Historical Redlining and Present-Day Nonsuicide Firearm Fatalities.

BACKGROUND: Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation. OBJECTIVE: To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities. DESIGN: Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference. SETTING: 202 cities with areas graded by the HOLC in the 1930s. PARTICIPANTS: Population of the 8597 areas assessed by the HOLC. MEASUREMENTS: Nonsuicide firearm fatalities. RESULTS: From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively. LIMITATION: The Gun Violence Archive relies on media coverage and police reports. CONCLUSION: Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today. PRIMARY FUNDING SOURCE: Fred Lovejoy Housestaff Research and Education Fund.

Abortion Restrictiveness and Infant Mortality: An Ecologic Study, 2014-2018.

INTRODUCTION: The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018. METHODS: A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023. RESULTS: There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055). CONCLUSIONS: State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality.

Racial & ethnic disparities in geographic access to critical care in the United States: A geographic information systems analysis.

OBJECTIVE: It is important to identify gaps in access and reduce health outcome disparities, understanding access to intensive care unit (ICU) beds, especially by race and ethnicity, is crucial. Our objective was to evaluate the race and ethnicity-specific 60-minute drive time accessibility of ICU beds in the United States (US). DESIGN: We conducted a cross-sectional study using road network analysis to determine the number of ICU beds within a 60-minute drive time, and calculated adult intensive care bed ratios per 100,000 adults. We evaluated the US population at the Census block group level and stratified our analysis by race and ethnicity and by urbanicity. We classified block groups into four access levels: no access (0 adult intensive care beds/100,000 adults), below average access (>0-19.5), average access (19.6-32.0), and above average access (>32.0). We calculated the proportion of adults in each racial and ethnic group within the four access levels. SETTING: All 50 US states and the District of Columbia. PARTICIPANTS: Adults ≥15 years old. MAIN OUTCOME MEASURES: Adult intensive care beds/100,000 adults and percentage of adults national and state) within four access levels by race and ethnicity. RESULTS: High variability existed in access to ICU beds by state, and substantial disparities by race and ethnicity. 1.8% (n = 5,038,797) of Americans had no access to an ICU bed, and 26.8% (n = 73,095,752) had below average access, within a 60-minute drive time. Racial and ethnic analysis showed high rates of disparities (no access/below average access): American Indians/Alaskan Native 12.6%/28.5%, Asian 0.7%/23.1%, Black or African American 0.6%/16.5%, Hispanic or Latino 1.4%/23.0%, Native Hawaiian and other Pacific Islander 5.2%/35.0%, and White 2.1%/29.0%. A higher percentage of rural block groups had no (5.2%) or below average access (41.2%), compared to urban block groups (0.2% no access, 26.8% below average access). CONCLUSION: ICU bed availability varied substantially by geography, race and ethnicity, and by urbanicity, creating significant disparities in critical care access. The variability in ICU bed access may indicate inequalities in healthcare access overall by limiting resources for the management of critically ill patients.

Ten Years Later, Alarm Fatigue Is Still a Safety Concern.

Ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organizations aim to remediate. Alarm fatigue contributes to missed alarms and medical errors that result in patient death, increased clinical workload and burnout, and interference with patient recovery. Led by the American Association of Critical-Care Nurses, national patient safety organizations continue to prioritize efforts to battle alarm fatigue and have proposed alarm management strategies to mitigate the effects of alarm fatigue. Similarly, clinical efforts now use simulation studies, individualized alarm thresholds, and interdisciplinary teams to optimize alarm use. Finally, engineering research efforts have innovated the standard alarm to convey information more effectively for medical users. By focusing on patient and provider safety, clinical workflow, and alarm technology, efforts to reduce alarm fatigue over the past 10 years have been grounded in an evidence-based and personnel-focused approach.

Prehospital Transport Time and Outcomes for Pediatric Trauma: A National Study.

INTRODUCTION: Historically, emergency medical services have aimed to deliver trauma patients to definitive care within the 60 min (min) "Golden Hour" to optimize survival. There is little evidence to support or refute this for pediatric trauma. The objective of this investigation was to describe national trends in prehospital transport time, in relation to the "Golden Hour," and pediatric trauma outcomes. METHODS: Retrospective cohort study of patients (<15 y old) receiving emergency medical services trauma transport between 2017 and 2019. Transport time (less than or greater than 60 min) was the exposure variable, and analyses were adjusted for injury severity score (ISS). Continuous variables with a normal distribution were compared by t-test was and skewed variables were compared by Mann-Whitney U-test. Categorical variables were compared by Chi-Square test. RESULTS: 54,489 patients met our criteria: 49,628 blunt and 4861 penetrating. Most patients (62.2%) had transport times less than 60 min: 30,389 (61.2%) blunt and 3479 (71.6%) penetrating. The overall mortality rate was 1.6%, 1.2% for blunt and 5.5% for penetrating. For blunt trauma, mortality was higher for transport times less than 60 min (1.5%). For penetrating trauma, mortality was lower for transport times less than 60 min (0.7%). Mean ISS was greater for blunt (7.9) compared to penetrating trauma (7.1), and greater for both trauma types with transport times less than 60 min. For both trauma types, mean length of stay was significantly longer for transport times greater than 60 min, when adjusting for ISS (P < 0.001). CONCLUSIONS: We did not find evidence that prehospital transport within the "Golden Hour" had a substantial association with survival, though it may be associated with length of stay. There are many factors contributing to trauma outcomes, so efforts should continue to expand access and pediatric readiness.

Auditory roughness: a delicate balance.

Auditory roughness in medical alarm sounds is an important design attribute, and has been shown to impact user performance and perception. While roughness can assist in decreased signal-to-noise ratios (perceived loudness) and communicate urgency, it might also impact patient recovery. Therefore, considerations of neuroscience correlates, music theory, and patient impact are critical aspects to investigate in order to optimise alarm design.

Multisensory alarm to benefit alarm identification and decrease workload: a feasibility study.

The poor design of conventional auditory medical alarms has contributed to alarm desensitization, and eventually, alarm fatigue in medical personnel. This study tested a novel multisensory alarm system which aims to help medical personnel better interpret and respond to alarm annunciation during periods of high cognitive load such as those found within intensive care units. We tested a multisensory alarm that combined auditory and vibrotactile cues to convey alarm type, alarm priority, and patient identity. Testing was done in three phases: control (conventional auditory), Half (limited multisensory alarm), and Full (complete multisensory alarm). Participants (N = 19, undergraduates) identified alarm type, priority, and patient identity (patient 1 or 2) using conventional and multisensory alarms, while simultaneously completing a cognitively demanding task. Performance was based on reaction time (RT) and identification accuracy of alarm type and priority. Participants also reported their perceived workload. RT was significantly faster for the Control phase (p < 0.05). Participant performance in identifying alarm type, priority, and patient did not differ significantly between the three phase conditions (p = 0.87, 0.37, and 0.14 respectively). The Half multisensory phase produced the lowest mental demand, temporal demand, and overall perceived workload score. These data suggest that implementation of a multisensory alarm with alarm and patient information may decrease perceived workload without significant changes in alarm identification performance. Additionally, a ceiling effect may exist for multisensory stimuli, with only part of an alarm benefitting from multisensory integration.

Mobile Social Screening and Referral Intervention in a Pediatric Emergency Department.

OBJECTIVE: Many families in pediatric emergency departments (PED) have unmet social needs, which may be detected and addressed with the use of a digital social needs intervention. Our objective was to characterize the feasibility and effectiveness of utilizing personal phones or a PED tablet for screening and referral to social services. METHODS: We conducted a prospective single-arm intervention study using a convenience sample of caregivers and adult patients in an urban PED between May 2019 and October 2020. Participants chose either their personal phone or a PED-provided tablet to use an app, "HelpSteps." Participants self-selected need(s) then referrals to service agencies. Participants completed a 1-month follow-up. Clinicians were surveyed about screening and impact on visit. RESULTS: Of 266 participants enrolled, 55% of participants elected to use their personal phone. Of all participants, 67% self-selected at least 1 health-related social need; 34% selected 3 or more. The top 3 "most important" needs were housing (14%), education (12%), and fitness (12%). At one month follow-up, 44% of participants reported their top need was "completely" or "somewhat" solved. For 95% of encounters, clinicians reported the intervention did not increase length of stay. CONCLUSIONS: A mobile social needs intervention was feasible and effective at identifying and referring participants in the PED setting. While more than half of participants used their personal phones, several smartphone owners cited barriers and elected to use a tablet. Overall, participants found the app easy to use, appropriate for the PED, and the intervention had minimal impact on clinical flow.

Racial and Ethnic Disparities in Access to Pediatric Trauma Centers in the United States: A Geographic Information Systems Analysis.

STUDY OBJECTIVE: Injury is the leading cause of death and disability for children, making access to pediatric trauma centers crucial to pediatric trauma care. Our objective was to describe the pediatric population with timely access to a pediatric trauma center by demographics and geography in the United States. METHODS: Level 1, 2, and 3 pediatric trauma center locations were provided by the American Trauma Society. Geographic information systems road network and rotor wing analysis determined US Census Block Groups with the ground and/or air access to a pediatric trauma center within a 60-minute transport time. We then described, at the national and state levels, the 2020 pediatric population (< 15 years old) with and without pediatric trauma center access by ground and air, stratified by race, ethnicity, and urbanicity. RESULTS: There were 157 pediatric trauma centers (82 Level 1, 64 Level 2, 11 Level 3). Of the 2020 US pediatric population, 33,352,872 (54.5%) had timely access to Level 1-3 pediatric trauma centers by ground and 45,431,026 (74.1%) by air. The percentage of children with access by race and ethnicity were (by ground, by air): American Indian/Alaskan Native (31.0%, 43.5%), White (48.7%, 71.3%), Native Hawaiian/Pacific Islander (59.3%, 61.0%), Hispanic (60.2%, 76.9%), Black (64.2%, 78.0%), and Asian (76.5%, 89.5%). Only 48.2% of children living in rural block groups had access, compared with 83.6% in urban block groups. CONCLUSION: Significant disparities in current access to pediatric trauma centers exist by race and ethnicity, and geography, leaving some children at risk for poor trauma outcomes.

Association of Neighborhood Conditions and Resources for Children With Life Expectancy at Birth in the US.

Importance: To address inequities in life expectancy, we must understand the associations of modifiable socioeconomic and structural factors with life expectancy. However, the association of limited neighborhood resources and deleterious physical conditions with life expectancy is not well understood. Objective: To evaluate the association of community social and economic conditions and resources for children with life expectancy at birth. Design, Setting, and Participants: This cross-sectional study examined neighborhood child opportunity and life expectancy using data from residents of 65 662 US Census tracts in 2015. The analysis was conducted from July 6 to October 1, 2021. Exposures: Neighborhood conditions and resources for children in 2015. Main Outcomes and Measures: The primary outcome was life expectancy at birth at the Census tract level based on data from the US Small-Area Life Expectancy Estimates Project (January 1, 2010, to December 31, 2015). Neighborhood conditions and resources for children were quantified by Census tract Child Opportunity Index (COI) 2.0 scores for 2015. This index captures community conditions associated with children's health and long-term outcomes categorized into 5 levels, from very low to very high opportunity. It includes 29 indicators in 3 domains: education, health and environment, and social and economic factors. Mixed-effects and simple linear regression models were used to estimate the associations between standardized COI scores (composite and domain-specific) and life expectancy. Results: The study included residents from 65 662 of 73 057 US Census tracts (89.9%). Life expectancy at birth across Census tracts ranged from 56.3 years to 93.6 years (mean [SD], 78.2 [4.0] years). Life expectancy in Census tracts with very low COI scores was lower than life expectancy in Census tracts with very high COI scores (-7.06 years [95% CI, -7.13 to -6.99 years]). Stepwise associations were observed between COI scores and life expectancy. For each domain, life expectancy was shortest in Census tracts with very low compared with very high COI scores (education: ß = -2.02 years [95% CI, -2.12 to -1.92 years]); health and environment: ß = -2.30 years [95% CI, -2.41 to -2.20 years]; social and economic: ß = -4.16 years [95% CI, -4.26 to -4.06 years]). The models accounted for 41% to 54% of variability in life expectancy at birth (R2 = 0.41-0.54). Conclusions and Relevance: In this study, neighborhood conditions and resources for children were significantly associated with life expectancy at birth, accounting for substantial variability in life expectancy at the Census tract level. These findings suggest that community resources and conditions are important targets for antipoverty interventions and policies to improve life expectancy and address health inequities.

Improved Patient Monitoring with a Novel Multisensory Smartwatch Application.

The design of medical alarms has been heavily criticized in the past decade. Auditory medical alarms have poor learnability, discernibility, and relevance, leading to poor patient outcomes, and alarm fatigue, and overall poor informatic system design. We developed a novel trimodal patient monitoring smartwatch application for patient monitoring. Participants completed two phases: (1) control and (2) our novel trimodal system while identifying alarms (heart rate, oxygenation, and blood pressure) and completing a cognitively demanding task. Alarms were auditory icons presented as either solo or co-alarms. Participant performance was assessed by accuracy and response time (RT) of alarm identification. Using the novel system, accuracy was significantly improved overall (p < 0.01) and in co-alarm situations (p < 0.01), but not for solo alarms (p = 0.484). RT was also significantly faster (p < 0.01) while using the novel system for all alarm types. Participants reported decreased mental workload using the novel system. This feasibility study shows that our novel alarm system performs better than current standards. Improvements in accuracy, RT and perceived mental workload indicate the potential of this system to have a positive impact on medical informatic systems and clinical monitoring, for both the patient and the clinician.

Evaluation of Noninvasive Respiratory Volume Monitoring in the PACU of a Low Resource Kenyan Hospital.

This research aims to evaluate the use of the noninvasive respiratory volume monitor (RVM) compared to the standard of care (SOC) in the Post-Anesthesia Care Unit (PACU) of Kijabe Hospital, Kenya. The RVM provides real-time measurements for quantitative monitoring of non-intubated patients. Our evaluation was focused on the incidence of postoperative opioid-induced respiratory depression (OIRD). The RVM cohort (N = 50) received quantitative OIRD assessment via the RVM, which included respiratory rate, minute ventilation, and tidal volume. The SOC cohort (N = 46) received qualitative OIRD assessment via patient monitoring with oxygenation measurements (SpO2) and physical examination. All diagnosed cases of OIRD were in the RVM cohort (9/50). In the RVM cohort, participants stayed longer in the PACU and required more frequent airway maneuvers and supplemental oxygen, compared to SOC (all p < 0.05). The SOC cohort may have had fewer diagnoses of OIRD due to the challenging task of distinguishing hypoventilation versus OIRD in the absence of quantitative data. To account for the higher OIRD risk with general anesthesia (GA), a subgroup analysis was performed for only participants who underwent GA, which showed similar results. The use of RVM for respiratory monitoring of OIRD may allow for more proactive care.

Limitations of exome sequencing in detecting rare and undiagnosed diseases.

While exome sequencing (ES) is commonly the final diagnostic step in clinical genetics, it may miss diagnoses. To clarify the limitations of ES, we investigated the diagnostic yield of genetic tests beyond ES in our Undiagnosed Diseases Network (UDN) participants. We reviewed the yield of additional genetic testing including genome sequencing (GS), copy number variant (CNV), noncoding variant (NCV), repeat expansion (RE), or methylation testing in UDN cases with nondiagnostic ES results. Overall, 36/54 (67%) of total diagnoses were based on clinical findings and coding variants found by ES and 3/54 (6%) were based on clinical findings only. The remaining 15/54 (28%) required testing beyond ES. Of these, 7/15 (47%) had NCV, 6/15 (40%) CNV, and 2/15 (13%) had a RE or a DNA methylation disorder. Thus 18/54 (33%) of diagnoses were not solved exclusively by ES. Several methods were needed to detect and/or confirm the functional effects of the variants missed by ES, and in some cases by GS. These results indicate that tests to detect elusive variants should be considered after nondiagnostic preliminary steps. Further studies are needed to determine the cost-effectiveness of tests beyond ES that provide diagnoses and insights to possible treatment.

SAVIOR ICU: sonification and vibrotactile interface for the operating room and intensive care unit.

Alarm fatigue is an issue for healthcare providers in the intensive care unit, and may result from desensitization of overbearing and under-informing alarms. To directly increase the overall identification of medical alarms and potentially contribute to a downstream decrease in the prevalence of alarm fatigue, we propose advancing alarm sonification by combining auditory and tactile stimuli to create a multisensory alarm. Participants completed four trials-two multisensory (auditory and tactile) and two unisensory (auditory). Analysis compared the unisensory trials to the multisensory trials based on the percentage of correctly identified point of change, direction of change and identity of three physiological parameters (indicated by different instruments): heart rate (drums), blood pressure (piano), blood oxygenation (guitar). A repeated-measures of ANOVA yielded a significant improvement in performance for the multisensory group compared to the unisensory group (p < 0.05). Specifically, the multisensory group had better performance in correctly identifying parameter (p < 0.05) and point of change (p < 0.05) compared to the unisensory group. Participants demonstrated a higher accuracy of identification with the use of multisensory alarms. Therefore, multisensory alarms may relieve the auditory burden of the medical environment and increase the overall quality of care and patient safety.