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1.  Providers' Perceptions Of The Factors Influencing The Implementation Of The New York State Mandatory HIV Testing Law In Two Urban Academic Emergency Departments 
Of the 1.1 million people in the United States infected with human immunodeficiency virus (HIV), more than 20% are unaware of their infection. To increase early diagnosis and treatment, New York State recently passed legislation mandating that HIV testing be offered to all patients, ages 13 to 64 years, receiving health care services. Implementation of this legislation is complex, especially in the emergency department (ED). This study explores ED providers' perceptions of the factors affecting the implementation of the law.
The authors conducted six focus group sessions and three in-depth interviews with ED health care providers from two New York City teaching hospitals. Sessions were audiotaped and transcribed. Data were coded and summarized thematically through an iterative process after each session.
A total of 49 providers participated and data saturation was achieved. Six factors were identified that predispose a provider to offer an HIV test: 1) self-efficacy, 2) behavioral intention, 3) the testing process, 4) provider knowledge of the legislation, 5) type of HIV test, and 6) follow-up procedures. Five factors were identified that enable providers to offer an HIV test: 1) resources related to time, 2) space, 3) staff, 4) type of test, and 5) timing of the offer. Improving access to HIV testing, linkage to care, and public health were all key factors in reinforcing providers' desire to offer HIV tests. Concerns regarding overall cost saving and coverage for the test were indicated as barriers that needed to be resolved in order to reinforce the providers to offer an HIV test.
Understanding the factors influencing the practice of ED providers charged with carrying out this mandate is critical. Despite earlier research that indicated that offering HIV testing to ED patients is largely influenced by cost, this study found additional factors that are important to consider to effectively implementing HIV testing in the ED.
PMCID: PMC3608143  PMID: 23517260
2.  Prospective Multicenter Study of Children With Bronchiolitis Requiring Mechanical Ventilation 
Pediatrics  2012;130(3):e492-e500.
To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis.
We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens.
There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7–11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1–1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0–2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2–2.1), presence of apnea (OR 4.8; 95% CI 2.5–8.5), inadequate oral intake (OR 2.5; 95% CI 1.3–4.3), severe retractions (OR 11.1; 95% CI 2.4–33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0–4.8). The optimism-corrected c-statistic for the final model was 0.80.
In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.
PMCID: PMC3428760  PMID: 22869823
bronchiolitis; continuous positive airway pressure; intubation; ICU; respiratory syncytial virus; human rhinovirus
3.  Prospective, multicenter study of viral etiology and hospital length-of-stay in children with severe bronchiolitis 
To determine if hospital length-of-stay (LOS) for acute bronchiolitis is influenced by the infecting pathogen
Prospective observational cohort over 3 consecutive years.
16 US hospitals
Children age <2 years hospitalized with bronchiolitis
Main Exposure
Nasopharyngeal aspirate (NPA) polymerase chain reaction pathogen results
Main Outcome Measure
Hospital LOS
Of 2,207 participants, 72% had respiratory syncytial virus (RSV), 26% had human rhinovirus (HRV), while all other viruses and bacteria were each ≤8%. Multiple pathogen infections were present in 30%. There were 1,866 (85%) children with either RSV and/or HRV. Among these 1,866 children, the median age was 4 months and 60% were male. The median LOS was 2 days (interquartile range [IQR], 1–4). Compared to children with RSV alone, LOS ≥3 days was less likely among children with HRV alone (adjusted odds ratio [AOR], 0.36; 95% confidence interval [CI], 0.20–0.63; P<0.001) and those with HRV + non-RSV pathogens (AOR, 0.39; 95%CI, 0.23–0.66; P<0.001), but more likely among children with RSV + HRV (AOR, 1.33; 95%CI, 1.02–1.73; P=0.04), controlling for 15 demographic and clinical factors.
In this multicenter study of children hospitalized with bronchiolitis, RSV was the most common viral etiology, but HRV was detected in one-quarter of children. Since 1 in 3 children had multiple virus infections and HRV was associated with LOS, these data challenge the effectiveness of current RSV-based cohorting practices, the sporadic testing for HRV in bronchiolitis research, and current thinking that the infectious etiology of severe bronchiolitis does not affect short-term outcomes.
PMCID: PMC3394902  PMID: 22473882
4.  Nasopharyngeal Lactate Dehydrogenase Concentrations Predict Bronchiolitis Severity in a Prospective Multicenter Emergency Department Study 
We re-examined the finding of an inverse relationship between values of nasopharyngeal lactate dehydrogenase (LDH), a marker of the innate immune response, and bronchiolitis severity. In a prospective, multicenter study of 258 children we found in a mutlivariable model that higher nasopharyngeal LDH values in young children with bronchiolitis were independently associated with a decreased risk of hospitalization.
PMCID: PMC3375381  PMID: 22517336
Severity of illness; biomarker; respiratory syncytial virus; human rhinovirus
5.  Medical Emergency Team Calls in the Radiology Department: Patient Characteristics and Outcomes 
BMJ quality & safety  2012;21(6):509-518.
We sought to identify characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes.
Retrospective review of 111 in-patient MET-RD calls (5/2008-4/2010).
Academic medical center with a well-established MET system.
We extracted from medical records and administrative databases the characteristics of patients before, during, and after transport to Radiology. We compared these characteristics between patients with good and poor outcomes.
Main Results
The majority of patients experiencing MET-RD had a Charlson Comorbidity Index ≥4 and were from non-ICU units (60%). Almost half (43%) of MET-RD occurred during hospitalization day one. MET-RD patients commonly arrived with nasal cannula oxygen (38%), recent tachypnea (28%) and tachycardia (34%). A minority (16%) fulfilled MET call criteria in the 12 hours before MET-RD. MET-RD etiologies were cardiac (41%), respiratory (29%) or neurologic (25%), and occurred most frequently during computed tomography (CT) (44%) and magnetic resonance imaging (MRI) (22%) testing. Post MET-RD, the majority (70%) required a higher care level. Death before discharge (25%), was associated with need for cardiovascular support prior to RD transport (p=0.02), need for RD monitoring (p=0.02) and need for heightened RD surveillance (p=0.04).
The majority of MET-RD patients came from non-ICU units, with comorbidities and vital signs alterations prior to the RD. Risk appeared to be increased for those requiring CT and MRI. These findings suggest that prior identification of a subset of RD patients at risk of instability may be possible.
PMCID: PMC3630458  PMID: 22389020
patient safety; Medical Emergency Team; Radiology; patient outcomes; intrahospital transport
6.  Patients’ Instability, Emergency Response, and Outcomes in the Radiology Department 
Inpatients may be at risk of cardiopulmonary instability during radiologic testing. Calling the medical emergency team is one rescue intervention that brings a team of critical care providers to the unstable patient. Little is known, however, about patients’ instability and activations of the medical emergency team in the radiology department (RD-MET).
To describe the cause of activation of the RD-MET for hospitalized patients, temporal attributes of RD-MET involvement, characteristics of RD-MET patients, and characteristics associated with good and poor outcomes after RD-MET activation.
Retrospective pilot study of RD-MET calls for 64 inpatients in a tertiary care hospital during 2009.
Reasons for RD-MET activation were 39% neurological, 38% cardiac, and 22% respiratory, and nearly half (42%) occurred during a computed tomography scan. Most RD-MET calls were made between 10 AM and noon. RD-MET patients had a mean age of 61 (SD, 19) years; 52% were female, and 89% were white. Admitting diagnoses were most commonly neurological (20%), cardiovascular (16%), and abdominal (16%). The most common comorbid conditions were chronic obstructive pulmonary disease (23%) and diabetes (20%). Half of RD-MET inpatients were from a general care unit, and 56% required preexisting oxygen support. After RD-MET involvement, 61% of patients required a higher level of care; 3% died during the MET intervention, and 19% died later in hospitalization. Patients with preexisting comorbid conditions were more likely to have poor outcomes after the RD-MET intervention (P = .001).
RD-MET patients with comorbid conditions, from a general care unit, and at risk for neurological deterioration arrive in the radiology department with potentially underestimated support needs. Greater support in specific time frames and locations may be warranted to improve outcomes.
PMCID: PMC3667404  PMID: 22045143
7.  Multicenter Analysis of Quality Indicators for Children Treated in the Emergency Department for Asthma 
Pediatrics  2012;129(2):e325-e332.
To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department.
Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission.
In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely β-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely β-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association.
We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to children in a multicenter study. Although the quality of emergency department care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes.
PMCID: PMC3269108  PMID: 22250025
asthma; outcome and process assessments (health care); quality of health care; Severity of Illness Index; practice guideline; antiasthmatic agents; asthma; preschool child; child; adolescent
9.  Prospective Multicenter Study of Bronchiolitis: Predictors of an Unscheduled Visit After Discharge From the Emergency Department 
There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post-ED unscheduled visits.
The authors conducted a prospective cohort study of patients discharged from 2004 to 2006 at 30 EDs in 15 U.S. states. Inclusion criteria were diagnosis of bronchiolitis, age <2 years, and discharge home; the exclusion criterion was previous enrollment. Unscheduled visits were defined as urgent visits to an ED/clinic for worsened bronchiolitis within 2 weeks.
Of 722 patients eligible for the current analysis, 717 (99%) had unscheduled visit data, of whom 121 (17%; 95% confidence interval [CI] = 14% to 20%) had unscheduled visits. Unscheduled visits were more likely for children age <2 months (11% vs. 6%; p = 0.04), males (70% vs. 57%; p = 0.007), and those with history of hospitalization (27% vs. 18%; p = 0.01). The two groups were similar in other demographic and clinical factors (all p > 0.10). Using multivariable logistic regression, independent predictors of unscheduled visits were age <2 months, male, and history of hospitalization.
In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization.
PMCID: PMC3540104  PMID: 20370776
bronchiolitis; emergency department; risk factors; prediction rules; unscheduled visits
10.  Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum 
Medical Education Online  2013;18:10.3402/meo.v18i0.19775.
Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students’ knowledge acquisition, comfort, and perceived competence with regards to the AMS patient.
AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS.
A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not (p<0.001). Students who participated in a simulation session were more comfortable in their overall approach to treating AMS patients (p=0.05). They were also more likely to state that they could articulate a differential diagnosis (p=0.03), know what initial diagnostic tests are needed (p=0.01), and understand what interventions are useful in the first few minutes (p=0.003). Students who participated in a simulation session were more likely to find the overall AMS curriculum useful (p<0.001).
Students who participated in a simulation exercise performed better on a knowledge-based test and reported increased comfort and perceived competence in their clinical approach to AMS. SBME shows significant promise for teaching clinical skills to medical students during pre-clinical curriculum.
PMCID: PMC3617787  PMID: 23561054
mental status change; simulation; pre-clinical medical students
11.  Multicenter Study of Repeat Epinephrine Treatments for Food-Related Anaphylaxis 
Pediatrics  2010;125(4):e711-e718.
We sought to establish the frequency of receiving >1 dose of epinephrine in children who present to the emergency department (ED) with food-related anaphylaxis.
We performed a medical chart review at Boston hospitals of all children presenting to the ED for food-related acute allergic reactions between January 1, 2001, and December 31, 2006. We focused on causative foods, clinical presentations, and emergency treatments.
Through random sampling and appropriate weighting, the 605 reviewed cases represented a study cohort of 1255 patients. These patients had a median age of 5.8 years (95% confidence interval [CI]: 5.3– 6.3), and the cohort was 62% male. A variety of foods provoked the allergic reactions, including peanuts (23%), tree nuts (18%), and milk (15%). Approximately half (52% [95% CI: 48–57]) of the children met diagnostic criteria for food-related anaphylaxis. Among those with anaphylaxis, 31% received 1 dose and 3% received >1 dose of epinephrine before their arrival to the ED. In the ED, patients with anaphylaxis received antihistamines (59%), corticosteroids (57%), epinephrine (20%). Over the course of their reaction, 44% of patients with food-related anaphylaxis received epinephrine, and among this subset of patients, 12% (95% CI: 9–14) received >1 dose. Risk factors for repeat epinephrine use included older age and transfer from an outside hospital. Most patients (88%) were discharged from the hospital. On ED discharge, 43% were prescribed self-injectable epinephrine, and only 22% were referred to an allergist.
Among children with food-related anaphylaxis who received epinephrine, 12% received a second dose. Results of this study support the recommendation that children at risk for food-related anaphylaxis carry 2 doses of epinephrine.
PMCID: PMC3531711  PMID: 20308215
food allergy; anaphylaxis; emergency department; epinephrine
12.  A Prospective Multicenter Study of Written Action Plans among Emergency Department Patients with Acute Asthma 
The prevalence of written “action plans” (APs) among emergency department (ED) patients with acute asthma is unknown.
To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario.
Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2–54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents’ self-management knowledge.
The overall prevalence of APs was 32% (95% confidence interval [CI], 30%–34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1–2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge.
The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. “Confounding by severity” will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.
PMCID: PMC3526108  PMID: 18773321
asthma; action plans; emergency medicine; education; self-management
13.  Spirometric Correlates of Dyspnea Improvement Among Emergency Department Patients With Chronic Obstructive Pulmonary Disease Exacerbation 
Respiratory care  2008;53(7):892-896.
To examine whether change in slow vital capacity (SVC) correlates to dyspnea improvement during emergency department (ED) treatment of chronic obstructive pulmonary disease (COPD) exacerbation.
We performed a prospective cohort study and enrolled consecutive patients during a 3-week period. ED patients ≥ 55 years old with COPD exacerbation were asked to perform bedside spirometry shortly after ED arrival and again at discharge. SVC was measured first, then forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF), and forced vital capacity (FVC). Concurrent with spirometry, patients rated their dyspnea on a 10-cm visual analogue scale.
Thirty-six patients were enrolled. The median ED stay was 271 min (interquartile range 219–370 min). Seventy-one percent of the patients reported dyspnea improvement during their ED stay. Change in SVC was significantly higher among the patients whose dyspnea improved than among those whose did not (median increase of 0.15 L vs median decrease of 0.25 L, respectively, p < 0.01). By contrast, the change in spirometry values were similar for FEV1, PEF, and FVC (all p > 0.30). Spearman correlation supported these findings: SVC r = 0.45 (p = 0.02) versus nonsignificant correlation with FEV1 (r = 0.33), PEF (r = −0.22), and FVC (r = 0.35).
Increase in SVC significantly correlated with dyspnea improvement among ED patients with moderate-to-severe COPD exacerbation. Change in SVC merits consideration when evaluating therapeutic response during COPD exacerbation.
PMCID: PMC3523353  PMID: 18593490
chronic obstructive pulmonary disease; COPD; dyspnea; emergency department; exacerbation; slow vital capacity; spirometry
14.  Language Barriers among Patients in Boston Emergency Departments: Use of Medical Interpreters After Passage of Interpreter Legislation 
Since 2001, Massachusetts state law dictates that emergency department (ED) patients with limited English proficiency have the right to a professional interpreter.
one year later, for two 24-h periods, we interviewed adult patients presenting to four Boston EDs. We assessed language barriers and compared this need with the observed use and type of interpreter during the ED visit.
We interviewed 530 patients (70% of eligible) and estimated that an interpreter was needed for 60 (11%; 95% confidence interval, 7–12%) patients. The primary interpreter for these clinical encounters was a physician (30%), friend or family member age ≥18 years (22%), hospital interpreter services (15%), younger family member (11%), or other hospital staff (17%).
We found that 11% of ED patients had significant language barriers, but use of professional medical interpreters remained low. One year after passage of legislation mandating access, use of professional medical interpreters remained inadequate.
PMCID: PMC3469318  PMID: 18810638
Interpreters; Language barriers; Emergency department; Immigrants
15.  Validation of self-reported chronic obstructive pulmonary disease among patients in the ED☆ 
To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review.
This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a “spirometrically validated” diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity b70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD.
Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD.
Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.
PMCID: PMC3422655  PMID: 19371527
16.  Positive Association between Altitude and Suicide in 2584 U.S. Counties 
Brenner, Barry, David Cheng, Sunday Clark, and Carlos A. Camargo, Jr. Positive association between altitude and suicide in 2584 U.S.counties. High Alt. Med. Biol. 12: 31–35 2011.—Suicide is an important public health problem worldwide. Recent preliminary studies have reported a positive correlation between mean altitude and the suicide rate of the 48 contiguous U.S.states. Because intrastate altitude may have large variation, we examined all 2584 U.S. counties to evaluate whether an independent relationship between altitude and suicide exists. We hypothesized that counties at higher elevation would have higher suicide rates. This retrospective study examines 20 yr of county-specific mortality data from 1979 to 1998. County altitude was obtained from the U.S. Geologic Survey. Statistical analysis included Pearson correlation, t tests, and multivariable linear and logistic regression. Although there was a negative correlation between county altitude and all-cause mortality (r = −0.31, p < 0.001), there was a strong positive correlation between altitude and suicide rate (r = 0.50, p < 0.001). Mean altitude differed in the 50 counties, with the highest suicide rates compared to those with the lowest rates (4684 vs. 582 ft, p < 0.001). Controlling for percent of age >50 yr, percent male, percent white, median household income, and population density of each county, the higher-altitude counties had significantly higher suicide rates than the lower-altitude counties. Similar findings were observed for both firearm-related suicides (59% of suicides) and nonfirearm-related suicides. We conclude that altitude may be a novel risk factor for suicide in the contiguous United States.
PMCID: PMC3114154  PMID: 21214344
altitude; suicide; firearm; obesity; hypoxia
17.  Serum 25-Hydroxyvitamin D Levels Among Boston Trainee Doctors in Winter 
Nutrients  2012;4(3):197-207.
As indoor workers, trainee doctors may be at risk for inadequate vitamin D. All trainee doctors (residents) in a Boston pediatric training program (residency) were invited to complete a survey, and undergo testing for serum 25-hydroxyvitamin D [25(OH)D], PTH, and calcium during a 3-week period in March 2010. We examined the association between resident characteristics and serum 25(OH)D using Chi2 and Kruskal-Wallis test and multivariable linear and logistic regression. Of the 119 residents, 102 (86%) participated. Although the mean serum 25(OH)D level was 67 nmol/L (±26), 25 (25%) had a level <50 nmol/L and 3 (3%) residents had levels <25 nmol/L. In the multivariable model, factors associated with 25(OH)D levels were: female sex (β 12.7, 95% CI 3.6, 21.7), white race (β 21.7, 95% CI 11.7, 31.7), travel to more equatorial latitudes during the past 3 months (β 6.3, 95% CI 2.0, 10.5) and higher daily intake of vitamin D (β 1.1, 95% CI 0.04, 2.1). Although one in four residents in our study had a serum 25(OH)D <50 nmol/L, all of them would have been missed using current Centers for Medicare and Medicaid Services (CMS) screening guidelines. The use of traditional risk factors appears insufficient to identify low vitamin D in indoor workers at northern latitudes.
PMCID: PMC3347027  PMID: 22666546
vitamin D; deficiency; residents; indoor workers
18.  Age-related differences in the clinical presentation of food-induced anaphylaxis 
The Journal of pediatrics  2010;158(2):326-328.
Food-induced anaphylaxis may be more difficult to recognize in younger children. We describe age-related patterns in the clinical presentation of children with anaphylaxis, which may facilitate the early recognition and treatment of this potentially life-threatening condition.
PMCID: PMC3022088  PMID: 21094954
food allergy; anaphylaxis; emergency department; infant; child; adolescent
19.  Development and Validation of a Risk-Adjustment Tool in Acute Asthma 
Health Services Research  2009;44(5 Pt 1):1701-1717.
To develop and prospectively validate a risk-adjustment tool in acute asthma.
Data Sources
Data were obtained from two large studies on acute asthma, the Multicenter Airway Research Collaboration (MARC) and the National Emergency Department Safety Study (NEDSS) cohorts. Both studies involved >60 emergency departments (EDs) and were performed during 1996–2001 and 2003–2006, respectively. Both included patients aged 18–54 years presenting to the ED with acute asthma.
Study Design
Retrospective cohort studies.
Data Collection
Clinical information was obtained from medical record review. The risk index was derived in the MARC cohort and then was prospectively validated in the NEDSS cohort.
Principle Findings
There were 3,515 patients in the derivation cohort and 3,986 in the validation cohort. The risk index included nine variables (age, sex, current smoker, ever admitted for asthma, ever intubated for asthma, duration of symptoms, respiratory rate, peak expiratory flow, and number of beta-agonist treatments) and showed satisfactory discrimination (area under the receiver operating characteristic curve, 0.75) and calibration (p=.30 for Hosmer–Lemeshow test) when applied to the validation cohort.
We developed and validated a novel risk-adjustment tool in acute asthma. This tool can be used for health care provider profiling to identify outliers for quality improvement purposes.
PMCID: PMC2754555  PMID: 19619246
Asthma; emergency department; hospital admission; profiling; risk adjustment
20.  Risk Stratification for Hospitalization in Acute Asthma: The CHOP Classification Tree 
Simple risk stratification rules are limited in acute asthma. We developed and externally validated a classification tree for asthma hospitalization.
Data were obtained from two large, multicenter studies on acute asthma, the National Emergency Department Safety Study (NEDSS) and the Multicenter Airway Research Collaboration (MARC) cohorts. Both studies involved emergency department (ED) patients aged 18–54 years, presenting to the ED with acute asthma. Clinical information was obtained from medical record review. The classification and regression tree (CART) method was used to generate a simple decision tree. The tree was derived in the NEDSS cohort and then was validated in the MARC cohort.
There were 1,825 patients in the derivation cohort and 1,335 in the validation cohort. Admission rates were 18% and 21% in the derivation and validation cohorts, respectively. The CART method identified four important variables (CHOP): change [C] in peak expiratory flow (PEF) severity category, ever hospitalization [H] for asthma, oxygen [O] saturation on room air, and initial PEF [P]. In a simple 3-step process, the decision rule risk-stratified patients into 7 groups, with a risk of admission ranging from 9% to 48%. The classification tree performed satisfactorily on discrimination in both the derivation and validation cohorts, with an area under the receiver operating characteristic curve of 0.72 and 0.65, respectively.
We developed and externally validated a novel classification tree for hospitalization among ED patients with acute asthma. Use of this explicit risk stratification rule may aid decision-making in the emergency care of acute asthma.
PMCID: PMC2939861  PMID: 20837258
acute asthma; classification tree; emergency department; hospital admission; risk stratification
22.  Salmeterol Use and Risk of Admission among Emergency Department Patients with Acute Asthma 
The safety of inhaled long-acting 2-agonists (LABA) in chronic asthma management remains controversial and has not been evaluated in emergency department (ED) patients with acute asthma.
We hypothesized that ED patients on chronic LABA therapy would have increased risk of asthma-related hospitalization compared to those not on LABA therapy, and that concurrent chronic inhaled corticosteroid (ICS) therapy would mitigate this risk.
Prospective cohort study of patients age 12–54 with acute asthma in 115 EDs. Four patient groups were created based on their chronic asthma regimen: (A) no ICS or salmeterol; (B) salmeterol monotherapy; (C) ICS monotherapy; and (D) combination ICS and salmeterol.
Of the 2,236 included patients, Group A had 1,221 (55%) patients; B 48 (2%); C 787 (35%); and D 180 (8%); 489 (22%) patients required hospitalization. In a multivariable model controlling for 20 factors and using Group A as the reference, Group B had an increased risk of hospitalization (OR 2.2; 95%CI, 1.0–4.9), while Groups C (OR 1.1; 95%CI, 0.8–1.5) and D (OR 1.2; 95%CI, 0.8–1.9) did not.
Among ED patients with acute asthma, those on salmeterol monotherapy had an increased risk of hospitalization, however this risk was not seen among patients on combination ICS-salmeterol therapy. Our findings provide data from a unique ED population on clinical response to acute asthma treatment among patients on chronic LABA therapy.
PMCID: PMC2945216  PMID: 20568379
Asthma; Emergency department; Long-acting β2-agonists; Asthma exacerbation; Salmeterol
23.  Food Security, Health, and Medication Expenditures of Emergency Department Patients 
The Journal of emergency medicine  2009;38(4):524-528.
In the United States, 35 million people live in food-insecure households. Although food insecurity and hunger are undesirable in their own right, they also are potential precursors to nutritional, health, and developmental problems.
Study objectives
To examine the prevalence of household food insecurity and its association with health problems and medication expenditures among emergency department (ED) patients.
We conducted a cross-sectional study in four Boston-area EDs and enrolled consecutive adult patients during two 24-hour periods at each site. Food security status was measured using the validated 18-item US Household Food Security Survey Module.
Overall, 66 (13%; 95%CI, 10–17%) of 520 ED patients screened positive for food insecurity. Among these 66 patients, 32 (48%; 95% CI, 36–61%) reported food insecurity with hunger. Patients from food-insecure households differed from food-secure patients with respect to sociodemographic factors. Food-insecure patients were more likely than food-secure patients to report a variety of chronic and mental health problems (all P<0.05), including obesity. Food-insecure patients, compared to food-secure patients, also were more likely (all P<0.001) to put off paying for medication to have money for food (27% vs. 4%, respectively), to take medication less often because they couldn’t afford more (32% vs. 4%, respectively), to report needing to make a choice between buying medication and food (27% vs. 2%, respectively), and to report getting sick because they couldn’t afford to take medication (27% vs. 1%, respectively).
ED patients from food-insecure households report more chronic and mental health problems, and difficulty purchasing medication.
PMCID: PMC2891517  PMID: 19272731
food insecurity; hunger; emergency department
24.  Season of Birth is Associated with Food Allergy in Children 
The prevalence of food allergy is rising and etiologic factors remain uncertain. Evidence implicates a role of vitamin D in the development of atopic diseases. Based on seasonal patterns of UVB exposure (and consequent vitamin D status), we hypothesized that food allergy patients are more often born in fall or winter.
Investigate whether season of birth is associated with food allergy.
We performed a multicenter chart review of all patients presenting to three Boston emergency departments (EDs) for food-related acute allergic reactions between 1/1/01 and 12/31/06. Months of birth among food allergy patients were compared to those of patients visiting the ED for reasons other than food allergy.
We studied 1,002 food allergy patients. Among younger children with food allergy (age <5 years) – but not among older children or adults – 41% were born in spring/summer compared to 59% in fall/winter (P=0.002). This approximately 40/60 ratio differed from birth season of children treated in the ED for non-food allergy reasons (P=0.002). Children <5 years old born in fall/winter had a 53% higher odds of food allergy compared to controls. This finding was independent of the suspected triggering food and allergic comorbidities.
Food allergy is more common in Boston children who were born in the fall and winter seasons. We propose that these findings are mediated by seasonal differences in UVB exposure. These results add support to the hypothesis that seasonal fluctuations in sunlight and perhaps vitamin D may be involved in the pathogenesis of food allergy.
PMCID: PMC2941399  PMID: 20408340
Food allergy; season of birth; epidemiology; UVB; vitamin D
25.  Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation 
Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.
To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.
A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.
Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack-years of smoking (45 pack-years versus 53 pack-years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta-agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001).
Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.
PMCID: PMC2679560  PMID: 18818783
Canada-USA; Chronic obstructive pulmonary disease; Emergency department; Exacerbation

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