No abstract

Limited evidence is available on apparent temperature (AT) and hospital admissions for acute cardiac events. We examined the associations of AT with admissions for acute cardiac events and acute coronary syndrome (ACS), and explored the effect difference between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction ACS (NSTE-ACS). Poisson regression with distributed lag non-linear model was applied to examine the temperature-lag-admission associations. Stratified analyses were performed by gender and age-groups for acute cardiac events. A total of 11,657 acute cardiac events admissions were collected from hospital-based chest pain centers in Beijing, during 2017–2019. The single day effect of low AT (− 11 °C, 2.5th percentile) appeared on the 2nd day and persisted until the 11th day, with estimated relative risk (RR) ranging from 1.44 (95% CI: 1.159, 1.790) to 1.084 (95% CI: 1.022, 1.150) for acute cardiac events and from 1.034 (95% CI: 1.010, 1.059) to 1.006 (95% CI: 1.000, 1.011) for ACS. The single day effect of high AT (34 °C, 97.5th percentile) was only observed on the current day. The cold effect on acute cardiac events was more pronounced among female and older patients. The cumulative effect of high AT on STEMI admissions and low AT on NSTE-ACS reached a peak RR peak of 2.545 (95% CI: 1.016, 6.375) and 3.71 (95% CI: 1.315, 10.469) on lag 0–6 days, respectively. Both high and low ATs were associated with increased risk of acute cardiac events and ACS admissions. STEMI admissions may be more sensitive to high AT while NSTE-ACS to low AT.

Background : Global spread and impact of the coronavirus disease 2019 (COVID-19) pandemic are determined to a large extent, by resistance to the pandemic and public response of all countries in the world; while a country's resistance and response are in turn determined by its political and socio economic conditions. To inform future disease prevention and control, we analyzed global data to exam the relationship between state vulnerabilities and COVID-19 incidences and deaths. Methods : Vulnerability was measured using the Fragile States Index (FSI). FSI is created by the Fund for Peace to assess levels of fragility for individual countries. Total FSI score and scores for 12 specific indicators were used as the predictor variables. Outcome variables were national cumulative COVID-19 cases and deaths up to September 16, 2020, derived the World Health Organization. Cumulative incidence rates were computed using 2019 National population derived from the World Bank, and case fatality rates were computed as the ratio of deaths/COVID-19 cases. Countries with incomplete data were excluded, yielding a final sample of 146 countries. Multivariate regression was used to examine the association between the predictor and the outcome measures. Results : There were dramatic cross-country variations in both FSI and COVID-19 epidemiological measurements. FSI total scores were negatively associated with both COVID-19 cumulative incidence rates (β = -0.0135, P < 0.001) and case fatality rates (β = -0.0147, P < 0.05). Of the 12 FSI indicators, three negatively associated with COVID-19 incidences were E1(Economic Decline and Poverty), E3 (Human Flight and Brain Drain), and S2 (Refugees and Internally Displaced Persons); two positively associated were P1 (State Legitimacy) and X1 (External Intervention). With regard to association with case fatality rates, C1 (Security Apparatus) was positive, and P3 (Human Rights and Rule of Law) and X1 was negative. Conclusions : With FSI measures by the Fund of Peace, overall, more fragile countries are less likely to be affected by the COVID-19 pandemic, and even if affected, death rates were lower. However, poor in state legitimacy and lack of external intervention are risk for COVID-19 infection and lack of security apparatus is risky for COVID-19 death. Implications of the study findings are discussed and additional studies are needed to examine the mechanisms underpinning these relationships.

Background Ischemic heart disease causes a high disease burden globally and numerous challenges in treatment, particularly in developing countries such as China. The National Chest Pain Centers Program (NCPCP) was launched in China as the first nationwide, hospital-based, comprehensive, continuous quality improvement (QI) program to improve early diagnosis and standardized treatment of acute coronary syndromes (ACS) and improve patients’ clinical outcomes. With implementation and scaling up of the NCPCP, we investigated barriers and enablers in the NCPCP implementation process and provided examples and ideas for overcoming such barriers. Methods We conducted a nationally representative survey in six cities in China. A total of 165 key informant interviewees, including directors and coordinators of chest pain centers (CPCs) in 90 hospitals, participated in semi-structured interviews. The interviews were transcribed verbatim, translated into English, and analyzed in NVivo 12.0. We used the Consolidated Framework for Implementation Research (CFIR) to guide the codes and themes. Results Barriers to NCPCP implementation mainly arose from nine CFIR constructs. Barriers included the complexity of the intervention (complexity), low flexibility of requirements (adaptability), a lack of recognition of chest pain in patients with ACS (patient needs and resources), relatively low government support (external policies and incentives), staff mobility in the emergency department and other related departments (structural characteristics), resistance from related departments (networks and communications), overwhelming tasks for CPC coordinators (compatibility), lack of available resources for regular CPC operations (available resources), and fidelity to and sustainability of intervention implementation (executing). Enablers of intervention implementation were inner motivation for change (intervention sources), evidence strength and quality of intervention, relatively low cost (cost), individual knowledge and beliefs regarding the intervention, pressure from other hospitals (peer pressure), incentives and rewards of the intervention, and involvement of hospital leaders (leadership engagement, engaging). Conclusion Simplifying the intervention to adapt routine tasks for medical staff and optimizing operational mechanisms between the prehospital emergency system and in-hospital treatment system with government support, as well as enhancing emergency awareness among patients with chest pain are critically important to NCPCP implementation. Clarifying and addressing these barriers is key to designing a sustainable QI program for acute cardiovascular diseases in China and similar contexts across developing countries worldwide. Trial registration This study was registered in the Chinese Clinical Trial Registry (ChiCTR 2100043319), registered 10 February 2021.

Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.

BackgroundChronic exposure to particulate matter air pollution (PM2.5) is associated with chronic rhinosinusitis (CRS). Elevated ambient temperature may increase PM2.5 levels and thereby exacerbate sinonasal symptoms. This study investigates the association between high ambient temperature and the risk of CRS diagnosis.MethodsPatients with CRS were diagnosed at Johns Hopkins hospitals from May to October 2013–2022, and controls were matched patients without CRS meanwhile. A total of 4752 patients (2376 cases and 2376 controls) were identified with a mean (SD) age of 51.8 (16.8) years. The effect of maximum ambient temperature on symptoms was estimated with a distributed lag nonlinear model (DLNM). Extreme heat was defined as 35.0°C (95th percentile of the maximum temperature distribution). Conditional logistic regression models estimated the association between extreme heat and the risk of CRS diagnosis.ResultsExposure to extreme heat was associated with increased odds of exacerbation of CRS symptoms (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.03–1.19). The cumulative effect of extreme heat during 0–21 lag days was significant (OR 2.37, 95% CI 1.60–3.50) compared with the minimum morbidity temperature (MMT) at 25.3°C. Associations were more pronounced among young and middle‐aged patients and patients with abnormal weight.ConclusionsWe found that short‐term exposure to high ambient temperature is associated with increased CRS diagnosis, suggesting a cascading effect of meteorological phenomena. These results highlight climate change's potentially deleterious health effects on upper airway diseases, which could have a significant public health impact.

(1) Background: Chest pain center accreditation has been associated with improved timelines of primary percutaneous coronary intervention (PCI) for ST-segment elevated myocardial infarction (STEMI). However, evidence from low- and middle-income regions was insufficient, and whether the sensitivity to improvements differs between walk-in and emergency medical service (EMS)-transported patients remained unclear. In this study, we aimed to examine the association of chest pain center accreditation status with door-to-balloon (D2B) time and the potential modification effect of arrival mode. (2) Methods: The associations were examined using generalized linear mixed models, and the effect modification of arrival mode was examined by incorporating an interaction term in the models. (3) Results: In 4186 STEMI patients, during and after accreditation were respectively associated with 65% (95% CI: 54%, 73%) and 71% (95% CI: 61%, 79%) reduced risk of D2B time being more than 90 min (using before accreditation as the reference). Decreases of 27.88 (95% CI: 19.57, 36.22) minutes and 26.55 (95% CI: 17.45, 35.70) minutes in D2B were also observed for the during and after accreditation groups, respectively. The impact of accreditation on timeline improvement was greater for EMS-transported patients than for walk-in patients. (4) Conclusions: EMS-transported patients were more sensitive to the shortened in-hospital delay associated with the initiative, which could exacerbate the existing disparity among patients with different arrival modes.

Background Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care. Objective This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China. Methods This retrospective analysis was based on an integrated database of China’s MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score–matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes. Results A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: –1.67, 95% CI –2.33 to –1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: –3.81, 95% CI –4.63 to –2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes. Conclusions The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis.