Increase In Emergency Room Visits Research Articles

Effects of air pollution on emergency room visits for mental disorders: risks and effect modification by comorbid physical disorders and personal characteristics

Emerging evidence suggests that exposure to ambient air pollution negatively impacts mental health. However, little is known about potential moderators of such effects, including pre-existing physical disorders and personal characteristics. This study investigated if the effects of daily changes in levels of air pollutants among individuals with mental disorders (MDs) vary depending on comorbid physical disorders, age, sex, or race/ethnicity. We used a time-stratified case-crossover design that compared the levels of PM2.5 and NO2 on days leading up to MD-related emergency room (ER) visits to levels on control days. The sample consisted of individuals with MDs for their primary diagnosis, including both patients with a second diagnosis and those without. We conducted a stratified analysis to examine potential effect modifications by individuals’ demographic characteristics (sex, age, and race/ethnicity) or a diagnosis of a physical disorder (cardiovascular disease, diabetes mellitus, and respiratory disease). We found that both PM2.5 and NO2 were significantly associated with ER visits for MDs. Per 10 µg m−3 increase in daily PM2.5 and per 10 ppb increase in NO2 concentration were associated with 1.07% (95% CI: 0.81%, 1.34%) and 0.56% (95% CI: 0.42%, 0.69%) increase in ER visits for MDs, respectively. We also found significantly greater susceptibility among younger persons (below 18 years old), Black, and individuals with respiratory disease. Exposures to both PM2.5 and NO2 were significantly associated with ER visits for MDs, and these adverse effects were more pronounced among youth, Black and individuals with respiratory disease as a comorbid physical disorder.

Unique patterns of healthcare utilization following the opening of the Samson Assuta Ashdod University Hospital

Our aim was to examine the influence of the market entry of Samson Assuta Ashdod University Hospital on community and hospital-based healthcare utilization (HCU). A retrospective study was conducted among Maccabi Health Services enrollees in the regions of Ashdod (n = 94,575) and Netanya (control group, n = 80,200) before and after this market entry. Based on difference-in-differences framework, we examined the change in HCU of Ashdod region’s enrollees compared to the control group and following the market entry using multivariable generalized estimating equations models. Our results revealed that, as hypothesized, after the market entry and compared to the control group, there was a 4% increase in specialists visits not requiring referral (RR = 1.04, 95% CI 1.03–1.06, p < 0.001), a 4% increase in MRI and CT scans (RR = 1.04, 95% CI 1.01–1.08, p = 0.022), and a 33% increase in emergency room visits (RR = 1.33, 95% CI 1.29–1.38, p < 0.001). Unexpectedly, no changes were observed in the number of hospital admissions (RR = 1.05, 95% CI 0.97–1.14, p = 0.250), and hospitalization days (RR = 0.99, 95% CI 0.94–1.04, p = 0.668). Moreover, and unexpectedly, there was a 1% decrease in primary care physician visits (RR = 0.99, 95% CI 0.98–1.00, p = 0.002), a 11% decrease in specialists visits requiring a referral (RR = 0.89, 95% CI 0.86–0.91, p < 0.001), and a 42% decrease in elective surgeries (RR = 0.58, 95% CI 0.55–0.60, p < 0.001). We conclude that this market entry was not translated to an increase in utilization of all services. The unique model of maintaining the continuity of care that was adopted by the hospital and patients’ loyalty may led to the unique inter-relationship between the hospital and community care.

A Reduction in Opioid Prescription Size After Total Joint Arthroplasty Can be Safely Performed Without an Increase in Complications

BackgroundExcessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid-related events, chronic opioid use, and unlawful opioid diversion. Decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications, such as readmissions, emergency department (ED) visits, or worsened patient-reported outcomes (PROs). The purpose of this study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. MethodsData originated from a statewide database prospectively abstracted, including oral morphine equivalents prescribed at discharge, readmissions, ED visits, and PROs. Data were collected from 84,998 TJA occurring 1 year before and after the creation of an opioid-prescribing protocol that had decreased prescriptions by approximately 50%. Trends were monitored using Shewhart control charts. Regression models were used to determine statistically significant changes over time. ResultsAll groups showed a reduction in opioids prescribed by almost 50% without an increase in emergency room visits or readmissions and without a detrimental effect on PROs. Compared to baseline data before opioid reduction, opioid-naive total knee arthroplasty had significant improvements in all outcomes (P = .03, P = .02, P < .001, P < .001). Opioid-tolerant total knee arthroplasty and total hip arthroplasty had no worsened outcomes and significant improvement in (Knee Injury and Osteoarthritis Outcome score for Joint Replacement P = .03) and (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement P = .03). Opioid-naive total hip arthroplasty had significant improvements in Hip Disability and Osteoarthritis Outcome Score Joint Replacement (P = .003) and Patient Reported Outcomes Measurement Information System (P = .001). ConclusionsPostoperative opioid prescription recommendations from a statewide registry decreased prescribing by approximately 50% without decreasing PROs or increasing ED visits or readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without increased complications.

8532 Patient Satisfaction with Postoperative Follow up after Benign Minimally Invasive Hysterectomy: A Randomized, Controlled Trial

<h3>Study Objective</h3> To assess whether patient satisfaction varies with a single six week versus a two- and six-week postoperative visit after minimally invasive hysterectomy (MIH). Secondary aim was to determine the rate of postoperative complications between randomized groups. <h3>Design</h3> Prospective, randomized controlled trial of English-speaking women aged 18 to 70 undergoing MIH at an academic institution from August 2018 to December 2019. Patient satisfaction was determined by The Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS) global satisfaction response and compared between groups using a non-inferiority test with 12% non-inferiority limit. Comparison of postoperative outcomes were performed utilizing the Clavien-Dindo Classification System. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> 174 patients were randomized for postoperative follow up; 140 included in overall analysis. <h3>Interventions</h3> Randomization to either a two and six week or a single six-week postoperative appointment. <h3>Measurements and Main Results</h3> For the primary outcome of an S-CAHPS satisfaction score of 8 or higher, the six weeks only group was non-inferior to the two- and six-week group (93% satisfaction in both groups; non-inferiority p=0.003). There was no difference in satisfaction with number of postoperative appointments between groups: 94% for two and six week and 90% for six weeks only (p=0.694). When asked if more or fewer appointments were desired, there was no difference between groups (p=0.465). Patients with abnormal uterine bleeding were more likely to be satisfied (p=0.030). Between the two and six weeks versus six weeks only groups, there was no significant increase in emergency room visits (18% versus 20%, respectively, p=0.863) or hospital readmissions (3% versus 6%, respectively, p=0.682). <h3>Conclusion</h3> Patient satisfaction with postoperative visits are similar among women randomized to a two and six week and a single six week visit. Postoperative complications were rare and comparable between groups. A single six-week appointment showed non-inferior patient satisfaction relative to a two- and six-week schedule.

Safety of the Fiocruz ChAdOx COVID-19 vaccine used in a mass vaccination campaign in Botucatu, Brazil

IntroductionBrazil has been at the core of the COVID-19 pandemic, with the second-highest death toll worldwide. A mass vaccination campaign was initiated on May 16th, 2021, in Botucatu, Brazil, where two doses of ChadOx1-nCoV19 were offered 12 weeks apart to all 18–60- year-olds. This context offers a unique opportunity to study the vaccine safety during a mass campaign. MethodsThe first and second doses of the vaccine were administered in May and August 2021, respectively. Emergency room (ER) and hospitalization records were obtained from the Hospital das Clínicas da Faculdade de Medicina de Botucatu for six weeks before and six weeks after the first and second doses, from 4 April to 19 September 2021. Diagnoses with COVID-19-related ICD codes were excluded to distinguish any trends resulting from the COVID-19 pandemic. ER and hospital visits during the two time periods were compared, including an ICD code comparison, to identify any changes in disease distributions. Data were scanned for a defined list of Adverse Events of Special Interest (AESIs), as presented by the Safety Platform for Emergency Vaccines. Results and discussionA total of 77,683 and 74,051 subjects received dose 1 and dose 2 of ChadOx1-nCoV19, respectively. Vaccination was well tolerated and not associated with any major safety concerns. Increases in ER visits 1 week following both doses were primarily seen in ICD codes related to non-serious side effects of the vaccine, including vaccination site pain and other local events. The neurological AESIs identified (2 of 3 cases of multiple sclerosis) were relapses of a pre-existing condition. One potentially serious hospitalization event for Bell’s palsy had onset before vaccination with dose 1, in a patient who also had a viral infection of the central nervous system. There was no myocarditis, pericarditis cases, or vaccine-related increases in thromboembolic events.

Feasibility of an Opioid Sparing Discharge Protocol Following Laparoscopic Bariatric Surgery.

Opioids are commonly prescribed after laparoscopic bariatric surgery but have untoward effects including dependence and diversion. Prior investigation revealed that over three-fourths of discharge opioids prescribed to our patients went unused. To determine the feasibility of an opioid sparing discharge protocol following laparoscopic bariatric surgery. A total of 212 opioid-naïve patients undergoing laparoscopic bariatric surgery were examined and divided into two groups; 106 prior to (Cohort A) and 106 after implementation of an opioid sparing discharge protocol (Cohort B). Opioids were converted to morphine milligram equivalents (MME) and post-operative consumption was examined. Data was described as mean ± standard deviation. No patients in Cohort B and 54.7% (58) in Cohort A received an opioid discharge prescription (37.5 MME). Of the 154 patients that remained, only 1.3% (2) received one after discharge. Cohort A took greater amounts of opioids than Cohort B after discharge (4.74 ± 11 vs. 0.21 ± 2 MME; p < 0.001). During hospitalization, Cohort A took greater amounts of opioids (6.92 ± 11 vs. 2.74 ± 5 MME; p < 0.001) but lower amounts of methocarbamol (759 ± 590 vs. 966 ± 585 mg; p = 0.011). No patient requested an opioid prescription refill or presented to the emergency room secondary to pain. Following laparoscopic bariatric surgery, an opioid sparing discharge protocol is feasible with < 2% of patients receiving opioids after discharge and no increase in emergency room visits. Education regarding these protocols may impact the amount of opioids taken during hospitalization.

142 Simultaneous Versus Staged Bilateral Carpal Tunnel Release Surgeries: A Retrospective Propensity-Matched Patient Comorbidity Analysis

INTRODUCTION: Carpal Tunnel Entrapment is the most common peripheral neuropathy, accounting for ∼ 90% of all neuropathies and frequently, occurs bilaterally. While thousands of carpal tunnel releases are performed each year bilaterally, the current understanding of pre-operative factors and postoperative outcomes in simultaneous and staged bilateral carpal tunnel release remain poor. METHODS: We performed a retrospective database analysis of the TriNetX database, consisting of 92 health care networks throughout the United States. Patients were divided into two cohorts: individuals with simultaneous bilateral carpal tunnel release and individuals with staged carpal tunnel releases within 3 months of each other. Numerous pre-operative comorbidities were evaluated for surgical determination and then, matched via propensity score matching. Post-operative outcomes were measured within 180 of surgery with and without propensity score matching. Statistical analysis was done through TriNetX software, which utilizes JAVA, R, and Python programming languages. RESULTS: The two cohorts result in 17,513 patients for staged carpal tunnel releases and 9,649 for simultaneous bilateral carpal tunnel release surgery. After propensity score matching, 9,289 patients were used in the analysis. Overall, those that underwent staged surgeries had more pre-operative co-morbidities (Hypertension, obesity, chronic kidney disease, arthritis, etc.). Upon matching, patients with staged releases had significantly higher postprocedural aftercare (OR 2.023; 1.813, 2.258), hand/ joint pain (OR 1.876; 1.212-2.905), pain in the extremity (OR 1.161; 1.055, 1.277), trigger finger (OR 1.608; 1.387-1.865), and an upper respiratory tract infection (OR 1.366; 1.206-1.546). Patients with simultaneous bilateral carpal tunnel release had more emergency room visits (OR .835; .766-.91). Non-significant outcomes pulmonary or venous embolism, intraoperative complications, hematomas, surgical site infection, and rehospitalizations. CONCLUSION: These findings demonstrate selection variance between simultaneous and staged carpal tunnel releases. Even after matching, simultaneous bilateral carpal tunnel releases provide fewer post-operative complications while only showing a mild increase in emergency room visits. Further prospective studies could be used to validate these results as well as provide new findings to the management and treatment of these groups.

Maternal perinatal depression and health services utilisation in the first 2 years of life: a cohort study

ObjectivesMaternal perinatal depression is a common phenomenon, influencing infants’ development. Studies have shown an inconsistent association between perinatal depression and healthcare resource utilisation. This study aimed to assess whether perinatal...

Capacity Rationing in Primary Care: Provider Availability Shocks and Channel Diversion

We study capacity rationing by servers facing differentiated customer classes using data from the Veterans Health Administration, which is the largest integrated healthcare system in the U.S. Using more than 11 million health encounters over two years in which the system was capacity constrained, our study provides a comprehensive analysis of the impacts of provider availability shocks on care channel diversion and delays. The outcomes studied include emergency room (ER) visits broken down by type, urgent care center visits, office and phone visits with one’s own versus another provider, post-ER follow-up visits, and ER readmissions. Availability shocks in our analysis are a residualized measure characterizing weeks in which the provider has fewer (or more) office appointments than expected based on typical patterns. The main finding is that moving from two standard deviations above to two standard deviations below in availability shocks increases ER visits by 2.4%, or about 20,000 yearly ER visits. Interestingly, the increase in ER visits is only present for the non-emergent category, indicating differentiated service to emergent and non-emergent care requests; capacity-constrained providers still tend to the patients in most need. Another finding is that provider availability shocks delay and divert post-ER follow-up care. Yet there is no effect on ER readmissions, a severe outcome of delayed or foregone follow-up, indicating that providers ration by priority these follow-up appointments. This paper was accepted by Vishal Gaur, operations management.

Associations between fine particulate matter constituents and hospital outpatient and emergency room visits in Shanghai, China

BackgroundScarce evidence is available on the health effects of various chemical constituents of PM2.5 on hospital visits in China. ObjectivesTo examine the short-term associations between a wide range of PM2.5 constituents and hospital outpatient and emergency room visits in Shanghai. MethodsWe obtained daily concentrations of PM2.5 total mass, organic carbon (OC), elemental carbon (EC), eight water-soluble ions and thirteen elemental constituents between January 1, 2014 and December 31, 2015. We analyzed the data using over dispersed generalized additive models with Poisson regression. Single-constituent, PM2.5-adjusted and constituent-residual models were built respectively to assess the associations. Exposure-response curves for the PM2.5 constituents with robust effects were graphed. ResultsThe average daily mean PM2.5 concentration was 63.3 μg/m3 in Shanghai during the study period. An interquartile range (IQR) increase in PM2.5 was associated with a 2.57% (95% confidence interval [CI]: 1.28%, 3.87%) increase in outpatient visits, and a 3.60% (95% CI: 2.16%, 5.03%) increase in emergency room visits. We observed robust and positive associations between Mg2+, Ca2+, six elemental components (Ca, Mn, Fe, Zn, Ga and Se) and outpatient visits. OC, EC, Cl−, Mg2+, Ca2+ and ten elemental components (Ca, Cr, Mn, Fe, Zn, Ga, As, Se, Pb, and Ni) were significantly and positively associated with emergency room visits. The exposure-response relationships were positive and generally linear for the above constituents. ConclusionsThis time-series study in Shanghai demonstrated significant associations between various carbonaceous, water-soluble and elemental constituents of PM2.5 and hospital visits, providing evidence for source-specific control of particulate air pollution.

Effects of ambient air pollution on emergency room visits of children for acute respiratory symptoms in Delhi, India.

The present study explored the association between daily ambient air pollution and daily emergency room (ER) visits due to acute respiratory symptoms in children of Delhi. The daily counts of ER visits (ERV) of children (≤15 years) having acute respiratory symptoms were obtained from two hospitals of Delhi for 21 months. Simultaneously, data on daily concentrations of particulate matter (PM10 and PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon monoxide (CO), and ozone (O3) and weather variables were provided by the Delhi Pollution Control Committee. K-means clustering with time-series approach and multi-pollutant generalized additive models with Poisson link function was used to estimate the 0-6-day lagged change in daily ER visits with the change in multiple pollutants levels. Out of 1,32,029 children screened, 19,120 eligible children having acute respiratory symptoms for ≤2 weeks and residing in Delhi for the past 4 weeks were enrolled. There was a 29% and 21% increase in ERVs among children on high and moderate level pollution cluster days, respectively, compared to low pollution cluster days on the same day and previous 1-6 days of exposure to air pollutants. There was percentage increase (95% CI) 1.50% (0.76, 2.25) in ERVs for acute respiratory symptoms for 10 μg/m3 increase of NO2 on previous day 1, 46.78% (21.01, 78.05) for 10 μg/m3 of CO on previous day 3, and 13.15% (9.95, 16.45) for 10 μg/m3 of SO2 on same day of exposure. An increase in the daily ER visits of children for acute respiratory symptoms was observed after increase in daily ambient air pollution levels in Delhi.

Mental Health Outcomes Associated with Air Pollutants in California

Background: Epidemiologic studies of air pollution and mental health are limited. We examined ozone (O3), carbon monoxide (CO), nitrogen dioxide (NO2), and fine particles (PM2.5), and emergency room (ER) visits from all mental disorders, bipolar disorder, depression, schizophrenia, substance abuse, homicide/inflicted injury, and suicide/self-harm. We also evaluated effect modification by season, age, race/ethnicity, and gender.Methods: Air pollutant data, provided by the US EPA, and ER visit data from the California Office of Statewide Health and Development Planning, were merged from 2005 through 2013. Data analyses were conducted using two-stage quasi-Poisson regression models, adjusting for long-term trends, holidays, day of the week, and mean apparent temperature. Several lag periods were considered (same day up to average of 7 days and average of 30 days).Results: Per interquartile range, weekly mean O3 was associated with a 1.87% (95% confidence interval [CI]: 0.62, 3.15) increase in ER visits for depression (n = 162,451), a 1.43% (0.35, 2.51) increase for suicide/self-harm (n = 198,509), and a 2.83% (1.53, 4.15) increase for bipolar disorder (n = 158,906). O3 (30 day lag; n = 632, 787), CO (2 day lag; n = 229,138) and NO2 (2-day lag; n = 206,919) were associated with greater risks for homicides/self-inflicted injury (2.01% [1.01, 3.02]; 2.3% [1.3, 3.3]; and 2.6% [1.2, 4.0], respectively). Greater risk was found during the warm season for CO and NO2. For some outcomes, differential risk was observed by gender, age, and race/ethnicity. These associations generally remained robust in co-pollutant models. No associations were found between PM2.5 and any of the mental health outcomes considered.Conclusions: Our results suggest that short-term gaseous air pollution exposure increases the risk of homicides/inflicted injury (CO, NO2 and O3), and depression, suicide/self harm, and bipolar disorder (latter three outcomes for O3 only) in California.

Time-series analysis of ambient PM2.5 and cardiorespiratory emergency room visits in Lima, Peru during 2010-2016.

IntroductionThere have been no time-series studies of air pollution in Peru. Here we evaluate the effect of ambient PM2.5 on emergency room (ER) visits in Lima.MethodsWe estimated daily PM2.5 levels at a 1 km2 resolution during 2010–2016 using ground measurements, satellite data, and chemical transport model simulations. Population-weighted average daily PM2.5 levels were calculated for each district in Lima (n=40), and assigned to patients based on residence. ER visits for respiratory and circulatory diseases were gathered from 9 large public hospitals. Poisson regression was used to estimate the rate ratio for daily ER visits with change in daily PM2.5, controlling for meteorology, time trends, and district.ResultsFor each interquartile range (IQR) increase in PM2.5, respiratory disease ER visits increased 4% (95% CI: 0–5%), stroke visits 10% (3–18%), and ischemic heart disease visits (adults, 18–64 years) 11% (−1%, 24%). Districts with higher poverty showed significantly stronger associations of PM2.5 and respiratory disease ER visits than districts with lower poverty. Effects were diminished 24–42% using Lima-wide instead of district-specific PM2.5 levels.ConclusionShort-term exposure to ambient PM2.5 is associated with increases in ER visits in Lima for respiratory diseases and stroke, and among middle-aged adults, ischemic heart disease.

Legalization of Marijuana in Canada –Youth at Risk

Today’s generation of young people (age group 10-24), the largest cohort in history at present, holds great potential for economic and social progress. Unfortunately, misuse of alcohol and illicit drugs is contributing to large numbers of deaths and disabilities for young people in developed nations. Neither a policy of criminalization of drug use nor a policy of legalization are likely to bring any desired changes. The legal production costs of cannabis are likely to drive down the wholesale prices, which together with the lower perceived risk in the legalized sales environment, are likely to spur consumption substantially, and with it, increased risk of marijuana use by minors. This increased consumption is likely to result in an increase in emergency room visits, higher road fatalities, and increased environmental damage. The purported revenue gains have to be set off against increased public health and safety costs, in addition to the health dangers to adolescent users. Prevention of substance use disorders necessitates an entirely different and evidence-based approach to address the fundamental structural causes of adverse health behavior as well as the range of community-level risk factors. In this study, the application of partial least squares to cross-sectional data on OECD countries revealed the role of the availability of drugs, income and wealth inequalities, child poverty, and employment conditions for youth in explaining the prevalence of drug disorders in OECD countries. The active involvement of youth in the nation-building task requires governments to design a broadly based, inclusive development strategy to usher in a new era of shared prosperity and healthy youth.

From One Set of Pipes to Another: Gastrointestinal Illness following Sanitary Sewer Overflows.

Vol. 126, No. 4 Science SelectionOpen AccessFrom One Set of Pipes to Another: Gastrointestinal Illness following Sanitary Sewer Overflowsis accompanied bySanitary Sewer Overflows and Emergency Room Visits for Gastrointestinal Illness: Analysis of Massachusetts Data, 2006–2007 Carol Potera Carol Potera Search for more papers by this author Published:6 April 2018CID: 044001https://doi.org/10.1289/EHP3225View Article in:中文版AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit Sanitary sewer systems collect and carry wastewater from homes, businesses, and industrial sites to treatment facilities. An influx of water during maintenance or rainstorms can overwhelm sewers, sending raw wastewater into the environment in what is known as a sanitary sewer overflow (SSO). SSOs can contaminate drinking water sources, causing gastrointestinal (GI) illness that may be severe enough to send people to the hospital. In a paper published in Environmental Health Perspectives, researchers analyzed data on emergency room (ER) visits for GI illness to determine whether the odds of GI illness increase following an SSO event.1The researchers used data from four counties in northeastern Massachusetts—Essex, Middlesex, Norfolk, and Suffolk—for the period 2006–2007. During that time, 270 SSOs occurred, and 66,460 people visited ERs for GI illness. For their analysis the authors focused on three “hazard periods” following each SSO: 0–4 d, 5–9 d, and 10–14 d after the event. For both the 0- to 4-d and 5- to 9-d periods the authors found no evidence of an increase in ER visits for GI illness. However, the 10- to 14-d period was associated with an estimated 9% increased odds, on average, of visiting the ER with a GI illness. The strongest association was seen in children between ages 6 and 19 y. These estimates do not account for people with GI illnesses who did not go to the ER, so the overall association might be higher.An influx of water into sewer lines—often in combination with blockages, line breaks, or other damage—can send raw sewage overflowing into the environment. How can people help prevent SSOs? The two most important ways are not pouring fats or grease down the drain and not flushing sanitary products, even those labeled “flushable.”11 Image: © Dizzy/iStockphoto.The study “is the first that we know of to quantify an association between SSOs and gastrointestinal illness,” says first author Jyotsna Jagai, an epidemiologist at the University of Illinois at Chicago. Jagai previously estimated that combined sewer overflows in Massachusetts were associated with average increases in GI-related ER visits of 13% for all ages and 32% for elderly people.2 (Combined sewer systems carry both sewage and rainwater, as opposed to sanitary sewer systems, which carry only sewage.)Up to 75,000 SSOs are estimated to occur annually in the United States.3 Defects in sewer lines, blockages, line breaks, power failures, poor sewer design, and vandalism can all set the stage for overflows, with heavy rainfall a leading cause of the overflows themselves.4 Many sewer systems in the United States are 30–100 years old, making them particularly vulnerable to leaks, blockages, and malfunctions.5,6 Predicted increases in rainfall,6 combined with aging sewer infrastructure, could increase the incidence of GI illnesses related to flooding and sewage spills.“SSOs pose an upcoming water crisis triggered by deteriorating pipelines and a tendency not to enforce and, in some cases even relax, water quality regulations” says Elena Naumova, chair of the Division of Nutrition Data Sciences at Tufts University’s Friedman School of Nutrition Science and Policy. The price for not paying attention to deteriorating water infrastructure is likely to be decreased productivity and lost lives, predicts Naumova, who was not involved in the new study.Reporting of SSOs varies with states, and some have no reporting requirements.5 Massachusetts does require SSOs to be reported to the Massachusetts Department of Environmental Protection,7 but the public is not necessarily informed when an overflow occurs. For example, no public notice was issued during a 13-hour discharge of at least 8 million gallons of raw sewage into the Merrimack River in October 2017,8 although residents were later warned to avoid the water. The Merrimack River Watershed Council in Lawrence, Massachusetts, is now advocating for legislation9,10 that would require real-time public notification when raw sewage is discharged into a river or other water body in the state.

Effect of the 2014 attack on Gaza on the use of medical services in Al-Nasser Pediatric Hospital: a comparative study

BackgroundDuring the 51-day attack on Gaza in 2014, approximately 2145 people were killed, of whom 20% were children. This study was done to evaluate the use of medical services in Al-Nasser Paediatric Hospital during the attack. MethodsWe retrospectively compared the number and pattern of admissions to Al-Nasser Paediatric Hospital, the largest paediatric hospital in Gaza Strip, during the period of attacks in July to August, 2014, with those during July to August in 2013. Data were obtained from the patients’ medical records. Findings3018 patients were admitted during the 2014 attacks and 1706 during the corresponding period in 2013. There were no significant differences in sex (male: 60·6% in 2014 vs 59·4% in 2013) and geographical distribution (children from Gaza: 75·6% in 2014 vs 78·1% in 2013; North-governorate: 17·8% vs 18·8%) of the patients between the two periods. Moreover, there were no significant differences in the distribution of different disease categories, except for that of meningitis (43·2% in 2014 vs 21·9% in 2013; odds ratio [OR] 2·7, 95% CI 2·2–3·3). Number of emergency room visits (20 100 patients in 2014 and 20 400 in 2013) and hospital mortality rate (1·2% in 2014 and 1·3% in 2013) were similar in the two periods. Bed occupancy rate nearly doubled during the attack period (180% vs 95%; OR 1·9, 95% CI 1·3–2·7]). The median hospital stay was significantly shortened during the attack period (2 [IQR 1–3] days vs 3 [1–6] days; difference in means 0·67, 95% CI 0·65–0·68). InterpretationThe admission rate during the attack period was increased, without a significant increase in emergency room visits. This finding could be due to the closure of other health-care facilities (because of damage or insecurity), but also might be attributable to changes in health-care seeking behaviour during the attack period because only patients who are severely ill take the risk to come to the emergency department; this behaviour could be reflected by the increase in meningitis-related admissions during the attacks. Despite the increase in admission and bed-occupancy rate during the attack period, hospital mortality rates were similar in both periods. Required resources (including human workforce) should be prepared in advance to accommodate the increase in admission rate during emergency state. FundingNone.

Air pollution and children's asthma-related emergency hospital visits in southeastern France.

PM10 and certain meteorological conditions near children's homes increased the risk of emergency asthma-related hospital visits in 3- to 18-year-old children in Bouches-du-Rhône. What is Known: • A relationship between short-term exposure to air pollution and increase in emergency room visits or hospital admissions as a result of increased pollution levels has already been demonstrated. What is New: • This study confirms these results but took into account confounding factors (viral data, pollens, and meteorological conditions) and is based on estimated pollution levels assessed close to the children's homes, rather than those recorded at the hospital. • The study area, the Mediterranean, is favorable to creation of secondary pollutants in these sunny and dry seasons.

The Effects of PM2.5 from Asian Dust Storms on Emergency Room Visits for Cardiovascular and Respiratory Diseases.

A case-crossover study examined how PM2.5 from Asian Dust Storms (ADS) affects the number of emergency room (ER) admissions for cardiovascular diseases (CVDs) and respiratory diseases (RDs). Our data indicated that PM2.5 concentration from ADS was highly correlated with ER visits for CVDs and RDs. The odds ratios (OR) increased by 2.92 (95% CI: 1.22–5.08) and 1.86 (95% CI: 1.30–2.91) per 10 µg/m3 increase in PM2.5 levels, for CVDs and RDs, respectively. A 10 µg/m3 increase in PM2.5 from ADSs was significantly associated with an increase in ER visits for CVDs among those 65 years of age and older (an increase of 2.77 in OR) and for females (an increase of 3.09 in OR). In contrast, PM2.5 levels had a significant impact on RD ER visits among those under 65 years of age (OR = 1.77). The risk of ER visits for CVDs increased on the day when the ADS occurred in Taiwan and the day after (lag 0 and lag 1); the corresponding risk increase for RDs only increased on the fifth day after the ADS (lag 5). In Taiwan’s late winter and spring, the severity of ER visits for CVDs and RDs increases. Environmental protection agencies should employ an early warning system for ADS to reduce high-risk groups’ exposure to PM2.5.

Fine Particulate Air Pollution and Hospital Emergency Room Visits for Respiratory Disease in Urban Areas in Beijing, China, in 2013.

BackgroundHeavy fine particulate matter (PM2.5) air pollution occurs frequently in China. However, epidemiological research on the association between short-term exposure to PM2.5 pollution and respiratory disease morbidity is still limited. This study aimed to explore the association between PM2.5 pollution and hospital emergency room visits (ERV) for total and cause-specific respiratory diseases in urban areas in Beijing.MethodsDaily counts of respiratory ERV from Jan 1 to Dec 31, 2013, were obtained from ten general hospitals located in urban areas in Beijing. Concurrently, data on PM2.5 were collected from the Beijing Environmental Protection Bureau, including 17 ambient air quality monitoring stations. A generalized-additive model was used to explore the respiratory effects of PM2.5, after controlling for confounding variables. Subgroup analyses were also conducted by age and gender.ResultsA total of 92,464 respiratory emergency visits were recorded during the study period. The mean daily PM2.5 concentration was 102.1±73.6 μg/m3. Every 10 μg/m3 increase in PM2.5 concentration at lag0 was associated with an increase in ERV, as follows: 0.23% for total respiratory disease (95% confidence interval [CI]: 0.11%-0.34%), 0.19% for upper respiratory tract infection (URTI) (95%CI: 0.04%-0.35%), 0.34% for lower respiratory tract infection (LRTI) (95%CI: 0.14%-0.53%) and 1.46% for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) (95%CI: 0.13%-2.79%). The strongest association was identified between AECOPD and PM2.5 concentration at lag0-3 (3.15%, 95%CI: 1.39%-4.91%). The estimated effects were robust after adjusting for SO2, O3, CO and NO2. Females and people 60 years of age and older demonstrated a higher risk of respiratory disease after PM2.5 exposure.ConclusionPM2.5 was significantly associated with respiratory ERV, particularly for URTI, LRTI and AECOPD in Beijing. The susceptibility to PM2.5 pollution varied by gender and age.

Study of relationship between atmospheric fine particulate matter concentration and one grade a tertiary hospital emergency room visits during 2012 and 2013 in Beijing

To explore the concentration-response relationship between ambient concentration of PM2.5 and daily total hospital emergency room visits in Beijing during 2012 and 2013. This study also examined the effects of ambient PM2.5 during heavy polluted days on emergency room visits compared with the light polluted days. We collected the daily meteorological factors monitoring data and concentrations of air pollutants in Beijing during October 1, 2012 to December 31, 2013. We also collected the daily emergency room visits from a tertiary hospital in Beijing in the same time period. Generalized additive model was fitted to estimate the association between the ambient PM2.5 and the hospital emergency room visits, by using the smooth function to adjust long term trend of time, public holidays and day of week. In addition, constrained piecewise linear function was then used to estimate the excess risk for different segment of concentration-response function. The annual average concentration of PM2.5 was 90.9 µg/m(3) during October 1, 2012 and December 31, 2013. There were total 64 260 cases for total emergency room visits, of which respiratory disease had 9 849 cases and cardiovascular disease had 11 168 cases. PM2.5 was positive related with PM10, NO2 and SO2. The corresponding correlation coefficients were 0.87, 0.78 and 0.62, respectively (P<0.05). And PM2.5 was positively related with relative humidity, with correlation coefficient 0.45 (P<0.05). But PM2.5 was negatively related with mean temperature (r=-0.17, P< 0.05) and wind speed (- 0.32, P<0.05). In the single polluted model, after adjusting the effects of temperature, relative humidity and wind, every 10 µg/m(3) increase of concentration of ambient PM2.5, the corresponding excess risk of daily emergency room visits was 0.25% (95% CI: 0.07-0.43). In the two-pollutant model PM2.5+SO2 and PM2.5+NO2, every 10 µg/m(3) increase of concentration of ambient PM2.5, the corresponding excess risk of daily emergency room visits were 1.07% (95%CI:0.83-1.30) and 0.56% (95%CI: 0.32-0.80) respectively, which were higher than the effect in single pollutant model. Average concentration of ambient particulate matters (PM2.5) was 204.16 µg/m(3) during heavy pollution, higher than control period (85.24 µg/m(3)). When PM2.5 as the primary air pollutants during heavy polluted days, we observed a significant increase in emergency room visits, and the odd ratios was 1.16 (95% CI:1.09-1.22). There were positive correlation between high concentration of ambient particulate matters (PM2.5) and increasing daily emergency room visits. Especially during the heavy polluted days, the effects of elevated concentration of PM2.5 on hospital emergency room visits were much larger.