The San Diego 2007 wildfires and Medi-Cal emergency department presentations, inpatient hospitalizations, and outpatient visits: An observational study of smoke exposure periods and a bidirectional case-crossover analysis.

BACKGROUND: The frequency and intensity of wildfires is anticipated to increase as climate change creates longer, warmer, and drier seasons. Particulate matter (PM) from wildfire smoke has been linked to adverse respiratory and possibly cardiovascular outcomes. Children, older adults, and persons with underlying respiratory and cardiovascular conditions are thought to be particularly vulnerable. This study examines the healthcare utilization of Medi-Cal recipients during the fall 2007 San Diego wildfires, which exposed millions of persons to wildfire smoke. METHODS AND FINDINGS: Respiratory and cardiovascular International Classification of Diseases (ICD)-9 codes were identified from Medi-Cal fee-for-service claims for emergency department presentations, inpatient hospitalizations, and outpatient visits. For a respiratory index and a cardiovascular index of key diagnoses and individual diagnoses, we calculated rate ratios (RRs) for the study population and different age groups for 3 consecutive 5-day exposure periods (P1 [October 22-26], P2 [October 27-31], and P3 [November 1-5]) versus pre-fire comparison periods matched on day of week (5-day periods starting 3, 4, 5, 6, 8, and 9 weeks before each exposed period). We used a bidirectional symmetric case-crossover design to examine emergency department presentations with any respiratory diagnosis and asthma specifically, with exposure based on modeled wildfire-derived fine inhalable particles that are 2.5 micrometers and smaller (PM2.5). We used conditional logistic regression to estimate odds ratios (ORs), adjusting for temperature and relative humidity, to assess same-day and moving averages. We also evaluated the United States Environmental Protection Agency (EPA)'s Air Quality Index (AQI) with this conditional logistic regression method. We identified 21,353 inpatient hospitalizations, 25,922 emergency department presentations, and 297,698 outpatient visits between August 16 and December 15, 2007. During P1, total emergency department presentations were no different than the reference periods (1,071 versus 1,062.2; RR 1.01; 95% confidence interval [CI] 0.95-1.08), those for respiratory diagnoses increased by 34% (288 versus 215.3; RR 1.34; 95% CI 1.18-1.52), and those for asthma increased by 112% (58 versus 27.3; RR 2.12; 95% CI 1.57-2.86). Some visit types continued to be elevated in later time frames, e.g., a 72% increase in outpatient visits for acute bronchitis in P2. Among children aged 0-4, emergency department presentations for respiratory diagnoses increased by 70% in P1, and very young children (0-1) experienced a 243% increase for asthma diagnoses. Associated with a 10 µg/m3 increase in PM2.5 (72-hour moving average), we found 1.08 (95% CI 1.04-1.13) times greater odds of an emergency department presentation for asthma. The AQI level "unhealthy for sensitive groups" was associated with significantly elevated odds of an emergency department presentation for respiratory conditions the day following exposure, compared to the AQI level "good" (OR 1.73; 95% CI 1.18-2.53). Study limitations include the use of patient home address to estimate exposures and demographic differences between Medi-Cal beneficiaries and the general population. CONCLUSIONS: Respiratory diagnoses, especially asthma, were elevated during the wildfires in the vulnerable population of Medi-Cal beneficiaries. Wildfire-related healthcare utilization appeared to persist beyond the initial high-exposure period. Increased adverse health events were apparent even at mildly degraded AQI levels. Significant increases in health events, especially for respiratory conditions and among young children, are expected based on projected climate scenarios of wildfire frequency in California and globally.

Age, period, and cohort effects in adult lifetime asthma prevalence in California: an application of hierarchical age-period-cohort analysis.

PURPOSE: Using 27 years of survey data, the contributions of age, period, and cohort effects on the increase in adult lifetime asthma prevalence in California were examined. METHODS: Lifetime asthma diagnosis for adults was assessed in 1984-1992 and 1995-2011 through the California Behavioral Risk Factor Surveillance System, an annual, cross-sectional, population-based survey (n = 144,100). Using date of survey and date of birth, we classified 18,305 adult respondents with lifetime asthma into 7 age groups, 6 periods, and 17 cohorts. Using hierarchical, cross-classified random effects models, birth cohort, period, and age patterns in adult lifetime asthma prevalence were analyzed. RESULTS: After adjusting for sex, ethnicity, education, and smoking, age effects peak in young adulthood, flatten from 40 to 60 years old, and then decrease in older adulthood. A significant positive trend in asthma prevalence was observed in the two earliest survey periods (1984-1993; P value < .0001). Survey period trends appear to flatten beginning in 2004. Although the overall birth cohort effect was statistically significant, the magnitude of the effect for each birth cohort category was small (P value = .0005). CONCLUSIONS: We observed that strong age and period effects have been driving the increase in lifetime asthma prevalence in California over the past 3 decades.

Near-Roadway Air Pollution and Coronary Heart Disease: Burden of Disease and Potential Impact of a Greenhouse Gas Reduction Strategy in Southern California.

BACKGROUND: Several studies have estimated the burden of coronary heart disease (CHD) mortality from ambient regional particulate matter ≤ 2.5 µm (PM2.5). The burden of near-roadway air pollution (NRAP) generally has not been examined, despite evidence of a causal link with CHD. OBJECTIVE: We investigated the CHD burden from NRAP and compared it with the PM2.5 burden in the California South Coast Air Basin for 2008 and under a compact urban growth greenhouse gas reduction scenario for 2035. METHODS: We estimated the population attributable fraction and number of CHD events attributable to residential traffic density, proximity to a major road, elemental carbon (EC), and PM2.5 compared with the expected disease burden if the population were exposed to background levels of air pollution. RESULTS: In 2008, an estimated 1,300 CHD deaths (6.8% of the total) were attributable to traffic density, 430 deaths (2.4%) to residential proximity to a major road, and 690 (3.7%) to EC. There were 1,900 deaths (10.4%) attributable to PM2.5. Although reduced exposures in 2035 should result in smaller fractions of CHD attributable to traffic density, EC, and PM2.5, the numbers of estimated deaths attributable to each of these exposures are anticipated to increase to 2,500, 900, and 2,900, respectively, due to population aging. A similar pattern of increasing NRAP-attributable CHD hospitalizations was estimated to occur between 2008 and 2035. CONCLUSION: These results suggest that a large burden of preventable CHD mortality is attributable to NRAP and is likely to increase even with decreasing exposure by 2035 due to vulnerability of an aging population. Greenhouse gas reduction strategies developed to mitigate climate change offer unexploited opportunities for air pollution health co-benefits.

Blood product transfusions and clinical outcomes in pediatric patients with acute lung injury.

OBJECTIVE: There are data suggesting that blood product transfusions increase the risk of developing acute lung injury (ALI) in adults, and may be associated with increased mortality in adults with ALI. A possible association between transfusions and adverse outcomes of pediatric patients with ALI has not been studied previously. We tested the hypothesis that blood product transfusions to pediatric patients with ALI within the first 72 hours of the diagnosis would be associated with increased mortality and prolonged mechanical ventilation. DESIGN: An epidemiologic database of pediatric ALI prospectively gathered from July 1996 to May 2000 was analyzed. SETTING: Children were enrolled from both a tertiary referral hospital and a major community children's hospital. PATIENTS: Three hundred fifteen patients who met the 1994 American European Consensus Committee definition of ALI between the ages of 36 weeks corrected gestational age and 18 years. MAIN OUTCOME MEASURE: Mortality in the pediatric intensive care unit. RESULTS: Multivariate analyses indicated that the transfusion of fresh-frozen plasma (FFP) was associated with increased mortality, independent of the severity of hypoxemia (Pao2/Fio2), presence of multiple organ system failure or disseminated intravascular coagulation (odds ratio = 1.08, 95% confidence interval = 1.00-1.17, p = 0.04). FFP transfusion was analyzed as a continuous variable, so that for each milliliter of FFP transfused per kilogram patient body weight per day, the odds of death increased by 1.08. There was a trend toward an association of the transfusion of FFP with a fewer number of days of unassisted ventilation (regression coefficient = -0.21, 95% confidence interval = -0.42-0.01, p = 0.06). CONCLUSIONS: The transfusion of FFP is associated with an increased risk of mortality in children with ALI. The association between FFP and mortality in children with ALI should be investigated further.

Using acupuncture for acute pain in hospitalized children.

OBJECTIVE: Clinical study to determine the acceptability and feasibility of acupuncture for acute postoperative pain control in hospitalized children. DESIGN: Nonrandomized clinical trial. SETTING: A single, tertiary referral pediatric intensive care unit. PATIENTS: A total of 20 patients aged 7 months to 18 years. Eleven of the patients had posterior spinal fusion surgery and the remaining nine patients had other surgical diagnoses. INTERVENTIONS: Two 10- to 15-minute sessions of acupuncture 24-48 hours apart. OUTCOME MEASURES AND RESULTS: The treatment was highly accepted (27 patients were approached and 4 patients refused; of the 23 patients enrolled, 20 patients completed the study). Acupuncture was well tolerated by patients without adverse events related to treatment. In follow-up interviews, 70% of both parents and patients believed acupuncture helped the child's pain. Eighty-five percent of the parents said they would pay out of pocket for acupuncture if not covered by insurance. The pain scores, vital signs, and narcotic usage were recorded before and several times after acupuncture. In posterior spinal fusion patients, the mean pain scores (0-10) immediately before and 4 and 24 hours after acupuncture were: 3.7, 1.7, and 3.1, respectively, after the first acupuncture session and 3.7, 2.2, and 3.1, respectively, after the second session. In the other surgical cohort, the mean pain scores immediately before and 4 and 24 hours after the first session of acupuncture were 2.5, 0.3, and 1.6, respectively. CONCLUSIONS: Our results support that acupuncture is highly accepted and feasible in critically ill, postoperative pediatric patients with acute pain. Our findings suggest that acupuncture may be a potentially useful adjunctive tool for acute pediatric postoperative pain management. A randomized, controlled clinical trial is warranted to confirm these findings.

Disparity in the management of iron overload between patients with sickle cell disease and thalassemia who received transfusions.

BACKGROUND: Transfusion therapy is frequently used to prevent morbidity in sickle cell disease (SCD), and subsequent iron overload is common. The objective of this study was to evaluate the current standard of care in monitoring iron overload and related complications in patients with SCD compared to thalassemia (Thal). STUDY DESIGN AND METHODS: A cross-sectional study was conducted at 31 hematology clinics in the United States, Canada, or the United Kingdom. Patients who received transfusions with a mean serum ferritin level of least 2000 ng per mL were eligible. A total of 199 patients with SCD (113 female; 24.9 +/- 13.2 years) and 142 with Thal (66 female; 25.8 +/- 8.1 years) were recruited, and data were collected between 2001 and 2003 by interview and medical record review. RESULTS: Although both groups were recruited on the basis of significant iron overload, the likelihood of performing a liver biopsy for routine iron monitoring was significantly higher (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.2-5.3) in Thal than SCD. Thal patients were also more likely to be screened for iron-related organ injury including an echocardiograph for cardiomyopathy (OR, 2.6; p < 0.001; 95% CI, 1.6-4.2), alanine aminotransferase for liver function (OR, 8.3; CI, 1.05-64.4), and thyroid-stimulating hormone for hypothyroidism (OR, 12.3; CI, 7.0-21.5). For adult SCD patients, those maintained on simple transfusion with a serum ferritin level of greater than 2500 ng per mL were the least likely to have a liver biopsy (p < 0.03). CONCLUSIONS: These data highlight the unsystematic monitoring of iron and related organ injury in SCD. Until the relationship between iron and related comorbidities is better understood, routine monitoring of iron overload in SCD patients who receive transfusions should be considered a standard part of clinical care.

Fracture prevalence and relationship to endocrinopathy in iron overloaded patients with sickle cell disease and thalassemia.

Transfusional iron overload leads to gonadal failure and low bone mass in patients with thalassemia (Thal). However, gonadal failure is rarely reported in transfused patients with sickle cell disease (SCD) and the literature regarding fracture prevalence in SCD is limited. The objective of this study was to assess self-reported fracture prevalence and its relationship to endocrinopathy in transfused Thal or SCD subjects and compare to non-transfused subjects with SCD (NonTxSCD). Eligibility was based on age> or =12 years and liver iron concentration> or =10 mg/g dry wt or serum ferritin> or =2000 ng/mL (Thal or TxSCD) or for NonTxSCD, ferritin<500 ng/mL. Data were collected by patient interview and chart review at 31 clinical centers in the U.S., Canada and the U.K. 152 subjects with Thal (52% Male; 25.6+/-0.7 years), 203 subjects with TxSCD (44% Male, 24.7+/-0.9 years: Mean+/-SE), and 65 NonTxSCD (50% Male, 22.2+/-1.3 years) were enrolled. Overall, male subjects with Thal were more likely to have sustained a fracture in their lifetime (51%) compared to TxSCD (28%) or NonTxSCD (32%) (p=0.005). There was no difference in fracture prevalence among women (Thal: 26%, TxSCD 17%, NonTxSCD: 16%). Fracture was most frequently reported in the upper extremities (53.3% of all fractures) while spine and pelvic fractures were relatively common for such a young cohort: 10.6%. Though overall fracture prevalence was not distinctly different from published healthy cohorts, fewer fractures occurred during the adolescent years. In multivariate analysis, the significant predictors of fracture prevalence were Thal diagnosis (Odds Ratio: 2.3; 1.2-4.6; 95%CI), male gender (OR: 2.6; 1.5-4.5), hypothyroidism (OR: 3.3; 1.1-9.8) and age (OR: 1.1; 1.03-1.08). These data suggest that despite similar iron burden, transfused patients with Thal are at greater risk for fracture than subjects with SCD. Male subjects with Thal and hypothyroidism are at particular risk for fracture, in contrast, transfused subjects with SCD had no greater risk of fracture compared to non-transfused SCD. Though ethnic differences in fracture risk cannot be ignored, endocrinopathy is rare in TxSCD which may also provide some protection from fracture.

An association between asthma and BMI in adolescents: results from the California Healthy Kids Survey.

We examined the relationship between asthma prevalence and BMI in a cross-sectional survey of 471,969 adolescents. The size of the survey allowed us to investigate this relationship with much greater resolution than previously possible. Both lifetime and current asthma prevalence increased monotonically with increasing BMI, starting with individuals as low as the 45th to 55th percentiles of BMI. The pattern was similar between males and females and among six racial/ethnic groups. The results suggest that weight reduction even among persons not classified as overweight or obese may be an important component of asthma management.

Early elevation of plasma von Willebrand factor antigen in pediatric acute lung injury is associated with an increased risk of death and prolonged mechanical ventilation.

OBJECTIVE: Von Willebrand factor antigen (vWF-Ag) is a marker of pulmonary and systemic endothelial activation and injury. Adult studies indicate that patients with plasma vWF-Ag levels > or = 450% of control early in the course of acute lung injury (ALI) have an increased risk of death. The objective of this study was to evaluate whether vWF-Ag is elevated in the early phase of ALI in children and whether the magnitude of the increase was predictive of two important outcomes: mortality or duration of mechanical ventilation. DESIGN: Two-center, prospective observational study. SETTING: Two pediatric intensive care units: one in an academic university setting and one in a major community children's hospital. PATIENTS: After appropriate consent, plasma was collected from 48 pediatric patients on day 1 of ALI, 45 patients on day 2 of ALI, and four intubated controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mean PaO2/FiO2 at the onset of ALI was 140 +/- 70, and mortality rate was 17%. vWF-Ag levels on day 1 of ALI were higher in patients compared with controls (287 +/- 183 vs. 87 +/- 84% of control [mean +/- SD], p < .05). Patients with vWF-Ag levels > or = 450% of control on day 1 of ALI had a markedly greater risk of death (odds ratio, 7.0; confidence interval, 1.31, 37.30; p < .05). Multivariate analysis revealed that elevated vWF-Ag level and either presence of multiple organ system failure or Pediatric Risk of Mortality III score independently predict increased risk of death. vWF-Ag levels on day 2 of ALI were significantly higher in patients who required prolonged mechanical ventilation (316 +/- 173 vs. 191 +/- 89% of control, p < .05). CONCLUSIONS: Early injury to the systemic and pulmonary endothelium, as measured by plasma vWF-Ag levels, is associated with an increased risk of death and prolonged mechanical ventilation in pediatric patients with ALI.

Morbidity and mortality in chronically transfused subjects with thalassemia and sickle cell disease: A report from the multi-center study of iron overload.

A natural history study was conducted in 142 Thalassemic (Thal), 199 transfused Sickle Cell Disease (Tx-SCD, n = 199), and 64 non-Tx-SCD subjects to describe the frequency of iron-related morbidity and mortality. Subjects recruited from 31 centers in the US, Canada or the UK were similar with respect to age (overall: 25 +/- 11 years, mean +/- SD) and gender (52% female). We found that Tx-SCD subjects were hospitalized more frequently compared with Thal or non-Tx-SCD (P < 0.001). Among those hospitalized, Tx-SCD adult subjects were more likely to be unemployed compared with Thal (RR = 1.6, 95% CI 1.0-2.5) or non-Tx-SCD (RR = 3.1, 95% CI 1.3-7.3). There was a positive relationship between the severity of iron overload, assessed by serum ferritin, and the frequency of hospitalizations (r= 0.20; P = 0.009). Twenty-three deaths were reported (6 Thal, 17 Tx-SCD) in 23.5 +/- 10 months of follow-up. Within the Tx-SCD group, those who died began transfusion (25.3 vs. 12.4 years, P < 0.001) and chelation therapy later (26.8 vs. 14.2 years, P = 0.01) compared with those who survived. The unadjusted death rate in Thal was lower (2.2/100 person years) compared with that in Tx-SCD (7.0/100 person years; RR = 0.38: 95% CI 0.12-0.99). However, no difference was observed when age at death was considered. Despite improvements in therapy, death rate in this contemporary sample of transfused adult subjects with Thal or SCD is 3 times greater than the general US population. Long term follow-up of this unique cohort of subjects will be helpful in further defining the relationship of chronic, heavy iron overload to morbidity and mortality.

Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment.

BACKGROUND: Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and collapse of the femoral head occurs in 90% of patients within five years after the diagnosis of the osteonecrosis. However, the efficacy of hip core decompression to prevent the progression of osteonecrosis in these patients is still controversial. METHODS: In a prospective multicenter study, we evaluated the safety of hip core decompression and compared the results of decompression and physical therapy with those of physical therapy alone for the treatment of osteonecrosis of the femoral head in patients with sickle cell disease. Forty-six patients (forty-six hips) with sickle cell disease and Steinberg Stage-I, II, or III osteonecrosis of the femoral head were randomized to one of two treatment arms: (1) hip core decompression followed by a physical therapy program or (2) a physical therapy program alone. Eight patients withdrew from the study, leaving thirty-eight who participated. RESULTS: Seventeen patients (seventeen hips) underwent decompression combined with physical therapy, and no intraoperative or immediate postoperative complications occurred. Twenty-one patients (twenty-one hips) were treated with physical therapy alone. After a mean of three years, the hip survival rate was 82% in the group treated with decompression and physical therapy and 86% in the group treated with physical therapy alone. According to a modification of the Harris hip score, the mean clinical improvement was 18.1 points for the patients treated with hip core decompression and physical therapy compared with 15.7 points for those treated with physical therapy alone. With the numbers studied, the differences were not significant. CONCLUSIONS: In this randomized prospective study, physical therapy alone appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and postponing the need for additional surgical intervention at a mean of three years after treatment.

Increased prevalence of iron-overload associated endocrinopathy in thalassaemia versus sickle-cell disease.

Iron-overload associated endocrinopathy is the most frequently reported complication of chronic transfusion therapy in patients with thalassaemia (Thal). This study compared iron-overloaded subjects with Thal (n = 142; 54%M; age 25.8 +/- 8.1 years) and transfused sickle-cell disease (Tx-SCD; n = 199; 43%M, 24.9 +/- 13.2 years) to non-transfused SCD subjects (non-Tx-SCD; n = 64, 50%M, 25.3 +/- 11.3 years), to explore whether the underlying haemoglobinopathy influences the development of endocrinopathy. Subjects were recruited from 31 centres in the USA, Canada and the UK. Subjects with Thal had more evidence of diabetes (13% vs. 2%, P < 0.001), hypogonadism (40% vs. 4%, P < 0.001), hypothyroidism (10% vs. 2%, P = <0.001) and growth failure (33% vs. 7%, P < 0.001), versus Tx-SCD. Fifty-six per cent of Thal had more than one endocrinopathy compared with only 13% of Tx-SCD (P < 0.001). In contrast, Tx-SCD was not different from non-Tx-SCD. Multivariate analysis indicated that endocrinopathy was more likely in Thal than SCD [Odds Ratio (OR) = 9.4, P < 0.001], with duration of chronic transfusion a significant predictor (OR = 1.4 per 10 years of transfusion, P = 0.04). Despite iron overload, endocrinopathy was not increased in Tx-SCD versus non-Tx-SCD, suggesting that the underlying disease may modulate iron-related endocrine injury. However, because transfusion duration remained a significant predictor of endocrinopathy, these data should be confirmed in SCD subjects that have been chronically transfused for longer periods of time.

Indoor air pollution in rural China: cooking fuels, stoves, and health status.

Solid fuels are a major source of indoor air pollution, but in less developed countries the short-term health effects of indoor air pollution are poorly understood. The authors conducted a large cross-sectional study of rural Chinese households to determine associations between individual health status and domestic cooking as a source of indoor air pollution. The study included measures of health status as well as measures of indoor air-pollution sources, such as solid cooking fuels and cooking stoves. Compared with other fuel types, coal was associated with a lower health status, including negative impacts on exhaled carbon monoxide level, forced vital capacity, lifetime prevalence of chronic obstructive pulmonary disease and asthma, and health care utilization. Decreasing household coal use, increasing use of improved stove technology, and increasing kitchen ventilation may decrease the short-term health effects of indoor air pollution.

The variance of rural small-town hospitals' financial performance.

The profitability of rural small-town hospitals varies widely. Some are consistently profitable; others generate significant losses. This Policy Brief provides insights into why some rural small-town hospitals are financially successful and others struggle with persistent financial difficulties. Our analysis of Medicare cost report data reveals that financial difficulties are most likely in hospitals with fewer than 1000 admissions. Interviews with hospital administrators at selected hospitals indicate that bad debts, poor physician relations, and broad missions also may contribute to some hospitals' financial difficulties.

Hospital charity care policies and the California health care safety net.

Estimates of charity care expenditures provide a quantitative measure of hospitals' commitment to expanding access to the medically uninsured in their communities but fail to provide information about the subset of uninsured who benefit or the gaps in public insurance programs' coverage that are filled by these charity care programs. This brief provides an overview of a study, conducted for the California HealthCare Foundation, that gathered information on California hospitals' charity care policies. The objective of the study was to identify the eligibility criteria hospitals use for free care and to understand the gaps in Medi-Cal, California's version of Medicaid, and county indigent program coverage that these providers are capable of filling.