bronchiolitis; cathelicidin; vitamin D; respiratory syncytial virus; human rhinovirus
We evaluated vitamin D insufficiency in a nationally representative sample of women and assessed the role of vitamin supplementation.
We conducted secondary analysis of 928 pregnant and 5173 nonpregnant women aged 13–44 years from the National Health and Nutrition Examination Survey 2001–2006.
The mean 25-hydroxyvitamin D (25[OH]D) level was 65 nmol/L for pregnant women and 59 nmol/L for nonpregnant women. The prevalence of 25(OH)D <75 nmol/L was 69% and 78%, respectively. Pregnant women in the first trimester had similar 25(OH)D levels as nonpregnant women (55 vs 59 nmol/L), despite a higher proportion taking vitamin D supplementation (61% vs 32%). However, first-trimester women had lower 25(OH)D levels than third-trimester women (80 nmol/L), likely from shorter duration of supplement use.
Adolescent and adult women of childbearing age have a high prevalence of vitamin D insufficiency. Current prenatal multivitamins (400 IU vitamin D) helped to raise serum 25(OH)D levels, but higher doses and longer duration may be required.
epidemiology; nutrition; pregnancy; supplementation; vitamin D
The campaign against tobacco addiction and smoking continues to play an important role in public health. However, referrals to outpatient tobacco cessation programs by emergency physicians are rarely pursued by patients following discharge. This study explored cost as a barrier to follow-up.
The study was performed at a large urban hospital emergency department (ED) in Camden, New Jersey. Enrollment included adults who reported tobacco use in the past 30 days. Study participants were informed about a “Stop Smoking Clinic” affiliated with the hospital and, depending on enrollment date, cost of treatment was advertised as $150 (standard fee), $20 (reduced fee), or $0 (no fee). Monitoring of patient inquiries and visits to the clinic was performed for 6 months following enrollment of the last study subject.
The analyzed sample consisted of 577 tobacco users. There were no statistically significant demographic differences between treatment groups (p > 0.05). Two-hundred forty-seven (43%) participants reported “very much” interest in smoking cessation. However, there was no significant difference in initiating treatment with the Stop Smoking Clinic across experimental condition. Only a single subject, enrolled in the no-fee phase, initiated treatment with the clinic.
Cost is unlikely to be the only barrier to pursing outpatient tobacco treatment after an ED visit. Further research is needed to determine the critical components of counseling and referral that maximize postdischarge treatment initiation.
The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance.
To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ2 Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis.
We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49).
One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings.
Pulmonary embolism (PE) is common and associated with significant morbidity and mortality. An association between obesity and PE has been suggested, but the nature of the association has not been well defined. We performed a prospective cohort study of 87,226 women in the Nurses’ Health Study (1984–2002) to define the association between BMI and the risk of incident PE. Primary exposure was BMI (<22.5, 22.5–24.9, 25.0–27.4, 27.5–29.9, 30.0–34.9, and ≥35.0 kg/m2). Primary outcome was idiopathic PE (medical record confirmed cases of PE not associated with prior surgery, trauma, or malignancy). Secondary analysis of nonidiopathic PE was also performed. Multivariable Cox proportional hazards models were controlled for age, physical activity, caloric intake, smoking, pack-years, race, spouse’s educational attainment, parity, menopause, nonaspirin nonsteroidal anti-inflammatory drugs, warfarin, multivitamin supplements, hypertension, coronary heart disease, and rheumatological disease. There were 157 incident idiopathic PE and 338 nonidiopathic PE. There was a strong positive association between BMI, the risk of idiopathic PE (relative risk (RR) = 1.08 (95% confidence interval (CI), 1.06–1.10) per 1 kg/m2 increase in BMI, P < 0.001) and nonidiopathic PE (RR = 1.08 (95% CI, 1.07–1.10), P < 0.001). The association was linear, and apparent even with modest increases in BMI (22.5–25 kg/m2). The risk increased nearly sixfold among subjects with BMI ≥35 kg/m2, and was present in multiple subgroups. Increasing BMI has a strong, linear association with the development of PE in women. Clinicians should consider BMI when assessing the risk of PE in their patients.
Little is known about factors associated with systemic corticosteroid (SC) use in emergency department (ED) patients with acute asthma.
To determine the patient and system factors associated with delayed use or nonuse of SCs in the ED.
We analyzed the asthma component of the National Emergency Department Safety Study. Patients with acute asthma in 62 urban EDs in 23 US states between 2003 and 2006 were identified. The primary outcome measure was the pattern of SC use in the ED, which was categorized as timely use (≤60 minutes), delayed use (>60 minutes), or nonuse. Multinomial logistic regression was performed to identify factors associated with delayed use or nonuse of SCs.
A total of 2,559 of 3,798 patients with acute asthma (67.4%) received SCs. Of these, the median door-to-SC time was 62 minutes (interquartile range, 35–100 minutes), with 1,319 patients (51.5%) having delayed SC treatment. Nonuse of SCs was largely explained by markers of asthma exacerbations (never intubated for asthma, lower respiratory rate, and higher oxygen saturation). In contrast, in addition to these factors, delayed SC treatment was associated with age of 40 years or older, female sex, longer duration of symptoms, ED presentation between 8 AM and 11:59 PM, and ED with a longer average patient wait time.
Physicians in the ED seem to appropriately administer SCs to higher-acuity asthmatic patients; however, the additional nonmedical factors represent opportunities to improve the timeliness of SC treatment in the ED.
Single-center studies have suggested that hypovitaminosis D is widespread. Our objective was to determine the serum levels of 25-hydroxyvitamin D (25[OH]D) in a nationally representative sample of US children aged 1 to 11 years.
Data were obtained from the 2001–2006 National Health and Nutrition Examination Survey. Serum 25(OH)D levels were determined by radioimmunoassay and categorized as <25, <50, and <75 nmol/L. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (CIs).
During the 2001–2006 time period, the mean serum 25(OH)D level for US children aged 1 to 11 years was 68 nmol/L (95% CI: 66 –70). Children aged 6 to 11 years had lower mean levels of 25(OH)D (66 nmol/L [95% CI: 64 –68]) compared with children aged 1 to 5 years (70 nmol/L [95% CI: 68 –73]). Overall, the prevalence of levels at <25 nmol/L was 1% (95% CI: 0.7–1.4), <50 nmol/L was 18% (95% CI: 16–21), and <75 nmol/L was 69% (95% CI: 65–73). The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and non-Hispanic black (92%) and Hispanic (80%) children compared with non-Hispanic white children (59%).
On the basis of a nationally representative sample of US children aged 1 to 11 years, millions of children may have suboptimal levels of 25(OH)D, especially non-Hispanic black and Hispanic children. More data in children are needed not only to understand better the health implications of specific serum levels of 25(OH)D but also to determine the appropriate vitamin D supplement requirements for children.
vitamin D; deficiency; prevalence; supplementation
To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period.
Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950–E959) during 1993–2008.
Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (CI) 1.33–1.67] visits per 1,000 US population) and the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008. During the same timeframe, ED visits for these injuries per 1,000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). Visits were most common among ages 15–19 and the number of visits coded as urgent/emergent decreased.
ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.
Suicide; Emergency Departments; Public Health
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.
bronchiolitis; continuous positive airway pressure; intubation; ICU; respiratory syncytial virus; human rhinovirus
We examined the association of second trimester maternal plasma 25-hydroxyvitamin D (25[OH]D) during pregnancy with gestational diabetes mellitus(GDM).
Among 1314 pregnant women participating in Project Viva, a birth cohort study, we measured 25(OH)D levels at 26–28 weeks’ gestation during GDM screening using a 1-hour 50g glucose challenge test.
We found 25(OH)D levels <25nmol/L in 44/1087(4.0%) women with normal glucose tolerance, 9/159(5.7%) women with impaired glucose tolerance and 9/68(13.2%) women with GDM. Analyses adjusted for sociodemographics, season, maternal BMI, gestational weight gain and dietary factors, suggested that women with 25(OH)D levels <25 vs. ≥25 nmol/L may have higher odds of GDM (2.2 [0.8, 5.5]). Glucose levels after the glucose challenge test were inversely associated with 25(OH)D levels(P <0.01).
Second trimester 25(OH)D levels were inversely associated with glucose levels after 1-hour 50g glucose challenge test and low 25(OH)D levels may be associated with increased risk of GDM.
Vitamin D; Gestational Diabetes Mellitus; 25-hydroxyvitamin D; GDM; pregnancy
Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009.
Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001–2009.
National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States.
ED patients admitted a critical care unit.
Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients.
Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001–2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day.
The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.
critical care; crowding; emergency service; health care disparities; hospital/workforce
Purpose of review
The pleotropic effects of vitamin D on chronic diseases have received significant attention; however, its role in acute illness is less understood. The purpose of this review is to summarize the current evidence regarding the role of vitamin D in acute stress and critical illness.
25-Hydroxyvitamin D levels may affect risk of developing acute illnesses (e.g. respiratory infections), and low concentrations are associated with unfavorable outcomes during critical care. Inflammatory changes alone do not explain the observed deterioration in vitamin D status following acute stress. Hemodilution, interstitial extravasation, decreased synthesis of binding proteins, and renal wasting of 25-hydroxyvitamin D, all appear to play a more significant role in the regulation of vitamin D status during critical illness.
Single-point assessments of 25-hydroxyvitamin D following acute stress may provide an inaccurate assessment of vitamin D status. In such cases, measurement of binding proteins and free vitamin D metabolites may be essential to create a more realistic approximation of vitamin D status. Variations in patient responses to acute stress and critical illness may depend not only on the degree of systemic vitamin D insufficiency, but also on the individual tissue requirements.
25(OH)D; acute illness; critical care; vitamin D
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
Nasopharyngeal aspirate (NPA) polymerase chain reaction pathogen results
Main Outcome Measure
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.
In a prospective prenatal cohort study, we examined associations of second trimester and cord plasma 25-hydroxyvitamin D (25[OH]D) with small-for-gestational age (SGA), and the extent to which vitamin D might explain black/white differences in SGA.
We studied 1067 white and 236 black mother-infant pairs recruited from 8 obstetrical offices early in pregnancy in Massachusetts. We analyzed 25(OH)D levels using an immunoassay and performed multivariable logistic models to estimate the odds of SGA by category of 25(OH)D level.
Mean (standard deviation [SD]) second trimester 25(OH)D level was 60 nmol/L (21) and was lower for black (46 nmol/L ) than white (62 nmol/L ) women. 59 infants were SGA (4.5%) and more black than white infants were SGA (8.5% vs. 3.7%). The odds of SGA were higher with maternal 25(OH)D levels <25 vs. ≥25 nmol/L (adjusted odds ratio [OR] 3.17; 95% confidence interval [CI]:1.16, 8.63). The increased odds of SGA among black vs. white participants decreased from an OR of 2.04(1.04, 4.04) to 1.68(0.82, 3.46) after adjusting for 25(OH)D.
Second trimester 25(OH)D levels <25 nmol/L were associated with higher odds of SGA. Our data raise the possibility that Vitamin D status may contribute to racial disparities in SGA.
Vitamin D; Infant; Small for Gestational Age; African Continental Ancestry Group; Health Status Disparities; Pregnancy
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.
Severity of illness; biomarker; respiratory syncytial virus; human rhinovirus
Many believe that the “boarding” of emergency department (ED) patients awaiting inpatient beds compromises quality of care. To better study the quality of care of boarded patients, one should identify and understand the mechanisms accounting for any potential differences in care. This paper present a conceptual boarding “structure-process-outcome” model to help assess quality of care provided to boarded patients, and to aid in recognizing potential solutions to improve that quality, if it is deficient. The goal of the conceptual model is to create a practical framework on which a research and policy agenda can be based to measure and improve quality of care for boarded patients.
To provide estimates and predictors of screening for suicide in emergency departments (EDs).
Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening.
The cohort of 800 patients had a median age of 41 years (interquartile range 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%), or intentional illegal or prescription drug misuse (36%).
The presence of known psychiatric problems and substance use had the strongest associations with suicide screening; yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.
To identify predictors of becoming eating disordered among adolescents.
Prospective cohort study.
Girls (n=6916) and boys (n=5618), aged 9 to 15 years at baseline, in the ongoing Growing Up Today Study (GUTS).
Parent, peer, and media influences.
Main Outcome Measures
Onset of starting to binge eat or purge (ie, vomiting or using laxatives) at least weekly.
During 7 years of follow-up, 4.3% of female subjects and 2.3% of male subjects (hereafter referred to as “females” and “males”) started to binge eat and 5.3% of females and 0.8% of males started to purge to control their weight. Few participants started to both binge eat and purge. Rates and risk factors varied by sex and age group (<14 vs ≥14 years). Females younger than 14 years whose mothers had a history of an eating disorder were nearly 3 times more likely than their peers to start purging at least weekly (odds ratio, 2.8; 95% confidence interval, 1.3–5.9); however, maternal history of an eating disorder was unrelated to risk of starting to binge eat or purge in older adolescent females. Frequent dieting and trying to look like persons in the media were independent predictors of binge eating in females of all ages. In males, negative comments about weight by fathers was predictive of starting to binge at least weekly.
Risk factors for the development of binge eating and purging differ by sex and by age group in females. Maternal history of an eating disorder is a risk factor only in younger adolescent females.
The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) developed guidelines for the management of community-acquired pneumonia (CAP); however, there are sparse data on actual rates of antibiotic use in the emergency department (ED) setting.
Data were obtained from the National Hospital Ambulatory Medical Care Survey for ED visits during 1993 through 2008 for adults with a diagnosis of pneumonia.
During the study period there were an estimated 23,252,000 pneumonia visits, representing 1.8% of all ED visits. The visit rate for pneumonia during this 15-year period may have increased (P trend = 0.055). Overall, 66% of adult patients with a primary diagnosis of pneumonia had documentation of an antibiotic administered while in the ED. There was an increase in antibiotic administration for adults with pneumonia from 1993 through 2008 (49% to 80%; P trend < 0.001). Specifically, there was an increase in use of macrolides from 1993 to 2006 (20% to 30%, P trend < 0.001) and a marked increase in use of quinolones from 0% to 39% from 1993 through 2008 (P trend < 0.001). Penicillin and cephalosporin use remained stable. Use of an antibiotic consistent with 2007 IDSA/ATS guidelines increased from 22% (95% CI = 16% to 27%) of cases in 1993–1994, to 68% (95% CI = 63% to 73%) of cases in 2007–2008 (P trend < 0.001).
ED visit rates for pneumonia increased slightly from 1993 through 2008. Although antibiotic administration in the ED has increased for adults with community-acquired pneumonia, guideline-concordant antibiotics may not be consistently administered.
Background and Aims
The immune system is likely to play a key role in the etiology of gliomas. Genetic polymorphisms in the mannose-binding lectin gene, a key activator in the lectin complement pathway, have been associated with risk of several cancers.
To examine the role of the lectin complement pathway, we combined data from prospectively collected cohorts with available DNA specimens. Using a nested case-control design, we genotyped 85 single nucleotide polymorphisms (SNPs) in 9 genes in the lectin complement pathway and 3 additional SNPs in MBL2 were tested post hoc). Initial SNPs were selected using tagging SNPs for haplotypes; the second group of SNPs for MBL2 was selected based on functional SNPs related to phenotype. Associations were examined using logistic regression analysis. All statistical tests were two-sided. Nominal p-values are presented and are not corrected for multiple comparisons.
A total of 143 glioma cases and 419 controls were available for this analysis. Statistically significant associations were observed for two SNPs in the mannose-binding lectin 2 (ML2) gene and risk of glioma (rs1982266 and rs1800450, test for trend p = 0.003 and p = 0.04, respectively, using the additive model). One of these SNPs, rs1800450, was associated with a 58% increase in glioma risk among those carrying one or two mutated alleles (odds ratio = 1.58, 95% confidence interval = 0.99–2.54), compared to those homozygous for the wild type allele.
Overall, our findings suggest that MBL may play a role in the etiology of glioma. Future studies are needed to confirm these findings which may be due to chance, and if reproduced, to determine mechanisms that link glioma pathogenesis with the MBL complement pathway.
Background and Purpose
Light-to-moderate alcohol consumption has been consistently associated with lower risk of heart disease, but data for stroke are less certain. A lower risk of stroke with light-to-moderate alcohol intake has been suggested but the dose response among women remains uncertain and the data in this subgroup have been sparse.
A total of 83,578 female participants of the Nurses’ Health Study who were free of diagnosed cardiovascular disease and cancer at baseline, were followed from 1980–2006. Data on self-reported alcohol consumption were assessed at baseline and updated approximately every 4 years, while stroke and potential confounder data were updated at baseline and biennially. Strokes were classified according to the National Survey of Stroke criteria.
We observed 2,171 incident strokes over 1,695,324 person-years. In multivariable adjusted analyses, compared to abstainers, the relative risks of stroke were RR=0.83 (95% CI 0.75–0.92) for <5 g/day, RR=0.79 (95% CI: 0.70–0.90) for 5–14.9 g/day, RR=0.87 (0.72–1.05) for 15–29.9 g/day and RR=1.06 (95% CI=0.86–1.30) for 30–45 g/day. Results were similar for ischemic and hemorrhagic stroke.
Light-to-moderate alcohol consumption was associated with a lower risk of total stroke. In this population of women with modest alcohol consumption, an elevated risk of total stroke related to alcohol was not observed.
Risk factors for Stroke; alcohol; ischemic stroke; subarachnoid hemorrhage
Recent studies have shown that low serum 25-hydroxyvitamin D (25[OH]D) level is a risk factor for preeclampsia. The clinical significance of in vitro findings that vitamin D regulates vascular endothelial growth factor production is unclear. We sought to determine whether there is an association between midgestation serum 25(OH)D levels and angiogenic factor activity and to compare their predictive value for the development of severe preeclampsia. We conducted a nested case-control study of women with severe preeclampsia (n=41) versus women with uncomplicated term birth (n=123) who had second trimester genetic screening (15–20 weeks). Using banked frozen serum, we measured levels of 25(OH)D, vascular endothelial growth factor, soluble fms-like tyrosine kinase 1, and placental growth factor and compared their correlations and predictive values. We found no correlation between serum 25(OH)D and angiogenic factors levels. 25(OH)D alone was comparable to vascular endothelial growth factor and soluble fms-like tyrosine kinase 1/placental growth factor ratio as a predictive marker for severe preeclampsia. A composite of both 25(OH)D level and soluble fms-like tyrosine kinase 1/placental growth factor ratio was more predictive than either alone (area under curve: 0.83 versus 0.74 and 0.67, respectively). In conclusion, combining midpregnancy 25(OH)D level with soluble fms-like tyrosine kinase 1/placental growth factor ratio provides a better prediction for the development of severe preeclampsia.
25-hydroxyvitamin D; angiogenic factors; preeclampsia; sFLT-1/PlGF ratio; VEGF
The goals of asthma treatment include preventing recurrent exacerbations. Yet there is no consensus about the terminology for describing or defining “exacerbation,” or about how to characterize an episode’s severity.
National Institutes of Health (NIH) institutes and other federal agencies convened an expert group to propose how asthma exacerbation should be assessed as a standardized asthma outcome in future asthma clinical research studies.
We utilized comprehensive literature reviews and expert opinion to compile a list of asthma exacerbation outcomes, and classified them as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an NIH-organized workshop in March 2010 and finalized in September 2011.
No dominant definition of “exacerbation” was found. The most widely used definitions included 3 components, all related to treatment, rather than symptoms: (1) systemic use of corticosteroids, (2) asthma-specific emergency department visits or hospitalization, and (3) use of short-acting β-agonists (SABAs) as quick-relief (sometimes referred to as “rescue” or “reliever”) medications.
The working group participants propose that the definition of “asthma exacerbation” be “a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome.” As core outcomes, they propose inclusion and separate reporting of several essential variables of an exacerbation. Further, they propose the development of a standardized, component-based definition of “exacerbation” with clear thresholds of severity for each component.
Asthma exacerbations; severity of acute asthma; asthma outcomes; urgent asthma care
The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term “vertical patient flow,” i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.).
We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program.
We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation.
We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction.