Lynne D. Richardson

A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards.

BACKGROUND This project directly and empirically measured the level of gastrointestinal (GI) illness related to the consumption of tapwater prepared from sewage-contaminated surface waters and meeting current water quality criteria. METHODS A randomized intervention trial was carried out; 299 eligible households were supplied with domestic water filters (reverse-osmosis) that eliminate microbial and chemical contaminants from their water, and 307 households were left with their usual tapwater without a filter. The GI symptomatology was evaluated by means of a family health diary maintained prospectively by all study families over a 15-month period. RESULTS The estimated annual incidence of GI illness was 0.76 among tapwater drinkers compared with 0.50 among filtered water drinkers (p less than 0.01). These findings were consistently observed in all population subgroups. CONCLUSION It is estimated that 35% of the reported GI illnesses among the tapwater drinkers were water-related and preventable. Our results raise questions about the adequacy of current standards of drinking water quality to prevent water-borne endemic gastrointestinal illness.

The Effect of Emergency Department Crowding on the Management of Pain in Older Adults with Hip Fracture

OBJECTIVES: To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults.

Emergency Department Crowding and Decreased Quality of Pain Care

OBJECTIVES The objective of this study was to evaluate the association of emergency department (ED) crowding factors with the quality of pain care. METHODS This was a retrospective observational study of all adult patients (> or =18 years) with conditions warranting pain care seen at an academic, urban, tertiary care ED from July 1 to July 31, 2005, and December 1 to December 31, 2005. Patients were included if they presented with a chief complaint of pain and a final ED diagnosis of a painful condition. Predictor ED crowding variables studied were 1) census, 2) number of admitted patients waiting for inpatient beds (boarders), and 3) number of boarders divided by ED census (boarding burden). The outcomes of interest were process of pain care measures: documentation of clinician pain assessment, medications ordered, and times of activities (e.g., arrival, assessment, ordering of medications). RESULTS A total of 1,068 patient visits were reviewed. Fewer patients received analgesic medication during periods of high census (>50th percentile; parameter estimate = -0.47; 95% confidence interval [CI] = -0.80 to -0.07). There was a direct correlation with total ED census and increased time to pain assessment (Spearman r = 0.33, p < 0.0001), time to analgesic medication ordering (r = 0.22, p < 0.0001), and time to analgesic medication administration (r = 0.25, p < 0.0001). There were significant delays (>1 hour) for pain assessment and the ordering and administration of analgesic medication during periods of high ED census and number of boarders, but not with boarding burden. CONCLUSIONS ED crowding as measured by patient volume negatively impacts patient care. Greater numbers of patients in the ED, whether as total census or number of boarders, were associated with worse pain care.

Risk of brain tumours in relation to estimated RF dose from mobile phones: Results from five interphone countries

Objectives The objective of this study was to examine the associations of brain tumours with radio frequency (RF) fields from mobile phones. Methods Patients with brain tumour from the Australian, Canadian, French, Israeli and New Zealand components of the Interphone Study, whose tumours were localised by neuroradiologists, were analysed. Controls were matched on age, sex and region and allocated the ‘tumour location’ of their matched case. Analyses included 553 glioma and 676 meningioma cases and 1762 and 1911 controls, respectively. RF dose was estimated as total cumulative specific energy (TCSE; J/kg) absorbed at the tumours estimated centre taking into account multiple RF exposure determinants. Results ORs with ever having been a regular mobile phone user were 0.93 (95% CI 0.73 to 1.18) for glioma and 0.80 (95% CI 0.66 to 0.96) for meningioma. ORs for glioma were below 1 in the first four quintiles of TCSE but above 1 in the highest quintile, 1.35 (95% CI 0.96 to 1.90). The OR increased with increasing TCSE 7+ years before diagnosis (p-trend 0.01; OR 1.91, 95% CI 1.05 to 3.47 in the highest quintile). A complementary analysis in which 44 glioma and 135 meningioma cases in the most exposed area of the brain were compared with gliomas and meningiomas located elsewhere in the brain showed increased ORs for tumours in the most exposed part of the brain in those with 10+ years of mobile phone use (OR 2.80, 95% CI 1.13 to 6.94 for glioma). Patterns for meningioma were similar, but ORs were lower, many below 1.0. Conclusions There were suggestions of an increased risk of glioma in long-term mobile phone users with high RF exposure and of similar, but apparently much smaller, increases in meningioma risk. The uncertainty of these results requires that they be replicated before a causal interpretation can be made.

The Public Access Defibrillation (PAD) trial: study design and rationale.

The PAD Trial is a prospective, multicenter, randomized clinical study testing whether volunteer, non-medical responders can improve survival from out-of-hospital cardiac arrest (OOH-CA) by using automated external defibrillators (AEDs). These lay volunteers, who have no traditional responsibility to respond to a medical emergency as part of their primary job description, will form part of a comprehensive, integrated community approach to the treatment of OOH-CA. The study is being conducted at 24 field centers in the United States and Canada. Approximately 1000 community units (e.g. apartment or office buildings, gated communities, sports facilities, senior centers, shopping malls, etc.) were randomized to treatment by trained laypersons who will provide either cardiopulmonary resuscitation (CPR) alone or CPR plus use of an AED, while awaiting arrival of the communitys emergency medical services responders. The primary endpoint is the number of OOH-CA victims who survive to hospital discharge. Secondary endpoints include neurological status, health-related quality of life (HRQL), cost, and cost-effectiveness. Data collection will last approximately 15 months and is expected to be completed in September 2003.

Healthscapes: the role of the facility and physical environment on consumer attitudes, satisfaction, quality assessments, and behaviors.

The role of the health care physical or tangible environment, including the facility, is essentially an unstudied area. This article identifies and defines components of “atmospherics”1 concerning health care (Healthscapes), to assess their strengths and predictiveness in the relationship between patient and other customer outcomes, satisfaction, quality assessments, intention to return, and willingness to recommend a health care provider to others and to propose much needed research in the area.

Do appealing hospital rooms increase patient evaluations of physicians, nurses, and hospital services?

This article investigates the effects of appealing hospital rooms on patient evaluations of hospital services. A field study contrasting appealing and typical rooms finds that appealing rooms result in more positive patient evaluations of physicians and nurses, as well as more favorable patient judgments of the service.

Access to health and health care: how race and ethnicity matter.

Racial and ethnic disparities in health are multifactorial; they reflect differences in biological vulnerability to disease as well as differences in social resources, environmental factors, and health care interventions. Understanding and intervening in health inequity require an understanding of the disparate access to all of the personal resources and environmental conditions that are needed to generate and sustain health, a set of circumstances that constitute access to health. These include access to health information, participation in health promotion and disease prevention activities, safe housing, nutritious foods, convenient exercise spaces, freedom from ambient violence, adequate social support, communities with social capital, and access to quality health care. Access to health care is facilitated by health insurance, a regular source of care, and a usual primary care provider. Various mechanisms through which access to health and access to health care are mediated by race and ethnicity are discussed; these include the built environment, social environment, residential segregation, stress, racism, and discrimination. Empirical evidence supporting the association between these factors and health inequities is also reviewed.

Racial and Ethnic Disparities in the Clinical Practice of Emergency Medicine

There is convincing evidence that racial and ethnic disparities exist in the provision of health care, including the provision of emergency care; and that stereotyping, biases, and uncertainty on the part of health care providers all contribute to unequal treatment. Situations, such as the emergency department (ED), that are characterized by time pressure, incomplete information, and high demands on attention and cognitive resources increase the likelihood that stereotypes and bias will affect diagnostic and treatment decisions. It is likely that there are many as-yet-undocumented disparities in clinical emergency practice. Racial and ethnic disparities may arise in decisions made by out-of-hospital personnel regarding ambulance destination, triage assessments made by nursing personnel, diagnostic testing ordered by physicians or physician-extenders, and in disposition decisions. The potential for disparate treatment includes the timing and intensity of ED therapy as well as patterns of referral, prescription choices, and priority for hospital admission and bed assignment. At a national roundtable discussion, strategies suggested to address these disparities included: increased use of evidence-based clinical guidelines; use of continuous quality improvement methods to document individual and institutional disparities in performance; zero tolerance for stereotypical remarks in the workplace; cultural competence training for emergency providers; increased workforce diversity; and increased epidemiologic, clinical, and services research. Careful scrutiny of the clinical practice of emergency medicine and diligent implementation of strategies to prevent disparities will be required to eliminate the individual behaviors and systemic processes that result in the delivery of disparate care in EDs.

The Quality of Emergency Department Pain Care for Older Adult Patients

OBJECTIVES: To determine whether there are differences in emergency department (ED) pain assessment and treatment for older and younger adults.