Association between EMS Workforce Density and Population Health Outcomes in the U.S.

BACKGROUND: The prehospital care provided by emergency medical services (EMS) personnel is a critical component of the public health, public safety, and health care systems in the U.S.; however, the population-level value of EMS care is often overlooked. No studies have examined how the density of EMS personnel relates to population-level health outcomes. Our objectives were to examine the geographic distribution and density of EMS personnel in the U.S.; and quantify the association between EMS personnel density and population-level health outcomes. METHODS: We conducted a cross-sectional evaluation of county-level EMS personnel density using estimates from the National Registry of Emergency Medical Technicians in nine states that require continuous national certification (Alabama, Louisiana, Massachusetts, Minnesota, New Hampshire, North Dakota, South Carolina, Vermont, and Washington, D.C.). Outcomes of interest included life expectancy, all-cause mortality, and cardiac arrest mortality. We used quantile regression models to examine the association between a 10-person increase in EMS personnel density and each outcome at the 10th, 50th (median), and 90th percentiles, controlling for population characteristics and area health resources. RESULTS: There were 356 counties included, with a mean EMS density of 223 EMS personnel per 100,000 population. Density was higher in rural compared to urban counties (247 versus 186 per 100,000 population; p = 0.001). In unadjusted models, there was a significant association between increase in EMS personnel density and an increase in life expectancy at each examined percentile (e.g., 50th percentile, increase of 52.9 days; 95% CI 40.2, 65.5; p < 0.001), decrease in all-cause mortality at each examined percentile, and decrease in cardiac arrest mortality at the 50th and 90th percentiles. These associations were not statistically significant in the adjusted models. CONCLUSIONS: EMS personnel density differs between urban and rural areas, with higher density per population in rural areas. There were no statistically significant associations between EMS density and population-level health outcomes after controlling for population characteristics and other health resources. The best approach to quantifying the community-level value that EMS care may or may not provide remains unclear.

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment.

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US.Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests.Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids.Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.

Out-of-Hospital Presentation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbations in the United States: A Nationwide Retrospective Cohort Study.

STUDY OBJECTIVE: To describe the demographic, clinical, and emergency medical service (EMS) response characteristics associated with EMS activations for asthma and chronic obstructive pulmonary disease (COPD) exacerbations in the US. METHODS: Using a nationwide set of out-of-hospital patient care report data from 2018 to 2019, we analyzed 9-1-1 EMS activations where asthma/COPD exacerbation was indicated by symptom, impression, or treatment provided. We excluded patients with ages less than 2 years or unknown, nonemergency transports, and encounters with any indication of anaphylaxis. Demographic, clinical, and EMS response characteristics were described for pediatric and adult patients with asthma/COPD exacerbations. RESULTS: A total of 1,336,988 asthma/COPD exacerbations were included, comprising 5% of qualifying 9-1-1 scene activations from 2018 to 2019. Most patients were adults (96%). Most adult patients were female (55%), whereas most pediatric patients were male (58%). Most activations occurred in urban settings (82%), particularly in pediatric patients (90%). Most asthma/COPD exacerbations were managed by advanced life support units (94%). Inhaled bronchodilators and systemic corticosteroid therapy were administered to 75% and 14% of all patients, respectively. Adults more often had oxygen saturation <92% (43% vs 20% of pediatric patients) and were more often treated with assisted ventilation (9% vs 1%). CONCLUSION: In this large nationwide sample of 9-1-1 activations treated and transported by EMS, 5% were for asthma/COPD exacerbation. Future work should focus on evidence-based standardization of EMS protocols and practice for asthma/COPD exacerbations to improve the quality of EMS care.

Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings.

BACKGROUND: Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. METHODS: Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. RESULTS: A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93). CONCLUSION: In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.

Demographic and medical school characteristics associated with urban versus rural dermatology practice: A national cross-sectional study.

There are significant disparities in access to dermatologists in rural areas relative to urban areas. We examined the associations between demographic and medical school characteristics and entry into dermatology practice in urban versus rural counties. All dermatologists who graduated from U.S. allopathic or osteopathic medical schools in the 2020 Centers for Medicare & Medicaid Services Physician Compare Database were assessed. Dermatology practice locations were coded as metropolitan or non-metropolitan according to the Rural-Urban Continuum Codes. Of 10,076 dermatologists, 543 (5.4%) practiced in non-metropolitan counties. Male gender (odds ratio [OR] 1.48, 95% CI 1.23-1.77), public medical school attendance (OR 1.94, 95% CI 1.61-2.34), DO degree (OR 1.84, 95% CI 1.32-2.51), medical school location in a non-metropolitan county (OR 5.41, 95% CI 3.66-7.84), and medical school rural track program (OR 1.57, 95% CI 1.07-2.26) were associated with higher odds of non-metropolitan dermatology practice. Our findings highlight that male gender, graduation from a non-metropolitan or public medical school, DO degree, and rural tracks are associated with higher likelihood of non-metropolitan dermatology practice. These results can inform efforts within the field of dermatology to strengthen the rural dermatologist workforce and suggest that rural educational experiences during medical school may increase recruitment of rural dermatologists.

Pedometer-measured physical activity among emergency physicians during shifts.

OBJECTIVE: Tools to measure physical activity, such as pedometers, have become more prevalent and attracted popular interest in recent years. Despite this trend, research has not yet quantified pedometer-measured physical activity among Emergency Physicians. This study aims to provide the first characterization of physical activity among on-duty Emergency Physicians in terms of step count. METHODS: Emergency Physicians wore Empatica E4 research-grade accelerometers while performing routine clinical care in the Emergency Department. A publicly available algorithm was used to estimate the number of steps taken. RESULTS: Fifty-one Emergency Physicians, including thirty-four residents and seventeen attending physicians, contributed over 1500 h of accelerometer data. On average, this cohort took 577 steps per hour (SD: 72.6), totaling 4950 steps per recorded shift (SD: 737.8), which is approximately 2.6 miles (SD: 0.31). Residents walked more than attending physicians (595.9 steps per hour (SD: 99.7) vs 563.0 steps per hour (SD: 89.0), respectively; p = 0.02). CONCLUSION: The average emergency physician in this cohort walked roughly half the daily recommended number of steps during their recorded shift. Residents walk significantly more than attending physicians.

The geographic distribution of the US pediatric dermatologist workforce: A national cross-sectional study.

BACKGROUND /OBJECTIVES: Although 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists, the regions with greatest need for the specialty are not well-defined. We aimed to determine the geographic distribution of pediatric dermatologists relative to the number of children and pediatric generalists. METHODS: We performed a cross-sectional study of all US board-certified pediatric dermatologists, generalists (defined as pediatricians and family medicine physicians), and children in 2020. Data were obtained from the Society for Pediatric Dermatology, American Board of Pediatrics, Centers for Medicare and Medicaid, and US Census Bureau. Number of children, pediatric dermatologists, and pediatric generalists were tabulated in each county and state, and the distributions of pediatric dermatologists and generalists relative to the population of children were quantified with the Gini coefficient. RESULTS: Of 317 pediatric dermatologists, 243 (76.7%) were women and 311 (98.1%) worked in a metropolitan county. A pediatric dermatologist was present in 41/50 (82%) states and 142/3228 (4.4%) counties. Not a single pediatric dermatologist was found in 54/92 (58.7%) counties with 100 000-199 999 children, 15/53 (28.3%) counties with 200 000-499 999 children, and 4/13 (30.8%) counties with ≥500 000 children. The Gini coefficient for the state-level distribution of pediatric dermatologists relative to population of children was 0.488 compared to 0.132 for that of pediatric generalists. CONCLUSION: There is a maldistribution of pediatric dermatologists, resulting in children with unmet dermatologic needs in nine states and 96 heavily populated counties. These results can inform initiatives to recruit pediatric dermatologists and to expand telehealth access to specific high-density areas.

Patient-related Factors Associated with Potentially Unnecessary Transfers for Pediatric Patients with Asthma: A Retrospective Cohort Study.

Background/Objective: Asthma is a common chronic medical condition among children and the most common diagnosis associated with interfacility transports for pediatric patients. As many as 40% of pediatric transfers may be unnecessary, resulting in potential delays in care and unnecessary costs. Our objective was to identify the patient-related factors associated with potentially unnecessary transfers for pediatric patients with asthma. Methods: We used patient care data from the California Department of Health Care Access and Information patient discharge and emergency department (ED) datasets to capture ED visits where a pediatric patient (age 2-17 years) presented with asthma and was transferred to another ED or acute care hospital. The outcome of interest was a potentially unnecessary transfer, defined as a visit where length of stay after transfer was <24 hours and no advanced services were used, such as respiratory therapy or critical care. Patient-related characteristics were extracted, including age, gender, race/ethnicity, primary language, insurance status, and clinical characteristics. First, we used descriptive statistics to compare necessary vs unnecessary transfers. Second, we used generalized estimating equations accounting for clustering by ED to estimate odds ratios (OR) and identify factors associated with potentially unnecessary transfers. Results: A total of 4,233 pediatric ED patients were transferred with a diagnosis of asthma, including 461 (11%) transfers that met criteria as potentially unnecessary. Median age was 12 years (interquartile range 7-15), and 46% were female. Factors associated with increased odds of potentially unnecessary transfer while controlling for key factors included younger age (eg, 2-5 years, OR 2.0, 95% confidence interval [CI] 1.4-2.9), male gender (OR 1.4, 95% CI 1.1-1.7), and Hispanic ethnicity (OR 1.6, 95% CI 1.2-2.1), while multiple hospitalizations for asthma per year was associated with decreased odds (OR 0.2, 95% CI 0.1-0.4). Conclusion: Several patient-related factors were associated with increased or decreased odds of potentially unnecessary transfers among pediatric patients presenting to the ED with asthma. These factors can be considered in future work to better understand, predict, and reduce unnecessary transfers and their negative consequences.

Patients who use emergency medical services have greater severity of illness or injury compared to those who present to the emergency department via other means: A retrospective cohort study.

Objective: We aimed to evaluate the differences in characteristics and illness/injury severity among patients who present to the emergency department (ED) via emergency medical services (EMS) compared to patients who present via other means. Methods: We analyzed a nationwide sample of ED visits from the 2015-2019 National Hospital Ambulatory Medical Care Survey. We excluded patients <18 or >92 years old, who eloped or left against medical advice, or who arrived via interfacility transport. Mode of presentation was dichotomized to those presenting to the ED via EMS versus any other mode of transportation. Using the appropriate survey sampling weights, we described patient characteristics and compared measures of illness/injury severity between groups using a multivariable logistic regression model. Results: An unweighted total of 73,397 ED visits, representing a weighted estimate of 528,083,416 ED visits in the United States during 2015-2019, included 18% arriving via EMS and 82% via other means. EMS patients were older, more often male, more often had multiple chronic medical conditions, and less often had private insurance. EMS patients had higher priority triage scores, consumed more resources in the ED, and had longer lengths of stay. Arrival by EMS was associated with higher odds of hospital admission (odds ratio [OR] 2.7, 95% confidence interval [CI] 2.4-2.9) and in-hospital mortality (OR 11.1, 95% CI 7.3-17.2). Conclusions: Patients presenting via EMS had significantly different characteristics and outcomes than those presenting via other means. These important differences should be considered when comparing studies of all ED patients versus those who present via EMS.

The double-stranded RNA-binding protein, PACT, is required for postnatal anterior pituitary proliferation.

PACT is a double-stranded RNA-binding protein that also binds and activates the latent protein kinase, PKR, which plays a major role in cellular antiviral defense in mammals. For evaluating PACT's contribution to the innate immune system, Pact(-/-) mice have been generated; these mice exhibit notable developmental abnormalities including microtia, with craniofacial, ear, and hearing defects. Here we report that, in addition, Pact(-/-) mice had smaller body size and fertility defects, both of which were caused by defective pituitary functions. Pact(-/-) mice exhibited anterior pituitary lobe (AL) hypoplasia, which developed postnatally, when the second phase of pituitary expansion occurs. Among the 5 cell types in AL, the numbers of corticotrophs, gonadotrophs, and somatotrophs were equally decreased in Pact(-/-) mice with a greater impact on lactotrophs and a lesser impact on thyrotrophs. PACT mRNA and protein were highly expressed in the pituitary of wild-type (Wt) mice during the postnatal wave of AL proliferation, the same period in which the hypoplasia developed in Pact(-/-) mice. During this time, the pituitaries of Pact(-/-) mice did not exhibit significantly increased apoptosis compared with Wt mice but showed a decrease in cell proliferation. The inhibition of cell proliferation observed in vivo could be recapitulated in vitro in GH3 somato/lactotroph and LbetaT2 gonadotroph cell lines; knockdown of PACT expression with siRNA diminished the rate of proliferation of these cells. Our study revealed a physiologically significant role for PACT in cell proliferation and an essential role of a dsRNA-binding protein in mammalian pituitary expansion.

Disparity in prehospital scene time for geriatric trauma patients.

BACKGROUND: Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults. METHODS: Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity. RESULTS: Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29. CONCLUSIONS: Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

Prehospital care for traumatic cardiac arrest in the US: A cross-sectional analysis and call for a national guideline.

AIM: We describe emergency medical services (EMS) protocols and prehospital practice patterns related to traumatic cardiac arrest (TCA) management in the U.S. METHODS: We examined EMS management of TCA by 1) assessing variability in recommended treatments in state EMS protocols for TCA and 2) analyzing EMS care using a nationwide sample of EMS activations. We included EMS activations involving TCA in adult (≥18 years) patients where resuscitation was attempted by EMS. Descriptive statistics for recommended and actual treatments were calculated and compared between blunt and penetrating trauma using χ2 and independent 2-group Mann-Whitney U tests. RESULTS: There were 35 state EMS protocols publicly available for review, of which 16 (45.7%) had a specific TCA protocol and 17 (48.5%) had a specific termination of resuscitation protocol for TCA. Recommended treatments varied. We then analyzed 9,565 EMS activations involving TCA (79.1% blunt, 20.9% penetrating). Most activations (93%) were managed by advanced life support. Return of spontaneous circulation was achieved in 25.5% of activations, and resuscitation was terminated by EMS in 26.4% of activations. Median prehospital scene time was 16.4 minutes; scene time was shorter for penetrating mechanisms than blunt (12.0 vs 17.0 min, p < 0.001). Endotracheal intubation was performed in 32.0% of activations, vascular access obtained in 66.6%, crystalloid fluids administered in 28.8%, and adrenaline administered in 60.1%. CONCLUSION: Actual and recommended approaches to EMS treatment of TCA vary nationally. These variations in protocols and treatments highlight the need for a standardized approach to prehospital management of TCA in the U.S.

Trends in demographic and employment characteristics of US emergency medical technicians and paramedics, 2011-2019.

Background: Describing the US emergency medical services workforce is important to understand gaps in recruitment and retention and inform efforts to improve diversity. Our objective was to describe the characteristics and temporal trends of emergency medical technicians (EMTs) and paramedics in the United States. Methods: We performed a repeated cross-sectional evaluation of US Census Bureau's American Community Survey 1-year Public Use Microdata Sample data sets from 2011-2019. We included respondents working as an EMT or paramedic. Survey-weighted descriptive statistics of demographic and employment characteristics were calculated. Trend analysis was conducted using joinpoint regression to estimate slope and annual percent change (APC). Results: The total estimated number of EMTs and paramedics in the United States increased from 216,310 (95%CI 204,957-227,663) in 2011 to 289,830 (95%CI 276,918-302,743) in 2019 (APC 3.0%; 95%CI 1.4%, 4.7%). There was a slight increase in the proportion of females (2011, 31%; 2019, 35%). There was a significant decrease in proportion of non-Hispanic whites (2011, 80%; 2019, 72%; APC -1.5%; 95%CI -2.0%, -0.9%) with concurrent increases in other racial/ethnic groups (e.g., Hispanics, 2011, 10%; 2019, 13%). About half worked >40 hours per week, with little change over time. Between 15% and 18% lived and worked in different states, and about 40% traveled ≥30 minutes to their workplace. Conclusions: The number of EMTs and paramedics actively working in EMS as their primary paid occupation has increased over time. However, there have been only modest changes in their demographic diversity.

Gender differences in dermatologist practice locations in the United States: A cross-sectional analysis of current gender gaps.

BACKGROUND: The percentage of female dermatologists has increased from 6.9% in 1970 to 48.9% in 2017. Despite the changing gender composition of the dermatologist workforce, it is unknown whether there are gender-based differences in dermatology practice locations. OBJECTIVE: This study aimed to characterize gender-based differences in dermatology practice locations across the United States. METHODS: A cross-sectional study of all dermatologists in the 2020 Centers for Medicare and Medicaid Services Physician Compare Database was performed. The number of self-identified female dermatologists and total dermatologists in each county and state was tabulated, and Spearman's correlation coefficients between county-level demographic and socioeconomic characteristics and female practices were calculated. RESULTS: Among 11,911 dermatologists, 5945 (49.9%) self-identified as female and 5966 (50.1%) as male. Of the 1052 counties with a dermatologist, 291 (27.7%) had no female dermatologist and 149 (14.2%) had no male dermatologist. The percentage of female dermatologists in each state ranged from 18.4% to 62.2%. Female dermatologists practiced more in areas with a higher percentage of democratic voters (r = +0.22) and higher median household income (r = +0.18), and less in rural counties (r = -0.18) or counties with higher uninsured rates (r = -0.11). CONCLUSION: Female dermatologists remain significantly underrepresented in some regions in the United States, particularly in the Mountain states and rural counties. As women continue entering the dermatologist workforce, these results can inform workforce planning strategies to improve the distribution and accessibility of dermatologists across the United States.

Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018.

Importance: Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear. Objective: This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies. Design, Setting, and Participants: This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index. Exposures: Implementation of ACA on January 1, 2014. Main Outcomes and Measures: Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker. Results: In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04). Conclusions and Relevance: Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

Gp4 is a nuclease required for morphogenesis of T4-like bacteriophages.

An essential step in the morphogenesis of tailed bacteriophages is the joining of heads and tails to form infectious virions. Our understanding of the maturation of complete virus particles remains incomplete. Through an unknown mechanism, phage T4 gene product 4 (gp4) plays an essential role in the head-tail joining step of T4-like phages. Alignment of T4 gp4 homologs identified a type II restriction endonuclease motif. Purified gp4 from both T4 and a marine T4-like bacteriophage, YC, have non-specific nuclease activity in vitro. Mutation of a single conserved amino acid residue in the endonuclease fold of T4 and YC gp4 abrogates nuclease activity. When expressed in trans, the wild type T4 gp4, but neither the mutated T4 protein nor the YC homolog, rescues a T4 gene 4 amber mutant phage. Thus the nuclease activity appears essential for morphogenesis, potentially by cleaving packaged DNA to enable the joining of heads to tails.

Biochemical analysis of PKR activation by PACT.

Many extracellular stresses cause inhibition of translation initiation by triggering phosphorylation of the initiation factor, eIF-2alpha. A major protein kinase responsible for this phosphorylation is PKR, a latent kinase which itself needs to be activated by autophosphorylation. In stressed cells, this activation occurs when PACT, a PKR-binding protein, is phosphorylated and activates PKR. We have previously demonstrated that the presence of specific residues in domain 3 of PACT is necessary for its ability to activate PKR in vivo. Here, we analyze the biochemical properties of the inactive PACT mutants by assessing their ability to bind and activate PKR in vitro. Among the essential residues, two serines need to be phosphorylated in vivo for PACT's ability to activate PKR. We substituted those serines with aspartic acids, mimics of phosphoserines, and investigated the properties of the corresponding mutant PACTs. In vitro, they activate PKR more efficiently because they bind to PKR more tightly. These results indicate that stress-induced phosphorylation of specific serine residues in domain 3 of PACT increases its affinity for PKR, which leads to better activation of PKR and resultant eIF-2alpha phosphorylation.

Purulent bacterial pericarditis from Staphylococcus aureus.

Purulent pericarditis is a rare condition in the modern antibiotic era. The diagnosis should be suspected in patients with pericardial effusions and radiographic and laboratory investigations consistent with infection. Pericardial fluid culture is the gold standard. Early source control, in addition to antibiotics, is a cornerstone of treatment.

Progestin therapy to prevent preterm birth: History and effectiveness of current strategies and development of novel approaches.

In the 1930s the "progestin" hormone produced by the corpus luteum was isolated and found to be a Δ4-keto-steroid. It was aptly named progesterone (P4) and in the following 30 years the capacity of P4 and derivatives to prevent preterm birth (PTB) was examined. Outcomes of multiple small studies suggested that progestin prophylaxis beginning at mid-gestation decreases the risk for PTB. Subsequent larger trials found that prophylaxis with weekly intramuscular injections of 17α-hydroxyprogesterone caproate (17HPC) beginning at mid-gestation decreased PTB risk in women with a history of PTB. Other trials found that daily vaginal P4 prophylaxis, also beginning at mid-gestation decreased PTB risk in women with a short cervix. Currently, prophylaxis with 17HPC (in women with a history of PTB) or vaginal P4 (in women with a short cervix) are used to prevent PTB. Recent advances in understanding the molecular biology of P4 signaling in uterine cells is revealing novel progestin-based targets for PTB prevention. One possibility is to use selective P4 receptor (PR) modulators (SPRMs) to boost PR anti-inflammatory activity that blocks labor, while simultaneously preventing PR phosphorylation that causes loss of P4/PR anti-inflammatory activity. This may be achieved by SPRMs that induce a specific PR conformation that prevents site-specific serine phosphorylation that inhibits anti-inflammatory activity. Further advances in understanding how P4 promotes uterine quiescence and how its labor blocking actions are withdrawn to trigger parturition will reveal novel therapeutic targets to more effectively prevent PTB.