Annual Emergency Research Articles

347-OR: The Long-Term Effects of an Intensive Lifestyle Intervention on Medicare Outcomes

Research Objective: Interventions for type 2 diabetes (T2D) often focus on lifestyle, including diet and physical activity. The Look AHEAD (Action for Health in Diabetes) study is one of the largest randomized trials of an intensive lifestyle intervention (ILI). Starting in 2001, 5145 adults with overweight/obesity and T2D were randomized to ILI or conventional diabetes support and education. The ILI led to persistent reductions in weight (8.6% in first year), improved diabetes control, and reduced self-reported hospitalizations and prescription drug use during the 12-year intervention. However, it is unclear whether benefits persisted beyond the intervention. We linked Look AHEAD participants to Medicare data to estimate the long-term effects of ILI on health care use. Study Design: We estimated differences in healthcare use between ILI and control groups during 2012-2015 (immediately after the intervention), adjusting for baseline characteristics. We focused on measures of healthcare use that were available for traditional Medicare and private Medicare Advantage enrollees, including hospitalizations, emergency visits, and prescription drug use. We also estimated whether the ILI affected disability-related Medicare eligibility. Population Studied: We linked 2,796 participants to Medicare data out of 3,246 consenting to linkages after the Look AHEAD intervention phase. Principal Findings: We found significantly lower annual Part D drug costs for the ILI group between 2012-2015 (-$401, p=0.029). Annual emergency department visits and hospitalizations were not significantly different between intervention groups in 2012-2015. A similar percentage of ILI and control group participants were initially eligible for Medicare before age 65 due to disability. Conclusions: The ILI led to reductions in prescription drug use and costs that persisted beyond the intervention, but did not affect long-term hospitalizations, emergency visits, or eligibility for Medicare through disability. Disclosure P.J. Huckfeldt: Employee; Spouse/Partner; U.S. Department of Veterans Affairs. C. Frenier: None. N.M. Pajewski: None. M. Espeland: Research Support; Self; National Institutes of Health. Other Relationship; Self; Boehringer Ingelheim International GmbH, Ironwood Pharmaceuticals, Inc. A.L. Peters: Advisory Panel; Self; Abbott, Becton, Dickinson and Company, Bigfoot Biomedical, Eli Lilly and Company, Lexicon Pharmaceuticals, Inc., Livongo Health, MannKind Corporation, Medscape, Merck & Co., Inc., Omada Health, Inc., OptumRx, Inc., Sanofi US, Zafgen, Inc. Research Support; Self; AstraZeneca, Dexcom, Inc., Jaeb Center for Health Research, MannKind Corporation, National Institute of Diabetes and Digestive and Kidney Diseases. Speaker's Bureau; Self; Novo Nordisk Inc. R. Casanova: None. L.J. Cheskin: None. D. Goldman: Advisory Panel; Self; ACADIA Pharmaceuticals. Consultant; Self; Precision Health Economics. Stock/Shareholder; Self; Precision Medicine Group, Inc. Other Relationship; Self; Aspen Health Strategy Group, Celgene Corporation. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK107552)

Selection of a geographic area of interest for syndromic surveillance

Selection of a geographic area of interest for syndromic surveillance

Neighborhood Risk and Hospital Use for Pediatric Asthma, Rhode Island, 2005-2014.

IntroductionStudies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use. MethodsThis retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block–group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child’s sociodemographic information, season, and multiple measurements per child.ResultsFrom 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06–1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34–0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile. ConclusionInterventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.

PCN137 ECONOMIC BURDEN ASSOCIATED WITH ADVERSE EVENTS AMONG PATIENTS WITH NON-METASTATIC PROSTATE CANCER TREATED WITH BICALUTAMIDE, ENZALUTAMIDE OR ABIRATERONE FOLLOWING ANDROGEN DEPRIVATION THERAPY (SURGICAL/MEDICAL CASTRATION)

The non-metastatic castration-resistant prostate cancer (nmCRPC) treatment landscape has evolved following the approval of second-generation androgen biosynthesis (abiraterone) and receptor (enzalutamide) inhibitors. Skin rash, fractures and central nervous system (CNS) adverse events (AEs) have been reported among patients treated with these drugs. This analysis was conducted to estimate the economic burden of AEs among nmPC patients treated with abiraterone, enzalutamide, or bicalutamide (“study drugs”). NmPC patients switching to/adding a “study drug” ≥1 year after medical/surgical castration were identified in the MarketScan database (2012-2017). Patients with a claim for a prostate-specific antigen test or an oncologist visit ≤6 months before “study-drug” initiation; no hormonal therapies (except castration) or metastasis claim prior to starting “study drug”; and ≥3-month metastasis-free follow-up on “study drug” were included. Patients were categorized by presence of any of 18 CNS AEs, skin rash, fractures or no AEs. Annual healthcare resource use and costs were compared across groups (CNS AEs vs. no CNS AEs; composite AEs [defined as CNS AE, skin rash, fracture] vs. no AEs) using propensity-score weighted generalized linear models. 532 patients (Medians: Age:74 years; Follow-up:9 months) were included (bicalutamide: 477 (89.7%), enzalutamide: 23 (4.3%), abiraterone: 32 (6.0%)). 38% and 46% of patients experienced CNS AEs or the composite AEs, respectively. Compared to patients without CNS AEs, patients with CNS AEs had significantly higher per-person annual inpatient (0.34 vs 0.09), emergency room (0.90 vs 0.24), and outpatient (26.2 vs 18.4) visits and higher inpatient ($7,537 vs $2,844) and total ($51,116 vs $32,594) costs. Comparable results were observed for patients with the composite AEs vs no AE. NmPC patients treated with bicalutamide/abiraterone/enzalutamide have a high prevalence of CNS AEs and significant economic burden (incremental annual cost of $18,000/patient). Novel agents with better risk-benefit profiles may lower this economic burden and improve quality of survival.

(148) A Randomized Controlled Trial of the PTSD Coach Mobile Health App at Reducing Pain and Psychological Symptoms among Injured Emergency Department Patients: Preliminary Results

Motor vehicle accidents (MVAs) account for 4 million annual emergency department (ED) visits, and injured patients are at risk of chronic pain (CP). Posttraumatic stress disorder symptoms (PTSS) are common post-injury, and contribute to the transition from acute to CP. We tested a novel, biopsychosocial, non-pharmacological method to prevent post-injury PTSS and pain: the “PTSD Coach” smartphone app. PTSD Coach provides psychosocial support based on cognitive-behavioral therapy, and research supports its use in both Veteran and Civilians with established PTSD; it has yet to be tested to prevent post-injury sequelae. We enrolled 64 adults (63% female; M age = 37) from the EDs of two Level 1 trauma centers with injuries from MVAs

Correlation of Initial Echocardiographic Parameters and Emergency Room Admission Rates in Heart Failure Clinic Patients

Purpose The prevalence of heart failure (HF) has increased demand on the healthcare system. Echocardiography is a common non-invasive test in HF patients and is thought to have many clinical prognostic implications. This study sought to identify certain echocardiographic parameters that would act as predictors for relative health care resource utilization in HF patients, by correlating with their annual emergency room visits. Methods We conducted retrospective chart review on patients seen at a high-acuity tertiary care HF clinic. A total of 263 patients’ charts were reviewed and data regarding their initial baseline echocardiogram were recorded. Specific predictors evaluated included baseline ejection fraction (EF), left atrial volume index (LAVI), and tricuspid regurgitation peak gradient (TRPG). Each patient's total number of annual ER visits over one year from their initial referral to the clinic was recorded. Each predictor was analyzed separately and divided into subgroups based on specific clinical guideline cutoff ranges. Patients were divided by EF into two groups, HFpEF (EF>50%) and HFrEF (EF 31.6 mmHg. Possible diastolic dysfunction was defined by LAVI>34 mL/m2. For each individual predictor, we compared the average annual ER visits between each subgroup. Results There were no significant differences in annual ER visits when using LAVI (p=0.317) or TRPG (p=0.392) alone as a predictor. There was a significant difference in annual ER visits when using EF alone as a predictor, where patients with EF>50% had significantly more annual ER visits compared to patients with EF 50% were generally older (p Conclusion Neither LAVI nor TRPG were found to be a predictor of health care utilization through annual ER visits. Patients with HFpEF (EF>50%) had significantly more annual ER visits compared to patients with HFrEF (EF

Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?

An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope. A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods. The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings. hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.

Estimated Annual Deaths, Hospitalizations, and Emergency Department and Physician Office Visits from Foodborne Illness in Ontario.

Public Health Ontario is working to estimate the burden of disease from environmental hazards in Ontario, Canada. As part of this effort, we estimated deaths and health care utilization resulting from exposure to pathogens and toxic substances in food. We applied fractions for the proportion of illness attributable to foodborne transmission to the annual (2008–2012) counts of deaths, hospitalizations, emergency department (ED) visits, and physician office visits for 15 diseases (13 pathogen-specific diseases and 2 nonspecific syndromes) captured by administrative health data. Nonspecific gastroenteritis (causative agent unknown) was the dominant disease, accounting for 98% of ED visits, 94% of hospitalizations, and 88% of deaths annually attributed to the 15 diseases. We estimated that foodborne nonspecific gastroenteritis results in ∼137,000 physician office visits (1000/100,000 population), 40,000 ED visits (310/100,000), 6200 hospitalizations (47/100,000), and 59 deaths (0.45/100,000) in Ontario per year (mean estimates). Our results indicate that pathogen-specific approaches to foodborne disease surveillance can substantially underestimate the deaths and illness resulting from exposure to foodborne pathogens and other causes of foodborne illness.

THE IMPACT OF DOOR TO DIURETIC TIME IN ACUTE HEART FAILURE ON HOSPITAL LENGTH OF STAY AND INPATIENT MORTALITY

Acute heart failure (AHF) leads to an estimate of more than 658,000 annual emergency department (ED) encounters in the United States (US). Achieving adequate and prompt euvolemic state in AHF patient using intravenous (IV) diuretics is the cornerstone of the treatment, which not only reduces

Updates in Concussion Care: New Data, New Guidelines

There has been increased public awareness, research, and legislation regarding to concussion or mild traumatic brain injury (mTBI) in young athletes. Along with this, there has been an increase in the number of annual emergency department (ED) visits for the evaluation of sports- and non-sports-related head injuries. Several medical organizations have published recommendations regarding the management of concussion and subsequent return to activities. The purpose of this article is to: (1) summarize these guidelines and provide up-to-date recommendations regarding concussion treatment, and (2) provide this author's approach to the concussion management in both the ED and sports medicine clinic settings.

Seasonal occurrence and host range of the predatory gall midge Diadiplosis hirticornis (Diptera: Cecidomyiidae), a native natural enemy of Planococcus kraunhiae (Hemiptera: Pseudococcidae)

Diadiplosis hirticornis Felt (Diptera: Cecidomyiidae) larvae feed on the eggs of mealybugs and are potentially useful biological control agents against the Japanese mealybug Planococcus kraunhiae Kuwana (Hemiptera: Pseudococcidae). However, a detailed life history and their wild hosts remain unclear preventing effective use of this gall midge in orchards. We surveyed the seasonal occurrence and natural hosts of D. hirticornis in Saga, Northern Kyushu, Japan. Based on field surveys using pumpkin traps baited with P. kraunhiae, two peaks were detected in the annual adult emergence of D. hirticornis in both 2015 and 2016. Therefore, this gall midge appears to have at least two generations a year. In this study, D. hirticornis was observed to feed on at least three species of Pseudococcidae, including the important pests P. kraunhiae and Phenacoccus solenopsis Tinsley (Hemiptera: Pseudococcidae), in the field. However, D. hirticornis was not found on Icerya purchasi Maskell (Hemiptera: Margarodidae) collected from a neighboring site of P. kraunhiae colonies. These results suggest that the host range of D. hirticornis is restricted to only Pseudococcidae.

Hospital and ED charges for spina bifida care in the United States between 2006 and 2014: Over $2 billion annually.

BackgroundMore children with spina bifida (SB) are surviving into adulthood. Unfortunately, little data exist regarding the economic implications of modern SB care. ObjectiveWe examined economic data from two national databases to estimate the annual nationwide hospital and emergency charges of SB from 2006–14. MethodsWe analyzed the 2006–2014 Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS). SB patients were defined using ICD-9-CM codes. Demographic and charge data were obtained from each database. Multiple imputation was used to estimate missing data (1.6% for NIS and 22% in NEDS). The principal outcomes were mean, median, and total charges for encounters each year. ResultsThere were 725,646 encounters for individuals with SB between 2006 and 2014. The average age of captured SB patients who were admitted to a hospital or seen in an ER was 29 years. In 2014, the median charge for inpatient encounters was $31,071 (IQR: $15,947, $63,063) and for ER encounters was $2407.02 (IQR: $1321.91, $4211.35). In total, the sum of charges from all SB-related admissions in 2014 was $1,862,016,217 (95% CI: $1.69 billion, $2.03 billion), while the sum of charges of all SB-related ER encounters in 2014 was $176,843,522 (95% CI: $158 million, $196 million). There was a steady increase in charges over the study period. ConclusionCharges for SB-related inpatient and emergency care in the US in 2014 was in excess of $2 billion in contrast to $1.2 billion in 2006, after adjusting for inflation; this is an impressively high figure for a relatively small number of patients.

Aggressive.

Aggressive Anji Wall "The other faculty members don't think that you are aggressive enough to train with us." This is what my mentor shared with me in confidence when I did not match at my first-choice residency program. I was crushed. I could not understand how aggressive behavior in surgery is considered a positive personality trait. Moreover, as a champion athlete in college and medical school, I knew that I could be aggressive in appropriate settings. I had never considered that a hospital or operating room was a place where I should be aggressive. The term aggressive means ready to attack or confront, and it is synonymous with hostile, belligerent, and antagonistic. How, I wondered, could being aggressive be a desirable trait for a surgical resident? Reflecting on my journey so far, I think that the answer to this question lies in the culture that has been created by—as Joan Cassell states in "Doing Gender, Doing Surgery: Women Surgeons in a Man's Profession"—the 'adrenalized vocation' of surgery that values arrogance, courage and decisiveness. When I rotated at my first-choice hospital, it was everything I'd dreamed of in a surgical training program: intense cases, prestigious research, and teaching rounds with rapid-fire questions that ranged from surgical history to postoperative care. What I didn't notice at the time were the toxicities I'd been conditioned to see as normal. Abrasive, tough surgeons ruled the program. Their hierarchical culture left little room for collegiality. Attending surgeons reigned over the operating rooms, where they had permission to behave how they saw fit: verbally assaulting nurses, scrub technicians, anesthesiologists, and residents. Broken or undesired instruments were thrown to the OR floor for any reason. This behavior was not universal, but far too prevalent and obvious to excuse as one or two bad actors. The operating room culture accepted unprofessional, unkind, and unbelievable behavior as the norm. While my rejection was devastating, not matching at my first-choice program turned out to be the best thing that could have happened to me. The residency program that I did match into valued and promoted attending surgeons and surgical residents who were entirely different. The administrative chief resident's orientation lecture entitled "This is how we roll" outlined the first two rules of surgical residency: Be Nice and Respect Others. We were informed that the annual Emergency Room Consultation Award was a coveted honor for surgical residents. The emergency room residents selected the surgical resident who they determined performed the most timely, respectful, and helpful consultations. Beyond expecting me to become a competent clinical and technical surgeon, my residency taught me that I must also embrace collegiality and kindness. Being confrontational in the OR, ER, and wards was a detriment to patients and not an essential ingredient in excellent care to patients. Such care is best achieved when we work together with respect and lift each other up. When I left residency for transplant fellowship, I had grown accustomed to the collegial teamcentered culture of residency. I thought that I had chosen a place that had a similar culture, and I was so excited to spend two years gathering amazing technical training with staff who would build my surgical career. There were smooth cases, and I made some good relationships, but I can't ignore the fact that parts of the experience were unnecessarily abusive. There was a superficial collegial relationship among the staff and toward the fellows, but in the blink of an eye, attitudes would shift, and normal interactions would turn into confrontations on the wards, in the ER, or in the OR. Artificial or real disasters loomed all around, and an unsuspecting [End Page 209] nurse, circulator, anesthesiologist, or I would become the target of a rampage. If these situations had happened daily, I would have known what to expect. But the whims of any particular surgeon felt random, and, early on, I was entirely unprepared. I had so many positive interactions, but the negative ones were so powerful that I still get chest pain when I think back to my fellowship. By my second year of fellowship, I was getting more accustomed to the culture...

Quantitative resilience assessment in emergency response reveals how organizations trade efficiency for redundancy

Current frameworks to assess resilience are often based on low-dimensional models that describe a small number of inter-related components. However, for many infrastructures their resilience is a property that emerges from myriads of individual interactions. Here, we develop for the first time fully quantitative and data-driven indicators for several aspects that relate to resilient organizational behavior during emergency situations. We consider dynamic communication networks of emergency responders collected during the annual public emergency drill of the Hungarian National University of Public Service. Our key hypothesis is that the time-dependent network structure derived from these communication flows conveys information as to how redundant, vulnerable, and efficient individual organizations acted during the drill. The resulting indicators can be applied on two different levels—the level of the entire network and the level of individual participants. To validate our framework, we show that when the personnel is prepared for a given event (e.g., critical weather conditions), effective communication within the organization is dominated by vertical flows of information. However, under surprise the affected units concentrated on horizontal communication, thereby creating bottlenecks and losses of efficiency in the network. Our results indicate a generic trade-off between efficiency, vulnerability and redundancy of communication networks in emergency response. Moreover, we can relate the origin of this trade-off to the specific way of how individual organizations adapted their communication behavior in times of crisis. We do so in a fully quantitative and data-driven way that is directly linked to real-world networks, infrastructures, and the people acting within them.

The association between blood urea nitrogen to creatinine ratio and mortality in patients with upper gastrointestinal bleeding

Background and study aimsAzotaemia is commonly identified among patients with upper gastrointestinal bleeding (UGIB) due to absorption of blood products in the small bowel. Previous studies have found blood urea nitrogen-to-creatinine (BUN/Cr) ratio to be significantly elevated among patients UGIB bleeding compared to patients with lower GI bleeding. However, no studies have explored the relationship between BUN/Cr ratio and mortality. This study is aimed at investigating how BUN/Cr ratio relates to outcomes for UGIB patients. Patients and methodsThis study was conducted prospectively at a university-affiliated teaching hospital with approximate 70,000 annual emergency department (ED) visits. Data from a total of 258 adult UGIB patients were collected between March 1, 2011 and March 1, 2012. Cox regression analysis was used to identify risk factors for 30-day mortality. ResultsMalignancy and Rockall score were associated with increased risk of 30-day mortality (Unadjusted hazard ratio (HR): 3.87, 95% CI: 1.59–9.41, p = 0.0029; HR: 1.31, 95% CI: 1.02–1.71, p = 0.0476, respectively). However, BUN/Cr > 30 was associated with lower risk of 30-day mortality (HR: 0.32, 95% CI: 0.11–0.97, p = 0.0441). ConclusionsA BUN/Cr ratio of >30 was found to be an independent risk factor for mortality and may be useful for pre-endoscopic assessment. Development of future risk scoring systems might warrant consideration of including BUN/Cr ratio as a parameter for estimating risk.

Multi-centre randomised controlled trial of a smart phone-based event recorder alongside standard care versus standard care for patients presenting to the Emergency Department with palpitations and pre-syncope - the IPED (Investigation of Palpitations in the ED) study: study protocol for a randomised controlled trial

BackgroundPalpitations and pre-syncope are together responsible for 300,000 annual Emergency Department (ED) attendances in the United Kingdom (UK). Diagnosis of the underlying rhythm is difficult as many patients are fully recovered on ED arrival; and examination and presenting electrocardiogram (ECG) are commonly normal. The only way to establish the underlying heart rhythm is to capture an ECG during symptoms. Recent technology advances have led to several novel ECG monitoring devices appearing on the market. This trial aims to compare the symptomatic rhythm detection rate at 90 days of one such smart phone-based event recorder (AliveCor Heart Monitor and AliveECG) with standard care for participants presenting to the ED with palpitations and pre-syncope and no obvious cause in the ED.Methods/DesignThis is a multi-centre hospital ED / Acute Medical Unit (AMU) open label, randomised controlled trial. Participants will be recruited in 10 tertiary and district general hospitals in the UK. Participants aged ≥ 16 years presenting with an episode of palpitations or pre-syncope with no obvious cause and whose underlying ECG rhythm during these episodes remains undiagnosed after clinical assessment will be included. Participants will be randomised to either: (1) the intervention arm, standard care plus the use of a smart phone-based event recorder; or (2) the control arm, standard care. Primary endpoint will be symptomatic rhythm detection rate at 90 days. A number of secondary clinical, process and cost-effectiveness endpoints will be collected and analysed. Analysis will be on an intention-to-treat basis.DiscussionThe Investigation of Palpitations in the ED (IPED) study aims to recruit 242 participants across 10 hospital sites. It will be the first study to investigate the ability of a smart phone-based event recorder to detect symptomatic cardiac rhythms compared to standard care for ED patients with palpitations and pre-syncope with no obvious cause in the ED. This smart phone event recorder will allow ED patients who have presented with palpitations or pre-syncope to record their ECG tracing if they have a further episode and may increase the rate of underlying rhythm diagnosis.Trial registrationClinicalTrials.gov, NCT02783898. Registered on 26 May 2016.

The association between Type 1 diabetes mellitus and periodontal diseases

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease affecting oral health. Evidence shows possible association between T1DM and periodontal diseases (PDs). We conducted a nationwide population-based study in Taiwan, with a 14-year follow-up to investigate the risk of PDs in T1DM patients. We used data from the National Health Insurance Research Database in Taiwan. The T1DM cohort was identified with newly diagnosed T1DM from 1998 to 2011. The non-T1DM cohort was frequency matched with the T1DM cohort. Participants comprised 4248 patients in the T1DM cohort and 16992 persons in the non-T1DM cohort. The T1DM patients showed an increased risk of PDs compared to non-T1DM individuals [adjusted hazard ratio (aHR)=1.45]. T1DM patients who visited the emergency room more than twice per year had a higher aHR of 13.0 for developing PDs. The aHR for PDs was 13.2 in the T1DM patients who had been hospitalized more than twice per year. T1DM patients are at higher risk of developing PDs than non-T1DM individuals. Our results further showed that the number of T1DM interventions; that is, annual emergency visits and hospitalizations were associated with increased the risk of developing PDs.

Psychotropic medication use before and after suicidal presentations to the emergency department: A longitudinal analysis

ObjectiveThe rates of annual emergency department (ED) visits in the United States for suicidal behaviour has nearly doubled over the last 10–15 years, with a decreased rate of hospitalizations, indicating the importance of intervention in the ED presentation. This paper describes the patterns of psychotropic use immediately before and after emergency department presentation to enhance understanding of interventions for increasing safety in these individuals. Methods5070 adults seen in psychiatric consultation in two tertiary EDs with linkage to population-based administrative data to describe psychotropic prescriptions immediately before and after ED presentation. Results55.9% of suicide attempts were by overdose, with 13.4% of suicide attempts occurring in the 18–21 age group. While no causal relationship can be inferred, half of those who presented to the ED with suicidal ideation or behaviour or non-suicidal self-injury were prescribed an antidepressant prior to ED presentation, with a spike in new prescriptions in the month immediately prior. 20% of those who presented to the ED with thoughts or behaviour received a new or different prescription for an antidepressant in the 1-month post-presentation. Prescribing of tricyclic antidepressants and opioids were decreased following ED presentation, however 21% of people still received opioids after a suicide attempt. Rates of antipsychotic prescriptions were increased. ConclusionPatients are seeking help in the one-month prior to emergency presentation. Clinicians must consider the risk in this period of heightened clinical distress, especially among those under age 21. It is important to consider the changes that can be made in the ED to impact safety.

Estimates of the Global Burden of Ambient [Formula: see text], Ozone, and [Formula: see text] on Asthma Incidence and Emergency Room Visits.

Background:Asthma is the most prevalent chronic respiratory disease worldwide, affecting 358 million people in 2015. Ambient air pollution exacerbates asthma among populations around the world and may also contribute to new-onset asthma.Objectives:We aimed to estimate the number of asthma emergency room visits and new onset asthma cases globally attributable to fine particulate matter (), ozone, and nitrogen dioxide () concentrations.Methods:We used epidemiological health impact functions combined with data describing population, baseline asthma incidence and prevalence, and pollutant concentrations. We constructed a new dataset of national and regional emergency room visit rates among people with asthma using published survey data.Results:We estimated that 9–23 million and 5–10 million annual asthma emergency room visits globally in 2015 could be attributable to ozone and , respectively, representing 8–20% and 4–9% of the annual number of global visits, respectively. The range reflects the application of central risk estimates from different epidemiological meta-analyses. Anthropogenic emissions were responsible for and 73% of ozone and impacts, respectively. Remaining impacts were attributable to naturally occurring ozone precursor emissions (e.g., from vegetation, lightning) and (e.g., dust, sea salt), though several of these sources are also influenced by humans. The largest impacts were estimated in China and India.Conclusions:These findings estimate the magnitude of the global asthma burden that could be avoided by reducing ambient air pollution. We also identified key uncertainties and data limitations to be addressed to enable refined estimation. https://doi.org/10.1289/EHP3766

Epidemiological analysis and disease spectrum characteristics of emergency patients with critical illness: 3 176 emergency cases in 2017 in a hospital in Beijing were analyzed

To investigate the epidemiological characteristics of emergency critical illness and disease spectrum in emergency department of a hospital in Beijing. A retrospective study was conducted. The data of 3 176 critically ill patients aged ≥ 14 years old admitted to the emergency room of Xuanwu Hospital Capital Medical University from January 1st to December 31st in 2017 were analyzed, including gender, age, clinical time, discharge diagnosis, outcomes, etc. To analyze the epidemiological characteristics and disease spectrum distribution of emergency critically ill patients, annual and daily 24-hour emergency visits in 2017 were analyzed. Among the 3 176 cases of acute critical illness, there were more males than females (1 824 vs. 1 352, 1.35:1); the age ranged from 14 to 100 years old, with an average of (66.52±17.18) years old; the highest incidence age was 75-89 years old (35.2%, 516 males and 603 females), followed by 60-70 years old (30.0%, 572 males and 381 females). The top four prevalence diseases in the emergency critical disease spectrum were cardiovascular diseases [41.8%, 716 males and 610 females, age (70.25±15.08) years old], nervous system diseases [26.7%, 502 males and 346 females, age (60.28±17.57) years old], respiratory disease [12.3%, 226 males and 166 females, age (72.96±16.23) years old] and digestive system diseases [5.6%, 119 males and 60 females, age (65.40±17.96) years old], accounting for 86.4% of the total. There were more males than females (all P < 0.05), and the age difference was statistically significant (F = 84.094, P < 0.001). Arrhythmia was the most common cardiovascular disease (16.7%), followed by acute coronary syndrome (12.0%) and heart failure (9.1%); the main nervous system diseases were stroke (20.9%); respiratory diseases mainly included severe pneumonia (8.3%); digestive system diseases were mainly with digestive tract bleeding (4.4%). The high incidence of acute critical illness in the emergency department occurred in winter (287 cases in December and 277 cases in January) and the early stage of spring (282 cases in March). The daily peak period was midday and at night, especially from 18:00 to 23:00 (163 cases at 18:00, 173 cases at 19:00, 172 cases at 20:00, 186 cases at 21:00, 167 cases at 22:00, 169 cases at 23:00). The average treatment time of critically ill patients in emergency room was 1.5 days (the longest was 23.0 days, the shortest was 6 minutes), among them, 85.6% of the patients could be discharged from the emergency within 3 days, and 1.9% of the patients stayed in the emergency for more than 7 days. There were 305 deaths (9.6%), mainly among the elderly, with an average age of (71.10±16.08) years old. Cardiovascular and cerebrovascular diseases, respiratory and digestive diseases are the main causes of acute critical diseases in department of emergency of Xuanwu Hospital Capital Medical University in 2017. Male and elderly patients are more common; different types of acute and severe patients tend to attack at different ages.