RESUMO
BACKGROUND: Tropical cyclones are associated with acute increases in mortality and morbidity, but few studies have examined their longer-term health consequences. We assessed whether tropical cyclones are associated with a higher frequency of symptom exacerbation among children with asthma in the following 12 months in eastern United States counties, 2000-2018. METHODS: We defined exposure to tropical cyclones as a maximum sustained windspeed >21 meters/second at the county center and used coarsened exact matching to match each exposed county to one or more unexposed counties. We used longitudinal, de-identified administrative claims data to estimate the county-level, monthly risk of experiencing at least one asthma exacerbation requiring medical attention among commercially insured children aged 5-17 with prior diagnosis of asthma. We used a difference-in-differences approach implemented via a Poisson fixed effects model to compare the risk of asthma exacerbation in the 12 months before versus after each storm in exposed versus unexposed counties. RESULTS: Across 43 tropical cyclones impacting the eastern United States, we did not observe evidence of an increase in the risk of symptom exacerbation in the 12 months following the storm (random-effects meta-analytic summary estimate: risk ratio = 1.03 [95% confidence interval = 0.96, 1.10], I2 = 17%). However, certain storms, such as Hurricane Sandy, were associated with a higher risk of symptom exacerbation. CONCLUSIONS: These findings are consistent with the hypothesis that some tropical cyclones are detrimental to children's respiratory health. However, tropical cyclones were not associated in aggregate with long-term exacerbation of clinically apparent asthma symptoms among a population of children with commercial health insurance.
Assuntos
Asma , Tempestades Ciclônicas , Criança , Humanos , Exacerbação dos Sintomas , Asma/epidemiologia , Saúde da Criança , Progressão da DoençaRESUMO
Climate change has increased the frequency of extreme weather events and compounded natural disasters. Heat, wildfires, flooding, and pollen are already threatening public health and disproportionately affecting individuals in susceptible situations and vulnerable locations. In this theme issue of the Journal of Allergy and Clinical Immunology, we address what is known and not known about the biologic as well as clinical upstream and downstream effects of climate change on asthma and allergy development and exacerbation. We present potential actions that individuals can take at the family, neighborhood, community, health care system, and national and international levels to build climate resilience and protect their own health and the health and welfare of others. We emphasize the importance of actions and policies that are context specific and just. We emphasize the need for the health care system, which contributes between 3% and 5% of global greenhouse gas emissions, to reduce its carbon footprint and build resiliency. Health care providers play a pivotal role in helping policymakers understand the effects of climate on the health of our patients. There is still a window to avoid the most serious effects of climate change on human health and our planet.
Assuntos
Asma , Hipersensibilidade , Humanos , Mudança Climática , Hipersensibilidade/epidemiologia , Asma/epidemiologia , Atenção à Saúde , Pessoal de SaúdeRESUMO
Ozone exposure is associated with higher risk of asthma-related emergency department visits. The meteorological conditions that govern ozone concentration are projected to be more favorable to ozone formation over much of the United States due to continued climate change, even as emissions of anthropogenic ozone precursors are expected to decrease by 2050. Our goal is to quantify the health benefits of a climate change mitigation scenario versus a "business-as-usual" scenario, defined by the United Nations Intergovernmental Panel on Climate Change Representative Concentration Pathways (RCPs) 4.5 and 8.5, respectively, using the health impact analytical program Benefits Mapping and Analysis Program - Community Edition (BenMAP - CE) to project the number of asthma ED visits in 2045-2055. We project an annual average of 3100 averted ozone-related asthma ED visits during the 2045-2055 period under RCP4.5 versus RCP8.5, with all other factors held constant, which translates to USD $1.7 million in averted costs annually. We identify counties with tens to hundreds of avoided ozone-related asthma ED visits under RCP4.5 versus RCP8.5. Overall, we project a heterogeneous distribution of ozone-related asthma ED visits at different spatial resolutions, specifically national, regional, and county levels, and a substantial net health and economic benefit of climate change mitigation.
Assuntos
Poluentes Atmosféricos , Asma , Serviço Hospitalar de Emergência , Ozônio , Asma/epidemiologia , Mudança Climática , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Ozônio/toxicidade , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Exposure to heat, air pollution, and pollen are associated with health outcomes, including cardiovascular and respiratory disease. Studies assessing the health impacts of climate change have considered increased exposure to these risk factors separately, though they may be increasing simultaneously for some populations and may act synergistically on health. Our objective is to systematically review epidemiological evidence for interactive effects of multiple exposures to heat, air pollution, and pollen on human health. METHODS: We systematically searched electronic literature databases (last search, April 29, 2019) for studies reporting quantitative measurements of associations between at least two of the exposures and mortality from any cause and cardiovascular and respiratory morbidity and mortality specifically. Following the Navigation Guide systematic review methodology, we evaluated the risk of bias of individual studies and the overall quality and strength of evidence. RESULTS: We found 56 studies that met the inclusion criteria. Of these, six measured air pollution, heat, and pollen; 39 measured air pollution and heat; 10 measured air pollution and pollen; and one measured heat and pollen. Nearly all studies were at risk of bias from exposure assessment error. However, consistent exposure-response across studies led us to conclude that there is overall moderate quality and sufficient evidence for synergistic effects of heat and air pollution. We concluded that there is overall low quality and limited evidence for synergistic effects from simultaneous exposure to (1) air pollution, pollen, and heat; and (2) air pollution and pollen. With only one study, we were unable to assess the evidence for synergistic effects of heat and pollen. CONCLUSIONS: If synergistic effects between heat and air pollution are confirmed with additional research, the health impacts from climate change-driven increases in air pollution and heat exposure may be larger than previously estimated in studies that consider these risk factors individually.
Assuntos
Poluição do Ar , Doenças Cardiovasculares/epidemiologia , Temperatura Alta , Pólen , Doenças Respiratórias/epidemiologia , HumanosRESUMO
OBJECTIVE: Among rheumatoid arthritis (RA) patients, the intensity of pain may be out of proportion to the severity of peripheral inflammation. This observation suggests that mechanisms of central nervous system pain amplification, such as diminished conditioned pain modulation (CPM), may play a role in enhancing pain perception among some RA patients. This study was undertaken to examine the level of CPM, pressure-pain threshold, and pressure-pain tolerance among RA patients compared to healthy controls. METHODS: Fifty-eight female RA patients and 54 age-matched female control subjects without chronic pain underwent quantitative sensory testing (QST) to assess CPM levels, pressure-pain thresholds, and pressure-pain tolerance levels. CPM was induced using a cold water bath, and the pain threshold (when patients first felt pain) and pain tolerance (when pain was too much to bear) were assessed with an algometer. Associations between RA and each QST outcome were analyzed using linear regression. Sleep problems, mental health, and inflammation were assessed as mediators of the relationship between RA and QST outcomes. RESULTS: The median CPM level was 0.5 kg/cm2 (interquartile range [IQR] -0.1, 1.6) among RA patients, compared to a median of 1.5 kg/cm2 (IQR -0.1, 2.5) among controls (P=0.04). RA patients, compared to controls, had a lower pain threshold and lower pain tolerance at the wrists (each P≤0.05). In addition, RA patients had greater problems with sleep, pain catastrophizing, depression, and anxiety (P<0.0001 versus controls). Results of mediation analyses suggested that low CPM levels might be attributed, in part, to sleep disturbance (P=0.04). CONCLUSION: RA patients have impaired CPM when compared to pain-free control subjects. Sleep problems may mediate the association between RA and attenuated CPM.
Assuntos
Artrite Reumatoide/fisiopatologia , Limiar da Dor/fisiologia , Transtornos do Sono-Vigília/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite Reumatoide/psicologia , Feminino , Humanos , Pessoa de Meia-Idade , Medição da DorRESUMO
INTRODUCTION: Pollen exposure is known to exacerbate allergic asthma and allergic rhinitis symptoms, yet few studies have investigated if exposure to pollen affects lung function or airway inflammation in healthy children. METHODS: We evaluated the extent to which higher pollen exposure was associated with differences in airway inflammation and lung function among 490 early adolescent participants (mean age of 12.9 years) in Project Viva, a prebirth cohort based in Massachusetts. We obtained regional daily total pollen counts, including tree, grass, and weed pollen, from a Rotorod pollen counter. We evaluated associations of 3- and 7-day moving averages of pollen with fractional exhaled nitric oxide (FeNO) and lung function using linear regression models and evaluated the linearity of associations with penalized splines. We tested if associations of pollen with FeNO and lung function were modified by current asthma diagnosis, history of allergic rhinitis, aeroallergen sensitivity, temperature, precipitation, and air pollution. RESULTS: Three- and 7-day median pollen concentrations were 19.0 grains/m3 (IQR: 73.4) and 20.9 grains/m3 (IQR: 89.7). In main models, higher concentrations of total pollen over the preceding 3 and 7 days were associated with a 4.6% (95% CI: 0.1,9.2) and 7.4% (95% CI: 0.9,14.3) higher FeNO per IQR of pollen, respectively. We did not find associations of pollen with lung function in main models. Asthma, allergic rhinitis, precipitation, and air pollution (nitrogen dioxide and ozone) modified associations of pollen with lung function (Pinteraction < 0.1), while temperature, sex, and aeroallergen sensitization did not. CONCLUSION: Short-term exposure to pollen was associated with higher FeNO in early adolescents, even in the absence of allergic sensitization and asthma.
Assuntos
Asma , Óxido Nítrico , Pólen , Humanos , Pólen/imunologia , Pólen/efeitos adversos , Feminino , Masculino , Adolescente , Asma/fisiopatologia , Asma/epidemiologia , Asma/imunologia , Criança , Óxido Nítrico/metabolismo , Óxido Nítrico/análise , Alérgenos/imunologia , Rinite Alérgica Sazonal/epidemiologia , Rinite Alérgica Sazonal/imunologia , Rinite Alérgica Sazonal/fisiopatologia , Exposição Ambiental/efeitos adversos , Massachusetts/epidemiologia , Testes RespiratóriosRESUMO
BACKGROUND: Pulmonary function tests (PFTs) have historically used race-specific prediction equations. The recent American Thoracic Society guidelines recommend the use of a race-neutral approach in prediction equations. There are limited studies centering the opinions of practicing pulmonologists on the use of race in spirometry. Provider opinion will impact adoption of the new guideline. The aim of this study was to ascertain the beliefs of academic pulmonary and critical care providers regarding the use of race as a variable in spirometry prediction equations. METHODS: We report data from 151 open-ended responses from a voluntary, nationwide survey (distributed by the Association of Pulmonary Critical Care Medicine Program Directors) of academic pulmonary and critical care providers regarding the use of race in PFT prediction equations. Responses were coded using inductive and deductive methods, and a thematic content analysis was conducted. RESULTS: There was a balanced distribution of opinions among respondents supporting, opposing, or being unsure about the incorporation of race in spirometry prediction equations. Responses demonstrated a wide array of understanding related to the concept and definition of race and its relationship to physiology. CONCLUSIONS: There was no consensus among providers regarding the use of race in spirometry prediction equations. Concepts of race having biologic implications persist among pulmonary providers and will likely affect the uptake of the Global Lung Function Initiative per the American Thoracic Society guidelines.
RESUMO
INTRODUCTION: Exposure to particulate matter (PM) pollution has been associated with lower lung function in adults with chronic obstructive pulmonary disease (COPD). Patients with eosinophilic COPD have been found to have higher levels of airway inflammation, greater responsiveness to anti-inflammatory steroid inhalers and a greater lung function response to PM pollution exposure compared with those with lower eosinophil levels. This study will evaluate if reducing home PM exposure by high-efficiency particulate air (HEPA) air filtration improves respiratory health in eosinophilic COPD. METHODS AND ANALYSIS: The Air Purification for Eosinophilic COPD Study (APECS) is a double-blinded randomised placebo-controlled trial that will enrol 160 participants with eosinophilic COPD living in the area of Boston, Massachusetts. Real and sham air purifiers will be placed in the bedroom and living rooms of the participants in the intervention and control group, respectively, for 12 months. The primary trial outcome will be the change in forced expiratory volume in 1 s (FEV1). Lung function will be assessed twice preintervention and three times during the intervention phase (at 7 days, 6 months and 12 months postrandomisation). Secondary trial outcomes include changes in (1) health status by St. George's Respiratory Questionnaire; (2) respiratory symptoms by Breathlessness, Cough and Sputum Scale (BCSS); and (3) 6-Minute Walk Test (6MWT). Inflammatory mediators were measured in the nasal epithelial lining fluid (NELF). Indoor PM will be measured in the home for the week preceding each study visit. The data will be analysed to contrast changes in outcomes in the intervention and control groups using a repeated measures framework. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board of Beth Israel Deaconess Medical Centre (protocol #2019P0001129). The results of the APECS trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION: NCT04252235. Version: October 2023.
Assuntos
Asma , Doença Pulmonar Obstrutiva Crônica , Adulto , Humanos , Asma/complicações , Projetos de Pesquisa , Dispneia/complicações , Poeira , Material Particulado , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Indoor sources of air pollution worsen indoor and outdoor air quality. Thus, identifying and reducing indoor pollutant sources would decrease both indoor and outdoor air pollution, benefit public health, and help address the climate crisis. As outdoor sources come under regulatory control, unregulated indoor sources become a rising percentage of the problem. This American Thoracic Society workshop was convened in 2022 to evaluate this increasing proportion of indoor contributions to outdoor air quality. The workshop was conducted by physicians and scientists, including atmospheric and aerosol scientists, environmental engineers, toxicologists, epidemiologists, regulatory policy experts, and pediatric and adult pulmonologists. Presentations and discussion sessions were centered on 1) the generation and migration of pollutants from indoors to outdoors, 2) the sources and circumstances representing the greatest threat, and 3) effective remedies to reduce the health burden of indoor sources of air pollution. The scope of the workshop was residential and commercial sources of indoor air pollution in the United States. Topics included wood burning, natural gas, cooking, evaporative volatile organic compounds, source apportionment, and regulatory policy. The workshop concluded that indoor sources of air pollution are significant contributors to outdoor air quality and that source control and filtration are the most effective measures to reduce indoor contributions to outdoor air. Interventions should prioritize environmental justice: Households of lower socioeconomic status have higher concentrations of indoor air pollutants from both indoor and outdoor sources. We identify research priorities, potential health benefits, and mitigation actions to consider (e.g., switching from natural gas to electric stoves and transitioning to scent-free consumer products). The workshop committee emphasizes the benefits of combustion-free homes and businesses and recommends economic, legislative, and education strategies aimed at achieving this goal.
Assuntos
Poluentes Atmosféricos , Poluição do Ar em Ambientes Fechados , Poluição do Ar , Humanos , Criança , Estados Unidos , Poluição do Ar em Ambientes Fechados/efeitos adversos , Poluição do Ar em Ambientes Fechados/prevenção & controle , Poluição do Ar em Ambientes Fechados/análise , Gás Natural , Monitoramento Ambiental , Poluição do Ar/efeitos adversos , Poluição do Ar/prevenção & controle , Poluição do Ar/análise , Poluentes Atmosféricos/efeitos adversos , Poluentes Atmosféricos/análise , Material Particulado/análiseRESUMO
Rationale: With more frequent and intense precipitation events across the globe due to a changing climate, there is a need to understand the relationship between precipitation and respiratory health. Precipitation may trigger asthma exacerbations, but little is known about how precipitation affects lung function and airway inflammation in early adolescents. Objectives: To determine if short-term precipitation exposure is associated with lung function and airway inflammation in early adolescents and if ever having a diagnosis of asthma modifies associations of precipitation with lung function and airway inflammation. Methods: In a prospective prebirth cohort, Project Viva, that included 1,019 early adolescents born in the northeastern United States, we evaluated associations of 1-, 2-, 3-, and 7-day moving averages of precipitation in the preceding week and forced expiratory volume in 1 second, forced vital capacity, and fractional exhaled nitric oxide (FeNO) using linear regression. We used log-transformed FeNO with effect estimates presented as percentage change. We adjusted for maternal education and household income at enrollment; any smoking in the home in early adolescence; child sex, race/ethnicity, and ever asthma diagnosis; and age, height, weight, date, and season (as sine and cosine functions of visit date) at the early adolescent visit and moving averages for mean daily temperature (same time window as exposure). Results: In fully adjusted linear models, 3- and 7-day moving averages for precipitation were positively associated with FeNO but not lung function. Every 2-mm increase in the 7-day moving average for precipitation was associated with a 4.0% (95% confidence interval, 1.1, 6.9) higher FeNO. There was evidence of effect modification by asthma status: Precipitation was associated with lower forced vital capacity and higher FeNO among adolescents with asthma. We also found that outdoor aeroallergen sensitization (immunoglobulin E against common ragweed, oak, ryegrass, or silver birch) modified associations of precipitation with FeNO, with higher FeNO in sensitized adolescents compared with nonsensitized adolescents. The associations of precipitation with FeNO were not explained by relative humidity or air pollution exposure. Conclusions: We found that greater short-term precipitation may trigger airway inflammation in adolescents, particularly among those with asthma.
Assuntos
Poluição do Ar , Asma , Criança , Humanos , Adolescente , Estados Unidos , Estudos Prospectivos , Óxido Nítrico/análise , Inflamação , Testes Respiratórios , ExpiraçãoRESUMO
Background: Structural health inequities and racism adversely affect patient health and the culture of academic medicine. Formal training to educate fellows and faculty on antiracism is lacking. Objective: Our objective was to design, implement, and assess the feasibility and preliminary efficacy of a year-long antiracism curriculum within a pulmonary, critical care, and sleep medicine division. Methods: This was a pre- and postintervention observational study conducted between July 2020 and June 2021. The curriculum was offered during an allotted educational meeting time slot at a single-center pulmonary, critical care, and sleep medicine division at a large academic institution to fellows and faculty. The curriculum consisted of 13 1-hour virtual interactive workshops delivered by local experts in diversity, equity, and inclusion topics. Surveys assessed knowledge on racism in medicine; opinions, understanding, and comfort surrounding race and racism in medicine; as well as additional questions to solicit feedback on the curriculum itself via visual analog scale and write-in comments. Results: Before initiating the curriculum, 74% (n = 28) of respondents reported interest in an antiracism curriculum, and the majority (95%, n = 36) believed that discrimination affects medical staff and patients. Respondents reported only moderate comfort in talking about race (median, 58; interquartile range 41-70 on visual analog scale 0-100, where 100 is strongly agree with "I feel comfortable talking about race"). The postintervention survey demonstrated stability of the belief of the presence of racial discrimination and a 15% increase in self-directed learning about related topics. Although knowledge related to the use of race in medical algorithms improved, 14% fewer participants reported interest in continuing to engage in a division-wide structured antiracism curriculum. Conclusion: Implementation of a curriculum on justice, equity, diversity, and inclusion within a fellowship program is feasible and addresses an unmet need within graduate medical education.
RESUMO
Exposure to fine particulate matter (PM2.5) is associated with asthma development as well as asthma exacerbation in children. PM2.5 can be directly emitted or can form in the atmosphere from pollutant precursors. PM2.5 emitted and formed in the atmosphere is influenced by meteorology; future changes in climate may alter the concentration and distribution of PM2.5. Our aim is to estimate the future burden of climate change and PM2.5 on new and exacerbated cases of childhood asthma. Projected concentrations of PM2.5 are based on the Geophysical Fluid Dynamics Laboratory Coupled Model version 3 climate model, the Representative Concentration Pathway 8.5 greenhouse gas scenario, and two air pollution emissions datasets: a 2011 emissions dataset and a 2040 emissions dataset that reflects substantial reductions in emissions of PM2.5 as compared to the 2011 inventory. We estimate additional PM2.5-attributable asthma as well as PM2.5-attributable albuterol inhaler use for four future years (2030, 2050, 2075, and 2095) relative to the year 2000. Exacerbations, regardless of the trigger, are counted as attributable to PM2.5 if the incident disease is attributable to PM2.5. We project 38 thousand (95% CI 36, 39 thousand) additional PM2.5-attributable incident childhood asthma cases and 29 million (95% CI 27, 31 million) additional PM2.5-attributable albuterol inhaler uses per year in 2030, increasing to 200 thousand (95% CI 190, 210 thousand) additional incident cases and 160 million (95% CI 150, 160 million) inhaler uses per year by 2095 relative to 2000 under the 2011 emissions dataset. These additional PM2.5-attributable incident asthma cases and albuterol inhaler use would cost billions of additional U.S. dollars per year by the late century. These outcomes could be mitigated by reducing air pollution emissions.
RESUMO
BACKGROUND: Ground-level ozone (O3) is an air pollutant and known trigger for asthma exacerbation. We sought to estimate the number of summertime emergency department (ED) visits for asthma exacerbations attributable to ozone in each county in New England (Rhode Island, Massachusetts, Connecticut, New Hampshire, Maine, and Vermont) in 2010. METHODS: We performed a health impact assessment using BenMAP. We used population and incidence rates in New England, daily maximum 8-hour O3 levels, and a concentration-response function derived from the epidemiological literature to quantify ozone-attributable asthma ED visits. RESULTS: We estimate that in 2010 there were 4,612 (95% CI 2192, 6866) excess ED visits for asthma exacerbation attributable to summertime ozone across New England. Rates of ozone-attributable asthma ED visits were highest in Connecticut and Massachusetts. CONCLUSIONS: There was a substantial number of ozone-attributable asthma ED visits in New England in 2010 with geographic heterogeneity across states and counties.
Assuntos
Poluentes Atmosféricos , Poluição do Ar , Asma , Ozônio , Poluentes Atmosféricos/análise , Poluentes Atmosféricos/toxicidade , Poluição do Ar/estatística & dados numéricos , Asma/induzido quimicamente , Asma/epidemiologia , Serviço Hospitalar de Emergência , Humanos , New England/epidemiologia , Ozônio/análise , Ozônio/toxicidadeRESUMO
Maternal mortality is increasing in the United States; many maternal deaths are linked to substandard care and withholding diagnostic tests or therapeutic options for fear of harm. Respiratory conditions are common in this population; however, caring for pregnant women with respiratory disease is complicated by physiologic changes. Safety of diagnostic tests as well as therapeutic interventions, changes in pharmacodynamics, and potential teratogenicity complicate the care of this population further. Appropriate care of pregnant women with respiratory conditions requires a good understanding of these nuances in the management, to provide appropriate care and improve the health and well-being of pregnant women.
Assuntos
Pulmão , Gestantes , Feminino , Humanos , Gravidez , Estados Unidos/epidemiologiaRESUMO
Importance: Future changes in climate are likely to adversely affect human health by affecting concentrations of particulate matter sized less than 2.5 µm (PM2.5) and ozone (O3) in many areas. However, the degree to which these outcomes may be mitigated by reducing air pollutant emissions is not well understood. Objective: To model the associations between future changes in climate, air quality, and human health for 2 climate models and under 2 air pollutant emission scenarios. Design, Setting, and Participants: This modeling study simulated meteorological conditions over the coterminous continental US during a 1995 to 2005 baseline and over the 21st century (2025-2100) by dynamically downscaling representations of a high warming scenario from the Community Earth System Model (CESM) and the Coupled Model version 3 (CM3) global climate models. Using a chemical transport model, PM2.5 and O3 concentrations were simulated under a 2011 air pollutant emission data set and a 2040 projection. The changes in PM2.5 and O3-attributable deaths associated with climate change among the US census-projected population were estimated for 2030, 2050, 2075, and 2095 for each of 2 emission inventories and climate models. Data were analyzed from June 2018 to June 2020. Main Outcomes and Measures: The main outcomes were simulated change in summer season means of the maximum daily 8-hour mean O3, annual mean PM2.5, population-weighted exposure, and the number of avoided or incurred deaths associated with these pollutants. Results are reported for 2030, 2050, 2075, and 2095, compared with 2000, for 2 climate models and 2 air pollutant emissions data sets. Results: The projected increased maximum daily temperatures through 2095 were up to 7.6 °C for the CESM model and 11.8 °C for the CM3 model. Under each climate model scenario by 2095, compared with 2000, an estimated additional 21â¯000 (95% CI, 14â¯000-28â¯000) PM2.5-attributable deaths and 4100 (95% CI, 2200-6000) O3-attributable deaths were projected to occur. These projections decreased to an estimated 15â¯000 (95% CI, 10â¯000-20â¯000) PM2.5-attributable deaths and 640 (95% CI, 340-940) O3-attributable deaths when simulated using a future emission inventory that accounted for reduced anthropogenic emissions. Conclusions and Relevance: These findings suggest that reducing future air pollutant emissions could also reduce the climate-driven increase in deaths associated with air pollution by hundreds to thousands.
Assuntos
Poluentes Atmosféricos/toxicidade , Poluição do Ar , Mudança Climática , Mortalidade/tendências , Previsões , Humanos , Modelos Teóricos , Ozônio/toxicidade , Material Particulado/toxicidade , Estações do Ano , Estados UnidosRESUMO
INTRODUCTION: Two-thirds of chronically ill patients do not have an advance directive. The primary aim of this study was to develop an intervention to increase the documentation of advance directives in elderly adults in an internal medicine resident primary care clinic. The secondary aims were to improve resident confidence in discussing advance care planning and increase the number of discussions. METHODS: The study was a pre- and postintervention study. The study intervention was a 30-minute educational session on advance care planning. Study participants were patients aged 65 years and older who were seen in an internal medicine residency primary care clinic over a 6-month period and internal medicine residents. Clinic encounters were reviewed for the presence of advance care planning discussions before and after the intervention. Resident confidence was measured on a Likert scale. RESULTS: Two hundred ninety-five eligible patients were seen in the clinic from January 1, 2017, to June 30, 2017, and included in the analysis performed between 2017 and 2018. The mean number of documented advance care planning discussions increased from 2.24 (95% confidence interval [CI]: 1.0-4.9) during the preintervention period to 8.94 (95% CI: 5.94-13.24]) during the postintervention period (P = .0011). Following the intervention, residents overall reported increased confidence in discussing advance care planning. CONCLUSION: A relatively modest intervention to increase advance care planning discussions is feasible in an internal medicine primary care clinic and can improve the confidence of residents with end-of-life discussion.
Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Documentação/métodos , Documentação/estatística & dados numéricos , Educação Médica/organização & administração , Internato e Residência/organização & administração , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Adulto , Planejamento Antecipado de Cuidados , Idoso , Idoso de 80 Anos ou mais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Médicos , Estados UnidosRESUMO
OBJECTIVE: To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN: Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING: An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS: Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION: Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS: There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS: Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.