Prenatal Exposure to Acid Suppressor Medications and Development of Ductus Arteriosus in Term Newborns.

OBJECTIVE: The ductus arteriosus normally closes after birth. Histamine 2 receptor antagonist (H2RA) has been associated with patent ductus arteriosus (PDA). We aimed to study the characteristics of term infants with PDA and their possible association with prenatal exposure to antacids-proton pump inhibitors (PPIs) and H2RA. STUDY DESIGN: This was a population-based matched case-control study of mothers registered at "Clalit" Health Maintenance Organization (HMO) and their infants born at "Soroka" University Medical Center (SUMC) between 2001 and 2018. Cases are defined as term infants born with PDA diagnosed by echocardiography and registered in the postdelivery discharge form. Each case was matched with four term newborns without PDA diagnosis. Exposure window was defined by the timing of first purchase of H2RA or PPI during pregnancy and based on information from a computerized medication database (Clalit HMO, SUMC). RESULTS: PDA was diagnosed in 1,884 term infants (4.9%). Characteristics included a significantly higher percentage of lack of prenatal care, cesarean section, in vitro fertilization, polyhydramnios, oligohydramnios, Apgar 1 minute <5, and prenatal exposure to H2RA (odds ratio [OR] 4.18) and PPIs (OR 3.50; all p < 0.001). PDA association with exposure window was similar in each trimester (1.5-2%) for both H2RA and PPI. CONCLUSION: PDA incidence in term infants in our population was greater than previously reported. PPI and H2RA are both antiacids with different mechanisms of action. The similar OR for exposure to one as well as the other, and the lack of influence of the initial exposure period, are compatible with bias. KEY POINTS: · Term newborns with PDA have different characteristics than newborns without PDA.. · Prenatal exposure to PPIs or H2RA is associated with greater risk of PDA in term newborns.. · The possible effect mechanism of PPIs on the ductus is unclear and understudied..

Myocarditis-A Helpful Algorithm to Overcome Diagnostic Challenges in the Pediatric Population.

OBJECTIVES: This study was designed to investigate clinical differences between pediatric patients who presented with chest pain, tachycardia, and/or tachypnea who subsequently were or were not diagnosed with myocarditis. The results were used to develop a decision tree to aid in rapid diagnosis of pediatric myocarditis. METHODS: A retrospective case-control study was performed using the electronic medical records of children aged 0 to 18 years between the years 2003 and 2020 with a complaint of chest pain, tachycardia, and/or tachypnea. Patients included in the study were those diagnosed with myocarditis and those with suspected myocarditis, which was ultimately ruled out. Demographic and clinical differences between the research groups were analyzed. A decision tree was rendered using the rpart (Recursive Partitioning and Regression Trees) package. RESULTS: Four thousand one hundred twenty-five patients were screened for eligibility. Seventy-three myocarditis patients and 292 nonmyocarditis patients were included. Compared with the control group, the study group was found to have a higher mean respiratory rate (37 ± 23 vs 23 ± 7 breaths per minute) and mean heart rate (121 ± 44 vs 97 ± 25 beats per minute) and lower mean systolic and diastolic blood pressure (102 ± 27/56 ± 17 mm Hg vs 114 ± 14/67 ± 10 mm Hg). The mean white blood cell count was greater in the case group (13 ± 6 vs 10 ± 5 × 103/µL). A decision tree was rendered using simple demographic and clinical variables. The accuracy of the algorithm was 85.2%, with 100% accuracy in patients aged 0 to 2.5 years and 69% in patients aged 2.5 to 18 years. CONCLUSION: The clinical and laboratory characteristics described in this study were similar to what is described in the literature. The decision tree may aid in the diagnosis of myocarditis in patients 2.5 years and younger. In the population aged 2.5 to 18 years, the decision tree did not constitute an adequate tool for detecting myocarditis.

Factors Associated With Complete Pathologic Necrosis of Hepatocellular Carcinoma on Explant Evaluation After Locoregional Therapy: A National Analysis Using the UNOS Database.

BACKGROUND. Complete pathologic necrosis (CPN) is associated with improved survival in patients who undergo liver transplant (LT) after locoregional therapy (LRT) for hepatocellular carcinoma (HCC). OBJECTIVE. The purpose of this article was to identify patient, HCC, and transplant center characteristics associated with rates of CPN on explant evaluation using a large national sample of patients undergoing LT after LRT for HCC measuring 3 cm or smaller. METHODS. This retrospective study used data from the United Network for Organ Sharing database. The study included 6265 adults (median age, 62 years; 1505 women, 4760 men) who underwent LT after a single type of LRT (either transarterial chemoembolization [TACE], thermal ablation, or transarterial radioembolization [TARE]) for HCCs measuring 3 cm or smaller at one of 118 U.S. transplant centers from April 12, 2012, to March 31, 2020. Patients were classified as having CPN if explant evaluation showed 100% necrosis of all HCCs. Associations with CPN were explored. Centers were categorized into tertiles on the basis of center-level CPN rates, and tertiles were compared. RESULTS. LRT was performed by TACE in 69.5% (4352/6265), thermal ablation in 19.4% (1217/6265), and TARE in 11.1% (696/6265) of patients. CPN rate was 18.5% (805/4352) after TACE, 35.8% (436/1217) after thermal ablation, 33.6% (234/696) after TARE, and 23.5% (1475/6265) overall. In multivariable analysis incorporating age, sex, model for end-stage liver disease score, α-fetoprotein level before LRT, wait list time, number of HCCs, HCC size, and the transplant center (as a random factor), use of thermal ablation (OR, 2.19; 95% CI, 1.86-2.57; p < .001) or TARE (OR, 1.92; 95% CI, 1.57-2.36; p < .001), with TACE as reference, independently predicted greater likelihood of CPN. Center-level CPN rates ranged from 0.0% to 50.0%. With centers stratified by CPN rates, ablation was performed more frequently than TACE in 5.0% of centers in the first, 15.4% in the second, and 23.1% in the third tertiles (p = .07). CONCLUSION. CPN rate on explant evaluation was low. Thermal ablation or TARE, rather than TACE, was associated with higher likelihood of CPN in patient-level and center-level analyses. CLINICAL IMPACT. Findings from this large national sample support a potential role of thermal ablation or TARE for achieving CPN of HCC measuring 3 cm or smaller.

National Weekly SARS-CoV-2 RT-PCR Screening of All Workers in Long-Term Care Facilities Associated with Decrease in Resident Mortality Rate.

INTRODUCTION: Outbreaks of COVID-19 in long-term care facilities (LTCFs) have resulted mainly from disease transmission by asymptomatic health care workers. This study examines whether routine screening tests carried out on health care workers can help in reducing COVID-19 outbreaks, morbidity, and mortality of LTCF residents. METHODS: The study followed a weekly, nationwide, government-funded screening program of LTCF personnel for SARS-CoV-2, by using reverse transcription polymerase chain reaction as the main testing technology. It included all residents and employees in Israeli LTCFs who were screened weekly during the second wave of COVID-19, during the period of time between July 13, 2020, and November 21, 2020. RESULTS: During the study period, 1,107 LTCFs were screened on a weekly basis, including 62,159 HCWs and 100,046 residents. The program screened a median of 55,282 (range 16,249, min 45,910, max 62,159) employees per week, 0.05-1.5% of which were positive for SARS-CoV-2. LTCF mortality in the first wave accounted for 45.3% of all COVID-19 deaths recorded nationally (252 of 556), and in the second wave, this ratio was reduced to 30.3% (709 of 2,337) representing a reduction of 33.8% in expected mortality (p < 0.001). A significant reduction was detected also in hospitalization rate (13.59 vs. 11.41%, p < 0.001) and elder (≥75 years old) mortality rate (52.89 vs. 41.42%, p < 0.001). 214 outbreaks in the second wave were avoided by early identification of SARS-CoV-2 positive HCWs and successful prevention of subsequent infections in the facility. CONCLUSION: Routine weekly SARS-CoV-2 RT-PCR testing of LTCF employees was associated with reduced national LTCF residents' hospitalizations and mortality rate.

Suicide behavior and meteorological characteristics in hot and arid climate.

BACKGROUND: Suicidal behavior is determined by the consequence of an interaction between biological, psychological and sociological factors, as well as between individual and environmental effects. Fluctuations in meteorological factors can modify human behavior and affect suicidal rates. We hypothesize that high temperatures can be associated with an increase rate of suicidal attempts. METHODS: We included all the patients admitted to Soroka University Medical Center (SUMC) due to suicide attempts between the years 2002-2017 and were residents of Southern Israel. We computed two sets of regression models: first, a time stratified case-crossover design to control for seasonality and individual differences. Results are presented as odds ratio (OR) with confidence interval (CI); and then, time-series analyses to calculate the incidence rate ratio (IRR) and the cumulative effect of temperature on the daily incidences of emergency department (ED) admissions after suicide attempts. We stratified the analyses by demographic variables to identify significant individual differences. RESULTS: We identified 3100 attempts, by 2338 patients who lived in Be'er Sheva between 16 and 90 years of age; 421 patients made 2+ attempts. Suicide attempts were associated with a 5 °C increase during the summer season (OR 1.59, 95% CI 1.22-2.08) and a 5 °C increase in all seasons was associated with those who have made multiple attempts (OR 1.18, 95% CI 1.0005-1.38). The cumulative effect of 5 °C increment is associated with more suicide attempts over 2 days (IRR 1.10, 95% CI 0.98; 1.24) and 5 days (IRR 1.04, 95% CI 1.00; 1.08). The associations were greater for patients with psychiatric diagnosis and patients with multiple attempts. In a stratified analysis by individual characteristics we didn't find significant association. CONCLUSION: High temperatures and low amount of precipitations are evidently of great impact on people's susceptibility to suicidal behavior, especially for individuals who have had a prior suicide attempt. Our findings indicate the need for public health attention in the summer when temperature increases precipitously over days, especially for those who have made a prior suicide attempt.

Human biologic monitoring based on blood donations to the National Blood Services.

BACKGROUND: The ambient exposure does not always reflect the internal levels of pollution absorbed in the body. While human biomonitoring (HBM) could provide a valid estimate of exposure extent, it is usually an expensive and a heavily manpowered enterprise. Using samples collected during blood donations for HMB may provide a more efficient platform for a routine biomonitoring. METHODS: The current study is aimed to explore the feasibility of using the national blood banking system for the purposes of HBM, to compare between residents of a suspected polluted area in northern Israel (Haifa Bay) to the rest of the country. Specifically, we will assemble a geographically representative sample of blood donors residing in the study area and of the general population, to test for four industry and traffic-related metals: lead (Pb), cadmium (Cd), arsenic (As) and chromium (Cr). Samples of whole blood from donors will be tested in the Laboratory of Public Health Services managed by the Ministry of Health. The information on donors' biomarkers levels will be further linked with the air pollution and meteorological data assessed at the location of the blood collection sites (short-term exposure) and donors' permanent address (long-term exposure), as recorded by the monitoring stations spread throughout Israel and the satellite-based exposure models. The association between biomarkers and ambient environmental exposures will be assessed. The samples' collection is planned for 2 years of 2020-2021. DISCUSSION: The information collected in this study could lead to environmental regulations within Haifa Bay area aimed to prevent exposure to high levels of hazardous chemicals.

The effects of ambient particulate matter on human adipose tissue.

The effects of particulate matter (PM) air pollution on adipose tissue have mainly been studied in animal models. The aim of this study was to examine the potential associations between PM exposure and 25 cellular markers in human omental (OM) and subcutaneous (SC) adipose tissue. The PM exposure assessments for both PM2.5 (PM <2.5 µm in diameter) and PM10 (<10 µm) were based upon a novel hybrid satellite-based spatio-temporally resolved model. We calculated the PM exposure above the background threshold for 1 week (acute phase), 3 and 6 months (intermediate phase), and 1 year (chronic phase) prior to tissue harvesting and tested the associations with adipose cell metabolic effects using multiple linear regressions and heat maps strategy. Chemokine levels were found to increase after acute and intermediate exposure duration to PM10. The levels of stress signaling biomarkers in the SC and OM tissues rose after acute exposure to PM10 and PM2.5. Macrophage and leucocyte counts were associated with severity of PM exposure in all three duration groups. Adipocyte diameter decreased in all exposure periods. Our results provide evidence for significant contribution of air pollutants exposure to adipose tissue inflammation as well as for pathophysiological mechanisms of metabolic dysregulation that may be involved in the observed responses.

Challenging the Interpretation of White Blood Cell Counts in Patients with Sepsis Following Packed Cell Transfusion.

Critically ill patients with sepsis often require packed cell transfusions (PCT). However, PCT may affect white blood cell (WBC) counts. We conducted a population-based retrospective cohort study to trace changes in WBC count following PCT in critically ill patients with sepsis. We included 962 patients who received one unit of PCT while hospitalized in a general intensive care unit, and 994 matched patients who did not receive PCT. We calculated the mean values of WBC count for the 24 h before and 24 h after PCT. Multivariable analyses using a mixed linear regression model were performed. The mean WBC count decreased in both groups, but more in the non-PCT group (from 13.9 × 109/L to 12.2 × 109/L versus 13.9 × 109/L to 12.8 × 109/L). A linear regression model showed a mean decrease of 0.45 × 109/L in WBC count over the 24 h following the start of PCT. Every 1.0 × 109/L increase in the WBC count prior to PCT administration showed a corresponding decrease of 0.19 × 109/L in the final WBC count. In conclusion, among critically ill patients with sepsis, PCT causes only mild and clinically non-prominent changes in WBC count.

BODY TEMPERATURE VARIATION AFTER PACKED CELL TRANSFUSION IN ADULT PATIENTS WITH SEPSIS-WHERE WILL THE PENDULUM STOP?

ABSTRACT: Background : Critically ill patients with sepsis often require packed cell transfusions (PCTs). Packed cell transfusion causes changes in body's core temperature. Objective : To trace the course and amplitude of body core temperature after PCT in adults with sepsis. Methods : We conducted a population-based retrospective cohort study of patients with sepsis who received one unit of PCT during their hospitalization in a general intensive care unit during 2000-2019. A control group was established by matching each of these patients to a patient who did not receive PCT. We calculated the mean values of urinary bladder temperature for the 24 h before and 24 h after PCT. To evaluate the effect of PCT on body core temperature, multivariable analyses using a mixed linear regression model were performed. Results : The study comprised 1,100 patients who received one unit of PCT and 1,100 matched patients. The mean temperature before PCT was 37.3°C. Immediately from initiation of PCT, body temperature decreased, to a minimum of 37.0°C. During the 24 subsequent hours, the temperature increased gradually and consistently, until a peak temperature of 37.4°C. In a linear regression model, body core temperature increased by a mean 0.06°C in the first 24 h after PCT and decreased by a mean 0.65°C for every 1.0°C increase before PCT. Conclusions : Among critically ill patients with sepsis, PCT itself causes only mild and clinically insignificant temperature changes. Thus, significant changes in core temperature during the 24 h after PCT may indicate an unusual clinical event that requires clinicians' immediate attention.

Linking between ambient pollution and metals concentration in blood. Nationwide study based on the national blood banking system.

This study was aimed to describe the chemical traces of air pollution in blood of residents and evaluate the association between ambient pollution and its dose absorbed internally by a human body. The national Magen David Adom Blood Services blood donation collection platform and the National Public Health Laboratory's testing services were utilized to conduct a human biomonitoring study among blood donors in Israel. The donors' residential addresses and donations sites' locations were geocoded and merged with the levels of pollutants recorded by the nearby monitoring stations. Pollutants included nitrogen dioxide (NO2), sulfate dioxide (SO2), ozone (O3), carbon monoxide (CO) and particulate matter of size <10 and 2.5 µm in diameter (PM10 & PM2.5). Metal concentrations were statistically analyzed by ratio t-test and a lognormal regression, and adjusted to age, gender and smoking (defined based on Cadmium values). The findings indicate an independent positive association between pollutants and metals' concentrations in blood. Specifically, an increase in interquartile range (IQR) of NO2 was associated with 9.5 % increase in As in blood. The increase in one IQR of PM10 and SO2 was associated with an increase in Pb, of 16.6 % and 12.4 %, respectively. SO2 was also adversely associated with Cd concentrations, by increasing its levels by 5.7 %. The donors' proximity to quarries was related to the Pb blood levels higher 1.47 times compared to donors without quarries close to their residence (p-value = 0.013). To conclude, ambient pollution levels are associated with internal metals' concentrations, reaffirming the link between the two in the pathological pathway from air pollution to morbidity.

National blood bank services as a platform for national human biomonitoring - A proof-of-concept study.

BACKGROUND: Human biomonitoring (HBM) is crucial for identifying potential risks to human health from exposure to environmental hazards. However, it is an expensive and labor-intensive endeavor. To save on samples' collection process we suggested using a national blood banking system as a platform for a national HBM program. For the case study, we used a comparison of blood donors from heavily industrialized Haifa Bay region, northern Israel, with donors from the rest of the country. METHODS: The study population comprised a random sample of blood donors donating blood all over Israel. Samples of whole blood were tested for arsenic (As), cadmium (Cd), chromium (Cr) and lead (Pb). Donors' donations sites and residential locations were geocoded. Smoking status was verified based on Cd levels, after calibrating their concentrations vs Cotinine in a sub-sample of 45 subjects. Metal concentrations were compared between regions using a lognormal regression, while controlling for age, gender, and predicted probability of smoking. RESULTS: During Mar 2020-Feb 2022, we collected 6230 and tested 911 samples. Concentrations of most of the metals were modified by age, gender, and smoking. Cr and Pb appeared to be 1.08-1.10 times higher among Haifa Bay residents than in the rest of the country (although with borderline significance of 0.069 for Cr). Cr and Pb were 1.13-1.15 times higher for those who donated blood in the Haifa Bay region, but not necessarily resided in the area. Donors from Haifa Bay had lower levels of As and Cd as compared to other donors in Israel. CONCLUSIONS: Using a national blood banking system for HBM proved to be feasible and efficient. Blood donors from Haifa Bay area were characterized by elevated levels of Cr and Pb and lower levels of As and Cd. An extensive investigation of industries in the area is warranted.

Potassium Level Variation Following Packed Cell Transfusion in Critically Ill Adult Patients-How Alert Should We Be?

One of the most clinically important effects following the administration of packed cell transfusion (PCT) is hyperkalemia, which can cause severe life-threatening cardiac arrhythmias. This retrospective population-based cohort study included adults hospitalized between January 2007 and December 2019 in a general intensive care unit for 24 h or more, with normal levels of serum potassium on admission. We assessed changes in serum potassium levels after administration of one unit of packed cells and sought to identify clinical parameters that may affect these changes. We applied adjusted linear mixed models to assess changes in serum potassium. The mean increase in serum potassium was 0.09 mEq/L (C.U 0.04−0.14, p-value < 0.001) among the 366 patients who were treated with a single PCT compared to those not treated with PCT. Increased serum potassium levels were also found in patients who required mechanical ventilation, and to a lesser degree in those treated with vasopressors. Hypertension, the occurrence of a cerebrovascular accident, and increased creatinine levels were all associated with reduced serum potassium levels. Due to the small rise in serum potassium levels following PCT, we do not suggest any particular follow-up measures for critically ill patients who receive PCT.

Analysis of Trauma Injuries Among the Minority Population in Southern Israel-a District-Wide Study.

BACKGROUND: We compared characteristics of traumatic injury between the Bedouin subpopulation, the largest minority group in southern Israel, and the other residents in this region. METHODS: We assessed all the patients admitted with traumatic injuries during 2014-2018 to the only regional hospital in southern Israel. RESULTS: The cohort comprised 10,734 patients, 4553 (42.5%) of Bedouin origin. Compared to the non-Bedouin subpopulation, in the Bedouin subpopulation, the proportion of injuries that occurred in males was higher, 74.3% vs. 53.7%, P < 0.001, and the proportion of burn injuries that occurred in children aged 0-14 years was higher, 84% vs. 49%. Among the Bedouin and non-Bedouin patients, the respective proportions with penetrating injuries were 10.7 and 5.4%; the respective proportions who arrived at the hospital by private vehicles were 62.0 and 33.1%. In multivariate analysis, the variables that were significant for increased odds for severe trauma were Bedouin origin, male gender, and arrival to the emergency room at night. CONCLUSION: This study highlights the lack of access to basic infrastructure and healthcare among Bedouins in southern Israel. The high proportion of penetrating injuries in this subpopulation is apparently due to explosions of unexploded ordnance. The unavailability of electricity and waste removal in unrecognized villages contributes to burn injuries among Bedouin children. Poor accessibility of healthcare facilities and emergency medical transportation necessitates travel to hospitals by private car. The findings should direct trauma prevention programs to reduce burn and penetrating injuries and to increase accessibility to healthcare.

Can the Duration of In-Hospital Ventilation in Patients with Sepsis Help Predict Long-Term Survival?

Mechanical ventilation is a cornerstone in the treatment of critical illness, especially sepsis. Prolonged mechanical ventilation, for a duration exceeding 21 days, is associated with higher rates of in-hospital and post-discharge mortality. Our aim was to assess the association between in-hospital ventilation duration and long-term life expectancy in patients ventilated in intensive care units specifically due to sepsis of any origin. We conducted a population-based retrospective cohort study of adults hospitalized in a general intensive care unit for 24 h or more during 2007-2017, who were diagnosed with sepsis or septic shock, treated with invasive mechanical ventilation for a maximum of 60 days and survived hospitalization. The primary exposure was the length of invasive mechanical ventilation. In an adjusted multivariable regression model, survival rates at 1, 2, 3 and 4 years post-hospitalization did not differ significantly between patients who were ventilated for 3-8 days (n = 169), 9-21 days (n = 160) or 22-60 days (n = 170), and those who were ventilated for 1-2 days (n = 192). We concluded that the duration of in-hospital ventilation in patients with sepsis cannot serve as a predictor for long-term survival. Thus, the duration of ventilation in itself should not guide the level of care in ventilated patients with sepsis.

Estimation of Potassium Changes Following Potassium Supplements in Hypokalemic Critically Ill Adult Patients-A Patient Personalized Practical Treatment Formula.

Hypokalemia is common among critically ill patients. Parenteral correction of hyperkalemia depends on dosages and patient characteristics. Our aims were to assess changes in potassium levels following parenteral administration, and to derive a formula for predicting rises in serum potassium based on patient characteristics. We conducted a population-based retrospective cohort study of adults hospitalized in a general intensive care unit for 24 h or more between December 2006 and December 2017, with hypokalemia. The primary exposures were absolute cumulative intravenous doses of 20, 40, 60 or 80 mEq potassium supplement. Adjusted linear mixed models were used to estimate changes in serum potassium. Of 683 patients, 422 had mild and 261 moderate hypokalemia (serum potassium 3.0-3.5 mEq/L and 2.5-2.99 mEq, respectively). Following doses of 20-80 mEq potassium, serum potassium levels rose by a mean 0.27 (±0.4) mEq/L and 0.45 (±0.54) mEq/L in patients with mild and moderate hypokalemia, respectively. Changes were associated with creatinine level, and the use of mechanical ventilation and vasopressors. Among critically ill patients with mild to moderate hypokalemia, increases in serum potassium after intravenous potassium supplement are influenced by several clinical parameters. We generated a formula to predict the expected rise in serum potassium based on clinical parameters.

The impact of socioeconomic status on emergency department outcome in a low-income country setting: A registry-based analysis.

BACKGROUND: The impact of socioeconomic status on health has been established via a broad body of literature, largely from high-income countries. Investigative efforts in low- and middle-income countries have suffered from a lack of reporting standardization required to draw comparisons across countries of varying economic strata. In this study we aimed to evaluate the impact of socioeconomic status on emergency department outcomes in a low-income African country using international data classification systems. METHODS: This was a retrospective cohort study was conducted at a tertiary care center in northern Madagascar. Data were abstracted from paper charts into an electronic registry using Integrated Public Use Microdata Series codes for occupation, Nam-Powers-Boyd (NPB) scores for socioeconomic status, and Clinical Classifications Software ICD-9 equivalents for diagnosis. Outcome was dichotomized to the combined disposition of death or transfer directly to operating theater (OT) versus discharge. We used t-tests to compare baseline characteristics between these groups. We used chi-square analysis to test the association between occupational class and diagnosis. Finally, multivariate logistic regression analysis was performed examining the impact of NPB score on death/OT outcome, adjusting for age, gender, diagnosis and occupation. RESULTS: 5271 patients were seen during the 21-month study period with a death/OT rate of 9.7%. Older age and male gender were more common in death/OT patients (both p<0.001), and were shown to have positive odds ratios for this outcome in multivariate modeling (p<0.006 and <0.001). Occupational class was found to influence diagnosis for all classes (p<0.001) except Sales and Office. Adjusting for these 3 factors, we found a strong independent association between NPB quartile and death/OT outcome. Relative to the 1st quartile, the odds ratio in the 4th quartile was 2.9 (p = 0.004), the 3rd quartile 1.8 (p = 0.094), and the 2nd quartile 3.1 (p<0.001). CONCLUSION: To our knowledge, this is the first Malagasy study describing the relationship between socioeconomic status on emergency care outcomes. We found a stronger effect on health in this setting than in high-income countries, highlighting an important healthcare disparity. By using standardized classification systems we hope this study will serve as a model to facilitate future comparative efforts.