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Introduction: Prior studies have examined the cross-sectional relationship between adolescent sleep and substance use; however, fewer have explored the long-term connections between childhood sleep and adolescent substance use., Methods: This study investigated both cross-sectional associations during adolescence and prospective associations between childhood weeknight sleep and later alcohol and marijuana use in the Future of Families and Child Wellbeing Study, a diverse national birth cohort of urban children from 20 cities with populations greater than 200,000. Parents reported their child's bedtime at ages 3, 5, and 9 and their child's sleep duration at ages 5 and 9., Results: At age 15, adolescents self-reported their bedtime, sleep duration, and alcohol and marijuana use (n = 1514). Logistic regression analyses for each substance use outcome at age 15 were adjusted for sex, age at time of assessment, race/ethnicity, income-relative-to-poverty threshold, family structure, and caregiver education level. At age 15, later bedtime (AOR=1.39; 95 % CI=1.22, 1.57) and shorter sleep duration (AOR=1.28; 95 % CI=1.14, 1.43) were associated with greater odds of consuming a full drink of alcohol more than once, and later bedtime was associated with greater odds of trying marijuana (AOR=1.35; 95 % CI=1.20, 1.51). Unexpectedly, later bedtimes at age 3 were associated with lower odds of drinking alcohol by age 15 (AOR=0.74; 95 % CI=0.59, 0.92). In contrast, later bedtimes at age 9 were associated with greater odds of drinking alcohol (AOR=1.45; 95 % CI=1.11, 1.90). Additionally, later bedtime at age 5 (AOR=1.26; 95 % CI=1.01, 1.58) and shorter sleep duration at age 9 (AOR=1.19; 95 % CI=1.04, 1.36) were associated with greater odds of trying marijuana., Conclusion: Taken together, these associations support the importance of protecting childhood sleep habits to reduce the likelihood of substance use starting as early as mid-adolescence., Implications and Contribution: In this longitudinal cohort study, adolescents were more likely to have consumed alcohol or tried marijuana by age 15 if they had later bedtimes and shorter sleep duration during childhood and adolescence. Protecting sleep health throughout childhood may reduce the likelihood of substance use during early adolescence., Competing Interests: Declaration of Competing Interest David A. Reichenberger, Lauren Hale, and Anne-Marie Chang received a small honorarium from the National Sleep Foundation for participation in an expert consensus panel. Orfeu M. Buxton received subcontract grants to Penn State from Proactive Life LLC (formerly Mobile Sleep Technologies) doing business as SleepSpace (NSF/STTR #1622766, NIH/NIA SBIR R43-AG056250, R44-AG056250), received honoraria/travel support for lectures from Boston University, Boston College, Tufts School of Dental Medicine, New York University, Eric H. Angle Society of Orthodontists, University of Miami, University of South Florida, University of Utah, University of Arizona, Spencer Study Club, and Allstate, and receives an honorarium for his role as the Editor-in-Chief of Sleep Health. Lauren Hale previously received an honorarium from the National Sleep Foundation for her role as Editor-in-Chief of the journal Sleep Health, in addition to honoraria for lectures/consultation from University of Miami, Baylor College of Medicine, Auburn University, Columbia University, and Idorsia. Anne-Marie Chang received a grant to the Pennsylvania State University from Kunasan, and honoraria and travel support from the University of Miami. The remaining authors have no financial relationships relevant to this article to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: Long-term sequelae after symptomatic SARS-CoV-2 infection may impact well-being, yet existing data primarily focus on discrete symptoms and/or health care use., Objective: To compare patient-reported outcomes of physical, mental, and social well-being among adults with symptomatic illness who received a positive vs negative test result for SARS-CoV-2 infection., Design, Setting, and Participants: This cohort study was a planned interim analysis of an ongoing multicenter prospective longitudinal registry study (the Innovative Support for Patients With SARS-CoV-2 Infections Registry [INSPIRE]). Participants were enrolled from December 11, 2020, to September 10, 2021, and comprised adults (aged ≥18 years) with acute symptoms suggestive of SARS-CoV-2 infection at the time of receipt of a SARS-CoV-2 test approved by the US Food and Drug Administration. The analysis included the first 1000 participants who completed baseline and 3-month follow-up surveys consisting of questions from the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29; 7 subscales, including physical function, anxiety, depression, fatigue, social participation, sleep disturbance, and pain interference) and the PROMIS Short Form-Cognitive Function 8a scale, for which population-normed T scores were reported., Exposures: SARS-CoV-2 status (positive or negative test result) at enrollment., Main Outcomes and Measures: Mean PROMIS scores for participants with positive COVID-19 tests vs negative COVID-19 tests were compared descriptively and using multivariable regression analysis., Results: Among 1000 participants, 722 (72.2%) received a positive COVID-19 result and 278 (27.8%) received a negative result; 406 of 998 participants (40.7%) were aged 18 to 34 years, 644 of 972 (66.3%) were female, 833 of 984 (84.7%) were non-Hispanic, and 685 of 974 (70.3%) were White. A total of 282 of 712 participants (39.6%) in the COVID-19-positive group and 147 of 275 participants (53.5%) in the COVID-19-negative group reported persistently poor physical, mental, or social well-being at 3-month follow-up. After adjustment, improvements in well-being were statistically and clinically greater for participants in the COVID-19-positive group vs the COVID-19-negative group only for social participation (β = 3.32; 95% CI, 1.84-4.80; P < .001); changes in other well-being domains were not clinically different between groups. Improvements in well-being in the COVID-19-positive group were concentrated among participants aged 18 to 34 years (eg, social participation: β = 3.90; 95% CI, 1.75-6.05; P < .001) and those who presented for COVID-19 testing in an ambulatory setting (eg, social participation: β = 4.16; 95% CI, 2.12-6.20; P < .001)., Conclusions and Relevance: In this study, participants in both the COVID-19-positive and COVID-19-negative groups reported persistently poor physical, mental, or social well-being at 3-month follow-up. Although some individuals had clinically meaningful improvements over time, many reported moderate to severe impairments in well-being 3 months later. These results highlight the importance of including a control group of participants with negative COVID-19 results for comparison when examining the sequelae of COVID-19.

Objective: Major negative life events, such as trauma exposure, can play a key role in igniting or exacerbating psychopathology. However, few disorders are diagnosed with respect to precipitating events, and the role of these events in the unfolding of new psychopathology is not well understood. The authors conducted a multisite transdiagnostic longitudinal study of trauma exposure and related mental health outcomes to identify neurobiological predictors of risk, resilience, and different symptom presentations., Methods: A total of 146 participants (discovery cohort: N=69; internal replication cohort: N=77) were recruited from emergency departments within 72 hours of a trauma and followed for the next 6 months with a survey, MRI, and physiological assessments., Results: Task-based functional MRI 2 weeks after a motor vehicle collision identified four clusters of individuals based on profiles of neural activity reflecting threat reactivity, reward reactivity, and inhibitory engagement. Three clusters were replicated in an independent sample with a variety of trauma types. The clusters showed different longitudinal patterns of posttrauma symptoms., Conclusions: These findings provide a novel characterization of heterogeneous stress responses shortly after trauma exposure, identifying potential neuroimaging-based biotypes of trauma resilience and psychopathology.

Background: Secondhand smoke exposure has been cross-sectionally associated with worse sleep health outcomes in children and shorter sleep duration in adolescents., Objectives: We assessed longitudinal and cross-sectional associations between secondhand smoke (SHS) exposure and shorter sleep duration in children from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort. We additionally examined whether associations would persist after controlling for potential confounders., Participants: Mothers (n = 4898) were recruited using a stratified random sample of large United States cities and oversampling for nonmarital births., Measurements: Mothers were asked about whether they smoked during pregnancy, whether their child spent time with someone who is smoking, and their child's weekday sleep duration. Sociodemographic factors, asthma diagnosis, and bedtime routines were assessed as potential confounders. Data collected at ages 3, 5, and 9 years were analyzed using multivariable regression models (N = 1912; 51.6% boys)., Results: SHS exposure at age 3 predicted 15.0 fewer minutes at age 5 (P = .001) and 12.3 fewer minutes at age 9 (P = .003). SHS exposure at age 9 was cross-sectionally associated with 14.4 fewer minutes of sleep duration at age 9 (P = .002). Findings persisted after controlling for potential confounders., Conclusion: These results provide associational support for the hypothesis that SHS exposure may have long-term consequences for childhood sleep duration. Future studies should investigate the relationship between SHS exposure and shorter sleep duration using objective measurements of serum cotinine and sleep actigraphy and by exploring potential mechanisms., (Copyright © 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Study Objective: Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care., Methods: This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt., Results: Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED., Conclusion: ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations., (Copyright © 2021 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: During the early months of the COVID-19 pandemic, mortality associated with the disease declined in the United States. The standard of care for pharmacological interventions evolved during this period as new and repurposed treatments were used alone and in combination. Though these medications have been studied individually, data are limited regarding the relative impact of different medication combinations. The objectives of this study were to evaluate the association of COVID-19-related mortality and observed medication combinations and to determine whether changes in medication-related practice patterns and measured patient characteristics, alone, explain the decline in mortality seen early in the COVID-19 pandemic., Methods: A retrospective cohort study was conducted at a multi-hospital healthcare system exploring the association of mortality and combinations of remdesivir, corticosteroids, anticoagulants, tocilizumab, and hydroxychloroquine. Multivariable logistic regression was used to identify predictors of mortality for both the overall population and the population stratified by intensive care and non-intensive care unit admissions. A separate model was created to control for the change in unmeasured variables over time., Results: For all patients, four treatment combinations were associated with lower mortality: Anticoagulation Only (OR 0.24, p < 0.0001), Anticoagulation and Remdesivir (OR 0.25, p = 0.0031), Anticoagulation and Corticosteroids (OR 0.53, p = 0.0263), and Anticoagulation, Corticosteroids and Remdesivir (OR 0.42, p = 0.026). For non-intensive care unit patients, the same combinations were significantly associated with lower mortality. For patients admitted to the intensive care unit, Anticoagulation Only was the sole treatment category associated with decreased mortality. When adjusted for demographics, clinical characteristics, and all treatment combinations there was an absolute decrease in the mortality rate by 2.5% between early and late periods of the study. However, when including an additional control for changes in unmeasured variables overtime, the absolute mortality rate decreased by 5.4%., Conclusions: This study found that anticoagulation was the most significant treatment for the reduction of COVID-related mortality. Anticoagulation Only was the sole treatment category associated with a significant decrease in mortality for both intensive care and non-intensive care patients. Treatment combinations that additionally included corticosteroids and/or remdesivir were also associated with decreased mortality, though only in the non-intensive care stratum. Further, we found that factors other than measured changes in demographics, clinical characteristics or pharmacological interventions accounted for an additional decrease in the COVID-19-related mortality rate over time., Competing Interests: The authors have declared that no competing interests exist.

There is a lack of research on associations of social jetlag with eating behaviours and obesity among adolescents. We examined the associations of social jetlag with eating behaviours and BMI in adolescents before and after adjustment for potential confounders. Self-report data were collected from 3060 adolescents (48·1 % female, mean age 15·59 (sd 0·77) years) from the Fragile Families and Child Wellbeing Study. In regression models, social jetlag predicted odds of consumption of breakfast, fruits/vegetables, fast food and sweetened drinks and BMI percentile. Primary models adjusted for school night sleep duration, sex, age, household income and youth living arrangements; secondary models further adjusted for race/ethnicity. In fully adjusted models, greater social jetlag was associated with lower odds of consumption of breakfast (OR = 0·92, P = 0·003) and fruits/vegetables (OR = 0·92, P = 0·009) and higher odds of consumption of fast food (OR = 1·18, P < 0·001) and sweetened drinks (OR = 1·18, P < 0·001). Social jetlag was positively associated with BMI percentile after additional adjustment for eating behaviours (b = 0·84, P = 0·037), but this relationship was attenuated after adjustment for race/ethnicity (b = 0·72, P = 0·072). Ethnoracial differences in social jetlag may attenuate the association of social jetlag with BMI and should be considered in future studies of circadian misalignment, eating behaviours and obesity markers.

Job discrimination, a social stressor, may lead to sleep health disparities among workers; yet, limited research has examined this relationship and specific sources of job discrimination. We used a US sample of working women (n = 26,085), participants in the Sister Study (2008-2016), to examine the associations of perceived job discrimination due to sex, race, age, health conditions, and/or sexual orientation with sleep health. Cross-sectionally, linear or logistic regression models revealed that each source of job discrimination was independently associated with different sleep problems after controlling for other sources of job discrimination. Longitudinally, among participants without short sleep (<7 hours/night) at time 1 (2012-2014), age-specific job discrimination was associated with 21% increased odds of new-onset short sleep (odds ratio = 1.21, 95% confidence interval: 1.03, 1.43) at time 2 (2014-2016). Among those without insomnia symptoms at time 1, race-specific job discrimination was associated with 37% increased odds of new-onset insomnia symptoms (odds ratio = 1.37, 95% confidence interval: 1.07, 1.75) at time 2. Sex- and health-specific job discrimination also predicted new-onset sleepiness. There were dose-response relationships such that a greater number of sources of job discrimination (≥3) was associated with greater odds of prevalent and incident sleep problems. Perceived job discrimination may contribute to working women's poor sleep health over time, raising concerns about sleep health disparities emanating from the workplace., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: Ethnoracial disparities in sleep health across the lifecourse, may underlie other disparities in health and well-being among adults in the United States (U.S.). We evaluated if socioenvironmental stressors, which likely differ by the race/ethnicity of college students, may contribute to sleep disparities in this demographic group., Design/measurements: National Health Interview Survey data pooled from 2004 to 2017 were used to test the hypothesis that ethnoracial disparities in sleep exist among college students residing in dormitories in the U.S., Setting: Nationally representative survey data., Participants: A total of 2,119 college students residing in dormitories (71% White, 16% Black/African-American, 7% Hispanic/Latino, and 6% Asian) participated in the study., Results: The prevalence of short sleep duration was higher among Black/African-Americans than among White students, but not among Hispanics/Latinos and Asians, after adjusting for age, gender, and region of residence. In fully adjusted models, Black/African-Americans, although no longer statistically significant after adjustments, were more likely to report short sleep duration compared with White students (adjusted prevalence ratio; [aPR] = 1.30, 95% confidence interval [CI]: 0.98-1.71). The prevalence of separate insomnia symptoms did not differ by ethnoracial group in adjusted models. Only Asian students had a higher prevalence (aPR = 1.40, 95% CI: 1.12-1.75) of nonrestorative sleep than White students., Conclusion: Black/African-American but not Hispanic/Latino or Asian college students were more likely to report short sleep duration than Whites. Insomnia symptoms did not differ between groups, while Asians experienced more nonrestorative sleep. Future studies should investigate the socioenvironmental causes of disparities using longitudinal designs, larger sample sizes, better socioeconomic status (SES) indicators, and objective sleep measures., (Published by Elsevier Inc.)

Purpose of Review: The goals of this paper were to examine recent literature on the social determinants of health as they relate to hypertension and cardiovascular disease, and discuss relevance to the practice of emergency medicine., Recent Findings: Social determinants of health, defined by the World Health Organization as "the conditions in which people are born, grow, live, work, and age" ( https://www.who.int/social&#95;determinants/thecommission/en/ ) play a complex role in the development of hypertension and cardiovascular disease and the persistence of racial disparities in related health outcomes. Deciphering the independent association between minority status and social determinants in the United States is challenging. As a result, much of the recent interventional work has targeted populations by race or ethnicity in order to address these disparities. There is opportunity to expand the work on social determinants of health and hypertension. This includes exploring innovative approaches to identifying at-need individuals and breaking down traditional siloes to develop multidimensional interventions. New funding and payment mechanisms will allow for providers and health systems to identify and target modifiable social determinants of health at the level of the individual patient to improve outcomes.

Background: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope., Methods: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED., Results: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis., Conclusions: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Objectives: Short and long sleep durations are linked to reduced kidney function, but little research has examined how sleep is associated with hydration status. Our aim was to assess the relationship between sleep duration and urinary hydration biomarkers among adults in a cross-cultural context., Methods: Three samples of adults aged ≥20 years were analyzed: 2007-2008 National Health and Nutrition Examination Survey (NHANES; n = 4680), 2009-2012 NHANES (n = 9559), and 2012 cross-sectional wave of the Chinese Kailuan Study (n = 11903), excluding pregnant women and adults with failing kidneys. We estimated multiple linear regression models between self-reported usual night-time sleep duration (<6, 6, 7, 8 (reference), and ≥9 hr/day) and urine specific gravity (Usg) and urine osmolality (Uosm) as continuous variables and logistic regression models dichotomized as inadequate hydration (>1.020 g/mL; >831 mOsm/kg). In primary analyses, we estimated models excluding diabetes and diuretic medications for healthier subpopulations (NHANES, n = 11353; Kailuan, n = 8766)., Results: In the healthier NHANES subset, 6 hr was associated with significantly higher Usg and odds of inadequate hydration (adjusted OR: 1.59, 95% CI: 1.25, 2.03) compared with 8 hr. Regression results were mixed using Uosm, but in the same direction as Usg. Among Chinese adults, short sleep duration (<6 and 6 hr) was associated with Usg and higher likelihood of inadequate hydration (6 hr adjusted OR: 1.42, 95% CI: 1.26, 1.60). No consistent association was found with sleeping ≥9 hr., Conclusions: Short sleep duration was associated with higher odds of inadequate hydration in US and Chinese adults relative to sleeping 8 hr.

Importance: We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur., Objective: To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred., Design, Setting, and Participants: This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics., Main Outcomes and Measures: Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge., Results: We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (<25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90; >75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P < .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival., Conclusions and Relevance: Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.

Study Objective: The Centers for Medicare & Medicaid Services (CMS) recently published emergency department (ED) timeliness measures. These data show substantial variation in hospital performance and suggest the need for process improvement initiatives. However, the CMS measures are not risk adjusted and may provide misleading information about hospital performance and variation. We hypothesize that substantial hospital-level variation will persist after risk adjustment., Methods: This cross-sectional study included hospitals that participated in the Emergency Department Benchmarking Alliance and CMS ED measure reporting in 2012. Outcomes included the CMS measures corresponding to median annual boarding time, length of stay of admitted patients, length of stay of discharged patients, and waiting time of discharged patients. Covariates included hospital structural characteristics and case-mix information from the American Hospital Association Survey, CMS cost reports, and the Emergency Department Benchmarking Alliance. We used a γ regression with a log link to model the skewed outcomes. We used indirect standardization to create risk-adjusted measures. We defined "substantial" variation as coefficient of variation greater than 0.15., Results: The study cohort included 723 hospitals. Risk-adjusted performance on the CMS measures varied substantially across hospitals, with coefficient of variation greater than 0.15 for all measures. Ratios between the 10th and 90th percentiles of performance ranged from 1.5-fold for length of stay of discharged patients to 3-fold for waiting time of discharged patients., Conclusion: Policy-relevant variations in publicly reported CMS ED timeliness measures persist after risk adjustment for nonmodifiable hospital and case-mix characteristics. Future "positive deviance" studies should identify modifiable process measures associated with high performance., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Prior studies suggest that a decreased cardiac catheterization rate for women with acute coronary syndrome (ACS) is partially attributed to gender differences in patient preferences for testing. The hypothesis was that these preferences are influenced by physician recommendations for cardiovascular testing., Methods: This was a cohort study of patients who presented to an emergency department (ED) with chest pain. At the time of ED disposition, patients were surveyed to assess whether or not the doctor discussed the possibility of coronary artery disease (CAD), the physician's recommendations for diagnostic testing, and the patient's preferences for further testing. The survey was repeated at the time of discharge from the hospital if the patient was admitted and again at 30 days for all patients. The main outcome was patient-reported physician recommendation for testing, and the secondary outcome was patient preference for cardiovascular testing., Results: There were 206 patients enrolled (118 women, 88 men). Women were less likely than men to receive cardiac catheterization as inpatients (9.8% vs. 20.0%, p = 0.04). In the ED, women were less likely to be recommended for stress testing (8.5% vs. 19.3%, p = 0.02) or cardiac catheterization (4.2% vs. 13.6%, p = 0.02) or to see a cardiologist (8.5% vs. 22.7%, p < 0.01). As inpatients, women were more likely to be told that no further testing was needed (70.5% vs. 50.0%, p = 0.03). While there was higher incidence of prior CAD and myocardial infarction among the men in the study, analysis after removal of these patients did not alter results. Physicians were less likely to counsel women about diagnostic testing options in the ED (10.1% vs. 22.7%, p = 0.03), as inpatients (11.5% vs. 40.0%, p < 0.01), and as outpatients (26.1% vs. 48.6%, p = 0.04). No patients in the study refused their doctors' recommendations. Women were less likely to prefer catheterization in the ED (5.1% vs. 15.9%, p = 0.01) and were more likely to prefer no further testing as inpatients (60.7% vs. 40.0%, p = 0.02)., Conclusions: Women who presented to the ED with symptoms concerning for ACS reported lower rates of physician recommendation for cardiovascular testing, as well as lower rates of counseling regarding cardiac etiologies of their chest pain. These findings suggest sex differences in preference for cardiovascular testing may be partially explained by the discussions between women and their doctors., (© 2013 by the Society for Academic Emergency Medicine.)

Study Objective: Women with potential acute coronary syndromes are less likely to receive cardiac catheterization or revascularization than men. We hypothesize that this may be due to different diagnostic test preferences of female and male patients., Methods: We conducted a cohort study at 4 emergency departments enrolling patients who presented with symptoms of potential acute coronary syndromes. After hearing the potential benefits and harms of each test, subjects completed a 21-item survey assessing their preference for noninvasive testing versus cardiac catheterization. Based on hypothetical test results, similar questions about medical versus interventional management were asked. Subjects were also queried about likelihood of following physician recommendation for each test or intervention. Actual 30-day testing and interventions were recorded. The main outcome was patient preference about each procedure and the likelihood of patient saying they would accept the physician recommendation., Results: One thousand eighty patients enrolled; 652 (60%) were admitted to the hospital. With regard to diagnostic test preference, both women and men preferred stress test to catheterization (women 58% versus men 52%; difference 6% [95% confidence interval {CI} -0.06% to 12%]), and the proportion of women and men who would accept the physician recommendation for stress tests was similar (85% for both); however, the stated acceptance rate for cardiac catheterization was lower for women (65% versus 75%; difference -10% [95% CI -15% to -4%]). Women were 6% less likely (67% versus 73%; 95% CI for difference 12% to 0.5%) to accept percutaneous coronary intervention over medical therapy and 7% less likely (61% versus 68%; 95% CI for difference -13% to 1%) to desire coronary artery bypass grafting over medical therapy. The survey results are consistent with the patients' clinical course. During the initial hospitalization, women were less likely to receive diagnostic testing of any type (38% versus 45%; difference -7%; 95% CI for the difference -13% to -1.5%) and cardiac catheterization (10% versus 17%; difference -7% [95% CI -11% to -2%]). Revascularization was infrequent in both groups (4% versus 6%; difference -2% [95% CI -5% to 0.6%])., Conclusion: Although women and men had similar preferences about cardiac diagnostic tests and treatment options, women were less likely than men to say they would accept the physician recommendation for any intervention. Patient preference may partially explain the disparity in cardiovascular testing between women and men., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objectives: Myocardial dysfunction is an important aspect of sepsis pathophysiology. B-type natriuretic peptide (BNP) is a neurohormone released from the ventricles in response to myocardial stretch and volume overload. The authors hypothesized that an elevated BNP in patients presenting to the emergency department (ED) with suspected sepsis are at increased risk for development of adverse events., Methods: This was a prospective, observational, multicenter cohort study in 10 EDs. Patients were eligible if they were older than 18 years, had two or more systemic inflammatory response syndrome (SIRS) criteria, and had suspected infection or a serum lactate level > 2.5 mmol/L. Patients were excluded if they were pregnant, had do-not-attempt-resuscitation status, sustained a cardiac arrest prior to hospital arrival, had known chronic renal insufficiency, or were on dialysis. BNP levels were obtained at arrival. The primary outcome was a composite of severe sepsis, septic shock within 72 hours, or in-hospital mortality., Results: There were 825 patients enrolled (mean ± standard deviation [SD] age = 53.5 ± 19.6 years; 51% were female and 37% were African American). The area under the curve (AUC) for BNP to predict the triple composite outcome was 0.69, and the optimal cut-point of BNP was 49 pg/mL. Patients with a BNP > 49 pg/mL had a greater mortality rate (11.6% vs. 2.1%; p = 0.0001), a greater risk of development of severe sepsis (67.7% vs. 36.8%; p = 0.0001) and septic shock (51.7% vs. 26.4%; p = 0.0001), and a higher rate of the triple composite outcome (69% vs. 37%; unadjusted odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.6 to 2.1; p < 0.001). The sensitivity was 63% (95% CI = 58% to 67%), specificity was 69% (95% CI = 65% to 73%), negative predictive value (NPV) was 63% (95% CI = 58% to 67%), and positive predictive value (PPV) was 69% (95% CI = 65% to 74%). In multivariate modeling, after adjusting for age, sex, heart rate, white blood cell count, and creatinine, an elevated BNP was associated with increased odds of having the composite outcome. The outcome was similar in the subset of patients who did not have severe sepsis or septic shock upon arrival., Conclusions: In patients who present to the ED with SIRS criteria and suspected infection, an elevated BNP is associated with a worse prognosis but has limited diagnostic utility., (© 2011 by the Society for Academic Emergency Medicine.)