Estimates of HIV testing at visits to United States emergency departments

OBJECTIVES

Emergency department-based HIV testing rates are historically low, but recent testing trends surrounding the COVID-19 pandemic and launch of the Ending the HIV Epidemic (EHE) initiative are unknown. The objective of the study is to estimate recent trends in the proportion of emergency department visits that included HIV testing.

METHODS

We performed a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a weighted nationally representative survey of US emergency departments, from 2014 to 2020. Given EHE's focus on several rural Southern jurisdictions as well as populations disproportionately affected by HIV, we stratified by characteristics including US region and visit-listed race and ethnicity.

RESULTS

The proportion of emergency department visits that included HIV testing increased from 2014 (0.6%) to 2018 (1.1%) but was lower in 2019 and 2020 (0.8%). Compared with other regions, the South had the lowest rates of testing in both 2019 (0.6%) and 2020 (0.5%); testing rates in the nonmetropolitan South remained 0.1% or less across all years. Testing rates for emergency department visits by persons who identified as Hispanic/Latino were highest in 2018 (2.2%) but were sharply lower in 2019 and 2020 (0.8%).

CONCLUSION

After a small but insufficient increase in emergency department-based HIV testing since 2014, rates decreased between 2018 and 2019 and were stable between 2019 and 2020. Overall, very few emergency department visits during our entire study period included an HIV test, and there were persistently low rates of HIV testing for populations prioritized in national efforts and during visits in rural jurisdictions in the South.

Comparison of US emergency departments by HIV priority jurisdiction designation: A case for geographically targeted screening in teaching hospitals

The Ending the HIV Epidemic (EHE) Initiative targets a subset of United States (US) priority jurisdictions hardest hit by HIV. It remains unclear which emergency departments (EDs) are the most appropriate targets for EHE-related efforts. To explore this, we used the 2001-2019 National Emergency Department Inventories (NEDI)-USA as a framework to characterize all US EDs, focusing on those in priority jurisdictions and those affiliated with a teaching hospital. We then incorporate multivariable regression to explore the association between ED characteristics and location in an HIV priority jurisdiction. Further, to provide context on the communities these EDs serve, demographic and socioeconomic information and sexually transmitted infection case rate data were included. This reflected 2019 US Census Bureau data on age, race, ethnicity, and proportion uninsured and living in poverty along with 2001-2019 Centers for Disease Control and Prevention case rate data on chlamydia, gonorrhea, and syphilis. We found that EDs in priority jurisdictions (compared to EDs not in priority jurisdictions) more often served populations emphasized in HIV-related efforts (i.e., Black or African American or Hispanic or Latino populations), communities with higher proportions uninsured and living in poverty, and counties with higher rates of chlamydia, gonorrhea, and syphilis. Further, of the groups studied, EDs with teaching hospital affiliations had the highest visit volumes and had steady visit volume growth. In regression, ED annual visit volume was associated with an increased odds of an ED being located in a priority jurisdiction. Our results suggest that geographically targeted screening for HIV in a subset of US priority jurisdiction EDs with a teaching hospital affiliation could be an efficient means to reach vulnerable populations and reduce the burden of undiagnosed HIV in the US.

Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties

BACKGROUND

Refocused national HIV testing initiatives include a geographic focus.

OBJECTIVE

Using a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example.

METHODS

Retrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties.

RESULTS

Of the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01).

CONCLUSIONS

EDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.

HIV Testing at Visits to US Emergency Departments, 2018

BACKGROUND

An early HIV diagnosis improves patient outcomes, reduces the burden of undiagnosed HIV, and limits transmission. There is a need for an updated assessment of HIV testing rates in the emergency department (ED).

SETTING

The National Hospital Ambulatory Medical Care Survey sampling ED visits were weighted to give an estimate of ED visits across all US states in 2018.

METHODS

We analyzed patients aged 13-64 years without known HIV and estimated ED visits with HIV testing and then stratified by race, ethnicity, and region. Descriptive statistics and mapping were used to illustrate and compare patient, visit, and hospital characteristics for visits with HIV testing.

RESULTS

Of 83.0 million weighted visits to EDs in 2018 by patients aged 13-64 years without a known HIV infection (based on 13,237 National Hospital Ambulatory Medical Care Survey sample visits), HIV testing was performed in 1.05% of visits. HIV testing was more frequent for patients aged 13-34 years compared with that for patients aged 35-64 years (1.32% vs. 0.82%, P = 0.056), Black patients compared with that for White and other patients (1.73% vs. 0.79% and 0.41%, P = 0.002), Hispanic or Latino patients compared with that for non-Hispanic or Latino patients (2.18% vs. 0.84%, P = 0.001), and patients insured by Medicaid compared with that for patients insured by private or other insurance (1.71% vs. 0.64% and 0.96%, P = 0.003). HIV testing rates were the highest in the Northeast (1.72%), followed by the South (1.05%).

CONCLUSIONS

HIV testing occurred in a minority of ED visits. There are differences in rates of HIV testing by race, ethnicity, and location. Although rates of testing have increased, rates of ED-based HIV testing remain low.

Periocular Facial Scald Burns in Children: Is Ophthalmology Consultation Necessary?

OBJECTIVES

Criteria that predict the need for ocular injury treatment in children who suffer periocular facial scald burns are not known. The purpose of this study was to evaluate the incidence and management of ocular injuries among children sustaining facial scald burns and to determine predictors of injuries requiring additional treatment.

METHODS

Children treated at a burn center with periocular facial scald burns were analyzed. Patient and injury profiles were compared between those evaluated and not evaluated by an ophthalmologist. Factors associated with an ocular injury requiring treatment were determined, and treatment differences before and after ophthalmology consultation were evaluated.

RESULTS

Seventy-three children with facial scald burns were identified, none with a full-thickness injury. Thirteen children had ocular findings on examination including corneal abrasion, conjunctivitis, scleral burn, and chemosis of the conjunctiva. Twenty-three patients received erythromycin ointment, only 8 of whom had a documented ocular injury. Children seen by an ophthalmologist (n = 24) more often had a positive finding on examination (37.5% vs 8.2%, P = 0.007) and received treatment (66.7% vs 14.3%, P < 0.001). Only 4 patients had modification in their treatment plan after consultation, 3 of whom were started on treatment despite not having a positive finding on examination.

CONCLUSIONS

Ocular injury after periocular facial scald burns is an infrequent finding. Among children with partial-thickness periocular facial scald burns, initial evaluation and treatment without ophthalmology consultation are appropriate. Ophthalmic antibiotic ointment is an appropriate initial treatment in most symptomatic patients, with ophthalmologic consultation being limited to children without symptomatic improvement.

Evaluation of the 2020 Pediatric Emergency Physician Workforce in the US

IMPORTANCE

Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however.

OBJECTIVE

To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020.

MAIN OUTCOMES AND MEASURES

The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates.

RESULTS

A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population.

CONCLUSIONS AND RELEVANCE

This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Geographic Distribution of Accredited Paramedic Education Programs in the United States

Background: The geographic distribution and access to paramedic education programs is unclear but often cited as a reason for emergency medical services (EMS) workforce shortages. Our aims were: 1) to examine the spatial distribution of accredited paramedic programs and 2) to compare characteristics of communities with and without existing programs. Methods: We performed a cross-sectional study of US paramedic education programs accredited by the Commission on Accreditation of Allied Health Education Programs as of April 2020. Program locations were geocoded to county, and population estimates from the US Census Bureau were used to determine the adult population within the program's potential catchment area (30, 50, and 100 miles). Clustering of programs was examined using Moran's I. We compared community characteristics obtained from the 2018 American Community Survey, 2018-2019 Area Health Resources Files, and 2018 National Emergency Department Inventory between counties with and without programs. Logistic regression models were used to determine associations of community characteristics and existence of a paramedic program, controlling for urbanicity. Results: There were 790 paramedic program locations in the US, located in 596/3142 (19%) counties. Every state, except Rhode Island and Washington, DC, had at least one paramedic program site. The population within potential catchment areas ranged from 182 million (30 miles) to 248 million (100 miles), representing 73% to 99% of the US adult population, respectively. However, among counties classified as rural (n = 644), this decreased to 22% (30 miles) to 95% (100 miles). There was significant clustering of programs (p < 0.001). There were significantly higher odds of having a paramedic program for counties classified as metro compared to non-metro (OR 4.42, 95% CI 3.60-5.42) and with the presence of healthcare resources (e.g., emergency department in the county: OR 2.42, 95% CI 1.87-3.14). Conclusions: Approximately 73% of the US adult population lives within 30 miles of an existing paramedic education program; however, this decreases to 22% in rural areas. Geographic barriers to accessing paramedic education remain a challenge for ongoing efforts to address the rural EMS workforce shortage.

Supply and Demand of Emergency Medicine Board-certified Emergency Physicians by U.S. State, 2017

OBJECTIVES

Our objective was to estimate the emergency medicine board-certified emergency physician (EMBC EP) workforce supply and demand by U.S. state.

METHODS

To estimate state demand, we applied the methodology from our 2005 analysis to calculate full-time equivalent (FTE) EMBC EP demand for each emergency department (ED). The 2017 National Emergency Department Inventory-USA provided visit volumes for all EDs, while the American Board of Medical Specialties supplied the 2017 number of EMBC EPs per state. Assuming that at least one EMBC EP should be present 24/7 in each ED (requiring 5.35 FTEs minimum), we calculated the total FTEs required by dividing each ED's visit volume by the estimated average visits seen by an EMBC EP (3,548 visits per year) and then summed FTEs by state. The U.S. Census Bureau provided state demographic characteristics. We used multivariable linear regression to examine the association between state demographics and the density of EMBC EPs per state and compared 2017 results to our prior 2005 analysis.

RESULTS

There were 40,716 total EMBC EPs in 2017, fulfilling 77% of the estimated national demand. This was a substantial increase from 23,035 total EMBC EPs fulfilling 58% of demand in 2005. The 2017 supply ranged from 24% of demand in North Dakota to 142% in Hawaii. A lower density of EMBC EPs was associated with states in the Midwest and South (p < 0.001) and with a more rural population (p = 0.02). The absolute shortage of EMBC EPs worsened or remained the same in one-fourth of states.

CONCLUSION

While the total number of EMBC EPs nearly doubled between 2005 and 2017, a shortage of full-time coverage persists. The supply and demand vary greatly by state. Worsening absolute shortages in several states show that the distribution of EMBC EPs is not meeting demand across the United States, particularly in rural areas.

Early de novo gene expression is required for 15-deoxy-Delta 12,14-prostaglandin J2-induced apoptosis in breast cancer cells

Cyclopentenone prostaglandin derivatives of arachidonic acid are potent inducers of apoptosis in a variety of cancer cell types. Several investigators have shown that the terminal derivative of prostaglandin J(2) (PGJ(2)) metabolism, 15-deoxy-Delta(12,14)-PGJ(2) (15dPGJ(2)), induces apoptosis in breast cancer cells and is a potent activator of the nuclear hormone receptor peroxisome proliferator-activated receptor gamma (PPARgamma), but 15dPGJ(2) effects can be mediated by PPARgamma-dependent and PPARgamma-independent mechanisms. Here we report that 15dPGJ(2) regulates early gene expression critical to apoptosis. Specifically, 15dPGJ(2) induces potent and irreversible S phase arrest that is correlated with expression of genes critical to cell cycle arrest and apoptosis, including the cyclin-dependent kinase inhibitor p21(Waf1/Cip1) (p21). Inhibition of RNA or protein synthesis abrogates apoptosis induced by 15dPGJ(2) in breast cancer cells but potentiates apoptosis induced by tumor necrosis factor-alpha or CD95/Fas ligand. Additionally, 15dPGJ(2) induces caspase activation that is blocked by peptide caspase inhibitors. These data show that de novo gene transcription is necessary for 15dPGJ(2)-induced apoptosis in breast cancer cells. Critical candidate genes are likely to be revealed through analysis of differential cDNA array expression.

Magnitude of peroxisome proliferator-activated receptor-gamma activation is associated with important and seemingly opposite biological responses in breast cancer cells

BACKGROUND

The nuclear receptor peroxisome proliferator-activated receptor-gamma (PPARgamma) has become a potential target for the prevention and treatment of breast cancer. However, recent in vitro and in vivo studies have raised the question of whether activation of PPARgamma leads to the promotion or reduction of tumor formation. Studies using several cancer cell lines, animal models, and a variety of PPARgamma agonists have shown discordant results, including changes in cellular proliferation, differentiation, and apoptosis of cancer cells and tumors.

METHODS

We studied the effects of low-, moderate-, and high-dose treatment of the PPARgamma ligands 15-deoxy-delta1214 prostaglandin J2 (15dPGJ2) and troglitazone (TGZ) on parameters of cell growth, differentiation, and apoptosis in the epithelial breast cancer cell line MDA-MB-231.

RESULTS

The biologic effects of these compounds depend largely on ligand concentration and the degree of PPARgamma activation. For example, low concentrations of 15dPGJ2 (<2.5 microM) and TGZ (<5 microM) increased cellular proliferation, but concentrations of 15dPGJ2 > or = 10 microM and of TGZ at 100 microM blocked cell growth. TGZ (100 microM) slowed cell cycle progression, and 15dPGJ2 (10 microM) caused an S-phase arrest in the cell cycle and induced morphological characteristics consistent with apoptosis. Expression of CD36, a marker of differentiation in these cells, was induced by 2.5 microM 15dPGJ2 or 5 to 100 microM TGZ. However, higher concentrations of 15dPGJ2 did not alter CD36 expression. Transcriptional activation studies demonstrated that 15dPGJ2 is a more potent PPARgamma ligand than TGZ. Regardless of the ligand used, though, low transcriptional activation correlated with an increased cellular proliferation, whereas higher levels of activation correlated with cell cycle arrest and apoptosis.

CONCLUSIONS

PPARgamma activation induces several important and seemingly opposite changes in neoplastic cells, depending on the magnitude of PPARgamma activation. These data may explain, at least in part, some of the discordant results previously reported.

Influence of coenzyme A-independent transacylase and cyclooxygenase inhibitors on the proliferation of breast cancer cells

Recent studies have demonstrated that arachidonic acid (AA) may serve as an important signal that blocks cell proliferation of certain neoplastic cells. The current study was conducted to determine whether disruption of AA homeostasis influences breast cancer cell proliferation and death. Initial experiments revealed that inhibition of AA remodeling through membrane phospholipids by inhibitors of the enzyme, coenzyme A-independent transacylase (CoA-IT), attenuates the proliferation of the estrogen receptor-negative, MDA-MB-231, and estrogen receptor-positive, MCF-7 breast cancer cell lines. This growth inhibition was accompanied by a marked accumulation of AA in both free fatty acid and triglyceride forms, a marker of intracellular AA stress within mammalian cells. Cell cycle synchronization experiments revealed that the CoA-IT inhibitor, SB-98625, blocked MDA-MB-231 cell replication in early to mid G1 phase. Time-lapse video microscopy, used to observe the changes in cell morphology associated with apoptosis, indicated that SB-98625 treatment induced early rounding and occasional blebbing but not late apoptotic events, blistering, and lysis. The cyclooxygenase inhibitors, NS-398 and indomethacin, were found to be less potent blockers of cell proliferation and poor inducers of cellular AA accumulation than CoA-IT inhibitors in these breast cancer cell lines. Finally, AA provided exogenously blocked the proliferation of MCF-7 cells, and this effect could be attenuated in MCF-7 cells overexpressing the glutathione peroxidase gene, GSHPx-1. Taken together, these experiments suggest that disruption of AA remodeling in a manner that increases intracellular AA may represent a novel therapeutic strategy to reduce cancer cell proliferation and that an oxidized AA metabolite is likely to mediate this effect.

Influence of J series prostaglandins on apoptosis and tumorigenesis of breast cancer cells

This study was undertaken to investigate the influence of the peroxisome proliferator-activated receptor gamma (PPARgamma) agonists on the proliferation, apoptosis and tumorigenesis of breast cancer cells. PPARgamma investigation has been largely restricted to adipose tissue, where it plays a key role in differentiation, but recent data reveal that PPARgamma is expressed in several transformed cells. However, the function of PPARgamma activation in neoplastic cells is unclear. Activation of PPARgamma with the known prostanoid agonist 15-deoxy-Delta12,14-prostaglandin J(2) (15dPGJ(2)) or the thiazolidinedione (TZD) agonist troglitazone (TGZ) attenuated cellular proliferation of the estrogen receptor-negative breast cancer cell line MDA-MB-231, as well as the estrogen receptor-positive breast cancer cell line MCF-7. This was marked by a decrease in total cell number and by an inhibition of cell cycle progression. Addition of 15dPGJ(2) was not associated with an increase in cellular differentiation, as has been seen in other neoplastic cells, but rather induction of cellular events associated with programmed cell death, apoptosis. Video time-lapse microscopy revealed that 15dPGJ(2) induced morphological changes associated with apoptosis, including cellular rounding, blebbing, the production of echinoid spikes, blistering and cell lysis. In contrast, TGZ caused only a modest induction of apoptosis. These results were verified by histochemistry using the specific DNA stain DAPI to observe nuclear condensation, a marker of apoptosis. Finally, a brief exposure of MDA-MB-231 cells to 15dPGJ(2) initiated an irreversible apoptotic pathway that inhibited the growth of tumors in a nude mouse model. These findings illustrate that induction of apoptosis may be the primary biological response resulting from PPARgamma activation in some breast cancer cells and further suggests a potential role for PPARgamma ligands for the treatment of breast cancer.

The effects of ethanol and acetaldehyde on the metabolism of prostaglandin E2 and leukotriene B4 in isolated rat hepatocytes

The effects of ethanol and acetaldehyde on the metabolism of leukotriene B4 (LTB4) and PGE2 were investigated in isolated cultures of rat hepatocytes. LTB4 undergoes initial cytochrome P450-dependent omega-oxidation leading to the principal metabolites 20-hydroxy-LTB4, 20-carboxy-LTB4 and the omega/beta-oxidation product 18-carboxy-LTB4. The addition of low concentrations of ethanol (25 mM) dramatically changes the relative amounts of these metabolite products by inhibiting the alcohol dehydrogenase-mediated oxidation of 20-hydroxy-LTB4. Addition of acetaldehyde to the incubation, up to 1 mM, had no significant effect on overall metabolism or distribution of metabolites. Above 1 mM acetaldehyde, beta-oxidation of LTB4 was inhibited. Thus the effect of ethanol on the metabolism of LTB4 appears to be due to ethanol itself and not to secondary effects from the metabolic transformation of ethanol to acetaldehyde in the cells. PGE2 is metabolized in isolated rat hepatocytes to produce chain-shortened products of beta-oxidation characterized as dinor-PGE1, dinor-PGE2, tetranor-PGE1, tauro-dinor-PGE1 and tauro-dinor-PGE2. Low concentrations of ethanol (25 mM) were found to increase the relative concentration of dinor-PGE1 in the metabolic distribution, with a corresponding decrease in concentration of tetranor-PGE1. The amount of dinor-PGE2 that was produced remained relatively unchanged in response to increasing concentrations of ethanol. Acetaldehyde concentrations from 0.1 mM to 1 mM did not affect metabolite distribution or the overall magnitude of PGE2 metabolism. Concentrations of acetaldehyde higher than 1 mM decreased all beta-oxidation metabolites. Ethanol, at physiologically relevant concentrations, could alter eicosanoid metabolism in the liver by inhibiting LTB4 metabolism and altering that of PGE2.

Effect of faecal extract on the growth of Salmonella enteritidis in artificially contaminated hens' eggs

1. Salmonella enteritidis PT 4 grew in eggs stored at 25 degrees C, but not at 10 degrees C. 2. The incidence of generalised infection of the egg contents (greater than 10(6) salmonellas/ml) was greater in eggs inoculated with cells suspended in faecal extract compared to those with cells in Ringer's solution. 3. The removal of most of the iron did not decrease the growth-promoting effect of the faecal extract.

Growth of Salmonella enteritidis in artificially contaminated hens' shell eggs

The effect of some factors on the growth of Salmonella enteritidis phage type 4 in artificially contaminated shell eggs was investigated. Salmonella enteritidis was found to be resistant to the antimicrobial properties of the albumen. Growth occurred on storage at 25 degrees C but not at 4 or 10 degrees C. The rate and extent of infection was influenced by the size of inoculum, the site of contamination relative to yolk movement, and the presence of iron in the inoculum.

Congenital nuclear cataracts in cattle

A description is given of the investigation into two outbreaks of congenital cataract in dairy herds. There is a description of the clinical signs, the incidence, the period of time over which the cases occurred and of the seasonal distribution of the births. The type of herd management is descirbed and a hereditary factor is not considered to occur. The possibility of the involvement of other toxic and environmental agents is discussed. The macroscopic and microscopical findings are described; the relation to the early period of lens development of the bovine fetus suggested.