Knox H. Todd

Ambient air pollution and respiratory emergency department visits

Background: A number of emergency department studies have corroborated findings from mortality and hospital admission studies regarding an association of ambient air pollution and respiratory outcomes. More refined assessment has been limited by study size and available air quality data. Methods: Measurements of 5 pollutants (particulate matter [PM10], ozone, nitrogen dioxide [NO2], carbon monoxide [CO], and sulfur dioxide [SO2]) were available for the entire study period (1 January 1993 to 31 August 2000); detailed measurements of particulate matter were available for 25 months. We obtained data on 4 million emergency department visits from 31 hospitals in Atlanta. Visits for asthma, chronic obstructive pulmonary disease, upper respiratory infection, and pneumonia were assessed in relation to air pollutants using Poisson generalized estimating equations. Results: In single-pollutant models examining 3-day moving averages of pollutants (lags 0, 1, and 2): standard deviation increases of ozone, NO2, CO, and PM10 were associated with 1–3% increases in URI visits; a 2 μg/m3 increase of PM2.5 organic carbon was associated with a 3% increase in pneumonia visits; and standard deviation increases of NO2 and CO were associated with 2–3% increases in chronic obstructive pulmonary disease visits. Positive associations persisted beyond 3 days for several of the outcomes, and over a week for asthma. Conclusions: The results of this study contribute to the evidence of an association of several correlated gaseous and particulate pollutants, including ozone, NO2, CO, PM, and organic carbon, with specific respiratory conditions.

Ambient Air Pollution and Cardiovascular Emergency Department Visits

Background: Despite evidence supporting an association between ambient air pollutants and cardiovascular disease (CVD), the roles of the physicochemical components of particulate matter (PM) and copollutants are not fully understood. This time-series study examined the relation between ambient air pollution and cardiovascular conditions using ambient air quality data and emergency department visit data in Atlanta, Georgia, from January 1, 1993, to August 31, 2000. Methods: Outcome data on 4,407,535 emergency department visits were compiled from 31 hospitals in Atlanta. The air quality data included measurements of criteria pollutants for the entire study period, as well as detailed measurements of mass concentrations for the fine and coarse fractions of PM and several physical and chemical characteristics of PM for the final 25 months of the study. Emergency department visits for CVD and for cardiovascular subgroups were assessed in relation to daily measures of air pollutants using Poisson generalized linear models controlling for long-term temporal trends and meteorologic conditions with cubic splines. Results: Using an a priori 3-day moving average in single-pollutant models, CVD visits were associated with NO2, CO, PM2.5, organic carbon, elemental carbon, and oxygenated hydrocarbons. Secondary analyses suggested that these associations tended to be strongest with same-day pollution levels. Conclusions: These findings provide evidence for an association between CVD visits and several correlated pollutants, including gases, PM2.5, and PM2.5 components.

Selective Cervical Spine Radiography in Blunt Trauma: Methodology of the National Emergency X-Radiography Utilization Study (NEXUS)

Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.

Randomized, controlled trial of video self-instruction versus traditional CPR training

STUDY OBJECTIVE We conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would yield comparable or better CPR performance than the current community standard, the American Heart Association Heartsaver course. METHODS Incoming freshman medical students were randomly assigned to VSI or the Heartsaver CPR course. Two to 6 months after training, we tested subjects to determine their ability to perform CPR in a simulated cardiac arrest setting. Blinded observers used explicit criteria to assess our primary outcome, CPR performance skill. In addition, we assessed secondary outcomes including sequential performance of individual skills, ventilation and chest compression characteristics, and written tests of CPR-related knowledge and attitudes. RESULTS VSI trainees displayed superior overall performance compared with traditional trainees. Twenty of 47 traditional trainees (43%) were judged not competent in their performance of CPR, compared with only 8 of 42 VSI trainees (19%; absolute difference, 24%; 95% confidence interval, 5% to 42%). CONCLUSION In a group of incoming freshman medical students, we found that a half-hour of VSI resulted in superior overall CPR performance compared with that in traditional trainees. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population.

Clinical Versus Statistical Significance in the Assessment of Pain Relief

Abstract [Todd KH: Clinical versus statistical significance in the assessment of pain relief. Ann Emerg Med April 1996;27:439-441.]

Leading Causes of Unintentional and Intentional Injury Mortality: United States, 2000–2009

OBJECTIVES We have described national trends for the 5 leading external causes of injury mortality. METHODS We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. RESULTS Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. CONCLUSIONS Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.

Chest Pain Associated With Cocaine: An Assessment of Prevalence in Suburban and Urban Emergency Departments

STUDY OBJECTIVE Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. DESIGN During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. SETTING One suburban and three urban EDs. RESULTS We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% (P < .0001). Of the 60 patients who tested positive for cocaine, only 43 (72%) admitted recent use. CONCLUSION Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable.

The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey.

Pain is one of the most common medical complaints, but despite its prevalence, many individuals still suffer with unrelieved or undertreated pain. This marketing research survey was designed to determine the physical, psychological, and economic impact pain has on the lives of individuals suffering with pain and to identify the unmet needs of patients who have taken opioid medications to treat their pain. In addition, the survey sought to address the challenges physicians face when treating patients with pain.Pain sufferers were recruited through e-mail invitation to an Internet survey; 173,854 invitations were sent out, 22,018 people responded (12.7%), and 606 met the criteria for inclusion in the survey as pain sufferers. Of these, 359 people had moderate to moderately severe chronic pain and 247 people had moderate to moderately severe acute pain. Additionally, physicians currently treating pain were recruited through e-mail and postal mail invitations and 492 met eligibility criteria: 241 specialists (orthopedic or general surgeons, pain specialists or anesthesiologists), 125 primary care, and 126 emergency medicine physicians.Results of this survey supported what many physicians observe in their practice and hear from their patients, that pain has a negative impact on daily activities in the majority of pain sufferers. Many chronic pain sufferers reported that pain had deleterious effects on their mental health, employment status, sleep, and personal relationships.The impact of pain on patient quality of life and the unmet needs in pain management were recognized by the majority of physicians surveyed, with inadequate pain control, end-of-dose pain, and side effects associated with increased dosing reported as negative factors influencing their choice of pain medication.In conclusion, effective communication between physicians and patients is encouraged to not only improve overall pain management but also to establish shared treatment goals with functional outcomes.

Impact of Physician and Patient Gender on Pain Management in the Emergency Department—A Multicenter Study

OBJECTIVE Pain is a complex experience influenced by factors such as age, race, and ethnicity. We conducted a multicenter study to better understand emergency department (ED) pain management practices and examined the influence of patient and provider gender on analgesic administration. DESIGN Prospective, multicenter, observational study. SETTING Consecutive patients, >or=8-years-old, presenting with complaints of moderate to severe pain (pain numerical rating scale [NRS] > 3) at 16 U.S. and three Canadian hospitals. OUTCOMES MEASURES Receipt of any ED analgesic, receipt of opioids, and adequate pain relief in the ED. RESULTS Eight hundred forty-two patients participated including 56% women. Baseline pain scores were similar in both genders. Analgesic administration rates were not significantly different for female and male patients (63% vs 57%, P = 0.08), although females presenting with severe pain (NRS >or=8) were more likely to receive analgesics (74% vs 64%, P = 0.02). Female physicians were more likely to administer analgesics than male physicians (66% vs 57%, P = 0.009). In logistic regression models, predictors of ED analgesic administration were male physician (odds ratio [OR] = 0.7), arrival pain (OR = 1.3), number of pain assessments (OR = 1.83), and charted follow-up plans (OR = 2.16). With regard to opioid administration, female physicians were more likely to prescribe opioids to females (P = 0.006) while male physicians were more likely to prescribe to males (P = 0.05). In logistic regression models, predictors of opioids administration included male patient gender (OR = 0.58), male patient-physician interaction (OR = 2.58), arrival pain score (OR = 1.28), average pain score (OR = 1.10), and number of pain assessments (OR = 1.5). Pain relief was not impacted by gender. CONCLUSION Provider gender as opposed to patient gender appears to influence pain management decisions in the ED.

Interim results of the study of particulates and health in Atlanta (SOPHIA)

Substantial evidence supports an association of particulate matter (PM) with cardiorespiratory illnesses, but little is known regarding characteristics of PM that might contribute to this association and the mechanisms of action. The Atlanta superstation sponsored by the Electric Power Research Institute as part of the Aerosol Research and Inhalation Epidemiology Study (ARIES) study is monitoring chemical composition of ambient particles by size fraction, as well as a comprehensive suite of other pollutants, at a site in downtown Atlanta during the 25-month period, August 1, 1998–August 31, 2000. Our investigative team is making use of this unique resource in several morbidity studies, called the “Study of Particulates and Health in Atlanta (SOPHIA)”. The study includes the following components: (1) a time series investigation of emergency department (ED) visits for the period during which the superstation is operating; (2) a time series investigation of ED visits during the 5 years prior to implementation of the superstation; and (3) a study of arrhythmic events in patients equipped with automatic implantable cardioverter defibrillators (AICDs) for the period January 1, 1993–August 31, 2000. Thirty-three of 39 Atlanta area EDs are participating in the ED studies, comprising over a million annual ED visits. In this paper, we present initial analyses of data from 18 of the 33 participating EDs. The preliminary data set includes 1,662,713 ED visits during the pre-superstation time period and 559,480 visits during the superstation time period. Visits for four case groupings — asthma, chronic obstructive pulmonary disease (COPD), dysrhythmia, and all cardiovascular diseases (CVDs) combined — have been assessed relative to daily air quality indices, controlling for long-term temporal trends and meteorologic variables, using general linear models, generalized estimating equations and generalized additive models. Single-pollutant models predicting case visitation rates using moving averages of 0-, 1-, and 2-day lagged air quality variables were run. For the pre-superstation period, PM10 (24-h), ozone (8-h), SO2 (1-h), NO2 (1-h) and CO (1-h) were studied. For the first 12 months of superstation operation, the following air quality variables of a priori interest were available: ozone (8-h), NO2 (1-h), SO2 (1-h), CO (1-h), and 24-h measurements of PM10, coarse PM (PM 2.5–10 µm), PM2.5, polar VOCs, 10–100 nm particulate count and surface area, and in the PM2.5 fraction: sulfates, acidity, water-soluble metals, organic matter (OM), and elemental carbon (EC). During the pre-superstation time period, statistically significant, positive associations were observed for adult asthma with ozone, and for COPD with ozone, NO2 and PM10. During the superstation time period, the following statistically significant, positive associations were observed: dysrhythmia with CO, coarse PM, and PM2.5 EC; and all CVDs with CO, PM2.5 EC and PM2.5 OM. While covariation of many of the air quality indices limits the informativeness of this analysis, the study provides one of the first assessments of PM components in relation to ED visits.