Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84–0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72–0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
The study was designed to determine whether there was an association between indoor levels of nitrogen dioxide (NO2) and respiratory illness and lung function in schoolchildren. NO2 was measured for one week in the winter outside and inside the homes of children aged 6-7 years living and attending primary schools in a defined 4 square km area in Middlesbrough, Cleveland, UK. Outdoor levels of NO2 measured at 75 points within the area ranged from 14-24 ppb weekly average. Measurements were also made in 428 kitchens with gas cookers, range 5-317 ppb, mean 112.2 ppb, and in 87 kitchens with electric cookers, range 6-188 ppb, mean 18.0 ppb. In a random subsample of homes the range of NO2 levels in 107 children's bedrooms in homes where gas was used for cooking was 4-169 ppb, mean 30.5 ppb, in 18 bedrooms in electric cooking homes the range was 3-37 ppb, mean 13.9 ppb. NO2 levels in the gas cooking kitchens were positively related to the presence of pilot lights, use of gas fires for main heating, number of regular smokers, and the number of people in the home. Information from 29 homes with the highest kitchen NO2 levels paired with 29 low NO2 gas cooking homes showed that the daily number of meals eaten and the frequency with which the cooker was used for heating and drying clothes were significantly greater in the high NO2 homes.
The relation of respiratory illness to nitrogen dioxide (NO2), temperature and relative humidity in homes with a gas cooker was investigated in five and six year old children living in an urban area of the northern England. NO2 was measured for one week in the child's bedroom and living room of each home, and temperature and relative humidity were measured in the bedroom only. Information on respiratory conditions experienced by the child and characteristics of the home was collected in a self-administered questionnaire completed by the child's mother. Access was gained to 183 homes (54.3% of 337) where only gas was used for cooking. Complete information was obtained for 179 (93.7%) of 191 children who lived in the 183 homes. After allowing for the effects of age, sex, social class, and number of cigarette smokers in the home and temperature or relative humidity, no statistically significant relation was found between the prevalence of having one or more respiratory conditions and weekly average levels of NO2 in the bedroom (range 4.7 to 160.8 ppb) or living room (range 9.0 to 292.2 ppb). However, the prevalence of having one or more respiratory conditions tended to be highest in homes with high levels of NO2 and lowest in homes with low levels, consistent with earlier findings. A significant positive association was found between the prevalence of respiratory conditions and relative humidity (p less than .05). A harmful effect on health from NO2 cannot be totally dismissed but if it exists it is weak and difficult to detect in small samples of children.
Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. Here we discuss two specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. Conversely, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.
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