aged 15 to 54 years who were admitted to hospital for endometriosis in Spain from 1999 to 2019. Data on hospitalizations were drawn from the minimum basic data set. The data source used for the population was the continuous civil registry. The study variables were: age, year of admission, type of admission (elective/emergency), if there was surgical intervention during admission and length of hospital stay. Direct age-standardized admission rates were calculated using the 2013 European Standard Population differentiating between hospital admissions for elective surgery and any emergency admissions. Joinpoint regression models were fitted to estimate the annual percent change (APC). Results Admissions for elective surgery increased significantly, by 5.7% annually, until 2003, when they began to decrease slightly at different speeds until 2019. The mean APC for the entire study period was −0.88% (95%CI: −2.74; 1.02). There was a significant mean decrease of 4% in annual emergency admissions until 2012. Then, there was a significant average increase of 2% per year until 2019. Regarding the length of stay, there was a gradual decrease until 2012, after which slight, oscillating increases were apparent. Conclusion There was a reduction of hospital admissions for elective surgery to treat endometriosis from 2003 to 2019 in Spain but emergency hospitalizations due to endometriosis have been growing since 2012. The mean length of hospital decreased for the study period.

Seasonal Dynamics of Sand Flies (Diptera, Pshycodidae), Vectors of Cutaneous Leishmaniasis, in the City of Fez, Northern Morocco.

The infections transmitted by sand flies (Diptera, Psychodidae) pose always a real health problem due to the increasing number of cases detected each year and the annual emergence of new leishmaniasis outbreaks. This study evaluated the temporal evolution of six species of sand flies in five stations inventoried between May 2017 and April 2018, in order to determine for the first time the extent of cutaneous leishmaniasis (CL) transmission in the city of Fez. The monthly impact of Fez sand fly density has been studied using all multivariate statistical analyses, including multiple factor correspondence analysis (MCA), which were performed using XLSTAT and the version of SPSS 20.0 test. Differences between concentrations were considered significant if P < 0.05. To better study the results obtained, different ecological indices have been studied. This study showed that these vectors developed in different sectors of the city of Fez. A total of 816 sand flies were collected from five stations in the city, belonging to three species of the genus Phlebotomus (46.82%) and three species of the genus Sergentomyia (53.18%). The seasonal fluctuation of the average density followed a bimodal evolution for the three stations Dhar Richa, Ain Nokbi, and Boujloud. The stations of Ain Nokbi (0.87 ph/m2) and Dhar Richa (0.467 ph/m2) exposed the sites to a high average density with a maximum peak during August (1.965 ph/m2) and July (1.87 Ph/m2), respectively. S. minuta (44.24%), Ph. sergenti (26.96%), Ph. perniciosus (10.78%), and Ph. papatasi (9.07%) were the most qualified species. The calculated P value is above the 5% significance level, so the relative abundance of these species between study sites shows no significant difference. The period of phlebotomy activity of the genus Phlebotomus in Fez lasts seven months from May to November with a bimodal or trimodal evolution and varies according to the species or the surveyed station. The seasonal fluctuation of sand flies could be conditioned by climatic factors where the period of activity of the species coincides with the hot months (May, June, July, and August). We have observed that the temperature factor favors the prevalence of sand flies, while the difference in the relative abundance of species between the sites is related to the difference in the bioecological conditions of each site.

Difference in medical service use among Korean gastric cancer survivors according to regional healthcare vulnerabilities: a cohort study

PurposeThis study investigated the relationship between medical service use and healthcare vulnerability, pre- and post-gastric cancer diagnosis. Differences between healthcare-vulnerable and healthcare-nonvulnerable regions identified inequities that require intervention.MethodsThis cohort study was done using the National Health Insurance claims data of patients diagnosed with gastric cancer between 2004 and 2013. The Position Value for Relative Comparison Index was used to determine whether the patients lived in a healthcare-vulnerable region. Medical service use was classified into annual outpatient treatment, hospitalization days, and emergency treatment. We used a generalized linear model to which the Poisson distribution was applied and compared regional differences in medical service use.ResultsA total of 1797 gastric cancer patients who had survived 5 years post-diagnosis were included in the study, of which 14.2% lived in healthcare-vulnerable regions. The patients in vulnerable regions surviving 5–7 years post-diagnosis had a higher number of outpatient visits than those in nonvulnerable regions. Furthermore, hospitalization days were lesser for patients in vulnerable regions who survived 6 years post-diagnosis than those in nonvulnerable regions; however, this number increased in the seventh year.ConclusionsOur results suggest that gastric cancer survivors living in healthcare-vulnerable regions have a higher probability of increased medical service use 5 years post-diagnosis compared with patients in nonvulnerable regions, which may significantly increase healthcare disparities over time. Therefore, in the future, additional research is needed to elucidate the causes of the disparities in healthcare use and the results of the differences in health outcomes.

Health Care Utilization Trends Across the Transition Period in a National Cohort of Adolescents and Young Adults With Type 1 Diabetes.

Lack of effective transition from pediatric to adult care may contribute to adverse outcomes in young adults with type 1 diabetes. The understanding of outpatient and acute care utilization patterns across the adolescent to young adult transition age in type 1 diabetes populations is suboptimal in the U.S. We studied claims data from 14,616 individuals diagnosed with type 1 diabetes, aged 16-24 years, and enrolled in a large national health plan for ≥1 year from 2005 to 2012. Annual outpatient and emergency department visits and hospitalization rates were calculated at each age. Generalized estimating equations were used to assess the association of age-group (adolescents [age 16-18 years] vs. young adults [age 19-24 years]), outpatient visits, and sociodemographic variables with emergency department visit and hospitalization rates. Endocrinologist visits declined from 2.3 per year at age 16 years to 1.5 per year by age 22. Emergency department rates increased per year from 45 per 100 at age 16 to 63 per 100 at age 20, then decreased to 60 per 100 by age 24. Hospitalizations per year climbed from 14 per 100 at age 16 to 21 per 100 at age 19, then decreased to 17 per 100 by age 24. In statistical models, young adults experienced higher rates of emergency department visits (incidence rate ratio [IRR] 1.24 [95% CI 1.18, 1.31]) and hospitalizations (IRR 1.25 [95% CI 1.15, 1.36]) than adolescents. Additional significant predictors of emergency department visits and hospitalizations included female sex and Black race. Individuals with two or more endocrinologist visits per year were less likely to have emergency department visits and hospitalizations; higher income was also protective. Results highlight concerning increases in acute care utilization for young adults with type 1 diabetes who are less engaged with outpatient diabetes care and highlight socioeconomic risk factors that warrant further study.

Impacts of Productive Safety Net Program on Households ‘Calorie Intake per Adult Equivalent, Expenditure and Livestock Asset Holding; Empirical evidence from Eastern Ethiopia

Chronic food insecurity is one of the main problems, which affected millions of Ethiopians for centuries. To solve the food insecurity problem and move away from the previous system of annual emergency appeals, the Ethiopian government in collaboration with development partners launched social protection program called productive safety net program. This study evaluated the impacts of productive safety net program on household poverty alleviation, by measuring the wellbeing of rural households using outcome indicators of the program i.e. calorie intake, consumption expenditure and livestock asset using cross-sectional survey data collected from 200 households in ECC-SDCOH facilitated kebeles of productive safety net program in eastern Ethiopia. Multistage stage sampling technique was used to randomly select representative household heads. Both primary and secondary data were analyzed using descriptive and econometric statistics. Applying a propensity score matching technique, the study found that the program has significantly increased participating households’ calorie intake by 30% (i.e., 856 calories), the consumption expenditure by 2.84% and livestock asset by 40% compared to that of non-participating households. The results of the logit model also indicated that program participation is significantly influenced by family size, education, marital status, dependency ratio, size of land holding and credit use. Therefore, to reduce poverty level of the country, due attention has to be given by the program to reducing gender disparity in poverty and sustained effort is needed to government-administered productive safety net program districts to accelerate the rate of poverty reduction. And the program should consider roles of significant variables in the selection of participant households for the desired impact under related locations.

Depression among patient with sickle cell disease: Prevalence and prediction.

Depression is a widespread disorder with either an independent or interrelated relationship with chronic disease. This study aims to assess depression prevalence and its predictors among patients with sickle cell disease (SCD). This is a cross-sectional study conducted in Saudi Arabia where patients with SCD assessed for having depression through Patient Health Questionnaire (PHQ9). Depression was evaluated among 88 patients with SCD with a median age of 32.6 ± 11.8. Out of 88 patients, 44 (50%) participants had some form of depression. Out of those with depression, 25 (56.8%) had mild depression and 18 (40.9%) had moderate depression. However, there was a significant relationship between depression and the number of annual emergency visits, intensive care unit admissions, and frequency of blood transfusion (P-value < 0.05). There was no significant relationship between depression with neither hemoglobin nor HbS (P-value > 0.05). However, depression score found to be inversely proportional to the HbF level. Both gender and annual emergency visits were significantly related to depression (P-value = 0.01, 0.001. respectively). Depression is quite prevalent in patients with SCD though it is still being overlooked. Several clinical and laboratory indices found to be closely linked to depression. Constellations of these factors may help early recognition of depression and disease severity modulation.

Association between traffic related air pollution exposure and direct health care costs in Northern California

BackgroundTraffic related air pollution (TRAP) is associated with a complex and diverse array of health effects. It is unknown whether these effects may be reflected by higher health care costs. ObjectivesEvaluate the association between TRAP exposure and direct health care costs in an elderly population. MethodsThis multi-ethnic population-based cohort of 25,684 elderly subjects, served by Kaiser Permanente Northern California (KPNC), were followed between 2013 and 2017. Hyperlocal long-term pollutant concentrations for nitrogen dioxide [NO2], nitric oxide [NO], and black carbon [BC] were measured at a resolution of 30 m using repeated street-level mobile measurements and linked to residential addresses. Health care utilization and costs were derived from KPNC databases and were used to calculate individual annual total health care, inpatient, outpatient, and emergency room (ER) and pharmacy costs. The associations between TRAP exposures and health care costs were evaluated using generalized estimating equation models adjusted for age, sex, race, BMI, smoking, SES and comorbidities. Subgroup analyses and interaction models were used to assess differences among specific susceptible population subgroups. ResultsAn IQR difference (10.1 ppb vs 4.2 ppb) in NO2 concentration was associated with a 3% (95% CI: -1%, 6%), 22% (95% CI:11%, 35%), and 5% (95% CI:1%, 8%) increase in annual total health care, ER and outpatient costs in the baseline model. Associations with black carbon showed similar patterns but were smaller in magnitude. Among those with cardiovascular diseases, an IQR increase in NO2 was associated with a 7% (95% CI: 1%, 13%) increase in total annual health care cost and 23% (95% CI: 17%, 29%) increase in ER costs. DiscussionHigher long-term TRAP exposure was associated with higher direct annual health care cost in this elderly cohort. Those with existing cardiovascular disease had particularly strong associations between TRAP exposure and direct annual health care costs.

Suicide attempt-related emergency department visits among adolescents: a nationwide population-based study in Korea, 2016–2019

BackgroundThe incidence of adolescent suicide in Korea is increasing; however, nationwide data regarding short-term prediction of suicide attempts (SAs) is still limited. Therefore, this study aimed to investigate the incidence of SA-related annual emergency department (ED) visits among adolescents in Korea from 2016 to 2019 and to summarize the corresponding demographic and clinical characteristics based on the dispositions of SA-related ED visits.MethodsMost referral hospitals provide relevant essential ED information to the National Emergency Medical Center through the National Emergency Department Information System (NEDIS). We analyzed NEDIS data on adolescent visits (aged < 20 years) for a 4-year period from 2016 to 2019. Patients were classified into the discharge and hospitalization groups for comparison, and jointpoint regression analysis was used to identify the years in which there was a change in annual percentage change (APC) in age- and sex-standardized incidence rates of SA-related ED visits. The characteristics of patients in the discharge group and hospitalization group subgroups were also compared.ResultsThe APC in the incidence rate of SA-related ED visits in the 4-year study period revealed a 35.61% increase. The incidence rate increase was higher among females (APC: 46.26%) than among males (APC: 17.95%). Moreover, the incidence rate increased faster in mid-adolescence patients (APC: 51.12%) than in late-adolescence patients (APC: 26.98%). The proportion of poisoning as the SA method was 69.7% in the hospitalization group and 34.5% in the discharge group (p < 0.001).DiscussionOur findings suggest that an increase in the number of SA-related ED visits among female and mid-adolescent patients represented the largest increase in SA-related ED visits from 2016 to 2019. Accordingly, evidence-based suicide prevention programs need to be customized based on sex and age, and further diversification of health care systems is needed through analysis of the characteristics of the dispositions of SA-related ED visits.

Risk of Pleural Empyema in Adult Patients With Asthma: A Nationwide Retrospective Cohort Study

BackgroundRespiratory system infections commonly occur among individuals with asthma. However, whether asthma patients have a higher risk of pleural empyema development remains unclear.MethodsThis is a retrospective cohort study based on data from the National Health Insurance Research Database of Taiwan. The asthma cohort consisted of 48,360 newly diagnosed adult individuals from 2000 to 2012. The comparison cohort consisted of the same number of adults who did not have asthma and was matched for age, gender, comorbidity, and the year of diagnosis. The development of pleural empyema was followed up to 2013.ResultsPleural empyema incidence was 2.03-fold higher in the asthma cohort compared to the comparison cohort (8.65 vs. 4.25 per 10,000 person-years), with an adjusted hazard ratio (HR) of 2.12 [95% confidence interval (CI) = 1.76–2.56]. Stratified analyses by age, gender, comorbidity, and corticosteroid use revealed that the crude and adjusted HRs of pleural empyema associated with asthma were all significant. Among patients with asthma, the risk of pleural empyema elevated with increased frequency of annual asthma-related emergency room visits and hospital admissions (≥1 vs. <1, aHR = 8.07, 95% CI = 4.31–15.1 and aHR = 9.31, 95% CI = 5.56–15.6).ConclusionAn increased risk of pleural empyema occurrence was observed in adult patients with asthma than those without asthma. Furthermore, the risk of pleural empyema may increase with poor control of asthma.

Development and Application of an Open Tool for Sharing and Analyzing Integrated Clinical and Environmental Exposures Data: Asthma Use Case.

BackgroundThe Integrated Clinical and Environmental Exposures Service (ICEES) serves as an open-source, disease-agnostic, regulatory-compliant framework and approach for openly exposing and exploring clinical data that have been integrated at the patient level with a variety of environmental exposures data. ICEES is equipped with tools to support basic statistical exploration of the integrated data in a completely open manner.ObjectiveThis study aims to further develop and apply ICEES as a novel tool for openly exposing and exploring integrated clinical and environmental data. We focus on an asthma use case.MethodsWe queried the ICEES open application programming interface (OpenAPI) using a functionality that supports chi-square tests between feature variables and a primary outcome measure, with a Bonferroni correction for multiple comparisons (α=.001). We focused on 2 primary outcomes that are indicative of asthma exacerbations: annual emergency department (ED) or inpatient visits for respiratory issues; and annual prescriptions for prednisone.ResultsOf the 157,410 patients within the asthma cohort, 26,332 (16.73%) had 1 or more annual ED or inpatient visits for respiratory issues, and 17,056 (10.84%) had 1 or more annual prescriptions for prednisone. We found that close proximity to a major roadway or highway, exposure to high levels of particulate matter ≤2.5 μm (PM2.5) or ozone, female sex, Caucasian race, low residential density, lack of health insurance, and low household income were significantly associated with asthma exacerbations (P<.001). Asthma exacerbations did not vary by rural versus urban residence. Moreover, the results were largely consistent across outcome measures.ConclusionsOur results demonstrate that the open-source ICEES can be used to replicate and extend published findings on factors that influence asthma exacerbations. As a disease-agnostic, open-source approach for integrating, exposing, and exploring patient-level clinical and environmental exposures data, we believe that ICEES will have broad adoption by other institutions and application in environmental health and other biomedical fields.

A Comparative Assessment of Three Mandibular Retention Protocols: A Prospective Cohort Study.

Fixed retainers have been advocated for the prevention of anterior mandibular crowding after orthodontic treatment. However, limited data is available to help clinicians choose a retention protocol that is acceptable in terms of stability, emergencies, and side effects in the long term. It was the aim of this study to assess survival and alignment stability of the 0.016" x 0.022" stainless steel wire compared to more common protocols. Three different mandibular fixed retention protocols were compared in 600 consecutive patients: 1. 0.0215" multistrand wire (MW) with separate curing of resin and composite; 2. 0.016" x 0.022" stainless-steel wire with simultaneous curing of resin and composite (SS1C); and 3. 0.016" x 0.022" stainless-steel wire with separate curing of resin and composite (SS2C). The hazard rate for detachment across wire groups was assessed with a Cox frailty model. Incisor alignment was maintained with all retention wires. One incisor with unexpected torque change was observed in group MW. The average annual emergency rate was below 2% for all three protocols. Fewer emergency visits were found in patients with solid steel wires than with multistrand wires. Detachment of the wire is the most common cause of emergency visits with no difference between wire types. Multistrand wires were more often damaged than were solid steel wires. There was no evidence that direct application of the composite on the uncured primer influenced retainer adhesion to the enamel. The mandibular anterior teeth can be predictably stabilised with a 0.016" x 0.022" stainless steel wire..

Epidemiological investigation of multiple sclerosis and related medical utilisation in Taiwan

Background The increasing trend in the prevalence of multiple sclerosis (MS) cannot be neglected. Long-term epidemiological investigations of MS patients who have been registered in Taiwan are very scarce. Objective The aim of this study was to investigate the epidemiology of MS and medical utilisation among MS patients in Taiwan. Methods The National Health Insurance Research Database was used as the source of the research population; the time period investigated was 2001–2015. A descriptive statistical analysis of the number of MS patients was conducted. For newly diagnosed MS patients, the frequencies of emergency visits and hospitalisations and changes in their temporal distributions were calculated. Results The standardised incidence of MS peaked at 0.50/100,000 in 2003, and the highest standardised prevalence was 7.14/100,000 in 2015. The highest standardised mortality was 0.11/100,000 in 2015, with an overall mortality rate of 13.34/1000 person-years. The number of annual emergency visits for MS patients peaked at 0.9 ± 3.5 in 2011, and the longest annual length of hospital stays was 19.2 ± 40.1 days in 2001, which decreased to 5.6 ± 23.5 days in 2015. Conclusion The standardised prevalence of MS steadily increased, and its incidence slightly decreased from 2001 to 2015.

Trends in abundance and reproductive success of the hawksbill turtle nesting population at Buck Island Reef National Monument, St. Croix, US Virgin Islands

Index nesting sites for the Critically Endangered hawksbill turtle Eretmochelys imbricata are essential for assessing population trends and demographics, and informing conservation strategies. Using 29 yr (1988-2017) of saturation tagging data from a protected Caribbean index site, we assessed annual trends in abundance and reproductive success for the hawksbill nesting population at Buck Island Reef National Monument (BIRNM), St. Croix, US Virgin Islands. Approximately 43 ± 21 (mean ± SD) females and 154 ± 60 nests were encountered each year during nocturnal patrols. Remigration interval and inter-nesting period averaged 3.2 ± 1.6 yr and 17.4 ± 7.1 d, respectively. After a significant recovery since 1988, female abundance stabilized during 2007-2017 (p &lt; 0.01, R2 = 0.82), whereas nest abundance declined (p &lt; 0.01, R2 = 0.71) and neophyte recruitment exhibited a decreasing trend. There was no trend in annual mean hatch success (69.4 ± 26.6%), emergence success (63.0 ± 29.1%), and hatchling production (89.2 ± 45.0 individuals clutch-1) during the study period; but clutch size (p &lt; 0.01, R2 = 0.65; 142.8 ± 28.9 eggs clutch-1) and female curved carapace length (p &lt; 0.01, R2 = 0.56; 88.4 ± 4.7 cm) significantly decreased. The BIRNM population has stabilized, but declines in body size and nest abundance highlight the need for evaluating demographics to diagnose the factor(s) driving changes in abundance and productivity. Our study provides a foundation for evaluating Caribbean hawksbill demographics, while contributing a valuable assessment of clutch size and in situ nest success for the species.

People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study.

Background:The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use.Methods:This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health–related hospitalization data.Results:We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use–related presentations, mental health hospitalizations and instances of leaving hospital against medical advice.Interpretation:Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Medical manifestations and health care utilization among adult MyCode participants with neurodevelopmental psychiatric copy number variants

PurposeRecurrent pathogenic copy number variants (pCNVs) have large-effect impacts on brain function and represent important etiologies of neurodevelopmental psychiatric disorders (NPDs), including autism and schizophrenia. Patterns of health care utilization in adults with pCNVs have gone largely unstudied and are likely to differ in significant ways from those of children. MethodsWe compared the prevalence of NPDs and electronic health record–based medical conditions in 928 adults with 26 pCNVs to a demographically-matched cohort of pCNV-negative controls from >135,000 patient-participants in Geisinger’s MyCode Community Health Initiative. We also evaluated 3 quantitative health care utilization measures (outpatient, inpatient, and emergency department visits) in both groups. ResultsAdults with pCNVs (24.9%) were more likely than controls (16.0%) to have a documented NPD. They had significantly higher rates of several chronic diseases, including diabetes (29.3% in participants with pCNVs vs 20.4% in participants without pCNVs) and dementia (2.2% in participants with pCNVs vs 1.0% participants without pCNVs), and twice as many annual emergency department visits. ConclusionThese findings highlight the potential for genetic information—specifically, pCNVs—to inform the study of health care outcomes and utilization in adults. If, as our findings suggest, adults with pCNVs have poorer health and require disproportionate health care resources, early genetic diagnosis paired with patient-centered interventions may help to anticipate problems, improve outcomes, and reduce the associated economic burden.