Jon Mark Hirshon

Diarrheagenic Escherichia coli Infection in Baltimore, Maryland, and New Haven, Connecticut

BACKGROUND Diarrhea remains a common complaint among US patients who seek medical attention. METHODS We performed a prospective study to determine the etiology of diarrheal illness among patients and control subjects of all ages presenting to the emergency departments and outpatient clinics of 2 large academic hospitals in Baltimore, Maryland, and New Haven, Connecticut. We used molecular methods to detect the presence of diarrheagenic Escherichia coli pathotypes, including enteroaggregative E. coli (EAEC), as well as Shiga toxin-producing, cytodetaching, enterotoxigenic and enteropathogenic E. coli. RESULTS Of the pathotypes sought, only EAEC was found in an appreciable proportion (4.5%) of case patients, and it was found more frequently among case patients than control subjects (P<.02). Surprisingly, EAEC was the most common bacterial cause of diarrhea in our population. EAEC was common in all age strata and was not associated with foreign travel or immunodeficiency. EAEC infection is frequently accompanied by fever and abdominal pain, though this did not happen more frequently in patients with EAEC infection than in patients with diarrhea due to other causes. CONCLUSIONS Our data suggest that EAEC infection should be considered among persons with diarrhea that does not yield another known etiologic agent.

Elevated ambient air zinc increases pediatric asthma morbidity.

Background Recent studies indicate that the composition of fine particulate matter [PM ≤ 2.5 μm in aerodynamic diameter (PM2.5)] is associated with increased hospitalizations for cardiovascular and respiratory diseases. The metal composition of PM2.5 influences allergic and/or inflammatory reactions, and ambient zinc contributes to worsening pulmonary function in susceptible adults. However, information is limited concerning associations between ambient air zinc levels and health care utilization for asthma, especially among children. Objective We aimed to investigate the relationship between outdoor ambient air PM2.5 zinc levels and urgent health care utilization for children living in an urban area. Methods We used a time-series study to estimate the association of ambient air PM2.5 zinc levels with hospital admissions and emergency department (ED) utilization by children in Baltimore, Maryland, controlling for time trends. We used data from daily discharge administrative claims of ED and hospital utilization for asthma in children, 0–17 years of age for Greater Baltimore from June 2002 through November 2002. We collected ambient air PM2.5 metal concentration data, determined by X-ray fluorescence spectroscopy, during the U.S. Environmental Protection Agency–sponsored Baltimore Supersite project. Results Previous-day medium levels of zinc (8.63–20.76 ng/m3) are associated with risks of pediatric asthma exacerbations that are 1.23 (95% confidence interval, 1.07–1.41) times higher than those with previous-day low levels of zinc (< 8.63 ng/m3) after accounting for time-varying potential confounders. Conclusion Results suggest that high ambient air PM2.5 zinc levels are associated with an increase in ED visits/hospital admissions for asthma on the following day among children living in an urban area.

Placing Emergency Care on the Global Agenda

Emergency care serves a key function within health care systems by providing an entry point to health care and by decreasing morbidity and mortality. Although primarily focused on evaluation and treatment for acute conditions, emergency care also serves as an important locus of provision for preventive care with regard to injuries and disease progression. Despite its important and increasing role, however, emergency care has been frequently overlooked in the discussion of health systems and delivery platforms, particularly in developing countries. Little research has been done in lower- and middle-income countries on the burden of disease reduction attributable to emergency care, whether through injury treatment and prevention, urgent and emergency treatment of acute conditions, or emergency treatment of complications from chronic conditions. There is a critical need for research documenting the role of emergency care services in reducing the global burden of disease. In addition to applying existing methodologies toward this aim, new methodologies should be developed to determine the cost-effectiveness of these interventions and how to effectively cover the costs of and demands for emergency care needs. These analyses could be used to emphasize the public health and clinical importance of emergency care within health systems as policymakers determine health and budgeting priorities in resource-limited settings.

Health systems and services: the role of acute care

As populations continue to grow and age, there will be increasing demand for acute curative services responsive to life-threatening emergencies, acute exacerba -tion of chronic illnesses and many routine health problems that nevertheless require prompt action. Emergency interven-tions and services should be integrated with primary care and public health measures to complete and strengthen health systems. This paper focuses on acute care within that context. First, we draw on standard World Health Organi -zation (WHO) terminology to propose working terms to define “acute care”. Second, we highlight the fragmentation of service delivery that results from not adopting the proposed definition. Third, we show the potential contribution of acute care to integrated health systems designed to reduce all-cause morbidity and mortality. Finally, we propose key steps to further the development of acute care that leaders, researchers and health workers, who are the people responsible for maintaining strong national health systems, should consider taking.

The National Report Card on the State of Emergency Medicine: Evaluating the Emergency Care Environment State by State 2009 Edition

Becher • Editorial E this year, the American College of Emergency Physicians (ACEP) released its first-ever National Report Card on the State of Emergency Medicine with the intention of bringing the critical issues confronting emergency care in the United States before the public eye. The ACEP Report Card is an assessment of the support that each state provides for its emergency medicine system. The January 2006 report card is the first in a proposed series that the ACEP plans to issue, and it will serve as a baseline measure for comparison with future changes as data become available from state government offices. It is hoped that the results of the ACEP Report Card will serve as a much-needed wake-up call to state legislators and the public that the system they depend on for lifesaving emergency care is itself in critical condition. For the first time, the public saw the support—or lack of support—provided by the states to their local emergency care systems. The ACEP Report Card analyzed 2500 data points, all directly related to the financial support provided by the individual states. This was the first definitive look at the entire range of issues confronting the provision of emergency care. Fifty objective and quantifiable criteria were used to measure the performance of each state and the District of Columbia. These measurements were weighted and aggregated, and grades were assigned based on comparison to the best state’s performance (ie, a “sliding scale”). Each state received an overall grade as well as individual grades in each of four specific categories. Recognizing that not all categories or criteria were of equal importance, the task force assigned weighted scores to reflect “real world” priorities: ▫ access to emergency care, 40%; ▫ quality and patient safety, 25%; ▫ public health and injury/crisis prevention, 10%; and ▫ medical liability environment, 25%. It is important to note that these grades are not evaluations of the quality of care provided by emergency physicians, residency programs, or hospital emergency departments. Rather, the grades in the ACEP Report Card show the overall effort of states to support effective emergency medicine systems. Local emergency departments are at the front line of a national healthcare crisis. They are increasingly crowded— often to the point that ambulances en route must be diverted to another hospital.1,2 A key cause of emergency department crowding is the lack of staffed inpatient beds.1,2 Another cause of crowding is the high cost of medical liability insurance, which has led some specialty physicians to leave the practice of medicine or to be less willing to be “on-call” for emergency situations, aggravating hospitals’ difficulties in providing emergency care.3 The ACEP Report Card indicates that the national emergency healthcare system is in serious condition, with many states in critical condition. While no state received an overall failing grade, many have serious deficiencies, and almost all states have areas in which there is substantial room for improvement. Currently, emergency care is this country’s safety net for the entire healthcare system.2 The growing number of uninsured citizens, the lack of participation in preventive health programs, and the relentless demographic shift that accompanies the baby-boom generation all contribute to the increasing burden on the emergency medicine system.2,4,5 No state received an overall grade of A, and only California, Connecticut, Massachusetts, and Washington, DC, earned a solid B. A summary of the grades for the states with the highest number of hospitals accredited by the American Osteopathic Association (AOA) is provided in Table. Clearly, in those states with the worst environment for medical liability reform, the effects of a low score for that portion of the formula (25%) would have a negative impact on the overall grade. Therefore, those states in which emergency departments have closed because medical specialists such as neurosurgeons, obstetricians, and orthopedists could not obtain medical liability insurance would be inclined toward lower overall scores than states with more reformfriendly environments. States with hospitals that do not have critical on-call specialists available because of a fear of lawsuits would be similarly affected. The AOA, American Medical Association, and ACEP advocate several possible solutions to the crisis in emergency medicine, including: The National Report Card on the State of Emergency Medicine

Monitoring of Stool Microbiota in Subjects with Diarrhea Indicates Distortions in Composition

ABSTRACT We utilized denaturing gradient gel electrophoresis profiling to survey stool microbiota in 175 persons with diarrhea and 113 asymptomatic persons in a diarrhea surveillance study. Compared with healthy controls, the microbiota profiles in diarrhea cases more frequently exhibited decreased diversity and strong bands indicating the overgrowth of selected bacteria or bacterial groups.

Venous thromboembolic disease in the HIV-infected patient.

OBJECTIVE Infection with the HIV has developed into a chronic illness, with longer-term complications increasingly being seen. There is increasing evidence that infection with HIV may be associated with a hypercoagulable state. This study examines the association of HIV infection with the incidence of both pulmonary embolism and deep venous thrombosis. METHODS This study was a weighted analysis of data from National Hospital Discharge Survey, a national annual probability survey of discharges from short-stay non-Federal hospitals, from 1996-2004. The risk of pulmonary embolism and/or deep venous thrombosis in an HIV+ individual was ascertained for each age group by calculation of an odds ratio (OR) with a 95% confidence interval (CI). A common OR was computed across strata to evaluate the overall association between PE/DVT and HIV while adjusting for effects of age. RESULTS The overall age-adjusted OR indicates a statistically significant increase of 43% for PE in HIV+ individuals as opposed to HIV- individuals (OR, 1.43; 95% CI, 1.39-1.46). This increase differs by age group, with age group 21 to 50 years having the highest odds for PE among HIV+ individuals (OR, 1.58; 95% CI, 1.54-1.63). CONCLUSIONS The data supports the hypothesis that HIV-infected individuals are more likely to have clinically detected thromboembolic disease as opposed to non-HIV-infected individuals. This study reveals up to a 43% increase in OR of developing a PE, 10% increase in developing a DVT, and 40% increase in developing PE or DVT in an HIV-infected individual over the 9-year study period after adjusting for age.

Drowning and near-drowning in children and adolescents: a succinct review for emergency physicians and nurses

TARGET AUDIENCE This Continuing Medical Education (CME) activity is intended for anyone who treats pediatric drowning and near-drowning victims or who provides injury prevention counseling. Although targeted at emergency physicians and nurses in particular, we believe other healthcare providers— including critical care doctors and nurses, pediatricians, family practitioners, respiratory therapists, and paramedics—will find it informative.

Respiratory hygiene in the emergency department.

The emergency department (ED) is an essential component of the public health response plan for control of acute respiratory infectious threats. Effective respiratory hygiene in the ED is imperative to limit the spread of dangerous respiratory pathogens, including influenza, severe acute respiratory syndrome, avian influenza, and bioterrorism agents, particularly given that these agents may not be immediately identifiable. Sustaining effective respiratory control measures is especially challenging in the ED because of patient crowding, inadequate staffing and resources, and ever-increasing numbers of immunocompromised patients. Threat of contagion exists not only for ED patients but also for visitors, health care workers, and inpatient populations. Potential physical sites for respiratory disease transmission extend from out-of-hospital care, to triage, waiting room, ED treatment area, and the hospital at large. This article presents a summary of the most current information available in the literature about respiratory hygiene in the ED, including administrative, patient, and legal issues. Wherever possible, specific recommendations and references to practical information from the Centers for Disease Control and Prevention are provided. The “Administrative Issues” section describes coordination with public health departments, procedures for effective facility planning, and measures for health care worker protection (education, staffing optimization, and vaccination). The patient care section addresses the potentially infected ED patient, including emergency medical services concerns, triage planning, and patient transport. “Legal Issues” discusses the interplay between public safety and patient privacy. Emergency physicians play a critical role in early identification, treatment, and containment of potentially lethal respiratory pathogens. This brief synopsis should help clinicians and administrators understand, develop, and implement appropriate policies and procedures to address respiratory hygiene in the ED. The emergency department (ED) is an essential component of the public health response plan for control of acute respiratory infectious threats. Effective respiratory hygiene in the ED is imperative to limit the spread of dangerous respiratory pathogens, including influenza, severe acute respiratory syndrome, avian influenza, and bioterrorism agents, particularly given that these agents may not be immediately identifiable. Sustaining effective respiratory control measures is especially challenging in the ED because of patient crowding, inadequate staffing and resources, and ever-increasing numbers of immunocompromised patients. Threat of contagion exists not only for ED patients but also for visitors, health care workers, and inpatient populations. Potential physical sites for respiratory disease transmission extend from out-of-hospital care, to triage, waiting room, ED treatment area, and the hospital at large. This article presents a summary of the most current information available in the literature about respiratory hygiene in the ED, including administrative, patient, and legal issues. Wherever possible, specific recommendations and references to practical information from the Centers for Disease Control and Prevention are provided. The “Administrative Issues” section describes coordination with public health departments, procedures for effective facility planning, and measures for health care worker protection (education, staffing optimization, and vaccination). The patient care section addresses the potentially infected ED patient, including emergency medical services concerns, triage planning, and patient transport. “Legal Issues” discusses the interplay between public safety and patient privacy. Emergency physicians play a critical role in early identification, treatment, and containment of potentially lethal respiratory pathogens. This brief synopsis should help clinicians and administrators understand, develop, and implement appropriate policies and procedures to address respiratory hygiene in the ED.

Clostridium difficile infection in outpatients, Maryland and Connecticut, USA, 2002-2007.

Clostridium difficile, the most commonly recognized diarrheagenic pathogen among hospitalized persons, can cause outpatient diarrhea. Of 1,091 outpatients with diarrhea, we found 43 (3.9%) who were positive for C. difficile toxin. Only 7 had no recognized risk factors, and 3 had neither risk factors nor co-infection with another enteric pathogen.