Importance Suicide is a leading cause of deaths in the U.S. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. Objective To determine if an ED-initiated intervention reduces subsequent suicidal behavior. Design This multicenter study was composed of three sequential phases: 1) Treatment as Usual (TAU) (August 2010–December 2011), 2) Universal Screening (Screening) (September 2011–December 2012, and 3) Universal Screening + Intervention (Intervention)(July 2012-November 2013. Setting Eight EDs in the United States Participants Adults with a recent suicidal attempt or ideation were enrolled. Intervention Universal Screening consisted of universal suicide risk screening. The Intervention phase consisted of universal screening plus an intervention which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. Main Outcomes The primary outcome was suicide attempts (non-fatal and fatal) over the 52-week follow-up. The proportion and total number of attempts were analyzed. Results 1,376 participants (56% female, median age 36 years) were recruited. 288 participants (21%) made at least one suicide attempt. There were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and Screening phases (23% vs. 22%). However, when compared to the TAU Phase, subjects in the Intervention phase showed a 5 % absolute reduction in suicide attempt risk (23% vs. 18%) with a relative risk reduction of 20%. Participants in the Intervention Phase had 30% fewer total suicide attempts than participants in the TAU Phase. Negative binomial regression analysis indicated that the participants in the Intervention Phase had significantly fewer total suicide attempts than participants in the TAU Phase (IRR, 0.72, 95%CI 0.52–1.00, P=0.05), but no differences between the TAU and Screening phases (IRR, 1, 95%CI 0.71–1.41, P=0.99). Conclusions Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Little is known about the relationship between specific composition of the airway microbiota and severity of bronchiolitis. We aimed to identify nasopharyngeal microbiota profiles and to link these profiles to acute severity in infants hospitalized for bronchiolitis. We conducted a multicenter prospective cohort study of 1005 infants (age <1 year) hospitalized for bronchiolitis over three winters, 2011-2014. By applying a 16S rRNA gene sequence and clustering approach to the nasopharyngeal aspirates collected within 24 hours of hospitalization, we determined nasopharyngeal microbiota profiles and their association with bronchiolitis severity. The primary outcome was intensive care use – i.e., admission to an intensive care unit or use of mechanical ventilation. We identified four distinct nasopharyngeal microbiota profiles – three profiles were dominated by either Haemophilus, Moraxella, or Streptococcus, while the fourth profile had the highest bacterial richness. The rate of intensive care use was highest in infants with a Haemophilus-dominant profile and lowest in those with a Moraxella-dominant profile (20.2% vs 12.3%; unadjusted OR, 1.81; 95%CI, 1.07-3.11; P=0.03). After adjusting for 11 patient-level confounders, the rate remained significantly higher in infants with a Haemophilus-dominant profile (OR, 1.98; 95%CI, 1.08-3.62; P=0.03). These findings were externally validated in a separate cohort of 307 children hospitalized for bronchiolitis.

OBJECTIVE We evaluated vitamin D insufficiency in a nationally representative sample of women and assessed the role of vitamin supplementation. STUDY DESIGN We conducted secondary analysis of 928 pregnant and 5173 nonpregnant women aged 13–44 years from the National Health and Nutrition Examination Survey 2001–2006. RESULTS The mean 25-hydroxyvitamin D (25[OH]D) level was 65 nmol/L for pregnant women and 59 nmol/L for nonpregnant women. The prevalence of 25(OH)D <75 nmol/L was 69% and 78%, respectively. Pregnant women in the first trimester had similar 25(OH)D levels as nonpregnant women (55 vs 59 nmol/L), despite a higher proportion taking vitamin D supplementation (61% vs 32%). However, first-trimester women had lower 25(OH)D levels than third-trimester women (80 nmol/L), likely from shorter duration of supplement use. CONCLUSION Adolescent and adult women of childbearing age have a high prevalence of vitamin D insufficiency. Current prenatal multivitamins (400 IU vitamin D) helped to raise serum 25(OH)D levels, but higher doses and longer duration may be required.

Objective To describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period. Method Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950–E959) during 1993–2008. Results Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury (1.50 [95% confidence interval (CI) 1.33–1.67] visits per 1,000 US population) and the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008. During the same timeframe, ED visits for these injuries per 1,000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82), and blacks (1.14 to 2.10). Visits were most common among ages 15–19 and the number of visits coded as urgent/emergent decreased. Conclusions ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs.

Objective: To determine whether hospital length of stay (LOS) for acute bronchiolitis is influenced by the infecting pathogen.Design: A prospective observational cohort study was performed during 3 consecutive years.Setting: Sixteen US hospitals participated in the study.Participants: Children younger than 2 years hospitalized with bronchiolitis were included.Main Exposure: The results of nasopharyngeal aspirate polymerase chain reaction pathogen testing served as the main exposure.Main Outcome Measure: Hospital LOS was determined.Results: Of 2207 participants, 72.0% had respiratory syncytial virus (RSV) and 25.6% had human rhinovirus (HRV); the incidence of each of the other viruses and bacteria was 7.8% or less. Multiple pathogen infections were present in 29.8% of the children. There were 1866 children (84.5%) with RSV and/or HRV. Among these 1866 children, the median age was 4 months and 59.5% were male. The median LOS was 2 days (interquartile range, 1-4 days). Compared with children who had only RSV, an LOS of 3 or more days was less likely among children with HRV alone (adjusted odds ratio [AOR], 0.36; 95% CI, 0.20-0.63; PϽ .001) and those with HRV plus non-RSV pathogens (AOR, 0.39; 95% CI, 0.23-0.66; PϽ.001) but more likely among children with RSV plus HRV (AOR, 1.33; 95% CI, 1.02-1.73; P=.04), controlling for 15 demographic and clinical factors. Conclusions:In this multicenter study of children hospitalized with bronchiolitis, RSV was the most common virus detected, but HRV was detected in one-quarter of the children. Since 1 in 3 children had multiple virus infections and HRV was associated with LOS, these data challenge the effectiveness of current RSV-based cohorting practices, the sporadic testing for HRV in bronchiolitis research, and current thinking that the infectious etiology of severe bronchiolitis does not affect shortterm outcomes.

Objective-Rapid access to emergency services is essential for emergency care sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We sought to determine US population access to an emergency department (ED).Methods-The National Emergency Department Inventories (NEDI) -USA was used to identify the location, annual visit volume, and teaching status of all EDs in the US. EDs were categorized as 1) any ED, 2) by patient volume, and 3) by teaching status. Driving distances, driving speeds, and prehospital times were estimated using validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified time intervals.Results-Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs.Conclusions-Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care sensitive conditions. The development of a regionalized emergency care delivery system should be explored.

Objective Although bronchiolitis is generally considered a single disease, recent studies suggest heterogeneity. We aimed to identify severe bronchiolitis profiles using a clustering approach. Methods We analyzed data from two prospective, multi-center cohorts of children younger than 2 years hospitalized with bronchiolitis, one in the U.S. (2007–2010 winter seasons, n=2,207) and one in Finland (2008–2010 winter seasons, n=408). Severe bronchiolitis profiles were determined by latent class analysis, classifying children based on clinical factors and viral etiology. Results In the U.S. study, four profiles were identified. Profile A (12%) was characterized by history of wheezing and eczema, wheezing at the ED presentation and rhinovirus infection. Profile B (36%) included children with wheezing at the ED presentation, but, in contrast to profile A, most did not have history of wheezing or eczema; this profile had the largest probability of RSV-infection. Profile C (34%) was the most severely ill group, with longer hospital stay and moderate-to-severe retractions. Profile D (17%) had the least severe illness, including non-wheezing children with shorter length-of-stay. Two of these profiles (A and D) were replicated in the Finnish cohort; a third group (“BC”) included Finnish children with characteristics of profiles B and/or C in the U.S. population. Conclusion Several distinct clinical profiles (phenotypes) were identified by a clustering approach in two multicenter studies of children hospitalized for bronchiolitis. The observed heterogeneity has important implications for future research on the etiology, management and long-term outcomes of bronchiolitis, such as future risk of childhood asthma.

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