Arvind Venkat

Association of exposure to particulate matter (PM2.5) air pollution and biomarkers of cardiovascular disease risk in adult NHANES participants (2001–2008)

BACKGROUND AND OBJECTIVES Exposure to particulate matter (PM2.5) has been associated with increased cardiovascular outcomes, mediated by a hypothesized biological mechanism of systemic inflammation and oxidation. Although PM10 has been linked to inflammatory markers in a nationally representative sample (NHANES) using data from earlier cycles (1989-1994); no study has considered these relationships for PM2.5 in more recent time periods. We examined the association of ambient PM2.5 exposure and inflammatory markers in adult NHANES participants for cycles 2001-2008. METHODS We linked each of the adult NHANES participants address with meteorological and modeled air pollution data for each census tract in conterminous United States. The effects of short and long term PM2.5 on C-reactive protein, white blood cells, fibrinogen and homocysteine were analyzed using multiple linear regression, adjusting for cardiovascular risk factors, temperature and ozone. SAS SURVEYREG was used to account for the complex survey design of NHANES. RESULTS In the overall population, no significant positive associations were noted for either short or long term PM2.5 exposures for any of the biomarkers after controlling for confounders. However, stronger associations were found among obese, diabetics, hypertensive and smokers. For every 10μg/m(3) increase in PM2.5, there was an increase of (a) 36.9% (95% CI: 0.1%, 87.2%) in CRP at annual average PM2.5 (adjusting for short term exposure) among diabetics (b) 2.6% (95% CI: 0.1%, 5.1%) in homocysteine at lag 0 among smokers. CONCLUSIONS In a nationally representative sample of individuals we noted no overall association between PM2.5 and biomarkers of cardiovascular risk. However, sensitive subgroups manifested increases in these markers to PM2.5 exposure. Further studies should concentrate on the impact of PM2.5 on these biomarkers in those with multiple cardiovascular risk factors.

Development and Evaluation of Educational Materials for Pre-hospital and Emergency Department Personnel on the Care of Patients with Autism Spectrum Disorder

With the rising prevalence of patients with autism spectrum disorder (ASD), there has been an increase in the acute presentation of these individuals to the general health care system. Emergency medical services and emergency department personnel commonly address the health care needs of patients with ASD at times of crisis. Unfortunately, there is little education provided to front-line emergency medical technicians, paramedics and emergency nurses on the characteristics of ASD and how these characteristics can create challenges for individuals with ASD and their health care providers in the pre-hospital and emergency department settings. This paper describes the development of educational materials on ASD and the results of training of emergency medical services and emergency department personnel.

Care of the HIV-positive patient in the emergency department in the era of highly active antiretroviral therapy.

More than 1 million individuals in the United States are HIV positive, with greater than 40,000 new patients being diagnosed per year. With the advent of highly active antiretroviral therapy (HAART), HIV-infected patients in the United States are living longer. HIV-infected patients receiving HAART now more commonly have noninfectious and nonopportunistic complications of their disease. This review article will discuss the assessment and treatment of HIV-positive patients in the era of HAART, with an emphasis on the noninfectious and changing infectious complications that require emergency care.

Physician Orders for Life-Sustaining Treatment and Emergency Medicine: Ethical Considerations, Legal Issues, and Emerging Trends

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.

Feasibility of integrating a clinical decision support tool into an existing computerized physician order entry system to increase seasonal influenza vaccination in the emergency department

While emergency department (ED) seasonal influenza vaccination programs are feasible, reported implementation barriers include added staffing requirements to identify eligible patients and getting busy ED personnel to order and provide vaccination. We present a prospective, observational trial of integrating a clinical decision support tool into an existing ED computerized physician order entry (CPOE) system to increase ED seasonal influenza vaccination without added staffing resources, the operational barriers identified to program implementation, the revenue generated and data on opportunities for future quality improvement. Compared to the comparable pre-protocol period, ED influenza vaccination rose by 17.5% with a resultant profit margin of 34.5%.

Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

Ethical controversies surrounding the management of potential organ donors in the emergency department.

BACKGROUND On a daily basis, emergency physicians are confronted by patients with devastating neurological injuries and insults. Some of these patients, despite our best efforts, will not survive. However, from these tragedies, there may be benefit given to others who are awaiting organ transplantation. Steps taken in the emergency department (ED) can be critical to preserving the option of organ donation in patients whose neurologic insult places them on a potential path to declaration of brain death. Much of the literature on this subject has focused on the utilitarian value of clinical interventions in the potential organ donor to optimize the likelihood of effective organ procurement. CASE PRESENTATION In this article, we present an actual case that reveals additional ethical perspectives to consider in how emergency physicians manage patients in the ED who can be confidently predicted to progress to death, as attested by neurologic criteria, and become organ donors. The case involves a patient with a devastating, nonsurvivable intracerebral hemorrhage who rapidly progressed to hemodynamic instability. DISCUSSION This case reveals how the current organ donor referral and maintenance system raises ethical tensions for emergency physicians and ED personnel. CONCLUSION This process imposes limitations on communication with patient surrogate decision-makers while calling for interventions with the primary purpose of benefiting off-site patients awaiting transplantation.

Race/ethnicity and asthma management among adults presenting to the emergency department.

We investigated whether racial/ethnic disparities exist in asthma management among 1785 adults requiring emergency department (ED) treatment. In this multicentre study, non‐Hispanic blacks with increased chronic asthma severity were only as likely (P > 0.05) as non‐Hispanic whites or Hispanics to utilize controller medications or see asthma specialists before ED presentation and to be prescribed recommended inhaled corticosteroids at ED discharge. Improved ED education on evidence‐based chronic disease management is needed to address continuing race/ethnicity‐based asthma disparities.

Evaluation of a hospital admission prediction model adding coded chief complaint data using neural network methodology

Objective Our objective was to apply neural network methodology to determine whether adding coded chief complaint (CCC) data to triage information would result in an improved hospital admission prediction model than one without CCC data. Participants and methods We carried out a retrospective derivation and validation cohort study of all adult emergency department visits to a single center. We downloaded triage, chief complaint, and admission/discharge data on each included visit. Using a CCC algorithm and the Levenberg–Marquardt back-propagation learning method, we derived hospital admission prediction models without and with CCC data and applied these to the validation cohort, reporting the prediction models’ characteristics. Results A total of 74 056 emergency department visits were included in the derivation cohort, 85 144 in the validation cohort with 213 CCC categories. The sensitivity/specificity of the derivation cohort models without and with CCC data were 64.0% [95% confidence interval (CI): 63.7–64.3], 87.7% (95% CI: 87.4–88.0), 59.8% (95% CI: 59.5–60.3%), and 91.7% (95% CI: 91.4–92.0) respectively. The sensitivity/specificity of the derived models without and with CCC data applied to the validation cohort were 60.7% (95% CI: 60.4–61.0), 87.7% (95% CI: 87.4–88.0), 59.8% (95% CI: 59.5–60.3), and 90.6% (95% CI: 90.3–90.9) respectively. The area under the curve in the validation cohort for the derived models without and with CCC data were 0.840 (95% CI: 0.838–0.842) and 0.860 (95% CI: 0.858–0.862). Net reclassification index (0.156; 95% CI: 0.148–0.163) and integrated discrimination improvement (0.060; 95% CI: 0.058–0.061) in the CCC model were significant. Conclusion Neural net methodology application resulted in the derivation and validation of a modestly stronger hospital admission prediction model after the addition of CCC data.

An ethical framework for the management of pain in the emergency department.

Pain is a ubiquitous problem, affecting more than 100 million individuals in the United States chronically and many more in the acute setting. Up to three-quarters of patients presenting to the emergency department (ED) report pain as a key component of their reasons for requiring acute care. While pain management is a fundamental component of emergency medicine (EM), there are numerous attitudinal and structural barriers that have been identified to effectively providing pain control in the ED. Coupled with public demands and administrative mandates, concerns surrounding ED pain management have reached a crisis level that should be considered an ethical issue in the profession of EM. In this article, the authors propose an ethical framework based on a combination of virtue, narrative, and relationship theories that can be used to address the clinical dilemmas that arise in managing pain in ED patients.