Publications by authors named "Stephen P Wall"

48 Publications

Global decrease in brain sodium concentration after mild traumatic brain injury.

Brain Commun 2021 23;3(2):fcab051. Epub 2021 Mar 23.

Department of Radiology, Center for Biomedical Imaging, New York University Grossman School of Medicine, New York, NY 10016, USA.

The pathological cascade of tissue damage in mild traumatic brain injury is set forth by a perturbation in ionic homeostasis. However, whether this class of injury can be detected and serve as a surrogate marker of clinical outcome is unknown. We employ sodium MRI to test the hypotheses that regional and global total sodium concentrations: (i) are higher in patients than in controls and (ii) correlate with clinical presentation and neuropsychological function. Given the novelty of sodium imaging in traumatic brain injury, effect sizes from (i), and correlation types and strength from (ii), were compared to those obtained using standard diffusion imaging metrics. Twenty-seven patients (20 female, age 35.9 ± 12.2 years) within 2 months after injury and 19 controls were scanned with proton and sodium MRI at 3 Tesla. Total sodium concentration, fractional anisotropy and apparent diffusion coefficient were obtained with voxel averaging across 12 grey and white matter regions. Linear regression was used to obtain global grey and white matter total sodium concentrations. Patient outcome was assessed with global functioning, symptom profiles and neuropsychological function assessments. In the regional analysis, there were no statistically significant differences between patients and controls in apparent diffusion coefficient, while differences in sodium concentration and fractional anisotropy were found only in single regions. However, for each of the 12 regions, sodium concentration effect sizes were uni-directional, due to lower mean sodium concentration in patients compared to controls. Consequently, linear regression analysis found statistically significant lower global grey and white matter sodium concentrations in patients compared to controls. The strongest correlation with outcome was between global grey matter sodium concentration and the composite -score from the neuropsychological testing. In conclusion, both sodium concentration and diffusion showed poor utility in differentiating patients from controls, and weak correlations with clinical presentation, when using a region-based approach. In contrast, sodium linear regression, capitalizing on partial volume correction and high sensitivity to global changes, revealed high effect sizes and associations with patient outcome. This suggests that well-recognized sodium imbalances in traumatic brain injury are (i) detectable non-invasively; (ii) non-focal; (iii) occur even when the antecedent injury is clinically mild. Finally, in contrast to our principle hypothesis, patients' sodium concentrations were than controls, indicating that the biological effect of traumatic brain injury on the sodium homeostasis may differ from that in other neurological disorders. Note: This figure has been annotated.
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http://dx.doi.org/10.1093/braincomms/fcab051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066885PMC
March 2021

Emergency Medicine's Role in the Crossroads of Social Revolution and the COVID-19 Pandemic.

Acad Emerg Med 2020 12 10;27(12):1350-1352. Epub 2020 Nov 10.

and the, Department of Emergency Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA.

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http://dx.doi.org/10.1111/acem.14155DOI Listing
December 2020

Hyperbaric oxygen therapy for COVID-19 patients with respiratory distress: treated cases versus propensity-matched controls.

Undersea Hyperb Med 2020 Third Quarter;47(3):405-413

Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, U.S.

Objective: Given the high mortality and prolonged duration of mechanical ventilation of COVID-19 patients, we evaluated the safety and efficacy of hyperbaric oxygen for COVID-19 patients with respiratory distress.

Methods: This is a single-center clinical trial of COVID-19 patients at NYU Winthrop Hospital from March 31 to April 28, 2020. Patients in this trial received hyperbaric oxygen therapy at 2.0 atmospheres of pressure in monoplace hyperbaric chambers for 90 minutes daily for a maximum of five total treatments. Controls were identified using propensity score matching among COVID-19 patients admitted during the same time period. Using competing-risks survival regression, we analyzed our primary outcome of inpatient mortality and secondary outcome of mechanical ventilation.

Results: We treated 20 COVID-19 patients with hyperbaric oxygen. Ages ranged from 30 to 79 years with an oxygen requirement ranging from 2 to 15 liters on hospital days 0 to 14. Of these 20 patients, two (10%) were intubated and died, and none remain hospitalized. Among 60 propensity-matched controls based on age, sex, body mass index, coronary artery disease, troponin, D-dimer, hospital day, and oxygen requirement, 18 (30%) were intubated, 13 (22%) have died, and three (5%) remain hospitalized (with one still requiring mechanical ventilation). Assuming no further deaths among controls, we estimate that the adjusted subdistribution hazard ratios were 0.37 for inpatient mortality (p=0.14) and 0.26 for mechanical ventilation (p=0.046).

Conclusion: Though limited by its study design, our results demonstrate the safety of hyperbaric oxygen among COVID-19 patients and strongly suggests the need for a well-designed, multicenter randomized control trial.
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September 2020

Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department.

Ann Emerg Med 2020 09;76(3):e13-e39

This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? (2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (3) In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms? (4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? Evidence was graded and recommendations were made based on the strength of the available data.
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http://dx.doi.org/10.1016/j.annemergmed.2020.06.049DOI Listing
September 2020

Not all protected bike lanes are the same: Infrastructure and risk of cyclist collisions and falls leading to emergency department visits in three U.S. cities.

Accid Anal Prev 2020 May 6;141:105490. Epub 2020 May 6.

Insurance Institute for Highway Safety, Arlington, VA, United States.

Objective: Protected bike lanes separated from the roadway by physical barriers are relatively new in the United States. This study examined the risk of collisions or falls leading to emergency department visits associated with bicycle facilities (e.g., protected bike lanes, conventional bike lanes demarcated by painted lines, sharrows) and other roadway characteristics in three U.S. cities.

Methods: We prospectively recruited 604 patients from emergency departments in Washington, DC; New York City; and Portland, Oregon during 2015-2017 who fell or crashed while cycling. We used a case-crossover design and conditional logistic regression to compare each fall or crash site with a randomly selected control location along the route leading to the incident. We validated the presence of site characteristics described by participants using Google Street View and city GIS inventories of bicycle facilities and other roadway features.

Results: Compared with cycling on lanes of major roads without bicycle facilities, the risk of crashing or falling was lower on conventional bike lanes (adjusted OR = 0.53; 95 % CI = 0.33, 0.86) and local roads with (adjusted OR = 0.31; 95 % CI = 0.13, 0.75) or without bicycle facilities or traffic calming (adjusted OR = 0.39; 95 % CI = 0.23, 0.65). Protected bike lanes with heavy separation (tall, continuous barriers or grade and horizontal separation) were associated with lower risk (adjusted OR = 0.10; 95 % CI = 0.01, 0.95), but those with lighter separation (e.g., parked cars, posts, low curb) had similar risk to major roads when one way (adjusted OR = 1.19; 95 % CI = 0.46, 3.10) and higher risk when they were two way (adjusted OR = 11.38; 95 % CI = 1.40, 92.57); this risk increase was primarily driven by one lane in Washington. Risk increased in the presence of streetcar or train tracks relative to their absence (adjusted OR = 26.65; 95 % CI = 3.23, 220.17), on downhill relative to flat grades (adjusted OR = 1.92; 95 % CI = 1.38, 2.66), and when temporary features like construction or parked cars blocked the cyclist's path relative to when they did not (adjusted OR = 2.23; 95 % CI = 1.46, 3.39).

Conclusions: Certain bicycle facilities are safer for cyclists than riding on major roads. Protected bike lanes vary in how well they shield riders from crashes and falls. Heavier separation, less frequent intersections with roads and driveways, and less complexity appear to contribute to reduced risk in protected bike lanes. Future research should systematically examine the characteristics that reduce risk in protected lanes to guide design. Planners should minimize conflict points when choosing where to place protected bike lanes and should implement countermeasures to increase visibility at these locations when they are unavoidable.
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http://dx.doi.org/10.1016/j.aap.2020.105490DOI Listing
May 2020

Community-Based Hemoglobin A1C Testing in Barbershops to Identify Black Men With Undiagnosed Diabetes.

JAMA Intern Med 2020 04;180(4):596-597

Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York.

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http://dx.doi.org/10.1001/jamainternmed.2019.6867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990850PMC
April 2020

US Organ Donation Policy.

JAMA 2020 01;323(3):278

Division of Medical Ethics, NYU Langone Health, New York, New York.

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http://dx.doi.org/10.1001/jama.2019.18643DOI Listing
January 2020

Injuries associated with electric-powered bikes and scooters: analysis of US consumer product data.

Inj Prev 2020 12 11;26(6):524-528. Epub 2019 Nov 11.

Department of Pediatrics, Division of Critical Care, NYU Langone Health, NYU School of Medicine, New York City, New York, USA.

Background: Powered, two-wheeled transportation devices like electric bicycles (E-bikes) and scooters are increasingly popular, but little is known about their relative injury risk compared to pedal operated bicycles.

Methods: Descriptive and comparative analysis of injury patterns and trends associated with E-bikes, powered scooters and pedal bicycles from 2000 to 2017 using the US National Electronic Injury Surveillance System.

Results: While persons injured using E-bikes were more likely to suffer internal injuries (17.1%; 95% CI 5.6 to 28.6) and require hospital admission (OR=2.8, 95% CI 1.3 to 6.1), powered scooter injuries were nearly three times more likely to result in a diagnosis of concussion (3% of scooter injuries vs 0.5% of E-bike injuries). E-bike-related injuries were also more than three times more likely to involve a collision with a pedestrian than either pedal bicycles (OR=3.3, 95% CI 0.5 to 23.6) or powered scooters (OR=3.3, 95% CI 0.3 to 32.9), but there was no evidence that powered scooters were more likely than bicycles to be involved in a collision with a pedestrian (OR=1.0, 95% CI 0.3 to 3.1). While population-based rates of pedal bicycle-related injuries have been decreasing, particularly among children, reported E-bike injuries have been increasing dramatically particularly among older persons.

Conclusions: E-bike and powered scooter use and injury patterns differ from more traditional pedal operated bicycles. Efforts to address injury prevention and control are warranted, and further studies examining demographics and hospital resource utilisation are necessary.
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http://dx.doi.org/10.1136/injuryprev-2019-043418DOI Listing
December 2020

The unique moral permissibility of uncontrolled lung donation after circulatory death.

Am J Transplant 2020 02 18;20(2):382-388. Epub 2019 Oct 18.

Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York.

Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from US pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (a) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (b) using non-invasive strategies that confine oxygenation to lungs; and (c) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
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http://dx.doi.org/10.1111/ajt.15603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984986PMC
February 2020

Age Disparities Among Patients With Type 2 Diabetes and Associated Rates of Hospital Use and Diabetic Complications.

Prev Chronic Dis 2019 08 1;16:E101. Epub 2019 Aug 1.

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York.

Introduction: Although screening for diabetes is recommended at age 45, some populations may be at greater risk at earlier ages. Our objective was to quantify age disparities among patients with type 2 diabetes in New York City.

Methods: Using all-payer hospital claims data for New York City, we performed a cross-sectional analysis of patients with type 2 diabetes identified from emergency department visits during the 5-year period 2011-2015. We estimated type 2 diabetes prevalence at each year of life, the age distribution of patients stratified by decade, and the average age of patients by sex, race/ethnicity, and geographic location.

Results: We identified 576,306 unique patients with type 2 diabetes. These patients represented more than half of all people with type 2 diabetes in New York City. Patients in racial/ethnic minority groups were on average 5.5 to 8.4 years younger than non-Hispanic white patients. At age 45, type 2 diabetes prevalence was 10.9% among non-Hispanic black patients and 5.2% among non-Hispanic white patients. In our geospatial analyses, patients with type 2 diabetes were on average 6 years younger in hotspots of diabetes-related emergency department use and inpatient hospitalizations. The average age of patients with type 2 diabetes was also 1 to 2 years younger in hotspots of microvascular diabetic complications.

Conclusion: We identified profound age disparities among patients with type 2 diabetes in racial/ethnic minority groups and in neighborhoods with poor health outcomes. The younger age of these patients may be due to earlier onset of diabetes and/or earlier death from diabetic complications. Our findings demonstrate the need for geographically targeted interventions that promote earlier diagnosis and better glycemic control.
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http://dx.doi.org/10.5888/pcd16.180681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716392PMC
August 2019

Identifying Geographic Disparities in Diabetes Prevalence Among Adults and Children Using Emergency Claims Data.

J Endocr Soc 2018 May 17;2(5):460-470. Epub 2018 Apr 17.

Department of Population Health, New York University School of Medicine, New York, New York.

Geographic surveillance can identify hotspots of disease and reveal associations between health and the environment. Our study used emergency department surveillance to investigate geographic disparities in type 1 and type 2 diabetes prevalence among adults and children. Using all-payer emergency claims data from 2009 to 2013, we identified unique New York City residents with diabetes and geocoded their location using home addresses. Geospatial analysis was performed to estimate diabetes prevalence by New York City Census tract. We also used multivariable regression to identify neighborhood-level factors associated with higher diabetes prevalence. We estimated type 1 and type 2 diabetes prevalence at 0.23% and 10.5%, respectively, among adults and 0.20% and 0.11%, respectively, among children in New York City. Pediatric type 1 diabetes was associated with higher income ( = 0.001), whereas adult type 2 diabetes was associated with lower income ( < 0.001). Areas with a higher proportion of nearby restaurants categorized as fast food had a higher prevalence of all types of diabetes ( < 0.001) except for pediatric type 2 diabetes. Type 2 diabetes among children was only higher in neighborhoods with higher proportions of African American residents ( < 0.001). Our findings identify geographic disparities in diabetes prevalence that may require special attention to address the specific needs of adults and children living in these areas. Our results suggest that the food environment may be associated with higher type 1 diabetes prevalence. However, our analysis did not find a robust association with the food environment and pediatric type 2 diabetes, which was predominantly focused in African American neighborhoods.
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http://dx.doi.org/10.1210/js.2018-00001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5920312PMC
May 2018

Building an Outpatient Kidney Palliative Care Clinical Program.

J Pain Symptom Manage 2018 01 10;55(1):108-116.e2. Epub 2017 Aug 10.

Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA; Department of Population Health, NYU School of Medicine, New York, New York, USA.

Context: A diagnosis of advanced chronic kidney disease or end-stage renal disease represents a significant life change for patients and families. Individuals often experience high symptom burden, decreased quality of life, increased health care utilization, and end-of-life care discordant with their preferences. Early integration of palliative care with standard nephrology practice in the outpatient setting has the potential to improve quality of life through provision of expert symptom management, emotional support, and facilitation of advance care planning that honors the individual's values and goals.

Objectives: This special report describes application of participatory action research methods to develop an outpatient integrated nephrology and palliative care program.

Methods: Stakeholder concerns were thematically analyzed to inform translation of a known successful model of outpatient kidney palliative care to a practice in a large urban medical center in the U.S.

Results: Stakeholder needs and challenges to meeting these needs were identified. We uncovered a shared understanding of the clinical need for palliative care services in nephrology practice but apprehension toward practice change. Action steps to modify the base model were created in response to stakeholder feedback.

Conclusion: The development of a model of care that provides a new approach to clinical practice requires attention to relevant stakeholder concerns. Participatory action research is a useful methodological approach that engages stakeholders and builds partnerships. This creation of shared ownership can facilitate innovation and practice change. We synthesized stakeholder concerns to build a conceptual model for an integrated nephrology and palliative care clinical program.
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http://dx.doi.org/10.1016/j.jpainsymman.2017.08.005DOI Listing
January 2018

Using Geospatial Analysis and Emergency Claims Data to Improve Minority Health Surveillance.

J Racial Ethn Health Disparities 2018 08 8;5(4):712-720. Epub 2017 Aug 8.

Department of Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA.

Traditional methods of health surveillance often under-represent racial and ethnic minorities. Our objective was to use geospatial analysis and emergency claims data to estimate local chronic disease prevalence separately for specific racial and ethnic groups. We also performed a regression analysis to identify associations between median household income and local disease prevalence among Black, Hispanic, Asian, and White adults in New York City. The study population included individuals who visited an emergency department at least once from 2009 to 2013. Our main outcomes were geospatial estimates of diabetes, hypertension, and asthma prevalence by Census tract as stratified by race and ethnicity. Using emergency claims data, we identified 4.9 million unique New York City adults with 28.5% of identifying as Black, 25.2% Hispanic, and 6.1% Asian. Age-adjusted disease prevalence was highest among Black and Hispanic adults for diabetes (13.4 and 13.1%), hypertension (28.7 and 24.1%), and asthma (9.9 and 10.1%). Correlation between disease prevalence maps demonstrated moderate overlap between Black and Hispanic adults for diabetes (0.49), hypertension (0.57), and asthma (0.58). In our regression analysis, we found that the association between low income and high disease prevalence was strongest for Hispanic adults, whereas increases in income had more modest reductions in disease prevalence for Black adults, especially for diabetes. Our geographically detailed maps of disease prevalence generate actionable evidence that can help direct health interventions to those communities with the highest health disparities. Using these novel geographic approaches, we reveal the underlying epidemiology of chronic disease for a racially and culturally diverse population.
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http://dx.doi.org/10.1007/s40615-017-0415-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803484PMC
August 2018

The Epidemiology of Emergency Department Trauma Discharges in the United States.

Acad Emerg Med 2017 10 27;24(10):1244-1256. Epub 2017 Sep 27.

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY.

Objective: Injury-related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.

Methods: We conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer ED survey database in the United States. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age-stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey-adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status.

Results: There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year-to-year decrease of 143 (95% CI = -184.3 to -68.5) visits per 100,000 U.S. population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case-fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm-related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation-adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion).

Conclusions: Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges.
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http://dx.doi.org/10.1111/acem.13223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5647215PMC
October 2017

Identifying Local Hot Spots of Pediatric Chronic Diseases Using Emergency Department Surveillance.

Acad Pediatr 2017 04;17(3):267-274

Department of Population Health, NYU School of Medicine, New York, NY; Wagner Graduate School of Public Service, New York University, New York, NY.

Objective: To use novel geographic methods and large-scale claims data to identify the local distribution of pediatric chronic diseases in New York City.

Methods: Using a 2009 all-payer emergency claims database, we identified the proportion of unique children aged 0 to 17 with diagnosis codes for specific medical and psychiatric conditions. As a proof of concept, we compared these prevalence estimates to traditional health surveys and registry data using the most geographically granular data available. In addition, we used home addresses to map local variation in pediatric disease burden.

Results: We identified 549,547 New York City children who visited an emergency department at least once in 2009. Though our sample included more publicly insured and uninsured children, we found moderate to strong correlations of prevalence estimates when compared to health surveys and registry data at prespecified geographic levels. Strongest correlations were found for asthma and mental health conditions by county among younger children (0.88, P = .05 and 0.99, P < .01, respectively). Moderate correlations by neighborhood were identified for obesity and cancer (0.53 and 0.54, P < .01). Among adolescents, correlations by health districts were strong for obesity (0.95, P = .05), and depression estimates had a nonsignificant, but strong negative correlation with suicide attempts (-0.88, P = .12). Using SaTScan, we also identified local hot spots of pediatric chronic disease.

Conclusions: For conditions easily identified in claims data, emergency department surveillance may help estimate pediatric chronic disease prevalence with higher geographic resolution. More studies are needed to investigate limitations of these methods and assess reliability of local disease estimates.
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http://dx.doi.org/10.1016/j.acap.2016.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385887PMC
April 2017

Shared Decision Making With Vulnerable Populations in the Emergency Department.

Acad Emerg Med 2016 12;23(12):1410-1416

Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.

The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.
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http://dx.doi.org/10.1111/acem.13134DOI Listing
December 2016

Assessment of acute head injury in an emergency department population using sport concussion assessment tool - 3rd edition.

Appl Neuropsychol Adult 2018 Mar-Apr;25(2):110-119. Epub 2016 Nov 17.

a Division of Neurosurgery , Hennepin County Medical Center , Minneapolis , Minnesota , USA.

Sport Concussion Assessment Tool version 3 (SCAT-3) is one of the most widely researched concussion assessment tools in athletes. Here normative data for SCAT3 in nonathletes are presented. The SCAT3 was administered to 98 nonathlete healthy controls, as well as 118 participants with head-injury and 46 participants with other body trauma (OI) presenting to the ED. Reference values were derived and classifier functions were built to assess the accuracy of SCAT3. The control population had a mean of 2.30 (SD = 3.62) symptoms, 4.38 (SD = 8.73) symptom severity score (SSS), and 26.02 (SD = 2.52) standardized assessment of concussion score (SAC). Participants were more likely to be diagnosed with a concussion (from among healthy controls) if the SSS > 7; or SSS ≤ 7 and SAC ≤22 (sensitivity = 96%, specificity = 77%). Identification of head injury patients from among both, healthy controls and body trauma was possible using rule SSS > 7 and headache or pressure in head present, or SSS ≤ 7 and SAC ≤ 22 (sensitivity = 87%, specificity = 80%). In this current study, the SCAT-3 provided high sensitivity to discriminate acute symptoms of TBI in the ED setting. Individuals with a SSS > 7 and headache or pressure in head, or SSS ≤ 7 but with a SAC ≤ 22 within 48-hours of an injury should undergo further testing.
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http://dx.doi.org/10.1080/23279095.2016.1248765DOI Listing
August 2018

Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy.

BMJ Open Diabetes Res Care 2016 26;4(1):e000248. Epub 2016 Jul 26.

Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York, New York , USA.

Objective: To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy.

Research Design And Methods: Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012.

Results: In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions.

Conclusions: We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.
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http://dx.doi.org/10.1136/bmjdrc-2016-000248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964212PMC
August 2016

The local geographic distribution of diabetic complications in New York City: Associated population characteristics and differences by type of complication.

Diabetes Res Clin Pract 2016 Sep 28;119:88-96. Epub 2016 Jul 28.

Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 560 First Avenue, New York, NY 10016, United States.

Aims: To identify population characteristics associated with local variation in the prevalence of diabetic complications and compare the geographic distribution of different types of complications in New York City.

Methods: Using an all-payer database of emergency visits, we identified the proportion of unique adults with diabetes who also had cardiac, neurologic, renal and lower extremity complications. We performed multivariable regression to identify associations of demographic and socioeconomic factors, and diabetes-specific emergency department use with the prevalence of diabetic complications by Census tract. We also used geospatial analysis to compare local hotspots of diabetic complications.

Results: We identified 4.6million unique New York City adults, of which 10.5% had diabetes. Adjusting for demographic and socioeconomic factors, diabetes-specific emergency department use was associated with severe microvascular renal and lower extremity complications (p-values<0.001), but not with severe macrovascular cardiac or neurologic complications (p-values of 0.39 and 0.29). Our hotspot analysis demonstrated significant geographic heterogeneity in the prevalence of diabetic complications depending on the type of complication. Notably, the geographic distribution of hotspots of myocardial infarction were inversely correlated with hotspots of end-stage renal disease and lower extremity amputations (coefficients: -0.28 and -0.28).

Conclusions: We found differences in the local geographic distribution of diabetic complications, which highlight the contrasting risk factors for developing macrovascular versus microvascular diabetic complications. Based on our analysis, we also found that high diabetes-specific emergency department use was correlated with poor diabetic outcomes. Emergency department utilization data can help identify the location of specific populations with poor glycemic control.
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http://dx.doi.org/10.1016/j.diabres.2016.07.008DOI Listing
September 2016

The Effect of Sharrows, Painted Bicycle Lanes and Physically Protected Paths on the Severity of Bicycle Injuries Caused by Motor Vehicles.

Safety (Basel) 2016 10;2(4). Epub 2016 Dec 10.

Department of Population Health, New York University School of Medicine, New York, NY 10016, USA.

We conducted individual and ecologic analyses of prospectively collected data from 839 injured bicyclists who collided with motorized vehicles and presented to Bellevue Hospital, an urban Level-1 trauma center in New York City, from December 2008 to August 2014. Variables included demographics, scene information, rider behaviors, bicycle route availability, and whether the collision occurred before the road segment was converted to a bicycle route. We used negative binomial modeling to assess the risk of injury occurrence following bicycle path or lane implementation. We dichotomized U.S. National Trauma Data Bank Injury Severity Scores (ISS) into none/mild (0-8) versus moderate, severe, or critical (>8) and used adjusted multivariable logistic regression to model the association of ISS with collision proximity to sharrows (i.e., bicycle lanes designated for sharing with cars), painted bicycle lanes, or physically protected paths. Negative binomial modeling of monthly counts, while adjusting for pedestrian activity, revealed that physically protected paths were associated with 23% fewer injuries. Painted bicycle lanes reduced injury risk by nearly 90% (IDR 0.09, 95% CI 0.02-0.33). Holding all else equal, compared to no bicycle route, a bicycle injury nearby sharrows was nearly twice as likely to be moderate, severe, or critical (adjusted odds ratio 1.94; 95% confidence interval (CI) 0.91-4.15). Painted bicycle lanes and physically protected paths were 1.52 (95% CI 0.85-2.71) and 1.66 (95% CI 0.85-3.22) times as likely to be associated with more than mild injury respectively.
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http://dx.doi.org/10.3390/safety2040026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858726PMC
December 2016

Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program.

Ann Emerg Med 2016 Apr 25;67(4):531-537.e39. Epub 2015 Nov 25.

Bellevue Hospital Center, New York, NY; Department of Emergency Medicine, NYU School of Medicine, New York, NY. Electronic address:

Study Objective: In 2006, the Institute of Medicine emphasized substantial potential to expand organ donation opportunities through uncontrolled donation after circulatory determination of death (uDCDD). We pilot an out-of-hospital uDCDD kidney program for New York City in partnership with communities that it was intended to benefit. We evaluate protocol process and outcomes while identifying barriers to success and means for improvement.

Methods: We conducted a prospective, participatory action research study in Manhattan from December 2010 to May 2011. Daily from 4 to 12 pm, our organ preservation unit monitored emergency medical services (EMS) frequencies for cardiac arrests occurring in private locations. After EMS providers independently ordered termination of resuscitation, organ preservation unit staff determined clinical eligibility and donor status. Authorized parties, persons authorized to make organ donation decisions, were approached about in vivo preservation. The study population included organ preservation unit staff, authorized parties, passersby, and other New York City agency personnel. Organ preservation unit staff independently documented shift activities with daily operations notes and teleconference summaries that we analyzed with mixed qualitative and quantitative methods.

Results: The organ preservation unit entered 9 private locations; all the deceased lacked previous registration, although 4 met clinical screening eligibility. No kidneys were recovered. We collected 837 notes from 35 organ preservation unit staff. Despite frequently recounting protocol breaches, most responses from passersby including New York City agencies were favorable. No authorized parties were offended by preservation requests, yielding a Bayesian posterior median 98% (95% credible interval 76% to 100%).

Conclusion: In summary, the New York City out-of-hospital uDCDD program was not feasible. There were frequent protocol breaches and confusion in determining clinical eligibility. In the small sample of authorized persons we encountered during the immediate grieving period, negative reactions were infrequent.
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http://dx.doi.org/10.1016/j.annemergmed.2015.09.017DOI Listing
April 2016

Organ Donation After Circulatory Death--Reply.

JAMA 2015 Oct;314(15):1646-7

Division of Medical Ethics, NYU School of Medicine, New York, New York.

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http://dx.doi.org/10.1001/jama.2015.11444DOI Listing
October 2015

Drawing the Curtain Back on Injured Commercial Bicyclists.

Am J Public Health 2015 Oct 13;105(10):2131-6. Epub 2015 Aug 13.

Jessica H. Heyer, Monica Sethi, Patricia Ayoung-Chee, Dekeya Slaughter, Sally Jacko, Charles J. DiMaggio, and Spiros G. Frangos are with Department of Surgery, New York University School of Medicine/Bellevue Hospital Center, New York, NY. Stephen P. Wall is with Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center.

Objectives: We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City's (NYC's) central business district.

Methods: Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses.

Results: Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723).

Conclusions: Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.
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http://dx.doi.org/10.2105/AJPH.2015.302738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566558PMC
October 2015

Bicycle helmets are highly protective against traumatic brain injury within a dense urban setting.

Injury 2015 Dec 29;46(12):2483-90. Epub 2015 Jul 29.

New York University School of Medicine, Bellevue Hospital Center, Department of Surgery, New York, New York, USA. Electronic address:

Background: New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety.

Methods: A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24 h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score.

Results: Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS ≥3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61).

Conclusions: Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.
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http://dx.doi.org/10.1016/j.injury.2015.07.030DOI Listing
December 2015

Determining Chronic Disease Prevalence in Local Populations Using Emergency Department Surveillance.

Am J Public Health 2015 Sep 16;105(9):e67-74. Epub 2015 Jul 16.

David C. Lee and Stephen P. Wall are with the Ronald O. Perelman Department of Emergency Medicine and R. Scott Braithwaite and Brian Elbel are with the Department of Population Health, New York University School of Medicine, New York, NY. Judith A. Long is with the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA. Brendan G. Carr is with the Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA. Samantha N. Satchell is with the Milken Institute School of Public Health, George Washington University, Washington, DC.

Objectives: We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence.

Methods: Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses.

Results: We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts.

Conclusions: Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence.
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http://dx.doi.org/10.2105/AJPH.2015.302679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539836PMC
September 2015

A Potential Solution to the Shortage of Solid Organs for Transplantation.

JAMA 2015 Jun;313(23):2321-2

Division of Medical Ethics, NYU School of Medicine, New York, New York.

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http://dx.doi.org/10.1001/jama.2015.5328DOI Listing
June 2015

A community traffic safety analysis of pedestrian and bicyclist injuries based on the catchment area of a trauma center.

J Trauma Acute Care Surg 2014 Apr;76(4):1103-10

From the Departments of Surgery (D.R.S., N.E.G., R.S., S.R.T., O.S.B., S.J., C.T.W., G.M., P.-A.C., H.L.P., S.G.F.), Emergency Medicine (N.W., S.W., D.A.L.), and Pediatrics (D.A.L.), Bellevue Hospital Center, New York University School of Medicine; and Office of Research, Implementation and Safety (M.R.), NYC Department of Transportation, New York, New York.

Background: This study was designed to examine the characteristics of pedestrian and bicyclist collisions with motor vehicles within New York City's high-density hub. The primary objectives were to map crash locations and to identify hot spots within these injury clusters. The secondary objective was to quantify differences in injury severity based on road type and user behaviors.

Methods: Between December 2008 and June 2011, data were prospectively collected from pedestrians and bicyclists struck by motor vehicles and brought to Bellevue Hospital, a Level 1 trauma center in New York City. Behaviors by cohort (i.e., crossing patterns for pedestrians, riding patterns for bicyclists), Injury Severity Score (ISS), and collision locations were extracted from the database. Analyses of mean ISS were performed using a Student's t test with a p < 0.05 considered significant. Geomaps were created to identify clusters or "hot spots," where higher volumes of crashes occurred over time. Spatial analysis was performed to demonstrate whether these were random events.

Results: A total of 1,457 patients (1,075 pedestrians and 382 bicyclists) were enrolled. Collision locations were known for 97.5%. Of the injured pedestrians, those crossing avenues (n = 277) had higher ISSs than those crossing streets (n = 522) (p = 0.01) and were more likely to die (p = 0.002). Pedestrians crossing midblock (n = 185) had higher mean ISSs than those crossing with the signal in the crosswalk (n = 320) (8.12 vs. 5.01, p < 0.001). Based on density mapping, hot spots of pedestrian collisions were detected in midtown Manhattan, while hot spots for bicyclists were detected at bridge and tunnel portals. Spatial analysis indicates that these are not random events (p < 0.05).

Conclusion: Pedestrians injured on avenues sustained more serious injuries than those injured on narrower streets. A better understanding of collision locations and features may allow for tailored injury prevention strategies. Trauma centers serve an important role in public health surveillance within their local communities.

Level Of Evidence: Epidemiologic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000000176DOI Listing
April 2014

Reasons for emergency department use: do frequent users differ?

Am J Manag Care 2014 Nov 1;20(11):e506-14. Epub 2014 Nov 1.

Department of Emergency Medicine, Bellevue Hospital Center Room A-345, First Ave and 27th St, New York, NY 10016. E-mail:

Objectives: To examine patients' reasons for using the emergency department (ED) for low-acuity health complaints, and determine whether reasons differed for frequent ED users versus nonfrequent ED users.

Study Design: Prospective cross-sectional survey.

Methods: Patients presenting to an urban public hospital for low-acuity health complaints were surveyed about their reasons for visiting the ED rather than a private doctor's office or clinic. Patients with 3 or more visits to the study hospital ED over the past year were classified as frequent ED users. Multivariable logistic regression was used to determine if frequent ED users gave different reasons for ED use than nonfrequent ED users, while controlling for differences in other baseline patient characteristics.

Results: 940 patients, including 163 frequent ED users, completed the study questionnaire. Commonly cited reasons for using the ED were that coming to the ED was easier than making a clinic appointment (82.3% agreed); the problem could not wait (78.8%); they didn't know how to make a clinic appointment (66.7%); they felt the ED provided better care (56.7%); and they believed the clinic would cost more (54.8%). After controlling for other patient characteristics, there were no significant differences found in reasons for ED use given by frequent versus nonfrequent ED users.

Conclusions: Frequent ED users gave similar reasons for using the ED for low-acuity health complaints compared with nonfrequent ED users. Access, convenience, cost, and quality concerns, as well as feeling that ED care was needed, were all commonly cited as reasons for using the ED.
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November 2014

Uncontrolled organ donation after circulatory determination of death: US policy failures and call to action.

Ann Emerg Med 2014 Apr 20;63(4):392-400. Epub 2013 Nov 20.

Department of Emergency Medicine, Bellevue Hospital Center, NYU School of Medicine, New York, NY. Electronic address:

In the United States, more than 115,000 patients are wait-listed for organ transplants despite that there are 12,000 patients each year who die or become too ill for transplantation. One reason for the organ shortage is that candidates for donation must die in the hospital, not the emergency department (ED), either from neurologic or circulatory-respiratory death under controlled circumstances. Evidence from Spain and France suggests that a substantial number of deaths from cardiac arrest may qualify for organ donation using uncontrolled donation after circulatory determination of death (uDCDD) protocols that rapidly initiate organ preservation in out-of-hospital and ED settings. Despite its potential, uDCDD has been criticized by panels of experts that included neurologists, intensivists, attorneys, and ethicists who suggest that organ preservation strategies that reestablish oxygenated circulation to the brain retroactively negate previous death determination based on circulatory-respiratory criteria and hence violate the dead donor rule. In this article, we assert that in uDCDD, all efforts at saving lives are exhausted before organ donation is considered, and death is determined according to "irreversible cessation of circulatory and respiratory functions" evidenced by "persistent cessation of functions during an appropriate period of observation and/or trial of therapy." Therefore, postmortem in vivo organ preservation with chest compressions, mechanical ventilation, and extracorporeal membrane oxygenation is legally and ethically appropriate. As frontline providers for patients presenting with unexpected cardiac arrest, emergency medicine practitioners need be included in the uDCDD debate to advocate for patients and honor the wishes of the deceased.
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http://dx.doi.org/10.1016/j.annemergmed.2013.10.014DOI Listing
April 2014

Resource-limited, collaborative pilot intervention for chronically homeless, alcohol-dependent frequent emergency department users.

Am J Public Health 2013 Dec 22;103 Suppl 2:S221-4. Epub 2013 Oct 22.

Ryan P. McCormack, Lily F. Hoffman, Stephen P. Wall, and Lewis R. Goldfrank are with the Department of Emergency Medicine, New York University School of Medicine, New York, NY.

We introduced case management and homeless outreach to chronically homeless, alcohol-dependent, frequent emergency department (ED) visitors using existing resources. We assessed the difference in differences of ED visits 6 months pre- and postintervention using a prospective, nonequivalent control group trial. Secondary outcomes included changes in hospitalizations and housing. The differences in differences between intervention and prospective patients and retrospective controls were -12.1 (95% CI = -22.1, -2.0) and -12.8 (95% CI = -26.1, 0.6) for ED visits and -8.5 (95% CI = -22.8, 5.8) and -19.0 (95% CI = -34.3, -3.6) for inpatient days, respectively. Eighteen participants accepted shelter; no controls were housed. Through intervention, ED use decreased and housing was achieved.
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http://dx.doi.org/10.2105/AJPH.2013.301373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3969119PMC
December 2013