Understanding Barriers and Distress Experienced Among Cancer Patients: Analysis from an Urban Academic Emergency Department.

The purpose of this study was to examine barriers and facilitators to compliance for cancer care in patients utilizing an emergency department (ED)-based assessment. Adult ED patients who either had active cancer or a history of cancer were enrolled between August 2020 and Jan 2022 for this prospective cohort study. We piloted the National Comprehensive Cancer Network (NCCN) Distress Thermometer. Multivariable regression analyses were used to assess the predictors of high distress. Of the 152 patients enrolled, 73% were Black patients, 11% were non-Hispanic White, and 16% included patients from other racial and ethnic groups (including 10.5% Hispanic patients); 73% of the sample had active cancer. The current ED visit was cancer related for 44%. The mean score on the Distress Thermometer was 4 (SD = 2; range 0-8) with 30% having a high distress level of ≥ 6. Having an active cancer and race/ethnicity were significant predictors of high distress. Patients who had active cancer had three times (aOR = 3.01; 95% CI 1.12-8.10) higher odds of experiencing high distress in the past week compared to those who did not have active cancer, after adjusting for race/ethnicity and reason for visit. Practical problems and physical problems were the most common, with 43% (n = 66) and 40% (n = 61) of the patients reporting these problems, respectively. Despite significant progress in cancer care, cancer patients/survivors face difficulty in transitioning between care environments and end up seeking episodic care in the ED and experience a high level of distress.

Optimal Veterinary Team Utilization Leads to Team Retention.

Retaining and attracting talent in VetMed has become an increasingly difficult challenge and applies to all roles in the veterinary practice. Culture, leadership, training and development, and full role utilization are key factors in retaining current talent, as well as attracting future team members. These elements must work synergistically together to create an environment that team members do not want to leave while also being able to deliver exceptional patient care (fulfilling each team member's sense of purpose).

Medical complications of obesity: heightened importance in a COVID era.

BACKGROUND: Obesity is a major public health problem associated with significant medical complications. MAIN BODY: This review examines 8 primary diseases: type 2 diabetes, hypertension, dementia, non-alcoholic fatty liver disease, polycystic ovarian syndrome, dyslipidemia, cancer, and their manifestations in obese patients. A total of 39 articles were used for this review. The authors conducted limited review, searching PubMed and Google Scholar databases using a combination of key words "COVID-19" or "SARS-COV2", "type 2 diabetes", "hypertension", "dementia", "non-alcoholic fatty liver disease", "polycystic ovarian syndrome", "dyslipidemia", "cancer", and "obesity". No specific date limitation was used. Obesity exacerbates many medical conditions and has recently been identified as an independent risk factor for COVID-19 severity. This sets obesity at the pinnacle of all disease complications. The long-term impact of obesity ranges from financial burden on the health system, lower life expectancy, and reduced survival rates. CONCLUSION: Obesity is an important modifiable risk factor. There is the need for healthcare providers to understand the medical complications associated with obesity to optimize patient care.

Emergency Department Management of Hypertension in the Context of COVID-19.

PURPOSE OF REVIEW: This review describes the relationship between COVID-19 and hypertension (HTN), and considerations for emergency medicine providers in the management of hypertensive patients during the COVID-19 pandemic. RECENT FINDINGS: Hypertensive patients with COVID-19 have a higher risk of severe disease/complications, hospitalizations, intensive care unit (ICU) admissions, and mortality than non-hypertensive patients. Studies have also shown the importance of consideration of various demographic factors (such as older age) and socioeconomic factors that may confound these relationships. Despite concerns at the start of the pandemic that RAAS inhibiting antihypertension medications may contribute to worsened outcomes in COVID-19 patients, subsequent research has shown that use of ACEi/ARBs is associated with neutral or even improved COVID-19 outcomes. Socioeconomic factors must also be considered including patients' potential delay of health care due to fear of contracting COVID-19, loss of health insurance, and barriers to accessing primary care appointments for post-ED follow-up care. While there is mixed evidence on biological considerations for HTN care during the COVID-19 pandemic, the pandemic has undoubtedly been a major stressor and barrier to effective chronic disease management. Emergency medicine and other providers should consider this when evaluating acute care patients with a history of HTN or newly elevated blood pressure.

Personalized Analytics and a Wearable Biosensor Platform for Early Detection of COVID-19 Decompensation (DeCODe): Protocol for the Development of the COVID-19 Decompensation Index.

BACKGROUND: During the COVID-19 pandemic, novel digital health technologies have the potential to improve our understanding of SARS-CoV-2 and COVID-19, improve care delivery, and produce better health outcomes. The National Institutes of Health called on digital health leaders to contribute to a high-quality data repository that will support researchers to make discoveries that are otherwise not possible with small, limited data sets. OBJECTIVE: To this end, we seek to develop a COVID-19 digital biomarker for early detection of physiological exacerbation or decompensation. We propose the development and validation of a COVID-19 decompensation Index (CDI) in a 2-phase study that builds on existing wearable biosensor-derived analytics generated by physIQ's end-to-end cloud platform for continuous physiological monitoring with wearable biosensors. This effort serves to achieve two primary objectives: (1) to collect adequate data to help develop the CDI and (2) to collect rich deidentified clinical data correlating with outcomes and symptoms related to COVID-19 progression. Our secondary objectives include evaluation of the feasibility and usability of pinpointIQ, a digital platform through which data are gathered, analyzed, and displayed. METHODS: This is a prospective, nonrandomized, open-label, 2-phase study. Phase I will involve data collection for the digital data hub of the National Institutes of Health as well as data to support the preliminary development of the CDI. Phase II will involve data collection for the hub and contribute to continued refinement and validation of the CDI. While this study will focus on the development of a CDI, the digital platform will also be evaluated for feasibility and usability while clinicians deliver care to continuously monitored patients enrolled in the study. RESULTS: Our target CDI will be a binary classifier trained to distinguish participants with and those without decompensation. The primary performance metric for CDI will be the area under the receiver operating characteristic curve with a minimum performance criterion of ≥0.75 (α=.05; power [1-ß]=0.80). Furthermore, we will determine the sex or gender and race or ethnicity of the participants, which would account for differences in the CDI performance, as well as the lead time-time to predict decompensation-and its relationship with the ultimate disease severity based on the World Health Organization COVID-19 ordinal scale. CONCLUSIONS: Using machine learning techniques on a large data set of patients with COVID-19 could provide valuable insights into the pathophysiology of COVID-19 and a digital biomarker for COVID-19 decompensation. Through this study, we intend to develop a tool that can uniquely reflect physiological data of a diverse population and contribute to high-quality data that will help researchers better understand COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov NCT04575532; https://www.clinicaltrials.gov/ct2/show/NCT04575532. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27271.

Effect of an emergency department education and empowerment intervention on uncontrolled hypertension in a predominately minority population: The AHEAD2 randomized clinical pilot trial.

OBJECTIVE: To determine whether an emergency department (ED) education and empowerment intervention coupled with early risk assessment can help improve blood pressure (BP) in a high-risk population. METHODS: A hypertension emergency department intervention aimed at decreasing disparities (AHEAD2) is a 3-arm, single-site randomized pilot trial for feasibility in an urban academic ED. A total of 150 predominantly ethnic minorities with no primary care provider and severely elevated blood pressure (BP) (≥160/100 mm Hg) were enrolled over 10 months. Participants were randomized into 1 of 3 study arms: (1) enhanced usual care (EUC), (2) ED-initiated screening, brief intervention, and referral for treatment (ED-SBIRT), or (3) ED- SBIRT plus a 48-72 hours post-acute care hypertension transition clinic (ED-SBIRT+PACHT-c). Primary outcomes were change in systolic and diastolic BP (SBP and DBP) from baseline to 9 months. Secondary outcomes were BP control (BP <140/90 mm Hg), changes in hypertension knowledge, medication adherence, and limited bedside echocardiogram (LBE) findings. RESULTS: SBP reduction from baseline to month 9 was -26.8 (95% confidence interval [CI]: -32.8, -20.7) mm Hg for ED-SBIRT, -23.4 (95% CI: -29.5, -17.3) mm Hg for ED-SBIRT+PACHT-c, and -18.9 (95% CI: -24.9, -12.9) mm Hg for EUC. DBP decreased by -12.5 (95% CI: -16.1, -9.0) mm Hg for ED-SBIRT, -11.3 (95% CI: -14.8, -7.7) mm Hg for ED-SBIRT+PACHT-c, and -8.4 (95% CI: -11.9, -4.9) mm Hg for EUC. A multicomponent intervention compared with EUC resulted in SBP decrease of -7.9 mm Hg (95% CI: -16.4, 0.6). At 9 months, hypertension was controlled for 29.3% (95% CI: 20.3, 38.3) of intervention and 23.5% (95% CI: 11.9, 35.2) of EUC participants. All groups saw improvements in hypertension knowledge, medication adherence, and LBEs, with greater improvements in intervention groups. CONCLUSIONS: The study findings suggest that a multicomponent intervention comprising of ED education and empowerment coupled with early risk assessment may help improve BP in a high-risk population.

Targeting of uncontrolled hypertension in the emergency department (TOUCHED): Design of a randomized controlled trial.

BACKGROUND: Uncontrolled or undiagnosed hypertension (HTN) is estimated to be as high as 46% in emergency departments (EDs). Uncontrolled HTN contributes significantly to cardiovascular morbidity and disproportionately affects communities of color. EDs serve high risk populations with uncontrolled conditions that are often missed by other clinical settings and effective interventions for uncontrolled HTN in the ED are critically needed. The ED is well situated to decrease the disparities in HTN control by providing a streamlined intervention to high risk populations that may use the ED as their primary care. METHODS: Targeting of UnControlled Hypertension in the Emergency Department (TOUCHED), is a two-arm single site randomized controlled trial of 770 adults aged 18-75 presenting to the ED with uncontrolled HTN comparing (1) usual care, versus (2) an Educational and Empowerment (E2) intervention that integrates a Post-Acute Care Hypertension Consultation (PACHT-c) with a mobile health BP self-monitoring kit. The primary outcome is differences in mean systolic blood pressure (SBP) at 6-months post enrollment. Secondary outcomes include differences in mean SBP and mean diastolic BP (DBP) at 3-months and mean DBP at 6-months. Additionally, improvement in cardiovascular risk score, medication adherence, primary care engagement, and HTN knowledge will also be assessed as part of this study. CONCLUSIONS: The TOUCHED trial will be instrumental in determining the effectiveness of a brief ED-based intervention that is portable to other urban EDs with high-risk populations. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03749499.

Community Targeting of Uncontrolled Hypertension: Results of a Hypertension Screening and Education Intervention in Community Churches Serving Predominantly Racial/Ethnic Minority Populations.

Background. Uncontrolled hypertension is the primary risk factor for the development of cardiovascular complications and particularly burdens racial/ethnic minority populations. Aim. To determine the effectiveness of a community hypertension screening, education, and empowerment intervention on blood pressure (BP) improvement. Method. We screened 152 participants across four churches in predominantly racial/ethnic minority neighborhoods for elevated BP. During this visit, those with BP ≥ 140/90 mmHg were enrolled in the study and completed interventions. Individuals with moderately elevated BP (≥140/90 and <160/100 mmHg; Group 1) viewed a 3-minute hypertension education video. Individuals with severely elevated BP (≥160/100 mmHg; Group 2) additionally viewed echocardiograms images with subclinical changes from uncontrolled hypertension and had a brief on-site medication review with a pharmacist. Both groups received automated BP monitors and information on neighborhood federally qualified health centers for primary care. Participants returned to each church for follow-up 3 months later. We analyzed BP difference at 3 months and percentage with controlled BP for each group. Results. For Group 1, mean baseline and follow-up BPs were 143.5/88.0 mmHg and 138.5/85.8 mmHg, respectively. For Group 2, BPs significantly decreased from 165.4/98.3 mmHg to 150.4/90.8 mmHg. After the intervention, participants with controlled BP for Groups 1 and 2 were 35.5% and 55.2%, respectively. Discussion. Participants in both groups had BP improvements. Greater improvements were in individuals at higher cardiovascular risk due to severely elevated BPs (≥160/100 mmHg). Conclusion. This pilot highlights the impact that streamlined empowerment interventions with dedicated health personnel can have in high-risk communities with elevated BPs.

Barriers and Facilitators to Hypertension Control Following Participation in a Church-Based Hypertension Intervention Study.

PURPOSE: Hypertension is the primary risk factor for development of cardiovascular complications. Community-initiated interventions have proven effective in reducing cardiovascular disease risk among individuals who might otherwise face barriers to care. The purposes of this study were to gain feedback on a church-based hypertension intervention study and assess barriers and facilitators to hypertension control after participation in the study. DESIGN: Qualitative study of 4 focus groups. SETTING: Focus groups took place at 4 churches in primarily minority neighborhoods of Chicago, Illinois, in summer 2017. PARTICIPANTS: Thirty-one community members participated in the focus groups. METHOD: The Community Targeting of Uncontrolled Hypertension (CTOUCH) study was a church-based screening, brief intervention, and referral for treatment program for hypertension. Following the study completion, participants were invited to join a focus group to provide feedback on the study and discuss barriers and facilitators to hypertension control. The authors used the Framework Method to analyze the data. RESULTS: Community Targeting of Uncontrolled Hypertension was well received by participants, particularly the awareness of their individual blood pressure and subsequent education on risk modification. The most common facilitators for hypertension control were social support, knowing how to control hypertension, and community resources. The most common barriers to hypertension control were lack of hypertension knowledge, negative primary care experiences, and lack of disease awareness. CONCLUSION: Knowledge of barriers and facilitators can inform areas of success and opportunities for improvement in community-based hypertension programs including future renditions in CTOUCH.

Evaluation of an Enhanced Peer Mentoring Program on Scholarly Productivity and Promotion in Academic Emergency Medicine: A Five-Year Review.

OBJECTIVE: To design, implement, and evaluate the effectiveness of an enhanced peer mentoring program (EPMP) for faculty in emergency medicine aimed at overcoming traditional mentoring challenges. METHODS: Full time faculty (Clinical Instructor, Assistant, and Associate levels) were placed into peer groups (based upon their primary academic roles) led by senior faculty advisors at the Professor level. Peer groups met at least quarterly from 2012 to 2017. In lieu of a structured curriculum, session topics were informed by individual faculty surveys and peer group consensus. Areas of focus included work-life balance, prioritizing academic commitments, identification of mentors (both within and external to the department and university), networking opportunities, promotions goals, and career satisfaction. RESULTS: Effectiveness of the EPMP was evaluated by academic productivity and advancement over a 5- year period. A total of 22 faculty members participated in the program. There was an increase in promotions to the next academic level, from 3 promotions in the five years before the program to 7 promotions in the five years of the program. Total grant funding increased 3-fold from $500,000 to $1,706,479 from the first year to the last year of the evaluation period. CONCLUSIONS: This enhanced peer mentoring program was effective in mitigating many of the traditional mentoring challenges faced by faculty in academia and was successful in improving both academic productivity and advancement.

Bedside ultrasound as a predictive tool for acute chest syndrome in sickle cell patients.

BACKGROUND: Acute chest syndrome (ACS) is the leading cause of death for patients with sickle cell disease (SCD). Early recognition of ACS improves prognosis. OBJECTIVE: Investigate the use of bedside lung ultrasound (BLU) in identification of early pulmonary findings associated with ACS in SCD patients. METHODS: Prospective, observational study of a convenience sample of SCD patients presenting to the Emergency Department (ED) for a pain crisis. BLU interpretations were made by an emergency physician blinded to the diagnosis of ACS, and were validated by a second reviewer. The electronic medical record was reviewed at discharge and at 30 days. RESULTS: Twenty SCD patients were enrolled. Median age was 31 years, median hemoglobin was 7.7 g/dL. Six patients developed ACS. Five patients in the ACS group had lung consolidations on BLU (83%) compared to 3 patients in the non-ACS group (21%), p = 0.0181, (OR = 12.05, 95% CI 1.24 to 116.73). The ACS group was also more likely to have a pleural effusion and B-lines on BLU than the non-ACS group, p = 0.0175; 0.1657, respectively. In the ACS group, peripheral and frank consolidations on BLU was 83% and 50% sensitive, 79% and 100% specific for ACS, respectively; whereas an infiltrate on initial chest X-ray (CXR) was only 17% sensitive. BLU identified lung abnormalities sooner than CXR (median 3.6 vs. 31.8 h). CONCLUSIONS: Pulmonary abnormalities on BLU of an adult SCD patient presenting to the ED for a painful crisis appear before CXR, and highly suggest ACS. BLU is a promising predictive tool for ACS.

Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study.

INTRODUCTION: This study evaluates the agreement between emergency physician (EP) assessment of diastolic dysfunction (DD) by a simplified approach using average peak mitral excursion velocity (e'A) and an independent cardiologist's diagnosis of DD by estimating left atrial (LA) pressure using American Society of Echocardiography (ASE) guidelines. METHODS: This was a secondary analysis of 48 limited bedside echocardiograms (LBE) performed as a part of a research study of patients presenting to the Emergency Department (ED) with elevated blood pressure but without decompensated heart failure. EPs diagnosed DD based on e'A < 9 cm/s alone. A blinded board-certified cardiologist reviewed LBEs to estimate LA filling pressures following ASE guidelines. An unweighted kappa measure was calculated to determine agreement between EP and cardiologist. RESULTS: Six LBEs were deemed indeterminate by the cardiologist and excluded from the analysis. Agreement was reached in 41 out of 48 cases (85.4%). The unweighted kappa coefficient was 0.74 (95% CI 0.57-0.92). EPs identified 18 out of 20 LBEs diagnosed with diastolic dysfunction by the cardiologist. CONCLUSION: There is a good agreement between (e'A) by EP and cardiologist interpretation of LBEs. Future studies should investigate this simplified approach as a one-step method of screening for LV diastolic dysfunction in the ED.

A hypertension emergency department intervention aimed at decreasing disparities: Design of a randomized clinical trial.

Effective interventions to identify and treat uncontrolled hypertension (HTN), particularly in underrepresented populations that use the emergency department (ED) for primary care, are critically needed. Uncontrolled HTN contributes significantly to cardiovascular morbidity and mortality and is more frequently encountered among patients presenting to the ED as compared to the primary care setting. EDs serve as the point of entry into the health care system for high-risk patient populations, including minority and low-income patients. Previous studies have demonstrated that the prevalence of uncontrolled/undiagnosed HTN in patients presenting to the ED is alarmingly high. Thus ED engagement and early risk assessment/stratification is a feasible innovation to help close health disparity gaps in HTN. A Hypertension Emergency Department Intervention Aimed at Decreasing Disparities (AHEAD2) trial, funded by the National Heart, Lung, and Blood Institute (NHLBI) is a three-arm single site randomized clinical pilot trial of adults presenting to the ED with Stage 2 hypertension (blood pressure [BP]>160/100) comparing (1) an ED-initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) focused on HTN, (2) the same ED-initiated SBIRT coupled with a Post-Acute Care Hypertension Transition Consultation by ED Clinical Pharmacists, and (3) usual care. The primary outcome is mean BP differences between study arms. Secondary outcomes are proportion of participants with BP control (BP<140/90mmHg), and improvements in HTN knowledge and medication adherence scores between study arms. The objective of this report is to describe the development of the AHEAD2 trial, including the methods, research infrastructure, and other features of the randomized clinical trial design.

Correlation between Subclinical Heart Disease and Cardiovascular Risk Profiles in an Urban Emergency Department Population with Elevated Blood Pressures: A Pilot Study.

BACKGROUND: Uncontrolled hypertension is a primary risk factor for development of cardiovascular complications. OBJECTIVE: Determine the point prevalence of left ventricular hypertrophy (LVH) and diastolic dysfunction in an urban emergency department (ED) population with elevated blood pressures (BP) and examine correlations between subclinical disease and patient cardiovascular risk profiles. METHODS: A convenience sample of patients with EBP (>140/90 on two measurements) had limited bedside echocardiograms (LBE). Subclinical hypertensive heart disease was classified as the presence of: LVH, abnormal ejection fraction (EF), or diastolic dysfunction. RESULTS: Thirty-nine patients with EBP were enrolled. The mean age was 46 years (SD = 10.9), 59% were women, 21% were smokers, and 92% had a history of hypertension. The average body mass index was 30.7 (SD = 8.7). Patients were 67% African American, 23% Latino, 5% Caucasian, 3% Asian, and 3% Native American. Subclinical disease was found in 39%: 31% had LVH, 15% had diastolic dysfunction, and 8% had abnormal EF. On bivariate analysis, elevated BP (p = 0.039) and blood urea nitrogen (p = 0.016) were correlated with subclinical heart disease. After adjusting for other covariates, receiving oral/intravenous antihypertensive medications in the ED (p = 0.005) was associated with subclinical heart disease. CONCLUSIONS: We found a point prevalence of subclinical heart disease of 39% in this urban ED population, using LBE. Real-time identification of subclinical heart disease at early stages in the ED in conjunction with abnormal renal function can help emergency physicians identify those patients in need of more aggressive therapy and urgent follow-up.

Antihypertensive medications and diastolic dysfunction progression in an African American population.

BACKGROUND: There have been no studies examining the association between antihypertensive medications and progression of diastolic dysfunction. The purpose of this study is to determine whether there is an association between class of antihypertensive medication and diastolic dysfunction progression in an African American population. METHODS: A retrospective cohort study of African American patients with at least two echocardiograms demonstrating diastolic dysfunction drawn from an echocardiogram database at an academic medical center. The main outcome measures were change in diastolic function grade as a function of time and association with hypertension medication classification. RESULTS: There were 96 African American patients in the database with 2 or more echocardiograms demonstrating diastolic dysfunction; representing 302 echocardiograms. The mean time between echocardiograms was 2.6 years. The mean age was 64.2 (±10.1) years, 78 % were women, and mean BMI 31.2 (±7.4) kg/m(2). The majority of subjects had Grade I diastolic dysfunction at their initial examination [N = 87 (90.6 %)]. Approximately 22.9 % (n = 22) of the study cohort demonstrated diastolic dysfunction progression. In multivariate analysis use of calcium channel blockers (CCB) was protective against diastolic dysfunction progression (OR for CCB users vs. non-users 0.28, 95 % confidence interval, 0.09-0.90, p < 0.05). CONCLUSIONS: These findings suggest that use of calcium channel blockers may have a protective effect against progression of diastolic dysfunction among African American patients. Further studies are required to confirm these findings and identify specific factors that can mediate disease progression among African American individuals with hypertension, who face substantial risk of complications such as diastolic heart failure.

Progression of left ventricular diastolic dysfunction in ethnic minorities.

BACKGROUND: Approximately 50 % of heart failure cases are due to diastolic failure. Generally, it is thought that asymptomatic diastolic dysfunction precedes the development of diastolic heart failure, representing an ideal time for intervention. Previous studies have examined progression rates in non-minority populations only. OBJECTIVE: To determine the rate of diastolic dysfunction progression and the associated risk factors in a predominately ethnic minority population. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of participants drawn from the echocardiogram database and Electronic Health Record (EHR) for an academic medical center. Individuals with 2 or more echocardiograms showing diastolic dysfunction during a six year study period (2006­2012) were selected. MAIN OUTCOME MEASURES: Change in diastolic function grade over time and risk factors associated with this change. RESULTS: During the six-year retrospective study period, 154 patients with 2 or more echocardiograms demonstrating diastolic dysfunction were reviewed; these represented 496 echocardiograms. The mean time between echocardiograms was 1.9 years. Mean age was 64.6 (±10.1) years,81 % were female, and average BMI was 30.5(±7.4). The majority of subjects had Grade I diastolic dysfunction at the initial examination (87.7 % (n = 135)); 9 % (n = 14) had Grade II, and 3 % (n = 5) had Grade III. Approximately 27.9 % (n = 43) of the study cohort demonstrated overall worsening grade of diastolic dysfunction over time. Diastolic dysfunction grade was unchanged in 62 %(n = 96), improved in 9.7 % (n = 14), and worsened then improved in 0.7 % (n = 1). CONCLUSIONS: Our study showed a slightly higher rate of diastolic dysfunction progression in this predominately ethnic minority population. This is consistent with a previous study in a non-minority population demonstrating the progressive nature of diastolic dysfunction over time.Understanding the role of cardiovascular disease risk factors in accelerating progression rates from asymptomatic diastolic dysfunction to symptomatic stages is paramount to optimize intervention strategies.

The Aging Waistline: Impact of the Geriatric Obesity Epidemic on an Urban Emergency Department: Original Communication.

PURPOSE: Reviews adult emergency department (ED) visits for patients age 65 and older during one calendar year; determine the prevalence of weight classifications; identifies trends between BMI and discharge/admitting diagnoses, vital signs, and severity index. METHODS: The electronic medical records system and data from the ED billing service was reviewed for an urban academic institution with an annual volume of 125,000 for patients age > 65. Using a random number table, a retrospective cohort of 328 elderly patients was selected for review, representing a convenience sample of 2.6% of elderly ED visits. Body Mass Index (BMI) was calculated, using the Center for Disease Control (CDC) formula with underweight (<18.5), normal (18.5 - 24.9), overweight (25 - 29.9), and obese (≥30). RESULTS: The majority of the cohort in this study was African-American and Hispanic (60% and 27% respectively), and there were a higher percentage of females than males (60% and 40% respectively). Approximately 29% of the patients were classified as normal weight, 35% classified as overweight, and 36% as obese. The older the patient, the more likely that patient belonged to a lower weight classification (p < 0.01). Those presenting with neurological, pulmonary or gastrointestinal complaints were more likely to be of a higher weight classification (p < 0.05). Patients who were hypertensive on arrival to the ED were more likely to be in a higher weight classification (p < 0.01). CONCLUSION: Those patients with a higher weight classification had a strong correlation with selected abnormal vital signs and disease presentations. EDs are important sources of care for the elderly. EDs can serve as a previously untapped resource for screening and early referral exercise programs aimed at improving physical function/functional status and quality of life in the elderly patient population.

On the frontline: pediatric obesity in the emergency department.

Obesity among children is rising at an alarming rate. This study examines pediatric emergency department visits for children aged 2 to 17 years to determine the prevalence of normal, overweight, and obesity as well as to characterize discharge diagnosis and level of service among the different groups. The electronic emergency department medical record and billing service data were used in the review process. Body mass index (BMI) and percentiles were calculated using the Centers for Disease Control formulas with overweight being defined as BMI between 85th and 94th sex- and age-specific percentiles and obesity as greater than 95th sex- and age-specific percentile. The study was reviewed and approved by the institutional review board. Of the 596 patients meeting inclusion criteria, there was a predominance of African American and Hispanic patients. Approximately 53% (313) of patients were classified as normal weight, while 46% (272) of patients were either overweight or obese. The percentages of overweight and obesity were similar across racial/ethnic classifications, with a slight predominance of obesity among minority groups (30% and 35%, respectively, in minority groups vs 28% and 25%, respectively, in nonminority groups). There were no statistically significant differences between discharge diagnosis and level of service among the different weight categories. Rates of overweight and obesity in this predominately minority pediatric population were significantly greater than the published national rates. The impact of the epidemic of childhood obesity mandates the need for innovative strategies of weight control and reduction. Emergency departments routinely treat high-risk pediatric populations and can therefore serve as a resource for screening and early referral that has been previously untapped in combating childhood obesity.

Preparing the front line for the increase in the aging population: geriatric curriculum development for an emergency medicine residency program.

BACKGROUND: Emergency Departments (EDs) are common entry points to the health care system for elders. Emergency Medicine residents need specialized education about geriatric patients to maximize health outcomes. OBJECTIVES: To determine whether geriatric education provided to residents in Emergency Medicine results in improved knowledge of and attitudes toward geriatric patients. METHOD: A pre- and post-intervention survey was conducted in a 3-year university-based residency program in Emergency Medicine. Participants were Emergency Medicine residents (PGY 1-3). The curriculum "Care of the Aging Patient in Emergency Medicine" was introduced. Topic selection was based upon geriatric curriculum recommendations and resident surveys. Before starting the curriculum and at its conclusion, residents completed Geriatric Clinical Decision-making Assessments and the Geriatric Attitude Scale Survey. Pre- and post-assessments were compared. Residents also completed written assessments for each educational activity in the curriculum. RESULTS: After participating in the program, residents demonstrated improved knowledge of the geriatric patient, and their attitudes toward caring for geriatric patients had shifted from negative to neutral or positive. One statistically relevant change centered on the item, "Taking a medical history from an elderly patient is an ordeal" (p = 0.033) Pre-intervention, 8.3% (n = 3) of residents strongly agreed with the statement. After the intervention, strong disagreement with the statement increased from 2.8% (n = 1) to 11% (n = 4) on the educational surveys. In addition, an increase in the percentage of neutral responses was observed. CONCLUSIONS: Using familiar educational formats with heavy emphasis on "hands-on" activities to present the geriatric care curriculum had a positive impact on resident knowledge and confidence in dealing with geriatric patients.