Environmental pollutant risk factors for worse COVID-19 related clinical outcomes in predominately hispanic and latino populations.

BACKGROUND: Per- and poly-fluorinated compounds (PFAS) and heavy metals constitute two classes of environmental exposures with known immunotoxicant effects. In this pilot study, we aimed to evaluate the impact of exposure to heavy metals and PFAS on COVID-19 severity. We hypothesized that elevated plasma-PFAS concentrations and urinary heavy metal concentrations would be associated with increased odds of ICU admission in COVID-19 hospitalized individuals. METHODS: Using the University of Southern California Clinical Translational Sciences Institute (SC-CTSI) biorepository of hospitalized COVID-19 patients, urinary concentrations of 15 heavy metals and urinary creatinine were measured in n = 101 patients and plasma concentrations of 13 PFAS were measured in n = 126 patients. COVID-19 severity was determined based on whether a patient was admitted to the ICU during hospitalization. Associations of metals and PFAS with ICU admission were assessed using logistic regression models, controlling for age, sex, ethnicity, smoking status, and for metals, urinary dilution. RESULTS: The average age of patients was 55 ± 14.2 years. Among SC-CTSI participants with urinary measurement of heavy metals and blood measures of PFAS, 54.5% (n = 61) and 54.8% (n = 80) were admitted to the ICU, respectively. For heavy metals, we observed higher levels of Cd, Cr, and Cu in ICU patients. The strongest associations were with Cadmium (Cd). After accounting for covariates, each 1 SD increase in Cd resulted in a 2.00 (95% CI: 1.10-3.60; p = 0.03) times higher odds of admission to the ICU. When including only Hispanic or Latino participants, the effect estimates between cadmium and ICU admission remained similar. Results for PFAS were less consistent, with perfluorodecanesulfonic acid (PFDS) exhibiting a positive but non-significant association with ICU admission (Odds ratio, 95% CI: 1.50, 0.97-2.20) and perfluorodecanoic acid (PFDA) exhibiting a negative association with ICU admission (0.53, 0.31-0.88). CONCLUSIONS: This study supports the hypothesis that environmental exposures may impact COVID-19 severity.

Mindful attention is inversely associated with pain via mediation by psychological distress in orthopedic patients.

BACKGROUND: Orthopedic patients report pain as their main symptom complaint. Subjective pain experience is correlated with self-reported psychological state, such as distress. PURPOSE: This study tests whether scores from a measure of mindful attention are associated with subjective pain levels and whether psychological distress scores function as a mediation path. METHODS: During routine visits to a single orthopedic clinic in East Los Angeles, California, 525 patients were recruited to participate in the study. Participants reported on measures of pain (Universal Pain Assessment Tool [UPAT]), mindful attention (Five-Facet Mindfulness Questionnaire [FFMQ]), and psychological distress (Depression, Anxiety, Stress Scale [DASS]). We used Pearson correlations to examine relationships between FFMQ and UPAT scores and mediation analyses to test indirect effects of DASS scores as a mediation path. RESULTS: The average age of the sample was 54 years (range 18-98 years), 61% were male, and 64% were non-Hispanic White individuals. The locations of injury were the shoulder (72%), elbow (21%), and clavicle or wrist (7%). Ninety-one percent reported mild or greater pain in the prior 2 weeks (mean = 4.2 ± 2.5, range 0-10), and 49% reported mild or more severe distress symptoms (DASS: 13.0 ± 11.5). FFMQ scores inversely predicted UPAT scores (ß = -0.22, P < .01), mediated through DASS scores. DASS subscale scores for depression (ß = -0.10, P = .02) and stress (ß = -0.08, P = .04) but not anxiety (ß = -0.03, P = .33) produced significant indirect effects. FFMQ acting-with-awareness and non-judging subscales had the largest effect on depression and stress DASS subscale scores. CONCLUSIONS: We find statistical support to suggest that distress-particularly depressed mood and stress-mediates the association between mindful attention and pain intensity among orthopedic patients. A disposition of mindful attention might counter distress ailments that exacerbate subjective pain, and this has possible implications for mindfulness training interventions offered to orthopedic patients.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Did prioritizing essential workers help to achieve racial/ethnic equity in early COVID-19 vaccine distribution? The LA pandemic surveillance cohort study.

BACKGROUND: Most US states and counties prioritized essential workers for early access to COVID-19 vaccines due to their heightened occupational risk. Racial/ethnic groups most impacted by COVID-19 are overrepresented among essential workers. This study estimates the effects of prioritizing essential workers on racial/ethnic equity in COVID-19 vaccination. METHODS: Survey data were collected from 5500 Los Angeles County adult residents in March and April 2021. Multivariate regression models were used to assess marginal changes in probabilities of vaccination attributable to essential worker status by race/ethnicity. These probabilities were multiplied by population proportions of essential workers in each racial/ethnic group to estimate the effects of prioritizing essential workers on vaccine equity in the population. RESULTS: While Latinos (24.9%), Blacks (22.4%), and Asians (21.4%) were more likely to be prioritized essential workers than Whites (14.3%), their marginal gains in vaccine uptake due to their essential worker status did not significantly differ from that of Whites. At the population-level, prioritizing vaccines for essential workers increased the probabilities of vaccination by small and similar amounts among Asians (5.3%; 95% confidence interval [CI]: 3.3%, 7.5%), Blacks (4.0%; 95% CI: 1.7%, 6.5%), Latinos (3.7%; 95% CI: 2.3%, 5.1%), and Whites (2.9%; 95% CI :1.9%, 3.9%). CONCLUSIONS: Prioritizing essential workers did not provide proportionally greater early vaccine uptake benefits to racial/ethnic groups that were disproportionately affected by COVID-19. Early prioritization of essential workers during vaccine campaigns is an important but insufficient strategy for reducing racial/ethnic disparities in early vaccine uptake. Additional strategies addressing access and trust are needed to achieve greater equity in vaccine distribution.

The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events.

OBJECTIVES: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation. MATERIALS AND METHODS: A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year. RESULTS: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals. CONCLUSIONS: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

National trends in mental health-related emergency department visits by children and adults, 2009-2015.

OBJECTIVES: Examine trends in mental health-related emergency department (ED) visits, changes in disposition and length of stay (LOS), describe disposition by age and estimate proportion of ED treatment hours dedicated to mental health-related visits. METHODS: Retrospective analysis of ED encounters in the National Hospital Ambulatory Medical Care Visit Survey with a mental health primary, secondary or tertiary discharge diagnosis from 2009 to 2015. We report survey-weighted estimates of the number and proportion of ED visits that were mental health-related and disposition by age and survey year. We estimate the proportion of ED treatment hours dedicated to mental health-related visits. We analyze trends in disposition and LOS for mental health and non-mental health-related visits using multivariate regression analysis. RESULTS: Mental health-related ED visits increased by 56.4% for pediatric patients and 40.8% for adults, accounting for over 10% of ED visits by 15-64 year-olds and nearly 9% by 10-14 year-olds in 2015. Mental health-related visit disposition of admission or transfer declined from 29.8% to 20.4% (p < .001); predicted median ED LOS for admissions or transfers increased from 6.5 to 9.0 hours while median LOS for discharges was stable at 4.4 hours. During the study period, mental health-related visits accounted for 5.0% (95% CI 4.6-5.3) of all pediatric and 11.1% (95% CI 11.0-11.3) of adult ED treatment hours. CONCLUSIONS: Mental health-related visits account for an increasing proportion of ED visits and a considerable proportion of treatment hours. A decreasing proportion of mental health-related visits resulted in inpatient disposition and ED LOS increased for admissions and transfers.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014.

STUDY OBJECTIVE: We determine the incidence of and trends in enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) during the past decade. METHODS: We obtained a comprehensive list of all EMTALA investigations conducted between 2005 and 2014 directly from the Centers for Medicare & Medicaid Services (CMS) through a Freedom of Information Act request. Characteristics of EMTALA investigations and resulting citation for violations during the study period are described. RESULTS: Between 2005 and 2014, there were 4,772 investigations, of which 2,118 (44%) resulted in citations for EMTALA deficiencies at 1,498 (62%) of 2,417 hospitals investigated. Investigations were conducted at 43% of hospitals with CMS provider agreements, and citations issued at 27%. On average, 9% of hospitals were investigated and 4.3% were cited for EMTALA violation annually. The proportion of hospitals subject to EMTALA investigation decreased from 10.8% to 7.2%, and citations from 5.3% to 3.2%, between 2005 and 2014. There were 3.9 EMTALA investigations and 1.7 citations per million emergency department (ED) visits during the study period. CONCLUSION: We report the first national estimates of EMTALA enforcement activities in more than a decade. Although EMTALA investigations and citations were common at the hospital level, they were rare at the ED-visit level. CMS actively pursued EMTALA investigations and issued citations throughout the study period, with half of hospitals subject to EMTALA investigations and a quarter receiving a citation for EMTALA violation, although there was a declining trend in enforcement. Further investigation is needed to determine the effect of EMTALA on access to or quality of emergency care.

Exposure to and Use of Electronic Cigarettes: Does Language Matter?

OBJECTIVES: To determine whether patients who are English proficient become aware of e-cigarettes through different marketing tactics and have dissimilar patterns of use than patients who are non-English speaking. DESIGN: This was a cross-sectional study surveying adult English- and Spanish-speaking patients. ANOVA and chi-squared tests were used to examine differences between groups. SETTING: A large public, safety-net hospital in Los Angeles County, California. RESULTS: Respondents (N=1899) were predominately Hispanic (78%), foreign-born (68%), and reported Spanish as a primary language (64%). Native English speakers reported the highest use of e-cigarettes (26%), followed by non-native (13%) and non-English speakers (2%) (P<.001). In terms of marketing, native and non-native English speakers were more likely to have friends and family as sources of e-cigarette information (P<.001). Native speakers were more likely to see advertisements for e-cigarettes on storefronts (P=.004) and on billboards (P<.001). Non-English speakers were most likely to learn about e-cigarettes on the news (P<.001) and in advertisements on the television and radio (P=.002). Differences in reasons for use were not significant between the three groups. CONCLUSIONS: Native and non-native English speakers become aware of e-cigarettes through different mechanisms and use e-cigarettes at a significantly higher rate than non-English speakers. These results highlight an opportunity for public health programs to concentrate on specific channels of communication that introduce patient populations to e-cigarettes to slow the spread of e-cigarette usage.

Prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the United States.

BACKGROUND: Despite a growing body of scientific literature exploring the nature of meditation there is limited information on the characteristics of individuals who use it. This is particularly true of comparative studies examining prevalence and predictors of use of various forms of meditation. METHODS: A secondary analysis was conducted using data from the 2012 National Health Interview Survey (n = 34,525). Three popular forms of meditation were compared-mantra, mindfulness, and spiritual-to determine lifetime and 12-month use related to key sociodemographic, health behavior, health status, and healthcare access variables. RESULTS: The 12-month prevalence for meditation practice was 3.1% for spiritual meditation, 1.9% for mindfulness meditation, and 1.6% for mantra meditation. This represents approximately 7.0, 4.3, and 3.6 million adults respectively. A comparison across the three meditation practices found many similarities in user characteristics, suggesting interest in meditation may be more related to the type of person meditating than to the type of practice selected. Across meditation styles use was more prevalent among respondents who were female, non-Hispanic White, college educated, physically active; who used other complementary health practices; and who reported depression. Higher utilization of conventional healthcare services was one of the strongest predictors of use of all three styles. In addition to similarities, important distinctions were observed. For example, spiritual meditation practice was more prevalent among former drinkers. This may reflect use of spiritual meditation practices in support of alcohol treatment and sobriety. Reasons for use of meditation were examined using the sample of respondents who practiced mindfulness meditation. Wellness and prevention (74%) was a more common reason than use to treat a specific health condition (30%). Common reasons for use included stress management (92%) and emotional well-being (91%), and to support other health behaviors. Meditation was viewed positively because it was self-care oriented (81%) and focused on the whole person (79%). CONCLUSION: Meditation appears to provide an accessible, self-care resource that has potential value for mental health, behavioral self-regulation, and integrative medical care. Considering consumer preference for distinct types of meditation practices, understanding the underlying mechanisms, benefits, and applications of practice variations is important.

Do emergency pediatric psychiatric visits for danger to self or others correspond to times of school attendance?

BACKGROUND: Pediatric and adolescent mental health complaints are growing problems for emergency departments and inpatient facilities. We sought to investigate the relationship between weeks when school is in session (vs vacation) and presentation with concern for danger to self or others. METHODS: We retrospectively studied the risk of presenting with these complaints while school is in attendance compared to the risk while on vacation over a 4-year period (2009-2012) at an academic pediatric emergency department. The week of presentation was recorded for all children making psychiatric visits related to suicidality or homicidality, and these were correlated with the public school calendar for the local school district. The incidence rate ratio (IRR) was calculated for psychiatric visits while in school status vs vacation. Similar data were collected for a diagnosis of urinary tract infection to serve as a control. RESULTS: Of 3223 eligible patients (mean age, 13.8 years), 82.7% presented while in school, although the students only spent 68.6% of their time in school, yielding an IRR of 2.18. By comparison, the IRR for the diagnosis of urinary tract infection was 1.25. CONCLUSIONS: Children and adolescents are more likely to present with concerns for danger to self or others while attending school compared with while on vacations. Causation and opportunities for intervention require further study.

Acid-citrate-dextrose Formula A versus heparin as primary catheter lock solutions for therapeutic apheresis.

BACKGROUND: Unfractionated heparin (UFH) is a commonly used catheter lock solution, but may lead to various complications. Acid-citrate-dextrose Formula A (ACD-A), the standard anticoagulant used in therapeutic apheresis (TA), is an alternative. We compared the efficacy of these two anticoagulants as primary catheter lock solutions. STUDY DESIGN AND METHODS: The following outcomes were analyzed retrospectively for all TA procedures performed between July 2009 and March 2012: patent, partial occlusion, total occlusion, catheter-related blood stream infection, tissue plasminogen activator use, and premature catheter removal. RESULTS: Our primary data set included 5964 total catheter days, 3020 procedures, and 427 TA courses. The UFH group comprised 3444 catheter days and 1880 procedures; the ACD-A group, 2520 catheter days and 1140 procedures. Overall catheter-related outcomes differed by not more than 5.3% for the primary analysis and when stratified by short-term (≤10 days) duration or short dwell times (<3 days). When stratified by long-term duration (>10 days) and long dwell times (>3 days), differences increased to not more than 10.4 and 22.4%, respectively. CONCLUSIONS: For short-term courses and short dwell times, UFH and ACD-A appear equally effective; UFH appears superior to ACD-A in the setting of long-term courses and long dwell times. Major catheter-related complications were rare and occurred with similar frequency in both groups. For most indications, ACD-A appears to be a reasonable alternative to heparin; however, an adequately powered, randomized trial would be required to definitively address this issue.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.

STUDY OBJECTIVE: Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population. METHODS: We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction. RESULTS: Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends. CONCLUSION: The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.

Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance.

STUDY OBJECTIVE: We assess whether screening laboratory tests obtained to medically clear pediatric psychiatric patients altered management or disposition. METHODS: This was a retrospective chart review of consecutive patients younger than 18 years and presenting to an academic pediatric emergency department for medical clearance of an acute psychiatric emergency potentially requiring an involuntary hold (danger to self, danger to others, grave disability) from July 2009 to December 2010. Patients were identified by discharge diagnosis codes. History and physical examination and screening laboratory tests were reviewed for changes in management or disposition. Further analysis compared length of stay according to type of laboratory test performed. To avoid missing patients presenting with or for evaluation of an involuntary hold for whom an organic cause was diagnosed, charts with psychiatric chief complaints were reviewed for the same period. RESULTS: One thousand eighty-two visits resulting in 13,725 individual laboratory tests were analyzed. Of 871 visits with laboratory tests performed, abnormal laboratory tests were associated with 7 disposition changes (0.8%) and 50 management changes (5.7%) not associated with a disposition change. Twenty-five patients with noncontributory history and physical examination results had management changes, all non-urgent. One patient with a noncontributory history and physical examination result had a disposition-changing laboratory result, a positive urine pregnancy test. Patients who had any screening test performed had a longer length of stay than patients without testing (117 minutes longer; 95% confidence interval 109.7 to 124.4 minutes). In charts reviewed according to chief complaint, no patient was found to have an organic cause of their symptoms according to only screening tests. CONCLUSION: Screening laboratory tests resulted in few management and disposition changes in patients with noncontributory history and physical examination results but were associated with increased length of stay.

Is medical clearance necessary for pediatric psychiatric patients?

BACKGROUND: Although most studies have found low rates of organic illness in patients with isolated psychiatric complaints, psychiatric patients are frequently brought to emergency departments (EDs) for medical clearance. STUDY OBJECTIVES: To assess the utility of ED medical clearance before transfer of pediatric patients on psychiatric holds to inpatient psychiatric facilities, and to evaluate charges associated with ED medical clearance. METHODS: Retrospective study of pediatric psychiatric patients in one urban pediatric ED with 22,000 annual patient visits over an 18-month period. Patients were included if transported to the ED for medical clearance after being placed on an involuntary psychiatric hold in the prehospital setting. Main outcome measures were charges for screening laboratory tests and secondary ambulance transfers and wages for sitters resulting from ED visits for medical screening examinations of patients on psychiatric holds. We also determined what percentage of patients truly warranted a medical screen and the percentage of psychiatric holds overturned, avoiding transfer to a psychiatric hospital. RESULTS: There were 789 patients included; 72 (9.1%) were determined to require medical screening. Total charges for laboratory assessments and secondary ambulance transfers and wages for sitters were $1,241,295, or US$17,240 per patient requiring a medical screen. Only 35 (4.4%) holds were overturned in the ED. CONCLUSION: Few patients brought to the ED on an involuntary hold required a medical screen. Use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) could have led to significant savings.

Treating psychiatric emergencies in incarcerated minors in the emergency department: what is the cost and what is their disposition?

BACKGROUND: Although mental health disorders are common among incarcerated minors, psychiatric urgencies and emergencies often cannot be treated in juvenile detention facilities, necessitating emergency department (ED) transfers. The cost of this ED care has not been well studied. OBJECTIVE: This study aimed to provide information on disposition and cost related to ED visits by juvenile hall patients transported for urgent psychiatric evaluation. METHODS: A retrospective cross-sectional descriptive study of patients presenting to 1 ED from juvenile detention centers for consideration of psychiatric holds was conducted. Eligible patients were identified by a search of the International Classification of Diseases, Ninth Revision, discharge diagnosis codes and chart review. We collected information on patient demographics and disposition and calculated costs of ED visits, screening laboratories performed, inpatient stays on a medical ward, sitter and parole officer salaries, and ambulance transfers. RESULTS: One hundred eight patients accounting for 196 visits were transported from juvenile hall for urgent psychiatric evaluation. Of the 196 visits, 131 (67%) resulted in an involuntary psychiatric hold. More than half of the patients on hold (75 patients) were admitted to a medical ward for boarding because of lack of psychiatric inpatient beds. Included charges for the 196 visits during the 18-month period totaled US $1,357,884, with most of the costs due to boarding on the medical ward. CONCLUSIONS: We describe the magnitude and cost associated with addressing psychiatric emergencies in a juvenile correctional system relying on transport of patients to an ED for acute psychiatric evaluation and treatment. Further research is needed to determine if costs could be decreased by increasing psychiatric resources in juvenile detention centers.

Disparities in access to COVID-19 testing in Los Angeles County.

COVID-19 has disparately impacted low-income persons and racial and ethnic minorities-primarily Black and Hispanic populations. Our objective is to quantify disparities in access to COVID-19 testing and identify barriers to testing during the winter 2020-2021 surge in COVID-19 infections in Los Angeles County. An online survey was administered between December 2020 and January 2021 through which respondents were asked about their use of COVID testing and the barriers to testing they experienced. Our sample of 1,984 was reweighted to match the demographics of Los Angeles County. Despite similar testing rates to White residents, Hispanic residents were more likely to report testing positive. Persons with an annual income of $20,000 or less were less likely to receive a test than those with an income of $100,000 or more. Barriers to testing were more prevalent among racial/ethnic minorities and low-income persons. White respondents and high-income persons were more likely to report the ability to take time off work to await test results. Rates of testing were not commensurate with the rates of infection across racial/ethnic groups, which may be explained by higher rates of reported barriers to testing among Black and Hispanic residents. These findings may inform policies that address structural barriers to testing that disproportionately impact racial/ethnic minorities and low-income populations.

Demographic Characteristics Associated With Intentions to Receive the 2023-2024 COVID-19 Vaccine.

INTRODUCTION: The U.S. Food and Drug Administration approved the updated 2023-2024 COVID-19 vaccines by Pfizer-BioNTech and Moderna on September 11, 2023. Despite the Centers for Disease Control and Prevention's recommendation that everyone aged ≥6 years receive the updated COVID-19 vaccine, the general public's intentions to receive the new 2023-2024 vaccine are unknown. METHODS: Intentions to receive the new COVID-19 vaccine and the demographic predictors of those intentions were assessed from a survey of adult residents, aged ≥18 years, of Los Angeles County, California conducted in October 2023. RESULTS: Of the 1,090 participants, 701 (64.3%) indicated they were planning on receiving the new COVID-19 vaccine, 217 (19.9%) responded no, and 172 (15.8%) were unsure. Male gender (versus female); age groups of 50-64 and ≥65 years (versus 18-29 years); and ≥$100,000 household income (versus ≤$49,999) were associated with higher odds of reporting yes than reporting no regarding their vaccination intentions. Asian and Hispanic race/ethnicity (versus Non-Hispanic White) were associated with higher odds of indicating not sure than the odds of indicating no vaccination intentions. A significantly higher proportion of not-sure respondents reported "I plan to wait and see if it is safe and may get it later", whereas a significantly higher proportion of no respondents reported "I don't believe I need a COVID-19 vaccine booster" and "I don't trust COVID-19 vaccines." CONCLUSIONS: This study demonstrates demographic differences in attitudes toward COVID-19 vaccination intentions and highlights the importance of promotional messages and initiatives that target more hesitant populations. These messages should address possible side effects and vaccine safety.

The differential impacts of COVID-19 mortality on mental health by residential geographic regions: The Los Angeles Pandemic Surveillance Cohort Study.

OBJECTIVE: This study examines the association between changes in mental health before and during the COVID-19 pandemic and COVID-19 mortality across geographic areas and by race/ethnicity. METHODS: A cross-sectional survey was conducted in Los Angeles County between April and May 2021. The study used the Patient Health Questionnaire-2 to assess major depression risk. Participants' home ZIP codes were classified into low, middle, and high COVID-19 mortality impacted areas (CMIA). RESULTS: While there were existing mental health disparities due to differences in demographics and social determinants of health across CMIA in 2018, the pandemic exacerbated the disparities, especially for residents living in high CMIA. Non-White residents in high CMIA reported the largest deterioration in mental health. Differences in mental health by CMIA persisted after controlling for resident characteristics. CONCLUSIONS: Living in an area with higher COVID-19 mortality rates may have been associated with worse mental health, with Non-White residents reporting worse mental health outcomes in the high mortality area. POLICY IMPLICATIONS: It is crucial to advocate for greater mental health resources in high COVID-19 mortality areas especially for racial/ethnic minorities.