Joel B. Rodgers

Unrecognized chronic hepatitis C virus infection among baby boomers in the emergency department

The Centers for Disease Control and Prevention and U.S. Preventive Services Task Force have highlighted public screening as an essential strategy for increasing hepatitis C virus (HCV) detection in persons born between 1945 and 1965 (“baby boomers”). Because earlier HCV screening efforts have not targeted emergency department (ED) baby boomer patients, we describe early experience with integrated opt‐out HCV antibody (Ab) screening of medically stable baby boomers presenting to an urban academic ED. We performed HCV Ab testing 24 hours per day and confirmed positive test results using polymerase chain reaction (PCR). The primary outcome was prevalence of unrecognized HCV infection. Among 2,325 unique HCV‐unaware baby boomers, 289 (12.7%) opted out of HCV screening. We performed HCV Ab tests on 1,529 individuals, of which 170 (11.1%) were reactive. Among Ab reactive cases, follow‐up PCR was performed on 150 (88.2%), of which 102 (68.0%) were confirmed RNA positive. HCV Ab reactivity was more likely in males compared to females (14.7% vs. 7.4%; P < 0.001), African Americans compared to whites (13.3% vs. 8.8%; P = 0.010), and underinsured/ uninsured patients compared to insured patients (16.8%/16.9% vs. 5.0%; P = 0.001). Linkage‐to‐care service activities were recorded for 100 of the 102 confirmed cases. Overall, 54 (54%) RNA‐positive individuals were successfully contacted by phone within five call‐back attempts. We confirmed initial follow‐up appointments for 38 (70.4%) RNA‐positive individuals successfully contacted, and 21 (55.3%) individuals with confirmed appointments attended their initial visit with a liver specialist; 3 (7.9%) are awaiting an upcoming scheduled appointment. Conclusion: We observed high prevalence of unrecognized chronic HCV infection in this series of baby boomers presenting to the ED, highlighting the ED as an important venue for high‐impact HCV screening and linkage to care. (Hepatology 2015;61:776–782)

High-sensitivity C-reactive protein and risk of sepsis.

Background Conventional C-reactive protein assays have been used to detect or guide the treatment of acute sepsis. The objective of this study was to determine the association between elevated baseline high-sensitivity C-reactive protein (hsCRP) and the risk of future sepsis events. Methods We studied data from 30,239 community dwelling, black and white individuals, age ≥45 years old enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Baseline hsCRP and participant characteristics were determined at the start of the study. We identified sepsis events through review of hospital records. Elevated hsCRP was defined as values >3.0 mg/L. Using Cox regression, we determined the association between elevated hsCRP and first sepsis event, adjusting for sociodemographic factors (age, sex, race, region, education, income), health behaviors (tobacco and alcohol use), chronic medical conditions (coronary artery disease, diabetes, dyslipidemia, hypertension, chronic kidney disease, chronic lung disease) and statin use. Results Over the mean observation time of 5.7 years (IQR 4.5–7.1), 974 individuals experienced a sepsis event, and 11,447 (37.9%) had elevated baseline hsCRP (>3.0 mg/L). Elevated baseline hsCRP was independently associated with subsequent sepsis (adjusted HR 1.56; 95% CI 1.36–1.79), adjusted for sociodemographics, health behaviors, chronic medical conditions and statin use. Conclusion Elevated baseline hsCRP was associated with increased risk of future sepsis events. hsCRP may help to identify individuals at increased risk for sepsis.

Agroterrorism: where are we in the ongoing war on terrorism?

The U.S. agricultural infrastructure is one of the most productive and efficient food-producing systems in the world. Many of the characteristics that contribute to its high productivity and efficiency also make this infrastructure extremely vulnerable to a terrorist attack by a biological weapon. Several experts have repeatedly stated that taking advantage of these vulnerabilities would not require a significant undertaking and that the nations agricultural infrastructure remains highly vulnerable. As a result of continuing criticism, many initiatives at all levels of government and within the private sector have been undertaken to improve our ability to detect and respond to an agroterrorist attack. However, outbreaks, such as the 1999 West Nile outbreak, the 2001 anthrax attacks, the 2003 monkeypox outbreak, and the 2004 Escherichia coli O157:H7 outbreak, have demonstrated the need for improvements in the areas of communication, emergency response and surveillance efforts, and education for all levels of government, the agricultural community, and the private sector. We recommend establishing an interdisciplinary advisory group that consists of experts from public health, human health, and animal health communities to prioritize improvement efforts in these areas. The primary objective of this group would include establishing communication, surveillance, and education benchmarks to determine current weaknesses in preparedness and activities designed to mitigate weaknesses. We also recommend broader utilization of current food and agricultural preparedness guidelines, such as those developed by the U.S. Department of Agriculture and the U.S. Food and Drug Administration.

Comparison of methods for the determination of cardiopulmonary resuscitation chest compression fraction

OBJECTIVE While cardiopulmonary resuscitation (CPR) chest compression fraction (CCF) is associated with out-of-hospital cardiac arrest (OHCA) outcomes, there is no standard method for the determination of CCF. We compared nine methods for calculating CCF. METHODS We studied consecutive adult OHCA patients treated by Alabama Emergency Medical Services (EMS) agencies of the Resuscitation Outcomes Consortium (ROC) during January 1, 2010 to October 28, 2010. Paramedics used portable cardiac monitors with real-time chest compression detection technology (LifePak 12, Physio-Control, Redmond, WA). We performed both automated CCF calculation for the entire care episode as well as manual review of CPR data in 1-min epochs, defining CCF as the proportion of each treatment interval with active chest compressions. We compared the CCF values resulting from 9 calculation methods: (1) mean CCF for the entire patient care episode (automated calculation by manufacturer software), (2) mean CCF for first 3 min of patient care, (3) mean CCF for first 5 min, (4) mean CCF for first 10 min, (5) mean CCF for the entire episode except first 5 min, (6) mean CCF for last 5 min, (7) mean CCF from start to first shock, (8) mean CCF for the first half of resuscitation, and (9) mean CCF for the second half of resuscitation. We compared CCF for Methods 2-9 with Method 1 using paired t-tests with a Bonferroni-adjusted p-value of 0.006 (99.5% confidence intervals). RESULTS Among 102 adult OHCA, patient demographics were: mean age 60.3 years (SD 20.8 years), African American 56.9%, male 63.7%, and shockable ECG rhythm 23.5%. Mean CPR duration was 728 s (95% CI: 647-809 s). Mean CCF for the 9 CCF calculation methods were: (1) 0.587%; (2) 0.526%; (3) 0.541%; (4) 0.566%; (5) 0.562%; (6) 0.597%; (7) 0.530%; (8) 0.550%; and (9) 0.590%. Compared with Method 1, Method 7 CCF (start to first shock) was slightly lower (-0.057; 99.5% CI: -0.100 to -0.014). There were no other statistically significant CCF differences (range: -0.054 to 0.013). Correlation between CCF 2-9 and CCF varied (ρ=0.48-0.85). CONCLUSION CCF varies minimally with different calculation methods. Automated CCF determination may prove sufficient for evaluating CPR quality.

Evolution and Escalation of an Emergency Department Routine, Opt-out HIV Screening and Linkage-to-Care Program.

Objective. The Centers for Disease Control and Prevention has recommended emergency department (ED) opt-out HIV screening since 2006. Routine screening can prove challenging due to the EDs complexity and competing priorities. This study examined the implementation and evolution of a routine, integrated, opt-out HIV screening program at an urban academic ED in Alabama since August 2011. Methods. ED routine, opt-out HIV screening was implemented as a standard of care in September 2011. To describe the outcomes and escalation of the screening program, data analyses were performed from three separate data queries: (1) encounter-level HIV screening questionnaire and test results from September 21, 2011, through December 31, 2013; (2) test-level, fourth-generation HIV results from July 9 through December 31, 2013; and (3) daily HIV testing rates and trends from September 9, 2011, through June 30, 2014. Results. Of the 46,385 HIV screening tests performed, 252 (0.5%) were confirmed to be positive. Acute HIV infection accounted for 11.8% of all HIV patients identified using the fourth-generation HIV screening assay. Seventy-six percent of confirmed HIV-positive patients had successful linkage to care. Implementation of fourth-generation HIV instrument-based testing resulted in a 15.0% decline in weekly HIV testing rates. Displacement of nursing provider HIV test offers from triage to the bedside resulted in a 31.6% decline in weekly HIV testing rates. Conclusion. This program demonstrated the capacity for high-volume, routine, opt-out HIV screening. Evolving ED challenges require program monitoring and adaptation to sustain scalable HIV screening in EDs.

Continuum of care for hepatitis C virus among patients diagnosed in the emergency department setting

Background. Urban emergency departments (EDs) seem to be able to detect new hepatitis C virus (HCV) infections at a high rate, but it is unknown the extent to which individuals screened in the ED can progress to treatment and cure. We evaluate the HCV Continuum of Care for patients identified with HCV in 2 urban EDs, and consider the results in the context of outcomes from ambulatory screening venues where 2%-10% of chronically infected patients are treated. Methods. This is a multicenter, retrospective cohort study of 2 ED HCV screening programs. Patients who screened HCV antibody reactive between 1 May and 31 October 2014 were followed for up to 18 months. The main outcome was the absolute number and proportion of eligible patients who completed each stage of the HCV Continuum of Care. Results. A total of 3704 ED patients were estimated to have undiagnosed HCV infection, and screening identified 532 (14.4%) HCV antibody-reactive patients. Of the 532 HCV antibody-reactive patients, 435 completed viral load testing (82%), of whom 301 (69%) were chronically infected. Of the 301 chronically infected patients, 158 had follow-up arranged (52%), of whom 97 attended their appointment (61%). Of these 97, 24 began treatment (25%), and 19 of these 24 achieved sustained virological response (79%). Conclusions. Urban EDs serve patients with poor access to preventive care services who have a high prevalence of HCV infection. Because ED patients identified with HCV infection can progress to treatment and cure with rates comparable to ambulatory care settings, implementation of ED HCV screening should be expanded.

Characterizing Failure to Establish Hepatitis C Care of Baby Boomers Diagnosed in the Emergency Department

Background. Emergency departments (EDs) are high-yield sites for hepatitis C virus (HCV) screening, but data regarding linkage to care (LTC) determinants are limited. Methods. Between September 2013 and June 2014, 4371 baby boomers unaware of their HCV status presented to the University of Alabama at Birmingham ED and underwent opt-out screening. A linkage coordinator facilitated referrals for positive cases. Demographic data, International Classification of Diseases, Ninth Revision codes, and clinic visits were collected, and patients were (retrospectively) followed up until February 2015. Linkage to care was defined as an HCV clinic visit within the hospital system. Results. Overall, 332 baby boomers had reactive HCV antibody and detectable plasma ribonucleic acid. The mean age was 57.3 years (standard deviation = 4.8); 70% were male and 61% were African Americans. Substance abuse (37%) and psychiatric diagnoses (30%) were prevalent; 9% were identified with cirrhosis. During a median follow-up of 433 days (interquartile range, 354–500), 117 (35%) linked to care and 48% needed inpatient care. In multivariable analysis, the odds of LTC failure were significantly higher for white males (adjusted odds ratio [aOR], 2.57; 95% confidence interval [CI], 1.03–6.38) and uninsured individuals (aOR, 5.16; 95% CI, 1.43–18.63) and lower for patients with cirrhosis (aOR, 0.36; 95% CI, 0.14–0.92) and access to primary care (aOR, 0.20; 95% CI, 0.10–0.41). Conclusions. In this cohort of baby boomers with newly diagnosed HCV in the ED, only 1 in 3 were linked to HCV care. Although awareness of HCV diagnosis remains important, intensive strategies to improve LTC and access to curative therapy for diagnosed individuals are needed.

Readying the Health Education Specialist for Emergencies.

This article provides a resourceful guide for the health education specialist to improve emergency management knowledge and skills specific to their setting, including training and preparing for emergencies and providing adequate support to students, clients, and colleagues. Five steps guide competent health education practice before, during, and after a crisis event. Free training resources and priority actions are emphasized. The authors underscore professional benefits of emergency readiness that align with performance expectations established by the Coalition of National Health Education Organizations, including promoting and protecting the health of individuals, families, and communities and providing education and services to reduce costly premature deaths and disability.