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AbstractBackgroundSoluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker associated with anatomical CAD burden and cardiovascular outcomes including myocardial infarction (MI) and death. We aimed to validate previous findings of the prognostic value of suPAR and to evaluate its diagnostic potential for functional relevant CAD (fCAD).MethodsConsecutive patients with suspected fCAD were enrolled. Adjudication of fCAD was performed blinded to suPAR concentrations by myocardial perfusion single-photon emission tomography (MPI-SPECT) and coronary angiography. Prognostic outcome measures included all-cause death, cardiovascular death, and incident MI during 2-year follow-up.ResultsAmong consecutive 968 patients, suPAR concentrations were higher in patients with fCAD compared to those without (3.45 vs.3.20 ng/mL, p = 0.007), but did not provide acceptable diagnostic accuracy (area under the curve [AUC]: 0.56, 95%CI 0.52–0.60). SuPAR correlated with high-sensitivity cardiac-troponin T (Spearman’s rho (ρ) 0.393, p < 0.001), NT-proBNP (ρ = 0.327, p < 0.001), age (ρ = 0.364, p < 0.001) and very weakly with coronary atherosclerosis (ρ = 0.123, p < 0.001). Prognostic discrimination of suPAR was moderate for cardiovascular death (AUC = 0.72, 95%CI 0.62–0.81) and all-cause death (AUC = 0.72, 95%CI 0.65–0.79) at 2-years. SuPAR remained a significant predictor for all-cause death in multivariable Cox regression (HR = 1.96, p = 0.001).ConclusionsSuPAR was an independent predictor of all-cause death, without diagnostic utility for fCAD.Clinical trial registrationNCT01838148

The Environmental Protection Agency (EPA) is charged with safeguarding the well-being of environmental justice (EJ) communities. Sadly, EJ communities are often burdened with gathering their own evidence of harm to prompt regulators to action. This article provides a case study of how one grassroots organization, Citizens for Environmental Justice, uncovered evidence of public health problems that are linked to living near heavy industry in Corpus Christi, Texas. It demonstrates that even when dedicated citizen activism produces strong evidence of harm, regulators are often slow or unwilling to act. We conclude by arguing that the use of risk assessment to establish harm can provide a shield to delay regulatory action and protect industry at the expense of EJ communities. [ABSTRACT FROM AUTHOR]

Consideration of children's health-related quality of life (HRQOL) after injury is a critical aspect of outcome in assessing the effectiveness of trauma care. Numerous instruments are available today for measuring the HRQOL of injured children. HRQOL instruments reflect the subjective perspective of the impact an injury or disease has on a child's physical, emotional, and social well being. Most studies to date have examined children's HRQOL during the first year postinjury, relatively little is known about children's long-term HRQOL after trauma. Most trauma outcome studies have included children with heterogeneous injuries so the impact of specific injuries on HRQOL outcomes has not been well established. The majority of outcome studies have focused on injured children who have been hospitalized, however the research should be extended to the emergency department because a large proportion of injured children are treated and released from there. In addition to documenting recovery, investigators should use HRQOL instruments to evaluate the quality of care we offer injured children and their families. Rigorously conducted HRQOL assessment will provide valuable information that we can use to successfully optimize children's recovery after trauma.

Objectives:To examine the influence of insurance, race, and gender on the likelihood of hospitalization among trauma patients. Methods:Statewide hospital discharge and emergency department (ED) visit data collected between 1996 and 2000 were merged to examine factors that influence hospitalization among patients who sustained an injury. Multivariate logistic regression was used to model the likelihood of hospitalization as a function of patient, injury, and hospital characteristics. Results:Of 1,512,611 patients who presented to an ED in South Carolina for treatment of a traumatic injury during the five‐year study period, 8% were hospitalized and 92% were treated and released. One fourth (26%) of the study population was uninsured. Insurance, race, and gender were significant predictors of hospitalization despite controlling for injury severity, comorbidities, age, trauma center level, place of residence, and year of injury. Regardless of injury severity, uninsured patients were significantly less likely to be hospitalized compared with privately insured patients (odds ratio [OR] 0.63, 99% CI = 0.62 to 0.65). Among those mildly to moderately injured, patients covered by Medicare or other government insurance policies were significantly more likely to be admitted compared with those with private coverage (OR 1.46, 99% CI = 1.41 to 1.52; OR 1.56, 99% CI = 1.36 to 1.78). Finally, among those mildly injured, African American females were significantly less likely to be admitted compared with white females (OR 0.63, 99% CI = 0.61 to 0.65). Conclusions:These results suggest that the disposition of trauma patients from the ED may be influenced by insurance and demographic characteristics in addition to the patient's clinical condition.

Objectives:To describe the epidemiology of traumatic brain injury (TBI) among children in Maryland and to examine factors that influence hospital admission. Methods:Statewide mortality, hospital discharge, and ambulatory care data were used to identify all TBI‐related emergency department (ED) visits, hospitalizations, and deaths that occurred in 1998 to children aged 0‐19 years according to the Centers for Disease Control and Prevention's standard case definition and protocol. Inpatient admission was modeled as a function of patient, injury, and hospital characteristics. Results:The overall incidence of pediatric TBI (i.e., ED visits, hospitalizations, and deaths) in 1998 was 670/100,000. After controlling for injury severity and other factors, uninsured children were 40% less likely to be hospitalized (95% CI = 0.43 to 0.82) and children with Medicaid were 90% more likely to be hospitalized (95% CI = 1.42 to 2.54) than were those with private insurance. The presence of a major associated injury significantly influenced the likelihood of hospitalization, especially among children with a minor (OR = 8.8) to moderate (OR = 11.6) TBI. Children who presented to a trauma center hospital were significantly more likely to be hospitalized than children treated at a non‐trauma center hospital, although this varied depending on income (OR = 1.8 for high versus low) and hospital volume (OR = 2.6 for a small hospital and OR = 29.0 for a large hospital). Conclusions:After adjusting for TBI severity and the presence of associated injuries, significant differences in hospitalization rates may exist among different patient subgroups and hospitals for children who sustain TBIs.

Objective:To examine the impact primary care referral has on subsequent emergency department (ED) utilization. Methods:Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital‐based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. Results:Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self‐pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre‐ or post‐ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). Conclusions:For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.

Inpatient treatment of alcoholism is an option indicated by certain clinical criteria. The American Society of Addiction Medicine suggests four levels of care, and six assessment dimensions determine which level of care is indicated. An addiction medicine physician can consult with the primary care physician to recommend appropriate placement in difficult cases.