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ACADEMIC EMERGENCY MEDICINE 2012; 19:139–146 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to identify high-risk census tracts, defined as those areas that have both a high incidence of out-of-hospital cardiac arrest (OHCA) and a low prevalence of bystander cardiopulmonary resuscitation (CPR), by using three spatial statistical methods. Methods: This was a secondary analysis of two prospectively collected registries in the city of Columbus, Ohio. Consecutive adult (≥18 years) OHCA patients, restricted to those of cardiac etiology and treated by emergency medical services (EMS) from April 1, 2004, to April 30, 2009, were studied. Three different spatial analysis methods (Global Empirical Bayes, Local Moran’s I, and SaTScan’s spatial scan statistic) were used to identify high-risk census tracts. Results: A total of 4,553 arrests in 200 census tracts occurred during the study period, with 1,632 arrests included in the final sample after exclusions for no resuscitation attempt, noncardiac etiology, etc. The overall incidence for OHCA was 0.70 per 1,000 people for the 6-year study period (SD = ±0.52). Bystander CPR occurred in 20.2% (n = 329), with 10.0% (n = 167) surviving to hospital discharge. Five high-risk census tracts were identified by all three analytic methods. Conclusions: The five high-risk census tracts identified may be possible sites for high-yield targeted community-based interventions to improve CPR training and cardiovascular disease education efforts and ultimately improve survival from OHCA.

Objectives: Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children’s hospital. Methods: This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child’s home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children’s hospital. The outcome variable was each child’s ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations. Results: On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP. Conclusions: Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.

Objectives: To assess and compare overall satisfaction in pediatric emergency department (ED) patients and their accompanying parents. To identify aspects of health care delivery that influence satisfaction in these groups. Methods: Pediatric patients (ages 5-17 years) and their parents (or guardians) seen at a university hospital pediatric ED were eligible. A convenience sample of English-speaking subject pairs (n = 101 pairs) was enrolled. Questionnaires were administered to both children and their parents at the completion of their ED care. The survey instruments used a modified Wong-Baker FACES Pain Rating Scale and a six-point interval scale. Factors measured included overall satisfaction, perceptions of pain and fear, and other characteristics of the ED visit. Data were analyzed using paired Wilcoxon signed-rank tests, Spearman rank correlation coefficients, and Fischer's exact chi-square tests (α= 0.05) where appropriate. Results: Parent satisfaction was associated with the quality of provider—patient interactions (R = 0.54, p = 0.0001), the adequacy of information provided (R = 0.47, p = 0.0001), and shorter waiting room times (R = -0.24, p = 0.01). Child satisfaction was associated with the quality of provider—patient interactions (R = 0.24, p 0.04), adequacy of information provided (R = 0.51, p = 0.003), and resolution of pain (R = 0.25, p = 0.03). Parent estimates were similar to children's initial pain scores; however, children reported greater resolution of pain than appreciated by their parents (p = 0.006). Conclusions: Satisfaction can be validly and reliably measured in pediatric patients using a visual scale instrument. Factors that influence patient satisfaction were similar among both children and their parents. The influence of pain resolution on pediatric ED satisfaction is a novel finding, which demonstrates the importance of appropriate pain and anxiety assessment and treatment in children.

Mushroom poisoning leading to acute renal failure is extremely rare in North America. Cortinarius species and Amanita smithiana both can cause acute renal failure and inhabit the Pacific northwest. This article describes 4 patients who presented in acute renal failure and who ingested mushrooms described as resembling A. smithiana. Two patients (a 74-year-old Korean couple) described eating mushrooms with an approximately 6 × 0.5-inch stipe with a white cap, 1.25-1.5 inches in diameter. The other 2 patients (a 55-year-old male and a 30-year-old female) also described a white-capped mushroom. All believed they were eating the matsutake (Tricho-loma magnivalere) mushroom, which can be mistaken for A. smithiana. Onset of gastrointestinal symptoms ranged from 20 minutes to 12 hours, and presentation in acute renal failure ranged from 4 to 6 days postingestion (initial BUN and creatinine were 72–91 mg/dL and 12–13.9 mg/dL, respectively). One patient had underlying mild renal insufficiency and one had hypertension that was under control, while the others had no risk factors for renal disease. None had any other explanation for the episode of acute renal failure. All underwent acute hemodialysis for at least several weeks, eventually returning to baseline renal function.